Sociodemographic Factors Affect Home Dialysis Referral, But Not Success

Catherine Moore, MD

Credit: University of Rochester Medical Center

Results from a retrospective cohort study of patients with end-stage renal disease (ESRD) on dialysis are calling attention to disparities in-home therapy referral despite equal success along sociodemographic lines on home dialysis.

Despite similar markers of medical comorbidity and sociodemographic stress, fewer non-white patients started home dialysis compared to in-center dialysis. Among patients on home dialysis, neither social deprivation nor race predicted success.¹

“What we were looking at was predictors, be they medical or social or demographic, that might influence referral to home therapy and success on home therapy,” said Catherine Moore, MD, associate professor in the division of medicine at the University of Rochester, in an interview with HCPLive Nephrology. “What we found was people with advancing age and increased measures of social deprivation were less likely to be referred to home therapy, which isn’t surprising. But once somebody was on home therapy, those things did not predict success.”

ESRD affects 808,000 people in the US, 69% of whom are on hemodialysis. At the end of 2020, 13.7% of all patients undergoing dialysis received treatment at home, a 50% increase from 2010. However, the majority of hemodialysis patients continue to receive in-center treatment despite the availability of home dialysis, which warrants further investigation into potential barriers to home therapy referral and success.²

To assess the impact of sociodemographic stress on outcomes in home dialysis among patients with ESRD, Moore and colleagues collected data for adult incident ESRD patients admitted to providers within the University of Rochester division of nephrology from January 1, 2015, through December 31, 2021. In total, 898 patients were enrolled in the study, including 794 on in-center hemodialysis and 104 on home hemodialysis. Investigators used Cox proportional hazards models to compare race to social deprivation index as predictors for home dialysis failure, defined as conversion to in-center dialysis or death.¹

The majority of patients were male in both the home start (63.46%) and center start (60%) groups. Investigators noted there was no significant difference between mean social deprivation index (SDI) or Charlson co-morbidity index (CCI) scores among participants starting in-center compared to at home, although Black (31%) and African American (16.3%) patients were more heavily represented among study participants starting in-center hemodialysis.¹

Over the observation period, 128 participants received home dialysis for a mean duration of 45 months. Upon analysis, age at the start of dialysis and SDI were predictors of referral to home dialysis (Z < .001 and .01, respectively). However, none of the variables evaluated were predictors of success on home therapy:

• Age (Hazard ratio [HR], 1.00; confidence interval [CI], 0.99-1.01; Z = .85)
• Male sex (HR, 0.75; CI, 0.49-1.13; Z = .18)
• White race (HR, 1.06; CI, 0.65-1.70; Z = .83)
• SDI (HR, 0.99; CI, 0.99-1.00; Z = .07)
• CCI (HR, 1.07; CI, 0.98-1.16; Z = .12)

“What was most surprising for us was that individuals who had moderate social deprivation scores rather than higher scores were more likely to fail home therapy. We don’t know exactly why this happened, but we wonder if this has to do with access to other social network resources that those that have intermediate risk don’t have,” Moore Concluded.

References:

1. Weissberg J, Liu C, Sachsenmeier E, et al. Racial and Socioeconomic Differences in Success on Home Dialysis. Paper Presented at: American Society of Nephrology Kidney Week 2023. November 1-5, 2023.
2. National Institute of Diabetes and Digestive and Kidney Diseases. Kidney Disease Statistics for the United States. May 1, 2023. Accessed November 5, 2023. https://www.niddk.nih.gov/health-information/health-statistics/kidney-disease