Fluid overload and intradialytic hypotension are associated with cardiovascular events
and mortality in patients on hemodialysis. We investigated associations between hemodialysis
facility practices related to fluid volume and intradialytic hypotension and patient
outcomes. Data were analyzed from 10,250 patients in 273 facilities across 12 countries,
from phase 4 of the Dialysis Outcomes and Practice Patterns Study (DOPPS; 2009–2012).
Cox regression models (shared frailty) were used to estimate associations between
facility practices reported by medical directors in response to the DOPPS Medical
Directors Survey and all-cause and cardiovascular mortality and hospitalization, and
cardiovascular events, adjusting for country, age, sex, dialysis vintage, predialysis
systolic BP, cardiovascular comorbidities, diabetes, body mass index, smoking, residual
kidney function, dialysis adequacy, and vascular access type. Of ten facility practices
tested (chosen a priori ), having a protocol that specifies how often to assess dry
weight in most patients was associated with lower all-cause (hazard ratio [HR], 0.78;
99% confidence interval [99% CI], 0.64 to 0.94) and cardiovascular mortality (HR,
0.72; 99% CI, 0.55 to 0.95). Routine orthostatic BP measurement to assess dry weight
was associated with lower all-cause hospitalization (HR, 0.86; 99% CI, 0.77 to 0.97)
and cardiovascular events (HR, 0.85; 99% CI, 0.73 to 0.98). Routine use of lower dialysate
temperature to limit or prevent intradialytic hypotension was associated with lower
cardiovascular mortality (HR, 0.76; 99% CI, 0.58 to 0.98). Routine use of an online
volume indicator to assess dry weight was associated with higher all-cause hospitalization
(HR, 1.19; 99% CI, 1.02 to 1.38). Routine use of sodium modeling/profiling to limit
or prevent intradialytic hypotension was associated with higher all-cause mortality
(HR, 1.36; 99% CI, 1.14 to 1.63), cardiovascular mortality (HR, 1.34; 99% CI, 1.04
to 1.73), and cardiovascular events (HR, 1.21; 99% CI, 1.03 to 1.43). Hemodialysis
facility practices relating to the management of fluid volume and intradialytic hypotension
are associated with patient outcomes.