morbidity & mortality

morbidity & mortality

esrd introduction of ESRD treatment. We examine these concerns throughout the ADR, particularly in Chapter One. This year we focus on infectious complications, especially those related to vascular access, and report that mortality in the first year of hemodialysis has at last begun to decline, an important public health finding for the hemodialysis population. Since 1998 the first-year death rate among hemodialysis patients has fallen 1.3 percent, with most of the decline occurring after 23 24; this is in contrast to a 16 17 percent decrease during years 2 5, but still indicates significant progress. While overall hospital admission rates have altered little since the mid-199s, the types of hospitalization have changed considerably. Since 1994, rates of hospitalization for infection among hemodialysis patients have increased 45.8 percent. Hospitalizations related to cardiovascular disease have risen 8.6 percent, but have declined in the last four years, consistent with changes in the use of cardiovascular procedures noted later in the chapter. There has also been a decline in the number of hospital days for both peritoneal and hemodialysis patients, so that days per year are now similar for both populations. While rates of hospitalization for pneumonia appear stable, those for bacteremia/sepsis have increased since their low in 21, and among both hemodialysis and peritoneal dialysis patients. Overall, the odds of an infectious hospitalization are now 18 percent greater than in 1997 1998. All-cause mortality differs quite dramatically in the ESRD, dialysis, transplant, and general Medicare populations. Rates for prevalent dialysis patients age 65 and older, for example, are nearly seven times higher than those in the general population. These rates essentially flat during the 199s have been falling for the past five years across all patient vintages. And five-year survival rates for ESRD patients improved 8.4 percent between 1994 1998 and 1999 23.

This year we present new mortality analyses that use matched hemodialysis and peritoneal dialysis populations. Since selection bias related to the choice of peritoneal dialysis therapy is very complex, with many hemodialysis patients not candidates for peritoneal dialysis, we attempted to match patients directly based on all available information from the Medical Evidence form including age, gender, race, cause of kidney failure, comorbidity, egfr, BMI, and hemoglobin level. This makes the populations more comparable than does the use of simple adjustments that do not address issues of confounding by indication. In future ADRs we will follow these first-year comparisons with analyses of changes over time in years 2 5 of follow-up. The last spread of this chapter addresses cause-specific hospitalization and mortality. Rates of hospitalization for infection, cardiovascular procedures, and inpatient vascular access procedures have changed in 1ii Deaths per 1, patient years at risk All patients 35 3 25 2 15 Peritoneal dialysis 5 4 3 2 1 Adjusted mortality rates, by modality & year of treatment 8 84 88 92 96 4 1st year 2nd year 3rd year 4th year 5th year 8 84 88 92 96 4 important ways. Those for cardiovascular disease, for example, have declined since 24, even as mortality rates are falling, suggesting that patients are not as sick or that treatment with oral medications may be more effective than previously thought. And while there has been some decline in hospitalizations for infections due to an internal device, hospitalizations for bacteremia/sepsis have increased. It is not clear if this is related to the change to longer-term cuffed catheters, or to other factors such as influenza virulence. The USRDS Coordinating Center will continue to explore trends in morbidity and mortality to determine the impact of programs addressing high early mortality and of the new CKD Stage 4 education benefit, which is intended to improve the planned transition to dialysis. Incident ESRD patients. Adj: age/gender/race/ primary diagnosis; ref: incident ESRD patients, 25.

