Choosing home hemodialysis for end-stage kidney disease

INTRODUCTION — Home hemodialysis (HHD) remains underutilized in most countries. There are a myriad of barriers towards home dialysis adoption, which are reviewed elsewhere. (See "Home hemodialysis (HHD): Establishment of a program".)

This topic will review the different patient-related factors and clinical indications that are taken into account prior to selection of an HHD modality and its prescription. Other issues related to HHD, including nocturnal hemodialysis and short daily hemodialysis, are discussed elsewhere:

●(See "Home hemodialysis (HHD): Establishment of a program".)

●(See "Technical aspects of nocturnal hemodialysis".)

●(See "Outcomes associated with nocturnal hemodialysis".)

●(See "Short daily hemodialysis".)

●(See "Short daily home hemodialysis: The low dialysate volume approach".)

FACTORS THAT INFLUENCE PATIENT SELECTION OF HHD

Patient education — The awareness of HHD by patients and care providers as an established alternate kidney replacement modality is relatively low [1,2]. Globally, there is a recognition of the utility of multidisciplinary chronic kidney disease (CKD) management and education in promoting home dialysis [3]. Observational studies and randomized controlled trials have shown that patient education programs augment patients' willingness to adopt independent kidney replacement therapies [4-6]. When patient education occurs in a CKD clinic, dialysis facility, or even in an acute hospital setting, approximately 5 to 10 percent of patients will select HHD as their modality of choice. There are also several jurisdictions that apply a "home first and/or peritoneal dialysis first" philosophy. Nonetheless, the provision of modality education is often associated with enhancement of patient sense of control and quality of life [7,8].

Education is often conducted through multimodal means. Typically, written, audio, and video materials are made available for all patients with CKD. Internet-based decision guides and electronic tools are also gaining popularity in allowing patients to understand the goals and scope of each type of dialysis therapy. Different care providers may also provide nurse navigator (a clinical nurse specialist or a nurse practitioner with expertise in modality education) visits to patients with different stages of CKD [5]. Facility tours and simulation (digital or high fidelity [9]) may also enhance the patient's perception of performing home dialysis therapies [10,11].

Clinical benefits — Through CKD education, patients must be informed of the clinical advantages and disadvantages of frequent HHD (table 1). Both observational studies and randomized controlled trials have documented improvements in blood pressure, extracellular fluid volume, and phosphate control by frequent and nocturnal hemodialysis. In addition, more frequent and nocturnal hemodialysis regresses left ventricular hypertrophy, stabilizes left ventricular remodeling, and corrects obstructive sleep apnea. Furthermore, nocturnal hemodialysis is associated with term pregnancy and a reduction in maternal and fetal complications. (See "Outcomes associated with nocturnal hemodialysis" and "Short daily hemodialysis", section on 'Outcomes'.)

Vascular access complications and technique burnout are suggested to be the leading disadvantages of frequent HHD [12]. (See 'Vascular access considerations' below.)

Quality of life — Although the clinical benefits of HHD may be important to some patients, more often the patient's decision is determined by quality-of-life considerations. Some patients prefer to perform dialysis in the comfort of their own home rather than traveling to and from a busy and noisy clinic. The rigid schedule of in-center hemodialysis often precludes a patient's ability to work, care for family members, or travel. Patients who have been on in-center hemodialysis no longer want to experience intradialytic hypotension, nausea, vomiting, headaches, and hours of postdialysis fatigue syndrome. Patients waiting for a kidney transplant or who have a failed transplant due to recurrent primary kidney disease want to live a healthy life for as long as they can. For the aforementioned patients, the quality-of-life benefits of HHD can certainly outweigh the burdens [13].

EVALUATION BY THE HOME DIALYSIS PROGRAM — Patient enrollment is a fundamental aspect of HHD. Although most registries suggest that patients on HHD are younger and have a less comorbid disease profile, patients should not be excluded from HHD on the sole basis of age and/or comorbidities.

All patients should undergo a medical assessment. There are few absolute contraindications to HHD (table 2). Most often, we encounter relative contraindications such as intradialytic hemodynamic instability and lack of adherence to in-center hemodialysis schedule and restrictions. However, the flexibility and enhanced dialysis dosing of frequent HHD may act as salvage therapy to the aforementioned barriers. As an example, some patients are nonadherent because of the inability to control any aspect of their in-center treatments. On HHD, they can establish control over their own treatments. The need for home support and an available caregiver have also been suggested as a necessary prerequisite for HHD. Studies suggest that 30 percent of patients may perform HHD without a partner, and pilot programs using a personal support worker or caregiver-assisted HHD are associated with positive and feasible outcomes [14].

