Home Dialysis in Patients with Cardiovascular Diseases

Abstract

Kidney failure with replacement therapy and cardiovascular disease are frequently comorbid. In patients with kidney failure with replacement therapy, cardiovascular disease is a major contributor to morbidity and mortality. Conventional thrice-weekly in-center dialysis confers risk factors for cardiovascular disease, including acute hemodynamic fluctuations and rapid shifts in volume and solute concentration. Home hemodialysis and peritoneal dialysis (PD) may offer benefits in attenuation of cardiovascular disease risk factors primarily through improved volume and BP control, reduction (or slowing progression) of left ventricular mass, decreased myocardial stunning, and improved bone and mineral metabolism. Importantly, although trial data are available for several of these risk factors for home hemodialysis, evidence for PD is limited. Among patients with prevalent cardiovascular disease, home hemodialysis and PD may also have potential benefits. PD may offer particular advantages in heart failure given it removes volume directly from the splanchnic circulation, thus offering an efficient method of relieving intravascular congestion. PD also avoids the risk of blood stream infections in patients with cardiac devices or venous wires. We recognize that both home hemodialysis and PD are also associated with potential risks, and these are described in more detail. We conclude with a discussion of barriers to home dialysis and the critical importance of interdisciplinary care models as one component of advancing health equity with respect to home dialysis.

Background

Kidney failure with replacement therapy (KFRT) and cardiovascular disease are frequently comorbid, with each complicating the management of the other, leading to poor patient outcomes. Compared with the general population, dialysis patients are 10–20 times more likely to die of cardiovascular disease.¹ Using the 2022 United States Renal Data System Annual Data Report, an estimated 76% of patients receiving hemodialysis had a diagnosis of cardiovascular disease, and cardiovascular disease accounted for more than half of all deaths with known cause among patients receiving hemodialysis.² Similar findings were observed for patients receiving peritoneal dialysis (PD).² The high prevalence of cardiovascular disease among patients receiving dialysis is due not only to traditional cardiovascular risk factors, such as diabetes and hypertension, but also reflects risk conferred by kidney failure, including volume overload, anemia, electrolyte imbalances, and CKD mineral bone disease (CKD-MBD). Conventional thrice-weekly in-center hemodialysis (henceforth referred to as “conventional hemodialysis”) confers its own risks of cardiovascular disease secondary to acute fluctuations in volume and hemodynamic status, as well as rapid shifts in solute concentration.

The 2022 American Heart Association Scientific Statement on Cardiovascular Effects of Home Dialysis therapies concluded that home dialysis, including home hemodialysis and PD, may attenuate hemodynamic fluctuations by using a more physiologically consistent approach.³ Home hemodialysis typically incorporates either more frequent or longer hemodialysis sessions, leading to less ultrafiltration per session. Similarly, as a daily and often continuous therapy, ultrafiltration rates with PD are a fraction of those seen with conventional hemodialysis. Critically, the American Heart Association Scientific Statement noted that much of the current evidence regarding home dialysis therapies in comparison with conventional hemodialysis is based on observational studies with their associated limitations, including confounding by patient-level factors, selection, and indication biases.³

In January 2023, a Kidney Disease: Improving Global Outcomes Controversies Conferences on Home Dialysis recommended that all patients with KFRT have the option of receiving home dialysis.⁴ Yet in 2020, only 13% of incident dialysis patients and 14% of prevalent dialysis patients in the United States received home dialysis.² The potential reasons for this are multifold, including financial factors, insufficient expertise, and discomfort among clinicians, including non-nephrologists, with home dialysis, and lack of experience with PD in inpatient and nursing home settings.⁵ The Advancing American Kidney Health initiative sought to significantly increase the rates of home dialysis such that 80% of patients with ESKD would receive home dialysis or a kidney transplant by 2025. To facilitate this goal, the Centers for Medicare & Medicaid services implemented the ESKD Treatment Choices model, which incentivizes home dialysis via substantial reimbursement increases for both managing clinicians and dialysis providers.⁶

In this review, we first discuss the potential mechanisms by which home dialysis may ameliorate cardiovascular risk factors. We focus more on home hemodialysis given trial data comparing patients receiving more frequent or extended duration hemodialysis in comparison with conventional hemodialysis. We then discuss home dialysis in the setting of known cardiovascular disease, with a particular focus on PD in those with heart failure. We acknowledge that there are limited trial data comparing PD with conventional hemodialysis, particularly regarding cardiovascular outcomes. Finally, we discuss approaches to interdisciplinary care (IDC) of dialysis patients with cardiovascular disease.

