Patient-Centered Home Hemodialysis

Abstract

Writing a home hemodialysis (HD) prescription is a complex, multifactorial process that requires the incorporation of patient values, preferences, and lifestyle. Knowledge of the different options available for home HD modality (conventional, nocturnal, short daily, and alternate nightly) is also important when customizing a prescription. Finally, an understanding of the different home HD machines currently approved for use at home and their different attributes and limitations helps guide providers when formulating their prescriptions. In this review article, we set out to address these different aspects to help guide providers in providing a patient-centered home HD approach.

Incorporating Patient Values, Preferences, and Lifestyle into the Home Hemodialysis Prescription

Home hemodialysis (home HD) offers a pragmatic opportunity to tailor the prescription to fit individual patient preferences, goals, and lifestyles. In the past, the HD prescription has been narrowly described in terms of whether it will achieve adequacy, a term commonly used to describe urea clearance targets. However, this view is increasingly being replaced by a more holistic view of kidney failure care, incorporating patient preferences and controlling other important complications of advanced CKD.

The 2015 Kidney Disease Outcomes Quality Initiative clinical practice guidelines for HD adequacy explicitly acknowledge that the ultimate goal of dialysis is improvement in the quality of life for the patient and not the isolated achievement of a specific urea Kt/V adequacy target.¹ The 2018 Kidney Disease Improving Global Outcomes Controversies Conference focusing on the dialysis initiation, modality choice, and prescription supported a move from the term adequate dialysis to goal-directed dialysis, which specifically refers to using shared decision making to allow the patient to meet personalized life goals and allow the clinician to prescribe individualized, high-quality dialysis.²

The 2020 International Society for Peritoneal Dialysis practice recommendations for prescribing high-quality, goal-directed peritoneal dialysis recommend that the peritoneal dialysis prescription be arrived at through the use of shared decision making with the aim of establishing realistic goals of care that maintain quality of life and minimize symptoms and treatment burden while ensuring high-quality care is provided through a focus on a number of assessments of important aspects of advanced CKD complication management.³ Similar to peritoneal dialysis, there is limited evidence to support specific small-molecule clearance targets in home HD, particularly because the therapy is prescribed in the United States at a frequency of other than three times per week in 87.2% of patients, and prospective studies of urea Kt/V have examined three times per week schedules.⁴ Moreover, a retrospective study of 2373 patients on home HD found no association of standard weekly Kt/V with hospitalization, markers of uremic syndrome or mortality.⁵

We propose a high-quality, goal-directed approach to home HD prescribing including patient goals and preferences along with controlling volume and BP, malnutrition, metabolic acidosis, electrolytes, anemia, small solute levels, and bone mineral disease markers.

Individualizing the Prescription

There are several different approaches when determining a home HD prescription and schedule: conventional HD, short-daily home HD, traditional nocturnal HD, and alternate nightly nocturnal HD (nocturnal HD is discussed in a separate section below).⁶ Typical home HD prescription parameters are summarized in Table 1.

Table 1.

Home hemodialysis prescription parameters based on modality of choice

Modality	Treatments per Week	Sessional Duration, h	BFR, ml/min	DFR, ml/min	Dialysate Potassium, mmol/L	Dialysate Calcium, mmol/L	Phosphate Additive
Conventional	3	3–5	300–400	500–800	2,3	1.25	None
Alternate nightly	3.5	6–8	250–350	300–500	2,3	1.25	Rare
Short daily	5–6	2–3.5	350–400	500–800	1,2	1.25	None
Nocturnal	4–6	6–8	250–350	300	2,3	1.5–1.75	20%–30%
Low-flow dialysate (short daily)	5–6	2.5–4	300–400	90–300	1,2	1.5	None
Low-flow dialysate (nocturnal)	3.5–6	6–8	300–350	83–166	2,3	1.5	None

BFR, blood flow rate; DFR, dialysate flow rate.

