Hemodialysis Patients Overestimate Survival

Especially after 1 year, patients receiving hemodialysis tend to rate their chances of survival higher than their nephrologists do, reports a study in JAMA Internal Medicine.

Using medical records data and validated prognostic tools, the researchers identified 150 hemodialysis patients (out of a group of 207) with predicted 1-year mortality of at least 20 percent. The patients and their nephrologists were then interviewed regarding their expectations for survival. The patients’ and physicians’ perceptions of the prognosis and likelihood of transplantation were compared with each other and with actual survival.

The analysis included interviews with 62 of 80 eligible patients. Eighty-one percent of patients believed they had at least a 90 percent chance of being alive 1 year later. By contrast, nephrologists estimated that only 25 percent of patients stood a 90 percent chance of surviving for 1 year.

Just 6 percent of patients said they had less than a 50 percent chance of surviving for 5 years, whereas nephrologists rated the chances of 5-year survival at less than 40 percent for 56 percent of patients. Sixty-six percent of patients believed they were candidates for kidney transplantation, whereas nephrologists thought so for only 39 percent.

None of the patients reported discussing their estimated life expectancy with their nephrologists. Of patients who expected to survive for 1 year, only 44 percent said they would want life-extending treatments if it meant increased discomfort. Actual survival was 93 percent at 1 year but dropped sharply with longer follow-up times: to 79 percent at 17 months and 56 percent at 23 months.

The mortality risk for hemodialysis patients exceeds 20 percent per year, a risk similar to that for some types of cancer. Studies have shown that cancer patients overestimate their chances of survival.

The new study suggests that the same is true of hemodialysis patients. Although patients’ estimates of 1-year survival are accurate, their expectations of longer-term survival are much higher than their nephrologists’ predictions. The researchers call for “interventions to help providers communicate effectively with patients about prognosis” [Wachterman MW, et al. Relationship between the prognostic expectations of seriously ill patients undergoing hemodialysis and their nephrologists. JAMA Intern Med 2013; 173:1206–1214].