Relationship of missed and shortened hemodialysis treatments to hospitalization and mortality: observations from a US dialysis network

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Abstract

Background

The relationship of missed and shortened hemodialysis (HD) to clinical outcomes has not been well characterized in HD patients in the USA. Here we explored the frequency of missed and shortened treatments and their impact on mortality and hospitalization.

Methods

A retrospective review of data from a cohort of 15 340 HD patients treated in facilities operated by Dialysis Clinics, Inc. We compared the frequency of missed and shortened treatments by gender, race, age and treatment schedules [Mondays, Wednesdays, Fridays (MWF) versus Tuesdays, Thursdays, Saturdays (TTS)].

Results

Of the 15 340 patients, 48% were non-Hispanic whites (NHWs), 41% African Americans (AAs), 6% Hispanics, 2% Native American (NA), 2% Asians and 1% other races. The median number of years on HD was 1.8 years and the median follow-up was 12.4 months. The odds of missing at least one treatment in a month were higher in: patients aged <55 years, odds ratio (OR) 1.33 ( P<0.0001); in AAs, OR 1.51 ( P < 0.0001); in NAs, OR 1.50 ( P = 0.0003); and in Hispanics, OR 1.33 ( P = 0.0003) compared with NHWs and in patients who dialyzed on TTS compared with MWF, OR 1.33 ( P < 0.0001). Similar findings were observed for treatments shortened by at least 10 min per month. Missed and shortened treatments were most prevalent on Saturdays and were also associated with progressive increases in hospitalization and mortality.

Conclusion

Missed and shortened HD treatments pose a challenge to providers. Improved adherence to prescribed dialysis may decrease the morbidity and mortality.

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Most cited references 29

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Association of comorbid conditions and mortality in hemodialysis patients in Europe, Japan, and the United States: the Dialysis Outcomes and Practice Patterns Study (DOPPS).

P H Rayner, Takashi Akiba, Jock W. Young … (2003)

Mortality rates among hemodialysis patients vary greatly across regions. Representative databases containing extensive profiles of patient characteristics and outcomes are lacking. The Dialysis Outcomes and Practice Patterns Study (DOPPS) is a prospective, observational study of representative samples of hemodialysis patients in France, Germany, Italy, Japan, Spain, the United Kingdom, and the United States (US) that captures extensive data relating to patient characteristics, prescriptions, laboratory values, practice patterns, and outcomes. This report describes the case-mix features and mortality among 16,720 patients followed up to 5 yr. The crude 1-yr mortality rates were 6.6% in Japan, 15.6% in Europe, and 21.7% in the US. After adjusting for age, gender, race, and 25 comorbid conditions, the relative risk (RR) of mortality was 2.84 (P < 0.0001) for Europe compared with Japan (reference group) and was 3.78 (P < 0.0001) for the US compared with Japan. The adjusted RR of mortality for the US versus Europe was 1.33 (P < 0.0001). For most comorbid diseases, prevalence was highest in the US, where the mean age (60.5 +/- 15.5 yr) was also highest. Older age and comorbidities were associated with increased risk of death (except for hypertension, which carried a multivariate RR of mortality of 0.74 [P < 0.0001]). Variability in demographic and comorbid conditions (as identified by dialysis facilities) explains only part of the differences in mortality between dialysis centers, both for comparisons made across continents and within the US. Adjustments for the observed variability will allow study of association between practice patterns and outcomes.

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Cardiac diseases in maintenance hemodialysis patients: results of the HEMO Study.

Alfred Cheung, Mark J. Sarnak, Guofen Yan … (2004)

Cardiac disease is a common cause of death in chronic hemodialysis patients. A subanalysis of the data on cardiac diseases in the Hemodialysis (HEMO) Study was performed. The specific objectives were: (1) to analyze the prevalence of cardiac disease at baseline; (2) to characterize the incidence of various types of cardiac events during follow-up; (3) to examine the association of cardiac events during follow-up with baseline cardiac diseases; and (4) to examine the effect of dose and flux interventions on various types of cardiac events. The HEMO Study is a randomized multi-center trial on 1846 chronic hemodialysis patients at 15 clinical centers comprising 72 dialysis units. The scheduled maximum follow-up duration was 0.9 to 6.6 years, with the mean actual follow-up of 2.84 years. The interventions were standard-dose versus high-dose and low-flux versus high-flux hemodialysis in a 2 x 2 factorial design. At baseline, 80% of patients had cardiac diseases, including ischemic heart disease (IHD) (39%), congestive heart failure (40%), arrhythmia (31%), and other heart diseases (63%). There were a total of 1685 cardiac hospitalizations, with angina and acute myocardial infarction accounting for 42.7% of these hospitalizations. There were 343 cardiac deaths during follow-up, accounting for 39.4% of all deaths. IHD was implicated in 61.5% of the cardiac deaths. Any cardiac disease at baseline was highly predictive of cardiac death during follow-up [relative risk (RR) 2.57; 95% CI 1.73-3.83]. There were no significant effects of dose or flux assignments on the primary outcome of all-cause mortality or the main secondary cardiac composite outcome of first cardiac hospitalization or all-cause mortality. Assignment to high-flux dialysis was, however, associated with decreased cardiac mortality and the composite outcome of first cardiac hospitalization or death from cardiac causes. The HEMO Study identified IHD to be a major cause of cardiac hospitalizations and cardiac deaths. Future strategies for the prevention of cardiac diseases in the maintenance hemodialysis population should focus on this entity. Although high-flux dialysis did not reduce all-cause mortality, it might improve cardiac outcomes. This hypothesis needs to be further examined.

