Daily home hemodialysis (HHD) is associated with lower risks of mortality, hospitalization, and technique failure than peritoneal dialysis (PD), according to researchers. Among patients who started home dialysis shortly after onset of end-stage renal disease (ESRD), however, mortality and hospitalization risks were similar for HHD and PD.
The investigators concluded that “daily HHD may be a viable first modality for patients who choose to dialyze at home and may keep patients at home longer than PD does.”
For the study, Eric D. Weinhandl, PhD, and colleagues with the Chronic Disease Research Group, Minneapolis Medical Research Foundation, matched 4,201 new HHD patients in 2007–2010 to 4,201 new PD patients identified using the U.S. Renal Data System database. The mean time from onset of end-stage renal disease to home dialysis therapy initiation was 44.6 months for HHD patients and 44.3 months for PD patients.
In an intention-to-treat analysis, daily HHD was associated with a significant 20% lower risk for all-cause mortality, 8% decreased risk for all-cause hospitalization, and 37% decreased risk for technique failure compared with PD, Dr. Weinhandl’s team reported online ahead of print in the American Journal of Kidney Diseases. In a subset of 1,368 patients who started home dialysis within 6 months of ESRD onset, daily HHD and PD were associated with similar risks for all-cause mortality and all-cause hospitalization, but daily HHD was associated with a significant 30% decreased risk for technique failure.
The researchers defined technical failure as conversion to in-center hemodialysis for at least two months.
In intention-to-treat analyses involving all patients, daily HHD patients had a significant 19%, 38%, and 29% decreased risk of death from cardiovascular disease (CVD), cachexia or dialysis withdrawal, and infection, respectively. The researchers found no difference in these death risks in the patients who started dialysis within 6 months of ESRD onset.
With respect to hospitalization, risk comparisons favored daily HHD for cardiovascular disease (CVD) and dialysis access infection and PD for bloodstream infection. For example, in intention-to-treat analysis involving all patients, daily HHD patients had a significant 15% decreased risk of CVD-related hospitalization compared with PD patients. Daily HHD patients had a significant 18% increased risk of hospitalization for bacteremia and sepsis and three-fold increased risk of hospitalization for cardiac infection compared with PD patients.
The authors acknowledge some study limitations, including the observational design. “Matching is unlikely to reduce confounding attributable to unmeasured factors,” they noted. “Residual differences in biochemistry, residual kidney function, and peripheral vascular health may underlie observed relative risks.” Additionally, the investigators lacked data regarding dialysis frequency, duration, and dose in daily HHD patients and frequency and solution in PD patients. A third limitation was the use of diagnosis codes to classify hospital admissions. “Principal codes on inpatient claims may not accurately reflect morbidity,” they pointed out.