Deaths, heart attacks remain high among Asian ESRF patients on dialysis

In Singapore, the high incidence of death and acute myocardial infarction (AMI) in the short term persists among patients with end-stage renal failure (ESRF) on different modalities of dialysis, reports a recent study.

“To our knowledge, this is one of the few studies in Southeast Asia looking at mortality and AMI outcomes in incident dialysis patients at a population-based level,” the researchers said. “It underscores the high incidence of mortality and acute coronary syndrome in ESRF patients in Singapore despite progress in clinical care, medications, and dialysis facilities.”

Data from a population-based database (National Registry Disease Offices) in Singapore were collected and analysed to examine the incidence and predictors of death and AMI in ESRF patients on dialysis.

All adult patients initiated on dialysis between 2007 and 2012 who were closely followed for the development of death and AMI until September 2014 were included. The researchers identified the predictors of mortality and AMI using Cox regression methods.

A total of 5,309 patients (mean age 61 years, 44 percent women, 67 percent Chinese ethnicity, 25 percent Malay, 7 percent Indian) were identified. Of these, 4,449 were on haemodialysis and 860 on peritoneal dialysis (PD). [Ann Acad Med Singap 2022;51:136-142]

The incidence of all-cause death by September 2014 was 34 percent, with nearly one-third of the patients dying from a cardiovascular cause. The following factors independently predicted all-cause mortality: older age (>60 years) and the presence of ischaemic heart disease (IHD), diabetes, stroke, peripheral vascular disease (PVD), and PD.

Patients on PD were less likely to survive than those on haemodialysis (hazard ratio, 1.51, 95 percent confidence interval, 1.35‒1.70; p<0.0001). Like all-cause death, AMI predictors included older age (>60 years) and the presence of IHD, diabetes, stroke, PVD, and smoking. Of note, no significant differences were seen in AMI incidence between patients on PD and haemodialysis.

“Findings of poorer outcomes of PD patients in Asian studies contrasts with most Western studies, which show no difference between the two modalities or better survival of PD in the initial period of dialysis initiation,” the researchers said. [Arch Intern Med 2011;171:110-118; BMC Nephrol 2015;16:179; Am J Kidney Dis 199;34:1065-1074; Nephrol Dial Transplant 2011;26:2940-2947]

“Furthermore, patients selected for PD may be those who are frailer, with cardiac comorbidity. Also, PD patients are reviewed less frequently by medical staff as PD is largely managed at home, when compared to dialysis patients who are reviewed more frequently by medical personnel when they get to dialysis centre,” they added. [PLoS One 2015;10:e0140195]

The current study had certain limitations. First, the reasons for selecting haemodialysis or PD could not be established in this retrospective analysis. Second, variables such as socioeconomic circumstances, frailty, nutrition status, and blood pressure, among others, were not available in the analysis. Finally, crossovers from PD to haemodialysis and vice versa were not considered in this study.

“Future studies should investigate the benefits of a tighter control of cardiovascular risk factors among ESRF patients on dialysis,” the researchers said.