For the first time in its history, the U.S. Renal Data System Annual Data Report included a chapter devoted to home dialysis, offering an unprecedented view of the evolution of home therapies during the past decade.

To the nation’s credit, the overarching story is excellent progress in increasing the use of home therapies — with opportunities to continue growth but also to improve quality.

In 2009, 6.8% of new patients on dialysis were treated at home. In 2019, that percentage was 12.6%. Correspondingly, the percentage of all patients on dialysis who were treated at home increased from 8.9% in 2009 to 13.1% in 2019 – with more than one percentage point of that growth between just 2017 and 2019.

The United States may be many years away from matching Canada or Australia in use of home therapies, but the country is closing in on the United Kingdom, where 17.1% of patients on dialysis in 2019 were treated at home.

The use of both therapies – peritoneal dialysis and home hemodialysis – have expanded here, with HHD utilization moving from 1.2% to 1.9% of all patients on dialysis between 2009 and 2019, and PD moving from 7.7% to 11.2%.

While home dialysis growth has been broad-based across adult age brackets, sexes, race and and ethnicity, there are stubborn disparities. Home dialysis utilization declines with advancing age. Both non-Hispanic white and Asian patients are at one level of utilization, whereas both Black and Hispanic patients are at a different, lower level.

Socioeconomics likely play a role. Whereas home dialysis utilization exceeded 30% of all patients on dialysis with Medicare as secondary payer in 2019, utilization was less than 10% among patients with both Medicare and Medicaid, many of whom have low or no income.

Among all Medicare-certified dialysis facilities in 2019, 47% had active home therapy programs, while another 8% were certified to offer at least one home modality but had no patients. Roughly 30% of facilities offered HHD, although more than one-third of them had no patients. In contrast, only one-sixth of facilities that offered PD had no patients.

Active programs tended to be small — a unique feature of home dialysis in the United States. More than half of facilities with active home therapy programs had 15 or fewer patients, and just 23% had more than 25 patients. Six in 10 HHD programs had no more than five patients.

The preponderance of small programs presents an interesting conundrum as the country moves forward. Encouraging more facilities to offer home dialysis might place the option in front of all patients. However, medicine is dominated by practice effects — more patients, better outcomes. Investing in centers of excellence might encourage better outcomes with home therapies.

In 2019, 85% of patients who initiated PD did so during the first year after diagnosis of kidney failure, and another 5% did so during the second year. Generally, PD is an “early” therapy. On the other hand, only 43% of patients who initiated HHD in 2019 did so during the first year after diagnosis of kidney failure. Coincidentally, another 43% initiated HHD after 2 years or more since diagnosis of kidney failure. Generally, HHD is a “late” therapy, owing in part to its use when patients are seen as likely to benefit from dialysis intensification.

By 2019, 86% of patients on PD used a cycler. In other words, only 14% of patients used continuous ambulatory PD (CAPD). Simply put, there is no high-income country that resembles the United States in this regard.

In both Canada and Australia, approximately 30% of patients on PD use CAPD. There may be no “ideal” mix of CAPD and automated PD, but in the absence of randomized trials that conclusively show that one form of PD is superior to another, there is value in asking whether the country’s outlying status is justified. The reality is that CAPD is a convenient therapy.

HHD is a unique creature in the United States, insofar as daytime dialysis and low dialysate flow rates are dominant. The U.S. Renal Data System Annual Data Report offers a few views of HHD intensity. More than 77% of patients on HHD in 2019 were prescribed either four or five treatments per week, with roughly equal shares of each. Only 5% of patients were prescribed six or seven treatments per week. The increasing popularity of four treatments per week is an interesting development that continues to escape the scrutiny of research. There is little evidence, randomized or otherwise, that establishes the relative efficacy and safety of four vs. three treatments per week.

Roughly half of patients on HHD in 2019 were prescribed treatments between 2.5 and 3.5 hours, and 4% were prescribed treatments longer than 6 hours. Indeed, nocturnal HHD remains an unpopular therapy in the United States, possibly reflecting the legacy of the Frequent Hemodialysis Network trial. Interestingly, more than one-third of all patients on HHD in 2019 were prescribed less than 12 treatment hours per week, an amount that is commensurate with in-center hemodialysis. There is substantial focus on home dialysis retention, especially with HHD, but after one accepts that home dialysis is always “work” for patients, the question must be asked: Are HHD prescriptions delivering enough benefit to justify the work?

Rates of hospitalization for PD catheter complications and peritonitis steadily declined between 2009 and 2019, as did the rate of hospitalization for vascular access complications with HHD. However, a portion of those declines were canceled by apparent increases in the rate of hospitalization for sepsis. It is difficult to discern from claims data what is real, and what is coding drift. Ultimately, access-related hospitalizations with home dialysis have become less common.

The 2-year incidence of conversion from HHD to in-center hemodialysis — so-called technique failure — declined slightly between 2013 and 2018, as did the incidence of conversion from PD to in-center hemodialysis. Survival on HHD has been stable, while survival on PD has improved somewhat. Since 2013, the incidence of kidney transplantation has increased with both home modalities, despite declines in the percentage of patients on the transplant waitlist.

The ESRD Treatment Choices payment model is the newest elephant in the room, but the past decade shows the dialysis system is perfectly capable of steady transformation. After all, home dialysis reimbursement has changed little since the advent of the ESRD Prospective Payment System in 2011.

The challenge now is to identify a set of strategies that will take the country to 20% utilization of home dialysis. USRDS data suggest some of the following avenues to pursue:

The world is an oyster, and so is the dialysis system. Home dialysis has great momentum, and targeted efforts aimed at the longstanding issues that are evident in national data can advance home therapies further.

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