NDT Advance Access published December 8, 2013

Nephrol Dial Transplant (2013) 0: 110

doi: 10.1093/ndt/gft472

Original Article
Two-times weekly hemodialysis in China: frequency, associated
patient and treatment characteristics and quality of life in the
China dialysis outcomes and practice patterns study
1

Arbor Research Collaborative for Health, Ann Arbor, MI, USA,

Brian Bieber1*,
Jiaqi Qian2,*,

Renal Division, Renji Hospital, Shanghai Jiaotong University School

Shuchi Anand3,

Division of Nephrology, Stanford University School of Medicine,

Palo Alto, CA, USA,

Yucheng Yan ,

Department of Nephrology, Ruijin Hospital, Shanghai Jiaotong

Nan Chen4,

University School of Medicine, Shanghai, China,

Mia Wang1,

Peoples Hospital, Peking University, Beijing, China,

Peking University First Hospital, Beijing, China,

Mei Wang5,

Institute of Nephrology, Peking University, Beijing, China and

Li Zuo6,7,

Division of Nephrology, Nanfang Hospital, Southern Medical

University, Guangzhou, China

Fan Fan Hou ,

Ronald L. Pisoni1,
Bruce M. Robinson1
and Sylvia P.B. Ramirez1

Keywords: hemodialysis adequacy, hemodialysis frequency,

outcomes, practice patterns, quality of life

Correspondence and offprint requests to: B. Bieber;

E-mail: brian.bieber@arborresearch.org
*
Co-rst author.

DOPPS countries (collected 200911). Among China DOPPS

patients, logistic and linear regression were used to describe
the association of dialysis frequency with patient and treatment characteristics and quality of life.
Results. A total of 26% of the patients in China were dialyzing
two times weekly, compared with < 5% in other DOPPS regions.
Standardized Kt/V was lowest in China (2.01) compared with
other regions (2.122.27). Female sex, shorter dialysis vintage,
lower socioeconomic status, less health insurance coverage, and
lack of diabetes and hypertension were associated with dialyzing
two times weekly (versus three times weekly). Patients dialyzing
two times per week had longer treatment times and lower
standardized Kt/V, but similar quality of life scores.
Conclusions. Two-times weekly dialysis is common in China,
particularly among patients, who started dialysis more recently,

A B S T R AC T
Background. Renal replacement therapy is rapidly expanding
in China, and two-times weekly dialysis is common, but
detailed data on practice patterns are currently limited. Using
cross-sectional data from the China Dialysis Outcomes and
Practice Patterns Study (DOPPS), we describe the hemodialysis practice in China compared with other DOPPS countries,
examining demographic, social and clinical characteristics of
patients on two-times weekly dialysis.
Methods. The DOPPS protocol was implemented in 2011
among a cross-section of 1379 patients in 45 facilities in
Beijing, Guangzhou and Shanghai. Data from China were
compared with a cross section of 11 054 patients from the core
The Author 2013. Published by Oxford University Press on
behalf of ERA-EDTA. All rights reserved.

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of Medicine, Shanghai, China,

have a lower comorbidity burden and have nancial constraints.

Quality of life scores do not differ between the two-times and
three-times weekly groups. The effect on clinical outcomes
merits further study.

ORIGINAL ARTICLE

INTRODUCTION
The prevalence of chronic kidney disease (CKD) in China
approaches that of the United States [1]. The use of renal replacement therapy (RRT) for patients reaching end-stage renal
disease (ESRD) is rising rapidly: in Shanghai, the incidence of
RRT more than doubled between 2000 and 2005 [2]. Though
there are regional variations, a majority of patients with ESRD
are on hemodialysis (HD) [3]. However, data on HD practice
and outcomes remain sparse.
The recently launched Chinese Renal Data System and published data from city registries have reported that a signicant
proportion of patients are on two-times weekly HD [2, 46].
Given that patients may shoulder a signicant share of cost for
HD care in China [7], complex factorssuch as patients comorbidity burden, residual function, preference to start HD
gradually and insurance statusmay underlie a decision to pursue
two-times weekly dialysis. The effect on Chinese patients healthrelated quality of life (HR-QOL) and survival is unknown.
Using cross-sectional data from the China Dialysis Outcomes and Practice Patterns (DOPPS) study, we describe the
current state of HD in China in comparison with other
DOPPS countries. We also tested the hypothesis that the
decision to pursue two-times weekly HD would be related to
both clinical and economic factors. As such, we expected that
patients with lower comorbidity burden, greater residual function, shorter dialysis vintage (i.e., years since initiation of
dialysis) and greater share of cost for treatment would be more
likely to undergo two-times weekly HD. Despite attempts to
select a healthier group of patients for less frequent dialysis,
we expected that this group would face a greater likelihood of
inadequate dialysis therapy and require strict diet restrictions.
We therefore hypothesized that this group would exhibit poorer
control of anemia and markers of mineral-bone disease, and
experience worse quality of life [8, 9].