In considering how to design a home HD prescription, it is helpful to understand what the person receiving dialysis values. The ideal prescription for a patient might also change over time. Keeping as much independence as possible, the ability to travel, flexibility of daily schedule, and performing dialysis in the privacy and comfort of home are important factors frequently expressed by patients in the dialysis modality decision-making process.^7–9 The burden on patients and their care partners, as well as home-assisted dialysis (not currently available in the United States but is currently available in many countries around the world) are all important considerations. As examples, someone who works 5 days per week during business hours who places high value on continuing to be employed may prefer to dialyze at night, while someone who is elderly and retired with significant residual kidney function who wants to maximize their time during the week with family may opt for a two times per week incremental home HD prescription (Table 2). This is achieved by assessing patients' residual kidney function through interdialytic urine collection, calculation of the urine urea clearance, and residual weekly Kt/V. By incorporating residual kidney function, the dialysis dose and frequency can be reduced while still achieving the total goal weekly standard Kt/V of 2.1.

Table 2.

Examples of prescription flexibility

Home HD Modality	Lifestyle Advantages to the Patient
Incremental	Can be prescribed two times per week or more frequently accounting for residual kidney function
Three times per week	Offers the flexibility of time and days of the week with the potential for weekends off
Every other day	Rotating schedule with less dialysis days than short daily
Short daily (4–7×/wk)	Allows greater liberalization of fluid and food intake while lowering dialysis recovery time
Nocturnal	Allows freedom during the day and uses time asleep to perform HD that would otherwise consume awake time

HD, hemodialysis.

It should be noted that there are also a number of clinical benefits to home HD that can align with priorities identified by patients. These include better BP, volume and phosphate control, reduced postdialytic recovery times, improvements in sleep apnea, depressive symptom burden, and improved fertility and pregnancy outcomes.¹⁰ More frequent dialysis (daily home HD versus peritoneal dialysis and thrice weekly versus six times weekly in-center HD) has also been associated with lower mortality in long-term follow-up of the Frequent HD Network Daily cohort and in retrospective analyses.^11,12 Longer treatment duration with home HD has not been studied well outside of prolonged nocturnal HD, which is covered separately, and trials with modest increases in dialysis duration in-center HD at fixed frequency have been inconclusive or not demonstrated benefit.^13,14 The American Heart Association 2022 scientific statement on the cardiovascular benefits of home therapies directly recognizes the improvement in cardiovascular outcomes that can accompany intensive home HD.¹⁵ However, more frequent home HD is also associated with higher risks of vascular access complications, loss of residual kidney function, and infection-related hospitalizations.¹⁶

In contrast to home HD, it is often more challenging to customize the dialysis prescription under the constraints imposed by in-center HD where scheduling of the time, place, and day of dialysis is rigid. However, in a survey conducted by the American Association of Kidney Patients, home HD was rarely presented as the best option to patients for KRT, and over half of the patients on home HD reported that modality options were not presented in fair and balanced manner.¹⁷ The Standardised Outcomes in Nephrology-Hemodialysis initiative identified outcomes relating to lifestyle and well-being as being of higher importance among patients and caregivers than health professionals.¹⁸ Although misalignment between patients and clinicians can be seen in some studies such as the above, nephrologists rank patient preferences and the quality of life afforded by modality choice of high importance when making a modality decision.¹⁹ Patient preferences are sometimes counter to clinician expectations, as is illustrated by a discrete choice study where patients were willing to trade 23 months of life expectancy with home-based dialysis in exchange for the increased ability to travel.²⁰ As such, it is important when discussing modality options with patients to highlight these practical realities and how they may affect the ability to achieve patient goals.

