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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2008  |  Volume : 19  |  Issue : 2  |  Page : 268-273
5-year Mortality in Hemodialysis Patients: A Single Center Study in Tripoli


Alshat Hemodialysis Center, Tripoli, Libya

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   Abstract 

To investigate the 5-year mortality of patients undergoing maintenance hemo­dialysis (HD) at Al-Shat center Tripoli, we reviewed during June 2007 the records of all the HD patients initiated on HD from Jun 2000 and Jan 2002.There were 124 patients in the study, 77 males (63.6%) and 47 (36.4%) females, with a mean age of 49 ± 14 years. Diabetic nephropathy (DN) was the underlying kidney disease in 34 (27.4%) patients. After 5 years; 3 patients were transferred to other centers, 18 (14.9%) patients underwent kidney transplan­tation. Out of the 103 patients who continued on hemodialysis, 53 (51.4%) expired during the 5-year follow-up. Mortality was associated with older age (p< 0.001 and odd ratio (OR) of 4.2 for age > 50 years) and DN (p< 0.002 and OR of 3.9). Mortality rate in diabetics was 74.1% and significantly associated with male sex (p< 0.0067 and OR of 2.4), older age (p< 0.004), presence of hypertension (p< 0.003 and OR of 3.9), type 1 diabetes (OR 1.6), and elevated mean body weight (p< 0.046). Mortality was also relatively higher in black patients (OR of 2.0) and smokers (OR of 1.39). In conclusion, the overall 5- year mortality for dialysis patients was elevated and higher in the diabetics.

Keywords: 5-year Mortality, Hemodialysis, Tripoli

How to cite this article:
Buargub MA. 5-year Mortality in Hemodialysis Patients: A Single Center Study in Tripoli. Saudi J Kidney Dis Transpl 2008;19:268-73

How to cite this URL:
Buargub MA. 5-year Mortality in Hemodialysis Patients: A Single Center Study in Tripoli. Saudi J Kidney Dis Transpl [serial online] 2008 [cited 2019 Nov 12];19:268-73. Available from: http://www.sjkdt.org/text.asp?2008/19/2/268/39044

   Introduction Top


The dialysis population is increasing world­wide with prevalence 215 patients per million population on dialysis. [1] Dialysis is a costly service, and despite the continuous improve­ments of dialysis technology and pharma­cological treatment, mortality rates for dia­lysis patients are still high. [2],[3] Mortality and morbidity of hemodialysis patients are influenced, among other factors, by their demographic profile and the underlying pathologic process. [4]

At present, there are around 2500 patients on maintenance hemodialysis therapy in Libya. [5] The target was to evaluate the 5-year mortality of patients undergoing mainte­nance hemodialysis in our center, and the demographic and pathologic risk factors associated with it.


   Patients and Methods Top


This study was performed in Al-Shat center, which is one of the main outpatient dialysis centers in Tripoli. In March 2007, files of consecutive patients who were admitted to hemodialysis between June 2000 and January 2002 were reviewed. Patients who were not clinically stable (with stroke, cancer, or unfit elderly), or patients who were on hemodialysis for more than 1 years were excluded. There were 124 patients eligible for analysis that included age, sex, race, smoking habit, primary kidney disease such as diabetes, hypertension, and HCV status, dialysis frequency, and mean volume gain between dialysis sessions.


   Statistical analysis Top


Statistical analysis was performed using the SPSS10 program. The different groups were compared using Pearson Chi-square for nominal data, and "t" test for numerical data. The level of significance was set as p< 0.05.


   Results Top


[Table - 1] shows the demographic profiles of the 124 study patients. There were 77 males (62%) and male/female ratio of 1.6 with mean age 47.4 ± 15 years; 11 (8.8%) patients were older than 65 years. Seventeen (13.7%) patients were black, the remaining were either white, or of mixed race. Twenty­one (16.9%) patients were either current or ex-smokers. Only 57% of the patients was on thrice weekly hemodialysis program, 61.2% was HCV positive and none of the patient was HBV or HIV positive. The mean systolic BP before dialysis sessions was 142 ± 21 mm Hg, and the mean inter-dialytic volume gain was 1.9 ± 0.9 L.

