Dialysis, There's No Place Like Home

HWN Team | Heads or Tails
Dialysis, There's No Place Like Home

image by: Anna Frodesiak

Kidney failure and its treatment dialysis is overwhelming the medical systems of many countries. Could home hemodialysis be the answer? Besides that, people may actually live longer and healthier lives!

Another epidemic is ongoing and it's not the flu or malaria or even HIV. It's end stage renal disease (ESRD) or kidney failure. ESRD is caused by many conditions but usually is secondary to hypertension, diabetes and obesity. Essentially the kidneys are no longer capable of doing the job of cleaning the waste products of the body, so that toxic wastes and fluids accumulate in the body, resulting in damage to other organs and eventually death.

To prevent death in patients with renal failure, renal replacement therapy (RRT) is needed and consists of either kidney transplant or dialysis. Although kidney transplant is the ideal RRT it is not always feasible or immediately available. Plus, transplants may fail or donors may not be available or patients may not simply be eligible for transplantation.  So, in most cases, dialysis remains the treatment of choice.

The global prevalence of ESRD in 2004 was 280 persons per million population, with the highest numbers (74%) reported in North America and Europe. In Asia, Japan has the highest incidence.1 In 2004, about 1.78 million people worldwide were undergoing treatment for ESRD and 1.37 million were on dialysis. In 2008, for every 1 million American residents, 1,752 were being treated for ESRD.  In 2010, more than 10% of Americans, or more than 20 million, ages 20 years and older have chronic kidney disease.2

ESRD is becoming one of the most expensive diseases to treat on a per capita basis due to the large and rapidly growing number of ESRD patients who are dialysis dependant. In 2008, the ESRD program in the U.S. cost $39.46 billion in public and private spending.  Medicare spends approximately $73,000 annually per dialysis patient and expenditures for ESRD by 2010 was expected to be $28.3 billion. Annual hemodialysis costs per patient in other countries is estimated to be: Brazil US$ 7332, China US$ 7500, India US$ 5000 and Indonesia US$ 6240.3,4

And ESRD, especially hemodialysis is big business. There are an estimated 4200 commercial kidney dialysis centers in the U.S., with revenue of approximately $18 billion. A small center treating about 170 ESRD patients could cost up to $5 million. More than 90% of these centers are run by large health care companies that include DaVita, Renal Care Group, DSI Renal, Renal Advantage, and Fresenius Medical Care. In addition, there are also publicly owned dialysis centers or hospitals providing dialysis care.5

So let’s look at the three methods of dialysis

Peritoneal dialysis (PD), the oldest

In PD, a fluid solution is repeatedly infused into the peritoneal cavity via a permanent catheter. The solution, usually a concentrated glucose solution, stays for a few hours in the cavity, during which the peritoneum acts as a 'natural filter'. Based on the principle of osmosis and diffusion, toxic metabolites in the blood cross the peritoneal membrane into the dialysis solution in the peritoneal cavity.  The solution containing the toxic waste is then drained out.

PD may be performed at home by the patient or a care giver, who performs the infusion repeatedly four times a day, the so-called continuous ambulatory PD (CAPD) or "manual" PD. An alternative is the automated peritoneal dialysis (APD) which uses a device that performs the dialysis at night while the patient is asleep.

PD is a widely preferred form of dialysis in many parts of the world, especially in Europe. This is probably due to studies suggesting that the quality of life of patients treated with PD is better than those treated with conventional HD. PD gives the patient more independence and spares them the necessity of travelling to dialysis centers. For young, active patients, APD is the preferred mode of RRT which allow them to perform their daily activities and even engage in employment while on the transplant list. PD is also more cost-efficient and easier to use than HD. It has few out-of-pocket expenses and it does not require a large infrastructure.6,7

However, PD is not without its risks and complications. Glucose solutions are conventionally used as the osmotic agent for PD. The glucose in the PD solution is absorbed systemically while in the peritoneal cavity. With long-term PD use, this absorption leads to several complications with consequent adverse metabolic and cardiovascular problems, increased morbidity and mortality among PD patients.

Some of these complications are: temporary hyperglycemia that can occur at each PD, but which may lead to a permanent state of hyperglycemia and insulin resistance, weight gain due to accumulation of abdominal adipose tissue, lipid imbalance (hyperlipidaemia) including increased levels of cholesterol (hypercholesterolaemia) and hormonal imbalance due to adipose tissue hormones adipokines, transient increase in blood pressure during PD and atherosclerosis.

