Dr. Jillian Caldwell is a Postdoctoral Research Fellow and Clinical Scholar in the Division of Nephrology at Stanford University. She completed her internal medicine training at the University of Illinois at Chicago and her clinical nephrology training at Stanford University where she obtained a Master of Science in Health Policy. Her research focuses on exploring the intended (and sometimes unintended) consequences of health policies and healthcare delivery for the end-stage kidney disease population. In her free time, she can be found on her Peloton or hanging out with her husband and four cats. Follow her @jcaldwelldo. Dr Caldwell is a 2024-25 AJKD Editorial Intern.

In recent years, national initiatives like the Advancing American Kidney Health (AAKH) initiative have pushed to expand home dialysis, recognizing its potential to improve quality of life and reduce healthcare costs. Yet, despite these efforts, the uptake of home dialysis in the U.S. remains modest. Only 13.4% of incident dialysis patients used home modalities in 2021, well below the AAKH’s goal of treating 80% of patients with new end-stage kidney disease (ESKD) diagnoses with home dialysis or kidney transplant by 2025.

A new study by Kim and colleagues in the American Journal of Kidney Diseases offers insight into why uptake of home dialysis by incident dialysis patients continues to lag, revealing that where patients live may influence home dialysis utilization. Prior studies suggested that living close to dialysis facilities may discourage patients from choosing home dialysis. Additionally, performing dialysis at home requires adequate space to store supplies and appropriate conditions that reduce the risk of infection, which may be more difficult to achieve in crowded or attached housing (Figure 1). Using data from over 1.1 million U.S. adults initiating dialysis between 2010 and 2019, the authors investigated how specific neighborhood and housing characteristics, such as how close they lived to the nearest dialysis facility, and whether they lived in crowded homes, influence home dialysis uptake. As opposed to the usual urban-versus-rural classification, the authors looked at these factors in urban, suburban, small-town, and rural areas separately.

Figure 1. Factors influencing home dialysis utilization. © Caldwell

Three main environmental characteristics were studied:

1. Medically Underserved Areas (MUAs), areas known to have inadequate healthcare resources,
2. Distance to the nearest dialysis facility,
3. Housing conditions (overcrowding or detached housing).

The authors found that urban and suburban residents in MUAs were less likely to initiate home dialysis. Presence of pre-dialysis nephrology care partially explained this association, suggesting that improving availability of health services in MUAs could increase home dialysis uptake. In addition, the further a patient lived from a dialysis facility, the more likely they were to start home dialysis. This effect was greatest in small-town and rural areas, where for each standard deviation increase in distance, odds of home dialysis rose 14% and 17%, respectively. This finding suggests that patients may choose home therapies to avoid long commutes to dialysis treatments. In contrast, housing overcrowding was a major barrier to home dialysis, but only in urban and suburban neighborhoods. Overcrowded housing was associated with 12% and 9% lower odds of home dialysis in urban and suburban settings, respectively. Detached housing (i.e., single-family homes) was associated with increased home dialysis use across all community types.

These findings should prompt policymakers and health system leaders to recalibrate their strategies for promoting home dialysis. One-size-fits-all solutions, such as national payment models that incentivize or penalize providers, may inadvertently deepen disparities if they fail to account for neighborhood-level barriers.

For urban and suburban communities, addressing space constraints is key. Monthly delivery of large volumes of dialysate and supplies may not be feasible for patients living in apartments or crowded homes. More frequent (e.g., weekly) deliveries, or centralized storage hubs, could make home dialysis more practical. Additionally, improving access to nephrology care in MUAs, especially before patients reach kidney failure, could increase the pool of patients who are educated and prepared to choose home dialysis.

In contrast, for patients in rural and small-town settings, policies might focus on using distance to dialysis facilities as a flag to identify patients for early home dialysis education and spare patients from grueling travel to dialysis clinics multiple times per week.

The study also cautions CMS’s End-Stage Renal Disease Treatment Choices (ETC) model, which adjusts provider payments based on home dialysis uptake. Without adjustments for geographic context, these policies could penalize providers who serve disadvantaged neighborhoods where patients face real structural barriers to home dialysis. The authors suggest that incentives rather than penalties may be a more effective and equitable approach to improving home dialysis uptake.

Kim et al.’s study is a compelling reminder of how environmental context influences health choices. Home dialysis is not just a clinical decision, but a logistical one, dependent on geography, infrastructure, and housing. By mapping these associations more granularly, the study offers a roadmap for smarter, more targeted interventions that can bring the promise of home dialysis closer to reality for more patients.