Understanding barriers to home‐based and self‐care in‐center hemodialysis

Despite superior outcomes and lower associated costs, relatively few patients with end‐stage renal disease undergo self‐care or home hemodialysis. Few studies have examined patient‐ and physician‐specific barriers to self‐care and home hemodialysis in the modern era. The degree to which innovative technology might facilitate the adoption of these modalities is unknown. We surveyed 250 patients receiving in‐center hemodialysis and 51 board‐certified nephrologists to identify key barriers to adoption of self‐care and home hemodialysis. Overall, 172 (69%) patients reported that they were “likely” or “very likely” to consider self‐care hemodialysis if they were properly trained on a new hemodialysis system designed for self‐care or home use. Nephrologists believed that patients were capable of performing many dialysis‐relevant tasks, including: weighing themselves (98%), wiping down the chair and machine (84%), clearing alarms during treatment (53%), taking vital signs (46%), and cannulating vascular access (41%), but thought that patients would be willing to do the same in only 69%, 34%, 31%, 29%, and 16%, respectively. Reasons that nephrologists believe patients are hesitant to pursue self‐care or home hemodialysis do not correspond in parallel or by priority to reasons reported by patients. Self‐care and home hemodialysis offer several advantages to patients and dialysis providers. Overcoming real and perceived barriers with new technology, education and coordinated care will be required for these modalities to gain traction in the coming years.     

What Went Wrong with Home Hemodialysis in the United States and What Can Be Done Now?

In 1973, almost 40% of the more than 10 000 dialysis patients were treated by home hemodialysis. Today, with more than a quarter of a million dialysis patients in the United States, fewer than 2000 are on home hemodialysis. A number of factors have contributed to this change. First, many nephrologists and administrators who were developing new dialysis units had little or no practical experience with dialysis for chronic renal failure. Second, more elderly and diabetic patients were admitted to treatment. Home hemodialysis was more difficult for such patients, and often their helpers were themselves were elderly. Third, hemodialysis machines were difficult to learn and operate. Fourth, following publication of the results of the National Cooperative Dialysis Study, there developed the erroneous concept that a Kt/V equal to 1.0 was “adequate dialysis.” As bigger dialyzers became available, there was a widespread shortening of dialysis time. This decrease in time was embraced by for‐profit dialysis facilities and inadequately educated patients, and assembly‐line dialysis became generally accepted. Finally, continuous ambulatory peritoneal dialysis, with its simplicity and short training time, began to fill the need of many patients for home dialysis and independence, at least temporarily. Fortunately, the trend is now reversing. Two developments clearly have benefits for home hemodialysis. The first is an increasing interest in the use of more frequent dialysis. The second is the development of new equipment designed specifically for use by the patient, and requiring a minimum of effort on the patient's part.     

Physician knowledge,attitudes, and practices regarding physical activity restrictions in pediatric hemodialysis patients

Introduction

Epidemiologic studies of physical activity among pediatric hemodialysis (HD) patients are lacking. A sedentary lifestyle in End-Stage Kidney Disease is associated with a higher cardiovascular mortality risk. In those patients receiving HD, time spent on dialysis and restrictions on physical activity due to access also contribute. No consensus exists regarding physical activity restrictions based on vascular access type. The aim of this study was to describe the patterns of physical activity restrictions imposed by pediatric nephrologists on pediatric HD patients and to understand the basis for these restrictions.

Methods

We conducted a cross-sectional study involving US pediatric nephrologists using an anonymized survey through Pediatric Nephrology Research Consortium. The survey consisted of 19 items, 6 questions detailed physician characteristics with the subsequent 13 addressing physical activity restrictions.

Findings

A total of 35 responses (35% response rate) were received. The average years in practice after fellowship was 11.5 years. Significant restrictions were placed on physical activity and water exposure. None of the participants reported accesses damage or loss that was attributed to physical activity and sport participation. Physicians practice is based on their personal experience, standard practice at their HD center, and clinical practices they were taught.

Discussion

There is no consensus among pediatric nephrologists about allowable physical activity in children receiving HD. Due to the lack of objective data, individual physician beliefs have been utilized to restrict activities in the absence of any deleterious effects to accesses. This survey clearly demonstrates the need for more prospective and detailed studies to develop guidelines regarding physical activity and dialysis access in order to optimize quality of care in these children.     

