Telemedicine-supported assisted home hemodialysis in elderly and multimorbid patients: a real-world cohort study in a public healthcare system

PURPOSE: The aging of the hemodialysis (HD) population and the growing burden of multimorbidity increasingly challenge the sustainability and equity of conventional in-center dialysis within publicly funded healthcare systems. Although home hemodialysis (HHD) may offer clinical and organizational advantages, its implementation remains limited among elderly and functionally dependent patients. We evaluated the real-world feasibility, retention, and system-level impact of a telemedicine-supported assisted-HHD (A-HHD) program aimed at broadening access to complex individuals. We performed a retrospective, descriptive observational cohort study including all patients enrolled in an A-HHD program within a public healthcare authority in Southern Italy from June 2018 to June 2025. In September 2023, a structured telemedicine platform enabling real-time remote monitoring and audiovisual supervision was integrated into routine care. We assessed epidemiological trends, patient complexity, vascular access patterns, dialysis prescription and delivered dose, treatment retention, causes of discontinuation, and transportation-related economic outcomes. RESULTS: A total of 146 patients (mean age 79 ± 7 years) with substantial cardiovascular, metabolic, and respiratory comorbidity were treated. Central venous catheters were used in 64% of cases. Following early program expansion, annual incidence stabilized at approximately 20-25 patients, while prevalence steadily increased, exceeding 20 active patients per month. More than half of patients remained on therapy beyond 6 months. Despite shorter individual sessions, increased treatment frequency achieved a weekly standard Kt/V comparable to conventional in-center HD. Treatment discontinuation was predominantly related to mortality or clinical indications rather than program failure. CONCLUSION: Telemedicine-supported A-HHD represents a feasible and organizationally sustainable model capable of expanding equitable access to home-based dialysis while supporting organizational sustainability in public healthcare systems.