Role of peritoneal dialysis in the era of the resurgence of home hemodialysis

In recent years, there has been a resurgence of home hemodialysis (HHD) therapies. Given the small percentage of prevalent patients in the United States currently on home dialysis, an appropriate question is: What is the role of peritoneal dialysis (PD) in this era? Data suggest that in centers that are promoting the growth of HHD, their PD programs also tend to be very active. Furthermore, our experience and other data suggest that one should not worry about cannibalizing PD in order to grow HHD. Most HHD patients come from in‐center hemodialysis or those patients transitioning from PD to another therapy. In fact, data suggest that in order to promote the growth of HHD, a certain minimal infrastructure is needed in terms of staff. An active PD program not only supports a robust infrastructure that allows for HHD growth but also fosters profitability of a home program.     

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.     

Comparison of Staff‐Assisted Home Hemodialysis with In‐Center Hemodialysis and In‐Hospital Hemodialysis

Home hemodialysis (HHD) is superior to in‐center hemodialysis (ICHD) in terms of survival, quality of life, and cost‐effectiveness. However, assistance from family members in performing HHD is not always available to patients, and professional assistance for HHD can be cost prohibitive. For certain patients, ICHD can be impractical due to difficulties in transportation, which may necessitate ambulance transportation or hospitalization for in‐hospital hemodialysis (IHHD). We describe 4 patients that have had problems receiving ICHD for various reasons. Two of these patients had problems with transportation, while the other two could not remain on dialysis for the prescribed duration of time and, therefore, received inadequate dialysis. These patients had difficulty while receiving ICHD in meeting the adequacy criteria set by Dialysis Outcomes Quality Initiative. One of these patients had a neuropsychiatric disorder and displayed disruptive behavior. When these 4 patients were switched to staff‐assisted home hemodialysis (SAHD), the dialysis core indicators improved compared with ICHD, and the patients needed significantly fewer hospitalization days. In this paper, we demonstrate that, in patients that cannot be easily transferred, and in patients with neuropsychiatric disorders, SAHD can be a less expensive and more efficacious modality of dialysis.     

What happened in Finland to increase home hemodialysis?

Finland is geographically a rather large country with a relatively sparse population (5.3 million). Home hemodialysis (HHD) was started in Helsinki 40 years ago and in the early years it was only used in selected patients. However, by the late 1980s HHD almost disappeared owing to the advent of CAPD and new HD centers. Towards the end of the 1990s, it became evident that PD had limitations and new ways had to be found to individualize HD, improve the outcome, increase capacity, and limit the growth of costs of HD. After careful planning, HHD was reinstituted at the Helsinki University Hospital in 1998 and since then the program has grown steadily. By December 31, 2007, altogether 163 patients had started at home. This has required changes in the predialysis program where the "home first" policy was adopted. Other important features include close cooperation with other nephrological centers as well as centralized HHD training that also supports more remote hospitals. Since then this therapy has been started in several other academic and in some smaller hospitals, and at the end of last year about 4% of all Finnish dialysis patients (n=1.600) were on HHD (prevalence 11.8/million). In the Helsinki metropolitan area this treatment is the most economical modality (estimated annual global costs euro37.000), comparable to self-care satellite HD and CAPD. A successful HHD program requires a well-organized predialysis program, a highly motivated multidisciplinary team, and well-developed training networks.     

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.     

Determinants of training and technique failure in home hemodialysis

Home hemodialysis (HHD) has clinical and economic advantages compared with in‐center conventional hemodialysis. Many health systems wish to broaden the population to which this modality can be successfully offered. However, determinants of successful HHD training and technique survival are unknown. We hypothesize that both medical and social factors play a role when patients fail to successfully adopt HHD. We examined characteristics of consecutive patients who initiated training for HHD between 2003 and 2011. Patients were classified as “failure” if they failed to complete HHD training or experienced technique failure (TF) within the first year of treatment. Remaining patients were classified as “success.” One hundred seventy‐seven patients initiated HHD training. In the “failure” group (n = 32), 24 did not finish training and 8 had TF. In the “success” group (n = 145), 65 (45%) patients remained on NHD, 49 (34%) discontinued HHD because of renal transplantation and 21 (14%) because of death, while only 10 (7%) eventually transferred to another dialysis modality. In a multivariable logistic regression analysis, the strongest predictors of “failure” were end‐stage renal disease because of diabetes (odds ratio [OR] 3.8, 95% confidence interval [CI] 1.4–10.3, P = 0.008) and use of rental housing (OR 3.1, 95% CI 1.3–6.0, P = 0.01). Both medical and social factors are associated with failure to adopt HHD. Enhanced supports or a customized education strategy for these vulnerable patients should be considered.     

