Survival in daily home hemodialysis and matched thrice-weekly in-center hemodialysis patients

Abstract

Frequent hemodialysis improves cardiovascular surrogates and quality-of-life indicators, but its effect on survival remains unclear. We used a matched-cohort design to assess relative mortality in daily home hemodialysis and thrice-weekly in-center hemodialysis patients between 2005 and 2008. We matched 1873 home hemodialysis patients with 9365 in-center patients (i.e., 1:5 ratio) selected from the prevalent population in the US Renal Data System database. Matching variables included first date of follow-up, demographic characteristics, and measures of disease severity. The cumulative incidence of death was 19.2% and 21.7% in the home hemodialysis and in-center patients, respectively. In the intention-to-treat analysis, home hemodialysis associated with a 13% lower risk for all-cause mortality than in-center hemodialysis (hazard ratio [HR], 0.87; 95% confidence interval [95% CI], 0.78-0.97). Cause-specific mortality HRs were 0.92 (95% CI, 0.78-1.09) for cardiovascular disease, 1.13 (95% CI, 0.84-1.53) for infection, 0.63 (95% CI, 0.41-0.95) for cachexia/dialysis withdrawal, 1.06 (95% CI, 0.81-1.37) for other specified cause, and 0.59 (95% CI, 0.44-0.79) for unknown cause. Findings were similar using as-treated analyses. We did not detect statistically significant evidence of heterogeneity of treatment effects in subgroup analyses. In summary, these data suggest that relative to thrice-weekly in-center hemodialysis, daily home hemodialysis associates with modest improvements in survival. Continued surveillance should strengthen inference about causes of mortality and determine whether treatment effects are homogeneous throughout the dialysis population.

Figure 1.

Kaplan–Meier estimates of survival for daily home hemodialysis (DHHD) and matched thrice-weekly in-center hemodialysis (3xIHD) patients, by analytical approach. (A) Intention-to-treat analysis. (B) As-treated analysis.

Figure 2.

Relative hazards of death for daily home hemodialysis patients in intention-to-treat analysis, by strata (referent: matched thrice-weekly in-center hemodialysis patients). HRs are displayed by dark circles and 95% CIs by solid lines. Cardiovascular disease was defined by any of atherosclerotic heart disease, cerebrovascular disease, congestive heart failure, peripheral vascular disease, or other cardiovascular disease. MPP, Medicare as primary payer.