Diabetic nephropathy (DN) was the cause of chronic kidney disease in 34 (27.4%) patients hypertensive nephropathy in 13 (10.5%) patients, chronic glomerulonephritis (CGN) in 10 (8%), nephrolithiasis in 9 (7.3%), ADPKD in 5 (4%), chronic interstitial nephritis in 8 (6.4%), ischemic nephropathy in 4 (3.2%), familial amyloidosis in 1 (0.8%), and lupus nephritis in 1(0.8%) patient. Un­known etiology labeled the remaining 38 (30.6%) patients.

The patients who discontinued follow-up at our center included 3 (2.5%) patients who transferred to other centers, 18 (14.5%) under went kidney transplantation of whom 4 (22.2%) of them expired. In the remaining group of 103 patients who continued on hemodialysis, 50 are still alive and 53 expired with estimated 5-year mortality rate of 51.4%.

[Table - 2] shows the analysis of mortality related factors in our dialysis patients. Mortality was significantly associated with older age (the mean age of the expired group was 54.4 ± 13 years, and 44.34 ± 13 years in years in non-expired, p< 0.001), and the odds ratio (OR) of mortality in patients older than 50 years was 4.2. Factors that showed signi­ficant negative associations with mortality included DN (p< 0.005 and OR= 3.25), kidney transplantation (p< 0.022 and OR= 3.7), ADPKD (p= 0.028), and CGN (p< 0.02 and OR= 0.12).

There was no significant association bet­ween mortality and; gender, HCV status, smoking habit, skin color, presence of treated hypertension, frequency of hemodialysis, or inter-dialytic weight gain.

[Table - 3] shows the characteristics of the 34 patients with ESRD due to DN, of whom 26 (76.5%) were males, 12 (35.3%) were black, 12 (35.3%) had type 1 DM, and 27 (79.4%) had high blood pressure. The mean age in this group of patients was 55 ± 11.5 years with a mean 18.1 ± 7.6 years duration of the disease.

[Table - 4] shows the mortality significantly associated factors in the DN subgroup, which included male sex (p< 0.0067 and OR 2.4), older age (p< 0.004), hypertension (p< 0.003 and OR 3.9), increased body weight (p< 0.046), type 1 diabetes (OR= 1.6), black race (OR= 2), and smoking (OR= 1.39). Only 3 (8%) patients with DN received kidney transplantation, who remain alive and healthy, while 24 out of the 31 patients who continued on dialysis expired (5-year mortality of 70.7%).


   Discussion Top


Our study patients had a mean age of 47.4 years, which is less than that reported from other countries, such as 51.3 years in Saudi Arabia (SCOT data 1999), [2] 52.3 years in the European registry data (EDTA), and 58.2 years in the US registry data (USRDS ). [2],[6] The percentage of patients older than 65 was 8.8%, which is lower than the inter­national reported figure; 38% in the EDTA in 1992, and 48% in the USRDS. This could have been due to exclusion of the elderly from the study, or it may reflect the res­tricted admission of older patients to dia­lysis therapy at our center. In addition, the male to female ratio of 1.6:1 was compatible with the international trends; 1.4 in EDTA 1999 and 1.5 in SCOT 1999. [2],[6]

In USA, DN constitutes 30% of all incident cases on renal replacement therapy and is the fastest growing group of ESRD patients. [7] In our study, DN was the underlying renal disease in 27.4% of the patients, a figure less than that of the US, but higher than figures reported in the neighboring countries; e.g. Tunisia (19.3%), [8] North Africa (5-20%), [9] Saudi Arabia (16-25%), [10],[11] and Kuwait (21.2%). [12] This finding cannot be explained by a higher prevalence of DM in Libya, as it is around 4.6%, which is comparable to 4.9 % prevalence in Saudi Arabia and 3.5­4.6% in Tunisia. [13] Our study found that out of the diabetic patients 35.3% were type 1 diabetes, in contrast with 2-7% prevalence of type 1 DM in Libyan patients. [13] the male to female ratio in this subgroup was 3.25, and 35.3% of them were from the black race.

