The use of home dialysis has increased substantially by ~93% over the 10-year period from 2007 to 2017, based on a 2019 report published by the United States Renal Data System (USRDS). Home dialysis and transplants currently account for ~39% of all treatments (~30% transplants, ~7% peritoneal dialysis [PD], and ~2% home hemodialysis [HHD]) (1–3). However, the most recent update to dialysis public policy has set a goal that by 2025, 80% of end-stage kidney disease (ESKD) be treated at home or via transplant. Unless there is a significant increase in kidneys available for transplant, HHD and PD will need to be increased massively to reach these goals.
Advancements in PD treatments have given physicians more confidence in using PD, with increased survival rates and decreased complications. Consequently, large dialysis organizations have increased the number of PD clinics, but most are operating well below maximum census due to low patient census and lack of qualified nurses. This has led to an inefficient use of the workforce where nephrologists are managing patients in sub-optimal office settings where they lack the ability to coordinate with nurses, social workers, and dieticians.
Furthermore, a declining nephrology workforce, along with an acute shortage of nurses and trained home nurses specifically, presents unique challenges to growth of at-home programs. Depending on the area in the United States, another factor that plays a key role is the availability of surgeons trained to put in PD catheters in a successful and timely manner. Finally, for a physician in a busy private practice, the decentralized process of treatment at home versus treatment at a central clinic adds to the burden of optimizing care for patients.
Whereas the public policy framework has laid out the guidelines and rationale to increase home dialysis, numerous obstacles remain. The difficulty for physicians to manage home dialysis for their patients can limit its use in nephrology.
As a community of nephrologists in private practice, we need to embrace these challenges and overcome the obstacles to see how we can better offer and promote home dialysis for our patients. The efficiency of centralized home programs would optimize the use of nursing staff to support surgical development of PD catheter placement, resulting in enhanced workflow for the nephrologist.
United States Renal Data System (USRDS). 2019 USRDS Annual Data Report: Epidemiology of kidney disease in the United States. https://www.usrds.org/media/2371/2019-executive-summary.pdf
Flanagin EP, et al. Home dialysis in the United States: A roadmap for increasing peritoneal dialysis utilization. Am J Kidney Dis 2020; 75:413–416. doi: 10.1053/j.ajkd.2019.10.013
Mehrotra R, et al. The current state of peritoneal dialysis. J Am Soc Nephrol 2016; 27:3238–3252. doi: 10.1681/ASN.2016010112