A After peaking in 25, rates of hospitalization for infection in hemodialysis patients showed a decline in the following two years. In 28, however, they increased again, to a point 45.8 percent above their 1993 level. Vascular access admissions continue to fall, with more procedures now performed in an outpatient setting, and are 45.1 percent below levels noted in 1993. Other encouraging results include a 22.9 percent fall in dialysis access admissions since 1999 for peritoneal dialysis patients, and declines of 14.5, 32.2, and 1.7 percent, respectively, in all-cause, cardiovascular, and infectious admissions for transplant patients. Period prevalent ESRD patients. Adj: age/gender/race/ primary diagnosis; ref: ESRD patients, 25. 2ii Change in adjusted all-cause & cause-specific hospitalization rates, by modality All 5 Infection (28: 33.%) Infection (45.8%) 25 CV (5.2%) Cardiovascular (8.6%) All-cause (-1.%) All-cause (1.1%) Percent change from 1993-25 -5 5 25 Peritoneal dialysis Vascular access (-45.1%) -25-5 All-cause (-9.6%) Cardiovascular (-12.4%) Infection (7.5%) Dialysis access (since 1999; -22.9%) 94 96 98 2 4 6 8 All-cause (-14.5%) Cardiovascular (-32.2%) Infection (-1.7%) 94 96 98 2 4 6 8 esrd In I 28, hospital admissions per patient year for hemodialysis patients were nearly identical to those in 1993, at 1.9. Rates for peritoneal dialysis and transplant patients, in contrast, have fallen 9.6 and 14.5 percent. Hospital days per patient year have fallen to 12.8 and 13.3 for hemodialysis and peritoneal dialysis patients, and to 5.9 for those with a transplant. Period prevalent ESRD patients. Adj: age/gender/race/primary diagnosis; ref: ESRD patients, 25. 3ii overall hospitalization Admissions per patient year 2.5 2. 1.5 1..5 Adjusted hospital admission rates & days, by modality Peritoneal dialysis All dialysis. 93 95 97 99 1 3 5 7 Hospital days per patient year 2 16 12 8 4 93 95 97 99 1 3 5 7

A Admissions for pneumonia in hemodialysis patients rose to 83.4 per 1, patient years in 28, 1.9 2.6 times greater than the rates of 43.8 and 31.9 among peritoneal dialysis and transplant patients. Among hemodialysis patients, admissions for bacteremia/septicemia continue to rise sharply, reaching 112 per 1, patient years similar to the rate of 19 for vascular access infections, and possibly reflecting an increased use of cuffed catheters. Period prevalent ESRD patients. Adj: age/gender/race/primary diagnosis; ref: ESRD patients, 25. 4ii Admissions per 1, patient years Adjusted rates of admission, by principal diagnosis & modality Pneumonia Bacteremia/septicemia Cellulitis Infection (dialysis related) 1 12 4 2 Peritoneal dialysis: peritonitis 75 9 3 15 Peritoneal dialysis 5 6 2 1 : Peritoneal vascular access 25 dialysis 3 1 Peritoneal dialysis 5 infection 93 95 97 99 1 3 5 7 93 95 97 99 1 3 5 7 93 95 97 99 1 3 5 7 93 95 97 99 1 3 5 7 aii Adjusted rates (per patient year) & relative risks of all-cause & cause-specific hospitalization in hemodialysis patients, by year, & by age, gender, race, & primary diagnosis in 27 28 All-cause Cardiovascular Infection Vascular access Adjusted Adjusted Adjusted Adjusted Adjusted Adjusted Adjusted Adjusted rate relative risk rate relative risk rate relative risk rate relative risk 1997 1998 1.91 ref.56 ref.39 ref.36 ref 1999 2 1.95 1.2.58 1.2.41 1.4.37 1.2 21 22 1.99 1.5.59 1.6.43 1.9.35.97 23 24 2.1 1.6.61 1.9.45 1.15.32.89 25 26 1.99 1.5.59 1.5.47 1.21.3.82 27 28 1.92 1.1.56 1..47 1.18.25.7 27 28 2 44 2.6.96.49.77.48.91.31 1.29 45 64 1.83.9.52.83.44.85.25 1.5 65 74 1.93.93.59.94.46.89.24.98 75+ 2.6 ref.63 ref.52 ref.24 ref Male 1.79 ref.53 ref.44 ref.22 ref Female 2.8 1.16.59 1.11.5 1.14.29 1.29 White 1.93 ref.56 ref.48 ref.23 ref African American 1.98 1.3.58 1.5.46.97.29 1.24 Other race 1.54.8.43.78.39.82.22.91 Diabetes 2.15 ref.6 ref.52 ref.27 ref Hypertension 1.81.86.59.97.41.8.24.91 Glomerulonephritis 1.65.76.49.79.38.72.22.82 Other cause 1.84.86.47.77.49.93.26.97 B By two-year time period, the adjusted relative risks of allcause and cardiovascular hospitalization among hemodialysis patients vary little when compared to the reference period of 1997 1998; the risk of hospitalization for infection, however, is now 18 percent greater than in the reference period, while that of a vascular access hospitalization is 3 percent less. In 27 28, women treated with hemodialysis were 16 percent more likely to be hospitalized, overall, than their male counterparts. They also had a greater risk than men of cardiovascular, infectious, and vascular access hospitalizations 11, 14, and 29 percent greater, respectively. Among African American patients, the relative risk of an all-cause hospitalization or one related to infection is almost equal to that of white patients; the risk of a vascular access hospitalization, however, is 24 percent higher. Period prevalent hemodialysis patients age 2 & older. Adj: age/gender/race/primary diagnosis; rates by one factor adjusted for other three; ref: hemodialysis patients, 25.

