Home Hemodialysis and Peritoneal Dialysis
Abstract, Introduction, Methods, Results, and Discussion.
A Comparison of Home Peritoneal Dialysis and Facility Hemodialysis in Patients with End-Stage Renal Disease: Improvement in Patient Outcomes and Health-Related Quality of Life (HRQoL)
When kidneys fail, they go through five distinct stages from very mild damage to a complete and irreversible failure of kidney function. It is these stages that are used to classify kidney disease. The five stages are what are collectively referred to as chronic kidney disease or CKD. The staging of CKD is based on how well the kidneys are filtering waste from the blood and also how well they are balancing the fluid requirements of the body. The efficiency of the kidneys in performing this function is clinically determined using the estimated glomerular filtration rate or eGFR (American Kidney Fund, 2021). It is the serum creatinine levels that determine what the eGFR will be. But this relationship is not directly proportional at all. Even though the eGFR is calculated from the blood creatinine levels, three patients of vastly different ages may have the same blood creatinine but different eGFR values. Home Hemodialysis and Peritoneal Dialysis Creatinine is the by-product of protein metabolism and muscle breakdown that must be removed from the body through the urine. But absolute blood creatinine levels in themselves are not an accurate measure of kidney function, as already stated above (Hammer & McPhee, 2018; Jameson et al., 2018). This is because blood creatinine levels are determined by age, race, gender, and body mass index (BMI) amongst other factors. A low eGFR reading means that one’s kidney function is deteriorating. Clinically, early detection of deteriorating kidney function enables evidence-based interventions to be instituted to slow down the progression to end-stage renal disease. In adults without kidney failure, a normal eGFR is above 90 mL/min/1.73 m2. However, the eGFR is known to decline progressively with age. As a matter of fact, after the age of 60 years, the gender difference in eGFR readings between males and females disappears (National Kidney Foundation, 2021). End stage kidney disease (ESKD) is the last of the five stages of kidney disease (CKD) mentioned at the beginning of the introduction above. At this stage, the kidneys are functioning at just 10% to 15% of their normal physiologic capacity. They cannot effectively carry out the function of waste removal from the body anymore at this stage. Therefore, at this last stage of CKD the only therapy available is renal replacement therapy through dialysis or kidney transplantation. This maintenance dialysis is usually in the form of either home peritoneal dialysis (PD) or in-center hemodialysis or HD (Ferguson et al., 2020; Lee et al., 2019; Katerji, 2017). However, transplantation is not a very accessible option to many because there is a shortage of organs that can satisfy the demand renal allografts. The purpose of this paper is to determine if home peritoneal dialysis (PD) is more effective in producing better ESKD patient outcomes than in-facility hemodialysis (HD).
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According to the latest available data, more than 500,000 patients in the United States suffer from stage V CKD which is ESRD. All these patients require renal replacement therapy in the form of PD, HD, or renal transplantation. Those who are at stages III to V of CKD are estimated to represent up to 10% of the entire US population. The data also shows that another 500,000 patients are at the pre-dialysis stage IV of CKD in the US (University of Florida, 2021). These numbers demonstrate the current and potential pressure that is placed on the available renal replacement therapies (RRTs) which remain resource intensive. As alluded to earlier, three evidence-based modalities of RRT are currently available. These are PD, HD, and transplantation. However, the mainstay of ESRD management today is maintenance dialysis in the form of PD or HD. The reason for this is that the viability of renal transplantation is questionable due to the scarcity of donor organs. Yet another reason why transplantation is not a viable option as a RRT is that many of the ESRD patients requiring RRT are unsuitable for the major surgery of transplantation due to multiple comorbidities (University of Florida, 2021; Bonenkamp et al., 2020; Maruyama et al., 2019). As is evident, most of the patients with ESRD originally come from the hypertension and diabetes clinics because these two are major risk factors. Dialysis as the only remaining viable option for the majority of ESRD patients is still however quite expensive, with PD being cheaper than HD (Wong et al., 2017; Klarenbach et al., 2014). This is especially considering the fact that the patient has to continue doing it for the rest of their remaining lives, unless they get an organ for transplantation.Home Hemodialysis and Peritoneal Dialysis
The choice as to which method of dialysis to use is normally made by the patient but also influenced by a number of other suitability factors such as the eGFR, age, and pre-existing comorbidities. But the most important consideration of all would be the ability of the dialysis procedure chosen in bringing about improved patient outcomes. Many studies have been done to compare the effectiveness of PD and HD in bringing about desired patient outcomes such as improved health-related quality of life (QoL). For instance, a Canadian study that compared PD and HD in ESRD patients who started on either at the same time found PD cheaper and resulting to a better QoL (Neumann, 2021). Five of these studies comparing the two are evaluated here in terms of the methodologies used to arrive at the results and conclusions. However, the five stages of CKD are first presented to crystallize the severity and magnitude of mild, moderate, and severe CKD (National Kidney Foundation, 2021). In this particular case, particular attention is paid to stage V CKD as these are the patients who require dialysis RRT in the form of either PD or HD.
