DialyzeED - Frontline Hemodialysis in the Emergency Department: Patterns, Outcomes, and Challenges in Al Ain, UAE

DialyzeED - Frontline Hemodialysis in the Emergency Department: Patterns, Outcomes, and Challenges in Al Ain, UAE | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article DialyzeED - Frontline Hemodialysis in the Emergency Department: Patterns, Outcomes, and Challenges in Al Ain, UAE Phaguni Sai Preethi Asapu, Antria Jenifer, Neema Francis, Roxanne Roby, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9290549/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Emergency departments (EDs) play a vital role in managing patients with acute kidney injury (AKI) and chronic kidney disease (CKD) who require urgent renal replacement therapy (RRT). RRT restores physiological balance by removing toxins and regulating fluid, electrolyte, and acid–base homeostasis, with hemodialysis accounting for approximately 85% of its use (Himmelfarb & Ikizler, 2020). Emergent hemodialysis is indicated in life-threatening conditions such as hyperkalemia, metabolic acidosis, hypervolemia, uremia, and certain toxicological emergencies. Traditionally performed in nephrology or intensive care settings, increasing patient volumes and the rising burden of CKD have driven interest in initiating dialysis within the ED to reduce treatment delays and improve outcomes. However, evidence regarding its feasibility and safety remains limited, particularly in the Middle East. This study represents a pioneering effort in the United Arab Emirates to evaluate the feasibility and clinical outcomes of ED-based hemodialysis. Objectives: Assess patient outcomes following hemodialysis in the ED. Identify clinical and sociodemographic factors linked to potentially preventable ED visits among patients receiving maintenance dialysis. Examine predictors of ED utilization among hemodialysis patients and explore interventions to reduce ED visits. Determine if there were reduced admissions to the ICU. Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Introduction Chronic kidney disease (CKD) is a major global health challenge. It is expected to become the fifth leading cause of death worldwide by 2040. The economic cost of end-stage renal disease (ESRD) is significant. Dialysis-related expenses are estimated at around USD 15 billion annually. Total Medicare spending in the United States amounts to USD 136 billion (Himmelfarb & Ikizler, 2020). Hemodialysis (HD) remains the most common form of renal replacement therapy worldwide, making up nearly 85% of treatments, followed by Peritoneal dialysis and kidney transplants. Emergency departments (EDs) often serve as the first point of care for patients with acute renal failure complications, such as severe hyperkalemia, metabolic acidosis, pulmonary edema, and uremia. Studies show that patients needing emergency HD commonly present with major metabolic derangements, mainly hyperkalemia and acidosis, both linked to higher short-term mortality (Rosedee, Mohd Fauzi & Nik Ab Rahman, 2024). Predictors of poor outcomes include delayed presentation, need for ventilatory support, and multiple comorbidities (Harel et al., 2019). Traditionally, emergency HD has been delivered in intensive care units or specialized nephrology wards. However, increasing patient volumes, ED overcrowding, and the rising prevalence of CKD have prompted several institutions to explore initiating HD directly within the ED. This approach may reduce treatment delays and improve hemodynamic stabilization before admission. It also has the potential to enhance overall patient outcomes (Alao, Thomas, Patil & Marshall, 2021; Rinzin, Dorji, Tshering & Wangchuk, 2025). Evidence from other regions suggests that ED-based HD may streamline care and minimize complications from delayed therapy (Rinzin, Dorji, Tshering & Wangchuk, 2025; Rosedee, Mohd Fauzi & Nik Ab Rahman, 2024). Worldwide, maintenance dialysis patients frequently use emergency department (ED) services, often due to missed dialysis sessions, vascular access issues, and inadequate outpatient follow-up (Komenda, Ferguson, Rigatto, Tangri, Bueti, Harford & Fergusson, 2018). Identifying predictors of ED visits is essential for implementing preventive strategies, optimizing dialysis scheduling, and enhancing care quality (Lin et al., 2019; Briscoe, Heerschap, Kane & Quatrara, 2018). Within the Gulf region, especially in the United Arab Emirates (UAE), data on ED-based HD are limited. The UAE has a highly diverse expatriate population, outnumbering Emiratis by about 4:1 and representing over 200 nationalities, leading to considerable variation in disease prevalence and healthcare access. According to the Abu Dhabi Dialysis Prevention Study, the UAE has an estimated CKD prevalence of 370 patients per million people, which equals roughly 4,200 individuals needing HD (Richards, Hassan, Saleh, Dastoor, Bernieh, Abouchacra, Al Jabri, Fleischmann, Richards & Marcelli, 2015). The burden of CKD continues to grow, mainly driven by high rates of diabetes, hypertension, and cardiovascular disease, with a majority among younger male expatriates (Al-Sahlawi, Al-Mheiri, Sheek-Hussein, Loney & Ali, 2021). Although these estimates may have limitations, they give an important overview of the CKD burden in the UAE. Despite a well-established outpatient dialysis network under the Abu Dhabi Health Service Company (SEHA), the adoption of HD in ED settings is still in its early phase. To our knowledge, this study is among the first systematic evaluations of ED-initiated HD in Al Ain, UAE. Specifically, it aims to (1) assess patient outcomes following hemodialysis in the ED, (2) identify clinical and sociodemographic predictors of emergency dialysis use, including preventable ED visits, and (3) evaluate the reasons for first-time ED HD initiation and their effects on hospital admission and survival. To achieve these objectives, the study intends to generate local evidence to inform clinical practice and contribute to the global literature on the feasibility and safety of emergency HD. Methodology and Study Design This retrospective cohort study was conducted from December 2024 to December 2025 at Sheikh Tahnoon Medical City (STMC) in Al Ain, Abu Dhabi, United Arab Emirates. STMC is a tertiary care hospital with approximately 718 inpatient beds and one of the largest emergency medicine departments in the region. Study Population and Eligibility Criteria Study Population The study included all adult patients aged 16 years or older who received hemodialysis in the emergency department during the study period. Inclusion Criteria Age ≥16 years Hemodialysis performed in the emergency department Exclusion Criteria Patients younger than 16 years Patients evaluated in the emergency department but receiving dialysis only in inpatient dialysis units Sample Size and Sampling Technique A total of 104 patients were identified through the SEHA electronic medical record system (Cerner) at Sheikh Tahnoon Medical City (STMC) in Al Ain, UAE. After applying eligibility criteria, 78 patients were included in the final analysis. Data Collection and Sources Clinical data were retrospectively obtained from the Cerner electronic medical record system and included: Demographic Variables Age Sex Nationality Insurance status Clinical Characteristics Primary renal diagnosis Comorbidities (diabetes mellitus, hypertension, cardiovascular disease) Presenting Symptoms Dyspnea Edema Altered mental status Laboratory Parameters Serum electrolytes Creatinine Blood urea nitrogen Arterial blood gas values Hemoglobin Dialysis Variables Indication for dialysis Number of dialysis sessions Dialysis duration Dialysis complications Clinical Outcomes Admission