TOPLINE: 

Patients with end-stage renal disease who presented to the emergency department (ED) after missing hemodialysis sessions showed distinct clinical and social risk factors, including higher rates of severe electrolyte abnormalities and longer travel times to dialysis centers, a study finds.

METHODOLOGY:

• Researchers conducted a prospective case-cohort study at a single urban academic ED and included 129 adults (mean age, 60 years; 54% women; 91% Black individuals; 83% publicly insured individuals) with end-stage renal disease who received outpatient hemodialysis between 2022 and 2023.
• Patients were categorized as having missed hemodialysis (n = 66) if they missed at least one session in the previous 7 days or as being adherent (n = 63) if they had not missed any sessions over that period. Data on clinical characteristics, demographics, and the ED course were extracted from electronic records.
• Participants completed validated surveys assessing social determinants of health, substance use, and health-related quality of life and were asked about barriers to hemodialysis adherence. A retrospective chart review was conducted at 30 days and 12 months post-enrollment to capture acute care utilization.
• The primary outcome was the comparison of clinical and social risk factors between the groups, and secondary outcomes included ED revisits within 12 months of the index visit.

TAKEAWAY:

• Patients who missed hemodialysis had significantly higher laboratory values — including higher serum potassium levels (5.3 vs 4.7 mmol/L; P < .001), blood urea nitrogen levels (76.4 vs 43.8 mmol/L; P < .001), and creatinine levels (12.1 vs 7.4 mmol/L; P < .001) — than those who were adherent. They also more frequently required treatment for hyperkalemia, including calcium gluconate (30% vs 6%; P = .001), intravenous insulin (33% vs 3%; P < .001), albuterol (29% vs 8%; P = .005), and furosemide (30% vs 8%; P = .003).
• Patients who missed hemodialysis had higher rates of prior ED visits for dialysis-related issues (58% vs 37%; P = .03) and multiple missed sessions in the previous month (43% vs 17%; P = .005).
• Transportation barriers were prominent among patients who missed hemodialysis. Among these patients, 30% reported travel times ≥ 30 minutes, whereas only 8% of patients who were adherent reported travel times of the same duration (P = .004).
• Patients who missed hemodialysis had more ED revisits at 12 months than those who were adherent (3.2 vs 2.1); however, the difference was not statistically significant.

IN PRACTICE:

"ED patients with ESRD [end-stage renal disease] who miss hemodialysis differ from adherent patients in both clinical and social risk factors. Targeted interventions that address barriers such as transportation and psychosocial needs may improve adherence and reduce repeat ED utilization in this high-needs population," the authors wrote.

SOURCE:

The study was led by Christopher Payette, MD, The George Washington University School of Medicine and Health Sciences, Washington, DC. It was published online on December 24, 2025, in The American Journal of Emergency Medicine.

LIMITATIONS: 

The study was conducted at a single urban academic ED, potentially limiting generalizability. Patient screening occurred only on weekdays, possibly missing eligible patients. The modest sample size restricted the statistical power to detect less common outcomes such as ICU admission or mortality. Data on arrhythmias requiring intervention or emergency dialysis initiation were not captured. Self-reported reasons for missed sessions may have been subject to recall and social desirability biases.

DISCLOSURES:

The study did not receive any external funding. The authors reported having no conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.