Survival and transplantation in end-stage renal disease: a prospective study of a multiethnic population

Abstract

Introduction: Accurate assessment of determinants of patient survival in end-stage renal disease is important for counselling, clinical management and resource planning. To address this we have analysed survival and risk factors for survival for patients treated for end-stage renal disease in a multi-ethnic UK population.

Methods: A multicentre prospective observational cohort study was performed in four teaching hospital renal units serving a total population of four million people. A total of 884 consecutive patients treated with renal replacement therapy were studied. Cox proportional hazard modelling and adjusted survival curves were used to assess the impact of a range of variables on patients surviving dialysis for more than 90 days. Further analysis was undertaken to determine the likelihood of transplantation in different ethnic groups.

Results: Survival was 29% after a mean and median follow up of 4.6 and 4.2 years, respectively. Factors associated with worse survival included the following: age; for each decade of life the relative risk (RR) of death was 1.52 (95% confidence intervals 1.41-1.65, p < 0.0001); comorbidity, one or two comorbid conditions, RR = 1.56 (95% CI 1.24-1.95, p < 0.001) and three or more comorbid conditions, RR = 2.34 (1.68-3.27, p < 0.001). Factors associated with better survival included the following: south-Asian ethnicity, RR = 0.6 (0.46-0.80, p < 0.001); renal transplantation, RR = 0.20 (95% CI 0.11-0.59, p < 0.0001) and glomerulonephritis as the primary renal disease, RR = 0.70 (0.50-0.97, p = 0.04). Factors associated with likelihood of transplantion were having a functioning fistula/peritoneal dialysis catheter at start of dialysis (RR 1.91, 95% CI 1.24-2.94, p = 0.003) and glomerulonephritis (RR 9.54, 95% CI 2.43-37.64, p = 0.001). Patients were less likely to receive if they were black (RR 0.10, 95% CI 0.02-0.34, p < 0.001), South Asian (RR 0.64, 95% CI 0.42-0.97, p = 0.037), diabetic (RR 0.06, 95% CI 0.01-0.23, p < 0.001) and had one or two comorbid conditions (RR 0.51, 95% CI 0.32-0.82, p = 0.06). Every decade increase in age was also associated with a lesser likelihood of transplantation (RR 0.55, 95% CI 0.49-0.61, p < 0.001). Discussion. Risk stratification at commencement of chronic dialysis may predict long-term survival in different patient groups. As expected ethnic minorities are less likely to receive a transplant and this should be addressed by the new waiting list prioritization. The better survival on dialysis in this population of patients with south-Asian ethnicity is unexplained and this requires further investigation.