to hospital ward Admission to intensive care unit Discharge from the emergency department Mortality Data Management and Ethical Considerations All patient data were anonymized and coded to maintain confidentiality. This study was conducted in accordance with the principles of the Declaration of Helsinki . Ethical approval was granted by the SEHA Institutional Review Board (IRB) prior to the study's initiation. Due to the retrospective use of de-identified data, the requirement for informed consent was waived by the IRB. Ethical Considerations Ethical approval was obtained from the SEHA Institutional Review Board (IRB) before the study began. All patient data were anonymized and coded to protect confidentiality. Since the study involved secondary analysis of de-identified data, individual patient consent was waived. Ethics Approval and Consent to Participate This study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval was obtained from the SEHA Institutional Review Board (IRB) prior to the initiation of the study. Due to the retrospective nature of the study and the use of de-identified data, the requirement for informed consent was waived by the SEHA IRB. Human Ethics and Consent to Participate Human Ethics and Consent to Participate declarations: applicable as described above. Funding This research received no external funding. Statistical Analysis All the data collected were entered into an electronic Excel database on the secure SEHA computer. Data analysis was performed using SPSS version 28.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were used to summarize demographic and clinical characteristics. Results A total of 78 patients received hemodialysis in the emergency department during the study period (Table 1). The cohort consisted of 45 males (57.7%) and 33 females (42.3%) (Figure 1). Most patients were older adults, with the 60–80-year age group accounting for the largest share (41.0%), followed by the 39–59-year group (38.5%) (Figure 2). Insurance coverage revealed that 34 patients (43.6%) were insured, while 44 patients (56.4%) lacked comprehensive insurance coverage or needed social support (Figure 3). Table 1. Demographic characteristics of patients undergoing hemodialysis in the ED Comorbidities Comorbid conditions were very common among the study population. Hypertension was the most frequent (82.1%), followed by diabetes mellitus (47.4%), dyslipidemia (30.8%), and cardiovascular disease (11.5%) (Table 2, Figure 4). Table 2. Distribution of comorbidities among study participants Comorbidity n % Hypertension 64 82.1 Diabetes mellitus 37 47.4 Dyslipidemia 24 30.8 Cardiovascular disease 9 11.5 Hypothyroidism 5 6.4 No risk factor 1 1.3 Dialysis Sessions and Indications Pulmonary edema was the most common reason for emergency dialysis, affecting 79.5% of patients, hyperkalemia was present in 34.6%, and metabolic acidosis occurred in 11.5% (Table3, figure 6). Thirty-three patients (42.3%) had a single dialysis session in the emergency department. Fifteen patients (19.2%) needed multiple dialysis sessions. Five patients (6.4%) had their first dialysis session during the emergency department visit (Table 3, Figure 5). Table 3. Frequency and indication for dialysis in the emergency department Biochemical Profile Pre-dialysis arterial blood gas analysis revealed metabolic acidosis in a significant number of patients. Thirty-six patients (46.2%) had an initial pH below 7.3 before starting dialysis (Table 4, Figure 7). Clinical Outcomes Following emergency department dialysis: 66 patients (84.6%) were admitted to hospital wards 3 patients (3.8%) required ICU admission 6 patients (7.7%) were discharged home 3 patients (3.8%) left against medical advice No deaths occurred within the emergency department during the study period. Table 4. Distribution of patients according to pre-dialysis pH Initial pH before dialysis n % < 7.3 36 46.2 ≥ 7.3 42 53.8 Disposition and Outcomes Following ED evaluation and/or emergency HD, most patients required hospital admission (Table 5). Ward admission was the most common outcome ( 66 patients; 84.6% ), while three patients (3.8%) required ICU admissions . Six patients (7.7%) were discharged directly home after stabilization, and three patients (3.8%) left against medical advice (LAMA) (Figure 8). Table 5. Patient disposition following emergency hemodialysis Disposition n % Ward admission 66 84.6 ICU admission 3 3.8 Discharged home 6 7.7 LAMA 3 3.8 Complications Dialysis-related complications were rare. Only one patient experienced muscle cramps during dialysis, which resolved after a temporary interruption of the procedure. No cases of hypotension, arrhythmias, cardiac arrest, or other major complications were recorded. Discussion This study examined the clinical features and outcomes of patients receiving emergency hemodialysis (HD) within the emergency department (ED) of Sheikh Tahnoon Medical City (STMC), a 718-bed tertiary care hospital in Abu Dhabi, United Arab Emirates. STMC features the largest emergency medicine department in the region, along with a dedicated dialysis unit equipped with 68 private stations and plans to expand to 90. Our results show that ED-initiated dialysis is both practical and safe, with few complications and a low rate of needing intensive care escalation. Between December 2024 and December 2025, 104 patients were identified, of whom 78 met the inclusion criteria. The cohort showed a male predominance (57.7% vs. 42.3%), with most patients aged 60–80 years, reflecting global trends of increasing dialysis dependence among older populations. Hypertension (82.1%) and diabetes mellitus (47.4%) were the most common comorbidities, consistent with their established role in CKD progression (Kim et al., 2024). These demographic characteristics align with international epidemiological data, emphasizing the burden of cardiometabolic disease in ESRD populations. Pulmonary edema was the leading reason for emergency dialysis (79.5%), followed by hyperkalemia (34.6%) and metabolic acidosis (11.5%). These results match previous studies highlighting fluid overload and metabolic imbalances as key triggers for urgent dialysis in acute care settings (Rosedee, Mohd Fauzi and Nik Ab Rahman, 2024). In the ED, 42.3% of patients had a single HD session, while 19.2% needed multiple sessions. Overall, 84.6% required hospital admission, 3.8% needed ICU care, and 7.7% were safely discharged home after stabilization. Importantly, there were no deaths in the ED, and only one minor complication was reported, supporting the safety of ED-based HD (Tugcan and Urfalioglu, 2025; Rosedee, Mohd Fauzi and Nik Ab Rahman, 2024; Rinzin et al., 2025). From an operational standpoint, integrating dialysis services within the ED provides notable clinical and logistical benefits. Starting HD early in the ED shortens time-to-treatment, improves hemodynamic stability, and may cut down ICU admissions. Past studies have shown that ED-based dialysis pathways can lower hospital stays and enhance patient flow (Duggal et al., 2021; Al-Jaghbeer et al., 2019). Dedicated resuscitation bay cubicles, like those in our facility, enable swift initiation of high-acuity care without transfer delays, thereby improving clinical outcomes and patient satisfaction (Rosedee et al., 2024). Protocol-driven methods, including fast-track dialysis pathways, have demonstrated further reductions in ED and hospital length of stay, time to HD start, and healthcare costs (O’Donnell et al., 2021). The economic implications are also notable. Emergency department–based HD is much more cost-effective than ICU-based renal replacement therapy, with average costs around $1,363 per ED visit compared to up to $3,629 per day for ICU