Staff-assisted nursing home haemodialysis: patient characteristics and outcomes

Abstract

Background: The number of elderly patients undergoing chronic haemodialysis (HD) in the nursing home (NH) setting is growing; however, little published data exists on this group of patients.

Methods: We describe our experience with 271 patients undergoing staff-assisted HD in the NH setting from 1 January 2001 to 30 June 2004. Acceptance into the programme required that the patients were mentally responsive, haemodynamically stable without sepsis and not be considered terminal or in hospice.

Results: Mean age at entry was 70.5+/-12.1 years, 53% were female, 54% were white and 34% black. Main causes of end-stage renal disease (ESRD) were diabetes mellitus (DM, 48%) and hypertension (HTN, 25%). Comorbid conditions included HTN-90%, DM-65%, coronary artery disease-54%, congestive heart failure-59%, cerebrovascular accident-31%, and 40% could not ambulate. The average time on chronic dialysis prior to entering the nursing programme was 18+/-27 months, and the median time was 4 months (range: 0.1-191 months). The average time in the NH programme was 2.9+/-3.6 months (median: 1.6 months, range: 0.1-24 months). During the study period 42% of the patients died, 37% were discharged from the NH, 4.4% withdrew from dialysis, and 16% remained active in the programme. Patient survival from entry into the NH programme was 82% at 1 month, 64% at 3 months, 38% at 6 months and 26% at 12 months (median survival of 4.1 months). However, the patient survival from initiation of chronic dialysis was 75% at 6 months, 66% at 12 months and 38% at 60 months with a median survival of 3.4 years. When evaluating patients based on the duration of chronic dialysis prior to entering the NH programme we found that established HD patients (on HD>or=12 months prior to programme entry) had fewer myocardial infarctions (15 vs 26%, P=0.05), more amputations (19 vs 8%, P=0.01), higher creatinine (6.7 vs 4.7 mg/dl, P<0.01), haemoglobin (11.1 vs 10.5 g/dl, P<0.01) and albumin (3.2 vs 3.0 g/dl, P=0.09) compared with new HD patients (on HD<or=3 months prior to programme entry). New HD patients had a higher mortality rate (50 vs 31%, P<0.01) and poorer median survival (3 vs 5 months, P<0.01) than established HD patients.

Conclusion: NH dialysis provides a means for dialysing our most ill and debilitated patients in the convenience and comfort of the NH setting. The success of this programme is demonstrated by the fact that almost 40% of patients are successfully rehabilitated and discharged home. Nonetheless, healthcare providers and families must recognize that patients entering an NH HD programme are a high risk population with significant morbidity and mortality. Compared with established dialysis patients, patients entering the NH programme who are new to dialysis represent a particularly high risk group. However, it is likely that the poor survival seen in the NH programme may represent end of life care, as the overall survival from initiation of chronic dialysis in this population is consistent with that of patients entering the ESRD programme at a similar age.