Bringing the Revolution in Kidney Care to Canada’s Remote Communities


Stephen Thompson

In less than a century, end-stage kidney disease has gone from being a death sentence to being a chronic but manageable condition. More recently, innovations in medical technology have made it possible for dialysis patients to lead less restricted, more active lives. And it means lower costs and greater access for Canadians, especially those who live outside major population centres.  

Every great invention has an origin story. While most people think of the dialysis machine as an inherent element of our medical landscape, the story of its creation belongs in the annals of manifest genius with Alexander Graham Bell’s telephone, Marie Curie’s discovery of radioactivity and Alan Turing’s pioneering Universal Machine. 

In 1940, after the Nazi invasion of Holland, Dr. Willem J. Kolff moved from Groningen to a rural hospital in Kampen rather than cooperate with the occupying force. While there, Dr. Kolff, moved by the excruciating fate of patients stricken by kidney failure, began refining his idea for a machine that could fulfill the kidney’s detoxification duties outside the body. The early prototypes included the use of sausage casings, orange juice cans and a washing machine. After more than a dozen failed attempts, Dr. Kolff’s artificial kidney saved the life of its first patient in 1945 and the age of dialysis was born. (Meanwhile, Dr. Kolff had also saved the lives of more than 800 people, many of them Dutch Jews, by hiding them in his hospital.) In 1950, he emigrated to America and went on to build the first artificial heart. Today, millions of lives worldwide are being extended by the process Willem Kolff first envisioned amid the duress of war on the certainty that humanity’s instinct for saving rather than destroying life would prevail. 

In its 2017 report, High Risk and High Cost: Focus on Opportunities to Reduce Hospitalizations of Dialysis Patients in Canada, the Canadian Institute for Health Information said that 36, 251 Canadians outside Quebec were living with end-stage kidney disease (ESKD)—an increase of 36 per cent since 2006. That increase, largely due to the epidemiological impact of aging baby boomers, makes life-saving, cost-saving innovation all the more urgent.

There have been so many improvements on the standard dialysis machine of the second half of the 20th century that what was once a life-altering prognosis is now far less so. For decades, if you knew anyone—or of anyone—on dialysis, the one thing you knew was that they were tethered to a machine in a hospital multiple times a week. While it was the opposite of a death sentence, dialysis meant a circumscribed life without travel and, absent an accommodating employer, with limited professional possibilities. 

For many patients, thanks to breakthroughs in medical technology, the picture of life on dialysis in 2018 is vastly different. In hemodialysis (HD) the patient’s blood is still circulated to an external dialysis machine, which filters wastes and extra water from the blood before returning it to the body. Conventional HD is typically performed three days a week for three to four hours per session, either at home or in a hospital. But many patients living with ESKD can now also use peritoneal dialysis (PD), which can be managed by patients outside a clinical setting. First introduced in 1983, it allows for greater mobility and independence and less disruption of the pre-dialysis status quo for most patients. There are two main types of PD: continuous ambulatory PD (CAPD) and automated PD (APD). Both involve the filtering and evacuation of toxins and waste products with the flushing of a cleansing fluid called dialysate inserted through a catheter directly into the abdomen. Treatments can be self-administered at home, at work or even while traveling. 

In its March, 2017 report Dialysis Modalities for the Treatment of End-Stage Kidney Disease, the Canadian Agency for Drugs and Technologies in Health (CADTH) said the available evidence weighed in their health technology assessment showed no discernible difference in effectiveness between clinical-setting and home dialysis, and that a “home first” approach for dialysis modalities should be considered. “The evidence tells us that in-centre and home-based dialysis offer similar benefits in terms of clinical outcomes,” said Dr. Brian O’Rourke, President and CEO of CADTH. “And in terms of offering patients and caregivers more choice around treatment options, and realizing some cost savings in the health system, this work tells us that we should be considering how home-based dialysis could be more effectively implemented.”