care (Shafqat et al., 2023; Uchino et al., 2010). Developing ED-based dialysis pathways can reduce unnecessary admissions and lower overall hospital expenses, especially for chronic dialysis patients with preventable issues such as volume overload or hyperkalemia (Wald et al., 2015). Our findings also highlight important socioeconomic factors that influence ED use. In this group, 56.4% of patients lacked comprehensive insurance, indicating that financial barriers to routine outpatient dialysis may lead to delays and greater dependence on emergency services. Policies that limit access to scheduled dialysis for uninsured or undocumented patients might result in higher rates of emergency-only HD, which is linked to increased healthcare costs, more resource use, and worse clinical outcomes (Shafqat et al., 2023). These patients often receive less frequent dialysis, leading to higher hospitalization and death rates. Chronic maintenance HD patients are known to have high ED utilization and ICU needs, highlighting the importance of streamlined, efficient care delivery models (Lin et al., 2019; Rosedee et al., 2024). ED-based dialysis units, supported by structured clinical pathways, can improve patient flow, decrease overcrowding, and ensure timely care. Evidence indicates that such models provide care comparable to that of traditional nephrology units, with early intervention preventing clinical deterioration and reducing morbidity (Han et al., 2021; Korean Observational Study, 2023; Ikizler and Kliger, 2020). Notably, 7.7% of patients in our cohort were safely discharged home directly from the ED after dialysis, showing that, with proper monitoring and follow-up, hospitalization can be avoided in certain cases. Post-discharge interventions, including nephrology-led phone follow-up, have been shown to reduce 30-day ED visits and readmissions (Briscoe et al., 2018), while interdisciplinary CKD care models further lower healthcare use (Mateo Chavez et al., 2025). However, national data still highlight high rates of unplanned 30-day ED visits and hospital readmissions among maintenance HD patients (Chan et al., 2017). While the sample size is modest, this study is the first comprehensive evaluation of emergency HD in the UAE. The findings align with global literature supporting the safety, feasibility, and cost-effectiveness of ED-based dialysis (Toker Dincer et al., 2024; Rosedee, Mohd Fauzi and Nik Ab Rahman, 2024). Future multicenter prospective studies across the SEHA network are needed to assess long-term outcomes, include patient-reported measures, and determine cost-effectiveness. These efforts will be crucial for guiding policy development and establishing standardized ED-based dialysis pathways, ultimately improving emergency renal care, reducing hospital congestion, and enhancing patient outcomes. Strengths This study has several strengths. It is among the first to analyze emergency department–initiated hemodialysis in the UAE. Conducted at a large tertiary care center with a high-volume emergency department, it increases the relevance of its findings. Additionally, comprehensive electronic medical records allowed for detailed analysis of patient demographics, clinical features, and outcomes. Limitations Several limitations should be acknowledged. The study was conducted at a single center, which may limit its applicability to other healthcare settings. The retrospective design introduces the potential for incomplete documentation and unmeasured confounding variables. Additionally, the sample size was modest, and long-term outcomes such as readmission rates and mortality beyond the initial hospitalization were not evaluated. Conclusion This study is a pioneering effort to thoroughly assess emergency hemodialysis in the Middle East, filling a significant gap in regional healthcare knowledge. In the United Arab Emirates (UAE), the increasing prevalence of chronic kidney disease (CKD), along with a large and diverse expatriate population, highlights the need for context-specific data, even though current estimates remain limited. By examining patient outcomes and factors that influence emergency department (ED) use, this study offers valuable insights into the feasibility, safety, and clinical impact of ED-initiated hemodialysis within this unique healthcare environment. Our findings indicate that emergency department-initiated hemodialysis is both a safe and practical approach for managing acute metabolic complications of renal failure. Starting dialysis early in the ED helps stabilize patients effectively, reducing complications and the need for escalation to intensive care. These findings support the integration of structured emergency dialysis protocols within tertiary care EDs to improve care delivery and optimize resource use. As the global burden of CKD continues to grow, integrating dialysis capabilities into emergency settings could be a vital step forward in acute kidney care. More multicenter prospective studies across the UAE and the wider Gulf region are needed to assess long-term outcomes and inform policy making on standardized emergency dialysis procedures. Declarations Ethics Approval and Consent to Participate This study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval was obtained from the SEHA Institutional Review Board (IRB) prior to the initiation of the study. Due to the retrospective nature of the study and the use of de-identified data, the requirement for informed consent was waived by the SEHA IRB. Funding This research received no external funding. Author Contribution P.A Worte the main manuscript, prepared figures, collected and analyzed the data A.J prepared figures, collected and analyzed the data N.F collected and analyzed the data R.R collected and analyzed the data S.L collected and analyzed the data M.H reviewed the manuscript and edited the manuscript H.C reviewed the manuscript and edited the manuscript T.J reviewed the manuscript and edited the manuscript References Al‑Jaghbeer, M., Dealmeida, D., Bilderback, A., Ambrosino, R., & Kellum, J. A. (2018). Clinical decision support for in‑hospital AKI. Journal of the American Society of Nephrology, 29 (2), 654–660. https://doi.org/10.1681/ASN.2017070765 Briscoe, G. T., Heerschap, A., Kane, C. F., & Quatrara, B. D. (2018). 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9290549","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":633629113,"identity":"e3c3cdde-7e50-4c32-bbb6-08f9e8ed7543","order_by":0,"name":"Phaguni Sai Preethi 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10:42:55","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9290549/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9290549/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108409444,"identity":"661152de-a0b8-422a-a708-f9afeb286205","added_by":"auto","created_at":"2026-05-04 10:00:33","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":14721,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe pie chart illustrates the gender distribution of patients undergoing emergency hemodialysis.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9290549/v1/1c038a41396253f4273f2a7b.png"},{"id":108409445,"identity":"9337e08d-8c79-4e25-9199-861810cc4eb9","added_by":"auto","created_at":"2026-05-04 10:00:33","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":28256,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe pie chart illustrates\u003c/strong\u003e \u003cstrong\u003eage distribution of patients undergoing emergency department hemodialysis.