|
Pacients Dyng in The First Year of Renal
Replacement Therapy.
Analysis of 5 Years
Luciano V Pinto(1); Jaelson G
Gomes(2); José Luís Bevilacqua(2); Pedro José Patrício(1)
(Trabalho apresentado em San Francisco,
USA, durante o último congresso mundial de Nefrologia)
(1) CLINEF, (2) IHS
Introdução:
Renal
replacement therapy (RRT) programs have expanded significantly over recent
years all the world (1-9). Many of the patients beginning RRT have multiple
comorbid condition and up to 20% of them do not survive the first year of
dialysis (7,9,10). RRT is an expensive and highly technical therapy that
prolongs life. However, the increasing dialysis population poses a major
financial burden for health services and some authorities in world have
suggested withholding treatment from patients who are considered unlikely to
survive more than 12 months on RRT. Some studies show that it is impossible
to do a prevision about the survive the patient beginning RRT (9) but there
is nothing about this in the development countries. By this way this study
was done to describe the demographic and clinical characteristics of all
patients who died until 1 year of starting RRT in 2 RTS associated
facilities in Brazil, over a period of 5 years. Comorbid at initiation of
dialysis was assessed using 2 scoring systems to try to determine whether
who died could be categorized as high risk. The aims of the study is: (a) to
describe demographic, clinical and treatment related characteristics of
patients who died within 12 months of starting RRT and (b) to asses the
proportion of these patients categorized as high risk by two risk scores.Patients
accepted in program at CLINEF (Rio de Janeiro) and IHS (Sorocaba – SP)
between 10/01/1996 and 31/12/2000, who died in the 1st
year
of RRT were identified. Cause of primary renal disease and cause of death
were obtained from our database. The following comorbidity data were
collected: the presence or absence of diabetes mellitus, cerebrovascular
disease, previous myocardial infarction, angina, peripheral vascular
disease, cardiac diseases, liver diseases, malignancy and hypertension. Two
published scoring systems were used to assess whether patients who did not
survive 12 months on RRT fill into high-risk group (table 1).
Table
1: Risk
classification scales
| Risk
Group
Khan
(1)
Renal Association (2) |
| Low |
Age <
70 |
Age < 55; no DM |
| Medium |
Age 70 - 80 or |
Age 55-64; no DM or |
| |
Age < 80 with cardiac, pulmonary or liver disease or |
Age 15-54 with DM |
| |
Age < 70 with DM |
|
| High |
Age > 80 or |
Age > 64 or |
| |
Any age with 2 or more dysfunctions with ESRF or |
Age > 54 with DM or |
| |
Any age with visceral malignancy |
All HIV-positiv |
A
total of 710 patients were accepted in the facilities onto dialysis program
during the 5 years period of study. 520 (73%) were on hemodialysis (HD) and
190 (27%) on peritoneal dialysis. Of theses 81 (11,4%) died within the 12
months (30 males,
51 female). 22 deaths (9 male, 13 female)
occurred
until 90 days of
starting
treatment. Patients
who died had an age range from 26 to 88 years old with a median of 65 years,
which was the same for both sexes. Diabetic
nephropathy (43/81) and hypertension (22/81) were the main cause of ESKD (table
2). Fifty
one (63%) of patients were on HD and 30 (37%) on PD (table 3). There is no
statistic significance between the dialysis methods ( x2 =
0,02645).
Causes
of death have been classified into seven categories: cardiac,
cerebrovascular, infection, malignancy, sudden death, unknown and others.
Malignancy cause
was a patient with AIDS. It was considered as sudden death patients
who died possibly due to cardiac arrhythmias.
