NDT Advance Access originally published online on January 27, 2007
Nephrology Dialysis Transplantation 2007 22(5):1399-1406; doi:10.1093/ndt/gfl809
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Staff-assisted nursing home haemodialysis: patient characteristics and outcomes
Rush University Medical Center, Section of Nephrology, and Circle Medical Management, Chicago, IL, USA
Correspondence and offprint requests to: Stephen M. Korbet, MD, 1426 W. Washington Blvd, Chicago, IL 60607, USA. Email: skorbet{at}aol.com
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Abstract |
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Background. The number of elderly patients undergoing chronic haemodialysis (HD) in the nursing home (NH) setting is growing; however, little published data exists on this group of patients.
Methods. We describe our experience with 271 patients undergoing staff-assisted HD in the NH setting from 1 January 2001 to 30 June 2004. Acceptance into the programme required that the patients were mentally responsive, haemodynamically stable without sepsis and not be considered terminal or in hospice.
Results. Mean age at entry was 70.5 ± 12.1 years, 53% were female, 54% were white and 34% black. Main causes of end-stage renal disease (ESRD) were diabetes mellitus (DM, 48%) and hypertension (HTN, 25%). Comorbid conditions included HTN-90%, DM-65%, coronary artery disease-54%, congestive heart failure-59%, cerebrovascular accident-31%, and 40% could not ambulate. The average time on chronic dialysis prior to entering the nursing programme was 18 ± 27 months, and the median time was 4 months (range: 0.1–191 months). The average time in the NH programme was 2.9 ± 3.6 months (median: 1.6 months, range: 0.1–24 months). During the study period 42% of the patients died, 37% were discharged from the NH, 4.4% withdrew from dialysis, and 16% remained active in the programme. Patient survival from entry into the NH programme was 82% at 1 month, 64% at 3 months, 38% at 6 months and 26% at 12 months (median survival of 4.1 months). However, the patient survival from initiation of chronic dialysis was 75% at 6 months, 66% at 12 months and 38% at 60 months with a median survival of 3.4 years. When evaluating patients based on the duration of chronic dialysis prior to entering the NH programme we found that established HD patients (on HD 
12 months prior to programme entry) had fewer myocardial infarctions (15 vs 26%, P = 0.05), more amputations (19 vs 8%, P = 0.01), higher creatinine (6.7 vs 4.7 mg/dl, P < 0.01), haemoglobin (11.1 vs 10.5 g/dl, P < 0.01) and albumin (3.2 vs 3.0 g/dl, P = 0.09) compared with new HD patients (on HD 
3 months prior to programme entry). New HD patients had a higher mortality rate (50 vs 31%, P < 0.01) and poorer median survival (3 vs 5 months, P < 0.01) than established HD patients.
Conclusion. NH dialysis provides a means for dialysing our most ill and debilitated patients in the convenience and comfort of the NH setting. The success of this programme is demonstrated by the fact that almost 40% of patients are successfully rehabilitated and discharged home. Nonetheless, healthcare providers and families must recognize that patients entering an NH HD programme are a high risk population with significant morbidity and mortality. Compared with established dialysis patients, patients entering the NH programme who are new to dialysis represent a particularly high risk group. However, it is likely that the poor survival seen in the NH programme may represent end of life care, as the overall survival from initiation of chronic dialysis in this population is consistent with that of patients entering the ESRD programme at a similar age.
Keywords: hemodialysis; Staff-assisted hemodialysis; nursing home dialysis; elderly
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Introduction |
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The population of patients in the end-stage renal disease (ESRD) programme in the United States has become increasingly older over the past 10 years. The median age of patients entering the ESRD programme has risen from 59 years in 1993 to 65 years in 2002 and 26% of patients are over the age of 75 [1,2]. As a result, it is no surprise that many elderly ESRD patients reside in extended care facilities. In 1999, over 16 000 (4.8%) of the dialysis population in the United States lived in a nursing home (NH) [1], with an estimated 2000–3000 haemodialysis (HD) patients entering an NH yearly [3].
