INTRODUCTION — Home hemodialysis began in the early 1960s in Boston, Seattle, and London [1-5]. Studies since then have shown that patients using conventional, three times weekly home hemodialysis have an increased survival [6-13] and better quality of life [14-16] compared with those who use other dialysis modalities. This modality also costs significantly less than conventional in-center hemodialysis [17-21].

These findings led some investigators to believe that home hemodialysis is the best renal replacement therapy, other than renal transplantation. Despite these apparent benefits, the proportion of prevalent dialysis patients with end-stage renal disease (ESRD) treated by home hemodialysis in the United States declined steadily from the start of the Medicare ESRD program in 1973 until 2002, when it was 0.57 percent [22]. Similar changes occurred in other countries (figure 1 and figure 2) [23-25].

Since 2002, there has been a gradual increase in the number and percent of all United States dialysis patients treated by home hemodialysis; by 2008, there were 3826 patients (1.09 percent) on home hemodialysis [22], and preliminary estimates for 2010 suggested that the number of patients was between 5000 and 6000. This reflects the increasing interest in more frequent home hemodialysis [26]. Based on United States Renal Data System (USRDS) 2013 data for incident 2011 patients, total home dialysis patients have risen but mainly due to a significant increase in the number of patients utilizing continuous cycler peritoneal dialysis [27]. There are multiple barriers to patients choosing a home modality [28]. (See 'Barriers to increased use of home hemodialysis modalities' below.)

Issues relating to patient survival and other benefits derived from home hemodialysis, the declining incidence of this modality in the United States, and developments with more frequent daily and nightly hemodialysis (which are generally performed at home at night) are discussed here and elsewhere [29]. How home, short daily, and nocturnal hemodialysis are performed is discussed separately. (See "Home hemodialysis (HHD): Establishment of a program" and "Technical aspects of nocturnal hemodialysis" and "Short daily hemodialysis".)

INCIDENCE AND PREVALENCE — The number of patients using any home dialysis modality (hemodialysis or peritoneal dialysis) decreased for over 10 years from 1996 to 2008, when the trend began to change. By 2010, there was a large increase in all home dialysis, with most new patients choosing peritoneal dialysis. There was also a clear increase in home hemodialysis by 2011 to 2013, though less than 1500 patients out of the nearly 13,000 patients chose a home modality [30]. The overall use of home hemodialysis remains low. Among incident end-stage renal disease (ESRD) patients, only 9.1 percent of home dialysis patients were treated with home hemodialysis in 2013 (figure 3).

Internationally, there is little or no home hemodialysis, except in a number of high-income countries with an annual per capita gross national income greater than US $10,000, and, until recently, the number of home dialysis patients had been declining in most of these countries [25]. The prevalence of home hemodialysis in 2001 to 2003 varied from zero per million population (pmp) in Portugal to 58.4 pmp in New Zealand, and country-to-country variation was more than that of any other modality of ESRD treatment. In the United States in 2002, the home hemodialysis rate was 6.1 pmp and, in 2008, had doubled to 12.3 pmp.

Home hemodialysis prevalence is positively associated with the prevalence of peritoneal dialysis but not with the median age of the ESRD population. There is no correlation with the prevalence of diabetic nephropathy, national healthcare expenditures, or population density. In the United States, a study using 2007 ESRD Network data and Medicare’s Dialysis Facility Compare file examined facility and patient characteristics related to use of home hemodialysis [31]. This showed a positive association between home hemodialysis and unit size, percent of patients who were employed full or part time, a younger patient population, and the number of years the facility had been certified by Medicare. Negative associations included a larger number of patients per dialysis station, chain association, rural location, denser general population density in the area, a late dialysis shift, and a greater population of black patients [31].