The overall 5-year mortality was 51.4%, which was higher than USA (40%), [14] Saudi Arabia (44-48%), [2] and UK (48%). [15]

When we compared the expired and the survived dialysis patients, there was a signi­ficant statistical association between mortality and increased age with OR= 4.2 in patients older than 50 years, which is compatible with the international trends. [2],[14],[15],[16],[17],[18],[19] The mortality was also significantly high in patients with DN compatible with the international trends. [2],[15],[17],[18],[19],[20],[21],[22],[23],[24]

There was no significant association of mortality in our patients with gender, HCV status, smoking, race, hypertension, fre­quency of hemodialysis, and inter-dialytic volume gain.

Further analysis disclosed 74.1% morta­lity in our diabetics, which is higher than USRDS (40%), [4],[6] and significantly associated with male sex, older age presence of hyper­tension, higher mean body weight, type 1 DM, smokers, and black race. This latter finding contrasts with the international findings of better survival in black dialysis patients. [15],[23]

Kidney transplantation was performed in 14.9% of the study patients, but in only 8% of patients with DN. The mortality rate among the transplanted patients was only 22.2%, which represents a selected group of patients who were both medically and economically advantaged over the dialysis patient.

This study is limited because its retros­pective nature. It did not address the other important factors known to affect the morta­lity in dialysis patients including the quality and efficiency of dialysis, the quality of medical care before and after onset of dialysis, particularly in regards to control of; blood sugar, anemia, bone and mineral metabolism, lipids, and nutrition, and the presence of co- morbidity. The exact causes of death also could not be confirmed as most deaths occurred outside the center, and because post-mortem examination was not routinely performed in our hospitals.

In conclusion, this study found an overall high mortality of hemodialysis patients, especially in patients with DN. Further studies are required to confirm these findings, and how to correct them.

