NDT Advance Access published online on September 15, 2009
Nephrology Dialysis Transplantation, doi:10.1093/ndt/gfp455
Survival and transplantation in end-stage renal disease: a prospective study of a multiethnic population
1 Department of Nephrology, University Hospital Birmingham 2 Department of Nephrology, Queen Elizabeth Medical Centre, Birmingham, West Midlands 3 Department of Nephrology, United Lincolnshire Hospitals NHS Trust, Lincoln, Lincolnshire 4 Department of Renal Medicine, Birmingham Heartlands Hospital, Birmingham 5 Department of Nephrology, New Cross Hospital, Wolverhampton 6 Fresenius Medical care, Birmingham 7 Renal Unit, University Hospitals Coventry and Warwickshire, Coventry 8 Department of Renal Medicine, Birmingham Heartlands Hospital, Birmingham, West Midlands, UK
Correspondence and offprint requests to: Poorva Jain; E-mail: poorva.jain{at}doctors.org.uk
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Abstract |
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Introduction. Accurate assessment of determinants of patient survival in end-stage renal disease is important for counselling, clinical management and resource planning. To address this we have analysed survival and risk factors for survival for patients treated for end-stage renal disease in a multi-ethnic UK population.
Methods. A multicentre prospective observational cohort study was performed in four teaching hospital renal units serving a total population of four million people. A total of 884 consecutive patients treated with renal replacement therapy were studied. Cox proportional hazard modelling and adjusted survival curves were used to assess the impact of a range of variables on patients surviving dialysis for more than 90 days. Further analysis was undertaken to determine the likelihood of transplantation in different ethnic groups.
Results. Survival was 29% after a mean and median follow up of 4.6 and 4.2 years, respectively. Factors associated with worse survival included the following: age; for each decade of life the relative risk (RR) of death was 1.52 (95% confidence intervals 1.41–1.65, p < 0.0001); comorbidity, one or two comorbid conditions, RR = 1.56 (95% CI 1.24–1.95, p < 0.001) and three or more comorbid conditions, RR = 2.34 (1.68–3.27, p < 0.001). Factors associated with better survival included the following: south-Asian ethnicity, RR = 0.6 (0.46–0.80, p < 0.001); renal transplantation, RR = 0.20 (95% CI 0.11–0.59, p < 0.0001) and glomerulonephritis as the primary renal disease, RR = 0.70 (0.50–0.97, p = 0.04). Factors associated with likelihood of transplantion were having a functioning fistula/peritoneal dialysis catheter at start of dialysis (RR 1.91, 95% CI 1.24–2.94, p = 0.003) and glomerulonephritis (RR 9.54, 95% CI 2.43–37.64, p = 0.001). Patients were less likely to receive if they were black (RR 0.10, 95% CI 0.02–0.34, p < 0.001), South Asian (RR 0.64, 95% CI 0.42–0.97, p = 0.037), diabetic (RR 0.06, 95% CI 0.01–0.23, p < 0.001) and had one or two comorbid conditions (RR 0.51, 95% CI 0.32–0.82, p = 0.06). Every decade increase in age was also associated with a lesser likelihood of transplantation (RR 0.55, 95% CI 0.49–0.61, p < 0.001).
Discussion. Risk stratification at commencement of chronic dialysis may predict long-term survival in different patient groups. As expected ethnic minorities are less likely to receive a transplant and this should be addressed by the new waiting list prioritization. The better survival on dialysis in this population of patients with south-Asian ethnicity is unexplained and this requires further investigation.
Keywords: comorbidity; end-stage renal disease; ethnicity; survival; transplantation
Received for publication: 16. 2.08
Accepted in revised form: 12. 8.09