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ORIGINAL ARTICLE
Year : 2014  |  Volume : 17  |  Issue : 2  |  Page : 43-46

Prevalence and risk factors associated with intradialysis mortality among renal failure patients in a tertiary hospital in a developing nation


1 Department of Medicine, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
2 Department of Medicine, Ahmadu Bello University Teaching Hospital, Shika, Zaria, Nigeria
3 Department of Medicine, Ibrahim Babangida Specialist Hospital, Minna, Nigeria
4 Department of Nursing, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria

Date of Web Publication13-Jun-2014

Correspondence Address:
Hamidu M. Liman
Department of Medicine, Usmanu Danfodiyo University and Teaching, Sokoto
Nigeria
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DOI: 10.4103/1118-8561.134471

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  Abstract 

Background: Hemodialysis is associated with potential risk of intradialysis death as a complication. We set out to determine some predialysis factors associated with intradialysis death in hemodialysis patients. Materials and Methods: We retrospectively reviewed the records of 457 patients who had hemodialysis at our facility over a 5-year period. Demographic and clinical data of patients who died during dialysis were compared with a control group made of the survivors of hemodialysis. Data was analyzed using SPSS IBM version 20. Numerical data were reported as mean ± SD. Comparison of means of continuous variables was done using student t-test. Chi square was used for comparing proportions. Multivariate logistic regression was done to determine the independent determinants of intradialysis mortality. P value < 0.05 was considered significant. Results: Of the 457 patients who had hemodialysis, 20 (4.4%) died while on hemodialysis during the review period. They were aged 47.35 ± 21.16 years (range, 16-85 years). The deceased were more likely to be elderly (P = 0.003), have pre dialysis hypotension (P < 0.004), depressed level of consciousness (P < 0.0001), predialysis pulmonary edema, and hospital admission (P = 0.047). Multivariate regression analysis identified low Glasgow coma scale (coma) as an independent risk factor for intradialysis death (P < 0.017). Conclusion: Intradialysis mortality risk is increased in a setting of elderly patients, impaired level of consciousness, pulmonary edema, and predialysis hypotension.

Keywords: Hemodialysis, intradialysis death, renal failure


How to cite this article:
Liman HM, Makusidi MA, Zagga MU, Nuhu S, Bosan IB, Umar IA, Sadeeq A, Idris K, Onyema P. Prevalence and risk factors associated with intradialysis mortality among renal failure patients in a tertiary hospital in a developing nation. Sahel Med J 2014;17:43-6

How to cite this URL:
Liman HM, Makusidi MA, Zagga MU, Nuhu S, Bosan IB, Umar IA, Sadeeq A, Idris K, Onyema P. Prevalence and risk factors associated with intradialysis mortality among renal failure patients in a tertiary hospital in a developing nation. Sahel Med J [serial online] 2014 [cited 2019 Oct 18];17:43-6. Available from: http://www.smjonline.org/text.asp?2014/17/2/43/134471


  Introduction Top


The incidence of end stage renal disease requiring renal replacement therapy is rising globally. [1] Intermittent hemodialysis as a form of renal replacement therapy remains one of the viable options in the management of patients with both severe acute kidney injury and end stage renal disease. However, like all other therapeutic interventions, it has potential complications, including death. [2] High incidence of intradialysis deaths has the potential of reducing staff morale, depress caregivers, and tarnish the image of a dialysis center.

Several studies have described some predictors of overall mortality in patients undergoing hemodialysis. [3],[4],[5] These factors include male gender, elevated serum lipids on admission, elderly patients, presence of extrarenal microangiopathy, arterial occlusive disease, and severe hypotension during hemodialysis. Similarly, the presence of diabetes mellitus, [6],[7],[8] hypertension, [9],[10] predialysis hypotension, [11],[12],[13] left ventricular hypertrophy, [14] malnutrition, [15],[16] and wide pulse pressure [17] have also been implicated in predicting mortality in dialysis patients.

There are limited data on intradialysis mortality in developing nations. We reviewed the clinical parameters of our patients who died while undergoing hemodialysis over a 5-year period in order to determine the factors that are associated with intradialysis mortality. The findings may provide a rational for therapeutic interventions that may potentially reduce the risk of intradialysis deaths.