The use of vascular access audit and infections in home hemodialysis

Vascular access‐related infection is an important adverse event in home hemodialysis (HHD). We hypothesize that errors in self‐cannulation or manipulation of dialysis vascular access are associated with increased incidence of access‐related infection. We conducted a retrospective cohort study of all prevalent HHD patients at the University Health Network. All vascular access‐related infections were recorded from 2006 to 2013. Errors in dialysis access were ascertained by nurse‐administered vascular access checklist. Ninety‐two patients had completed at least one vascular access audit. Median HHD vintage was 2.3 (0.9–5.0) years in patients with appropriate vascular access technique and 5.8 (1.5–9.4) years in patients with erroneous vascular access technique. The overall rate of infection between patients with and without appropriate vascular access technique was similar (0.27 and 0.28 infections per year, P = 0.166). Among patients who were identified with errors in dialysis access manipulation, patients with five or more errors were associated with higher rate of access‐related infection (mean of 0.47 vs. 0.16 infection per patient‐year, P < 0.001). The use of vascular access audit is a feasible strategy, which can identify errors in vascular access technique. Patients with a longer median HHD vintage are associated with higher risk of inappropriate vascular access technique. Patients with multiple errors in vascular access technique are associated with a higher risk of dialysis access‐related infection. Prospective evaluation of the impact of vascular access audit on adverse vascular access events is warranted.     

Forty‐five years on home hemodialysis,a case of exceptional longevity

End‐stage renal disease is associated with dismal long‐term survival in general. Home hemodialysis (HHD) has been advocated as a modality affirming better quality of life and longer survival. We report a 62‐year‐old Caucasian female with end‐stage renal disease who has been exclusively on HHD for a total of 45 years, utilizing various platforms over the years. She has been one of the first home dialysis patients of the founding father of renal dialysis in the state of Mississippi, John D. Bower and cared by him throughout his career. Throughout this period, her life bore witness to the evolving technology of dialysis accesses, platforms, and evolution of HHD in its entirety. After review of the literature, we find that the longest vintage time on HHD documented to date was around 35 years. This extraordinary longevity bears testimony to the extraordinary self‐motivation of the patient, the dedication of her providers and the true potential of HHD in motivated subjects.     

Pathways to improve nephrologist comfort in managing patients on in-center or home self-care dialysis

In end-stage kidney disease (ESKD), patient engagement and empowerment are associated with improved survival and complications. However, patients lack education and confidence to participate in self-care. The development of in center self-care hemodialysis can enable motivated patients to allocate autonomy, increase satisfaction and engagement, reduce human resource intensiveness, and cultivate a curiosity about home dialysis. In this review, we emphasize the role of education to overcome barriers to home dialysis, strategies of improving home dialysis utilization in the COVID 19 era, the significance of in-center self-care dialysis (e.g., cost containment and empowering patients), and implementation of an in-center self-care dialysis as a bridge to home hemodialysis (HHD).     

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.     

Coronary and aortic calcifications in patients new to dialysis

Background: Vascular calcification has been associated with all cause and cardiovascular mortality in patients with end‐stage kidney disease (ESRD). Whether vascular calcification is present in persons with advanced chronic kidney disease starting dialysis or develops in patients on dialysis is unknown. The purpose of this study was to examine the prevalence of vascular and coronary calcification in patients new to hemodialysis. Methods: A total of 129 subjects new to dialysis were evaluated using electron beam computed tomography. The primary outcome was the presence and extent of coronary artery, aortic, and valvular calcification. Results: Forty‐three percent of subjects had no significant coronary artery calcification (total score ≤ 30) and 27% had no detectable aortic calcification. Thirty‐four percent had coronary artery scores that placed them above the 90th percentile for age and sex. Coronary artery calcification was significantly associated with a history of coronary artery disease and atherosclerotic vascular disease (ASVD) whereas aortic calcification was significantly associated with ASVD. Age (p < 0.0001), pulse pressure (p = 0.004), diabetes mellitus (p = 0.009), and a history of smoking (p = 0.026) were independently associated with the extent of coronary artery calcification. Age (p < 0.0001) and pulse pressure (p = 0.0003) were independently associated with the extent of aortic calcification. Conclusions: A large fraction of patients new to hemodialysis had no evidence of coronary artery or aortic calcification. Coupled with the extensive vascular calcification reported by others in prevalent dialysis patients these findings suggest that dialysis‐specific factors contribute to calcific vascular disease in ESRD.     

