Association of a maximum ultrafiltration rate policy with intermediate outcomes in a prevalent underserved population undergoing hemodialysis Open Access
Pai, Rima (Spring 2020)
Abstract
Introduction: Recent observational studies have shown an association between higher ultrafiltration (UF) rates and increased mortality among individuals receiving maintenance hemodialysis (HD). Here, we leveraged a local rollout of a maximal UF policy to assess the association of maximum UF rate policy at the clinic level with intermediate patient outcomes, particularly blood pressure, among a prevalent underserved population undergoing HD.
Methods: We conducted a retrospective cohort study of data collected from 2,353 in center-HD patients treated at 23 not-for-profit dialysis facilities in Georgia and North Carolina at and after the rollout of a local UF rate policy (4/30/12). Patients were followed for 180 days for patient systolic and diastolic blood pressure outcomes [post-dialysis sitting systolic blood pressure (SBP) and diastolic blood pressure (DBP) and the lowest SBP and DBP recorded during the dialysis session (lowest intra-dialytic SBP and DBP)]. Using generalized estimating equations modeling, we examined the linear association between the presence of a UF rate policy at the treating clinic (12/23 clinics) and patients’ mean blood pressure values.
Results: In crude analyses, the presence vs. absence of a UF rate policy was associated with 5.3 mmHg (95% CI (-7.1, -3.4)) higher post-dialysis SBP, 1.6 mmHg (95% CI (-3.8, 0.7)) higher post-dialysis DBP, and 3.3 mmHg (95% CI (-4.9, -1.7)) lower intradialytic SBP; the difference in lowest intradialytic DBP was <1 mmHg (95% CI (-2.4, 0.7)). In a fully adjusted model, presence vs. absence of UF rate policy was associated with 2.3 mmHg lower post-dialysis SBP (95% CI (-4.8, 0.3)), 2.2 mmHg higher post-dialysis DBP (95 % CI (1.0, 3.4)), 0.4 mmHg lower average lowest intradialytic SBP (95% CI (-2.8, 2.1)) and 2.5 mmHg higher lowest intra-dialytic DBP (95% CI (1.4, 3.6)).
Conclusion: In general, we found that the presence of a maximum UF policy at the dialysis clinic was not independently associated with patient blood pressure outcomes in a prevalent underserved population undergoing HD. Further studies are needed to identify how UF policies are implemented and how they ultimately affect morbidity and mortality among HD patients.
Table of Contents
TABLE OF CONTENTS
Chapter I: Literature Review........................................................................................1
Chapter II: Manuscript .................................................................................................5
2.1 Abstract.......................................................................................................................5
2.2 Introduction ................................................................................................................6
2.3 Methods ......................................................................................................................7
2.3.1 Study Design…………............................................................................................7
2.3.2 Study Variables…………........................................................................................8
2.3.3 Exposure…………………......................................................................................8
2.3.4 Outcome……………….……………………….…………….................................9
2.3.5 Intermediate Outcomes……….…………………………………...……...…….....9
2.3.6 Other Variables…. ………….………….………….……………………………...9
2.3.7 Statistical Analysis ……………………………………………………….……...10
2.4 Results…………………………………...................................................................11
2.4.1 Cohort Characteristics............................................................................................11
2.4.2 Primary Analysis…………....................................................................................12
2.4.3 Secondary Analysis…………………..……..........................................................13
2.5 Discussion………………….....................................................................................14
2.6 Tables …………………………………………………...........................................18
2.7 Figures ……………………………..........................................................................22
Chapter III: Implications.............................................................................................25
3.1 Summary...................................................................................................................25
3.2 Public Health Implications………...........................................................................26
3.2.1 Future Directions...................................................................................................26
References…….………………………………………………………………………28
Appendices ………………………………………………………………………...…32
Centers for Medicare & Medicaid (CMS)-2728 form……………………………....................................................................................33
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