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Outpatient home hemodialysis (HHD) began contemporaneously in the 1960s with chronic center-based hemodialysis (HD) and before the routine provision of home peritoneal dialysis (PD).1 Prior to the establishment of the Medicare End-Stage Renal Disease program in 1973 in the United States, approximately 40% of US dialysis patients were treated with HHD, although the patient demographics and clinical conditions were much different than today.2 Over the following decade, home-based PD and conventional thrice-weekly facility-based HD—with over 7000 locations currently—overwhelmed HHD. The subsequent elimination of any assistance on care partner financial support and the economic unfeasibility of staff-assisted HHD further pushed HHD to near extinction by the late 1990s. As a result, a substantial number of nephrologists have neither encountered an HHD patient nor observed a treatment.3,4

From this nadir, the prevalence of HHD has nearly tripled over the last 15 years for a variety of reasons, and this trend is expected to continue.2,3,5 In order to provide adequate access to HHD, more HHD programs will be needed with engaged nephrologists participating in the program-building process. This chapter will focus on setting up, building, and sustaining an HHD program, mainly based on practices in North America. A well-developed strategic plan that addresses financial sustainability, practical logistical issues, and administrative policies are the foundation of a successful program.



The first step in developing an HHD program is to estimate its ultimate size. Estimation of scale is a relatively straightforward process but is rarely handled well. First, one should determine the potential geographic “catchment area.” Then, obtain the number of end-stage kidney disease (ESKD) patients within the geographic area, and after discussion with several nephrologists, determine what percentage of patients are potential home dialysis patients (10% to 40% is the current range). Lastly, ascertain what the most likely breakdown between PD and HHD will be (65%:35% is a reasonable place to start). No further steps should be taken—as the correct course of action depends upon the interpretation of these results—until all stakeholders concur on these issues.

Management and Ownership

The next step is deciding who will have ownership of the dialysis center and who will be responsible for managing the center. This identifies the entity that has control over decision-making and the culture that is fostered in the home dialysis program. Home dialysis programs cannot succeed without appropriate allocation of resources and a supportive culture, which is difficult to change once established. The variety of ownership and management structures available are beyond the scope of this text, but all should be considered.

Administrative Tasks

In the United States, the Centers for Medicare & Medicaid Services (CMS) certifies every new facility that offers any form of dialysis therapy. No payment from CMS for dialysis is made until successful ...

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