The risk of hospitalization and modality failure with home dialysis

While home dialysis is being promoted, there are few comparative effectiveness studies of home-based modalities to guide patient decisions. To address this, we matched 1116 daily home hemodialysis (DHD) patients by propensity scores to 2784 contemporaneous USRDS patients receiving home peritoneal dialysis (PD), and compared hospitalization rates from cardiovascular, infectious, access-related or bleeding causes (prespecified composite), and modality failure risk. We performed similar analyses for 1187 DHD patients matched to 3173 USRDS patients receiving in-center conventional hemodialysis (CHD). The composite hospitalization rate was significantly lower with DHD than with PD (0.93 vs. 1.35/patient-year, hazard ratio=0.73 (95% CI=0.67–0.79)). DHD patients spent significantly fewer days in hospital than PD patients (5.2 vs. 9.2 days/patient-year), and significantly more DHD patients remained admission-free (52% DHD vs. 32% PD). In contrast, there was no significant difference in hospitalizations between DHD and CHD (DHD vs. CHD: 0.93 vs. 1.10/patient-year, hazard ratio 0.92 (0.85–1.00)). Cardiovascular hospitalizations were lower with DHD than with CHD (0.68 (0.61–0.77)), while infectious and access hospitalizations were higher (1.15 (1.04–1.29) and 1.25 (1.08–1.43), respectively). Significantly more PD than DHD patients switched back to in-center HD (44% vs. 15%; 3.4 (2.9–4.0)). In this prevalent cohort, home DHD was associated with fewer admissions and hospital days than PD, and a substantially lower risk of modality failure. While home dialysis is being promoted, there are few comparative effectiveness studies of home-based modalities to guide patient decisions. To address this, we matched 1116 daily home hemodialysis (DHD) patients by propensity scores to 2784 contemporaneous USRDS patients receiving home peritoneal dialysis (PD), and compared hospitalization rates from cardiovascular, infectious, access-related or bleeding causes (prespecified composite), and modality failure risk. We performed similar analyses for 1187 DHD patients matched to 3173 USRDS patients receiving in-center conventional hemodialysis (CHD). The composite hospitalization rate was significantly lower with DHD than with PD (0.93 vs. 1.35/patient-year, hazard ratio=0.73 (95% CI=0.67–0.79)). DHD patients spent significantly fewer days in hospital than PD patients (5.2 vs. 9.2 days/patient-year), and significantly more DHD patients remained admission-free (52% DHD vs. 32% PD). In contrast, there was no significant difference in hospitalizations between DHD and CHD (DHD vs. CHD: 0.93 vs. 1.10/patient-year, hazard ratio 0.92 (0.85–1.00)). Cardiovascular hospitalizations were lower with DHD than with CHD (0.68 (0.61–0.77)), while infectious and access hospitalizations were higher (1.15 (1.04–1.29) and 1.25 (1.08–1.43), respectively). Significantly more PD than DHD patients switched back to in-center HD (44% vs. 15%; 3.4 (2.9–4.0)). In this prevalent cohort, home DHD was associated with fewer admissions and hospital days than PD, and a substantially lower risk of modality failure. Home-based dialysis modalities are being increasingly promoted internationally as preferred renal replacement therapy options when transplantation is not immediately feasible.1.Thodis E.D. Oreopoulos D.G. Home dialysis first: a new paradigm for new ESRD patients.J Nephrol. 2011; 24: 398-404Crossref PubMed Scopus (18) Google Scholar, 2.Burkart J. Role of peritoneal dialysis in the era of the resurgence of home hemodialysis.Hemodial Int. 2008; 12: S51-S54Crossref PubMed Scopus (4) Google Scholar, 3.Burkart J. 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Foley R.N. et al.Mortality studies comparing peritoneal dialysis and hemodialysis: what do they tell us?.Kidney Int. 2006; 103: S3-11Abstract Full Text Full Text PDF Scopus (239) Google Scholar while offering better patient autonomy and quality of life,8.Ginieri-Coccossis M. Theofilou P. Synodinou C. et al.Quality of life, mental health and health beliefs in haemodialysis and peritoneal dialysis patients: investigating differences in early and later years of current treatment.BMC Nephrol. 2008; 9: 14Crossref PubMed Scopus (111) Google Scholar,9.Chanouzas D. Ng K.P. Fallouh B. et al.What influences patient choice of treatment modality at the pre-dialysis stage?.Nephrol Dial Transplant. 2012; 27: 1542-1547Crossref PubMed Scopus (87) Google Scholar at lower cost.10.Komenda P. Gavaghan M.B. Garfield S.S. et al.An economic assessment model for in-center, conventional home, and more frequent home hemodialysis.Kidney Int. 2012; 81: 307-313Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar,11.Karopadi AN RE, Ronco C Relative Cost of PD and HD: Data from 44 Countries.World Congress of Nephrology. 2013http://www.abstracts2view.com/wcn/view.php?nu=WCN13L_499Google Scholar PD remains the dominant home dialysis therapy, comprising 15% of dialysis in developed countries.12.Jain A.K. Blake P. Cordy P. et al.Global trends in rates of peritoneal dialysis.J Am Soc Nephrol. 