Independent community house hemodialysis as a novel dialysis setting: an observational cohort study

Abstract

Background: There is revived interest in home hemodialysis (HD), which is spurred by cost containment and experience indicating lower mortality risk compared with facility HD and peritoneal dialysis (PD). Social barriers to home HD include disruptions to the home environment, interference with family life, overburdening of support networks, and fear of social isolation. A submodality of home HD, in which patients from urban settings undertake independent HD in unstaffed nonmedical community-based home-like settings, is described in this study. The survival of patients treated in this manner is compared with that of those using conventional home HD.

Study design: An observational cohort study using the Australia and New Zealand Dialysis and Transplant Registry.

Setting & participants: All adult patients starting renal replacement therapy in New Zealand since March 31, 2000, followed up through December 31, 2010.

Predictor: The main predictor was time-varying dialysis modality (home HD, facility HD, PD, and community house HD), adjusting for the confounding effects of patient demographics and time-varying comorbid conditions.

Outcome: Patient mortality.

Results: 4,709 patients with 12,883 patient-years of follow-up (5,591, PD; 1,532, home HD; 5,647, facility HD; and 113, community house HD) were analyzed. Community house HD patients were younger, healthier, and more likely to be Pacific people than those using other modalities, including home HD. Relative to home HD, adjusted mortality HRs were 2.18 (95% CI, 1.78-2.67) for facility HD, 2.17 (95% CI, 1.77-2.66) for PD, and 1.48 (95% CI, 0.64-3.40) for community house HD.

Limitations: Small number of patients receiving community house HD, possible residual confounding from the limited collection of comorbid conditions (eg, no collection of cognitive or motor impairment), and absence of socioeconomic, medication, and biochemical data in analyses.

Conclusions: Within limits, this study shows community house HD to be both safe and effective. Community house HD provides an option to improve the uptake of home HD.