Abstract
BackgroundThe survival rate for dialysis patients is poor. Previous studies have shown improved survival with home hemodialysis (HHD), but this could be due to patient selection, since HHD patients tend to be younger and healthier. The aim of the present study is to analyse the long-term effects of HHD on patient survival and on subsequent renal transplantation, compared with institutional hemodialysis (IHD) and peritoneal dialysis (PD), taking age and comorbidity into account.MethodsPatients starting HHD as initial renal replacement therapy (RRT) were matched with patients on IHD or PD, according to gender, age, Charlson Comorbidity Index and start date of RRT, using the Swedish Renal Registry from 1991 to 2012. Survival analyses were performed as intention-to-treat (disregarding changes in RRT) and per-protocol (as on initial RRT).ResultsA total of 152 patients with HHD as initial RRT were matched with 608 IHD and 456 PD patients, respectively. Median survival was longer for HHD in intention-to-treat analyses: 18.5 years compared with 11.9 for IHD (p < 0.001) and 15.0 for PD (p = 0.002). The difference remained significant in per-protocol analyses omitting the contribution of subsequent transplantation. Patients on HHD were more likely to receive a renal transplant compared with IHD and PD, although treatment modality did not affect subsequent graft survival (p > 0.05).ConclusionHHD as initial RRT showed improved long-term patient survival compared with IHD and PD. This survival advantage persisted after matching and adjusting for a higher transplantation rate. Dialysis modality had no impact on subsequent graft survival.
Highlights
The survival rate for dialysis patients is poor
Most patients had an index of 0 (63%), 28% had an index of 1, 8% had an index of 2 and 2% an index of 3 (Table 1). This cohort of incident home hemodialysis (HHD) patients was compared with two matched cohorts - one starting on institutional hemodialysis (IHD) and one starting on peritoneal dialysis (PD)
Most other variables in the analyses were not significantly related to survival. In both comparisons between HHD and IHD, comprising all patients and those with a renal transplantation immediately subsequent to the initial renal replacement therapy (RRT) (p = 0.005; p = 0.006) and in the comparison between all HHD and all PD patients (p = 0.038), an earlier decade of start of RRT was significantly related to a worse graft survival. This population-based study including all Swedish patients with HHD as initial RRT showed an improved long-term survival for HHD compared with both IHD and PD
Summary
The survival rate for dialysis patients is poor. Previous studies have shown improved survival with home hemodialysis (HHD), but this could be due to patient selection, since HHD patients tend to be younger and healthier. The aim of the present study is to analyse the long-term effects of HHD on patient survival and on subsequent renal transplantation, compared with institutional hemodialysis (IHD) and peritoneal dialysis (PD), taking age and comorbidity into account. Earlier studies have indicated improved survival for patients on home hemodialysis (HHD) compared with institutional hemodialysis (IHD) [4,5,6,7,8,9,10] and peritoneal. The primary aim of this study was to compare long-term survival for patients with HHD as initial renal replacement therapy (RRT) with matched control patients with either IHD or PD as initial RRT. The secondary aim was to compare subsequent renal graft survival for patients with either HHD, IHD or PD as initial RRT
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