Home Dialysis Services: Peritoneal and Home Hemodialysis Options
Kidney failure doesn't confine people to a clinic — and for hundreds of thousands of Americans, it doesn't have to. Home dialysis encompasses two distinct modalities, peritoneal dialysis and home hemodialysis, that allow individuals with end-stage renal disease (ESRD) or advanced chronic kidney disease to receive life-sustaining treatment in their own homes. The choice between these approaches depends on medical suitability, lifestyle, and support infrastructure — factors that play out differently for every patient and household.
Definition and scope
Dialysis is the process of filtering waste products and excess fluid from the blood when the kidneys can no longer do it adequately — typically defined as kidney function falling below roughly 10–15% of normal capacity. In the United States, approximately 808,000 people are living with kidney failure, according to the United States Renal Data System (USRDS) 2022 Annual Data Report. Of those receiving dialysis treatment, roughly 12% use a home modality — a share that has grown steadily since the Centers for Medicare & Medicaid Services launched its ESRD Treatment Choices (ETC) Model in 2021, specifically designed to increase home dialysis uptake.
Home dialysis sits firmly within the broader landscape of home care for chronic conditions, and it pairs naturally with skilled nursing at home for patients who need supplementary clinical oversight during the early months of treatment.
The two home dialysis modalities operate on fundamentally different principles:
- Peritoneal dialysis (PD): Uses the lining of the abdominal cavity (the peritoneum) as a natural filter. Fluid called dialysate is introduced into the abdomen, dwells for a set period, and is then drained, carrying waste products with it.
- Home hemodialysis (HHD): Uses a machine to pump blood out of the body, filter it through an artificial membrane, and return it — the same mechanism used in in-center hemodialysis, but performed at home with a more compact machine.
How it works
Peritoneal dialysis is delivered through a soft catheter surgically placed in the abdomen. There are two primary schedules:
- Continuous Ambulatory Peritoneal Dialysis (CAPD): Performed manually, 4–5 exchanges per day, each taking about 30 minutes. No machine required — just gravity, sterile bags, and a clean space.
- Automated Peritoneal Dialysis (APD): A cycler machine handles exchanges overnight, typically over 8–10 hours, while the patient sleeps. Most patients using APD are free of dialysis tasks during the day.
Home hemodialysis requires a machine — devices such as the NxStage System One or the Outset Tablo (cleared by the FDA for home use) process blood outside the body using a dialyzer membrane. The key distinction from in-center hemodialysis is frequency. In-center treatment runs three sessions per week, each around four hours. Home hemodialysis patients frequently dialyze five to seven times per week, with each session running shorter — often 2.5 to 3.5 hours. More frequent treatment means less fluid and waste accumulation between sessions, which most nephrologists consider physiologically advantageous.
Both modalities require formal training — typically 2 to 6 weeks for PD and 3 to 8 weeks for HHD — conducted through a certified dialysis center before independent home treatment begins. A care partner is generally required for home hemodialysis, though not always for peritoneal dialysis.
Common scenarios
Home dialysis fits a recognizable pattern of patient circumstances, though it's far from a one-size situation.
Peritoneal dialysis tends to work well for people with stable cardiac status, sufficient manual dexterity for exchanges, and living situations that allow for storage of dialysate bags (which arrive by monthly delivery and require meaningful storage space — roughly the size of a small bedroom closet). It is frequently the starting modality for newly diagnosed ESRD patients because it preserves residual kidney function longer than hemodialysis, according to data cited by the National Kidney Foundation.
Home hemodialysis is common among working-age adults who want to schedule treatment around employment or family obligations, and among patients who have exhausted peritoneal options due to abdominal scarring or prior surgeries. It also appears frequently in home care for veterans contexts, given the VA's active home dialysis programs at facilities including the VA Greater Los Angeles Healthcare System.
Both modalities integrate with post-surgical home care when catheter placement or access creation (fistula surgery for HHD) precedes the start of home treatment.
Decision boundaries
Not every patient is a candidate for home dialysis, and the factors that determine suitability follow a reasonably clear logic:
- Residual abdominal anatomy: Prior abdominal surgeries, hernias, or inflammatory bowel disease can contraindicate peritoneal dialysis. A nephrology team will assess via imaging and physical exam.
- Vascular access: Home hemodialysis requires a functioning arteriovenous fistula or graft — which takes 6 to 12 weeks to mature after surgical creation. Urgently initiated dialysis usually begins in-center while access matures.
- Cognitive and physical capacity: Patients must be able to follow precise sterile protocols. Cognitive impairment — as seen in some dementia and Alzheimer's home care situations — may require a dedicated care partner to manage the technical steps entirely.
- Home environment: Adequate water supply (HHD machines require specific water quality), electrical capacity, and storage are physical prerequisites that a home visit from the dialysis program will evaluate.
- Psychosocial readiness: Both the patient and any household members need to be comfortable managing a medical device in a domestic space — a factor that home care assessments and care plans can help formalize before equipment is installed.
Medicare covers both peritoneal and home hemodialysis under the ESRD benefit, with a bundled payment structure established by the CMS ESRD Prospective Payment System. Patients exploring Medicare coverage for home care should confirm that their dialysis supplier and equipment are enrolled as Medicare ESRD providers — a separate credentialing track from standard home health agencies.