Home dialysis in older adults: challenges and solutions

There is a rising demand for dialysis in the older population given the increased numbers of older adults living with chronic kidney disease (CKD) progressing to kidney failure. Home dialysis, i.e. peritoneal dialysis (PD) and home hemodialysis (HHD), has been available for decades, but more recently there has been a rapid increase in home dialysis utilization as patients and clinicians consider its practical and clinical advantages. For older adults, incident home dialysis utilization more than doubled and prevalent home dialysis growth nearly doubled over the past decade. Whilst its advantages and recent rise in popularity are evident, there are numerous barriers and challenges that are important to consider prior to initiating older adults on home dialysis. Some nephrology healthcare professionals do not view home dialysis as an option for older adults. Successful delivery of home dialysis for older adults may be made even more difficult by physical or cognitive limitations, concerns around dialysis adequacy, and treatment-related complications, as well as challenges relating to caregiver burnout and patient frailty that are unique to home dialysis and older adults. Ultimately, it would be important for clinicians, patients and their caregivers to define what constitutes a 'successful therapy' to ensure treatment goals are aligned towards each individual's priorities of care, considering the complex challenges that surround an older adult receiving home dialysis. In this review, we evaluate some of the key challenges surrounding the delivery of home dialysis to older adults and propose potential solutions based on updated evidence to overcome these challenges. Lay Summary There are a greater number of older people living with chronic kidney disease progressing to kidney failure, increasing the demands of dialysis. Home dialysis uptake in older people has markedly increased over recent years, as patients, families and medical teams see multiple advantages in having dialysis at home rather than hospital or dialysis center settings. Nevertheless, there are numerous barriers and challenges in providing home-based dialysis for older people considering many may be living with other long-term illnesses in addition to kidney disease, affecting their physical and functional ability to cope with home-based dialysis. The ability to manage treatment-related complications at home could be challenging, even more so for frail, older people. Inadequate caregiver support for older people undertaking home dialysis is also an important issue to consider. In this article, we discuss some of the key challenges surrounding home dialysis for older people and potential ways to overcome these challenges.