| Abstract|| |
Home hemodialysis (HD) is a modality of renal replacement therapy that can be safely and independently performed at home by end-stage renal disease (ESRD) patients. Home HD can be performed at the convenience of the patients on a daily basis, every other day and overnight (nocturnal). Despite the great and many perceived benefits of home HD, including the significant improvements in health outcomes and resource utilization, the adoption of home HD has been limited; lack or inadequate pre-dialysis education and training constitute a major barrier. The lack of self-confidence and/or self-efficacy to manage own therapy, lack of family and/or social support, fear of machine and cannulation of blood access and worries of possible catastrophic events represent other barriers for the implementation of home HD besides inadequate competence and/or expertise in caring for home HD patients among renal care providers (nephrologists, dialysis nurses, educators). A well-studied, planned and prepared and carefully implemented central country program supported by adequate budget can play a positive role in overcoming the challenges to home HD. Healthcare authorities, with the increasingly financial and logistic demands and the relatively higher mortality and morbidity rates of the conventional in-center HD, should tackle home HD as an attractive and cost-effective modality with more freedom, quality of life and improvement of clinical outcomes for the ESRD patients.
|How to cite this article:|
Karkar A, Hegbrant J, Strippoli GF. Benefits and implementation of home hemodialysis: A narrative review. Saudi J Kidney Dis Transpl 2015;26:1095-107
|How to cite this URL:|
Karkar A, Hegbrant J, Strippoli GF. Benefits and implementation of home hemodialysis: A narrative review. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2019 Jun 18];26:1095-107. Available from: http://www.sjkdt.org/text.asp?2015/26/6/1095/168556
| Introduction|| |
Home hemodialysis (HD) is a modality of renal replacement therapy that can be safely and independently performed at home by in-need end-stage renal disease (ESRD) patients. , However, in certain circumstances, the patients are supported by caregivers and, occasionally, HD treatment is initiated by qualified and trained HD nurses.  Home HD is usually supported by adequate education and training of the ESRD patients, suitable setup at home and backup services including storage for medical devices and disposables, water treatment, proper disposal of medical waste products and consultation of the in-center or hospital HD unit.  HD can be performed at the convenience of the patients on a daily basis, every other day or overnight (nocturnal).  The duration of HD treatment can last from few , hours daily to several ,,,, hours overnight. , In some settings, the results and adequacy of dialysis can be remotely monitored by a computer connected to the in-center or hospital HD units. ,
Home HD was first performed by Nosé in Japan in 1961  followed by Scribner in 1963 and then by Shaldon in 1964. ,,, In 1971, Alwall et al  initiated a home HD program at the Lund University Hospital in southern Sweden. In 1994, Uldall et al  were the first to implement 8 h nocturnal HD five to seven nights per week.
Home HD has long been established as an acceptable form of therapy for a variety of patients,  although the potential benefits were only seen in case series and observational cohorts. Recent evidence shows an upward trend toward adoption of home HD. It is mostly implemented in Australia and New Zealand, where 10-12% of all the dialysis patients receive home HD.  Nocturnal home HD is more common in Finland and Canada. ,, In the United States, 9.4% of 8202 incident patients who received renal replacement therapy at home in 2011 were treated with home HD, and short daily home HD practice has also increased to 1.3%.  The United Kingdom Renal Registry has illustrated promising trends of this therapy over three decades.  In addition, there is emerging interest in Asia in home HD after implementing the nocturnal home HD program in Hong Kong. 
Despite the potential benefits of in-center HD, including the direct help and support of the professional team (medical and nursing staff, technicians, dieticians and social workers), it remains quite inconvenient for many patients to travel three times a week with a strict schedule to attend regular sessions. In addition, many of the in-center HD patients find it quite difficult to comply fully with prescribed medications, restrictions in diet and the allowed inter-dialysis fluid intake. , Consequently, lack of compliance can result in poor quality of life with increased rates of morbidity and mortality. , Inadequate HD delivery also has cost implications as a consequence of increased hospitalization rate, days stayed at hospital and inpatient expenditures.  Although in-center HD treatment had improved the survival rates of the ESRD patients over many years, hospitalization and mortality rates however remain elevated,  especially when compared with the short daily HD, , the intensified HD ,, and the home HD. 
