Hospitalizations are frequent among dialysis patients, and reducing repeat hospitalizations could decrease costs and improve outcomes. Chan et al. found that hemoglobin monitoring along with erythropoietin-stimulating agent dose modification and vitamin D administration reduced the risk of repeat hospitalization. These and other interventions, especially those related to close monitoring immediately after hospitalization and better communication between hospital and dialysis providers to assure continuity of care, should be further explored in observational or randomized studies

Jaar, Bernard G.

Plantinga, Laura C.

Elsevier - Publisher Connector 

commentar y
Kidney International (2009) 76    249
 accurately assessed and is actually under-
estimated. Inevitably, regular follow-up 
visits, emergency assessment of sympto-
matic patients, periodic 12-lead electrocar-
diographic recordings, and 24-h Holter 
recordings have a low yield of AF detection 
given that many episodes are brief and 
asymptomatic. ; e exact AF burden over 
long time periods can be reliably assessed 
only in patients with implanted modern 
pacemakers and implantable cardioverter 
de brilators  able to record atrial high-rate 
episodes. Another issue that needs further 
clari cation in future studies is the relative 
signi cance of di4 erent types of AF. In the 
general population it is now well established 
that paroxysmal AF carries the same risk in 
terms of morbidity and mortality compared 
with persistent and permanent AF. Whether 
there is a similar risk in the setting of ESRD 
is uncertain. ; e di4 erences in the underly-
ing etiology and pathophysiology may 
imply di4 erent e4 ects on morbidity and 
mortality. For instance, the acute changes 
in electrolyte levels and especially the rela-
tive hypokalemia have been associated with 
brief paroxysmal AF episodes. 3 
 ; e pathophysiology of AF in ESRD is 
complex ( Figure 1 ). It should be recognized 
that ESRD  per se is associated with volume 
overload and neurohormonal alterations 
(mainly activation of the sympathetic system 
and the renin – angiotensin – aldosterone sys-
tem) that promote ventricular hypertrophy 
and dilation as well as increased le/  atrial 
size and pressure. 3 Inevitably, these abnor-
malities contribute to the structural and 
electrical remodeling of the atria. In addi-
tion, inM ammation and  oxidative stress have 
been implicated in the pathophysiology of 
ESRD and represent major mechanisms of 
cardiovascular dysfunction in this setting. 
Recently, AF has been associated with 
inM ammation and oxidative stress, and much 
of the current interest regarding pharma-
cologic therapy has shi/ ed to non-channel-
blocking drugs with pleiotropic properties. 
Whether these interventions have a speci c 
value in ESRD patients is unknown. 
 In conclusion, AF is prevalent among 
ESRD patients, representing an additional 
threat in this frail population. Undoubt-
edly, further larger studies with longer 
 follow-up are needed in order to elucidate 
the impact of AF on various clinical 
parameters, as well as the role of di4 erent 
 prognostic factors and therapeutic modal-
ities in this setting. Finally, the  clari cation 
of the complex underlying pathophysiol-
ogy may favor the development of e4 ective 
preventive and  treatment strategies. 
 DISCLOSURE 
 The authors declared no competing interests. 
 REFERENCES 
 1 .  Shik  J ,  Parfrey  PS .  The clinical epidemiology of 
cardiovascular disease in chronic kidney disease . 
 Curr Opin Nephrol Hypertens  2005 ;  14 :  550 – 557 . 
 2 .  Remppis  A ,  Ritz  E .  Cardiac problems in the dialysis 
patients: beyond coronary disease .  Semin Dial 
 2008 ;  21 :  319 – 325 . 
 3 .  Korantzopoulos  P ,  Kokkoris  S ,  Liu  T  et al.  Atrial 
fibrillation in end-stage renal disease .  Pacing Clin 
Electrophysiol  2007 ;  30 :  1391 – 1397 . 
