Blog entry by Meguid El Nahas

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by Meguid El Nahas - Wednesday, 30 May 2012, 10:38 AM
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Survival in Daily Home Hemodialysis and Matched Thrice-Weekly In-Center Hemodialysis Patients

Eric D. Weinhandl,* Jiannong Liu,* David T. Gilbertson,* Thomas J. Arneson,* and Allan J. Collins*†

*Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota; and †Department of Medicine, University of Minnesota, Minneapolis, Minnesota

ABSTRACT

Frequent hemodialysis improves cardiovascular surrogates and quality-of-life indicators, but its effect on survival remains unclear. We used a matched-cohort design to assess relative mortality in daily home hemodialysis and thrice-weekly in-center hemodialysis patients between 2005 and 2008. We matched 1873 home hemodialysis patients with 9365 in-center patients (i.e., 1:5 ratio) selected from the prevalent population in the US Renal Data System database. Matching variables included first date of follow-up, demographic characteristics, and measures of disease severity. The cumulative incidence of death was 19.2% and 21.7% in the home hemodialysis and in-center patients, respectively. In the intention-to-treat analysis, home hemodialysis associated with a 13% lower risk for all-cause mortality than in-center hemo- dialysis (hazard ratio [HR], 0.87; 95% confidence interval [95% CI], 0.78–0.97). Cause-specific mortality HRs were 0.92 (95% CI, 0.78–1.09) for cardiovascular disease, 1.13 (95% CI, 0.84–1.53) for infection, 0.63 (95% CI, 0.41–0.95) for cachexia/dialysis withdrawal, 1.06 (95% CI, 0.81–1.37) for other specified cause, and 0.59 (95% CI, 0.44–0.79) for unknown cause. Findings were similar using as-treated analyses. We did not detect statistically significant evidence of heterogeneity of treatment effects in subgroup analyses. In summary, these data suggest that relative to thrice-weekly in-center hemodialysis, daily home hemodialysis asso- ciates with modest improvements in survival. Continued surveillance should strengthen inference about causes of mortality and determine whether treatment effects are homogeneous throughout the dialysis population.

J Am Soc Nephrol 23: 895–904, 2012. doi: 10.1681/ASN.2011080761 

 

Once more, these authors, like those before them reporting on the Frequent HD Network, fail to consider the fact that perhaps the Frequent HD group had more HD (in terms of duration/hours per week and in terms of higher weekly KT/V).

Once more, the authors do not seem to distinguishe between Frequent HD and Longer HD.

The Tassin group implied 20 years ago that longer hours on HD per week was good for HD patients, now the whole bandwagon of Frequent HD is rolling without considering that the adequate control group should be:

Group A: Frequent HD

Group B: Thrice weekly HD, BUT with same duration of HD per week copmpared to group A.

That is the propensity analysis that these studies should undertake; comparing hours on HD not how frequent people get on the machine...

Then the modest difference will be even more modest...non-existent!

Even the editorial by David Wheeler doesnt seem to get the point of longer hours versus More Frequent; the FHN study was all about longer hours and better KT/V not too mention better ultrafiltration.

What do we expect the average reader to conclude if even the editorial board doesnt get it!

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