| Benefits of Home HD|| |
Different studies have confirmed that dialysis duration of <4 h is associated with an increased mortality rate up to 42%. ,, Home HD may provide the options and the ability for increased frequency and extended duration of dialysis treatment. Home HD can be used in patients with less blood flow rates and less-efficient vascular access systems.  Because this process occurs more slowly, there is less of a chance of cramps and hypotension during dialysis.  Unlike the in-center HD, the patients on nocturnal HD do not report the "washed out" feeling after longer dialysis (no need to take a nap after treatment). Different studies have repeatedly confirmed the strong positive impact of nocturnal or more frequent dialysis on much better control of fluid excess, clearance of uremic toxins and adequacy of dialysis, ,,, with better control of blood pressure, ,,, where the majority of dialysis patients discontinued antihypertensive medications after 6-12 months of daily/nocturnal dialysis. , Furthermore, increasing dialysis frequency, and in particular nocturnal HD, has also been linked to a significant improvement in renal anemia ,, and reduction in erythropoietin dosage  and iron supplements  with a significant reduction in the left ventricular mass index. ,,, Moreover, this modality has been associated with an improvement in mineral metabolism and a reduction in fibroblast growth factor 23 due to the efficient removal of phosphorus and significant reduction in phosphorus binders. ,,, In addition, the different studies disclosed improvements in muscle exercise,  the nutritional status, , the quality of life ,, and the cumulative survival rate. , The patients on nocturnal HD have a similar survival rate as the deceased kidney transplant recipients  and better patient survival than those on peritoneal dialysis  or in-center HD. ,, Home HD, and particularly its nocturnal version, has been shown to improve sleep quality and to eliminate the need for dietary restrictions.  Finally, home HD is cheaper than in-center HD ,,, and patients are more fully rehabilitated.  The benefits of home HD are summarized in [Table 1].
| Implementation of Home HD|| |
Despite the great and many perceived benefits of home HD, including the significant improvements in health outcomes and resource utilization, the adoption of home HD has been limited, , may be due to the lack of randomized controlled trials as evidence of benefits. , Following its early successful implementation in the 1960s and the trends of increased use due to its considerable advantages, home HD worldwide implementation has not been well perceived or achieved. In fact, the overwhelming majority of chronic HD patients in the United States, and other parts of the world, continued to receive thrice-weekly in-center HD.  The initial decline or lack of widespread adoption of this modality of treatment was due, at least in part, to the improved availability of dialysis facilities, the wide spread of continuous ambulatory peritoneal dialysis in the late 1970s, the increasing success of cadaveric kidney transplantation once cyclosporine became available in the early 1980s and the increasing use of live donor kidney transplantation in the 1990s.  More recently, various factors may have contributed to the reduced or lack of interest in home HD. These include (1) the wider use of the cyclers with automated peritoneal dialysis, improved in-center care (including the backup of social and dietician support) and quality of HD treatment and (3) successful programs of living and cadaveric kidney transplantation. A recent survey, which was conducted to understand the beliefs, attitudes and practice patterns of providers offering home HD, was developed and posted on the Nephrology Dialysis Transplantation-Educational (NDT-E) website.  This survey showed that 55% of physicians view homes as being the ideal location for offering intensive HD schedules, but the key barriers to widespread adoption of this therapy included lack of appropriately trained personnel (35%) and funding for home adaptation (50.4%).
In addition, not all ESRD patients are suitable or eligible to perform home HD without special consideration such as dependent patients, patients with lack of suitable vascular access, patients with bleeding disorders and patients with uncontrolled psychosis. , Furthermore, repeated vascular access interventions in home HD therapies may result in adverse events such as vascular access repair or loss and access-related hospitalization. , There are, however, other important and direct challenges to the adoption and implementation of home HD, as shown in [Table 2].
| Implementation of Home HD and Overcoming Barriers|| |
Orientation and commitment of authorities
Implementation of a successful home HD program requires prior assessment of important community variations in cultural differences and challenges, availability of backup services and personnel and reimbursement for specific therapies. A well-prepared structured program and moral and financial support from health authorities can enhance implementation, expansion and maintenance of home HD therapies.
