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      Hospitalizations in Dialysis Patients in Canada: A National Cohort Study

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          Abstract

          Background:

          Hospitalizations of chronic dialysis patients have not been previously studied at a national level in Canada. Understanding the scope and variables associated with hospitalizations will inform measures for improvement.

          Objective:

          To describe the risk of all-cause and infection-related hospitalizations in patients on dialysis.

          Design:

          Retrospective cohort study using health care administrative databases.

          Setting:

          Provinces and territories across Canada (excluding Manitoba and Quebec).

          Patients:

          Incident chronic dialysis patients with a dialysis start date between January 1, 2005, and March 31, 2014. Patients with a prior history of kidney transplantation were excluded.

          Measurements:

          Patient characteristics were recorded at baseline. Dialysis modality was treated as a time-varying covariate. The primary outcomes of interest were all-cause and dialysis-specific infection-related hospitalizations.

          Methods:

          Crude rates for all-cause hospitalization and infection-related hospitalization were determined per patient year (PPY) at 7 and 30 days, and at 3, 6, and 12 months postdialysis initiation. A stratified, gamma-distributed frailty model was used to assess repeat hospital admissions and to determine the inter-recurrence dependence of hospitalizations within individuals, as well as the hazard ratio (HR) attributed to each covariate of interest.

          Results:

          A total of 38 369 incident chronic dialysis patients were included: 38 088 adults and 281 pediatric patients (age less than 18 years). There were 112 374 hospitalizations, of which 11.5% were infection-related hospitalizations. The all-cause hospitalization rate was similar for all adult age groups (age 65 years and older: 1.40, 1.35, and 1.18 admissions PPY at 7 days, 30 days, and 6 months, respectively). The all-cause hospitalization rate was higher for pediatric patients (1.67, 2.48, and 2.47 admissions PPY at 7 days, 30 days, and 6 months, respectively; adjusted HR: 2.73, 95% confidence interval [CI]: 2.37-3.15, referent age group: 45-64 years). Within the first 7 days after dialysis initiation, patients on peritoneal dialysis had a higher risk of all-cause hospitalization (HR: 1.27, 95% CI: 1.07-1.50) and infection-related hospitalization (HR: 2.05, 95% CI: 1.19-3.55) compared with patients on hemodialysis. Beyond 7 days, the risk did not differ significantly by dialysis modality. Female sex and Indigenous race were significant risk factors for all-cause hospitalization.

          Limitations:

          The cohort had too few home hemodialysis patients to examine this subgroup. The outcome of infection-related hospitalization was determined using diagnostic codes. Dialysis patients from Manitoba and Quebec were not included.

          Conclusions:

          In Canada, the rates of hospitalization were not influenced by dialysis modality beyond the initial 7-day period following dialysis initiation; however, the rate of hospitalization in pediatric patients was higher than in adults at every time frame examined.

          Abrégé

          Contexte:

          Le taux d’hospitalisation des patients dialysés n’avait jamais fait l’objet d’une étude pancanadienne. Une connaissance approfondie de la portée et des variables associées aux hospitalisations orientera les mesures d’amélioration.

          Objectif de l’étude:

          L’étude visait à mieux évaluer les risques d’hospitalisations des patients dialysés; toutes causes confondues ou liées spécifiquement à une infection.

          Type d’étude:

          Il s’agit d’une étude de cohorte rétrospective fondée sur des bases de données administratives en santé.

          Cadre de l’étude:

          L’étude couvrait les provinces et territoires du Canada à l’exception du Québec et du Manitoba.

          Patients:

          L’étude a porté sur tous les patients dialysés à vie dont le traitement avait commencé entre le 1er janvier 2005 et le 31 mars 2014. Les patients ayant reçu une greffe rénale ont été exclus.

          Mesures:

          Les caractéristiques initiales des patients ont été consignées, et la modalité de dialyse a été traitée comme une co-variable sujette à changement dans le temps. La principale issue d’intérêt était une hospitalisation due à une infection directement liée à la dialyse, ou une hospitalisation toutes causes confondues.