Providing dialysis and caring for elderly NH patients presents a number of challenges. Elderly NH dialysis patients have significant morbidity and mortality [3–9] and require extra attention to meet their dialysis, dietary and social needs [8]. Additionally, transportation is a major issue for NH residents on HD in out-patient dialysis facilities. Transporting the elderly is often uncomfortable and inconvenient for elderly patients and time consuming, interfering with valuable rehabilitation needs, social interaction and meals [10–12]. Transporting patients to dialysis facilities is also costly, as many patients require special vans with wheelchair access and many must be transported by ambulance [10]. In order to alleviate the burden of transportation and to improve the quality of life of NH patients, dialysis programmes have begun exploring the delivery of dialysis in the NH setting.
Currently the experience with providing dialysis in the NH setting has been positive but small, and the largest experience has been with the use of peritoneal dialysis [3–5,13,14]. The experience with providing HD to these patients has been limited to hospital-based special care facilities [6,8]. To our knowledge, no study has examined the provision of HD in the NH setting. In order to better understand the characteristics and outcomes of elderly patients requiring HD in the NH setting, we present our experience over 3.5 years with staff-assisted NH HD.
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Methods |
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We retrospectively reviewed our experience with patients accepted into our staff-assisted NH HD programme from 1 January 2001 to 30 June 2004. The programme is comprised of five NHs located throughout Chicago, each with a designated area within the NH designed and equipped specifically for staff-assisted chronic HD. Nephrological care was provided by a carefully selected group of 10 nephrologists and overseen by one medical director. The nephrologists are required to see the patients within 1 week of entry into the programme and at least twice a month and they are on-call 24 h a day. The dialysis technicians providing the dialysis are required to have
3 years experience (median 12 years, range: 3–25 years) and there is a registered nurse on-staff in the NH who is available for any emergency. The NH staff, including nurses, is available to assist with the numerous non-dialysis patient issues. Entry into the programme required that the patients were mentally responsive, haemodynamically stable without sepsis and not be considered terminal or in hospice. The study was conducted by the Section of Nephrology of Rush University Medical Center and Circle Medical Management, Chicago, IL with approval from the Rush University Institutional Review Board. A total of 371 hospitalized patients met the criteria for acceptance into the NH dialysis programme but 75 (20%) patients never arrived for admission into the NH. The remaining 296 patients were admitted to the NH and entered the dialysis programme. Of the 296 patients entering the programme, 25 patients had insufficient records for review, leaving 271 patients with adequate information for this study. Data was collected from available 2728 forms, hospitalization records, and NH charts. The date of entry into the ESRD programme was obtained and the duration of chronic dialysis prior to entry into the NH programme was determined. Baseline characteristics (demographic, clinical and laboratory data) at entry into the NH dialysis programme were collected. Demographic variables included age, race, gender and ethnicity. Baseline clinical data included height, weight, body surface area, body mass index and type of dialysis access. The comorbid conditions assessed were coronary artery disease (CAD), coronary artery bypass graft surgery (CABG), myocardial infarction (MI), congestive heart failure (CHF), left ventricular hypertrophy (LVH), arrhythmias, pacemaker, cerebrovascular disease (CVD-stroke or transient ischaemic attack), peripheral vascular disease (PVD), amputations, chronic obstructive pulmonary disease (COPD), cancer, hypertension (HTN), diabetes mellitus (DM), obesity (body mass index (BMI) >30 kg/m2), inability to ambulate, history of smoking, alcohol or drug abuse, cirrhosis, systemic lupus erythematosus (SLE) or vasculitis, HIV, tuberculosis (TB), hepatitis B and C, severe infection within 3 months prior to entering the programme (including sepsis, pneumonia, cellulitis, infected decubitus ulcers, cholecystitis or diverticulitis) and respiratory failure. Laboratory data collected at entry included serum creatinine (n = 271), serum albumin (n = 261), haemoglobin (n = 269), calcium (n = 271), phosphorous (n = 259) and urea reduction ratio (URR) (n = 227). Erythropoietin was given subcutaneously three times weekly in 258 patients and the units (U) per treatment was calculated for these patients. For those patients who left the programme prior to their initial blood draw, labs from their most recent hospitalization were used. Follow-up data included time spent in the NH dialysis programme and the eventual outcome for each patient (death, discharge from the NH, withdrawal of HD or continuation in the programme). The cause of death was obtained from 2746 forms and NH charts.
