Suboptimal Initiation of Home Hemodialysis: Determinants and Clinical Outcomes

Abstract

Background/Aims: Suboptimal initiation of conventional hemodialysis is associated with poor clinical outcomes. In this study, we aimed to ascertain the determinants and adverse events associated with suboptimal starts in home hemodialysis (HHD). Methods: We conducted a retrospective cohort study including consecutive incident HHD patients from January 1996 to December 2011. All patients had HHD as their first renal replacement therapy or returned to HHD after kidney transplantation. A suboptimal start was defined by dialysis initiation as an inpatient or with a central venous catheter. The primary outcome was time to first hospitalization, technique failure or death. Secondary outcomes included hospitalization rate, hospital days and determinants of suboptimal starts. Suboptimal starts were further categorized as unavoidable as adjudicated by two independent observers with prespecified criteria. Results: Among 95 incident HHD patients, 44 (46%) and 51 (54%) had optimal and suboptimal starts, respectively. A suboptimal start was associated with a shorter time to the primary outcome (log-rank p < 0.001). In a multivariable Cox proportional hazards model, the hazard ratio for the composite outcome (comparing suboptimal to optimal starts) was 2.94 (95% confidence interval, CI, 1.49-5.78, p = 0.002). Transplantation clinic follow-up (OR 3.18, 95% CI 1.15-8.79) and the Charlson comorbidity index (OR 1.47, 95% CI 1.09-1.97) were associated with higher odds of suboptimal start. Conclusion: Suboptimal initiation of HHD is associated with adverse clinical events including early hospitalization. Given the high proportion of suboptimal starts in patients returning from transplantation, better incorporation of dialysis planning and renal replacement therapy education is warranted.

An Incident Cohort Study Comparing Survival on Home Hemodialysis and Peritoneal Dialysis (Australia and New Zealand Dialysis and Transplantation Registry)

“…Patients treated with HHD tend to be younger, have less comorbidity, and have different etiologies of primary kidney disease (8,18,27,39). They are also less likely to have late nephrology referral, another factor associated with poor clinical outcomes (50)(51)(52). Although the previous factors can be addressed by statistical adjustment, other components, such as commitment to dialysis treatment, education level, psychologic skills, social support, and economic status, are much harder to account for, especially in a registry analysis.…”

Vascular Access Management for Haemodialysis: A Value-Based Approach from NephroCare Experience

“…The reason for this reorganisation is especially needed as currently approximately 32-73% of the CKD patient population experiences an unplanned start of dialysis [166][167][168][169]. This unplanned start leads to the use of the least optimal VA type (CVC) rather than AVF as this requires a 6-month maturity phase.…”

Risk Factors for Unplanned Dialysis Initiation: A Systematic Review of the Literature

“…Eligible studies included incident chronic dialysis patients (n = 42) 2-4,6,8,9,13-48 and patients with CKD known to nephrology (n = 6). 5,49-53 Study designs included retrospective cohort studies (n = 27), 2,3,5,6,14-16,19-24,26,28,31-36,38,47…”

“…13 No randomized control trials were found in the search. The majority of studies were conducted in Europe (n = 26; 22 unique cohorts) 2,8,9,15-19,22-25,29,30,33,36,40-43,45-48,50,51 ; 11 studies were conducted in North America 3-6,14,21,26,28,31,52,53 (Canada, n = 9; 8 unique cohorts). Study cohort sizes ranged from 43 to 45 785 persons.…”

“…The proportion of patients with an unplanned dialysis start differed across studies, ranging from 7% to 100%, but most studies reported a proportion between 40% and 60% (n = 21). 2,3,5,6,14,15,19,23,24,26-31,36,38,48,51-53…”