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Emergency-only hemodialysis for end-stage renal disease linked to increased mortality

Undocumented immigrants with end-stage renal disease who were treated with emergency-only hemodialysis had greater mortality rates and spent more days in the hospital than their counterparts who were treated with standard hemodialysis, according to a study published in JAMA Internal Medicine.

“In the United States, approximately 6500 undocumented immigrants have end-stage renal disease (ESRD) ... The accessibility to emergency-only hemodialysis vs. standard hemodialysis (three times weekly at a health care center) varies between and within states for undocumented immigrants despite evidence-based clinical practice guidelines recommending standard hemodialysis,” Lilia Cervantes, MD, from the department of medicine at Denver Health, and colleagues wrote.

Cervantes and colleagues conducted a retrospective cohort study to compare mortality and health care use, including acute care days and ambulatory care visits, among undocumented immigrants who were treated with emergency-only hemodialysis and standard hemodialysis for incident ESRD between Jan. 1, 2007, and July 15, 2014. The researchers identified 211 eligible patients (125 men; mean age, 46.5 years); of whom, 42 received standard hemodialysis and 169 received emergency-only hemodialysis.

Data showed that initiating hemodialysis with an arteriovenous fistula or graft was more common among standard hemodialysis recipients than among emergency-only hemodialysis recipients.

Additionally, albumin and hemoglobin levels were higher in patients treated with standard hemodialysis.

There was a nearly five times greater relative hazard of mortality among patients treated with emergency-only hemodialysis after a mean of 3 years and adjustment for propensity score (HR = 4.96; 95% CI, 0.93-26.45; P = .06) than those treated with standard hemodialysis. After a mean of 5 years, the relative hazard of mortality grew to more than 14 times higher for patients treated with emergency-only hemodialysis (HR = 14.13; 95% CI, 1.24-161.00; P = .03), compared with those treated with standard hemodialysis.

After adjustment for propensity score, the number of acute care days was almost 10-fold greater for patients treated with emergency-only hemodialysis (HR = 9.81; 95% CI, 6.27-15.35; P < .001) than those treated with standard hemodialysis. Conversely, patients who received emergency-only hemodialysis were 0.31 times less likely to make ambulatory care visits than those who received standard hemodialysis.

“An emergency-only hemodialysis treatment strategy to treat undocumented immigrants with ESRD is strongly associated with increased mortality and more acute hospital days compared with a treatment strategy of standard hemodialysis,” Cervantes and colleagues concluded.

“The life-and-death nature of emergency-only hemodialysis demands that we establish policies guiding care for undocumented immigrants with ESRD and balancing the many conflicting issues. States across the country providing emergency-only hemodialysis to undocumented immigrants should reconsider the substantial human and economic effect of providing less-than-standard hemodialysis care.” – by Alaina Tedesco

Disclosure: The authors report no relevant financial disclosures.