High National Rates of Missed Hemodialysis Linked to Poor Outcomes

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Countries with high rates of missed hemodialysis (HD) treatments have elevated rates of death and other adverse outcomes, reports a study in American Journal of Kidney Diseases.

The researchers analyzed data on 8501 patients in 20 countries participating in the international Dialysis Outcomes and Practice Patterns Study (DOPPS). All patients had been on HD therapy for longer than 120 days. The 4-month missed treatment rate varied from less than 1% in Italy and Japan to 24% in the United States.

After exclusion of patients from six countries with 4-month missed treatment rates of less than 5%, longitudinal and cross-sectional analyses were performed using data on 4493 patients. Potential predictors of missed HD treatments were analyzed, including country and patient and clinical variables.

On adjusted analysis, factors associated with a higher rate of missed treatments included younger age, shorter dialysis vintage, shorter prescribed HD treatment time, lower achieved Kt/V, more than 1-hour travel time to HD centers, and higher depression symptom score. The association with travel time was stronger in the United States: adjusted odds ratio 3.17, compared to 1.60 in other countries.

Patients with missed treatments were at increased risk of death from any cause: hazard ratio 1.68. Other adverse outcomes linked to missed HD sessions included death from cardiovascular causes, sudden death or cardiac arrest, hospital admission, serum phosphorus greater than 5.5 mg/dL, parathyroid hormone greater than 300 pg/mL, hemoglobin level less than 10 g/dL, higher perceived burden of kidney disease, and poorer general and mental health.

These findings add to previous evidence of poor outcomes among patients with missed HD sessions not due to hospitalization. Missed treatments may be a potentially modifiable factor to improve patient outcomes—particularly in the United States, which has the highest 4-month missed treatment rate of all DOPPS countries [Al Salmi I, et al. Missed hemodialysis treatments: international variation, predictors, and outcomes in the Dialysis Outcomes and Practice Patterns Study (DOPPS). Am J Kidney Dis 2018; 72:634–643].