In the JournalsPerspective

Patients who transition from PD to home hemodialysis have lower mortality risk, more transplants

Sheru K. Kansal
Sheru K. Kansal

Patients on PD who transition to home hemodialysis instead of in-center dialysis care after technique failure had a lower risk of death and greater incidence of transplant, a study shows.

“Transitioning patients from PD to home hemodialysis (HHD) may improve continuity of lifestyle and facilitate delivery of more frequent treatment,” wrote author Sheru K. Kansal, MD, and colleagues. “Heterogeneity in relative risks by Medicare coverage suggests uncertainty about the magnitude of benefit. Still, these data suggest that clinical outcomes after PD technique failure can be improved.”

Increasing the use of PD in the incident ESRD patient population will generate increasing counts of PD technique failures per year, the authors noted.

“Although PD is associated with similar or better survival and quality of life relative to HD, effective strategies are needed to manage the transition from PD to HD in order to avoid induction of collateral risk when PD becomes either clinically ineffective or unviable. Home HD is a potentially effective strategy, because patients are already accustomed to dialysis not only in the home, but also on a daily basis,” the authors wrote.

Using United States Renal Data System data, the researchers compared the incidence of death and the occurrence of a kidney transplant in 521 patients who transferred from PD to HHD and matched patients who transferred from PD to in-center HD (IHD). Survival in patients on HHD was 89.1% at 1 year and was 80.5% at 2 years. In an intention-to-treat review, the hazard ratio of death for patients on HHD vs. matched patients on IHD was 0.76. Kidney transplant incidence in patients on HHD was 10.6% at 1 year and was 21% at 2 years. In a modified intention-to-treat analysis, the HR of transplant for patients on HHD vs. matched patients on IHD was 1.36 (1.14 to 1.61). The study cohort included inclusion criterion of survival for great than or equal to 2 months following the last day of PD.

Although the researchers said they saw better survival in those patients who moved to home hemodialysis, Medicare patients did not see the same benefit. The weaker connections “may have been attributable to superior control of confounding by comorbidity in this subset and differences in patient characteristics between non-Medicare and Medicare patients,” the authors wrote. Likewise, Medicare patients who transitioned from PD to IHD accumulated nearly 19 hospitalized days during a 6-month transfer interval. That length of stay was three times the rate of 11 hospitalized days per year among Medicare patients on dialysis in 2014, the authors wrote.

“In conclusion, we found that while transfer from PD to HHD has been relatively rare in the U.S., such a transfer was associated with a lower risk of death and higher incidence of kidney transplant than transfer from PD to IHD,” the authors wrote. “Because PD patients are already accustomed to dialysis in the home, expanded prescription of HHD after PD technique failure may primarily demand anticipation of failure and planning of a clinical response. To refine the process of transitioning patients from PD to HHD, dialysis providers and researchers should continue to assess and report outcomes in patients who transition accordingly.”– by Mark E. Neumann

Disclosures: Kansal reports he has received compensation as a physician consultant to NxStage Medical and was previously a member of the Scientific Advisory Board of NxStage Medical. Please see the full study for a list of other authors’ relevant financial disclosures.

 

 

 

Sheru K. Kansal
Sheru K. Kansal

Patients on PD who transition to home hemodialysis instead of in-center dialysis care after technique failure had a lower risk of death and greater incidence of transplant, a study shows.

“Transitioning patients from PD to home hemodialysis (HHD) may improve continuity of lifestyle and facilitate delivery of more frequent treatment,” wrote author Sheru K. Kansal, MD, and colleagues. “Heterogeneity in relative risks by Medicare coverage suggests uncertainty about the magnitude of benefit. Still, these data suggest that clinical outcomes after PD technique failure can be improved.”

Increasing the use of PD in the incident ESRD patient population will generate increasing counts of PD technique failures per year, the authors noted.

“Although PD is associated with similar or better survival and quality of life relative to HD, effective strategies are needed to manage the transition from PD to HD in order to avoid induction of collateral risk when PD becomes either clinically ineffective or unviable. Home HD is a potentially effective strategy, because patients are already accustomed to dialysis not only in the home, but also on a daily basis,” the authors wrote.

Using United States Renal Data System data, the researchers compared the incidence of death and the occurrence of a kidney transplant in 521 patients who transferred from PD to HHD and matched patients who transferred from PD to in-center HD (IHD). Survival in patients on HHD was 89.1% at 1 year and was 80.5% at 2 years. In an intention-to-treat review, the hazard ratio of death for patients on HHD vs. matched patients on IHD was 0.76. Kidney transplant incidence in patients on HHD was 10.6% at 1 year and was 21% at 2 years. In a modified intention-to-treat analysis, the HR of transplant for patients on HHD vs. matched patients on IHD was 1.36 (1.14 to 1.61). The study cohort included inclusion criterion of survival for great than or equal to 2 months following the last day of PD.

Although the researchers said they saw better survival in those patients who moved to home hemodialysis, Medicare patients did not see the same benefit. The weaker connections “may have been attributable to superior control of confounding by comorbidity in this subset and differences in patient characteristics between non-Medicare and Medicare patients,” the authors wrote. Likewise, Medicare patients who transitioned from PD to IHD accumulated nearly 19 hospitalized days during a 6-month transfer interval. That length of stay was three times the rate of 11 hospitalized days per year among Medicare patients on dialysis in 2014, the authors wrote.

“In conclusion, we found that while transfer from PD to HHD has been relatively rare in the U.S., such a transfer was associated with a lower risk of death and higher incidence of kidney transplant than transfer from PD to IHD,” the authors wrote. “Because PD patients are already accustomed to dialysis in the home, expanded prescription of HHD after PD technique failure may primarily demand anticipation of failure and planning of a clinical response. To refine the process of transitioning patients from PD to HHD, dialysis providers and researchers should continue to assess and report outcomes in patients who transition accordingly.”– by Mark E. Neumann

Disclosures: Kansal reports he has received compensation as a physician consultant to NxStage Medical and was previously a member of the Scientific Advisory Board of NxStage Medical. Please see the full study for a list of other authors’ relevant financial disclosures.

 

 

 

    Perspective

    The article in Peritoneal Dialysis International by Kansal and colleagues presents data showing that patients who transition from PD to home hemodialysis (HHD) after technique failure fare better in terms of survival and access to a transplant than if they had transferred to in-center hemodialysis (IHD) care. Those who are well and transfer to HHD will do better than those who are ill and transfer to IHD. From our perspective, patient selection, called confounding by indication, is an important approach. But there is a lot of detail in the execution, including the process of transferring the patient to HHD or IHD before they get ill. We can exclude peritonitis and membrane failure in this discussion because all clinics focus on prevention of one and can recognize the other.

    We think the “30% psychosocial and other” failures is where we can do better. Clinicians knowing as much about who their patients are as they do about their disease process is key. What’s going on at work, how is their relationship with the kids/spouse, how are the finances, etc.? People would be surprised at how much we can help our patients thrive on PD when we are intentional with our questions.

    Our IDT conversation starts with the social worker. We place a lot of weight in their assessment and opinion of how the patient is doing with PD. We set ourselves up for potential failure when we just look at quality indicators and not consider patients’ perception of their quality of life.

    If we only focus on labs and ignore the patient’s psychosocial status, we will continue to lose 30% of our home patients to this type of technique failure.   

    • Craig Cornelison, RN, and Thomas Golper, MD
    • Vanderbilt University Home Dialysis Program
      Vanderbilt University Medical Center
      Nashville, Tennessee
      Nephrology News & Issues Editorial Advisory Board Members

    Disclosures: Cornelison and Golper report no relevant financial disclosures.