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A recent paper in Kidney International on the French experience with COVID-19 in dialysis patients states that between March 16 and May 4, 2020, of the 1621 infected patients listed in the REIN registry, 344 patients died, a confirmation of the high death toll among dialysis patients during the COVID-19 epidemic [1]. In this nationwide report, the prevalence of patients with COVID-19 varied between regions from less than 1% to over 10%. The incidence of the disease was higher in males, and in patients with diabetes and other comorbidities, while being on dialysis at home was associated with a lower rate of infection. In fact, during the SARS-CoV-2 pandemic, numerous studies showed that end-stage kidney disease (ESKD) is a major risk factor for developing severe COVID-19 [2, 3]. Acknowledging this grim prognosis has been a stimulus for reconsidering dialysis policy from a different point of view [1, 3, 4]. Home dialysis has been advocated as a safer option in times of epidemic and, among others, the French health care authorities strongly supported the development of home-based techniques in their documents which appeared in response to the COVID-19 epidemic [5, 6]. Potential drawbacks were also underlined, as were patients’ need to have frequent contacts with a dialysis center and to avoid being isolated. Home hemodialysis is still a Cinderella in Europe: while daily hemodialysis is considered to be one of the best renal replacement treatments, combining higher survival and a good quality of life, its penetration is limited. In France this technique has undergone a relatively rapid diffusion in the last 5 years. According to the data from the French Biomedicine Agency, during the peak period of the epidemic, between March 1 and June 15, 2020, only 7 of the 423 patients on home hemodialysis in France were diagnosed with COVID-19; the incidence is similar to that observed in patients treated with peritoneal dialysis (1.8%). Even considering the different distribution of home dialysis in France (Fig. 1), the recorded incidence is significantly lower than that observed in patients on in-center hemodialysis (1856 COVID out of 48,840 patients, 3.8%; p = 0.02) [7]. Interestingly, the virus diffusion was the highest in the regions with the highest prevalence of home hemodialysis, and the favorable effect was more evident in settings with high virus circulation. For instance, in the Ile de France region, one of the most affected by the pandemic, data from the Biomedicine Agency indicate that 930 out of 8,025 patients (11.5%) on in-center hemodialysis were diagnosed with COVID-19, whereas only 4 out of 109 patients on home hemodialysis developed the disease (3.6%) (p = 0.001). Presumably because of the lower age (mean 54 years ± 14 years) and comorbidity burden, none of the patients on home hemodialysis died. Furthermore, while home dialysis encompasses 7% of all French dialysis patients, data from the French Biomedicine Agency show that the proportion of home dialysis patients (whether on hemodialysis or on peritoneal dialysis) represented 2.6% of the total number of dialysis patients * Hafedh Fessi hafedh.fessi@aphp.fr

Home hemodialysis during the COVID-19 epidemic: comment on the French experience from the viewpoint of a French home hemodialysis care network