In addition to medical assessment, examinations of visual acuity, dexterity, physical fitness, and home environment are also important considerations for HHD candidacy. Depending upon the type of dialysis equipment that will be used, accommodation of potential home renovation and water quality require important attention for the actual deployment of HHD [15].

In general, a home visit addresses the practicality of a patient performing home treatment [16]. Important considerations include:

●Assessment of personal hygiene

●Audit for space for treatment area, supplies, and equipment storage

●Proximity of water source and drain to treatment area

●Availability of telephone and/or internet connection for ongoing communication with the medical team

●Assessment for the amount and willingness of family/caregivers to support HHD

HOME HEMODIALYSIS TRAINING — All patients interested in HHD must understand and agree to the requirements of the home dialysis training program. The primary goal of this training is to enable a patient to perform HHD safely and effectively [17]. (See "Home hemodialysis (HHD): Establishment of a program", section on 'Training of the patient'.)

HHD training programs differ in scope and complexity. In general, most HHD training programs range from three to eight weeks in duration. More recent efforts have been made to focus on the individual learning preferences of patients. Indeed, the use of Visual, Aural, Read/write, and Kinesthetic (VARK) tools has been used to document learning preferences [18]. Interestingly, patients with a visual learning preference may have a lower likelihood of vascular access complications and bacteremia [18]. Confirmation of learning is also critically important [19].

Other efforts in verification of knowledge transmission are ongoing. Different groups have used standardized exams to validate acquisition of hemodialysis knowledge. Most programs utilize a "teach back" methodology in which patients have to "teach back" to the trainer or even "teach" the home care partner (in the presence of the trainer). The use of high-fidelity simulation in patients on HHD has also been linked with a reduction in home visitation after graduation to HHD.

VASCULAR ACCESS CONSIDERATIONS — Vascular access remains the Achilles' heel of any hemodialysis treatment, and cannulation is one the most significant barriers to adoption of HHD. Some data suggest that permanent vascular access has improved overall technique and patient survival compared with central venous catheter [20,21]. However, the training of vascular access cannulation may be one of the most challenging aspects of HHD training [22].

Cannulation may be taught to either patients or caregivers by experienced hemodialysis staff. Instructions through demonstration, videos, and models have all been shown to be effective. Expectedly, concerns surround the risk of vascular access malfunction, thrombosis, and infection. Given that vascular access complications are the primary safety concern of HHD, extra efforts must be made in stressing personal hygiene, daily examination of the access, appropriate use of antibiotic ointment (especially with buttonhole techniques), and vascular access auditing [23,24]. Although both rope ladder and buttonhole techniques are used for HHD, most centers have advocated use of the rope ladder technique because of lesser infection risk and similar patient comfort and infiltrative risk. (See "Overview of hemodialysis arteriovenous fistula maintenance and thrombosis prevention", section on 'Cannulation and decannulation'.)

All patients should be taught to recognize signs and symptoms of infection so that diagnosis and treatment of bacteremia can be done expeditiously. The use of audits and checklists have been used by various groups to enhance the quality of vascular access training and may reduce errors in vascular access cannulation and/or manipulation.

DIALYSIS PRESCRIPTIONS AND CLINICAL OUTCOMES — HHD practice patterns vary globally. Within the United States, most patients on HHD undergo low dialysate flow, platform-based, short daily hemodialysis. Outside of the United States, most HHD prescriptions are conducted with a conventional single pass system, with either more frequent hemodialysis and/or nocturnal hemodialysis schedules. (See "Short daily hemodialysis", section on 'Dialysis prescription and dose monitoring' and "Short daily home hemodialysis: The low dialysate volume approach" and "Technical aspects of nocturnal hemodialysis", section on 'Dialysis regimen and prescription'.)