2012; 23: 533-544Crossref PubMed Scopus (378) Google Scholar In contrast, <2% of patients with end-stage renal disease receive home HD.13.Blagg C.R. The renaissance of home hemodialysis: where we are, why we got here, what is happening in the United States and elsewhere.Hemodial Int. 2008; 12: S2-S5Crossref PubMed Scopus (10) Google Scholar Yet, although the use of PD has been steadily decreasing in developed countries,12.Jain A.K. Blake P. Cordy P. et al.Global trends in rates of peritoneal dialysis.J Am Soc Nephrol. 2012; 23: 533-544Crossref PubMed Scopus (378) Google Scholar the prevalence of home HD is increasing.13.Blagg C.R. The renaissance of home hemodialysis: where we are, why we got here, what is happening in the United States and elsewhere.Hemodial Int. 2008; 12: S2-S5Crossref PubMed Scopus (10) Google Scholar,14.Agar J.W. Hawley C.M. George C.R. et al.Home haemodialysis in Australia–is the wheel turning full circle?.Med J Aust. 2010; 192: 403-406PubMed Google Scholar Many advocate home HD in order to facilitate the delivery of more intensive dialysis, delivered as more frequent (at least 5 days per week) and/or longer (at least 6 h per treatment) sessions. However, whether such intensive HD therapies improve hard outcomes over conventional three times per week HD or PD is as yet unknown. Prior observational studies suggested that home frequent HD was associated with better survival than in-center three times per week HD.15.Weinhandl E.D. Liu J. Gilbertson D.T. et al.Survival in daily home hemodialysis and matched thrice-weekly in-center hemodialysis patients.J Am Soc Nephrol. 2012; 23: 895-904Crossref PubMed Scopus (151) Google Scholar, 16.Nesrallah G.E. Lindsay R.M. Cuerden M.S. et al.Intensive hemodialysis associates with improved survival compared with conventional hemodialysis.J Am Soc Nephrol. 2012; 23: 696-705Crossref PubMed Scopus (154) Google Scholar, 17.Johansen K.L. Zhang R. Huang Y. et al.Survival and hospitalization among patients using nocturnal and short daily compared to conventional hemodialysis: a USRDS study.Kidney Int. 2009; 76: 984-990Abstract Full Text Full Text PDF PubMed Scopus (160) Google Scholar, 18.Kjellstrand C.M. Buoncristiani U. Ting G. et al.Short daily haemodialysis: survival in 415 patients treated for 1006 patient-years.Nephrol Dial Transplant. 2008; 23: 3283-3289Crossref PubMed Scopus (162) Google Scholar, 19.Blagg C.R. Kjellstrand C.M. Ting G.O. et al.Comparison of survival between short-daily hemodialysis and conventional hemodialysis using the standardized mortality ratio.Hemodial Int. 2006; 10: 371-374Crossref PubMed Scopus (71) Google Scholar Despite rigorous methods used in some of these studies to match groups on known prognostic variables,15.Weinhandl E.D. Liu J. Gilbertson D.T. et al.Survival in daily home hemodialysis and matched thrice-weekly in-center hemodialysis patients.J Am Soc Nephrol. 2012; 23: 895-904Crossref PubMed Scopus (151) Google Scholar, 16.Nesrallah G.E. Lindsay R.M. Cuerden M.S. et al.Intensive hemodialysis associates with improved survival compared with conventional hemodialysis.J Am Soc Nephrol. 2012; 23: 696-705Crossref PubMed Scopus (154) Google Scholar, 17.Johansen K.L. Zhang R. Huang Y. et al.Survival and hospitalization among patients using nocturnal and short daily compared to conventional hemodialysis: a USRDS study.Kidney Int. 2009; 76: 984-990Abstract Full Text Full Text PDF PubMed Scopus (160) Google Scholar these studies are difficult to interpret, as they compared home patients with in-center patients. Compared with patients receiving in-center HD, patients performing their own treatments at home may have better health literacy, social support, financial resources, cognitive function, and motivation. It is thus unclear whether the observed improvements in survival in these studies were related to greater HD frequency and duration, or to these other unmeasured factors. A recent observational study comparing home intensive with home CHD found no difference in survival between groups,20.Marshall M.R. Hawley C.M. Kerr P.G. et al.Home hemodialysis and mortality risk in Australian and New Zealand populations.Am J Kidney Dis. 2011; 58: 782-793Abstract Full Text Full Text PDF PubMed Scopus (147) Google Scholar and the Frequent Hemodialysis Network Nocturnal Randomized Trial surprisingly noted significantly increased mortality with six nights per week home HD compared with three days per week home HD.21.Chertow G.M.L.N. Beck G.J. Eggers P.W. The FHN Trial Group et al.Effects of randomization to frequent in-center hemodialysis on long- term mortality: frequent hemodialysis daily trial (abstract).J Am Soc Nephrol. FR-PO342. 2013Google Scholar Nevertheless, the recent growth in home HD has likely been facilitated by options for more frequent and/or longer treatments, the of treatments, the recent of and better C.R. The renaissance of home hemodialysis: where we are, why we got here, what is happening in the United States and elsewhere.Hemodial Int. 2008; 12: S2-S5Crossref PubMed Scopus (10) Google C. C. et to and a home HD J Am Soc Nephrol. 