Why Not Home Dialysis?

Although conventional hemodialysis remains the mainstay of renal replacement therapy particularly in North America, there is a resurgent interest in the use of home dialysis worldwide. This has been fuelled by encouraging clinical outcomes from observational data of frequent hemodialysis. Although there is a relative increase in home hemodialysis, especially in Canada and Australia, the trends in peritoneal dialysis show significant international variation. Undoubtedly, dialysis modality selection is complex and consists of a dynamic interplay among (1) physician knowledge and practice, (2) patient autonomy and preference, (3) clinical benefits and limitations, (4) resource allocation and financial incentives, and (5) geographic differences.

Why shouldn't a patient select home dialysis? Ideally, one would expect that a patient with chronic kidney disease or returning from renal transplantation would be cognizant of the pros and cons of each renal replacement option before the initiation of dialysis in order to make an informed decision. The multidisciplinary care provider team is well educated and able to guide the patient with regard to the various risks and benefits of each therapeutic option in a patient-focused approach to care. The patient and team are in regular contact so that the preparation and training required for the appropriate modality is implemented in a timely manner. Furthermore, scarcity of resources should not be a factor for patient's modality selection. Unfortunately, the ideal circumstance is far from reality at the present. Most data reflect a lack of home dialysis knowledge from both patients and physicians or care providers. In addition, financial resources and system bureaucracy often create barriers for home dialysis implementation in various jurisdictions. It is therefore not surprising that the relative proportion of home dialysis remains dwarfed compared with the in-center dialysis population.

In order to encourage patients and care providers to adopt home dialysis, it is obvious that additional resources, incentives, and innovations are needed. It is clear that more generalized and robust data are needed to convince the consumers and practitioners of dialysis to consider home dialysis as a viable option. Financially, appropriate reimbursement for home dialysis techniques will be imperative to allow one to build and sustain the needed infrastructure to promote home dialysis modalities. Innovations in technology are also required to transform the present available machines to home-ready, user-centric designs. The consumers of home dialysis technology must also be informed of this option early before modality selection, which requires intensive education initiatives and changes to our present practice pattern. Ultimately, the adoption rate of home dialysis by patients will be the parameter to decide if we are successful or not in changing clinical practice.

A contemporary example of a system-wide change to promote home dialysis occurred in Finland. After involving various stakeholders, a “home-first” policy was adopted. A predialysis education program promoting home dialysis was implemented. Centralized infrastructure and competitive reimbursement strategies were included within this policy. As a result, over a 10-year period, 4% of all Finnish dialysis patients (n = 1,600) were on home hemodialysis, while growing other home renal replacement techniques.1 In this issue of Advances in Chronic Kidney Disease, we have invited an international expert panel to help us understand the emerging body of literature in home dialysis. Clinical benefits of frequent hemodialysis were summarized by Drs Hanly (sleep physiology) and Chan (cardiovascular outcomes). Dr Moran detailed the latest technical advances in home dialysis. Financial implications and the economics of home dialysis were described by Drs Komenda and Sood. Dr Pauly outlined the intriguing contemporary literature regarding the potential survival advantages of alternative hemodialysis modalities. The sustained excellence in peritoneal dialysis was described by Dr Li. The unique contrast in home dialysis trends in the United States and other parts of the world was captured by Drs Piraino and Agar.

Great advances have been made since the first publication on the use of the peritoneal cavity in experimental uremia by Ganter in 19232 and the first home hemodialysis machine, which was made in only 3 months by the clinical team of Dr Scribner and engineering team of Dr Albert Babb.3 As the evolution of dialysis technology and practice pattern continues, the niche of home dialysis will likely become more dominant. Ultimately, the various stakeholders of dialysis care will decide on the appropriate incentives and allocation of home dialysis as a viable and competitive form of renal replacement therapy.