Introduction to Home Dialysis: Fundamentals and Beyond

Kidney failure is a rapidly growing global public health problem and fatal without dialysis or transplantation. CKD is reported to affect >10% of the general population worldwide, which amounts to >800 million individuals.1 Although the global prevalence of kidney failure is uncertain, it is estimated to exceed 5 million people with concerns for capacity to meet the growing demand.2 Dialysis is lifesaving but at the same time burdensome and intrusive for patients and care partners and expensive for health care systems. In the United States, treatment of kidney failure consumes more than 6% of the total Medicare budget to care for <1% of the covered population.3 CKD (including kidney failure) is not only one of the leading causes of death, but it has also become the 12th leading cause of years of life lost (which is calculated from the number of deaths attributable to CKD and the life expectancy of individuals in various age groups at the time of their death from CKD) in 2017 and predicted to be the fifth highest cause of years of life lost globally by 2040.2,4 Worldwide, facility-based hemodialysis remains the most common form of dialysis despite numerous shortcomings including travel burden to patients, high ultrafiltration rates, inflexibility of treatment schedules, and its association with myriad dialysis-related symptoms including postdialysis fatigue.5 Home dialysis modalities, including peritoneal dialysis (PD) and home hemodialysis, offer greater patient autonomy, flexibility, and treatment satisfaction and can be less costly compared with facility-based hemodialysis. In recognition of these advantages, various efforts around the world have been implemented with a goal to enhance home dialysis uptake, with mixed results. Such efforts have included policy and payment innovations such as the Advancing American Kidney Health Initiatives, as well as governmental prioritization of home dialysis such as the PD-first policy in Hong Kong. There are multiple reasons underpinning low uptake of home dialysis globally, which may relate to health care system (e.g., home dialysis–preferred policies, relative delivery costs, reimbursement of center versus home dialysis), clinic/facility (e.g., clinician bias about home dialysis, education and expertise of health care professionals, reimbursement to patients for dialysis-related costs), and patients (e.g., suitable home environment, physical and cognitive limitations, health literacy). The Kidney Disease: Improving Global Outcomes Controversies Conference on home dialysis held in 2021 recommended alignment of policy, resources at the center level, and clear leadership from informed and motivated clinical teams to facilitate greater access to home dialysis.6 In this context, we are pleased to announce a new CJASN series titled Home Dialysis: Fundamentals and Beyond. In this series, we have curated state-of-the-art, practice-centered reviews on home dialysis to highlight the most cogent issues needed for the nephrologist providing primary or consultative care for patients receiving home dialysis, with a focus on recent advances and innovations. The series will comprise a number of sets of review articles authored by clinical experts in the field of PD and home hemodialysis. The first set of articles will serve as a primer on home dialysis for the practicing nephrologist and will cover metrics interpretation and targets, quality and policy initiatives, approaches to setting up programs, and systems innovations to increase home dialysis utilization. The second set of articles will separately cover core topics in PD and home hemodialysis and will include physiology and basic principles in providing high-quality dialysis, approaches to the dialysis prescription, and modality-specific issues, such as PD-related infections and vascular access considerations in home hemodialysis. The final set of articles will cover the impact of recent advances in remote and virtual technology, the development and future potential of wearable dialysis technologies, and home dialysis management issues in special populations. We believe a change in the treatment paradigm for kidney failure is necessary where home dialysis becomes the standard of care to meet holistic goals of patients with kidney failure and where systems innovations lead the way for growing availability and accessibility of home dialysis modalities. We hope this collection of articles will facilitate a deeper understanding in how to best deliver home dialysis and achieve optimal outcomes for all key stakeholders, as well as inspire readers about the current state and future growth potential for home dialysis modalities.