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Time Trends and Causes of Infection-Related Mortality Among Patients Starting Dialysis in Finland: A Nationwide
Susanna Kinnunen1, Ilkka Helanterä2, Auni Juutilainen3
1Division of Nephrology, Department of Medicine, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland.
Rationale & Objective:
Previously, we reported a decrease in infection-related mortality in kidney transplant recipients. Regarding patients treated with dialysis, it is unclear whether infection-related mortality is decreasing. Therefore, we investigated current time trends and specific causes of infection-related mortality over 2 decades in a large cohort of patients treated with dialysis.
Study Design:
A nationwide cohort study.
Setting & Participants:
Patients starting kidney replacement therapy were identified through the Finnish Registry for Kidney Diseases. Follow-up continued until death of any cause, kidney transplantation, moving abroad, recovery of kidney function, loss of follow-up, or end of study.
Exposure:
Long-term kidney replacement therapy.
Outcome:
Death due to infection.
Analytical Approach:
Incidence rates, incidence rate ratios, and adjusted Cox regression hazard ratios for infection-related deaths were calculated by sub-cohorts consisting of patients whose kidney replacement therapy was started either 2000-2004, 2005-2009, 2010-2014, or 2015-2019. As sensitivity analyses, we studied infection-related mortality within 1 year of dialysis initiation and performed competing risk analysis.
Results:
A total of 9,671 adult patients started long-term dialysis from 2000 to 2019. Infection-related deaths declined from 47 to 23 deaths per 1,000 person-years over the four 5-year intervals from 2000-2004 to 2015-2019. The hazard ratio of a Cox model including identified risk factors was 0.49 (95% CI, 0.39-0.62) for patients who started dialysis in 2015-2019 compared with those who started in 2000-2004. The most common specific causes of infection-related deaths were septicemia (38%), pulmonary infection (36%), and peritonitis (8%), whereas opportunistic infections rarely caused death.
Limitations:
Death certificates may have low sensitivity for infectious diseases. Only one cause of death is available. Categories of infectious deaths may overlap.
Conclusions:
Risk of dying due to infections has halved since the beginning of the millennium despite aging among patients treated with dialysis. The reason for this development requires further studies.
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