Background Home hemodialysis (HHD) is associated with improved clinical and quality of life outcomes compared with in-center hemodialysis but remains an underused modality in the United States. Discontinuation from HHD may be an important contributor to the low utilization of this modality. This study aimed to describe the rate and timing of HHD discontinuation, or technique failure, and identify contributing factors. Study Design Retrospective cohort study Setting & Participants Using data from a large dialysis provider, we identified a nationally representative cohort of patients who initiated HHD from 2007 – 2009 (N=2840). Factors Demographics, ESRD duration, kidney transplant listing status, co-morbid conditions, level of urbanization or rurality based on residence zip code, socioeconomic status based on residence zip code, and dialysis facility factors. Outcomes Discontinuation from HHD, defined as ≥60 days with no HHD treatments. Measurements Competing risk models were used to produce cumulative incidence plots and to identify socio-demographic and clinical variables associated with HHD discontinuation. Transplantation and death were treated as competing risks for HHD discontinuation. Results The 1-year incidence of discontinuation was 24.9% and the 1-year mortality estimate was 7.6%. Median ESRD duration prior to initiating HHD was 2.1 years. Diabetes and smoking/alcohol/drug use were associated with increased risk of HHD discontinuation (HRs of 1.34 [95% CI, 1.07–1.68] and 1.34 [95% CI, 1.01–1.78], respectively). Listing for kidney transplant and rural residence (rural-urban commuting area ≥ 7) were associated with decreased risk of HHD discontinuation (HRs of 0.73 [95% CI, 0.61–0.87] and 0.78 [95% CI, 0.59–1.02], respectively). Limitations Limited to variables available within the DaVita dialysis and US Renal Data System datasets. Conclusions A substantial proportion of patients discontinue HHD within the first 12 months of use of the modality. Patients with diabetes, substance use, non-listing for kidney transplant, and urban residence are at greater risk for discontinuation. Targeting high-risk patients for increased support from clinical teams is a potential strategy for reducing HHD discontinuation and increasing technique survival.

SummaryDabigatran is an oral direct thrombin inhibitor widely used to prevent and treat various thromboembolic complications. An advantage of this agent over other anticoagulants is that routine laboratory monitoring and related dose adjustments are considered unnecessary. A major disadvantage is the absence of a reliable means of reversing its anticoagulant effect. After U.S. Food and Drug Administration approval, recently emerged data suggest a higher bleeding risk with dabigatran, especially in the elderly. Clinicians are thus faced with caring for patients with serious bleeding events without readily available tests to measure drug levels or the anticoagulant effects of dabigatran and without effective antidotes to rapidly reverse the anticoagulant effect. On the basis of dabigatran's pharmacokinetic profile, hemodialysis and continuous renal replacement therapy have been used to remove dabigatran with the hope, still unproven, that this would rapidly reverse the anticoagulant effect and reduce bleeding in patients with normal and those with reduced kidney function. However, the best clinical approach to the patient with serious bleeding is not known, and the risks of placing a hemodialysis catheter in an anticoagulated patient can be substantial. This article reviews this issue, addressing clinical indications, drug pharmacokinetics, clinical and laboratory monitoring tests, and dialytic and nondialytic approaches to reduce bleeding in dabigatran-treated patients.

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