Tabela 2 e 3: Main Causes of End
Stage Failure in Study Group
|
Female
Male
Total |
| Glomerulonephrite |
2 |
2 |
4 |
| Diabetic
Nephropathy |
28 |
15 |
43 |
| Hypertension |
13 |
9 |
22 |
| APKD |
0 |
1 |
1 |
| HIV |
0 |
1 |
1 |
| ESRF;
unknown cause |
4 |
1 |
5 |
| Others |
3 |
2 |
5 |
| |
50 |
31 |
8 |
|
HD
PD
Total |
| Glomerulonephrite |
4 |
|
4 |
| Diabetic
Nephropathy |
25 |
18 |
43 |
| Hypertension |
15 |
7 |
22 |
| APKD |
0 |
1 |
1 |
| HIV |
1 |
0 |
1 |
| ESRF;
unknown cause |
5 |
3 |
8 |
| Others |
1 |
1 |
2 |
| |
51 |
30 |
81 |
Table
4 compares the causes of death between patients in HD and PD. Cardiovascular
causes
(cardiac + cerebrovascular + sudden death) was the principal cause of death
in both groups (HD 61%; PD70%). It is also the first cause of death in males
and females (M 73%; 54%) Table 5. In table 6 we can see that the incidence
is the same for diabetics and non-diabetics (D 70% ND 50%). Twenty two (27%)
of patients died in less than 90 days of treatment. Cardiovascular (12/22)
follow by infectious causes (4/22) were the principal cause of death in this
group. In patients who were treated for 90 days or more cardiovascular cause
were responsible for 71% of deaths in the group (42/59). The
last out attendance prior to RRT was documented to see the influence of
early nephrology following in subsequent prognosis. Of the 81 patients 50
(62%) had not been seen by a specialist prior the beginning or RRT. 32% of
them died before complete 90 days of treatment and 68 % at 90 days or more,
This dates are similar to previous studies that report 35-50% for unplanned
starts to dialysis (11-12).
Table
4: Cause of death by mode of dialysis(number of deaths with % of patients
in each modality in parentheses)
|
HD PD |
| Cardiac |
16
(31) |
10
(33) |
| Cerebrovascular |
9
(18) |
5
(17) |
| Infection |
6
(12) |
4
(13) |
| Malignancy |
1
(2) |
0
(0) |
| Sudden
death |
6
(12) |
6
(20) |
| Unknow |
5
(10) |
0
(0) |
| Others |
8
(16) |
5
(17) |
| |
51 |
30 |
Albumin
is a marker for survives in RRT (13-15). Albumin levels before RRT had been
registered in 57% (46/81) of patients. 44% (20/46) of these patients had
shown seric albumin levels under 3,5g%.
There is no statistic significance between albumin’s levels and the
death before or after 90 days RRT (x2 0,2324). The
distribution of patients in the Khan and Renal Association risk group is
shown in fig 1 and table7. In the Khan group 45 of 81 (56%) patients were
classified as medium risk while 56 (69%) were of high risk when we used the
Renal Association classification. There was no difference for patients died
under or more 90 days of treatment.
An
analysis of the patients dying under 90 days of RRT and those with 90 days more
had been done and the result are in table 8. There is no difference in the
age
(p= 0,234281); diabetes mellitus and hypertensions were, respectively, the
first and second cause of EKD
Table
5 : Cause of death by sex
|
FEMALE
MALE |
| |
HD |
PD |
Total |
% |
HD |
PD |
Total |
% |
| Cardiac |
10 |
2 |
13 |
26 |
6 |
7 |
13 |
42 |
| Cerabrovascular |
6 |
3 |
9 |
18 |
3 |
2 |
5 |
16 |
| Infeccion |
2 |
4 |
6 |
12 |
4 |
0 |
4 |
13 |
| Malignancy |
1 |
0 |
1 |
2 |
0 |
0 |
0 |
0 |
| Sudden
death |
5 |
5 |
8 |
16 |
2 |
2 |
2 |
6 |
| Inknown |
3 |
0 |
3 |
6 |
2 |
0 |
2 |
6 |
| Others |
5 |
5 |
10 |
20 |
3 |
0 |
3 |
10 |
| |
31 |
19 |
50 |
|
20 |
11 |
31 |
|
Table
6: Cause of death Diabetic x Non Diabetic
|
Diabetic
Non Diabetic |
| Cardiac |
14 |
33% |
12 |
32% |
| Cerebrovascular |
9 |
21% |
5 |
13% |
| Infection |
3 |
7% |
7 |
18% |
| Malignancy |
0 |
0% |
1 |
3% |
| Sudden
death |
10 |
23% |
2 |
5% |
| Unknow |
2 |
5% |
3 |
8% |
| Others |
5 |
12% |
8 |
21% |
| |
43 |
|
38 |
|
Table
7: Distribution of patients accord Kahn and Renal Association risk group
|
< 90 days > 90
days
Total
% |
| Khan |
| |
High |
4 |
17 |
21 |
26 |
| |
Mediun |
15 |
30 |
45 |
56 |
| |
Low |
3 |
12 |
15 |
19 |
| RA |
| |
High |
17 |
39 |
56 |
69 |
| |
Mediun |
4 |
12 |
16 |
20 |
| |
Low |
1 |
8 |
9 |
11 |
Table
8: Comparison
of patients dying within 3 months and those dying between 3 and 12 months
Fig.
