Early withdrawal and non‐withdrawal death in the months following hemodialysis initiation: A retrospective cohort analysis

Abstract

Introduction: Whether and how factors associated with elective hemodialysis withdrawal differ from those associated with non‐withdrawal death soon after maintenance hemodialysis initiation have not been well studied. Methods: A retrospective cohort analysis was performed using USRDS data from 2011 to 2014. Patients were randomly categorized 2:1 into training and validation samples. Elective withdrawal deaths were identified using the Death Notification form. Multinomial logistic regression was used to fit a prediction model for three outcome categories (withdrawal, non‐withdrawal death, survival at 6 months) as a function of demographic, comorbidity, and functional status. Findings: The training sample comprised 80,284 hemodialysis patients. Mean age was 71.7 ± 11.4 years, 44.9% were female, 72.9% were white, and 22.8% were black. Within 6 months, 19.1% died, of whom 2099 (2.6%) withdrew and 13,223 (16.5%) died of a non‐withdrawal cause; 13.7% of all deaths were withdrawals. Baseline characteristics and event rates were similar among the 40,142 patients in the validation sample. The model was calibrated adequately and could discriminate moderately well between withdrawal and survival (area under ROC curve [AUC]: 0.77) and between non‐withdrawal death and survival (AUC: 0.73). However, discrimination between withdrawal and non‐withdrawal death was relatively low (AUC: 0.62). Older age and white, compared with non‐white, race were each associated with greater odds of death, and these associations were stronger for withdrawal than for non‐withdrawal death. Discussion: Advanced age and white, as opposed to black, race were most strongly associated with early elective hemodialysis withdrawal compared with non‐withdrawal death. However, it is difficult to differentiate between patients who will experience early withdrawal vs. non‐withdrawal death, as many factors are similarly associated with both outcomes.

Temporal changes and risk factors for death from early withdrawal within 12 months of dialysis initiation—a cohort study

“…Caucasians have been reported to have a greater risk of dialysis withdrawal attributed to social supports and cultural acceptance of treatment withdrawal [ 24 , 42 ]. Although our study showed similar findings, it is difficult to ascertain the correlation due to the high proportion (70%) of Caucasian dialysis patients in Australia, which was also observed in other dialysis withdrawal studies [ 6 , 13 , 24 ]. In many non-Western countries, dialysis initiation and withdrawal may not be based on patients’ preferences, due to systemic differences in dialysis resources, palliative care access and ethico-legal regulations [ 43 , 44 ].…”

“…Early mortality after dialysis initiation is known to be high [ 10–12 ]. A recent US Renal Data System (USRDS) registry study suggested that the risk factors associated with death from dialysis withdrawal were similar to other causes of death within 6-month post-initiation of haemodialysis (HD) [ 13 ]. Risk factors associated with death from cause-specific withdrawals have not been studied previously.…”

Changing landscape of dialysis withdrawal in patients with kidney failure: Implications for clinical practice

“…Figure 1 and Table 1 provide a summary of the definitions of dialysis withdrawal classified by the reasons for withdrawal and causes of death. Country‐specific registry studies often define dialysis withdrawal by reasons for withdrawal, irrespective of the underlying cause of death by kidney failure or comorbid conditions, 5,23–32 with the exception of the United States Renal Data System 2,33–36 . Dialysis withdrawal is classified as per reporting personnel in registries, and the risk of misclassification and oversimplification is high, especially when only a single cause of death is reported without the details of death.…”

“…United States Renal Data System (USRDS) Wetmore et al, 2018 33 Wetmore et al, 2019 34 Wetmore et al, 2020 35 Roberts et al, 2021 36 …”

“…Country-specific registry studies often define dialysis withdrawal by reasons for withdrawal, irrespective of the underlying cause of death by kidney failure or comorbid conditions, 5,[23][24][25][26][27][28][29][30][31][32] with the exception of the United States Renal Data System. 2,[33][34][35][36] Dialysis withdrawal is classified as per reporting personnel in registries, and the risk of misclassification and oversimplification is high, especially when only a single cause of death is reported without the details of death. The main outcomes examined are temporal trends and risk factors for dialysis withdrawal which have implications on recourse allocation and healthcare strategies.…”