In Case You Missed It—The 2021 USRDS Annual Report Has a New Chapter on Home Dialysis

In 1988, the NIH National Institutes of Diabetes, Digestive and Kidney Diseases (NIDDK) established the United States Renal Data System (USRDS), the largest national surveillance system for patients with ESRD and CKD. The USRDS has published Annual Data Reports (ADRs) for decades, adding CKD in 2003. For the first time in 2021, the USRDS published a chapter devoted entirely to home dialysis, including patients on PD and home HD. The Methodology section describes how the data analysis attempted to report just those doing home dialysis in their residence by screening out patients getting dialysis in a skilled nursing facility. Data on home dialysis are collected when the patient first starts dialysis, one year later, and each December 31 thereafter.

The new chapter starts with a listing of highlights, and here are some of them (quoted verbatim):

From

• 2009 to 2019, the percentage of incident dialysis patients performing home dialysis increased from 6.8% to 12.6% (Figure 2.1a).

• From 2009 to 2019, the percentage of patients performing home dialysis at 1 year after dialysis initiation increased from 10.5% to 18.2% (Figure 2.1a).

• From 2009 to 2019, the percentage of prevalent patients performing home dialysis increased from 8.9% to 13.1% (Figure 2.1a). Those 13.1% of patients in 2019 included 1.9% who performed home hemodialysis and 11.2% who performed peritoneal dialysis.



• In 2019, 45% of Medicare-certified dialysis facilities were not certified to offer either home dialysis modality; 8% were certified to offer at least 1 home dialysis modality but had no active patients; and 47% were certified to offer at least 1 home dialysis modality and had active patients (Figure 2.2).

• For home hemodialysis, 43% of patients initiate the therapy during the first year of ESRD. For peritoneal dialysis, 85% of patients do. (Figure 2.5). Amazingly, 3% started PD more than 10 years after the ESRD diagnosis.

• Between 2009 and 2019, utilization of automated peritoneal dialysis among patients performing peritoneal dialysis steadily increased, from 68% in 2009 to 86% in 2019 (Figure 2.7).

• Medicare covered 3.8 home hemodialysis treatment sessions per week in 2019 (Figure 2.8d).

• Among patients who initiated home hemodialysis in 2017-2018, the 2-year cumulative incidence of conversion from home dialysis to in-facility hemodialysis was 25%. The corresponding incidence with peritoneal dialysis was 24% (Figure 2.11).

Some interesting data that were not included in the Highlights:

• Number of home patients by modality:

  • Clinics with home HD: 61% had 1-5 patients, 21% had 6-10 patients, 10% had 11-15 patients, 9% had 16 patients or more.

  • Clinics with PD: 22% had 1-5 patients, 20% had 6-10 patients, 17% had 11-15 patients, 12% had 16-20 patients, 8% had 21-25, 5% had 26-30, 4% had 31-35, 6% had 36-50, and 8% had more than 50.

• Patient characteristics:

  • For home HD patients in 2019, more than half of the new and established patients were age 18-64, White, and male. Among new patients that year, 30.4% were Black.

  • For PD patients in 2019, more than half of the new and established patients were age 18-64, White, and male; 20.4% were Black.

• Training sessions varied. Medicare covers 25 sessions without justification for home HD and 15 for PD:

• For home HD patients, 12% had 1-4 training sessions, 9% had 5-8, 10% had 9-12, 16% had 13-16 session, 18% had 17-20, 14% had 21-24, 10% had 25-28, 4% had 29-32, and 7% had 33 sessions or more. The authors speculated that some who had fewer training sessions may have dropped out, but we don’t know that.

• For PD patients, 26% had 1-4 sessions, 46% had 5-8, 21% had 9-12 sessions, 5% had 13-16, and 1% had 17-20 sessions.

• 

  Treatment time per home HD session varied as well. Research has found that fewer than 4 hours of dialysis has been associated with higher ultrafiltration rate, i.e., faster fluid removal that has been found to stun organs. Only 18.7% had treatments that lasted 4 or more hours. More patients under age 18 as well as those who were male and patients who were Black dialyzed longer. Alarmingly, 45.6% patients dialyzed fewer than 12 hours per week, and of those, 16.3% dialyzed less than 10 hours a week. Just 9.2% dialyzed more than 20 hours a week.

• Complications:

• With home HD, hospitalizations due to vascular access complications dropped from 22.6% in 2009 to 13.1% in 2019, but were higher in women and Black patients. Hospitalizations due to sepsis increased from 11.3 to 17.8% and were higher in older patients and those with diabetes.

• With PD, hospitalizations due to catheter complications dropped from 22.8% in 2009 to 16.2% in 2019 and were higher among those 18-44 years old, women, and Black patients. Hospitalization for peritonitis dropped from 15.1% in 2009 to 5.9% in 2019 and were higher among older patients and those with diabetes.

• Transplant Waitlist

• The percentage of home HD patients who were waitlisted declined from 37.7% in 2009 to 28.1% in 2019.

• The percentage of PD patients who were waitlisted declined from 35.1% in 2009 to 29.8% in 2019.

Conclusion & Suggestions for Future Data Reporting

We are excited that the USRDS has reported data for home dialysis this year, and hope that future USRDS Annual Reports will update these data and consider including data on:

• Percentage of patients by home HD modality (PD modality is reported) and outcomes (complications, deaths, transplant and transplant waitlist), specifically for:

  • Short daily home HD (<3 hours/session, 4-7 times per week)

  • Standard home HD (3-5 hours/session, 3-3.5 times per week)

  • Nocturnal/extended home HD (>5 hours/session, 3-7 times per week)

• Percentage of patients ages 18-55 on home HD and PD who are employed full or part-time by type of PD and home HD treatment, as above.

• Percentage of patients by type of PD and home HD treatment above who screen positive for depression.

Having these data reported annually could help the renal community better identify and overcome challenges to successful home dialysis and better meet home patients’ needs.

Reference

United States Renal Data System. 2021 USRDS Annual Data Report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2021.