  Materials and methods Top


A retrospective study of 457 patients who had hemodialysis was carried out. Demographic and clinical data were retrieved from the medical records of all deceased patients and the control group made of survivors of hemodialysis, selected using EXCEL generated random numbers.

Information retrieved included age, gender, occupation, type of renal failure, cause of renal disease, number of days from diagnosis to first dialysis (dialysis reaction time), number of dialysis sessions ever received, inpatient status at last dialysis, day and time of death, level of consciousness before the last dialysis, presence of pulmonary edema at last dialysis, last predialysis systolic and diastolic blood pressures, packed cell volume and serum potassium prior to last dialysis, duration on hemodialysis machine prior to death, and outcome of dialysis.

The data obtained was analyzed using IBM SPSS Version 20. Numerical data were reported as mean ± SD and compared using student t-test. Chi square was used for comparing proportions. Multivariate logistic regression was done to determine the variables that were independently associated with to intradialysis mortality. P value < 0.05 was considered significant.


  Results Top


Among 457 patients enrolled into the hemodialysis program, 20 (4.4%) patients aged 47.35 + 21.16 years (range 16-85) and made of 15 (75%) and 5 (25%) males and females, respectively, died during dialysis over the 5-year study period. Sixty five percent (65%) of them were gainfully employed. Only 15% of them were admitted on account of acute kidney injury (AKI). Fifty five percent (55%) of the patients died while receiving the first session of hemodialysis. The most common causes of renal disease in patients who died [Table 1] included hypertension (30%) and chronic glomerulonephritis (20%). All the patients (100%) were dialyzed using temporary femoral vascular access.
Table 1: Baseline characteristics of intradialysis deaths

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Most (30%) of the deaths occurred during the midweek (Wednesday followed by Friday, the last working day [20%]). There was equal distribution of death during the day time and night. The median time on dialysis before death was 120 minutes (range, 10-240 minutes).

Compared to the survivors, the deceased (patients who died during dialysis) [Table 2] were significantly older (P = 0.003) and had significantly worse impaired level of consciousness (as assessed by Glasgow coma scale) (P < 0.0001) and lower predialysis systolic and diastolic blood pressures (P < 0.004 and 0.009, respectively). The deceased also had significantly higher proportions of patients with predialysis pulmonary edema (P = 0.006).
Table 2: Factors associated with intradialysis deaths

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Multivariate logistic regression analysis [Table 3] however revealed that only low predialysis Glasgow coma scale (coma) had significant impact on intradialysis death (P < 0.017).
Table 3: Determinants of intradialysis mortality

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  Discussion Top


Our data showed that the intradialysis mortality rate at our facility is 4.4%. This is far below the 13% reported by Karnik et al., in a cohort of over 77,000 hemodialysis patients in the United States. [18] The difference may be explained by the relatively small volume of patients being handled by our center. Majority of the patients who died were gainfully employed and had chronic kidney disease with hypertension being the most frequent cause. This contrasts with the US population where the major cause of chronic kidney disease is from Diabetes Mellitus. [19] Vascular access was through temporary femoral catheter because of late presentation and the expertise of the medical staff. This compares with the findings of Ekpe et al.[20] who reported the utilization of temporary vascular access to commence dialysis in 95% of their patients. However, the double lumen internal jugular catheter is now recently favored as a temporary vascular access [21] while the Arteriovenous fistula remains the best option for patients who need chronic dialysis as it offers the best blood flow rate during dialysis. [22]

For reasons that are still unclear, most of the deaths occurred on Wednesday and Friday but with equal distribution between day time and night. This contrasts with the findings of Bleyer et al.[23] who found an increased risk of death of patients on Mondays and Tuesdays. They postulated that the deaths way have occurred from excessive fluid removal of fluid that may have accumulated over the previous weekend. Death was also more common midway into a dialysis session. Patients who died during dialysis were older than the control group. This compares with the findings of Koch et al. and Tatsuya et al.[3],[4] who reported higher risk of death in elderly patients on dialysis.

Patients who died during dialysis were more likely to have been connected with impaired level of consciousness. This compares with the findings of Ryan et al.[24] who also identified decreased Glasgow coma scale as a significant factor in mortality of patients with organ failure. Predialysis hypotension and predialysis pulmonary edema were also significant risk factors of intradialysis mortality. Predialysis hypotension has previously been shown to be a significant risk factor for death in dialysis patients. [11],[12],[13] Van Der Sande et al.[25] were able to demonstrate the usefulness of peritoneal dialysis as an alternative means of renal replacement therapy in patients with hypotension and heart failure. The risk of death during dialysis was also significantly higher during first session of hemodialysis (55% of all mortalities) and in patients whose illness requires hospitalization.

