Is there a Role for Home Dialysis and what is Home Dialysis Today?

Abstract

The global economic crisis, the pressure toward de-hospitalization of chronic patients, and the innovations in the treatment of chronic uremia are the basis of the increased interest in “non-conventional or intensive” dialysis treatments, often necessarily performed at home. A first point highlighted in this narrative review is the overcoming of the historical antagonism between home hemodialysis (HHD) and peritoneal dialysis (PD), by the motto “home dialysis first”. In fact, justifying the decreased use of an HHD technique with the competition with another technique, PD, is as simplistic as considering that the ideal HHD patients are those who dropped out from PD. On the contrary, PD and HHD may even potentiate one another in settings requiring specific care. In this review we analyzed the issue of home dialysis also according to the four principles of the so-called principlism bioethics: beneficium, non maleficium, justice, and autonomy. If the benefit is not easy to prove, mainly because of the peculiar selection of the patients, the non maleficium is evident: in all the studies analyzed home hemodialysis (standard, daily, or intensive) led to results that were never significantly lower than conventional treatments, and were actually superior in most of the cases. The principle of justice, considered in a reductive way as “distributive” economical justice, was analyzed by evaluating the cost of treatment. Once more the issue is complex; in brief, direct costs were divided in costs of disposables and machines, and cost of medical and nursing staff. The economic benefit of reducing the workforce is obvious; however, a home treatment needs a “critical mass” of patients to be favorable from the economic point of view. Furthermore, the “indirect” costs (e.g., the hospital “structure”) are difficult to quantify. In any case, in no study the cost of HHD was higher than that of in-center HD. The fourth principle is patient's autonomy: there is however no choice without offer. Hence, physicians should be able to offer HHD to all patients without contraindications, by creating accessible reference centers where patients can be counseled by doctors, nurses, and patients with specific experience.