Blood Urea Nitrogen Stability: A Feasibility Study for Home Hemodialysis Adequacy Testing Through Mail

Urea kinetic modeling measures the delivered dose of hemodialysis and is used to monitor dialysis adequacy. Obtaining samples for adequacy calculations is a challenge for home hemodialysis (HHD) patients. Ideally, the urea reduction ratio (URR) should be measured at a typical dialysis session; therefore, for HHD patients test specimens should be drawn at home and transferred to a clinical laboratory. Would blood urea nitrogen (BUN) remain stable if samples were mailed to the laboratory? To answer this question, BUN was measured in pre- and postdialysis samples from 20 patients over 8 days of laboratory storage. While BUN values varied among the patient population, neither pre- nor postdialysis values showed any significant variation during the 8-day storage time. These results suggest that BUN values are sufficiently stable for specimens to be drawn at home and mailed to a testing laboratory.     

Heparin Use in Daily Hemodialysis

More frequent dialysis is thought to be associated with increased heparin requirements; however, limited data are available which compare heparin requirements of conventional to daily dialysis. Objectives: To determine differences in heparin dose during conventional thrice‐weekly dialysis (CHD) compared to daily hemodialysis (DHD). Methods: All patients within the daily home hemodialysis at the Northwest Kidney Centers were evaluated for heparin dose both pre‐ and post initiation of daily hemodialysis. Patients on DHD received an initial bolus of heparin, without a continuous heparin drip, and supplemental heparin midway through the dialysis run as needed to maintain adequate activated clotting times (ACTs). CHD patients received a heparin bolus, followed by initiation of heparin drip as needed to maintain adequate ACTs. Results: Of the 1117 patients who dialyze at the NKC, 55% were Caucasian, 21% African‐American, 20% Asian/Pacific Islander, and 35% were of other ethnicity. The majority of patients were greater than 60 years (56%), while 36% ranged from 40–60 years and 13% ranged from 20–40 years. Male patients constituted 54% of patients. Diabetes was the primary cause of renal disease (36%), followed by hypertension (21%) and glomerular disease (18%). Of those patients in the home hemodialysis program (n = 45), 10 patients started daily home hemodialysis using the Aksys daily home hemodialysis system. Of those, the majority was male (100%), Caucasian (78.8%) with an average age of 46.7 ± 18 years. Glomerulonephritis was the primary cause of end‐stage renal disease (40%), while the percentages of other diseases were similar [Alport's syndrome (20%), hypertension (20%) and diabetes (10%)]. Compared to initial DHD heparin requirements (10,111 ± 2219 units), CHD heparin dose requirements (6833 ± 2715 units) were significantly lower (p = 0.045); however, total heparin needs were similar between groups (10,166 ± 4380 units vs. 10,778 ± 2959 units) (p = 0.324). Conclusion: Although patients initiating DHD have greater initial heparin requirements than when on CHD, total heparin doses remain similar to those required on conventional thrice‐weekly hemodialysis. Greater initial heparin doses required during short daily dialysis appear safe compared to those of conventional dialysis.     

Determinants of hemodialysis‐induced segmental wall motion abnormalities

Patients who demonstrate worsening of cardiac wall motion (WM) during hemodialysis have higher 1‐year mortality. We sought to identify risk factors for dialysis‐induced WM abnormalities. Additionally, we examined the effects of hemodialysis on other parameters of cardiac function. Forty patients underwent echocardiography directly before dialysis and during the last hour of dialysis (79 dialysis sessions). Candidate predictors for intradialytic worsening of WM included age, a history of heart failure (HF) or coronary artery disease, changes in blood pressure or heart rate, high sensitivity cardiac troponin T and N‐terminal brain natriuretic peptide. Among 40 patients, WM worsened segmentally in eight patients (20%), worsened globally in one patient (3%), and improved segmentally in four patients (10%). Diastolic function worsened in 44% of patients, and left ventricular ejection fraction was largely unchanged during dialysis. The case of globally worsened WM occurred in the setting of intradialytic hypertension in a patient without HF. Surprisingly, history of coronary artery disease, hemodynamics, and serologic factors were not associated with worsened segmental WM during dialysis. After adjustment for history of coronary artery disease and other cardiac risk factors, patients with a history of HF had a threefold higher risk of worsening segmental WM during dialysis (RR 3.1, 95% CI [1.1, 9], p = 0.04). In conclusion, patients with a history of clinical HF were at higher risk of intradialytic worsening of segmental WM. Further studies are needed to determine the mechanism of this association and whether cardioprotective medications could ameliorate this adverse cardiac effect of hemodialysis.     

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.     

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.     

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.     

