Patient and Technique Survival among a Canadian Multicenter Nocturnal Home Hemodialysis Cohort

Abstract

Background and objectives: As a result of improved clinical and quality-of-life outcomes compared with conventional hemodialysis, interest in nocturnal home hemodialysis (NHD) has steadily increased in the past decade; however, little is known about the flow of patients through NHD programs or about patient-specific predictors of mortality or technique failure associated with this modality. This study addressed this gap in knowledge. Design, setting, participants, & measurements: This study included 247 NHD patients of the Canadian Slow Long nightly ExtEnded dialysis Programs (CAN-SLEEP) cohort from 1994 through 2006 inclusive. The association between program-and patient-specific variables and risk for adverse outcomes was determined using uni-and multivariable Cox regression.Results: A total of 14.6% of the cohort experienced death or technique failure. Unadjusted 1-and 5-year adverse event-free survival was 95.2 and 80.1%, respectively. Significant predictors of a composite of mortality and technique failure included advanced age (P < 0.001), diabetes (P < 0.001), central venous catheter use (P ‫؍‬ 0.01), and inability to perform NHD independently (P ‫؍‬ 0.009) and were adjusted for center effect. Weekly frequency of NHD was not predictive. Age and diabetes remained significant with multivariable analysis (hazard ratio 1.07 and 2.64, respectively). Unadjusted 1-and 5-year technique survival was 97.9 and 95.2%, respectively. Only age was a significant predictor of technique failure.Conclusions: NHD is associated with excellent adverse event-free survival. This study underscores the importance of modality-specific predictors in the success of home hemodialysis, as well as favorable baseline characteristics such as younger age and the absence of diabetes.

Economic Evaluation of Frequent Home Nocturnal Hemodialysis Based on a Randomized Controlled Trial

“…This finding is highlighted by sensitivity analysis showing that the incremental cost-utility ratio exceeds $75,000 per QALY when the annual technique failure rate exceeds 19%. Observational data from a Canadian cohort indicate a technique failure rate of 4% 14 (lower than our base case of 7.6%), and in our reference case, NHD would remain dominant over CvHD. However, other home dialysis cohorts have reported technique failure rates that exceed 20%, 15 which would make NHD much less economically attractive.…”

“…7 Canadian data from observational cohorts show a far lower mortality rate than the typical dialysis population. 14,19 We examined the cost-effectiveness of FHNHD in an eligible patient population; however, the cost-effectiveness of FHNHD in a broader dialysis population may be significantly less attractive if mortality, technique failure rates, or duration of training is greater (because in sensitivity analysis, we noted that these variables reduced the attractiveness of FHNHD).…”

How to Overcome Barriers and Establish a Successful Home HD Program

“…One of the best-matched cohort studies looked at patient and technique survival among 247 Canadian patients treated with nocturnal home HD. The unadjusted 1-and 5-year adverse event-free survival rates were 95% and 80%, respectively, and the technique survival rates at 1 and 5 years were 98% and 95% (28,31). Additionally, according to the International Quotidian Dialysis Registry compared with the Dialysis Outcomes and Practice Patterns Study, patients receiving intensive (.5.5 hours per day or night) HD had a 45% better survival (HR, 0.55; 95% CI, 0.34-0.87) than incenter HD patients after adjustment (28).…”

Clinical, patient-related, and economic outcomes of home-based high-dose hemodialysis versus conventional in-center hemodialysis

“…The evidence points toward a better survival for patients receiving SDHD and NHD compared to those treated with conventional regimes. [23][24][25][26][27][28][29][30] Some studies would even suggest that the survival benefit of SDHD and NHD is comparable to that of deceased donor transplant recipients, 31,32 although in the most recent retrospective cohort study of high-dose home HD patients and kidney transplant recipients, kidney transplantation was associated with superior treatment and patient survival. 33 Blood pressure (BP) control is one of the most consistent benefits of high-dose HD in randomized and nonrandomized studies.…”