Estimating the Fraction of First-Year Hemodialysis Deaths Attributable to Potentially Modifiable Risk Factors: Results from the DOPPS

Abstract

Purpose

Mortality among first-year hemodialysis (HD) patients remains unacceptably high. To address this problem, we estimate the proportions of early HD deaths that are potentially preventable by modifying known risk factors.

Methods

We included 15,891 HD patients (within 60 days of starting HD) from 21 countries in the Dialysis Outcomes and Practice Patterns Study (1996–2015), a prospective cohort study. Using Cox regression adjusted for potential confounders, we estimated the fraction of first-year deaths attributable to one or more of twelve modifiable risk factors (the population attributable fraction, AF) identified from the published literature by comparing predicted survival based on risk factors observed vs counterfactually set to reference levels.

Results

The highest AFs were for catheter use (22%), albumin <3.5 g/dL (19%), and creatinine <6 mg/dL (12%). AFs were 5%-9% for no pre-HD nephrology care, no residual urine volume, systolic blood pressure <130 or ≥160 mm Hg, phosphorus <3.5 or ≥5.5 mg/dL, hemoglobin <10 or ≥12 g/dL, and white blood cell count >10,000/μL. AFs for ferritin, calcium, and PTH were <3%. Overall, 65% (95% CI: 59%-71%) of deaths were attributable to these 12 risk factors. Additionally, the AF for C-reactive protein >10 mg/L was 21% in facilities where it was routinely measured.

Conclusion

A substantial proportion of first-year HD deaths could be prevented by successfully modifying a few risk factors. Highest priorities should be decreasing catheter use and limiting malnutrition/inflammation whenever possible.

Keywords:

• hemodialysis
• incidence
• mortality
• attributable fraction
• cohort study

Acknowledgments

Jennifer McCready-Maynes, an employee of Arbor Research Collaborative for Health, provided editorial assistance for this paper. The results presented in this paper have not been published previously in whole or part, except in abstract format. The abstract was presented as part of ASN’s Kidney Week 2018. The citation is: Robinson BM, Morgenstern H, Karaboyas A, Li Y, Bieber B, Hakim RM, Hasegawa T, Jadoul M, Schaeffner E, Vanholder R, Pisoni RL. Estimating the fraction of first-year hemodialysis deaths attributable to potentially modifiable risk factors: results from the DOPPS [abstract]. J Am Soc Nephrol. 2018;29: 629-630.

Disclosure

Friedrich K Port has a consultancy contract with Arbor Research Collaborative for Health. Hal Morgenstern is consultant at Arbor Research Collaborative for Health. Takeshi Hasagawa has consulted for Kyowa Hakko Kirin, received research funding from JSPS KAKENHI (Grant Number 15K00877) and received speaker honoraria from Kyowa Hakko Kirin, Chugai Pharmaceutical, Torii Pharmaceutical, and Daiichi-Sankyo Pharmaceutical. Raymond Vanholder has received travel support and speaker’s honoraria from B. Braun and Nikisho. Michel Jadoul has served as a consultant for Astellas, MSD, Vifor Fresenius Medical Care Renal Pharma, received grant/research support from Amgen, Astra-Zeneca, Janssen-Cilag, MSD, Otsuka, Roche, been a speaker for AbbVie, Amgen, Menarini, MSD, Vifor Fresenius Medical Care Renal Pharma, received travel compensation from Amgen; all monies paid to institution including non-financial support from Sanofi-Genzyme, outside the submitted work. Elke Schaeffner reports speaker honorarium from Fresenius Medical Care, Fresenius Kabi, Siemens healthineers and grants from E.N.D.I foundation and DDnÄ, outside the submitted work. Angelo Karaboyas, Bruce M. Robinson, Ronald L Pisoni, Brian A. Bieber are employees of Arbor Research Collaborative for Health, which administers the DOPPS. Angelo Karaboyas reports grants from Akebia Therapeutics, Amgen, AstraZeneca, Bard Peripheral Vascular, Baxter Healthcare, Bayer Yakuhin, Chugai Pharmaceutical, Fresenius Medical Care Asia-Pacific, Japanese Society for Peritoneal Dialysis, JMS Co, Kidney Research UK, Kidney Foundation Japan, Kissei Pharmaceutical Co, Kyowa Kirin Co, MEDICE Arzneimittel Pütter GmbH & Co KG, Nikkiso, ONO Pharmaceutical Co, Sanofi-Aventis Deutschland GmbH, Terumo Corporation, Torii Pharmaceutical Co, Vifor-Fresenius Medical Care Renal Pharma Ltd, during the conduct of the study. The authors report no other conflicts of interest in this work.

Additional information

Funding

Global support for the ongoing DOPPS Programs is provided by a consortium of funders listed in the provided URL without restriction on publications. See https://www.dopps.org/AboutUs/Support.aspx for more information.