Temporal changes and risk factors for death from early withdrawal within 12 months of dialysis initiation - a cohort study
Nephrology Dialysis Transplantation
Background: Mortality risk is high soon after dialysis initiation in patients with kidney failure, and dialysis withdrawal is a major cause of early mortality, attributed to psychosocial or medical reasons. The temporal trends and risk factors associated with cause-specific early dialysis withdrawal within 12 months of dialysis initiation remain uncertain. Methods: Using data from the Australia and New Zealand Dialysis and Transplant Registry, we examined the temporal trends and risk factors associated with mortality attributed to early psychosocial and medical withdrawals in incident adult dialysis patients in Australia between 2005 and 2018 using adjusted competing risk analyses. Results: Of 32 274 incident dialysis patients, 3390 (11%) experienced death within 12 months post-dialysis initiation. Of these, 1225 (36%) were attributed to dialysis withdrawal, with 484 (14%) psychosocial withdrawals and 741 (22%) medical withdrawals. These patterns remained unchanged over the past two decades. Factors associated with increased risk of death from early psychosocial and medical withdrawals were older age, dialysis via central venous catheter, late referral and the presence of cerebrovascular disease; obesity and Asian ethnicity were associated with decreased risk. Risk factors associated with early psychosocial withdrawals were underweight and higher socioeconomic status. Presence of peripheral vascular disease, chronic lung disease and cancers were associated with early medical withdrawals. KEY LEARNING POINTS What is already known about this subject? dialysis withdrawal is a major cause of death in patients with kidney failure, and international registry reports suggested temporal increase in withdrawal-related mortality; and risk factors associated with mortality from dialysis withdrawal were older age, Caucasian ethnicity, late nephrologist referral and haemodialysis as initial dialysis modality. What this study adds? the proportion of early mortality from dialysis withdrawal has remained unchanged in Australia since 2005; the annual proportion of early mortality attributed to medical withdrawals consistently surpassed the proportion of psychosocial withdrawals; and early mortality attributed to psychosocial and medical withdrawals was associated with similar risk factors. What impact this may have on practice or policy? recognizing the patient at risk of early mortality attributed to dialysis withdrawal may better inform the shared decision-making process, empower patient-focused treatment choices and facilitate advanced care planning. Conclusions: Death from dialysis withdrawal accounted for >30% of early deaths in kidney failure patients initiated on dialysis and remained unchanged over the past two decades. Several shared risk factors were observed between mortality attributed to early psychosocial and medical withdrawals.
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