| Abstract|| |
Care in dialysis is often associated with significant morbidity and mortality during the first year. Knowledge of its magnitude and causes could improve the prognosis of these patients. The aim of this study was to evaluate the survival and morbidity during the first year of dialysis for patients who initiated their dialysis between January 1, 2009 and December 31, 2009 and to study their possible correlation with baseline status at the beginning of treatment. A multicenter retrospective study was conducted in 11 dialysis centers. Clinical data at the beginning of dialysis and during the following year were collected. Mortality and morbidity risk factors were assessed by comparing different groups. Statistical analysis was performed with SPSS version 11. This study involved 134 patients, 79 men and 55 women, of whom 132 were on hemodialysis and two patients were on peritoneal dialysis. The mean age at initiation of treatment was 54.37 ± 18.09 years. Initial causes of nephropathy were dominated by diabetes (44.02%) and hypertension (11.19%). Among these patients, 39.55% had never received prior nephrological follow-up and 64.92% had started renal replacement therapy on an emergency basis. The initial clinical state was dominated by the presence of hypertension (50.74%), diabetes (44.02%), coronary insufficiency (13.43%) and heart failure (7.46%). Only 26.86% of the incident patients showed no comorbidity. During the first year of follow-up, 37.31% of the patients experienced at least one episode of comorbidity. Hospitalization was necessary in about half of these cases (17.91% of all patients). The overall mortality rate was 14.17%. One patient received a kidney transplant. The mortality rate in the first year of dialysis was lower in our study than in other series. Regular nephrological follow-up of these patients before they reach end-stage could have a significant influence on survival in dialysis.
|How to cite this article:|
El Khayat SS, Hallal K, Gharbi MB, Ramdani B. Fate of patients during the first year of dialysis. Saudi J Kidney Dis Transpl 2013;24:605-9
|How to cite this URL:|
El Khayat SS, Hallal K, Gharbi MB, Ramdani B. Fate of patients during the first year of dialysis. Saudi J Kidney Dis Transpl [serial online] 2013 [cited 2014 Mar 8];24:605-9. Available from: http://www.sjkdt.org/text.asp?2013/24/3/605/111085
| Introduction|| |
End-stage renal disease (ESRD) is a major public health problem. Its incidence in Morocco is steadily increasing, with 3000 new cases being reported each year.  Hemodialysis (HD) remains the most common renal replacement therapy, and although major therapeutic advances have been made, it is still burdened with high mortality, mainly from cardiovascular causes.  Indeed, mortality during the first year of dialysis varies from 17% to 27.7%. , We have no accurate data on the morbidity and mortality in patients on HD or its possible causes. Their evaluation would allow us to identify the factors involved and to propose appropriate preventive strategies to improve patient survival.
The aim of this work was to study the characteristics of patients prior to initiation of dialysis and to identify factors affecting survival during the first year of treatment.
| Subjects and Methods|| |
This is a retrospective cohort study conducted between September and December 2010 at 11 dialysis centers. We included all patients who began their dialysis between January 1 2009 and December 31 2009. Data concerning the characteristics and co-morbidities of patients at initiation of renal replacement therapy and complications and deaths during the first year of dialysis were collected.
To assess the risk of mortality in these patients, we divided them into three groups according to the Wright score, which takes into account age and various co-morbidities such as diabetes, cardiovascular disease and neoplasia [Table 1]. The risk factors for mortality were sought by comparing patients who died with the survivors.
Statistical analysis was performed using SPSS version 11. Results were expressed as number of cases and percentage for qualitative data and mean ± standard deviation for quantitative data. Comparative analysis was performed using the chi square test. A P-value <0.05 was considered significant.
| Results|| |
A total of 134 patients were included in this study. The characteristics of the study population are summarized in [Table 2]. Male predominance was noted (58.65%), with a malefemale ratio of 1.43. The mean age of the patients was 54.37 ± 18.09 years; 38.8% were over 60 years.
At initiation of renal replacement therapy, 68.7% of the patients were inactive (unemployed or retired). Two patients were on peritoneal dialysis and 132 were on HD. The number of sessions of HD was three per week in 71% of those on this form of dialysis.
Diabetes was the leading cause of ESRD (44.02%). Other causes included hypertension (11.19%), chronic interstitial nephritis (9.7%), chronic glomerulonephritis (3.73%) and lupus nephritis and hemolytic uremic syndrome in one patient each; the cause of nephropathy was unknown in 26.11% of the cases. Among all patients, four had undergone renal biopsy (2.98%).
