Factors Associated With Discontinuation of Home Hemodialysis

Abstract

Background: Home hemodialysis (HHD) is associated with improved clinical and quality-of-life outcomes compared to in-center hemodialysis, but remains an underused modality in the United States. Discontinuation from HHD therapy may be an important contributor to the low use of this modality. This study aimed to describe the rate and timing of HHD therapy discontinuation, or technique failure, and identify contributing factors.

Study design: Retrospective cohort study.

Setting & participants: Using data from a large dialysis provider, we identified a nationally representative cohort of patients who initiated HHD therapy from 2007 to 2009 (N=2,840).

Factors: Demographics, end-stage renal disease duration, kidney transplant listing status, comorbid conditions, level of urbanization or rurality based on residence zip code, socioeconomic status based on residence zip code, and dialysis facility factors.

Outcomes: Discontinuation from HHD therapy, defined as 60 or more days with no HHD treatments.

Measurements: Competing-risk models were used to produce cumulative incidence plots and identify sociodemographic and clinical variables associated with HHD therapy discontinuation. Transplantation and death were treated as competing risks for HHD therapy discontinuation.

Results: The 1-year incidence of discontinuation was 24.9%, and the 1-year mortality estimate was 7.6%. Median end-stage renal disease duration prior to initiating HHD therapy was 2.1 years. Diabetes and smoking/alcohol/drug use were associated with increased risk for HHD discontinuation (HRs of 1.34 [95% CI, 1.07-1.68] and 1.34 [95% CI, 1.01-1.78], respectively). Listing for kidney transplantation and rural residence (rural-urban commuting area ≥ 7) were associated with decreased risk for HHD therapy discontinuation (HRs of 0.73 [95% CI, 0.61-0.87] and 0.78 [95% CI, 0.59-1.02], respectively).

Limitations: Limited to variables available within the DaVita dialysis and US Renal Data System data sets.

Conclusions: A substantial proportion of patients discontinue HHD therapy within the first 12 months of use of the modality. Patients with diabetes, substance use, nonlisting for kidney transplantation, and urban residence are at greater risk for discontinuation. Targeting high-risk patients for increased support from clinical teams is a potential strategy for reducing HHD therapy discontinuation and increasing technique survival.

Keywords: Hemodialysis; RRT modality; US Renal Data System (USRDS); discontinuation; end-stage renal disease (ESRD); home dialysis; home hemodialysis (HHD); renal replacement therapy (RRT); technique failure; technique survival.

Fig. 1

Cumulative incidence of home hemodialysis discontinuation among incident home hemodialysis patients, treating death and kidney transplantation as competing risks of discontinuation.