The “Right” of Passage: Surviving the First Year of Dialysis

• Published in: Clinical journal of the American Society of Nephrology Vol. 4; no. Supplement 1; pp. S114 - S120
• Main Authors: Wingard, Rebecca L, Chan, Kevin E, Lazarus, J Michael, Hakim, Raymond M
• Format: Journal Article
• Language: English
• Published: United States American Society of Nephrology 01.12.2009
• Subjects: Arteriovenous Shunt, Surgical - statistics & numerical data; Biomarkers - blood; Blood Vessel Prosthesis Implantation - statistics & numerical data; Case-Control Studies; Catheterization, Central Venous - statistics & numerical data; Drug Utilization; Female; Health Behavior; Health Knowledge, Attitudes, Practice; Hemoglobins - metabolism; Hospitalization - statistics & numerical data; Humans; Kidney Failure, Chronic - blood; Kidney Failure, Chronic - mortality; Kidney Failure, Chronic - therapy; Male; Middle Aged; Patient Education as Topic; Phosphorus - blood; Program Evaluation; Proportional Hazards Models; Renal Dialysis - adverse effects; Renal Dialysis - mortality; Retrospective Studies; Risk Assessment; Risk Factors; Serum Albumin - metabolism; Time Factors; Treatment Outcome; United States - epidemiology; Vitamin D - therapeutic use; United States
• ISSN: 1555-9041; 1555-905X
• DOI: 10.2215/CJN.04360709

Mortality risk for dialysis patients is highest in the first year. We previously showed a 41% mortality benefit associated with a pilot case management program for incident hemodialysis patients (n = 918). The RightStart Program (RSP) provided prompt medical management and self-management education and was recently expanded to more facilities. We conducted a matched cohort analysis to validate the expanded program's continued effectiveness. Death risk was reduced for RS patients (n = 4308) versus matched controls (C; n = 4308) by 34% (hazard ratio = 0.66, P < 0.0001) at 120 d and 22% at 1 yr (hazard ratio = 0.78, P < 0.0001). RS patients had lower hospitalization during the first year (RS = 15.5 days per patient year versus C = 16.9, P < 0.01). At 120 d, more RS patients achieved hemoglobin 11 to 12 g/dl (RS = 22.4% versus C = 19.7%, P < 0.01), eKt/V > or = 1.2 (RS = 66% versus C = 53.5%, P < 0.01), albumin > or = 4.0 g/dl (RS = 26% versus C = 22%, P < 0.01), and phosphorus 3.5 to 5.5 mg/dl (RS = 52.4% versus C = 45.4%). At 120 d, RS patients had a greater reduction in catheter use (RS = 32% versus C = 25%, P < 0.01) and more vitamin D orders (RS = 60% versus C = 55%, P < 0.01). Expansion of RS to a larger incident patient population results in significant reduction of morbidity and mortality associated with improvement of intermediate outcomes.