- Email: [email protected]
Survival, Mortality, & Causes of Death
EIGHT Survival, Mortality, 8sd Causes o f Death
He was excellent indeed, madam: the king very lately spoke of him admiringly and mourningly: he was skillful enough to have lived still, if knowledge could be set up against mortality. William Shakespeare, All's Well That Ends Well
American Journal of Kidney Diseases, Vol 36, No 6, Suppl 2 (December), 2000: pp S127-S142
Si28
· 2000
ATLAS
OF
ESRD
IN
THE
UNITED
STATES
Since 1988, first-year death rates for all incident
The association over time between death rates
dialysis patients have fallen 38.5%, with the great
and hematocrit levels varies by diabetic status (figs
est decrease (63.7%) occurring in patients on
8.16-18). While the death rates decline with
peritoneal dialysis (fig 8.1). Death rates for trans
higher hematocrits in both diabetics and non-
plant patients, consistently much lower than those
diabetics, they tend to flatten out as hematocrit
for patients on dialysis, fell 93% in the same pe
levels reach 33%. The consistently lower death
riod. Rates have decreased for all age groups of
rates at higher hematocrit levels support the
both hemodialysis and peritoneal dialysis pa
DOQI target range of 33-36%.
tients, with younger patients consistently having lower death rates than their older counterparts.
In figures 8.1-15 and 8.19-21 data are adjusted
Declines infirst-yeardeath rates have been com
for age, race, gender, and/or diabetic status; they
parable for male and female patients on both mo
are not, however, adjusted for other clinical fac
dalities—approximately 48% for hemodialysis,
tors, such as comorbidity and disease severity,
and 64% for peritoneal dialysis (figs 8.4-5).
which may influence the death rates. Adjustments for these latter factors, however, are made in fig
In terms of race, first-year death rates have de
ures 8.16-18, which show associations between
clined most in Asian patients, 58.3% for hemo
hematocrit and mortality.
dialysis and 71.9% for peritoneal dialysis. The rate for white hemodialysis patients shows a slightly
Figures 8.22-32 present death rates for prevalent
higher decline (48%) than that for blacks and
patient cohorts. Since these cohorts consist of
Native Americans, 43.1% and 38.8% respectively.
patients with varying amounts of time on ESRD
This trend is somewhat different for peritoneal
and varying modality histories, and are affected
patients, however, with the decrease for blacks
as well by the selection bias related to transplan
being 64% compared to 61.7% in whites and
tation, the graphs should be interpreted with cau
53.9% in Native Americans (figs 8.6-7).
tion.
Death rates for diabetics, hypertensive patients,
Overall, the fall in death rates has been concur
and patients with other renal diseases have be
rent with improvements in dialysis therapy and
gun to converge for hemodialysis patients, but
anemia treatment, and with changes in mem
this is not the case for the peritoneal dialysis popu
brane use from cuprophane to synthetic mem
lation, in which diabetics continue to have the
branes (see Chapter Ten).
All data underlying the highest rates of death (figs 8.8-9). Differences by modality are also apparent in first, second-, and figures in this chapter, third-to-fifth year death rates (fig 8.10). These patterns suggest that the two dialysis modalities as well as additional related are not proportional to one another over time, a fact that complicates comparisons between them. data, may be viewed & Five-year survival curves show that female padownloaded at
tients live longer than males across most age groups, races, primary diagnoses, and modalities
www.usrds.org.
(figs 8.11-14).
Included in this chapter ♦ Graphs of first-year death rates by modality, age group.gender, race.and primary diagnosis ♦ Five-year survival curves by gendecage group, race,primary di agnosis, and modality ♦ Maps of first-,second-,third-,and fourth-year overall death rates, as well as maps of all-cause, infectious, and cardiac death rates ♦ Graphs of the association between mortality and hematocrit ♦ Graphs of cause-specific death rates by modality, race.and age group
CHAPTER
8 ·
SURVIVAL,
30 -
20 ■
10 -
All dialysis (29.9, -38.5%) Hemodialysis (28.1,-48%) Peritoneal dialysis (27.8, -63.7%) Transplant (2.9,-93%)
40 ■
a
30 ■
DEATH
· S129
Reference population: the aver age 1997 incident patient in each modality.
Figure 8.2 First-year death rates by age group incident hemodialysis patients, adjusted for gender, race, & primary diagnosis of diabetes
45
35
OF
The number of deaths per 100 patient years in 1988, and the percent change in values be tween 1988and 1997,are shown in the legend.
25
15 ■
& CAUSES
Figure 8.1 First-year death rates by modality incident patients, adjusted for age, gender, race, & primary diagnosis of diabetes
35
S
MORTALITY,
■ 0-19(9.7,-71.1 20-44(16.7,-63.1 ■ 45-64 (24.6, -50.4%) ■ 65+ (42.7, -32.3%)
The number of deaths per 100 patient years in 1988, and the percent change in values be tween 1988 and 1997,are shown in the legend. Reference population: the aver age 1997 incident hemodialysis patient in each age group.
Figure 8.3 First-year death rates by age group incident peritoneal dialysis patients, adjusted for gender, race, & primary diagnosis of diabetes The number of deaths per 100 patient years in 1988, and the percent change in values be tween 1988 and 1997,are shown in the legend. Reference population: the aver age 1997 incident peritoneal di alysis patient in each age group.
Si30
■ 2000
ATLAS
OF
ESRD
IN
THE UNITED
STATES
Figure 8.4 First-year death rates by gender incident hemodialysis patients, adjusted for age, race, & primary diagnosis of diabetes The number of deaths per 100 patient years in 1988, and the percent change in values be tween 1988and 1997,are shown in the legend.
30 ω 25
Reference population: the aver age 1997 incident hemodialysis patient of each gender.
Male (30.2, -49.7%) Female (25.9, -46.3%)
1990
1991
1992
1993
1994
1995
1996
1993
1994
1995
1996
1997
1996
1997
Figure 8.5 First-year death rates by gender incident peritoneal dialysis patients, adjusted for age, race, & primary diagnosis of diabetes The number of deaths per 100 patient years in 1988, and the percent change in values be tween 1988and 1997,are shown in the legend.