2012; PubMed Scopus Google Scholar home HD more patients dialysis are with a of hospital or home-based PD or home HD, what frequency and comparative effectiveness studies of these options to guide these that patients for home daily HD have the choice of PD studies comparing the of these therapies on outcomes are differences in and home between home daily HD and PD, matched of home daily HD with PD have the of being to by as therapies are performed at may of home HD with that have improved the of for home daily A. home hemodialysis for Google Scholar these we performed an observational matched study to hospitalization risk associated with DHD We that DHD in cardiovascular, infectious, and bleeding similar access-related hospitalizations compared with was on the of DHD over PD, higher daily greater with improved and function, an to access or PD the of home in-center analyses we compared hospitalization risk between home DHD and in-center three times per week CHD to as a in the of DHD 1116 were matched to 2784 PD and 1187 were matched to 3173 in-center CHD of was similar between DHD and groups with standardized differences of for The treatment by DHD was h and h by of DHD patients used rates of the in was per treatment PD PD, 32% used a of patients in the was as renal replacement therapy as end-stage renal disease patients were more in the USRDS this In patients PD between and were to as PD as DHD HD this or or or Prior no conventional daily home HD, home PD, peritoneal United States Renal Data The was as renal replacement therapy as end-stage renal disease patients were more in the USRDS this In patients PD between and were to as PD as DHD HD this in a new DHD PD DHD CHD years years years years years years for conventional daily end-stage renal PD, peritoneal are as or as in a new conventional daily home HD, home PD, peritoneal United States Renal Data conventional daily end-stage renal PD, peritoneal are as or as were patients hospitalizations The composite hospitalization rate was significantly lower for DHD compared with PD hazard ratio (95% were similar when we to three hospitalizations per hospitalizations days of a and the to the was of end-stage renal The of to hospitalization with DHD PD, for the of and was similar to the (95% receiving DHD spent a of days per in compared with PD patients spent 9.2 days per of DHD 32% of PD patients remained admission-free rates to the causes were significantly lower with DHD than with PD were patients hospitalizations over was no significant difference in the composite hospitalization rate between home DHD and in-center CHD CHD: (95% were similar when we to three hospitalizations per hospitalizations days of a and the to the was the of end-stage renal The of to hospitalization with DHD for the of and was similar to the (95% receiving home DHD spent fewer days in hospital than patients receiving in-center CHD (5.2 vs. days per However, there was no significant difference between groups in the of patients admission-free (DHD vs. CHD Cardiovascular hospitalizations were significantly lower with DHD than with CHD (95% infectious and access-related hospitalizations were significantly higher (95% and (95% the access to for the higher observed of DHD patients switched to PD, of PD patients switched to home HD as 15% of the DHD compared with of the PD switched back to in-center CHD as In of the modality the by The hazard of back to in-center CHD with PD to DHD was 3.4 (95% Home dialysis patients spent in dialysis and autonomy to the dialysis modality they that home dialysis is B. et al.What do dialysis modality J Kidney Dis. Full Text PDF PubMed Scopus Google Scholar and the of patient in home dialysis is J. Role of peritoneal dialysis in the era of the resurgence of home hemodialysis.Hemodial Int. 2008; 12: S51-S54Crossref PubMed Scopus (4) Google Scholar, R. M.S. The of patient in home 2013; PubMed Scopus Google Scholar, patient in the Kidney Dis. 2013; Full Text Full Text PDF PubMed Scopus Google Scholar, M. M. et use of home Google Scholar Home HD and PD are as with modality choice by patient E.D. Oreopoulos D.G. Home dialysis first: a new paradigm for new ESRD patients.J Nephrol. 2011; 24: 398-404Crossref PubMed Scopus (18) Google J. 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Lobbedez T. et al.Educating end-stage renal disease patients on dialysis modality selection: clinical advice from the European Renal Best Practice (ERBP) Advisory Board.Nephrol Dial Transplant. 2010; 25: 1757-1759Crossref PubMed Scopus (75) Google Scholar In study for prevalent patients home that in prevalent patients hospitalization risk is between home DHD and in-center that PD is associated with higher of hospitalization and a substantially greater risk of modality failure. the of hospitalizations on and quality of life, these have for and patients. studies are to these and to better whether the observed are by the studies the for the higher rates of modality failure in prevalent patients PD We patients receiving a dialysis for patients receiving dialysis its We patients receiving PD and in-center CHD from the The USRDS is an national that on dialysis treatment and for patients with end-stage renal disease in the USRDS to the USRDS Scholar We dialysis and treatment for DHD patients from the To we other for study modality and from the The the and to USRDS for a the no the study or analyses to a and we this to et G. outcomes and quality of in patients on peritoneal dialysis Dial Int. 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