The lack of or insufficient orientation and commitment of health authorities to providing home HD may contribute to the delay or inadequate implementation of home HD. Some studies analyzing the international trends of home HD showed a dramatic variation in the use of home HD, which were not explained by the national healthcare expenditure, population density or utilization of other dialysis modalities. , The studies suggested that (1) the existence of committed clinicians and centralization of the home HD program seem to be the main features in countries with an expanding home HD program, (2) the political imperatives and healthcare funding structure could have a major impact on the implementation of home HD and (3) the attitude of the nephrologists could eventually affect the choice of dialysis modality. ,
The health authorities, with the increasing financial restrictions and logistic demands, together with the relatively higher mortality and morbidity rates of the in-center HD, should consider home HD as an attractive option with its valuable clinical outcomes, improved quality of life, social and psychological benefits, increased freedom and cost-effectiveness. ,, In reality, healthcare organizations continue to face resource challenges to accommodate the sustained increase in the number of ESRD patients requiring renal replacement therapy. This burden has been accompanied by aging of the dialysis population, increased hospitalization costs and increased costs to cover the continuous need for expansion and establishment of new HD facilities and recruitment of qualified staff.  The home HD program can be an excellent and cost-effective alternative to the in-center HD treatment in managing a large proportion of ESRD patients in need for dialysis therapy. 
Home HD should be considered as a system and not only as a treatment.  It should also be considered as a central country program that needs to be customized according to needs. It should be carefully implemented and adequately budgeted with close supervision and follow-up for quality improvement and continuity.  One possible approach for its successful implementation is the establishment of "Home HD Department" with its appropriate budget.  This department should contain different sections with specific responsibilities to cover all required services and to ensure the successful implementation and continuity of the program [Table 3]. Alternatively, improved reimbursement for home HD may assist the establishment of home HD services. ,
Medical competence in caring for home HD patient
Lack of competence and/or expertise in caring for the home HD patients among renal care providers (nephrologists, dialysis nurses, educators) represents a major challenge in the success of home HD. The majority of renal care providers have no or limited exposure to home HD. In a survey of trainees in a nephrology fellowship program, only about 16% of the respondents were competent in home HD.  In a multicenter, semi-structured and qualitative interview study, the nephrologists practicing in Europe and South America in regions where home HD is not established recognize the potential benefits of home HD, but doubted the feasibility of developing such programs and expressed concern about the quality and safety of home HD.  Worldwide, only few established infrastructures for training and monitoring home HD patients are available and mostly existing in high-income countries. , In addition, there have been no published evidence-based clinical practice guidelines from the international guideline-producing bodies that can be used to standardize procedures and protocols in home HD to promote safe and optimal implementation of home HD programs. ,, More recently, however, a "Global Forum for Home Hemodialysis" has been initiated by an internationally recognized panel comprised of nephrologists, home HD nurses, administrators and patient advocates, including a patient who has undergone home HD for more than 10 years.  The authors stated that "the mission of this collaborative is to develop and deliver a comprehensive, open-source, web-enabled, practical manual for health care teams and providers to create and/or expand a home HD program."