30 ω 25
Reference population: the aver age 1997 incident peritoneal di alysis patient of each gender.
20
Figure 8.6 First-year death rates by race incident hemodialysis patients, adjusted for age, gender, & primary diagnosis of diabetes The number of deaths per 100 patient years in 1988, and the percent change in values be tween 1988 and 1997,are shown in the legend. Reference population: the aver age 1997 incident hemodialysis patient of each race.
40 -, 35 30' ω 25 20
Q
10 5
Black (19.5,-43.1 Native American (17, -38.8%) Asian (22.3, -58.3%)
0 1989
1990
CHAPTER
8 ·
SURVIVAL,
MORTALITY,
& CAUSES
OF
DEATH
· S131
Figure 8.7 First-year death rates by race incident peritoneal dialysis patients, adjusted for age, gender, & primary diagnosis of diabetes The number of deaths per 100 patient years in 1988, and the percent change in values be tween 1988 and 1997,are shown in the legend.
30 ω 25
Reference population: the aver age 1997 incident peritoneal di alysis patient of each race.
20 15 10 -
White (31.3,-61.7%) Black (20.3, -64%) Native American (14.3, -53. Asian (15.3,-71.9%) 1990
1991
1995
1992
1996
1997
Figure 8.8 First-year death rates by primary diagnosis incident hemodialysis patients, adjusted for age, gender, & race The number of deaths per 100 patient years in 1988, and the percent change in values be tween 1988and 1997,areshown in the legend.
25
Reference population: the aver age 1997 incident hemodialysis patient with each primary diag nosis.
20 ■ 15 10 -
■ Diabetes (32.8, -50.3%) ■ Hypertension (26.7, -44.8%) ■ Glomerulonephritis (17.7, -59.3%) Other (25.0,-39.2%) 1990
1991
1993
1994
1995
1996
1997
Figure 8.9 First-year death rates by primary diagnosis incident peritoneal dialysis patients, adjusted for age, gender, & race
Diabetes (35.7, -53.5%) Hypertension (29.5, -66.8 Glomerulonephritis (16.6, -78.3%) Other (21.3,-624
35 £ 30
The number of deaths per 100 patient years in 1988, and the percent change in values be tween 1988and 1997,are shown in the legend.
25
Reference population: the aver age 1997 incident peritoneal di alysis patient with each primary diagnosis.
20 ■
10 ■
1989
1990
1995
1996
1997
Si32
· 2000
ATLAS
Figure 8.10 First-, second-, &third-to-fifth year annual death rates incident patients, adjusted for age, gender, race, & primary diagnosis of diabetes The number of deaths per 100 patient years in 1988, and the percent change in values be tween 1988 and the last year shown for each death rate, are shown in the legends. Reference population: the aver age 1997 incident patient on each modality.
OF
ESRD
IN
THE UNITED
Peritoneal dialysis
Hemodialysis
30
STATES
r 20
-£ 10
• First-year (27.8,-63.7%)
First-year (28.1,-48%) Second-year (25.8, -36%) ■ Third-to-fifth year (26, -8.8%)
• Second-year (27.8, -45.7%) ■ Third-to-fifth year (28.1,-18.19
_l_ _l_ 1990 1991 1992 1993 1994 1995 1996 1997 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997
Table 8.1 Expected remaining lifetimes (years) by race & gender prevalent patients, 1998 Reference: Table H.3, H.4, H.12, andH.13.
Figure 8.11 Five-year survival curves by age group & gender incident dialysis patients, 1993, adjusted for race & primary diagnosis of diabetes
Age 0-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85 +
Dialysis White M 19.5 16.4 13.6 11.5 9.7 8.3 7.2 6.2 5.3 4.5 3.7 3.0 2.7 2.3 2.0 1.6
100 -,
Black M F| 18.7 23.1 15.8 20.8 17.6 13.0 11.0 15.1 12.9 9.3 11.1 8.1 7.1 9.6 6.3 8.3 5.2 7.0 4.6 5.9 3.9 5.0 3.2 4.0 3.4 2.7 2.4 2.9 2.4 2.0 1.9 1.6
I Nat. American j Asian M F M F 30.4 27.1 26.0 22.2 24.1 21.2 20.6 19.9 20.5 17.9 17.3 16.8 14.7 17.6 15.3 14.4 12.4 15.0 13.0 12.3 12.9 11.3 10.6 10.7 11.0 9.7 9.1 9.3 7.7 9.3 8.3 8.0 7.7 7.0 6.5 6.8 6.6 6.0 5.4 5.9 5.4 4.9 4.5 5.0 4.3 4.0 3.6 4.1 3.6 3.4 3.0 3.5 2.9 2.8 2.5 2.9 2.4 2.4 2.4 2.0 1.9 1.9 1.5 1.9
Transplant Black White F M M F 47.4 45.9 30.9 47.5 24.4 35.4 35.6 35.1 32.3 31.6 20.9 31.9 28.1 27.4 18.0 27.6 24.4 23.6 15.4 23.7 20.9 20.0 13.3 20.1 17.4 16.4 16.7 11.5 13.4 14.3 13.7 9.8 10.4 11.1 10.7 8.2 7.5 8.0 7.7 7.0 4.2 4.4 4.2 5.7 4.6 3.9 3.2 2.7 2.1
Male
Female
Reference population: the aver age 1997 incident dialysis pa tient of the same gender and age group. 60
40
20
5
1
Years of ESRD
F 44.2 34.0 30.9 26.8 23.1 19.7 16.4 13.4 10.5 7.6 4.3
Nat. American Asian M F M 52.3 50.1 52.3 39.4 37.3 39.1 35.2 33.3 34.9 30.6 28.9 30.3 26.4 24.8 26.0 20.9 21.9 22.3 18.3 17.2 18.0 14.4 14.8 13.9 10.7 11.3 11.0 7.9 7.6 7.8 4.3 4.2 4.3
F 54.5 41.5 37.3 32.7 28.3 24.1 20.0 16.1 12.3 8.6 4.6
CHAPTER
100
8 ·
SURVIVAL,
MORTALITY,
Male
Female
& CAUSES
OF
DEATH
· Sl 3 3
Figure 8.12 Five-year survival by race & gender incident dialysis patients, 1993, adjusted for age & primary diagnosis of diabetes Reference population: the aver age 1997 incident dialysis pa tient of the same gender and race.
