| Abstract|| |
End-stage renal disease (ESRD), due to its high morbidity and mortality as well as social and financial implications, is a major public health problem. Outcome depends not only on different modalities of treatment like hemodialysis and peritoneal dialysis, but also on existing co-morbidities, age, duration on dialysis, supportive therapies and infection control strategies. Thus, a detailed study becomes necessary to improve health care delivery, provide medical care and to establish a geographical reference. The present study was undertaken to characterize the ESRD patients by their demographic and co-morbid conditions and relate this to the morbidity and mortality trends. The medical records of 110 ESRD patients seen over a fiveyear period (June 1995 to December 1999) in two tertiary-care hospitals in Riyadh, Saudi Arabia were studied retrospectively. There were 79 (64.5%) males and 31 (35.5%) females; their age ranged from 17 to 92 years (mean age 53.8 ± 17.8 years). Diabetes was the commonest cause of ESRD seen in 26 (26.6%) followed by nephrosclerosis, unknown etiology, lupus nephritis, pyelonephritis and primary glomerulonephritis. Diabetes mellitus was the most prevalent co-morbidity seen during the study period and occurred in 65 patients (59%) followed by heart disease in 36 (32.7%), liver disease in 30 (27.3%), cerebrovascular accidents in 13 (11.8%) and neoplasm in 11 (10%). Seven (6.3%) patients only were smokers. Hemodialysis was the most frequent treatment choice as renal replacement therapy. Among the causes of hospitalization, cardiovascular conditions were the leading single cause (19.1%), followed by access related reasons and infections (11.5% each). The overall hospitalization rate was 11.2 days/year. The overall mortality rate was 8.07 deaths/year. The leading cause of death was cardiovascular in 15 (51.7%) followed by unknown/sudden death in eight (27.5%). Other causes of death included fluid overload, gastrointestinal hemorrhage, septicemia, liver disease and pulmonary embolism. Diabetes was the commonest co-morbid cause among the deceased. Old age, diabetes mellitus, prolonged duration on dialysis and cardiac diseases were the common causes of mortality. Our findings are consistent with worldwide reports. The study provides a reference data and will hopefully be helpful in improving the medical care.
Keywords: End-stage renal disease, Hemodialysis, Peritoneal dialysis, Mortality, Morbidity.
|How to cite this article:|
Al Wakeel JS, Mitwalli AH, Al Mohaya S, Abu-Aisha H, Tarif N, Malik GH, Hammad D. Morbidity and Mortality in ESRD Patients on Dialysis. Saudi J Kidney Dis Transpl 2002;13:473-7
|How to cite this URL:|
Al Wakeel JS, Mitwalli AH, Al Mohaya S, Abu-Aisha H, Tarif N, Malik GH, Hammad D. Morbidity and Mortality in ESRD Patients on Dialysis. Saudi J Kidney Dis Transpl [serial online] 2002 [cited 2014 Nov 22];13:473-7. Available from: http://www.sjkdt.org/text.asp?2002/13/4/473/33101
| Introduction|| |
End-stage renal disease (ESRD) is a devastating medical, social and economic problem in the community and needs dedicated supervision and health care. It is fatal unless treated properly. 
Before 1955, ESRD was an invariably fatal condition. In spite of advancement in the treatment, the ESRD population is growing world wide. In the USA alone, the US Renal Data System (USRDS) reported in 1999 more than 300,000 ESRD patients are on hemodialysis.  ESRD not only affects the fiscal expenditure, but also morbidity quality of life and mortality of patients.
Cardiovascular and cerebrovascular diseases are the two most important causes of morbidity and mortality in ESRD patients , especially in diabetics , and those with lupus erythematosus.  Cardiovascular diseases are more common in ESRD patients as compared to the general population. ,,, According to the USRDS 1999, congestive heart failure was present in 34.7%, coronary heart disease in 21.5%, and myocardial infarction in 7.9% of the ESRD patients. Cardiovascular diseases are the leading cause of death in ESRD patients; cardiac arrest accounts for 47.1% of total deaths.  Cardiovascular disease related morbidity and mortality are higher in diabetics than non-diabetics. ,
The most fundamental measure of outcome in dialysis patients is survival rate. According to the USRDS, life expectancy for ESRD patients is from two years to 16 years. Mortality rate is 29.8 per 100 patients/year in the age-group 6574 years and increases to 46 per 100 patients/ year in patients 75 years and older. Mortality rate depends upon age, sex, race, cause of ESRD, modality of treatment and its complication besides unknown reasons. Higher mortality rates are seen among white American male patients, those on peritoneal dialysis, and those suffering from diabetes, hypertension or infections. 
