Is Home Dialysis a Good Choice for You?

Dialysis is one treatment for chronic kidney disease (CKD). The job of the kidneys is to filter our blood. But when they no longer work as they should, dialysis can help. Dialysis filters blood using a machine, or fluid, to do the work the kidneys usually do. It may be needed long term to treat end-stage renal disease (ESRD) or kidney failure. 

Here we’ll talk more about dialysis, including the types, benefits, and costs of doing dialysis at home versus in a dialysis center.

What is in-home dialysis?

In-home dialysis allows people to do dialysis treatments at home without needing to go to a dialysis center or clinic. It requires certain space, equipment, supplies, and training. But it can offer more independence and flexibility.

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In the U.S., over 600,000 people have kidney failure. Over 70% of them receive dialysis treatments to manage their kidney disease. Most people in the U.S. receive their dialysis treatments at a center. In-home dialysis is available, but it’s less common. Only about 12% of people on dialysis were treated at home in 2017. 

What types of in-home dialysis are offered?

Two types of home dialysis are available in the U.S.: hemodialysis (HD) and peritoneal dialysis (PD). 

Hemodialysis

HD involves using a dialysis machine and a special filter called a dialyzer to clean the blood. This works like an artificial kidney. To do HD you need vascular access, or a way to move your blood from your body, through the dialyzer, and back to your body. Access for HD can be obtained through:

• A catheter: This is a small tube that’s placed in a large vein in the neck.

• An arteriovenous (AV) fistula: A surgeon joins a vein to an artery in the arm or leg.

• A graft: A surgeon uses a prosthetic material to join a vein and artery in the arm or leg.

Once you have access, HD is done by inserting two small needles into the access point. These connect to small plastic tubing that carries your blood through the dialyzer and then back to you. HD removes toxins, controls fluid levels, and regulates blood pressure. It also keeps sodium, potassium, and bicarbonate levels in check, like the kidneys normally would.

Peritoneal dialysis

PD differs from HD in that it uses space in the abdomen, or peritoneal cavity, to filter the body’s toxins instead of removing blood from vessels. To do PD, you need a different type of access. A surgeon will place a small tube, or catheter, into your abdomen. The catheter delivers and removes dialysis fluid, or dialysate. 

PD works by using the abdomen’s natural lining — the peritoneum — as a filter. The dialysate pulls toxins into the fluid from the blood vessels that line the peritoneal cavity. After a few hours, this fluid is removed from the abdomen and disposed of. This is called an exchange. 

There are two main types of PD:

• Continuous ambulatory PD (CAPD): This allows for a few exchanges each day, which are done by hand. 

• Automated PD (APD): APD uses a machine called a cycler to automatically add and remove the fluid for you. Usually this is done while you sleep. 

What’s the difference between home dialysis and center dialysis?

Home dialysis is currently less common in the U.S. But it may lead to higher survival compared to in-center dialysis. People receiving home dialysis have also reported better quality of life, with more flexibility and control over their treatments.

When dialysis is done in a center, people often need to go 3 times per week for up to 4 hours at a time. This makes it difficult for most people who receive dialysis to keep employment. If you live in a rural area, you may have to travel a few hours to get to the nearest center. 

Advantages of home dialysis are flexibility and convenience. It can be done more frequently for shorter periods of time and at night — all without travel to a center. 

That said, in-home dialysis requires more planning and setup. Dialysis at a center only requires you to show up. 

To do dialysis at home, you’ll need:

• Training: This may take a few weeks. Dialysis nurses and staff will teach you how to do HD or PD at home and care for your equipment.

• Equipment: You will need a dialysis machine or cycler, related supplies (dialyzers, fluid, tubing), and cleaning supplies. 

• Space: You’ll need space to store your dialysis machine and/or supplies.

• Help at home: It’s a good idea to have someone at home who can support you and help you with your treatments. 

With in-home dialysis, you’ll still work with your healthcare team to oversee everything. You’ll have regular visits and blood work to be sure that your home dialysis is safe and effective.

