Changing hemodialysis thresholds for optimal survival

The urea reduction ratio (URR), a measure quantitating solute removal during hemodialysis, is the fractional reduction of the blood urea concentration during a single hemodialysis treatment. The URR is the principal measure of hemodialysis dose in the United States. Based on studies of patients dialyzed prior to 1994, a minimum URR value of 65% was recommended to optimize survival. Because of new hemodialysis technologies and evolving demographics of the hemodialysis population, the relationship between the amount of hemodialysis and mortality was examined in contemporary cohorts.

This retrospective cohort included> 15,000 patients per year receiving hemodialysis during 1994 through 1997. Each patient's URR was averaged for the three months prior to the beginning of each year. Mortality odds ratios were calculated for patients by URR. To determine the URR value above which no further improvement in mortality was seen ("threshold"), spline functions were tested in logistic regression models, both unadjusted and adjusted for case mix measures. The strength of fit for URR, defined by a range of candidate thresholds from 55 to 75%, was evaluated in increments of 1% for each year using spline functions.

The median URR was 63.2, 65.4, 67.4, and 68.1% for 1994 through 1997, respectively. The median length of hemodialysis treatments increased only six minutes from the beginning to the end of the period of analysis. Using spline functions, the threshold URR values were 61.1, 65.0, 68.0, and 71.0% for 1994 through 1997 in models adjusted for case mix. The ratio of median URR to URR threshold decreased from 1.03 in 1994 to 0.97 in 1997.

From 1994 to 1997, the median URR and the URR threshold for mortality benefit increased. Although an increased need in the amount of hemodialysis may be a consequence of changes in patients' demographic characteristics, the likely explanation(s) is a change in the dialysis procedure and/or blood sampling favoring higher URR values without changing the amount of dialysis provided. The recommended minimum URR of 65% appears to be too low to confer an optimal mortality benefit in the context of current practices.