title: Intensive Hemodialysis and Mortality Risk in Australian and New Zealand Populations.
abstract: BACKGROUND
  Intensive hemodialysis (HD) is characterized by increased frequency and/or session length compared to conventional HD. Previous analyses from Australia and New Zealand did not suggest benefit with intensive HD, although recent research suggests that relationships have changed. We present updated analyses.
  
  
  METHODS
  Observational cohort study using marginal structural modeling to adjust for changes in renal replacement modality and time-varying medical comorbid conditions.
  
  
  METHODS
  Adults initiating renal replacement therapy since March 31, 1996, followed up through December 31, 2012; this analysis included 40,842 patients over 2,187,689 patient-months.
  
  
  METHODS
  Time-varying renal replacement modality: conventional facility HD (≤3 times per week, ≤6 hours per session), quasi-intensive facility HD (between conventional and intensive), intensive facility HD (≥5 times per week, any hours per session), conventional home HD, quasi-intensive home HD, intensive home HD, peritoneal dialysis, deceased donor kidney transplantation, and living donor kidney transplantation.
  
  
  RESULTS
  Patient mortality, with a 3-month lag in primary analyses and 6- and 12-month lags in sensitivity analyses.
  
  
  RESULTS
  Conventional facility HD was the reference group. Conventional home HD had a similar mortality risk. For quasi-intensive home HD, mortality risk was lower (HR, 0.56; 95% CI, 0.44-0.73). For intensive home HD, mortality risk was nonsignificantly lower in primary analyses and significantly lower using a 6-month lag (HR, 0.41; 95% CI, 0.20-0.85), but not using a 12-month lag. For quasi-intensive facility HD, mortality risk was nonsignificantly lower in primary analyses, although significantly lower using 6- (HR, 0.41; 95% CI, 0.20-0.85) and 12-month lags (HR, 0.59; 95% CI, 0.44-0.80). Mortality risk was similar between intensive and conventional facility HD. For peritoneal dialysis, mortality risk was greater than for conventional facility HD (HR, 1.07; 95% CI, 1.03-1.12). Kidney transplantation had the lowest mortality risk.
  
  
  CONCLUSIONS
  Potential residual confounding from limited collection of comorbid condition, socioeconomic, and medication data.
  
  
  CONCLUSIONS
  There is an emerging HD dose-effect in Australia and New Zealand, with lower mortality risks associated with some of the more intensive HD regimens in these countries.
authors.affiliation: Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Department of Renal Medicine, Counties Manukau Health, Auckland, New Zealand; Baxter Healthcare (Asia Pacific), Shanghai, People's Republic of China. Electronic address: mrmarsh@woosh.co.nz.
authors.forename: Mark R
authors.initials: MR
authors.lastname: Marshall
authors.affiliation: Department of Nephrology, Monash Medical Centre, Clayton, Victoria, Australia; Department of Medicine, Monash University, Clayton, Victoria, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Clayton, Victoria, Australia; Department of Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia; Australia and New Zealand Dialysis and Transplant Registry (ANZDATA), The Royal Adelaide Hospital, Adelaide, South Australia, Australia.
authors.forename: Kevan R
authors.initials: KR
authors.lastname: Polkinghorne
authors.affiliation: Department of Nephrology, Monash Medical Centre, Clayton, Victoria, Australia; Department of Medicine, Monash University, Clayton, Victoria, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Clayton, Victoria, Australia; Department of Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia.
authors.forename: Peter G
authors.initials: PG
authors.lastname: Kerr
authors.affiliation: Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia; School of Medicine, University of Queensland, Princess Alexandra Hospital, Brisbane, Queensland, Australia.
authors.forename: Carmel M
authors.initials: CM
authors.lastname: Hawley
authors.affiliation: Renal Unit, Geelong Hospital, Barwon Health, Geelong, Victoria, Australia.
authors.forename: John W M
authors.initials: JW
authors.lastname: Agar
authors.affiliation: Australia and New Zealand Dialysis and Transplant Registry (ANZDATA), The Royal Adelaide Hospital, Adelaide, South Australia, Australia; School of Medicine, University of Adelaide, Adelaide, South Australia, Australia.
authors.forename: Stephen P
authors.initials: SP
authors.lastname: McDonald
mesh_terms: D000368:Aged; D001315:Australia; D015331:Cohort Studies; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000401:mortality* / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D009520:New Zealand; D006435:Renal Dialysis / Q000379:methods* / Q000401:mortality*; D012307:Risk Factors; D013997:Time Factors
keywords: ANZDATA (The Australia and New Zealand Dialysis and Transplant Registry); Intensive hemodialysis; dialysis modality; end-stage kidney disease (ESKD); facility hemodialysis; home hemodialysis; marginal structural analysis; multivariate analysis; patient mortality; peritoneal dialysis (PD); renal replacement therapy (RRT); temporal change