The goal of this study is to review the comorbidities and primary renal diseases, causes as well as rate and duration of hospitalization, mortality rate and its causes among ESRD patients on dialysis.
| Materials and Methods|| |
Medical records of 110 ESRD patients on dialysis were reviewed at two tertiary-care hospitals, the King Khalid University Hospital and Security Forces Hospital, Riyadh, Saudi Arabia between January 1995 and June 2000. Demographic data (name, age, sex), etiology of ESRD and duration of renal replacement therapy were recorded. Medications, type of dialysis, access related problems, complications during dialysis, cause and duration of hospitalization and cause of death were also studied. Co-morbid conditions like diabetes mellitus, cardiovascular diseases, liver diseases, neoplasms, vascular diseases, smoking and hypertension were considered. Laboratory investigations done at the initial and last follow-up included serum electrolyte estimation, bone profile, uric acid estimation and liver function tests.
Results were systematically tabulated and statistically analyzed. Descriptive statistics were calculated for quantitative variables (mean, SD, and median in the case of skewed distribution) and for qualitative variables, absolute and percentage frequencies.
| Results|| |
The mean age of the study patients was 53.8 + 17.5 years (range; 17-92 years) and median 55 years. There were 71 (64.5%) males and 39 (35.5%) females. The number of patients in different age groups is given in [Table - 1]. The laboratory parameters are shown in [Table - 2].
Diabetic nephropathy was the commonest cause of ESRD seen in 26 (23.6%) followed by unknown causes in 22 (20%), nephrosclerosis in 22 (20%), lupus nephritis in 11 (10%) and pyelonephritis in 12 (10.9%). Other causes such as IgA nephropathy, membranous glomerulonephritis (GN), crescentic GN, focal and segmental glomerulosclerosis (FSGS), and amyloidosis were seen in 17 (15.5%) patients. The initial renal replacement therapy was hemodialysis in 65 (59.1%), renal transplant in 13 (11.8%) and peritoneal dialysis in 32 (29.1%) patients. Mean duration on dialysis was 5.74 + 3.15 years (maximum 11 years, median 3 years).
During the course of the study the co-morbid factors noted were hypertension in 95 (86.4%), diabetes in 65 (59%), cardiac disease in 36 (33%), liver disease in 30 (27%), cerebrovascular accidents in 13 (12%), neoplasm in 11 (10%) and smoking habit in seven (6%) patients, some patients had more than one disease. The dialysis related parameters are shown in [Table - 3].
The total numbers of hospital admissions was 623 days. The total duration of stay in hospital was 4,528 days during the study period constituting 11.6 days/patient/year, with a mean of 7.3 days of stay per patient per admission. The number of admissions per patient per year was 1.7.
The majority of hospitalizations were related to cardiovascular and cardiovascular reasons like chest pain, myocardial infarction, arrhythmias, heart failure, mitral valvotomy, stroke, cerebrovascular accidents and transient ischemic attacks these constituted 19.1% of total hospitalizations. This was followed by vascular-access related problems (11.1%), dialysis and its related conditions (13.6%), transplant preparations (4.7%) and fluid and electrolyte related admissions (3.7%). Other reasons for hospital admissions included obstetrics and gynecologic problems (4.6%), gastrointestinal tract related reasons (3.1%), diabetic complications (2.7%), bronchial asthma (1.1%), biopsies (1.5%), malignancy (0.8%), and other miscellaneous causes 22.5% [Table - 4].
