An Integrated Peritoneal Dialysis/Home Hemodialysis “Home-First” Vision: A Call to Action for an Integrated Home Dialysis–First System

Dialysis leads to massive changes in an individual’s lifestyle. This is especially true for in-center conventional hemodialysis (CHD), which necessitates that patients constantly travel back and forth to their dialysis facility at least three times a week.

Home dialysis, which includes peritoneal dialysis (PD) and home hemodialysis (HHD), is an attractive alternative to CHD, allowing dialysis treatment in the patient’s own environment. Home dialysis also helps to preserve quality of life and gives patients a sense of empowerment. Patients who undergo dialysis at home generally have superior survival and quality of life compared with those who use a dialysis facility. From a socioeconomic perspective, home dialysis substantially reduces dialysis-related costs. It especially decreases the staff requirements at dialysis facilities and limits technique-related expenses, particularly for PD. These patient-centered and economic advantages have led to the promotion of home dialysis in many regions.

Traditionally, PD has been the most common form of home dialysis, accounting for 11 percent of the world’s total dialysis population and ranging between 2 percent and 74 percent of dialysis patients in different countries. PD offers several significant advantages compared with hemodialysis, including possibly enhanced survival in the first few years, better preservation of residual kidney function, greater suitability to incremental (progressive) dialysis, delayed need for fistula surgery, reduced erythropoietin requirements, reduced blood transfusion requirements, decreased risk of blood-borne infections, and higher levels of patient satisfaction with treatment. PD also delivers a more continuous form of dialysis and, by its home modality nature, helps to better maintain patient autonomy. Balanced against these advantages, a main limitation of PD is that many patients are unable to continue with the treatment after 2 or 3 years, often because of infection (peritonitis), catheter-related problems, or inadequate removal of wastes or fluid. Given that PD is an excellent first dialysis modality because of its benefits and possibly early survival advantage, the classic integrated dialysis model (also known as the PD-first model) was proposed some years ago. According to this model, to achieve the best possible outcomes, patients would start dialysis with PD and then transfer to CHD when PD was no longer possible or no longer the best option for the patient. For example, a new dialysis patient would stay with PD for a few years and then switch to CHD when clearance or infection became an issue. Although interesting, this classic integrated dialysis model completely overlooked the important option of HHD.

Home HD can be performed according to a variety of regimens, including short daily (2.5 to 3 hours, five or more times per week), long (more than 5.5 hours, three to four times per week) or long frequent (more than 5.5 hours, five or more times per week). Independently of the chosen regimen, HHD provides high-quality dialysis and is more cost-effective than CHD. On top of the general advantages of home dialysis, such as independence and better quality and length of life, HHD has been shown to be associated with improved heart structure and function, blood pressure, and blood chemistry (including phosphate control). However, despite these clear advantages of HHD, the prevalent belief among kidney specialists that HHD is superior to CHD, and the growing interest in HHD over the past decade, the global uptake of HHD is very low (less than 5 to 10 percent) except in a few countries (such as Australia, New Zealand, and Uruguay).

We therefore propose a new integrated home dialysis model that should be the new paradigm of home-based dialysis. In this home-first model, a patient would begin dialysis with PD and then be referred to HHD once PD is no longer suitable. Hence, CHD would be considered only as a last resort, once both PD and HHD have been unsuccessful, or if these modalities are not suitable for the patient. As stated before, PD is an excellent first dialysis modality for patients with ESRD. Transition from PD to HHD takes advantage of the significant patient benefits that accrue from both dialysis modalities and potentially avoids the appreciable lifestyle upheaval and deterioration in functional status that not infrequently accompanies the transfer to CHD. Moreover, the ability of PD patients to understand dialysis principles and to manage their own treatments puts them one step ahead for a successful HHD training experience. Given that only a small number of patients will quit PD because of failure to cope with home-based self-care treatments, we propose that a substantial proportion of patients in whom PD is unsuccessful could be transferred to HHD programs. To date, small studies have evaluated the feasibility and outcome of such a transition. However, even in centers with a specific interest in home-based dialysis, only a small proportion of patients completing PD therapy transferred directly to HHD. Although the more complicated HHD training can also limit the transition from PD to HHD, we believe that further evaluation and promotion of the integrated home dialysis model can significantly increase the overall capture for home dialysis modalities and improve patients’ care, quality of life, and outcomes. It is time to rethink our dialysis model to implement a home-first vision.