Home haemodialysis brings its own “major challenges and barriers”

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Recent years have brought a change to the landscape of dialysis. With the COVID-19 pandemic, we have seen reignited efforts to support home dialysis options for patients, including HHD. The risk of contagion during in-centre dialysis is one factor that has accelerated this trend, but other, significant benefits of HHD uptake have also garnered increased attention. Patient preferences for HHD mainly relate to the clinical benefits achieved through high-intensity dialysis at home alongside what is often an improved quality of life. Many patients find it easier to manage HHD treatment with competing commitments such as employment and childcare. The HHD option also reduces the burden of travel, particularly for those with mobility problems and multimorbidities. On a broader level, reduced transportation needs and fewer demands for in-centre dialysis services can translate into greater public health cost savings. The advantages of HHD extend beyond the individual patient.

Whilst these represent considerable benefits, there are also major challenges and barriers associated with HHD for patients, families and clinicians, particularly for older patients who may find it more difficult to maintain the technical demands required to deliver home dialysis as effectively as their younger counterparts. Challenges are already apparent from the selection and training phases prior to HHD initiation. Patient fears relating to illness intrusiveness and being isolated from well-supported care are barriers when they consider selecting HHD as their dialysis modality.

There is uncertainty deciding upon an optimal length of training time before HHD commencement. Whether there is the capacity and infrastructure to support training needs for patients needs to be factored in, too. With previous studies demonstrating the length of training time required for competency in HHD being correlated with age, there is more difficulty training older adults, especially those with cognitive impairment. Greater frequency of retraining opportunities is ideal for older patients, though this may not be practically and financially viable to continuously promote over time. If caregiver support is not available and a patient is deemed incapable to continue HHD independently, they are more suited for in-centre dialysis.

Another conundrum relates to vascular access within the home setting. Many kidney failure patients have cardiac and vascular comorbidities, and it can be challenging for them to acquire adequate vascular access consistently. Older patients tend to have reduced manual dexterity, reduced vision, and increased tremors—they will therefore find it even more difficult without caregiver or healthcare professional support. In remote environments where specialist services are not readily accessible, there could be greater challenges in managing vascular access complications such as infections, acute bleeding and thromboembolism.

Cardiovascular complications during HHD are important to consider and potentially tricky to manage. There may be difficulties in finding a strategy to optimise HHD intensity and session frequencies to control circulatory volume overload in some patients. Outside of dialytic factors, an often-underestimated component of care is patient compliance towards fluid intake restrictions and patient discipline of maintaining low-salt dietary intake patterns. Another challenge is tackling blood pressure (BP) instability. Whilst avoiding symptomatic hypotension or overtly low BP is vital, how best to decide on personalised BP target ranges remain uncertain. Accurate measurement of BP could be challenging, and there is debate over whether automated or manual measurement devices are better within the HHD context. Other treatment-related complications that are complex to manage holistically include protein-energy wasting, malnutrition and electrolyte abnormalities.

The physical practicalities of administering HHD are not the only potential challenges. Socioeconomic barriers of HHD implementation could occur in health systems where there is a lack of government-funded initiatives and financial reimbursement for patients and caregivers. Patients could find it very difficult to perform HHD adequately with limited housing space and increased utilities costs, while caregivers may need to find full-time employment to achieve financial sustainability for the family. They may also need to sacrifice other commitments to care for their loved one receiving HHD, which can increase caregiver stress and psychological burden.

There have been advances to ease some of these challenges, not least in telehealth platforms, which have brought new avenues for HHD care. They eradicate the pressures around maintaining social distancing that come with in-person consultations, and they enhance regular HHD care for those living in rural locations. However, the inability to perform physical examination (i.e. examination of an arteriovenous fistula), concerns relating to patient privacy, and the magnification of socio-economic inequalities in dialysis care are noticeable issues. Poorer patients may not have access to updated electronic devices and broadband internet to receive a high-quality HHD service through telehealth, and it has been highlighted that ethnic minorities receiving home dialysis are underrepresented in the uptake of telehealth.

Despite these challenges, there are a host of other potential strategies to overcome the challenges and barriers of HHD beyond telehealth services. First, it is important to deliver educational initiatives for a wider community of patients and their families, addressing misconceptions regarding HHD and providing reassurance that they are not alone without healthcare staff support during therapy if this is required. At present, increased government funding to improve the capacity, infrastructure and quality of healthcare staff training in delivering HHD is planned for many parts of the world. An enhanced training programme for patients to practice performing HHD, initially with guidance from staff and caregivers before doing so independently (if they can) will hone their preparedness and competency, and increase their confidence. It may be helpful to set up annual retraining or refresher training courses for patients and caregivers, to ensure competency is maintained.

Clinicians should determine an optimal vascular access option for each patient during consultation to ensure safe and effective HHD delivery. Older patients, and those with pre-existing vascular disease, where a greater likelihood of challenges exist regarding vascular access, should be most carefully considered. Continuation of multicentre quality improvement initiatives aimed at minimising symptom burden and ensuring early identification and intervention of HHD complications and comorbidities is required, too. It should come in conjunction with the development of a robust support service in the community involving multidisciplinary teams to respond quickly and adequately could improve patient outcomes, should treatment-associated complications occur.

Disclosures: Henry Wu is supported by the Australian Government Research Training Program. Sandip Mitra is supported by the National Institute for Health Research at Manchester, UK, and Devices for Dignity MedTech & In Vitro Diagnostics Co-operative, Sheffield, UK. Both Henry Wu and Sandip Mitra do not have competing interests to disclose for the contents presented in this article.

Assisted HHD care models are another answer being developed for those having to chronically care for the family member receiving HHD. Cost-effective respite care may bring benefits in patient outcomes, as well as alleviation of caregiver burnout and psychological stress. Creation of financial reimbursement schemes, usually collaborations between governments and industry, could find solutions in addressing financial concerns for patients and their caregivers. Regarding telehealth, it would be important to identify areas for continued innovation and industry collaboration to improve existing and new technological platforms (such as virtual ward, digital rehabilitation programs) in HHD. As well as reducing the attrition of care for patients and caregivers, we should explore ways to widen participation of telehealth services in HHD to encompass a greater diversity of socioeconomic and ethnic groups.

A review like this therefore alerts us to the variety and scale of barriers to performing HHD, important considerations despite the advantages of pursuing this dialysis modality. There is increased awareness from the nephrology community on these issues and the need to address them. With concerted efforts in establishing more consensus guidance, health policies and government backing to support HHD care as well as creating opportunities to enable advances in technology for a wider population, we are confident in finding solutions to tackle these challenges and barriers going forward.