Michael Kraus, MD, Podcast | ESRD NCC

Michael Kraus, MD, Podcast | ESRD NCC


Hello and thank you for joining us today for
one of three podcasts about home dialysis. Today, our special guest is Dr. Michael Kraus,
who is going to share about his role as a doctor in helping people choose home dialysis
based on their lifestyle and offer some advice he has for other physicians who are in a position
to do the same. My name is Kim Buettner, and I’m the Associate
Director of Patient and Family Engagement with the End Stage Renal Disease (ESRD) National
Coordinating Center. We partner with patients, caregivers, healthcare
providers, and the Centers for Medicare & Medicaid Services, also known as CMS, to create resources
to help kidney patients improve their quality of life. There are several treatment choices available
when someone’s kidneys don’t work well enough to maintain health, and a few of those
choices include receiving treatment at home. We have heard from patients who have made
the decision to perform their dialysis at home that a key component to making this decision
was the relationship they have with their healthcare team. Many times, they mentioned the value of their
doctor partnering with them to help choose the best option based on their lifestyle preferences. Our guest today, Dr. Kraus, is well-established
as an authority in the renal community. Michael Kraus, MD, is currently associate
chief medical officer at Fresenius Kidney Care, focusing on home therapies, and held
a similar role with NxStage Medical Incorporated, before the company merged with Fresenius earlier
this year. He is the former Line Service Chief for Indiana
University Health Physicians Kidney Diseases and Clinical Chief of Nephrology at Indiana
University School of Medicine. He is a leader in the field of Short Daily
Home Hemodialysis and received a Lifetime Achievement Award from the National Kidney
Foundation of Indiana. Welcome Dr. Kraus. Thank you for joining us to discuss home dialysis
options and encouraging the conversations among everyone involved with the patient. Thanks for inviting me Kim, and thanks for
all you do for patients and providers, and growing home dialysis is an exciting place
to be. And it’s exceedingly important in the future
of the care of our patients. When do you start the conversation about home
dialysis with your patients? Well, ideally you would like to start this
very early. But unfortunately, in the world of kidney
disease, we don’t always have that luxury. So, we can look at that in three different
ways of when to start the conversation. If we are fortunate, and are able to follow
people through their chronic kidney disease course trying to slow down the progress of
chronic kidney disease, and hopefully, preventing the need for dialysis, you’re going to start
that discussion very early in their career. I usually start and introduce dialysis very
early on with my patients in the first probably [sic] year of visits with them, not to scare
them about dialysis, but to begin to think about a process that might occur. We mention it, this is something that may
happen in your future and it may not, but we believe home dialysis is the best option,
and I want you to know these things are available. And we just sprinkle that in and slowly increase
the amount of education over the course, hopefully, of years at that point, but sometimes months. You can’t start too early, because it’s just
sprinkling a little education, but you don’t want to scare patients as well; it’s just
how you present it. Unfortunately, about half of our patients
present for the need for dialysis within six months or less of starting dialysis, and 30
to 40 percent actually just crash in, meaning they’ve not had any renal care prior to finding
out they need dialysis. Unfortunately, that’s when we have to start
our conversation frequently. That is a very difficult time. These are patients that are ill. They are scared. They are anxious. They are, frankly, mad and depressed. And you’re trying to educate them on very
difficult decisions. So again, that is also a process that starts
early. And I think you need to say, we have hope
that we can make you better with home dialysis and these are the reasons why, and you don’t
have to do what you interpret as dialysis or what you may have seen from somebody in
your family members before. We can actually give a brighter prognosis
and a brighter future to these patients, and so then you’re starting these conversations
in the hospitals or shortly thereafter when they get out to renal replacement therapy. And thirdly, unfortunately, in the United
States today most of our patients in-center dialysis don’t really understand the options
of home therapy. So, it’s a discussion I have in the in-center
unit. You can start off with starter points like
you’re discussing phosphorus. If it’s a difficult chore for your patient,
you can discuss the fact that you can get phosphorus removed better with more continuous
therapy, such as home hemodialysis on a more frequent basis, or even peritoneal dialysis. In addition, if they are having troubles with
transportation, you can discuss how home dialysis takes the transportation out. Or troubles with schedules, or troubles with
their heart. And you can discuss the benefits of more frequent
dialysis at home with their heart. So, it’s a [sic] matter of when depends on
the patient, but how you do it is the important part, and making sure you’re teaching the
patient what they need to know, when they need to know it, in a way they can understand
it, and certainly not trying, not trying to scare patients. How do you figure out if a patient will do
well on home dialysis? That’s a good question, but I like to term
it the other way: how do I figure out they won’t do well? Because I personally think with appropriate
education, proper resources, professional nurses, social workers, care technicians,
dietitians, and even physicians that understand home therapies, most patients will do well
