Home hemodialysis treatment and outcomes: retrospective analysis of the Knowledge to Improve Home Dialysis Network in Europe (KIHDNEy) cohort

Abstract

BackgroundUtilization of home hemodialysis (HHD) is low in Europe. The Knowledge to Improve Home Dialysis Network in Europe (KIHDNEy) is a multi-center study of HHD patients who have used a transportable hemodialysis machine that employs a low volume of lactate-buffered, ultrapure dialysate per session. In this retrospective cohort analysis, we describe patient factors, HHD prescription factors, and biochemistry and medication use during the first 6 months of HHD and rates of clinical outcomes thereafter.MethodsUsing a standardized digital form, we recorded data from 7 centers in 4 Western European countries. We retained patients who completed ≥6 months of HHD. We summarized patient and HHD prescription factors with descriptive statistics and used mixed modeling to assess trends in biochemistry and medication use. We also estimated long-term rates of kidney transplant and death.ResultsWe identified 129 HHD patients; 104 (81%) were followed for ≥6 months. Mean age was 49 years and 66% were male. Over 70% of patients were prescribed 6 sessions per week, and the mean treatment duration was 15.0 h per week. Median HHD training duration was 2.5 weeks. Mean standard Kt/Vurea was nearly 2.7 at months 3 and 6. Pre-dialysis biochemistry was generally stable. Between baseline and month 6, mean serum bicarbonate increased from 23.1 to 24.1 mmol/L (P = 0.01), mean serum albumin increased from 36.8 to 37.8 g/L (P = 0.03), mean serum C-reactive protein increased from 7.3 to 12.4 mg/L (P = 0.05), and mean serum potassium decreased from 4.80 to 4.59 mmol/L (P = 0.01). Regarding medication use, the mean number of antihypertensive medications fell from 1.46 agents per day at HHD initiation to 1.01 agents per day at 6 months (P < 0.001), but phosphate binder use and erythropoiesis-stimulating agent dose were stable. Long-term rates of kidney transplant and death were 15.3 and 5.4 events per 100 patient-years, respectively.ConclusionsIntensive HHD with low-flow dialysate delivers adequate urea clearance and good biochemical outcomes in Western European patients. Intensive HHD coincided with a large decrease in antihypertensive medication use. With relatively rapid training, HHD should be considered in more patients.

No evidence of a legacy effect on survival following randomization to extended hours dialysis in the ACTIVE Dialysis trial

“…Moreover, overall survival in our cohort was high -80% at 5 years and was consistent with survival seen in other cohorts of extended or more frequent dialysis. 3,4,21,22 This suggests that our cohort was representative of patients typically offered more intensive dialysis schedules, who are known to have better prognostic characteristics than those performing standard hours. 2,6,11 Cohort studies utilize a variety of matching methodologies to account for the difference in the characteristics of people practising more intensive dialysis schedules when assessing the impact of these schedules and obtain wide variation in estimates of the survival benefit.…”

“…14 The low persistence with extended hours dialysis in this cohort is in contrast with observational studies that report 68% to 85% of those performing frequent or extended haemodialysis will continue with that modality over follow-up periods between 18 months and 5 years. 3,22,26 These studies were entirely or predominantly homebased and there is little data assessing persistence with in-centre intensive haemodialysis. The only other randomized evidence comes from the FHN Nocturnal study, which reported adherence to frequent long nocturnal dialysis (totalling more than 27 h/wk) of over 50% during the follow-up period among those randomized to this schedule (as opposed to approximately 30% cross-over in the standard arm).…”

Heimhämodialyse

“…10 000 weltweit behandelten Patienten am meisten Daten vor. In retrospektiven Analysen konnte gezeigt werden, dass mit diesem System eine sehr gute chronische Dialysequalität erreicht werden kann, die der konventionellen Zentrumsdialyse nicht unterlegen ist [9,13]. Hieraus ergibt sich allerdings auch eine Herausforderung für die deutsche Nephrologie, da es sich abzeichnet, dass die Verbrauchsmaterialien aufgrund der komplexen Kassettensysteme und der höheren Behandlungsfrequenz wohl kostenaufwendiger sein werden, als dies beim herkömmlichen Dialyseregime der Fall ist.…”

“…Eine solche Regelung wäre für die HHD auch deshalb sinnvoll, weil alle detaillierteren Berechnungen von einer gesellschaftsökonomischen Kostenreduktion durch die HHD ausgehen. Diese hängt v. a. mit dem Wegfall der Fahrtkosten, niedrigerer Hospitalisierungsfrequenz und geringerem Pflegeaufwand zusammen [13,14].…”

“…1). Heimdialyseverfahren sind ideale Instrumente, um dem zunehmenden Wunsch unserer Dialysepatienten nach Selbstbestimmung gerecht zu werden [13]. Hinzu kommen innovative informationstechnologische Veränderungen, die wir in den kommenden Jahren zur besseren telemedizinischen Steuerung einsetzen können [18]…”