Can we improve early mortality in patients receiving renal replacement therapy?

Background Approximately one in eight patients with endstage renal disease (ESRD) die within the first three months of starting renal replacement ther apy (RRT). We investigated which factors might improve this early mortality . Methods. We performed a prospective nationwide study of all patients commen cing RRT for ESRD in Scotland over one year. Patients were classified accor ding to how they presented to start RRT, their burden of comorbid diseases, access prepared for dialysis, and duration of care by a nephrologist prior to commencing RRT. Those factors most strongly associated with death withi n 90 days of commencing treatment were determined by logistic regression an alysis. Results. Patients with an acute unexpected element to their presentation fo r RRT had early mortality rates between 6.0 and 8.9 times greater than thos e who commenced RRT electively after a period of care from a nephrologist. Patients in high and medium comorbidity risk groups had early mortality rat es of 4.7 and 2.2 times greater than those in the low-risk group. Low serum albumin had a significant association with early death. Patients who progr essed steadily to ESRD, who had a planned start to dialysis, and who had ma ture access were 3.6 times more likely to survive beyond three months than those with no access; they were, however, also younger with less comorbidit y. Conclusions. The factors principally associated with early mortality are no nelective presentation for RRT, comorbid illness, and low serum albumin. Pa tients cared for by a nephrologist before requiring RRT who have mature acc ess have better short-term survival than those without access. They are als o younger with less comorbidity. It may be possible to improve short-term s urvival in this "unplanned" group if referred early to facilitate reducing cardiovascular risk factors and preparation for RRT.