Characteristics and predictors of mortality on haemodialysis in Brazil: a cohort of 5,081 incident patients

Abstract

Background Although Brazil has one of the largest populations on haemodialysis (HD) in the world, data regarding patients’ characteristics and the variables associated with risk of death are scanty. Methods This is a retrospective analysis of all adult patients who initiated on maintenance HD at 23 dialysis centres in Brazil between 2012 and 2017. Patients were censored after 60 months of follow-up or at the end of 2019. Results A total of 5,081 patients were included in the analysis. The median age was 59 years, 59.4% were men, 37.5% had diabetes as the cause of kidney failure. Almost 70% had a central venous catheter (CVC) as the initial vascular access, about 60% started dialysis in the hospital, and fluid overload (FO) by bioimpedance assessment was seen in 45% of patients. The 60-month survival rate was 51.4%. In the Cox regression analysis, being older (P<0.0001), starting dialysis in the hospital (P=0.016), having diabetes as the cause of kidney failure (P=0.001), high alkaline phosphatase (P=0.005), CVC as first vascular access (P=0.023), and FO (P<0.0001) were associated with higher death risk, whereas higher body mass index (P=0.015), haemoglobin (P=0.004), transferrin saturation (P=0.002), and serum albumin (P<0.0001) were associated with better survival. The same variables, except initial CVC use (P=0.14), were associated with death risk in an analysis of subdistribution proportional hazards ratio including the competing outcomes. Conclusions The present study gives an overview of a large HD population in a developing country and identifies the main predictors of mortality, including some potentially modifiable ones, such as unplanned initiation of dialysis in the hospital and fluid overload.

Sobrevida na hemodiálise no Brasil de acordo com a fonte pagadora do tratamento: Sistema Único de Saúde versus convênio privado

“…As demais variáveis na admissão encontradas associadas ao risco de morte no presente estudo foram idade, diabetes, o início da HD em hospital, o índice de massa corporal, o índice de saturação da transferrina, os níveis de hemoglobina, albumina e fosfatase alcalina e a presença de sobrecarga hídrica (Tabela 2). A associação entre estas variáveis e o risco de morte são bem conhecidas 8,[16][17][18][19][20][21] e não são o foco do presente estudo, pois já analisamos e discutimos mais detalhadamente tais associações num estudo prévio com esta mesma coorte 7 .…”

“…O restante dos pacientes tem o tratamento coberto por convênios privados de saúde e geralmente dialisam nas mesmas clínicas que tratam os pacientes custeados pelo SUS 4 . A taxa de mortalidade entre os pacientes em HD é extremamente elevada [4][5][6][7] . No entanto, pouco se conhece acerca da sobrevida dos pacientes em HD no Brasil de acordo com a fonte pagadora do tratamento.…”

Survival in hemodialysis in Brazil according to the source of payment for the treatment: Public Healthcare System (SUS) versus private insurance

“…The rest of the patients have their treatments covered by private healthcare insurance, and generally undergo dialysis in the same clinics that treat patients funded by the SUS 4 . The mortality rate among HD patients is extremely high [4][5][6][7] . However, little is known about the survival of HD patients in Brazil according to the source paying for the treatment.…”

Bioimpedance Indices of Fluid Overload and Cardiorenal Outcomes in Heart Failure and Chronic Kidney Disease: a Systematic Review

“…Widespread measurement of BCM-determined fluid overload across the Nephrocare-FMC 26-country dialysis center network has facilitated large-scale observational studies, which have demonstrated strong positive associations with risk of all-cause mortality in patients requiring dialysis, independent of blood pressure (17)(18)(19). These studies used relative fluid overload derived by indexing absolute excess fluid volume to the volume of the extracellular water (ECW) compartment as the exposure, thereby allowing for comparisons between individuals (20).…”

“…These studies used relative fluid overload derived by indexing absolute excess fluid volume to the volume of the extracellular water (ECW) compartment as the exposure, thereby allowing for comparisons between individuals (20). A threshold of >15% relative fluid overload, equivalent to approximately +2.5 L absolute fluid overload (20), has often been used in analyses (17)(18)(19), while other studies have also employed the more modest threshold of >7% relative fluid overload (approximately equivalent to +1.1L absolute fluid overload) (19,21). These dialysis studies have been subject to systematic reviews (22)(23)(24)(25), but reviews of studies of heart failure and non-dialysis CKD have not been reported.…”