Individualizing the Choice of Home HD Device

The currently Food and Drug Administration (FDA)–approved home HD machines and their different attributes can be found in Table 3. Although the choice of device is often dictated by the contractual arrangements of the dialysis provider, nephrologists play an important role in advocating for the device that best suits individual patient needs. The NxStage System One received original FDA approval in 2005, with subsequent approvals for nocturnal therapy in 2014 and solo patient therapy in 2017. The Fresenius 2008K@Home and Tablo devices were approved for home HD with observation by a trained and qualified person in 2011 and 2020, respectively. A more detailed description of the different home HD machines and their prescription considerations is discussed in a later section. Off-label, single-needle HD machines are used for home HD in the United States by some providers to address cannulation issues. There are multiple additional devices either in or entering home HD FDA approval trials, which will further expand options, with designs focused on nocturnal therapy, ease of use, and higher dialysate flows in compact devices.

Table 3.

Home hemodialysis machines

Device	Features and Associated Lifestyle Advantages to the Patient
Fresenius 2008K@Home	• On-demand dialysate lowers preparation time • High dialysate flow allowing broader range of treatment times
NxStage (system one, system one S, VersiHD)	• Small profile device, less medicalization of the home • Portable system • Prepackaged dialysate option for areas with poor water quality, frequent natural disasters, or other interruption in water supply • On-demand dialysate when using the PureFlow SL system • FDA approved for nocturnal and solo use • Ease of use with prestrung dialysis tubing in cartridge • Electronic capture of treatment logs with VersiHD
Tablo	• Small profile device with integrated water treatment, less medicalization of the home • Touch screen instructions enables simplicity for training and use • On demand dialysate lowers preparation time • Ease of use with prestrung dialysis tubing in cartridge • Automated saline flushes and fluid removal for patients unable to use heparin products • Ability for nurse real-time monitoring of treatment for patients concerned about lack of direct professional monitoring • Electronic capture of treatment logs

FDA, Food and Drug Administration.

Individualizing the Vascular Access

Tunneled HD catheters in home HD are associated with higher rates of hospitalizations because of infections and higher all-cause mortality.¹¹ Therefore, transition to an arteriovenous fistula or graft is warranted whenever possible and aligned with patient goals. However, fear of cannulation is a commonly cited patient barrier to home HD,²¹ and some patients either do not have adequate vasculature for arteriovenous access creation or failed previous arteriovenous accesses. In those cases, a home-first, vascular access–second approach using a tunneled HD catheter allows these patients to experience the advantages of home HD.

Interestingly, only 24.4% of patients begin home HD with a tunneled HD catheter in contrast to the approximately 80% of patients on in-center HD, likely partially reflecting the longer dialysis vintage of new home HD patients but also possibly reflecting a hesitance to begin patients on home HD without an arteriovenous fistula or graft on the part of some providers.²² Appropriate mitigation of needle phobia through nurse-guided stepwise cannulation, relation techniques, topic anesthetics, and buttonhole cannulation are all approaches than can be taken to assist with patient fears.²³

Home HD Equipment and Systems in the United States

When formulating a home HD prescription, it is important to tailor it to the individual patient's needs. However, there are some basic principles to keep in mind. Avoiding a 3-day interdialytic break is important because it is associated with adverse outcomes in in-center HD studies.²⁴ Paying close attention to patients' interdialytic weight gain is also important because maintaining gains of ≤3 kg has been found to be associated with improved survival.²⁵ Finally, targeting a minimal standardized Kt/V (stdKt/V) of 2.1 as recommended by the Kidney Disease Outcomes Quality Initiative is critical.¹ While there has been some data showing no association between standardized Kt/V_urea and risk for mortality, hospitalization, or transfer to in-center HD among patients undergoing home HD,⁵ the current Centers for Medicare & Medicaid Services conditions for coverage for dialysis facilities in the United States dictates that “centers achieve a professionally accepted clinical practice standard for adequacy of dialysis.”²⁶

Depending on the type of dialysis machine in use, the recommended prescription, maximum dialysate flow rates (DFRs), and dialysate compositions vary. There are currently five FDA-approved home HD machines: Fresenius 2008K@Home, NxStage Systems (One, One S, VersiHD±PureFlow SL), and Tablo.

