Solo home hemodialysis can be safe for patients and clinicians
Among the top three barriers to home dialysis, cited independently by both patients and clinicians, is the need for home-based support, according to data published in the American Journal of Kidney Disease in 2024.
The most recent USRDS Annual Data Report shows 14.5% of U.S. patients with end-stage kidney disease use home dialysis. For the 2.4% of patients who use home hemodialysis, the 2017 FDA clearance of the NxStage System One eliminated the requirement of assistance when using the machine at home during waking hours.
But whether clinicians knew it or not, patients were going solo before 2017, and others today are choosing unassisted HHD with systems not cleared for independent use, according to sources who spoke to Healio | Nephrology News & Issues.
“Ask yourself: Of your patients who are at home with partners, how many of your patients’ partners are actually in the room with them [while they perform HHD]?” Lisa Koester, ANP, CS, CNN-NP, MSN, a nephrology nurse practitioner in the nephrology division at the Washington University School of Medicine in St. Louis, and a Healio | Nephrology News & Issues Editorial Board Member, said during a debate about solo HHD at the Annual Dialysis Conference in March.
In a survey of her patients who used HHD, half reported dialyzing unassisted and another 20% said they considered going solo, Koester said.
“Ask your patients how much their care partner is doing for them. You will find out there is a lot of solo going on,” she said.
Although some patients are comfortable with unassisted HHD, some clinicians are not. During the March debate, Joanna Lee Neumann, RN, CNN, senior director of clinical services – quality at Satellite Healthcare in San Jose, California, argued risks for medical complications and mental health burden are too great to recommend solo HHD for all but a small group of patients.
Strategies are available to make solo HHD safer for patients and clinicians, according to Osama El Shamy, MD, FASN, FNKF, assistant professor of medicine in the division of kidney disease and hypertension at George Washington University School of Medicine in Washington, D.C., and a Healio | Nephrology News & Issues Editorial Board Member.
“There are providers who are worried about solo,” El Shamy said in an interview. “I need to make you as a provider more comfortable with solo, because otherwise you are depriving your patient of an option that you know they may be open to, and we have the technology to help support you as the provider to make you feel more comfortable.”
Patient preferences
The discussion to allow unassisted HHD went public during a workshop that was part of the Kidney Health Initiative in August 2015, according to El Shamy.
“The FDA heard from patient representatives that argued that the care partner requirement really ruled out home treatment for a lot of patients,” he said.
In 2017, a patient survey revealed 15% of HHD users routinely dialyzed independently, and of those who performed dialysis with a care partner, 16% reported going solo at least sometimes and 5% more than half the time.
“That was one of the first instances where the quiet part was said out loud,” El Shamy said.
Fresenius Medical Care conducted the survey to support its application for FDA clearance for the NxStage System One for independent use during waking hours. The company shared its unpublished survey data with Healio | Nephrology News & Issues.
For the survey, a third party collected emailed responses from 142 patients using HHD with a care partner (for a 13.5% response rate) from 129 dialysis clinics unaffiliated with DaVita or Fresenius Medical Care. Of respondents, 53% were younger than 60 years, 70% were men, 78% were white, 58% were retired and 78% had used HHD for at least 1 year.
Most respondents, including those who never went solo, said they were at least moderately confident in performing HHD tasks independently. Areas of least confidence were inserting needles and disconnecting — 41% and 39% of respondents, respectively, said they were slightly/not at all confident in performing the task by themselves.
When asked to consider all risks, including for needle dislodgement, hypotension and death, 60% of respondents said they would prefer solo HHD to in-center hemodialysis. Preference for solo HHD was stronger among younger, female, Black and employed patients.
‘Not for everyone’
In the Fresenius Medical Care survey, 27% of the respondents using HHD with a care partner said they had physical limitations preventing independent HHD. Of those, 28% said they would choose in-center dialysis over solo HHD, if they did not have assistance at home. However, other respondents expressed psychological concerns, such as fear of inserting their own needles or uncertainties about machine setup or ability to handle problems on their own, as reasons to avoid solo HHD.
Patient empowerment is what matters, according to Rachael Buening, RN, BSN, lead nephrology clinical specialist at Dialyze Direct, a company that provides hemodialysis to patients in skilled nursing home facilities and at home.
“When we are able to customize patient care to each individual based on their current needs, it’s a huge win for the patient,” Buening told Healio | Nephrology News & Issues. “With all the technology we have access to, we can accommodate and empower patients to take charge of their health needs, giving them back the autonomy that most patients lose when going through health issues and advanced disease processes, such as end-stage kidney disease. We also understand [solo HHD] is not for everyone.”
