New perspec)ves on withdrawal from dialysis. Jennifer Chan, Phil Clayton, Stephen McDonald, John Agar, Ma?hew Jose
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1 New perspec)ves on withdrawal from dialysis Jennifer Chan, Phil Clayton, Stephen McDonald, John Agar, Ma?hew Jose
2 Figure 3.8 Cause of Death by RRT Modality Cause of Death 1-Jan-2009 to 31-Dec-2009 Australia New Zealand Dialysis Transplant Dialysis Transplant Cardiac C ardiac arrest Haemorrhagic Pericarditis Hy perkalaemia Hy pertensiv e cardiac failure My ocardial infarction My ocardial infarction (presumed) O ther causes of cardiac failure Pulmonary oedema Sub T otal 515 (34%) 33 (23%) 148 (45%) 9 (26%) Infection CNS - bacterial Lung - bacterial Lung -viral 4 (i) (sf) 3 (cmv ) - - Lung - fungal 2 (as) (ca ) 2 (as) - - Lung - protozoa - 1 (pn) - - Lung - other 6 (ni) 1 (ni) 2 (ni) 1 (ni) Urinary tract - bacterial Urinary tract - fungal 1 (ca) Wound - ba cterial Wound - fungal 2 (ca) Wound - other 1 (ni) Shunt - bacterial Peritoneum - bacterial Peritoneum - fungal 3 (ca) - 3 (ca) - Peritoneum - other (ni) - Septicaemia - bacterial Septicaemia - fungal - 2 (cr) 1 (ca) - Septicaemia - other 9 (ni) - 2 (ni) - Liv er - viral 3 (hb) 1 (hb) 1 (hb) - O ther site - bacterial O ther site - viral - 1 (cmv ) - - O ther site - other (ni) - Sub T otal 176 (12%) 28 (20%) 46 (14%) 3 (9%) Vascular Bowel infarction C erebrov ascular accident Gastrointestinal haemorrhage Haemorrhage - dialy sis access site Haemorrhage - elsew here Pulmonary embolus Ruptured aortic aneury sm Sub T otal 137 (9%) 17 (12%) 32 (10%) - Social A ccident Patient refused treatment Suicide Therapy ceased Withdraw al - access problems Withdraw al - cardiov ascular Withdraw al - cerebrov ascular Withdraw al - malignancy Withdraw al - periphe ral v ascular Withdraw al - psy chosocial Sub Total 565 (37%) 11 (8%) 83 (25%) 2 (6%) Miscellaneous C achexia C hronic respiratory failure Hepatic failure Malignancy O ther Pancreatitis Perforation abdominal v iscus Sclerosing peritonitis Uraemia caused by graft failure Unknow n Sub T otal 132 (9%) 52 (37%) 22 (7%) 20 (59%) Cardiac 34% Infection 12% Vascular 9% Cause of death on dialysis Social causes 37% Misc including cancer 9% Total (100%) (as) aspergillus (ca) candida (cmv ) cmv (cr) cry ptococcus (hb) hepatitis b (i) influenza (sf) sw ine flu (pn) pneumocystis (ni) organism not isolated ANZDATA Registry
3 Pre-October 2003 Dialysis withdrawal: Coding
4 Pre-October 2003 Dialysis withdrawal: Coding
5 Study: Dialysis withdrawal in Australia and New Zealand ANZDATA source Incident cohort Follow-up to end 2008 n=28,884 Of which there were 10,073 deaths
6 Incident pa)ents Overall cohort DW deaths Non-DW deaths P-value! Total Number of patients, N Age at the time of RRT (years) 59±15 69±11 64±13 <0.001 Male, N (%) (59.6) 1625 (57.1) 4265(59.0) BMI at entry (kg/m 2 ) 27±6 26±6 27±6 <0.001 Racial origin <0.001 Caucasian, N (%) Asian, N (%) Aboriginal/Torres Strait Islander, N (%) M!ori, N (%) Pacific Islander, N (%) Other, N (%) (73.9) 1646 (6.6) 1921 (7.7) 1514 (6.1) 997 (4.0) 416 (1.7) 2399 (84.4) 113 (4.0) 136 (4.8) 122 (4.3) 56 (2.0) 18 (0.6) 5195(71.9) 365(5.0) 643(8.9) 657(9.1) 290(4.0) 79(1.1) Comorbidity at entry Diabetes mellitus, N (%) Chronic lung disease, N (%) Coronary artery disease, N (%) Peripheral vascular disease, N (%) Cerebrovascular disease, N (%) (41.2) 3926 (15.8) 9867 (39.7) 6414 (25.8) 3738 (15.0) 1239 (43.6) 606 (21.3) 1588 (55.8) 1087 (38.2) 740 (26.0) 3591(49.7) 1562(21.6) 3912(54.1) 2605(36.0) 1483(20.5) < <0.001 Late referral, N (%) 6021 (24.2) 833 (29.3) 2050(28.4) 0.352!