on home therapies. The problem is we have barriers and we have
biases where we, as health professionals, sometimes don’t understand how well patients
can do. So to me, a patient that won’t do well on
home therapy is someone who has untreated psychiatric illness or it’s difficult for
them to care for themselves, or untreated substance abuse, alcohol abuse. So, it’s difficult to care for themselves. Everything else is a barrier that we as health
professionals should be able to help patients get through. We can take people who maybe aren’t literate
in English or can’t read and teach them in ways that they can understand. We can take people who have physical barriers
and try to adapt therapy to meet those barriers. So, most as what has been perceived by healthcare
professionals as reasons not to do home dialysis are barriers. We should strive to do a better job of making
it available for those patients. So, I kind of turned that question around. And I have an example if we have a quick minute. I had a patient who presented to us many years
ago, early in our dialysis program. And he came about three hours away because
in the early days we were the only ones who did home hemo at Indiana University. So, his wife brought him up because his doctor
said they couldn’t help him any better. He was getting what we call adequate in-center
dialysis as appropriate schedule and certainly nothing was medically wrong with his care. It’s just he was deteriorating because his
heart was bad. He had a lot of low blood pressure during
dialysis. He was in the hospital a lot. He became non-ambulatory. He developed a condition called tardive dyskinesia
where he had trouble talking and had tics all the time. And his doctors just figured that’s the best
they could do for him. So, his wife, you know, loaded him up in the
car in the wheelchair, and drove to Indianapolis, and sat down with my nurses, and they looked
at him said, I’m sorry he’s just gonna [sic] be too sick to do home dialysis. And again, this [sic] was our early days. So, I went in and sat down with the wife because
the nurses have me do the final visit and we discussed. She said, look I will do anything to make
my husband better. It’s worth whatever chores it takes. We’ll come to Indianapolis to learn training,
etc., and realizing we have to [sic] back once a month. I’ll put that work in to make him better. We went to the nurses and discussed it. And we all agreed it was worth a trial. And he did exceedingly well for a period of
many years and I’m actually still in contact with his wife, who is grateful for the care
we gave. So, it’s not who will do well, because motivation
is the key factor. It’s how we get everybody to do well, I think,
is the key question. Are there specific educational tools you use
to educate your patients about their home dialysis options, and if so, which ones do
you use? Well, I think there are a lot. Obviously, conversation is the important one. And so, it’s just face-to-face conversation. Not necessarily only with the patient, but
trying to involve the family and caregivers as much as possible. Everybody is involved and everybody is affected
by the healthcare of the patient stricken by end stage renal disease or kidney failure. So, that’s the first and foremost is just
an open conversation with the benefits and risks of all therapies, but obviously you
have to then tailor the rest of the education to what the patients needs are. And fortunately, we have lots of things that
are available to us. I like the website FreseniusKidneyCare.com. It’s just been revamped. It has a lot of information about all sorts
of questions patients may have. And the other website, and frankly, when I
was in practice, what I did all the time is I gave almost every patient a copy of the
book, Help I Need Dialysis, which is from the nonprofit group call MEI. Their website is HomeDialysis.org, which then
will let you go through a whole range of things as a patient that you can learn about therapies
and you can take tests to figure out which therapy might be best for you. And it helps you in settings where your physicians
or nurses may not be quite as comfortable with home therapies yet and you need just
a little [sic] more talking points to help your physicians get where you need to be. So, it allows the patient to learn on their
own, at a pace they want to learn, in a way that’s well designed, so they can then have
further discussions with their healthcare professionals. At Fresenius, the other thing we offer now
is kidney care advocates, so their physicians should be able to call our kidney care advocates
[to] come talk to the patients and educate them as well. So, you can get education where you want it
as a patient and family, and not just in the doctor office. And, as you know, in the doctor office, something
[sic] we are more rushed than we would like to be, and we can’t give you the full story
or give you enough time to ask all the questions. And then finally, I find the most usefulness
out of just peer-to-peer discussions. When I practiced at Indiana University, we
had a lot of patients. So, we could match patients to talk to patients. A 75-year-old was concerned with cannulation
and bringing a device into their home can have those same questions and discussions
with somebody who has successfully conquered all those fears they have today. And they could say, well if you look like
me, you smell like me, if you can do it, I think I can do it, and it’s worth a try. So, all the literature that’s out there, the
sources that I use are very good, and then follow up with patient-to-patient contact,
one way or another. How do you include family members in the discussion
about home dialysis? Well, well, as I said, family is exceedingly
important. And people don’t recognize that even if you
say, well I don’t want to burden my family, so I’m going to go in-center dialysis. Studies have shown in-center dialysis is,
unfortunately, a burden on family as well. As you still have transportation issues, you