1: Percentages
of patients in risk group of Khan (1) and Renal Association (2) scales
Conclusion
- The
percentage of patients dying in the first year of treatment is similar
to others studies (10)
and
can be considered high (11,4%).
- The
principal causes of ESRD are diabetes mellitus and hypertension and
cardiovascular events are the most common event of death.
- There
is no influence of the type of RRT on the mortality and also there are
no differences in age, etiology and cause of mortality when we separate
the patients, who died before 90 days of treatment and those that died
until 12 months of therapy,
- The
comparison between the two risk assessment scales provides clear picture
of how it can be to identify the high-risk patient.
- It
is clear that these strategies are unable to identify patients who can
dye in the beginning of RRT, perhaps because they assess only the
presence or absence of disease and not its severity.
1.Khan
IH, Catto GRD, Edwar DN, Fleming L, Henderson IS, Macleod AM, Influence of
coexisting disease on survival on renal replacement therapy. Lancet 311:415,
1993
2.The
treatment of renal failure in adults. London. The Renal Association and
Royal College of Physicians of London. 1997
3.Geerlings
W, Tufverson G, Ehrich JHH, Jones EHP, Landais P, Loirat C. Report on
management of renal failure in Europe, XXIII. Nephrol Dial Transplant 6
(S1): 25, 1994
4,Keane
WF, Collins AJ. Influence of comorbidity on mortality and morbidity in
patients treated with hemodialysis. Am J Kidney Dis 24:1010,1994
5.Roderick
PJ, Ferris, Feest TG. The provision of renal replacement therapy for adults
in England and Wales. Q J Med 91:581,1998
6.Ansell
D, Feest T. The first annual report. Bristol. The UK Renal Registry. 1998
7.Molzahn
M. Future evolution of the ESKD patient population – A perspective for the
year 2000. Nephrol Dial Transplant 11 (S8):59,1996
8.Vestergaard
P, Lokkegaard H. Predicting future trends in the number of patients on renal
replacement therapy in Denmark. Nephrol Dial Transplant 12:2117,1997
9.US
Renal Data Systems: USDS 1998 Annual Report. Bethesda. The NIH, NIDD. 1998
10.Walters
G, Warwick G, Walls J. Analysis of patients dying within one year of
starting renal replacement therapy. Am J Nephrol 20:358,2000.
11.Eadington
DW. Delayed referral for dialysis. Nephrol Dial Transplant 11:2124,1996.
12.
Innes A, Rowe PA, Burden R, Morgan A. Early deaths on renal replacement
therapy: the need of early nephrological referral. Nephrol Dial Transplant
7:467,1992.
13.Jassal
SV, Douglas JF, Stout RW. Prognostic markers in older patients starting
renal replacement therapy Nephrol Dial Transplant 11:1052,1996
14.
Avram MM, Mittman N, Bonomini L, Chattopadhyay J, Fein P. Markers for
survival in dialysis: seven years prospective study. Am J Kidney Dis
26:209,195
15.Loerie
EG, Huang WH, Lew NL. Death risk predictors among peritoneal dialysis and
hemodialysis patients: a preliminary comparison. Am J Kidney Dis 26:220,1995
|
 |
|