40 ■
White Black ■ Native American ■ Asian
20 ■
1
5 Years of ESRD
100
Male
Female
Figure 8.13 Five-year survival by primary diagnosis & gender incident dialysis patients, 1993, adjusted for age & race Reference population: the aver age 1997 incident dialysis pa tient of the same gender and primary diagnosis.
60 ■
40 Diabetes Hypertension Glomerulonephritis Other
20 ■
Years of ESRD
100
Male
Female
Figure 8.14 Five-year survival by modality & gender incident dialysis patients, 1993, adjusted for age, race, & primary diagnosis of diabetes Reference population: the aver age 1997 incident dialysis pa tient of the same gender and modality.
60 ■
40 -
20
Hemodialysis Peritoneal dialysis
5
1 Years of ESRD
Si34
■ 2000
ATLAS
OF
ESRD
IN
THE UNITED
STATES
First-year death rates,1993-1995 combined
First-year death rates, 1990-1992 combined
■ ■ ■ •
28.0 + 25.1 to 28.0 23.6 to 25.1 21.7 to 23.6 below 21.7
Second-year death rates, 1990-1992 combined
■ 28.0 + ■ 55.1 to 28.0 4 23.6 to 25.1 21.7 to 23.6 uelow 21.7
Second-year death rates, 1993-1995 combined
■ ■ % li
283 + 26.0 to 28.3 243 to 26.0 20.8 to 243 below 20B
Third-year death rates, 1990-1992 combined
.3 + ■ 26.0 to 283 «* 24.3 to 26.0 20.8 to 243 below 20.8 Third-year death rates,1993-1995 combined
29.3 + 262 to 293 B 25.2 to 262 . 22.9 to 252 below 22.9
Fourth-year death rates, 1990-1992 combined
_-J_
"
•\ r
^
■ 29.3 + ■ 26.2 to 293 * 25.2 to 262 22.9 to 252 below 22.9
Fourth-year death rates,1993-1995 combined
31.0 + 28.5 to 31.0 B 25.7 to 28.5 * 23.6 to 25.7 below 23.6
Figure 8.15 First-, second-, third-, & fourth-year death rates per 100 patient years at risky incident dialysis patients, by state, adjusted for age, gender, race, & primary diagnosis of diabetes Reference population:the average 1997 incident dialysis patient.
\.
31.0 + 28.5 to 31.0 ■ 25.7 to 285 23.6 to 25.7 below 23.6
C H A P T E R
8
·
SURVIVAL,
M O R T A L I T Y ,
&
CAUSES
OF
2nd year 3rd year Overall
27-<30
30-<33
33-<36
36+
Diabetic
<27
27-<30
30-<33
33-<36
36+
Figure 8.17 Associations between mortality & hematocrit level by years of follow-up
Non-diabetic
incident hemodialysispatients, 1993-1996 combined, adjusted for patient characteristics, comorbidity, & severity of disease in the entry period
1st year 2nd year 3rd year Overall
<27
27-<30
30-<33
33-<36
36+
Diabetic
<27
27-<30
30-<33
33-<36
36+
Figure 8.18 Associations between mortality & hematocrit level by years of follow-up
Non-diabetic
incident peritoneal dialysis patients, 1993-1996 combined, adjusted for patient characteris tics, comorbidity, & severity of disease in the entry period
1st year 2nd year 3rd year Overall
<27
27-<30
30-<33
33-<36
36+
lulu«! <27
S135
incident dialysis patients, 19931996 combined, adjusted for patient characteristics. comorbtdity, & severity of disease in the entry period
1st year
<27
·
Figure 8.16 Associations between mortality & hematocrit level by years of follow-up
Non-diabetic
Diabetic
DEATH
27-<30
30-<33
33-<36
36+
Si36
·
2000
ATLAS
OF
ESRD
IN
THE
UNITED
STATES
Hemodialysis, first-year death rates, 1990-1992 combined
Hemodialysis,first-year death rates, 1993-1995 combined
Hemodialysis, second-year death rates, 1990-1992 combined
Hemodialysis, second-year death rates, 1993-1995 combined
Peritoneal dialysis,first-year death rates, 1990-1992 combined
Peritoneal dialysis, first-year death rates, 1993-1995 combined
Peritoneal dialysis, second-year death rates, 1990-1992 combined
Peritoneal dialysis, second-year death rates, 1993-1995 combined
Figure 8.19 All-cause death rates
per 100 patient years at risk, incident patients, by state, adjusted for age, gender, race, & diabetic status While all-cause death rates have clearly decreased since 1992, an analysis that includes more detailed adjustments is required to understand the geographic patterns. Death rates are influenced not only by age, gender, race, and diabetic status, but by dialysis therapy, hematocrit level, membrane use, transplant rates, and modality change rates. The complexity of comparing hemodialysis and peritoneal dialysis, particularly over vary ing lengths of follow-up time, should also be considered. Reference population: the av erage 1997 incident patient of the same modality.
CHAPTER
8 · SURVIVAL,
MORTA
ITY,
& CAUSES
OF
DEATH
Hemodialysis, first-year death rates,1990-1992 combined
Hemodialysis,first-year death rates, 1993-1995 combined
Hemodialysis, second-year death rates, 1990-1992 combined
Hemodialysis, second-year death rates, 1993-1995 combined
Peritoneal dialysis,first-year death rates, 1990-1992 combined
Peritoneal dialysis, first-year death rates, 1993-1995 combined
Peritoneal dialysis, second-year death rates, 1990-1992 combined
Peritoneal dialysis, second-year death rates, 1993-1995 combined
Figure 8.20 Infectious death rates
per 100 patient years at risk, incident patients, by state, adjusted for age, gender, race, & diabetic status The distribution of infectious death rates parallels the pattern of insertion rates for cen tral venous catheters (fig 4.15). Rates of peritonitis and catheter complications should be investigated for their possible contribution to the geographic variation in infectious death rates, as should the effect of recently improved peritoneal dialysis delivery sys tems (which reduce the risk of contamination) and the differences between CAPD and CCPD. Reference population:the average 1997 incident patient of the same modality.