          Méthodologie:

          Les taux bruts d’hospitalisations toutes causes confondues (global) et d’hospitalisations liées à une infection ont été calculés en années-patients (HAP) à différents moments suivant le début de la dialyse (7 jours, 30 jours, 3 mois, 6 mois et 12 mois). Un modèle stratifié de fragilité à distribution gamma a été employé pour i) répertorier les hospitalisations répétées; ii) déterminer l’interrécurrence et le lien de dépendance entre les hospitalisations pour chaque patient; et iii) établir le rapport de risque (RR) attribué à chaque covariable d’intérêt.

          Résultats:

          En tout, 38 369 patients dialysés, soit 38 088 adultes et 281 patients mineurs (moins de 18 ans) ont été inclus dans l’étude. Au cours de la période étudiée, on a répertorié 112 374 hospitalisations, dont 11,5 % étaient dues à une infection en lien direct avec la dialyse. Le taux d’hospitalisations global était similaire pour tous les groupes d’âge chez les patients adultes. Par exemple, chez les patients âgés de 65 ans et plus, ce taux se situait respectivement à 1,40 HAP, à 1,35 HAP et à 1,18 HAP lorsque calculé 7 jours, 30 jours et 6 mois après l’initiation de la dialyse. Lorsque comparé au groupe des 45-64 ans, le taux d’hospitalisations global s’est avéré plus élevé chez les patients pédiatriques (1,67 HAP à 7 jours, 2,48 HAP à 30 jours et 2,47 HAP à 6 mois) post-initiation de la dialyse (RR: 2,73; IC 95 %: 2,37-3,15). Dans les 7 jours suivant l’initiation du traitement, les patients traités par dialyse péritonéale présentaient un risque plus élevé d’hospitalisation toutes causes confondues (RR: 1,27; IC 95 %: 1,07-1,50) ou d’hospitalisation liée à une infection (RR: 2,05; IC 95 %: 1,19-3,55) que les patients hémodialysés. Par contre, cet écart entre les modalités de dialyse n’était plus observable au-delà des sept premiers jours. Enfin, le fait d’être autochtone ou de sexe féminin s’avérait un facteur de risque d’hospitalisation significatif (toutes causes confondues).

          Limites de l’étude:

          Plusieurs facteurs limitent la portée des résultats: i) la cohorte comptait trop peu de patients hémodialysés à domicile pour permettre une analyse de ce sous-groupe; ii) les hospitalisations relatives à une infection ont été établies à l’aide de codes diagnostiques; et iii) les patients dialysés résidant au Québec et au Manitoba étaient exclus de l’étude.

          Conclusion:

          Au Canada, au-delà des sept jours suivant l’initiation de la dialyse, la modalité employée n’a plus d’influence sur les taux d’hospitalisations. Cependant, à tous les moments post-initiation mesurés, les taux d’hospitalisations se sont avérés plus élevés chez les patients pédiatriques que chez les adultes.

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          Most cited references30

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          Frailty as a novel predictor of mortality and hospitalization in individuals of all ages undergoing hemodialysis.

          To quantify the prevalence of frailty in adults of all ages undergoing chronic hemodialysis, its relationship to comorbidity and disability, and its association with adverse outcomes of mortality and hospitalization. Prospective cohort study. Single hemodialysis center in Baltimore, Maryland. One hundred forty-six individuals undergoing hemodialysis enrolled between January 2009 and March 2010 and followed through August 2012. Frailty, comorbidity, and disability on enrollment in the study and subsequent mortality and hospitalizations. At enrollment, 50.0% of older (≥ 65) and 35.4% of younger (<65) individuals undergoing hemodialysis were frail; 35.9% and 29.3%, respectively, were intermediately frail. Three-year mortality was 16.2% for nonfrail, 34.4% for intermediately frail, and 40.2% for frail participants. Intermediate frailty and frailty were associated with a 2.7 times (95% confidence interval (CI) = 1.02-7.07, P = .046) and 2.6 times (95% CI = 1.04-6.49, P = .04) greater risk of death independent of age, sex, comorbidity, and disability. In the year after enrollment, median number of hospitalizations was 1 (interquartile range 0-3). The proportion with two or more hospitalizations was 28.2% for nonfrail, 25.5% for intermediately frail, and 42.6% for frail participants. Although intermediate frailty was not associated with number of hospitalizations (relative risk = 0.76, 95% CI = 0.49-1.16, P = .21), frailty was associated with 1.4 times (95% CI = 1.00-2.03, P = .049) more hospitalizations independent of age, sex, comorbidity, and disability. The association between frailty and mortality (interaction P = .64) and hospitalizations (P = .14) did not differ between older and younger participants. Adults of all ages undergoing hemodialysis have a high prevalence of frailty, more than five times as high as community-dwelling older adults. In this population, regardless of age, frailty is a strong, independent predictor of mortality and number of hospitalizations. © 2013, Copyright the Authors Journal compilation © 2013, The American Geriatrics Society.
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            Trends in US Vascular Access Use, Patient Preferences, and Related Practices: An Update From the US DOPPS Practice Monitor With International Comparisons.