Associated co-morbidities at the initiation of renal replacement therapy were diabetes (44.02%) and hypertension (50.74%), both being present in 45 patients (33.58%). The most common cardiovascular disease was coronary artery disease, seen in 13.43% of the cases, followed by heart failure in 7.46%. Three patients had lower limb arteritis and one patient had received a heart transplant. 26.86% of the patients had no co-morbidity. The distribution of patients according to Wright score is shown in [Figure 1].
|Figure 1: Distribution of patients according to Wright score (mortality risk) in the study population.|
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Renal replacement therapy was started as an emergency in 64.92% of the patients. 39.55% of the patients had never previously consulted a nephrologist for kidney failure. The mean follow-up before starting dialysis for the remaining patients was 13.67 ± 28.79 months.
At initiation of treatment, the mean hemoglobin was 8.33 ± 1.88 g/dL, ranging from 4 to 13 g/dL. About 46.26% of the patients had received transfusions during their initial sessions, and 21.64% were receiving erythropoietin.
During the first year of dialysis, 37.31% of the patients had various complications, with hospitalization being required in 48% of the cases. These complications were cardiovascular in 36.20%, related to vascular access in 25.86% and of infectious origin in 17.24%.
At the end of the first year of dialysis, 19 patients died (14.17%). These deaths occurred after a mean period of 4.3 months after initiation of replacement therapy, with the range being from one to 12 months. Death was from cardiovascular cause in six patients (31.57%), severe sepsis in two patients and metastatic neoplasia in one patient, while ten patients died of unknown cause.
Statistical analysis comparing the patients who survived and those who died showed the following: age >60 years, the number of co-morbidities ≥3, a Wright score of 3 and the lack of nephrologist follow-up before dialysis. The type of causal nephropathy, including diabetes, was not found among these factors [Table 3].
|Table 3: Risk factors for mortality in the first year of dialysis in the study population.|
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| Discussion|| |
This study revealed a high prevalence of diabetes among patients with ESRD. Also, in the United States in 2006, diabetic nephropathy was recorded in 45.5% of the incident patients.  However, this rate remains higher than in the European series: 20% in France  and 19.8% in the United Kingdom in 2007. 
The mortality rate during the first year of dialysis in this series is lower than the western series: 17% in France,  23.4% in the UK  and 27.7% in the United States.  This could be explained by the fact that, in our country, the number of dialysis centers in the public sector is still insufficient. Thus, access to replacement therapy in the private sector is restricted to patients with insurance coverage in most cases, allowing them proper follow-up and thus preventing or treating other co-morbidities.
Among the risk factors for mortality, age plays an important role. In France, in 2007, a survival rate between 91% and 98% was reported among patients under 65 years, but this rate dropped dramatically to 63% for patients over 85 years.  In the UK also, the survival rate decreased from 91.5% when age was less than 65 years to 72.9% after this age.  These results therefore join those of our series: 91.4% survival for patients under 60 years and 76.9% at a higher age.
The presence of superimposed co-morbidities also influences mortality in dialysis. Miskulin et al compared different mortality scores and their impact on survival.  Wright score equal to three was correlated with 31.7% of mortality (vs 27.02% in our series). In France, in 2007, it was noted that the survival rate in the absence of cardiovascular co-morbidity was 90%, while it decreased to 71% in patients who had two or more co-morbidities. 
Delayed nephrological care of patients with chronic renal failure is consistently associated with higher early mortality of 20-37% by the end of the first year of dialysis, regardless of age, level of residual renal function and associated co-morbidities.  In phases I and II of the DOPPS study, a decreased risk of mortality by 43% was seen in patients who consulted a nephrologist at least one month prior to initiation of renal replacement therapy.  Lorenzo et al also found in their study that the mortality rate during the first year of dialysis is multiplied by three in the absence of prior follow-up.  In another study by Kazmi et al, the mortality rate during the first year increased by 44% in patients who consulted a nephrologist less than four months before the start of dialysis. 
In summary, our study highlights the impact of advanced age, presence of co-morbidities and lack of nephrological follow-up as risk factors of mortality at one year in patients on HD. Indeed, early nephrological follow-up is crucial both in screening for patients at risk of developing chronic kidney disease and thereafter to deal efficiently with the associated morbidities so as to ensure optimal nephro-protection and cardio-protection. In advanced stages of renal failure, adequate preparation for replacement therapy significantly reduces mortality.
Moreover, this study also demonstrated the high prevalence of diabetes as causal nephropathy in patients on HD.
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Selma Siham El Khayat
Department of Nephrology, University Hospital Center of Ibn Rochd, Casablanca
[Table 1], [Table 2], [Table 3]