State of Dialysis Care in the US: Patients, the Pandemic and the Need for Home Treatment

Updated on September 19, 2023

The ongoing COVID-19 pandemic is moving into its third year, and healthcare providers who care for patients with Chronic Kidney Disease (CKD) and End Stage Renal Disease (ESRD) are faced with daily crises in care delivery. In honor of National Kidney Month, we will examine the current state of dialysis treatment and facilities, and what is happening to this most vulnerable group of Americans who depend on dialysis to live.

For a multitude of reasons, this group of patients are faced with the challenge of having their access to dialysis restricted, risking a significant decline in health. Among the many obstacles in dialysis today are drastic shortages of staff and supplies that severely impact the operation of many dialysis facilities forcing patients to reduce their prescribed treatments or go to a hospital for routine care. The problem has become so dire that the National Kidney Foundation (NKF) and the American Society of Nephrology (ASN) are pleading with federal, state and local governments for help to resolve staffing shortages, supply shortfalls and exposure to COVID among patients. 

The shortages have already resulted in facility closures and backlogs as patients are moved among dialysis centers and hospitals. As many of these patients with ESRD are immunocompromised, being in a dialysis facility alone is dangerous without the additional risk of concentrating patients in fewer clinics or exposing them to acutely ill patients in a hospital setting. According to the United States Renal Data System 2021 annual report , dialysis patients who tested positive for COVID were more likely to have received dialysis in environments where they were in close contact with other patients, such as at a skilled nursing facility, and less likely to have been dialyzing at home.

The time to help patients is now

These patients need immediate help from our healthcare community. The number of dialysis patients is shrinking for the first time in nearly 50 years but unfortunately, not because of improved transplant rates or better CKD management. Mortality rates amongst ESRD patients has significantly increased since the beginning of the pandemic. 

According to the USRDS, 15.8% of all US patients on dialysis had contracted COVID by the end of 2020, and weekly deaths in the winter of 2020 were at nearly 20%. Overall, the mortality rate of kidney patients in 2020 was 18% higher than in 2019, (98,897 vs 83,797) with 2021 tracking along a similar trajectory. Supply and staff shortages leading to shortened and missed treatments threaten to worsen these already devastating outcomes.

Bringing healthcare home

Taking healthcare into a home setting not only decreases staffing needs but also decreases the risk of exposure to infection. The global home healthcare market reached $299 billion in 2020 and is expected to grow at a CAGR of 7.88% from 2021 to 2028. This was a shift from 2019 to 2020, when the home healthcare market declined 1.64%. Patients at risk for serious illness after exposure to COVID-19 benefit the most from home healthcare.

At Outset Medical, we developed the Tablo® Hemodialysis System as a next-generation, self-contained, enterprise all-in-one solution for treatment. Tablo can be used from the ICU to home, facilitating new care models and expansion of current home dialysis programs while limiting exposure to infection in a typical dialysis clinic setting. 

Home hemodialysis resolves three concerns

Home hemodialysis can be the answer for many patients who are currently receiving dialysis in a clinic, and yet only 12% of patients are currently using it. Home hemodialysis has long been associated with positive outcomes such as improved health, better quality of life, and more personal freedom to pursue or maintain employment. Home hemodialysis also offers the opportunity to personalize ultrafiltration rates, dialysis duration, and treatment frequencies to meet each patient’s individual needs. 

Home hemodialysis also addresses many of the concerns raised in this article and in the recommendations from the NKF and ASN: 

  • Supply chain shortages – Some home dialysis machines do not require additional dialysate supplies because they produce their own dialysate as needed with integrated water purification.
  • Staffing shortages – There’s no need for on-site staff with patients doing dialysis in their own home. 
  • COVID Exposure – Patients dialyzing at home are socially distanced and not at risk for exposure to COVID or other illnesses when they are receiving treatment.

Why it matters

Today, nearly half a million people in the U.S. require dialysis three times a week, four hours a day. With a total of 37 million U.S. adults estimated to have kidney disease, the number of Americans who need dialysis will only continue to increase. 

It’s essential to find a better, safer, more efficient way for kidney patients to receive high quality dialysis care while relieving dialysis providers of staffing and supply shortages. As a healthcare community, it is our responsibility to eliminate these barriers and create a system that protects our most vulnerable populations, like patients with ESRD, now and in the future.

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Michael Aragon, MD
Chief Medical Officer at Outset Medical

As Chief Medical Officer at Outset Medical, Michael Aragon, MD, a board-certified internist and nephrologist, has the unique opportunity to support innovation to revolutionize dialysis treatment, such as with the Tablo Hemodialysis System as an all-in-one solution for treatment. Before joining Outset, Dr. Aragon spent 14 years in clinical practice as a founding partner and president of North Texas Kidney Consultants – DFW. His clinical research focus has been on the expansion and improvement of home dialysis options for patients with renal disease. Dr. Aragon received his undergraduate degree from Texas A&M University, and his medical degree from The University of Texas Medical School. For more information, visit