Abstract

Nursing home patients on dialysis are higher-acuity compared to the broader end-stage renal disease population, and historically have poor outcomes. The objective of this epidemiological study was to compare outcomes in ESRD patients in the nursing home setting treated with daily home hemodialysis versus conventional three-day-a-week hemodialysis. Health status was evaluated for 3,919 patients (n=3391 conventional, n=528 daily home dialysis; April 2007 to June 2013 for conventional; April 2011 to June 2013 for daily home hemodialysis). Analyses included monthly mortality rates, Kaplan-Meier survival analysis, and laboratory values. Results showed monthly mortality rates were consistently lower in the daily home hemodialysis population over the same time period vs. conventional dialysis care. In the incident three months of treatment, annualized monthly mortality rates were 70%, 72%, and 64% in the conventional dialysis population vs. 50%, 24%, and 17% in the daily home population. Patients treated with daily home dialysis had generally similar or higher albumin and hemoglobin values and lower ferritin values over the same time period. Patients treated with daily home hemodialysis had lower monthly mortality rates and generally improved health status compared to patients treated with conventional dialysis. The results of this study are provocative and should be evaluated in a prospective study.

Introduction

Adults aged 75 years and older make up an increasing percentage of new patients initiating dialysis. In 2011, 20.8% of all patients on dialysis—nearly 90,000 patients—were 75 years or older, and this patient subset represented nearly one quarter of all new end-stage renal disease (ESRD) patients.1 Because the probability of comorbidities and disability increases with age, more patients on dialysis are now requiring nursing home care. In general, nursing home patients on dialysis are a higher acuity population compared to the broader ESRD population, and historically, this population has been associated with poorer outcomes. Population-based data from the United States Renal Data System Annual Data Report (USRDS ADR) has shown that the annual mortality rate for nursing home patients was 3.5 times higher than the general ESRD population,2 and survival at 3, 6 and 12 months has been estimated at 50%, 26%, and 14%.3 Unfortunately, few research studies have been performed to characterize the health outcomes of nursing home patients on dialysis.4 In particular, studies are needed to determine the best treatment options and course of care for this important patient population.

The results of the Frequent Hemodialysis Network (FHN) Trial demonstrated that more frequent hemodialysis was associated with significant benefit compared with conventional dialysis.5 Similarly, USRDS database studies have demonstrated that daily home hemodialysis is associated with improved outcomes, including a lower risk of cardiovascular-related hospitalizations and all-cause mortality.6-8 Given the poor prognosis of nursing home patients on dialysis, identifying beneficial treatment paradigms for these patients is a significant clinical priority; however, the effect of more frequent dialysis on outcomes of nursing home patients has not been examined.

We previously published the results of a large epidemiological study using longitudinal data from an independent nursing home dialysis provider to evaluate health status and outcomes over time in patients on dialysis in a nursing home setting.9 The results of this study, the largest database and reporting of patients dialyzed in the nursing home setting to date, confirmed that nursing home patients on dialysis had poor initial health status; however, health status improved during months 4-12 as well as year-over-year. The objective of this sub-study was to compare outcomes in dialysis patients in the nursing home setting who were treated with daily home hemodialysis vs. conventional three-days-per-week hemodialysis.

Methods

Study population

The study population included 3,919 ESRD patients treated by Affiliated Dialysis Centers (Peoria, Ill.) in the nursing home setting. Patients received either conventional hemodialysis (TIW) or daily home hemodialysis (daily 5 times/week). Data were collected between April 2007 to June 2013 (conventional hemodialysis), and April 2011 to June 2013 (daily home hemodialysis). Patients were excluded from analysis if there was no record of dialysis treatment, laboratory values, or medications in the database.

Analyses

Retrospective analyses were performed on the incident populations. Health status was evaluated through analysis of mortality and laboratory values (albumin, hemoglobin, and ferritin). Monthly mortality rates were annualized. Median overall survival (OS) was estimated by Kaplan-Meier survival analysis. Mean lab values were calculated for each patient, and then averaged across all patients during the time frame of analysis.

Results

Patient baseline characteristics are presented in Table 1. A larger proportion of patients received conventional hemodialysis (86.5%) than daily home hemodialysis (13.5%). Baseline characteristics were generally similar between groups. The mean age was 67 years. There were similar proportions of men (52%) and women (48%) in the overall population and in each treatment cohort. Comorbid conditions were similar between groups.

Mean monthly mortality rates were consistently lower in the daily home hemodialysis cohort (see Figure 1). In the incident 3 months of treatment, annualized monthly mortality rates were 70%, 72%, and 64% in the conventional dialysis population vs. 50%, 24%, and 17% in the daily home population. Monthly mortality rates remained lower in the daily home hemodialysis population throughout follow-up (see Figure 1).

