Home Dialysis �Jo Abraham MD

CONFIDENTIAL

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Case

• 44 year old male with history of Lupus Nephritis status post transplant in 2015 with recurrence of Lupus Nephritis and progressive loss of renal function
• Stage 5 CKD
• Admitted with volume overload and acute hypoxic respiratory failure
• Had a functional AVF
• Started on hemodialysis
• Discharged to outpatient dialysis with dialysis three days a week

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Case

• Referred for transplant evaluation
• Dialysis complicated by uncontrolled hypertension
• Sporadic non compliance
• Teaches music theater at a community college
• Enjoyed traveling with his students
• Is incenter dialysis the appropriate dialysis modality………

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Case

• 70 year old male with AL Amyloidosis with cardiac and renal involvement
• Status post chemotherapy followed stem cell transplant
• Progression of CKD
• Referred for transplant evaluation – which was denied
• Not a candidate for PD due to adhesions
• Referred for AVF
• Started on incenter hemodialysis
• Tolerated hemodialysis poorly due to intradialytic hypotension and post dialysis fatigue. Contemplating hospice.
• What are his options……

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Case

• 26 year old patient with stage 5 CKD secondary to renal dysplasia
• Followed in CKD clinic
• Uber driver – prefers to drive at night due to better reimbursement
• Renal replacement therapies and options discussed at length
• Referred for pre transplant evaluation
• Decided on doing peritoneal dialysis when dialysis was needed

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Case

• 60 year old Native American with CKD secondary to Diabetes Mellitus
• Reservation in Idaho
• Enjoyed camping and fishing
• What are his dialysis options……

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Case

• 30 year old with stage 5 CKD from IgA nephropathy
• Listed for renal transplant
• Progressive CKD with concern for uremia
• RRT options discussed
• Planned on PD
• Started on PD which was complicated by non compliance
• What are his options…..

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Objectives

• Describe treatment options for renal replacement therapy
• Understand the general principles of dialysis modalities & compare their outcomes
• Describe the various home dialysis modalities
• Epidemiology of home dialysis
• Indications and Contraindications
• Complications

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Options for management of ESRD

• Hemodialysis

Incenter

Home hemodialysis

• Peritoneal Dialysis
• ** Transplant
• Conservative management/palliation

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Indications for dialysis in CKD

• Hyperkalemia
• Metabolic acidosis
• Fluid overload (recurrent CHF admissions)
• Uremic pericarditis (rub)
• Other non spec uremic symptoms: anorexia and nausea, impaired nutritional status, increased sleepiness, and decreased energy level, attentiveness, and cognitive tasking, …

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• Hyperkalemia
• Metabolic acidosis
• Fluid overload (recurrent CHF admissions)
• Uremic pericarditis (rub)
• Uremic platelet dysfunction

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• Other non specific uremic symptoms: anorexia and nausea, impaired nutritional status, increased sleepiness, and decreased energy level, attentiveness, and cognitive tasking

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Timing of dialysis

• When should dialysis be initiated for people with advanced chronic kidney disease?
• There is no recommended estimated glomerular filtration rate (eGFR) threshold for initiation of dialysis.
• Persistent signs and symptoms of uremia and volume overload, such as nausea, fatigue, dyspnea, and peripheral edema, that are refractory to medical therapies and worsening eGFR, metabolic acidosis, and hyperkalemia inform the timing of dialysis initiation.

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Basic principles of dialysis

Home Dialysis

• What is home dialysis?
• Treatment of kidney failure at home with dialysis performed at home instead of at a center

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• What are the home dialysis modalities?
• Peritoneal dialysis
• Home Hemodialysis

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Peritoneal dialysis

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PD catheter exit site

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Peritoneal Dialysis

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Home Hemodialysis

Hemodialysis Filter (Dialyzer)

Home Hemodialysis

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Home Dialysis: Epidemiology

• Based on the most recent USRDS data (2026), more than 132,000 individuals with end stage renal disease (ESRD) initiated renal replacement therapy in 2023, and the prevalent U.S. dialysis population currently exceeds 830,000 patients.
• The percentage of new patients starting on home dialysis increased by 70% between 2012 and 2024
• 15% of the new ESRD patients started home dialysis
• Peritoneal dialysis (PD) usage for new cases hit an all-time high of 14% in 2023.
• 23,000 patients on dialysis received a kidney transplant in 2024. Preemptive transplants reached a new high in 2023, though they still represent less than 4% of new cases.

Home Dialysis

• Potential benefits:
• Freedom to dialyze at your own convenience  
• More flexibility with what they can eat and drink 
• Improved quality of life and energy to do the things they enjoy  
• Potential to experience less dialysis side effects  
• Peritoneal dialysis is a needle-free treatment  
• Lower transportation costs and travel time to the dialysis center 

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Home Dialysis

• Potential disadvantages:
• Some clinics may require that the patients have a care partner to be eligible for home hemodialysis  
• Training for home dialysis will take a few weeks to complete  
• Additional storage space for home dialysis supplies needed  
• Lack of immediate access to trained staff to assist with treatment 
• Special electrical connections and plumbing may be needed depending on your dialysis machine

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Comparison of dialytic modalities

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• No clear survival difference exists between hemodialysis (HD) and peritoneal dialysis (PD) based on the best available evidence.

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Comparison of HHD to in center HD

• May be associated
• with decreased cardiovascular and all‐cause death
• decreased hospitalization rate
• slower post‐dialysis recovery time
• decreased Systolic Blood Pressure
• lower left ventricular mass index
• Increased vascular access issues

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CHOICE - Treatment Satisfaction: PD vs HD

• PD patients were significantly more likely to give excellent ratings of dialysis care overall compared to HD patients (85% vs 56%).

