In the JournalsPerspective

Similar survival rates seen for intensive home hemodialysis, deceased donor transplant

According to the results of a recently published study, patients with ESKD who are placed on intensive home hemodialysis — more than 20 hours a week — have similar survival rates to patients who receive a deceased donor transplant.

“Kidney transplant remains the treatment of choice for end-stage kidney disease, but access to transplant is limited by a disparity between supply and demand for suitable organs,” Angie G. Nishio-Lucar, MD, of the University of Virginia Medical Center, and colleagues from the Lynchburg Nephrology Physicians, PLLC, wrote. “This organ shortfall has resulted in the use of a wider range of donor kidneys and, in parallel, a re-examination of potential alternative renal replacement therapies.”

For the study, 3,073 patients from the Scientific Registry of Transplant Recipients who received living or deceased donor kidneys were compared to 116 patients in an intensive home hemodialysis program (IHHD) in Lynchburg, Virginia. Patients from both study groups were in the same geographic region and were treated between October 1997 and June 2014.

“There is no standard definition of IHHD but most commonly, it is defined as hemodialysis treatment during four or more times per week, preferably totaling 20 hours or more, and eliminating the 2-day interdialytic gap,” the researchers wrote. “IHHD, in the form of nocturnal home hemodialysis, not only provides survival, cardiovascular and metabolic advantage but it is associated with improved sleep apnea and nocturnal oxygen saturation. Moreover, nocturnal home hemodialysis patients usually perceive their dialysis as less cumbersome despite its increased frequency and length.”

Patients with a living donor kidney transplantation (n=1,212) had the highest survival and a 47% reduction in risk of death compared to IHHD. However, “survival of intensive home hemodialysis patients did not statistically differ from that of deceased donor transplant recipients (n=1,834) in adjusted analyses (HR=0.96, 95% CI: 0.62-1.48) or when exclusively compared to marginal (kidney donor profile index > 85%) transplant recipients (HR=1.35, 95% CI: 0.84-2.16),” the authors wrote.

Robert Lockridge

Intensive home hemodialysis requires a higher commitment from patients compared to conventional in-center treatment, Robert Lockridge, MD, a co-author on the paper, told Healio Nephrology. Lockridge was in charge of the home hemodialysis program at Lynchburg Nephrology.

During the 17-year study period, IHHD hours were gradually reduced.

“All patients in the IHHD program from 1997 to 2003 were prescribed 6 days per week for 6-, 7- or 8-hours per treatment (typically Sunday through Friday),” Lockridge said. Mean dialysis time per week was 42 hours. From 2004 to 2012 most patients were prescribed 5 days per week with a mean of 35 hours per week. From 2012 to 2014, days on dialysis were reduced even further; the IHHD program prescribed 4 to 5 days per week for 6-, 7- or 8-hours per treatment. Mean dialysis time per week was 28 to 35 hours, Lockridge told Healio Nephrology.

“If you have a patient on the deceased donor list with a significant wait time, you should talk with them about IHHD as a possible option while waiting for a transplant,” Lockridge told Healio Nephrology. “If you have a patient with significant comorbid conditions or other conditions that preclude them from being transplanted, you should talk with them about IHHD as a possible option. If you have a patient working or going to school full time and the main goal is to have less perceived dialysis burden you should talk with them about IHHD as a possible option.”

Patients who have a catheter at initiation of dialysis should also talk with their kidney care team about IHHD, Lockridge told Healio Nephrology. He said 62% of the patients on IHHD started with a central venous catheter in the Lynchburg group and most still had catheters after 17 years of follow-up.

“Our study showed comparable overall survival between intensive home hemodialysis and deceased donor kidney transplantation,” the researchers concluded. “For appropriate patients, intensive home hemodialysis could serve as bridging therapy to transplant and a tenable long-term renal replacement therapy.”

Disclosures: Lockridge reports he receives honorarium for educational presentations for DaVita, Fresenius Medical Care and NxStage. The other authors report no relevant financial disclosures.

According to the results of a recently published study, patients with ESKD who are placed on intensive home hemodialysis — more than 20 hours a week — have similar survival rates to patients who receive a deceased donor transplant.

“Kidney transplant remains the treatment of choice for end-stage kidney disease, but access to transplant is limited by a disparity between supply and demand for suitable organs,” Angie G. Nishio-Lucar, MD, of the University of Virginia Medical Center, and colleagues from the Lynchburg Nephrology Physicians, PLLC, wrote. “This organ shortfall has resulted in the use of a wider range of donor kidneys and, in parallel, a re-examination of potential alternative renal replacement therapies.”

For the study, 3,073 patients from the Scientific Registry of Transplant Recipients who received living or deceased donor kidneys were compared to 116 patients in an intensive home hemodialysis program (IHHD) in Lynchburg, Virginia. Patients from both study groups were in the same geographic region and were treated between October 1997 and June 2014.