The concerns of clinicians about the quality and safety of home HD can possibly be improved by staff education and increasing their clinical experience and care of the home HD patients.  Training programs that provide clinicians with direct experience in home HD could increase acceptance, motivation and successful development of the home HD program. , The entire dialysis staff (physician, dialysis nurses, dietitian and social worker) should receive adequate training in home HD.  A centralized training facility with established infrastructure can be a good training ground for renal care providers and deliver support to home HD programs. Offering a comprehensive and accurate course on home HD to prevalent renal care providers (by inviting lecturers who are leaders in this therapy) and giving privilege to the motivated staff (nephrologist and dialysis nurses) to be further trained in centers with established home HD programs could be a good investment. The presence of educated and confident staff can support and improve modality education for patients and may result in better choice for home HD. Actually, much of the fears and lack of self-efficacy of potential patients can be overcome by well trained and competent staff dedicated to home dialysis, as, for example, nurse-directed cannulation training and home monitoring. ,
| Patient Education|| |
Lack or inadequate pre-dialysis education and introduction of ESRD patients to home HD and ways of its implementation constitute another important barrier to the adoption of home HD. ,,, Although an informed choice of treatment modality is advocated, a great majority of patients remain unaware of home HD as a possible alternative and valuable treatment option.  For example, up to 88% of patients in the United States were reported to be unaware of home HD.  In addition, the lack of motivation for the self-care therapies, including home HD, have been singled out as one of the most common obstacles to adopting home HD. ,, The lack of motivation may stem from various factors such as inadequate education on therapy modality, lack of self-confidence/self-efficacy to manage own therapy, fear of machine, fear of cannulation and worries of possible catastrophic events.  In a multicenter, semi-structured and qualitative interview study, home HD was perceived as confronting and unsafe by the patients on in-center HD and their caregivers in regions without home HD services. 
Training of potential patients and providing round-the-clock technical and medical advice are important strategies to increase the acceptability of home HD.  Recent studies in home HD patients demonstrated that the most adverse events were related to needle dislodgement or air embolism,  but life-threatening or serious adverse events were relatively rare, , and they concluded that strategies to prevent these events include patient retraining as well as a review of home HD-related policies and procedures and periodic vascular access technique audit. Training and re-training of potential home HD patients by practical demonstration of self-cannulation, proper positioning of the needle, awareness of the alarms of needle dislodgement and ways of management cannot only increase their awareness about the values and benefits of home HD but also possible ways of its implementation and how to overcome difficulties. ,, One possible way is to implement a step-wise approach to those patients who are overwhelmed by the multiple tasks in learning dialysis and self-cannulation. This approach may help motivating patients to adopt and continue with this modality,  strengthening self-confidence and self-efficacy to manage therapy, relieving the fear of machine and cannulation and needle disconnect and relieving the worries of possible catastrophic events. For example, the nurse-directed cannulation training and home monitoring may help patients overcome these fears. Education and training should be performed by a well-trained and enthusiastic team.  Education that is repeatedly provided to patients and families with the involvement of current home HD patients and their partners can help increase the yield of potential candidates. ,, Education and training of potential home HD candidates can be enforced by the setup of a home training room  and/or by a central education and training section. This section should contain a lecture room, HD machines, all required disposables, audio-visual system/DVDs and demonstration materials (related posters and leaflets that cover different aspects of home HD, including vascular access care, needle insertion, water treatment and medical waste disposal).
HD machines' orientation
Another important part of patients' education includes knowing the HD machines. A practical challenge for the HD patients to accept and implement home HD is the complexity of the HD machines and their technical operations.  Most, if not all, of the in-center HD machines may seem complex even to healthcare providers who have not previously been exposed or received a comprehensive training in dialysis techniques. This is particularly the case when facing the machine set-up, priming, dialysis treatment operation, take-off, heat and chemical disinfection and water requirements for generation of dialysates.
HD is a technically complex procedure, and HD machines are not easy to use without adequate training. Simplifying the design for home HD machines could encourage more patients to choose home HD.  Home HD machines could be made more patient friendly with (1) on-screen clear and easy instructions including interactive illustration/diagram for all stages of operation (set-up and priming, start-up, troubleshooting, take-off and cleanup), (2) less operator intervention (automated set-up and priming, start-up, take-off and clean-up) with few buttons/keys to press, (3) incorporate more safety features (allows remote monitoring by healthcare providers and biofeedback system-automated response/machine intervention in life-threatening situations, i.e. detected access disconnection or severe hypotension) and (4) more compact and portable body to make it space saving and more convenient for use in a home setting as well as adaptable for travel.  Some single-pass home HD machines that are currently available in the market are the 2008 K@home, the NxStage System,  wearable artificial kidney (WAK),  the Quanta SelfCare+ and Baxter's VIVIA HD System, which achieved the CE mark in Europe.  Some machines that use sorbent technology and are in development are the Fresenius Medical Care-Portable Artificial Kidney (PAK)  and the Automated Portable Artificial Kidney (APAK HD).  The concept of using recycled fluid to generate dialysate (sorbent system) is a practical and an attractive solution to avoid the burden of set-up and maintenance of a complex water purification system, the storage and cost of bags of ultrapure dialysate and the excessive usage of water and electricity, in addition to reducing carbon footprint  and gaining the feature of portability. The most physiologic buffers in dialysis solutions should also be used to enhance patient's safety and well-being.