Fresenius 2008K@Home

The 2008K@Home uses the same prescription and system as the In-center 2008T HD machine. It uses bicarbonate and citric acid/acetate concentrates. There is also an on-board heparin pump and remote monitoring and data capture capabilities. For the purposes of writing a home HD prescription, dialysate and blood flow rates (BFRs) are the same as those normally used in the in-center dialysis setting.

Typical Prescription

Frequency: 5–7 times per week

BFR: 300–450 ml/min

DFR: 500–800 ml/min

Treatment time per session: 2–3 hours

Dimensions of the machine (height×width×depth): 52×21×25 inches

NxStage System One, One S, and VersiHD (with or without PureFlow SL)

When using NxStage, the emphasis is on minimizing the amount of dialysate needed as much as possible, thereby reducing storage space required in patients' homes for supplies. However, the goal is to provide patients with a prescription that is practical and that they can perform at home while balancing treatment time, supplies needed, flow rates, and patients' lifestyle.

Dialysis regimens of >3 days/week use the stdKt/V to determine dialysis adequacy. Based on the curve establishing the relationship between single-pool Kt/V (spKt/V) and stdKt/V by Gotch,²⁷ the spKt/V values needed to achieve a stdKt/V of 2.1 vary depending on the number of dialysis days. For example, a regimen that is 4 days/week would require a spKt/V of approximately 0.8, and 5 days/week would require a spKt/V of approximately 0.6.

With that in mind, if we have an 80-kg woman with an arteriovenous fistula who is planning to start home HD 5 days a week, the first step is determining the patient's minimum required dialysate volume. Her total body water volume is 40 L (assuming total body water of 50%). Now, to determine the minimum volume of dialysate needed to achieve a spKt/V of 0.6, we solve for Kt by multiplying 40 by 0.6=24 L of dialysate. This 24 L of dialysate would be 100% saturated.

NxStage provides premixed dialysate bag formulations in 5-L bags. That means that the smallest number of bags per treatment for this patient would be five 5-L bags (total dialysate volume of 25 L).

This takes us to the next step in the process whereby we determine a metric that is unique to the NxStage system, flow fraction (FF). The total effluent volume comprises the dialysate+ultrafiltration (UF) volumes per treatment. FF is the effluent flow rate divided by the BFR (Qb). We will discuss UF later on, so for the purposes of the calculations that follow, UF will be zero. The currently accepted FF values are closer to 40%, correlating to a dialysate urea saturation of approximately 90%.^28,29 It then follows that the lower the FF, the more saturated your dialysate (the DFR is a fraction of that of the BFR and therefore becomes more saturated). For the purposes of this example, let us aim for a FF of 50%.

Given the fact the NxStage System One machine allows for a maximum DFR (Qd) of 12 L/h (200 ml/min), let us use that as our Qd. Assuming no UF, the FF is equal to Qd divided by Qb. Qb would therefore be 400 ml/min. Based on this, we can now determine the length of the treatment—assuming no UF—to be as follows: 25,000/200=125 minutes.

The patient's prescription would therefore be as follows:

Five days a week

Total dialysate volume=25 L

Qb 400 ml/min, Qd 200 ml/min

FF=50%

Time per session=125 minutes

It is important to note, however, that the newer NxStage System One S can deliver a maximum Qd of 18 L/h (300 ml/min).

Continuing with our NxStage System One prescription, let us examine the effect of UF on treatment time. Let us assume a UF of 2 L per dialysis session, using this latest prescription. That would mean that the total effluent volume would be 25 L (dialysate)+2 L (UF)=27 L. Assuming a FF of 50%, that would mean a total treatment time of 27,000 ml/200 (ml/min)=135 minutes. Therefore, a UF of 2 L added only 10 minutes to the patient's treatment time.

Treatment time can be decreased by increasing the FF, using a smaller dialysate volume (not possible in this case), lowering the UF goal, and using greater Qb rates (we do not recommend increasing Qb above 400 ml/min because of increased vessel wall sheer stress).