Table: Stages of CKD as per the National Kidney Foundation (NKF)
|Stage||Description||Glomerular Filtration Rate (GFR)||Percentage of Kidney Function Remaining|
|Stage I||Renal damage with normal function||≥ 90 mL/min/1.73 m2||90-100%|
|Stage II||Renal damage with mild functional loss||89-60 mL/min/1.73 m2||89-60%|
|Stage IIIa||Mild to moderate loss of renal function||59-45 mL/min/1.73 m2||59-45%|
|Stage IIIb||Moderate to severe loss of renal function||44-30 mL/min/1.73 m2||44-30%|
|Stage IV||Severe loss of renal function||29-15 mL/min/1.73 m2||29-15%|
|Stage V||Complete renal failure (requiring RRT)||< 15 mL/min/1.73 m2||< 15%|
In a study by Bonenkamp et al. (2020), they set out to compare home dialysis by PD and in-center HD in terms of which one produced the outcome of better health-related quality of life (HRQoL). Being a systematic review and metal-analysis, this study is high in evidentiary value because systematic reviews and meta-analyses provide number 1 level of evidence or LOE. The researchers were cognizant of the fact that ESRD patients requiring dialysis place a lot of emphasis on the procedure being able to result in a higher overall HRQoL. The defined the home interventions as being both PD and home HD (HHD). The electronic databases that they searched for scholarly evidence were EMBASE, Cochrane Library, and PubMed. The database search occurred between 2007 and 2019. The inclusion criteria were that studies had to be either observational studies or randomized controlled trials. They also had to be comparing the HRQoL in home dialysis ESRD patients on the one hand and in-center ESRD HD patients on the other. A random-effects model was used to pool data and the same was expressed as standardized mean difference (SMD).
In the Canadian study that was mentioned earlier, Ferguson et al. (2020) employed a cost-utility model design with microsimulation to compare patient outcomes in PD, HD, and non-dialysis. The objective was to assess patient outcomes in terms of cost-effectiveness, survival, and utility. The study sample included all adults that in Canada who started either home PD or facility HD between the years of 2004 and 2013. That is a longitudinal period of ten years. To determine cost-effectiveness, the researchers adopted the standpoint of the payers. They then compared the interventions of HD and PD separately with non-intervention. Follow-up of every ESRD patient was done for the entire ten years.Home Hemodialysis and Peritoneal Dialysis
Lee et al. (2019) opted to use the methodology of analysis of historical data from medical records. They embraced a population-based approach to determine patient outcomes in Korea between PD and HD. The researchers identified a total convenience sample of n = 96,596 ESRD patients from the Korean National health Insurance Service Database. These are new ESRD patients who commenced either HD or PD from 2004 to 2015. Maruyama et al. (2019) were the other researchers who also published their work within the same year as Lee et al. (2019). They chose to compare patient outcomes between PD and HD but in those ESRD patients who also had diabetes. Their methodology, just like with Bonenkamp et al. (2020) was a systematic review but without meta-analysis. The databases they searched were EMBASE, CENTRAL, and Medline. They used the GRADE approach to assess the quality of articles published only between 2014 and 2017. The patient outcomes of interest for these researchers included glycemic control, infections, all-cause mortality, and major morbid events such as CVD amongst others. Lastly, Pajek et al. (2014) carried out a competing risks analysis of PD and HD among ESRD patients requiring RRT. Their study sample was comprised of n = 286 subjects who commenced home PD between 2004 and 2010. Competing risk analysis using would then be done on those who would switch to facility HD after technique failure. Cox proportional hazards model with time-varying covariate would also be used in the methodology.
