HDD cannot be advocated for all patients

Sir,

Saner and colleagues have made a good case for home haemodialysis (HHD) as an effective renal replacement therapy in Switzerland [1]. Yet, in the last paragraph of their case–cohort study of 58 patients, they admit that patient selection may have influenced their results. We agree. Our analysis of a much larger cohort, that of the United States Renal Data System, used the standardized mortality ratio (SMR) to compare HHD patients with in-centre haemodialysis patients. The SMR takes age, race, gender and diabetes into account. Contrary to older reports, we found that HHD had a higher SMR compared with in-centre dialysis (see Table 1) [2].


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Table 1.
 
In addition, the cost of HHD was not cheap, while somewhat less than in-centre dialysis, which was $54 917 per year over the same time of study.

Our data run counter to accepted wisdom about HHD. Increasing patient co-morbidity, decreasing family support and waning of doctor and nurse expertise may explain the inferior HHD outcomes in the USA. It is also likely that in-centre dialysis has improved its dialysis delivery to a greater extent than has HHD in recent years.

HHD cannot be advocated for all patients. Even the still-infrequent newer daily HHD therapies will require scrutiny and proper outcome analysis.

Conflict of interest statement. None declared.

Eric Cohen and Deane Charba

Medical College of Wisconsin Milwaukee WI USA Email: ecohen{at}mcw.edu

References

  1. Saner E, Nitsch D, Descoeudres C et al. Outcome of home hemodialysis patients: a case–cohort study. Nephrol Dial Transplant 2005; in press
  2. Cohen EP, Charba DS. Rising mortality on home hemodialysis. J Am Soc Nephrol 2003; 14: 245a




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