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Dialysis has primarily been dominated by the conventional three times per week schedule. In the thrice-weekly world, dialysis prescriptions have been based mostly on achieving urea adequacy and managing the symptoms and morbidity associated with dialysis using medications, and expecting the patient to live with some symptoms. However, over the past several years, an interest in expanding home dialysis, specifically home hemodialysis (HHD), has been a focus of dialysis clinicians across the United States. This drive may be attributed to the following factors: growth of peritoneal dialysis (PD) stemming from changes in the payment system, modernization of technology that has decreased the burden of HHD, increasing interest in person-centered care, and increased awareness of the potential benefits of home therapies. This interest has not been missed by the US government, which has actively encouraged the expansion of home dialysis and transplantation through policy reform.

Indeed, HHD provides the opportunity for suitable patients to achieve more frequent dialysis with less burden and greater freedom to travel. Thus, the proper prescription for HHD can allow exploration of “optimal” versus “adequate” dialysis. The optimal dialysis prescription not only provides adequate dialysis but also provides improved volume and blood pressure control, decreasing the medication burden and symptoms associated with end-stage kidney disease (ESKD). Optimal dialysis, as opposed to adequate dialysis, must address sodium and water as the major dialyzable toxins, followed by phosphorus and middle molecular toxins, while maintaining the conventionally held urea adequacy targets. Using currently available technologies, dialysis can be optimized to improve morbidity and possibly even survival, hopefully increasing access to kidney transplant as well.

Dialysis populations across the world continue to increase, but growth in the United States has recently slowed. This growth primarily has been attributed to improved ESKD survival. Nevertheless, mortality rates remain much higher than in the age-matched US population.1 In fact, this improving survival has flattened out over the last 4 years without further improvement.2 Conventional three times a week dialysis fails to adequately address high cardiovascular morbidity and mortality, decreased quality-of-life (QOL) measures, high pill burden, and intolerability of conventional dialysis treatments.

HHD provides an opportunity to prescribe more frequent dialysis regimens that may improve overall survival and QOL for ESKD patients. Increasing adoption of HHD requires addressing barriers for both patients and clinicians. Improving modality education and ensuring patients understand all of their dialysis options and the benefits of each is an important initiative in growing home therapies. Lack of healthcare provider exposure to and education about HHD therapy perpetuates lack of familiarity and therefore creates a hesitancy to refer patients. The goal of this chapter is to review dosing and prescription management practices of HHD.

[For more information, see Chapter 14.]


In the past decade, there has been an increase in both observational and randomized controlled data ...

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