To determine if a patient receiving hemodialysis newly diagnosed with a malignancy might benefit from aggressive cancer treatment, an oncologist colleague posed the following question to me: “What is the typical survival rate for end-stage kidney disease (ESKD) patients on dialysis?”
In general, survival rates for patients on dialysis are poor. Based on the United States Renal Data System (USRDS) report, the adjusted survival rate for patients on hemodialysis (HD) is 57% at 3 years after onset of ESKD as compared to 68% for patients receiving peritoneal dialysis (PD). The 5-year survival for patients receiving HD and PD is 42% and 52%, respectively. With deceased donor kidney transplantation, 3-year survival improves to 85%. For comparison, the general population survival rate (matched for age and sex) is 92-94%. 5-year survival for patients on long-term dialysis has been shown to be either longer or shorter than patients with cancer, depending on the type of malignancy in an Italian registry of patients on dialysis. (Figure 1).
The range of the expected life span in the United States Renal Data System (USRDS) report was approximately 8 years for patients on dialysis 40 – 44 years of age and approximately 4.5 years for those 60 – 64 years of age. Let’s take a look at a few factors that have been associated with survival of the dialysis population:
1. Patient Demographics
As expected, survival for patients on dialysis declines with increasing age. Males younger than 45 years do better than females within the same age group. However, males have a lower adjusted mortality rate once above the age of 65.
Mortality rates among different races are not constant at all age groups, but overall, Asian-Americans and African-Americans have a better survival rate as compared to Caucasian patients.
2. Dialysis Vintage
The mortality rate of patients with ESKD also depends on the time since initiation of dialysis. For hemodialysis patients, there is a drop in the mortality rate initially which reaches its lowest point during Year 2, after which it continually rises. In patients receiving PD, we do not see this dip, rather the rate increases after initiation.
Despite the decrease in mortality in patients on HD by year 2, the first 120 days remain a period of high risk for patients who are starting HD. This was reported by Robinson and colleagues who examined all-cause mortality rates from patients receiving HD using data from the ongoing Dialysis Outcomes and Practice Patterns Study (DOPPS). This “high-risk period” after dialysis initiation is not seen in patients receiving PD and may be a result of patient selection (for PD).
3. Burden of Cardiovascular Disease
Patients with ESKD have a significant burden of cardiovascular disease which is much higher than that of the general population. Coronary artery disease is the most common cardiac condition found in patients with ESKD patients, with CVD as the leading cause of death for patients receiving dialysis (Figure 2).
4. Dialysis Modality: HD vs PD
There is a lack of good data that supports one modality over the other.
Previous observational data had favored PD in terms of mortality in the first years of treatment – but after 2 years, the survival advantage switches to HD. This is explained by the better preservation of residual kidney function initially in patients receiving PD followed by the loss of ultrafiltration capacity in the later years. On the other hand, the inclusion of sicker patients and urgent starts may bias against HD early in the treatment course because they have a much higher initial mortality rate and these sicker patients are treated almost exclusively with HD. More recently, a cohort study showed no difference in survival between this patients.
In summary, overall mortality is 10-20 times higher than the general population for patients receiving dialysis. The risk is greatest during the first 3 months after starting dialysis. Annual mortality is around 9% per year with 40-50% 5-year survival. The main cause of death in patients receiving dialysis is cardiovascular disease, followed by infectious complications. Thus far, studies have shown comparable outcomes for HD and PD.
Post written by:
Dr. Aldo Rodrigo Jimenez Vega (@aldorodrigo)
Nephrology Fellow
Sinaloa, Mexico
Lots of hope out there for all. I’ve been leaving with one kidney since birth. Never knew it until 1974 when I tested for a job in New York. I’m turning 79 on the 23rd and feel great. I see my kidney doctor at the VA on November 7th… Wish me luck 🤞
My mother survived on dialysis when it was first approved to be covered by Medicare. She was 29 and sent home from the hospital to die. She lived until 62 dialysis 3 times a week the entire duration. No transplants. She passed away in 2003. She was vigilant about diet. She was diagnosed with ESR Failure at 18. She lived on 15% kidney function through diet and liquid restrictions for 11 years. I was born when she was 20.
Miriam I hope you are still living the good life. I ended up here looking for stats on people making it to 11 years on hemo. My twin started 2 weeks before I did but passed away in 4 years. I have had over 30 surgeries since I started dialysis, most of them had nothing to do with dialysis. I am working again as a Nanny for older kids and I cook and am on my feet 3-4 hours a day . None of my Drs or loved ones ever expected me to get here and be healthier than I was when I started. I will turn 56 soon. I plan on enjoying every extra day I have.
I didn’t really get my answer but I saw your post and it made me happy for you
Thank you Miriam for your note! And you’re correct there is a paucity of positive information about dialysis!
Miriam – thank you for your comment and for sharing your inspiring story with the nephrology community. As nephrologists, we are committed to doing better for our patients and innovating to improve outcomes. We hope to continue to improve the lives of kidney disease patients and are optimistic about the future!
While I know that your statistics are based on large groups of dialysis patients, I would like you and your fellow colleagues to know that some of us CKD5 folks on dialysis live a lot longer than you might expect. I, for example, have been on dialysis for 24 YEARS! I did 6 years of PD first, then 6 years of in-center HD, and 12 years (so far) of home HD. Lest you think my survival is due to no comorbidities, I have Type 1 diabetes, peripheral vascular disease, and have had a triple CABG, and aortic valve replacements, among other woes. I have never had a transplant.
I share this because I have encountered in my medical journey a tremendous amount of medical pessimism when it comes to CKD5, and no focus in the nephrology/dialysis industry on rehabilitation of any sort. i have bucked the statistical odds through the luck of having a few great doctors, by educating myself as much as possible, by exercising nearly every day, insisting on optimal dialysis, not the minimal standards accepted by for-profit business entities, and by challenging the assumptions that ESRD is automatically an END STAGE DEATH SENTENCE. I just turned 58 and I’m still going.
Excellent post
My only quibble: the author quotes the USRDS data with 5 year 42% survival quoted, but shows the figure 1 (which seems to have a higher 5 year survival of ~ 55%) . Fortunately the link is provided, which goes to https://www.ncbi.nlm.nih.gov/pubmed/22361043 which is an Italian registry data. Not USRDS!
For US cancer stats – the SEER registry provides easy to use and explore stats – see https://seer.cancer.gov/faststats/
eg for lung cancer, the 5 year survival (in US) is now just over 20%, stomach CA is now over 30% and so on.
Swapnil