Premixed dialysate bags have potassium concentrations ranging from 1 to 3 mEq/L. They also use lactate as the buffer, rather than bicarbonate. This is to because bicarbonate would bind with calcium and precipitate as calcium carbonate. Lactate levels range anywhere from 35 to 45 mEq/L, this is because it is a larger molecule than bicarbonate and therefore takes longer to diffuse across the dialyzer membrane. A higher concentration, therefore, helps to ensure adequate buffer balance. The choice of lactate concentration is usually based on patients' serum bicarbonate levels. We recommend the use of 45 mEq/L lactate solutions for patients with serum bicarbonate levels ≤20 mEq/L and 35–40 mEq/L lactate solutions for those with bicarbonate levels ≥24 mEq/L. Once in the circulation, it is rapidly converted to bicarbonate on a 1:1 basis by the liver and skeletal muscle. It is important to note that in patients with reduced lactate metabolism, such as liver failure, bicarbonate-buffered solutions should be used as the dialysate.

Systemic heparin is the typically prescribed anticoagulation for patients on NxStage therapy. Multiple protocols exist for its prescription, a commonly used one is: bolus of 1000–2000 units at the initiation of treatment, followed by 500–1500 units/hour maintenance as needed. For longer therapies, an external syringe pump can be connected to the NxStage blood circuit to provide continuous anticoagulant administration, or long-acting low-molecular weight heparin can be used as a bolus dose.

While the NxStage One system relies on 5-L bags of prepacked dialysate, the PureFlow SL prepares batches of dialysate onsite with volumes ranging from 40 to 60 L (equivalent to 8–12 prepacked bags). In deciding on the PureFlow SL batch size, the dialysis team takes into account the prescribed amount of dialysate per dialysis session to minimize wastage and number of batches that need to be produced per week along with dialysate composition needs because these vary by batch size. This requires special plumbing modifications to patients' homes; however, it minimizes the storage space required and disposal challenges of prepacked bags. It is important to note that generating a full batch of dialysate takes approximately 8 hours and increases patients' home water bills, albeit minimally. Lactate concentrations are either 40 or 45 mEq/L, and potassium concentrations are either 1 or 2 mEq/L.

The NxStage VersiHD provides the same dialysis treatments and prescription methodology as the NxStage One and One S. It is used in conjunction with the PureFlow SL system for dialysate generation. What differentiates it is the connectivity to the Nx2me platform, automatically transmitting treatment information, thereby reducing manual tasks and potential for errors. It also has an iPad app where patients can record their flowsheet information and submit it electronically to the clinician portal. Another unique feature that separates the VersiHD from the other NxStage products is the new GuideMe Software, which provides graphical walk-through guidance for patients using the cycler.

Typical Prescription

Frequency: 4–7 times per week

BFR: ≥300 ml/min

DFR: ≤200 ml/min

Treatment time per session: 2–3.5 hours

Dimensions of the machine (height×width×depth):   NxStage System One 15×15×15 inches

  NxStage System One S 15×15×18 inches

  PureFlow SL 19×20×26 inches

  VersiHD 18×15×15+PureFlow SL

Tablo

In the home setting, the Tablo HD machine can be used for standard HD and sequential therapy (HD-UF or UF-HD). It uses wireless connectivity for data transfer and offers the ability to monitor patients in real time while on treatment.

When used for standard HD, the Tablo HD system can deliver DFRs of up to 300 ml/min. Using an integrated water purification system, it produces dialysate on demand with a prime time of 8 minutes. Dialysate concentrates are bicarbonate and acetate/citric acid, with buffer concentrations ranging from 30 to 40 mEq/L. However, use of the manufacturer's concentrates is not necessary, as long as the concentrates used have a 45× mix ratio (acid:base:water ratios of 1:1.72:42.28); this is denoted on the packaging.

