Association Between Implementation Of Novel Therapies And Improved Survival In Patients Starting Hemodialysis: The Swedish Renal Registry 2006-2015

Nephrol Dial Transplant. 2020 Dec 16;36(7):1298-1306. doi: 10.1093/ndt/gfaa357. Online ahead of print.


Background: The recent years have witnessed significant therapeutic advances for patients on hemodialysis. We evaluated temporal changes in treatments practices and survival rates among incident hemodialysis patients.

Methods: Observational study of patients initiating hemodialysis in Sweden 2006-2015. Trends of hemodialysis-related practices, medications, and routine laboratory biomarkers were evaluated. The incidence of death and major cardiovascular events (MACE) across calendar years were compared against the age-sex-matched general population. Via Cox regression, we explored whether adjustment for implementation of therapeutic advances modified observed survival and MACE risks.

Results: Among 6,612 patients, age and sex were similar, but the burden of co-morbidities increased over time. The proportion of patients receiving treatment by hemodiafiltration, >3 sessions/week, lower ultrafiltration rate, and working fistulas increased progressively, as did use of non-calcium phosphate binders, cinacalcet, and vitamin D3. The standardized 1-year mortality decreased from 13.2% in 2006/07 to 11.1% in 2014/15. The risk of death decreased by 6% (HR 0.94, 95% CI 0.90-0.99) every two years, and the risk of MACE by 4% (HR 0.96; 0.92-1.00). Adjustment for changes in treatment characteristics abrogated these associations (HR 1.00; 0.92-1.09 for death and 1.00; 0.94-1.06 for MACE). Compared with the general population, the risk of death declined from 6 times higher 2006/2007 [standardized incidence rate ratio, sIRR 6.0 (5.3-6.9)], to 5.6 higher 2014/15 [sIRR 5.57 (4.8-6.4)].

Conclusions: Gradual implementation of therapeutic advances over the last decade was associated with a parallel reduction in short-term risk of death and MACE among hemodialysis patients.

Keywords: death; hemodialysis; survival; trend; trial.