Background Life-sustaining hemodialysis (HD) is onerous for patients, especially those with multiple co-morbidities and advanced age. A standard HD prescription is 720 minutes per week. Alternative HD regiments have been proposed in attempt to maintain quality of life (QOL). Studies are needed to investigate the efficacy and safety of less frequent HD prescriptions in this population. This is an institution-wide observational study in New Brunswick, Canada to compare HD prescriptions and the impact on QOL and mortality.

Objective The purpose of this study is to assess the current HD prescribing practices at a provincial healthcare institution in relation to patient QOL.

Design Prospective Observational Study.

Setting Single centre hospital and satellite hemodialysis units.

Patients Voluntarily consented patients undergoing in-centre hemodialysis treatment.

Measurements Observational clinical data was collected for each study participant from their hospital and dialysis electronic medical records. The KDQOL-36TM questionnaire was used to assess patient-reported quality of life at the time of consent.

Methods Adults undergoing in-centre or satellite site HD for at least 3 months were eligible to participate. Consenting patient participants were grouped by HD prescription whether they were prescribed 720 minutes or more per week or less than 720 minutes per week. All participants completed the KDQOL-36 TM questionnaire to estimate QOL and groups were compared using the Mann-Whitney U statistical test. Emergency department visits, hospitalizations, and mortality were analyzed using a negative binomial regression or a logistic regression.

Results We enrolled 140 patient participants; 41 were undergoing less than 720 minutes per week of HD and 99 were undergoing 720 minutes or more of HD per week. Patients who were undergoing less than 720 minutes per week of HD were older [Median (IQR): 76 (72- 81) yrs. vs. 64 (55 - 75) yrs.; p < 0.001], had higher median (IQR) QOL scores on the ‘Symptoms/ Problems List’ scale on the KDQOL-36 TM questionnaire [79.2 (70.8 – 88.5 vs. 70.8 (62.5 – 81.3); p = 0.0022], and were less likely to present to the emergency department (incident rate ratio 0.52, 95% confidence interval [CI] 0.33-0.81). Mortality was similar between groups, even when adjusted for age and comorbidity score (odds ratio 1.62, 95% CI 0.59-4.49).

Limitations Patient participant enrollment was limited by the single centre nature of this study. As this was an observational study, we did not account for how long the patients had been prescribed less than 720 minutes of hemodialysis. We did not include a frailty assessment of the study participants. A higher number of study participants may have identified significant trends in mortality.

Conclusions The results of this study show that patients undergoing less than 720 minutes of weekly HD had a higher QOL score for the ‘KDQOL-36 TM ‘Symptoms/ Problems List’ scale, were less frequently in the emergency department and were not more likely to die than patients undergoing 720 minutes or more of weekly HD. Further studies are required to assess the feasibility and safety of a conservative model of HD prescribing to improve QOL of patients with palliative care treatment goals.

The authors have declared no competing interest.

This study was supported by funding, in part, by a Clinical Scholarship awarded to MGM from the New Brunswick Health Research Foundation (currently named Research NB) and by funding from the Saint John Regional Hospital Foundation.

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

Yes

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

This study was reviewed and approved by the Horizon Health Network Research Ethics Board (RS#: 2023-3305).

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Yes

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I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

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The authors are willing to share the de-identified data used in the analyses for this study, upon reasonable request.