Dialysis modality and patient outcome

INTRODUCTION — Although the rate of all-cause mortality for patients on dialysis remains substantially higher than the general population, the life expectancy of patients with end-stage kidney disease (ESKD) has gradually improved since the introduction of dialysis in the 1960s. According to the United States Renal Data System (USRDS) 2023 report, the adjusted five-year survival for patients starting hemodialysis or peritoneal dialysis in 2017 was approximately 40 percent [1].

Previously, one partial explanation for the poor survival in the United States was inadequate dialysis since substantially higher survival rates have been reported in Europe and Japan, even after case adjustment for age, sex, and kidney diagnoses [2]. However, it is more likely that factors such as a higher prevalence of diabetes mellitus, more comorbid conditions, and an inability to accurately capture severity of any noted comorbid disease are components of the higher dialysis mortality in the United States [3-5]. This is particularly true as an increasing dialysis dose has been realized in the United States [5].

This topic reviews the selection of dialysis modality and patient outcomes that are associated with specific modalities. Patient outcomes associated with dialysis adequacy, the use of daily or nocturnal hemodialysis, and the selection of different types of peritoneal dialysis are discussed elsewhere.

●(See "Patient survival and maintenance dialysis".)

●(See "Short daily hemodialysis".)

●(See "Prolonged intermittent kidney replacement therapy".)

●(See "Outcomes associated with nocturnal hemodialysis".)

●(See "Evaluating patients for chronic peritoneal dialysis and selection of modality".)

SELECTION OF DIALYSIS MODALITY — Dialysis modalities include hemodialysis, either in a dialysis center or at home, or peritoneal dialysis, including chronic ambulatory peritoneal dialysis (CAPD) or automated peritoneal dialysis (APD). In Europe, some patients are treated with hemofiltration technologies.

The selection of dialysis modality is influenced by a number of clinical and socioeconomic consideration, such as availability and convenience, comorbid conditions, dialysis-center factors, the patient's home situation, clinician comfort with home therapies, the method of clinician reimbursement, and the ability to tolerate volume shifts [6-13].

For some patients, there may be medical contraindications to either modality. As an example, a patient with multiple prior abdominal surgeries with resultant adhesions would not be an optimal candidate for peritoneal dialysis. Similarly, a patient with severe aortic stenosis or end-stage heart failure may not be an optimal candidate for standard, three times a week, in-center hemodialysis. If a patient is a candidate for multiple dialysis modalities, and these modalities are available, the patient should receive education about these choices so that they can select a modality that would fit best with their lifestyle and life goals.

However, at times, patients are not given unbiased information about their choices. Predialysis education regarding different modalities may increase the patient selection of peritoneal dialysis. In a systematic review and meta-analysis that included mostly observational studies, structured, patient-targeted educational interventions were associated with a two- to fourfold increase in the odds of choosing peritoneal dialysis compared with standard care [13]. However, there was significant heterogeneity between studies due in part to differences in study populations and in interventions, and many of the included studies did not include adequate description of a control intervention.

In 2011, reimbursement in the United States changed to a bundled payment that removed unintended financial payment incentives favoring in-center hemodialysis and replaced them with a system that provided equal pay for peritoneal dialysis and in-center hemodialysis [14]. Since that change in reimbursement, utilization of peritoneal dialysis in prevalent patients on dialysis in the 10 largest dialysis providers in the United States increased from 8.5 to 11.2 percent between 2010 and 2014 [14]. By 2021, 12.3 percent of prevalent patients on dialysis in the United States received peritoneal dialysis, 2.3 percent received home hemodialysis, and 85.4 percent received in-center hemodialysis [1]. To date, the growing use of home dialysis that was encouraged by Medicare dialysis payment reform has not been associated with worsening overall outcomes among incident patients with end-stage kidney disease (ESKD) receiving peritoneal dialysis [15].

Patients who are selected for peritoneal dialysis may have fewer comorbidities compared with those who undergo hemodialysis. This was best shown in the Choices for Healthy Outcomes in Caring for ESRD (CHOICE) cohort study in which the baseline characteristics of 279 and 759 incident patients on peritoneal dialysis and hemodialysis, respectively, were assessed using the index of coexistent diseases [16]. Comorbidity was significantly less severe among patients on peritoneal dialysis, with the odds ratio (OR) of choosing peritoneal dialysis being much less for those with the most severe coexistent conditions (OR 0.50, 95% CI 0.28-0.90).

