Home HD has been started in the Middle East for the last several years. Simple machines were developed only for the purpose of Home HD. The 1st one was the NxStage machine that had been developed in USA and was introduced to KSA, UAE and Qatar, in 2012. The 2nd one was the DIMI machine that had been developed in Switzerland and was approved by the Saudi FDA, in late 2019.
The mean age of patients in the retrospective study was 68.5, while that in the prospective study was 61.8 years. This age differences were related to an involvement of less elderly and healthier patients in the last few years.
The mean BMI was slightly higher in patients of the prospective part as it was 26.2 while it was 25.7 kg/m2, in patients of the retrospective part
Most ESRD patients have multiple comorbidities that increase with age. IHD was present in 28% of patients of the prospective part while it was 54.9% in patients of the retrospective part.
Regarding the cause of treatment with home HD, the situation was serious. For patients of the retrospective part, only 23.5% of them were treated as per their personal choice. The remaining were treated due to serious morbidities with frequencies as following: bed-ridden 18.5%, CVA 17.3%, fracture femur 14.8%, PVD 12.3% and others 13.5% (see table 1). For patients of the prospective part, the situation was different as 50% of them were treated as per their personal choice because of the serious world-wide pandemic of Covid-19. The other 50% were treated due to disabling morbidities with frequencies as following: bed-ridden 18%, dementia 12%, fracture femur/tibia 12%, CVA 8% and others 6% (see table 2)
The frequency of home HD was 13 sessions/month, in 59% of all patients. The remaining patients were treated with higher frequencies, mainly with 15 or 17 sessions/month (see tables 3 and 4)
Most patients reported no complications during their sessions. This was noted in about 86% of all patients. The remaining 14% of patients reported occasional hypotension, hypoxemia, chest pain …. Etc (see tables 7 and 8)
The mean URR% was 56 and 63 for those in the retrospective and prospective parts, respectively. Also, the mean KT/V was 1.1 for patients in the retrospective part and 1.18 for patients in the prospective part.
Regarding the 1st year mortality as the 1ry outcome of the whole study, the results were alarming. It was significantly high in all involved patients, about 36%. It was also significantly higher in patients of the retrospective part as it was 40.7% (see table 5) while it was 28% for those of the prospective part (see table 6). This reported high mortality warrants searching for the possible mortality predictors.
Mortality predictors with a + ve correlation were as following: age, BMI, vascular access : AVF / catheter, virology status : -ve / +ve, Phosphorus, TIBC, CRP, ferritin, frequency of hospitalization and complications: no/yes ( see table 9)
Mortality predictors with a–ve correlation were as following: psychological status: depressed/borderline/good, creatinine, albumin, PTH, Hb.%, HCT and iron ( see table 9)
Surprisingly, both URR% and KT/V were insignificantly correlated with 1st year mortality. However, this is explained by the fact that efficient hemodialysis per se isn’t enough to improve mortality rates in ESRD patients.
Regarding the frequency of hospitalization, there were many predictors with either a + ve or a –ve correlation of significant values. Most of these predictors were similar to those of the 1st year mortality. Both URR% and KT/V were not significantly correlated with the frequency of hospitalization.
Regarding URR% and KT/V, there were some important predictors with either direct or indirect effects. Of course, DFR, BFR and duration are strongly related. The other predictors were as following and all were of a –ve correlation: BMI, type of machine: DIMI / NxStage, frequency of HD and complications. In fact, these 4 predictors needs further discussions and explanations.
For BMI, hemodialysis clearance is negatively correlated. Most home HD patients were of low URR% and KT/V, mainly due to the low DFR as compared with in-center HD patients. So, patients with subnormal BMI may have adequate clearance. However, patients with even normal BMI rather than overweight ones, will have insufficient clearance. These observations were thoroughly discussed before with all related authorities that we are doing insufficient hemodialysis for most of these patients. However, this form of HD was found as the best to be offered to some patients who were bed-ridden, very elderly, demented or with non-union fractures. These patients were hardly brought to hospitals to get their regular HD sessions and some of them were left as neglected at home to finally die of uremia.
Regarding the frequency of HD sessions, it will be already negatively correlated with HD clearance as more frequent HD will decrease the pre-dialysis urea. Furthermore, with more frequent HD, the duration of treatment mostly will be decreased as mainly per patient choice.
Regarding the cost of home HD, each session is almost of double the cost of that in-center HD. However, it saves the extra cost of transportation especially of bed-ridden patients and avoids the psychological burden of both them and their involved care-givers and/or relatives.