In June, 2016, in keeping with our record of—and commitment to—medical technology innovation, Baxter received approval from Health Canada for the Amia automated peritoneal dialysis cycler. With our cloud-based Sharesource remote patient management technology, Amia provides the first treatment mechanism with two-way connectivity between the device in the patient’s home and the clinic, allowing doctors and nurses to monitor the treatment remotely and adjust prescriptions in real time. At Baxter, we support these renal patients in their homes, and the connection our employees have with these patients is often very personal. We live and see patient stories every day, and our care and passion drives us to do more. 

Telehealth has been a critical part of our drive to increase access, improve efficiency of care and drive better outcomes- especially in Canada, a country second-largest in the world by area but with only 35 million inhabitants. The combined treatment impacts of the digital revolution on health care access via telehealth and on products and services through medical technology innovation has, in turn, revolutionized our approach to patient care, especially among previously under-served populations. In Canada, Indigenous communities in remote areas top that list. Indigenous people in Canada have an exceptionally high burden of kidney disease, with a rate of ESKD four times higher than that among non-Indigenous people. While diabetes is the leading cause of ESKD in Indigenous patients, per the January 2018 research article Barriers to Peritoneal Dialysis in Aboriginal Patients, a combination of medical and societal factors all contribute to this growing burden of ESKD. The study, conducted by researchers from McMaster University, Hofstra University, the University of Ottawa and Queen’s University with funding from Baxter, concluded that PD could provide an alternative to in-center hemodialysis for those living in rural areas. With approximately half of Canada’s Indigenous population living outside urban centers, in-centre HD usually requires relocation to an area with a hospital dialysis facility. Patients who have relocated to access HD suffer a loss of community, cultural and spiritual isolation, and alienation from family and friends, effectively making them “health care refugees.” 

In 2014-15, Non-Insured Health Benefits Medical Transportation expenditures by the federal government amounted to $356.6 million or 34.7 per cent of total NIHB expenditures. For Indigenous patients who require medical treatment, including dialysis, in urban centres away from their homes, logistics take over their lives. A February 2017 report by the Canadian Institute for Health Information said that Indigenous ESKD patients are 30 per cent more likely to be admitted to hospital due to a dialysis infection, partly because they must travel longer distances to receive treatment, meaning problems don’t get caught early. We now have the technology to address these issues.

In 2005, Baxter Renal Therapy Services Colombia launched a pilot program to establish remote PD centers in Colombia to help overcome geographic and financial access barriers for patients desiring PD therapy. While the terrain and climate conditions in the mountainous South American country are different from those in Canada’s remote Indigenous communities, they present similar barriers to dialysis treatment. The study demonstrated that, with the support of a remote PD centre, home PD therapy is an appropriate treatment option for patients who live in remote areas. It can mitigate a patient’s financial and health care inequities and provide the additional benefit of reducing travel time. We believe the same principles apply here in Canada, and that Baxter can play a key role in improving access and treatment for remote dialysis patients. 

Our mission of “Saving and Sustaining Lives” has been transformed by technological innovation. The phenomenal changes of the past two decades, especially in health care, have recalibrated the mindsets of many companies, including Baxter, as we address both the opportunities and challenges of increased connectivity—including data protection and patient privacy. Companies, hospitals and governments will have to work together to address regulations in this area to effectively bring these new technologies to market and ultimately improve the overall patient experience. As the efficiencies produced by telehealth and home treatment transform not just the current reality of ESKD but the whole health care system, the greater public will benefit from reduced government costs at a time of significant fiscal pressure from other sources. 

In its 2009 obituary of Dr. Willem Kolff, who had died at 97 at his home in Pennsylvania, the New York Times said of his early wartime prototype for the dialysis machine, “The device was an exemplar of Rube Goldberg ingenuity.” With the right combination of collaboration and incentivization, the medical technology innovations of the next half-century will make the breakthroughs of today seem just as creative, and just as obsolete.  

Stephen Thompson is President and General Manager for Baxter Canada.