Original Paper Nephron Clin Pract 2013;124:132–140 DOI: 10.1159/000356383
Received: June 7, 2013 Accepted: October 14, 2013 Published online: November 20, 2013
Suboptimal Initiation of Home Hemodialysis: Determinants and Clinical Outcomes Annie-Claire Nadeau-Fredette Karthik K. Tennankore S. Joseph Kim Christopher T. Chan Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ont., Canada
Key Words Home hemodialysis · Hospitalization · Predialysis care · Suboptimal start · Survival · Transplantation
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
© 2013 S. Karger AG, Basel 1660–2110/13/1242–0132$38.00/0 E-Mail [email protected] www.karger.com/nec
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 followup (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. © 2013 S. Karger AG, Basel
Introduction
In cohort studies of conventional hemodialysis (CHD) initiation, early preparation has a major impact on patient outcomes [1, 2]. Timely referral of patients with chronic kidney disease (CKD) and multidisciplinary in-
A.-C.N.-F. and K.K.T. contributed equally to this study.
Dr. Christopher T. Chan Toronto General Hospital, University Health Network 200 Elizabeth Street Toronto, ON M5G 2C4 (Canada) E-Mail christopher.chan @ uhn.on.ca
volvement are associated with reduced morbidity and mortality, and higher odds of establishing arteriovenous fistula or arteriovenous graft dialysis access [1, 3–6]. However, even among patients followed by nephrologists, a significant proportion initiate CHD suboptimally (with a central venous catheter or as an inpatient) [7–9]. Age and burden of comorbidity have been correlated with suboptimal starts. In addition, suboptimal starts were associated with an increased risk of adverse clinical events in patients undergoing CHD [7]. Given that transitioning a CKD patient to home hemodialysis (HHD) often requires timely referral to allow for adequate predialysis education and planning [5, 10, 11], it is logical to assume that most HHD patients should initiate renal replacement therapy optimally. However, recent data suggest that a high proportion of patients started HHD without permanent internal dialysis access [12–16]. To date, a detailed analysis of the clinical consequences of suboptimal initiation of HHD has not been conducted. The purpose of the present study is to identify the factors associated with a suboptimal dialysis start in HHD, and to determine if a suboptimal start is associated with poor clinical outcomes. Although patients who are selected for HHD may have improved survival and lower rates of hospitalization compared to those on CHD [16–18], we hypothesize that there are systematic differences in patient characteristics associated with suboptimal start. We also postulate that suboptimal HHD starts are associated with adverse clinical outcomes.
Subjects and Methods Study Population We conducted a single-center retrospective cohort study of all consecutive, adult CKD patients who transitioned directly to HHD training or within 30 days of CHD initiation. We included patients initiated on HHD after a failing kidney transplant since we considered transplant as a form of CKD. All patients in the cohort started and completed HHD training between 01 Jan 1996 and 31 Dec 2011. The time frame was selected to maximize patient inclusion and ensure availability of relevant demographic, comorbid and outcome data in our HHD database. Exposure Assessment Patients were defined as a suboptimal start if they initiated dialysis with a central venous catheter or during an inpatient admission. Remaining patients were defined as an optimal start. The definition of suboptimal versus optimal was made based on status at the start of training among those who transitioned directly to HHD, or at the start of dialysis among those who were exposed to a brief period of CHD (
Received: June 7, 2013 Accepted: October 14, 2013 Published online: November 20, 2013
Suboptimal Initiation of Home Hemodialysis: Determinants and Clinical Outcomes Annie-Claire Nadeau-Fredette Karthik K. Tennankore S. Joseph Kim Christopher T. Chan Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ont., Canada
Key Words Home hemodialysis · Hospitalization · Predialysis care · Suboptimal start · Survival · Transplantation
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
© 2013 S. Karger AG, Basel 1660–2110/13/1242–0132$38.00/0 E-Mail [email protected] www.karger.com/nec
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 followup (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. © 2013 S. Karger AG, Basel
Introduction
In cohort studies of conventional hemodialysis (CHD) initiation, early preparation has a major impact on patient outcomes [1, 2]. Timely referral of patients with chronic kidney disease (CKD) and multidisciplinary in-
A.-C.N.-F. and K.K.T. contributed equally to this study.
Dr. Christopher T. Chan Toronto General Hospital, University Health Network 200 Elizabeth Street Toronto, ON M5G 2C4 (Canada) E-Mail christopher.chan @ uhn.on.ca
volvement are associated with reduced morbidity and mortality, and higher odds of establishing arteriovenous fistula or arteriovenous graft dialysis access [1, 3–6]. However, even among patients followed by nephrologists, a significant proportion initiate CHD suboptimally (with a central venous catheter or as an inpatient) [7–9]. Age and burden of comorbidity have been correlated with suboptimal starts. In addition, suboptimal starts were associated with an increased risk of adverse clinical events in patients undergoing CHD [7]. Given that transitioning a CKD patient to home hemodialysis (HHD) often requires timely referral to allow for adequate predialysis education and planning [5, 10, 11], it is logical to assume that most HHD patients should initiate renal replacement therapy optimally. However, recent data suggest that a high proportion of patients started HHD without permanent internal dialysis access [12–16]. To date, a detailed analysis of the clinical consequences of suboptimal initiation of HHD has not been conducted. The purpose of the present study is to identify the factors associated with a suboptimal dialysis start in HHD, and to determine if a suboptimal start is associated with poor clinical outcomes. Although patients who are selected for HHD may have improved survival and lower rates of hospitalization compared to those on CHD [16–18], we hypothesize that there are systematic differences in patient characteristics associated with suboptimal start. We also postulate that suboptimal HHD starts are associated with adverse clinical outcomes.
Subjects and Methods Study Population We conducted a single-center retrospective cohort study of all consecutive, adult CKD patients who transitioned directly to HHD training or within 30 days of CHD initiation. We included patients initiated on HHD after a failing kidney transplant since we considered transplant as a form of CKD. All patients in the cohort started and completed HHD training between 01 Jan 1996 and 31 Dec 2011. The time frame was selected to maximize patient inclusion and ensure availability of relevant demographic, comorbid and outcome data in our HHD database. Exposure Assessment Patients were defined as a suboptimal start if they initiated dialysis with a central venous catheter or during an inpatient admission. Remaining patients were defined as an optimal start. The definition of suboptimal versus optimal was made based on status at the start of training among those who transitioned directly to HHD, or at the start of dialysis among those who were exposed to a brief period of CHD (
