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Woods JD, Port FK, Stannard D, Blagg CR, Held PJ
Comparison of mortality with home hemodialysis and center hemodialysis: A national study
Kidney Int (May) 49:1464-1470 1996
From 1983 to 1993, home hemodialysis has been decreasing in prevalence despite a 9-13% increase in the prevalence of ESRD treatment. The prevalence of continuous peritoneal therapies appears to have plateaued [HCFA data - 1994]. Not much has been published about the benefits of home hemodialysis, especially with regard to rehabilitation or survival.
This paper presents survival data of patients starting dialysis in 1986-1987 using the USRDS Case Mix Severity dataset. Using an intent-to-treat design, survival was compared in patients initially assigned to center dialysis vs. those initially assigned to home hemodialysis. Previous reports have suggested decreased mortality in home HD patients, but the results may have been due to differences in patient selection and/or comorbidity. The selection bias is impossible to compensate for in any retrospective study, but patient comorbidity was controlled for in this study by adjusting survival date for age, sex, race, presence of diabetes, and about 18 additional comorbid factors using a proportional hazards model.
The home HD patients were younger, had less comorbidity and were less likely to be diabetic than patients assigned to center dialysis. Crude mortality was 63% less in home HD patients. Even after adjusting for age, sex, race, diabetes, and comorbid conditions, a 42% lower mortality risk persisted in the home HD patients.
What are the other factors that might have resulted in the better patient outcome for the home HD patients? The authors speculate that patient selection may still play an important role. Also, comorbidity was assessed using an ON/OFF design instead of a graded scale. Comorbidity may have still been less in the home HD patients. The authors also point out that center patients are now getting a higher Kt/V than that of the patients analyzed in the present report, due to the recent increase in Kt/V nationwide. Nevertheless, the result remains that home HD patients still had a 42% lower mortality after adjustment for a large number of confounding covariates.
Comment: Every nephrologist should read this brief, simple, and very pertinent and cogent article. The data suggest that we need to re-evaluate and reverse the recent decline in home HD therapy in the United States. Parenthetically, readers of HDCN might wish to peruse the April 1996 issue of Advances in Renal Replacemnt Therapy which is devoted entirely to home hemodialysis. (Lionel U. Mailloux, M.D., Manhasset, NY)
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