Mortality in chronic kidney disease and renal replacement therapy: a population-based cohort study

Abstract

Objective: To compare mortality in chronic kidney disease (CKD) stages 4 and 5 (estimated glomerular filtration rate <30 mL/min/1.73 m(2)), peritoneal dialysis, haemodialysis and transplanted patients.

Design: Population-based cohort study.

Setting: Swedish national healthcare system.

Participants: Swedish adult patients with CKD stages 4 and 5 (n=3040; mean age 66 years), peritoneal dialysis (n=725; 60 years), haemodialysis (n=1791; 62 years) and renal transplantation (n=606; 48 years) were identified in Stockholm County clinical quality registers for renal disease between 1999 and 2010. Five general population controls were matched to each patient by age, sex and index year.

Exposure: CKD status (stage 4 or 5/peritoneal dialysis/haemodialysis/transplanted).

Primary outcome: All-cause mortality was ascertained from the Swedish Causes of Death Register. Mortality HRs were estimated using Cox regression conditioned on age, sex, diabetes status, education level and index year.

Results: During 6553 person-years, 766 patients with CKD stages 4 and 5 died (deaths/100 person-years 12, 95% CI 11 to 13) compared with 186 deaths during 1113 person-years in peritoneal dialysis (17, 95% CI 15 to 19), 924 deaths during 3680 person-years in haemodialysis (25, 95% CI 23 to 27) and 53 deaths during 2935 person-years in transplanted patients (1.8, 95% CI 1.4 to 2.4). Against matched general population controls, the mortality HR was 3.6 (95% CI 3.2 to 4.0) for CKD, 5.6 (95% CI 3.5 to 8.9) for transplanted patients, 9.2 (95% CI 6.6 to 12.7) for peritoneal dialysis and 12.6 (95% CI 10.8 to 14.6) for haemodialysis. In direct comparison versus CKD, the mortality HR was 1.7 (95% CI 1.4 to 2.1) for peritoneal dialysis, 2.6 (95% CI 2.3 to 2.9) for haemodialysis and 0.5 (95% CI 0.3 to 0.7) for transplanted patients.

Conclusions: We did not find support for mortality in CKD to be similar to dialysis mortality. The patients with CKD stages 4 and 5 had considerably lower mortality risk than dialysis patients, and considerably higher risk than transplanted patients and matched general population controls.

Keywords: chronic kidney disease; mortality; renal replacement therapy; transplantation.

Figure 1

Survival curves describing time to death for patients with chronic kidney disease, peritoneal dialysis, haemodialysis and transplanted patients, as well as matched general population controls.

Figure 2

Crude mortality rates by health state and age.

Figure 3

Conditional all-cause, cardiovascular (CVD) and non-cardiovascular (non-CVD) mortality HRs versus matched general population controls.

Figure 4

Mortality HRs by education level using >12 years of education as reference.