EDITORIAL Nephrol Dial Transplant (2022) 37: 1393–1395 https://doi.org/10.1093/ndt/gfac057 Advance Access publication date 15 March 2022 Comparing survival between home hemodialysis and peritoneal dialysis—is the controversy over? Angela Yee-Moon Wang Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pok Fu Lam, 0000, Hong Kong SAR Correspondence to: Angela Yee-Moon Wang; E-mail: angela_wang@connect.hku.hk Globally, home dialysis remains very underutilized in many parts of the world: only limited countries such as Hong Kong, Thailand, Mexico, Canada, the Netherlands, Iceland, Finland, Denmark, Australia and New Zealand utilize home dialysis in over 20% of the dialysis population [1]. In most high and middle-income countries, home dialysis is generally more cost-saving than in-center dialysis [2]. However, cost calculations for in-center and home dialysis are complex and comparisons may vary between countries. Several previous studies compared patient survival between hemodialysis (HD) and peritoneal dialysis (PD), but these studies were generally non-randomized [3–8] as randomizing patients by their dialysis modalities proved to be difcult [9]. As a result, these studies generally sufered from bias inherent to the choice of dialysis modalities. Some studies used a matched cohort analysis and observed survival advantage with home HD (30– 40% higher) compared with PD [4, 5, 8] but there could be residual confounding not captured by the analysis. On the other hand, there was suggestion from the New Zealand home dialysis program that patients receiving PD may enjoy better survival within the frst 3 years, after which PD was associated with 33% higher mortality risk than home HD [3]. The discussion of survival outcomes among diferent dialysis modalities is important for healthcare professionals and other stakeholders involved in kidney failure care and also for patients who receive these dialysis modalities. In recent years, there is a global advocacy from many kidney organizations to promote global policy and practice changes to increase the accessibility and adoption of home dialysis [10, 11]. The current coronavirus disease 2019 (COVID-19) pandemic further encourages more utilization of home dialysis therapies as it enables patients to carry out their dialysis treatment at home, minimizing their need to travel to hospitals or dialysis centers for in-center dialysis, and may thus reduce the risk of COVID-19 infections [12]. The comparison of COVID-19 incidence between patients undergoing in-center HD versus home dialysis has to be interpreted with caution as patients undergoing in-center HD would likely undergo more screening than those on home therapies. Nevertheless, data from the United States Renal Data System (USRDS) showed that the COVID-19 hospitalization rate was 3 to 4 times higher for patients doing in-center HD compared with those receiving home PD or HD [13]. Patients receiving in-center dialysis were also three times more likely to test positive for COVID- 19 than patients receiving home dialysis [14, 15]. This adds further incentives to promote uptake and growth of home dialysis worldwide. Furthermore, home dialysis is associated with lower overall costs, better patient quality of life and allows more fexibility and free time for patients’ life participation compared with in-center dialysis. In September 2021, a new bipartisan legislation was passed in the USA that aims to make home dialysis more accessible and afordable to kidney patients. In their study, Bitar and co-workers [16] analyzed all adult subjects who started kidney replacement therapy (KRT) between 2004 and 2017 (n = 536) in Finland in the district of Helsinki-Uusimaa. The study was not randomized. Subjects who were on home dialysis modalities at 90 days from starting KRT were included in the analysis. Survival of patients on home HD, automated peritoneal dialysis (APD) and continuous ambulatory peritoneal dialysis (CAPD) were compared using an intention-to-treat approach. Of note is the infrastructure of Finland’s medical provision system, which adopts a ‘home-dialysis frst’ policy, allows a free choice of home dialysis modality and uses a multidisciplinary care approach with a well-developed training network to promote home therapies. The multidisciplinary team provides patients with pre-dialysis education of diferent dialysis modalities options equally, with lectures and on-the-spot information resulting in a much higher rate of patients choosing a home dialysis therapy [17, 18]. Furthermore, the medical team evalu- ate patients for any contraindications and suitability for various modalities and inform the patients. If there are no medical contraindications, patients could choose the modality that they fnd most suitable for themselves taking into consideration their work life, social situation, lifestyle and hobbies, etc. © The Author(s) 2022. Published by Oxford University Press on behalf of the ERA. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com Downloaded from https://academic.oup.com/ndt/article/37/8/1393/6548903 by guest on 28 July 2022