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NDT Advance Access published online on September 23, 2006
Nephrology Dialysis Transplantation, doi:10.1093/ndt/gfl502
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© The Author [2006]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
Received January 11, 2006
Accepted July 26, 2006

Original Article

Confounding effect of comorbidity in survival studies in patients on renal replacement therapy

Jeannette G. van Manen 1, Paul C. W. van Dijk 2, Vianda S. Stel 2, Friedo W. Dekker 1, Montse Clèries 3, Ferruccio Conte 4, Terry Feest 5, Reinhard Kramar 6, Torbjørn Leivestad 7, J. Douglas Briggs 2, Bénédicte Stengel 8, and Kitty J. Jager 2 *

1 Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
2 ERA-EDTA Registry, Dept. of Medical Informatics, Academic Medical Center - University of Amsterdam, Amsterdam, The Netherlands
3 Catalan Renal Registry (RMRC), Catalan Transplant Organisation, Catalan Health Service, Autonomous Government of Catalonia, Barcelona, Spain
4 Registro Lombardo Dialisi e Trapianto, "Ospedale UBOLDO", Cernusco S7/N, Milano, Italy
5 The UK Renal Registry, Southmead Hospital, Bristol, UK
6 Austrian Dialysis and Transplant Registry (OEDTR), General Hospital of Wels, Wels, Austria
7 Norwegian Renal Registry, Institute of Immunology, Rikshospitalet University Hospital, Oslo, Norway
8 Institut National de la Santé et de la Recherche Médicale, INSERM Unité 258, Villejuif, France

* To whom correspondence should be addressed.
Kitty J. Jager, E-mail: k.j.jager{at}amc.uva.nl



  Abstract

Background. After taking other confounding factors into account, the impact of comorbidity on mortality was investigated when comparing mortality between five European countries, dialysis modalities and renal disease groups.

Methods. The study included 15 571 incident patients on renal replacement therapy (RRT) from five national or regional registries participating in the European Renal Association--European Dialysis and Transplant Association Registry that collect comorbidity data. The presence of diabetes mellitus, ischaemic heart disease, peripheral vascular disease, cerebrovascular disease and malignancy was recorded at the start of RRT.

Results. The comorbidities were each independently associated with mortality, with hazard ratios (HRs) ranging from 1.40 (95% CI: 1.30-1.51) for peripheral vascular disease to 1.65 (95% CI: 1.48-1.83) for diabetes. Age, gender, primary renal disease, modality and country together explained 14.4% of the variance in mortality; the comorbidities explained an additional 1.9%. In the comparison of renal vascular disease with glomerulonephritis, the crude HR of 2.40 (95% CI: 2.12-2.72) changed to 1.24 (95% CI: 1.09-1.41) after adjustment for age, gender, primary renal disease, treatment modality and country and to 1.06 (95% CI: 0.93-1.22) after further adjustment for the comorbidities. For the comparison between countries and other patient groups, the change in the survival estimate after adjustment for comorbidity was less.

Conclusion. Comorbidity is an important predictor for mortality. However, after adjustment for age, gender, primary renal disease, treatment modality and country, when comparing outcomes between patient groups the influence of comorbidity may be less important than expected.

Keywords: comorbidity; confounding; renal replacement therapy; survival.
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