SURVIVAL PATTERNS OF PATIENTS WITH CHRONIC KIDNEY DISEASE ON HEMODIALYSIS: AN AMBI-DIRECTIONAL COHORT STUDY FROM NEPAL

Introduction:

Hemodialysis is a common mode of renal replacement therapy (RRT) for kidney failure in Nepal. Securing regular sessions for maintenance hemodialysis is challenging because of limited hemodialysis (HD) services. Many patients receive dialysis on an “as-needed basis.” Data on the survival patterns of patients on hemodialysis in Nepal and South Asia are limited. The primary objective of this study is to investigate the survival pattern and determinants of survival among patients undergoing hemodialysis for kidney failure in Nepal.

Methods:

We used an ambi-directional cohort design analyzing HD records from January 2011 to January 2023, incorporating both retrospective and prospective data from a tertiary care center in Nepal. A total of 1682 patients who received hemodialysis for kidney failure were assessed for eligibility. The study included 397 patients aged 18-65 years who had undergone HD for at least three months. Patients who received a kidney transplant or peritoneal dialysis were excluded. We plotted a Kaplan-Meier survival curve for the overall survival of patients. Log-rank test was used to compare survival between groups. We performed Cox regression analysis using a backward elimination strategy to find out the determinants of survival.

Results:

The study revealed a median survival time of 1.39 years (95% CI=1.09-1.68) as shown in Figure 1 and a mortality rate of 59.1%. Survival rates were 85% at six months, 64.2% at one year, 40.9% at two years, 29% at three years, 21.7% at four years, and 13.5% at five years. Key determinants of survival identified in the study are regular hemodialysis (HD) services received, control of systolic blood pressure, and serum levels of creatinine and sodium at the time of dialysis initiation. For every 1mg/dl rise of serum creatinine at initiation, the risk of mortality increases by 4% (HR= 1.040, 95% CI=1.011-1.069, p=0.006). Each 10 mm Hg rise in pre-dialysis systolic blood pressure is associated with an 8% increase in mortality risk (HR=1.008, 95% CI=1.001-1.014, p=0.017). Similarly, for one milliequivalent decrease in serum sodium, the risk of mortality increases by 1% (HR=0.990, 95%CI=0.980-1.00, p=0.017). Conversely, providing once-weekly regular hemodialysis sessions for a patient with CKD requiring maintenance hemodialysis can reduce mortality by 49% (HR=0.508, 95% CI=0.337-0.767, p value=0.001). While allotment of twice/thrice a week regular hemodialysis service to the patient within three months of initiation can reduce the mortality by 89% (HR=0.108, 95% CI=0.071-0.164, p value<0.001) compared to those patients with kidney failure who are taking dialysis services only on “as-needed basis.”

Conclusions:

This study highlights the need for improving access to HD services. Adequate blood pressure control, early detection, and appropriate management of hyponatremia can enhance the survival of kidney failure patients on hemodialysis. These findings indicate the need to prioritize making HD machines and other resources available for patients who require RRT.

I have no potential conflict of interest to disclose.

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