The range of HD treatments used in the study which allowed FDA clearance for the home HD indication in March 2020 had treatment parameters as follows:

Frequency: four times per week

BFR: ≥300 ml/min

DFR: ≤300 ml/min

Mean prescribed treatment time (per treatment): 196–207 minutes (3.3–3.5 hours)

Mean prescribed UF volume (per treatment): 1251–2232 mL

Mean standard weekly Kt/V achieved: 2.3–2.8

Dimensions of the machine (height×width×depth): 33.5×17.5×19 inches

A summary of all FDA-approved home HD machines in the United States and their prescription parameters can be found in Table 4.

Table 4.

A summary of all Food and Drug Administration–approved home hemodialysis machines in the United States and their prescription parameters

Prescription Parameter	2008K@Home	NxStage System One (Prepacked Dialysate bags)	NxStage System One S (Prepacked Dialysate bags)	NxStage System One, One S, VersiHD (PureFlow SL)	Tablo
Frequency (per week)	5–7	4–7	4–7	4–7	4
DFR, ml/min	500–800	≤200	≤300	≤200	≤300
BFR, ml/min	300–450	≥300	≥300	≥300	≥300
Treatment time per session, h	2–3	2–3.5	2–3.5	2–3.5	3.3–3.5
Sodium, mEq/L	135–145	140	140	140	130–145
Potassium, mEq/L	0–4	1,2,3	1,2,3	1,2	0,1,2,3
Calcium, mEq/L	2.0–3.5	3–3.5	3–3.5	3	0–3.5
Buffer/base	Bicarbonate, acetate/citric acid	Lactate	Lactate	Lactate	Bicarbonate, acetate/citric acid

DFR, dialysate flow rate; BFR, blood flow rate.

Nocturnal Home HD: Balancing Dose and Goals

The classical implementation of nocturnal HD was described by Uldall et al. in Toronto, 1996.³⁰ The typical prescription includes 5–6 nights of HD, 6–8 hours per session using BFRs of 200–250 ml/min, and DFRs of 300–350 ml/min with a high-flux dialyzer. The evolution of nocturnal HD now includes alternative schedules, machines (high and low dialysate flow systems), and location (at home versus in-center). To date, the most intensive form of HD remains traditional nocturnal HD.³¹

Home HD has flexibility in frequency and duration of therapy. Increases in frequency and duration of HD will increase dialysis dose. The augmentation in frequency has a significant effect on dampening the oscillation of solutes, toxins, and extracellular volume (Figure 1). In comparison, prolongation in HD duration enhances removal of small and middle molecules and minimizes UF rate.³¹ Combined increases in both frequency and treatment duration provides the highest HD dose and has been associated with improved cardiovascular outcomes, solutes removal, liberalization of diet, and restoration of normal physiology such as fertility and full-term pregnancies.³²

Figure 1.

Comparison of the clearance achieved with CAPD, short daily HD, and nocturnal HD. CAPD, continuous ambulatory peritoneal dialysis; HD, hemodialysis.

Cardiovascular Adaptations of Nocturnal HD

A growing body of literature supports the cardiovascular benefits of nocturnal HD. The initial data came from Toronto using a controlled cohort design. Nocturnal HD was superior to conventional HD in controlling BP without the need for vasoactive medications. Left ventricular hypertrophy regressed with the use of nocturnal HD (from 147±42 to 114±40 g/m², P = 0.004).³³ Interestingly, hemodynamic changes were associated with a fall in total peripheral resistance rather than a drop in extracellular fluid volume control.³⁴ Ensuing randomized controlled trials showed consistent results.^35,36 Systematic reviews and meta-analyses confirmed that 12 months of more frequent HD is associated with a 13-g reduction in left ventricular mass reduction.

