In July 1997, one of the authors [KS] was diagnosed with Atypical Hemolytic Uremic Syndrome at the age of 21. He was initiated on dialysis immediately and has been on dialysis ever since. For the first two years, in-center hemodialysis meant frequent trips to the hospital, a compromised lifestyle, and a future filled with uncertainty.  Two decades later, he lives a full, normal, and fulfilling life. And, he credits much of that to home dialysis.

From 1999 to 2005, he was on Peritoneal Dialysis (PD).  Subsequently, he has been on Home Hemodialysis (HHD) which he performs five nights a week while he is asleep. He works full-time, travels, pursues his interests, and even co-founded NephroPlus, a dialysis network that now spans the country. His journey is living proof of the potential of home therapies—not just to sustain life, but to let patients thrive. Unfortunately, stories like his are still rare in India and other countries.

Dr. Mala Sachdeva is an advocate for home dialysis therapies.  She emphasizes patient empowerment, flexibility, and improved quality of life through home modalities like PD and HHD. Despite existing and potential barriers that are perceived with home dialysis, she does believe that many of these barriers can be overcome, and home therapies should be viable options for all on renal replacement therapy who cannot receive a pre-emptive transplant.

The Power and Promise of Home Dialysis

As kidney disease progresses, it is ideal for patients to start having conversations with their Nephrologist regarding what to do when they are reaching End Stage Kidney Disease.  Options include pre-emptive kidney transplantation, in-center hemodialysis, palliative care, or home dialysis.

If transplantation is not a viable option at the time when kidney disease has progressed, home dialysis should be the next best therapy. There are two types of home dialysis: Peritoneal Dialysis (PD) and Home Hemodialysis (HHD).  Peritoneal Dialysis is performed with a peritoneal dialysis catheter and utilizes special premade fluids that are filled and drained into and out of the abdomen, using the natural lining of the abdomen (the parietal and visceral peritoneal membranes) and requires a cycler machine for dialysis.  Home Hemodialysis is performed using a dialysis machine and preferably an arm access called arteriovenous fistula or graft.  Here, blood is filtered through the dialyzer of the machine to remove wastes and excess fluid.

Benefits of Home Dialysis

Both these home modalities can be performed in the familiarity of a patient's home environment.  This means less clinic visits.  Instead of three times a week, in-center treatment visits, patients can go to the clinic on average one or two times a month, allowing them more flexibility with time to do other things.

Many patients on a home modality feel a sense of autonomy and independence regarding the timing of dialysis.  Again, this allows ability to continue with one's day to day routine, allowing them to work, go to appointments, or fulfil other personal commitments.

There are many medical benefits of more frequent home hemodialysis. These include but are not limited to: better blood pressure control, less phosphorus and dietary restrictions, improved anemia, and improved cardiovascular outcomes.

Where Does India Stand Today?

Despite a growing dialysis population, now estimated to exceed 250,000 chronic patients according to the India CKD Registry, less than 10% are on PD, and an even smaller fraction are on home HD. The vast majority are dependent on three times a week in-center hemodialysis.

The government's Pradhan Mantri National Dialysis Programme (PMNDP), launched in 2016, has expanded access to in-center HD in district hospitals. However, home dialysis has not been systematically integrated into public health frameworks. Consequently, most Indian patients are never even offered the choice of home therapy.

Where Does The United States Stand Today?

In 2019, the U.S. President passed the Advancing American Kidney Health (AAKH) initiative1. Its aim was to improve care for patients with kidney disease by increasing home dialysis as well as kidney transplantation. It involved changing regulations and putting different payment plans into place.

From 2024 USRDS data, there has been both an increase in home dialysis incidence and prevalence from 2012 to 2022, with numbers increasing from 8.3% to 14.0% for incident PD, and 0.3% to 0.4% for incident HHD, 8.8% to 12.1% for prevalent PD, and 1.5% to 2.4% for prevalent HHD.  In 2022, 14.5% of all dialysis patients were on a home modality (PD or HHD)2.  These numbers, however, are still considered low, despite national efforts to increase kidney care.

Perceived Barriers to Home Dialysis and How Can They Be Overcome?

Home therapies can be empowering, however structural and societal barriers exist.  These barriers can be overcome with careful and timely implementation.

