Sunit Kabaria, MD, Nephrologist at the Kidney and Hypertension Center of New Jersey talks about Tablo hemodialysis kidney home treatment.
Can you describe what happens with dialysis?
Dr. Kabaria: When a patient has kidney failure, they need life-sustaining dialysis. Typically, the dialysis is done in the center or at home. Ninety percent of patients prefer to do it in the center and they typically come three times a week. The average treatment is about four hours. So, they are spending at least 12 hours a week doing treatments plus travel time. That is a huge time commitment for the patient and the family.
What does dialysis do?
Dr. Kabaria: The kidney has two functions, one is clearance of toxins, and the second is clearance of water. What the dialysis does is clears the toxins by passing blood through a filter. Also, dialysis removes excess water from the body that the kidney is not able to remove.
What happens if a patient is not getting the regular dialysis?
Dr. Kabaria: If a patient is not getting regular dialysis, they can get elevated kidney toxins and fluid in the body which can cause hospitalizations or make patients feel sick. If you do not get dialysis and your kidney failure worsens you can die.
What conditions would cause kidney failure?
Dr. Kabaria: The most common cause of kidney failure is diabetes, and the second most common cause is high blood pressure. Those are the two major causes of kidney failure in the
You mentioned it is a serious time commitment. Are there other drawbacks to having dialysis in a center?
Dr. Kabaria: For most patients, their quality of life is better when they do dialysis at home. They get to schedule their dialysis at home on the schedule they want. By being able to do that, they can work around their work schedule or they can work around family responsibilities.
Has there always been that option for patients to have dialysis at home?
Dr. Kabaria: The opportunity has always been there. I think technology now allows patients to do different types of dialysis at home and patients are more comfortable with that. There is also been a push from the medical community, insurance companies and the government to try to encourage patients to do dialysis at home.
Are there drawbacks to having dialysis at home?
Dr. Kabaria: I think part of it is that patients must do their own dialysis. But we must realize that if the patient is not able to fully do their own dialysis, but they have adequate family support they can do the dialysis at home. I think some of this is patient education. As we educate patients about doing dialysis at home, I think more patients will be willing to try it.
What is involved in doing your own dialysis?
Dr. Kabaria: Typically, home dialysis involves two types. One called peritoneal dialysis, has traditionally been the method of home dialysis where a tube is placed in the belly and the patients do dialysis every night between eight to 10 hours and it is done seven days a week. Over the last decade or so, we have been able to offer hemodialysis at home and as the technology has evolved, we have gotten to the point where patients can actually do the exact same treatment they would do in the center. They can do it in the same amount of time, and the same days of the week at home.
Describe peritoneal dialysis and what patients must do?
Dr. Kabaria: Peritoneal dialysis traditionally is the one that is done at home. Now, they are doing hemodialysis, which is where the blood passes through the filter and the machine removes toxins and excess water. The machine is like the one they would use in the center. So, I think the big difference is the patients only have to do it four days to three days a week, for four hours, as opposed to peritoneal dialysis where you have to do it seven days a week for eight to 10 hours every night.
You talked about technology improving. Is tablo an example of where technology is brought up to the need?
Dr. Kabaria: I think patients do want to do dialysis at home, but they are worried about the time commitment. That’s a big issue and now that we are able to do dialysis at home within the same time constraints as we would in the center, I think more patients will be encouraged to do the hemodialysis at home.
Can you describe Tablo for me?
Dr. Kabaria: It is the same as doing dialysis in the center where you do it three days a week typically, alternating days for about four hours or so. Some patients a bit more, some a bit less. The patients are taught to hook themselves up to the machine. Technology plays a part in that we can train patients at the center in under a week to use the machine. Because of technology, the nurses have access to the machine by Wi-Fi to see how the patients are doing in the treatments and the interface on the machine itself actually walks the patient through how to set up the machine. So, the technology is the simplicity of it.
Where are they hooked up?
Dr. Kabaria: There are two ways to hook it up. The preferred way is called a fistula, which is a connection between an artery and a vein placed in the patient’s forearm. The patient will then insert two needles into the fistula to get the blood to the machine so it can remove excess water and clean the blood. The initial way, patients get dialysis through a port that is placed in the upper chest area. But the ideal way would be the fistula.
So, in their forearm they are using small needles?
Dr. Kabaria: They put the needles in three times a week and usually in the same area. That is part of the apprehension, that patients are concerned about putting in their own needles as opposed to when they are in the center the nurses put in the needles. But we can get through that apprehension with adequate family support, training from the nurses and reassurance.