The best type of dialysis for you depends on your personal preferences, cost, and the details of your medical conditions. If you have CKD, it’s important to learn about ESRD treatment options early, before you need to start dialysis. This can help you make an informed decision about the best treatment for you. 

Why don’t more people do in-home dialysis?

So far, in-center hemodialysis has been the most common type provided in the U.S. This is likely due to a couple of things. Many people aren’t aware of all ESRD treatment options, including home dialysis. There’s also not enough support for healthcare providers who are interested in providing home dialysis.

But experts want to expand in-home dialysis and kidney transplant as the primary treatment for ESRD. The U.S. Department of Health and Human Services announced in 2019 the Advancing American Kidney Health initiative. One goal of the initiative is to have 80% of new ESRD patients receive home dialysis or kidney transplant as their first treatment by 2025.

Additionally, the Centers for Medicare and Medicaid Services (CMS) announced a plan to support and increase the use of home dialysis and kidney transplants for people with ESRD on Medicare.

Who should opt for home dialysis over center dialysis?

Deciding on home versus in-center dialysis is a choice you will make with the help of your healthcare team. There are advantages to home dialysis, including:

• A more flexible dialysis schedule

• More independence and autonomy over your treatment

• Easier time keeping employment

• More time to spend with loved ones

That said, home dialysis isn’t for everyone. There are reasons it can be more challenging, including:

• Less contact with medical personnel during treatment

• Increased stress on caregivers who may need to assist with dialysis

• Social isolation when treatment is done alone at home

• Desire to keep dialysis treatment and supplies separate from the home

Where can you find a center that offers in-home dialysis?

If you’re interested in home dialysis, be sure to discuss this with your kidney specialist and healthcare team. You will want to find a center or clinic that supports home dialysis. Private, for-profit dialysis centers do this, as do those affiliated with hospitals and larger health systems. 

The center can review with you the different types of dialysis, details about training, and arrangements for home dialysis. They will also support you along the way. You can also use the Medicare.gov search tool to find dialysis centers near you that offer home dialysis programs. 

Are there alternative treatment options to dialysis?

Kidney transplant is an alternative treatment for ESRD. In fact, transplant is associated with fewer complications and longer life expectancy than dialysis. But most people with ESRD receive dialysis – there are fewer who live with a working kidney transplant. Most people will wait about 4 years on a transplant list before a kidney is available. Many will need dialysis while waiting. 

The Advancing American Kidney Health initiative aims to double the number of kidneys available for transplant by 2030. Their goal is to make it easier for living donors to donate and to increase the number of kidneys used from deceased donors. The hope is this will decrease wait times and make transplant a more common treatment option for people with ESRD in the near future. 

If you have CKD, consider talking to your kidney specialist early on about your treatment options. An early discussion can help you prepare in case you need future treatment for kidney failure.

Does insurance cover in-home dialysis?

If you have ESRD, you become eligible for Medicare at any age, as long as you meet all the requirements. Medicare (Part B) does cover in-home dialysis training, equipment, supplies, and support. For home dialysis training, Medicare pays 80% of the cost once the annual deductible is met, and you pay the remaining 20%. If you have other insurance coverage (from a commercial plan, Medicaid, Medigap, or Medicare advantage plan), it may cover costs that Medicare won’t. 

It’s important to understand your coverage. Dialysis centers have staff and social workers who can help you decide what coverage to use to get the treatment you need. You can read more about Medicare coverage for in-home dialysis here.

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Written by:

Sarah Pozniak, MD

Sarah Pozniak, MD, has 9 years of experience since graduating medical school (6 since completing residency). She is a board-certified general internal medicine physician and has practiced as a primary care physician in both Utah and Washington, D.C. Currently, she cares for patients with chronic illnesses such as diabetes and high blood pressure using telemedicine as part of a virtual care program.

Edited by:

Mandy Armitage, MD

Mandy Armitage, MD, has combined her interests in clinical medicine with her passion for education and content development for many years. She served as medical director for the health technology companies HealthLoop (now Get Well) and Doximity.

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