Estimating the Fraction of First-Year Hemodialysis Deaths Attributable to Potentially Modifiable Risk Factors: Results from the DOPPS
Received 2 October 2019
Accepted for publication 12 December 2019
Published 16 January 2020 Volume 2020:12 Pages 51—60
Checked for plagiarism Yes
Review by Single-blind
Peer reviewer comments 2
Editor who approved publication: Dr Eyal Cohen
Angelo Karaboyas, 1 Hal Morgenstern, 2 Yun Li, 3 Brian A Bieber, 1 Raymond Hakim, 4 Takeshi Hasegawa, 5 Michel Jadoul, 6 Elke Schaeffner, 7 Raymond Vanholder, 8 Ronald L Pisoni, 1 Friedrich K Port, 9 Bruce M Robinson 1
1Arbor Research Collaborative for Health, Ann Arbor, MI, USA; 2Departments of Epidemiology and Environmental Health Sciences, School of Public Health, and Department of Urology, Medical School, University of Michigan, Ann Arbor, MI, USA; 3Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, USA; 4Vanderbilt University Medical Center, Nashville, TN, USA; 5Division of Nephrology, Department of Medicine, Showa University Fujigaoka Hospital, Yokohama, Japan, and Showa University Research Administration Center (SURAC), Showa University, Tokyo, Japan; 6Cliniques universitaires St Luc, Université Catholique de Louvain, Brussels, Belgium; 7Institute of Public Health, Charité – Universitätsmedizin Berlin, Berlin, Germany; 8Department of Nephrology, University Hospital Ghent, Ghent, Belgium; 9Department of Epidemiology, University of Michigan School of Public Health, and Department of Internal Medicine-Nephrology, University of Michigan Medical School, Ann Arbor, MI, USA
Correspondence: Angelo Karaboyas
Arbor Research Collaborative for Health, 3700 Earhart Drive, Ann Arbor, MI 48105, USA
Tel +1 734 665-4108
Fax +1 734 665-2103
Purpose: Mortality among first-year hemodialysis (HD) patients remains unacceptably high. To address this problem, we estimate the proportions of early HD deaths that are potentially preventable by modifying known risk factors.
Methods: We included 15,891 HD patients (within 60 days of starting HD) from 21 countries in the Dialysis Outcomes and Practice Patterns Study (1996– 2015), a prospective cohort study. Using Cox regression adjusted for potential confounders, we estimated the fraction of first-year deaths attributable to one or more of twelve modifiable risk factors (the population attributable fraction, AF) identified from the published literature by comparing predicted survival based on risk factors observed vs counterfactually set to reference levels.
Results: The highest AFs were for catheter use (22%), albumin < 3.5 g/dL (19%), and creatinine < 6 mg/dL (12%). AFs were 5%-9% for no pre-HD nephrology care, no residual urine volume, systolic blood pressure < 130 or ≥ 160 mm Hg, phosphorus < 3.5 or ≥ 5.5 mg/dL, hemoglobin < 10 or ≥ 12 g/dL, and white blood cell count > 10,000/μL. AFs for ferritin, calcium, and PTH were < 3%. Overall, 65% (95% CI: 59%-71%) of deaths were attributable to these 12 risk factors. Additionally, the AF for C-reactive protein > 10 mg/L was 21% in facilities where it was routinely measured.
Conclusion: A substantial proportion of first-year HD deaths could be prevented by successfully modifying a few risk factors. Highest priorities should be decreasing catheter use and limiting malnutrition/inflammation whenever possible.
Keywords: hemodialysis, incidence, mortality, attributable fraction, cohort study
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