R E S U LT S
Facility and patient characteristics
Of the 45 sampled facilities from the three metropolitan
areas in China (Beijing, Guangzhou and Shanghai), 23 were
academic or military facilities and 22 were non-academic
facilities. On average, the Chinese facilities treated a comparable number of HD patients (95) to facilities in Japan (97). In
contrast, facilities in North America and Europe-Australia/
New Zealand (EUR-A/NZ) treated substantially fewer patients
on average (72) (Table 1).
Compared with study patients in the other DOPPS regions,
the Chinese patients were younger, more likely to be female
and less likely to have diabetes as the cause of ESRD (Table 1).
Time on dialysis in China was comparable with that in North
America and Eur-A/NZ, but shorter than in Japan. The
average body mass index (BMI) among patients in China was
similar to that in Japan but lower than in North America and
Eur-A/NZ.

M AT E R I A L S A N D M E T H O D S
Patients and data collection
Begun in 1996, the DOPPS is an international prospective
cohort study of HD patients 18 years of age in Australia,
Belgium, Canada, France, Germany, Italy, Japan, New
Zealand, Spain, Sweden, the United Kingdom and the United
States (core DOPPS countries). Patients in the DOPPS are selected randomly from a representative sample of HD facilities
within each nation [10, 11]. In 2011, cross-sectional data were
collected in China using the baseline DOPPS questionnaires
and study protocols. Due to feasibility considerations, the
China study was limited to representative data from the metropolitan areas in the three largest cities in China (Beijing,
Guangzhou and Shanghai). These cities were identied based
2
B. Bieber et al.

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on feasibility of data collection and availability of registry

information should a comparison between DOPPS and registry data be required. In each metropolitan area, 15 HD facilities were randomly selected from a comprehensive roster of
HD units (total selected Chinese HD facilities = 45). Study approval and patient consent were obtained as required by national and local ethics committee regulations.
A study coordinator at each participating site collected
clinical data. At the time of patient enrollment, the study coordinator abstracted demographic data, comorbid conditions,
laboratory values, insurance status and medications from
patient records. Practice-level data were obtained through a
survey administered to the medical director at each facility.
Individual patients completed a questionnaire that included
the Kidney Disease Quality of Life-Short Form (KDQOL-SF)
12 and questions related to socioeconomic status [12, 13].
Single-pool Kt/V was calculated using the Daugirdas formula
among patients dialyzing 3 per week for at least 1 year. To
account for patients dialyzing at a frequency other than three
times per week, a standardized Kt/V was calculated from the
equation reported by Leypoldt et al. [14]. Normalized protein
catabolic rate (nPCR) was calculated by the equations reported
by Depner and Daugirdas [15].
Data from 10 947 patients sampled in the DOPPS 4 prevalent cross section of HD patients in the core DOPPS countries
between 2009 and 2011 were compared with data from 1379
prevalent Chinese patients collected in 2011. Standard
descriptive analyses were used to characterize the DOPPS
patients and practices in each country as well as within China,
by frequency of dialysis. Generalized estimating equation
(GEE) models with a logit link were used to describe the
adjusted association of patient characteristics with two-times
(versus three-times) per week HD, accounting for facility clustering. Mixed models were used to describe the adjusted
association between HD frequency and laboratory values and
quality of life, accounting for facility clustering. All analyses
used SAS software, version 9.2 (SAS Institute, Cary, NC).