Mechanistic analyses of the vascular effects of nocturnal HD demonstrated association with higher arterial baroreflex sensitivity and improved total arterial compliance (measured by stroke volume/pulse pressure)³⁷ and augmentation of brachial artery responsiveness to hyperemia and to nitroglycerin.³⁴ The present body of work supports the notion that nocturnal HD has a direct vascular protective effect. It is tempting to speculate that enhanced dialysis dose is associated with a vascular repair mechanism.³⁸

In a seminal article published by Pierratos and Hanly, nocturnal HD was shown to correct obstructive sleep apnea.³⁹ Interestingly, there is a correlation between the changes in apnea–hypopnea index and UF volume.⁴⁰ The use of nocturnal HD may alter the central chemosensitivity, altering central respiratory drive.⁴¹ Correction of sleep apnea has only been reported in patients who are undergoing home HD more than four times a week, suggesting that daily HD is needed to correct chronic volume overload and/or alteration of chemosensitivity.

Enhanced Solutes Removal with Nocturnal HD

The advent of nocturnal HD allows for modification in small and middle molecules removal.⁴² Musci et al.⁴³ described the doubling of phosphate removal by nocturnal HD. As a result, elimination of phosphate binders and liberalization of diet is achievable.

Clinical outcomes in dialysis ought to be considered as multidimensional (e.g., BP control, cardiac geometry and function, nutrition, and quality of life).⁴⁴ The advent of frequent HD has demonstrated that solute removal accounts for only one facet of the dialysis dose. The metabolic complexity of uremic toxins, intestinal generations of toxins, and uremic cellular changes will undoubtedly reinvent the quantification of dialysis dose in the era of personalized HD.

Restoration of Normal Physiology and Fertility

More frequent and prolonged HD provides the closest approximation of normal physiology. Although pregnancy in women on dialysis is rare and is often accompanied by multiple maternal and/or fetal complications, emerging data suggest that nocturnal HD provides the most feasible and safe therapeutic option for pregnant women on dialysis. The most recent report compared the Toronto nocturnal HD data with the American Registry for Pregnancy in Dialysis Patients. The live birth rate was higher in the Canadian cohort compared with the American controls (86.4% versus 61.4%, P = 0.03). The median duration of pregnancy was 36 weeks in the nocturnal HD cohort compared with 27 weeks in the control group. There was a significant correlation between delivery of dialysis dose and pregnancy outcomes. Live birth rate was only 48% among patients who dialyzed <20 hours per week versus 85% in the women who received >36 hours of dialysis per week.⁴⁵

When deciding on the best home HD treatment approach, we see that there is a multitude of options available for us to choose from. Emphasizing dialysis adequacy as the focal point of the prescription is not advised. To date, there are no randomized controlled trials to dictate small solute clearance goals in home HD. Guideline recommendations are based on extrapolation of in-center HD trials. A discussion with the patient outlining the vascular access, prescription, and home HD machine options is key. Shared decision making tailored to the patients' treatment goals, lifestyle, and quality of life can only be achieved through incorporating a multifaceted approach.

Disclosures

G. Abra reports employment with Satellite Healthcare, consultancy for Baxter, role as site investigator on the Tablo and Quanta SC+ Investigational Device Exemption Trials, and advisory or leadership roles as Nephrology News & Issues Associate Editor (unpaid) and PDOPPS US Advisory Group member (unpaid). C. Chan holds the R Fraser Elliott Chair in Home Dialysis and reports consultancy for Dialco, Medtronic, and Quanta; research funding from Medtronic through their external grant program; advisory or leadership roles for DaVita, Medtronic, and Quanta; and role as an Associate Editor of CJASN. O. El Shamy reports consultancy for Outset Medical, honoraria from Home Dialysis University and UpToDate, and other interests or relationships with Home Dialysis Academy of Excellence.

Funding

None.

Author Contributions

Conceptualization: Graham Abra, Christopher Chan, Osama El Shamy.

Methodology: Graham Abra, Osama El Shamy.

Supervision: Osama El Shamy.

Validation: Graham Abra, Christopher Chan, Osama El Shamy.

Writing – original draft: Graham Abra, Christopher Chan, Osama El Shamy.

Writing – review & editing: Graham Abra, Christopher Chan, Osama El Shamy.