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Varying hemodialysis facility practices associated with different patient outcomes
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Certain hemodialysis facility practices relating to the management of fluid volume and intradialytic hypotension were associated with varying outcomes, including patient survival, according to a study published in the Clinical Journal of the American Society of Nephrology.
“The findings emphasize the importance of regular and careful clinical assessment of target weight and fluid balance in patients on hemodialysis,” Indranil Dasgupta, DM, consultant nephrologist at Heartlands Hospital and honorary reader at the Institute of Applied Health Research, University of Birmingham in the United Kingdom, told Healio/Nephrology.
To determine if careful management of fluid overload and intradialytic hypotension led to better patient outcomes, researchers analyzed data from 10,250 patients in 273 dialysis facilities across 12 countries participating in phase 4 of the Dialysis Outcomes and Practice Patterns Study (DOPPS) between 2009 and 2012. Focusing on five outcomes (patient all-cause and cardiovascular mortality, cardiovascular events and all-cause and cardiovascular hospitalizations), researchers used multilevel Cox regression models to estimate associations between facility practices – reported by medical directors in response to the DOPPS Medical Directors Survey – and the outcomes.
Researchers found facilities with a protocol specifying how often to assess dry weight in most patients were associated with lower all-cause (HR = 0.78) and cardiovascular mortality (HR = 0.72), with routine measurement of orthostatic BP to assess dry weight associated with lower all-cause hospitalization (HR = 0.86) and cardiovascular events (HR = 0.85). In addition, researchers observed an association between the routine use of lower dialysate temperature to limit or prevent intradialytic hypotension and lower cardiovascular mortality (HR = 0.76) and between the routine use of on-line volume indicator to assess dry weight and higher all-cause hospitalization (HR = 1.19).
Finally, it was determined that routine use of sodium modelling/profiling to limit or prevent intradialytic hypotension was associated with higher all-cause mortality (HR = 1.36), cardiovascular mortality (HR = 1.34) and cardiovascular events (HR = 1.21).
“The nationally representative sample makes the results generalizable to the population of in-center hemodialysis patients in each country,” Dasgupta said. “The practices that have been found to be associated with improved outcomes in this study merit further investigation to define the features that are likely to be beneficial and then study in adequately powered randomized controlled clinical trials.”
In a related editorial, Andrew Davenport, MD, of the department of nephrology at the Center for Dialysis and Physiology at the Royal Free Hospital, University College London, wrote: “Although of interest, this analysis of 10 of the 29 questions administered to dialysis center directors raises more questions than it provides answers. Answers to some of the subsidiary questions remain to be analyzed, and the responses analyzed so far open up further avenues that require greater exploration. However, one has to be cautious, because previous attempts, for example, to introduce BP targets led to an increase in intradialytic hypotension. As such, rather than targeting one particular aspect of clinical practice, just like reducing catheter associated infections, a bundle approach reviewing both frequency and thoroughness of clinical assessments and incorporating biomarkers and technological advances may well be needed to improve patient outcomes.” – by Melissa J. Webb
Disclosures: Dasgupta reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
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