Modification of Cardiovascular Risk Factors with Home Dialysis

Regarding cardiovascular risk factors, much of the evidence for home dialysis is derived from studies comparing conventional hemodialysis to more frequent or extended in-center dialysis and extrapolating these data to the home hemodialysis setting. Trials directly comparing conventional hemodialysis with home hemodialysis or PD are limited. Several potential risk factors may be modified by home dialysis. These include volume control, which in turn influences BP, left ventricular (LV) remodeling, and LV hypertrophy; myocardial stunning; and CKD-MBD. LV hypertrophy represents the downstream effect of hypertension (pressure overload) often in conjunction with volume overload leading to increased LV mass due to increased wall thickness and/or increased LV cavity size.⁷ LV hypertrophy is common among dialysis patients and is independently associated with poor outcomes.⁸ Regression of LV hypertrophy, in turn, may decrease all-cause mortality or cardiovascular hospitalization.⁸

Volume Overload, BP, and LV Remodeling

Kidney failure results in salt and water retention. Increased extracellular volume is one of the principal contributors to hypertension among patients receiving dialysis,⁹ and increased extracellular water on bioelectrical impedance is directly associated with postdialysis hypertension.¹⁰ Levels of brain natriuretic peptide are indicative of the cardiac stress induced by fluid overload, including elevated filling pressures, LV hypertrophy, and reduced ventricular function.^11–13 As such, they are often elevated among dialysis patients. A systematic review of 61 studies (19,688 patients), of which 49 were included in a meta-analysis, found that higher levels of N-terminal pro-B-type natriuretic peptide and brain natriuretic peptide were associated with increased risk for all-cause and cardiovascular mortality among patients with eGFR ≤15 ml/min per 1.73 m², including those on dialysis.¹⁴

Home Hemodialysis

The Frequent Hemodialysis Network (FHN) Daily and Nocturnal trials compared volume status, BP, and LV mass among patients receiving intensive (six times weekly) hemodialysis versus conventional hemodialysis.^15,16 We consider the FHN Daily trial as being similar to home hemodialysis, which is often performed with comparable frequency and duration. We recognize however that the results of FHN daily trial may not always generalize to the home setting. The FHN Daily trial found that more frequent dialysis was associated with lower predialysis systolic BP, reduced biventricular end diastolic volume, and reduced LV mass on cardiac magnetic resonance imaging (Figure 1).¹⁵ The FHN Nocturnal trial also showed that a longer duration of dialysis reduced BP, although there was no significant difference in change in ventricular volumes or LV mass between comparator arms.¹⁶ The latter null findings have been attributed to differences in patient population between trials and potentially inadequate power, reflecting challenges with recruitment. The ACTIVE trial (A Clinical Trial of IntensIVe Dialysis), which randomized prevalent dialysis patients to standard or extended hemodialysis hours for 12 months, showed a reduction in use of BP lowering agents and a trend toward lower LV mass in the extended hour cohort.¹⁷ A 2012 meta-analysis, incorporating the two FHN Trials, a clinical trial from Canada and multiple single-arm and cross-over studies, demonstrated that more frequent or extended duration hemodialysis consistently reduced BP as well as parameters of LV mass (Table 1).¹⁸

Figure 1.