have arrangement issues, and you have dealing with the ill loved one. What I promote in my home patients is that
they tend to feel better, and they tend to do a lot more, and they tend to be part of
the family, and that reduces the burden. Even though you are taking over the burden
of dialysis, which frankly is difficult, but with assurance, and with help of your dialysis,
we can make it so it’s comfortable. You become more functional, more of a partner
in the family, and it helps. So, including the family is very important. You should bring your family with you when
you go visit a home dialysis program and talk to the nurses and social workers. And I always encourage my patients to share
the book, Help I Need Dialysis, with their families and surf the Web as well to those
sites if they have questions. Why do you recommend home dialysis treatment
options to your patients? I’ve been a practicing nephrologist since
1988 and home hemodialysis made a nice resurgence with technology improvements in the early
2000s and I’ve been dealing with that directly so. The reason that it makes it easy for me, or
the reason I want to discuss this with my patients is, I see the effects. I’ve first hand seen what patients do and
how much better they feel when they go from an in-center program to a more frequent dialysis
program at home or they develop the freedom to take care of themselves with peritoneal
dialysis. So, the first is to [sic], because I think
they just do that much better. Secondly, we see the benefits to the patient. They feel better. They eat better. They do better. They sleep better. Their activity improves. Their blood pressure, if we provide dialysis,
while [sic] your blood pressure should be close to normal. You should be on one or no medications. We see that with both more frequent dialysis
and peritoneal dialysis when they are done well. So, the real reasons I recommend that is that
the patient’s quality of life is markedly improved, and I believe the quantity of life
is improved. The secondary reason is that I think I can
reduce hospitalizations when I do it well. And the third reason is, it gives patients
what we all want, the independence to care for themselves. There’s no other chronic disease I can think
of where we spend our time trying to keep patients from caring for themselves as much
as we’ve seen in in-center dialysis. It’s exciting to me to see the times are changing. At the end of the day, it’s the right thing
to do for our patients and I believe we should be doing it. How would you suggest a patient or caregiver
advocate for dialyzing at home with his or her healthcare team? So as a patient, it’s always good to get as
much information as you can. Reach out to Fresenius. You can talk to a kidney care advocate, even
if you don’t have a physician who referred you to one. You can go to the websites we discussed previously
and learn as much as you can. But you know, simply look at your healthcare
professional and go through why you think home is important, and say what you’re looking
for in dialysis: improvement in the quality of your life, improvement of your cardiac
status, ability to have freedom to run your own dialysis at your own needs, and discuss
where in-center versus home fits in there. If your physicians and nurses are uncomfortable
with that, you want to help them get to where they need to be. But sometimes, it even turns out you may want
to discuss that with other healthcare professionals as well. What advice would you offer to other physicians
when discussing home dialysis therapy options with their patients? Sometimes when I talk to patients, I look
back and I say, I sound like a car salesman. And I tell them, I’m not a salesman, but I
need you to understand what’s best for you and why. And that’s what it is, patients want to do
what’s best for their quality of life first, what’s best for their family in that first/second
range, and what’s best for quantity of life, probably third. And the beauty of home therapies done well
is that’s what we do. So, when you’re discussing with the patient[s],
you have to understand what their goals of dialysis are or will be, or you can ask them,
We’re going to start dialysis. What do you want to accomplish in the next
one, three, and five years? And then, you go through what the mortality
of in-center dialysis versus home dialysis are with the quality of life benefits. In more frequent dialysis, the recovery time
is less than an hour in most patients. And in peritoneal dialysis, there is no recovery
time. It’s a matter of working with the patient. If they’re new to dialysis, if they’re scared,
ask them where they want to be and telling [sic] them the best pathway to good health
and they’ll listen. Or if they are on in-center dialysis, it’s
what are your problems with in-center dialysis today? How can I impact that and make your life better? And these are the tools I have today that
I think will make you live better and longer. It’s a matter of getting to the patient’s
goals and understanding they really want hope. They want to be healthy. And then you work with the patient just like
you do virtually any other disease to come up with the best therapy every day. I’m not as much, as much a proponent of saying
things like, home first or PD first all those things. I think it should be the right therapy and
the right prescription, every day for every patient. That means as physicians and care providers,
we have to examine that and we should give patients hope. And that’s the direction we should go. And that’s how you talk to patients as well. Dr. Kraus, it has been a pleasure to speak
with you today. We are grateful for your time and dedication
to improving the quality and experience of care for all those touched by ESRD. We thank you for listening to this podcast. To listen to the rest of our podcast series
on home dialysis or for additional information on home dialysis options, visit the End Stage
Renal Disease National Coordinating Center website at www.esrdncc.org, or talk to your
healthcare provider.