Turkish study shows 40% lower mortality for patients on HHD vs. in-center dialysis
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Key takeaways:
- Turkish patients on home hemodialysis had a 40% lower rate of death vs. those on in-center dialysis.
- Mean systolic blood pressure decreased in patients on HHD but did not change for in-center patients.
Patients living in Turkey with end-stage kidney disease had a 40% lower mortality rate when receiving dialysis at home vs. patients receiving in-center treatment, a new study shows.
Mean systolic blood pressure decreased among patients on home hemodialysis but did not change in the in-center treatment group.
The researchers also observed an 86.5% technique survival in patients on HHD over 5 years. In addition to better BP control, the patients showed reduced inflammation, improved nutrition and better phosphorus control.
“Despite HHD being more economical than [in-center hemodialysis] utilization of HHD in low-/middle-income countries (LMICs) remains rare,” Ercan Ok, MD, a professor in internal medicine and nephrology and head of the nephrology division at the Ege University School of Medicine in Izmir, Turkey, and colleagues wrote on behalf of the Turkish Home Hemodialysis Initiative. “The HHD program initiated in June 2010, as the first effort of its kind in Turkey, has shown a remarkable development over time, reaching 1,218 patients as of Dec. 31, 2021. To our knowledge, the HHD program recently implemented in Turkey may be the largest one among those in LMICs.”
Patients who had chosen HHD between June 2010 and December 2014 in Fresenius Medical Care dialysis clinics in Turkey and were more than 18 years old were screened for the study. Patients using in-center hemodialysis had to be on the therapy for more than 3 months.
The study included 349 patients who received extended HHD (3 times/week for 418 minutes) vs. 1,047 patients who received in-center hemodialysis (3 times/week for 242 minutes). The primary outcome for the study was overall survival; the secondary outcomes were technique survival, hospitalization and changes in clinical, laboratory and medication parameters.
In an interview with Healio, Ok said all patients began the study as prevalent in-center hemodialysis patients. “Before propensity score matching, hemoglobin and C-reactive protein levels and vascular access were comparable” between the two study groups, she said. “After propensity score matching, the two groups were matched well regarding age, sex, [end-stage kidney disease (ESKD)] duration, diabetes, BMI, albumin, phosphate and systolic BP.”
In their intention-to-treat analysis, the researchers found a 40% reduction in the risk of all-cause mortality in the patient group on HHD compared with patients on in-center hemodialysis. Through follow-up, all-cause mortality was 3.76 per 100 patient years in the HHD group and 6.27 per 100 patient years in the ICHD.
Post-dialysis body weight and albumin level increased in the HHD group. “The difference was significant for post-dialysis [body weight] BW (P = .03), and at borderline significance for albumin (P = .05),” the researchers wrote. “The difference between the changes of neutrophil/lymphocyte ratio in [the] two groups was significant.”
Annual hospitalization rates were lower in the HHD group (2.2 days/year) compared with the ICHD group (4.6 days/year).
The patients in the HHD group “said they felt healthy, hungry and happy, with no intradialytic hypotension, no post-dialysis fatigue, etc.,” Ok told Healio. “Patients felt more self-confident and more energetic. Dietary restrictions were reduced, and in many patients, medication use was eliminated after the first year.”
Perspective
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The search for the “holy grail” of dialysis that could improve patient survival continues. This study is a retrospective, propensity-matched analysis of patients on HHD showing a 40% reduction in all-cause mortality compared with patients on in-center hemodialysis group (HR = 0.6; 95% CI, 0.45-0.80). The study also reports improved systolic BP and reduced pill burden, along with higher technique survival in the HHD group. The patients were matched according to age, dialysis vintage and comorbidities.
Previous observational studies on mortality and technique survival have produced inconsistent results due to methodical drawbacks. The Frequent Hemodialysis Trial, the only randomized controlled study looking at extended HHD, was underpowered with a higher dropout rate and shorter follow-up than anticipated. However, post hoc analysis did show an improvement in left ventricular mass index, a surrogate marker.
This study by Ercan Ok, MD, and colleagues found that the HHD group primarily received nocturnal home hemodialysis, with a higher median dialysis time, while both groups received treatment three times per week. In the U.S., HHD is often called short daily hemodialysis (SDHD), with an average treatment frequency of dialysis sessions. Previous data have led to a debate about the frequency of HHD and the impact of increased time on dialysis, as well as selection bias on the survival of HHD. However, the findings of this study suggest that clinical practice could shift from predominantly SDHD in the U.S. to three times per week nocturnal HHD. This may be a welcome change from a patient perspective, reducing the number of sessions to achieve solute clearance. The volume status and the ultrafiltration rate per hour needs to be cautiously monitored in three times weekly HHD as reduced frequency may lead to decreased ultrafiltration. That can lead to volume overload.
The findings of the study emphasize that the dialysis modality, which includes HHD, is not the only factor that affects survival rates. HHD encompasses a broader range of hemodialysis options that can be performed at home, such as short daily sessions with increased frequency, three times weekly with or without extended time, or even nocturnal dialysis.
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