Dean Preddie

The stunning view of the Hudson River from the 20-foot floor-to-ceiling windows is the first thing people notice when visiting the dialysis center at CUMC.
      Although this is a vista few people in New York probably get to see regularly, most of the patients who come here would gladly give it up if they could. “The patients who must stare out of these windows three days a week, for up to five hours a day, would certainly say they would rather be home,” says Dean Preddie, M.D., the center’s medical director for home hemodialysis.
      In a few months, some may get to do just that. Under Dr. Preddie’s supervision, the dialysis center will soon begin training patients to perform kidney dialysis at home. The endeavor is part of a growing movement among nephrologists in the United States toward home hemodialysis and away from in-center dialysis three times per week. This trend is not only to make dialysis more convenient for patients, but also to improve health.
      “Having dialysis only three days a week is not necessarily optimum,” says Donald Landry, M.D., Ph.D., chief of the nephrology division and interim chair of medicine. “This number is a compromise. If dialysis can be done at home, it can be done more often, which is better for the patient because it more closely matches the natural function of the kidneys.”

A Burgeoning Problem
As Dr. Preddie makes his way around the 24-station center, another reason why home dialysis is so desperately needed becomes clear. The room is packed, and there are no empty stations. The center runs through three shifts per day, six days a week, and is considering adding a fourth shift in the next year.
      “Even with the added shift, we will soon run out of units to accommodate everyone,” Dr. Preddie says. Diabetes and kidney disease are on the rise and New York State is projecting 3,000 to 4,000 new stations will be needed within the next four years to deal with the growing numbers. Home hemodialysis will help meet the need in a way that will help the patient.
      “The medical community has been trying to improve kidney dialysis for more than 30 years, but the outcomes have barely changed,” Dr. Preddie says. “The most important thing for us is not the convenience; we strongly believe patients do better and live longer.”
      With more frequent dialysis possible at home, Dr. Preddie says, the number of medications a patient must take to reduce high blood pressure decreases drastically. As blood pressure decreases, less stress is placed on the heart. In addition, less calcium is leached from bones and it is easier to manage the anemia that often results from kidney disease.
      Such benefits – which weren’t so clear when home dialysis first appeared 30 years ago – are the main reason interest in home dialysis has risen so dramatically across the country.
      New dialysis machine designs also mean patients no longer need to be wealthy to afford home dialysis. Today’s machines are portable and simpler to operate, so the patient does not need a full-time nurse. Some of the new machines do not require extensive plumbing renovations, which can reach as high as $20,000.

Patient Support
The first Columbia patient is slated to begin the four-to-six week training program in January 2008. Once dialysis starts at home, a nurse will periodically visit to ensure the patient is comfortable and proficient. Eventually, Dr. Preddie expects the program to train two to three patients a month – and more later.
      Though Dr. Preddie thinks home dialysis has the potential to greatly improve health and quality of life, he says it is not for everyone. Such patients must be highly motivated, have good hand-eye coordination and have the help of a trained family member or friend to operate the equipment.
      “We need to be cautious and make sure the home support is strong,” Dr. Preddie says. “Some programs have had 30 to 40 percent dropout rates. In the cases where it doesn’t work, we must learn what went wrong to ensure we don’t repeat the same mistakes.”
      One obstacle may be that some patients with kidney disease are not mentally prepared for dialysis, a problem Dr. Preddie says also exists for in-center dialysis.
      “Patients need to be referred to a nephrologist by the time their kidney function drops to 50 percent of normal,” Dr. Preddie says. “Not only can we delay progression to kidney failure, we need that time to educate and psychologically prepare patients for dialysis. When patients are not prepared, they tend to be noncompliant.”
      Despite the challenges, Dr. Preddie says, “Home hemodialysis is probably the next best thing to a kidney transplant for a person with kidney failure. It’s far and away the wave of the future.”


—Susan Conova