Lack of Awareness and Counselling:

A 2023 study in BMC Nephrology found that more than 70% of Indian dialysis patients surveyed had never heard of home dialysis options. Pre-dialysis counselling remains inconsistent, and many nephrologists are not trained in home dialysis initiation.  Increased awareness of home dialysis is needed in India and worldwide.

Despite resources and change in payment plans, numbers on home dialysis in the U.S. are still low. Continued counselling and education for patients, their families, and nephrologists is still needed.  Home dialysis coordinators or virtual support teams can bridge gaps in smaller towns.

More pre-dialysis education that presents all options to chronic kidney disease patients is needed.  Patient advocacy organizations and dialysis networks must champion “modality neutrality,” where the best option and patient choice is offered.  At the author's (MS) institution, a comprehensive kidney program, healthy transition program, was developed that focused on improving late stage kidney disease outcomes, including transplantation and home dialysis.  These efforts have shown success and perhaps also serve as a model program for other countries3.

Financial Barriers:

While in-center hemodialysis is reimbursed under schemes like PMNDP, Ayushman Bharat, and state health insurance programs, home dialysis costs–PD fluid, cyclers, or home HD machines–are largely out-of-pocket expenses in India. Perhaps, PMNDP should evolve to reimburse PD and HHD through government schemes. Kerala's PD-first policy is a positive step, but wider implementation is needed.  A 2022 Health Technology Assessment by the Department of Health Research noted that PD could be cost-competitive if scaled, but uptake remains low. Other countries such as the U.S. may be able to serve as a model regarding reimbursement.

Infrastructure and Support Gaps:

Home hemodialysis machines and PD cyclers require electricity backup. In the event of electricity or power outage, there has to be a backup plan in place.  In addition, the need for sterility of the home environment and also for clean water supply meeting appropriate chemical and microbiological standards is needed for home haemodialysis.  Delivery of supplies for dialysis from companies especially in rural areas or many cities in India may also limit and create gaps in care.

 Cultural and Social Barriers:

If a patient cannot perform their own dialysis, a trained caregiver can assist.  Sometimes this can create caregiver burden, yet other times there may not be an available caregiver. Some countries have assisted peritoneal dialysis as a model of care for the dialysis patients and perhaps these options need to be explored by countries that do not implement this model4.

Some families fear infections, lack confidence in medical procedures at home, or worry about turning their homes into “mini-hospitals.”  They may not accept doing dialysis at home. In joint families, there may be resistance to invasive devices or clinical equipment in shared spaces. More counselling and support to family members can be of help in these situations.

Success Stories Exist Which Can be Multiplied

According to KS, in cities like Hyderabad and Chennai, some patients have successfully transitioned to home dialysis with supportive clinicians. Dialysis providers like NephroPlus and Apex Kidney Care offer Assisted Home HD services as well. Pilot programs in Maharashtra and Delhi are beginning to show that PD can be delivered affordably at scale.

International models, such as Hong Kong's PD-first strategy (used in 80% of ESKD cases), or Canada's and the United States bundled payment systems can serve as models.

Conclusion: Bringing Dialysis Home

Home dialysis is a safe and effective option for many patients. It offers improved quality of life and many medical benefits.  Although it has its challenges, these challenges can be easily overcome. Home dialysis should be a bridge–a way to reclaim normalcy. For many, home is the best place to cross it.  Patients living with kidney disease in India need more choice, access, and dignity.  It's time to bring dialysis home.

1.         https://trumpwhitehouse.archives.gov/presidential-actions/executive-order-advancing-american-kidney-health/

2.         https://homedialysis.org/news-and-research/blog/628-home-dialysis-updates-from-the-2024-usrds-annual-data-report?utm_source=chatgpt.com

3.         Fishbane S, Halinski, C,  Alaiev, A, Porzelt, E,  Sakhiya, V,  McGroarty, Noreen. Challenges and Opportunities in Advanced Chronic Kidney Disease.

Clinical Journal of the American Society of Nephrology 19(12):p1656-1658 (2024)

4.         Giuliani, A., Sgarabotto, L., Manani, S.M. et al. Assisted peritoneal dialysis: strategies and outcomes. Ren Replace Ther 8, 2 (2022)