Home Dialysis in North America: The Current State.

There is widespread interest in expanding the uptake of home dialysis in North America. While kidney transplantation should be the preferred option in eligible patients, home hemodialysis (HD) and peritoneal dialysis (PD) offer cost-effective options for kidney replacement therapy. In this review, the motivation for promoting home dialysis is presented and the literature supporting it is critically reviewed. Randomized comparisons of home HD and PD to in-center HD have been challenging to conduct and provide limited information. Non-randomized studies are heterogeneous in their design and have often yielded conflicting results. They are prone to bias and this must be carefully considered when evaluating this literature. Home modalities appear to have equivalent clinical outcomes and quality of life when compared to in-center HD. However, the cost of providing home therapies, particularly PD, is lower than conventional, in-center HD. Measures of home dialysis utilization, the philosophy behind their measurement, and important factors to consider when interpreting them are discussed. The importance of understanding measures of home dialysis utilization in the context of rates of kidney failure, the proportion of individuals who opt for conservative care, and rates of kidney transplantation is highlighted and a framework for proposing targets is presented, using PD as an example.