title: Skipped treatments, markers of nutritional nonadherence, and survival among incident hemodialysis patients.
abstract: BACKGROUND
  Skipping hemodialysis treatments and failing to adhere to prescribed diets are thought to injure hemodialysis patients.
  
  
  METHODS
  We examined predictors of hemodialysis skipping and laboratory measures of nonadherence and then examined the association of dialysis skipping and serum potassium and phosphate levels with survival.
  
  
  RESULTS
  Of 739 patients, 67 were classified as skippers because they were absent for greater than 3% of scheduled treatments. Black race (odds ratio [OR], 2.26; 95% confidence interval [CI], 1.30 to 3.92), current smoking (OR, 1.79; 95% CI, 1.02 to 3.13), and use of illicit drugs (OR, 3.96; 95% CI, 2.16 to 7.24) were associated with skipping. White race, increased serum phosphate level, greater creatinine level, and lower body mass index increased the likelihood of a serum potassium level greater than 5.0 mEq/L (mmol/L); younger age, greater serum potassium level, and greater serum creatinine level were associated with a serum phosphate level greater than 5.5 mg/dL (>1.78 mmol/L). Skipping was associated with an increased risk for death (hazard ratio [HR], 1.69; 95% CI, 1.24 to 2.31), as were phosphate level greater than 5.5 mg/dL (HR, 1.59; 95% CI, 1.16 to 2.17) and potassium level greater than 5.0 mEq/L (HR, 1.50; 95% CI, 1.10 to 2.06). Skipping was associated with a lower likelihood of kidney transplantation in those younger than 65 years (OR, 0.41; 95% CI, 0.18 to 0.93).
  
  
  CONCLUSIONS
  These findings show that hemodialysis patients of black race and those with current tobacco or illicit drug use are at risk for skipping dialysis treatments. Skipping treatments and markers of poor dietary adherence are strongly associated with greater risk for death. Targeting high-risk patients to understand reasons for nonadherence and to intervene could prevent premature death.
authors.affiliation: Renal-Electrolyte Division, Epidemiology Data Center, University of Pittsburgh Medical Center, Pittsburgh, PA 15261, USA. unruh@pitt.edu
authors.forename: Mark L
authors.initials: ML
authors.lastname: Unruh
authors.forename: Idris V
authors.initials: IV
authors.lastname: Evans
authors.forename: Nancy E
authors.initials: NE
authors.lastname: Fink
authors.forename: Neil R
authors.initials: NR
authors.lastname: Powe
authors.forename: Klemens B
authors.initials: KB
authors.lastname: Meyer
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D015415:Biomarkers; D015897:Comorbidity; D004032:Diet; D005006:Ethnicity / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000097:blood / Q000178:diet therapy / Q000401:mortality* / Q000523:psychology / Q000628:therapy; D007677:Kidney Function Tests; D016030:Kidney Transplantation / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D017060:Patient Satisfaction; D016016:Proportional Hazards Models; D011446:Prospective Studies; D011788:Quality of Life; D006435:Renal Dialysis / Q000523:psychology / Q000706:statistics & numerical data; D012680:Sensitivity and Specificity; D012907:Smoking / Q000453:epidemiology; D012944:Social Support; D019966:Substance-Related Disorders / Q000453:epidemiology; D016019:Survival Analysis; D017211:Treatment Failure; D016312:Treatment Refusal / Q000706:statistics & numerical data*
chemical_list: D015415:Biomarkers