The duration of renal symptoms prior to first dialysis, dialysis reaction time, last interdialystic period, duration on dialysis therapy, and duration in care of Nephrologist did not appear to influence the risk of intradialysis death. This contrast with the findings of Kawaguchi et al.[26] who concluded that patient-doctor contact may improve clinical outcomes after studying the association between the frequency and duration of patient doctor contacts during dialysis treatments on clinical outcomes among 24,498 patients. The last predialysis hematocrit and the last predialysis serum potassium also did not appear to influence the risk of intradialysis death in our study. Anemia is an independent risk factor for mortality. [16] However, our center maintains a policy of accepting only patients with corrected anemia and this could explain the loss of impact of anemia in our study. Hyperkalemia is also known to provoke arrhythmias in hemodialysis patients. [27] However, the patients in our study presented with normal serum potassium prior to dialysis.

In conclusion, the risk of intradialysis mortality is increased in a setting of elderly patients, impaired level of consciousness, pulmonary edema, and predialysis hypotension. We recommend proper patient selection and preparation be done prior to dialysis to address the needs of patients who possess any of the identified risk factors. Proper education of caregivers on the identified risk factors needs to be done prior to dialysis, in order to reduce the psychological trauma of losing a loved one during the procedure.

 
  References Top

1.Meguid El Nahas A, Bello AK. Chronic kidney disease: The global challenge. Lancet 2005;365:331-40.  Back to cited text no. 1
    
2.Karnik JA, Young BS, Lew NL, Herget M, Dubinsky C, Lazarus JM, et al. Cardiac arrest and sudden death in dialysis units. Kidney Int 2001;60:350-7.  Back to cited text no. 2
    
3.Koch M, Thomas B, Tschope W, Ritz E. Survival and predictors of death in dialysed diabetic patients. Diabetologia 1993;36:1113-7.  Back to cited text no. 3
    
4.Tatsuya S, Yoshiharu T, Masamitsu F, Enyu M. Haemodialysis associated hypotension as an independent risk factor for two-year mortality in haemodialysis patients. Kidney Int 2004;66:1212-20.  Back to cited text no. 4
    
5.Iseki K, Miyasato F, Tokuyama K, Nishime K, Uehara H, Shiohira Y, et al. Low diastolic blood pressure, hypoalbuminaemia and risk of death in a cohort of chronic haemodialysis patients. Kidney Int 1997;51:1212-7.  Back to cited text no. 5
    
6.Ghavamian M, Gutch CG, Kopp KF, Kolff WJ. The sad truth about haemodialysis in diabetic nephropathy. J Am Med Assoc 1972;222:1386-9.  Back to cited text no. 6
    
7.Ritz E, Koch M. Renal failure in diabetic nephropathy. In: Cameron ST, Davison AM, Grunfeld JP, Kerr D, Ritz E, editors. Oxford textbook of clinical nephrology. Oxford: Oxford university press; 1992. p. 1635-76.  Back to cited text no. 7
    
8.Krolewski AS, Canessa M, Warram JH, Laffel LM, Christlieb AR, Knowler WC, et al. Predisposition to hypertension and susceptibility to renal disease in insulin-dependent diabetes mellitus. N Engl J Med 1988;318:140-5.  Back to cited text no. 8
    
9.Charra B, Calemard E, Ruffet M, Chazot C, Terrat JC, Vanel T, et al. Survival as an index of adequacy of dialysis. Kidney Int 1992;41:1286-91.  Back to cited text no. 9
    
10.Jacobs C. Medical management of the dialysis patients. In: Davidson A, Cameron J, Grundfeld J, Editors. In Oxford Textbook of clinical Nephrology, 2 nd ed. Vol 3. New York: Oxford University press; 1998. p. 2089-111.  Back to cited text no. 10
    
11.Zager PG, Nikolic J, Brown RH, Campbell MA, Hunt WC, Peterson D, et al. U curve association of blood pressure and mortality in haemodialysis patients. Medical Directors of Dialysis Clinics Inc. Kidney Int 1998;54:561-9.  Back to cited text no. 11
    
