Assisted home hemodialysis in Spain: findings from a national survey on implementation, barriers, and challenges

INTRODUCTION: Assisted home hemodialysis (assisted HHD) has emerged as a strategy to expand access to home-based dialysis therapies in patients with chronic kidney disease who have functional limitations or difficulties performing the technique independently. However, data on its real-world implementation in Spain and on the profile of caregivers involved remain limited. METHODS: A national, structured, and anonymous survey was conducted under the auspices of the Home Hemodialysis Working Group of the Spanish Society of Nephrology. The survey was addressed to all home hemodialysis units in Spain. The questionnaire comprised 30 items distributed across six thematic sections and was completed by a single healthcare professional per center. It collected information on organizational aspects, characteristics of patients receiving assisted HHD, caregiver profile and burden, available resources, perceived benefits, and barriers to the implementation of structured assisted HHD programs. RESULTS: A total of 39 centers from 14 autonomous communities participated, most of them public hospitals. Overall, 311 prevalent patients on home hemodialysis were reported, of whom 26% were receiving assisted HHD. More than 30% of these patients were older than 70 years, and central venous catheters were the predominant vascular access. The main indications for assisted HHD were reduced mobility, fear of performing the technique independently, and cognitive impairment. Caregivers were predominantly family members and mostly female, with limited involvement of paid caregivers and scarce systematic assessment of caregiver burden. CONCLUSIONS: Assisted HHD enables access to home hemodialysis in an older, frail population with functional limitations. However, its development in Spain remains heterogeneous and largely dependent on informal caregiving. Advancing toward structured assisted HHD models that incorporate appropriate funding, dedicated human resources, and formal caregiver support is essential to ensure equitable, safe, and sustainable implementation.