Dialysis education and options for late presenters—An ongoing dilemma

Pre-dialysis education forms a crucial part of dialysis preparation. Acute start dialysis patients often commence and remain on in-center hemodialysis (ICHD) without the benefit of an informed decision making process for kidney replacement therapy options. The aim of this review is to evaluate the evidence surrounding methods of education provision to the acute dialysis start population and their associated outcomes. Publications have described a holistic education pathway with multimedia provision of information and interactive experiences. One or more trained specialist nurses provided information over 3–5 sessions. Formal education was mostly initiated as an inpatient. 86%–100% of acute start dialysis patients are initiated and remain on ICHD. Following formal education, 21%–58% of patients chose peritoneal dialysis (PD), 10%–24% home hemodialysis, 33%–58% ICHD. This brings the number of patients maintained on an independent form of dialysis similar to the planned dialysis start population. Patients commenced on PD without needing temporary hemodialysis, hence avoided complications associated with such. Patients aged under 75 (p < 0.0001) and males (p = 0.006) were more likely to be influenced by education to select PD. The adjusted 5 year survival rates among discharged patients were similar between home and ICHD groups (73% vs. 71% respectively), with a comparable age of death. A targeted education program in the acute dialysis start population has proven to be feasible. Adaptations are likely required for each center; however, various methods have been shown to be effective, with an increased number of patients choosing an independent dialysis modality when given the choice.     

Excellent long time survival for Swedish patients starting home‐hemodialysis with and without subsequent renal transplantations

Survival for patients on dialysis is poor. Earlier reports have indicated that home‐hemodialysis is associated with improved survival but most of the studies are old and report only short‐time survival. The characteristics of patient populations are often incompletely described. In this study, we report long‐term survival for patients starting home‐hemodialysis as first treatment and estimate the impact on survival of age, comorbidity, decade of start of home‐hemodialysis, sex, primary renal disease and subsequent renal transplantation. One hundred twenty‐eight patients starting home‐hemodialysis as first renal replacement therapy 1971–1998 in Lund were included. Data were collected from patient files, the Swedish Renal Registry and Swedish census. Survival analysis was made as intention‐to‐treat analysis (including survival after transplantation) and on‐dialysis‐treatment analysis with patients censored at the day of transplantation. Ten‐, twenty‐ and thirty‐year survival were 68%, 36% and 18%. Survival was significantly affected by comorbidity, age and what decade the patients started home‐hemodialysis. For patients younger than 60 years and with no comorbidities, the corresponding figures were 75%, 47% and 23% and a subsequent renal transplantation did not significantly influence survival. Long‐term survival for patients starting home‐hemodialysis is good, and improves decade by decade. Survival is significantly affected by patient age and comorbidity, but the contribution of subsequent renal transplantation was not significant for younger patients without comorbidities.     

Relative risk of home hemodialysis attrition in patients using a telehealth platform

Introduction : Home hemodialysis (HHD) facilitates increased treatment frequency, which may improve patient outcomes. However, attrition due to technique failure limits the clinical effectiveness of the modality. Nx2me Connected Health is a telehealth platform that enables ongoing assessment of HHD patients using NxStage equipment, and that may reduce patient burden. We aimed to assess whether use of Nx2me was associated with risk of HHD attrition. Methods : We compared risks of all‐cause attrition, dialysis cessation (i.e., death or transplant), and technique failure in Nx2me users and matched control patients, using a retrospective cohort study. We also compared the likelihood of HHD training graduation in patients who initiated use of Nx2me during training with the likelihood in matched control patients. Matching factors included date of HHD initiation, NxStage treatment duration at initiation of follow‐up, and prescribed treatment frequency. We used stratified Fine‐Gray and Cox regression to compare risks, with adjustment for demographic factors and vascular access modality, and stratification by matched cluster. Findings : We identified 606 Nx2me users; 49.5% initiated use of Nx2me in <3 months after initiation of HHD with NxStage equipment. Adjusted hazard ratios (AHRs) of all‐cause attrition, dialysis cessation, and technique failure were 0.80 (95% confidence interval, 0.68–0.95), 1.10 (0.86–1.41), and 0.71 (0.57–0.87), respectively, for Nx2me users vs. matched controls. AHRs were similar in patients who initiated use of Nx2me in <3 months after initiation of HHD. The AHR of HHD training graduation was 1.61 (1.10–2.36) in patients who initiated use of Nx2me within 2 weeks of training initiation vs. matched controls. Discussion : Use of Nx2me was associated with lower risk of all‐cause attrition, lower risk of technique failure, and higher likelihood of HHD training graduation. Further studies are needed to identify the mechanisms by which use of a telehealth platform may improve clinical outcomes and reduce patient burden.