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      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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          Most cited references 25

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

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

            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.
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              Characteristics of sudden death in hemodialysis patients.

              Hemodialysis (HD) is an intermittent procedure during which large fluid and electrolyte shifts occur. We hypothesized that sudden death occurrences in HD patients are related to the timing of HD, and that they occur more frequently in the 12 h period starting with dialysis and in the 12 h period at the end of the dialysis-free weekend interval. In a retrospective study, 228 patient deaths were screened to determine if they met the criteria for sudden death. Information was obtained from clinic charts, dialysis center records, and interview of witnesses of the death event. There were 80 HD patients who met the criteria for sudden death. A bimodal distribution of death occurrences was present, with a 1.7-fold increased death risk occurring in the 12 h period starting with the dialysis procedure and a threefold increased risk of death in the 12 h before HD at the end of the weekend interval (P=0.011). Patients with sudden death had a high prevalence of congestive heart failure and coronary artery disease. Only 40% of patients experiencing sudden death were receiving beta-blockers, and the prior monthly serum potassium value was less than 4 mEq/l in 25%. Sudden death is temporally related to the HD procedure. Every other day HD could be beneficial in preventing sudden death. Careful attention to the usage of beta-blockers and to the maintenance of normal serum potassium values is indicated in HD patients at risk for sudden death.
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                Author and article information

                Journal
                0323470
                5428
                Kidney Int
                Kidney Int.
                Kidney International
                0085-2538
                1523-1755
                22 May 2012
                01 February 2012
                June 2012
                01 December 2012
                : 81
                : 11
                : 1108-1115
                Affiliations
                [1 ]University of Michigan-Kidney Epidemiology and Cost Center, Ann Arbor, MI, United States
                [2 ]Department of Biostatistics, University of Michigan, Ann Arbor, MI, United States
                [3 ]Arbor Research Collaborative for Health, Ann Arbor, MI, United States
                [4 ]Lapeyronie University Hospital, Montpellier, France
                [5 ]Cliniques Universitaires St-Luc, Université Catholique de Louvain, Bruxelles, Belgium
                [6 ]Tokyo Women's Medical University, Tokyo, Japan
                [7 ]Division of Nephrology, Department of Medicine, Yokohama Dai-ichi Hospital, Atami, Japan
                Author notes
                Corresponding Author: Douglas E. Schaubel, PhD, Associate Professor, University of Michigan, Department of Biostatistics, 1415 Washington Hts., Ann Arbor, MI, 48109-2029, Tel: (734) 395-5992, Fax: (734) 763-2215, deschau@ 123456umich.edu
                Article
                NIHMS346735
                10.1038/ki.2011.481
                3365564
                22297673
                Funding
                Funded by: National Institute of Diabetes and Digestive and Kidney Diseases : NIDDK
                Award ID: R01 DK070869 || DK
                Categories
                Article

                Nephrology

                hemodialysis, schedule, mortality, day of week, dopps

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