·
S137
Si38
·
2000
ATLAS
OF
ESRD
IN
THE
UNITED
STATES
Hemodialysis, first-year death rates,1990-1992 combined
Hemodialysis, first-year death rates, 1993-1995 combined
Hemodialysis, second-year death rates, 1990-1992 combined
Hemodialysis, second-year death rates, 1993-1995 combined
Peritoneal dialysis,first-year death rates, 1990-1992 combined
Peritoneal dialysis, first-year death rates, 1993-1995 combined
f
Peritoneal dialysis, second-year death rates, 1990-1992 combined
Peritoneal dialysis, second-year death rates, 1993-1995 combined
Figure 8.21 Cardiac death rates
per 100 patient years at risk, incident patients, by state, adjusted for age, gender, race, & diabetic status More detailed analyses of regional differences in cardiac death rates should evaluate the influences of comorbidity disease severity, transplantation rates, cardiovascular inter vention, and monitoring of diabetic patients for glycemic control and lipid disorders. Reference population:the average 1997 incident patient of the same modality.
CHAPTER
8
·
SURVIVAL,
Acute myocardial infarction Cardiac arrest, cause unknown Cardiac, other Atherosclerotic heart disease Cardiac arrhythmia Cardiomyopathy Pericarditis, including cardiac tamponade Pulmonary edema due to exogenous fluid Valvular heart disease Cerebrovascular (CVD, CVA/TIA) Cerebrovascular accident Ischemic brain damage Infection AIDS Fungal peritonitis Hepatitis B Infection, other Other viral hepatitis Pulmonary infection, bacterial Pulmonary infection, fungal Pulmonary infection, other
MORTALITY,
Septicemia, peritonitis Septicemia, PVD/gangrene Septicemia, vascular access Septicemia, other Tuberculosis Viral infection, CMV Viral infection, other Malignancy Malignant disease, history of immunosuppressive treatment Malignant disease, other Other known causes Accident related to treatment Accident unrelated to treatment Air embolism Bone marrow depression Cachexia Chronic obstr. pulmonary disease Cirrhosis Complications of surgery Dementia Diabetic coma, hypo/hyperglycemia Drug overdose
& CAUSES
OF
Drug overdose, street drugs Gl hemorrhage Hemorrhage, dialysis circuit Hemorrhage, ruptured vascular access Hemorrhage, surgery Hemorrhage, transplant site Hemorrhage, vascular access Hyperkalemia Liver failure, cause unknown Liver-drug toxicity Mesenteric infarction/ischemic bowel Other hemorrhage Other identified cause Pancreatitis Perforation of bowel Perforation of peptic ulcer Polycystic liver disease Pulmonary embolus Seizures Suicide Unknown Includes causes of death not recorded or no Death Notification form
DEATH
·
S139
Table 8.2 Cause of death categories
from HCFA Death Notification Form 2746
Figure 8.22 Cause-specific death rates by modality
prevalent diabetic patients aged 20 & older, i 996-i 998 combined, unadjusted
Hemodialysis Peritoneal dialysis Transplant
Myocardial infarction
Cardiac arrest
Cardiac other
CVD, CVA/TIA
Infection
Malignancy
Other known
Unknown
Figure 8.23 Cause-specific death rates by modality
prevalent non-diabetic patients aged 20 & older, 1996-1998 combined, unadjusted
70 -, Hemodialysis Peritoneal dialysis
Comparisons of prevalent death rates across modalities should be made with caution, as the rates may be influenced by patient time on ESRD, transplant rates, comorbiditydisease severity,dialysis therapy, and hematocrit level.
I Transplant ■
a
20
Myocardial infarction
Cardiac arrest
Cardiac other
CVD, CVA/TIA
Infection
Malignancy
Other known
Unknown
Si40
·
2000
ATLAS
OF
ESRD
IN
THE
UNITED
STATES
Figure 8.24 Cause-specific death rates by race prevalent male hemodialysis patients aged 20 & older, 1996} 998 combined, unadjusted
Other known
Unknown
Other known
Unknown
Other known
Unknown
Figure 8.25 Cause-specific death rates by race prevalent female hemodialysis panents aged 20 & older, 19961998 combined, unadjusted
Myocardia infarction
Figure 8.26 Cause-specific death rates by race prevalent male peritoneal dialysis panents aged 20 & older, 1996-1998 combined, unadjusted
CHAPTER
8
·
SURVIVAL,
MORTALITY,
& CAUSES
OF
DEATH
·
S141
Figure 8.27 Cause-specific death rates by race
60
prevalent female peritoneal dialysis patients aged 20 & older, 1996-1998 combined, unadjusted
White Black Native American Asian
Myocardial infarction
25
Cardiac arrest
Cardiac other
CVD, CVA/TIA
Infection
Malignancy
Other known
Unknown
Figure 8.28 Cause-specific death rates by race prevalent male transplant patients aged 20 & older, 19961998 combined, unadjusted
White Black
20
Native American Asian
Myocardial infarction
25
Cardiac arrest
Cardiac other
CVD, CVA/TIA
Infection
Malignancy
Other known
Unknown
Figure 8.29 Cause-specific death rates by race prevalent female transplant patients aged 20 & older, 19961998 combined, unadjusted
White Black Native American Asian
Myocardial infarction
Cardiac arrest
Cardiac other
CVD, CVA/TIA
nfection
Malignancy
Other known
Unknown
S i
4
2
·
2 0 0 0
A T L A S
OF
ESRD
IN
T H E
U N I T E D
S T A T E S
Figure 8.30 Cause-specific death rates by age group prevalent hemodialysis patients, 1996-1998 combined. unadjusted
Myocardial infarction
Malignancy
Other known
Unknown
Malignancy
Other known
Unknown
figure 8.31 Cause-specific death rates by age group prevalent peritoneal dialysis patients, 1996-1998 combined, unadjusted
Myocardial infarction
Figure 8.32 Cause-specific death rates by age group prevalent transplant patients, 1996-1998 combined, unadjusted 70 S 60
ΰ
Cardiac arrest
Cardiac other
CVD, CVA/TIA
Infection
0-19 20-44 45-64 65+
20 10 -
Myocardial infarction
Cardiac arrest
Cardiac other
CVD, CVA/TIA
Infection
Malignancy
Other known
Unknown
He was excellent indeed, madam: the king very lately spoke of him admiringly and mourningly: he was skillful enough to have lived still, if knowledge could be set up against mortality. William Shakespeare, All's Well That Ends Well
American Journal of Kidney Diseases, Vol 36, No 6, Suppl 2 (December), 2000: pp S127-S142
Si28
· 2000
ATLAS
OF
ESRD
IN
THE
UNITED
STATES
Since 1988, first-year death rates for all incident
The association over time between death rates
dialysis patients have fallen 38.5%, with the great
and hematocrit levels varies by diabetic status (figs
est decrease (63.7%) occurring in patients on
8.16-18). While the death rates decline with
peritoneal dialysis (fig 8.1). Death rates for trans
higher hematocrits in both diabetics and non-
plant patients, consistently much lower than those
diabetics, they tend to flatten out as hematocrit
for patients on dialysis, fell 93% in the same pe
levels reach 33%. The consistently lower death
riod. Rates have decreased for all age groups of
rates at higher hematocrit levels support the
both hemodialysis and peritoneal dialysis pa
DOQI target range of 33-36%.
