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CLINICIAN'S CORNER
Cardiovascular and Noncardiovascular Mortality Among Patients Starting Dialysis
Dinanda J. de Jager, MSc;
Diana C. Grootendorst, PhD;
Kitty J. Jager, MD, PhD;
Paul C. van Dijk, PhD;
Lonneke M. J. Tomas;
David Ansell, PhD;
Frederic Collart, MD, PhD;
Patrik Finne, MD, PhD;
James G. Heaf, MD, DMSc;
Johan De Meester, MD, PhD;
Jack F. M. Wetzels, MD, PhD;
Frits R. Rosendaal, MD, PhD;
Friedo W. Dekker, PhD
JAMA. 2009;302(16):1782-1789.
Context Cardiovascular mortality is considered the main cause of death in patients receiving dialysis and is 10 to 20 times higher in such patients than in the general population.
Objective To evaluate if high overall mortality in patients starting dialysis is a consequence of increased cardiovascular mortality risk only or whether noncardiovascular mortality is equally increased.
Design, Setting, and Patients Using data from between January 1, 1994, and January 1, 2007, age-stratified mortality in a European cohort of adults starting dialysis and receiving follow-up for a mean of 1.8 (SD, 1.1) years (European Renal Association–European Dialysis and Transplant Association [ERA-EDTA] Registry [N = 123 407]) was compared with the European general population (Eurostat).
Main Outcome Measures Cause of death was recorded by ERA-EDTA codes in patients and matching International Statistical Classification of Diseases, 10th Revision codes in the general population. Standardized cardiovascular and noncardiovascular mortality rates, their ratio, difference, and relative excess of cardiovascular over noncardiovascular mortality were calculated.
Results Overall all-cause mortality rates in patients and the general population were 192 per 1000 person-years (95% confidence interval [CI], 190-193) and 12.055 per 1000 person-years (95% CI, 12.05-12.06), respectively. Cause of death was known for 90% of the patients and 99% of the general population. In patients, 16 654 deaths (39%) were cardiovascular and 21 654 (51%) were noncardiovascular. In the general population, 7 041 747 deaths (40%) were cardiovascular and 10 183 322 (58%) were noncardiovascular. Cardiovascular and noncardiovascular mortality rates in patients were respectively 38.1 per 1000 person-years (95% CI, 37.2-39.0) and 50.1 per 1000 person-years (95% CI, 48.9-51.2) higher than in the general population. On a relative scale, standardized cardiovascular and noncardiovascular mortality were respectively 8.8 (95% CI, 8.6-9.0) and 8.1 (95% CI, 7.9-8.3) times higher than in the general population. The ratio of these rates, ie, relative excess of cardiovascular over noncardiovascular mortality in patients starting dialysis compared with the general population, was 1.09 (95% CI, 1.06-1.12). Relative excess in a sensitivity analysis in which unknown/missing causes of death were regarded either as noncardiovascular or cardiovascular varied between 0.90 (95% CI, 0.88-0.93) and 1.39 (95% CI, 1.35-1.43).
Conclusion Patients starting dialysis have a generally increased risk of death that is not specifically caused by excess cardiovascular mortality.
Author Affiliations: Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands (Drs Grootendorst, Rosendaal, and Dekker and Mss De Jager and Tomas); ERA-EDTA Registry, Academic Medical Center, Department of Medical Informatics, Amsterdam, the Netherlands (Drs Jager and van Dijk); United Kingdom Renal Registry, Bristol (Dr Ansell); French-Speaking Belgium ESRD Registry, Bruxelles (Dr Collart); Finnish Registry for Kidney Disease, Helsinki (Dr Finne); Department of Nephrology, Copenhagen University Hospital at Herlev, Herlev, Denmark (Dr Heaf); Department of Nephrology, Dialysis and Hypertension, AZ Nikolaas, Sint-Niklaas, Belgium (Dr De Meester); and Department of Nephrology, Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands (Dr Wetzels).
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