The impact of co-morbid risk factors at the start of dialysis upon the survival of ESRD patients.

By using a computerized database, we have catalogued the presence of 29 co-morbid risk factors in 683 patients with end-stage renal disease who started dialysis from 1970 through 1989, with follow-up through 1992. The authors hypothesized that current end-stage renal disease patients have more serious co-morbid risk factors impacting upon their mortality rate. Quantitation of dialysis patient co-morbidity, as a measure of patient illness, is lacking in the general nephrology literature. Seven co-morbid risk factors have been reserved for new dialysis patients: hypertension, low albumin, cerebral vascular disease, peripheral vascular disease, pre-existing cardiac disease, abnormal EKG/old myocardial infarction, and congestive heart failure. Except for low serum albumin, the proportion of patients with the six other co-morbid risk factors has increased significantly over this 20-year period (p < 0.0001, chi-square test for hypertension, peripheral vascular disease, pre-existing cardiac disease, abnormal EKG/old myocardial infarction, and congestive heart failure, and p < 0.006 for cerebral vascular disease). In addition, the co-morbid risk factors of hypertension, low serum albumin, and pre-existing cardiac disease at the start of dialysis were strongly prognostic of survival. The Cox proportional hazards regression model identified these three risks, among other factors, that were significantly associated with a decreased survival, with risk ratios ranging from 1.40-1.66. These results support the authors' hypothesis that incoming end-stage renal disease patients, who recently start dialysis, are sicker than in the earlier years of the authors' program. If the authors' patients reflect the national end-stage renal disease population, the presence of co-morbid risk factors may, in part, explain the continuing high mortality of dialysis patients.

Home hemodialysis: patient outcomes during a 24-year period of time from 1970 through 1993.

In the United States, from 1983 to 1993, home hemodialysis use has decreased from 6% to 1.3% of the dialysis population, whereas continuous ambulatory peritoneal dialysis (CAPD) has increased to 20%. Most home hemodialysis programs have withered away because of current patient mix, increase in CAPD, proliferation of outpatient centers, disinterest in nephrologists, and fear of self-cannulation by patients. From 1970 through 1993, 896 patients began dialysis at North Shore and were followed up through 1994. During this period, 687 patients were on in-center hemodialysis, 95 on CAPD, 74 on home hemodialysis, and 40 on in-center peritoneal dialysis. The home hemodialysis patients were younger, with a median age of 44 versus 59 years for in-center hemodialysis patients, and had less comorbidity. The home hemodialysis group had fewer diabetic patients and no renal vascular patients. The 5-year and median survival estimates were significantly better for the home hemodialysis patients versus other dialysis modalities. More home hemodialysis patients received transplants. Compared with the other dialysis modalities, home hemodialysis patients showed significantly improved survival rates. When matched by age, sex, and end-stage renal disease (ESRD) diagnosis to corresponding in-center hemodialysis, the home hemodialysis patients still had significantly better survival rates, but the home hemodialysis patients had less comorbidity. In conclusion, home hemodialysis patients survive longer and have better rehabilitation than other dialysis patients. Reasons for better survival in addition to a younger age and more favorable ESRD diagnosis may include less comorbidity, more patient involvement, and longer dialysis time. Because of these better outcomes, home hemodialysis should be offered to more ESRD patients.

Comparison of methods for measuring albumin in peritoneal dialysis and hemodialysis patients.

Serum albumin levels have been used extensively as an indicator of morbidity in patients with end-stage renal disease. Recent evidence suggests that albumin levels vary considerably in hemodialysis patients depending on the laboratory method used, but formulas for comparing albumin values by different methods have not been developed. We prospectively evaluated the effects of measuring albumin by three different methods on paired plasma and serum from 23 patients on continuous ambulatory peritoneal dialysis (CAPD) and 53 patients on chronic maintenance hemodialysis. Plasma and serum gave virtually identical results independent of method used. In CAPD patients, bromcresol green and nephelometry gave nearly identical albumin measurements through the entire range of plasma levels. In contrast, bromcresol purple gave values that were 9.9 percent +/- 1.3 percent lower (P < 0.05). Hemodialysis patients showed a similar pattern with close agreement between bromcresol green and nephelometry, but bromcresol purple gave lower albumin levels by 19.1 percent +/- 1.2 percent (P < 0.05). The discrepancy in albumin in CAPD patients was significantly less than in the hemodialysis patients (P < 0.05), suggesting that there were fewer interfering substances in the blood of CAPD patients than in hemodialysis patients. Linear regression analysis was used to develop simple formulas for comparing albumin values obtained by the different methods in CAPD and hemodialysis patients. These studies show that values for albumin in blood vary significantly by method of analysis in CAPD and hemodialysis patients. By the use of these formulas, it becomes possible to compare albumin values between centers using different methods for the purpose of quality management.

