title: Can we improve early mortality in patients receiving renal replacement therapy?
abstract: BACKGROUND
  Approximately one in eight patients with end-stage renal disease (ESRD) die within the first three months of starting renal replacement therapy (RRT). We investigated which factors might improve this early mortality.
  
  
  METHODS
  We performed a prospective nationwide study of all patients commencing RRT for ESRD in Scotland over one year. Patients were classified according 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 within 90 days of commencing treatment were determined by logistic regression analysis.
  
  
  RESULTS
  Patients with an acute unexpected element to their presentation for RRT had early mortality rates between 6.0 and 8.9 times greater than those who commenced RRT electively after a period of care from a nephrologist. Patients in high and medium comorbidity risk groups had early mortality rates 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 progressed steadily to ESRD, who had a planned start to dialysis, and who had mature access were 3.6 times more likely to survive beyond three months than those with no access; they were, however, also younger with less comorbidity.
  
  
  CONCLUSIONS
  The factors principally associated with early mortality are nonelective presentation for RRT, comorbid illness, and low serum albumin. Patients cared for by a nephrologist before requiring RRT who have mature access have better short-term survival than those without access. They are also younger with less comorbidity. It may be possible to improve short-term survival in this "unplanned" group if referred early to facilitate reducing cardiovascular risk factors and preparation for RRT.
authors.affiliation: Department of Medicine and Therapeutics, University of Aberdeen, Renal Unit, Aberdeen Royal Infirmary, Aberdeen, Scotland, United Kingdom. w.metcalfe@abdn.ac.uk
authors.forename: W
authors.initials: W
authors.lastname: Metcalfe
authors.forename: I H
authors.initials: IH
authors.lastname: Khan
authors.forename: G J
authors.initials: GJ
authors.lastname: Prescott
authors.forename: K
authors.initials: K
authors.lastname: Simpson
authors.forename: A M
authors.initials: AM
authors.lastname: MacLeod
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015897:Comorbidity; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000453:epidemiology / Q000401:mortality* / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012044:Regression Analysis; D017582:Renal Replacement Therapy; D012307:Risk Factors; D013997:Time Factors