Hemodialysis in the United Kingdom

Hemodialysis was a neglected aspect of nephrology in the UK. At the request of the Renal Association, the first UK Haemodialysis Masterclass was organized in 2007. The articles in this supplement arose from that meeting. Here, an overview of UK hemodialysis services and nephrology training is presented as background. Government‐funded dialysis should be provided to all UK citizens who require it. In 2005, there were 17,645 patients receiving hemodialysis, 5057 on peritoneal dialysis and 19,074 with kidney transplants, looked after by 359 nephrologists working in 73 National Health Service renal units. Renal replacement therapy incidence and prevalence remain comparatively low, at 108 and 694 per million population, respectively. Whether this represents inadequate provision or genuinely lower need remains unclear. The Renal Association sets clinical practice guidelines for dialysis, and audits performance via the UK Renal Registry. Postgraduate medical education is undergoing radical change in the UK. This is driven by the reduction in trainee doctors' working hours to 48 hr/week (mandated by the European Working Time Directive), and the governments' wish to reduce the duration of training, but also by a desire to formalize training, Our challenge is to continue to produce talented clinical nephrologists educated in breadth and depth, despite the reduced emphasis on clinical experience and omission of period of scientific research. The future for hemodialysis services in the UK is, however, promising with an expansion in the number of specialists and dialysis centers, and a growing interest in dialysis practice and research.     

Left ventricular assist device patient maintained on home hemodialysis: A novel class of patients to the home dialysis population

Severe heart failure is increasingly being managed by cardiac transplantation, and in some cases mechanical support devices serve as destination therapies. Left ventricular assist devices (LVADs) were approved for destination therapy for end stage heart failure patients before the more advanced total artificial heart modality became available. One common complication of mechanical assist device placement is acute kidney injury. Historically, patients with mechanical support devices have had to have inpatient hemodialysis until combined heart kidney transplant. Though, some units have started accepting LVAD patients in outpatient dialysis clinics. The cost of in center hemodialysis remains high and home dialysis modalities are becoming increasingly popular. We report the first patient with an LVAD to undergo training and successful home hemodialysis while awaiting combined heart kidney transplantation.     

What limits the expansion of self‐care dialysis at home?

Self-care dialysis at home, whether peritoneal dialysis or hemodialysis, is more cost-effective than in-center dialysis and treatment outcome is at least comparable. Still, both self-care modalities are considered underutilized and we wished to identify the perceived reasons for this underutilization among nephrology professionals. A questionnaire was distributed at 5 international nephrology meetings in 2006. Questions addressed the most important stakeholders and the most important issues for patients and nephrology professionals to enable the expansion of self-care dialysis and commonly mentioned barriers were given as alternative responses. The proportion of patients considered suitable for self-care was also investigated. Seven thousand responses were collected. The listed stakeholders, i.e., health care and reimbursement authorities, nurses and physicians, and finally patients and their families, are considered approximately equally important for the process. Nephrology professionals feel that patient motivation for choosing and performing self-care dialysis is the strongest driver. The need for dedicated resources for self-care is judged to be vital for the expansion of this modality of treatment. Thirty-two percent of incident patients are considered able to perform self-care dialysis at home. This international survey among 7000 nephrology professionals has identified patient motivation as one of the strongest drivers of self-care dialysis at home. The need for dedicated resources for the staff to devote time to developing such motivation is given as one of the major reasons for the slow adoption. Under ideal conditions, it is felt that one-third of all patients starting dialysis can be trained to perform self-care dialysis.     

Nightly Home Hemodialysis: Fifteen Months of Experience in Lynchburg,Virginia

What constitutes adequate dialysis has been debated in the nephrology literature over the past eight years. The mortality rate of patients on dialysis in the United States is about 20% per year. We believed that short and infrequent dialysis sessions contributed to poor outcomes. To improve the results, Lynchburg Nephrology started the nightly home hemodialysis (NHHD) program in September 1997. Ten patients were trained in the first 15 months of the program. Patients dialyzed 7 – 9 hours, 6 nights/week, using the Fresenius 2008H machine. A standard dialysis solution with 2.0 mEq/L potassium, calcium concentration of 3.0 – 3.5 mEq/L was used. Dialysis solution flow rates were 200 – 300 mL/min. Serum phosphate levels were maintained above 2.5 mg/dL by adding 0 – 45 mL Fleet's Phosphosoda to the bicarbonate bath. Patients had marked improvement in quality of life as measured with the SF-36. Blood pressure was better controlled with fewer medications. All phosphate binders were eliminated. Caloric intake and protein intake increased to normal levels as measured by three-day dietary histories pre-NHHD, and at 3, 6, and 12 months on NHHD. Epoetin alfa dosages were reduced by about 50%. Nightly home hemodialysis should be considered as a valuable modality option for end-stage renal disease patients; it is potentially superior to conventional thrice-weekly hemodialysis.     