Hemodialysis (HD), the most common

According to MedlinePlus: It “removes blood from the body and sends it across a special filter with solutions. The filter helps remove harmful substances. The blood is then returned to the body.” Blood is taken out and returned into the body through so-called “accesses.” HD access may be temporary or permanent.  A temporary access is usually a catheter inserted into a large vein located in the arm, neck, groin or chest whereas permanent access is through an arteriovenous fistula (AVF) or graft (AVG) which is basically an artery and vein in the arm surgically connected. Conventional HD is done in a dialysis center three times a week with each treatment lasting 3 to 4 hours.8

HD is associated with fewer cardiovascular complications than PD. The main barrier to HD is the necessity to travel to a dialysis center at least three times a week. This especially exerts a large burden on patients (and their families) who reside in places far away from dialysis centers. The trip may take several hours each way. The treatment clearly has a drastic effect on the patients’ quality of life and that of their care givers and family members who have to provide transport to dialysis centers. Some patients actually refuse any treatment when HD is the only option. A Canadian review reported that 61% of 584 patients studied regretted their decision to start HD and many who started HD tend to discontinue treatment.

Home hemodialysis (HHD), the outsider

Surprisingly, the idea of HD which can be performed at home, similar to PD, is not a new idea and has been around since the 1960’s but the dialyzing machines in those days were very large and difficult to use. Thanks to new technology, HHD machines are smaller and more user friendly.

In many countries, HHD is only allowed by their health care system to be used in remote and isolated areas. In Australia and New Zealand, however, HHD is the norm in terms of the dialysis rather than the exception. This could well be due to geography but there are other reasons as we will explain later. In contrast, in North America, HHD is usually only provided in geographically isolated areas. As an example: “Manitoba has the highest prevalence of ESRD in Canada. Northern Manitoba is a very sparsely settled area with a high proportion of aboriginal ESRD patients. Relocating to urban areas for dialysis is psychosocially and culturally stressful to patients. Delivering dialysis care in a home setting has demonstrated advantages in both clinical, economic, and health related quality of life domains".9

Examples of currently available HHD are NxStage-System One and Fresenius-K. Both systems are simple and easy to use and NxStage has the advantage of being portable, with an efficient supply chain for travelers.

So, what are the pluses of HHD?

Easy to use 

The HHD machines of the 1960s were dinosaurs compared to what is currently available as home dialysis devices. Aside from being small and user-friendly, they are also more reliable, easier to set up, clean and disinfect and require less supplies. Due to microelectronics and long-lasting batteries, there are even portable HHDs that allow patients more independence in terms of travelling.

Improves quality of life

“Increasing the frequency of HD to 5 or 6 times per week, either as short daily HD or nocturnal HD can improve quality of life, reduce cardiovascular risk and prolong survival, compared with conventional HD.”  

According to the National Kidney Foundation (NKF): …people using short daily and nocturnal home hemodialysis live longer, experience a better quality of life, have fewer and shorter hospital stays and feel better both during and after dialysis. In addition, home dialysis-both peritoneal dialysis or home hemodialysis - allows patients more flexibility in terms of schedule, more control over their health and treatment, and the convenience of exchanging multiple visits weekly for a monthly checkup to the center.10,11

HHD allows for dialysis to be performed more frequently than just three times a week. A regimen could be, for example, shorter (2 - 3 hours) but more frequent (5 - 7 days per week) treatments. Many dialysis centers are fully booked, allowing only a couple of hours of dialysis time for patients. HHD allows for more flexibility in timing as well as the duration of dialysis (e.g. up to 6 hours). Longer dialysis time translates to better toxic waste disposal.

And HHD allows for dialysis at night, thus relieving the burden of treatment on the daily activity of the patient. Conventional three times weekly HD has an impact on the diet of the patient, often leading to malnutrition. Nighttime dialysis with HHD resolves this problem. Nocturnal dialysis allows for longer, nightly treatments done 3 - 6 nights per week during sleep.