Other studies that have examined this issue have yielded conflicting results [16-19]. However, many of these reports, particularly those in the United States, were flawed because comorbidity was commonly assessed among prevalent (and not incident) patients and was principally defined as the relative contributions from age, diabetes, and/or the underlying cause of kidney disease.

Reimbursement strategies favor using one modality at a time. However, among some patients, it may be optimal to utilize both hemodialysis and peritoneal dialysis in a way that provides the advantages of each modality but without the disadvantages. This is seldom done in the United States but is not uncommon in Japan [20]. An example would be to do peritoneal dialysis five or six days a week and hemodialysis on the one or two off days [21,22]. Another strategy, for example, may be an integrated-care approach in which incident patients on dialysis initially undergo peritoneal dialysis, with transfer to hemodialysis once complications ensue with peritoneal dialysis. This is based in part on the hypothesis that, principally via its ability to preserve residual kidney function, peritoneal dialysis provides significant benefits as an initial modality [23-25]. Other benefits may include preservation of vascular access and, perhaps, better survival during the first few years of dialysis [26,27]. (See 'Peritoneal dialysis versus in-center hemodialysis' below.)

SURVIVAL BY MODALITY — The ideal method to compare survival on peritoneal dialysis and hemodialysis is a prospective study that randomly assigns patients to peritoneal dialysis or in-center hemodialysis. Although such trials have been attempted, none have been completed in a way that provides conclusive answers [28-31]. One such a study was initiated in the Netherlands [31]. However, among 738 patients who were eligible to participate, only 38 agreed to be randomly assigned. Because of the small number of enrolled patients and of deaths (nine and five with hemodialysis and peritoneal dialysis, respectively), no significant survival data could be derived from this trial. Unfortunately, this study suggests that an appropriately powered trial to answer this important question will be extremely difficult to perform.

Many observational studies have attempted to compare outcomes among patients on in-center hemodialysis versus peritoneal dialysis. Our opinion is that, for most patients dialyzing at a center that is equally qualified to provide both in-center hemodialysis and peritoneal dialysis, the expected outcomes for either modality would be similar. The following is an overview of some of the relative survival data related to the different available chronic dialysis modalities.

Peritoneal dialysis versus in-center hemodialysis — Many observational studies have examined the relative effect upon mortality of peritoneal dialysis versus in-center hemodialysis. The results have been conflicting, with hemodialysis reportedly having no difference, a relative benefit, or a relative adverse effect upon survival compared with peritoneal dialysis [32-41]. Reasons for these variable results include selection bias, flawed study design, differences in mortality effects with time from initiation of dialysis, differences in comorbid diseases, and other factors.

Observational data suggest that peritoneal dialysis may provide relative short-term survival benefits but comparable or decreased survival after one to two years [42-48]:

●An intention-to-treat analysis of 35,265 Canadian patients who initiated dialysis between 1991 and 2004 demonstrated better survival associated with peritoneal dialysis for the first 18 months and with hemodialysis after 36 months [49]. Analysis of patients who started dialysis between 2001 and 2004 showed better survival with peritoneal dialysis for two years and comparable survival thereafter.

●One study from the Canadian registry using an "as-treated" analysis (in which treatment modality switches were incorporated) found that continuous ambulatory peritoneal dialysis (CAPD)/continuous cycler peritoneal dialysis (CCPD), compared with hemodialysis, was associated with a significantly lower risk of death (relative risk [RR] of 0.73) [42]. Most of the survival benefit was observed during the first two years after the initiation of kidney replacement therapy (KRT). By comparison, the survival benefit of peritoneal dialysis largely disappeared (hazard ratio [HR] of 0.93) with an "intent-to-treat" analysis (in which treatments were classified based upon modality 90 days post-initiation).

●A study of over 117,000 incident patients on dialysis in the United States reported an advantage in short-term, but not long-term, survival with CAPD/CCPD compared with hemodialysis [43]. Compared with patients on hemodialysis, the RR of death at three months for patients on CAPD/CCPD was 0.62 for those without diabetes and 0.73 for those with diabetes; however, there was no significant difference in mortality risk at two years.

●The 2023 United States Renal Data System (USRDS) report showed that the putative survival benefit of peritoneal dialysis relative to hemodialysis during the first few years of KRT declined over time. At five years, the survival of patients on peritoneal dialysis was similar to that of patients on hemodialysis (figure 1) [1].

