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Saudi Journal of Kidney Diseases and Transplantation
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RENAL DATA FROM THE ARAB WORLD  
Year : 2013  |  Volume : 24  |  Issue : 3  |  Page : 605-609
Fate of patients during the first year of dialysis


Department of Nephrology, Ibn Rochd University Hospital Center, Casablanca, Morocco

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Date of Web Publication24-Apr-2013
 

   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 Jul 24];24:605-9. Available from: http://www.sjkdt.org/text.asp?2013/24/3/605/111085

   Introduction Top


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. [1] 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. [2] Indeed, mortality during the first year of dialysis varies from 17% to 27.7%. [3],[4] 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 Top


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.
Table 1: Definition of the three groups of Wright score.

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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 Top


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.
Table 2: Characteristics of the study population.

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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 Top


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. [4] However, this rate remains higher than in the European series: 20% in France [3] and 19.8% in the United Kingdom in 2007. [5]

The mortality rate during the first year of dia­lysis in this series is lower than the western series: 17% in France, [3] 23.4% in the UK [6] and 27.7% in the United States. [4] 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. [3] In the UK also, the survival rate decreased from 91.5% when age was less than 65 years to 72.9% after this age. [7] 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. [8] 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. [3]

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. [9] 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. [10] 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. [11] 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. [12]

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.

 
   References Top

1.Benghanem Gharbi M. Renal replacement therapies for end stage renal disease in North Africa. Clin Nephrol 2010;74 Suppl 1:S17- 9.  Back to cited text no. 1
    
2.Foley RN, Parfrey PS, Sarnack MJ. Clinical epidemiology of cardiovascular disease in chronic renal failure. Am J Kidney Dis 1998; 32 Suppl 5:S112-9.  Back to cited text no. 2
    
3.Registre REIN. Rapport annuel 2007.  Back to cited text no. 3
    
4.Foley RN, Collins AJ. End-stage renal disease in the United States: an update from the United States Renal Data System. JASN 2007;18(10): 2644-8.  Back to cited text no. 4
    
5.Farrington K, Udayaraj U, Gilg J, Feehally J. UK Renal Registry 11th Annual Report (December 2008): Chapter 3 ESRD incident rates in 2007 in the UK: National and centre-specific analyses. Nephron Clin Pract 2009; 111 Suppl 1:c13-41.  Back to cited text no. 5
    
6.Cherukuri A, Bhandari S. Analysis of risk factors for mortality of incident patients commencing dialysis in East Yorkshire, UK. Q J Med 2010;103:41-8.  Back to cited text no. 6
    
7.Ansell D, Roderick P, Hodsman A, Ford D, Steenkamp R, Tomson C. UK Renal Registry 11th Annual Report (December 2008): Chapter 7 Survival and causes of death of UK adult patients on renal replacement therapy in 2007: National and centre-specific analyses. Nephron Clin Pract 2009;111 Suppl 1:c113-39.  Back to cited text no. 7
    
8.Miskulin DC, Martin AA, Brown R, et al, and the Medical Directors of Dialysis Clinic, Inc. Predicting 1year mortality in an outpatient haemodialysis population: A comparison of comorbidity instruments. Nephrol Dial Transplant 2004;19:413-20  Back to cited text no. 8
    
9.Hoffmann M, Binaut R, Maisonneuve N, et al. Patterns of nephrology referral and predialysis management of patients with chronic kidney disease. Nephrol Ther 2006;2(1):15-23.  Back to cited text no. 9
    
10.Hasegawa T, Bragg-Gresham JL, Yamazaki S, et al. Greater first-year survival on hemodialysis in facilities in which patients are provided earlier and more frequent pre-nephrology visits. Clin J Am Soc Nephrol 2009;4:595-602.  Back to cited text no. 10
    
11.Lorenzo V, Martn M, Rufino M, Hernández D, Torres A, Ayus JC. Predialysis nephrologic care and a functioning arteriovenous fistula at entry are associated with better survival in incident hemodialysis patients: An observation cohort study. Am J Kidney Dis 2004;43:999-1007.  Back to cited text no. 11
    
12.Hakim RM. Reducing early mortality in hemodialysis patients. Curr Opin Nephrol Hypertens 2008;17:595-9.  Back to cited text no. 12
    

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Correspondence Address:
Selma Siham El Khayat
Department of Nephrology, University Hospital Center of Ibn Rochd, Casablanca
Morocco
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DOI: 10.4103/1319-2442.111085

PMID: 23640647

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