12.Port FK, Hulbert-Shearon TE, Wolfe RA, Bloembergen WE, Golper TA, Agodoa LY, et al. Predialysis blood pressure and mortality risk in a national sample of maintenance haemodialysis patients. Am J Kidney Dis 1999;33:507-17.  Back to cited text no. 12
    
13.Foley RN, Parfrey PS, Harnett JD, Kent GM, Murray DC, Barre PE. Impact of hypertension on cardiomyopathy, morbidity and mortality in end-stage renal disease. Kidney Int 1996;49:1379-85.  Back to cited text no. 13
    
14.Silberberg JS, Barre PE, Prichard SS, Sniderman AD. Impact of LVH on survival in end-stage renal disease. Kidney Int 1989;36:286-90.  Back to cited text no. 14
    
15.Degoulet P, Legrain M, Réach I, Aimé F, Devriés C, Rojas P, et al. Mortality risk factors in patients treated by chronic haemodialysis. Nephron 1982;31:103-10.  Back to cited text no. 15
    
16.Lowrie EG, Lew NL. Death risk in haemodialysis patients: The predictive value of commonly measured variables and an evaluation of death rate differences between facilities. Am J Kidney Dis 1990;15:458-82.  Back to cited text no. 16
    
17.Held PJ, Brunner F, Odeka M, Garcia JR, Port FK, Gayhn DS. Five-year survival for end stage renal disease in patients in the United States, Europe and Japan, 1982 - 1987. AM J Kidney Dis 1990;15:452-7.  Back to cited text no. 17
    
18.Karnik JA, Young BS, Lew NL, Herget M, Dubinsky C, Lazarus JM, et al. Cardiac arrest and sudden death in dialysis units. Kidney Int 2001;60;350-7.  Back to cited text no. 18
    
19.Brancati FL, Whittle JC, Whelton PK, Seidler AJ, Klag MJ. The excess incidence of diabetic endstage renal disease among blacks: A population-based study of potential explanatory factors. JAMA 1992;268:3079-84.  Back to cited text no. 19
    
20.Ekpe EE, Ekirikpo U. Challenges of vascular access in a new dialysis centre-Uyo experience. Pan Afr Med J 2011;7;23-7.  Back to cited text no. 20
    
21.Arogundade FA, Sanusi AA, Badmus TA, Ibrahim A, Akinsola A. Internal jugular and subclavian catheterisation: Indications, problems and prospects in a nigerian dialysis centre. Niger Postgrad Med J 2006;13:26-30.  Back to cited text no. 21
    
22.Burkhart HM, Cikrit DF. Arteriovenous fistula for haemodialysis. Semin Vasc Surg 1997;10:162-5.  Back to cited text no. 22
    
23.Bleyer AJ, Russell GB, Satko SG. Sudden cardiac death rates in haemodialysis patients. Kidney Int 1999;55;1553-9.  Back to cited text no. 23
    
24.Ryan TA, Rady MY, Bashour CA, Leventhal M, Lytle B, Starr NJ. Predictors of outcome in cardiac surgical patients with prolonged intensive care stay. Chest 1997;112:1035-42.  Back to cited text no. 24
    
25.Van Der Sande FM, Cnossen TT, Cornelis T, Konings CJ, Kooman JP, Leunissen KM. Peritoneal dialysis in patients with heart failure. Minerva Urol Nefrol 2012;64:163-72.  Back to cited text no. 25
    
26.Kawaguchi T, Karaboyas A, Robinson BM, Li Y, Fukuhara S, Bieber BA, et al. Associations of frequency and duration of Patient-Doctor contact in Haemodialysis Facilities with Mortality. J Am Soc Nephrol 2013;24:1493-502.  Back to cited text no. 26
    
27.Santoro A, Mancini E, Gaggi R, Cavalcanti S, Severi S, Cagnoli L, Badiali F, Perrone B, London G, Fessy H, Mercadal L and Grandi F. Electrophysiological response to dialysis: The role of dialysate potassium content and profiling. In: Ronco C, Brendolan A, Levin NW, editors. Cardiovascular disorders in haemodialysis. Vol. 149, Contrib Nephrol. Basel: Karger; 2005. p. 295-305.  Back to cited text no. 27
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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