Comparative Effectiveness of Home Dialysis Therapies: A Matched Cohort Study

Abstract

Background: Home dialysis is being increasingly promoted among patients with end-stage renal disease, but the comparative effectiveness of home hemodialysis and peritoneal dialysis is unknown. Objective: To determine whether patients receiving home daily hemodialysis have reduced mortality risk compared with matched patients receiving home peritoneal dialysis. Design: This study is an observational, propensity-matched, new-user cohort study. Setting: Linked electronic data were from the United States Renal Data System (USRDS) and a large dialysis provider's database. Patients: The patients were adults receiving in-center hemodialysis in the USA between 2004 and 2011 and registered in the USRDS. Measurements: Baseline comorbidities, demographics, and outcomes for both groups were ascertained from the United States Renal Data System. Methods: We identified 3142 consecutive adult patients initiating home daily hemodialysis (≥5 days/week for ≥1.5 h/day) and matched 2688 of them by propensity score to 2688 contemporaneous US patients initiating home peritoneal dialysis. We used Cox regression to compare all-cause mortality between groups. Results: After matching, the two groups were well balanced on all baseline characteristics. Mean age was 51 years, 66 % were male, 72 % were white, and 29 % had diabetes. During 10,221 patient-years of follow-up, 1493/5336 patients died. There were significantly fewer deaths among patients receiving home daily hemodialysis than those receiving peritoneal dialysis (12.7 vs 16.7 deaths per 100 patient-years, respectively; hazard ratio (HR) 0.75; 95 % CI 0.68–0.82; p < 0.001). Similar results were noted with several different analytic methods and for all pre-specified subgroups. Limitations: We cannot exclude residual confounding in this observational study. Conclusions: Home daily hemodialysis was associated with lower mortality risk than home peritoneal dialysis.