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Bliwise DL, Kutner NG, Zhang R, Parker KP. Survival by Time of Day of Hemodialysis in an Elderly Cohort. JAMA. 2001;286(21):2690–2694. doi:10.1001/jama.286.21.2690
Author Affiliations: Departments of Neurology (Dr Bliwise) and Rehabilitation Medicine (Dr Kutner), School of Medicine, Department of Biostatistics, Rollins School of Public Health (Ms Zhang), and Department of Adult and Elder Health, Nell Hodgson School of Nursing (Dr Parker), Emory University, Atlanta, Ga.
Context Patients with end-stage renal disease (ESRD) typically undergo hemodialysis
(HD) during the morning or afternoon, with time of treatment generally based
on space availability or patient preference. No studies have investigated
variation in patient survival as a function of the time of day when they receive
Objective To investigate the association of elderly patients' HD treatment shift
with their continued survival, controlling for well-established HD-related
mortality risk factors.
Design, Setting, and Participants An 11-year follow-up cohort study conducted among 242 ESRD patients
aged 60 years or older who underwent HD at 58 dialysis facilities in Georgia
either during a morning shift (n = 167) or an afternoon shift (n = 75) and
who completed baseline (1998) and follow-up (1991) interviews.
Main Outcome Measure Mortality from all causes occurring through July 7, 1999, as verified
by death-certificate reviews, and compared by morning vs afternoon-shift HD.
Results Morning-shift HD patients survived significantly longer than afternoon-shift
patients (median survival, 941 days vs 470 days; P<.001).
A Cox proportional hazards model indicated that the morning shift was protective
(relative risk, 0.71; 95% confidence interval, 0.53-0.95) independent of age,
race, sex, body mass index, functional status, diabetic ESRD, cardiovascular
comorbidity, weekly hours of dialysis, and months of dialysis.
Conclusions Possible explanations for differential survival in association with
morning vs afternoon dialysis include salutary effects of sleep in the morning
or less efficient biochemical exchange during afternoon dialysis. Results
from this cohort study may warrant prospective observational studies and randomized
clinical trials that systematically alter the time of day at which HD is administered.
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