            Since the bundled end-stage renal disease prospective payment system began in 2011 in the United States, some hemodialysis practices have changed substantially, raising the question of whether vascular access practice also has changed. We describe monthly US vascular access use from August 2010 to August 2013 with international comparisons, and other aspects of US vascular access practice.
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              • Record: found
              • Abstract: found
              • Article: not found

              Association between hemoglobin variability, serum ferritin levels, and adverse events/mortality in maintenance hemodialysis patients.

              In recent times, therapy for renal anemia has changed dramatically in that iron administration has increased and doses of erythropoiesis-stimulating agents (ESAs) have decreased. Here we used a prospective, observational, multicenter design and measured the serum ferritin and hemoglobin levels every 3 months for 2 years in 1086 patients on maintenance hemodialysis therapy. The associations of adverse events with fluctuations in ferritin and hemoglobin levels and ESA and iron doses were measured using a Cox proportional hazards model for time-dependent variables. The risks of cerebrovascular and cardiovascular disease (CCVD), infection, and hospitalization were higher among patients who failed to maintain a target-range hemoglobin level and who exhibited high-amplitude fluctuations in hemoglobin compared with patients who maintained a target-range hemoglobin level. Patients with a higher compared with a lower ferritin level had an elevated risk of CCVD and infectious disease. Moreover, the risk of death was significantly higher among patients with high-amplitude ferritin fluctuations compared with those with a low ferritin level. The risks of CCVD, infection, and hospitalization were significantly higher among patients who were treated with high weekly doses of intravenous iron compared with no intravenous iron. Thus, there is a high risk of death and/or adverse events in patients with hemoglobin levels outside the target range, in those with high-amplitude hemoglobin fluctuations, in those with consistently high serum ferritin levels, and in those with high-amplitude ferritin fluctuations.
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                Author and article information

                Journal
                Can J Kidney Health Dis
                Can J Kidney Health Dis
                CJK
                spcjk
                Canadian Journal of Kidney Health and Disease
                SAGE Publications (Sage CA: Los Angeles, CA )
                2054-3581
                1 June 2018
                2018
                : 5
                : 2054358118780372
                Affiliations
                [1 ]Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
                [2 ]Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
                [3 ]Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada
                [4 ]Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Canada
                [5 ]Department of Pharmacology and Physiology, University of Montreal, Quebec, Canada
                [6 ]Division of Nephrology, University Health Network, Department of Medicine, University of Toronto, Ontario, Canada
                [7 ]Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
                [8 ]Division of Nephrology, St. Michael’s Hospital, Department of Medicine, University of Toronto, Ontario, Canada
                [9 ]Division of Nephrology, Department of Medicine, University of Saskatchewan, Saskatoon, Canada
                [10 ]Canadian Institute of Health Information, Toronto, Ontario, Canada
                [11 ]Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, Canada
                [12 ]Division of Nephrology, Department of Medicine, University of Ottawa, Ontario, Canada
                Author notes
                [*]Amber O. Molnar, Division of Nephrology, Department of Medicine, McMaster University, 50 Charlton Ave, Hamilton, Ontario, Canada L8N 4A6. Email: amolnar@ 123456stjosham.on.ca
                Article
                10.1177_2054358118780372
                10.1177/2054358118780372
                5985541
                29900002
                51e92e34-f098-41b5-bf82-c267196ef7f2
                © The Author(s) 2018

                This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License ( http://www.creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages ( https://us.sagepub.com/en-us/nam/open-access-at-sage).

                History
                : 2 January 2018
                : 14 March 2018
                Categories
                Original Research Article
                Custom metadata
                January-December 2018

                dialysis,administrative data,risk factor,canadian
                dialysis, administrative data, risk factor, canadian

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