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• Also PD patients were more likely to give better ratings for specific aspects of care:
• information on choosing a dialysis modality
• information on fluid removal
• staff and nephrologist availability
• coordination with other physicians
• caring of nurses or staff

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• Rubin HR et al. JAMA 2004; 291: 697-703

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Rubin HR et al. JAMA 2004; 291: 697-703

What are the Costs of the Different Renal Replacement Therapy Modalities?

Cost of Dialysis

ESRD and Medicare

•  Medicare expenditures for patients on dialysis increased from $45.1B in 2012 to $55 B in 2023
• ESRD accounted for nearly 7% of total Medicare FFS expenditures in 2023
• End-Stage Renal Disease patients make up about 1% of the total Medicare population but account for roughly 7% of fee-for-service (FFS) spending

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Contraindications to Peritoneal Dialysis

Complications of Peritoneal dialysis

Encapsulating peritoneal sclerosis

Causes of PD Technique Failure (Switching from PD to HD)

Peritonitis

Ultrafiltration Failure

Malnutrition

Abdominal Surgery

Psychological Issues

Jaar BG et al. BMC Nephrol 2009; 10: 3

Complications of home hemodialysis

Vascular Access Complications

The Frequent Hemodialysis Network (FHN) trials demonstrated a 76% higher risk of a first vascular access event with daily hemodialysis compared to conventional thrice-weekly hemodialysis

 Frequent cannulation increases the risk of access-related complications, including thrombosis, stenosis, and aneurysm formation.

The KDOQI guidelines recommend that patients considering frequent HHD be explicitly informed about the possible increase in vascular access complications. 

Buttonhole cannulation, commonly used in HHD for self-cannulation, may further increase the risk of metastatic infections.

Complications of home hemodialysis

• Infections:
• US Renal Data System analyses show that daily HHD is associated with a higher rate of infectious hospitalization compared to in-center hemodialysis
• This is attributed to reduced clinical oversight of sterile technique, increased cannulation frequency (each cannulation carrying a fixed probability of bacterial contamination), and potential lapses in infection control practices in the home setting. 
• Catheter-related bloodstream infections remain a particular concern for patients dialyzing via central venous catheters

Complications of home dialysis

• Procedural Adverse Events
• Although rare, the most consequential procedural complications include:
• Needle dislodgement — the most common serious technical event, which can lead to significant hemorrhage or exsanguination.
• Air embolism 
• Significant blood loss
• A systematic quality assurance framework including patient retraining and periodic technique audits is recommended. 

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Complications of home hemodialysis

• Psychosocial and Caregiver Burden
• HHD places substantial demands on patients and care partners, including:
• Treatment-related responsibilities (self-cannulation, equipment setup and maintenance, water treatment)
• Fear of catastrophic events and anxiety about dialyzing independently 
• Caregiver burnout —increased depressive symptoms over the first year of dialysis, regardless of modality
• Social isolation and "medicalization" of the home environment 
• These burdens can lead to technique failure and dropout from home therapy. 

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What do the guidelines recommend…

• The KDIGO Controversies Conference concluded that clinical outcomes across modalities are largely similar, making the choice preference-sensitive.  Key considerations include:
• Favoring PD: Desire for home-based therapy, autonomy, flexible schedule, preservation of RKF, avoidance of vascular access, lower cost
• Favoring HD: Inability to perform self-care, inadequate home environment, extensive abdominal surgery/adhesions, severe malnutrition, need for monitored setting
• Shared decision-making incorporating patient goals, lifestyle, clinical characteristics, caregiver support, and living environment is recommended

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Primary care in dialysis

• Key Aspects of Primary Care and Dialysis Coordination
• Improved Outcomes: Patients on dialysis who engage with primary care within 90 days of starting treatment have lower rates of all-cause mortality (9% reduction) and fewer hospitalizations.
• Reduced ED Utilization: Research indicates that patients with a PCP have a lower risk of ED visits that do not result in hospitalization (51.2% with a PCP vs. 72.1% without).
• Role of the PCP: PCPs play a key role in managing comorbid conditions such as diabetes, cardiovascular disease, and infections, which are common in dialysis patients. They also provide emotional support and facilitate care continuity.
• Collaboration: Effective care involves collaboration between the nephrologist and the PCP regarding dialysis access, medication management, immunizations and potential home dialysis options.
• Facilitating pre transplant work up of patients
• Primary care play a major role in the conservative management of ESRD

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Back to the cases…..

• Case 1
• The music teacher was started on HHD
• Improved mood and engagement, travels frequently
• Off all blood pressure medications with excellent control of phosphorus and potassium
• Case 2 patient with AL amyloidosis
• Started on HHD after extensive discussion
• Survived for 3 years, celebrated his 50^th wedding anniversary, passed away peacefully due to GIB

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Cases….

• Case 3
• 26 year old Uber driver
• Started on PD
• Drove during the night and connected to cycler during the day time
• Progressive malnutrition with hypokalemia and hypoalbuminemia
• Referred for AVF
• Switched to incenter hemodialysis while awaiting renal transplantation

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Case 4

• 60 year old native American
• Referred for renal transplantation
• Started on PD
• Does the cycler at home and while camping does day time exchanges while camping
• After 3 years on PD lost his home support system, developed recurrent peritonitis
• Referred for AVF and started on iHD

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Case 5

• 30 year old with IgA nephropathy and non compliance on PD
• Significant residual renal function
• Negotiated 5 days/ week of therapy
• Improved compliance
• Now status post renal transplantation.

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Our home dialysis team. Thanks!