These observations are not confined to the United States. There are similar trends in review of data from Canada [40], Northern Europe [44,46], and from Australia and New Zealand [47].

However, a large study of Korean patients showed improved survival over the entire duration of dialysis therapy among patients on hemodialysis compared with those on peritoneal dialysis [50]. This was a matched cohort study that included 32,280 incident patients on dialysis who were followed for a median of 26.5 months. After propensity-score matching and after censoring for KT, mortality was higher for patients on peritoneal dialysis compared with those on hemodialysis (HR 1.20, 95% CI 1.12-1.28). Age was an important determinant of mortality differences between groups. Among patients ≥55 years, mortality was higher among patients on peritoneal dialysis compared with those on hemodialysis, except among patients with malignancy. However, among patients <55 years, mortality was the same between groups.

Suggested reasons for the disparity between results of this study and studies of Western countries include differences between countries in the quality of dialysis modality or in patient population characteristics [51]. It is possible that results of studies of Western populations may not apply to Asian patients.

In studies that have shown an early survival benefit associated with peritoneal dialysis, the time after dialysis initiation at which the relative survival benefit is lost and survival comparisons start to favor hemodialysis depends on multiple variables, including the cause of ESKD, vintage (ie, the year the patient started KRT), sex, country of treatment, and presence or absence of comorbidities [52,53]. As an example, the survival advantage conferred by peritoneal dialysis is not as robust if the primary case of ESKD is diabetes, the patient is older, or the patient has comorbidities [46,47,53-56]. In one study that analyzed data from 398,940 patients who initiated dialysis between the years 1995 to 2000, mortality risk was higher with hemodialysis than peritoneal dialysis among those who had no baseline comorbidity (with RRs of 1.24, 1.13, and 1.13 among those between 18 to 44, 45 to 64, and older than 65 years, respectively) and among younger patients with diabetes with no comorbidity (RR 1.22, for age between 18 and 44 years) [53]. By comparison, hemodialysis was associated with a lower mortality risk in older patients with diabetes with either no comorbidity (RR 0.92 and 0.86 for ages 45 to 64 and greater than 65 years, respectively) or a baseline comorbidity (RR 0.82 and 0.80 for ages 45 to 64 and greater than 65 years, respectively).

The presence of heart failure may also attenuate the early survival benefit associated with peritoneal dialysis. Although one study found one- and two-year survivals of 90 and 64 percent among patients on peritoneal dialysis with severe systolic dysfunction [54], a subsequent study found poorer survival among new patients on dialysis with heart failure who were initially treated with peritoneal dialysis compared with hemodialysis [55].

One of the major limitations of these epidemiologic studies is that there is an age by modality interaction. In particular, the risk of death with modality varies with age, with peritoneal dialysis having a relatively increased and decreased mortality in older and younger patients, respectively. Overall, it appears that the variable results are due to differences among incident patients and the type of analytical method utilized [57].

Matched cohort studies have attempted to address some of these shortcomings [47,58,59]:

●A prospective cohort study (Choices for Healthy Outcomes in Caring for ESRD [CHOICE]) compared the risk of death among 1041 patients starting dialysis (274 and 767 receiving peritoneal dialysis and hemodialysis, respectively) who were followed for up to seven years [58].

After statistical adjustment, the risk of death at one year from dialysis initiation was similar with both modalities. In the second year, however, the risk of death was significantly higher with peritoneal dialysis (HR 2.34, 95% CI 1.19-4.59). This result was consistently observed with different statistical models including a propensity score model. With subgroup analysis, a higher risk of death with peritoneal dialysis was observed in patients with cardiovascular disease and those with an intermediate propensity score of being initially treated with peritoneal dialysis. Unlike other studies, an increased risk for death with peritoneal dialysis was not observed among patients with diabetes or cardiovascular disease or older patients. However, the overall mortality was relatively low for patients on hemodialysis, suggesting that the cohort may not be representative of the United States as a whole.

●Another retrospective cohort study analyzed 6337 matched patient pairs who initiated dialysis in the United States during 2003 [59]. In an intention-to-treat analysis, compared with patients on hemodialysis, cumulative survival was higher for those on peritoneal dialysis (HR 0.92, 95% CI 0.86-1.00).