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9290549/v1/ac97a666d378ef7a318f28aa.png"},{"id":108493645,"identity":"852f9368-ea57-43f3-94d6-8af4c9672348","added_by":"auto","created_at":"2026-05-05 10:01:10","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":16671,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe pie chart depicts the insurance status of the patient’s undergoing hemodialysis in the emergency department.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-9290549/v1/4847f39b16ec199afdfe3a87.png"},{"id":108492707,"identity":"29536209-4e68-4972-b171-54f70507a242","added_by":"auto","created_at":"2026-05-05 09:58:24","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":21697,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA bar graph which demonstrates a substantial comorbidity burden among patients undergoing emergency hemodialysis, dominated by hypertension and diabetes mellitus, reflecting the well-established association between cardiometabolic disease and advanced renal dysfunction.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-9290549/v1/b4b932cfcf2b69b418309c3c.png"},{"id":108409447,"identity":"f3488bbb-7a7d-4471-a16b-9ecc0b434dc7","added_by":"auto","created_at":"2026-05-04 10:00:33","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":22477,"visible":true,"origin":"","legend":"\u003cp\u003eA pie chart illustrates the number of Hemodialysis (HD) in the emergency department.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-9290549/v1/c0306d59054d0409ad4c625b.png"},{"id":108409449,"identity":"18d03176-50de-43bb-8f87-57f55533448b","added_by":"auto","created_at":"2026-05-04 10:00:33","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":16235,"visible":true,"origin":"","legend":"\u003cp\u003eThe bar graph depicts the number of patients corresponding to each primary indication and dialysis frequency.\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-9290549/v1/e14f1a73e4f66e1489221d2a.png"},{"id":108493686,"identity":"ebf2bd9e-e0f9-4feb-bc4f-965d59058d95","added_by":"auto","created_at":"2026-05-05 10:01:17","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":17427,"visible":true,"origin":"","legend":"\u003cp\u003eThe pie chart illustrates the initial acid–base status of patients prior to emergency dialysis.\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-9290549/v1/953ea87696c935ce451a156c.png"},{"id":108409451,"identity":"c56a4636-a0bc-4287-8331-aabf2bffd68f","added_by":"auto","created_at":"2026-05-04 10:00:33","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":11900,"visible":true,"origin":"","legend":"\u003cp\u003eThe bar graph depicts patient disposition following emergency department hemodialysis.\u003c/p\u003e","description":"","filename":"8.png","url":"https://assets-eu.researchsquare.com/files/rs-9290549/v1/ae851ceca688a082b05ce526.png"},{"id":108496544,"identity":"75b48f83-758b-40d7-b0f4-84bc5dd9f3b6","added_by":"auto","created_at":"2026-05-05 10:12:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":400694,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9290549/v1/48e2319c-ed40-4007-9546-85fd3c87e2de.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eDialyzeED - Frontline Hemodialysis in the Emergency Department: Patterns, Outcomes, and Challenges in Al Ain, UAE\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eChronic kidney disease (CKD) is a major global health challenge. It is expected to become the fifth leading cause of death worldwide by 2040. The economic cost of end-stage renal disease (ESRD) is significant. Dialysis-related expenses are estimated at around USD 15 billion annually. Total Medicare spending in the United States amounts to USD 136 billion (Himmelfarb \u0026amp; Ikizler, 2020). Hemodialysis (HD) remains the most common form of renal replacement therapy worldwide, making up nearly 85% of treatments, followed by Peritoneal dialysis and kidney transplants.\u003c/p\u003e\n\u003cp\u003eEmergency departments (EDs) often serve as the first point of care for patients with acute renal failure complications, such as severe hyperkalemia, metabolic acidosis, pulmonary edema, and uremia. Studies show that patients needing emergency HD commonly present with major metabolic derangements, mainly hyperkalemia and acidosis, both linked to higher short-term mortality (Rosedee, Mohd Fauzi \u0026amp; Nik Ab Rahman, 2024). Predictors of poor outcomes include delayed presentation, need for ventilatory support, and multiple comorbidities (Harel et al., 2019).\u003c/p\u003e\n\u003cp\u003eTraditionally, emergency HD has been delivered in intensive care units or specialized nephrology wards. However, increasing patient volumes, ED overcrowding, and the rising prevalence of CKD have prompted several institutions to explore initiating HD directly within the ED. This approach may reduce treatment delays and improve hemodynamic stabilization before admission. It also has the potential to enhance overall patient outcomes (Alao, Thomas, Patil \u0026amp; Marshall, 2021; Rinzin, Dorji, Tshering \u0026amp; Wangchuk, 2025). Evidence from other regions suggests that ED-based HD may streamline care and minimize complications from delayed therapy (Rinzin, Dorji, Tshering \u0026amp; Wangchuk, 2025; Rosedee, Mohd Fauzi \u0026amp; Nik Ab Rahman, 2024).\u003c/p\u003e\n\u003cp\u003eWorldwide, maintenance dialysis patients frequently use emergency department (ED) services, often due to missed dialysis sessions, vascular access issues, and inadequate outpatient follow-up (Komenda, Ferguson, Rigatto, Tangri, Bueti, Harford \u0026amp; Fergusson, 2018). Identifying predictors of ED visits is essential for implementing preventive strategies, optimizing dialysis scheduling, and enhancing care quality (Lin et al., 2019; Briscoe, Heerschap, Kane \u0026amp; Quatrara, 2018).\u003c/p\u003e\n\u003cp\u003eWithin the Gulf region, especially in the United Arab Emirates (UAE), data on ED-based HD are limited. The UAE has a highly diverse expatriate population, outnumbering Emiratis by about 4:1 and representing over 200 nationalities, leading to considerable variation in disease prevalence and healthcare access. According to the Abu Dhabi Dialysis Prevention Study, the UAE has an estimated CKD prevalence of 370 patients per million people, which equals roughly 4,200 individuals needing HD (Richards, Hassan, Saleh, Dastoor, Bernieh, Abouchacra, Al Jabri, Fleischmann, Richards \u0026amp; Marcelli, 2015). The burden of CKD continues to grow, mainly driven by high rates of diabetes, hypertension, and cardiovascular disease, with a majority among younger male expatriates (Al-Sahlawi, Al-Mheiri, Sheek-Hussein, Loney \u0026amp; Ali, 2021). Although these estimates may have limitations, they give an important overview of the CKD burden in the UAE. Despite a well-established outpatient dialysis network under the Abu Dhabi Health Service Company (SEHA), the adoption of HD in ED settings is still in its early phase.\u003c/p\u003e\n\u003cp\u003eTo our knowledge, this study is among the first systematic evaluations of ED-initiated HD in Al Ain, UAE. Specifically, it aims to (1) assess patient outcomes following hemodialysis in the ED, (2) identify clinical and sociodemographic predictors of emergency dialysis use, including preventable ED visits, and (3) evaluate the reasons for first-time ED HD initiation and their effects on hospital admission and survival. To achieve these objectives, the study intends to generate local evidence to inform clinical practice and contribute to the global literature on the feasibility and safety of emergency HD.\u003c/p\u003e"},{"header":"Methodology and Study Design","content":"\u003cp\u003eThis retrospective cohort study was conducted from December 2024 to December 2025 at Sheikh Tahnoon Medical City (STMC) in Al Ain, Abu Dhabi, United Arab Emirates. STMC is a tertiary care hospital with approximately 718 inpatient beds and one of the largest emergency medicine departments in the region.