Table 1. Facility and patient characteristics by region

China

Japan

North America

Eur-A/NZe

Facility, n

45

60

167

157

Facility size

95 (74)

97 (73)

72 (53)

71 (35)

Facility size, range

21379

20411

20294

21216

Study population, n

1379

1587

5106

4361

Age, years

59.4 (14.6)

64.7 (12.0)

62.9 (15.1)

65.9 (14.7)

Female, %

46.6

37.3

44.5

40.7

4.8 (4.6)

8.5 (7.5)

4.0 (4.2)

5.0 (5.7)

62

51.5

46.8

56.8

21.9 (3.5)

21.1 (3.3)

28.5 (7.0)

26.0 (5.5)

Diabetes

20.2

31.7

42.5

25.0

Glomerular disease

46.1

44.8

11.3

19.7

Other

33.8

23.5

46.2

55.3

Coronary heart disease

38.3

32.8

48.5

38.8

Congestive heart failure

31.5

21.0

35.5

20.9

Cerebrovascular disease

17.8

15.7

18.0

18.0

Peripheral vascular disease

10.8

19.8

34.9

34.9

Other cardiovascular disease

28.0

32.5

29.6

34.5

Diabetes

24.0

35.2

61.2

36.1

Hypertension

89.5

79.6

93.6

84.3

# Prescribed HD sessions/week

2.76 (0.55)

2.96 (0.21)

2.98 (0.24)

3.03 (0.33)

Dialysis session length, min

243 (22)

237 (29)

218 (34)

245 (39)

Blood ow rate, mL/min

235 (30)

202 (29)

413 (68)

317 (57)

1.38 (0.31)

1.42 (0.26)

1.59 (0.27)

1.58 (0.31)

29.1

19.3

6.5

9.6

2.01 (0.41)

2.12 (0.28)

2.23 (0.28)

2.27(0.32)

42.8

25.3

13.8

14.3

4.1 (2.0)

3.9 (1.7)

3.1 (1.7)

2.8 (1.6)

Fistula

88.0

90.7

57.8

69.7

Graft

1.8

7.0

17.5

7.3

Catheter

10.2

2.3

24.7

23.1

Measure
Facility characteristics

Patient demographics

Time on dialysis, years

a

Urine output >1 cup/day, %

BMI, kg/m

Cause of ESRD, %

Dialysis prescription

Single-pool Kt/V

Single-pool Kt/V <1.2, %

Standardized Kt/V

Standardized Kt/V <2.0

Intra-dialytic weight loss, %

Vascular access, %

Continued

3
China DOPPS dialysis adequacy and vascular access

ORIGINAL ARTICLE

Comorbidities, %

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Comorbidities

Table 1. Continued
China

Japan

North America

Eur-A/NZe

Pre-dialysis

49.2 (22.1)

66.5 (15.4)

55.9 (18.7)

62.0 (20.2)

Post-dialysis

15.7 (9.8)

21.3 (7.0)

15.1 (7.2)

17.2 (8.8)

nPCR, g urea nitrogen/kg/day

0.80 (0.31)

1.01 (0.21)

0.96 (0.26)

1.08 (0.28)

Urea reduction ratio, %

67.8 (10.4)

67.9 (7.2)

73.3 (7.4)

72.7 (8.5)

9.0 (1.0)

9.2 (0.8)

9.2 (0.7)

9.2 (0.8)

Serum albumin, g/dL

3.9 (0.5)

3.7 (0.4)

3.8 (0.4)

3.7 (0.5)

Serum PTH, pg/mL

386 (410)

167 (161)

350(315)

312 (302)

Serum phosphorus, mg/dL

6.1 (2.1)

5.5 (1.4)

5.3 (1.6)

5.0 (1.6)

Hemoglobin, g/dL

10.5 (2.0)

10.4 ((1.2)

11.5 (1.2)

11.5 (1.4)

Physical component summary

36.2 (9.2)

42.5 (10.0)

35.4 (10.7)

34.9 (10.6)

Mental component

43.8 (9.3)

43.4 (9.3)

47.4 (10.8)

44.7 (12.4)

Measure
Labs
BUN, mg/dL

Serum calcium, mg/dL

ORIGINAL ARTICLE

EUR-A/NZ, Europe-Australia/New Zealand; BMI, body mass index; ESRD, end-stage renal disease; HD, hemodialysis; BUN, blood urea
nitrogen; nPCR, normalized protein catabolic rate; PTH, parathyroid hormone.
Mean values are shown with (standard deviation) in parentheses; all values missing for <10% of patients in China with the exception of single-pool
Kt/Vb (39%), and standardized Kt/Vc (45%), post-dialysis BUN (31%), albumin adjusted calcium (15%), PTH (23%) and quality of life (22%).
a
Restricted to patients having ESRD <1 year.
b
Restricted to patients having ESRD 1 year, and received 3 HD sessions per week; single-pool Kt/V was calculated using the Daugirdas formula.
c
To account for patients dialyzing at a frequency other than 3 per week, a standardized Kt/V was calculated from the equation reported by
Leypoldt et al. [14].
d
Albumin-adjusted calcium.
e
The European DOPPS countries include Belgium, France, Germany, Italy, Spain, Sweden, and the United Kingdom.

