Despite the reported health benefits that home and more frequent hemodialysis may provide to patients with chronic kidney disease, this form of kidney replacement therapy is not suitable for everyone, involves risks, and will not result in the same aforementioned health and quality of life improvements for all patients.  

 The safety aspects of HHD include all complications that can occur in the dialysis center, as well as additional potential safety issues while the patient is at the forefront of his or her treatment. However, life-threatening adverse events in home hemodialysis (HHD) are uncommon, and most can be offset by adequate training and education and periodic review of HHD-related policies and procedures​^1,2​.

 While performing home hemodialysis, medical staff will not be present in person to respond to health emergencies or technical issues that might happen during treatment, such as dizziness, nausea, low blood pressure, fluid or blood leaks, needle or catheter damage or dislodge, air embolism, or machine malfunction, among others^​1​. While remote assistance is available, patients or their caregivers are responsible for all aspects of their hemodialysis treatment from start to finish and will need to be trained and feel comfortable with equipment setup, needling, proper aseptic technique, troubleshooting, and resolving system alarms. If a patient uses home hemodialysis without a caregiver present, health emergencies or technical issues such as needle dislodgement, blood loss, or low blood pressure pose an additional risk of injury or death since the patient may lose consciousness and be physically unable to correct the emergency. 

 In patients prescribed more frequent therapy, vascular access is exposed to more frequent use. This has been associated with access-related complications such as infection of the site, access failures, infection-related hospital admission, and surgical intervention​^2–8​. Calcium, phosphorus, and vitamin C may also become deficient in home HD patients who dialyze more frequently, which can result in a decrease in bone mineral content​^7​. These deficiencies associated with prolonged dialytic removal can be managed or prevented by decreasing the number of treatment hours, decreasing the dialysate flow rate, increasing dialysate calcium concentration, and potentially supplementing with water-soluble vitamins​^7​. 

 Nocturnal home hemodialysis poses additional risks both due to the length of treatment time and the fact that dialysis is performed while the patient and caregiver are sleeping. Nocturnal HD risks include vascular access dislodgement and blood loss, blood clotting due to slower blood flow or increased treatment time, and delayed responses to system alarms while waking. Medication considerations should also be factored in, with potential adjustments to phosphate binders, anticoagulants, iron, erythropoiesis-stimulating agents (ESA), and insulin/oral hypoglycemics.  

 Proper education of the patient and caregiver (including retraining and periodic vascular access technique audits) and safety protocols can mitigate these risks. Use of remote safety monitoring, on-site blood pressure and pulse monitoring, wetness detectors at venous needle sites, single-needle dialysis for nocturnal HHD, ensuring that the access site is tightly secured, and learning how to care for the access site and identify infections (signs of redness, tenderness, swelling, or leaking)​^7​ are also valuable tools and practices to ensure a safe treatment. Safety should be a priority of all home HD programs, at programs should implement quality assurance processes aimed at preventing serious adverse events and minimizing the effects of the adverse events that do occur​²​. 

References:

1. Tennankore KK, D’Gama C, Faratro R, Fung S, Wong E, Chan CT. Adverse Technical Events in Home Hemodialysis. Am J Kidney Dis. 2015;65(1):116-121. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25441436. 
2. ​More KM, Tennankore K. Quality Assurance and Preventing Serious Adverse Events in the Home Hemodialysis Setting. Adv Chronic Kidney Dis. 2021;28(2):170-177. 
3. ​Chertow GMG, Levin NNW, Beck GGJ, et al. In-center hemodialysis six times per week versus three times per week. N Engl J Med. 2010;363(24):2287-2300. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21091062. 
4. ​Rocco M V., Lockridge RS, Beck GJ, et al. The effects of frequent nocturnal home hemodialysis: the Frequent Hemodialysis Network Nocturnal Trial. Kidney Int. 2011;80(10):1080-1091. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21775973. 
5. ​Suri RS, Li L, Nesrallah GE. The risk of hospitalization and modality failure with home dialysis. Kidney Int. 2015;88(2):360-368. 
6. ​Weinhandl ED, Nieman KM, Gilbertson DT, Collins AJ. Hospitalization in daily home hemodialysis and matched thrice-weekly in-center hemodialysis patients. American Journal of Kidney Diseases. 2015;65(1):98-108. 
7. ​Gupta A, Zimmerman D. Complications and challenges of home hemodialysis: A historical review. Semin Dial. 2021;34(4):269-274. Available from: http://www.ncbi.nlm.nih.gov/pubmed/33609415. 
8. ​Jun M, Jardine MJ, Gray N, et al. Outcomes of extended-hours hemodialysis performed predominantly at home. Am J Kidney Dis. 2013;61(2):247-253. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23036929. 

​ GMO-001402  Rev A  11/2024