Is home hemodialysis a practical option for older people?

An increasing demand for in-center dialysis services has been largely driven by a rapid growth of the older population progressing to end-stage kidney disease. Since the onset of the COVID-19 pandemic, efforts to encourage home-based dialysis options have increased due to risks of infective transmission for patients receiving hemodialysis in center-based units. There are various practical and clinical advantages for patients receiving hemodialysis at home. However, the lack of caregiver support, cognitive and physical impairment, challenges of vascular access, and preparation and training for home hemodialysis (HHD) initiation may present as barriers to successful implementation of HHD in the older dialysis population. Assessment of an older patient's frailty status may help clinicians guide patients when making decisions about HHD. The development of an assisted HHD care delivery model and advancement of telehealth and technology in provision of HHD care may increase accessibility of HHD services for older patients. This review examines these factors and explores current unmet needs and barriers to increasing access, inclusion, and opportunities of HHD for the older dialysis population.     

Barriers,biases, and beliefs about arteriovenous fistula placement in children: A survey of the International Pediatric Fistula First Initiative (IPFFI) within the Midwest Pediatric Nephrology Consortium (MWPNC)

There has been recent emphasis on increased arteriovenous fistula (AVF) use and decreased central venous catheter use in hemodialysis (HD) patients. The International Pediatric Fistula First Initiative was founded via collaborative effort with the Midwest Pediatric Nephrology Consortium to alert nephrologists, surgeons, and dialysis staff to consider fistulae as the best access in pediatric HD patients. A multidisciplinary educational DVD outlining expectations and strategies to increase AVF placement and usage in children was created. Participants were administered a survey previewing and postviewing to identify barriers to placement and usage of AVF in children. A total of 52 surveys were subdivided as either “dialysis staff” or “proceduralist” at five centers. Thirty‐three percent of respondents were unaware if their practice was following published guidelines. Sixty‐five percent of respondents stated they referred to a dedicated vascular access surgeon at their respective institutions. Methods used to monitor AVF function included physical exam, venous pressure monitoring, and ultrasound dilution. Vascular access was placed within 3 months in only 35% of patients. Interdisciplinary communication problems between surgeons, interventional radiologists, and nephrologists were identified as a major barrier. Lack of AVF usage was often due to maturation failure. Routine access rounds did not occur in any centers. Regarding monitoring, 74% of the respondents use physical exam, 26% use venous pressure monitoring, and 9% use ultrasound dilution. Ninety‐three percent of dialysis staff stated they would change practice patterns following the intervention; however, 12% of surgeons stated they would alter practice patterns. To our knowledge, this is the first report to identify barriers to placement of AVF in children from the perspectives of multidisciplinary team members including pediatric nephrologists, surgeons, interventional radiologists, and multidisciplinary dialysis staff.     

A comparison of center-based vs. home-based daily hemodialysis for patients with end-stage renal disease

Home hemodialysis has been a therapeutic option for almost 4 decades. The complexity of dialysis equipment has been a factor-limiting adoption of this modality. We performed a feasibility study to demonstrate the safety of center-based vs. home-based daily hemodialysis with the NxStage System One portable hemodialysis device. We also performed a retrospective analysis to determine if clinical effects previously associated with short-daily dialysis were also seen using this novel device. We conducted a prospective, 2-treatment, 2-period, open-label, crossover study of in-center hemodialysis vs. home hemodialysis in 32 patients treated at 6 U.S. centers. The 8-week In-Center Phase (6 days/week) was followed by a 2-week transition period and then followed by the 8-week Home Phase (6 days/week). We retrospectively collected data on hemodialysis treatment parameters immediately preceding the study in a subset of patients. Twenty-six out of 32 patients (81%) successfully completed the study. Successful delivery of at least 90% of prescribed fluid volume (primary endpoint) was achieved in 98.5% of treatments in-center and 97.3% at home. Total effluent volume as a percentage of prescribed volume was between 94% and 100% for all study weeks. The composite rate of intradialytic and interdialytic adverse events per 100 treatments was significantly higher for the In-Center Phase (5.30) compared with the Home Phase (2.10; p=0.007). Compared with the period immediately preceding the study, there were reductions in blood pressure, antihypertensive medications, and interdialytic weight gain. Daily home hemodialysis with a small, easy-to-use hemodialysis device is a viable dialysis option for end-stage renal disease patients capable of self/partner-administered dialysis.     