Among patients on HD for at least 1 year who dialyzed

three times per week, mean single-pool Kt/V in Chinese facilities (1.38) was lower than that seen in other DOPPS regions,
and for these patients, more had Kt/V < 1.2 in China (29%)
than in other DOPPS countries (Table 1). Accounting for
number of sessions per week, the average standardized Kt/V
was lowest in China (2.01) compared with other DOPPS
regions (2.122.27), and China had the highest proportion
of patients with a standardized Kt/V < 2.0 (43 versus 1425%).

Dialysis access and prescription

A native arteriovenous (AV) stula for HD access was used
by 88% of China DOPPS patients compared with 91% in Japan,
58% in North America and 70% in Eur-A/NZ (Table 1). The
mean number of prescribed HD sessions per week was lower in
China (2.8) than in the other DOPPS countries (range 3.03.1)
(Table 1, Figure 1A). Twenty-six percent of HD patients in
China were dialyzing less than three times weekly (88% of this
group were undergoing two-times weekly dialysis) compared
with 16% in other DOPPS countries. The median Chinese facility reported 26% of patients dialyzing less than three times
weekly (22% two times weekly) compared with a range of 04%
for the median facility in other DOPPS countries (Figure 1B).
The mean HD session length in Chinese facilities (243 min)
was comparable with that in Eur-A/NZ (245 min) and Japan
(237 min) but higher than that in North America (218 min)
(Table 1). Session length did not vary greatly among Chinese
facilities, with half of all Chinese facilities reporting a mean treatment time of 240 min, the fourth highest among the DOPPS
countries. The mean blood ow rate of 235 mL/min was somewhat higher than in Japan (202 mL/min) but markedly lower
than in North America (414) and Eur-A/NZ (317) (Table 1).

Laboratory values and quality of life

Pre-dialysis blood urea nitrogen (BUN) was markedly
lower in the China DOPPS patients (49.2 mg/dL) than in
other DOPPS regions (range, 55.966.5 mg/dL) (Table 1).
nPCR was lower in China (0.8) than in other DOPPS regions
(0.961.08). Serum phosphorus (6.1 mg/dL), serum albumin
(3.9 g/dL) and intra-dialytic weight loss (IDWL, 4.1%) were
higher in China than in other DOPPS regions. Average hemoglobin levels in China (10.5 g/dL) were comparable with Japan
(10.4) but lower than in Eur-A/NZ and North America (11.5).
Overall, the quality of life in China was similar when compared with other DOPPS regions.
4

B. Bieber et al.

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Quality of Life

ORIGINAL ARTICLE

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F I G U R E 1 : Frequency of dialysis sessions/week by country: (A) patient frequency categories, (B) distribution of facility % of patients dialyzing

<3 per week. Among facilities with at least 7 patients with non-missing frequency data.

Characteristics of patients on two-times weekly

HD in China
Restricting to patients dialyzing two or three times per
week in China (95% of the China DOPPS sample), patients
dialyzing two times weekly were more likely to be female, had
shorter vintage (23% were on dialysis for < 1 year) and were
more likely to have residual urine output (Table 2). They also
had a lower comorbidity burden, particularly of diabetes, hypertension and coronary heart disease. Patients with <12 years
of education, those bearing higher out-of-pocket costs (Table 2
footnote) or without national health insurance coverage were
much more likely to receive two-times weekly HD, whereas
patients who had retired or had close to full coverage from the
national health insurance were much less likely to be on twotimes weekly HD. Finally, lack of sufcient HD station
capacity was rare in China (only cited by 3 of 44 medical directors in a survey regarding facility practices and resources) and
was not associated with patients receiving two-times weekly
HD (P = 0.63).

