Results of Treatment of Center Hemodialysis Patients

WILLIAM J. JOHNSON, M.D. , STEPHEN B. KURTZ, M.D. , JOHN C. MITCHELL I I I , M.D. , CHRISTIAN J. VAN DEN BERG, M.D. , DANIEL N. WOCHOS, M.D. , Division of Nephrology and Internal Medicine; WILLIAM M. O'FALLON, Ph.D., Department of Medical Statistics and Epidemiology; SYLVESTER STERIOFF, M.D. , Section of Transplantation Surgery, Department of Surgery

Four hundred eighty-three patients were maintained by hemodialysis in an outpatient hemodialysis center at the Mayo Clinic between 1963 and 1977. Although only 18 patients had experienced a myocardial infarction and 6 had had a cerebral infarction before beginning dialysis, 30 subsequently had acute myocardial infarction and 45 had a stroke. These two complications accounted for 48 of the 98 deaths that occurred during maintenance dialysis. Despite such complications, 183 patients were employed, 124 remained active at home or at school, and 115 were totally disabled. Survival of patients maintained solely by dialysis was 52% at 5 years. For the group as a whole, including patients who received their first allograft, the survival rate at 5 years was 65%.

Long-term intermittent dialysis in the treatment of chronic irreversible renal failure was initiated at the Mayo Clinic in 1963. Initially, only young patients with primary renal disease and without complications that involved other vital organs were accepted for treatment. After the early 1970s, patients were accepted regardless of age or the presence of extrarenal complications, and only those with rapidly progressive metastatic malignant lesions were excluded. Questions remain about the dura-tion of life, the complications encountered, and the rehabilitation achieved in patients maintained by means of hemodialysis in an institutional setting. This report includes all patients who began hemodialysis treatment between Aug. 1, 1963, and Dec. 3 1 , 1977, and were maintained at the Mayo Artificial Kidney Center.

MATERIAL AND METHODS Patients maintained by peritoneal dialysis, transients who were not under our long-term supervision, and patients who had only a few hemodialysis treatments in preparation for renal transplantation but were not rou-tinely maintained in our unit were excluded from this study. We also excluded patients who were maintained by dialysis while being trained for home hemodialysis because the results in that group have been reviewed in another report.1

The techniques of hemodialysis were essentially the same as those described for home hemodialysis.1 Blood tests were performed monthly. The patients had a con-sultation with a physician at the time of each hemo-

dialysis and were examined at least twice a year. An annual complete physical examination included appro-priate tests for cardiovascular complications, iron defi-ciency or iron overload, and progressive renal osteo-dystrophy. Survival rates were calculated by using the Kaplan-Meier method.2 Rehabilitation was determined during the period after stabilization on dialysis and before the first renal transplantation. For patients with failed renal grafts in whom dialysis was resumed, rehabilitation was determined at the time of last follow-up.

RESULTS Four hundred eighty-three patients (187 female and 296 male patients) were maintained by hemodialysis in our outpatient center. All but 17 of these patients (7 Blacks and 10 patients from other races) were Caucasians. The mean age of the patients was 41 years (range, 8 to 80 years). The diagnostic categories of the renal disease are listed in Table 1. In addition to the 65 patients with primary diabetic nephropathy, 17 patients had late-onset diabetes mellitus in conjunction with other forms of renal disease.

The mean ( ± standard deviation [SD]) of the highest blood urea concentration before the onset of dialysis was 250 ± 100 mg/dl (range, 61 to 668 mg/dl), and the mean of the highest plasma creatinine concentration was 14.5 ± 5.2 mg/dl (range, 1.2 to 37 mg/dl). The lowest values for urea and creatinine were noted in patients with geni-tourinary malignant lesions in whom dialysis had been initiated immediately after total nephrectomy.

Mayo Clin Proc 59:669-671, 1984 669

670 CENTER HEMODIALYSIS Mayo Clin Proc, October 1984, Vol 59

Table 1.—Diagnoses of Renal Disease*

Patients

Diagnostic category No.

Glomerular disease Tubulointerstitial disease Diabetic nephropathy Cystic disease Nephrosclerosis Congenital anomaly Genitourinary malignant lesion Other Unknown

Total

206 69 65 41 37 12 7

27 19

483

42.6 14.3 13.5 8.5 7.7 2.5 1.4 5.6 3.9

100.0

•Histologie diagnosis in 72% of patients.

