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. 2017;137(1):15-22.
doi: 10.1159/000473704. Epub 2017 Apr 27.

Early Mortality Associated with Inpatient versus Outpatient Hemodialysis Initiation in a Large Cohort of US Veterans with Incident End-Stage Renal Disease

Faisal M Arif  1 , Keiichi Sumida, Miklos Z Molnar, Praveen K Potukuchi, Jun Ling Lu, Fatima Hassan, Fridtjof Thomas, Omer A Siddiqui, Geeta G Gyamlani, Kamyar Kalantar-Zadeh, Csaba P Kovesdy
Affiliations

Early Mortality Associated with Inpatient versus Outpatient Hemodialysis Initiation in a Large Cohort of US Veterans with Incident End-Stage Renal Disease

Faisal M Arif et al. Nephron. 2017.

Abstract

Background: Mortality in the immediate post-hemodialysis transition period is extremely high. Many end-stage renal disease (ESRD) patients in the US start dialysis in an inpatient setting, but the characteristics of patients starting dialysis as inpatients, and the association of inpatient hemodialysis transition with mortality remain unclear.

Methods: We examined 48,261 US veterans who transitioned to hemodialysis between October 2007 and September 2011. Associations of inpatient hemodialysis starting with all-cause mortality were examined in Cox proportional hazard models, with adjustments for demographics, comorbidities, vascular access type, pre-dialysis nephrology care and medication use, and last pre-ESRD estimated glomerular filtration rate and hemoglobin.

Results: A total of 22,338 (46.3%) patients received the first hemodialysis treatment in an inpatient setting. Inpatient hemodialysis transition was associated with older age, presence of a tunneled catheter, higher comorbidity burden, and lack of pre-dialysis nephrology care. A total of 8,674 patients died (mortality rate 405/1,000 patient-years, 95% CI 397-413) during the first 6 months after transition to hemodialysis. The starting of inpatient vs. outpatient hemodialysis was associated with significantly higher crude all-cause mortality, but this association was attenuated after multivariable adjustments.

Conclusions: Transition to hemodialysis in an inpatient setting is more common in older and sicker individuals, and in patients without pre-dialysis nephrology care and those who used a catheter for vascular access. Future studies are needed to determine if a higher proportion of patients could start hemodialysis treatment in outpatient clinics, through interventions targeting modifiable risk factors such as timely vascular access placement or earlier nephrology referrals.

Keywords: Chronic kidney disease; End-stage renal disease; Hospitalization; Mortality.

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Conflict of interest statement

DISCLOSURES

None of the authors have relevant conflicts of interest.

Figures

Figure 1
Figure 1
Algorithm of cohort definition.
Figure 2
Figure 2
6-month all-cause mortality curves in patients transitioning to hemodialysis in an inpatient vs. an outpatient setting.
See this image and copyright information in PMC

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References

    1. Saran R, Li Y, Robinson B, Abbott KC, Agodoa LY, Ayanian J, Bragg-Gresham J, Balkrishnan R, Chen JL, Cope E, Eggers PW, Gillen D, Gipson D, Hailpern SM, Hall YN, He K, Herman W, Heung M, Hirth RA, Hutton D, Jacobsen SJ, Kalantar-Zadeh K, Kovesdy CP, Lu Y, Molnar MZ, Morgenstern H, Nallamothu B, Nguyen DV, O’Hare AM, Plattner B, Pisoni R, Port FK, Rao P, Rhee CM, Sakhuja A, Schaubel DE, Selewski DT, Shahinian V, Sim JJ, Song P, Streja E, Kurella Tamura M, Tentori F, White S, Woodside K, Hirth RA. US Renal Data System 2015 Annual Data Report: Epidemiology of Kidney Disease in the United States. Am J Kidney Dis. 2016;67:Svii, S1–305. - PMC - PubMed
    1. Soucie JM, McClellan WM. Early death in dialysis patients: risk factors and impact on incidence and mortality rates. Journal of the American Society of Nephrology. 1996;7:2169–2175. - PubMed
    1. Wong SP, Vig EK, Taylor JS, Burrows NR, Liu CF, Williams DE, Hebert PL, O’Hare AM. Timing of Initiation of Maintenance Dialysis: A Qualitative Analysis of the Electronic Medical Records of a National Cohort of Patients From the Department of Veterans Affairs. JAMA Intern Med. 2016;176:228–235. - PMC - PubMed
    1. Kausz AT, Obrador GT, Arora P, Ruthazer R, Levey AS, Pereira BJ. Late initiation of dialysis among women and ethnic minorities in the United States. J Am Soc Nephrol. 2000;11:2351–2357. - PubMed
    1. Korevaar JC, van Manen JG, Boeschoten EW, Dekker FW, Krediet RT, Group NS. When to start dialysis treatment: where do we stand? Perit Dial Int. 2005;25(Suppl 3):S69–72. - PubMed