Integrated Home Dialysis Model for Patients Initiating KRT

Selection of a dialysis modality is a crucial decision for patients requiring kidney replacement therapy (KRT). Patient autonomy can be enhanced with the selection of home hemodialysis or peritoneal dialysis, resulting in improved quality of life compared with in-center hemodialysis. Benefits associated with peritoneal dialysis compared with in-center hemodialysis include preservation of residual kidney function, the ability to travel, decreased risk of bacteremia, and reduced health care costs. However, up to 50% of patients cannot continue peritoneal dialysis beyond 2 years of treatment. In addition, compared with home hemodialysis, patients receiving peritoneal dialysis may face increased risk of hospitalization and mortality, particularly after the first year of treatment. 

The integrated home dialysis model is designed to initiate dialysis using peritoneal dialysis with a plan to transition to home hemodialysis, incorporating initial lifestyle advantages and a home-based option following termination of peritoneal dialysis. According to Louis-Charles Desbiens, MD, MSc, and colleagues, there are few data available on direct comparisons of outcomes of patients transitioning from peritoneal dialysis to home hemodialysis with those of patients who initiated KRT with home hemodialysis. 

The researchers performed an observational analysis of data from the Canadian Organ Replacement Register (CORR), a validated register that includes all adults initiating KRT in Canada. Results of the analysis were reported in the American Journal of Kidney Diseases. 

The analysis included data on all patients who initiated peritoneal dialysis or home hemodialysis within the first 90 days of KRT between 2005 and 2018. The exposure was patients who transitioned from peritoneal dialysis to home hemodialysis (PD + HHD group) versus those who initiated KRT with home hemodialysis (HHD group). The outcomes of interest were (1) a composite of all-cause mortality and modality transfer (to in-center hemodialysis or peritoneal dialysis for 90 days) and (2) all hospitalizations (considered as recurrent events). 

A total of 63,327 patients were identified in the CORR. At the 90th day of KRT, 745 patients received home hemodialysis and 18,726 received peritoneal dialysis. Of those, 4420 patients transitioned from peritoneal dialysis to in-center hemodialysis and 163 patients transitioned from peritoneal dialysis to home hemodialysis in less than 90 days following termination of peritoneal dialysis. Patients in the PD + HHD group remained on peritoneal dialysis for a median of 1.9 years and underwent a median of 4.0 days of in-center hemodialysis before transitioning to home hemodialysis. 

Compared with those in the HHD group (n=711), patients in the PD + HHD group were younger (51 years vs 52 years), more often of minority race (41% vs 26%), and had a lower burden of comorbidity. Patients in the PD + HHD group were more likely to reside in western Canada and less likely to live in Ontario. Median follow-up time in the HHD group was 2.4 years compared with 1.9 years in the PD + HHD group. In each group, a median of two hospitalizations per patient occurred. 

In the incident-match analysis, a median of 157 patients in the PD + HHD group were matched to 157 HHD patients. Following matching, the distribution of propensity scores was similar between the two groups. Patient characteristics were also similar between the two groups, with the exceptions of minority race (36.8% in the HHD group, 40.7% in the PD + HHD group), hemoglobin levels (102 g/L in the HHD group, 106 g/L in the PD + HHD group), and use of antihypertensive medications (72.6% in the HHD group, 78.5% in the PD + HHD group). 

There was no statistically significant difference in the incidence of the composite event (modality transfer or death) between the groups: hazard ratio [HR], 0.88; 95% CI, 0.58-1.32 for PD + HHD vs HHD). The risk of hospitalization was also similar between the two groups: 0.89 hospitalizations per patient-year in the PD + HHD group versus 0.85 in the HHD group (HR, 1.04; 95% CI, 0.76-1.41). Results were comparable in analysis of individual components of the composite outcome and in joint modeling of the composite outcome and hospitalizations. 

In the vintage-match analysis, follow-up of patients receiving home hemodialysis began after a KRT vintage equivalent to their PD + HHP counterpart at transition (median of 141 patient pairs). Baseline patient characteristics and propensity score distribution were similar between the groups, with the exception of hemoglobin levels and use of antihypertensive medications. The incidence of the terminal composite outcome was significantly lower in the PD + HHD group (HR, 0.61; 95% CI, 0.40-0.94), but comparable for recurrent hospitalizations (HR, 0.85; 95% CI, 0.59-1.24).  When joint or individual modeling of outcomes was used, results were similar. 

The researchers cited some limitations to their findings, including the risk of survivor bias in the PD + HHD group, limits to the generalizability of the findings related to the inability to assess patients who intended but could not transition to home hemodialysis and to the matching process, the relatively small size of the group of patients in the PD + HHD group, the inability to account for eligibility for kidney transplantation, and not evaluating patients’ quality of life. 

In conclusion, the authors said, “This registry study showed that patients who transition from peritoneal dialysis to home hemodialysis have similar risks of hospitalization, modality transfer, and death compared with patients who initiate home hemodialysis within the first 90 days of KRT, and this is despite a higher dialysis vintage. At equivalent dialysis vintages, peritoneal dialysis plus home hemodialysis patients displayed longer survival than patients treated with home hemodialysis but had similar rates of hospitalization. 

“This study reinforces the feasibility and safety of the integrated home dialysis model, capitalizing on the early lifestyle and economic benefits of peritoneal dialysis while preserving long-term clinical outcomes of home hemodialysis. However, our results are subject to survivorship bias and cannot be generalized to the entire peritoneal dialysis population intending to transfer into home hemodialysis. Future studies are required to optimize this KRT paradigm, with more personalized prediction of peritoneal dialysis ending and the identification of an optimal timing for the peritoneal dialysis-to-home hemodialysis transition.” 

Source: Journal of Kidney Diseases