We categorized patients based on the duration of dialysis prior to entering the NH programme: 3 months on dialysis—new HD (New-HD) patients (n = 128); 12 months on dialysis—established HD (Est-HD) patients (n = 106); >3 and <12 months on dialysis—intermediate HD (Int-HD) patients (n = 37). We evaluated for differences in presentation and outcome in patients entering the NH programme who were new to HD compared with established HD patients entering the programme.
Statistical analysis
Statistical analysis was performed using the unpaired t-test for continuous variables and Fisher's exact test for categorical data. Survival curves were created using the Kaplan–Meier method, and the comparison of curves was performed using the log-rank test. Results are reported as mean ± SD. Statistical significance was defined as P < 0.05.
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Results |
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All patients
Baseline clinical features
The average age of the group was 70.5 ± 12 years (median: 72.5, range: 29–90, 60% were 60–80 years), with 7% under the age of 50 and 23% of the patients over the age of 80 (Table 1). The majority of the patients were female (53%) and 54% were white. Blacks comprised 34% of patients and 10% of patients were Hispanic. The leading causes of ESRD were DM (48%) and HTN (25%). The average time on chronic dialysis prior to entering the programme was 18 ± 27 months, and the median time was 4 months (range: 0.1–191 months). A total of 47% of patients had been on dialysis
3 months prior to entering the programme and 39% had been on dialysis 12 months. The majority of patients had catheters (65%) as their vascular access while 30% had a functional arteriovenous (AV) accesses, and 5% had a catheter along with a maturing or non-functional AV access.
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Comorbid features
The most common comorbid conditions (Table 2) were HTN (90%) and DM (65%). Cardiac disease was extremely prevalent with CAD (54%) and CHF (59%) being the most common diagnoses. A cardiac arrhythmia was present in 35% of patients and 11% of patients had pacemakers. Nearly a third (31%) of the group had cerebrovascular disease. PVD was present in 37% of patients and 13% had a limb amputation. Only 60% of patients were able to ambulate. An infection within 3 months prior to starting the programme was observed in 31% of the patients. COPD was present in 19% of patients and 9% of the patients had a recent history (within 3 months) of respiratory failure requiring mechanical ventilation (15 patients had tracheostomies with eight still requiring ventilatory support). Overall, patients had 6.0 ± 2.5 comorbid conditions and 24% had
8 comorbidities.
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Laboratory features
The serum creatinine on entry into the programme was 5.7 ± 2.4 mg/dl (504 ± 212 µmol/l, Table 3). The serum albumin was 3.1 ± 0.5 g/dl (31 ± 5 g/l) with 25% of patients having an albumin level
3.5 g/dl (35 g/l) and only 4% with a level 4.0 g/dl (40 g/l). The average haemoglobin was 10.7 ± 1.7 g/dl (107 ± 17 g/l), and 41% of patients achieved a haemoglobin of 11.0 g/dl (110 g/l) while only 15% of patients had a haemoglobin concentration of 9.0 g/dl (90 g/l). The calcium-phosphorous product was 39 ± 15 and was >55 in only 15% of the patients. The URR was 66.5 ± 10%, and 64% of the group had a URR 65%. A URR > 65% was attained in 66% of patients with an AVF/G and in 61% of patients with catheters (P = NS).
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Outcome
The average time in the NH was 2.9 ± 3.6 months (Table 4) with a median time of 1.6 months (range: 0.1–24). During this time, 42% of patients died, 37% were successfully discharged from the NH and transferred to an out-patient dialysis centre, 4% withdrew from dialysis, and 16% remained active in the programme. Of all the patients, 60% died from cardiac arrest and an additional 10% died from cardiac and respiratory failure (Table 5). The patient survival from entry into the NH programme (Figure 1) was 82% at 1 month, 64% at 3 months, 38% at 6 months and 26% at 12 months with a median survival of 4.1 months. The patient survival from the time a patient was started on dialysis (Figure 2) was 75% at 6 months, 66% at 12 months and 38% at 60 months with a median survival of 3.4 years.
