For millions of people living with end-stage renal disease (ESRD), dialysis is not a treatment choice — it is a lifeline. Yet the form that treatment takes, where it happens, and how it fits into a patient’s daily existence, varies enormously across the world and profoundly shapes quality of life, clinical outcomes, and healthcare costs. Over recent decades, home-based dialysis modalities — principally peritoneal dialysis (PD) and home hemodialysis (HHD) — have emerged as scientifically validated, patient-centred alternatives to conventional in-centre hemodialysis. Despite compelling evidence in their favour, these modalities remain underutilised globally. The International Society of Nephrology has consistently championed the broader adoption of home therapies, recognising their potential to transform kidney care delivery worldwide. This article provides a comprehensive overview of the current evidence, the barriers to uptake, and the promising technologies that may redefine dialysis for future generations of patients.
systems in devices worn outside clinical settings.
Several research groups and commercial entities have made progress in each of these areas, and early clinical trials of prototype devices have been conducted. The International Society of Nephrology has followed this research frontier with close interest, recognising that wearable kidney technology — if successfully developed — could overcome many of the logistical limitations of current home modalities and substantially expand treatment access for ESRD patients worldwide.
Selecting the Right Modality: A Patient-Centred Approach
No single dialysis modality is optimal for all patients. The choice between in-centre HD, peritoneal dialysis, and home hemodialysis should be guided by a careful assessment of medical factors, patient preferences, lifestyle considerations, and practical circumstances.
Key considerations in modality selection include:
- Residual kidney function: PD is generally preferred when residual kidney function is better preserved, as it works synergistically with whatever filtration capacity the kidneys retain.
- Cardiovascular status: The more frequent sessions achievable with HHD may offer particular benefits for patients with significant cardiovascular disease.
- Peritoneal membrane function: PD suitability is partially determined by the patient’s peritoneal transport characteristics, assessed through testing.
- Patient capacity and support: The ability and willingness of the patient — and any caregiver — to undertake training and manage home procedures is central to the decision.
- Lifestyle and work commitments: Patients who wish to maintain employment or active travel may find automated PD or frequent short-session HHD more compatible with their goals.
Shared decision-making — in which the nephrologist and patient jointly weigh these factors — is increasingly recognised as the gold standard approach. This model, championed by the ISN, ensures that treatment decisions reflect the patient’s values and circumstances, not merely clinical convention.
Conclusion
Home-based dialysis modalities represent one of the most significant opportunities in contemporary nephrology to improve patient outcomes, quality of life, and healthcare system efficiency simultaneously. The clinical evidence, from the BOLDE study’s quality-of-life findings to the FHN Daily Trial’s cardiovascular benefits, is robust. The economic case is compelling. The alignment with patient-centred care principles is clear. Yet uptake remains far below what the evidence warrants in most countries, constrained by a complex web of system, provider, and patient-level barriers that require concerted, multifaceted action to dismantle.
The ISN (International Society of Nephrology) continues to play a vital role in translating evidence into policy and practice change — advocating for reimbursement reform, strengthening training infrastructure, and driving the research agenda toward future technologies that may one day make continuous, wearable dialysis a reality. As the global burden of kidney disease grows and health systems worldwide grapple with the challenge of providing renal replacement therapy equitably and sustainably, the expansion of home dialysis must be recognised not as a niche alternative, but as a central pillar of modern kidney care strategy.
Understanding End-Stage Renal Disease and the Need for Renal Replacement Therapy
The kidneys perform an extraordinary range of functions: filtering waste products from the blood, regulating fluid and electrolyte balance, controlling blood pressure, and producing hormones essential to red blood cell production and bone metabolism. When chronic kidney disease (CKD) progresses to its most severe stage — end-stage renal disease — the kidneys can no longer sustain these functions adequately, and renal replacement therapy (RRT) becomes necessary to maintain life.
The three primary forms of RRT are kidney transplantation, in-centre hemodialysis, and dialysis performed at home. While transplantation offers the best long-term outcomes for eligible patients, organ availability is severely limited worldwide. In-centre hemodialysis, in which patients travel to a clinical facility three times per week for sessions typically lasting three to four hours, remains the dominant modality globally — largely for historical, infrastructural, and reimbursement-related reasons. Home dialysis, though often producing comparable or superior outcomes, accounts for less than ten percent of dialysis care in most countries, as documented by the ISN Global Kidney Health Atlas (2019 edition, published in Kidney International Supplements).
What Is Home Dialysis? The Two Main Modalities
Peritoneal Dialysis
Peritoneal dialysis utilises the body’s own peritoneal membrane — a thin, semipermeable layer lining the abdominal cavity — as a natural filtration surface. A sterile dialysis fluid (dialysate) is introduced into the abdominal cavity through a surgically placed catheter. Over time, waste products and excess fluid move from the surrounding blood vessels into the dialysate through osmosis and diffusion. The fluid is then drained and replaced with fresh solution.