 
   References Top

1.Grassmann A, Gioberge S, Moeller S, Brown G. ESRD patients in 2004: Global overview of patient numbers, treatment modalities and associated trends. Nephrol Dial Transplant 2005;20(12):2587-93.  Back to cited text no. 1    
2.Jondeby MS, De-Los Santos GG, Al­Ghamdi AM, et al. Caring for hemodialysis patients in Saudi Arabia. Past present and future. Saudi Med J 2001;22(3):199-204.  Back to cited text no. 2    
3.Pozzoni P, Del Vecchio L, Pontoriero G, Di Filippo S, Locatelli F. Long term outcome in hemodialysis: Morbidity and mortality. J Nephrol 2004;17(Suppl 8):S87-95.  Back to cited text no. 3  [PUBMED]  
4.Massry SG, Glassock RJ. Massry and Glassock's Textbook of Nephrology. Vol. 2, 3 rd ed. 1995. p. 1542-50.  Back to cited text no. 4    
5.Ehtuish EF, Abouna GM, Shibani AA, et al. Early results of kidney transplantation in Libya. Jamahiriya MJ 2007;7(1):36-9.  Back to cited text no. 5    
6.United States Renal Data System Annual Data Report. Am J Kidney Dis 1997;30 (Suppl 1):.  Back to cited text no. 6    
7.Eggers P. Mortality rates among dialysis patients in Medicare's end-stage renal disease program. Am J Kidney Dis 1990;15(5): 414-21.  Back to cited text no. 7    
8.Gmar-Bouraoui S, Skhiri H, Achour A, et al. The predictors of early mortality in patients starting chronic hemodialysis. Saudi J Kidney Dis Transpl 2003;14(1):23-9.  Back to cited text no. 8    
9.Barsoum RS. End stage renal disease in North Africa. Kidney Int Suppl 2003;83 (Suppl):S111-4.  Back to cited text no. 9    
10.Shaheen F, Al-Khader A. Epidemiology and causes of end stage renal disease (ESRD). Saudi J Kidney Dis Transpl 2005;16(3):277-9.  Back to cited text no. 10    
11.Hussein MM, Mooij JM, Roujouleh H, El­Sayed H . Observations in a Saudi-Arabian dialysis population over a 13-year period. Nephrol Dial Transplant 1994;9(8):1072-6.  Back to cited text no. 11    
12.El-Reshaid K, Johny KV, Sugathan TN, Hakim A, Georgous M, Nampoory MR. End­stage renal disease and renal replacement therapy in Kuwait-epidemiological profile over the past 4½ years. Nephrol Dial Transplant 1994;9(5):532-8.  Back to cited text no. 12    
13.Hajjaji EM. Diabetes in Tripoli, Libya: Its frequency and clinical features. Int Diabetes Digest 1995;6(4):94-5.  Back to cited text no. 13    
14.Gaylin D, Port F, Garcia J, et al. Five year survival for end-stage renal disease patients in the US, Europe, and Japan. 1982-1987. Am J Kidney Dis 1990;15(5):451-7.  Back to cited text no. 14    
15.Levy J, Morgan J, Brown E. Oxford Handbook of Dialysis. 2nd ed. 2004. p. 16.  Back to cited text no. 15    
16.JJ de Lima, R Sesso, H Abensur, et al. Predictors of mortality in long-term haemo­dialysis patients with a low prevalence of comorbid conditions. Nephrol Dial Transplant 1995;10:1708-13.  Back to cited text no. 16    
17.Johnson JG, Gore SM, Firth J. The effect of age, diabetes, and other comorbidity on the survival of patients on dialysis: a systematic quantitative overview of the literature. Nephrol Dial Transplant 1999; 14:2156-64.  Back to cited text no. 17  [PUBMED]  [FULLTEXT]
18.Rayner HC Pisoni RL, Bommer J, et al. Mortality and hospitalization in haemo­dialysis patients in five European countries: results from the Dialysis Outcomes and Practice Patterns Study (DOPPS). Nephrol Dial Transplant 2004;19:108-20.  Back to cited text no. 18    
19.Avram MM, Mittman N, Bonomini L, Chattopadhyay J, Fein P. Markers for survival in dialysis: a seven-year prospective study. Am J Kidney Dis 1995;26 (1):209-19.  Back to cited text no. 19    
20.Racki S, Zaputovic L, Vujicic B, et al. Comparison of survival between diabetic and non-diabetic patients on maintenance hemodialysis: a single-centre experience. Diabetes Res Clin Pract 2007;75(2):169-75.  Back to cited text no. 20    
21.Marcelli D, Spotti D, Conte F, et al. Prognosis of diabetic patients on dialysis: analysis of Lombardy Registry data. Nephrol Dial Transplant 1995;10(10):1895-900.  Back to cited text no. 21    
22.Catalano C, Postorino M, Marino C. The impact of diabetes on patients' survival in dialysis patients with non-diabetic renal disease and in patients who develop diabetes during chronic dialysis. Nephrol Dial Transplant 1996;11(6):1124-8.  Back to cited text no. 22    
23.Enriquez J, Bastidas M, Mosquera M, et al. Survival on chronic dialysis: 10 years' experience of a single Colombian center. Adv Perit Dial 2005;21:164-7.  Back to cited text no. 23    
24.Lowrie E, Lew N. Death risk in hemodialysis patients: The predictive value of commonly measured variables and an evaluation of death rate differences between facilities. Am J Kidney Dis 1990;15(5):458-82.  Back to cited text no. 24    

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Correspondence Address:
Mahdia A Buargub
Alshat Hemodialysis Center, P.O. Box 83478, Tripoli
Libya
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PMID: 18310882

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    Introduction
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