Before beginning dialysis, some patients had already had a substantiated acute myocardial infarction (3.7%) or a stroke (1.2%). Sixty-five patients (13.5%) had severe hypertension in the sense that the diastolic blood pres-sure remained elevated above 100 mm Hg despite anti-hypertensive treatment and extracellular volume con-traction after three dialysis treatments. Twenty patients (4.1 %) had extrarenal malignant processes other than the genitourinary malignant lesions listed in Table 1.

After institution of hemodialysis, atherosclerotic com-plications became apparent in a large proportion of the patients. One hundred fourteen patients (23.6%) had manifestations of coronary artery disease, as summarized in Table 2. A smaller proportion of patients had cerebral ischemic episodes, symptomatic peripheral vascular dis-ease, or aortic aneurysms.

Pericarditis developed in 16 patients (3.3%), usually during the first month of dialysis or in association with surgical trauma, infection, or a prolonged interval be-tween dialysis treatments. In 12 patients (2.5%), hepatitis (positive for hepatitis B surface antigen) developed, and 13 patients had abnormal results of liver function tests without a positive test result for hepatitis B.

Table 2.—Atherosclerotic Complications Among the 483 Patients Maintained by Center Hemodialysis*

Complication

Diagnosed before dialysis Myocardial infarction Cerebral infarction Severe hypertension

Diagnosed after dialysis Angina pectoris Cardiac failure (digoxin requi Acute myocardial infarction

ί red)

Arrhythmia (other than extrasystoles) Cerebrovascular accidents Peripheral vascular disease Aortic aneurysm

Patients

No.

18 6

65

68 49 30 46 45 49

6

%

3.7 1.2

13.5

14.1 10.1 6.2 9.5 9.3

10.1 1.2

During the period in which the patients were being maintained by hemodialysis, 179 patients (37.1 %) were employed full time, 124 (25.7%) were active at home or at school, and only 115 (23.8%) were disabled (Table 3). Sixty-five patients (13.5%) changed occupations after beginning dialysis.

Table 3.—Rehabilitation of Patients Maintained by Center Hemodialysis

Patients

No. %

Full-time employment Part-time employment (<35 h/wk) Unemployed, able to work (housewife) Student Retired Totally disabled Unknown

Total

179 4 84 40 46 115 15

483

37.1 0.8 17.4 8.3 9.5 23.8 3.1

100.0

After beginning dialysis, 17 patients (3.5%) were di-vorced or separated. Nine (1.9%) reported major psy-chiatric problems in a spouse, and five (1.0%) reported major adjustment problems in children.

Of the 483 patients, 314 (65%) received renal allo-grafts. Of these patients, 50% underwent transplantation within 3 months and 75% within 9 months after initiation of hemodialysis, inasmuch as 70% of the 314 patients were recipients of grafts from living related donors. Two hundred thirty-nine patients (76.1%) had functioning grafts at the time of last follow-up, and two patients had recovered renal function and were no longer on main-tenance dialysis.

The causes of death in patients remaining on hemodi-alysis at the time of last follow-up are listed in Table 4. Deaths were due to cardiopulmonary complications and strokes in 49.0% of patients and to infections in 20.4%.

Table 4.—Causes of Death in Patients Maintained by Center Hemodialysis

Cause

Cardiopulmonary Infection Stroke Hemorrhage Malignant lesion Suicide Liver disease Other Unknown

Total

No.

41 20

7 7 3 2 1 5

12 98

Patients

%

41.8 20.4

7.1 7.1 3.1 2.1 1.0 5.1

12.3 100.0

•Some patients had more than one complication.

The duration of survival from the time of first hemo-dialysis to death or last follow-up is illustrated in Figure 1. The curve for group A depicts survival of patients, in-

Mayo Clin Proc, October 1984, Vol 59 CENTER HEMODIALYSIS 671

Percent surviving

100

so

eo

40

20

S Qroup A: from first dialysis to ^ dealt) or last foHow-up

"W Qroup B: from first dialysis to death. — ^ ^ ^ _ last foHow-up. or transplant

" V ^ * - * * ^ - ^ Qroup A (N=4»3|

- \ ^ ^ " - M K »

' (14) Oroup B (N=4S3I

—

1 I I I 1 1

0 1 2 3 4 5 6

Years from first dialysis

Fig. 1. Survival of center hemodialysis patients.

eluding those who received their first renal transplant; however, in the curve for group B, the effect of renal transplantation is cancelled. Patients maintained solely by intermittent hemodialysis experienced a survival rate of 52% at 5 years. For the group as a whole (group A), including those patients who received their first allograft, the survival rate was 65% at 5 years.

