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    Blagg CR. A brief history of home hemodialysis. Adv Ren Replace Ther 1996; 3:99105. doi: 10.1016/s1073-4449(96)80048-3

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    Nosé Y. Home hemodialysis: A crazy idea in 1963: A memoir. ASAIO J 2000; 46:1317. doi: 10.1097/00002480-200001000-00004

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    Quinton W, et al. Cannulation of blood vessels for prolonged hemodialysis. Trans Am Soc Artif Intern Organs 1960; 6:104113. PMID: 13738750

    • Search Google Scholar
    • Export Citation
  • 4.

    Lohani S, Knicely DH. Brief history of home hemodialysis. In: Knicely DH, et al., eds. Handbook of Home Hemodialysis. McGraw Hill, New York, 2021.

    • Search Google Scholar
    • Export Citation
  • 5.

    Curtis FK, et al. Hemodialysis in the home. Trans Am Soc Artif Intern Organs 1965; 11:710. doi: 10.1097/00002480-196504000-00003

  • 6.

    Agar JWM, et al. Home haemodialysis: How it began, where it went wrong, and what it may yet be. J Nephrol 2019; 32:331333. doi: 10.1007/s40620-019-00597-z

    • Crossref
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  • 7.

    Kerr PG, Jaw J. Home hemodialysis: What is old is new again. Contrib Nephrol 2017; 190:146155. doi: 10.1159/000468961

  • 8.

    Agar JWM. International variations and trends in home hemodialysis. Adv Chronic Kidney Disease 2009; 16:205214. doi: 10.1053/j.ackd.2009.02.007

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9.

    Blagg CR. The renaissance of home hemodialysis: Where we are, why we got here, what is happening in the United States and elsewhere. Hemodial Int 2008; 12:S2S5. doi: 10.1111/j.1542-4758.2008.00287.x

    • Crossref
    • Search Google Scholar
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  • 10.

    Australia & New Zealand Dialysis & Transplant Registry (ANZDATA). ANZDATA 41st Annual Report 2018 (Data to 2017), 2019. https://www.anzdata.org.au/report/anzdata-41st-annual-report-2018-anzdata/

    • Search Google Scholar
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  • 11.

    United States Renal Data System (USRDS). 2019 USRDS Annual Data Report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2019. https://www.usrds.org/media/2371/2019-executive-summary.pdf

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The Rise, Fall, and New Rise of Home Hemodialysis

  • 1 Sindhura Talluri, MD, and Sadichhya Lohani, MD, are with the Renal Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA.
Full access

The rise

Hemodialysis became a reality in 1960 with the development of Belding Scribner's Teflon arteriovenous shunt (1). Yukihiko Nosé started home hemodialysis (HHD) in Japan in 1961 (2). Shortly thereafter, in 1964, Scribner developed a hemodialysis machine that was used in a young patient at home (Figure 1), marking the beginning of HHD in the United States (1, 35). Subsequently, John Merrill and Stanley Shaldon developed HHD programs in Boston and London, respectively, which quickly spread to France and Italy. In 1967, with the direction of the Seattle Artificial Kidney Center Unit Board, all new patients were started on HHD, and patients using in-center hemodialysis were transitioned to HHD, leading to the establishment of a HHD training center in Seattle (1, 4). HHD rose to be the preferred modality into the 1970s, as HHD became safer compared to the former years and more cost effective compared to the limited in-center hemodialysis.

Figure 1.
Figure 1.

The first home hemodialysis patient

Citation: Kidney News 13, 9

The first home hemodialysis patient in Seattle, WA, 1964, who did not meet criteria for hemodialysis in-center. Reprinted with permission from Elsevier (1).

The fall

In 1972 when HHD accounted for 50% of all patients using dialysis in the United States, an addendum to the Social Security Amendment Act H.R.1 (section 2991) led to Medicare assuming responsibility for the payment for maintenance dialysis, establishing nearly universal coverage, which turned out to be favorable for the development of for-profit dialysis centers. This led to fiscal bias against HHD, as funding was preferably directed toward in-center hemodialysis, disincentivizing the growth of HHD (16). The complexity of training and support—complications without direct physician supervision—further contributed to the decline of HHD. With the growth of kidney transplant, the highly motivated patients using HHD became more likely to get transplantation (7). Peritoneal dialysis also emerged as a lucrative modality after the development of the Tenckhoff peritoneal catheter in 1968 (8).