Minimal change nephropathy associated with sclerosing mesenteritis.

A 65-year-old man with sclerosing mesenteritis developed the nephrotic syndrome. Percutaneous renal biopsy revealed classical histologic findings of minimal change nephropathy with a mild interstitial nephritis. Immunomodulation with prednisone led to a rapid and complete remission of the proteinuria but did not alter the course of the underlying sclerosing mesenteritis. The association of lymphomatous and nonlymphomatous neoplasms with minimal change nephropathy has been well-described. Our review of the literature indicates a parallel association of malignant lymphoma with sclerosing mesenteritis and a variety of disorders that constitute a spectrum of disease. The occurrence of this histopathologic form of renal injury and therapeutic response in the setting of a known lymphoreticular disorder suggests a role for a generalized alteration in cell-mediated immunity and not a tumor-induced elaboration of a factor(s) that directly damages the glomerular filtration barrier.

Renal vascular disease causing end-stage renal disease, incidence, clinical correlates, and outcomes: a 20-year clinical experience.

In the United States, the incidence of end-stage renal disease to hypertension has increased sharply over the last 8 years, especially in elderly white dialysis patients who demonstrate very poor survival rates. The 5-year survival rates were near 20% for patients 65 to 74 years old and 9% for those > or = 75 years of age. Our program experienced a sharp increase in cases of end-stage renal disease due to renal vascular disease after 1982. Renal vascular disease was characterized clinically in 83 of 683 dialysis patients either by angiography or asymmetric kidney size in patients with evidence of systemic atherosclerosis, hypertension, insignificant proteinuria, and a benign urinary sediment. The median age was 70 years, with 84% of the patients being older than 61 years. These patients had 56% 2-year, 18% 5-year, and 5% 10-year survival rates, which are quite similar to the 1992 US Renal Data System data. Patients with renal vascular disease have a significantly worse prognosis than other diagnostic groups, most likely due to their older age, underlying vascular disease, and coronary artery disease. We feel that a significant number of elderly white hypertensive patients described in the 1992 US Renal Data Service report have renal vascular disease as a cause of end-stage renal disease, highlighting the need to establish correct renal diagnoses. Hypertension should not be the end-stage renal disease diagnosis in elderly white hypertensive patients if clinical criteria suggest a diagnosis of renal vascular disease.

Survival estimates for 683 patients starting dialysis from 1970 through 1989: identification of risk factors for survival.

Survival estimates were performed on 683 chronic dialysis patients who started dialysis from 1970 through 1989 and followed through 1991. Patients were grouped by dialysis type, renal diagnosis, start-year group and age at start. During these 20 entry, years, the median starting age rose from 47 to 61 years. Patients with a renal diagnosis of diabetes mellitus or renal vascular disease increased to 41% of those starting dialysis during the last 8 years of study. Survival analysis for all of the 683 patients revealed a 51-month median survival and a 43% and 23% 5- and 10-year survival estimates, respectively. There was nearly a fourfold rise in the risk ratio as age increased from the youngest to oldest age groups. Home hemodialysis patients had the longest survival, 89% at 5 years; patients on CAPD had a 56% 5-year survival. In-center hemodialysis patients had a median survival of 48 months and a 5-year survival of 39%. Pairwise comparisons of the renal diagnostic groups found patients with polycystic kidneys, interstitial disease and chronic glomerulonephritis to have better survival than patients with diabetes mellitus, renal vascular disease or the "other" diagnoses (log-rank test, p < 0.001). Survival analyses showed age, renal diagnosis, race, type of dialysis and dialysis modality switch to be important predictors of survival. The results of the survival estimates, gross mortality rates and standardized mortality ratios were used as guides to the adequacy of dialysis and quality of care delivered for the years 1989 through 1992.

Death by withdrawal from dialysis: a 20-year clinical experience.