tients, with younger patients consistently having lower death rates than their older counterparts.
In figures 8.1-15 and 8.19-21 data are adjusted
Declines infirst-yeardeath rates have been com
for age, race, gender, and/or diabetic status; they
parable for male and female patients on both mo
are not, however, adjusted for other clinical fac
dalities—approximately 48% for hemodialysis,
tors, such as comorbidity and disease severity,
and 64% for peritoneal dialysis (figs 8.4-5).
which may influence the death rates. Adjustments for these latter factors, however, are made in fig
In terms of race, first-year death rates have de
ures 8.16-18, which show associations between
clined most in Asian patients, 58.3% for hemo
hematocrit and mortality.
dialysis and 71.9% for peritoneal dialysis. The rate for white hemodialysis patients shows a slightly
Figures 8.22-32 present death rates for prevalent
higher decline (48%) than that for blacks and
patient cohorts. Since these cohorts consist of
Native Americans, 43.1% and 38.8% respectively.
patients with varying amounts of time on ESRD
This trend is somewhat different for peritoneal
and varying modality histories, and are affected
patients, however, with the decrease for blacks
as well by the selection bias related to transplan
being 64% compared to 61.7% in whites and
tation, the graphs should be interpreted with cau
53.9% in Native Americans (figs 8.6-7).
tion.
Death rates for diabetics, hypertensive patients,
Overall, the fall in death rates has been concur
and patients with other renal diseases have be
rent with improvements in dialysis therapy and
gun to converge for hemodialysis patients, but
anemia treatment, and with changes in mem
this is not the case for the peritoneal dialysis popu
brane use from cuprophane to synthetic mem
lation, in which diabetics continue to have the
branes (see Chapter Ten).
All data underlying the highest rates of death (figs 8.8-9). Differences by modality are also apparent in first, second-, and figures in this chapter, third-to-fifth year death rates (fig 8.10). These patterns suggest that the two dialysis modalities as well as additional related are not proportional to one another over time, a fact that complicates comparisons between them. data, may be viewed & Five-year survival curves show that female padownloaded at
tients live longer than males across most age groups, races, primary diagnoses, and modalities
www.usrds.org.
(figs 8.11-14).
Included in this chapter ♦ Graphs of first-year death rates by modality, age group.gender, race.and primary diagnosis ♦ Five-year survival curves by gendecage group, race,primary di agnosis, and modality ♦ Maps of first-,second-,third-,and fourth-year overall death rates, as well as maps of all-cause, infectious, and cardiac death rates ♦ Graphs of the association between mortality and hematocrit ♦ Graphs of cause-specific death rates by modality, race.and age group
CHAPTER
8 ·
SURVIVAL,
30 -
20 ■
10 -
All dialysis (29.9, -38.5%) Hemodialysis (28.1,-48%) Peritoneal dialysis (27.8, -63.7%) Transplant (2.9,-93%)
40 ■
a
30 ■
DEATH
· S129
Reference population: the aver age 1997 incident patient in each modality.
Figure 8.2 First-year death rates by age group incident hemodialysis patients, adjusted for gender, race, & primary diagnosis of diabetes
45
35
OF
The number of deaths per 100 patient years in 1988, and the percent change in values be tween 1988and 1997,are shown in the legend.
25
15 ■
& CAUSES
Figure 8.1 First-year death rates by modality incident patients, adjusted for age, gender, race, & primary diagnosis of diabetes
35
S
MORTALITY,
■ 0-19(9.7,-71.1 20-44(16.7,-63.1 ■ 45-64 (24.6, -50.4%) ■ 65+ (42.7, -32.3%)
The number of deaths per 100 patient years in 1988, and the percent change in values be tween 1988 and 1997,are shown in the legend. Reference population: the aver age 1997 incident hemodialysis patient in each age group.
Figure 8.3 First-year death rates by age group incident peritoneal dialysis patients, adjusted for gender, race, & primary diagnosis of diabetes The number of deaths per 100 patient years in 1988, and the percent change in values be tween 1988 and 1997,are shown in the legend. Reference population: the aver age 1997 incident peritoneal di alysis patient in each age group.
Si30
■ 2000
ATLAS
OF
ESRD
IN
THE UNITED
STATES
Figure 8.4 First-year death rates by gender incident hemodialysis patients, adjusted for age, race, & primary diagnosis of diabetes The number of deaths per 100 patient years in 1988, and the percent change in values be tween 1988and 1997,are shown in the legend.
30 ω 25
Reference population: the aver age 1997 incident hemodialysis patient of each gender.
Male (30.2, -49.7%) Female (25.9, -46.3%)
1990
1991
1992
1993
1994
1995
1996
1993
1994
1995
1996
1997
1996
1997
Figure 8.5 First-year death rates by gender incident peritoneal dialysis patients, adjusted for age, race, & primary diagnosis of diabetes The number of deaths per 100 patient years in 1988, and the percent change in values be tween 1988and 1997,are shown in the legend.
30 ω 25
Reference population: the aver age 1997 incident peritoneal di alysis patient of each gender.