W When matched hemodialysis patients are compared to peritoneal dialysis patients, overall unadjusted survival is T Through the 198s, patients newer to similar for both modalities, at.87, and dialysis had higher mortality rates generally similar across all age, gender, A Adjusted rates of all-cause mortality than those on treatment for five years race, and comorbidity groups. are 6.4 7.8 times higher for dialysis patients than for individuals in the gen- the early 199s, and in 28 the rate of Incident dialysis patients, 27; unad- or more. This trend begin to change in eral population. Mortality rates for renal transplant patients approach those on therapy for five or more years was 236 per 1, patient years in patients justed. of the general population, yet remain 19.2 percent higher than the rate of 197 Unadjusted survival of dialysis patients, bii using HD matched to PD patients 1.2 1.5 times higher. in patients of younger vintage. Prevalent Period Matched patients ESRD patients (all ages) & general Medicare prevalent dialysis patients. Adj: age/ PD HD All HD patients (age 65+), 28. Adj: gender/race; gender/race/primary diagnosis; ref: di- All.87.87.76 ref: incident patients, 28. alysis patients, 25. -19.94 1..96 5ii Deaths per 1, patient years at risk 4 3 2 1 Adjusted all-cause mortality in the ESRD & general populations, by age, 28 ESRD Dialysis General Medicare 65+ <2 2-44 45-64 65+ 6ii Deaths per 1, patient years at risk 3 275 25 225 2 175 Adjusted mortality rates in prevalent dialysis patients, by vintage 2-<5 years 5+ years <2 years All 15 85 88 91 94 97 3 6 2-44.97.94.91 45-64.91.91.85 65+.79.8.69 Male.86.88.77 Female.87.86.76 White.85.85.73 African American.91.91.82 Other race.93.94.83 Diabetes.84.86.77 Hypertension.86.87.77 Glomerulonephritis.95.93.85 Cystic kidney.95.95.91 Cardiovascular disease.79.82.71 Pre-ESRD nephrology care.87.88.79 First access via catheter.87.81.74 esrd T The five-year probability of survival among 1999 23 incident ESRD patients was.39, an 8.4 percent increase when compared to survival among new patients in 1994 1998. Between the two periods, survival increased most in patients on peritoneal dialysis, at 17.6 percent, and rose 8.4 and 5.3 percent in hemodialysis and transplant patients, respectively. Survival improved 15.3 and 27.1 percent in hemodialysis and peritoneal dialysis with diabetes, and 4.2 and 14.6 percent in those with hypertension; in patients with glomerulonephritis, it increased 6.4 and 12.3 percent. Incident dialysis patients & patients receiving a first transplant in the calendar year. Adj: age/gender/race; overall also adj. for primary diagnosis; ref: ESRD patients, 25. 7ii Survival probability 1994-1998: All pts, by modality 1..8.6.4.2.8.6.4.2 Adjusted five-year survival, by modality & primary diagnosis Dial. (.32) HD (.32) PD (.3) Tx (.72) All (.36) 1999-23 1. Dial. (.35) HD (.34) PD (.35) Tx (.76) All (.39) 12 24 36 48 6 HD pts, by primary diagnosis DM (.25) HTN (.36) GN (.43) Other (.34) All (.32) DM (.29) HTN (.38) GN (.45) Other (.35) All (.34) Months after initiation PD pts, by primary diagnosis DM (.21) HTN (.36) GN (.44) Other (.37) All (.3) DM (.27) HTN (.41) GN (.49) Other (.4) All (.35) 12 24 36 48 6 12 24 36 48 6 outcomes; hemodialysis matched to peritoneal dialysis