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eStudy Population and Eligibility Criteria\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Population\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study included all adult patients aged 16 years or older who received hemodialysis in the emergency department during the study period.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eAge ≥16 years\u003c/li\u003e\n \u003cli\u003eHemodialysis performed in the emergency department\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eExclusion Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003ePatients younger than 16 years\u003c/li\u003e\n \u003cli\u003ePatients evaluated in the emergency department but receiving dialysis only in inpatient dialysis units\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eSample Size and Sampling Technique\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 104 patients were identified through the SEHA electronic medical record system (Cerner) at Sheikh Tahnoon Medical City (STMC) in Al Ain, UAE. After applying eligibility criteria, 78 patients were included in the final analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eData Collection and Sources\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eClinical data were retrospectively obtained from the Cerner electronic medical record system and included:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDemographic Variables\u003c/strong\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eAge\u003c/li\u003e\n \u003cli\u003eSex\u003c/li\u003e\n \u003cli\u003eNationality\u003c/li\u003e\n \u003cli\u003eInsurance status\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003ePrimary renal diagnosis\u003c/li\u003e\n \u003cli\u003eComorbidities (diabetes mellitus, hypertension, cardiovascular disease)\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003ePresenting Symptoms\u003c/strong\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eDyspnea\u003c/li\u003e\n \u003cli\u003eEdema\u003c/li\u003e\n \u003cli\u003eAltered mental status\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eLaboratory Parameters\u003c/strong\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eSerum electrolytes\u003c/li\u003e\n \u003cli\u003eCreatinine\u003c/li\u003e\n \u003cli\u003eBlood urea nitrogen\u003c/li\u003e\n \u003cli\u003eArterial blood gas values\u003c/li\u003e\n \u003cli\u003eHemoglobin\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eDialysis Variables\u003c/strong\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eIndication for dialysis\u003c/li\u003e\n \u003cli\u003eNumber of dialysis sessions\u003c/li\u003e\n \u003cli\u003eDialysis duration\u003c/li\u003e\n \u003cli\u003eDialysis complications\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eAdmission to hospital ward\u003c/li\u003e\n \u003cli\u003eAdmission to intensive care unit\u003c/li\u003e\n \u003cli\u003eDischarge from the emergency department\u003c/li\u003e\n \u003cli\u003eMortality\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eData Management and Ethical Considerations\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patient data were anonymized and coded to maintain confidentiality. This study was conducted in accordance with the principles of the \u003cstrong\u003eDeclaration of Helsinki\u003c/strong\u003e. Ethical approval was granted by the \u003cstrong\u003eSEHA Institutional Review Board (IRB)\u003c/strong\u003eprior to the study's initiation. Due to the retrospective use of de-identified data, the requirement for informed consent was waived by the IRB.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eEthical Considerations\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the SEHA Institutional Review Board (IRB) before the study began. All patient data were anonymized and coded to protect confidentiality. Since the study involved secondary analysis of de-identified data, individual patient consent was waived.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eEthics Approval and Consent to Participate\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the principles of the\u0026nbsp;Declaration of Helsinki. Ethical approval was obtained from the\u0026nbsp;SEHA Institutional Review Board (IRB)\u0026nbsp;prior to the initiation of the study. Due to the retrospective nature of the study and the use of de-identified data, the requirement for informed consent was waived by the SEHA IRB.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eHuman Ethics and Consent to Participate\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHuman Ethics and Consent to Participate declarations: applicable as described above.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eFunding\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eStatistical Analysis\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the data collected were entered into an electronic Excel database on the secure SEHA computer. Data analysis was performed using SPSS version 28.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were used to summarize demographic and clinical characteristics.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 78 patients received hemodialysis in the emergency department during the study period (Table 1). The cohort consisted of 45 males (57.7%) and 33 females (42.3%) (Figure 1). Most patients were older adults, with the 60\u0026ndash;80-year age group accounting for the largest share (41.0%), followed by the 39\u0026ndash;59-year group (38.5%) (Figure 2). Insurance coverage revealed that 34 patients (43.6%) were insured, while 44 patients (56.4%) lacked comprehensive insurance coverage or needed social support (Figure 3).\u003c/p\u003e\n\u003ch3\u003eTable 1. Demographic characteristics of patients undergoing hemodialysis in the ED\u003c/h3\u003e\n\u003cp\u003e\u003cimg 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\"\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003e\u003cu\u003eComorbidities\u003c/u\u003e\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eComorbid conditions were very common among the study population. Hypertension was the most frequent (82.1%), followed by diabetes mellitus (47.4%), dyslipidemia (30.8%), and cardiovascular disease (11.5%) (Table 2, Figure 4).\u003c/p\u003e\n\u003ch3\u003eTable 2. Distribution of comorbidities among study participants\u003c/h3\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eComorbidity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e82.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDiabetes mellitus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e47.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDyslipidemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e30.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCardiovascular disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHypothyroidism\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo risk factor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eDialysis Sessions and Indications\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePulmonary edema was the most common reason for emergency dialysis, affecting 79.5% of patients, hyperkalemia was present in 34.6%, and metabolic acidosis occurred in 11.5% (Table3, figure 6). Thirty-three patients (42.3%) had a single dialysis session in the emergency department. Fifteen patients (19.2%) needed multiple dialysis sessions. Five patients (6.4%) had their first dialysis session during the emergency department visit (Table 3, Figure 5).