Disparities in early mortality among chronic kidney disease patients who transition to peritoneal dialysis and hemodialysis with and without catheters
The early period after chronic kidney disease (CKD) patients transition to end-stage renal disease (ESRD) represents the highest mortality risk but is variable among different patient populations and clinical circumstances. We compared early mortality outcomes among a diverse CKD population that transitioned to ESRD.
A retrospective cohort study (1/1/2002 through 12/31/2013) of CKD patients (age ≥ 18 years) who transitioned to peritoneal dialysis (PD), hemodialysis (HD) with arteriovenous fistula/grafts, and HD with catheters was performed. Multivariable Cox regression modeling was used to estimate 6-month all-cause mortality hazard ratios (HR) among the three treatment groups after adjustment for patient and clinical characteristics.
Among 5373 ESRD patients (62.7 years, 41.3% females, 37.5% Hispanics, 13.3% PD, 34.9% HD with fistula/graft, 51.8% HD with catheter), 551 (10.3%) died at 6 months. Mortality rates were highest immediately after transition (299 deaths per 1000 person-years in first month). Compared to PD patients, the 6-month mortality HR (95% CI) was 1.87 (1.06–3.30) in HD with fistula/graft patients and 3.77 (2.17–6.57) in HD with catheter patients. Inpatient transition (HR 1.32), acute kidney injury (HR 2.06), and an eGFR ≥ 15 vs 5–9 (HR 1.68) at transition were also associated with higher early mortality risk.
Among a diverse CKD population who transitioned to ESRD, we observed considerable differences in early mortality risk among PD, HD with fistula/graft, and HD with catheter patients. The identification of patient-specific and clinical environmental factors related to high early mortality may provide insights for managing advanced stages of CKD and shared decision making.
KeywordsMortality End-stage renal disease transition Chronic kidney disease Epidemiology Comparative outcomes
The authors would like to thank Joanie Chung and David Yi for their work on programming and data extraction for this study. The authors also would like to thank Jose Pio for his literature support and administrative assistance on this study. Finally, we would like to thank and acknowledge the members and patients of KPSC who are the source for our findings and the foundation for why we perform research at KPSC. The results presented in this paper have not been published previously in whole or part, except in abstract format.
JJS and SJJ contributed to research area and study design; HZ and JS were involved in data acquisition; JJS, SJJ, HZ, JS, KKZ, and CPK participated in analysis or interpretation of data; JJS and SJJ were involved in study supervision; HZ was involved in statistical analysis; JJS drafted the manuscript; SJJ, HZ, SFS, KKZ, CPK, SH, and JS were involved in critical revision of the manuscript for important intellectual content; SFS and SJJ participated in administrative, technical, or material support. Each author contributed important intellectual content during the manuscript drafting or revision and accepts accountability of the overall work by ensuring that questions pertaining to the accuracy or integrity of any portion of the work are appropriately investigated and resolved. JJS takes responsibility that this study has been reported honestly, accurately, and transparently; that no important aspects of the study have been omitted, and that any discrepancies from the study as planned have been explained.
This study was funded by 5U01DK102163 from the National Institute of Health (NIH) to CPK and KKZ. This study was also supported by the Kaiser Permanente Southern California Clinician Investigator Award (JJS).
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Conflict of interest
All author declares that they have no conflict of interest
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