NEW ORLEANS — Rates of treatment failure and death are lower in patients who receive a kidney transplant than in those treated with intensive home hemodialysis, according to a study presented here at the American Society of Nephrology 35th Annual Dialysis Conference.
Studies have shown that survival is better with transplant than with conventional dialysis, and that outcomes are also best with intensive home dialysis than with conventional dialysis. "But what happens when we look at comparisons of these treatments together?" asked Karthik Tennankore, MD, from the Queen Elizabeth II Health Sciences Centre in Halifax, Nova Scotia, Canada.
The investigators compared home dialysis with kidney transplant at a large tertiary care center. They evaluated survival and hospitalization in the two groups. First results were published in the Journal of the American Society of Nephrology (2014 25:2113-2120).
The primary outcome of the study was time to death or treatment failure. Secondary outcomes included time to first hospitalization, hospitalization rate, and number of days spent in the hospital.
The 173 patients in the hemodialysis group were mandated to receive at least 16 hours of home dialysis each week. Treatment failure was defined as a permanent switch to a regimen other than intensive home dialysis, such as peritoneal dialysis or in-center dialysis.
The 1517 patients in the transplant group were stratified by donor status; 673 had a living donor, 642 had a standard-criteria donor, and 202 had an expanded-criteria donor.
Minimum follow-up was 6 months. Censoring occurred when patients were lost to follow-up or when dialysis patients underwent transplantation. "We didn't feel getting a transplant for hemodialysis patients was a bad outcome, so we felt it was more appropriately treated as a censoring event," Dr. Tennankore explained.
The primary analysis consisted of 285 events.
"When we adjusted for characteristic differences, keeping in mind that there were many of them between the groups, all three subgroups of transplant recipients had a lower hazard ratio for the primary outcome of time to treatment failure or death," Dr. Tennankore reported. "In other words, they did better overall compared with the intensive hemodialysis group."
Table. Primary Outcome for Transplant Compared With Hemodialysis
|Donor Status||Hazard Ratio||95% Confidence Interval|
"Intensive hemodialysis patients were most similar in characteristic to those who had living-donor recipients, but the hazard ratio was in favor of transplantation," he said.
In the first 3 months of treatment, the rate of hospitalization was lower in the dialysis patients than in the living-donor and expanded-criteria transplant patients.
In the first year of treatment, the rate was lower in the dialysis patients than in the standard-criteria transplant patients.
"Usually, the highest risk of hospitalization for transplant recipients is shortly after the transplant itself, so these numbers were expected," Dr. Tennankore explained.
Session moderator Robert Lockridge, MD, from Lynchburg Nephrology Physicians in Virginia, said he agrees. "The results are not surprising."
It is important to note that not all patients are eligible for transplant, Dr. Tennankore stressed. This study emphasizes the need to continue to promote transplants, "but we have to acknowledge that there are going to be patients who have contraindications and patients who don't want transplantation," he pointed out. "It is important to re-evaluate them periodically; our job isn't to force them into a treatment that they may not want."
On the basis of these data, Dr. Tennankore and his team conclude that transplant is associated with better treatment and patient survival than dialysis, but it is also associated with a higher risk for early short-term hospitalization. Over the long term, though, the risk for early hospitalization in the transplant group decreases and aligns more closely with that in the dialysis group.
Dr. Tennankore and Dr. Lockridge have disclosed no relevant financial relationships.
American Society of Nephrology 35th Annual Dialysis Conference. Presented January 31, 2015.
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Cite this: Transplant Survival High Compared With Home Dialysis - Medscape - Feb 10, 2015.