Sweden shows treatment changes have reduced mortality rates for patients on hemodialysis
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Various changes in treatment practices were associated with reductions in mortality and a decreased likelihood of cardiovascular events for patients who received hemodialysis in Sweden during a 10-year period.
According to Marie Evans, MD, of the division of renal medicine in the department of clinical sciences intervention and technology at Karolinska Institutet, and colleagues, “there have been substantial changes in both hemodialysis and cardiovascular treatment during the last decade.” Such therapeutic improvements, the researchers suggested, include the use of high-flux dialyzers, changes to vascular access practice patterns (eg, the Fistula First initiative), the use of more frequent sessions or longer sessions with lower ultrafiltration rates, changes to medication practices (such as calcium-free phosphate binders and calcimimetics) and more appropriate anemia treatment targets.
“Although admittedly, the efficacy of such new treatments in isolation has shown limited or at times no efficacy in improving hard clinical outcomes in pivotal clinical trials, the accumulated changes in treatment strategies may nevertheless have had a positive impact on patient survival,” the researchers wrote. “However, this has not been comprehensively evaluated, as it requires detailed serial registrations of patients, treatments and outcomes in large representative populations, and need to consider not only the possible effects of implementation of therapies over time, but also the changes in patient characteristics and comorbidities as well as the parallel temporal changes in mortality in the population at large.”
To this end, the researchers conducted an observational study of 6,612 patients who initiated hemodialysis between 2006 and 2015. Researchers evaluated patient characteristics, specific treatment changes and outcomes.
“During this 10-year time-period, there were no changes in the mean age (65 years), and about one-third of patients were women (33%),” they wrote of the study population. “Whereas body mass index (BMI), parathyroid hormone (PTH), and the proportion of some comorbidities (cerebrovascular disease including stroke, atrial fibrillation and history of cancer) increased, there was a statistically significantly decreasing trend for mean diastolic blood pressure, serum hemoglobin, phosphate and albumin during the investigated period.”
Regarding treatment practices during the study period, researchers observed an increase in the proportion of patients who received treatment by hemodiafiltration (5% to 30%) and an increase in the proportion who received three or more hemodialysis sessions per week (53% to 62%). This, the researchers contended, led to a lower ultrafiltration rate (median of 4.6 mL/BW/h to 3.8 mL/BW/h). Further, the proportion of patients with a working fistula increased from 41% to 48% and more patients were receiving non-calcium phosphate binders, cinacalcet and vitamin D3.
With these changes, researchers found the standardized 1-year mortality decreased from 13.2% in 2006/2007 to 11.1 % in 2014/2015, while the risk of mortality and major cardiovascular events (MACE) decreased by 6% and 4% every 2 years, respectively.
When comparing the incidence of death with the age- and sex-matched general population, results indicated the risk of mortality declined from six times higher in 2006/2007 to 5.6 higher in 2014/2015.
“Gradual implementation of therapeutic advances and guideline-recommended treatments in routine hemodialysis practice over the last decade in Sweden was associated with a parallel reduction in the short-term risk of death and MACE that was not explained by improved survival in the general population,” Evans and colleagues concluded. “While a long history of negative trials in hemodialysis patients may have generated some therapeutic nihilism, this study suggests that we are moving in the right direction. However, the risk for mortality and cardiovascular complications in this population remains unacceptably high, underlining that still much must be done for these patients.”
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