29
Table 3.5 Unadjusted ten-year survival of dialysis patients by diabetic status 1993-2002
Diabetes status
Diabetic Interval
months Survival
SE Survival
SE 6
96 93
12 93
86 24
87 73
1 36
82 60
1 48
77 1
50 1
60 71
1 41
1 72
67 1
34 1
84 62
1 29
1 96
58 1
21 1
108 54
1 17
2 120
51 1
14 2
Non-Diabetic
SE=standard error
Figure 3.5 Unadjusted ten-year survival of dialysis patients by diabetic status 1993-2002 cohort
Kaplan-Meier survival estimates, by Diabetes
C u
m u
la tiv
e su rv
iva l
duration in months 12
24 36
48 60
72 84
96 108
120 0.00
0.25 0.50
0.75 1.00
Non-diabetic
Diabetic
3.5 Patient Survival by Diabetic Status The presence of diabetes mellitus has a major
impact on survival. The one-year, 5-year and 10- year survival for non-diabetics were 93, 71 and
51, while that for diabetics were 86, 41 and 14 respectively. The divergence in survival was
noted 6 months after commencement of dialysis. The median time of survival for diabetics was 48
months compared to at least 120 months for non- diabetics. Table 3.5. Figure 3.5
Table 3.4 Unadjusted ten-year survival of dialysis patients by age 1993-2002 cohort
Age group 15 -
≤24 25 -
≤ 34 35—
≤ 44 Interval
months Survival
SE Survival
SE Survival
SE Survival
SE 6
98 1
97 1
97 1
97 12
97 1
95 1
95 1
94 1
24 92
2 89
1 92
1 90
1 36
88 3
88 1
89 1
85 1
48 88
3 85
2 86
1 82
1 60
85 3
82 2
84 1
78 1
72 80
4 80
2 81
1 74
1 84
75 6
78 3
79 2
71 1
96 75
6 77
3 78
2 65
2 108
56 17
75 3
76 2
61 2
120 56
17 75
3 73
3 60
2 ≤14
Age group 55—
≤ 64 ≥ 65
Interval months Survival
SE Survival
SE Survival
SE 6
96 93
91 1
12 91
1 87
1 84
1 24
83 1
78 1
68 1
36 74
1 66
1 54
1 48
67 1
57 1
44 1
60 60
1 49
1 34
1 72
55 1
41 1
27 2
84 49
1 35
1 21
2 96
41 2
29 2
18 2
108 37
2 24
2 14
2 120
33 3
19 3
14 2
45 - ≤ 54
SE=standard error
30
3.6 Adjusted Mortality of Dialysis Patients The 1997-2002 dialysis cohort was examined for
independent risk factors for death by Cox proportional hazard regression model. The clinical
and biochemical data for patients commencing dialysis before 1997 were incomplete and
unsuitable for analysis and hence were not included in the analysis. Furthermore the earlier data was
only available for patients on dialysis in the Ministry of Health facilities and therefore not representative
of the whole dialysis population where about 60 of patients received dialysis therapy in non-Ministry of
Health facilities.. The risk of death was adjusted for age, gender, primary diagnosis, time on renal
replacement therapy RRT, modality of dialysis, presence of cardiovascular disease, diabetic status,
body mass index BMI, serum concentrations of albumin, cholesterol, calcium, phosphate, calcium-
phosphate product and haemoglobin; blood pressure, and hepatitis status. Time averaged
values of biochemical data were used. Patient characteristics that had significant
impact on the hazard of death were age, gender, body mass index, year commencing dialysis,
dialysis modality, diastolic blood pressure and presence of diabetes or cardiovascular disease.
