Ajay K. Singh, MBBS, FRCP, MBA
Brigham and Women’s Hospital and Harvard Medical School
From the early days of hemodialysis, many, including the late Dr. Bernard Scribner at the University of Seattle, worked tirelessly to promote home hemodialysis. In the early 1970s, the use of home hemodialysis peaked, with nearly 40% of all patients in the United States receiving home hemodialysis (HHD). Since then, and for a variety of reasons, in-center hemodialysis has become dominant. In part, this has been because the population on dialysis is older and less stable from a cardiovascular perspective, but also because of changes in the way Medicare funds dialysis.
Frequent daily dialysis or nocturnal dialysis appears to have several benefits, including cardiovascular, mortality, and quality of life. However, the benefit depends on ensuring that the total duration of dialysis is not curtailed1,2. Management of volume and electrolytes also seems to be better with HHD. However, frequent dialysis attenuates residual kidney function3, which impacts volume control and, potentially, mortality4.
While HHD is attractive to some patients, there is substantial impact on a patient’s ability to work, unless HHD is performed at night. Further, until recently HHD required a caregiver be present. Currently, only approximately 10% of patients in the United States receive HHD.
The recently announced decision by the FDA to approve the NxStage Medical System One™5 allows patients, on their own, to perform HHD6. This represents major progress, and it is likely to result in more patients opting for HHD. The recent acquisition of NxStage by Fresenius7 might also represent a powerful signal, in that the dialysis industry sees tremendous financial benefit of shifting the patient mix back towards HHD; in addition, Fresenius championed in-center dialysis dating back to the origins of commercially available dialysis in the United States and now has more than 300,000 patients on hemodialysis globally.
The question is whether Fresenius’s $2 billion bet will pay off.
Rice Powell, chairman and CEO of Fresenius Medical Care, said, “The acquisition supports our 2020 strategic initiative of driving growth in the core business with innovation, better clinical outcomes through Care Coordination, and improving the patient experience…combining our two companies would strengthen and diversify our business in the United States and help meet the evolving needs of our patients.7”
What is Fresenius looking for in its purchase of NxStage? Two things: first, the financing of dialysis is now bundled. The onus is on providers to find savings, since many aspects of dialysis care, including injectable drugs such as erythropoietin, are covered in the bundle. Thus, shifting patients to a less expensive therapy could be financially beneficial. Second, HHD’s major survival benefits over more conventional forms of dialysis will ultimately lead to greater demand for HHD, and Fresenius will be able to serve this demand through NxStage.
Still, for some, the dream of a patient independently undergoing dialysis using a portable wearable device remains. Perhaps Fresenius is making an additional bet: NxStage is sufficiently innovative that even further portability in dialysis care beyond just “doing it at home” will emerge. Either way, acquiring NxStage seems to represent a masterful big step.
- Naso A, Scaparrotta G, Naso E, Calò LA. Intensive Home Hemodialysis: An Eye at the Past Looking for the Hemodialysis of the Future. Artif Organs. 2015 Sep;39(9):736-40. doi:10.1111/aor.12458. Epub 2015 Apr 29.
- Chertow GM, Levin NW, Beck GJ, et al. FHN Trial Group In-center hemodialysis six times per week versus three times per week.
N Engl J Med. 2010;363(24):2287–2300. doi:10.1056/NEJMoa1001593.
- Daugirdas JT, Greene T, Rocco et al FHN Trial Group Effect of frequent hemodialysis on residual kidney function. Kidney Int. 2013;83(5):949–958. doi:10.1038/ki.2012.457.
- Wang AY, Lai KN The importance of residual renal function in dialysis patients. Kidney Int. 2006;69(10):1726.
- https://www.medpagetoday.com/nephrology/esrd/67620 Accessed September 14, 2017