The increasing age and comorbidity of dialysis patients, the lack of self-confidence to manage own therapy, lack of family or social support, fear of machine or cannulation and worries of possible catastrophic events would necessitate the presence and help of a caregiver. The caregiver often assists partially or fully in the setup, takedown and cleaning of the machine. The increasing duration and, particularly, frequency of HD session at home would increase the workload and add to the burden of the caregiver as well as the patient.  Higher perceptions of burden by patients on their caregivers, especially when the caregiver is an unpaid family member, could potentially result in therapy refusal and non-adherence.  Well-trained and experienced caregivers are of great help and support, especially during the initiation period of home therapy and in particular with nocturnal home HD, and would make implementation of home HD more attractive. ,
Paid helpers could be a great asset for the home HD program, especially in taking care of older age patients and those with increased comorbidities, especially in the absence of family and/or social support. In addition, they may help in alleviating the burden on family caregivers  and ensure successful continuity of the program. Paid caregivers should be taken in consideration in budgeting and when arranging for a rewarding scheme for patients moving to home HD. ,
Backup services and support
There are a number of backup services that can support, maintain and improve the quality and continuity of a home HD program [Table 3]. These include (1) a visiting team (nephrologist/HD nurse/social worker/dietitian) who can supervise and ensure the adequacy of the setup and function of the operating system at home and performance of the patient, and they can also provide psychological support, especially with repeated regular visits, (2) a medical supply team who should assess the needs of all required HD machines, solutions and medical devices as well as regular home delivery, (3) a maintenance team who should regularly supervise and support the maintenance of the HD machine and water treatment (including chemical suitability and purity of bacterial growth and endotoxin) and ensure the proper functioning of the operating system at home, (4) a patient's monitoring team who has a vital role in taking care and providing support of the home HD patients with a 24-h telephone consultation service especially for patients who are treated with nocturnal HD (this team should also provide a sense of security and psychological support for the HD patients and should also contribute to quality improvement of the provided service), (5) the referral team (medical and nursing) who should be able to assess the suitability of a potential home HD patient, following adequate education and training, to independently manage his/her HD at home (this team should also be able to re-assess the need of home HD patients to be referred back to the in-center HD in case of any medical needs and/or following burnout), (6) the epidemiology team who should assess the total number of treated patients, types of HD (every other day, short daily or nocturnal HD), success and failure rates and causes and the remained barriers besides their contribution to quality improvement and (7) incentives for home HD should be available such as flexible duration of training (1-6 months), flexible dialysis schedules (2-7 days per week according to the residual glomerular filtration rate and individual needs), possible integration of home and in-center dialysis, available second dialysis machine for patients who change residence for over three months/year and financial incentives for programs, families and caregivers.
In conclusion, home HD is a modality of renal replacement therapy that is generally perceived as beneficial and superior to standard in-center HD for ESRD patients. Home HD can be safely and independently performed at home with anticipated significant improvements in health outcomes and resource utilization. A well-established and adequately budgeted central country program, including structured education and training curriculum for eligible and suitable patients as well as for medical staff, can play an important role in overcoming challenges and creating suitable solutions for the implementation and continuity of home HD. Governmental efforts toward boosting the adoption of home HD should require that this is performed in an experimental setting to guarantee that patients included in home HD do so within a comparative randomized trial of home versus in-center HD. This will provide a definitive answer to whether home HD does provide the anticipated incremental survival and quality of life advantage and be a solid basis for further promotion of such techniques.
Conflict of interest: None
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[Table 1], [Table 2], [Table 3]