Home dialysis: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference

Abstract

Home dialysis modalities (home hemodialysis [HD] and peritoneal dialysis [PD]) are associated with greater patient autonomy and treatment satisfaction compared with in-center modalities, yet the level of home-dialysis use worldwide is low. Reasons for limited utilization are context-dependent, informed by local resources, dialysis costs, access to healthcare, health system policies, provider bias or preferences, cultural beliefs, individual lifestyle concerns, potential care-partner time, and financial burdens. In May 2021, KDIGO (Kidney Disease: Improving Global Outcomes) convened a controversies conference on home dialysis, focusing on how modality choice and distribution are determined and strategies to expand home-dialysis use. Participants recognized that expanding use of home dialysis within a given health system requires alignment of policy, fiscal resources, organizational structure, provider incentives, and accountability. Clinical outcomes across all dialysis modalities are largely similar, but for specific clinical measures, one modality may have advantages over another. Therefore, choice among available modalities is preference-sensitive, with consideration of quality of life, life goals, clinical characteristics, family or care-partner support, and living environment. Ideally, individuals, their care-partners, and their healthcare teams will employ shared decision-making in assessing initial and subsequent kidney failure treatment options. To meet this goal, iterative, high-quality education and support for healthcare professionals, patients, and care-partners are priorities. Everyone who faces dialysis should have access to home therapy. Facilitating universal access to home dialysis and expanding utilization requires alignment of policy considerations and resources at the dialysis-center level, with clear leadership from informed and motivated clinical teams. Home dialysis modalities (home hemodialysis [HD] and peritoneal dialysis [PD]) are associated with greater patient autonomy and treatment satisfaction compared with in-center modalities, yet the level of home-dialysis use worldwide is low. Reasons for limited utilization are context-dependent, informed by local resources, dialysis costs, access to healthcare, health system policies, provider bias or preferences, cultural beliefs, individual lifestyle concerns, potential care-partner time, and financial burdens. In May 2021, KDIGO (Kidney Disease: Improving Global Outcomes) convened a controversies conference on home dialysis, focusing on how modality choice and distribution are determined and strategies to expand home-dialysis use. Participants recognized that expanding use of home dialysis within a given health system requires alignment of policy, fiscal resources, organizational structure, provider incentives, and accountability. Clinical outcomes across all dialysis modalities are largely similar, but for specific clinical measures, one modality may have advantages over another. Therefore, choice among available modalities is preference-sensitive, with consideration of quality of life, life goals, clinical characteristics, family or care-partner support, and living environment. Ideally, individuals, their care-partners, and their healthcare teams will employ shared decision-making in assessing initial and subsequent kidney failure treatment options. To meet this goal, iterative, high-quality education and support for healthcare professionals, patients, and care-partners are priorities. Everyone who faces dialysis should have access to home therapy. Facilitating universal access to home dialysis and expanding utilization requires alignment of policy considerations and resources at the dialysis-center level, with clear leadership from informed and motivated clinical teams. Home dialysis modalities, including home hemodialysis (HD) and peritoneal dialysis (PD), are associated with increased patient autonomy and treatment satisfaction and are sometimes less costly than in-center HD (ICHD).1Walker R.C. Hanson C.S. Palmer S.C. et al.Patient and caregiver perspectives on home hemodialysis: a systematic review.Am J Kidney Dis. 2015; 65: 451-463Abstract Full Text Full Text PDF PubMed Google Scholar, 2Dahlerus C. Quinn M. Messersmith E. et al.Patient perspectives on the choice of dialysis modality: results from the Empowering Patients on Choices for Renal Replacement Therapy (EPOCH-RRT) Study.Am J Kidney Dis. 2016; 68: 901-910Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar, 3Chaudhary K. Sangha H. Khanna R. Peritoneal dialysis first: rationale.Clin J Am Soc Nephrol. 2011; 6: 447-456Crossref PubMed Scopus (0) Google Scholar, 4Culleton B.F. Walsh M. Klarenbach S.W. et al.Effect of frequent nocturnal hemodialysis vs conventional hemodialysis on left ventricular mass and quality of life: a randomized controlled trial.JAMA. 2007; 298: 1291-1299Crossref PubMed Scopus (583) Google Scholar, 5McFarlane P.A. Pierratos A. Redelmeier D.A. Cost savings of home nocturnal versus conventional in-center hemodialysis.Kidney Int. 2002; 62: 2216-2222Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 6Rubin H.R. Fink N.E. Plantinga L.C. et al.Patient ratings of dialysis care with peritoneal dialysis vs hemodialysis.JAMA. 2004; 291: 697-703Crossref PubMed Scopus (241) Google Scholar, 7Chuasuwan A. Pooripussarakul S. Thakkinstian A. et al.Comparisons of quality of life between patients underwent peritoneal dialysis and hemodialysis: a systematic review and meta-analysis.Health Qual Life Outcomes. 2020; 18: 191Crossref PubMed Scopus (53) Google Scholar Yet, despite mounting evidence regarding the benefits of home dialysis, its use worldwide remains low. The availability and use of home-based dialysis therapies remain variable, shaped by a complex interplay among national healthcare policies, systems for dialysis delivery, financial considerations, and culture. In many regions, including several high-income areas, individuals facing kidney failure have limited or no access to home HD. For PD, recent substantial growth in use among low- and middle-income regions has been accompanied by a concomitant decline in PD among many high-income regions.8Jain A.K. Blake P. Cordy P. et al.Global trends in rates of peritoneal dialysis.J Am Soc Nephrol. 2012; 23: 533-544Crossref PubMed Scopus (374) Google Scholar Globally, the net burden of untreated kidney disease is rising.9Harris D.C.H. Davies S.J. Finkelstein F.O. et al.Increasing access to integrated ESKD care as part of universal health coverage.Kidney Int. 2019; Full Text Full Text PDF PubMed Scopus Google Scholar The of individuals dialysis is to from to et access to treatment for kidney a systematic 2015; Full Text Full Text PDF PubMed Scopus Google Scholar In worldwide home dialysis utilization may a to universal access to kidney in low- and middle-income regions by and In the Kidney Disease: Improving Global dialysis controversies and the that choice of dialysis modality a in a and to et modality and from a Kidney Disease: Improving Global Int. 2019; Full Text Full Text PDF PubMed Scopus Google Scholar In the KDIGO dialysis controversies conference and in of are and by dialysis et and in from a Kidney Disease: Improving Global Int. 2020; Full Text Full Text PDF PubMed Scopus Google Scholar of the KDIGO dialysis conference on policy, and patient home dialysis utilization as as considerations for expanding its use K. et of kidney quality of life, and among patients peritoneal dialysis and in-center hemodialysis: from the J Kidney Dis. 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