 4 .  Reinecke  H ,  Brand  E ,  Mesters  R  et al.  Dilemmas in 
the management of atrial fibrillation in chronic 
kidney disease .  J Am Soc Nephrol  2009 ;  20 :  705 – 711 . 
 5 .  Genovesi  S ,  Vincenti  A ,  Rossi  E  et al.  Atrial 
fibrillation and morbidity and mortality in a cohort 
 Hospitalizations are frequent for end-
stage renal disease (ESRD) patients treated 
with dialysis. In 2006, dialysis patients 
averaged nearly two hospital admis-
sions per patient-year. 1 Furthermore, 
hospitalizations of ESRD patients cost the 
US health-care system  $ 31.5 billion 
between 2002 and 2006, which repre-
sented more than one-third of the total 
costs of treating ESRD over this time 
period. 1 Many of these hospitalizations 
were probably repeat hospitalizations, 
defined as hospitalizations that occur 
within a short period (for example, 
30 days) following a previous hospitaliza-
tion. Preventing such repeat admissions 
 1 Department of Epidemiology, Johns Hopkins 
Bloomberg School of Public Health ,  Baltimore , 
 Maryland ,  USA ;   2 Department of Medicine, Johns 
Hopkins University School of Medicine ,  Baltimore , 
 Maryland ,  USA  and   3 Nephrology Center of 
Maryland ,  Baltimore ,  Maryland ,  USA 
 Correspondence: Laura C. Plantinga, San Francisco 
General Hospital, 1001 Potrero Avenue, Building 10, 
Floor 3, San Francisco, California 94110, USA, 
E-mail:  plantingal@medsfgh.ucsf.edu 
 Preventing repeat hospitalizations 
in dialysis patients: a call for action 
 Laura C.  Plantinga 1 and  Bernard G.  Jaar 1 , 2 , 3 
 Hospitalizations are frequent among dialysis patients, and reducing repeat 
hospitalizations could decrease costs and improve outcomes. Chan  et al. 
found that hemoglobin monitoring along with erythropoietin-stimulating 
agent dose modification and vitamin D administration reduced the risk of 
repeat hospitalization. These and other interventions, especially those 
related to close monitoring immediately after hospitalization and better 
communication between hospital and dialysis providers to assure continuity 
of care, should be further explored in observational or randomized studies. 
 Kidney International (2009)  76, 249 – 251.  doi: 10.1038/ki.2009.145 
see original article on page 331
of long-term hemodialysis patients .  Am J Kidney 
Dis  2008 ;  51 :  255 – 262 . 
 6 .  Iguchi  Y ,  Kimura  K ,  Kobayashi  K  et al.  Relation of 
atrial fibrillation to glomerular filtration rate .  
 Am J Cardiol  2008 ;  102 :  1056 – 1059 . 
 7 .  Vazquez  E ,  Sanchez-Perales  C ,  Garcia-Garcia  F  
 et al.  Atrial fibrillation in incident dialysis patients . 
 Kidney Int  2009 ;  76 :  324–330 . 
 8 .  Wiesholzer  M ,  Harm  F ,  Tomasec  G  et al.  Incidence 
of stroke among chronic hemodialysis patients 
with nonrheumatic atrial fibrillation .  Am J Nephrol 
 2001 ;  21 :  35 – 39 . 
 9 .  Abbott  KC ,  Trespalacios  FC ,  Taylor  AJ  et al.  Atrial 
fibrillation in chronic dialysis patients in the 
United States: risk factors for hospitalization and 
mortality .  BMC Nephrol [online]  2003 ;  4 :  1 . 
 10 .  Go  AS ,  Fang  MC ,  Udaltsova  N  et al.  Impact of 
proteinuria and glomerular filtration rate on risk 
of thromboembolism in atrial fibrillation: the 
anticoagulation and risk factors in atrial fibrillation 
(ATRIA) study .  Circulation  2009 ;  119 :  1363 – 1369 . 