There are two primary forms of peritoneal dialysis:
- Continuous Ambulatory Peritoneal Dialysis (CAPD): The patient manually exchanges the dialysate fluid several times throughout the day, typically four exchanges of approximately two litres each. No machine is required, allowing patients to continue normal activities between exchanges.
- Automated Peritoneal Dialysis (APD): A cycler machine performs fluid exchanges automatically during the night while the patient sleeps. This approach, sometimes called overnight automated peritoneal dialysis, minimises disruption to daytime activities and is increasingly preferred by patients with active lifestyles or work commitments.
Because peritoneal dialysis is a continuous or near-continuous process, it more closely mimics the steady filtration function of a healthy kidney compared to the intermittent nature of conventional three-times-weekly hemodialysis.
Home Hemodialysis
Home hemodialysis (HHD) works on the same principle as in-centre hemodialysis — blood is drawn from the patient, passed through a dialyser (an artificial kidney membrane), and returned to the body — but it is performed in the patient’s home using a portable or compact dialysis machine. The critical distinction from conventional in-centre HD lies in the frequency and duration of treatments.
Conventional in-centre HD typically involves three four-hour sessions per week. Home hemodialysis can be performed more frequently — five to six times per week — or for longer nocturnal sessions. This increased treatment intensity offers meaningful clinical advantages, including superior clearance of metabolic waste, better fluid balance, improved phosphate control, and reduced cardiovascular strain.
Clinical Evidence Supporting Home Dialysis
The evidence base for home dialysis has grown substantially over the past two decades. Key findings are summarised in the table below.
| Study | Modality | Key Findings |
|---|---|---|
| BOLDE Study (Brown et al., Nephrology Dialysis Transplantation, 2010) | Peritoneal Dialysis vs. In-Centre HD | PD patients reported equivalent or superior illness intrusiveness and depression scores compared to in-centre HD patients, supporting quality-of-life advantages of home therapy |
| FHN Daily Trial (Chertow et al., New England Journal of Medicine, 2010) | Home Hemodialysis (frequent) | Frequent in-home HD significantly improved left ventricular mass index and self-reported physical health scores; also improved phosphate control and blood pressure compared to conventional HD |
| ISN Global Kidney Health Atlas, 2019 (Kidney International Supplements) | Home Dialysis (PD & HHD) | Home dialysis uptake remains below 10% in most countries despite evidence of comparable or superior outcomes in appropriately selected patients |
| Economic analyses (American Journal of Kidney Diseases) | Home Dialysis (PD & HHD) | Home modalities demonstrate reduced per-patient costs relative to facility-based treatment in many health system contexts |
The BOLDE study was particularly significant in challenging the assumption that home-based therapies would be more burdensome for patients. By measuring illness intrusiveness — the degree to which a disease and its treatment interfere with important life domains — and depression, researchers found that patients on peritoneal dialysis fared at least as well as those receiving conventional hemodialysis. This finding directly supports the intuitive case for home therapies: when dialysis is integrated into home life rather than requiring repeated journeys to a clinical facility, patients retain greater autonomy, flexibility, and psychological wellbeing.
The FHN Daily Trial addressed a longstanding question in nephrology: does increasing the frequency of hemodialysis improve cardiovascular outcomes? The answer was clearly affirmative. More frequent dialysis reduced the burden on the heart — measurable through improvements in left ventricular mass index, a marker closely linked to cardiovascular mortality in dialysis patients. It also brought phosphate levels under better control, a significant clinical benefit given that uncontrolled hyperphosphatemia contributes to vascular calcification and bone disease in ESRD patients.
Quality of Life: A Central Consideration
Discussions of dialysis outcomes have historically centred on survival rates and laboratory values. However, there is growing recognition — central to the mission of the International Society of Nephrology — that patient-reported outcomes and quality of life must occupy an equal place in clinical decision-making.
For most patients, the rhythms of in-centre hemodialysis are deeply disruptive. Three full days of each week are consumed by travel, waiting, treatment, and recovery. Employment becomes difficult or impossible for many patients, and family and social life is constrained. Fatigue following conventional HD sessions is nearly universal, with many patients reporting that they spend the remainder of the treatment day recovering before the next session approaches.
Home dialysis, by contrast, allows patients to schedule therapy around their lives rather than the reverse. Those on automated PD sleep through their nightly treatment cycle. Patients on frequent home HD, while managing a more complex procedure, often report that the improved physiological stability — less fluid gain between sessions, steadier blood pressure, less post-dialysis fatigue — substantially improves their functional capacity and overall wellbeing. Employment rates, social participation, and travel are all more feasible for well-trained home dialysis patients.
These quality-of-life advantages are not trivial. They represent meaningful differences in patients’ ability to maintain their roles as parents, partners, workers, and members of their communities. The ISN has consistently emphasised that patient-centred care must account for these dimensions of wellbeing alongside clinical metrics.
