Home-Dialysis Patients Fare Better

Maureen Salamon

April 13, 2019

MELBOURNE, Australia — For patients with kidney failure, the risk of dying is markedly lower when patients receive home dialysis than when they undergo treatment at a satellite center, new research suggests.

"What we found adds to the body of evidence that there are mortality benefits to home dialysis, in addition to being able to keep on top of biochemical targets," said Emily Yeung, MBBS, from Monash Medical Centre in Clayton, Australia.

"Obviously, home-dialysis patients tend to be on dialysis for more hours, most of which are during the night," Yeung told Medscape Medical News. "They typically get 5 to 8 hours every other night instead of 4.5 to 5 hours three times a week at a satellite center. Home dialysis matches kidney function more closely, and I think that contributes to better outcomes."

But overall, outcomes are probably related to "a combination of treatment factors and patient factors," such as patient motivation and health literacy, neither of which was measured in this study, Yeung said here at the International Society of Nephrology: 2019 World Congress.

"Those on home dialysis tend to be really on top of their medications and aware of the importance of adhering to their dialysis," she pointed out.

Lower Mortality, Higher Transplantation Rates

In their single-center study, Yeung and her colleagues assessed 542 patients. Each home-dialysis patient was matched with three satellite patients for age, sex, and cause of end-stage kidney failure.

Primary outcomes were all-cause mortality and transplantation rates. Secondary outcomes were average biochemical levels, the percentage of patients with hemoglobin levels below 100 g/L and phosphate levels above 1.8 mmol/L, and survival 6 months after transplantation.

Body mass index in home-dialysis patients was significantly higher than in satellite patients (30.2 vs 27.3 kg/m²; P < .0001). This could indicate that home-dialysis patients are receiving better nutrition or are "more aware of the importance of eating well with a chronic disease," Yeung said.

At baseline, the rate of cerebrovascular disease was significantly lower in home-dialysis patients than in satellite patients, but there were no differences in rates of lung disease, coronary artery disease, peripheral vascular disease, cancer, diabetes, or hepatitis C.

Risk for death was 62% lower in home-dialysis patients than in satellite patients (hazard ratio, 0.38; P < .001), and rates of transplantation were higher with home dialysis (61.8% to 51.6%; P = .03).

Post-transplant survival was very high in both the home-dialysis and satellite groups (100% vs 99.5%).

"We've known for a long time that home dialysis has excellent outcomes, but it's nice to put some clear numbers around it," said study coauthor Peter Kerr, PhD, also from Monash Medical Centre, who is chair of the World Congress of Nephrology (WCN) local organizing committee.

There was no significant difference in hemoglobin levels between the two groups, but fewer patients in the home-dialysis group than in the satellite group had phosphate levels above 1.80 mmol/L (35.8% vs 46.6%; P < .05).

Because this was a single-center study, it is difficult to generalize the findings, Kerr acknowledged, noting that only about 5000 of the 400,000 dialysis patients in the United States use a home system.

In 2017, nearly 10% of dialysis patients in Australia were on a home system and about 51% were receiving treatment at a satellite center.

In the United States, "it has really bottomed out," he said, although "there's been a push to get people interested in home dialysis."

Not for Everyone

Home-dialysis equipment costs about $20,000, which is a large upfront investment but it yields savings in nursing costs down the road, Kerr said. Home utility costs rise because of electricity and water use, but in Australia, the government pays patients several thousand dollars a year to offset those costs, he explained.

Setting up home dialysis can be tricky. In some cases, renovations are needed to accommodate the water and electricity levels needed to power the equipment, Yeung added.

"There's also a lot of training involved with allowing patients to perform dialysis," she said. "The main caveat is to select patients who are able to manage home dialysis, making sure they feel sufficiently empowered about how to troubleshoot or get support if they have problems."

It is unclear what factors contribute to the better outcomes with home dialysis, said Stephen McDonald, MBBS, PhD, from the Australia and New Zealand Dialysis and Transplant Registry in Adelaide.

But it is likely that "being at home facilitates practical changes," he told Medscape Medical News. For instance, patients at home can be proactive about dialyzing to get rid of extra fluid if their intake of liquids is higher than normal.

Overall, home dialysis is underutilized, said Rukshana Shroff, MD, PhD, from Great Ormond Street Hospital in London.

The low rate of patients using home dialysis in Australia — 10% — is similar to the rate in the United Kingdom, "but there are far more satellite centers close to patients' homes" in the United Kingdom, she reported.

Still, "in most places, including Canada, the use of home dialysis is still under 10%," she told Medscape Medical News. It would be nice to understand "why the uptake isn't higher than this and what we can do to raise it."

Yeung and Shroff have disclosed no relevant financial relationships. Kerr is a member of the advisory board for Bayer. McDonald reports receiving research funding from Baxter.

International Society of Nephrology (ISN): 2019 World Congress: Abstract SAT-043. Presented April 13, 2019.

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