 11 .  Genovesi  S ,  Valsecchi  MG ,  Rossi  E  et al.  Sudden 
death and associated factors in a historical cohort 
of chronic haemodialysis patients .  Nephrol Dial 
Transplant  advance online publication, 16 March 
2009; doi:10.1093/ndt/gfp104 . 
commentar y
250   Kidney International (2009) 76 
would reduce overall costs due to hospi-
talization and would also likely increase 
the overall health of the dialysis patient, as 
each  hospitalization can have adverse 
consequences, including worsening ane-
mia, 2 malnutrition, infection, and, possi-
bly, in-hospital mortality. In addition, 
reducing repeat hospitalizations could 
potentially dramatically increase dialysis 
patients ’ quality of life, which may be as 
important as health outcomes from the 
perspective of patients and their families. 
 Chan  et al. 3 (this issue) describe the 
association of early post-hospitalization 
intervention with reduced risk of repeat 
hospitalization in a large observational 
cohort of prevalent hemodialysis patients 
receiving treatment at facilities managed 
by a national dialysis provider. ; e authors 
found that, a/ er hospitalization, hemo-
globin, albumin, phosphorus, calcium, 
parathyroid hormone, and dry weight 
were all signi cantly decreased relative to 
pre-hospitalization values. Although 
decreases in hemoglobin clearly represent 
worsening anemia, the picture is more 
complicated for decreases in the other 
examined markers during hospitalization. 
For example, a decrease in phosphate 
 during hospitalization would be problem-
atic only in the setting of hypophos-
phatemia, which is less common than 
 hyperphosphatemia among dialysis 
patients. In addition, the e4 ect of decreased 
oral intake and possible lack of nutritional 
support during hospitalization on the 
observed decreases in albumin, phospho-
rus, calcium, and dry weight — relative to 
the e4 ect of discontinuation of or change 
from usual pre-hospitalization therapy 
during hospitalization — is unknown. 
 Chan  et al. 3 also found that patients 
who had their hemoglobin monitored and 
their dosage of erythropoietin-stimulating 
agent modi ed were at 16 % reduced risk 
of repeat hospitalization; vitamin D 
administration was associated with a 6 % 
reduced risk. Target dry weight modi ca-
tion and monitoring of bone mineral 
metabolism markers were not associated 
with reduced risk of repeat hospitaliza-
tion. ; e e4 ects of these interventions 
were somewhat modest in reducing the 
risk of repeat admissions from any cause, 
probably because of the nonspeci city of 
the outcome to the intervention. Although 
the most common causes of repeat admis-
sion are not listed by Chan  et al. , 3 they 
were likely similar to those reported for 
new hospitalizations, that is, infection and 
vascular access problems. ; e association 
of decreased hemoglobin with increased 
risk of repeat admission due to anemia, 
for example, may have been stronger. ; e 
bene cial e4 ects of vitamin D administra-
tion on speci c causes of repeat hospitali-
zation are less clear. 
 ; ere are several post-hospitalization 
interventions, in addition to those 
reported by Chan  et al. , 3 that could be 
explored to help reduce repeat admis-
sions. In addition, some interventions or 
preventive measures could be undertaken 
earlier, during the initial hospitalization, 
to prevent repeat hospitalizations. A rep-
resentation of a comprehensive process of 
care for prevention of repeat hospitaliza-
tions is shown in  Figure 1 . For worsening 
anemia, which could lead to repeat hos-
pitalizations due to the anemia itself or 
associated morbidities, not only admin-
istration of an erythropoietin-stimulating 
agent but also intravenous iron, as appro-
priate, could be considered interventions. 
 Figure 1  |  Process of care for preventing repeat hospitalizations in dialysis patients. Ca, calcium; ESA, erythropoietin-stimulating agent; 
iPTH, intact parathyroid hormone; i.v., intravenous; PO 4 , phosphate. 
