More Frequent On-Site Dialysis May Hasten Return to Home for Nursing Home Patients with End-Stage Kidney Disease

Abstract

Key Points Prior efficacy study—established that more frequent dialysis achieved better outcomes than CONVENTIONAL dialysis in outpatients.We undertook an effectiveness observational on-site nursing home study (N=195) comparing on-site more frequent dialysis with CONVENTIONAL dialysis.More frequent dialysis patients, despite being sicker at baseline, returned home faster than CONVENTIONALLY dialyzed patients without worsened death or hospitalization. Background A direct outcome comparison between skilled nursing facility (SNF) patients receiving on-site more frequent dialysis (MFD) targeting 14 hours of treatment over five sessions weekly compared with on-site CONVENTIONAL dialysis for death, hospitalization, and speed of returning home has not been reported. Methods From January 1, 2022, to July 1, 2023, in a retrospective prospective observational design, using an intention-to-treat and competing risk strategy, all new admissions for an on-site SNF dialysis service done to nursing homes with on-site MFD were compared with admissions to nursing homes providing on-site CONVENTIONAL dialysis for the outcome goal of 90-day cumulative incidence of discharge to home, while monitoring safety issues represented by the competing risks of hospitalization and death. Results In total, 10,246 MFD dialytic episodes and 3451 CONVENTIONAL dialytic episodes were studied in 195 nursing homes in 12 states. At baseline, the MFD population was consistently sicker than CONVENTIONAL dialysis population with a first systolic BP of <100 mm Hg in 13% versus 7.6% (P < 0.001), lower mean hemoglobin (9.3 versus 10.4 g/dl; P < 0.001), lower iron saturation (25.7% versus 26.6%; P = 0.02), higher Charlson score (3.5 versus 3.0; P < 0.001), higher mean age (67.6 versus 66.7; P < 0.001), more complicated diabetes (31% versus 24%; P < 0.001), cerebrovascular disease (12.6% versus 6.8%; P<0.001), and congestive heart failure (24% versus 18%). At 42 days, discharge to home was 25% greater in the MFD than CONVENTIONAL dialysis group (17.5% versus 14%) without worsened hospitalization or death. Conclusions Despite a handicap of sicker patients at baseline, real-world application of MFD appears to hasten return to home from SNFs compared with CONVENTIONAL dialysis. The findings suggest that MFD allows for SNF acceptance of sicker patients, presumably permitting earlier discharge from hospital, without safety compromise as measured by death or rehospitalization, benefitting hospitals, patients, and payers.