Specific benefits of HHD includes better blood pressure control with fewer drugs, better control of phosphate levels in the blood, less limited diet and fluids than standard HD and reversal of some heart damage caused by high blood pressure.  In fact, patients who switched from conventional HD to more frequent HHD say “they have more energy, feel less nauseous, and sleep better. Many say they value the control they gain by doing their own treatments.” Also, HHD has the quality of life advantages of PD but without the cardiovascular complications of long-term PD use.12

HHD sounds like the real deal. Right?

The U.S. and to some extent Canada is spending more than any other country in the world for dialysis, but the outcomes are poorer and survival is lower.13 But according to statistics, only 35,000 (<10%) of the 382,000 dialysis patients in the U.S. use home hemodialysis. In contrast, in countries like Australia and New Zealand, HHD is the most common RRT modality.

So why the low use in the U.S. and Canada. The National Kidney Foundation cites several barriers namely:

Inadequate Education

There seems to be a lack of information about HHD not only among ESRD patients but also among caregivers and dialysis staff. This lack of education leads to skepticism and hinders the widespread use of a very helpful clinical tool. In particular, patients are scared of the fact that they have to perform the dialysis themselves without a doctor nearby.

A study performed by Australian researchers identified four themes that could influence the decision of patients in need of dialysis, namely:14 mortality (choosing life or death, being a burden, living in limbo), lack of choice (medical decision, lack of information, constraints on resources), gaining knowledge of options (peer influence, timing of information), and weighing alternatives (maintaining lifestyle, family influences, maintaining the status quo)

Of these, gaining knowledge options seem to be especially important for decision-making. Knowledge gained from peers is very influential, sometimes more than doctors. The timing of when the information was received also plays a role. Some patients may feel too sick or distressed to have a clear mind to objectively consider the options. In many cases, the options were presented to the patient only after dialysis has been initiated, a practice that is contrary to current clinical guidelines.  In such cases, dialysis is understandably the most preferred option, coupled with reluctance to change, thus maintaining the status quo.

Provider Philosophy and Practice

The current practices for providers and support services are tailored to the needs of dialysis centers and not for patients on HHD. In fact, HHD may be viewed as a threat to the existence of these institutions. Examples are:

Exclusivity contracts and financial considerations that compel some providers to enact restrictive policies on medication and machinery for home dialysis. Delayed, infrequent delivery of supplies to home dialysis programs. Subpar services in terms of responsiveness and data processing to home dialysis patients on the part of dialysis-provider affiliated laboratory services who favor in-center HD. Lack of access to prompt treatment of peritonitis for peritoneal dialysis patients since currently home dialysis programs are not allowed to stock these medications.

In contrast, health care providers and supply services in Australia and New Zealand are very supportive of HHD, leading to the efficiency and widespread use of HHD. Australian researchers write: “After early strong support, home hemodialysis (HHD) has all but disappeared as a viable modality in most western countries--except in Australia and New Zealand (ANZ), where a mean 12.9% of all HD (June 2010) is home-based. The reasons for this unique difference are neither demographic nor geographic; rather, they result from a strong belief held by ANZ nephrologists, nurses, and funding agencies in the clinical outcome and economic benefits of HHD. This "hemodialysis is best at home" approach has permitted ANZ programs to take full advantage of a renewed interest in extended hour and higher frequency dialysis".15

Furthermore patients unable to perform self-care are forced to choose in-center HD, despite the fact that the Canadian and European experiences indicate that home dialysis with home assistance is more economically efficient for the medical system than providing the same patient with in-center HD. And here's the kicker - patients on home hemodialysis are inconveniently required to visit the center more often than practically necessary.

Flawed Regulations

The U.S. FDA’s regulatory process is significantly more protracted than its European counterparts, and therefore many advances in home-dialysis technology which have been available in Europe for years are still not available to American potential home-dialysis patients. Certification of home-dialysis units is lengthy, often delayed, and involves multiple sets of regulations. In addition, Medicare seemed to have played a role in stopping HDD in its tracks. Very few are aware that way back in the 1960’s, home hemodialysis was introduced because it was most cost-efficient than dialysis centers.

