Background. There is strong evidence from a range of long-term conditions of improved outcomes where patients are involved in self-management. Against this background, the international trend for home dialysis continues to decline, with centre-based haemodialysis continuing its dominance. Methods. An opinion-based commentary exploring practice patterns and drivers for home dialysis internationally. Data are drawn from a number of sources including the 2010 United States Renal Data System report. Results. Drivers behind the use of home dialysis are complex including factors relating to the patient and their carers, health care team, health care system, geography and cultural factors. There are important examples where local champions or public health initiatives have had a positive impact on the use of home dialysis; however, in many settings significant barriers remain. Better systems for giving patient information, shared decision making and involving patients in their own care may have the potential to act as a driver for change. Conclusion. Centre-based haemodialysis continues to dominate renal replacement therapy internationally with notable exceptions. Such dominance suggests that most patients worldwide do not get much choice when it comes to modality selection.