Comparative effectiveness of home dialysis therapies: a matched cohort study

Patients’ perspectives of home and self-assist haemodialysis and factors influencing dialysis choices in Singapore

Background

The rise in end stage kidney disease (ESKD) prevalence globally calls for a need to deliver quality and cost-effective dialysis. While most are familiar with centre-based haemodialysis (HD), there is a move to increase uptake of home-based modalities (peritoneal dialysis (PD) or home haemodialysis (HHD)) and self-assist haemodialysis (SAHD) due to the economic, clinical and lifestyle advantages they confer. However, HHD and SAHD are not yet widely adopted in Singapore with majority of patients receiving in-centre HD. Although much research has examined patient decision-making around dialysis modality selection, there is limited literature evaluating patient’s perspectives of HHD and SAHD in Asia where the prevalence of these alternative modalities remained low. With this background, we aimed to evaluate patient’s perspectives of HHD and SAHD and the factors influencing their choice of dialysis modality in Singapore to determine the challenges and facilitators to establishing these modalities locally.

Methods

Semi-structured interviews were conducted with 17 patients on dialysis from a tertiary hospital in Singapore in this exploratory qualitative study. Data collected from one-to-one interviews were analysed via thematic content analysis and reported via an interpretative approach.

Results

The findings were segregated into: (1) factors influencing choices of dialysis modality; (2) perspectives of HHD; and (3) perspectives of SAHD. Modality choices were affected by environmental, personal, social, financial, information and family-related factors. Most perceived HHD as providing greater autonomy, convenience and flexibility while SAHD was perceived as a safer option than HHD. For both modalities, patients were concerned about self-care and burdening their family.

Conclusions

The findings provided a framework for healthcare providers to understand the determinants affecting patients’ dialysis modality decisions and uncovered the facilitators and challenges to be addressed to establish HHD and SAHD modalities in Singapore.

Cost of the quanta SC+ hemodialysis system for self-care in the United Kingdom

INTRODUCTION

New personal hemodialysis systems, such as the quanta SC+, are being developed; these systems are smaller and simpler to use while providing the clearances of conventional systems. Increasing the uptake of lower-intensity assistance and full self-care dialysis may provide economic benefits to the public health payer. In the United Kingdom, most hemodialysis patients currently receive facility-based dialysis costing more than £36,350 per year including patient transport. As such, we aimed to describe the annual costs of using the SC+ hemodialysis system in the United Kingdom for 3×-weekly and 3.5×-weekly dialysis regimens, for self-care hemodialysis provided both in-center and at home.

METHODS

We applied a cost minimization approach. Costs for human resources, equipment, and consumables were sourced from the dialysis machine developer (Quanta Dialysis Technologies) based upon discussions with dialysis providers. Facility overhead expenses and transport costs were taken from a review of the literature.

FINDINGS

Annual costs associated with the use of the SC+ hemodialysis system were estimated to be £26,642 for hemodialysis provided 3× weekly as home self-care; £30,235 for hemodialysis provided 3× weekly as self-care in-center; £29,866 for hemodialysis provided 3.5× weekly as home self-care; and £36,185 for hemodialysis provided 3.5× weekly as self-care in-center.

DISCUSSION

We found that the SC+ hemodialysis system offers improved cost-effectiveness for both 3×-weekly and 3.5×-weekly self-care dialysis performed at home or as self-care in-center versus fully assisted dialysis provided 3× weekly with conventional machines in facilities.

Survival comparisons in home hemodialysis: Understanding the present and looking to the future

A number of studies have compared relative survival for home hemodialysis patients (including longer hours/more frequent schedules) and other forms of renal replacement therapy. While informative, many of these studies have been limited by issues pertaining to their observational design including selection bias and residual confounding. Furthermore the few randomized controlled trials that have been conducted have been underpowered to detect a survival difference. Finally, in the face of a growing recognition of the value of patient-important outcomes beyond survival, the focus of comparisons between dialysis modalities may be changing. In this review, we will discuss the determinants of survival for patients receiving home hemodialysis and address the various studies that have compared relative survival for differing home hemodialysis schedules to each of in-center hemodialysis, peritoneal dialysis and transplantation. We will conclude this review by discussing whether there is an ongoing role for survival analyses in home hemodialysis.

Comparison of peritoneal dialysis with hemodialysis on survival of diabetic patients with end-stage kidney disease: a meta-analysis of cohort studies

Aim: Renal replacement therapy was primary treatment for end stage kidney (ESRD) patients. Numbers of studies comparing peritoneal dialysis (PD) and hemodialysis (HD) yielded inconsistent results. The aim of this study was to assess the mortality risk between diabetic PD patients and those in HD.

