Background Recent policy clarifications by the Centers for Medicare and Medicaid Services have changed access to outpatient dialysis care at end stage renal disease (ESRD) facilities for individuals with acute kidney injury in the United States. Tools to predict “ESRD” and “acute” status in terms of kidney function recovery among patients who previously initiated dialysis in the hospital could help inform patient management decisions. Study Design Historical cohort study Setting & Participants Incident hemodialysis patients in the Mayo Clinic Health System who initiated in-hospital RRT and continued outpatient dialysis following hospital dismissal (2006 to 2009) Predictor Baseline estimated glomerular filtration rate (eGFR), sepsis/surgery acute tubular necrosis (ATN), heart failure, intensive care unit, and dialysis access. Outcomes Kidney function recovery defined as sufficient kidney function for outpatient hemodialysis discontinuation. Results Cohort consisted of 281 patients with mean age 64 years, 63% men, 45% heart failure, and baseline eGFR ≥30 mL/min/1.73m2 in 46%. Over a median 8 months, 52 (19%) recovered, most (94%) within 6 months. Higher baseline eGFR (Hazard Ratio 1.27 per 10 ml/min/1.73m2; 95% CI 1.16–1.39; p<0.001), ATN from sepsis or surgery (HR 3.34; CI 1.83- 6.24; p<0.001), and heart failure (HR 0.40; CI 0.19–0.78, p=0.007) were independent predictors of recovery within 6 months while first RRT in the intensive care unit and a catheter dialysis access were not. There was a positive interaction between absence of heart failure and eGFR≥30 ml/min/1.73m2 for predicting kidney function recovery (p<0.001). Limitations Sample size. Conclusions Kidney function recovery in the outpatient hemodialysis unit following in-hospital RRT initiation is not rare. As expected, higher baseline eGFR is an important determinant of recovery. However, patients with heart failure are less likely to recover even with higher baseline eGFR. Consideration of these factors at hospital discharge informs decisions on “ESRD” status designation and long-term hemodialysis care.

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