The reasons for withdrawal from dialysis are not well understood. The goals of this study were to determine the risk of dying by withdrawal from dialysis over time and to elucidate pertinent clinical correlates in 716 long-term dialysis patients. These patients were monitored from the initiation of dialysis through the time of death, transplant or transfer to another program during a 20-yr period from 1970 through 1989. The causes of death in the 340 deceased patients were analyzed. Clinical correlates and associated risk factors were evaluated in the patients who died from withdrawal from dialysis. Withdrawal from dialysis was defined as: "Death with manifestations of uremia because of withdrawal from dialysis. Underlying medical conditions should not have been active, leading to rapid deterioration with imminent death." Withdrawal from dialysis and cardiac events were the second leading cause of death, each accounting for 18.5% of the deaths. Patients stopping dialysis were older at the start of dialysis than were patients dying of other causes (P < 0.0006; Kruskal-Wallis test), with 65.1% of these patients 61 yr of age and older. Cancer, malnutrition, catabolism, and "dissatisfaction with life" were important associations with the decision to withdraw. More than 50% of patients withdrawing from dialysis had either diabetic nephropathy or atherosclerotic renal vascular disease. Withdrawal from dialysis was a common cause of death in these dialysis patients especially if they were over 61 and had systemic diseases such as diabetes mellitus and renal vascular disease. The reasons for a higher incidence of withdrawal in certain programs deserve further study.

Mortality in dialysis patients: analysis of the causes of death.

The objective of this study was to identify the causes of death in maintenance dialysis patients who survived at least 90 days and were monitored during a 16-year period. Of 532 patients starting dialysis, 222 died. The causes of death were grouped into six categories: cardiac, infectious, withdrawal from dialysis, sudden, vascular, and "other." The greatest number of deaths were due to infections, followed by withdrawal from dialysis, cardiac, sudden death, vascular, and other. The risk of dying increased for the first 4 years of dialysis, decreased in years 5 through 10, and had a second increase at 11 years. The mortality during the first 4 years consisted largely of infectious and cardiac deaths. The late peak of deaths was mainly due to infections and withdrawal from dialysis. Overall, infections accounted for more than 36% of all deaths. Withdrawal occurred in 21.2% of the patients and was most common in patients over age 61. Notably, cardiac deaths accounted for only 14.4% of all deaths and no patient died from a cardiac cause after surviving on dialysis more than 8.5 years. We conclude that infection is the leading cause of death in our dialysis patient population. Withdrawal from dialysis was a common cause of death, especially in older patients. Cardiac mortality was not as frequent as anticipated and occurred mainly in patients on dialysis less than 4 years, suggesting that it is the result of preexisting disease.

Reduction in liver iron in hemodialysis patients with transfusional iron overload by deferoxamine mesylate.

Four hemodialysis patients with transfusional iron overload were treated with three times weekly intravenous (IV) deferoxamine mesylate during the dialysis treatment. Using a gamma ray scattering technique, significant reductions in liver iron content were documented, with a mean follow-up of 20 months. Three of the four patients showed significant improvements in liver enzymes. This decrease in liver iron content could not be predicted by clinical parameters or serum ferritin. Therapy proved to be safe and effective, but follow-up requires monitoring of tissue iron by means other than standard laboratory tests.

Predictors of survival in patients undergoing dialysis.

Survival and risk analyses were performed on all 532 patients in whom long-term dialysis was started from 1970 through 1985. During this 16-year period, starting age increased from 47 to 60 years (p less than 0.001), and the incidence of diabetes mellitus and renal vascular disease increased. Survival analysis showed age, renal diagnosis, type of dialysis, and year starting dialysis to be important predictors of survival. There was a fourfold rise in the risk ratio as starting age increased from 25 to 65 years. The risk was 1.5 times higher for those patients who did not start dialysis in 1978 through 1981 than for those who did. Risk decreased fivefold for patients choosing home hemodialysis. Home hemodialysis patients survived longer compared with patients utilizing other dialysis modalities, possibly because of a younger average age and a lower incidence of diabetes mellitus and renal vascular disease. There was greater than a threefold rise in risk ratio with the diagnosis of diabetes mellitus compared with either chronic glomerulonephritis or polycystic kidney disease. Older patients and those with diabetes mellitus formed the high-risk group; these two characteristics have been increasing during the last eight years of the study. It is concluded that although patients with high risk have an increased and a high mortality, overall survival has improved.