Dialysis for Decades, Then My Heart Breaks

No jokes. Instead, trepidation. Levity is my succor as I transfer from the gurney to the table. I chit chat with team members. I think I am charming. But they have heard it before. We all know—I am scared. This time is different than the two kidney transplants, two nephrectomies, the fistula and graft placements, and other “ectomies” and procedures. This time they look inside my heart. Cardiovascular disease is not in my family. On my twenty-fourth year of dialysis, I knew it should be on my horizon, but it was not. I started hemodialysis at the end of 2000. The next spring, the kidney that my wife, Andria, donated to me failed due to FSGS. I went home with full-size dialysis and reverse osmosis machines and started more frequent home hemodialysis (HHD). A year later, I was on automated peritoneal dialysis (PD) along with continuous ambulatory PD for 4 years. Then, another kidney transplant—FSGS again. I resumed HHD with a portable machine. In 2008, I switched to nocturnal HHD (NHHD). Each improved my outcome—to live long and prosper. I knew that NHHD and other modalities would be great for my heart because the literature, though sparse, supports this conclusion. In 2022, the American Heart Association released a scientific statement supporting the cardiovascular effects of home dialysis therapies relative to three times a week in-center hemodialysis (IHD).1 It orients their 2024 mission to champion a full and healthy life with the 2019 Advancing American Kidney Health Initiative goal of increasing home dialysis: To increase the use of home dialysis therapies in an equitable manner will contribute to the ultimate goal of improving outcomes for patients with kidney failure and cardiovascular disease.1 I am getting the best dialysis possible for my heart. Recently I was given the “Risk of Major Adverse Cardiovascular Events in Home Dialysis Compared to In-center Hemodialysis”2 to provide my perspective. The study by Bitar et al. compared the risk of major adverse cardiovascular events (MACEs) with continuous ambulatory PD, automated PD, and HHD with IHD patients. The study looks at nearly one thousand patients who started dialysis in the Helsinki-Uusimaa health care district in Finland. They defined MACE as acute myocardial infarction, stroke, or death due to cardiovascular disease.2 After adjusting for confounding factors, and following up after 1 and 5 years, their analysis included a surprising conclusion. The risk of MACEs was similar across all dialysis modalities, “suggesting that the risk of cardiovascular events may not be a decisive factor when selecting a particular dialysis modality.”2 Another 2024 US study with a similar time frame of home dialysis–only incidence and a larger patient sample drew a different conclusion.3 Shah et al. found that HHD compared with PD provides a decreased risk of stroke, acute coronary syndrome, cardiovascular death, and all-cause death. But, Bitar et al. recognizes that results similar to Shah et al. were common in the past. Their citations show that patients on HHD have “better BP control, left ventricular mass reduction, less often intradialytic hypotension” than those patients using IHD, which can all be contributing factors for increased risk of MACEs. This is why the results from the study by Bitar et al. are exceptional—they counter our past and current understanding. Back on the table I receive medicine for relaxation. Within a minute, the cardiologist says that three arteries are nearly 100% calcified and retracts his catheters. The procedure is done. Heart disease is my reality—it blows my mind. But, before I am faced with my own MACE, I am scheduled for a coronary bypass graft surgery the next week. With a few minor complications, the surgery is a success. I am now 6 months out and still recovering. The major comorbidity, heart disease, has rocked my world, just like my diagnosis of ESKD. I am still searching for a foothold for acceptance. But like then, with Andria, our children, friends, and my medical teams, I continue to live long and prosper. We need studies like that by Bitar et al. to look at longer term follow-ups. What happens 20 years out? We also need to look at other causes of MACEs, such as calcification. Diligent use of binders and blockers takes us so far, and diet further, but does home dialysis, especially NHHD, take us even further? My experience tells me that good phosphorous-calcium management took me almost 24 years. But I am just an anecdote. In addition, NHHD, perhaps practiced by a small and growing cohort, must now be seen as an equal home modality option. Studies need to include NHHD in their analysis.