Dialysis-related prescriptions, laboratory values and

quality of life associated with two-times weekly HD
in China
Patients dialyzing two times weekly (versus three times) in
China were much more likely to be prescribed session lengths
>270 or 300+ min (Table 3). On a weekly basis, these patients
were dialyzed for an average of 8.4 h compared with 12.0 h for
patients dialyzing three times weekly. Average blood ow rates
and vascular access were similar. Patients dialyzing two times
weekly (versus three times) in China had similar erythropoietinstimulating agent prescription rates (95%) but were less likely to
be prescribed intravenous iron (33 versus 43%), vitamin D
(48 versus 60%) or a phosphate binder (52 versus 60%).
Chinese patients dialyzing two times weekly had substantially lower mean weekly clearance (Table 4, standardized
Kt/V difference = 0.67) and nPCR (0.16 g urea nitrogen/
kg/day). They also had lower levels of serum calcium (0.26),
with a suggestion of higher average serum phosphorous levels
and parathyroid hormone (PTH) levels and lower hemoglobin.
5
China DOPPS dialysis adequacy and vascular access

Table 2. China DOPPS: Patient characteristics associated with odds of dialyzing two times versus
three times per week
Mean (SD) or %

Odds ratio: 2 sessions per week versus 3

Patient characteristics

2 per week
(n = 304)

3 per week
(n = 982)

Unadjusteda,
OR (95% CI)

Adjustedb,
OR (95% CI)

Age, years [OR per 10 years]

59.0 (15.2)

59.6 (14.4)

0.95 (0.861.05)

1.12 (0.99,1.26)

Female, %

52.0

44.6

1.31 (1.071.62)*

1.28 (1.06,1.54)*

3.51 (3.54)

5.16 (4.82)

0.91 (0.860.95)*

0.94 (0.90,0.98)*

BMI, kg/m

21.6 (3.4)

21.9 (3.6)

0.98 (0.951.01)

0.99 (0.96,1.02)

Urine output >200 mL/day, %

52.5

25.1

3.39 (2.334.93)*

2.92 (1.92,4.43)*

<12 years education

14.8

8.7

1.48 (1.072.04)*

1.55 (1.08,2.21)*

20.1

10.1

1.13 (0.791.63)

1.07 (0.74,1.54)

53.3

70.8

0.48 (0.350.65)*

0.55 (0.39,0.77)*

26.6

19.0

(ref)

(ref)

No national insurance

7.9

2.0

4.45 (2.139.33)*

2.49 (1.04,5.92)*

Nat. ins. coverage <50%

5.0

3.2

2.34 (0.955.75)

1.89 (0.74,4.87)

Nat. ins. coverage 5084%

24.8

18.6

2.03 (1.382.99)*

1.44 (0.96,2.17)

Nat. ins. coverage 8594%

29.7

32.9

(ref)

(ref)

Nat. ins. coverage 95+%

25.4

36.1

0.67 (0.480.95)*

0.69 (0.48,0.99)*

Coronary heart disease

34.9

39.7

0.78 (0.611.00)

1.03 (0.78,1.36)

Congestive heart failure

30.6

32.3

0.94 (0.681.30)

0.97 (0.72,1.29)

Cerebrovascular disease

16.4

18.5

0.80 (0.531.18)

0.92 (0.60,1.42)

Peripheral vascular disease

10.2

10.8

0.92 (0.581.45)

1.12 (0.65,1.93)

Other cardiovascular disease

25.7

28.8

0.85 (0.621.16)

1.02 (0.71,1.47)

Diabetes

16.9

26.1

0.54 (0.390.75)*

0.49 (0.34,0.71)*

Hypertension

85.5

90.9

0.51 (0.320.81)*

0.51 (0.31,0.83)*

Dialysis vintage, years

2

Employment status
Unemployed
Retired
Employed and other

ORIGINAL ARTICLE

Health insurance

d,e

Comorbidities, % [OR yes versus no]

Mean values are shown with (standard deviation) in parentheses.

a
Accounting for facility clustering.
b
Adjusted for variables listed in Table 1.
c
Other employment status includes employed full time (7%), employed part time (7%), homemaker(7%) and disabled (0.1%).
d
7% of patients were missing data on the % of national health insurance.
e
Patient-reported out-of-pocket medical healthcare costs were 2588 versus 1831 yuan for two-times weekly versus three-times weekly HD
(unadjusted OR = 1.01 per 100 yuan, 95% CI = 1.00, 1.02, P < 0.01). Out-of-pocket healthcare costs were calculated as the sum of monthly
dialysis, supplemental insurance, prescription medication and non-prescription medication costs. Out-of-pocket healthcare costs were
highly correlated with level of national insurance coverage so only insurance coverage was included as covariate in table.
*P < 0.05.