Bonenkamp et al. (2020) identified a total of 46 articles from the database search. Nine out of ten of all these studies were cross-sectional in their design, 95% were done on ESRD patients on home PD, and 83% made use of either the 12-item or the 36-item Short-Form Health Survey data collection tools or questionnaires. There was however a serious limitation in that more than 50% of the studies had evidence of moderate to high risk of bias. At a standard mean difference (SMD) of 0.14, and a confidence interval (CI) of between 0.04 to 0.24; analysis of n = 4,158 home PD patients and n = 7,854 in-center HD ESRD patients showed that home PD was borderline better in producing better HRQoL.
Within the 10-year period that the study by Ferguson et al. (2020) lasted, they found that the cost-utility ratio for all the ESRD patients in the study starting dialysis per quality-adjusted life-year or QALY was $103,779 compared to non-intervention (no dialysis). For ESRD patients who started dialysis at in-center settings, they were treated at a cost-utility ration of $104,880 per quality-adjusted life-year. For those who began home PD, their treatment was at a cost-utility ratio of $83,762/ QALY (Ferguson et al., 2020). In other words, this study found that it was more cost-effective to treat ESRD patient requiring RRT with home PD than with in-center facility HD.
General findings by Lee et al. (2019) were that PD patients were generally younger than HD patients, and more HD patients were of a lower income subgroup than those undergoing home PD. Also, more PD patients were found to be diabetic. The study found that between 2004 and 2007, mortality rate was higher among PD patients than HD patients. This was found to later improve. By the beginning of 2014, the mortality risk of PD was significantly lower than for HD. Just like with mortality, the incidence of non-fatal cardiovascular events (CVEs) was higher for PD than for HD at the beginning of the study. However, the final outcome showed that the risk of non-fatal CVEs was lower in ESRD patients undergoing PD than in those getting in-center HD. Because of this finding of lower mortality risk and a lower risk of CVEs in favor of home PD, the study concludes that patient outcomes are much better with home PD than with in-center HD.Home Hemodialysis and Peritoneal Dialysis
Maruyama et al. (2019) included a total of 16 studies in their systematic review. The limitations included that the risk of bias was high especially with regard to the control of the various confounding variables. Another limitation was that all the studies used in the systematic review were retrospective observational studies. But most importantly and within the limitations stated, this study by Maruyama et al. (2019) produced findings that are not in agreement with the other studies whose results have been presented so far. The previous studies have so far favored home PD as the dialysis modality with the highest probability of bringing about improved patient outcomes compared to in-center HD. But according to this study, 56.25% of the studies in the systematic review reported differences favoring facility HD rather than home PD as the most efficacious in terms of patient outcomes. Only 15.38% favored home PD. These findings are significant in that they are contradictory, even though significant limitations have been noted in its methodological approach.
