title: Survival and transplantation in end-stage renal disease: a prospective study of a multiethnic population.
abstract: BACKGROUND
  Accurate assessment of determinants of patient survival in end-stage renal disease is important for counselling, clinical management and resource planning. To address this we have analysed survival and risk factors for survival for patients treated for end-stage renal disease in a multi-ethnic UK population.
  
  
  METHODS
  A multicentre prospective observational cohort study was performed in four teaching hospital renal units serving a total population of four million people. A total of 884 consecutive patients treated with renal replacement therapy were studied. Cox proportional hazard modelling and adjusted survival curves were used to assess the impact of a range of variables on patients surviving dialysis for more than 90 days. Further analysis was undertaken to determine the likelihood of transplantation in different ethnic groups.
  
  
  RESULTS
  Survival was 29% after a mean and median follow up of 4.6 and 4.2 years, respectively. Factors associated with worse survival included the following: age; for each decade of life the relative risk (RR) of death was 1.52 (95% confidence intervals 1.41-1.65, p < 0.0001); comorbidity, one or two comorbid conditions, RR = 1.56 (95% CI 1.24-1.95, p < 0.001) and three or more comorbid conditions, RR = 2.34 (1.68-3.27, p < 0.001). Factors associated with better survival included the following: south-Asian ethnicity, RR = 0.6 (0.46-0.80, p < 0.001); renal transplantation, RR = 0.20 (95% CI 0.11-0.59, p < 0.0001) and glomerulonephritis as the primary renal disease, RR = 0.70 (0.50-0.97, p = 0.04). Factors associated with likelihood of transplantion were having a functioning fistula/peritoneal dialysis catheter at start of dialysis (RR 1.91, 95% CI 1.24-2.94, p = 0.003) and glomerulonephritis (RR 9.54, 95% CI 2.43-37.64, p = 0.001). Patients were less likely to receive if they were black (RR 0.10, 95% CI 0.02-0.34, p < 0.001), South Asian (RR 0.64, 95% CI 0.42-0.97, p = 0.037), diabetic (RR 0.06, 95% CI 0.01-0.23, p < 0.001) and had one or two comorbid conditions (RR 0.51, 95% CI 0.32-0.82, p = 0.06). Every decade increase in age was also associated with a lesser likelihood of transplantation (RR 0.55, 95% CI 0.49-0.61, p < 0.001). Discussion. Risk stratification at commencement of chronic dialysis may predict long-term survival in different patient groups. As expected ethnic minorities are less likely to receive a transplant and this should be addressed by the new waiting list prioritization. The better survival on dialysis in this population of patients with south-Asian ethnicity is unexplained and this requires further investigation.
authors.affiliation: Department of Nephrology, University Hospital Birmingham, West Midlands, UK. poorva.jain@doctors.org.uk
authors.forename: Poorva
authors.initials: P
authors.lastname: Jain
authors.forename: Paul
authors.initials: P
authors.lastname: Cockwell
authors.forename: Jane
authors.initials: J
authors.lastname: Little
authors.forename: Martin
authors.initials: M
authors.lastname: Ferring
authors.forename: Johann
authors.initials: J
authors.lastname: Nicholas
authors.forename: Nick
authors.initials: N
authors.lastname: Richards
authors.forename: Rob
authors.initials: R
authors.lastname: Higgins
authors.forename: Steve
authors.initials: S
authors.lastname: Smith
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D044466:Asian People; D044383:Black People; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000401:mortality* / Q000601:surgery*; D016030:Kidney Transplantation; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D015996:Survival Rate; D044465:White People; D055815:Young Adult