It was noted in 2006 that there was opportunity for significant expansion of the use of home hemodialysis in many countries [25]. Such expansion is beginning to occur in the United States and elsewhere [32]. A position statement on dialysis economics that was developed by an international group of nephrologists proposed that increasing home-based therapies (including peritoneal dialysis) would help address the growing dialysis burden around the world [33]. New home hemodialysis programs have been or are being developed in Turkey, India, China, and Hong Kong.

REASONS FOR THE DECLINE IN HOME HEMODIALYSIS — The lack of popularity of home hemodialysis as a treatment modality for end-stage renal disease (ESRD) patients in the United States is due to a number of factors [34], including:

●Increasing numbers of patients who are older or seriously ill, particularly those whose ESRD results from diabetes or severe vascular disease.

●The rapid increase in the number of outpatient dialysis units, particularly for-profit units that did not encourage home hemodialysis, although this has begun to change.

●Concern that patients should not dialyze without direct supervision by a nurse [35].

●Lack of satisfactory explanation of the advantages and disadvantages of the various modalities of treatment to patients [35].

●Lack of patient and/or family motivation, patient fears of sticking themselves, technical aspects of hemodialysis, risk of social isolation, and fear of dealing with their blood access and equipment and the possible burden on the family [35-37]. These factors can be overcome by a sympathetic staff committed to convincing patients that home hemodialysis is a superior form of treatment for ESRD.

●Lack of attention given to home hemodialysis, self-care hemodialysis, and peritoneal dialysis by most nephrology training programs in the United States [38].

●Lack of interest in and experience with home hemodialysis among practicing nephrologists.

●The small number of experienced dialysis programs available to train patients in home hemodialysis.

These and related issues have been discussed elsewhere [34,35].

IMPROVED OUTCOME — Despite these difficulties, home hemodialysis attracts increasing attention as a viable dialysis option for several reasons:

●Realization that home hemodialysis provides better patient outcomes, particularly patient survival, better control of hypertension with fewer or no antihypertensive agents [39], better quality of life [14-16] and opportunity for rehabilitation and employment [40], and greater cost effectiveness [17-21] without an adverse effect on fistula survival [41].

●Realization that longer and/or more frequent hemodialysis is best provided in the home.

●Concern about long-term dialysis adequacy with peritoneal dialysis.

●Concern for the future. While growth in the incidence rate of end-stage renal disease (ESRD) in the United States had slowed in the last few years, the number of new cases increased by 3.4 percent between 2005 and 2006, the first growth of more than 3 percent since 2001. However, since then, the growth rate has flattened again, being only 0.06 percent between 2006 and 2007 and 1.2 percent between 2007 and 2008. The growth of the prevalence rate has also flattened over the same time period, from 3.2 percent to -0.9 percent and 0.08 percent [22].

●Concern over costs. In 2008, Medicare spending on ESRD was USD $26.8 billion, which was approximately 5.9 percent of the total Medicare budget. Non-Medicare ESRD spending was USD $12.7 billion, for a total cost of almost USD $39.5 billion [22].

●The relative shortage of nephrologists will continue to increase and will be compounded by the need to provide care for an increasing number of patients with chronic kidney disease. The shortage of nurses and other staff will also continue [42,43].

Studies evaluating survival of patients on conventional home hemodialysis report survival rates of approximately 90 and 50 percent at 5 and 15 years, respectively [6,8-13]. Although these studies were performed by investigators who favor the use of this modality, the following results from a study using the United States Renal Data System (USRDS) database corroborate these findings [44]:

●Patients on home hemodialysis had an unadjusted decreased risk of death compared with those being dialyzed as outpatients (risk ratio 0.37 versus 1.00).

●Adjustments for age, diagnosis, comorbidity, and sex did not significantly alter the decreased risk of death for home hemodialysis patients, although this population was younger and had less comorbidity than the general dialysis population (risk ratio 0.56 versus 1.00).

Improved survival associated with home hemodialysis has also been found in countries other than the United States. As examples:

●Data from the French registry has shown improved 5- and 10-year survival compared with dialysis in a center (79 versus 59 percent and 56 versus 32 percent, respectively).