Serum levels of albumin among patients dialyzing two

times weekly were comparable with those dialyzing three times
per week. There was no meaningful difference in reported
quality of life for patients dialyzing two times versus three times
weekly.

DISCUSSION
We report data on patient characteristics, and HD access and
prescription practices from a representative sample of 45 HD
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Table 3. China DOPPS: Dialysis session prescription patterns in patients dialyzing two times versus
three times per week
Mean (SD) or %

Odds ratio (OR) or difference (): 2

(versus 3)

Dialysis session prescriptions

2 per week
(n = 304)

3 per week
(n = 982)

Unadjusteda,
OR or (95% CI)

Adjustedb,
OR or (95% CI)

Session length, min (OR: >240 versus 240)

253 (28)

240 (17)

5.55 (2.8810.68)*

6.82 (2.9715.63)*

< 240 min

240 min

65

88

270 min

10

300+ min

20

Blood ow rate, mL/min

233 (33)

235 (28)

+0.2 (3.0,3.4)

+0.4 (2.9,3.7)

Catheter use, % (OR: versus stula)

11

10

1.00 (0.681.47)

0.64 (0.381.09)

Mean (SD)

Difference (): 2 (versus 3)

Outcome measures

2 per week
(n = 304)

3 per week
(n = 982)

Unadjusteda,
(95% CI)

Adjustedb,
(95% CI)

Urea reduction ratio, %

69.1 (11.4)

67.4 (10.0)

+2.02 (0.39,3.66)*

+0.29 (1.45,2.02)

1.45 (0.19)

2.11 (0.26)

0.67 (0.72, 0.62)*

0.73 (0.77, 0.69)*

Intradialytic weight loss, %

4.1 (2.5)

4.1 (1.8)

0.02 (0.28,0.25)

+0.25 (0.03,0.52)

nPCR, g urea nitrogen/kg/day

0.68 (0.24)

0.83 (0.32)

0.13 (0.17, 0.09)*

0.16 (0.20, 0.11)*

8.7 (1.1)

9.1 (1.0)

0.35 (0.49, 0.21)*

0.26 (0.42, 0.10)*

Serum albumin, g/dL

4.0 (0.5)

3.9 (0.5)

+0.06 (0.01,0.12)

+0.03 (0.03,0.10)

Serum PTH, pg/mL

398 (425)

376 (408)

+20.6 (44.2,85.4)

+65.3 (5.3,135.9)

Serum phosphorus, mg/dL

6.3 (2.3)

6.0 (2.1)

+0.22 (0.07,0.51)

+0.25 (0.08,0.57)

Hemoglobin, g/dL

10.2 (2.2)

10.6 (2.0)

0.31 (0.57, 0.04)*

0.23 (0.53,0.07)

QoL: SF-12 physical component

summary

36.7 (9.5)

36.1 (9.1)

+0.78 (0.57,2.14)

0.61 (2.03,0.82)

QoL: SF-12 mental component

summary

43.4 (9.0)

43.8 (9.5)

0.24 (1.61,1.14)

1.13 (2.72,0.45)

Standardized Kt/V

Serum calciumAlb, mg/dL

Mean values are shown with (standard deviation) in parentheses.

a
Accounting for facility clustering.
b
Adjusted for variables listed in Tables 2 and 3, but not other variables in Table 4.
c
To account for patients dialyzing at a frequency other than 3 per week, a standardized Kt/V was calculated from the equation reported by
Leypoldt et al. [14].
d
Albumin-adjusted calcium.
*P < 0.05.
7
China DOPPS dialysis adequacy and vascular access

ORIGINAL ARTICLE

Table 4. China DOPPS: Laboratory values and quality of life in patients dialyzing two times versus
three times per week

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Mean values are shown with (standard deviation) in parentheses.

a
Accounting for facility clustering.
b
Adjusted for variables listed in Table 2 and all other treatment variables listed in Table 3.
*P < 0.05.

