Hospitalization Risk in the Integrated Home Dialysis Model: Analysis of the Canadian Organ Replacement Register

Patients transitioning from peritoneal dialysis to home hemodialysis experience higher hospitalization rate during this transition period. After peritoneal dialysis-to-home hemodialysis transitions, hospitalization rates normalize and match those of patients starting home hemodialysis directly. Shorter transition periods are associated with an attenuated hospitalization risk, suggesting that timely peritoneal dialysis-to-home hemodialysis transitions may improve outcomes.

Initiating dialysis with peritoneal dialysis (PD) followed by a transition to home hemodialysis (HHD) is known as integrated home dialysis . Hospitalization outcomes in this model are poorly known. We aimed to compare the hospitalization risk before, during, and after a PD-to-HHD transition with individuals receiving HHD as first home dialysis modality.

We analyzed the Canadian Organ Replacement Register and included individuals initiating home dialysis between 2005 and 2018. Patients transitioning from PD to HHD with <365 days of interim facility hemodialysis ("PD-HHD" group) were matched 1:1 to individuals receiving HHD as their first home dialysis modality ("HHD" group) using a propensity score. Patients were followed until December 2019, death, or a transfer to facility hemodialysis. In the PD-HHD group, the transition window was defined as the last 30 days of PD, the facility hemodialysis period and the first 30 days of HHD. Our primary outcome of all-cause hospitalizations (assessed before, during, and after transition) was analyzed using adjusted negative binomial regression.

Three hundred and one patients underwent the PD-to-HHD transition and 711 initiated home dialysis in HHD. Hospitalization rates up to 2.17/patient-year (95% confidence interval [CI], 1.91 to 2.43) were observed during the PD-to-HHD transition, with infectious-related hospitalizations being most frequent (30%). Compared with HHD, the PD-HHD group had higher rates of hospitalization during (incidence rate ratio [IRR], 2.89 [95% CI, 2.01 to 4.16]) and before the transition (IRR, 1.38 [95% CI, 1.03 to 1.85]; predominantly in the year before) but not afterward (IRR, 1.04 [95% CI, 0.80 to 1.36]). Higher risk was not observed for cardiovascular-related hospitalizations and less pronounced in patients with short (<90 days in facility hemodialysis) transitions.

Most patients transitioning from PD to HHD experience a higher hospitalization risk before and during the transfer (relative to incident HHD). Yet, their hospitalization risk stabilizes after the transition. This higher risk of hospitalization is less apparent for patients with shorter interim facility hemodialysis.