Home hemodialysis: Beliefs,attitudes, and practice patterns

There is increasing interest of the worldwide kidney community in home hemodialysis (HHD). This is due to emerging evidence of its superiority over conventional hemodialysis (HD), largely attributed to improved outcomes on intensive schedule HD, best deployed in patient's own homes. Despite published work in this area, universal uptake remains limited and reasons are poorly understood. All those who provide HD care were invited to participate in a survey on HHD, initiated to understand the beliefs, attitudes, and practice patterns of providers offering this therapy. The survey was developed and posted on the Nephrology Dialysis Transplantation‐Educational (NDT‐E) website. Two hundred and seventy‐two responses were deemed suitable for complete analysis. It is apparent from the survey that there is great variability in the prevalence of HHD. Physicians have a great deal of interest in this modality, with majority viewing home as being the ideal location for the offer of intensive HD schedules (55%). A significant number (21%) feel intensive HD may be offered even outside the home setting. Those who offer this therapy do not see a financial disadvantage in it. Many units identify lack of appropriately trained personnel (35%) and funding for home adaptation (50.4%) as key barriers to widespread adoption of this therapy. Despite the interest and belief in this therapy among practitioners, HHD therapy is still not within reach of a majority of patients. Modifiable organizational, physician, and patient factors exist, which could potentially redefine the landscape of HHD provision. Well‐designed systematic research of national and local barriers is needed to design interventions to help centers facilitate change.     

Short and long nightly hemodialysis in the United States

When hemodialysis first started in the United States in the 1960s, a large percentage of patients performed their treatments at home. However, because of reimbursement issues, home hemodialysis (HHD) gradually succumbed to an in-center approach and eventually a mindset. Since the introduction of nightly HHD by Uldall and Pierratos in 1993, there has been a resurgence of interest in HHD. This paper describes the different types of home hemodialysis being performed as of December 31, 2007 in this country. Because neither the United States Renal Data System (USRDS) nor the End Stage Renal Disease (ESRD) Networks break down home dialysis into the different modalities, a provider questionnaire was sent out to 2 major providers, a number of mid-level providers and other providers known to do HHD. In addition, a questionnaire was sent out to 3 machine providers to obtain the number of patients using their machine for HHD as of December 31, 2007. The results showed that 91.7% of patients are dialyzing in-center, 7.3% are doing peritoneal dialysis, and 0.7% are doing HHD. Currently about 1% of ESRD patients in the United States are doing home hemodialysis. NxStage, however, has started 1000 patients in the past year on short-daily home hemodialysis. Patients are beginning to understand that there are better options than 3 times a week in-center dialysis. And as a result of the "HEMO Study," nephrologists now believe that longer and more frequent dialysis is a better therapy for ESRD patients. Therefore, promotion of HHD should become a priority for the renal community in the future.     

The History of Home Hemodialysis: A View From Seattle

Home hemodialysis was first used for the treatment of end-stage renal disease in the early 1960s, primarily as a means of reducing the cost of treatment. It was soon found to be an effective form of treatment that provided patient independence, greater opportunity for rehabilitation, and better survival. In 1973, when the Medicare End-Stage Renal Disease Program began, some 40% of all U.S. dialysis patients were on home hemodialysis, but since then the percentage of patients on this treatment has steadily decreased. There are several reasons for this, one in particular being the lack of availability of suitable equipment. There is now renewed interest in home hemodialysis sparked by the knowledge that new equipment specifically designed for this is being developed, that this is the modality with the best survival rate, greatest opportunity for adequate dialysis and best quality of life, and an interest in the use of daily (or nightly) home hemodialysis. Consequently, more than 30 years later, it appears that home hemodialysis may again become the preferred treatment for many more patients.     