8ii Admissions per 1, patient years All 2 15 1 5 Unadjusted rates of hospital admissions in 27 dialysis patients, by race HD PD HD matched to PD All CVD Inf. Pneu. Bact/sept. White All CVD Inf. Pneu. Bact/sept. African American All CVD Inf. Pneu. Bact/sept. In I hemodialysis matched to peritoneal dialysis populations, hospitalization rates are lower overall for hemodialysis patients than for peritoneal patients, at 14.6 and 146.7, respectively, per 1, patient years. Rates for infectious hospitalizations, however, are higher for matched hemodialysis patients, at 42.5 versus 32.2 overall, 42.2 versus 33.4 in whites, and 48.2 versus 31.5 in African Americans. Incident dialysis patients, 27; unadjusted. 9ii Survival probability 1ii Survival probability All 1..9 DM: HD matched to PD.8 DM: PD NDM: HD matched to PD NDM: PD.7 2 4 6 8 1 12 2 4 6 8 1 12 2 4 6 8 1 12 2-64: Male Female 1..9.8.7 65+ 1..9.8 Unadjusted survival in 27 dialysis patients, by race & diabetic status DM: HD matched to PD DM: PD NDM: HD matched to PD NDM: PD White Unadjusted survival in 27 dialysis patients, by age, gender, & diabetic status Months after initiation African American.7 1 2 3 4 5 6 7 8 9 1 11 12 1 2 3 4 5 6 7 8 9 1 11 12 Months after initiation A Among patients with diabetes, unadjusted one-year survival in matched hemodialysis to peritoneal dialysis populations is slightly higher in those on hemodialysis compared to patients on a peritoneal modality, at.86 and.84, respectively. Survival in patients with no diabetes is similar, at.88 and.89. By race, white hemodialysis patients with diabetes have a slight survival advantage over their peritoneal counterparts, while the opposite is true for African Americans. Incident dialysis patients, 27; unadjusted. W When comparing unadjusted survival by modality in hemodialysis matched to peritoneal populations, no distinct patterns are evident. In males age 2 64 with diabetes, for example, neither dialysis modality shows any survival advantage; this is also true in males with no diabetes. Among females of this age with diabetes, in contrast, survival is approximately 5 percent better in patients on peritoneal dialysis. Among patients age 65 and older, survival in male hemodialysis patients with diabetes is approximately 6 percent higher than among their peritoneal counterparts. In women with diabetes, survival among those on hemodialysis is more than 8 percent higher. The reverse is true in females with no diabetes, with survival in those on peritoneal dialysis approximately 5 percent higher. Incident dialysis patients, 27; unadjusted.