\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eTable 3. Frequency and indication for dialysis in the emergency department\u003c/h3\u003e\n\u003cp\u003e\u003cimg 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\"\u003e\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003e\u003cu\u003eBiochemical Profile\u003c/u\u003e\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003ePre-dialysis arterial blood gas analysis revealed metabolic acidosis in a significant number of patients. Thirty-six patients (46.2%) had an initial pH below 7.3 before starting dialysis (Table 4, Figure 7).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFollowing emergency department dialysis:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e66 patients (84.6%) were admitted to hospital wards\u003c/li\u003e\n \u003cli\u003e3 patients (3.8%) required ICU admission\u003c/li\u003e\n \u003cli\u003e6 patients (7.7%) were discharged home\u003c/li\u003e\n \u003cli\u003e3 patients (3.8%) left against medical advice\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eNo deaths occurred within the emergency department during the study period.\u003c/p\u003e\n\u003ch3\u003eTable 4. Distribution of patients according to pre-dialysis pH\u003c/h3\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eInitial pH before dialysis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; 7.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e46.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026ge; 7.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e53.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch2\u003e\u003cstrong\u003e\u003cu\u003eDisposition and Outcomes\u003c/u\u003e\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eFollowing ED evaluation and/or emergency HD, most patients required hospital admission (Table 5). \u003cstrong\u003eWard admission\u003c/strong\u003e was the most common outcome (\u003cstrong\u003e66 patients; 84.6%\u003c/strong\u003e), while \u003cstrong\u003ethree patients (3.8%)\u003c/strong\u003e required \u003cstrong\u003eICU admissions\u003c/strong\u003e. \u003cstrong\u003eSix patients (7.7%)\u003c/strong\u003e were discharged directly home after stabilization, and \u003cstrong\u003ethree patients (3.8%)\u003c/strong\u003e left against medical advice (LAMA) (Figure 8).\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eTable 5. Patient disposition following emergency hemodialysis\u003c/h3\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDisposition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWard admission\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e84.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eICU admission\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDischarged home\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLAMA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch2\u003e\u003cstrong\u003e\u003cu\u003eComplications\u003c/u\u003e\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eDialysis-related complications were rare. Only one patient experienced muscle cramps during dialysis, which resolved after a temporary interruption of the procedure. No cases of hypotension, arrhythmias, cardiac arrest, or other major complications were recorded.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study examined the clinical features and outcomes of patients receiving emergency hemodialysis (HD) within the emergency department (ED) of Sheikh Tahnoon Medical City (STMC), a 718-bed tertiary care hospital in Abu Dhabi, United Arab Emirates. STMC features the largest emergency medicine department in the region, along with a dedicated dialysis unit equipped with 68 private stations and plans to expand to 90. Our results show that ED-initiated dialysis is both practical and safe, with few complications and a low rate of needing intensive care escalation.\u003c/p\u003e\n\u003cp\u003eBetween December 2024 and December 2025, 104 patients were identified, of whom 78 met the inclusion criteria. The cohort showed a male predominance (57.7% vs. 42.3%), with most patients aged 60–80 years, reflecting global trends of increasing dialysis dependence among older populations. Hypertension (82.1%) and diabetes mellitus (47.4%) were the most common comorbidities, consistent with their established role in CKD progression (Kim et al., 2024). These demographic characteristics align with international epidemiological data, emphasizing the burden of cardiometabolic disease in ESRD populations.\u003c/p\u003e\n\u003cp\u003ePulmonary edema was the leading reason for emergency dialysis (79.5%), followed by hyperkalemia (34.6%) and metabolic acidosis (11.5%). These results match previous studies highlighting fluid overload and metabolic imbalances as key triggers for urgent dialysis in acute care settings (Rosedee, Mohd Fauzi and Nik Ab Rahman, 2024). In the ED, 42.3% of patients had a single HD session, while 19.2% needed multiple sessions. Overall, 84.6% required hospital admission, 3.8% needed ICU care, and 7.7% were safely discharged home after stabilization. Importantly, there were no deaths in the ED, and only one minor complication was reported, supporting the safety of ED-based HD (Tugcan and Urfalioglu, 2025; Rosedee, Mohd Fauzi and Nik Ab Rahman, 2024; Rinzin et al., 2025).\u003c/p\u003e\n\u003cp\u003eFrom an operational standpoint, integrating dialysis services within the ED provides notable clinical and logistical benefits. Starting HD early in the ED shortens time-to-treatment, improves hemodynamic stability, and may cut down ICU admissions. Past studies have shown that ED-based dialysis pathways can lower hospital stays and enhance patient flow (Duggal et al., 2021; Al-Jaghbeer et al., 2019). Dedicated resuscitation bay cubicles, like those in our facility, enable swift initiation of high-acuity care without transfer delays, thereby improving clinical outcomes and patient satisfaction (Rosedee et al., 2024). Protocol-driven methods, including fast-track dialysis pathways, have demonstrated further reductions in ED and hospital length of stay, time to HD start, and healthcare costs (O’Donnell et al., 2021).\u003c/p\u003e\n\u003cp\u003eThe economic implications are also notable. Emergency department–based HD is much more cost-effective than ICU-based renal replacement therapy, with average costs around $1,363 per ED visit compared to up to $3,629 per day for ICU care (Shafqat et al., 2023; Uchino et al., 2010). Developing ED-based dialysis pathways can reduce unnecessary admissions and lower overall hospital expenses, especially for chronic dialysis patients with preventable issues such as volume overload or hyperkalemia (Wald et al., 2015).\u003c/p\u003e\n\u003cp\u003eOur findings also highlight important socioeconomic factors that influence ED use. In this group, 56.4% of patients lacked comprehensive insurance, indicating that financial barriers to routine outpatient dialysis may lead to delays and greater dependence on emergency services. Policies that limit access to scheduled dialysis for uninsured or undocumented patients might result in higher rates of emergency-only HD, which is linked to increased healthcare costs, more resource use, and worse clinical outcomes (Shafqat et al., 2023). These patients often receive less frequent dialysis, leading to higher hospitalization and death rates.\u003c/p\u003e\n\u003cp\u003eChronic maintenance HD patients are known to have high ED utilization and ICU needs, highlighting the importance of streamlined, efficient care delivery models (Lin et al., 2019; Rosedee et al., 2024). ED-based dialysis units, supported by structured clinical pathways, can improve patient flow, decrease overcrowding, and ensure timely care. Evidence indicates that such models provide care comparable to that of traditional nephrology units, with early intervention preventing clinical deterioration and reducing morbidity (Han et al., 2021; Korean Observational Study, 2023; Ikizler and Kliger, 2020).