Risk Factors for Dialysis Withdrawal

Abstract

Summary Background and objectives Dialysis withdrawal (DW) in patients with ESRD is increasing in importance. This study assessed causes of death and risk factors for DW in Australia and New Zealand in the first year of dialysis. Design, setting, participants, & measurements This retrospective observational cohort study included all adult Australians and New Zealanders beginning renal replacement therapy in 1999–2008. Results A total of 24,884 patients with 10,073 deaths were included. Deaths from cardiac and social causes (predominantly DW) accounted for 38% and 28% of all deaths, respectively. Cumulative incidence of DW was 3.5% at 1 year (95% confidence interval [CI], 3.3%–3.8%), 9.0% at 3 years (95% CI, 8.6%–9.4%), and 13.4% at 5 years (95% CI, 12.8%–13.9%). In multivariate analysis, predictors for DW in the first year were older age (subhazard ratio [SHR], 1.70 per decade [95% CI, 1.59–1.83]; P<0.001), late referral (SHR, 1.83 [95% CI, 1.59–2.11]; P<0.001), comorbid conditions (SHR, 1.33 per each additional comorbid condition [95% CI, 1.25–1.41]; P<0.001), and diabetes (SHR, 1.16 [95% CI, 1.00–1.34]; P=0.05). Negative predictors for DW included male sex (SHR, 0.75 [95% CI, 0.66–0.87]; P<0.001), indigenous ethnicity (SHR, 0.74 [95% CI, 0.58–0.95]; P=0.02), other nonwhite race (SHR, 0.66 [95% CI, 0.48–0.91]; P=0.01), and peritoneal dialysis user (SHR, 0.59 [95% CI, 0.49–0.72]; P<0.001). Conclusions DW is common among dialysis patients in Australia and New Zealand. Risk factors include older age, female sex, white race, diabetes, higher comorbidity burden, hemodialysis user, and late referral to nephrologist.

Early Dialysis Initiation and Rates and Timing of Withdrawal From Dialysis in Canada

“…Additional findings in our study include previously reported risk factors for dialysis withdrawal, such as increasing age, female sex, and white race (4,5,7). The reasons that nonwhite patients withdraw less often are unclear; however, it is likely that religious and cultural beliefs play a significant role (20).…”

“…In our study, modality type was not associated with withdrawal, but dialysis at home, in a community setting, and in an urban center were associated with fewer withdrawals, perhaps because of increased home and community supports. In contrast, Chan et al (7) found that patients undergoing hemodialysis were more likely to withdraw than those undergoing peritoneal dialysis. The authors surmised that the greater sense of personal control over treatment facilitated adherence to treatment, leading to less withdrawal; however, they could not rule out selection bias and unmeasured confounders leading to this result because frail patients are more likely to begin renal replacement therapy with hemodialysis.…”

Psychosocial factors in adults with chronic kidney disease: characteristics of pilot participants in the Tasmanian Chronic Kidney Disease study

“…According to Australian registry data, for every new case that receives dialysis another patient with ESKD dies without having received it [52]. Further, for those who do commence dialysis, around 37% will die via withdrawal from treatment [53]. For these patients, medical management may involve a shift from efforts to prolong life to a more supportive/palliative care model focusing on care, quality of life and symptom control.…”

Early withdrawal and non‐withdrawal death in the months following hemodialysis initiation: A retrospective cohort analysis

“…Several studies have sought to risk‐stratify dialysis initiators for all‐cause mortality, while others have examined the factors associated with dialysis withdrawal . However, few if any studies have rigorously examined early withdrawal in incident dialysis patients.…”