Twenty-nine (26.4%) out of the 110 study patients died in 3.54 + 2.11 years of follow-up. Mean age at death was 67.5 + 14.6 (42-99) years. Four deaths were from age-group of 40-50 years, 10 patients in the age-group of 51-70 years and 15 in the age-group >71 years.
The commonest cause of death was related to cardiac causes and was documented in 12 patients (41.4%). Stroke and cerebrovascular accidents were diagnosed in three (10.3%), and pulmonary edema and fluid overload in two patients (6.9%). Perhaps also related to cardiovascular reasons were those cases of sudden death that occurred outside the hospital or deaths at home due to unexplained reasons in eight (27.5%) patients. Less common causes of death were, one each (3.5%) of gastrointestinal hemorrhage, septicemia, liver disease and pulmonary embolism.
Diabetes was the most common co-morbid factor among the deceased, 7 out of 29 (24.5%). Of these, four had cardiovascular related death and one had sudden death, possibly due to cardiac cause.
| Discussion|| |
ESRD is a fatal condition if not managed appropriately.  In spite of effective therapeutic strategies to slow its progression there is an increasing trend of ESRD patients on dialysis, with increased load of morbidity, hospitalization and fiscal resource consumption.
Outcome researches can help in ESRD patient's care and can reduce unwanted outcome. For instance, an optimal hemoglobin level, which can enhance myocardial oxygenation with the effect on microcirculation and load on heart, can improve outcome.
In this study, the average age of ESRD patients was 53.7 + 17.48 years, younger than the 61.1 years reported by the USRDS 1999 Annual Report.  However, our patients were older than what was reported by Al Muhana et al from the Eastern part of Saudi Arabia.  Majority of our patients were between age of 50-80 years (median 55 years).
Diabetes was the commonest cause of ESRD; 26 (23.6%) as compared to 27.9% reported by Al Muhanna et al and 30% from the USRDS. , Diabetes and heart disease were the commonest co-morbidities followed by liver disease, malignancy and smoking as risk factors during the study period. Total hospital days/patient/year were 11.6, close to the 11.3 days/patient/year reported by the USRDS.  Heart disease was the leading cause of hospitalization similar to other studies ,
followed by access related reasons and infections. Diabetes, although very frequent, was not the major factor for hospit ali zation. It existed as a steady, fairly well controlled chronic condition with less acute emergencies. Malignancies were very infrequent.
Many factors influence the survival in dialysis patients. The mortality rate largely depends on the quality of management including strict control of infections, hypertension and diabetes. In the present study, 29 out of 110 patients died during 3.54 + 2.11 years of follow-up. Mean age at death was 67.48 + 14.0 years with a range of 42-92 years. Most of the patients were above the age of 60 years. Leading cause of death was heart disease in 12 patients (41.4%). A similar high cardiovascular causes of death has been reported in previous studies elsewhere  and in Saudi Arabia.  Only seven (24.1%) of the patients who died were diabetics in contrast to 25 (47.2%) reported by Al Muhanna et al in years 1986-1996, although the prevalence of different co-morbid factors were similar in the two studies.
In conclusion, the morbidity and mortality of patients with ESRD are serious concerns. In the present study, most ESRD patients were in their 5th and 6th decades of life, cardiovascular diseases and diabetes were the leading comorbidities, while cardiovascular diseases were responsible for longest hospitalizations. Diabetes, although very common, was not the frequent cause of hospitalization. Cardiovascular events were the leading causes of mortality.
| Acknowledgment|| |
The authors would like to thank Ms. Miriam Culanding Tampos for her secretarial assistance.