\u003c/p\u003e\n\u003cp\u003eNotably, 7.7% of patients in our cohort were safely discharged home directly from the ED after dialysis, showing that, with proper monitoring and follow-up, hospitalization can be avoided in certain cases. Post-discharge interventions, including nephrology-led phone follow-up, have been shown to reduce 30-day ED visits and readmissions (Briscoe et al., 2018), while interdisciplinary CKD care models further lower healthcare use (Mateo Chavez et al., 2025). However, national data still highlight high rates of unplanned 30-day ED visits and hospital readmissions among maintenance HD patients (Chan et al., 2017).\u003c/p\u003e\n\u003cp\u003eWhile the sample size is modest, this study is the first comprehensive evaluation of emergency HD in the UAE. The findings align with global literature supporting the safety, feasibility, and cost-effectiveness of ED-based dialysis (Toker Dincer et al., 2024; Rosedee, Mohd Fauzi and Nik Ab Rahman, 2024). Future multicenter prospective studies across the SEHA network are needed to assess long-term outcomes, include patient-reported measures, and determine cost-effectiveness. These efforts will be crucial for guiding policy development and establishing standardized ED-based dialysis pathways, ultimately improving emergency renal care, reducing hospital congestion, and enhancing patient outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrengths\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study has several strengths. It is among the first to analyze emergency department–initiated hemodialysis in the UAE. Conducted at a large tertiary care center with a high-volume emergency department, it increases the relevance of its findings. Additionally, comprehensive electronic medical records allowed for detailed analysis of patient demographics, clinical features, and outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSeveral limitations should be acknowledged. The study was conducted at a single center, which may limit its applicability to other healthcare settings. The retrospective design introduces the potential for incomplete documentation and unmeasured confounding variables. Additionally, the sample size was modest, and long-term outcomes such as readmission rates and mortality beyond the initial hospitalization were not evaluated.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study is a pioneering effort to thoroughly assess emergency hemodialysis in the Middle East, filling a significant gap in regional healthcare knowledge. In the United Arab Emirates (UAE), the increasing prevalence of chronic kidney disease (CKD), along with a large and diverse expatriate population, highlights the need for context-specific data, even though current estimates remain limited. By examining patient outcomes and factors that influence emergency department (ED) use, this study offers valuable insights into the feasibility, safety, and clinical impact of ED-initiated hemodialysis within this unique healthcare environment.\u003c/p\u003e\n\u003cp\u003eOur findings indicate that emergency department-initiated hemodialysis is both a safe and practical approach for managing acute metabolic complications of renal failure. Starting dialysis early in the ED helps stabilize patients effectively, reducing complications and the need for escalation to intensive care. These findings support the integration of structured emergency dialysis protocols within tertiary care EDs to improve care delivery and optimize resource use.\u003c/p\u003e\n\u003cp\u003eAs the global burden of CKD continues to grow, integrating dialysis capabilities into emergency settings could be a vital step forward in acute kidney care. More multicenter prospective studies across the UAE and the wider Gulf region are needed to assess long-term outcomes and inform policy making on standardized emergency dialysis procedures.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eEthics Approval and Consent to Participate\u003c/h2\u003e \u003cp\u003eThis study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval was obtained from the SEHA Institutional Review Board (IRB) prior to the initiation of the study. Due to the retrospective nature of the study and the use of de-identified data, the requirement for informed consent was waived by the SEHA IRB.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis research received no external funding.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eP.A Worte the main manuscript, prepared figures, collected and analyzed the data A.J prepared figures, collected and analyzed the data N.F collected and analyzed the data R.R collected and analyzed the data S.L collected and analyzed the data M.H reviewed the manuscript and edited the manuscript H.C reviewed the manuscript and edited the manuscript T.J reviewed the manuscript and edited the manuscript\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAl‑Jaghbeer, M., Dealmeida, D., Bilderback, A., Ambrosino, R., \u0026amp; Kellum, J. A. (2018). Clinical decision support for in‑hospital AKI. \u003cem\u003eJournal of the American Society of Nephrology, 29\u003c/em\u003e(2), 654\u0026ndash;660. https://doi.org/10.1681/ASN.2017070765\u003c/li\u003e\n\u003cli\u003eBriscoe, G. T., Heerschap, A., Kane, C. F., \u0026amp; Quatrara, B. D. (2018). Using post‑discharge telephone follow‑up by nephrology nurses to reduce 30‑day readmissions and post‑discharge complications for adult patients on hemodialysis. \u003cem\u003eNephrology Nursing Journal, 45\u003c/em\u003e(3), 243\u0026ndash;267. https://pubmed.ncbi.nlm.nih.gov/30304617/\u003c/li\u003e\n\u003cli\u003eChan, L., Chauhan, K., Poojary, P., Saha, A., Hammer, E., Vassalotti, J. A., Jubelt, L., Ferket, B., Coca, S. G., \u0026amp; Nadkarni, G. N. (2017). National estimates of 30‑day unplanned readmissions of patients on maintenance hemodialysis. \u003cem\u003eClinical Journal of the American Society of Nephrology, 12\u003c/em\u003e(10), 1652\u0026ndash;1662. https://pubmed.ncbi.nlm.nih.gov/28971982/\u003c/li\u003e\n\u003cli\u003eHarel, Z., Wald, R., Bargman, J. M., Mamdani, M., Perl, J., Bell, C. M., \u0026amp; Chertow, G. M. (2019). Outcomes of patients requiring urgent‑start hemodialysis in the emergency department. \u003cem\u003eClinical Journal of the American Society of Nephrology, 14\u003c/em\u003e, 100\u0026ndash;109.\u003c/li\u003e\n\u003cli\u003eHimmelfarb, J., \u0026amp; Ikizler, T. A. (2020). Hemodialysis. \u003cem\u003eNew England Journal of Medicine, 383\u003c/em\u003e, 1838\u0026ndash;1850.\u003c/li\u003e\n\u003cli\u003eKhwaja, A. (2012). KDIGO clinical practice guidelines for acute kidney injury. \u003cem\u003eNephron Clinical Practice, 120\u003c/em\u003e, c179\u0026ndash;c184.\u003c/li\u003e\n\u003cli\u003eKim, H., Jeong, S. A., Kim, K. M., Hwang, S. D., Choi, S. R., Lee, H., Kim, J. H., Kim, S. H., Kim, T. H., Koo, H. S., Yoon, C. Y., Kim, K., Ahn, S. H., Yoon, H. E., Kim, Y. K., Ban, T. H., \u0026amp; Hong, Y. A. (2024). Trends in clinical outcomes of older hemodialysis patients: Data from the 2023 Korean Renal Data System (KORDS). \u003cem\u003eKidney Research and Clinical Practice, 43\u003c/em\u003e(3), 263\u0026ndash;273. https://doi.org/10.23876/j.krcp.23.267\u003c/li\u003e\n\u003cli\u003eLin, Y. C., Hsu, H. K., Lai, T. S., Chiang, W. C., Lin, S. L., Chen, Y. M., Chen, C. C., \u0026amp; Chu, T. S. (2019). Emergency department utilization and resuscitation rate among patients receiving maintenance hemodialysis. \u003cem\u003eJournal of the Formosan Medical Association, 118\u003c/em\u003e(12), 1652\u0026ndash;1660. https://doi.org/10.1016/j.jfma.2019.01.007\u003c/li\u003e\n\u003cli\u003eMateo Chavez, M. B., Moran‑Melendez, A., Salter, L., et al. (2025). Effect of an interdisciplinary CKD clinic on disease progression, healthcare utilization, and ED visits. \u003cem\u003eKidney360\u003c/em\u003e.