7 Dialysis withdrawal: Cause of death Time period Total number of patients, N Patient refused further treatment, N (%) 392 (56.8) 4 (0.2) Therapy ceased for any other reason, N (%) 227 (32.9) 38 (1.8) Suicide, N (%) 12 (1.7) 12 (0.6) Withdrawal for psychosocial reasons, N (%) 20 (2.9) 832 (38.6) Withdrawal for cardiovascular comorbid conditions, N (%) 14 (2.0) 348 (16.2) Withdrawal for cerebrovascular comorbid conditions, N (%) 10 (1.4) 212 (9.8) Withdrawal for peripheral vascular comorbid conditions, N (%) 6 (0.9) 265 (12.3) Withdrawal related to malignancy, N (%) 7 (1.0) 345 (16.0) Withdrawal related to dialysis access difficulties, N (%) 2 (0.3) 98 (4.5)!
8 Cause of death
9 Dialysis withdrawal: Unit varia)on
10 Dialysis withdrawal: Unit varia)on #!!" +!" *!" )!"!"#$%&'($)*+,%(%&-'.''' (!" '!" &!" %!" $!" #!"!"!" $!!" &!!" (!!" *!!" #!!!" #$!!" /0123,'"4'5%637)'
11 Dialysis withdrawal: Age
12 Dialysis withdrawal: Place
13 Dialysis withdrawal: Remoteness Cause of death by location of renal unit by 5 year era Cause of death 5 year era Location Major Cities, N (%) Cardiac Vascular Infection Social malignancy Other Total, N (%) 1116(34.7) 292(9.1) 326(10.1) 1115(34.7) 203(6.3) 162(5) 3214(100) Inner Regional, N (%) 312(35) 75(8.4) 92(10.3) 305(34.2) 76(8.5) 31(3.5) 891(100) Outer Regional, N (%) 207(40.3) 47(9.1) 69(13.4) 121(23.5) 38(7.4) 32(6.2) 514(100) Remote, N (%) 71(42.5) 17(10.2) 28(16.8) 33(19.8) 6(3.6) 12(7.2) 167(100) Very Remote, N (%) 34(48.6) 9(12.9) 6(8.6) 9(12.9) 6(8.6) 6(8.6) 70(100) Total, N (%) 1740(35.8) 440(9.1) 521(10.7) 1583(32.6) 329(6.8) 243(5) 4856(100)
14 Early withdrawal? 10 Cumulative incidence (%) Other Withdrawal 3.5% Per Annum Months Number at risk
15 Predictors of withdrawal! Univariate Analysis Multivariate Analysis Variable N SHR * P-value SHR * P-value Age (per decade) ( ) < ( ) <0.001 Male sex ( ) ( ) <0.001 Race Caucasian Indigenous Other 1 (reference) 1 (reference) ( ) <0.001 # 0.74 ( ) # 0.49 ( ) 0.66 ( ) Late referral ( ) < ( ) <0.001 Diabetes ( ) ( ) 0.05 Comorbid burden ( ) < ( ) <0.001 Peritoneal dialysis ( ) < ( ) <0.001 Remoteness Major cities Inner regional Outer regional Remote Very remote 1 (reference) ( ) ( ) 0.02 # ( ) ( ) - - * SHR, subhazard ratio (95% confidence interval) # P-value for category as a whole Only available for Australian patients
16 Conclusion Dialysis withdrawal is common Unit coding is variable Risk factors in the first year include older age, female sex, Caucasian race, comorbid burden, use of HD and late referral to nephrologist. Acknowledgements We are grateful to the Australia and New Zealand renal units, patients and staffs for their cooperation and contribution to ANZDATA
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