ORIGINAL ARTICLE

treatment may be an important method of defraying direct

and indirect (travel) costs. These constraints, not experienced
by patients living in most other established DOPPS countries,
are the likely basis for the frequency decision in a majority of
cases. Our data on medications support this conclusion.
Despite laboratory values demonstrating equivalent to slightly
poorer control of mineral bone disease and anemia among
patients undergoing two-times weekly HD, this group was
much less likely to be taking phosphate binders, vitamin D
analogs or iron than the group undergoing three-times weekly
HD. This discrepancy again points to potential nancial
constraints that may limit access to a variety of treatments
in the two-times weekly group.
In the United States, the National Kidney Foundation/
Kidney Disease Outcomes Quality Initiative clinical practice
guidelines recommend at least three-times weekly HD for
individuals with <3 mL/min/1.73 m2 of residual kidney urea
clearance [16]. Aside from necessitating stricter restrictions on
uid and electrolyte intake, two-times weekly HD can be
expected to increase time-average urea concentrations and
attenuate clearance of solutes with small volume of distribution [17].
Clinical data on the effect of less frequent HD are sparse.
Lin et al. [5] reported that patients on two- or three-times
weekly HD had equivalent survival over a period of 2 years,
even for the subgroup on dialysis for >5 years. Another study
from Taiwan examined preservation of renal function among
23 patients undergoing two-times weekly HD compared with
51 patients undergoing three-times weekly HD [18]. After 18
months of follow-up, the study reported a slower decline in
renal function for two-times weekly patients, and similar nutrition and bone parameters in the two groups. In our study as
well, standardized Kt/V was signicantly lower among patients
undergoing two-times weekly HD. There was a suggestion of
poorer laboratory indicators (including hypocalcemia, hyperphosphatemia and anemia) among patients undergoing twotimes weekly HD, which could reect inadequacies in the
delivered dose of dialysis but must be interpreted with caution
given that this group was also less likely to be taking supporting medications. The lower nPCR measurement among
patients in the two-times weekly group also indicated that
patients were either following more strict protein restrictions
or were more malnourished, but their HR-QOL did not differ
from the patients undergoing three-times weekly HD.
These data raise the question of whether two-times weekly
HD may be appropriate for a select group, particularly given
the resource constraints of low- and middle-income countries.
However, a major methodological concern is confounding-byindication, as a selected healthier group may be prescribed
less-frequent HD, and the observed equivalent outcomes may
simply be a reection of their underlying health and not an
evaluation of the dialysis prescription per se.
A longer and appropriately powered study examining survival, hospitalizations and HR-QOLcontrolling for factors
such as age, comorbid conditions, residual function and HD
adequacycan answer the question of whether less frequent
(but longer) prescriptions can support some Chinese patients to
yield outcomes that approach those with three-times per week
8

B. Bieber et al.

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units in three major Chinese metropolitan areas. To our

knowledge, these are the rst analyses that utilize comparable
data collection methods in China and other countries, allowing us to present systematic comparisons in practice patterns
between the three cities in China and other DOPPS countries.
Preliminary ndings suggest important differences in the
patient population as well as HD-prescribing practices in
China compared with other DOPPS countries.
Chinese patients were younger, had smaller body size as
measured by BMI and experienced a generally lower co-morbidity
burden, when compared with other DOPPS countries. The
proportion with diabetic nephropathy was also lower than other
DOPPS countries. A majority of Chinese patients used a native
AV stula for HD therapy, while the prescribed access blood
ow rate was considerably lower in Chinese HD facilities than
that seen in other DOPPS countries, with the exception of
Japan. Most strikingly, at least a quarter of Chinese patients
underwent HD two times weekly compared with fewer than
5% in most DOPPS countries. Furthermore, 29% of Chinese
patients dialyzing three times per week achieved a Kt/V < 1.2
compared with at or below 10% in the majority of DOPPS
countries.
The sizeable fraction of patients undergoing two-times
weekly HD in our study is consistent with that reported by
single city registry data in China. Twenty-eight percent of
registered Beijing patients were undergoing two-times weekly
HD in 2002, according to the Beijing Hemodialysis Quality
Control and Improvement Center [4]. The 2005 Shanghai
Dialysis Registry reported patients were dialyzing for an
average of 2.6 times per week, similar to the 2.8 times per week
observed in our study [2].
One Chinese study limited to Shanghai has previously
characterized this population of patients undergoing twotimes weekly HD. Lin et al. [5] followed 2500 patients in
Shanghai for a period of 2 years. In their cohort, patients on
two-times (versus three times) weekly HD were younger, had
lower body surface area, shorter vintage on HD and higher
serum albumin concentrations. Similarly, in our study, patients
on two-times weekly HD had shorter vintage, greater residual
function and a lower comorbidity burden. We also found that
women were more likely to be prescribed this frequency, and
we hypothesize that this may be due to their smaller body size.
Their ndings as well as ours indicate that Chinese nephrologists are prescribing two-times weekly HD to patients who are
relatively healthier and potentially more able to tolerate the
less intensive uid and electrolyte management.
In addition, we found that patients without national insurance were more likely to be on two-times weekly HD. In fact,
many patients without national insurance may not be able to
access treatment at all. Although newly implemented insurance policies subsidize treatment to some extent for some
patients (e.g. government employees), large co-payments for
HD therapy (annual total cost $7500) likely severely strain
patient resources [7]. For example, a dialysis center from
Chinas Guangxi province reported that one-third of patients
presenting with advanced CKD refused initiation of RRT; a
majority cited the cost of HD therapy as a deterrent [1]. For
patients who do initiate treatment, reducing frequency of

