番茄社区

SAN DIEGO -- Hemodialysis at home seemed to yield better survival than in-center hemodialysis among incident dialysis patients, researchers reported here.

Comparing nearly 1,800 individuals who received home hemodialysis with over 555,000 patients who had hemodialysis in a center, home hemodialysis was tied to a 23% lower risk of death after 1 year (adjusted HR 0.77, 95% CI 0.66-0.91), according to Eric Weinhandl, PhD, of the University of Minnesota in Minneapolis, and colleagues.

During this year, nearly 92% of patients receiving home hemodialysis survived compared with only 81.4% of those who at in-center hemodialysis, they reported at the American Society of Nephrology ASN Kidney Week 2018.

Although the researchers expected to see this difference according to hemodialysis type, Weinhandl told 番茄社区 they were surprised to see this was further mediated by certain factors, including age, which has not been previously reported before. Specifically, younger people (ages <45) saw the largest reduced risk for mortality with at-home hemodialysis compared with in-center hemodialysis:

• Ages 20-44: aHR 0.56 (95% CI 0.30-1.04)
• 45-64: aHR 0.74 (95% CI 0.58-0.94)
• ≥65: aHR 0.89 (95% CI0.70-1.13)

The reduced mortality risk with at-home dialysis also varied based on eGFR range:

• eGFR <10 mL/min/1.73 m²: aHR 0.68 (95% CI 0.51-0.90)
• eGFR ≥10 mL/min/1.73 m²: aHR 0.80 (95% CI 0.65-1.00)

Weinhandl explained that his group wished to separately compare the outcomes of these two types of dialysis to each other because much of the existing literature includes patients who have converted from in-center hemodialysis to home hemodialysis.

"Correspondingly, we do not have much data about outcomes in patients who are prescribed home hemodialysis at, or shortly after, dialysis initiation. We aimed to assess whether home hemodialysis treatment was associated with better survival during the first year of dialysis treatment," he explained.

"The logic for this hypothesis is akin to the logic of primary versus secondary prevention. More frequent dialysis improves cardiovascular parameters -- blood pressure, left ventricular mass, etc. -- so targeting cardiovascular health at dialysis initiation with more frequent hemodialysis, rather than several years thereafter, may lead to larger improvements in clinical outcomes," he added.

The data for this analysis came from the United States Renal Data System. Patients on in-center hemodialysis were identified as receiving treatment at a dialysis center 45 days after initiation of dialysis, while home hemodialysis patients were identified as initiating at-home treatment with the NxStage System One within 90 days of dialysis initiation.

Relative to in-center hemodialysis patients, home hemodialysis patients were younger (mean age 55.3 vs 60.3), more likely white (81.3% vs 62.7%), more likely male (71.1% vs 57.0%), less likely enrolled in Medicaid (9.5% vs 28.3%), and less likely to have heart failure (15.8% vs 31.3%), the authors reported.

"Upon dialysis initiation, patients and health care professionals should consider the advantages and disadvantages of each of in-center hemodialysis, peritoneal dialysis in the home, or home hemodialysis," Weinhandl recommended. "To date, the vast majority of new dialysis patients in the U.S. have been prescribed either in-center hemodialysis or peritoneal dialysis. Home hemodialysis provides an ideal setting for customizing treatment frequency and/or duration to address clinical and lifestyle goals of patients."

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