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

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.

Non-recovery from dialysis-requiring acute kidney injury and short-term mortality and cardiovascular risk: a cohort study

“…It can also be clinically challenging to determine whether patients with chronic kidney disease who initiate dialysis during a hospitalization do so because of progression of underlying disease versus superimposed acute injury. However, prior single-center and VA data have reported similar proportions of incident ESRD patients initiating dialysis in the hospital [ 35 – 37 ]. Therefore, our finding that patients with incident ESRD due to AKI-D have significantly higher adjusted all-cause death rates compared to incident ESRD patients without AKI-D indicates that the large number of patients who reach ESRD via AKI-D may explain, in part, the high early mortality rate in the overall ESRD population.…”

Survival among Veterans Obtaining Dialysis in VA and Non-VA Settings

“…We also ascertained whether patients initiated dialysis in the inpatient setting, which may reflect illness severity/acuity and/or local practices. 27 We also constructed baseline financial and geographic access characteristics that might be expected to influence veterans' dialysis setting: insurance coverage derived from Medicare enrollment and self-report in the ESRD Medical Evidence Form 23 (Medicare, Medicaid, private insurance, other), VA copayment exempt versus nonexempt status (determined on the basis of low income or service-related disability), straightline distances from residence to nearest VA outpatient dialysis unit and to nearest VA medical center (VAMC), and degree of VA reliance for other outpatient care. 28 Finally, we adjusted for several characteristics of the VAMC most frequented by (or else nearest to) each veteran, including whether the VAMC had nephrology services or a dialysis unit on site, and the 2011 fiscal year occupancy rate of each veteran's nearest VA outpatient dialysis unit.…”

Comparative Assessment of Utilization and Hospital Outcomes of Veterans Receiving VA and Non‐VA Outpatient Dialysis

“…We also determined whether patients initiated dialysis in the inpatient vs. outpatient setting, which may reflect severity and/or acuity of patient illness (i.e., complication resulting in kidney failure) or local practices (i.e., initiating dialysis as an inpatient to demonstrate physical tolerance for treatment) (Arif et al. ). The clinical burden of disease borne by the patient was characterized by 29 indicators of diagnosed physical health conditions (Gagne et al.…”

“…VA reliance in our dialysis cohort was defined as the proportion of outpatient evaluation and management visits in or purchased by the VA, of all such visits identified from VA, VA-PC, and Medicare sources in the year prior to dialysis initiation; and categorized as no VA or Medicare use (5.5 percent), 0-50 percent outpatient use relying on VA (60.3 percent), and >50-100 percent relying on VA (34.2 percent). We also determined whether patients initiated dialysis in the inpatient vs. outpatient setting, which may reflect severity and/or acuity of patient illness (i.e., complication resulting in kidney failure) or local practices (i.e., initiating dialysis as an inpatient to demonstrate physical tolerance for treatment) (Arif et al 2017). The clinical burden of disease borne by the patient was characterized by 29 indicators of diagnosed physical health conditions (Gagne et al 2011), body mass index (BMI), as well as hospitalization and institutionalization through VA or Medicare in the year before starting dialysis and hospice use in the 90 days before dialysis initiation.…”