Hospitalization in daily home hemodialysis and matched thrice-weekly in-center hemodialysis patients

Background: Cardiovascular disease is a common cause of hospitalization in dialysis patients. Daily hemodialysis improves some parameters of cardiovascular function, but whether it associates with lower hospitalization risk is unclear. Study Design: Observational cohort study using US Renal Data System data. Setting & Participants: Medicare-enrolled daily (5 or 6 sessions weekly) home hemodialysis (HHD) patients initiating NxStage System One use from January 1, 2006, through December 31, 2009, and contemporary thriceweekly in-center hemodialysis patients, matched 5 to 1. Predictor: Daily HHD or thrice-weekly in-center hemodialysis. Outcomes & Measurements: All-cause and cause-specific hospital admissions, hospital readmissions, and hospital days assessed from Medicare Part A claims. Results: For 3,480 daily HHD and 17,400 thrice-weekly in-center hemodialysis patients in intention-to-treat analysis, the HR of all-cause admission for daily HHD versus in-center hemodialysis was 1.01 (95% CI, 0.98- 1.03). Cause-specific admission HRs were 0.89 (95% CI, 0.86-0.93) for cardiovascular disease, 1.18 (95% CI, 1.13-1.23) for infection, 1.01 (95% CI, 0.93-1.09) for vascular access dysfunction, and 1.02 (95% CI, 0.99- 1.06) for other morbidity. Regarding cardiovascular disease, first admission and readmission HRs for daily HHD versus in-center hemodialysis were 0.91 and 0.87, respectively. Regarding infection, first admission and readmission HRs were 1.35 and 1.03, respectively. Protective associations of daily HHD with heart failure and hypertensive disease were most pronounced, as were adverse associations of daily HHD with bacteremia/sepsis, cardiac infection, osteomyelitis, and vascular access infection. Limitations: Results may be confounded by unmeasured factors, including vascular access type; information about dialysis frequency, duration, and dose was lacking; causes of admission may be misclassified; results may not apply to patients without Medicare coverage. Conclusions: All-cause hospitalization risk was similar in daily HHD and thrice-weekly in-center hemodialysis patients. However, risk of cardiovascular-related admission was lower with daily HHD, and risk of infection-related admission was higher. More attention should be afforded to infection in HHD patients.