Coprimary composite outcomes and main secondary outcomes from the FHN Daily Trial. Kaplan–Meier curves are shown for the composite outcomes of death or change in LV mass (A) and death or change in the PHC score from the RAND 36-item health survey (B). For each value for the coprimary composite outcome on the horizontal axis, the Kaplan–Meier curve indicates the proportion of patients in the respective treatment groups with an equal or more favorable outcome. The horizontal distance between the Kaplan–Meier curves at the 50% value on the vertical axes indicates the median composite outcome results. Median outcomes for the composite outcome of death or change in LV mass correspond to a reduction in LV mass of 12.3 g in the frequent hemodialysis group, as compared with a reduction of 2.2 g in the conventional dialysis group (difference in medians, 10.1 g). The greater separation in the two curves on the right side of the graph of the change in LV mass is because nine patients had reductions in LV mass of at least 60 g; all of them were in the frequent hemodialysis group. The median results for the composite outcome of death or change in PHC score correspond to an increase in the PHC score of two points in the frequent hemodialysis group as compared with no change in the conventional dialysis group (difference in medians, two points). Changes in LV mass ranged from a decrease of 51.2 g to an increase of 68.8 g in the conventional dialysis group and from a decrease of 174.5 g to an increase of 61.9 g in the frequent hemodialysis group. Changes in the PHC score ranged from a decrease of 27 points to an increase of 22 points in conventional dialysis group, and from a decrease of 28 points to an increase of 29 points in the frequent hemodialysis group. The standardized effect sizes for the main secondary outcomes (C) were calculated as follows: the mean differences in LV mass, PHC score (in which higher scores indicate better physical health), beck depression inventory score (in which higher scores indicate more severe depression), albumin concentration before dialysis, phosphorus concentration before dialysis, and SBP before dialysis were divided by the baseline SD; the mean difference in log dose of ESA was divided by the SD of the log baseline ESA dose; the log risk ratio for failure to complete the trail making test part B was divided by square root ([1−p]/p), where p is the fraction of participants who did not complete the test within 5 minutes at baseline; the log hazard ratio for hospitalization unrelated to vascular access or death was divided by square root (1/p), where p is the fraction of patients with a hospitalization unrelated to vascular access or death. ESA doses of <5000 erythropoietin equivalent units were set to 5000 before log transformation. Reprinted from ref. 15, with permission. CI, confidence interval; ESA, erythropoiesis-stimulating agent; FHN, Frequent Hemodialysis Network; LV, left ventricular; PHC, physical health composite; SBP, systolic BP.

Table 1.

Summary effect of frequent or extended hemodialysis on cardiac morphology and function and BP parameters

Outcome Variables	No. of Studies	No. of Participants	Baseline Mean Value (95% CI)a	Mean Change (95% CI)a	P Value	Assessment of Heterogeneity
						I2 Indexb, %	Chi square P Value
Cardiac morphology and function
LVM, g	13	335	238.8 (197.9 to 279.7)	−60.5 (−90.8 to −30.2)	<0.001	95	<0.001
LVMI, g/m2	23	524	155.7 (109.4 to 135.2)	−31.2 (−39.8 to −22.5)	<0.001	84	<0.001
LV systolic diameter, mm	5	173	37.5 (33.9 to 41.0)	−4.3 (−6.8 to −1.7)	0.001	69	0.01
LV end diastolic diameter, mm	14	314	53.7 (50.7 to 56.7)	−4.7 (−6.0 to −3.5)	<0.001	55	0.007
LV posterior wall thickness, mm	12	213	11.0 (10.5 to 11.6)	−1.1 (−1.5 to −0.7)	<0.001	61	0.003
Intraventricular septum thickness, mm	11	196	12.3 (11.6 to 13.1)	−1.6 (−2.1 to −1.2)	<0.001	43	0.06
Left atrial end diastolic diameter, mm	3	62	40.7 (38.0 to 43.4)	−5.2 (−6.0 to −4.3)	<0.001	0	0.48
LVEF, %	4	137	45.1 (28.1 to 62.1)	6.7 (1.6 to 11.9)	0.011	74	0.009
BP parameters
SBP, mm Hg	35	928	147.7 (143.7 to 151.7)	−14.1 (−17.2 to −11.0)	<0.001	89	<0.001
DBP, mm Hg	31	733	84.1 (81.3 to 86.9)	−7.1 (−9.2 to −4.9)	<0.001	89	<0.001
MAP (mm Hg)	20	352	110.2 (106.2 to 114.1)	−11.8 (−13.8 to −9.8)	<0.001	75	<0.001
No. of antihypertensive medications	25	552	1.8 (1.6 to 2.1)	−0.8 (−1.2 to −0.5)	<0.001	97	<0.001

Reprinted from ref. 18, with permission. CI, confidence interval; DBP, diastolic BP; LV, left ventricular; LVEF, left ventricular ejection fraction; LVM, left ventricular mass; LVMI, left ventricular mass index; MAP, mean arterial pressure; SBP, systolic BP.

