Little is known about survival and hospitalization among alternative-regimen hemodialysis (HD) users compared to thrice-weekly conventional HD patients who have similar characteristics and medical histories. We conducted a cohort study of alternative-regimen HD users and propensity score (PS)-matched controls. Collaborating clinicians identified 101 patients in their programs who used nocturnal HD (NHD) and 44 patients who used short daily HD (SDHD) for 60 days or more. Ten PS-matched control patients for each NHD and SDHD patient were identified from the United States Renal Data System database. Primary outcomes were risk for all-cause mortality and risk for the composite outcome of mortality or major morbid event (AMI or stroke), investigated in Cox proportional hazards models. Risks for all-cause, cardiovascular-related, infection-related, and vascular access-related hospital admissions were also explored. NHD was associated with reduced mortality risk (HR 0.34; 95% CI, 0.21-0.58; P < 0.0001) and with reduced risk for mortality or major morbid event (HR 0.49; 95% CI, 0.31-0.78; P = 0.003) compared to controls. There was a reduced but non-significant risk of death for patients using SDHD compared to controls (HR 0.61; 95% CI, 0.30-1.24; P = 0.17). All-cause and specific hospitalizations did not differ significantly between NHD and SDHD patients and their matched control cohorts. This study provides additional evidence that NHD may improve patient survival.

Conclusions: Late initiation of dialysis is associated with a reduced risk of mortality, arguing against aggressive early dialysis initiation based primarily on eGFR alone.

Whether placing a fistula first is the superior predialysis approach among octogenarians is unknown. We analyzed data from a cohort of 115,425 incident hemodialysis patients $67 years old derived from the US Renal Data System with linked Medicare claims, which allowed us to identify the first predialysis vascular access placed rather than the first access used. We used proportional hazard models to evaluate all-cause mortality outcomes based on first vascular access placed, considering the fistula group as the reference. In the study population, 21,436 patients had fistulas as the first predialysis access placed, 3472 had grafts, and 90,517 had catheters. Those patients with a catheter as the first predialysis access placed had significantly inferior survival compared with those patients with a fistula (HR=1.77; 95% CI=1.73 to 1.81; P,0.001). However, we did not detect a significant mortality difference between those patients with a graft as the first access placed and those patients with a fistula (HR=1.05; 95% CI=1.00 to 1.11; P=0.06). Analyzing mortality stratified by age groups, grafts as the first predialysis access placed had inferior mortality outcomes compared with fistulas for the 67 to #79-years age group (HR=1.10; 95% CI=1.02 to 1.17; P=0.007), but differences between these groups were not statistically significant for the 80 to #89-and the .90-years age groups. In conclusion, fistula first does not seem to be clearly superior to graft placement first in the elderly, because each strategy associates with similar mortality outcomes in octogenarians and nonagenarians.

There is controversy regarding the influence of genetic versus environmental factors on kidney transplant outcome in minority groups. The goal of this project was to evaluate the role of certain socioeconomic factors in allograft and recipient survival. Graft and recipient survival data from the United States Renal Data System were analyzed using Cox modeling with primary variables of interest, including recipient education level, citizenship, and primary source of pay for medical service. College (hazard ratio [HR] 0.93, P < 0.005) and postcollege education (HR 0.85, P < 0.005) improved graft outcome in the whole group and in patients of white race. Similar trends were observed for recipient survival (HR 0.9, P < 0.005 for college; HR 0.88, P ‫؍‬ 0.09 for postcollege education) in the whole population and in white patients. Resident aliens had a significantly better graft outcome in the entire patient population (HR 0.81, P < 0.001) and in white patients in subgroup analysis (HR 0.823, P < 0.001) compared with US citizens. A similar effect was observed for recipient survival. Using Medicare as a reference group, there is a statistically significant benefit to graft survival from having private insurance in the whole group (HR 0.87, P < 0.001) and in the black (HR 0.8, P < 0.001) and the white (HR 0.89, P < 0.001) subgroups; a similar effect of private insurance is observed on recipient survival in the entire group of patients and across racial groups. Recipients with higher education level, resident aliens, and patients with private insurance have an advantage in the graft and recipient outcomes independent of racial differences.