Table 2.

Challenges when transitioning to HHD

Transition to HHD	Patient perspective	Health care staff perspective
From pre-dialysis	Psychological acceptance: Accepting the medical condition and the need for lifelong treatment Sensation of loss of freedom: accepting that ‘now I am dependent on a machine to continue living’ Fear of: Self-care Being alone and not having support if something happens at home Having problems at home and not being able to resolve them Being unqualified to manage technically complex dialysis machines Self-cannulation of vascular access Needling or blood Concerns about: Social isolation Medical disconnection Home adaptations and ‘medicalizing’ the home environment Caregiver burden	Encouraging the patient to choose a home-based technique Timely creation of vascular access to avoid catheters, if possible Adjusting the dialysis prescription to best address the patient’s individual needs Encouraging the patient to continue their life as normally as possible by adapting dialysis to their life, not their life to dialysis
From facility HD	Fear of: Self-care Being alone and not having support if something happens at home Having problems at home and not being able to resolve them Being unqualified to manage technically complex dialysis machines Self-cannulation of vascular access Needling or blood Concerns about: Social isolation Medical disconnection Home adaptations and ‘medicalizing’ the home environment Caregiver burden	Helping the patient: To change their attitude towards treatment and to favour self-care; teaching them how to take control of their medical condition and their own treatment To understand that they will not be alone at home and there will always be someone to whom they can turn in case of problems Adjusting the dialysis prescription to best address the patient’s individual needs Teaching the patient to have flexibility in treatment and that being at home will give them a greater sense of freedom
From failed PD	Fear of: A more complicated technique and being unqualified to manage technically complex dialysis machines Needling or blood Concerns about: Adapting to different and specific infrastructure, including the need for more space and more complex machines Different access (vascular access)	Encouraging the patient to continue treatment in a home-based setting, although this change will be difficult at the beginning, given PD is a much simpler technique in all aspects, compared with HHD Timely creation of vascular access to avoid catheters, if possible Adjusting parameters related to: Inadequate dialysis dose or ultrafiltration failure due to PD technique failure Dialysis prescription that best addresses the patient’s individual needs
From failed transplant	Fear of: Self-care Being alone and not having support if something happens at home Having problems at home and not being able to resolve them Being unqualified to manage technically complex dialysis machines Self-cannulation of vascular access Needling or blood Concerns about: Home adaptations for installing specific infrastructure to accommodate a dialysis machine and ‘medicalizing’ the home environment Caregiver burden Psychological acceptance of the needed of dialysis and loss of freedom Sensation of loss of freedom: accepting that ‘now I am dependent on a machine to continue living’	Helping the patient to psychologically assimilate the change. Encouraging the patient to gain control of their medical condition and take control of their own treatment Timely creation of vascular access to avoid catheters, if possible (if the patient does not have a previously created functioning access) Adjusting parameters related to: Malfunction of the renal graft Dialysis prescription that best addresses the patient’s individual needs Gradual decrease in immunosuppression Teaching the patient to have flexibility in treatment and that being at home will give them a greater sense of freedom Encouraging the patient to continue life as normally as possible by adapting dialysis to the patient’s life, not his/her life to dialysis

Each change (transition from pre-dialysis, facility HD or PD or due to kidney transplant failure) gives rise to different challenges and requires an individualized approach from the different perspectives of the patient and health care professionals in each specific situation.