^aBy random effects model meta-analysis.

^bA measure of statistical heterogeneity across study results; I² index ≥50% indicates medium to high heterogeneity.¹⁹

PD

Although PD may result in less fluctuation in volume status and thereby more hemodynamic stability, evidence regarding the effect of PD, in comparison with conventional hemodialysis, on both BP and LV mass is limited (Figure 2). One comparative, prospective study examined ambulatory BP between 38 PD patients and 76 thrice-weekly hemodialysis patients and found that the results of ambulatory BP monitoring did not differ significantly between the two modalities.²⁰ A retrospective study of 175 patients on continuous ambulatory PD showed that while mean BP did not differ by volume status, BP variability was associated with hypervolemia.²¹ There is some evidence that while PD patients may initially have improvements in BP after initiation of dialysis, these reductions are not sustained beyond the first year.²² There are multiple observational studies that describe risk factors for LV hypertrophy in patients receiving PD, but to date, we are aware of no trials focusing on cardiovascular outcomes comparing PD with conventional hemodialysis.^23–26 Theoretically, fluid management may be facilitated early in the PD course when residual kidney function remains; yet, over time, residual kidney function may decline, leading to volume overload.

Figure 2.

Potential cardiovascular benefits and harms of PD. The figure describes how PD may have benefits or harms on cardiovascular disease risk factors and outcomes. Given the lack of trial data, the effect in many cases is unknown. PD, peritoneal dialysis.

Myocardial Stunning

In addition to hypertension and volume overload, conventional hemodialysis may cause repeated cardiovascular stress (termed “stunning”), a process resulting from asymptomatic myocardial damage due to hemodialysis-associated subclinical ischemia.²⁷ Stunning has been associated with increased serum troponin levels,²⁸ development of autoantibodies to serum troponin that may lead to cardiac damage,²⁹ reduced LV ejection fraction (LVEF), and increased mortality.³⁰ Higher rates of ultrafiltration and intradialytic hypotension are factors that may contribute to stunning.³⁰ In a study in which intradialytic cardiac magnetic resonance imaging was performed during hemodialysis and hemodiafiltration sessions, patients experienced decreased contractile function, reduced segmental LV function, and decreased myocardial perfusion during dialysis, regardless of modality.³¹ Evidence regarding the relative benefits of home hemodialysis or PD in reducing stunning is limited, but one may surmise that home hemodialysis may reduce stunning through more frequent sessions requiring less volume remove per session. Similarly, it is intuitive to believe that PD does not cause stunning. In fact one small study was consistent with that hypothesis.³²

CKD Mineral and Bone Disorder

Disordered mineral and bone metabolism is common among patients undergoing dialysis and is a risk factor for adverse cardiovascular outcomes likely due to calcification of large vessels (arteriosclerosis), thereby resulting in increased stiffness and increasingly noncompliant vessels, high pulse pressure, and LV hypertrophy.³³ Abnormalities in bone and mineral metabolism in CKD are complex, but much of the available evidence in this area focuses on hyperphosphatemia and use of phosphate binders which are improved and lowered, respectively, with extended dialysis.³⁴

Home Hemodialysis

In both the FHN Daily and FHN Nocturnal trials, patients assigned to more frequent and extended dialysis had reductions in mean serum phosphorous and required fewer phosphate binders.³⁵ Notably, calcium and parathyroid hormone levels were not significantly different between frequent and extended duration dialysis in comparison with conventional hemodialysis. One observational study found either no or nonsignificant increases in coronary artery calcifications (CACs) 1 year after starting nocturnal hemodialysis or switching from other modalities to nocturnal dialysis.³⁶

PD

The role of PD in modifying risk of CKD-MBD–associated cardiovascular risk factors is unclear (Figure 2) due to the paucity of comparative data with conventional hemodialysis. In one prospective observational study of patients undergoing PD, 77% of patients had arterial or valvular calcifications by Doppler ultrasound or echocardiography, respectively, at baseline, and nearly three-quarters of patients had progression of calcifications.³⁷ Another prospective study compared CAC in hemodialysis and PD cohorts and found that CAC did not differ significantly between hemodialysis and PD and that PD was associated with possibly more CAC progression.³⁸