Methods: We included cohort studies comparing the risk of death among diabetic ESRD patients who receiving peritoneal dialysis or hemodialysis by searching Medline and Embase. Overall estimates were calculated using the random-effects model.

Results: Seventeen studies were included in the meta-analyses. Mortality comparison between PD and HD in the diabetic ESRD patients showed PD significantly increased mortality rate (hazard ratio (HR) 1.20; 95% confidence interval (CI) 1.10–1.30; I² = 89.1%). The overall HR using an intention-to-treat analysis was 1.23 with 95% CI (1.13 to 1.34). Meta-regression demonstrated PD patients from Asian country were associated with increase in mortality risk (coefficient = 0.270, SE = 0.112, p = .033).

Limitation: The high heterogeneity in our meta-analyses undermined the robustness of the findings.

Conclusion: ESRD patients with diabetes may benefit more from HD than PD.

Comparison of peritoneal dialysis and hemodialysis as first renal replacement therapy in patients with end-stage renal disease and diabetes: a systematic review

Background

Diabetes has become the most common cause of end-stage renal disease (ESRD) requiring renal replacement therapy (RRT) in most countries around the world. Peritoneal dialysis (PD) is valuable for patients newly requiring RRT because of the preservation of residual renal function (RRF), higher quality of life, and hemodynamic stability in comparison with hemodialysis (HD). A previous systematic review produced conflicting results regarding patient survival. As several advances have been made in therapy for diabetic patients receiving PD, we conducted a systematic review of studies published after 2014 to determine whether incident PD or HD is advantageous for the survival of patients with diabetes.

Methods

For this systematic review, the MEDLINE, EMBASE, and CENTRAL databases were searched to identify articles published between February 2014 and August 2017. The quality of studies was assessed using the GRADE approach. Outcomes of interest were all-cause mortality; RRF; major morbid events, including cardiovascular disease (CVD) and infectious disease; and glycemic control. This review was performed using a predefined protocol published in PROSPERO (CRD42018104258).

Results

Sixteen studies were included in this review. All were retrospective observational studies, and the risk of bias, especially failure to adequately control confounding factors, was high. Among them, 15 studies investigated all-cause mortality in diabetic patients initiating PD and HD. Differences favoring HD were observed in nine studies, whereas those favoring PD were observed in two studies. Two studies investigated effects on CVD, and both demonstrated the superiority of incident HD. No study investigated the effect of any other outcome.

Conclusions

In the present systematic review, the risk of death tended to be higher among diabetic patients with ESRD newly initiating RRT with incident PD in comparison with incident HD. However, we could not obtain definitive results reflecting the superiority of PD or HD with regard to patient outcomes because of the severe risk of bias and the heterogeneity of management strategies for diabetic patients receiving dialysis. Further studies are needed to clarify the advantages of PD and HD as RRT for diabetic patients with ESRD.

Health economic evaluation of peritoneal dialysis based on cost-effectiveness in Japan: a preliminary study

BACKGROUND

In Japan, the medical expenditures associated with dialysis have garnered considerable interest; however, a cost-effectiveness evaluation of peritoneal dialysis (PD) is yet to be evaluated. In particular, the health economics of the "PD first" concept, which can be advantageous for clinical practice and healthcare systems, must be evaluated.

METHODS

This multicenter study investigated the cost-effectiveness of PD. The major effectiveness indicator was quality-adjusted life year (QALY), with a preference-based utility value based on renal function, and the cost indicator was the amount billed for a medical service at each medical institution for qualifying illnesses. In comparison with hemodialysis (HD), a baseline analysis of PD therapy was conducted using a cost-utility analysis (CUA). Continuous ambulatory PD (CAPD) and automated PD (APD) were compared based on the incremental cost-utility ratio (ICUR) and propensity score (PS) with a limited number of cases.

RESULTS

The mean duration since the start of PD was 35.0±14.4 months. The overall CUA for PD (179 patients) was USD 55,019/QALY, which was more cost effective (USD/monthly utility) compared with that for HD for 12-24 months (4,367 vs. 4,852; p<0.05). The CUA reported significantly better results in the glomerulonephritis group than in the other diseases, and the baseline CUA was significantly age sensitive. The utility score was higher in the APD group (mean age, 70.1±3.5 years) than in the CAPD group (mean age, 70.6±4.2 years; 0.987 vs. 0.860; p<0.05, 9 patients). Compared with CAPD, APD had an overall ICUR of USD 126,034/QALY.

CONCLUSION

The cost-effectiveness of PD was potentially good in the elderly and in patients on dialysis for <24 months. Therefore, the prevalence of PD may influence the public health insurance system, particularly when applying the "PD first" concept.

