for patients in the older age group (greater than 74 years).12 A more recent report from this group reported that the effect of modality on mortality risk was not modified within subcategories of age. 11 The multinational study also reported no significant interaction with age. 13 One Australia/New Zealand study reported a significant interaction by ethnicity (P < .001) finding that the decrease in relative mortality risk associated with HHD was less for non-whites and non-Asians. 12 The authors also reported no difference in risk between patients with and without diabetes. The more recent report found no differences in risk based on ethnicity, BMI, presence of cardiovascular disease, or duration of ESRD therapy.11 The multi-national study reported non-significant interactions between mortality and duration of ESRD.13 Other Outcomes Cardiovascular Events (Appendix C, Table 1) One US registry study reported cardiovascular mortality.8 The overall (maximum follow-up of 4 years) cardiovascular mortality did not differ between HHD and HD (HR 0.92 [95% CI 0.78, 1.09]). From an Australia/New Zealand registry study, the percentages of cardiovascular deaths by dialysis modality were 65% for HHD and 47% for HD.12 Follow-up in this study was a maximum of 11 years and 9 months. Hospitalization (Appendix C, Table 4) One registry study reported hospitalizations.20 There were no significant differences between HHD and matched HD patient groups for all-cause hospitalization or hospitalization for vascular access dysfunction. There was a significantly greater risk of hospitalization for infection (RR 1.32 [95% CI 1.24, 1.40]) and decreased hospitalization for cardiovascular causes (RR 0.83 [95% CI 0.78, 0.88]) in the HHD group. One of the RCTs reported no difference in all-cause hospitalization with rates of 0.62 (HHD) and 0.84 (HD) per patient over the 6 month follow-up period.15 A CCT, also from Canada, found no difference in hospitalization between conventional HD and either nocturnal HHD or daily HHD patients.19 22 Home-based versus In-center Dialysis Evidence-based Synthesis Program Table 1. Mortality – In-center Hemodialysis (HD) vs Home Hemodialysis Dialysis (HHD) – Registry and Trial Data Country/ Region: Number of Reports Study Years Patients: Number of Reports or Sample Size Overall Mortality: Number of Reports Number of Studies Reporting Effects by: No difference Favor HHD Favor HD Age Gender Race BMI DM CVD ESRD Duration REGISTRY STUDIES USA: 3 1986-2008 Incident: 3 (1 with matched prevalent HD) 2a 1 Australia/ New Zealand: 2 1996-2011 Incident 2b 2 2 1 1 1 1 UK: 1 1997-2005 Incident 1 International : 1 2000-2010 Incident and prevalent HHD, matched HD 1c 1 1 RANDOMIZED CONTROLLED TRIALS Canada: 1 2004-2006 N=61 1 New Zealand: 1 NR N=9 (crossover RCT) 1 CONTROLLED CLINICAL TRIALS USA: 1 1997-2010 N=184 1 International : 1 1982-2005 N=415 1 Canada: 1 1998-2001 N=46 1 a One study reported no difference after 2 or more years b Overall, at 1 year, 2 years, and >3 years c HHD was intensive (>5.5 hours per session, 3-7 sessions per week) Quality of Life, Cognition, Depression (Appendix C, Table 4) Quality of life, cognition, and depression outcomes were not reported in the registry studies. In the Canadian RCT, no difference was noted between HHD and HD patients in change in EuroQol-5D scores over 6 months.15 There were significantly greater improvements in two elements of the KDQOL instrument, Effects of Kidney Disease (difference (HHD-HD) in change over 6 months: 8.6; P = .01) and Burden of Kidney Disease (difference (HHD-HD) in change over 6 months: 9.4; P = .02) in the HHD group compared to the HD group. The cross-over RCT from New Zealand also reported quality of life, finding that HHD interfered more with social activities (P < .05), tended to be to be more of a burden on families (P = .07), and was associated with less physical suffering (P < .005).16 The CCT from Canada found no difference between HHD and either daily or nocturnal HD in the SF-36 physical or mental component scores at 18 months.21 A cross-sectional study from the UK included 145 patients receiving HD, HHD, or PD.22 The study found a significant difference across modalities in scores on the Treatment Effects Questionnaire but subsequent analyses found that the difference was only between modalities of 23 Home-based versus In-center Dialysis Evidence-based Synthesis Program PD. Using a Beck Depression Inventory cut-off score of 16 or higher as an indication of depression, 42% of the HD group was classified as having depression compared to 8% of the HHD group but the difference was not statistically significant. Similarly, with a cut-off score of 10 or higher on the Cognitive Depression Index, 31% of the HD and 12% of the HHD group were classified as having depression but the difference was not statistically significant. It was noted that the duration of treatment was significantly longer in the HHD group (88 months) than the HD group (39 months). An earlier study from the UK with 192 patients receiving HD, HHD, or PD reported scores on components of the SF-36.23 There were significant differences across modalities (with HHD patients having higher scores) for Physical Functioning (HD 28, HHD 47), Role Physical (HD 17, HHD 41), Social Functioning (HD 49, HHD 63), and Role Emotional (HD 30, HHD