Comparative effectiveness of home dialysis therapies: a matched cohort study

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.