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New vs established dialysis patients
Baseline clinical and comorbid features
There were no differences in baseline clinical features (Table 6) between new HD and established HD patients with respect to age, gender, ethnicity, or causes of ESRD. However, new patients were more likely to have only a catheter as the dialysis access (89% vs 35%, P < 0.01) and less likely to have a functioning AV access (5 vs 62%, P < 0.01) than established HD patients. Patients new to HD had been on dialysis 0.9 ± 0.7 months and established patients 43 ± 29 months prior to entry in the NH programme.
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The proportion of patients with various comorbidities (Table 7) was similar between the new and established HD patients with the exception that patients new to HD were more likely to have a history of MI (26 vs 15%, P = 0.05), a recent serious infection (34 vs 22%, P = 0.04), and alcohol abuse (13 vs 2%, P = 0.002) than established HD patients. However, a larger proportion of established patients had a history of an amputation (19 vs 8%, P = 0.01) than new HD patients. The average number of comorbid conditions per patient was similar among new and established HD patients (6.2 ± 2.4 vs 5.8 ± 2.5, P = NS) as were the proportion of patients with
8 comorbidities (26 vs 22%, P = NS).
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Baseline laboratory features
The serum creatinine, haemoglobin and calcium levels were significantly higher at entry into the programme in established HD patients compared with new HD patients (Table 8). A haemoglobin concentration of >11 g/dl (110 g/l) was observed in 48% of established HD patients compared with 35% (P = 0.06) of new HD patients despite similar doses of erythropoietin. While the serum albumin concentration was also higher in established patients, this did not reach statistical significance. However, significantly fewer new HD patients had a serum albumin
3.5 g/dl (35 g/l) compared with established HD patients (20 vs 34%, P = 0.02). Phosphate and calcium phosphate products were similar among the two groups as were the proportion of patients with calcium phosphate products >55 (11% for new vs 18% for established HD patients, P = NS). There were no differences in the URR between the new and established HD patients or in the percentage of patients in each group with a URR 65% (62 vs 68%, P = NS).
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Outcomes
The follow-up time in the NH programme was similar among the two groups (Table 9). During that time, more new HD patients died (50 vs 31%, P = 0.01), and fewer were discharged from the NH and transferred to an out-patient dialysis centre (28 vs 48%, P = 0.01). No differences were observed in the proportion of patients who withdrew from dialysis or of those who remained active in the programme, and the causes of death were similar between the two groups. The patient survival from entry into the NH programme (Figure 3) for new HD patients was 77% at 1 month, 57% at 3 months, 30% at 6 months and 20% at 12 months with a median survival of 3.4 months. For established HD patients, it was 92% at 1 month, 76% at 3 months, 50% at 6 months and 36% at 12 months with a median survival of 5.1 months (P < 0.01). The patient survival for patients on dialysis >3 months but <12 months (intermediate HD patients) was 74% at 1 month, 51% at 3 months, 34% at 6 months and 23% at 12 months with a median survival of 3.5 months (P = 0.01 vs established HD patients and NS vs new HD patients, data not shown).
