Dialysis outcomes and analysis of practice patterns suggests the dialysis schedule affects day-of-week mortality

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Abstract

The risk of death for hemodialysis patients is thought to be highest on the days following the longest interval without dialysis (usually Mondays and Tuesdays); however, existing results are inconclusive. To clarify this we analyzed Dialysis Outcomes and Practice Patterns Study (DOPPS) data of 22,163 hemodialysis patients from the United States, Europe and Japan. Our study focused on the association between dialysis schedule and day-of-week of all-cause, cardiovascular and non-cardiovascular mortality with day-of-week coding as a time-dependent covariate. The models were adjusted for dialysis schedule, age, country, DOPPS Phase I or II, and other demographic and clinical covariates comparing mortality on each day to the 7-day average. Patients on a Monday-Wednesday-Friday (MFW) schedule had elevated all-cause mortality on Monday, and those on a Tuesday-Thursday-Saturday (TTS) schedule increased risk of mortality on Tuesday in all 3 regions. The association between day-of-week mortality and schedule was generally stronger for cardiovascular than non-cardiovascular mortality, and most pronounced in the United States. Unexpectedly, Japanese patients on a MWF schedule had a higher risk of non-cardiovascular mortality on Fridays, and European patients on a TTS schedule experienced an elevated cardiovascular mortality on Saturdays. Thus, future studies are needed to evaluate the influence of practice patterns on schedule-specific mortality and factors that could modulate this effect.

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Hemodialysis-associated hypotension as an independent risk factor for two-year mortality in hemodialysis patients.

Tatsuya Shoji, M Fujii, Yoshiharu Tsubakihara … (2004)

The relationship between blood pressure (BP) and mortality in hemodialysis patients has remained controversial. Some studies suggested that a lower pre- or postdialysis BP was associated with excess mortality, while others showed poorer outcome in patients with uncontrolled hypertension. We conducted a multicenter prospective cohort study to evaluate the impact of hemodialysis-associated hypotension on mortality. We recruited 1244 patients (685 males; mean age, 60 +/- 13 years) who underwent hemodialysis in 28 units during the two-year study period beginning in December 1999. Pre-, intra-, and postdialysis BP, and BP upon standing soon after hemodialysis, were measured in all patients at entry. Logistic regression analysis was used to assess the effect on mortality of pre-, intra-, and postdialysis BP, a fall in BP during hemodialysis, and a fall in BP upon standing soon after hemodialysis. During the study period, 149 patients died. Logistic models identified the lowest intradialysis systolic blood pressure (SBP) and degree of fall in SBP upon standing soon after hemodialysis as significant factors affecting mortality, but not pre- or postdialysis SBP and diastolic BP. The adjusted odds ratio for death was 0.79 (95% CI 0.64-0.98) when the lowest intradialysis SBP was analyzed in increments of 20 mm Hg, and was 0.82 (95% CI 0.67-0.98) when the fall in SBP upon standing soon after hemodialysis was analyzed in increments of 10 mm Hg. These results suggest that intradialysis hypotension and orthostatic hypotension after hemodialysis are significant and independent factors affecting mortality in hemodialysis patients.

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The Dialysis Outcomes and Practice Patterns Study (DOPPS): design, data elements, and methodology.

Kenneth Chen, Catherine W. Gillespie, Ronald L. Pisoni … (2004)

The Dialysis Outcomes and Practice Patterns Study (DOPPS) is a prospective, observational study designed to elucidate aspects of hemodialysis practice that are associated with the best outcomes for hemodialysis patients. In DOPPS I, 308 hemodialysis units from 7 countries participated, including 145 facilities from the United States (1996-2001), 62 facilities from Japan (1999-2001), and 101 facilities from France, Germany, Italy, Spain, and the United Kingdom (all 1998-2000). DOPPS II (2002-2004) has included 320 hemodialysis units and more than 12,400 hemodialysis patients from the 7 DOPPS I countries as well as Australia, Belgium, Canada, New Zealand, and Sweden. Dialysis units are chosen via a stratified random selection procedure to provide proportional sampling by region and type of facility within each country. In DOPPS I and II, longitudinal data have been collected from both a prevalent (cross-sectional) patient sample and an incident patient sample. Data have also been collected on numerous facility practice patterns. Most DOPPS analyses incorporate both facility- and patient-level data in regression-based analyses to investigate predictors of survival, hospitalization, quality of life, vascular access type, and other outcomes. DOPPS longitudinal data also help identify trends in subject characteristics, practice indicators, medication use, and outcomes. The DOPPS remains a unique source of data on hemodialysis patients and facilities. It continues to refine its methods of data collection and analysis with the goal of improving hemodialysis practice and end-stage renal disease patient lives worldwide.

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Impact of left ventricular hypertrophy on survival in end-stage renal disease.

Ruth Prichard, J. Silberberg, Allan D Sniderman … (1989)

We examined the prognostic significance of left ventricular hypertrophy determined by echocardiography in a cohort beginning renal replacement therapy. No patient had hemodynamically significant valvular disease or echocardiographic signs of obstructive cardiomyopathy. Using the Cox proportional hazards model, left ventricular hypertrophy was significantly associated with survival. The relative risk, based on comparison of upper and lower quintiles of left ventricular mass index, was 3.7 (95% confidence intervals, 1.6 to 8.3) for all-cause mortality and 3.7 (95% confidence intervals, 1.2 to 11.1) for cardiac mortality. The independent risk, adjusted for age, known coronary artery disease, diabetes, level of systolic blood pressure, and treatment (dialysis or transplantation), was 2.9 (95% confidence intervals, 1.3 to 6.9) for all-cause mortality and 2.7 (95% confidence intervals, 0.9 to 8.2) for cardiac mortality. Therefore, left ventricular hypertrophy appears to be an important, independent, determinant of survival in patients receiving therapy for end-stage renal failure.