Home and Facility Haemodialysis Patients

A Comparison of Outcomes in a Matched Cohort

Emily K. Yeung; Kevan R. Polkinghorne; Peter G. Kerr

Disclosures

Nephrol Dial Transplant. 2021;36(6):1070-1077. 

In This Article

Abstract and Introduction

Abstract

Background: Home haemodialysis (HHD) is utilized significantly less often than facility HD globally with few exceptions, despite being associated with improved survival and better quality of life. Previously HHD was exclusively offered to younger patients with a few comorbidities. However, with the increasing burden of end-stage kidney disease (ESKD) alongside an ageing population, increasing numbers of older patients are being treated with HHD. This study aims to re-evaluate survival and related outcomes in the context of this epidemiological shift.

Methods: A matched cohort design was used to compare all-cause mortality, transplantation, average biochemical values and graft survival 6 months post-transplant between HHD and facility HD patients. A total of 181 HHD patients from a major hospital network were included with 413 facility HD patients from the Australia and New Zealand Dialysis and Transplant Registry matched by age, gender and cause of ESKD. Survival analysis and competing risks analysis (for transplantation) were performed.

Results: After adjusting for body mass index, smoking status, racial group and comorbidities, HHD was associated with a significantly reduced risk of death compared with facility HD patients [hazard ratio 0.47 (95% confidence interval 0.30–0.74)]. Transplantation rates were comparable, with high rates of graft survival at 6 months in both groups. Haemoglobin, calcium and parathyroid hormone levels did not vary significantly. However, HHD patients had significantly lower phosphate levels.

Conclusions: In this study, improved survival outcomes were observed in patients on home compared with facility dialysis, with comparable rates of transplantation, graft survival and biochemical control.

Introduction

Chronic kidney disease (CKD) is a rapidly rising major cause of death globally. CKD mortality is the 12th most common cause of death worldwide and has increased by 31.7% in the last 10 years.[1] End-stage kidney disease (ESKD) prevalence has increased significantly, with a median increase of 50% from 2000 to 2013 from 32 renal registries across World Bank income groups. With trends projected to continue, expansion of facility and home dialysis, as well as of kidney transplantation services, will need to occur to meet global ESKD needs.[2]

At present, overall survival outcomes for haemodialysis (HD) patients globally are poor. In the USA (incident cohort 2011), overall survival is 57.4% at 3 years and 42% at 5 years, worse than for many malignancies.[3–5] In Europe (incident cohort 2007–11), 5-year survival is 42.1%.[6] By comparison, in Australia and New Zealand (incident cohort 2012–14), 3-year survival is 71% and 73%, respectively, and 5-year survival is 50% and 55%, respectively.[7]

Facility HD is the dominant modality in the vast majority of countries, with the exception of Hong Kong, Estonia, the Netherlands and some Nordic countries, who treat fewer than a third of ESKD patients in facilities.[2] Home HD (HHD) has been associated with improvements in clinical and non-clinical outcomes. Previous HHD studies have shown improvements in biochemical parameters and intradialytic blood pressure control, a reduction in recovery time after dialysis and in the frequency of adverse events, including hospitalization, and improved quality of life and survival.[8,9] Extended dialysis hours (such as nocturnal HD) has also been associated with improvements in anaemia management, phosphate control, physical and mental quality of life and superior cost utility.[10,11] Improved outcomes have been proposed to be mediated by beneficial cardiovascular remodelling and improved dialysis adequacy.[9,11]

At the end of 2019 there were 1074 patients on HHD in Australia, accounting for 7.7% of all dialysis patients and 9.3% of HD patients.[7] The proportion of HD patients dialysing at home has declined annually since 2014 (when it peaked at 12%). In comparison, facility dialysis accounts for 51.4% of dialysis patients.[7] Facility HD requires patients to travel to the HD centre, typically three days a week for 4–5 h of dialysis per session. HHD removes the need for travel while providing the opportunity to increase dialysis hours to 5–8 h and to dialyse on alternate days with less interference with other activities of living, as the majority of patients dialyse overnight.[7]

Historically, ESKD patients who took up HHD tended to be younger and have fewer comorbidities.[12] However, an ageing population globally has led to increasing numbers of older people with multimorbidity commencing both facility and HHD. In 2019, there were >3000 patients in the USA ≥65 years of age on HHD, a 3-fold increase since 2009.[13,14] In Australia and New Zealand, 291 people ≥65 years of age were receiving HHD in 2019, an increase of 54% since 2009.[7] It is therefore important to re-evaluate relative survival and outcomes between facility and home dialysis patients given the differences between them are now far less pronounced.

The aim of this study was to determine whether there were significant differences in outcomes between home and facility HD patients in a tertiary centre in Australia using a retrospective matched cohort study, with the hypothesis that HHD patients would experience improved outcomes compared with facility HD patients.

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