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Discussion |
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The ESRD population has grown rapidly over the last 20 years from 76 669 patients in 1982 to over 430 000 patients in 2002 and the proportion of patients
65 years of age has increased from 21 to 35% [1,15]. In fact, in 2002, 50% of the 100 359 patients entering the ESRD programme were 65 years of age and 26% were 75 years of age [1,15]. The primary form of dialysis utilized by patients in this age group is HD, at 95% with only 5% of patients on peritoneal dialysis. It has been estimated that almost 5% of the ESRD population resided in NHs in 1999 [1,15]. As the number of elderly patients on dialysis increases, a larger portion of the ESRD population will require NH care. Despite this ever increasing demand on dialysis providers to care for patients residing in the NH setting, there is a paucity of information regarding the characteristics and outcomes of this population of patients and even less information on the delivery of dialysis in the NH [3]. The few studies that specifically address the delivery of dialysis to NH patients have been limited to small numbers of patients provided either peritoneal dialysis in the NH [4,5,9,1314] or HD in a special dialysis care unit located within a hospital setting [6]. Our study is the first to assess the delivery of staff-assisted HD to a large population of patients in the NH setting. We find that while these patients are older, with a large number of comorbid conditions, they are able to be adequately dialysed. Despite the ability to provide adequate dialysis care, this population of patients has a high rate of mortality, particularly in patients new to dialysis, who initiated renal replacement therapy within 3 months prior to admission into the NH. Nonetheless, we believe that staff-assisted HD delivered in the NH setting provides a life-saving measure to the oldest and most debilitated ESRD patients in an environment of comfort and convenience. Our population of NH patients is representative of ESRD patients residing in NHs reported by the United States Renal Data System (USRDS), even though the USRDS only includes patients on chronic dialysis for >90 days while our study includes all patients from the time chronic dialysis was initiated [1,15]. The average age of the patients in our NH programme is 10 years older than that of the ESRD patients in general of 60 years old and is identical with that of NH ESRD patients reported by the USRDS of 70 ± 12 years [1,15]. As in our programme, the USRDS finds that the racial distribution is similar between NH and USRDS patients with white patients comprising 59% and black patients 36% of NH patients reported by the USRDS. Also consistent with our observations, the USRDS reports that ESRD patients residing in NHs are more often female (57 vs 45% for USRDS overall) and have DM as the primary diagnosis for ESRD (52 vs 33% for USRDS overall) compared with the overall USRDS population. Thus, the demographics of our NH patients are consistent with that of dialysis patients residing in NHs reported by the USRDS.
NH ESRD patients have significant morbidity. Compared with the USRDS population overall, NH patients are much more likely to have DM (50–75 vs 47% USRDS), CAD (47–73 vs 25% USRDS), and CVD (22–41 vs 9% USRDS) [1,3–5,8,15]. PVD is seen in 35–55% of NH patients compared with 14% of USRDS and 19–25% of NH patients have amputations [1,4,5,8,15]. Not only do NH patients have a higher proportion with any given comorbid condition, but as we have shown, patients commonly have a number of comorbidities. Similarly, Jassal et al. [6], found their NH dialysis population had 2.9 ± 1.4 severe comorbid conditions with 85% of patients having 2 severe comorbidities. Thus, ESRD patients residing in NHs have significant morbidity.
As a result of the older age and multiple comorbidities, NH patients are functionally dependent individuals whose care is more demanding than the typical ESRD patient. They have significant physical and cognitive impairments in comparison with other ESRD patients. While over 95% of ESRD patients reported by the USRDS [15] can ambulate, over 44% of ESRD patients residing in NHs are unable to ambulate (and this is consistent with our findings) and 25% cannot even transfer from a bed to a chair [1,8,15]. Furthermore, mental disability is a frequent problem with dementia, reported in 20–36% of NH patients on dialysis, and almost 60% of these patients have moderate to severely impaired decision-making ability [1,4,15]. Thus, NH patients can be demanding on dialysis and NH staff, and they require significantly more social service involvement [8].
Complicating the care of NH ESRD patients is the high rate of catheter usage. Several studies [6,8] have found that over 60% of NH patients have a catheter as the primary access for HD compared with 26% in the USRDS population overall [1,15]. This leads to an increased risk for catheter-related infections and problems with inadequate dialysis from poor blood flows and contributes to the increased intensity of care required by these patients [8]. The high catheter use, as well as the higher likelihood of hypotension, may impact on the ability to attain adequate dialysis. In one study [8], NH patients were almost three times as likely to have intradialytic hypotension requiring an intervention than other patients (36 vs 13%, P < 0.05). Despite these potential problems, we found that adequate dialysis was achievable in almost two-thirds of patients with no difference based on the type of access used. In assessing adequacy of anaemia management and nutrition status, we found that while the level of haemoglobin was <11 g/dl (110 g/l) and serum albumin was <3.5 g/dl (35 g/l) in the majority of patients at entry into the NH programme, the average values for these patients were consistent with that reported by the USRDS for patients of a similar age [i.e. haemoglobin 10.1 g/dl (101 g/l] and serum albumin 3.1 g/dl (31 g/l)] [15].
