Despite a higher rate of end-stage kidney disease (ESKD) among Black and Hispanic patients in the United States, these groups are less likely to use home dialysis therapies compared with their White counterparts, according to the authors of a recent perspective article published in the Journal of the American Society of Nephrology.

The federal Advancing American Kidney Health initiative, an executive order issued in 2019, aims to start 80% of patients with incident kidney failure on home dialysis or kidney transplantation by 2025, but it cannot reach its goals without “strategic efforts to care for racial and ethnic minorities,” Katherine Rizzolo, MD, and Lilia Cervantes, MD, of the University of Colorado in Denver and Aurora, discussed along with their colleague Jenny Shen, MD, of The Lundquist Institute at Harbor-ULCA Medical Center in Torrance, California.

Only 7.3% of Black and 7.4% of Hispanic patients are currently treated with home dialysis compared with 9.3% of White patients, according to the 2020 United States Renal Data System (USRDS) annual data report. Geographic, demographic, and clinical factors do not fully explain this disparity. Instead, the authors of this review pointed to environmental, social, and system-level barriers.

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Environmental factors include a lack of home space to store dialysis supplies. Social factors include unstable housing and a lack of social support. Zip code areas with higher Black populations are less likely to use home dialysis, according to research. Underinsurance is also associated with low referral rates.

With respect to system-level barriers, research shows that Black and Hispanic patients with kidney failure are less likely than their White counterparts to have timely referral to nephrologists, predialysis nephrology care, adequate dialysis education, and planned dialysis initiation.

Working Toward Solutions

Dr Rizzolo and colleagues pointed to innovative strategies in other countries that may increase home dialysis use in the US. Community house hemodialysis, where multiple patients perform home hemodialysis in a common house, is performed in New Zealand for patients with unstable housing. Peritoneal dialysis (PD) performed at home with the assistance of a trained caregiver is reimbursed by health care systems in Canada, Denmark, and France. Expanding urgent start PD programs in the US may foster home dialysis. Increasing telehealth and home visits, providing transportation assistance, and reimbursing patients for work days off for training may also reduce racial disparities in home dialysis use.

In October 2021, the Centers for Medicare & Medicaid Services released the Health Equity Incentive to improve financial incentives for dual-eligible patients in the US. The authors of the review recommended further revisions, such as incorporating social risk factor adjustments and universal social needs screening into alternative payment models.

According to Dr Rizzolo and colleagues, “Nephrologists must be confident in their knowledge of home therapies to offer the modality, as well as to dispel the myth that patients from under-resourced communities are not good candidates.”


Rizzolo K, Cervantes L, Shen J. Racial and ethnic disparities in home dialysis use in the United States: barriers and solutions. J Am Soc Nephrol. Published online April 19, 2022. doi:10.1681/ASN.2022030288