●In a nested case-control study from Switzerland, 58 home hemodialysis patients were matched with an in-center hemodialysis patient for gender, age, dialysis vintage, and renal disease by retrospective analysis [45]. Five-, 10-, and 20-year survival rates were markedly higher with home hemodialysis (93, 72, and 34 percent, respectively, versus 64, 48, and 23 percent).

●A retrospective cohort database analysis from Australia and New Zealand found that the mortality risk was approximately 50 percent lower among home hemodialysis patients compared with in-center hemodialysis patients in the time period between 1996 and 2011, noting though that home hemodialysis patients were younger and had fewer comorbid conditions compared with in-center patients [46,47].

In patients who maintain a similar dialysis regimen at home as those who are dialyzed in-center, the reasons why home hemodialysis is associated with improved patient survival are not well understood (other than selection bias). Decades ago, Blagg and Scribner and others highlighted the need for dialysis patients to maintain their independence and avoid the syndrome of "learned helplessness" [48,49]. Patients who exert considerable responsibility and know the most about their illnesses feel "in charge" of their own treatment and achieve more optimal outcomes [50]. Similar psychological forces could be playing a strong role in home hemodialysis patients. Such patients may also be less likely to cut corners or time from their treatments, especially if they dialyze overnight.

INCREASED DIALYSIS — Longer conventional dialysis, three times weekly, is associated with improved survival outcomes [51-53] As an example, among the best patient survival results in the world are those from Tassin, France, which show the remarkable benefits of three times weekly, eight-hour dialysis in center or at home [52] After five years, their patients show no evidence of the progressive nutritional impairment reported in the Hemodialysis (HEMO) study [54].

In Australia, many centers have adopted a concept of home hemodialysis that is synonymous with extended-hours dialysis because of the survival, physiological, quality-of-life, social, and economic benefits [55].

Even more benefits result from the implementation of more frequent short daily and/or long nightly hemodialysis, both of which are most easily done at home. These include more adequate dialysis with a higher Kt/V, better blood pressure control with fewer or no medications, regression of left ventricular hypertrophy and reduction in inflammatory markers, significantly improved removal of phosphate and beta-2 microglobulin (especially with nocturnal hemodialysis), significant subjective improvement in patient wellbeing both during and between dialyses, improved nutrition, and enhanced quality of life.

Both short daily and nocturnal hemodialysis are discussed in detail separately. (See "Short daily hemodialysis" and "Technical aspects of nocturnal hemodialysis".)

Nevertheless, there are concerns that more frequent hemodialysis costs more, even in the home, because of the increased supplies. Thus, it should be emphasized that overnight nocturnal hemodialysis three times a week can provide twice as many hours of dialysis per week than conventional in-center hemodialysis as practiced in the United States, costs less, and results in better outcomes.

Long, alternate-night hemodialysis in the home or center is an excellent compromise. It eliminates the weekly two-day gap between dialyses at weekends, and it has been shown that there is a threefold increased risk for sudden death in the 12 hours before dialysis after the weekend [56]. While it is not as effective as overnight hemodialysis six nights a week and requires more ultrafiltration, it produces relatively good phosphate control; however, it may not eliminate the need for phosphate binders [57]. One report suggests that it manages the biochemical factors associated with bone mineral metabolism almost as well as nightly and daily short dialysis [58]. Because costs and consumable needs are less than with nightly and daily hemodialysis, this regimen should be given greater consideration.

The 2015 Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines suggest considering home long hemodialysis three to six nights per week [59]. The KDOQI guidelines also recommend that patients considering this therapy be informed of associated risks, including potential increase in vascular access complications, increased burden for caregivers, and faster decline in residual renal function.

