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Cardiovascular and noncardiovascular mortality among patients starting dialysis
Dinanda J de Jager1, Diana C Grootendorst, Kitty J Jager
1Department of Clinical Epidemiology, Leiden University Medical Center, C7-104, PO Box 9600, 2300 RC Leiden, The Netherlands. d.j.de_jager@lumc.nl
Insights
Patients starting dialysis face a significantly higher overall mortality risk. This increased risk is not solely due to cardiovascular issues but also involves elevated noncardiovascular mortality rates.
Area of Science:
- Nephrology
- Public Health
- Epidemiology
Background:
- Cardiovascular mortality is the leading cause of death in dialysis patients, significantly exceeding general population rates.
- Dialysis patients experience a 10-20 fold higher mortality risk compared to the general population.
Purpose of the Study:
- To determine if the high mortality in dialysis patients stems exclusively from increased cardiovascular risk.
- To investigate whether noncardiovascular mortality is equally elevated in patients initiating dialysis.
Main Methods:
- Utilized European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry data (1994-2007) for 123,407 adult dialysis patients.
- Compared age-stratified mortality rates with the general European population (Eurostat) using standardized cardiovascular and noncardiovascular mortality metrics.
- Analyzed cause of death using ERA-EDTA and International Statistical Classification of Diseases, 10th Revision (ICD-10) codes.
Main Results:
- Dialysis patients exhibited significantly higher standardized cardiovascular (8.8 times) and noncardiovascular (8.1 times) mortality rates compared to the general population.
- Noncardiovascular deaths constituted a larger proportion (51%) of total mortality in dialysis patients than cardiovascular deaths (39%).
- The relative excess of cardiovascular over noncardiovascular mortality in dialysis patients was marginal (1.09).
Conclusions:
- Patients initiating dialysis face a generalized increase in mortality risk.
- The elevated mortality in dialysis patients is not exclusively driven by cardiovascular causes; noncardiovascular mortality also plays a significant role.
Context:
Cardiovascular mortality is considered the main cause of death in patients receiving dialysis and is 10 to 20 times higher in such patients than in the general population.
Objective:
To evaluate if high overall mortality in patients starting dialysis is a consequence of increased cardiovascular mortality risk only or whether noncardiovascular mortality is equally increased.
Design, Setting, And Patients:
Using data from between January 1, 1994, and January 1, 2007, age-stratified mortality in a European cohort of adults starting dialysis and receiving follow-up for a mean of 1.8 (SD, 1.1) years (European Renal Association-European Dialysis and Transplant Association [ERA-EDTA] Registry [N = 123,407]) was compared with the European general population (Eurostat).
Main Outcome Measures:
Cause of death was recorded by ERA-EDTA codes in patients and matching International Statistical Classification of Diseases, 10th Revision codes in the general population. Standardized cardiovascular and noncardiovascular mortality rates, their ratio, difference, and relative excess of cardiovascular over noncardiovascular mortality were calculated.
Results:
Overall all-cause mortality rates in patients and the general population were 192 per 1000 person-years (95% confidence interval [CI], 190-193) and 12.055 per 1000 person-years (95% CI, 12.05-12.06), respectively. Cause of death was known for 90% of the patients and 99% of the general population. In patients, 16,654 deaths (39%) were cardiovascular and 21,654 (51%) were noncardiovascular. In the general population, 7,041,747 deaths (40%) were cardiovascular and 10,183,322 (58%) were noncardiovascular. Cardiovascular and noncardiovascular mortality rates in patients were respectively 38.1 per 1000 person-years (95% CI, 37.2-39.0) and 50.1 per 1000 person-years (95% CI, 48.9-51.2) higher than in the general population. On a relative scale, standardized cardiovascular and noncardiovascular mortality were respectively 8.8 (95% CI, 8.6-9.0) and 8.1 (95% CI, 7.9-8.3) times higher than in the general population. The ratio of these rates, ie, relative excess of cardiovascular over noncardiovascular mortality in patients starting dialysis compared with the general population, was 1.09 (95% CI, 1.06-1.12). Relative excess in a sensitivity analysis in which unknown/missing causes of death were regarded either as noncardiovascular or cardiovascular varied between 0.90 (95% CI, 0.88-0.93) and 1.39 (95% CI, 1.35-1.43).
Conclusion:
Patients starting dialysis have a generally increased risk of death that is not specifically caused by excess cardiovascular mortality.
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