A multinational cohort study of in-center daily hemodialysis and patient survival

Abstract

Increasing hemodialysis frequency from three to six times per week improves left-ventricular mass and health-related quality of life; however, effects on survival remain uncertain. To study this, we identified 556 patients in the International Quotidian Dialysis Registry who received daily hemodialysis (more than five times per week) between 2001 and 2010. Using propensity score-based matching, we matched 318 of these patients to 575 contemporaneous patients receiving conventional (three times weekly) hemodialysis in the Dialysis Outcomes and Practice Patterns Study. All patients had session times of <5 h, and received dialysis in the clinic or hospital setting. Mortality rates between groups were compared using Cox proportional hazards regression. Mean dialysis frequency in the daily group was 5.8 sessions per week. Mean weekly treatment time was 15.7 h for daily and 11.9 h for conventional patients. During 1382 patient-years of follow-up, 170 patients died. Those receiving daily hemodialysis had a significantly higher mortality rate than those receiving conventional hemodialysis (15.6 and 10.9 deaths per 100 patient-years, respectively: hazard ratio 1.6). Similar results were found in prespecified subgroup and sensitivity analyses. Unlike previous studies, we found that in-center daily hemodialysis was not associated with any mortality benefit. Thus, decisions to undertake daily hemodialysis should be based on quality-of-life improvements, rather than on claims of improved survival.

Nocturnal intermittent hemodialysis

“…Suri et al found a poor long-term tolerability for SDHD [33]. In this large retrospective, study 30 % of the patients on SDHD switched to conventional dialysis during the first year of therapy.…”

“…Patients with higher motivation, fewer co-morbidities and a stable social environment will prefer home dialysis to incenter dialysis. In the prospective, controlled trials performed to date, as well as in a number of the larger retrospective trials, intensified dialysis and conventional dialysis were performed at the same location, either at home or in the dialysis center [23][24][25][26]33]. These studies will most likely be the best ones for investigating mortality rates.…”

“…These authors reported that mortality was lower in those patients on SDHD [23]. In a large, retrospective study in which 318 SDHD patients were matched using the propensity score with 575 patients on conventional dialysis, the mortality rate was higher in patients on SDHD [33]. One reason for the higher mortality rate in patients on SDHD could be that daily dialysis was prescribed as a rescue therapy.…”

“…Therefore, patients on SDHD could be more seriously ill than those maintained on conventional dialysis [33]. Other reasons for the higher mortality risk could be frequent exposure to the dialyzer, which may cause inflammation, or more frequent cannulation of the fistula, which may increase the risk of vascular access complications, potentially resulting in a greater use of catheters [33]. The greater risk of vascular access problems was also found in two RCTs in patients on daily HD [23,24].…”

Mind the Gap

“…17 In the only observational multinational study to date showing higher mortality in patients receiving daily hemodialysis compared with those receiving conventional hemodialysis, the authors speculate that some of the French patients may have been assigned daily hemodialysis as rescue therapy and thus were actually sicker than those who received conventional hemodialysis. 18 In addition and most crucially, this analysis could not be fully adjusted for the number of central venous catheters, a variable associated with mortality. 19 After matching, 115 patients were missing VA information in the daily hemodialysis group, in contrast with only four patients missing VA information in the conventional hemodialysis group.…”