As the incidence of end-stage renal disease increases, the healthcare costs associated with the provision of dialysis therapy are globally escalating. This review article, recently published in the Postgraduate Medical Journal, discussed the challenges and potential benefits of home haemodialysis therapies compared with the conventional approach of in centre (hospital-based) treatments.

The conventional schedule for haemodialysis applies treatments of 3-5 hours duration, three times a week. Such a schedule may be used in the home, but is most common in the hospital environment, the timing dictated by centre limitations such as staff numbers, number of dialysis machines and opening times. Studies have shown the two day interdialytic period inherent in centre-based haemodialysis to be associated with increased mortality.

In contrast, the home environment allows more frequent dialysis, of longer duration, to be applied. This may take the form of a quotidian schedule, with treatments of either

• less than four hours duration, 5-7 times per week (short daily haemodialysis, SDHD); or
• more than five hours duration, 3-5 times per week (extended hours haemodialysis, EHD).

Also more common in the home is nocturnal haemodialysis (NHD), where overnight treatment sessions last for up to eight hours. Various studies have suggested that such extended treatment times may significantly improve survival rates in patients when compared with conventional schedules; one observational study reported a 7% reduction in mortality for every 30-minute increase in dialysis treatment time. Despite these encouraging results, the authors could find no reports of random controlled trials that showed lower mortality rates amongst home-based haemodialysis patients compared with hospital dialysis.

Blood pressure management is a key aspect of haemodialysis therapy, and home-based treatment has been shown to be extremely beneficial in this area. Several studies have shown that both SDHD and NHD treatment schedules can achieve greater reductions in blood pressure (compared to predialysis levels) than conventional haemodialysis, and are also associated with a reduction in the use of antihypertensive medication.

In various observational studies, patients converting from conventional to nocturnal haemodialysis have reported an improvement in quality of life. In one qualitative study, patients switching to home haemodialysis reported improvements in physical symptoms such as nausea and fluid retention, improvements in concentration and socialisation, and a decreased perception of being ill. These are extremely positive results, although the authors note that such results may be confounded by self-selection of more positive-feeling patients.

In the medium to long term, home haemodialysis is more cost-effective than centre-based, with reductions in nursing costs, lower medication use and reduced hospitalisation rates. The initial start-up costs, however, are high, and this is identified as one potential barrier to home haemodialysis. Studies suggest that improving the education of both clinicians and patients in home therapies may help improve the take-up of haemodialysis in the home.

Power A and Ashby D, `Haemodialysis: hospital or home?', Postgraduate Medical Journal, Published Online First: Nov 12, 2013. doi: 10.1136/postgradmedj-2012-131405.