title: Factors influencing withdrawal from dialysis: a national registry study.
abstract: Dialysis withdrawal is the third most common cause of death in patients receiving dialysis for established renal failure (ERF) in Scotland. We describe incidence, risk factors and themes influencing decision-making in a national renal registry.
  
  
  
  Details of deaths in those receiving renal replacement therapy (RRT) for ERF in Scotland are reported to the Scottish Renal Registry via a unique mortality report. We extracted patient demographics and comorbidity, cause and location of death, duration of RRT and pertinent free text comments from 1 January 2008 to 31 December 2014. Withdrawal incidence was calculated and logistic regression used to identify significantly influential variables. Themes emerging from clinician comments were tabulated for descriptive purposes.
  
  
  
  There were 2596 deaths; median age at death was 68 [interquartile range (IQR) 58, 76] years, 41.5% were female. Median duration on RRT was 1110 (IQR 417, 2151) days. Dialysis withdrawal was the primary cause of death in 497 (19.1%) patients and withdrawal contributed to death in a further 442 cases (17.0%). The incidence was 41 episodes per 1000 patient-years. Regression analysis revealed increasing age, female sex and prior cerebrovascular disease were associated with dialysis withdrawal as a primary cause of death. Conversely, interstitial renal disease, angiographically proven ischaemic heart disease, valvular heart disease and malignancy were negatively associated. Analysis of free text comments revealed common themes, portraying an image of physical and psychological decline accelerated by acute illnesses.
  
  
  
  Death following dialysis withdrawal is common. Factors important to physical independence-prior cerebrovascular disease and increasing age-are associated with withdrawal. When combined with clinician comments this study provides an insight into the clinical decline affecting patients and the complexity of this decision. Early recognition of those likely to withdraw may improve end of life care.
authors.affiliation: The Glasgow Renal & Transplant Unit, South Glasgow University Hospital, Glasgow, UK.
authors.forename: Mark D
authors.initials: MD
authors.lastname: Findlay
authors.affiliation: Renal Unit, NHS Dumfries and Galloway, Dumfries, UK.
authors.forename: Ken
authors.initials: K
authors.lastname: Donaldson
authors.affiliation: Renal, Queen Margaret Hospital, Dunfermline, UK.
authors.forename: Arthur
authors.initials: A
authors.lastname: Doyle
authors.affiliation: The Glasgow Renal & Transplant Unit, South Glasgow University Hospital, Glasgow, UK.
authors.forename: Jonathan G
authors.initials: JG
authors.lastname: Fox
authors.affiliation: Aberdeen Royal Infirmary, Aberdeen, UK.
authors.forename: Izhar
authors.initials: I
authors.lastname: Khan
authors.affiliation: ISD Healthcare Information Group, NHS Scotland National Services Division, Edinburgh, UK.
authors.forename: Jackie
authors.initials: J
authors.lastname: McDonald
authors.affiliation: Department of Renal Medicine, Edinburgh Royal Infirmary, Edinburgh, UK.
authors.forename: Wendy
authors.initials: W
authors.lastname: Metcalfe
authors.affiliation: Renal Unit, Raigmore Hospital, Inverness, UK.
authors.forename: Robert K
authors.initials: RK
authors.lastname: Peel
authors.affiliation: Renal Unit, Monklands Hospital, Airdrie, UK.
authors.forename: Ilona
authors.initials: I
authors.lastname: Shilliday
authors.affiliation: The John Stevenson Lynch Renal Unit, Crosshouse Hospital, Kilmarnock, UK.
authors.forename: Elaine
authors.initials: E
authors.lastname: Spalding
authors.affiliation: Renal Unit, Ninewells Hospital, Dundee, UK.
authors.forename: Graham A
authors.initials: GA
authors.lastname: Stewart
authors.affiliation: The Glasgow Renal & Transplant Unit, South Glasgow University Hospital, Glasgow, UK.
authors.forename: Jamie P
authors.initials: JP
authors.lastname: Traynor
authors.affiliation: The Glasgow Renal & Transplant Unit, South Glasgow University Hospital, Glasgow, UK.
authors.forename: Bruce
authors.initials: B
authors.lastname: Mackinnon
mesh_terms: D000368:Aged; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000628:therapy*; D008297:Male; D012042:Registries / Q000706:statistics & numerical data*; D006435:Renal Dialysis / Q000401:mortality*; D015996:Survival Rate; D028761:Withholding Treatment / Q000706:statistics & numerical data*
keywords: ESRD; dialysis withdrawal; epidemiology; mortality; risk factors