title: Inpatient hemodialysis initiation: reasons, risk factors and outcomes.
abstract: OBJECTIVE
  Inpatient initiation of chronic hemodialysis is considered undesirable because of cost and possible harms of hospitalization. We examined the patient characteristics and outcomes associated with inpatient initiation.
  
  
  METHODS
  In a prospective cohort study of incident dialysis patients, the independent association of inpatient hemodialysis initiation with patient outcomes was assessed in multivariable analyses with adjustment for patient characteristics and propensity for inpatient initiation.
  
  
  RESULTS
  A total of 410 of 652 (63%) hemodialysis patients began as inpatients; uremia and volume overload were the most commonly documented reasons. Compared to outpatients, inpatients were more likely to be unmarried, report less social support, have multiple comorbidities and be referred to a nephrologist 4 months or less prior to initiation. Inpatient initiation was protective for subsequent all-cause hospitalization (incidence rate ratio (IRR) = 0.92, confidence interval (CI) 0.89-0.94); this was most pronounced among those who had the highest propensity for inpatient initiation (IRR = 0.66, CI 0.56-0.78), including those referred late to nephrology. Similar results were found for infectious hospitalization. Mortality [hazard ratio = 1.03, CI 0.82-1.30] and cardiovascular events were not significantly different for inpatients versus outpatients.
  
  
  CONCLUSIONS
  Inpatient hemodialysis initiation has a protective association with hospitalization among those patients referred late to nephrology, with multiple comorbidities and/or little social support.
authors.affiliation: Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA. dcrews1@jhmi.edu
authors.forename: Deidra C
authors.initials: DC
authors.lastname: Crews
authors.forename: Bernard G
authors.initials: BG
authors.lastname: Jaar
authors.forename: Laura C
authors.initials: LC
authors.lastname: Plantinga
authors.forename: Hania S
authors.initials: HS
authors.lastname: Kassem
authors.forename: Nancy E
authors.initials: NE
authors.lastname: Fink
authors.forename: Neil R
authors.initials: NR
authors.lastname: Powe
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D006760:Hospitalization; D006801:Humans; D007297:Inpatients / Q000706:statistics & numerical data; D007676:Kidney Failure, Chronic / Q000401:mortality / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D006435:Renal Dialysis / Q000706:statistics & numerical data*; D012307:Risk Factors; D016896:Treatment Outcome