Economic Considerations and Policy Implications
The global burden of ESRD is growing. As populations age and rates of diabetes and hypertension rise worldwide, the number of patients requiring renal replacement therapy is projected to increase substantially through the coming decades. This trajectory creates an urgent challenge for healthcare systems, many of which are already strained by the costs of providing conventional in-centre hemodialysis.
Economic analyses published in the American Journal of Kidney Diseases have demonstrated that home dialysis modalities, particularly peritoneal dialysis, can significantly reduce per-patient costs compared to facility-based treatment in many healthcare contexts. The savings arise from multiple sources: reduced infrastructure requirements (no dialysis unit needed), lower staffing ratios, and the elimination of transport costs for patients and systems. In lower- and middle-income countries where building and staffing dialysis centres presents a major financial barrier, PD in particular offers a viable pathway to expanding treatment access.
Despite this economic logic, reimbursement structures in many health systems have historically favoured in-centre hemodialysis, creating a financial disincentive for both providers and patients to consider home alternatives. The ISN (International Society of Nephrology) has actively advocated for healthcare policy reforms that align reimbursement incentives with evidence-based care, encouraging policymakers to redesign payment frameworks that reward home dialysis uptake and patient-centred outcomes.
Barriers to Home Dialysis Adoption
If the clinical evidence is favourable and the economic case is compelling, why does home dialysis remain underutilised in most parts of the world? The barriers are multiple and interrelated.
Patient-Level Barriers
- Caregiver burden: Many patients, particularly older individuals or those with physical limitations, rely on a family member or partner to assist with home dialysis procedures. The demands placed on caregivers can be significant and are not always adequately acknowledged or supported by health systems.
- Anxiety and confidence: The prospect of performing dialysis at home — inserting needles, managing equipment, troubleshooting complications — is understandably daunting for many patients. Effective training and ongoing psychological support are essential to building confidence.
- Home suitability: Not all patients have living situations conducive to home dialysis. Space requirements, access to clean water, and electrical supply can all present challenges, particularly for patients in lower-income circumstances or those living in rural or remote areas.
System-Level Barriers
- Inadequate training infrastructure: High-quality, comprehensive patient education programmes are essential to the success of home dialysis but are not universally available. Many nephrology centres lack dedicated home dialysis coordinators or training facilities.
- Reimbursement inequities: As noted above, payment structures that favour in-centre HD create systemic incentives that work against the expansion of home modalities, regardless of clinical evidence.
- Physician familiarity: Nephrologists whose training and practice experience has centred on in-centre HD may not be equally confident prescribing or managing home therapies. Addressing this requires changes in specialist education and training curricula.
- Supply chain and logistics: The delivery of dialysis supplies to patients’ homes — large volumes of dialysate, equipment, and consumables — requires reliable supply chains that are not always present, particularly in low- and middle-income countries.
The Role of the International Society of Nephrology
The International Society of Nephrology occupies a unique position in global kidney health: as a scientific and professional organisation with members in more than one hundred countries, ISN bridges the gap between cutting-edge research and clinical practice across vastly different health system contexts.
Through its Global Kidney Health Atlas initiative, the ISN has produced essential data on dialysis access and modality distribution worldwide, providing the evidence base that policymakers, clinicians, and advocates need to argue for systemic change. Through its educational programmes, advocacy activities, and clinical guidelines, ISN promotes the expansion of home dialysis as a core component of patient-centred, equitable kidney care.
The ISN’s commitment to addressing disparities in dialysis access is particularly important given the profound global inequity in renal replacement therapy. In high-income countries, access to dialysis — though imperfect — is broadly available. In many low- and middle-income countries, the majority of patients who develop ESRD have no access to any form of RRT. Scaling up home dialysis, especially peritoneal dialysis, in these contexts represents one of the most realistic pathways to expanding treatment access within existing resource constraints.
Emerging Technologies: Toward Wearable and Portable Artificial Kidneys
Even as the evidence for existing home dialysis modalities accumulates, researchers and engineers are working toward the next generation of renal replacement technology: wearable and portable artificial kidney devices. A roadmap for this field, published in the Clinical Journal of the American Society of Nephrology by Gura and colleagues in 2016, outlined the scientific and engineering challenges involved in miniaturising dialysis technology sufficiently to create devices that patients could wear or carry continuously.
The ambition is significant. Current home dialysis, while far more flexible than in-centre treatment, still imposes constraints on patients: nightly connections to cycler machines, home-based hemodialysis sessions of several hours, and the need for ongoing supply deliveries. A truly wearable artificial kidney would provide continuous, gentle dialysis integrated seamlessly into daily life — an approach that would more closely approximate the function of a healthy kidney than any currently available modality.
Technical challenges remain substantial. These include the miniaturisation of the dialyser and fluid management systems, the development of sorbent-based systems that can regenerate dialysate continuously without requiring large fluid volumes, the creation of reliable vascular access compatible with continuous wear, and the engineering of robust safety