What are the best management strategies to reduce mortality rates in patients with End-Stage Renal Disease (ESRD) undergoing dialysis?

Mortality Rates in Dialysis Centers

Dialysis centers should expect annual mortality rates of 17-20% for hemodialysis patients, with cardiovascular disease and infections being the leading causes of death. 1, 2

Expected Mortality Benchmarks

Overall Mortality Rates

• Annual mortality for hemodialysis patients in the United States ranges from 17-20%, with the HEMO Study reporting 17% and general U.S. data showing 20% per year 1
• For elderly patients (≥70 years), first-year mortality approaches 20% 2
• Three-year and five-year survival rates are only 55% and 40% respectively, even with dialysis 3
• Post-acute myocardial infarction, dialysis patients face approximately 75% mortality within 2 years 1

Comparative International Data

• Japanese dialysis centers achieve annual mortality rates below 10%, suggesting substantial room for improvement in U.S. outcomes 1
• This survival advantage persists even after adjusting for patient selection and comorbidity differences through DOPPS analyses 1
• Genetic factors may partially explain Asian patients' enhanced survival, whether treated in the U.S. or Japan 1

Primary Causes of Death

Leading Mortality Drivers

• Cardiovascular disease accounts for the majority of deaths, with acute coronary syndromes carrying particularly poor prognosis 1
• Infections represent 45% of deaths in some dialysis populations 4
• Cerebrovascular accidents and other cardiac diseases beyond coronary artery disease contribute significantly 1

Modifiable Factors Affecting Center-Specific Mortality

Dialysis Adequacy

• Facility-to-facility differences in delivered dialysis dose directly correlate with mortality rates 5
• Centers with higher average urea reduction ratio (URR) demonstrate significantly lower adjusted mortality (P = 0.009) 5
• The minimum adequate single-pool Kt/V of 1.2 for thrice-weekly dialysis must be maintained, though U.S. centers average 1.52 1
• Suboptimal dialysis doses adversely affect patient survival, particularly in adults with ischemic cardiac disease or left ventricular dysfunction 1

Vascular Access Type

• Arteriovenous fistulas provide superior one-year survival (84%) compared to grafts (78.2%) and catheters (69.6%) 2
• Central venous catheters carry the highest infection risk and worst survival outcomes 6

Facility Characteristics

• Free-standing dialysis centers show higher mortality compared to hospital-based facilities (P = 0.009) 5
• Decreasing frequency of physician supervision correlates with increased mortality (P = 0.01) 5

Strategies to Reduce Mortality

Cardiovascular Disease Management

• Treat acute coronary syndromes identically to the non-dialysis population, including percutaneous coronary intervention, CABG, antiplatelet agents, beta-blockers, and lipid-lowering agents 1
• For ST-elevation MI, emergent PCI is preferred over thrombolytic therapy due to increased hemorrhagic risk in dialysis patients 1
• Implement post-MI prophylactic care including aspirin, beta-blockers, and ACE inhibitors, which improve the otherwise 75% two-year mortality 1

Optimizing Dialysis Delivery

• Monitor and maintain adequate dialysis dose with target URR ≥65% or Kt/V ≥1.2 for thrice-weekly treatments 1, 5
• Ensure proper volume control through adequate ultrafiltration and sodium restriction 1
• Consider ultrapure water and alternative therapies (hemofiltration, daily dialysis) for high-risk patients 1

Infection Prevention

• Prioritize arteriovenous fistula creation and maturation over grafts or catheters 2, 6
• Preserve peripheral veins in stage III-V CKD patients to enable optimal vascular access 7
• Vaccinate against seasonal influenza, tetanus, hepatitis B, HPV (through age 26), and Streptococcus pneumoniae 7

Blood Pressure Control

• Target interdialytic home blood pressure measurements rather than pre/post-dialysis readings, as these better predict mortality 1
• Achieve dry weight through progressive ultrafiltration, which can reduce systolic/diastolic BP by 6.9/3.1 mmHg 1
• Use renin-angiotensin system blockers as first-line antihypertensive agents 1

Common Pitfalls

• Avoid relying solely on pre-dialysis or post-dialysis blood pressure measurements, as these correlate poorly with interdialytic ambulatory readings and mortality risk 1
• Do not withhold standard post-MI therapies due to dialysis status; retrospective studies show protective effects despite lack of randomized trials in dialysis populations 1
• Recognize that low blood pressure in dialysis patients may paradoxically indicate higher mortality risk due to underlying cardiac dysfunction, not adequate BP control 1
• Inadequate dialysis directly causes at least 10% of technique failures and transfers to alternative modalities 1