MECHANISMS OF BENEFIT — Longer, thrice-weekly dialysis sessions and/or more frequent hemodialysis have a variety of effects that could contribute to the apparent improvement in outcome. One important difference is the amelioration of the abnormal physiologic cycling of body water, serum osmolality, and total body solutes that occurs with intermittent and intense conventional dialysis schedules [60]. Short or long daily dialysis almost invariably results in more striking patient benefits than overnight hemodialysis three times a week, and, at least in the case of short frequent dialysis, this is not necessarily related to provision of an increased weekly dialysis dose [61].

Although a standard Kt/Vurea has become the usual mathematical method for dose calculation with more frequent dialysis, phosphate and middle-molecule removal are probably more important than small-molecule removal and increase with greater weekly dialysis duration [62]. Where laboratory measures to quantify elimination of beta2-microglobulin are not readily available, rather than rely on Kt/V, the quality of dialysis may be best estimated from outcomes and clinical symptoms. As an example, effective dialysis therapy may be best documented by a good quality of life, which is defined in part by low requirements for erythropoietin and antihypertensive drugs, a good appetite, and the absence of fatigue and pruritus [63].

POSSIBLE METHODS TO REVERSE THE DECLINE IN HOME HEMODIALYSIS — Many different hurdles must be overcome to increase the proportion of end-stage renal disease (ESRD) patients treated by home hemodialysis and more frequent dialysis. Some of the steps that the nephrology community can take to reverse the trend include:

●Early identification of potential home hemodialysis patients.

●Early referral to a designated home hemodialysis training program.

●Early placement of an arteriovenous fistula.

●Clinicians and staff devoting more time to emphasize to the patient the benefits of home hemodialysis: freedom, knowledge of technique, independence and availability of support, flexibility in scheduling dialysis, improved personal relationships with clinicians, and, in particular, improved patient survival with home hemodialysis and particularly with longer and/or more frequent dialysis [64,65].

●An ongoing education program that encourages questions and discussion and is particularly targeted at presenting all treatment options to pre-ESRD patients [66].

●Development of centrally coordinated regional home hemodialysis centers to conserve resources and make the best use of specialized training staff. This approach has been successful in the Canadian province of British Columbia [67].

●New access modalities and new equipment to increase the amount of dialysis, allow more frequent dialysis, decrease morbidity, and simplify dialysis.

●New equipment technology to make dialysis simpler and safer for patients to perform, with minimal help from a family member or other helper. One survey found that patients and family would like to have access to remote monitoring for nocturnal home hemodialysis, at least during the transition from training to home [68].

●Recognition that the costs of three times weekly home hemodialysis are significantly less than the costs of in-center hemodialysis [69,70].

●Establishment of programs to allow dialysis patients on conventional hemodialysis to participate in a short, in-center, frequent dialysis personal clinical trial for two to three weeks to experience the benefits of more frequent hemodialysis [65].

●Change in reimbursement policy by the Centers for Medicare and Medicaid Services to pay for more frequent dialysis. There is evidence that conventional home hemodialysis three times a week and particularly more frequent dialysis, whether short daily or long nightly, results in overall savings because of reduction in staff time, less frequent hospitalization and fewer hospital days, and decreased requirements for erythropoietin and antihypertensive agents [70]. The concept that, in the United States, Part A Medicare savings from reduced hospitalization cannot be used to offset Part B Medicare increased supply costs must be changed. It remains to be seen whether bundling of payment for erythropoietin-stimulating agents and other drugs into per dialysis reimbursement with consequent reduction in profit margins, beginning in 2011, will encourage greater use of home dialysis [71].

Morbidity and mortality from dialysis in general have decreased only slightly among patients in the United States over the last few years [22], despite implementation of Dialysis Outcomes Quality Initiative (DOQI) guidelines and improvements in hematocrit, serum albumin, and Kt/V levels. In addition, the Hemodialysis (HEMO) study showed that, with three times weekly hemodialysis, increasing the dose of dialysis above DOQI-recommended guidelines or using high-flux membranes had no significant effect on hospitalizations or patient mortality [62]. Mortality still compares unfavorably with that of Japanese, Western European, and Australian hemodialysis patients.

