title: Factors Associated With Discontinuation of Home Hemodialysis.
abstract: BACKGROUND
  Home hemodialysis (HHD) is associated with improved clinical and quality-of-life outcomes compared to in-center hemodialysis, but remains an underused modality in the United States. Discontinuation from HHD therapy may be an important contributor to the low use of this modality. This study aimed to describe the rate and timing of HHD therapy discontinuation, or technique failure, and identify contributing factors.
  
  
  METHODS
  Retrospective cohort study.
  
  
  METHODS
  Using data from a large dialysis provider, we identified a nationally representative cohort of patients who initiated HHD therapy from 2007 to 2009 (N=2,840).
  
  
  METHODS
  Demographics, end-stage renal disease duration, kidney transplant listing status, comorbid conditions, level of urbanization or rurality based on residence zip code, socioeconomic status based on residence zip code, and dialysis facility factors.
  
  
  RESULTS
  Discontinuation from HHD therapy, defined as 60 or more days with no HHD treatments.
  
  
  METHODS
  Competing-risk models were used to produce cumulative incidence plots and identify sociodemographic and clinical variables associated with HHD therapy discontinuation. Transplantation and death were treated as competing risks for HHD therapy discontinuation.
  
  
  RESULTS
  The 1-year incidence of discontinuation was 24.9%, and the 1-year mortality estimate was 7.6%. Median end-stage renal disease duration prior to initiating HHD therapy was 2.1 years. Diabetes and smoking/alcohol/drug use were associated with increased risk for HHD discontinuation (HRs of 1.34 [95% CI, 1.07-1.68] and 1.34 [95% CI, 1.01-1.78], respectively). Listing for kidney transplantation and rural residence (rural-urban commuting area ≥ 7) were associated with decreased risk for HHD therapy discontinuation (HRs of 0.73 [95% CI, 0.61-0.87] and 0.78 [95% CI, 0.59-1.02], respectively).
  
  
  CONCLUSIONS
  Limited to variables available within the DaVita dialysis and US Renal Data System data sets.
  
  
  CONCLUSIONS
  A substantial proportion of patients discontinue HHD therapy within the first 12 months of use of the modality. Patients with diabetes, substance use, nonlisting for kidney transplantation, and urban residence are at greater risk for discontinuation. Targeting high-risk patients for increased support from clinical teams is a potential strategy for reducing HHD therapy discontinuation and increasing technique survival.
authors.affiliation: Division of Nephrology and Hypertension. Department of Medicine, Drexel University College of Medicine, Philadelphia, PA. Electronic address: rebecca.seshasai@drexelmed.edu.
authors.forename: Rebecca Kurnik
authors.initials: RK
authors.lastname: Seshasai
authors.affiliation: Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
authors.forename: Nandita
authors.initials: N
authors.lastname: Mitra
authors.affiliation: Renal, Electrolyte and Hypertension Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA.
authors.forename: C Michael
authors.initials: CM
authors.lastname: Chaknos
authors.affiliation: Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
authors.forename: Jiaqi
authors.initials: J
authors.lastname: Li
authors.affiliation: Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
authors.forename: Christopher
authors.initials: C
authors.lastname: Wirtalla
authors.affiliation: Renal, Electrolyte and Hypertension Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA.
authors.forename: Dan
authors.initials: D
authors.lastname: Negoianu
authors.affiliation: Renal, Electrolyte and Hypertension Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA.
authors.forename: Joel D
authors.initials: JD
authors.lastname: Glickman
authors.affiliation: Renal, Electrolyte and Hypertension Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA.
authors.forename: Laura M
authors.initials: LM
authors.lastname: Dember
mesh_terms: D015331:Cohort Studies; D005260:Female; D006437:Hemodialysis, Home; D006801:Humans; D007676:Kidney Failure, Chronic / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors; D028761:Withholding Treatment / Q000706:statistics & numerical data*
keywords: Hemodialysis; RRT modality; US Renal Data System (USRDS); discontinuation; end-stage renal disease (ESRD); home dialysis; home hemodialysis (HHD); renal replacement therapy (RRT); technique failure; technique survival