20
Figure 8.6 First-year death rates by race incident hemodialysis patients, adjusted for age, gender, & primary diagnosis of diabetes The number of deaths per 100 patient years in 1988, and the percent change in values be tween 1988 and 1997,are shown in the legend. Reference population: the aver age 1997 incident hemodialysis patient of each race.
40 -, 35 30' ω 25 20
Q
10 5
Black (19.5,-43.1 Native American (17, -38.8%) Asian (22.3, -58.3%)
0 1989
1990
CHAPTER
8 ·
SURVIVAL,
MORTALITY,
& CAUSES
OF
DEATH
· S131
Figure 8.7 First-year death rates by race incident peritoneal dialysis patients, adjusted for age, gender, & primary diagnosis of diabetes The number of deaths per 100 patient years in 1988, and the percent change in values be tween 1988 and 1997,are shown in the legend.
30 ω 25
Reference population: the aver age 1997 incident peritoneal di alysis patient of each race.
20 15 10 -
White (31.3,-61.7%) Black (20.3, -64%) Native American (14.3, -53. Asian (15.3,-71.9%) 1990
1991
1995
1992
1996
1997
Figure 8.8 First-year death rates by primary diagnosis incident hemodialysis patients, adjusted for age, gender, & race The number of deaths per 100 patient years in 1988, and the percent change in values be tween 1988and 1997,areshown in the legend.
25
Reference population: the aver age 1997 incident hemodialysis patient with each primary diag nosis.
20 ■ 15 10 -
■ Diabetes (32.8, -50.3%) ■ Hypertension (26.7, -44.8%) ■ Glomerulonephritis (17.7, -59.3%) Other (25.0,-39.2%) 1990
1991
1993
1994
1995
1996
1997
Figure 8.9 First-year death rates by primary diagnosis incident peritoneal dialysis patients, adjusted for age, gender, & race
Diabetes (35.7, -53.5%) Hypertension (29.5, -66.8 Glomerulonephritis (16.6, -78.3%) Other (21.3,-624
35 £ 30
The number of deaths per 100 patient years in 1988, and the percent change in values be tween 1988and 1997,are shown in the legend.
25
Reference population: the aver age 1997 incident peritoneal di alysis patient with each primary diagnosis.
20 ■
10 ■
1989
1990
1995
1996
1997
Si32
· 2000
ATLAS
Figure 8.10 First-, second-, &third-to-fifth year annual death rates incident patients, adjusted for age, gender, race, & primary diagnosis of diabetes The number of deaths per 100 patient years in 1988, and the percent change in values be tween 1988 and the last year shown for each death rate, are shown in the legends. Reference population: the aver age 1997 incident patient on each modality.
OF
ESRD
IN
THE UNITED
Peritoneal dialysis
Hemodialysis
30
STATES
r 20
-£ 10
• First-year (27.8,-63.7%)
First-year (28.1,-48%) Second-year (25.8, -36%) ■ Third-to-fifth year (26, -8.8%)
• Second-year (27.8, -45.7%) ■ Third-to-fifth year (28.1,-18.19
_l_ _l_ 1990 1991 1992 1993 1994 1995 1996 1997 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997
Table 8.1 Expected remaining lifetimes (years) by race & gender prevalent patients, 1998 Reference: Table H.3, H.4, H.12, andH.13.
Figure 8.11 Five-year survival curves by age group & gender incident dialysis patients, 1993, adjusted for race & primary diagnosis of diabetes
Age 0-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85 +
Dialysis White M 19.5 16.4 13.6 11.5 9.7 8.3 7.2 6.2 5.3 4.5 3.7 3.0 2.7 2.3 2.0 1.6
100 -,
Black M F| 18.7 23.1 15.8 20.8 17.6 13.0 11.0 15.1 12.9 9.3 11.1 8.1 7.1 9.6 6.3 8.3 5.2 7.0 4.6 5.9 3.9 5.0 3.2 4.0 3.4 2.7 2.4 2.9 2.4 2.0 1.9 1.6
I Nat. American j Asian M F M F 30.4 27.1 26.0 22.2 24.1 21.2 20.6 19.9 20.5 17.9 17.3 16.8 14.7 17.6 15.3 14.4 12.4 15.0 13.0 12.3 12.9 11.3 10.6 10.7 11.0 9.7 9.1 9.3 7.7 9.3 8.3 8.0 7.7 7.0 6.5 6.8 6.6 6.0 5.4 5.9 5.4 4.9 4.5 5.0 4.3 4.0 3.6 4.1 3.6 3.4 3.0 3.5 2.9 2.8 2.5 2.9 2.4 2.4 2.4 2.0 1.9 1.9 1.5 1.9
Transplant Black White F M M F 47.4 45.9 30.9 47.5 24.4 35.4 35.6 35.1 32.3 31.6 20.9 31.9 28.1 27.4 18.0 27.6 24.4 23.6 15.4 23.7 20.9 20.0 13.3 20.1 17.4 16.4 16.7 11.5 13.4 14.3 13.7 9.8 10.4 11.1 10.7 8.2 7.5 8.0 7.7 7.0 4.2 4.4 4.2 5.7 4.6 3.9 3.2 2.7 2.1
Male
Female
Reference population: the aver age 1997 incident dialysis pa tient of the same gender and age group. 60
40
20
5
1
Years of ESRD
F 44.2 34.0 30.9 26.8 23.1 19.7 16.4 13.4 10.5 7.6 4.3
Nat. American Asian M F M 52.3 50.1 52.3 39.4 37.3 39.1 35.2 33.3 34.9 30.6 28.9 30.3 26.4 24.8 26.0 20.9 21.9 22.3 18.3 17.2 18.0 14.4 14.8 13.9 10.7 11.3 11.0 7.9 7.6 7.8 4.3 4.2 4.3
F 54.5 41.5 37.3 32.7 28.3 24.1 20.0 16.1 12.3 8.6 4.6
CHAPTER
100
8 ·
SURVIVAL,
MORTALITY,
Male
Female
& CAUSES
OF
DEATH
· Sl 3 3
Figure 8.12 Five-year survival by race & gender incident dialysis patients, 1993, adjusted for age & primary diagnosis of diabetes Reference population: the aver age 1997 incident dialysis pa tient of the same gender and race.
