Home haemodialysis: how it began, where it went wrong, and what it may yet be

Abstract

In the first period of maintenance dialysis (circa 1960–1972/3), there was a hope—even an expectation— among the pioneers of dialysis [Shaldon and Buoncristiani in the UK and Europe (both pictured), and Scribner in the US] that dialytic therapies may evolve into a primarily home-delivered self-care process that could be held at arms’ length from the hospital precinct. And ... for a time, this goal seemed achievable (Figs. 1, 2). However, as fate would have it, politics dealt home dialysis an unintended consequence [1]. One week prior to the US presidential election in 1972, an 11th hour addendum to the Social Security Amendment Act H.R.1 (Section 2991) saw Medicare assume responsibility for the provision of and payment for maintenance dialysis in the US—an addendum that opened the flood gates for for-profit dialysis in ‘centres’ while—likely unintentionally—fiscally biasing against home management. Home dialysis—at that time accounting for some 50% of all patients on dialysis in the US—was dead in the water. Most other jurisdictions followed suit. Ironically as it turns out, in that very same year, a new Labor government came to power in Australia with a highly popular platform to introduce universal healthcare for all. A stated and rapidly legislated subtext of that platform was that all dialysis modalities and regimens would be provided, free of charge, and at any site (home or centre), for any and all Australians who might reach end-stage renal failure [2]. That promise rapidly translated to legislation, and has remained in place to this day. So, here are two countries—so similar in many ways—yet with starkly divergent political policies around dialysis, both hatched contemporaneously. Not surprisingly and in relative terms, home dialysis continued to flourish in Australia, while it progressively withered across the US. At the end of 2017, ~ 18% of all dialysis in Australia is at home [3]. In the US, cumulative home peritoneal and haemodialysis was 8.3% [4]. Meanwhile, putting all to shame, at the end of 2017 47% of all patients in New Zealand were dialyzing at home [3]. Further, in Australia, where home dialysis is ~ 2/3rds the annual per-patient cost of centre-based dialysis [5], home dialysis modalities have been encouraged and actively supported. In the US, where profit-taking still dominates dialysis-delivery models, the lack of a profit margin in home management has remained a disincentive to growth in home care. This is so, despite clear data that demonstrates better outcomes and survival in home care programs [6]. In Europe, the development of home hemodialysis in the UK quickly triggered a similar interest in France, then Italy [7]. But no parallel legislative framework emerged to regulate home therapies. When the first Italian patient began