Cardiovascular Outcomes by Home Dialysis Modality in Patients with Prevalent Cardiovascular Disease

Heart Failure

The pathophysiology of heart failure, specifically as it relates to volume handling, is integral to understanding how home hemodialysis or PD may reduce the risk of acute decompensated heart failure. Specifically, heart failure results not only in salt and water retention but also in perturbations in distribution of fluid resulting from reduced capacitance of the splanchnic circulation leading to increased preload (Figure 3).³⁹ The splanchnic vasculature, which initially helps buffer against congestion by increasing capacitance to hold additional blood volume, ultimately is limited in this capacity by neurohormonally mediated increased sympathetic tone, a common feature in heart failure that results in splanchnic vasoconstriction.^39,40 Increased intra-abdominal pressure further exacerbates congestion by impeding flow to the abdominal vasculature and may worsen kidney injury through congestion of renal veins.⁴¹

Figure 3.

Role of splanchnic circulation in volume distribution of heart failure. The figure describes the distribution of intravascular volume between the splanchnic circulation and effective circulating volume. In compensated heart failure, the splanchnic vasculature remains in a high-capacitance state and can expand to accommodate increased intravascular volume. As sodium and water retention increase and neurohormonal stimulation occurs, splanchnic congestion develops along with decreased splanchnic capacitance, respectively. The overall result is increased effective circulating volume leading to increased preload and decompensated volume status.

Home Hemodialysis

Observational data, although limited by selection biases, suggest that home hemodialysis may have benefits regarding heart failure outcomes in comparison with conventional hemodialysis. In a cohort study of 3480 daily home hemodialysis patients matched to 17,400 conventional hemodialysis patients, home hemodialysis was associated with a lower risk of hospitalization for heart failure, fluid overload, or cardiomyopathy (hazard ratio, 0.69; 95% confidence interval, 0.62 to 0.77), although the risk of hospitalization for infection was higher (hazard ratio, 1.18; 95% confidence interval, 1.13 to 1.23).⁴² In another cohort study of 154 patients undergoing home hemodialysis, LVEF was mostly unchanged after mean 3.9 years of follow-up, suggesting no overt deterioration in cardiac function.⁴³ Similarly, in a small study (n=6) of patients with heart failure with reduced ejection fraction, there was a substantial improvement in LVEF (28%±12% to 41%±18%, P = 0.01) over a mean follow-up of 3.2 years after switching from conventional hemodialysis to frequent nocturnal dialysis.⁴⁴ There are no studies of which we are aware assessing comparative benefits of varying dialysis modalities in patients with severe pulmonary hypertension and/or right-sided heart failure.

PD

PD offers several potential advantages in patients with heart failure with advanced CKD or KFRT. PD results in less hemodynamic fluctuation relative to conventional hemodialysis. Furthermore, in contrast to hemodialysis, PD directly removes volume from the splanchnic circulation via the vasculature of the visceral peritoneum, thus providing a pathway for efficiently relieving intravascular congestion and potentially countering the catecholamine-mediated decrease in splanchnic capacitance that is present in heart failure.^3,45 Further research is needed to understand the interplay among the splanchnic circulation, neurohormonal mediators, and PD in individuals with heart failure.

PD also foregoes the need for vascular access. This is important in two respects: (1) no need for central venous catheters, which increase the risk of bacteremia and may be of particular concern in individuals with structural heart disease and with cardiac devices, and (2) no need for hemodialysis fistulas and grafts, which, particularly when they are high flow, may have adverse effects on cardiac remodeling and potentially lead to an increased risk of cardiac events in patients with prevalent cardiovascular disease. Ligation of arteriovenous fistulas in kidney transplantation recipients may be associated with improved surrogate cardiovascular outcomes with one trial showing reduced LV mass.⁴⁶

A recent meta-analysis of 20 studies, including 769 patients, evaluated PD in patients with heart failure refractory to medical therapy.⁴⁷ The findings suggest that the use of PD is associated with improved New York Heart Association functional class and reduced length of hospitalization and may also be associated with a small increase in LVEF. For adverse events, peritonitis ranged from 0 to 0.75 episodes per patient per year, and mean all-cause mortality at 1 year was 37.6%. The quality of evidence however was rated as very low with significant heterogeneity among studies. Similarly, many of the studies in the meta-analysis are retrospective and include precomparisons and postcomparisons and are therefore limited by survival bias.

