Home Dialysis in North America: The Current State

Abstract

There is widespread interest in expanding the uptake of home dialysis in North America. Although kidney transplantation should be the preferred option in eligible patients, home hemodialysis (HD) and peritoneal dialysis (PD) offer cost-effective options for KRT. In this review, the motivation for promoting home dialysis is presented, and the literature supporting it is critically reviewed. Randomized comparisons of home HD and PD with in-center HD have been challenging to conduct and provide only limited information. Nonrandomized studies are heterogeneous in their design and have often yielded conflicting results. They are prone to bias, and this must be carefully considered when evaluating this literature. Home modalities seem to have equivalent clinical outcomes and quality of life when compared with in-center HD. However, the cost of providing home therapies, particularly PD, is lower than conventional, in-center HD. Measures of home dialysis utilization, the philosophy behind their measurement, and important factors to consider when interpreting them are discussed. The importance of understanding measures of home dialysis utilization in the context of rates of kidney failure, the proportion of individuals who opt for conservative care, and rates of kidney transplantation is highlighted, and a framework for proposing targets is presented, using PD as an example.

Trial registration: ClinicalTrials.gov NCT01413074.

Figure 1

Decision making in individuals with kidney failure. Individuals with progressive CKD and/or AKI develop kidney failure. They are faced with a choice between conservative, symptom-based care or KRT in the form of dialysis or kidney transplantation (in eligible patients). This decision making may occur in advance of the development of kidney failure for some patients. If they opt for dialysis and are eligible for home therapies, they are faced with a choice between in-center HD, PD, or home HD. The information available and the decisions that are made upstream of this final decision point influence the number of dialysis patients as well as the characteristics of the population faced with a choice between in-center HD and home therapies. This in turn influences the observed number and proportion of patients treated with home therapies. HD, hemodialysis; PD, peritoneal dialysis.

Figure 2

Factors that influence the prevalent population of patients on home dialysis. The number of patients treated with home dialysis is influenced by the addition of new patients (incident rate), the time that individuals spend on home dialysis, and the loss of patients from therapy due to death, kidney transplantation, transfer to in-center HD, and other reasons (e.g., transfer out of the program). Interpreting changes in the number of individuals treated with home dialysis requires knowledge of the complex interplay of all of these factors.

Figure 3

A six-step framework for understanding drivers of incident PD utilization and targets for high-performing programs. In high-performing programs, all patients with kidney failure are identified, approximately 90% will be assessed for PD, 80% will be considered eligible, and nearly 100% of eligible patients will be offered PD. In an environment where patients are educated about their treatment options and encouraged to make an informed choice, up to 60% will choose PD. Approximately, 90% of those patients will start on therapy within 6 months of starting dialysis. When the percentage of individuals making it through each step are multiplied together, the result is the incident PD rate (percentage of all patients identified who ultimately are treated with PD) in a setting where shared decision making is practiced. Adapted from ref. , with permission.