BARRIERS TO INCREASED USE OF HOME HEMODIALYSIS MODALITIES — There are multiple barriers to using home hemodialysis modalities [28,72]. These include (but are not limited to) issues surrounding:

●Lack of education among clinicians, patients, and dialysis staff

●Reimbursement

●Concerns among patients about abandonment by staff

It is possible that the decline in home hemodialysis can be reversed now that the barriers have been identified [28,72]. Home hemodialysis provides many benefits in the sense that there is considerable opportunity for greater dialysis delivery and improvement in outcome, as has been noted [73]. In order to overcome these shortcomings, it is necessary for the physicians to take a leadership role with staff and patients and choose in advance those who are likely candidates for one of the home dialysis modalities.

HOME HEMODIALYSIS MACHINES — If the trend of improvement is to continue, new approaches and techniques will have to be developed to provide delivery of more frequent and increasingly physiologic dialysis in the home. A number of machines intended particularly for home hemodialysis have been developed or are under development:

●The Aksys PHD was the first machine designed specifically for ease of patient use and received US Food and Drug Administration (FDA) clearance in 2002 [67]. It made ultrapure dialysate, which was also readily available as replacement fluid (obviating the need for intravenous saline), and used hot water disinfection to allow reuse of dialyzer and tubing set in situ for up to 30 uses (significantly reducing storage requirements and medical waste). It was relatively biocompatible and met 2001 FDA recommendations for using non-DEHP products for repetitive procedures, including hemodialysis.

Disadvantages included its large size and weight; the requirement for plumbing and electrical modifications in the home, with some increase in utility bills; and its complexity, which mandated that maintenance and repairs be done by the company's own technicians. The device is no longer available because the Aksys Company filed for bankruptcy in 2007.

●The NxStage System One is a smaller machine (only 70 pounds) and more transportable than the older machines [74]. It uses four to six 5-liter bags of ultrapure lactate dialysate that are integrated onto a disposable cassette for each short daily dialysis, thereby increasing storage space needs in the home. Since it does not need electrical or plumbing modifications, patients can perform dialysis away from home without having to arrange treatments in other dialysis units. This machine is also easy for patients to learn to use. Larger patients may need five or six bags of dialysate to provide adequate dialysis. Because of the use of dialysate bags and a new dialyzer and tubing set for each dialysis session, there is more exposure to plastics and more medical waste.

●The NxStage PureFlow SL prepares up to 60 L of dialysate (sufficient for three treatments) using a prepackaged filtering system that the patient can use to prepare dialysate from tap water, eliminating the need for dialysate bags, except when traveling.

●The Renal Solutions Allient Sorbent Hemodialysis System was a sorbent cartridge-based system for use in the home and elsewhere. It was also patient friendly, only requiring an electrical source and 6 liters of drinking water for treatment. Water mixed with small packets of dry chemicals was converted to dialysate by the sorbent cartridge, and the dialysate was continuously regenerated and recirculated. Overnight treatment was possible since the sorbent cartridge was designed for three- to eight-hour sessions [75]. Renal Solutions was purchased by Fresenius in 2007, and it is anticipated that they will adapt the sorbent technology for use in Fresenius machines.

Each system is generally focused on using different schemes to make the procedure easier and safer, including improved computer monitoring, sterilization techniques, and feedback designs. A number of other new home hemodialysis devices are under development.

The other areas of interest relate to wearable artificial kidneys and an implantable artificial kidney. Wearable artificial kidneys are being developed by several small companies [76], and at least one is undergoing clinical testing [77]. The biggest question with wearable devices is blood access, and so two groups are developing wearable peritoneal dialysis devices [78,79].

The development of an implantable artificial kidney based on the University of Michigan Renal Assist Device has been pursued for several years [80]. It is not expected to be ready for clinical trials for several years.

Finally, it is important to remember that peritoneal dialysis is also a home treatment that could play a greater role in the future [81].