By the 1980s, only 4.6% of patients with end stage kidney disease (ESKD) were on HHD in the United States. This further declined to 0.58% by 2005 (9). Reimbursement policies in Europe also strongly favored for-profit in-center-based care, reducing interest in HHD (6). Only Australia, New Zealand, and Turkey continued to report significant use of HHD (around 11%-13%) in the early 2000s (7). Despite the similar legislation around dialysis coverage in both countries, Australia continued to flourish on HHD as opposed to the United States (6). At the end of 2017, ~18% of all patients using dialysis in Australia and 47% in New Zealand remained at home for hemodialysis (10).

The new rise—a promising future

After decades of decline, as studies demonstrated improved mortality outcome, blood pressure control, functional status with frequent hemodialysis, as well as cost effectiveness, the interest in HHD is rising again (Figure 2). HHD machines became safer, more efficient, and easier to operate as the Nx-Stage machine received clearance for this purpose in 2005. Technologies have reassured physicians and patients of safe HHD monitoring (4).

Figure 2.
Figure 2.

Trends of ESKD patients on home hemodialysis

Citation: Kidney News 13, 9

Graph showing trends in incidence and prevalence of home hemodialysis patients from 1996 to 2017. Although the prevalence of home hemodialysis has increased, the incidence has declined and plateaued (11). The data reported here have been supplied by the United States Renal Data System (USRDS). The interpretation and reporting of these data are the responsibility of the authors and in no way should be seen as an official policy or interpretation of the US government.

In 2020, the Centers for Medicare & Medicaid Services (CMS) announced the End-Stage Renal Disease (ESRD) Treatment Choices Model for ESRD Medicare beneficiaries. The home dialysis payment-adjustment model provides bonus payments for HHD for 3 years. Providers can use this to invest in home therapies and performance payment adjustment based on HHD increased accountability. Medicare started paying for a monthly comprehensive tele-visit in 2019, which removed any geographic limitations. In the past decade, HHD has seen a threefold increase from 0.4% to 1.5% (6) and is expected to increase with the new initiatives and as the ESKD population grows out of proportion to the existing in-center hemodialysis resources.

This enthusiasm for HHD is increasing worldwide. Incentive models like those used in Australia for HHD programs (4, 7), if modeled across the globe, could lead to significant increases in HHD usage. Moreover, the availability of newer technologies and improved patient education portends a very bright future for the further rise in HHD worldwide in the next decade.

References

  • 1.

    Blagg CR. A brief history of home hemodialysis. Adv Ren Replace Ther 1996; 3:99105. doi: 10.1016/s1073-4449(96)80048-3

  • 2.

    Nosé Y. Home hemodialysis: A crazy idea in 1963: A memoir. ASAIO J 2000; 46:1317. doi: 10.1097/00002480-200001000-00004

  • 3.

    Quinton W, et al. Cannulation of blood vessels for prolonged hemodialysis. Trans Am Soc Artif Intern Organs 1960; 6:104113. PMID: 13738750

    • Search Google Scholar
    • Export Citation
  • 4.

    Lohani S, Knicely DH. Brief history of home hemodialysis. In: Knicely DH, et al., eds. Handbook of Home Hemodialysis. McGraw Hill, New York, 2021.

    • Search Google Scholar
    • Export Citation
  • 5.

    Curtis FK, et al. Hemodialysis in the home. Trans Am Soc Artif Intern Organs 1965; 11:710. doi: 10.1097/00002480-196504000-00003

  • 6.

    Agar JWM, et al. Home haemodialysis: How it began, where it went wrong, and what it may yet be. J Nephrol 2019; 32:331333. doi: 10.1007/s40620-019-00597-z

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7.

    Kerr PG, Jaw J. Home hemodialysis: What is old is new again. Contrib Nephrol 2017; 190:146155. doi: 10.1159/000468961

  • 8.

    Agar JWM. International variations and trends in home hemodialysis. Adv Chronic Kidney Disease 2009; 16:205214. doi: 10.1053/j.ackd.2009.02.007

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9.

    Blagg CR. The renaissance of home hemodialysis: Where we are, why we got here, what is happening in the United States and elsewhere. Hemodial Int 2008; 12:S2S5. doi: 10.1111/j.1542-4758.2008.00287.x

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 10.

    Australia & New Zealand Dialysis & Transplant Registry (ANZDATA). ANZDATA 41st Annual Report 2018 (Data to 2017), 2019. https://www.anzdata.org.au/report/anzdata-41st-annual-report-2018-anzdata/

    • Search Google Scholar
    • Export Citation
  • 11.

    United States Renal Data System (USRDS). 2019 USRDS Annual Data Report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2019. https://www.usrds.org/media/2371/2019-executive-summary.pdf

    • Search Google Scholar
    • Export Citation
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