Results of human factors testing in a novel Hemodialysis system designed for ease of patient use

Introduction Home hemodialysis has not been widely adopted despite superior outcomes relative to conventional in‐center hemodialysis. Patients receiving home hemodialysis experience high rates of technique failure owing to machine complexity, training burden, and the inability to master treatments independently. Methods We conducted human factors testing on 15 health care professionals (HCPs) and 15 patients upon release of the defined training program on the Tablo? Hemodialysis System. Each participant completed one training and one testing session conducted in a simulated clinical environment. Training sessions lasted <3 hours for HCPs and <4 hours for patients, with an hour break between sessions for knowledge decay. During the testing session, we recorded participant behavior and data according to standard performance and safety‐based criteria. Findings Of 15 HCPs, 10 were registered nurses and five patient care technicians, with a broad range of dialysis work experience and no limitations other than visual correction. Of 15 patients (average age 48 years), 13 reported no limitations and two reported modest limitations—partial deafness and blindness in one eye, respectively. The average error rate was 4.4 per session for HCPs and 2.9 per session for patients out of a total possible 1,710 opportunities for errors. Despite having received minimal training, neither HCPs nor patients committed safety‐related errors that required mitigation; rather, we noted only minor errors and operational difficulties. Discussion The Tablo? Hemodialysis System is easy to use, and may help to enable self‐care and home hemodialysis in settings heretofore associated with high rates of technique failure.     

In‐center hemodialysis attendance: Patient perceptions of risks,barriers, and recommendations

Missed hemodialysis treatments lead to increased morbidity and mortality in the end‐stage renal disease population. Little is known about why patients have difficulty attending their scheduled in‐center dialysis treatments. Semistructured interviews with 15 adherent and 15 nonadherent hemodialysis patients were conducted to determine patients' attitudes about dialysis, health beliefs and risk perception regarding missed treatments, barriers and facilitators to hemodialysis attendance, and recommendations to improve the system to facilitate dialysis attendance. Average time on dialysis was 2.5 years for the nonadherent group and 7.3 years in the adherent group. In both groups, patients felt that dialysis is life‐saving and a necessity. A substantial number of patients in both groups understood that missing hemodialysis treatments is dangerous and several patients could clearly communicate the risk of skipping. The most common barriers to hemodialysis were inadequate or unreliable transportation (mentioned in both groups) and a lack of motivation to get to dialysis or that dialysis is not a priority (typically mentioned by the nonadherent group). Facilitators to hemodialysis attendance included explanations from the health care team regarding the risk of skipping and relationships with other dialysis patients. Patient recommendations to improve dialysis attendance included continued education about the risk of poor attendance and more accessible transportation. Patients did not feel that home dialysis would improve adherence. Hemodialysis patients must adhere to a complex and burdensome regimen. Through the elucidation of barriers and facilitators to hemodialysis attendance and through specific patient recommendations, at least three interventions may be further investigated to improve hemodialysis attendance: Improvement of the transportation system, education and supportive encouragement from the health care team, and peer support mentorship.     

Provision and quality of dialysis services in Libya

Dialysis is entirely funded by the public health care sector in Libya. Access to treatment is unrestricted for citizens but there is a lack of local information and no renal registry to gather national data. This cross-sectional study aimed to investigate dialysis provision and practice in Libyan dialysis facilities in 2009. A structured interview regarding dialysis capacity, staffing and methods of assessment of dialysis patients, and infection control measures was conducted with the medical directors of all 40 dialysis centers and 28 centers were visited. A total of 2417 adult patients were receiving maintenance dialysis in 40 centers, giving a population prevalence of approximately 624 per million. Most dialysis units were located in the northern part of the country and only 12.5% were free-standing units. Only three centers offered peritoneal dialysis. One hundred ninety-two hemodialysis rooms hosted 713 functioning hemodialysis stations, giving a ratio of one machine to 3.4 patients. Around half of centers operated only two dialysis shifts per day. Nephrologist/internist to patient ratio was 1:40 and nurse to patient ratio was 1:3.7. We found a wide variation in monitoring of dialysis patients, with dialysis adequacy assessed only in a minority. Separate rooms were allocated for chronic viral infection seropositive patients in 92.5% of the units. In general, the provision of dialysis is adequate but several areas for improvement have been identified, including a need for implementation of guidelines, recruitment of more nephrologists, and the development of more cost-effective alternatives such as peritoneal dialysis and transplantation.     

Home hemodialysis in Australia and New Zealand: practical problems and solutions

Home hemodialysis, as practiced in Australia and New Zealand, offers patients the return of self-control and self-esteem. It also allows reconnection with family, friends and (re)employment. Though there are emotional and time-related "costs" with home hemodialysis, these center on training time, commitment and patient or family stresses and, if carefully managed and properly resourced, can be overcome for most home-suitable patients. As we believe many center-based hemodialysis patients are home-suitable and that home care is severely under-utilized, assessment techniques to maximize uptake are examined. While patient dropout from home care relates more to staff attitudes than to true home-failure, dropout is minimized by ensuring the patient and not a carer takes full dialysis responsibility with the carer acting as a supporter and not the facilitator. Installation of home equipment is simple and cheap, the financial costs of home hemodialysis being substantially less than those of facility care where salary and infrastructure costs far exceed training, equipment, installation and maintenance costs at home. Home monitoring is not routinely required especially with longer, more frequent regimens-but effective 24-hour on-call nurse and technician cover is essential. Intravenous drug self-administration at home is safe and effective, reducing the need for hospital visits to a 2-3 monthly minimum. The debilitating effects of facility care cannot be over-emphasized while the liberating psychology of a well-supported hemodialysis program is truly satisfying for patient and staff alike.     

