Diabetes Associated with Risk for Discontinuation of Home Hemodialysis

There is an association between home hemodialysis (HHD) and improved clinical and quality-of-life outcomes compared with in-center hemodialysis, yet HHD remains an underused modality in the United States. There are approximately 450,000 individuals with end-stage renal disease (ESRD) in the United States receiving maintenance dialysis; of those, 90% receive dialysis three times a week at dialysis centers.

As life-saving as dialysis is, patients on maintenance hemodialysis have a mortality rate 6.1 to 7.8 times greater compared with age-matched Medicare beneficiaries, with a hospitalization rate of 1.73 admissions per patient-year. Further, quality of life and functional status are low among dialysis patients. To deal with these poor outcomes, alternative dialysis modalities, including HHD, have garnered interest in recent years.

HHD has a substantial discontinuation rate within the first 12 months of use. According to researchers, this discontinuation rate may be a factor in the low use of this dialysis modality. Rebecca Kurnik Seshasai, MD, and colleagues conducted a retrospective cohort study designed to identify the rate and timing of discontinuation of HHD therapy or technique failure, as well as contributing factors. The researchers reported results in the American Journal of Kidney Diseases [2016;67(4):629-637].

The researchers defined discontinuation of HHD therapy as ≥60 days with no HHD treatment. The analysis used data from DaVita dialysis facilities in the United States on all adult patients who initiated HHD therapy from January 1, 2007, to December 31, 2009.  Most of the patients were using NxStage equipment and performing short daily treatments. Dates of HHD service and, when applicable, the dialysis modality preceding and following home dialysis were included in the analysis.

The final study cohort comprised 2840 patients. The factors considered were demographics, duration of ESRD, kidney transplant listing status, comorbid condition, urban or rural residence (based on zip code), socioeconomic status (based on zip code), and dialysis facility factors. The researchers used competing-risk models to produce cumulative incidence plots and identify sociodemographic and clinical variables associated with discontinuation of HHD. Transplantation and death were treated as competing risks for HHD therapy discontinuation.

Of the 2840 patients, 729 discontinued HHD and switched to another dialysis modality during the 3-year study period, 232 underwent kidney transplantation, and 253 died. Average follow-up was 8.26 months.

Mean age at the time of initiation of HHD was 52 years, 66.1% of the overall cohort were men, 70.0% were white, and median ESRD duration prior to initiation of HHD was 2.1 years. In 32.0% of patients, diabetes was the primary cause of ESRD, and 34.4% were listed for transplantation at the time of initiation of HHD therapy. The majority of patients lived in an urban region; only 10.6% lived in a region classified as rural. Forty-eight states and the District of Columbia were represented in the cohort; California, Florida, and Pennsylvania had the greatest number of study participants.

The proportion of patients who discontinued at year 1 was 24.9%, corresponding to 29.4 discontinuations per 100 patient-years. The proportion of patients who died by year 1 was 7.6%, and the proportion of those who underwent kidney transplantation was 7%, corresponding to 10.2 deaths and 9.3 transplantations per 100 patient-years. Event proportions for discontinuation at 3 months, 6 months, and 2 years were 9%, 16%, and 35%, respectively.

Age was the only characteristic that differed among patients who discontinued within 3 months (n=239), between 3 and 12 months (n=353), or >12 months (n=137) following initiation of HHD therapy. Mean age of patients with early discontinuation was 54.3 years; those who discontinued between 3 and 12 months had a mean age of 52.2 years; and those with late discontinuation had a mean age of 50.8 years (P=.05).

Being listed for kidney transplantation at the time of HHD initiation was associated with a 27% decrease in risk for discontinuation (hazard ratio [HR], 0.73; 95% confidence interval [CI], 0.61-0.87), an association that did not reach statistical significance. Living in a rural area trended toward protection against discontinuation (HR, 0.78; 95% CI, 0.59-1.02); that also did not reach statistical significance.

Increased risk for discontinuation of HHD therapy was associated with diabetes (HR, 1.34; 95% CI, 1.07-1.68) and smoking/alcohol/drug use (HR, 1.34; 95% CI, 1.01-1.78). Results were similar in sensitivity analyses where discontinuation was defined as 30 rather than 60 days with no HHD sessions with the exception of the rural-urban commuting area score, which was not as suggestive a predictor for discontinuation.

In the subset of patients with available facilities data (2055 patients at 323 facilities), there was no association between discontinuation of HHD therapy and size of the HHD program, any indicators of the size of the facility, or duration of facility Medicare certification.

Study limitations cited by the authors included the limitations imposed by use of administrative data, i.e., the inability to evaluate psychosocial factors for patients and caregivers, comorbid conditions that developed following initiation of HHD, and technical aspects of the dialysis procedure.

The researchers concluded by saying, “We found that nearly 25% of patients discontinue HHD therapy within 1 year of initiation of the modality, and we identified several associated patient characteristics. The high rate of discontinuation, while not surprising given the complexity of performing hemodialysis in the home setting, suggests that increasing HHD use requires efforts directed not only at uptake of the modality, but also at retention. While additional work is required to identify contributing facility factors and the specific reasons that patients discontinue HHD therapy, targeting high-risk patients for increased support from clinical teams is a potential strategy for reducing HHD therapy discontinuation and increasing the overall use of this modality.”

Takeaway Points

  1. Home hemodialysis (HHD) is an underused modality in the United States despite improved clinical and quality-of-life outcomes associated with HHD.
  2. In a retrospective cohort study, diabetes and smoking/alcohol/drug use were associated with increased risk for discontinuation of HHD.
  3. Rural residence and being listed for kidney transplantation at the time of HHD initiation were associated with reduced risk for discontinuation of the modality.