Improved long-term survival with home hemodialysis compared with institutional hemodialysis and peritoneal dialysis: a matched cohort study

Background

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.

Methods

Patients 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).

Results

A 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).

Conclusion

HHD 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.

When is more frequent hemodialysis beneficial?

The use of frequent hemodialysis (HD) is growing, with the hope of improving outcomes in end-stage renal disease. We narratively review the three randomized trials, 15 comparative cohort studies, and several case series of frequent HD that empirically demonstrate the potential efficacy and adverse effects of these regimens. Taken together, the randomized studies suggest frequent HD may result in left ventricular mass regression. This effect is most pronounced when left ventricular mass is abnormal, but attenuated by significant residual urine output. Both frequent short and long HD consistently improved blood pressure control and reduced antihypertensive use, despite greater weekly interdialytic weight gains. Serum phosphate was lowered. Frequent short daytime HD improved health-related quality of life, while frequent long overnight HD did not. Regarding adverse effects, frequent HD patients underwent significantly more procedures to salvage arteriovenous vascular accesses. An absolute increase in hypotensive episodes was observed with frequent short HD, while frequent long HD accelerated residual renal function loss and increased perceived caregiver burden. The effect of frequent HD on mortality is controversial, due to conflicting results and limitations of published studies. Finally, pregnancy outcomes may be substantially better with frequent long HD. On the basis of these data, we suggest frequent HD is most likely to benefit patients with left ventricular hypertrophy particularly if there is minimal urine output, those unable to attain dry weight on a thrice weekly schedule, and pregnant women. All patients receiving frequent HD should be advised of and monitored for potential risks.

Mortality and Hospitalizations in Intensive Dialysis: A Systematic Review and Meta-Analysis

Background:

Survival and hospitalization are critically important outcomes considered when choosing between intensive hemodialysis (HD), conventional HD, and peritoneal dialysis (PD). However, the comparative effectiveness of these modalities is unclear.

Objective:

We had the following aims: (1) to compare the association of mortality and hospitalization in patients undergoing intensive HD, compared with conventional HD or PD and (2) to appraise the methodological quality of the supporting evidence.

Data Sources:

MEDLINE, Embase, ISI Web of Science, CENTRAL, and nephrology conference abstracts.

Study Eligibility, Participants, and Interventions:

We included cohort studies with comparator arm, and randomized controlled trials (RCTs) with >50% of adult patients (≥18 years) comparing any form of intensive HD (>4 sessions/wk or >5.5 h/session) with any form of chronic dialysis (PD, HD ≤4 sessions/wk or ≤5.5 h/session), that reported at least 1 predefined outcome (mortality or hospitalization).

Methods:

We used the GRADE approach to systematic reviews and quality appraisal. Two reviewers screened citations and full-text articles, and extracted study-level data independently, with discrepancies resolved by consensus. We pooled effect estimates of randomized and observational studies separately using generic inverse variance with random effects models, and used fixed-effects models when only 2 studies were available for pooling. Predefined subgroups for the intensive HD cohorts were classified by nocturnal versus short daily HD and home versus in-center HD.

Results:

Twenty-three studies with a total of 70 506 patients were included. Of the observational studies, compared with PD, intensive HD had a significantly lower mortality risk (hazard ratio [HR]: 0.67; 95% confidence interval [CI]: 0.53-0.84; I² = 91%). Compared with conventional HD, home nocturnal (HR: 0.46; 95% CI: 0.38-0.55; I² = 0%), in-center nocturnal (HR: 0.73; 95% CI: 0.60-0.90; I² = 57%) and home short daily (HR: 0.54; 95% CI: 0.31-0.95; I² = 82%) intensive regimens had lower mortality. Of the 2 RCTs assessing mortality, in-center short daily HD had lower mortality (HR: 0.54; 95% CI: 0.31-0.93), while home nocturnal HD had higher mortality (HR: 3.88; 95% CI: 1.27-11.79) in long-term observational follow-up. Hospitalization days per patient-year (mean difference: –1.98; 95% CI: –2.37 to −1.59; I² = 6%) were lower in nocturnal compared with conventional HD. Quality of evidence was similarly low or very low in RCTs (due to imprecision) and observational studies (due to residual confounding and selection bias).

Limitations:

The overall quality of evidence was low or very low for critical outcomes. Outcomes such as quality of life, transplantation, and vascular access outcomes were not included in our review.

Conclusions:

Intensive HD regimens may be associated with reduced mortality and hospitalization compared with conventional HD or PD. As the quality of supporting evidence is low, patients who place a high value on survival must be adequately advised and counseled of risks and benefits when choosing intensive dialysis. Practice guidelines that promote shared decision-making are likely to be helpful.