frequency used in most DOPPS countries. The longitudinal

component of China DOPPS, which began in autumn 2012,
has the potential to address some of the methodological issues
that may be present in previously published studies.
Our study has several strengths. It is one of the rst to
provide representative data describing practice patterns and
associated patient characteristics from a sample of three major
metropolitan areasin a country new to widespread use of
HD therapy. The use of standard DOPPS protocols and
questionnaires allows for comparisons with other DOPPS
countries with well-documented HD practices. Furthermore,
the representative facility sampling in DOPPS allowed us to
compare the range of practices across facilities within each
studied region or country. We have validated data collected
from 42 of the 45 participating Chinese facilities through reabstraction of 25 data elements for seven randomly selected
study patients at each of these study sites via the use of an external data collector. There was a high level of agreement
between the data originally abstracted by the study coordinator
and the re-abstracted data for all variables included in this
reliability study assessment.
Our results for China represent HD patients from three
large urban areas of China, with a total general population of
>50 million people. Although a majority of patients on HD are
concentrated in these types of urban areas, our study is likely
not representative of the overall Chinese HD population, and
we are not able to describe the unique set of challenges that
patients and clinicians face in rural areasincluding not being
able to capture patients who die without ever accessing treatment. The cross-sectional nature of the data to date limits us
to a determination of association without any ability to infer
causation. Detailed data on nutritional intake ( particularly
dietary protein) were not available. Finally, we could not describe practices and outcomes associated with peritoneal dialysis, although this modality is used by a minority of patients
undergoing dialytic therapy in China.
In summary, our study highlights important aspects of
patient characteristics and HD practices in China. Patients on
HD in China are generally younger and healthier than in most
other DOPPS countries. Most receive HD using a native AV
stula. A substantial proportion are dialyzing two times
weekly; the patients dialyzing two times weekly have shorter
vintage, greater residual function, lower co-morbidity and/or
face having to pay a large share of cost for HD. A longitudinal
component of the China DOPPS in these three major metropolitan areas was initiated in autumn 2012, which will help
elucidate uncertainty regarding the outcomes associated with
practice differences identied in the current cross-sectional
analyses of Chinese HD patients.

Research Collaborative for Health and is supported by scientic

research grants from Amgen (since 1996), Kyowa Hakko Kirin
(since 1999, in Japan), Sano Renal (since 2009), AbbVie (since
2009), Baxter (since 2011) and Vifor Fresenius Renal Pharma
(since 2011), without restrictions on publications.

C O N F L I C T O F I N T E R E S T S TAT E M E N T
The DOPPS is administered by Arbor Research Collaborative
for Health and is supported by scientic research grants from
Amgen (since 1996), Kyowa Hakko Kirin (since 1999, in
Japan), Sano Renal (since 2009), AbbVie (since 2009), Baxter
(since 2011) and Vifor Fresenius Renal Pharma (since 2011),
without restrictions on publications. The authors declare no
competing nancial interests. The authors conrm that the
results presented in this paper have not been published previously in whole or in part, except in abstract form.

AC K N O W L E D G E M E N T S
Heather Van Doren, MFA, a senior medical editor with Arbor
Research Collaborative for Health, provided editorial assistance
on this manuscript. The DOPPS is administered by Arbor

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China DOPPS dialysis adequacy and vascular access

ORIGINAL ARTICLE

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Received for publication: 26.4.2013; Accepted in revised form: 9.10.2013

ORIGINAL ARTICLE

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B. Bieber et al.