Adverse outcome
During hospitalization After hospitalization
Prevention/intervention
Worsening anemia
Malnutrition Nutritionist consult
Assess dry weight,
limit i.v. fluid
↑ ESA; i.v. iron
Infection
Medication
side effects/
interactions
Volume overload
Mineral metabolism
disorders
Monitor hemoglobin; ↑ ESA;
i.v. iron
Dietician follow-up,
monitor serum albumin
Adjust dry weight as
needed
Flu/pneumococcal
vaccination as
appropriate
Obtain medication list
from primary care
provider or dialysis clinic
Contact hospital for
treatment information
(drug name, dose, course);
monitor and continue
as needed
Monitor Ca, PO4,
iPTH; reassess vitamin D,
PO4 binder
Reassess PO4
binder and vitamin D
Reconcile medication after 
discharge (e.g., blood pressure
medications)
commentar y
Kidney International (2009) 76    251
Both require the monitoring of hemo-
globin and iron pro le immediately a/ er 
hospitalization, which in itself could be 
considered an intervention but was not 
performed for more than one-quarter of 
the patients in the study by Chan  et al. 3 
Malnutrition could be prevented or alle-
viated through nutritional interventions 
(hospital nutritional consults,  dietary 
 supplements, and post-hospitalization 
follow-ups by a dialysis clinic dietician) 
and by close monitoring of serum albu-
min. Volume overload could be prevented 
by limiting intravenous M uid during the 
hospital stay and by continual reassess-
ment and adjustment of dry weight, both 
during and a/ er hospitalization. Worsen-
ing of mineral metabolism disorders 
could be monitored through measure-
ment of calcium, phosphate, and intact 
parathyroid hormone; assessment and 
adjustment of vitamin D levels during 
and soon a/ er hospitalization; and reas-
sessment of phosphate binder use during 
and a/ er hospitalization. Monitoring of 
vascular access, as well, has been shown 
to be associated with better clinical out-
comes 4 and could be continued during 
and a/ er hospitalization to prevent repeat 
admissions due to this very common 
cause of hospitalization in hemodialysis 
patients. 1 For all of these adverse out-
comes, regular monitoring and reassess-
ment of indicated markers during and 
immediately a/ er hospitalization would 
provide better  continuity of care from the 
inpatient to the outpatient setting, which 
has been associated with increased risk of 
medical errors that could lead to repeat 
hospitalization. 5 
 Communication between the hospital 
and the dialysis provider is another very 
important category of intervention that 
could be addressed in chronically ill and 
often debilitated dialysis patients. For 
example, infections in the hospital would 
be treated as part of usual care, but, before 
discharge, the hospital could contact the 
dialysis clinic and provide timely and 
important information on the treatment 
course (for example, antibiotic name, dos-
age, and length of treatment) and contin-
ued monitoring. In this example, such 
timely communication is an intervention 
that could certainly help prevent recurrent 
infection and might help prevent repeat 
admission due to inadequate treatment. 
In fact, availability of discharge summa-
ries has been associated with decreased 
risk of hospital readmission in the general 
population. 6  In addition, hospital provid-
ers could access dialysis patients ’ outpa-
tient records and administer inM uenza 
and pneumococcal vaccinations as needed 
to prevent respiratory tract infections. 
