#191

Prognostication in Patients Receiving Dialysis

  • Matthew Hudson
  • Steven Weisbord MD
  • Robert Arnold MD

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Background     End stage renal disease (ESRD) is a highly prevalent and rapidly increasing condition.  While dialysis prolongs life in patients with ESRD, life expectancy remains only a third to a sixth as long as similar patients not on dialysis.  The overall one and five year mortality rates are 25% and 60%, respectively.  Approximately 20% of ESRD patient deaths occur after a decision to stop dialysis, highlighting the importance of discussions of prognosis and goals of care with this chronically ill population. This Fast Fact reviews the current 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    Several patient-specific factors influence prognosis:

  • 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 ³70 (see Fast Fact #13).
  • Albumin: a low serum albumin level, both at baseline and during the course of 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?”
     

Prognostic Tools    It has long been recognized that patient comorbidity is strongly correlated with prognosis in ESRD. An age-modified Charlson Comorbidity Index (CCI), which stratifies patients based on medical comorbidities and age, has been successfully used to predict mortality in dialysis-dependent patients (8):

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, 2006. Minneapolis, MN: USRDS Coordinating Center; 2006. Available at: http://www.usrds.org/2006/pdf/02_incid_prev_06.pdf.
  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.  Available at: http://jasn.asnjournals.org/cgi/content/full/11/7/1340.
  4. 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.
  5. 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.
  6. Owen WF, Price D. African-Americans on maintenance dialysis. Adv Ren Replace Ther. 1997; 4:3-12.
  7. Lowrie EG, Lew NL. Death risk in hemodialysis patients. Am J Kidney Dis. 1990; 15:458-482.
  8. 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.
  9. 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.
  10. 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.
  11. 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.
  12. 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 – references #8 and #9 were added and incorporated into the text.