40 ■
White Black ■ Native American ■ Asian
20 ■
1
5 Years of ESRD
100
Male
Female
Figure 8.13 Five-year survival by primary diagnosis & gender incident dialysis patients, 1993, adjusted for age & race Reference population: the aver age 1997 incident dialysis pa tient of the same gender and primary diagnosis.
60 ■
40 Diabetes Hypertension Glomerulonephritis Other
20 ■
Years of ESRD
100
Male
Female
Figure 8.14 Five-year survival by modality & gender incident dialysis patients, 1993, adjusted for age, race, & primary diagnosis of diabetes Reference population: the aver age 1997 incident dialysis pa tient of the same gender and modality.
60 ■
40 -
20
Hemodialysis Peritoneal dialysis
5
1 Years of ESRD
Si34
■ 2000
ATLAS
OF
ESRD
IN
THE UNITED
STATES
First-year death rates,1993-1995 combined
First-year death rates, 1990-1992 combined
■ ■ ■ •
28.0 + 25.1 to 28.0 23.6 to 25.1 21.7 to 23.6 below 21.7
Second-year death rates, 1990-1992 combined
■ 28.0 + ■ 55.1 to 28.0 4 23.6 to 25.1 21.7 to 23.6 uelow 21.7
Second-year death rates, 1993-1995 combined
■ ■ % li
283 + 26.0 to 28.3 243 to 26.0 20.8 to 243 below 20B
Third-year death rates, 1990-1992 combined
.3 + ■ 26.0 to 283 «* 24.3 to 26.0 20.8 to 243 below 20.8 Third-year death rates,1993-1995 combined
29.3 + 262 to 293 B 25.2 to 262 . 22.9 to 252 below 22.9
Fourth-year death rates, 1990-1992 combined
_-J_
"
•\ r
^
■ 29.3 + ■ 26.2 to 293 * 25.2 to 262 22.9 to 252 below 22.9
Fourth-year death rates,1993-1995 combined
31.0 + 28.5 to 31.0 B 25.7 to 28.5 * 23.6 to 25.7 below 23.6
Figure 8.15 First-, second-, third-, & fourth-year death rates per 100 patient years at risky incident dialysis patients, by state, adjusted for age, gender, race, & primary diagnosis of diabetes Reference population:the average 1997 incident dialysis patient.
\.
31.0 + 28.5 to 31.0 ■ 25.7 to 285 23.6 to 25.7 below 23.6
C H A P T E R
8
·
SURVIVAL,
M O R T A L I T Y ,
&
CAUSES
OF
2nd year 3rd year Overall
27-<30
30-<33
33-<36
36+
Diabetic
<27
27-<30
30-<33
33-<36
36+
Figure 8.17 Associations between mortality & hematocrit level by years of follow-up
Non-diabetic
incident hemodialysispatients, 1993-1996 combined, adjusted for patient characteristics, comorbidity, & severity of disease in the entry period
1st year 2nd year 3rd year Overall
<27
27-<30
30-<33
33-<36
36+
Diabetic
<27
27-<30
30-<33
33-<36
36+
Figure 8.18 Associations between mortality & hematocrit level by years of follow-up
Non-diabetic
incident peritoneal dialysis patients, 1993-1996 combined, adjusted for patient characteris tics, comorbidity, & severity of disease in the entry period
1st year 2nd year 3rd year Overall
<27
27-<30
30-<33
33-<36
36+
lulu«! <27
S135
incident dialysis patients, 19931996 combined, adjusted for patient characteristics. comorbtdity, & severity of disease in the entry period
1st year
<27
·
Figure 8.16 Associations between mortality & hematocrit level by years of follow-up
Non-diabetic
Diabetic
DEATH
27-<30
30-<33
33-<36
36+
Si36
·
2000
ATLAS
OF
ESRD
IN
THE
UNITED
STATES
Hemodialysis, first-year death rates, 1990-1992 combined
Hemodialysis,first-year death rates, 1993-1995 combined
Hemodialysis, second-year death rates, 1990-1992 combined
Hemodialysis, second-year death rates, 1993-1995 combined
Peritoneal dialysis,first-year death rates, 1990-1992 combined
Peritoneal dialysis, first-year death rates, 1993-1995 combined
Peritoneal dialysis, second-year death rates, 1990-1992 combined
Peritoneal dialysis, second-year death rates, 1993-1995 combined
Figure 8.19 All-cause death rates
per 100 patient years at risk, incident patients, by state, adjusted for age, gender, race, & diabetic status While all-cause death rates have clearly decreased since 1992, an analysis that includes more detailed adjustments is required to understand the geographic patterns. Death rates are influenced not only by age, gender, race, and diabetic status, but by dialysis therapy, hematocrit level, membrane use, transplant rates, and modality change rates. The complexity of comparing hemodialysis and peritoneal dialysis, particularly over vary ing lengths of follow-up time, should also be considered. Reference population: the av erage 1997 incident patient of the same modality.
CHAPTER
8 · SURVIVAL,
MORTA
ITY,
& CAUSES
OF
DEATH
Hemodialysis, first-year death rates,1990-1992 combined
Hemodialysis,first-year death rates, 1993-1995 combined
Hemodialysis, second-year death rates, 1990-1992 combined
Hemodialysis, second-year death rates, 1993-1995 combined
Peritoneal dialysis,first-year death rates, 1990-1992 combined
Peritoneal dialysis, first-year death rates, 1993-1995 combined
Peritoneal dialysis, second-year death rates, 1990-1992 combined
Peritoneal dialysis, second-year death rates, 1993-1995 combined
Figure 8.20 Infectious death rates
per 100 patient years at risk, incident patients, by state, adjusted for age, gender, race, & diabetic status The distribution of infectious death rates parallels the pattern of insertion rates for cen tral venous catheters (fig 4.15). Rates of peritonitis and catheter complications should be investigated for their possible contribution to the geographic variation in infectious death rates, as should the effect of recently improved peritoneal dialysis delivery sys tems (which reduce the risk of contamination) and the differences between CAPD and CCPD. Reference population:the average 1997 incident patient of the same modality.
