Background for FF #191     End stage renal disease (ESRD) is highly prevalent.  While dialysis prolongs life in patients with ESRD, life expectancy remains only a third to a sixth as long as similar patients without ESRD.  The overall one- and five-year mortality rates for patients on dialysis are 25% and 60%, respectively. Approximately 20% of ESRD-related deaths occur after a decision to stop dialysis, highlighting the importance of prognosis and goals of care discussions in this patient population. This Fast Fact reviews data regarding prognostication in patients receiving chronic hemo- and peritoneal dialysis.  Note: renal transplantation reduces mortality, and the following data do not consider patients with functioning kidney transplants.

Prognostic factors   The average life expectancy of patients on hemodialysis has been estimated to be 8.8 years, with an expected years of life lost (EYLL) estimated to be 11.5 years. Patients receiving peritoneal dialysis may live longer (average life expectancy 19.9 years and EYLL of 7.4 years) but the difference could be explained by selection factors based on matched control research. Regardless, many patients have lived 20 or even 30 years on dialysis.  Hence, there is quite a range.  Several patient-specific factors influence prognosis for patients on dialysis: 

• Age:  For 1-year increments beginning at age 18, there is a 3 to 4% increase in annual mortality compared to the general population.  1- and 2-year mortality rates go from 10 and 12% at 25-29 years of age, to 25% and 42% at 65-69 years, to 39% and 61% at 80-84 years of age.
• Functional status: the relative risk of dying within 3 years of starting dialysis is 1.44 for those with Karnofsky Performance Status scores of <70 compared to a score 70 (see Fast Fact #13).
• Frailty is common among patients older than 60 who are receiving hemodialysis – prevalence rate of 34.7% — and has been independently associated with a significantly increased risk of death in a year (20%) among patients older than 60.
• Albumin: a low serum albumin level, both at baseline and during dialysis treatment, is a consistent and strong predictor of death. For example, the 1- and 2-year survival of patients with an albumin of >3.5 g/dL is 86% and 76% respectively, compared to 50% and 17% if less than 3.5.
• Surprise question: in a multivariate analysis, the likelihood of death in 6 months was significantly greater when nephrologists answered no to the question “would I be surprised if this patient died within 6 months?”
• Comorbidities are strongly correlated with prognosis in ESRD. See prognostic tools below. 

Prognostic tools   An age-modified Charlson Comorbidity Index (CCI), which stratifies patients based on medical comorbidities and age, can predict mortality in dialysis-dependent patients (8):

Modified Charlson Comorbidity Index:  Total score is the sum of the comorbidity points

For example, a 66-year-old male on dialysis with a history of CHF, COPD, and diabetes with retinopathy would have a CCI score of 9 and a nearly 50% chance of dying within a year.  Using this, a provider could discuss with the patient his prognosis and use this to facilitate further discussion regarding planning for the future, including end-of-life decisions.  The Index of Coexistent Disease (ICED), a general illness severity index, has also shown predictive power in ESRD.   The scale’s complexity and length however, (it entails asking over 100 questions) limit its clinical usefulness.

Summary     The age-modified CCI, in conjunction with other prognostic factors such as serum albumin and functional status, can be used to help facilitate discussions with dialysis-dependent patients and their families regarding goals of care and end-of-life planning.

References: 

1. United States Renal Data System. Incidence and prevalence. Annual data report, 2024. Minneapolis, MN: USRDS Coordinating Center; 2024. Available at: Annual Data Report | USRDS.
2. Cohen LM, Moss AH, Weisbord SD, Germain MJ. Renal palliative care. J Pall Med. 2006; 9:977-992.
3. Renal Physicians Association and American Society of Nephrology. Clinical Practice Guideline on Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis. Washington, DC: Renal Physicians Association, 2000; 11(7):1340-2.
4. Kao T-W, Huang J-W, Hung K-Y, et al.  Life expectancy, expected years of life lost and survival of hemodialysis and peritoneal dialysis patients.  JN Journal of Nephrology 2010; 23(6):677-682/.
5. Moss AH. Revised dialysis clinical practice guideline promotes more informed decision-making.  Clin Ja Am Soc Nephrol 2010; 5(12):2380-3.
6. Ifudu O, Paul HR, Homel P, Friedman EA. Predictive value of functional status for mortality in patients on maintenance hemodialysis. Am J Nephrol. 1998; 18:109-116.
7. Li Y, Zhang D, Ma Q, et al.  The impact of frailty on prognosis in elderly hemodialysis patients: a prospective cohort study.  Clinical Interventions in Aging 2021; 16:1659-67.
8. Owen WF, Lew NL, Yiu Y, Lowry EG, Lazarus JM. The urea reduction ratio and serum albumin concentration as predictors of mortality in patients undergoing hemodialysis. NEJM. 1993; 329(14):1001-1006.
9. Cohen LM, Ruthazer R, et al.  Predicting six-month mortality for patients who are on maintenance hemodialysis. Clin J Am Soc Nephrol 2010;5:72-79.
10. Beddhu S, Bruns FJ, Saul M, Seddon P, Zeidel ML. A simple comorbidity scale predicts clinical outcomes and costs in dialysis patients. Am J Med. 2000; 108:609-613.
11. Miskulin DC, Martin AA, Brown R, et al. Predicting 1-year mortality in an outpatient hemodialysis population: a comparison of comorbidity instruments. Nephrol Dial Transplant. 2004; 19:413-420.
12. Moss AH. A new clinical practice guideline on initiation and withdrawal of dialysis that makes Explicit the role of palliative medicine.  J Palliat Med. 2000; 3:253-260.
13. Nicolucci A, Cubasso D, Labbrozzi D, et al. Effect of coexistent diseases on Survival of patients undergoing dialysis. ASAIO J. 1992; 38:M291-M295.

Version History:  Originally published October 2007.  Version re-copy-edited in May 2009; then again in July 2015; then again in February 2025.
Conflicts of Interest: None to report.