According to Dr. CR Blagg of the Department of Medicine, University of Washington, and Northwest Kidney Centers in Seattle and Washington: “Home hemodialysis was introduced because it was less expensive than center dialysis, so allowing more patients to be treated with the limited funds available in the 1960s. The start of the Medicare ESRD Program in July 1973, with almost universal entitlement, removed the financial barriers, and had many other effects including reducing the use of home dialysis. Bundled payment for dialysis, including necessary dialysis supplies and laboratory tests, was introduced as the "composite" rate in 1983".16  Up to now, Medicare will reimburse 3x weekly dialysis. However, more frequent dialysis as done through HHD needs justification entailing a lot of paperwork. 

If Art Buchwald was alive today he probably would have opted for HHD. Diagnosed with ESRD at age 80, he refused dialysis and checked himself into a hospice in February 2006. He was given only a few weeks to live but he survived for more than 11 months without any form of dialysis. He declared those months (when there was no more stress of making the treatment decision) as the “happiest days of my life”, during which he completed his last book Too Soon to say Goodbye that included eulogies written by family and friends.

The Bottom Line

Patients should have the right and the opportunity to choose the treatment type that best suits him/her or even choose to refuse treatment, not only taking into account the medical outcomes but also the quality of life outcomes.

Given the fact that HHD can prolong quality of life, along with the easy-to-use home hemodialysis machines, there is no doubt that with adequate training and education, an average patient should be able to easily perform HHD. And that means we should be able to decrease the cost to society, thanks to Australia and New Zealand.

The old cliché “an ounce of prevention is worth more than a pound of cure” still applies. ESRD is closely linked to diabetes, obesity and hypertension. In stepping up prevention of these diseases, we are also preventing development of ESRD in many patients.

With the combination of staying home and preventive measures, the cost to society should be less, ESRD patients will live longer and someday, just maybe, all dialysis centers will have to close their doors.


  1. Grassmann A, Gioberge S, Moeller S, et al, ESRD patients in 2004: global overview of patient numbers, treatment modalities and associated trends, Nephrol Dial Transplant. 2005 Dec: 20(12):2587-9
  2. Kidney and Urologic Diseases Statistics for the United States, National Kidney & Urologic Diseases Information Clearinghouse (NKUDIC)
  3. MacReady N, Skyrocketing Costs of Dialysis May Require Difficult Decisions, Medscape Today. November 9, 2009
  4. White SL et al, How can we achieve global equity in provision of renal replacement therapy? Bulletin of the World Health Organization
  5. Kidney dialysis centers, Hoovers
  6. Theofilou P, Quality of life in patients undergoing hemodialysis or peritoneal dialysis treatment, J Clin Med Res 2011; 3(3):132-8
  7. Dalal P, Sangha H, Chaudhary K, In peritoneal dialysis, is there sufficient evidence to make "PD First" therapy? Int J Nephrol; 2011:239515
  8. Dialysis, MedlinePlus
  9. Zacharias J, Komenda P, Olson J, Bourne A, FranklinD, Bernstein K, Home Hemodialysis in the Remote Canadian North: Treatment in Manitoba Fly-in Communities, Semin Dial. 2011 Nov;24(6):653-7. doi: 10.1111/j.1525-139X.2011.01004.x. Epub 2011 Nov 18
  10. Culleton BF, Asola MR, The impact of short daily and nocturnal hemodialysis on quality of life, cardiovascular risk and survival, J Nephrol. 2011 Jul-Aug;24(4):405-15. doi: 10.5301/JN.2011.8422.
  11. Kidney Failure Patients Missing out on Convenient,  Cost-Effective Therapy, Study Says, National Kidney Foundation Press Release  28 Nov 2011
  12. Home hemodialysis, National Kidney & Urologic Diseases Information Clearinghouse (NKUDIC)
  13. Rubin R,  Dialysis treatment in USA: High costs, high death rates, USA Today, Aug 24, 2009
  14. Morton RL, Tong A, Howard K et al,  The views of patients and carers in treatment decision making for chronic kidney disease: systematic review and thematic synthesis of qualitative studies,  BMJ. 2010; 340: c112
  15. Agar JW, Hawley CM, Kerr PG, Home Hemodialysis in Australia and New Zealand: How and Why it has been Successful, Semin Dial. 2011 Nov;24(6):658-63
  16. Blagg C, Dialysis composite rate bundling: potential effects on the utilization of home hemodialysis, daily and nocturnal hemodialysis, and peritoneal dialysis, Semin Dia, 2011 Nov;24(6):674-7


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