Phosphate control, fistula rate lowered mortality in U.S. patients on hemodialysis
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Key takeaways:
- Worldwide, case-mix adjusted survival has improved for patients on hemodialysis.
- Practices such as reducing serum phosphorus, improved fluid management and improved Kt/V among patients have succeeded.
During a 20-year period, patients with end-stage kidney disease treated with hemodialysis saw a reduction in mortality worldwide, study results show. The biggest gain in survival was among patients the United States.
“Case-mix adjusted hemodialysis mortality has decreased since 1998,” Keith P. McCullough, PhD, of Arbor Research Collaborative for Health, and colleagues wrote. “Many factors that influence mortality may have contributed to this trend and these associations may differ by continental region.
“We studied changes in hemodialysis facility practices over time and their potential role in mediating changes in patient survival,” the authors wrote.
Data for the study were from the Dialysis Outcomes and Practice Patterns Study (DOPPS) 7. Arbor Research administers the DOPPS research program in dialysis facilities around the world.
Participants in the study were adults with ESKD treated with hemodialysis in 500 facilities participating in the DOPPS between 1999 and 2015. Facilities were located in the United States, Japan, Germany, Italy, Spain and the United Kingdom.
Investigators looked at four practice measures of mortality at each facility: interdialytic weight gain (IDWG) of less than 5.7%, use of AV fistulas vs. other access methods, the percentages of patients with a Kt/V of greater 1.2 and phosphorus levels less than 6 mg/dL.
In the patient study group, researchers found a 13% improvement per decade in survival in Europe (Germany, Italy, Spain and the United Kingdom). “Trends in facility practice measures, especially Kt/V and phosphorus, explained 10% improvement in case-mix survival per decade, representing 77% (10% explained of 13% improvement) of the observed improvement,” the authors wrote.
Patients in Japan saw a 12%-per-decade improvement in case-mix adjusted survival, of which 73% “could be attributed to facility practices, especially Kt/V and IDWG,” the authors wrote.
The country with the biggest gain in survival among patients on hemodialysis was the United States, with a 47%-per-decade improvement. The authors wrote that 56% of the observed 47% improvement in case-mix adjusted survival “could be attributed to facility practices, especially AV fistula use and phosphorus control.”
Improvement in survival time were slightly greater in patients younger than 65 years in Europe and Japan, but not in the United States, the researchers wrote. “Relative improvements in female vs. male patient survival were greatest in Japan,” they wrote.
The impact of the four practice measures was linked to survival with different results, the investigators wrote. “The observed differences in the direct and indirect effects of each practice by region is due largely to differences in baseline practice,” the researchers wrote. “Fistula use in Japan was already 91%, giving very little room for improvement, while it was lowest in the U.S., thus being an important contributor to improved survival over time,” the authors wrote. “ ... We believe there is still substantial room for improvement in fistula use for U.S. patients, particularly during the earliest time periods on dialysis; 85% of the [hemodialysis] patients started with a catheter in 2021.”
“These findings suggest that further improvement in these practice measures may be attended by further reductions in mortality among patients treated with maintenance hemodialysis,” the researchers wrote.
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