Original Investigation
Mortality in Incident Maintenance Dialysis Patients Versus Incident Solid Organ Cancer Patients: A Population-Based Cohort

https://doi.org/10.1053/j.ajkd.2018.12.011Get rights and content

Rationale & Objective

The mortality rate is high among dialysis patients, but how this compares with other diseases such as cancer is poorly understood. We compared the survival of maintenance dialysis patients with that for patients with common cancers to enhance the understanding of the burden of end-stage kidney disease.

Study Design

Population-based cohort study.

Setting & Participants

33,500 incident maintenance dialysis patients in Ontario, Canada, and 532,452 incident patients with cancer (women: breast, colorectal, lung, or pancreas; men: prostate, colorectal, lung, or pancreas) from 1997 to 2015 using administrative health care databases.

Exposure

Incident kidney failure treated with maintenance dialysis versus incident diagnoses of cancer.

Outcome

All-cause mortality.

Analytical Approach

Kaplan-Meier product limit estimator was used to describe the survival of subgroups of study participants. Extended Cox regression with a Heaviside function was used to compare survival between patients with incident kidney failure treated with maintenance dialysis and individual diagnoses of various incident cancers.

Results

In men, dialysis had worse unadjusted 5-year survival (50.8%; 95% CI, 50.1%-51.6%) compared with prostate (83.3%; 95% CI, 83.1%-83.5%) and colorectal (56.1%; 95% CI, 55.7%-56.5%) cancer, but better survival than lung (14.0%; 95% CI, 13.7%-14.3%) and pancreas (9.1%; 95% CI, 8.5%-9.7%) cancer. In women, dialysis had worse unadjusted 5-year survival (49.8%; 95% CI, 48.9%-50.7%) compared with breast (82.1%; 95% CI, 81.9%-82.4%) and colorectal (56.8%; 95% CI, 56.3%-57.2%) cancer, but better survival than lung (19.7%; 95% CI, 19.4%-20.1%) and pancreas (9.4%; 95% CI, 8.9%-10.0%) cancer. After adjusting for clinical characteristics, similar results were found except when examining men and women with lung and pancreas cancer, for which dialysis patients had a higher rate of death 4 or more years after diagnosis. Women and men 70 years and older with incident kidney failure treated with maintenance dialysis had unadjusted 10-year survival probabilities that were comparable to pancreas and lung cancer.

Limitations

Cancer stage could be obtained for only a subpopulation.

Conclusions

Survival in incident dialysis patients was lower than in patients with several different solid-organ cancers. These results highlight the need to develop interventions to improve survival on dialysis therapy and can be used to aid advance care planning for elderly patients beginning treatment with maintenance dialysis.

Section snippets

Design and Setting

We conducted a population-based cohort study using administrative health care databases from Ontario, Canada, held at the ICES. These data sets were linked using unique encoded identifiers and analyzed at ICES. The use of data in this project was authorized under section 45 of Ontario’s Personal Health Information Protection Act (PHIPA), which does not require review by a Research Ethics Board. ICES is a designated prescribed entity under Section 45 of the PHIPA. Participant informed consent

Baseline Characteristics

We identified 33,500 maintenance dialysis patients (women, n = 13,587 [40.6%] and men, n = 19,913 [59.4%]) and 532,452 patients with cancer (women, n = 256,938 [48.3%]; men, n = 275,514 [51.7%]; Fig S1). Baseline characteristics for women on maintenance dialysis therapy and women with breast, lung, colorectal, or pancreas cancer are shown in Table 1, while baseline characteristics for men on maintenance dialysis therapy and men with prostate, lung, colorectal, or pancreas cancer are presented

Discussion

In this study, we found that survival in maintenance dialysis patients was lower than that for patients with several types of cancer. Specifically, maintenance dialysis patients had a better short- and long-term probability of survival compared with patients with pancreas and lung cancer, but poorer survival compared with patients with colorectal cancer (5- and 10-year survival) and breast and prostate cancer, for women and men, respectively. However, when we examined survival by age, women and

Article Information

Authors’ Full Names and Academic Degrees

Kyla L. Naylor, PhD, S. Joseph Kim, MD, PhD, Eric McArthur, MSc, Amit X. Garg, MD, PhD, Megan K. McCallum, MPH, and Gregory A. Knoll, MD, MSc.

Authors’ Contributions

Research idea and study design: KLN, SJK, EM, GAK; data analysis/interpretation: all authors; statistical analysis: EM; supervision or mentorship: SJK, GAK. Each author contributed important intellectual content during manuscript drafting or revision and accepts accountability for the overall work by ensuring that questions pertaining to the accuracy or

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    K.L.N. and S.J.K. contributed equally to this work.

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