APPROACH — All members of the dialysis team must become advocates for home hemodialysis and for more frequent dialysis when this becomes financially feasible. Until that time, conventional overnight three times a week or alternate-night hemodialysis, either at home or in a center, is an optimal treatment schedule. As of the end of 2007, 841 patients were on conventional home hemodialysis three times a week, 302 were on alternate nights, 2396 were on short daily, and 225 were on home hemodialysis five or six nights a week [82].

Although it may become more difficult to see potential end-stage renal disease (ESRD) patients early in the course of renal failure if they are enrolled in managed care programs, nephrologists must impress upon their colleagues that patients with stage 3 and 4 chronic kidney disease should be referred early to teach them about management of their disease and to introduce them to the benefits of home hemodialysis, more frequent hemodialysis, peritoneal dialysis, and transplantation. This knowledge will help reduce patient fear and depression. It will also make it possible for ESRD patients to face their illness realistically and positively and provide an opportunity for them to select the best available dialysis treatment. A website, Home Dialysis Central, is an excellent resource for those interested in home dialysis [83].

Studies reporting better patient outcomes with home hemodialysis and more frequent hemodialysis highlight the importance of informing patients about the various modalities of dialysis available to them and, in particular, the benefits of home hemodialysis and more frequent hemodialysis. Nephrologists in the United States and Canada believe that home dialysis therapies are underused and that 11 to 14 percent of all dialysis patients could be treated by home hemodialysis [84]. A 2007 survey of 6595 delegates at five international dialysis and nephrology conferences (57 percent physicians and 28 percent nurses) found that the majority considered frequent home or self-care hemodialysis the best long-term therapy [85]. In addition, at least two informal polls of nephrologists at meetings asking what treatment they would choose for themselves, if transplantation was not an option, found the vast majority would opt for home hemodialysis, whether they had any home dialysis patients or not. Thus, clinicians and the entire dialysis team should not let their emotions or economic need decide the dialysis modality choice if there is any possibility of the patient choosing home hemodialysis. This treatment is still the best option for many more patients than have the opportunity for it.

SUMMARY AND RECOMMENDATIONS

●Patients using conventional, three times weekly home hemodialysis have an increased survival and better quality of life compared with those who use conventional in-center hemodialysis in the United States. Home hemodialysis also costs significantly less than conventional in-center hemodialysis. Despite these benefits, relatively few patients use home hemodialysis either in the United States or internationally, although its use is increasing. (See 'Introduction' above and 'Incidence and prevalence' above.)

●The lack of popularity of home hemodialysis is probably due to a combination of various factors such as the large numbers of older or seriously ill patients, the rapid increase in the number of outpatient dialysis units, concern that patients should not dialyze without direct supervision by a nurse, lack of satisfactory explanation of advantages and disadvantages of home hemodialysis, lack of patient and/or family motivation, patient fears regarding technical aspects, lack of attention given to home hemodialysis by nephrology training programs, lack of interest and experience among practicing nephrologists, and few experienced dialysis programs available to train patients. (See 'Reasons for the decline in home hemodialysis' above.)

●The development of new technology to make dialysis simpler and safer for patients to perform and a change in reimbursement policy by the Centers for Medicare and Medicaid Services to pay for more frequent dialysis may encourage greater use of home dialysis. A number of machines intended particularly for home hemodialysis have been developed or are under development. Each system is generally focused on making the procedure easier and safer, including improved computer monitoring, sterilization techniques, and feedback designs. (See 'Possible methods to reverse the decline in home hemodialysis' above and 'Home hemodialysis machines' above.)

●To increase the proportion of end-stage renal disease (ESRD) patients treated by home hemodialysis, nephrologists should identify potential patients early for referral to a home hemodialysis training program and for placement of an arteriovenous fistula. Clinicians and staff should devote more time to emphasize the benefits of home hemodialysis. A website, Home Dialysis Central, is an excellent resource for those interested in home dialysis. (See 'Approach' above.)