In-Hospital Mortality in Cirrhotic Patients with End-Stage Renal Disease Treated with Hemodialysis Versus Peritoneal Dialysis: A Nationwide Study.

BACKGROUND: Cirrhotic patients often develop end-stage renal disease (ESRD) requiring renal replacement therapy in the form of hemodialysis (HD) or peritoneal dialysis (PD). Studies comparing the outcomes and difference in in-hospital mortality between these 2 groups, particularly among those with ascites, are sparse. We set our objective to determine the dialysis modality with a better in-hospital survival rate among cirrhotic patients with ESRD (ESRD-cirrhosis). METHODS: Data was extracted from the 2005 to 2012 Nationwide Inpatient Sample (NIS). Using propensity score matching, ESRD-cirrhosis patients on PD were matched with patients on HD at a 1:1 ratio. Another subgroup analysis of ESRD-cirrhosis patients with ascites was performed using the same matching algorithm. Analyses were performed using SAS version 9.3 (SAS Institute, Cary, NC, USA). RESULTS: Among 26,135 cirrhotic patients with incident ESRD, 25,686 (98.3%) and 449 (1.7%) were initiated on HD and PD, respectively, during the hospitalization. There was a nonsignificant mortality difference between the ESRD-cirrhosis patients treated with PD and those treated with HD. In a subgroup analysis of these patients with ascites, 18 patients underwent PD while 1,878 patients required HD. Also, PD had a significantly lower in-hospital mortality compared with HD in this subgroup (0% vs 26.67%, p = 0.03). Mean length of stay for those who received HD was 8.34 days compared with 7.06 days for the PD group (p < 0.0001). Similarly, mean hospital charges were greater for those who had HD compared with PD ($74,501 vs $57,460; p < 0.001). CONCLUSION: Cirrhotic patients with ESRD and ascites who undergo PD have a significantly lower mortality than those who are started on HD. However PD is rarely initiated for ESRD in cirrhotic patients with ascites during hospitalization in the United States. Due to the potential advantages of PD, nephrologists should encourage PD when selecting dialysis modality in this subgroup of patients whenever possible.

Variability in monthly serum bicarbonate measures in hemodialysis patients: a cohort study.

BACKGROUND: Some nephrologists have advocated an individualized approach to the prescription of bicarbonate hemodialysis. However, the utility of monthly serum bicarbonate levels for guiding and evaluating such treatment decisions has not been evaluated. We sought to define the variability of these measurements and to determine factors that are associated with month-to-month variability in pre-dialysis serum bicarbonate. METHODS: We examined the monthly variability in serum bicarbonate measurements among 181 hemodialysis patients admitted to a free-standing dialysis unit in the Bronx, NY from 1/1/2008-6/30/2012. All patients were treated with a uniform bicarbonate dialysis prescription (bicarbonate 35 mEq/L, acetate 8 mEq/L). Pre-dialysis serum bicarbonate values were obtained from monthly laboratory reports. Month-to-month variability was defined using a rolling measurement for each time point. RESULTS: Only 34 % of high serum bicarbonate values (>26 mEq/L) remained high in the subsequent month, whereas 60 % converted to normal (22-26 mEq/L). Of all low values (<22 mEq/L), 41 % were normal the following month, while 58 % remained low. Using the mean 3-month bicarbonate, only 29 % of high values remained high in the next 3-month period. In multivariable-adjusted longitudinal models, both low and high serum bicarbonate values were associated with greater variability than were normal values (ß = 0.12 (95 % CI 0.09-0.15) and 0.24 (0.18 to 0.29) respectively). Variability decreased with time, and was significantly associated with age, phosphate binder use, serum creatinine, potassium, and normalized protein catabolic rate. CONCLUSIONS: Monthly pre-dialysis serum bicarbonate levels are highly variable. Even if a clinician takes no action, approximately 50 % of bicarbonate values outside a normal range of 22-26 mEq/L will return to normal in the subsequent month. The decision to change the bicarbonate dialysis prescription should not be based on a single bicarbonate value, and even a 3-month mean may be insufficient.