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, 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 Kovesdy

Research output: Contribution to journalArticle

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Abstract

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.

Original languageEnglish (US)
Pages (from-to)15-22
Number of pages8
JournalNephron
Volume137
Issue number1
DOIs
StatePublished - Aug 1 2017

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Veterans
Chronic Kidney Failure
Renal Dialysis
Inpatients
Outpatients
Mortality
Nephrology
Dialysis
Blood Vessels
Comorbidity
Vascular Access Devices
Ambulatory Care Facilities
Glomerular Filtration Rate
Proportional Hazards Models
Hemoglobins
Referral and Consultation
Catheters
Demography

All Science Journal Classification (ASJC) codes

  • Physiology
  • Nephrology
  • Urology
  • Physiology (medical)

Cite this

Early Mortality Associated with Inpatient versus Outpatient Hemodialysis Initiation in a Large Cohort of US Veterans with Incident End-Stage Renal Disease. / Arif, Faisal M.; Sumida, Keiichi; Molnar, Miklos Z.; Potukuchi, Praveen K.; Lu, Jun Ling; Hassan, Fatima; Thomas, Fridtjof; Siddiqui, Omer A.; Gyamlani, Geeta G.; Kalantar-Zadeh, Kamyar; Kovesdy, Csaba.

In: Nephron, Vol. 137, No. 1, 01.08.2017, p. 15-22.

Research output: Contribution to journalArticle

Arif, FM, Sumida, K, Molnar, MZ, Potukuchi, PK, Lu, JL, Hassan, F, Thomas, F, Siddiqui, OA, Gyamlani, GG, Kalantar-Zadeh, K & Kovesdy, C 2017, 'Early Mortality Associated with Inpatient versus Outpatient Hemodialysis Initiation in a Large Cohort of US Veterans with Incident End-Stage Renal Disease', Nephron, vol. 137, no. 1, pp. 15-22. https://doi.org/10.1159/000473704
Arif, Faisal M. ; Sumida, Keiichi ; Molnar, Miklos Z. ; Potukuchi, Praveen K. ; Lu, Jun Ling ; Hassan, Fatima ; Thomas, Fridtjof ; Siddiqui, Omer A. ; Gyamlani, Geeta G. ; Kalantar-Zadeh, Kamyar ; Kovesdy, Csaba. / Early Mortality Associated with Inpatient versus Outpatient Hemodialysis Initiation in a Large Cohort of US Veterans with Incident End-Stage Renal Disease. In: Nephron. 2017 ; Vol. 137, No. 1. pp. 15-22.
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AU - Molnar, Miklos Z.

AU - Potukuchi, Praveen K.

AU - Lu, Jun Ling

AU - Hassan, Fatima

AU - Thomas, Fridtjof

AU - Siddiqui, Omer A.

AU - Gyamlani, Geeta G.

AU - Kalantar-Zadeh, Kamyar

AU - Kovesdy, Csaba

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N2 - 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.

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