DISCUSSION The results of this study in many respects are in agreement with other reports of rehabilitation, morbidity, and mor-tality among patients maintained in outpatient hemo-dialysis centers in the United States.3"6 They differ in that the mean age of the patients in our group was lower and a much smaller percentage of Blacks was included in our study.3 The percentage of patients with diabetes in our series was similar to that of other reports during the same period.5·6

The results of this study differ in minor respects from those available from the European Dialysis and Trans-plantation Registry of 1977.7 Overall 5-year survival of patients maintained by hospital dialysis was 54.1 ± 0.4% in Europe compared with our survival rate of 52% for patients maintained solely by center hemodialysis. Overall results of rehabilitation in Europe were 30.9% for full-time employment and 24.5% for part-time employ-ment compared with 3 7 . 1 % and 0.8%, respectively, in our series. Ofthe European patients, 12.5% were retired, 20.1 % were unable to work but able to be active at home when not on dialysis, and 2.5% required the equivalent of hospital care. The proportion of patients medically unfit for work was 22.6% for all hospital dialysis patients, irrespective of the patient's former occupation. These results are similar to our findings, albeit differences ex-

isted in socioeconomic factors and terminology. For example, in the current series, the term "totally disabled" simply meant that the patient was medically unfit for employment and was receiving disability insurance, so-cial security income, or welfare benefits and residing at home. Most of these patients were active and able to care for their personal needs at home.

There is some evidence that European patients were more carefully selected than those in the United States during the 1960s and 1970s.8 During this period, 204 patients per mill ion population in the United States8 and 87 per mill ion in the Upper Midwest9 underwent dialysis compared with 73 per mil l ion in Europe.8

The relatively low number of patients on maintenance dialysis in our region compared with the United States as a whole is related to the fact that a substantial percentage of patients (45% or 39 per mill ion in 1977) underwent renal transplantation.9 In our current series, 65% ofthe patients maintained by center dialysis received trans-plants, of which 70% were from living related donors. Generally, patients younger than 45 years of age, in-cluding those with diabetes, were selected for transplan-tation, only highly selected patients 45 to 60 years of age who were free of major complications were accepted for transplantation, and patients older than 60 years of age remained on dialysis. Selection of the low-risk patients for renal transplantation and leaving higher risk and older patients on dialysis contributed to the somewhat lower survival rates in this series compared with the European experience and also, at least in part, accounted for the lower survival rate of patients who never received a transplant (group B, Fig. 1).

REFERENCES 1. Johnson WJ, Kurtz SB, Anderson CF, Mitchell JC III, Zincke H,

O'Fallon WM: Results of treatment of renal failure by means of home hemodialysis. Mayo Clin Proc 59:663-668, 1984

2. Kaplan EL, Meier P: Nonparametric estimation from incomplete observations. J Am Stat Assoc 53:457-481, 1958

3. Vollmer WM, Wahl PW, Blagg CR: Survival with dialysis and transplantation in patients with end-stage renal disease. N Engl J Med 308:1553-1558, 1983

4. Krakauer H, Grauman JS, McMullan MR, Creede CC: The recent U.S. experience in the treatment of end-stage renal disease by dialysis and transplantation. N Engl J Med 308:1558-1563, 1983

5. Blagg CR, Wahl PW, Lamers JY: Treatment of chronic renal failure at the Northwest Kidney Center, from 1960-1982. Am Soc Artif Intern Organs 6:170-175, 1983

6. Shapiro FL, Urnen A: Risk factors in hemodialysis patients sur-vival. Am Soc Artif Intern Organs 6:176-184, 1983

7. Wing AJ, Brunner FP, Brynger H, ChantlerC, Donckerwolcke RA, Gurland HJ, Hathway RA, Jacobs C, Seiwood NH: Combined report on regular dialysis and transplantation in Europe, VIII, 1977. Dial Transplant Nephrol 15:4-76, 1978

8. Relman AS, Rennie D: Treatment of end-stage renal disease: free but not equal (editorial). N Engl J Med 303:996-998, 1980

9. Annual Report: End-Stage Renal Disease Program, Network 7, 1978