Emergency Department Utilization after Initiation of Intermittent Hemodialysis: A Retrospective Cohort Study in Regina, Saskatchewan.

Background: Emergency department (ED) use is common among patients with end-stage kidney disease (ESKD) initiating hemodialysis (HD), but potentially modifiable predictors of these visits remain poorly defined. Objective: To identify factors associated with ED visits among patients newly initiated on intermittent HD in Regina, Saskatchewan, Canada. Design: Retrospective cohort study. Setting: Regina General Hospital in Saskatchewan, Canada. Patients: 360 incident adult patients who received at least 90 days of HD between January 1, 2018, and December 31, 2022. Measurements: Patients were followed for one year from dialysis initiation to capture the number and causes of all-cause ED visits. Methods: Multinomial logistic regression was used to examine associations between patient characteristics and ED utilization, categorized as no visits, a single visit, 2-3 visits, or >3 visits, with no visits as the reference group. Results: Half of the cohort (n=180, 50%) had at least one ED visit during the first year, totaling 453 encounters. Gastrointestinal (GI) complaints were the most common reason for presentation (14.1%), followed by fluid overload (11.5%) and cardiovascular causes (8.3%). Dialysis non-adherence was independently associated with ED utilization across all categories, with the strongest association for >3 visits (RRR 7.34, 95% CI 2.81-19.20, p<0.001). Arteriovenous fistula use at dialysis initiation was associated with a lower risk of a single ED visit (RRR 0.28, 95% CI 0.09-0.90, p=0.033). In contrast, age, sex, diabetes, hypertension, and cardiovascular disease were not independently associated with ED utilization. Limitations: This single-center, retrospective study is limited by generalizability and could not analyze non-adherence factors. ED visits were grouped broadly, without assessing severity or preventability. Although ED visits were more frequent during the winter months, we did not examine whether missed dialysis treatments also varied by season. The study period from 2018 to 2022 overlaps with the COVID-19 pandemic, which may have affected ED utilization, dialysis attendance, outpatient access, and patient health-seeking behavior. This limits direct comparison with studies conducted entirely before or after the pandemic. Conclusions: Early ED utilization among incident HD patients may be reduced by improving dialysis adherence, ensuring timely permanent vascular access placement, and better management of GI symptoms.