Outcomes Associated with In-Center Nocturnal Hemodialysis from a Large Multicenter Program
TL;DR: Patients who were on INHD exhibited excellent quality indicators, with better survival and lower hospitalization rates, and the relative contributions of patient selection versus effect of therapy on outcomes remain to be elucidated in prospective clinical trials.
Abstract: Background and objectives: The objective of this study was to evaluate epidemiology and outcomes of a large in-center nocturnal hemodialysis (INHD) program. Design, setting, participants, & measurements: This case-control study compared patients who were on thrice-weekly INHD from 56 Fresenius Medical Care, North America facilities with conventional hemodialysis patients from 244 facilities within the surrounding geographic area. All INHD cases and conventional hemodialysis control subjects who were active as of January 1, 2007, were followed until December 31, 2007, for evaluation of mortality and hospitalization. Results: As of January 1, 2007, 655 patients had been on INHD for 51 ± 73 d. Patients were younger, there were more male and black patients, and vintage was longer, but they had less diabetes compared with 15,334 control subjects. Unadjusted hazard ratio was 0.59 for mortality and 0.76 for hospitalization. After adjustment for case mix and access type, only hospitalization remained significant. Fewer INHD patients were hospitalized (48 versus 59%) with a normalized rate of 9.6 versus 13.5 hospital days per patient-year. INHD patients had greater interdialytic weight gains but lower BP. At baseline, hemoglobin values were similar, whereas albumin and phosphorus values favored INHD. Mean equilibrated Kt/V was higher in INHD patients related to longer treatment time, despite lower blood and dialysate flow rates. Conclusions: Patients who were on INHD exhibited excellent quality indicators, with better survival and lower hospitalization rates. The relative contributions of patient selection versus effect of therapy on outcomes remain to be elucidated in prospective clinical trials.
"Outcomes Associated with In-Center ..." refers background or result in this paper
...Patients (n % ) 655 (4) 15,334 (96) Age (yr; mean SD) 51....
...While results from the Frequent Hemodialysis Network on two randomized trials that evaluated outcomes from short daily in-center and long nightly home dialysis are pending (4), two recent publications renewed interest in the potential impact of longer hemodialysis session length, also referred to as treatment time (TT), to improve survival within the most prevalent practice of a thrice-weekly regimen....
...The growth of INHD therapy is remarkable considering the barriers to implementing INHD in the United States: (1) Criticism that historical outcome data were skewed by highly selected patients; (2) competitive “modality choice” because many patients who are eligible for INHD are often also eligible for home dialysis options; (3) logistical issues facing clinic managers from accommodating longer TT for patients in outpatient dialysis units that are filled to capacity; (4) the constant struggle to convince patients to stay longer for in-center treatments, even by just a few minutes; (5) local staffing issues as a result of a variable supply of dialysis nurses and patient care technicians who are willing to do a night shift; and (6) increased cost of providing therapy without additional reimbursement, becoming apparent when patient participation falls below critical mass....
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