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.
"A retrospective matched-cohort study also reported a 45% improvement in survival with high-dose HD in the home versus thrice-weekly ICHD . Daily home HD has also been associated with a 13% lower risk for all-cause mortality than conventional ICHD performed three times weekly . "
[Show abstract][Hide abstract] ABSTRACT: In-centre haemodialysis (ICHD) is the most common dialysis method used by patients worldwide. However, quality of life and clinical outcomes in patients treated via ICHD have not improved for some time. 'High-dose' haemodialysis (HD) regimens - which are longer and/or more frequent than conventional regimens and are particularly suitable to delivery in the home - may offer a route to improved outcomes and quality of life. This survey aimed to determine nephrologists' views on the validity of alternatives to ICHD, particularly home HD and high-dose HD.
A total of 1,500 nephrologists from Europe, Canada and the United States were asked to respond to an online questionnaire that was designed following previous qualitative research. Certified nephrologists in practice for 2-35 years who managed >25 adult dialysis patients were eligible to take part.
A total of 324 nephrologists completed the survey. ICHD was the most common type of dialysis used by respondents' current patients (90%), followed by peritoneal dialysis (8%) and home HD (2%). The majority of respondents believed that: home HD provides better quality of life; increasing the frequency of dialysis beyond three times per week significantly improves clinical outcomes; and longer dialysis sessions performed nocturnally would result in significantly better clinical outcomes than traditional ICHD.
Survey results indicated that many nephrologists believe that home HD and high-dose HD are better for the patient. However, the majority of their patients were using ICHD. Education, training and support on alternative dialysis regimens are needed.
"They concluded: Statistical adjustment for co-morbid conditions in addition to age, sex, race, and diabetes explains only a small amount of the lower mortality with home haemodialysis (Woods et al. 1996). Weinhandel et al. (2012) conducted a matched control study of 1,873 patients on HHD compared with 9,365 in-centre patients, adjusted for demographics and disease severity. Although observational, intention to treat analysis indicated a 13% lower mortality with HHD. "
[Show abstract][Hide abstract] 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.
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.
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 03/2013; 39(S1):35-41. DOI:10.1111/j.1755-6686.2013.00344.x
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