Quality Assurance and Preventing Serious Adverse Events in the Home Hemodialysis Setting

Patient Training and Patient Safety in Home Hemodialysis

The success of a home hemodialysis program depends largely on a patient safety framework and the risk tolerance of a home dialysis program. Dialysis treatments require operators to perform dozens of steps repeatedly and reliably in a complex procedure. For home hemodialysis, those operators are patients themselves or their care partners, so attention to safety and risk mitigation is front of mind. While newer, smaller, and more user-friendly dialysis machines designed explicitly for home use are slowly entering the marketplace, teaching patients to perform their own treatments in an unsupervised setting hundreds of times remains a foundational programmatic obligation regardless of machine. Just how safe is home hemodialysis? How does patient training affect this safety? There is a surprising lack of literature surrounding these questions. No consensus exists among home hemodialysis programs regarding optimized training schedules or methods, with each program adopting its own approach on the basis of local experience. Furthermore, there are little available data on the safety of home hemodialysis as compared with conventional in-center hemodialysis. This review will outline considerations for training patients on home hemodialysis, discuss the safety of home hemodialysis with an emphasis on the risk of serious and life-threatening adverse effects, and address the methods by which adverse events are monitored and prevented.

Vascular Access Considerations in Home Hemodialysis

There is a global interest in expanding home dialysis utilization among patients with ESKD. Home hemodialysis (HHD) is an appealing KRT option for this population because of its multiple clinical and quality of life benefits. Central to successful HHD is the establishment and maintenance of a functioning vascular access that serves as a patient's lifeline while on therapy. While the selection of a vascular access type is influenced by individual patient circumstances, the arteriovenous fistula is generally the preferred access method. Training patients to use their dialysis access requires attention to safety, risk management, and monitoring for complications to minimize adverse events and technique failure. Policies incorporating systematic frameworks for quality improvement and assurance, in conjunction with the measurement of metrics relating to vascular access, are tools that should be used by HHD programs to enhance the value of care delivered. In this perspective, we aim to describe what is currently known about the various vascular access options in HHD and to elucidate what needs to be taken into consideration in the selection and care of this access.

Home-Based Dialysis: A Primer for the Internist

Home-based dialysis modalities offer both clinical and practical advantages to patients. The use of the home-based modalities, peritoneal dialysis and home hemodialysis, has been increasing over the past decade after a long period of decline. Given the increasing frequency of use of these types of dialysis, it is important for clinicians to be familiar with how these types of dialysis are performed and key clinical aspects of care related to their use in patients with end-stage kidney disease.