\u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Donnell, C., Molitch Hou, E., Kyle, J., Leong, T., Perry, M., Wood, D. N., Masud, T., Thomas, B., Ross, M. A., \u0026amp; Franks, N. (2021). Fast track dialysis: Improving emergency department and hospital throughput for patients requiring hemodialysis. \u003cem\u003eAmerican Journal of Emergency Medicine, 45\u003c/em\u003e, 92\u0026ndash;99.\u003c/li\u003e\n\u003cli\u003eRinzin, U., LeVine, S., Watts, M., Tshering, U., \u0026amp; Tshering, K. (2025). Frequency of ED visits and mortality among the adults with ESRD on twice‑weekly maintenance hemodialysis at a tertiary care hospital in Bhutan. \u003cem\u003eInternational Journal of Emergency Medicine, 18\u003c/em\u003e(1), Article 161. https://doi.org/10.1186/s12245‑025‑00894‑4\u003c/li\u003e\n\u003cli\u003eRosedee, N. A., Mohd Fauzi, M. F., \u0026amp; Nik Ab Rahman, N. H. (2024). Predictive factors of adverse clinical outcomes among patients receiving emergency hemodialysis in emergency department. \u003cem\u003eJournal of Emergency and Critical Care Medicine, 8\u003c/em\u003e, Article 22.\u003c/li\u003e\n\u003cli\u003eShafqat, F., Das, S., Wheatley, M. A., Kasper, L., Johnson, S., Pitts, S. R., \u0026amp; Ross, M. A. (2023). The impact of \u0026ldquo;emergency only\u0026rdquo; hemodialysis on hospital cost and resource utilization. \u003cem\u003eWestern Journal of Emergency Medicine, 24\u003c/em\u003e(2), 206\u0026ndash;209.\u003c/li\u003e\n\u003cli\u003eToker Dincer, Z., Dincer, M. T., Yalin, S. F., Trabulus, S., Seyahi, N., \u0026amp; Altiparmak, M. R. (2024). Renal and patient outcomes of emergency hemodialysis in elderly individuals: A retrospective cohort study. \u003cem\u003eInternational Urology and Nephrology, 56\u003c/em\u003e(12), 3869\u0026ndash;3876. https://doi.org/10.7007/s11255‑024‑04145‑y\u003c/li\u003e\n\u003cli\u003eTugcan, M. O., \u0026amp; Urfalioglu, A. B. (2025). Time to dialysis matters: A prospective study on emergency hemodialysis outcomes. \u003cem\u003eIrish Journal of Medical Science\u003c/em\u003e. Advance online publication. https://doi.org/10.1007/s11845‑025‑04217‑7\u003c/li\u003e\n\u003cli\u003eWald, R., Quinn, R. R., Luo, J., Li, P., \u0026amp; Clark, E. (2015). Chronic dialysis patients presenting to the emergency department: Epidemiology and outcomes. \u003cem\u003eNephrology Dialysis Transplantation, 30\u003c/em\u003e, 301\u0026ndash;309.\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eRichards, N., Hassan, M., Saleh, A.K., Dastoor, H., Bernieh, B., Abouchacra, S., Al Jabri, O., Fleischmann, A., Richards, M. \u0026amp; Marcelli, D. (2015)\u003c/strong\u003e\u003cem\u003eEpidemiology and referral patterns of patients with chronic kidney disease in the Emirate of Abu Dhabi.\u003c/em\u003e Saudi Journal of Kidney Diseases and Transplantation, 26(5), pp.1028\u0026ndash;1034. doi:10.4103/1319-2442.164600.\u003c/li\u003e\n\u003cli\u003eShafqat, F., Das, S., Wheatley, M.A., Kasper, L., Johnson, S., Pitts, S.R. \u0026amp; Ross, M.A. (2023) The impact of emergency-only hemodialysis on hospital cost and resource utilization. \u003cem\u003eWestern\u003c/em\u003e\u003cem\u003e \u003c/em\u003e\u003cem\u003eJournal\u003c/em\u003e\u003cem\u003e \u003c/em\u003e\u003cem\u003eof\u003c/em\u003e\u003cem\u003e \u003c/em\u003e\u003cem\u003eEmergency\u003c/em\u003e\u003cem\u003e \u003c/em\u003e\u003cem\u003eMedicine\u003c/em\u003e, 24(2), 206\u0026ndash;209. https://doi.org/10.5811/westjem.2022.11.58360\u003c/li\u003e\n\u003cli\u003eSrisawat, N., Lawsin, L., Uchino, S., Bellomo, R. \u0026amp; Kellum, J.A. (2010) Cost of acute renal replacement therapy in the intensive care unit: results from The Beginning and Ending Supportive Therapy for the Kidney (BEST Kidney) Study. \u003cem\u003eCritical\u003c/em\u003e\u003cem\u003e \u003c/em\u003e\u003cem\u003eCare\u003c/em\u003e, 14, R46. https://doi.org/10.1186/cc8933\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijem","sideBox":"Learn more about [International Journal of Emergency Medicine](https://intjem.biomedcentral.com/)","snPcode":"12245","submissionUrl":"https://submission.nature.com/new-submission/12245/3","title":"International Journal of Emergency Medicine","twitterHandle":"@IntJEmergMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-9290549/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9290549/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eEmergency departments (EDs) play a vital role in managing patients with acute kidney injury (AKI) and chronic kidney disease (CKD) who require urgent renal replacement therapy (RRT). RRT restores physiological balance by removing toxins and regulating fluid, electrolyte, and acid–base homeostasis, with hemodialysis accounting for approximately 85% of its use (Himmelfarb \u0026amp; Ikizler, 2020). Emergent hemodialysis is indicated in life-threatening conditions such as hyperkalemia, metabolic acidosis, hypervolemia, uremia, and certain toxicological emergencies.\u003c/p\u003e\n\u003cp\u003eTraditionally performed in nephrology or intensive care settings, increasing patient volumes and the rising burden of CKD have driven interest in initiating dialysis within the ED to reduce treatment delays and improve outcomes. However, evidence regarding its feasibility and safety remains limited, particularly in the Middle East. This study represents a pioneering effort in the United Arab Emirates to evaluate the feasibility and clinical outcomes of ED-based hemodialysis.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003eObjectives:\u003c/strong\u003e\u003c/u\u003e\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eAssess patient outcomes following hemodialysis in the ED.\u003c/li\u003e\n \u003cli\u003eIdentify clinical and sociodemographic factors linked to potentially preventable ED visits among patients receiving maintenance dialysis.\u003c/li\u003e\n \u003cli\u003eExamine predictors of ED utilization among hemodialysis patients and explore interventions to reduce ED visits.\u003c/li\u003e\n \u003cli\u003eDetermine if there were reduced admissions to the ICU.\u003c/li\u003e\n\u003c/ol\u003e","manuscriptTitle":"DialyzeED - Frontline Hemodialysis in the Emergency Department: Patterns, Outcomes, and Challenges in Al Ain, UAE","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-04 10:00:28","doi":"10.21203/rs.3.rs-9290549/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-04-23T13:44:18+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-15T09:49:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-15T09:49:37+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal of Emergency Medicine","date":"2026-04-01T10:08:06+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijem","sideBox":"Learn more about [International Journal of Emergency Medicine](https://intjem.biomedcentral.com/)","snPcode":"12245","submissionUrl":"https://submission.nature.com/new-submission/12245/3","title":"International Journal of Emergency Medicine","twitterHandle":"@IntJEmergMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3874b8eb-88ce-45bb-bba9-b34237162925","owner":[],"postedDate":"May 4th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-04T10:00:29+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-04 10:00:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9290549","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9290549","identity":"rs-9290549","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}