LV Assist Devices

Home dialysis modalities offer several potential benefits for patients with LV assist devices (LVADs) with concomitant kidney failure compared with conventional hemodialysis. From a practical standpoint, most hemodialysis clinics are not equipped to manage LVADs, so home dialysis modalities may provide a more feasible alternative.⁴⁸ In addition, daily dialysis modalities may offer more gentle ultrafiltration than conventional hemodialysis, thus reducing the likelihood of hemodynamic fluctuations and LVAD low-flow alarms. Importantly, in light of concern about increased risk of blood stream infections in individuals with LVADS and dialysis catheters, arteriovenous fistulas and arteriovenous grafts have been used successfully for long-term vascular access in individuals with these devices.⁴⁹

PD may warrant particular consideration given it does not require vascular access, thus reducing the risk of bacteremia in patients already vulnerable to blood stream infections. Importantly, drivelines and pump pockets are not a contraindication to PD catheter placement as these do not compromise the peritoneum. Critically, the more gentle ultrafiltration and less dramatic hemodynamic changes associated with PD in particular may reduce LVAD alarms and potentially increase the likelihood of kidney function recovery in those with AKI.⁵⁰

Evidence regarding the use of home hemodialysis or PD in patients with LVADs is limited to case reports.^50–55 There are also challenges with dialysis in individuals with LVADs. For example, LVADs vary in whether they result in pulsatile flow, a critical factor in assessing BP using automated oscillometric devices. The newer HeartMate 3 for example typically results in pulsatile flow, but reproducibility of automated BP assessments may be variable.⁵⁶ Accordingly, the ability to assess BP with a Doppler, which will provide the mean arterial pressure in individuals without pulsatility, is needed, regardless of whether dialysis is performed in-center or at home. At busy dialysis facilities, this atypical assessment of BP may introduce barriers to provision of hemodialysis care. In addition, very few in-center hemodialysis facilities accept patients with LVADs, presenting a barrier to care most notable for individuals residing far from an academic center where there may be more options. This logistic issue further supports the use of home dialysis in LVAD recipients.

Aortic Stenosis

Aortic stenosis is common among patients with KFRT. The prevalence of aortic stenosis ranged from 44% to 85% in hemodialysis patients and 24%–33% in PD patients in a recent review.⁵⁷ Patients with aortic stenosis may be particularly susceptible to low BP during conventional hemodialysis, and thus, home hemodialysis or PD should be considered, particularly if valve replacement is contraindicated. As discussed above, PD offers the benefit of foregoing need for vascular access and therefore reducing the risk of bacteremia and endocarditis. To date, there are no trials comparing outcomes in patients with aortic stenosis receiving home hemodialysis or PD versus conventional hemodialysis.

Arrhythmias

There is a high prevalence of both tachyarrhythmias and bradyarrhythmias in patients receiving dialysis, and one could hypothesize that home hemodialysis or PD may reduce arrhythmias.^58–62 Observational data suggest that conventional hemodialysis may be a risk factor for variation in daily risk of cardiac death compared with more frequent hemodialysis or PD.⁶³ There are no trial data comparing the burden of arrhythmias in conventional hemodialysis versus home hemodialysis or PD.

Potential Risks of Home Dialysis in Prevalent Cardiovascular Disease

While we have primarily discussed potential cardiovascular benefits of home dialysis, PD and home hemodialysis are not without risks. Home hemodialysis has many of the same risks associated with conventional hemodialysis, including risk of blood stream infection associated with dialysis access as well as potential hemodynamic and solute fluctuations depending on the frequency and duration of treatments. Additional risks of frequent home hemodialysis may be increased prevalence of access failure and possibly infection as well as more rapid loss of residual kidney function.^15,64 PD, on the other hand, may be associated with worse glucose control, particularly when higher dextrose containing solutions are used,⁶⁵ and, potentially reflecting increased glucose uptake, may be associated with a more atherogenic lipid profile.⁶⁶ Of note, however, this finding was not observed in a more recent report^66,67 (Figure 2).