Experience With Nocturnal Hemodialysis

In order to provide a highly efficient, long-duration form of hemodialysis, we developed nocturnal hemodialysis. Patients were dialyzed nightly at home for 8 – 10 hours, 6 – 7 nights/week. We kept the dialysate flow at 100 mL/min and the blood flow at 250 – 300 mL/min. Patients were monitored remotely from the hospital through a computer connection. An internal jugular line was used as an access. We have trained 12 patients over 30 months and have accumulated 160 patient-months worth of data. The patients tolerated the dialysis very well and slept through the night. There was a significant improvement in their sense of well-being. Nightly Kt/V was 0.99. Weekly removal of phosphate was two times as high and β ₂ -microglobulin four times as high as conventional hemodialysis. All patients have discontinued their phosphate binders and have increased their dietary phosphate and protein intake. Hypertension was controlled with fewer medications, and erythropoietin dosages decreased. Complications were infrequent and included catheter occlusion and infections. Reusing the dialyzers decreased the cost of the treatment to levels similar to continuous ambulatory peritoneal dialysis. Nocturnal hemodialysis represents a viable dialysis modality that combines high quality, low cost, and excellent tolerance.     

Physical functioning in end-stage renal disease patients: update 2005

Physical functioning in patients with end-stage renal disease treated with dialysis is low, whether measured using objective laboratory measures, physical performance testing, or self-reported measures. Peak oxygen uptake (VO2peak), self-reported functioning measures, and physical activity levels are independent predictors of mortality in these patients. Cardiovascular exercise training studies result in improvements in VO2peak, physical performance tests, and self-reported functioning. Resistance exercise training improves muscle strength. Exercise training may have positive benefits on other factors that are important clinical issues in dialysis patients, including cardiovascular risk profile, oxidative stress, and inflammation. Endothelial function, a surrogate marker of atherosclerosis, has been shown to improve with exercise training in dialysis patients. Although there have been numerous recent studies on benefits of exercise, few dialysis clinics or nephrologists provide encouragement or programs as a part of their routine care of their patients. There are many national guidelines that include exercise or increasing physical activity as a part of the treatment of many conditions that are relevant in dialysis patients, including hypertension, hyperlipidemia, and high cardiovascular disease risk. The nephrology community continues to state concern for outcomes; however, a simple, low-tech intervention that has many benefits to their patients (i.e., encouragement, recommendations, and opportunity for increasing physical activity) has not been adopted as part of the standard care. Adoption of routine counseling and encouragement for physical activity has the potential to improve outcomes, improve physical functioning, and optimize quality of life and overall health of dialysis patients.     

Survey of home hemodialysis patients and nursing staff regarding vascular access use and care

Vascular access infections are of concern to hemodialysis patients and nurses. Best demonstrated practices (BDPs) have not been developed for home hemodialysis (HHD) access use, but there have been generally accepted practices (GAPs) endorsed by dialysis professionals. We developed a survey to gather information about training provided and actual practices of HHD patients using the NxStage System One HHD machine. We used GAP to assess training used by nurses to teach HHD access care and then assess actual practice (adherence) by HHD patients. We also assessed training and adherence where GAPs do not exist. We received a 43% response rate from patients and 76% response from nurses representing 19 randomly selected HHD training centers. We found that nurses were not uniformly instructing HHD patients according to GAP, patients were not performing access cannulation according to GAP, nor were they adherent to their training procedures. Identification of signs and symptoms of infection was commonly trained appropriately, but we observed a reluctance to report some signs and symptoms of infection by patients. Of particular concern, when aggregating all steps surveyed, not a single nurse or patient reported training or performing all steps in accordance with GAP. We also identified practices for which there are no GAPs that require further study and may or may not impact outcomes such as infection. Further research is needed to develop strategies to implement and expand GAP, measure outcomes, and ultimately develop BDP for HHD to improve infectious complications.