Infection-related deaths from dialysis have declined but risk remains high
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Key takeaways:
- Of 38,463 deaths recorded during the follow-up, 12% were attributed to infections.
- Bacterial infection was the top cause of infection-related death for patients on dialysis.
Despite improvement over time, patients on dialysis have a risk for infection-related death that is 20 times that of the general population, according to recently published data.
Researchers, who presented findings in the American Journal of Kidney Diseases, evaluated long-term trends and risks for infection-related death in patients receiving maintenance dialysis in Australia and New Zealand.
The objective was to “estimate the temporal trends in the incidence of infection-related mortality on dialysis in patients with kidney failure,” Chanel H. Chong, MBBS, MM, of the Centre for Kidney Research at the Children’s Hospital at Westmead in Australia, and colleagues, wrote.
The retrospective study included data for 46,074 patients on hemodialysis and 20,653 patients on peritoneal dialysis from 1980 to 2018. Participants from the Australia and New Zealand Dialysis and Transplant Registry were followed between 164,536 and 69,846 person-years, which take into account the number of people and the amount of time each person spends in the study, for hemodialysis and peritoneal dialysis, respectively.
Results showed that among 38,463 deaths recorded during the follow-up, 12% were attributed to infections, with bacterial infection being the top cause of infection-related death (71%). The highest rate of death occurred within the first year of dialysis, the researchers wrote.
Other countries
While the cohort was based in Australia and New Zealand, results were similar in the U.S.; the proportion of infection-related death was 10% in the United States during a similar timeframe, according to data from the U.S. Renal Data System. However, the U.K. Renal Registry reported 18% of dialysis-related deaths due to infection, and the Korean End Stage Kidney Disease Registry reported 23% of deaths linked to infection.
Overall, the infection mortality rate in the study was 185 per 10,000 person-years for patients on hemodialysis and 232 per 10,000 person-years for those on peritoneal dialysis. Rates varied based on factors, like gender, age and when the patient began dialysis; women, older adults and patients who started earlier (1980-2005 vs. 2006-2018) had higher risk, the authors wrote.
Mortality over time
Notably, results revealed a decline in standardized mortality ratios (SMR) for infection mortality over time. The overall SMR decreased from 37.1 for patients who began dialysis between 1980 and 2005 to 19.3 for those who started between 2006 and 2018.
Although the risk for infection-related death was higher in patients on dialysis, “there was a reduction in the incidence of infection-related death in patients on maintenance dialysis over the last [2] decades,” the authors wrote. “Relative to the general population, the excess risk of infection-related death exceeded 100-fold in the 1980s but narrowed over time to around 20-fold, with improvement seen in both dialysis cohorts.”
That can be explained by an uptick in the absolute risk of infection-related death in the general population and a decline among patients on dialysis, according to the results.
Researchers were unable to conduct mediation analyses to determine causal relationships between infection types and infection-related mortality due to data disaggregation challenges, which future work may address, the authors wrote. However, the study underscores the importance of ongoing research and points to potential reasons for the decreasing rate of infection-related death.
“Timely introduction of prophylactic antibiotic prior to [peritoneal dialysis] PD catheter insertion and in wet contamination, as well as better management of constipation, may have contributed to the reduced risk,” Chong and colleagues wrote. “Early nephrologists’ referral has led to better dialysis planning, reducing the reliance on vascular catheters for dialysis and allowing for earlier referral for kidney transplantation.”
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