Cumulative survival probabilities for peritoneal versus hemodialysis were 85.8 versus 80.7 percent, 71.1 versus 68 percent, 58.1 versus 56.7 percent, and 48.4 percent versus 47.3 percent at 12, 24, 36, and 48 months, respectively. The survival advantage for peritoneal dialysis was most robust in patients less than 65 years old, those with no cardiovascular disease, and those without diabetes. If the observation was started at day 90, there was no difference between the modalities overall, but hemodialysis was associated with improved survival in patients with cardiovascular disease and diabetes.

●In a study of 27,015 patients from Australia and New Zealand, compared with hemodialysis, peritoneal dialysis was associated with a higher survival from day 90 to day 365 (HR 0.89, 95% CI 0.81-0.99) [47]. These benefits were most significant among younger patients without comorbid conditions. After one year, however, peritoneal dialysis was associated with markedly higher mortality (HR 1.33, 95% CI 1.24-1.42).

However, a propensity-score analysis (in which patients on peritoneal dialysis were matched with those on hemodialysis with known covariates) showed no difference in mortality between groups prior to one year (HR 0.99, 95% CI 0.89-1.10) and an increase in mortality associated with peritoneal dialysis after one year (HR 1.35, 95% CI 1.27-1.42).

●A subsequent propensity-matched cohort study compared survival between patients who initiated peritoneal dialysis or hemodialysis between 2001 and 2013 in a health care organization in the United States [60]. To remove the confounding effects on mortality of a hemodialysis catheter, only patients with an arteriovenous fistula or graft were included in the hemodialysis group.

By as-treated and intent-to treat analyses, the cumulative HRs for death after one year were 2.38 (95% CI 1.67-3.38) and 2.09 (95% CI 1.49-2.92), respectively, for hemodialysis relative to patients on peritoneal dialysis. The cumulative risk of death remained lower for patients on peritoneal dialysis for nearly three years in the as-treated analysis and two years in the intent-to-treat analysis. There was no difference between groups in survival thereafter.

In summary, data suggest that, at the start of KRT, for most patients, survival on hemodialysis and peritoneal dialysis is similar, with perhaps a slight advantage favoring peritoneal dialysis. We should embrace other factors such as quality of life, patient convenience, and ability to travel. A study specifically examining the prevalence of contraindications to peritoneal dialysis in several centers in the United States and Canada found that, in general, approximately 78 percent of patients were candidates for peritoneal dialysis [61]. Patients should be allowed to make a choice. We should be more proactive about providing an unbiased modality education and encourage patients to consider home dialysis much more often than has historically happened in the United States.

High-flux and high-efficiency hemodialysis — High efficiency refers to standard cellulosic membranes with a larger surface area, whereas high flux refers to more porous noncellulosic membranes with increased permeability, particularly to larger molecules.

These modalities may decrease morbidity (hypotension and symptoms such as nausea, vomiting, cramps, and headache) during dialysis. It has been proposed that biocompatible membranes produce fewer intradialytic symptoms due to the absence of complement activation and neutrophil aggregation.

High-flux dialysis may have a number of long-term benefits, including:

●Enhanced beta-2-microglobulin clearance and a possible reduction in late amyloid deposition (see "Dialysis-related amyloidosis")

●An improvement in the lipid abnormalities commonly seen in kidney failure (see "Lipid abnormalities in nephrotic syndrome")

●With biocompatible membranes, less stimulation of neutrophils and monocytes due to less activation of complement and cytokines (see "Clinical consequences of hemodialysis membrane biocompatibility")

There are several nonrandomized, observational studies suggesting that these and perhaps other factors may lead to higher patient survival with high-flux dialysis [62-66]. The question of a possible survival benefit with high-flux dialysis was best addressed in a large, randomized clinical trial, called the Hemodialysis (HEMO) study [67]. In this report, 1846 patients were randomly assigned to a low-flux or high-flux dialyzer (based on clearance of beta-2-microglobulin) and a standard or high dose of dialysis. The primary outcome was death from any cause, while the main secondary outcomes were the rate of all hospitalizations (but excluding those related to access) and the composite outcomes of the first hospitalization for a cardiac problem or death from any cause, the first hospitalization for an infectious cause or death, and the first decline of greater than 15 percent of the serum albumin from baseline value or death. Issues relating to dialysis dose and survival in this study are presented separately. (See "Prescribing and assessing adequate hemodialysis".)

The following results concerning survival and membrane flux were reported at a mean follow-up of 4.5 years:

●Impressive separation was obtained for the low- and high-flux groups, with clearances of beta-2-microglobulin of 3 and 34 mL/min, respectively.

