Skipped treatments, markers of nutritional nonadherence, and survival among incident hemodialysis patients.

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).
CONCLUSION: 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.