Home Hemodialysis (HHD) Has Benefits, Disadvantages
Risk of hospitalization for cardiovascular causes is lower, but risk for infections higher.
Daily home hemodialysis (HHD) is associated with a lower risk of cardiovascular-related hospitalizations but a higher risk of infection-related hospitalizations than convention thrice-weekly in-center hemodialysis (HD), according to a study. Both modalities are associated with a similar risk of all-cause hospitalization.
Eric D. Weinhandl, MS, and colleagues at the Chronic Disease Research Group, Minneapolis Medical Research Foundation in Minneapolis, Minn., studied 3,480 daily HHD and 17,400 matched thrice-weekly in-center HD patients.
In an intention-to-treat follow-up, the cumulative incidence of cardiovascular-related admissions after 1 year was 24.1% for the daily HHD patients compared with 26.7% for the conventional HD patients, the researchers reported online ahead of print in the American Journal of Kidney Diseases.
This difference translated into an 11% decreased likelihood of cardiovascular-related admissions in the daily HHD versus the conventional HD group. The daily HHD group had an 8% and 13% decreased risk of a first admission and readmission for cardiovascular causes, respectively, compared with the conventional HD group.
The cumulative incidence of infection-related admissions in the intention-to-treat follow-up at 1 year was 29.5% in the daily HHD group versus 22.9% in the conventional HD group, a difference that translated into an 18% increased risk of infection-related admissions in the daily HHD group relative to the conventional HD group.
Patients in the daily HHD group had a 35% and 3% increased risk of a first admission and readmission for infection-related causes, respectively, compared with those in the conventional HD group.
Weinhandl's team noted that the cardiovascular benefits of intensive HD have been reported previously. These benefits include reductions in left ventricular mass and decreases in both systolic and diastolic blood pressures, decreased use of antihypertensive medications, and increased left ventricular ejection fraction.
The investigators noted that more frequent dialysis might directly increase infection risk.
They cited a study of Australian patients undergoing HHD for 24 hours or more weekly demonstrating that each additional session per week was associated with a 56% increased risk of a first access-related adverse event, with 59% of events involving infection. In addition, HHD may engender risks not present with in-center HD.
“Medicare Conditions for Coverage require ESRD [end-stage renal disease] facilities to implement infection control practices,” they wrote. “At home, no such structure exists. The dialysis area and equipment may become contaminated and patients and care partner may not follow procedures taught during training.”
Weinhandl and his colleagues pointed out that a higher prevalence of catheter use in daily HHD patients could account for increased infection risk, although the prevalence of catheter access among daily HHD patients in the U.S. in 2009 was 24%, which is comparable to contemporary prevalence estimates among U.S. in-center HD patients.
The authors concluded that because cardiovascular disease (CVD) is the leading cause of death in HD patients, the protective association of daily HHD with CVD is important. “The adverse association of daily HHD with infection constitutes a safety concern that requires attention to infection control practices in the home, promptness of infection treatment, and cannulation technique,” they wrote.
“The clinical success of daily HHD likely depends on patients and providers recognizing the advantages and challenges of this increasingly popular modality,” they concluded.