●The risk of death from any cause, the primary outcome, was the same in the high- and low-flux groups (RR of death of 0.92 for high versus low flux, 95% CI 0.81-1.05) (figure 2).

●The risk of the main secondary outcomes was also the same for both flux groups. In the high-flux group, there were significant reductions, compared with the low-flux group, in the risk of death from cardiac causes and the combined outcome of hospitalizations or death from a cardiac cause. However, as previously mentioned, total mortality was the same in both groups.

●Subgroup analysis revealed a significant overall survival and cardiovascular survival benefit for patients with more than 3.7 years of dialysis receiving high-flux dialysis (32 percent lower risk than the low-flux group, CI 0.53-0.86). However, the strength of the interaction between the flux group and years of dialysis was weakened when years of dialysis were treated as a continuous variable or were further subdivided into five groups [68].

Thus, although there does not appear to be an overall survival benefit with high-flux dialysis membranes, subgroup analysis suggests a possible benefit with high-flux dialysis among patients on dialysis with longer vintage [68]. A similar finding showing a survival benefit with high-flux membranes among those undergoing dialysis was noted in a retrospective study from France [69]. In this study, among 650 patients undergoing dialysis therapy for a mean period of 96 to 102 months, multivariate analysis revealed that survival was significantly higher among those undergoing dialysis with high-flux membranes (RR 0.62, 95% CI 0.43-0.91).

A Cochrane systematic review and meta-analysis found that high-flux dialysis did not change all-cause mortality (10 studies, 2915 participants) but did decrease cardiovascular mortality (five studies, 2612 participants; RR 0.83, 95% CI 0.70–0.99) [70]. The dialysis vintage varied between studies, however, and subgroup analysis of patients with increased vintage was not performed.

Additional studies are required to confirm the suggested benefit of high-flux membranes among patients on dialysis of increasing vintage [68,69]. The patient is not involved in deciding to use a high-flux or a high-efficiency hemodialysis membrane. Rather, the clinician prescribing hemodialysis decides which membrane to use based on the hemodialysis membranes available for in-center or home use at the dialysis unit that will be providing the patient's care. As noted above, the patient should be involved in deciding on in-center care (almost always three/week daytime hemodialysis, although four/week daytime hemodialysis, in-center nocturnal hemodialysis, and rarely even in-center peritoneal dialysis are other options) or home dialysis.

If the patient is interested in home dialysis, then the next step is to decide if the patient should do peritoneal dialysis or home hemodialysis (frequent short daily or nocturnal).

Home, nocturnal, and short daily hemodialysis — Observed survival is generally highest in patients treated with home hemodialysis: up to 89 percent at 5 years, 74 percent at 15 years in patients without diabetes, and 50 percent at 15 years overall [71-73]. As was described for peritoneal dialysis versus in-center hemodialysis above, the magnitude of the survival advantage varies based on patient comorbidities and the time in the patient's ESKD lifetime that they decide to do home dialysis. However, despite this apparent survival advantage, the absolute number and relative percentage of patients with ESKD who use home hemodialysis in the United States has slowly declined over the last decade and is much lower than that in some other countries (see "Choosing home hemodialysis for end-stage kidney disease"). Based on these observations, it is important that home hemodialysis is presented to appropriate patients as a choice for their KRT. Nocturnal hemodialysis (ie, long, nightly, home hemodialysis, a form of quotidian hemodialysis) was introduced, principally in Canada, as a (possibly) more desirable alternative to conventional dialysis since it provides quantitatively more dialysis, based upon dose, duration, and frequency. This can be accomplished because it is performed during nightly sleep, an otherwise unproductive time.

Based on better outcomes in many biochemical areas, quality-of-life issues, blood pressure control, regression of left ventricular hypertrophy, improved sleep patterns, and improved general well-being, one would expect improved survival rates of these patients. There now are prospective randomized trial data, using cardiovascular endpoints as a surrogate for survival, that suggest that survival is truly improved with these modalities, with lower mortalities and similar survival rates to deceased-donor kidney transplants. For all these reasons, it is the author's opinion that nocturnal hemodialysis will be associated with improved patient survival since it provides the best clearance of uremic products, along with remarkable hemodynamic stability (with only gradual changes in physiologic parameters), generally slower rates of ultrafiltration (in mL/kg/hr), and improved cardiovascular function with regression of left ventricular hypertrophy (which is a potent cardiovascular disease risk factor). (See "Technical aspects of nocturnal hemodialysis" and "Outcomes associated with nocturnal hemodialysis".)