Interdisciplinary Care and Equitable Access to Home Dialysis

For patients with cardiovascular disease, who may already spend significant amounts of time in health care settings, home hemodialysis and PD may offer quality of life improvements including, but not limited to, more time at home, and, in the case of PD, avoidance of cannulation. Accordingly, given potential cardiovascular advantages combined with possible quality of life improvements, we believe that patients with cardiovascular disease may derive particular benefit from home dialysis and that equitable access to home dialysis for all patients is imperative. Despite this, substantial barriers in access remain. Access to home dialysis may be limited for patients who do not have a stable source of housing, space for dialysis supplies, resources for increased associated costs (e.g., home hemodialysis requires higher water and electricity use), internet access to facilitate remote monitoring systems, or a family member or friend who can serve as a care partner. Importantly, clinicians may also have biases in assessing patients' capability for home dialysis and significant disparities in home dialysis use persist.⁶⁸

To achieve equitable access to home dialysis and goal-directed, patient-centered care, an interdisciplinary approach should be used.^4,69 An IDC team for a patient with cardiovascular disease undergoing home dialysis may include, but is not limited to, a primary care clinician, nephrologist, dialysis nurse, cardiologist or vascular surgeon, advanced practice provider (nurse practitioner or physician assistant), social worker, dietitian, pharmacist, transplant team, and palliative care team.^70,71 For dialysis patients with cardiovascular disease, an IDC approach may help address care fragmentation that may be present with multiple subspecialty teams providing care.^72,73 While evidence regarding IDC is limited, a 2015 meta-analysis suggested that IDC is associated with improved outcomes in CKD,⁷⁴ and thus, we hypothesize the same may be true for dialysis patients with comorbid cardiovascular disease.

Home dialysis modalities may offer several potential benefits to patients with cardiovascular disease, but the paucity of randomized trials comparing home dialysis modalities with conventional hemodialysis limits our ability to predict whether increased uptake of home dialysis may meaningfully affect outcomes. Much of the current evidence examines surrogates either due to limited sample size or inadequate follow-up time. On the basis of the available literature, it is likely that more frequent and particularly extended duration hemodialysis improves BP and LV remodeling, while PD may reduce myocardial stunning, improve management of patients with severe heart failure, and lower the risk of blood stream infections. Importantly, there is significant variability in both home hemodialysis and PD prescriptions, which may influence outcomes. The decision to start home dialysis in a patient with comorbid cardiovascular disease requires a patient-centered discussion about the possible benefits and potential harms and an unbiased assessment of patient's ability to undergo dialysis in the home. These are best achieved with an IDC approach to care. Currently, substantial barriers remain regarding access to home dialysis. Addressing these barriers remains a critical component of improving health equity and advancing kidney and cardiovascular care.

Disclosures

A.C. Reaves was a member of the ASN Quality Committee. M.J. Sarnak reports consultancy for Akebia (the Steering Committee of a trial, Boehringer Ingelheim Advisory Board, and Cardurian and research funding from NIH. M.J. Sarnak's spouse reports employment and ownership interest in Eli Lilly. D.E. Weiner reports research funding from Bayer (site PI), Cara (site PI), and Vertex (site PI), with all compensation paid to employer Tufts MC; advisory or leadership role as Co-Editor-in-Chief of NKF Primer on Kidney Diseases 8th Edition, Editor-in-Chief of Kidney Medicine, Medical Director of Clinical Research for Dialysis Clinic Inc., member of ASN Quality and Policy Committees and ASN representative to KCP, and member of Scientific Advisory Board of National Kidney Foundation; and other interests or relationships as a member of the Safety and Clinical Events Committee for “A Prospective, Multicenter, Open-Label Assessment of Efficacy and Safety of Quanta SC+ for Home Hemodialysis” Trial (Avania CRO) and as a member of Adjudications Committee for ProKidney REACT Trial (George Institute CRO).

Funding

A.C. Reaves: National Center for Advancing Translational Sciences (TL1TR002546) and Driscoll Family Fund in Nephrology at Tufts Medical Center.

Author Contributions

Conceptualization: Allison C. Reaves, Mark J. Sarnak.

Writing – original draft: Allison C. Reaves, Mark J. Sarnak.

Writing – review & editing: Allison C. Reaves, Mark J. Sarnak, Daniel E. Weiner.