Mortality from Early Dialysis Withdrawal: Trends and Risk Factors

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Early dialysis withdrawal consistently accounts for about one-third of early deaths in the year after dialysis initiation, concludes an Australian study in Nephrology Dialysis Transplantation.

The researchers analyzed data on 32,274 patients initiating dialysis in Australia between 2005 and 2018, drawn from the Australian and New Zealand Dialysis and Transplant Registry. Early deaths (within 12 months) from dialysis withdrawal attributed to psychosocial or medical reasons were analyzed, including trends over time and associated risk factors.

Overall, 11% of patients died within 12 months after dialysis initiation. Twenty-two percent of these early deaths were ascribed to early withdrawal due to medical reasons and 14% due to psychosocial reasons. The proportion of deaths from early withdrawal remained unchanged during the study period, with a range from 33% to 38% per year. However, incidence rates of early withdrawal-related mortality decreased from 5.3 per 100 person-years in 2006 to 3.1 per 100 in 2018.

In both categories of early withdrawal, risk factors for early mortality included older age, central venous catheter access, late referral, and cerebrovascular disease. Underweight and high socioeconomic status were risk factors for early psychosocial withdrawal, whereas peripheral vascular disease, chronic lung disease, and cancer were risk factors for early medical withdrawal. Center-level factors were not associated with death related to early withdrawal.

Dialysis withdrawal is a major contributor to the high risk of death in the first year after dialysis initiation. International registry data have suggested upward trends in the proportion of deaths in incident dialysis patients attributed to early withdrawal.

These Australian data show no significant change in the percentage of early deaths from dialysis withdrawal over the past two decades. Early deaths from medical withdrawals exceed those from psychosocial withdrawals.

Similar risk factors apply to both types of early withdrawal-associated mortality. The researchers conclude: “Recognising the patient at-risk of early mortality attributed to dialysis withdrawal may better inform the shared decision-making process, empower patient-focused treatment choices, and facilitate advanced care planning” [Chen JHC, et al. Temporal changes and risk factors of death from early withdrawal within 12 months of dialysis initiation—A cohort study. Nephrol Dial Transpl, published online ahead of print June 27, 2021. doi: 10.1093/ndt/gfab207;].