End-Stage Renal Disease (ESRD) represents the complete or near-complete failure of the kidneys. In the United States, approximately 517,000 patients currently receive some form of dialysis treatment. Dialysis cleans the blood by filtering out waste products and excess fluid when the kidneys can no longer perform this function. While most patients receive care in a specialized facility, home dialysis offers an alternative that allows treatment to occur in a patient’s own residence. This article explores the current utilization of home-based care and the factors that influence its adoption.
The Current Landscape: Home Dialysis Statistics in the U.S.
A substantial majority of the nation’s dialysis population receives treatment in a clinic setting. As of the most recent census data, approximately 78,400 individuals with ESRD manage their treatment at home. This number translates to roughly 15.2% of the total prevalent dialysis population in the United States.
This percentage indicates that the vast majority of patients are still treated with in-center hemodialysis, highlighting a significant gap between facility-based and home-based care options. Although home treatment rates have been increasing over the last decade, the growth in home modalities is a clear trend, with the percentage of home-based patients steadily climbing.
Understanding Home Treatment Modalities
Home dialysis consists of two primary methods: peritoneal dialysis (PD) and home hemodialysis (HHD). These two modalities differ fundamentally in how they clean the blood and the equipment required.
Peritoneal dialysis utilizes the body’s own peritoneal membrane, the lining of the abdomen, as a natural filter. A surgically placed catheter delivers a sterile solution called dialysate into the abdominal cavity, where it dwells for a period to draw out waste products and excess fluid. The used fluid is then drained and replaced, a process performed either manually several times a day or overnight using an automated cycling machine.
Home hemodialysis (HHD) functions similarly to in-center treatment but uses a smaller machine set up in the patient’s home. This method requires a vascular access, such as a fistula or graft, to draw blood out of the body, filter it through an external artificial kidney called a dialyzer, and return the cleaned blood. HHD is typically performed more frequently than the standard three-times-per-week in-center schedule, often five to six days a week for shorter sessions.
Peritoneal dialysis currently represents the dominant home treatment option, accounting for a significantly larger portion of the total home dialysis percentage than HHD. The choice between these two methods depends on a patient’s lifestyle, physical condition, and capacity to perform the treatment independently or with a care partner.
Factors Influencing Home Dialysis Uptake
The relatively low percentage of patients treating themselves at home is influenced by a complex interplay of systemic and patient-specific barriers. Systemic hurdles often center on the financial structure of kidney care, where historical reimbursement models have favored the higher volume and lower fixed costs of in-center care. Provider education and referral patterns also play a role, as some nephrologists and care teams may be less comfortable with or inclined to offer home options due to a lack of training or established infrastructure.
Patient eligibility is determined by specific criteria, including the need for a stable and appropriate home environment. Patients must have adequate storage space for supplies, which can be voluminous, and a clean area to perform exchanges or set up the equipment. Factors like housing overcrowding or living in a medically underserved area can also reduce the likelihood of a patient initiating home care.
The requirement for a capable care partner or sufficient patient dexterity and health literacy presents another layer of selection. Home treatment demands a high degree of patient involvement and self-management, which can be challenging for individuals with limited social support or certain physical and cognitive impairments.
Shifting Policy and Future Projections
Recent government policy has been specifically designed to address these barriers and promote a substantial shift toward home-based care. The Advancing American Kidney Health initiative, launched in 2019, set an ambitious goal to have 80% of new ESRD patients either start on home dialysis or receive a kidney transplant by 2025. This initiative introduced new payment models to encourage providers to prioritize home treatment.
The Centers for Medicare & Medicaid Services (CMS) launched the ESRD Treatment Choices (ETC) Model to adjust payments for providers based on their rates of home dialysis and transplant utilization. This model includes financial incentives for providers who increase their home treatment numbers, aiming to counteract the historical bias toward in-center care. While initial evaluations of the ETC model have shown only a modest increase in home dialysis rates in the first two years, the policy pressure remains.
Technological advancements, such as more compact and user-friendly HHD machines and improved telehealth support, are also helping to make home dialysis more accessible. Given the sustained policy focus and ongoing technological innovation, projections suggest the percentage of U.S. dialysis patients treating themselves at home will continue to rise over the next five to ten years. Although the ambitious 80% goal will likely not be met in the near term, the growth trajectory is clear as the infrastructure for home care expands.