The length of stay for ESRD patients in the NH is short, averaging 3.4–5.9 months in most studies [4–6,14] and 2.9 months in our experience. Despite this short stay, it is not surprising that mortality rates are high, ranging from 35 to 63% of patients [4–6], given the elderly patient population with numerous comorbid conditions. Almost 40% (35–37%) of patients are discharged home [4–6]. The patient survival from entry into the NH programme at 3, 6 and 12 months was 64, 38 and 26% in our experience and this is consistent with that observed in two studies of NH patients on peritoneal dialysis [4,5]. Carey et al. [5], reported a patient survival of 50% at 6 months and 40% at 12 months while Anderson et al. [4], reported the survival at 6 and 12 months of 52 and 37%. However, when patient survival is assessed from the time of entry into the ESRD programme as done by Anderson et al. [3], the patient survival rates at 1, 2, 3 and 5 years were 83, 63, 45 and 24%, respectively, which is comparable with the dialysis population in general. Our observations are consistent with this as well. In fact, the median patient survival of 3.4 years seen in our patients compares with a median life expectancy for dialysis patients reported by the USRDS ranging from 3.6 years for patients 65–69 years of age to 2.6 years for patients 75–79 years of age [1,15]. Thus, it has been suggested that the poor survival observed in the NH setting may merely represent end of life care for this group of elderly dialysis patients [3].
When we evaluated patients entering the NH programme who were new to dialysis (3 months), we found the outcome was significantly worse than for patients who were established on dialysis (>12 months) prior to entering the programme. New dialysis patients entering the programme had a greater likelihood of dying in the NH (50 vs 33%, P = 0.005) and were less likely to be discharged home (28 vs 48%, P = 0.0018) compared with patients established on dialysis prior to entering the NH programme. The median patient survival in the programme for new patients was 3.4 months compared with 5.1 months for established patients. While patients starting dialysis 3 months prior to entering the NH programme were considered as having chronic kidney disease that progressed to ESRD, the apparent sudden need for dialysis, most likely a result of an acute medical event, is reflected in the high rate of catheters being used for vascular access (95 vs 38%) compared with established patients. The increased mortality for new patients may be a result of increased morbidity as reflected in the fact that new patients had a higher proportion of patients with myocardial infarctions, recent infections, and had lower serum albumin levels than established dialysis patients. Additionally, new patients had lower haemoglobin levels than established patients despite receiving similar doses of erythropoietin, and this has been shown to be a marker of greater comorbidity as well [16]. Established dialysis patients were more likely to have had PVD and significantly more amputations, possibly reflecting less severe morbidity and a primary need for rehabilitation services. Thus, ESRD patients entering the NH programme who are new to dialysis have significantly more morbidity and mortality than established dialysis patients. The poorer prognosis observed in this group of elderly patients must be taken into account by healthcare workers, families and patients when decisions for initiating chronic dialysis are being made.
NH patients requiring chronic dialysis are older and sicker than the overall ESRD population which makes caring for these patients uniquely challenging. Unfortunately, a proven model to best care for these patients is not known. NH dialysis provides a means for dialysing our most ill and debilitated patients in the convenience and comfort of the NH setting. The success of this programme is demonstrated by the fact that almost 40% of patients are successfully rehabilitated and discharged home. Nonetheless, healthcare providers and families must recognize that patients entering an NH HD programme are a high risk population with significant morbidity and mortality. Compared with established dialysis patients, patients entering the NH programme who are new to dialysis represent a particularly high risk group. However, it is likely that the poor survival seen in the NH programme may represent end of life care as the overall survival from initiation of chronic dialysis in this population is consistent with that of patients entering the ESRD programme at a similar age.
Conflict of interest statement. None declared.
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Accepted in revised form: 12.12.06
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