Emergent Hemodialysis Initiation: A Marker of Suboptimal Pre-Dialysis Care Rather Than an Independent Predictor of Mortality

Objective: Emergent hemodialysis (HD) initiation has been consistently linked to higher mortality in prior studies, but evidence from Thailand is limited. This study evaluated the impact of elective versus emergent HD initiation in a tertiary-care setting. Materials and Methods: This retrospective cohort study included adults with stage 5 chronic kidney disease who initiated HD at Siriraj Hospital between 2013 and 2022. Emergent initiation was defined as HD started for urgent indications without permanent vascular access, elective initiation was nephrologist-scheduled HD without acute complications. The primary outcomes were two-year all-cause mortality, cardiovascular events, hospitalizations, and vascular-access complications. Results: Among 240 patients, 104 (43.3%) initiated HD emergently. These patients had higher rates of diabetes, poorer nutritional and metabolic profiles, less pre-dialysis care, and greater catheter use. Crude mortality was higher in the emergent group (15.4% vs. 10.3%), but after adjustment for comorbidities, functional status, and laboratory parameters, emergent initiation was not independently associated with mortality (adjusted HR 1.42, 95% CI 0.61–3.29). Infection-related deaths and vascular access infections were more frequent with emergent initiation, while vascular access dysfunction occurred more often in the elective group. Median hospitalization-free survival was shorter in the emergent group. Conclusion: Emergent HD initiation was not an independent predictor of mortality, suggesting that excess risk observed in prior cohorts may reflect comorbidity and nutritional status rather than initiation type itself. Nevertheless, emergent initiation remained a marker of suboptimal pre-dialysis care and higher infection risk. Strengthening early nephrology referral, structured pre-dialysis planning, and infection prevention remains essential for optimizing ESRD outcomes.