Emergency-dialysis Patients Who Transition Home Early Tend to Have Programmatic Support

By Rob Goodier

November 15, 2019

NEW YORK (Reuters Health) - Few patients who begin emergency dialysis make an early transition to home care, but those who do tend to start the procedure in a center that has programs to support the move, new research suggests.

The transition, however, may be linked to a higher mortality rate for home-hemodialysis patients, according to research presented November 7 at the annual meeting of the American Society of Nephrology in Washington, D.C.

"We also found that the ones who transition to peritoneal dialysis (PD) are very different from the ones who transition to home hemodialysis (HHD)," the study's senior author, Dr. Jenny Shen of Harbor-UCLA Medical Center, in Los Angeles, told Reuters Health by email.

Dr. Shen and her colleagues mined data from the U.S. Renal Data System to identify more than 190,000 patients who began emergency in-center dialysis with a central venous catheter from 2005-2013. These patients had begun dialysis unexpectedly with no prior nephrology referral and no maturing arteriovenous access.

Few made an early home transition within 90 days of beginning dialysis, the study found. Nearly 4,000, representing 2%, switched to PD and remained on it for 413 days on average. Even fewer, 853, or 0.4%, began HHD and stayed on it for an average of 224 days.

Factors associated with a higher chance of early PD transition were younger age, white race, private insurance, rural neighborhoods and starting dialysis at a center with a PD program.

Older age, frailty, urban neighborhoods and starting dialysis in a unit with a HHD program was linked to higher odds of making an early HHD transition.

Patients who transitioned to PD within 90 days had significantly lower mortality (adjusted hazard ratio, 0.86) than those who remained at medical centers. Transitioning to HDD within 90, however, was linked to significantly higher mortality (aHR, 1.31).

Dr. Shen said the "difference in patient populations might explain the difference in mortality outcomes," although "more research needs to be done to understand the increased risk of death associated with early transitions to HHD."

The researchers adjusted the statistical model for age and other confounders, but unobserved factors may have affected the difference in mortality rates, Dr. Shen noted.

"One of these unobserved factors is vascular access after Day 1," she said. "It is possible that home hemodialysis patients used central venous catheters longer than patients who remained in-center, putting them at higher risk of potentially fatal bloodstream infections. This risk could be compounded by the more frequent schedule of home hemodialysis, which increases the risk of vascular access infection."

Dr. Pascale Lane, a pediatric nephrologist at the University of Oklahoma in Oklahoma City, said HHD is a relatively new practice, especially in the first half of the study period.

"It requires a lot more out of the patient in their home and they have to have a care partner and other things like that," Dr. Lane, who was not involved in the study, told Reuters Health by phone. She speculated that patients might not have been fully prepared for a transition to HHD.

"If they stayed on hemo in the unit longer, they might have had a background on trouble shooting their dialysis," Dr. Lane said. "I might want to drill down and learn more about the patients, why they died. There's always another story there when you see something that looks a little odd."

SOURCE: https://bit.ly/2paKB6y

ASN Kidney Week 2019.