In the last decade, the number of patients treated with home haemodialysis (HHD) has increased considerably,1 and the treatment has seen growing interest worldwide due to the benefits it provides with respect to other options.2 However, although more and more people opt for this method, currently only an estimated 0.3% of patients of patients on renal replacement therapy (RRT) are treated with this technique. There are some differences between the different autonomous communities in Spain, but in general the number of patients who choose this option remains small.3
According to a survey carried out among nephrologists, published in this journal,4 it has been observed that as HHD programmes are developed, the initial barriers derived from the lack of practical knowledge of the technique gradually disappear, and only those dependent on financial and training resources remain4 (staff dedicated exclusively to HHD with specific training).
For this reason, it seems appropriate to present our experience performing a retrospective analysis of the patients included in the HHD programme, their characteristics and adverse events suffered from January 2018 to June 2020, at the Haemodialysis Unit of the Torrecárdenas University Hospital (Almeria). In Table 1, we present the characteristics of the five patients included in the HHD programme.
Characteristics of patients in the HHD Unit.
| Patient variables (n = 5) | |
|---|---|
| Gender (M/F) | (3/2) |
| Mean age | 47.6 years (±2.3 years) |
| BMI | 21.5 kg/m2 |
| AHT | 80% |
| Dyslipidaemia | 40% |
| Smoker | 20% |
| Work activity | 80% |
| CKD aetiology | - Malformation of the urinary tract: 2 |
| - Extracapillary glomerulonephritis: 1 | |
| - Unidentified: 2 | |
| Average length of time on HD | 78 months (±56 months) |
| Average length of time on HHD | 26.4 months |
| Average duration of HD session | 168 min (±16.4 min) |
| Number of weekly sessions | 5.8 sessions/week (±0.5) |
| Blood flow | 350−400 ml/min |
| Dialysis flow rate | 350−600 ml/min |
| Average ultrafiltration rate | 0.66 l/h (±0.16) |
| HHD machine | - NxStage System One: 2 |
| - Physidia S3: 3 | |
| Prior kidney transplant | 100% |
| Included on the transplant waiting list | 60% |
| Type of vascular access | AVF with buttonhole puncture technique: 100% |
| Adverse events at home | 0 |
BMI: body mass index; AHT: arterial hypertension; CKD: chronic kidney disease; HD: haemodialysis; HHD: home haemodialysis; AVF: arteriovenous fistula.
It should be noted that the patients not only complied with an optimised quality treatment guideline, as demonstrated both at an analytical and clinical level, but also patients may adapt the prescribed regimen to each individual case which facilitate work and social integration, continuing with a their life as normal as possible, with their kidney disease.
It is noteworthy that in this high-risk patient profile, HHD prevents exposure and the consequent increase in the incidence of infections related to the healthcare setting, of much greater importance during the SARS-CoV-2 pandemic.5
For further justification of the importance and advantage of starting HHD at a time like the one we are currently experiencing, we refer to the official records of the Spanish Society of Nephrology regarding SARS-CoV-2 infection of November 2020, in which it is highlighted that, although the incidence among patients on RRT has grown in the second wave of infection in a similar manner as in the general population, with a decrease in the average age of affected patients (−7 years with respect to the first wave), we should bear in mind that we are dealing with a fragile patient, with an state of immunosuppression associated to the technique of renal replacement and from which they derive many other comorbidities.6
Analysing the data to date, during the first wave, haemodialysis in both hospitals and peripheral health centres was the RRT modality with the highest percentage of SARS-CoV-2 infections (60%), followed by transplant patients (37%). Peritoneal dialysis (PD) accounted for 2.7% of cases. It should be noted at this point that HHD accounted for only 0.5% of RRT patients infected. However, in the second wave, transplant patients were the most affected (49%), slightly above patients on in-centre haemodialysis (48%). Overall, 2% of the cases occurred in patients on PD and 1% in those on HHD. Making a global summary of COVID-19 infection, 5.7% of the total population on haemodialysis in Spain were infected vs. 2.6% of kidney transplant recipients and 2% of patients on peritoneal dialysis.
It is more than possible that these figures are biased due to the large difference in the number of patients in each of the different RRT modalities used in Spain. However, it is also evident that the probability of contagion will decrease if the patient does not have to come into contact regularly with other people outside their usual home environment, and they only interact with their cohabitants, as indicated in the action protocols of the Spanish Ministry of Health.7
It is also worth highlighting that despite the established protocols to minimise the risk of contagion there is a notable incidence of SARS-CoV-2 infection among health personnel; this is due to exposure to asymptomatic patients attending scheduled sessions. Reducing the care load in these dialysis centres with patients undergoing HHD, provided they are candidates for it, would maximise precautions and the rate of exposure to the virus.8
To conclude, we want to emphasise that HHD is much more than a prescription for medical treatment: it is a lifestyle that allows patients to participate actively in their disease and increase their independence.
FundingNo funding was received for this study.
Conflicts of interestThe authors declare no conflict of interest in preparing this article.