11ii Admissions per patient year at risk All hospitalizations 2.5 2.2 1.9 Adjusted rates of cause-specific hospitalizations, by age 1.6 93 95 97 99 1 3 5 7.8 Cardiovascular disease.5 Infection (other than int. device).3 Infection due to internal device.6.4.2 93 95 97 99 1 3 5 7.4.3 2-44 45-64 65-74 75+.2 93 95 97 99 1 3 5 7.2.1. 99 1 3 5 7 12ii Adjusted rates of inpatient coronary revascularization procedures, by age Procedures per 1, pt years at risk All coronary revascularizations Angioplasty Bypass 6 45 2 45 3 2-44 15 45-64 65-74 75+ 93 95 97 99 1 3 5 7 3 15 93 95 97 99 1 3 5 7 15 1 5 93 95 97 99 1 3 5 7 Coronary stents 4 3 2 1 97 99 1 3 5 7 13ii Placements per 1, pt years at risk 9 6 3 Adjusted rates of inpatient vascular access placements, by age All vascular access placements 93 95 97 99 1 3 5 7 6 Catheters 6 Arteriovenous fistulas 3 Arteriovenous grafts 4 2 2-44 45-64 65-74 75+ 93 95 97 99 1 3 5 7 4 2 93 95 97 99 1 3 5 7 2 1 93 95 97 99 1 3 5 7 esrd A All-cause admissions by age remained stable in 28, with the exception of a 2 percent decline among those age 45 64. Cardiovascular admissions declined across age groups, and in 28 ranged from.46 per patient year at risk among those age 2 44 to.63 among those 75 and older. Event rates for inpatient coronary revascularization procedures are greatest in patients age 65 74. Rates for this age group continue to decline, in 28 reaching 51.1 events per 1, patient years at risk overall, 36.8 for angioplasty, and 14.1 and 33.3 for bypass and coronary stents. Rates of inpatient vascular access placements fell in 28, remaining highest in those age 2 44. Since 1993, the overall rate has fallen 57 61 percent in those age 65 and older. Period prevalent dialysis (6.11 12) & hemodialysis (6.13) patients age 2 & older. Adj: gender/race/primary diagnosis; ref: dialysis patients, 25. cause-specific hospitalization & mortality

14ii Deaths per 1, patient years at risk 5 4 3 2 1 Adjusted rates of cause-specific mortality in the first months of therapy Month 1 Cardiovascular disease Infection Other cause All 91 93 95 97 99 1 3 5 7 Month 3 Month 6 91 93 95 97 99 1 3 5 7 91 93 95 97 99 1 3 5 7 Month 12 91 93 95 97 99 1 3 5 7 15ii Deaths per 1, patient years at risk Month 1 5 4 3 2 1 Adjusted rates of mortality due to cardiovascular disease in the first months of therapy, by age 91 93 95 97 99 1 3 5 7 Month 3 Month 6 2-44 45-64 65-74 75+ 91 93 95 97 99 1 3 5 7 91 93 95 97 99 1 3 5 7 Month 12 91 93 95 97 99 1 3 5 7 16ii Deaths per 1, patient years at risk Month 1 125 1 75 5 25 Adjusted rates of mortality due to infection in the first months of therapy, by age 2-44 45-64 65-74 75+ 91 93 95 97 99 1 3 5 7 Month 3 Month 6 91 93 95 97 99 1 3 5 7 91 93 95 97 99 1 3 5 7 Month 12 91 93 95 97 99 1 3 5 7 A Adjusted all-cause and cause-specific mortality rates are highest in the third month after the initiation of dialysis, and in following months return to levels close to or lower than those found in month one. For month three, the overall number of deaths per 1, patient years at risk fell 3. percent in 27, to 399, and has decreased 8.5 percent since peaking in 23 at 433. Mortality rates in month 12 have fallen nearly 27 percent since 1991, but may be flattening, as evidenced by a slight.4 percent rise in 27. In 27, cardiovascular death rates in month one were more than six times higher than those for infection, and in months three, six, and twelve were 3 4 times higher. Not surprisingly, rates in all months were highest in older patients. Incident dialysis patients. Adj: age/gender/race/primary diagnosis; ref: incident dialysis patients, 25.

The five-year probability of survival among 1999 23 incident ESRD patients was.39, an 8.4 percent increase when compared to survival among new patients in 1994 1998. Among hemodialysis patients age 65 and older, rates of inpatient vascular access placements have fallen 57 61 percent since 1993. Rates of vascular access admissions continue to fall, with more procedures now performed in an outpatient setting, and are 45.1 percent below levels noted in 1993. In 28, rates of hospital admissions per patient year for hemodialysis patients were nearly identical to those in 1993, at 1.9; rates for peritoneal dialysis and transplant patients, in contrast, have fallen 9.6 and 14.5 percent. In 27 28, women treated with hemodialysis were 16 percent more likely to be hospitalized than their male counterparts. When hemodialysis patients are matched to peritoneal dialysis patients, overall unadjusted survival is similar for both modalities, at.87, and is generally similar across all age, gender, race, and comorbidity groups. Adjusted rates of all-cause mortality are 6.4 7.8 times higher for dialysis patients than for individuals in the general population. esrd summary