UK nephrology misunderstood

Blagg criticises the UK renal community for lagging behind some other high income countries in the proportion of patients receiving home haemodialysis (HD).¹

A generation of UK nephrologists was forced, by lack of facilities, to give patients a stark choice between home HD, home peritoneal dialysis, or death. As hospital and satellite dialysis facilities have expanded, the proportion of patients receiving home based treatment has rightly reduced. Whether that reduction is due to poor availability or to free choice between home HD and other options remains open to question.

Many patients perceive no advantage of home HD when the alternative is a local satellite dialysis unit. Patients receiving satellite or hospital based HD can also control many aspects of their own treatment. What the “correct” proportion should be cannot be based on comparisons with Australia and New Zealand, where for reasons of geographical dispersion, home HD remains the only viable option for many patients. Provision of home HD requires a community team of nurses and technologists. Some UK units therefore choose to refer their patients to a neighbouring unit for home HD rather than run their own home HD programme; this is not evidence in itself that suitable patients are not offered home HD.

Policy in the UK supporting the use of home HD is set by the Departments of Health and the National Institute for Health and Clinical Excellence (NICE). UK nephrologists fully agree that home HD should be offered to all suitable patients, but they have doubts that the NICE target—15% of all HD should be performed at home—is based on good evidence. Similarly, whereas they are enthusiastic about daily short hours or nightly long hours HD, this treatment is not endorsed by national policy or by NICE—largely because there is not, at this point, sound evidence of benefit.