Median overall survival was 50 months in the daily home vs. 30 months in the conventional dialysis population (P<0.001; see Figure 2). Patients treated with daily home dialysis had generally similar hemoglobin values, similar or higher albumin, and similar or lower ferritin across the follow-up period (see Figure 3).

Discussion

The results of this large longitudinal study demonstrated that patients treated with daily home hemodialysis had generally improved health status, lower monthly mortality rates, and significantly longer median survival compared to patients treated with conventional hemodialysis. This study utilized the largest independent database of patients on dialysis in a nursing home setting—a patient population known to be higher acuity than the broader ESRD population, and historically associated with poor outcomes—and the results contribute to identifying best practices to improve outcomes in the nursing home dialysis population.

Table1-HD

Relatively few real world studies have investigated patients undergoing dialysis in the nursing home setting, and, importantly, these studies have reported on relatively small patient cohorts and have not compared treatment methodologies.10-12 Thus, there has been a lack of quality data to inform optimal treatment paradigms for these patients. Recent results from both prospective and retrospective studies have indicated improved outcomes in patients treated with daily hemodialysis vs. conventional TIW hemodialysis;5-8 however, there has been a lack of data regarding the potential impact of more frequent dialysis in the nursing home setting.

HD-figure1-2_2015

The strengths of this study include the large population of dialysis patients treated in the nursing home setting, a population poorly characterized in the scientific literature, as well as a long follow-up period. In addition, this study had a significant number of patients treated with daily home hemodialysis in the nursing home setting, and a well-matched control group in terms of baseline characteristics. The limitations of this study include that the analysis population was obtained from a single dialysis provider; thus, the results may not be generalizable to the population in general. However, a single-provider database does provide some reliability due to consistency and continuity of care. Second, the timeframes of data collection were not identical for the two cohorts, which could have influenced the results. Finally, the retrospective, descriptive design allows for the characterization of health status and outcomes and is hypothesis generating, but does not allow for a definitive assessment of the impact of a daily home vs. conventional dialysis on outcomes.

HD-figure2-2_2015

Figure3-HD

Summary

As the average age of the U.S. population increases, the number of older patients on dialysis and those in nursing homes are likely to increase. It is critical to understand the health status and outcomes in this population in order to assess and improve delivery of care, quality of life, and patient outcomes. Future studies will include ongoing periodic updates of these analyses. The results of this study are provocative and should be evaluated in a prospective outcomes study.

References

1. U.S. Renal Data System, USRDS 2013 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Md., 2013.

2. U.S. Renal Data System, USRDS 2004 Annual Data Report: Atlas of End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Md., 2004

3. U S Renal Data System, USRDS 2010 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Md., 2010.

4. Hall RK, O’Hare AM, Anderson RA, Colón-Emeric CS. End-stage renal disease in nursing homes: a systematic review. J Am Med Dir Assoc. 2013;14:242-7.

5. FHN Trial Group, Chertow GM, Levin NW, et al. In-center hemodialysis six times per week versus three times per week. N Engl J Med. 2010;363(24):2287-300.

6. Johansen KL, Zhang R, Huang Y, et al. Survival and hospitalization among patients using nocturnal and short daily compared to conventional hemodialysis: a USRDS study. Kidney Int. 2009 Nov;76(9):984-90.

7. Weinhandl ED, Liu J, Gilbertson DT, et al. Survival in daily home hemodialysis and matched thrice-weekly in-center hemodialysis patients. J Am Soc Nephrol. 2012 May;23(5):895-904.

8. Weinhandl ED, Nieman KM, Gilbertson DT, Collins AJ. Hospitalization in daily home hemodialysis and matched thrice-weekly in-center hemodialysis patients. Am J Kidney Dis. 2014; Jul 29. pii: S0272-6386(14)00973-1. doi: 10.1053/j.ajkd.2014.06.015. [Epub ahead of print].

9. Hocking K, Yang A. Health outcomes in nursing home patients on dialysis. Presented at the 34TH Annual Dialysis Conference. Atlanta, Ga. Feb. 8-11, 2014.

10. Anderson JE. Ten years’ experience with CAPD in a nursing home setting. Perit Dial Int. 1997;17:255e261.

11. Carey HB, Chorney W, Pherson K, et al. Continuous peritoneal dialysis and the extended care facility. Am J Kidney Dis. 2001;37:580e587.

12. Reddy NC, Korbet SM, Wozniak JA, et al. Staff-assisted nursing home haemodialysis: patient characteristics and outcomes. Nephrol Dial Transplant. 2007;22:1399-406.