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Nonadherence in hemodialysis: associations with mortality, hospitalization, and practice patterns in the DOPPS.

P J Held, Friedrich Port, Akira Saito … (2003)

Nonadherence among hemodialysis patients compromises dialysis delivery, which could influence patient morbidity and mortality. The Dialysis Outcomes and Practice Patterns Study (DOPPS) provides a unique opportunity to review this problem and its determinants on a global level. Nonadherence was studied using data from the DOPPS, an international, observational, prospective hemodialysis study. Patients were considered nonadherent if they skipped one or more sessions per month, shortened one or more sessions by more than 10 minutes per month, had a serum potassium level openface>6.0 mEq/L, a serum phosphate level openface>7.5 mg/dL (>2.4 mmol/L), or interdialytic weight gain (IDWG)>5.7% of body weight. Predictors of nonadherence were identified using logistic regression. Survival analysis used the Cox proportional hazards model adjusting for case-mix. Skipping treatment was associated with increased mortality [relative risk (RR) = 1.30, P = 0.01], as were excessive IDWG (RR = 1.12, P = 0.047) and high phosphate levels (RR = 1.17, P = 0.001). Skipping also was associated with increased hospitalization (RR = 1.13, P = 0.04), as were high phosphate levels (RR = 1.07, P = 0.05). Larger facility size (per 10 patients) was associated with higher odds ratios (OR) of skipping (OR = 1.03, P = 0.06), shortening (OR = 1.03, P = 0.05), and IDWG (OR = 1.02, P = 0.07). An increased percentage of highly trained staff hours was associated with lower OR of skipping (OR = 0.84 per 10%, P = 0.02); presence of a dietitian was associated with lower OR of excessive IDWG (OR = 0.75, P = 0.08). Nonadherence was associated with increased mortality risk (skipping treatment, excessive IDWG, and high phosphate) and with hospitalization risk (skipping, high phosphate). Certain patient/facility characteristics also were associated with nonadherence.

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Author and article information

Journal

Journal ID (nlm-ta): Clin Kidney J

Journal ID (iso-abbrev): Clin Kidney J

Journal ID (publisher-id): ckj

Journal ID (hwp): ndtplus

Title: Clinical Kidney Journal

Publisher: Oxford University Press

ISSN (Print): 2048-8505

ISSN (Electronic): 2048-8513

Publication date (Print): August 2012

Publication date PMC-release: August 2012

Volume: 5

Issue: 4

Pages: 315-319

Affiliations

[1 ]Renal Section, Department of Medicine, Morehouse School of Medicine , Atlanta, GA, USA

[2 ]Dialysis Clinic Inc. , Albuquerque, NM, USA

Author notes

Correspondence and offprint requests to: Chamberlain I. Obialo; E-mail: cobialo@ 123456msm.edu

Article

Publisher ID: sfs071

DOI: 10.1093/ckj/sfs071

PMC ID: 4393476

SO-VID: 3f1eb467-fcf2-435f-baaf-8e17183055cb

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

History

Date received : 30 March 2012

Date accepted : 4 June 2012

Page count

Pages: 5

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Relationship of missed and shortened hemodialysis treatments to hospitalization and mortality: observations from a US dialysis network

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Karger: Nephrology

Most cited references 29

Association of comorbid conditions and mortality in hemodialysis patients in Europe, Japan, and the United States: the Dialysis Outcomes and Practice Patterns Study (DOPPS).

Cardiac diseases in maintenance hemodialysis patients: results of the HEMO Study.

Nonadherence in hemodialysis: associations with mortality, hospitalization, and practice patterns in the DOPPS.

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Cited by 14

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