Abstract
Most patients with end-stage renal disease in the United States are initiated on thrice-weekly hemodialysis (HD) regimens. However, an incremental approach to HD may provide several patient benefits. We tested whether initiation of incremental HD does or does not compromise survival compared with a conventional HD regimen. The survival of 434 incremental, 50,162 conventional, and 160 frequent HD patients were compared using Cox regression analysis after matching for demographic and comorbid factors in a longitudinal national cohort of adult incident HD patients enrolled between January 2007 and December 2011. Sensitivity analysis included adjustment for residual kidney function. After adjustment for residual kidney function, all-cause mortality was not significantly different in the incremental compared with conventional HD group (hazard ratio 0.88, 95% confidence interval 0.72-1.08), but was higher in the frequent compared with the conventional HD group (hazard ratio, 1.56, 95% confidence interval 1.21-2.03). The comorbidity burden modified the association of treatment frequency and mortality, with higher comorbidity associated with higher mortality in the incremental HD group (hazard ratio, 1.77, 95% confidence interval 1.20-2.62) for a Charlson Comorbidity Index of≥5. Thus, among incident HD patients with low or moderate comorbid disease, survival was similar for patients initiated on an incremental or conventional HD regimen. Clinical trials are needed to examine the safety and effectiveness of incremental HD and the selected patient populations who may benefit from an incremental approach to HDs initiation.
Highlights
I n the United States, there are >450,000 prevalent patients with end-stage renal disease treated with maintenance dialysis, with w114,800 patients who newly initiated hemodialysis (HD) as of 2012.1 Most HD patients are conventionally prescribed a standard thrice-weekly schedule with little individualization of the initial HD regimen.[2,3,4] Dialysis patients have a 6 to 8 times higher mortality risk than age-matched Medicare patients in the general population,[1] with the highest risk observed during the first 6 months after HD initiation.[5]
We examined a 5-year nationally representative cohort of incident HD patients to determine the outcome of mortality with a conventional HD treatment regimen compared with incremental or frequent HD regimen
We hypothesized that initiation of HD with an incremental approach does not compromise survival compared with a conventional HD regimen
Summary
I n the United States, there are >450,000 prevalent patients with end-stage renal disease treated with maintenance dialysis, with w114,800 patients who newly initiated hemodialysis (HD) as of 2012.1 Most HD patients are conventionally prescribed a standard thrice-weekly schedule with little individualization of the initial HD regimen.[2,3,4] Dialysis patients have a 6 to 8 times higher mortality risk than age-matched Medicare patients in the general population,[1] with the highest risk observed during the first 6 months after HD initiation.[5]. Less frequent (i.e., twice weekly) HD has been associated with greater preservation of RKF after initiation of HD,[14,15,16] and higher RKF is associated with better patient survival in both PD and HD patients.[17,18] Preservation of RKF may play a key role in the potential association of less frequent HD and survival. This may be of particular importance among incident HD patients because many patients have substantial RKF when transitioning to end-stage renal disease.[16]. We hypothesized that initiation of HD with an incremental approach does not compromise survival compared with a conventional HD regimen
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