“There is no standard definition of IHHD but most commonly, it is defined as hemodialysis treatment during four or more times per week, preferably totaling 20 hours or more, and eliminating the 2-day interdialytic gap,” the researchers wrote. “IHHD, in the form of nocturnal home hemodialysis, not only provides survival, cardiovascular and metabolic advantage but it is associated with improved sleep apnea and nocturnal oxygen saturation. Moreover, nocturnal home hemodialysis patients usually perceive their dialysis as less cumbersome despite its increased frequency and length.”

Patients with a living donor kidney transplantation (n=1,212) had the highest survival and a 47% reduction in risk of death compared to IHHD. However, “survival of intensive home hemodialysis patients did not statistically differ from that of deceased donor transplant recipients (n=1,834) in adjusted analyses (HR=0.96, 95% CI: 0.62-1.48) or when exclusively compared to marginal (kidney donor profile index > 85%) transplant recipients (HR=1.35, 95% CI: 0.84-2.16),” the authors wrote.

Robert Lockridge

Intensive home hemodialysis requires a higher commitment from patients compared to conventional in-center treatment, Robert Lockridge, MD, a co-author on the paper, told Healio Nephrology. Lockridge was in charge of the home hemodialysis program at Lynchburg Nephrology.

During the 17-year study period, IHHD hours were gradually reduced.

“All patients in the IHHD program from 1997 to 2003 were prescribed 6 days per week for 6-, 7- or 8-hours per treatment (typically Sunday through Friday),” Lockridge said. Mean dialysis time per week was 42 hours. From 2004 to 2012 most patients were prescribed 5 days per week with a mean of 35 hours per week. From 2012 to 2014, days on dialysis were reduced even further; the IHHD program prescribed 4 to 5 days per week for 6-, 7- or 8-hours per treatment. Mean dialysis time per week was 28 to 35 hours, Lockridge told Healio Nephrology.

“If you have a patient on the deceased donor list with a significant wait time, you should talk with them about IHHD as a possible option while waiting for a transplant,” Lockridge told Healio Nephrology. “If you have a patient with significant comorbid conditions or other conditions that preclude them from being transplanted, you should talk with them about IHHD as a possible option. If you have a patient working or going to school full time and the main goal is to have less perceived dialysis burden you should talk with them about IHHD as a possible option.”

Patients who have a catheter at initiation of dialysis should also talk with their kidney care team about IHHD, Lockridge told Healio Nephrology. He said 62% of the patients on IHHD started with a central venous catheter in the Lynchburg group and most still had catheters after 17 years of follow-up.

“Our study showed comparable overall survival between intensive home hemodialysis and deceased donor kidney transplantation,” the researchers concluded. “For appropriate patients, intensive home hemodialysis could serve as bridging therapy to transplant and a tenable long-term renal replacement therapy.”

Disclosures: Lockridge reports he receives honorarium for educational presentations for DaVita, Fresenius Medical Care and NxStage. The other authors report no relevant financial disclosures.

    Perspective
    Graham Abra

    Graham Abra

    This is a retrospective case-control study that examined mortality for 116 patients receiving IHHD during a nearly 17-year period compared with kidney transplant recipients who received organs from either living or deceased donors of varying clinical quality in the same geographic region. IHHD was defined as more than 20 hours a week of treatment delivered in four or more dialysis sessions with no more than a 1-day gap between dialysis days.

    Previous studies that have evaluated mortality between patients performing IHHD and kidney transplant recipients have found mixed results. A study by Pauly and colleagues demonstrated that survival among a cohort of Canadian nocturnal IHHD patients was not significantly different than among U.S. deceased donor kidney transplant recipients. However, a subsequent retrospective analysis suggested that survival after kidney transplant was superior to home hemodialysis. Patients in that study, however, received an average of 10 hours of hemodialysis treatment delivered in fewer than four sessions per week, significantly less dialysis than in the present report.

    Nishio-Lucar and colleagues found, as expected, living donors exhibited the highest survival rates. Median survival for deceased donor recipients and patients on IHHD were 14.3 and 10.4 years, respectively. Hazard ratios for mortality were similar across statistical matching techniques when IHHD was compared with deceased donor kidney transplants, including when compared with those with a high kidney donor profile index (KDPI). Typically, patients with a high KDPI are expected to have worse outcomes. However, living donor transplants displayed statistically significant survival advantage in unadjusted and propensity score adjusted models in this study but not when adjusted for baseline covariates or in a propensity score-matched analysis.

    This study is a welcome addition to the body of evidence documenting the potential advantages of frequent prolonged hemodialysis. As the authors point out, the national conversation has moved on from, “Should we support home modalities, such as IHHD?” to “How do we scale them to achieve the Advancing American Kidney Health goal of having 80% of patients begin kidney replacement therapy with a home modality or a preemptive kidney transplant by 2025?”

    • Graham Abra, MD
    • Clinical Assistant Professor
      Stanford University
      Palo Alto, California
      Senior Director, Medical Clinical Affairs
      Satellite Healthcare
      San Jose, California

    Disclosures: Abra reports he has no relevant financial disclosures.