Home haemodialysis - international trends and variation

Background. Home haemodialysis (HD) has the best patient outcomes and is the most cost-effective of any dialysis modality, but its use has been declining in many countries. Methods. Point prevalence rates of different dialysis modalities and transplantation were obtained from national and regional registries for the most recent available year (2001-03) for 21 high-income and 12 middle-income countries. Relationships with median age and prevalence of diabetic nephropathy, healthcare expenditure and population density were assessed. Long-term trends in the use of home HD during the last two to four decades were obtained for seven countries. Results. The prevalence of home HD varies from 0 to 58.4 per million population, and varies between countries, more than any other renal replacement therapy (RRT) modality. There is a positive association between the use of peritoneal dialysis and home HD (Spearman's rho = 0.531, P = 0.013), but no correlation with transplantation prevalence. There is a negative correlation with median age of the renal replacement population (rho = -0.552, P = 0.018). There is no association with prevalence of diabetic nephropathy, healthcare expenditure or population density. Temporal trends in home HD prevalence are dramatically different in different countries, with several countries expanding its use in the last few years. Conclusion. The use of home HD varies dramatically between and within countries. The variation cannot be explained by the variation in the use of other RRT modalities, nor by prevalence of diabetic nephropathy, national wealth or population density. The inverse correlation with median age is difficult to explain. Significant expansion of home HD is likely to be possible in most countries, and will be increasingly important as the impressive results of more frequent HD gain credence.