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Despite overwhelming evidence of enhanced survival and quality of life among end-stage renal disease (ESRD) patients treated with home hemodialysis (HHD) and home peritoneal dialysis (PD), use of those two modalities is decreasing. Our analysis of data obtained over the past 6 years reveals that, at the same time as the national ESRD population has grown by more than 33%, the fraction of those patients on home dialysis has decreased by 36%. Similar trends are observable in the State of Texas. At our institution, the percentage of ESRD patients receiving home dialysis dropped by 52% in 6 years. Our capture rate during the same interval ranged from 1% to 9% (mean +/- standard deviation: 3.66% +/- 2.64%). To improve the capture rate and to strengthen our home dialysis program, we adopted these measures: Nephrologists participated in dialysis education and explained renal replacement therapy (RRT) options to each patient and to accompanying family members. The home dialysis coordinator later met with the patients individually. The new patients were then encouraged to meet with patients already enrolled in the home dialysis program. Finally, patients choosing home dialysis were given a questionnaire to rank their reasons for selecting that modality. From April 2001 to July 2002, we initiated 136 patients onto dialysis. Of those patients, 118 selected in-center hemodialysis and 18 chose home dialysis, representing a capture rate of 13% and resultant growth of 117% in our home dialysis program. Our survey revealed that the prime reason for selection of home dialysis was independence (31%), followed by physician guidance, coordinator education, and work schedule (17% each). Familial assistance, familial employment, and privacy were less important (7%, 7%, and 3% respectively). We conclude that, by devoting more time to patient education and discussion of RRTs, nephrologists and dialysis coordinators can significantly increase home dialysis enrollment.

Peritoneal dialysis (PD), despite being advantageous to patient, physician, and society, has failed to show the growth it deserves. On the contrary, PD utilization has declined. Over the past several years, we have noticed a decline in the number of our home dialysis patients. When compared to the national trend, we find our trend to be not significantly different from other centers across the country. A similar trend has also been noticed in Canada. Although several reasons may exist for the decline, we intend to concentrate on local factors. In the first quarter of 1996, we had a total of 46 adult and pediatric end-stage renal disease (ESRD) patients on PD. That number decreased to 23 at the end of fourth quarter of the year 2001. The losses in our program far exceeded the gains. We lost our patients mainly to in-center hemodialysis (ICHD) and to transplantation. Peritonitis and membrane failure remained the major grounds for the loss to ICHD. In our center, geographic location and a lack of structured pre-ESRD education probably played a major role in the decline. Many of our patients are from distant counties that have a contract with University of Texas Medical Branch for providing health care to their indigent population. However, once those patients develop complications, the counties rely on the expertise of local physicians and nephrologists.