| References|| |
|1.||Reikes ST. Trends in end-stage renal disease. Epidemiology, morbidity and mortality. Postgrad Med 2000;108(1):124-6. |
|2.||United States Renal Data System 1999 Annual Data Report. Am J Kidney Dis 1999;34(2 Suppl 1):S1-176. |
|3.||Parfrey PS, Foley RN. The clinical epidemiology of cardiac disease in chronic renal failure. J Am Soc Nephrol 1999;10:1606-15. [PUBMED] [FULLTEXT]|
|4.||Foley RN, Parfrey PS, Sarnak MJ. Clinical epidemiology of cardiovascular disease in chronic renal disease. Am J Kidney Dis 1998;32(Suppl 3): S112-9. |
|5.||Parfrey PS, Foley RN, Hernet JD, et al. Outcome and risk factors of ischaemic heart disease in chronic uremia. Kidney Int 1996;49:1428-34. |
|6.||Iseki K, Kinjo K, Kimura Y, Osawa A, Fujiyama K. Evidence for high risk of cerebral hemorrhage in chronic dialysis patients. Kidney Int 1993;44:1086-90. |
|7.||Ward MM. Cardiovascular and cerebro-vascular morbidity and mortality among women with end-stage renal diseases attributable to lupus nephritis. Am J Kidney Dis 2000;36(3):516-25. |
|8.||Lazarus JM, Lowrie EG, Hampers CL, et al. Cardiovascular diseases in uremic patients on hemodialysis. Kidney Int 1975;7:S167-75. |
|9.||Foley RN, Parfrey PS, Harnett JD, et al. Impact of hypertension on cardiomyopathy, morbidity and mortality in end-stage renal disease. Kidney Int 1996;49:1379-85. [PUBMED] |
|10.||Iseki K, Fukiyama K. Long-term prognosis and incidence of acute myocardial infarction in patients on chronic hemodialysis. Am J Kidney Dis 2000; 36(4):820-5. |
|11.||Salem M. Hypertension in the hemodialysis population? High time for answers. Am J Kidney Dis 1999;33:592-4. |
|12.||Locatelli F, Del Vecchio L, Manzoni C. Morbidity and mortality on maintenance hemodialysis. Nephron 1998;80(4):380-400. |
|13.||Feest TG, Dunn EJ, Burton CJ. Can intensive treatment alter the progress of established diabetic nephropathy to end-stage renal failure. Q J M 1999; 92(5):275-82. |
|14.||Ibrahim HA, Vora JP. Diabetic nephropathy. Baillieres Best Pract Res Clin Endocrinol Metab 1999;13(2):239-64. |
|15.||Vanholder R, Ringoir S. Infectious morbidity and defects of phagocytic function in end-stage renal disease: a review. J Am Soc Nephrol 1993;3:154154. [PUBMED] |
|16.||Powe NR, Jaar B, Furth SL, et al. Septicemia in dialysis patients: incidence, risk factors, and prognosis. Kidney Int 1999;55:1081-90. [PUBMED] [FULLTEXT]|
|17.||Iseki K, Kwazoe N, Fukiyama K. Serum albumin is a strong predictor of death in chronic dialysis patients. Kidney Int 1993;44:115-9. |
|18.||Joles JA, Willekes-Koolshing N, Koomans HA. Hypoalbuminemia causes high blood viscosity by increasing red cell lysophosphatidylcholine. Kidney Int 1997;52:761-70. |
|19.||Tsakiris D. Morbidity and mortality reduction associated with the use of erythropoietin. Nephron 2000;85(Suppl 1):2-8. [PUBMED] [FULLTEXT]|
|20.||O'Riordan E, Foley RN. Effects of anemia on cardiovascular status. Nephrol Dial Transplant 2000; 15(Suppl 3):19-22. [PUBMED] [FULLTEXT]|
|21.||Collins AJ, Ma JZ, Ebben J. Impact of hematocrit on morbidity and mortality. Semin Nephrol 2000;20(4): 345-9. |
|22.||Al Muhanna FA, Saeed I, Al Muelo S, Larbi E, Rubaish A. Disease profile, complications and outcome in patients on maintenance hemodialysis at King Faisal University Hospital, Saudi Arabia. East Afr Med J 1999;76(12):664-7. |
|23.||London GM. Alterations of arterial function in end stage renal disease. Nephron 2000;84(2):111-8. |
|24.||Ward MM. Cardiovascular and cerebrovascular morbidity and mortality among women with endstage renal disease attributable to lupus nephritis. Am J Kidney Dis 2000;36(3):516-25. |
Jamal S Al Wakeel
Department of Medicine (38), King Khalid University Hospital, P.O. Box 2925, Riyadh 11461
[Table - 1], [Table - 2], [Table - 3], [Table - 4]