Survival in Daily Home Hemodialysis and Matched Thrice-Weekly In-Center Hemodialysis Patients
ABSTRACT Frequent hemodialysis improves cardiovascular surrogates and quality-of-life indicators, but its effect on survival remains unclear. We used a matched-cohort design to assess relative mortality in daily home hemodialysis and thrice-weekly in-center hemodialysis patients between 2005 and 2008. We matched 1873 home hemodialysis patients with 9365 in-center patients (i.e., 1:5 ratio) selected from the prevalent population in the US Renal Data System database. Matching variables included first date of follow-up, demographic characteristics, and measures of disease severity. The cumulative incidence of death was 19.2% and 21.7% in the home hemodialysis and in-center patients, respectively. In the intention-to-treat analysis, home hemodialysis associated with a 13% lower risk for all-cause mortality than in-center hemodialysis (hazard ratio [HR], 0.87; 95% confidence interval [95% CI], 0.78-0.97). Cause-specific mortality HRs were 0.92 (95% CI, 0.78-1.09) for cardiovascular disease, 1.13 (95% CI, 0.84-1.53) for infection, 0.63 (95% CI, 0.41-0.95) for cachexia/dialysis withdrawal, 1.06 (95% CI, 0.81-1.37) for other specified cause, and 0.59 (95% CI, 0.44-0.79) for unknown cause. Findings were similar using as-treated analyses. We did not detect statistically significant evidence of heterogeneity of treatment effects in subgroup analyses. In summary, these data suggest that relative to thrice-weekly in-center hemodialysis, daily home hemodialysis associates with modest improvements in survival. Continued surveillance should strengthen inference about causes of mortality and determine whether treatment effects are homogeneous throughout the dialysis population.
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ABSTRACT: BACKGROUND: Home dialysis (peritoneal or haemodialysis) in any reasonable guise offers potential benefits compared with in-centre dialysis. Benefits may be overtly patient centred (independence, quality of life), outcome oriented (survival, resolution of left ventricular hypertrophy) or resource friendly (savings on staff costs). The priority placed on each of these areas is likely to vary from patient to patient, and possibly provider to provider. This is the one strength of home haemodialysis (HHD) rather than being viewed as a weakness, as it can offer different benefits to different people. Intuitively, more haemodialysis is better than less, and this is most realistically achieved at home. Indications are that both long nocturnal dialysis and short daily dialysis can offer real objective benefits. LITERATURE REVIEW: Critics argue correctly that there is a paucity of robust randomised controlled study data. The complexity of HHD regimens and practice and in-homogeneity of patients means such firm data are unlikely to be forthcoming. However, the positive reports both subjective and objective of patients dialysing at home, and results from the available research suggest that advantages may be seen purely with changing the location of dialysis to home, and independently with enhancing dialysis schedules. CONCLUSION: The logical conclusion is that patients undertaking haemodialysis at home should have at least the recommended minimum of four hours three times per week (or equivalent), preferably avoiding the long inter-dialytic interval, but beyond that rigid adherence to a schedule as dogma should be subjugated to patient choice and flexibility, albeit by prior agreement with supervising medical and nursing staff.Journal of Renal Care 01/2013; 39(S1):35-41. DOI:10.1111/j.1755-6686.2013.00344.x
- Journal of the American Society of Nephrology 04/2012; 23(5):770-3. DOI:10.1681/ASN.2012030311 · 9.47 Impact Factor
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ABSTRACT: Accumulating evidence of the benefits of intensive home haemodialysis has led to increased international interest in this modality as a viable option for renal replacement therapy. Until the late 1970s, haemodialysis was primarily performed at home; however, the development of in-centre and satellite dialysis units and the advent of peritoneal dialysis led to decreased numbers of patients being managed by home haemodialysis. Over the past decade, a move towards once again providing and supporting haemodialysis at home has emerged, due to a desire to offer a more convenient form of dialysis for the patient in a more cost-effective manner. This shift has generated clinical evidence indicating benefits both from receiving haemodialysis at home, and from the option to provide intensive dialysis treatment in this setting. With the development of new home haemodialysis programs, specific patient-related, physician-related and cost-related barriers to their introduction have been encountered, including patient fear of self-cannulation and lack of expert medical knowledge in the area. This Review discusses the benefits and barriers associated with intensive home haemodialysis.Nature Reviews Nephrology 07/2012; 8(9):515-22. DOI:10.1038/nrneph.2012.145 · 8.37 Impact Factor