title: Suboptimal initiation of home hemodialysis: determinants and clinical outcomes.
abstract: OBJECTIVE
  Suboptimal initiation of conventional hemodialysis is associated with poor clinical outcomes. In this study, we aimed to ascertain the determinants and adverse events associated with suboptimal starts in home hemodialysis (HHD).
  
  
  METHODS
  We conducted a retrospective cohort study including consecutive incident HHD patients from January 1996 to December 2011. All patients had HHD as their first renal replacement therapy or returned to HHD after kidney transplantation. A suboptimal start was defined by dialysis initiation as an inpatient or with a central venous catheter. The primary outcome was time to first hospitalization, technique failure or death. Secondary outcomes included hospitalization rate, hospital days and determinants of suboptimal starts. Suboptimal starts were further categorized as unavoidable as adjudicated by two independent observers with prespecified criteria.
  
  
  RESULTS
  Among 95 incident HHD patients, 44 (46%) and 51 (54%) had optimal and suboptimal starts, respectively. A suboptimal start was associated with a shorter time to the primary outcome (log-rank p < 0.001). In a multivariable Cox proportional hazards model, the hazard ratio for the composite outcome (comparing suboptimal to optimal starts) was 2.94 (95% confidence interval, CI, 1.49-5.78, p = 0.002). Transplantation clinic follow-up (OR 3.18, 95% CI 1.15-8.79) and the Charlson comorbidity index (OR 1.47, 95% CI 1.09-1.97) were associated with higher odds of suboptimal start.
  
  
  CONCLUSIONS
  Suboptimal initiation of HHD is associated with adverse clinical events including early hospitalization. Given the high proportion of suboptimal starts in patients returning from transplantation, better incorporation of dialysis planning and renal replacement therapy education is warranted.
authors.affiliation: Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ont., Canada.
authors.forename: Annie-Claire
authors.initials: AC
authors.lastname: Nadeau-Fredette
authors.forename: Karthik K
authors.initials: KK
authors.lastname: Tennankore
authors.forename: S Joseph
authors.initials: SJ
authors.lastname: Kim
authors.forename: Christopher T
authors.initials: CT
authors.lastname: Chan
mesh_terms: D000328:Adult; D015331:Cohort Studies; D005260:Female; D006437:Hemodialysis, Home / Q000401:mortality* / Q000706:statistics & numerical data; D017052:Hospital Mortality; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009864:Ontario / Q000453:epidemiology; D051436:Renal Insufficiency, Chronic / Q000401:mortality* / Q000628:therapy*; D012189:Retrospective Studies; D018570:Risk Assessment; D015996:Survival Rate; D017211:Treatment Failure