What is the benefit for patients to be able to do this at home?
Dr. Kabaria: There have been good clinical studies that have shown that patient outcomes and clinical parameters are better. But what patients really notice is their quality of life is a lot better. I think because dialysis is an ongoing treatment the patient sometimes spends 15 to 20 hours including travel time and planning for dialysis. We aim to make it not the only thing they do in their life. We try to make it part of their life. When they can do it at home, arrange their schedules, do things with their families, and are able to work because they can do it early in the morning or late at night, I think their mental health and quality of life is better. I think that translates into better clinical outcomes.
For most patients, is this a bridge to a kidney transplant?
Dr. Kabaria: Dialysis is generally thought of as a bridge to a kidney transplant. Unfortunately, there are more people that need transplants than organs that are available. So as time has gone on, the wait times have gotten longer. The improvement in technology and treatments keeps patients well until they can get a kidney transplant.
About how many people are on dialysis in the United States? And are those numbers going up?
Dr. Kabaria: There are approximately 500,000 patients on dialysis in the United States right now. We were seeing an increase in incidents in the past years, but it seems to be leveling off now. I think we are getting better care prior to dialysis. I think patients are getting referred to kidney doctors earlier and diabetes management is better now because we have more treatments. I think in general, because of the internet, patients are better educated. So, our hope is if patients take better care of themselves, control their blood pressure, control their diabetes, that the actual incidence of kidney disease could decrease over time.
Anything I did not ask you about the Tablo that you would want to make sure people know?
Dr. Kabaria: The main thing is the patients are getting the same treatment they would get in the center. People feel that the machine is smaller, or it is new technology, but it’s been well tested and has FDA approval and we feel that the patients do get adequate treatment at home.
When was it approved for home use?
Dr. Kabaria: I believe the first patient that I started on dialysis it was approved about two weeks before she started. So roughly March.
Do you mind telling me a little bit about your patient Tracy?
Dr. Kabaria: So, Tracy has been a long-term patient of mine and was one of my first patients. Many years ago, she was on dialysis. Fortunately, she received a kidney transplant. For years, she did well without dialysis but over time the kidney transplant started failing. Fortunately, we had time to talk and as we were talking Tracy was very proactive, very motivated to do her own treatments. At the same time, I was following the approval of Tablo. I mentioned it to her. We showed her some videos online and she was motivated to get started on the treatment. So, then we had to wait until there was FDA approval. After that, she took care of it herself. She was really motivated to do it at home herself.
Which patients do best with Tablo?
Dr. Kabaria: You need to have self-motivation to do your own dialysis at home. Those tend to be younger patients but not always. If you are a bit older, even if you are cautious about doing the treatments at home, as long as you have family support or a spouse, siblings, or children who can be trained on the machine, I think those patients will do well.
How’s Tracy doing now?
Dr. Kabaria: She’s doing very well. Coincidentally, the machine was commercially available and approved by the FDA about the same time that the COVID pandemic started. It’s been nice to be able to offer treatment to patients, especially those that are at high risk of complications from COVID, those with chronic medical issues, the elderly and be able to offer them the opportunity to do treatments at home where they don’t have to have infection exposure. I think that is a secondary benefit that came out of this, but it is a particularly important one.
Is it covered by insurance?
Dr. Kabaria: Yes. All major insurance carriers and Medicare cover home dialysis and Tablo is considered home dialysis.
So, the machine just goes home with you and it stays in the home?
Dr. Kabaria: The machine is delivered at home. There is a technician that will come and set it up. The machine just needs a water supply. They adjust some plumbing in your home and set the machine up. Then every couple of months, the technician will come out and change the filters.
Is there anything I did not ask you that you want people to know?
Dr. Kabaria: I am very encouraged by this technology. I think we are finally able to use technology to help patients and some of this is just education. I think as time goes on, as patients become more educated about the options, I am encouraged that patients will do the treatments at home. I think their outcomes will be better, their mental health will be better, and I think it is a good treatment for patients.
Is the Tablo the only machine of its kind or are there a couple of others?
Dr. Kabaria: There are other home dialysis machines that were present prior to this. Tracy was on one of those machines before she got the transplant. Those machines required a little different treatment and those patients had to dialyze four to five days a week. Now it is better time savings, and I think patients prefer that.
Is it about the same size or is this a little smaller?
Dr. Kabaria: They’re smaller. This is a larger machine because the dialysis is dependent on clearing an adequate amount of toxins. So, you need the size of the machine to be able to accomplish the treatment three times a week.
Interview conducted by Ivanhoe Broadcast News.
END OF INTERVIEW
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