Patients who do well with solo HHD tend to be younger and have good mobility in their own home, Buening said. They need to have dexterity with their hands and the mental capacity to understand the processes and react appropriately to feedback and alarms. In addition, some patients may feel extra stress when managing dialysis alone. Others may feel isolated or lonely and prefer the safety and social aspects of a dialysis center.
Benefits for patients, care partners
However, “with the right patients, [solo HHD] really can change their lives.” Buening said.
HHD has benefits over in-center hemodialysis. In the Fresenius Medical Care survey, patients cited “better physical and emotional health,” “doing treatments on my own schedule,” “shorter recovery time after treatment” and “working and/or participating in more activities” among other perceived benefits. Solo HHD can extend those benefits to patients without a care partner.
Performing HHD unassisted can have additional benefits, according to Buening. Patients can take control of their own health and without needing to rely on a care partner’s schedule and ability. Patients’ greater involvement can increase adherence to their treatment plan, treatment satisfaction and quality of life.
Benefits extend to care partners, too, who are at risk for burnout, according to Koester.
“[Solo HHD] allows the responsibility to fall on the patient as opposed to the care partner,” she said. “Doing home dialysis gives them more control, and they learn reliance upon themselves, as opposed their care partners.”
Making solo safer
Patients choosing solo HHD typically receive more training on how their dialysis machine works and how to calculate volume as well as on preventive care and identifying and responding to complications quickly, Buening said.
Additional safety measures can include use of connected equipment, such as a Bluetooth blood pressure cuff that reports measurements and real-time communication with nurses through NxStage VersiHD with GuideMe software and Nx2me Connected Health. An alarm such as that from Red-sense Medical can detect needle dislodgment and bleeding. Buening also suggests an Alexa or hands-free cellphone for making emergency calls.
Patients dialyzing alone should prepare their space to have within reach all equipment and other desired items, such as a TV remote control or book, phone charger and flashlight, Koester said.
“People who do solo will tell you they have everything organized where the machine is, where their supplies are,” she said. “And the nurse helps them figure this out.”
Patients should also let someone know when they start and stop a dialysis session and leave a door unlocked in case emergency workers need access.
Patient-clinician agreement
Choosing solo HHD, whether with a NxStage system cleared for solo use or with another HHD system, should be a decision taken after discussion between patient and clinician about benefits and risks, according to El Shamy.
“CMS doesn’t really prohibit solo home hemodialysis, and the Department of Health will allow waivers for providers that are looking to let their patients do home hemodialysis solo,” he said.
For clinicians who do not want to pursue that official route, the waiver requirements might still provide reasonable guidance for talking with patients about solo HHD, he said. Points to cover in-clude the following:
- sleep cycle assessment and agreement that the patient will dialyze unassisted only during waking hours;
- agreement that solo HHD will be performed in an appropriate chair and not a bed;
- home visits three times per year to assess safety;
- emergency plan review at every monthly visit;
- patients continue to meet selection criteria, such as stable cognitive functioning and comorbidities;
- treatment adherence; and
- informed consent.
Finally, the discussion should be noted in the patient’s chart.
“This is really more about the patient than it is about me,” El Shamy said. “Like in anything else, if I can’t offer my patient what my patient is looking for, my patient is entitled to go and find someone who can.”
References:
- Fresenius Medical Care. Solo home hemodialysis: Patient experiences and attitudes about home hemodialysis without a care partner. 2017. Available at https://assets.mediafly.com/shares/641640cd243b4466b8f37efdcd389664product421897/9eea8 Accessed March 25, 2025.
- United States Renal Data System. 2024 USRDS Annual Data Report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2024. https://usrds-adr.niddk.nih.gov/2024. Accessed March 4, 2025.
- Reddy YNV, et al. Am J Kidney Dis. 2024;doi:10.1053/j.ajkd.2024.04.007.
- Koester L. Session 17: Home Dialysis Debates. Presented at: Annual Dialysis Conference.; March 13-16, 2025; Las Vegas.
For more information:
Rachael Buening, RN, BSN, can be reached at rbuening@dialyzedirect.com.
Osama El Shamy, MD, FASN, FNKF, can be reached at omelshamy@gmail.com; X @osamaelshamy88.
Lisa Koester, ANP, CNN-NP, can be reached at lkoester@wustl.edu; X @lisakoester11.
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