It is important to note that HHD modality has the flexibility to modulate frequency and duration. In essence, health providers and patients may adjust the dose of hemodialysis to the goals and clinical outcomes that they aspire to achieve [15]. High-intensity hemodialysis (five or more times a week, six to eight hours per session) is known to be associated with:

●Regression of left ventricular hypertrophy

●Stabilization of left ventricular remodeling

●Normalization of blood pressure with reduction of vasoactive medications

●Augmentation of left ventricular ejection fraction

●Correction of obstructive sleep apnea

●Normalization of phosphate levels without dietary restrictions

●Improvement in kidney-disease-specific quality-of-life scores

●Term delivery with reduced maternal and fetal complications

●Minimized interdialytic fluctuations in fluid and biochemistry control

●Enhanced survival compared with conventional three times per week hemodialysis

While patients and health care providers may modify frequency and duration of dialysis, the provision of alternate-day hemodialysis may mitigate a "long" interdialytic break and provide a more moderate ultrafiltration rate. Unfortunately, there are no meaningful studies that compare outcomes of different intervals of more frequent treatments. Often, the appropriate frequency of treatment for a particular patient is informed by the degree of residual kidney function and amount of interdialytic weight gain. Short daily hemodialysis is the most popular HHD modality in the United States. Clinical advantages include (see "Short daily hemodialysis", section on 'Outcomes'):

●Improvement in blood pressure control

●Regression of left ventricular hypertrophy

●Reduction in cardiovascular-related hospitalization

●Improved overall survival

●Improved phosphorus control

While there is no perfect HHD prescription, the use of "goal-directed" hemodialysis prescriptions represents a new paradigm shift in defining the goal of the patient while balancing the prescription of hemodialysis dose at the home [25].

ENHANCING HOME HEMODIALYSIS UPTAKE — HHD selection should be promoted to all patients requiring kidney replacement therapy. However, clinician comfort and confidence with managing home modalities represent one barrier to the greater adoption of HHD. Enhancing knowledge awareness of HHD through education initiatives for all patients on dialysis may help to augment home dialysis uptake, but more data are needed [26].

Patients on home dialysis (peritoneal dialysis or HHD) who wish to stay at home should be given the opportunity to do so. For patients who can no longer perform peritoneal dialysis, transitioning to HHD (also known as home-to-home transition) is a viable option. However, since clinicians do not always consider this option, there is a paucity of patients transitioning from peritoneal dialysis to HHD, and many such patients are unfortunately transferred to in-center hemodialysis. In a recent registry survey, less than 10 percent of all patients on peritoneal dialysis exiting their prevalent kidney replacement therapy were converted to HHD [27].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Dialysis".)

SUMMARY

●Factors influencing patient selection – There is emerging interest in increasing the adoption of home hemodialysis (HHD) globally. Unfortunately, HHD remains underutilized in most countries. Factors that influence patient selection of HHD include patient education, understanding of the clinical advantages and disadvantages of HHD, and quality-of-life considerations. (See 'Factors that influence patient selection of HHD' above.)

●Evaluation by the HHD program – Patient enrollment is a fundamental aspect of HHD. All patients should undergo a medical assessment. There are few absolute contraindications to HHD (table 2). In addition, examinations of visual acuity, dexterity, physical fitness, and home environment are also important considerations for HHD candidacy. (See 'Evaluation by the home dialysis program' above.)

●HHD training – All patients interested in HHD must understand and agree to the requirements of the home dialysis training program. The primary goal of this training is to enable a patient to perform HHD safely and effectively. (See 'Home hemodialysis training' above.)

●Vascular access considerations – Vascular access remains the Achilles' heel of any hemodialysis treatment, and cannulation is one the most significant barriers to adoption of HHD. Cannulation may be taught to either patients or caregivers by experienced hemodialysis staff. Instructions through demonstration, videos, and models have all been shown to be effective. All patients should be taught to recognize signs and symptoms of infection so that diagnosis and treatment of bacteremia can be done expeditiously. (See 'Vascular access considerations' above.)

●Dialysis prescriptions and clinical outcomes – HHD practice patterns vary globally. Within the United States, most patients on HHD undergo low dialysate flow, platform-based, short daily hemodialysis. Outside of the United States, most HHD prescriptions are conducted with a conventional single pass system, with either more frequent hemodialysis and/or nocturnal hemodialysis schedules. It is important to note that HHD modality has the flexibility to modulate frequency and duration. Health providers and patients may adjust the dose of hemodialysis to the goals and clinical outcomes that they aspire to achieve. (See 'Dialysis prescriptions and clinical outcomes' above.)

ACKNOWLEDGMENTS

The UpToDate editorial staff acknowledges Lionel U Mailloux, MD, FACP, who contributed to earlier versions of this topic review.

The UpToDate editorial staff also acknowledges Christopher R Blagg, MD, FRCP (deceased), who contributed to earlier versions of this topic review.