Medication errors and adverse drug events 
a/ er hospitalization have been shown to 
be associated with discontinuity of care 
and readmissions. 5,7,8 For example, in 
dialysis patients, blood pressure medica-
tions that are similar to those taken by the 
patient as part of usual outpatient care 
may be prescribed by the hospital pro-
vider, which may lead the patient to 
unknowingly take two similar medica-
tions upon discharge and increase the risk 
of adverse side e4 ects, with sometimes 
severe consequences. Such errors could be 
prevented by improvement of communi-
cation between the hospital and dialysis 
providers during hospitalization and 
 reconciliation of medication records a/ er 
discharge using the discharge summary. 9 
Regular and timely multidisciplinary con-
ferences on dialysis patients a/ er hospi-
talization could also help prevent repeat 
hospitalization by reassessing the patient 
plan of care, including medications. Previ-
ous studies have shown that this type of 
patient-care conference is associated with 
better patient outcomes, including an 
increased chance of meeting the albumin 
clinical performance target, decreased 
hospitalization, and decreased risk of 
mortality. 10 
 Chan  et al. 3 have published a well-
conducted study that is a  rst examination 
of the important issue of preventing repeat 
hospitalizations of dialysis patients 
through appropriate intervention. Future 
studies could focus on additional possible 
areas of intervention, including better 
monitoring and reassessment of other 
health indicators and better communica-
tion between the hospital and dialysis pro-
vider to provide continuity of care and 
prevent medical errors. Examination of 
associations between interventions and 
cause-speci c hospitalizations would also 
be of great interest. Additional observa-
tional studies would add to and strengthen 
existing evidence. However, such studies 
always have the limitations of possible 
residual confounding and selection bias. 
; us, other study designs should be con-
sidered, such as pre- / post-intervention 
studies or even randomized clinical trials 
(examining the intervention versus usual 
care), which would provide more  de nitive 
evidence of the e4 ect of interventions on 
repeat hospitalizations. Con rmation of 
the e4 ect of interventions in such studies 
could lead to improved outcomes for dial-
ysis patients and lower costs for the health-
care  system. 
 DISCLOSURE 
 The authors declared no competing interests. 
 REFERENCES 
 1 .  United States Renal Data System .  2008 Annual 
Data Report: Atlas of Chronic Kidney Disease and 
End-Stage Renal Disease in the United States . 
 National Institutes of Health, National Institute 
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Bethesda, Maryland, USA,  2008 . 
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 Erythropoietin requirements increase following 
hospitalization in end-stage renal disease patients . 
 Am J Nephrol  2001 ;  21 :  390 – 396 . 
 3 .  Chan  KE ,  Lazarus  JM ,  Wingard  RL  et al.  Association 
between repeat hospitalization and early 
intervention in dialysis patients following hospital 
discharge .  Kidney Int  2009 ;  76 :  331–341 . 
 4 .  Plantinga  LC ,  Jaar  BG ,  Astor  B  et al.  Association 
of clinic vascular access monitoring practices 
with clinical outcomes in hemodialysis patients . 
 Nephron Clin Pract  2006 ;  104 :  c151 – c159 . 
 5 .  Moore  C ,  Wisnivesky  J ,  Williams  S  et al.  Medical 
errors related to discontinuity of care from an 
inpatient to an outpatient setting .  J Gen Intern 
Med  2003 ;  18 :  646 – 651 . 
 6 .  van Walraven  C ,  Seth  R ,  Austin  PC  et al.  Effect of 
discharge summary availability during post-
discharge visits on hospital readmission .  J Gen 
Intern Med  2002 ;  17 :  186 – 192 . 
 7 .  Forster  AJ ,  Murff  HJ ,  Peterson  JF  et al.  Adverse drug 
events occurring following hospital discharge .  
 J Gen Intern Med  2005 ;  20 :  317 – 323 . 
 8 .  Vira  T ,  Colquhoun  M ,  Etchells  E .  Reconcilable 
differences: correcting medication errors at 
hospital admission and discharge .  Qual Saf Health 
Care  2006 ;  15 :  122 – 126 . 
 9 .  Ledger  S ,  Choma  G .  Medication reconciliation in 
hemodialysis patients .  CANNT J  2008 ;  18 :  41 – 43 . 
 10 .  Plantinga  LC ,  Fink  NE ,  Jaar  BG  et al.  Frequency 
of sit-down patient care rounds, attainment of 
clinical performance targets, hospitalization, 
and mortality in hemodialysis patients .  J Am Soc 
Nephrol  2004 ;  15 :  3144 – 3153 . 


Preventing repeat hospitalizations in dialysis patients: a call for action 

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Preventing repeat hospitalizations in dialysis patients: a call for action

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