Temporal Trends and Factors Associated with Home Hemodialysis Technique Survival in Canada

Abstract

Background and objectives: The last 15 years has seen growth in home hemodialysis (HD) utilization in Canada owing to reports of improved outcomes relative to patients on conventional in-center HD. What effect growth has had on home HD technique and patient survival during this period is not known.

Design, settings, participants, & measurements: We compared the risk of home HD technique failure, mortality, and the composite outcome among three incident cohorts of patients on home HD in Canada: 1996-2002, 2003-2007, and 2008-2012. A multivariable piece-wise exponential model was used to evaluate all outcomes using inverse probability of treatment and censoring weights.

Results: A total of 1869 incident patients on home HD were identified from the Canadian Organ Replacement Register. Relative to those treated between 2003 and 2007 (n=568), the risk of home HD technique failure was similar between patients treated between 1996 and 2002 (n=233; adjusted hazard ratio [AHR], 1.39; 95% confidence interval [95% CI], 0.78 to 2.46) but higher among incident patients on home HD treated between 2008 and 2012 (n=1068; AHR, 1.51; 95% CI, 1.06 to 2.15). Relative to patients treated between 2003 and 2007, adjusted mortality was similar among those treated between 2008 and 2012 (AHR, 0.83; 95% CI, 0.58 to 1.19) and those treated between 1996 and 2002 (AHR, 0.67; 95% CI, 0.38 to 1.21). The risk of the composite outcome of death and technique failure was similar across cohorts, as was the risk of receiving a kidney transplant. Increasing age, diabetes as a comorbidity, and smoking status were associated with an increased risk of death as well as the composite outcome. Medium-sized facilities had a lower risk of death, technique failure, and the composite outcome compared with larger facilities.

Conclusions: A higher risk of technique failure was seen in the most contemporary era. Further characterization of the risk factors for, and causes of technique failure is needed to develop strategies to improve patient retention on home HD.

Keywords: Canada; Canadian Organ Replacement Register; Comorbidity; Death; Dialysis Modality Discontinuation; Hemodialysis; Hemodialysis, Home; Home Dialysis Discontinuation; Humans; Proportional Hazards Models; Smoking; Technique Failure; diabetes mellitus; home hemodialysis; kidney transplantation; risk factors; short daily hemodialysis; slow nocturnal hemodialysis; survival; technique survival.

Graphical abstract

Figure 1.

Direct adjusted patient survival, technique survival, and the composite of patient and technique survival among patients on home hemodialysis demonstrating a higher risk of technique failure in the 2008–2012 cohort relative to the 2003–2007 cohort. (A) Patient survival, (B) technique survival, and (C) patient and technique survival. 95% CI, 95% confidence interval; HHD, home hemodialysis.

Figure 1.

Direct adjusted patient survival, technique survival, and the composite of patient and technique survival among patients on home hemodialysis demonstrating a higher risk of technique failure in the 2008–2012 cohort relative to the 2003–2007 cohort. (A) Patient survival, (B) technique survival, and (C) patient and technique survival. 95% CI, 95% confidence interval; HHD, home hemodialysis.

Figure 1.

Direct adjusted patient survival, technique survival, and the composite of patient and technique survival among patients on home hemodialysis demonstrating a higher risk of technique failure in the 2008–2012 cohort relative to the 2003–2007 cohort. (A) Patient survival, (B) technique survival, and (C) patient and technique survival. 95% CI, 95% confidence interval; HHD, home hemodialysis.