ALL CAUSE 5-YEAR MORTALITY IN PATIENTS INITIATED ON MAINTENANCE HEMODIALYSIS, A RETROSPECTIVE ANALYSIS

Introduction:

There are an estimated 1.5 lakh patients in India on maintenance hemodialysis. End stage renal disease (ESRD) is a diagnosis that carries high mortality burden. It has been historically reported that 1 in 10 patients on maintenance hemodialysis die every year, with life threatening infections and cardiac failure being the two most common causes of death. The first 12 months after dialysis initiation have especially been noted to carry the maximum risk of mortality. Data from the Indian subcontinent has been largely limited to small cohorts with short follow up periods and variable results (annual mortality ranging from 10% to 50%). We aimed to conduct a retrospective analysis at our tertiary care centre to analyse the mortality rate and patterns in patients with ESRD in an attempt to better understand local epidemiology and improve overall patient care.

Methods:

Data of patients with ESRD who were initiated on maintenance hemodialysis in 2018 at our centre was studied retrospectively. Kidney transplant recipients and children were excluded. Baseline duration of CKD, diabetes and hypertension status, presence of heart disease and baseline blood pressures were noted. Patients could be receiving their dialysis at any centre of their choice. The families were contacted telephonically to enquire about the present status. The primary endpoints were discontinuation of hemodialysis and death. Those who underwent kidney transplant or changed to a different modality of renal replacement like peritoneal dialysis were excluded. Patients who moved abroad were excluded. Information was gathered on the cause of death, duration from hemodialysis initiation and the patients’ compliance to their dialysis before demise. Continuous variables were expressed using mean and standard deviation and categorical variables were expressed using frequency and percentage. Chi square test was used for comparison of categorical variables and independent two-tailed T-test for continuous variables between the two groups. P value less than 0.05 was considered statistically significant.

Results:

A total of 193 patients were found to be initiated on maintenance hemodialysis in our center five years before the conduct of this analysis. There was a 3:1 male predominance and the mean age was 54 years (Table 1). Prevalence of hypertension and diabetes at the time of dialysis initiation was 88% (n=169) and 65% (n=120) respectively. Those with diabetes had a mean duration of 12 years. Mean blood pressure was 150/86 mm of Hg. One fourth of the patients (n=43) had pre-existing heart disease. Diabetic kidney disease was the most prevalent native kidney disease (56%, n= 107) followed by chronic glomerulonephritis (23%, n=44) and chronic interstitial nephritis (6%, n=8). Mean duration of CKD was 3 years. Most of our patients were initiated on hemodialysis through an uncuffed, non tunneled dialysis catheter (60%) followed by tunneled cuffed catheter (33%). AV fistula was the initial access in 7% (n=13) of the population. 

60 patients could not be contacted satisfactorily and 19 patients underwent kidney transplant within the 5 years. Of the remaining 114 patients, all-cause mortality rate was found to be 40% (n=46). Mean time of demise was found to be 2.5 years from initiation of hemodialysis. The most common cause was found to be infection (41%, n= 19) followed by heart disease (25%, n=12), stroke (7%, n=3) and hemorrhage (4%, n=2)(Table 2).

When compared to those who were alive and continuing hemodialysis, patients who died were found to have a higher prevalence of diabetic kidney disease which was statistically significant (76% vs 50%, p=0.005)(Table 3). They were also found to have a longer duration of diabetes (15.6 years vs 10 years, p=0.003). Although there was an increased prevalence of diabetes mellitus and hypertension, it was statistically insignificant. Mean age at initiation of dialysis was 54 ± 11 years among survivors as compared to 59 ± 12 years among those who died (p=0.02). There was no significant difference in the distribution of gender, duration of CKD and baseline blood pressure control. There was also no significant difference noted in the vascular access or dialysis frequency between the two groups. 

Conclusions:

ESRD is associated with high risk for mortality. Results from our study were generally comparable to those available in literature from similar populations. All cause 5-year mortality was around 40%, and infections and cardiac disease were the two most common causes. One fifth of the patients had died in the first year after dialysis initiation and those who were older at the time of dialysis initiation were found to have fared poorer. Unique to our study, however, there was a statistically significant association with the duration of diabetes and diabetic kidney disease in the mortality cohort. We conclude, with the help of our analysis, to reinforce the following aspects of patient care. Discussion on local trends of mortality with the patient should be essential when choosing the mode of long term renal replacement therapy. Control of underlying chronic illnesses like diabetes should be instilled early with an aim to delay progress to ESRD. And lastly, there is glaring need for more elaborate studies to identify specific mortality predictors in ESRD secondary to diabetic nephropathy, and to compare both short term and long term mortality among different modalities of renal replacement therapies.

I have no potential conflict of interest to disclose.

I did not use generative AI and AI-assisted technologies in the writing process.