Another modality is short-hours, high-efficiency daily hemodialysis (short daily hemodialysis), another form of quotidian hemodialysis. This consists of hemodialysis occurring five to six days/week, with a total duration of 1.5 to 2.5 hours per day. Limited data have suggested relatively better survival among patients on short daily hemodialysis compared with in-center conventional hemodialysis. (See "Short daily hemodialysis", section on 'Survival'.)

When considering home hemodialysis versus peritoneal dialysis, there are limited data on survival comparisons. Patients who could do either home therapy should be educated about both modalities. A propensity-matched analysis of 1915 patients on home hemodialysis and peritoneal dialysis suggested that survival rates were similar for those patients who started home hemodialysis or peritoneal dialysis within 12 months of starting dialysis [74]. However, patients transitioned to peritoneal dialysis >12 months after starting dialysis had a higher risk of mortality compared with those who transitioned to home hemodialysis >12 months of starting dialysis. Data such as these suggest that when discussing dialysis modality with patients, one also must consider time on dialysis therapy and other comorbid diseases or social issues that may have developed since the onset of ESKD.

A comparison of technical survival among 15,314 Canadian patients on peritoneal dialysis or home hemodialysis who started home therapy within one year of onset of ESKD suggested that those who received home hemodialysis were more likely to remain on the therapy [75]. The reasons for technique failure differed between groups and were most likely to be social-related issues in the home hemodialysis group compared with what was most likely to be a medical-related issue in the peritoneal dialysis group.

Hemodialysis versus hemodiafiltration — Although virtually not used in the United States for chronic KRT, hemodiafiltration is common in Europe [76]. Mortality data comparing hemodialysis with hemodiafiltration are presented separately. (See "Alternative kidney replacement therapies in end-stage kidney disease", section on 'Mortality'.)

PRETRANSPLANTATION DIALYSIS MODALITY — Issues surrounding pretransplantation dialysis modality and outcomes post-kidney transplantation are discussed in detail separately. If possible, kidney transplantation often offers the best survival and quality of life for the patient, and therefore, if being considered, any impact the dialysis modality choice may have on transplantation should be considered. (See "Kidney transplantation in adults: Timing of transplantation and issues related to dialysis".)

SUMMARY

●Selection of dialysis modality – Dialysis modalities include hemodialysis, either in a dialysis center or at home, or peritoneal dialysis, including chronic ambulatory peritoneal dialysis (CAPD) or automated peritoneal dialysis (APD). In Europe, some patients are treated with hemofiltration technologies. The selection of dialysis modality is influenced by a number of considerations such as availability and convenience, comorbid conditions, socioeconomic and dialysis-center factors, the patient's home situation, method of clinician reimbursement, and the ability to tolerate volume shifts. Among some patients, it may be optimal to utilize both hemodialysis and peritoneal dialysis over the course of treatment. (See 'Selection of dialysis modality' above.)

●Peritoneal dialysis versus in-center hemodialysis – Compared with in-center hemodialysis, peritoneal dialysis may provide relative short-term survival benefits but comparable or decreased survival after the first few years. Comorbidities such as diabetes or heart failure may attenuate the early relative benefit associated with peritoneal dialysis. (See 'Peritoneal dialysis versus in-center hemodialysis' above.)

●High-flux and high-efficiency hemodialysis – High-flux dialysis may have a number of long-term benefits, including enhanced beta-2-microglobulin clearance, improved lipid profiles, and, with biocompatible membranes, less stimulation of neutrophils and monocytes. High-flux dialysis does not improve survival, except possibly among patients who have been on dialysis for many years. (See 'High-flux and high-efficiency hemodialysis' above.)

●Home, nocturnal, and short daily hemodialysis – Compared with all other kidney replacement modalities, survival is generally highest in patients treated with home hemodialysis. Despite this apparent advantage, the number of patients with end-stage kidney disease (ESKD) who use home hemodialysis in the United States is much lower than that in some other countries. Nocturnal hemodialysis and short daily hemodialysis may be associated with improved patient survival compared with conventional in-center hemodialysis. (See 'Home, nocturnal, and short daily hemodialysis' above and "Technical aspects of nocturnal hemodialysis" and "Outcomes associated with nocturnal hemodialysis" and "Short daily hemodialysis", section on 'Survival'.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Lionel U Mailloux, MD, FACP, who contributed to an earlier version of this topic review.