The significant biochemical risk factors for death were serum albumin, haemoglobin, cholesterol,
calcium and calcium-phosphate product. Table 3.6
As expected age was an independent risk factor for death. The risk rose progressively with
each decade of life. The hazard of death for an elderly patient more than 65 years of age was 5.8
times higher compared to a patient less than 15 years of age. This is consistent with the ERA- EDTA
registry data. In their report the relative risk of death increased by 5 for each one year increment in
age.[3] Female patients had a 14 lower risk of death compared to their male counterparts. This is
consistent with the USRDS data.[1] However, the ERA-EDTA registry reported that females had a 5
higher risk of death compared to males.[3] Diabetic patients on dialysis had about 2 times
higher risk of death compared to the non-diabetics. This is comparable with the ERA-EDTA Registry
report where the risk of death in diabetics was 2.46 times higher the than non-diabetics.[3] As reported
by other authors, dialysis patients with underlying cardiovascular disease had a higher risk of mortality
49 when compared to patients with no reported history of cardiovascular disease.[4]
CAPD patients had a 74 higher risk of death compared to haemodialysis patients. The ERA-
EDTA showed a 25 higher risk of death for those who started renal replacement therapy with
peritoneal dialysis.[3] In contrast two other studies did not find any difference in survival between
CAPD and haemodialysis patients.[5][6]. The reasons for the lower survival in our CAPD patients
are unclear and needs further studies. The US and European registries have reported
improved survival of patients starting dialysis in later vintage. ERA-EDTA data showed that after
adjustment for age, gender and diabetes, patient survival for the 1990-1994 relative risk RR 0.94
and the 1995-1999 cohorts RR 0.88 were better compared to the 1980-1984 cohort.[2] Their
improved survival on RRT was attributed to the improved efficiency and safety of dialysis. However
our study indicates the reverse - a higher risk of death in patients commencing dialysis from 1999-
2002 compared to patients starting dialysis before 1999. Compared to the 1997-1998 cohort the
mortality risks of the 1999-2000 and the 2001-2002 cohorts were increased by 21 and 27
respectively. The higher mortality may be due to increased intake of high risk patients into dialysis
centres with limited medical care. However, this trend is worrying and more analysis is urgently
needed to examine for possible centre-treatment interaction and other as yet unidentified reasons for
this trend. Three nutritional markers serum albumin
concentration, body mass index and serum cholesterol concentration were identified as
independent risk factors for death. Serum albumin concentration was inversely related to the risk of
death. Compared to a serum albumin of 40gl or more, the risk of death was 4.37, 2.24 and 1.38
times higher in patients with serum albumin less than 30gl, 30-34gl and 35-39gl respectively. This
relationship has been well described in the literature.[7]
Low body mass index BMI and low serum cholesterol concentration were also associated with
increased risk of death. Compared to a BMI of 25 kgm
2
or higher, a BMI of less than 18.5 kgm
2
was associated with a 41 increased risk of death. The
USRDS data also showed higher death rate in haemodialysis patients with lower body mass index.
[8][9] Similarly, a serum cholesterol of less than 3.2 mmoll was associated with a 47 increased risk of
death compared to patients with serum cholesterol of more than 5.2 mmoll. The USRDS data showed
similar findings.[1] This inverse relationship in dialysis patients is at variance with the evidence
from the normal population. This discrepancy is probably due to the association of low cholesterol
with malnutrition and inflammation.[10] Further studies are needed to establish the relationship
between higher serum cholesterol and the risk of death from cardiovascular disease.
A prescribed KtV
urea
of less than 1.0 was associated with a 73 higher risk of death
compared to a KtV
urea
of 1.2 to 1.4. There was a trend of better survival in patients with KtV
urea
1.4, but this was not statistically significant.
In the general population high blood pressure is associated with increased mortality. Even borderline
high blood pressure has been associated with increased cardiovascular events.[11] Evidence now
shows that there is no J-curve relationship between blood pressure and mortality in the general
population. In the dialysis population however, several studies have shown a higher risk of death in
patients with low blood pressure.[12][13] In our cohort, there is a U-shaped or J-shaped relationship
between blood pressure and risk of death. Figure 3.6a Compared to the reference range of 80-