·
S137
Si38
·
2000
ATLAS
OF
ESRD
IN
THE
UNITED
STATES
Hemodialysis, first-year death rates,1990-1992 combined
Hemodialysis, first-year death rates, 1993-1995 combined
Hemodialysis, second-year death rates, 1990-1992 combined
Hemodialysis, second-year death rates, 1993-1995 combined
Peritoneal dialysis,first-year death rates, 1990-1992 combined
Peritoneal dialysis, first-year death rates, 1993-1995 combined
f
Peritoneal dialysis, second-year death rates, 1990-1992 combined
Peritoneal dialysis, second-year death rates, 1993-1995 combined
Figure 8.21 Cardiac death rates
per 100 patient years at risk, incident patients, by state, adjusted for age, gender, race, & diabetic status More detailed analyses of regional differences in cardiac death rates should evaluate the influences of comorbidity disease severity, transplantation rates, cardiovascular inter vention, and monitoring of diabetic patients for glycemic control and lipid disorders. Reference population:the average 1997 incident patient of the same modality.
CHAPTER
8
·
SURVIVAL,
Acute myocardial infarction Cardiac arrest, cause unknown Cardiac, other Atherosclerotic heart disease Cardiac arrhythmia Cardiomyopathy Pericarditis, including cardiac tamponade Pulmonary edema due to exogenous fluid Valvular heart disease Cerebrovascular (CVD, CVA/TIA) Cerebrovascular accident Ischemic brain damage Infection AIDS Fungal peritonitis Hepatitis B Infection, other Other viral hepatitis Pulmonary infection, bacterial Pulmonary infection, fungal Pulmonary infection, other
MORTALITY,
Septicemia, peritonitis Septicemia, PVD/gangrene Septicemia, vascular access Septicemia, other Tuberculosis Viral infection, CMV Viral infection, other Malignancy Malignant disease, history of immunosuppressive treatment Malignant disease, other Other known causes Accident related to treatment Accident unrelated to treatment Air embolism Bone marrow depression Cachexia Chronic obstr. pulmonary disease Cirrhosis Complications of surgery Dementia Diabetic coma, hypo/hyperglycemia Drug overdose
& CAUSES
OF
Drug overdose, street drugs Gl hemorrhage Hemorrhage, dialysis circuit Hemorrhage, ruptured vascular access Hemorrhage, surgery Hemorrhage, transplant site Hemorrhage, vascular access Hyperkalemia Liver failure, cause unknown Liver-drug toxicity Mesenteric infarction/ischemic bowel Other hemorrhage Other identified cause Pancreatitis Perforation of bowel Perforation of peptic ulcer Polycystic liver disease Pulmonary embolus Seizures Suicide Unknown Includes causes of death not recorded or no Death Notification form
DEATH
·
S139
Table 8.2 Cause of death categories
from HCFA Death Notification Form 2746
Figure 8.22 Cause-specific death rates by modality
prevalent diabetic patients aged 20 & older, i 996-i 998 combined, unadjusted
Hemodialysis Peritoneal dialysis Transplant
Myocardial infarction
Cardiac arrest
Cardiac other
CVD, CVA/TIA
Infection
Malignancy
Other known
Unknown
Figure 8.23 Cause-specific death rates by modality
prevalent non-diabetic patients aged 20 & older, 1996-1998 combined, unadjusted
70 -, Hemodialysis Peritoneal dialysis
Comparisons of prevalent death rates across modalities should be made with caution, as the rates may be influenced by patient time on ESRD, transplant rates, comorbiditydisease severity,dialysis therapy, and hematocrit level.
I Transplant ■
a
20
Myocardial infarction
Cardiac arrest
Cardiac other
CVD, CVA/TIA
Infection
Malignancy
Other known
Unknown
Si40
·
2000
ATLAS
OF
ESRD
IN
THE
UNITED
STATES
Figure 8.24 Cause-specific death rates by race prevalent male hemodialysis patients aged 20 & older, 1996} 998 combined, unadjusted
Other known
Unknown
Other known
Unknown
Other known
Unknown
Figure 8.25 Cause-specific death rates by race prevalent female hemodialysis panents aged 20 & older, 19961998 combined, unadjusted
Myocardia infarction
Figure 8.26 Cause-specific death rates by race prevalent male peritoneal dialysis panents aged 20 & older, 1996-1998 combined, unadjusted
CHAPTER
8
·
SURVIVAL,
MORTALITY,
& CAUSES
OF
DEATH
·
S141
Figure 8.27 Cause-specific death rates by race
60
prevalent female peritoneal dialysis patients aged 20 & older, 1996-1998 combined, unadjusted
White Black Native American Asian
Myocardial infarction
25
Cardiac arrest
Cardiac other
CVD, CVA/TIA
Infection
Malignancy
Other known
Unknown
Figure 8.28 Cause-specific death rates by race prevalent male transplant patients aged 20 & older, 19961998 combined, unadjusted
White Black
20
Native American Asian
Myocardial infarction
25
Cardiac arrest
Cardiac other
CVD, CVA/TIA
Infection
Malignancy
Other known
Unknown
Figure 8.29 Cause-specific death rates by race prevalent female transplant patients aged 20 & older, 19961998 combined, unadjusted
White Black Native American Asian
Myocardial infarction
Cardiac arrest
Cardiac other
CVD, CVA/TIA
nfection
Malignancy
Other known
Unknown
S i
4
2
·
2 0 0 0
A T L A S
OF
ESRD
IN
T H E
U N I T E D
S T A T E S
Figure 8.30 Cause-specific death rates by age group prevalent hemodialysis patients, 1996-1998 combined. unadjusted
Myocardial infarction
Malignancy
Other known
Unknown
Malignancy
Other known
Unknown
figure 8.31 Cause-specific death rates by age group prevalent peritoneal dialysis patients, 1996-1998 combined, unadjusted
Myocardial infarction
Figure 8.32 Cause-specific death rates by age group prevalent transplant patients, 1996-1998 combined, unadjusted 70 S 60
ΰ
Cardiac arrest
Cardiac other
CVD, CVA/TIA
Infection
0-19 20-44 45-64 65+
20 10 -
Myocardial infarction
Cardiac arrest
Cardiac other
CVD, CVA/TIA
Infection
Malignancy
Other known
Unknown