Lastly but not least, Pajek et al. (2014) in their competing risks analysis found that technique failure (of home PD) was caused by peritonitis in 42% of the patients. Only 6.3% was due to ultrafiltration failure. Some of the factors that predicted technique failure were creatinine levels, the body mass index or BMI (obesity), as well as the comorbidity grade. A successful switch to HD was possible after 60 days post technique failure. Importantly, hemodialysis through a central venous catheter was found to carry a higher risk of mortality compared to HD through a fistula or even staying with home PD (Pajek et al., 2014). In other words, this study’s findings agree with most of the other studies that home PD is efficacious with regard to improving patient outcomes. However, technique failure is a real possibility and therefore in-facility HD is there as an alternative when this happens.
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The meta-analysis by Bonenkamp et al. (2020) reveals that home PD produces better physical health-related quality of life (HRQoL) compared to in-facility HD where the ESRD CKD patients do not benefit from this. However, the study shows that the mental HRQoL between home PD ESRD patients and in-center ESRD patients is practically the same for the two groups. An important geographical distinction has however to be clarified in the context of these results of this study by Bonenkamp et al. (2020). The higher physical HRQoL scores were realized only in home PD ESRD patients studied in Western Europe. In poorer Latin America, the opposite was the case. For those ESRD patients doing home PD in Latin America, physical HRQoL indicators were worse than for the patients attending in-center HD sessions. Contextually, it would therefore appear that the standard of living of the patients undergoing home PD plays a role in the realization of better patient outcomes. This makes sense because a very high level of hygiene is required for a patient to safely and effectively use home PD. This finding is however far from conclusive because there were only a few other studies done from Africa and the Middle East with none from Russia. Therefore, a complete comparison is not possible and therefore the study findings lack the needed robustness for generalizability. This may be an area for further research.Home Hemodialysis and Peritoneal Dialysis
For the ten years of the study by Ferguson et al. (2020), they tracked the cost of providing dialysis for the two sets of ESRD patients – the home PD patients and the in-facility HD patients. Using the model’s simulation, those patients that were chosen to start on home PD received the treatment at a cost-utility ratio of $83,762/ QALY. Those that were selected to begin in-center hemodialysis on the other hand received the treatment at a cost-utility ratio of $104,879.66/ QALY (Ferguson et al., 2020). The model used in this study is an evidence-based model that can accurately provide comprehensive analysis of the cost-utility of these interventions. The model is also able to account for and adjust for changes in intervention modality from PD to HD and vice versa.
Lee et al. (2019) opine that the provision of hemodialysis in Korea has exponentially increased over the past few years. However the opposite has been the case with the use of home peritoneal dialysis or PD. They state that the reasons for this paradoxical relationship are not yet clear, but surmise that it may be partly due to the potential hazard for mortality that home PD presents compared to in-center HD. But from the above synthesis of literature, this observation by these authors does not seem to have support from scholarly evidence. At least three of the four studies analyzed in this paper present findings that suggest that home PD is more likely to provide improved patient outcomes than in-facility HD. What’s more, Lee et al. (2019) themselves have admitted in their findings that mortality was indeed high for home PD patients at the beginning of the study, but that this improved as the study progressed. The final verdict was therefore that home PD had lower mortality risk compared to in-facility HD. Their conclusion is therefore contradictory and confusing to say the least.
The systematic review carried out by Maruyama et al. (2019) was to find out which one between home PD and in-center HD would bring about improved clinical outcomes in ESRD patients with diabetes starting dialysis as RRT. In-facility HD emerged as the most favored by the results since nine out of the sixteen studies showed it to be more efficacious with regard to positive patient outcomes. This result was also far from conclusive because the authors admit to inconsistencies and a high risk of bias in some of the studies. For this reason, the superiority of PD over HD cannot be confirmed with these results. There may be need for further studies in this area. Lastly but not least, Pajek et al. (2014) performed a competing risks analysis to find out the outcomes that could be expected when an ESRD patient switches from PD to HD due to technique failure. They conclude that PD is efficacious but with challenges related to infection and sepsis. They also observe that the risk of technique failure among home PD ESRD patients is high. For this reason, the other viable option as RRT is in-center HD.Home Hemodialysis and Peritoneal Dialysis
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Home Hemodialysis and Peritoneal Dialysis