Impact of clinical, sociodemographic and quality of life factors on dialysis patient survival: a nine-year follow-up cohort study

Brito, Daniela Cristina Sampaio de; Machado, Elaine Leandro; Reis, Ilka Afonso; Cherchiglia, Mariangela Leal

doi:10.1590/0102-311X00007320

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Cadernos de Saúde Pública

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ARTICLE • Cad. Saúde Pública 36 (12) • 2020 • https://doi.org/10.1590/0102-311X00007320 copy

Impact of clinical, sociodemographic and quality of life factors on dialysis patient survival: a nine-year follow-up cohort study

Impacto de fatores clínicos, sociodemográficos e de qualidade de vida na sobrevida de pacientes em diálise: um estudo de coorte com nove anos de seguimento

Impacto clínico, sociodemográfico y factores de calidad de vida en la supervivencia de pacientes con diálisis: estudio de cohorte durante un periodo de nueve años

Authorship SCIMAGO INSTITUTIONS RANKINGS

Although renal replacement therapy has contributed to the survival of chronic kidney failure (CKF) patients, mortality remains a major concern. This study aimed to identify the factors associated with mortality in a prospective cohort of CKF patients. Sociodemographic, clinical, nutritional, lifestyle and quality of life data were collected from 712 patients. The instruments used were the Short-Form Health Survey (SF-36), Global Subjective Assessment (GSA) and Charlson Comorbidity Index (CCI) questionnaires. A total of 444 patients died during the study. After five years of follow-up, factors such as not being married (hazard ratio - HR = 1.289, 95%CI: 1.001; 1.660), a low frequency of leisure activities (HR = 1.321; 95%CI: 1.010; 1.727) and not being transplanted (HR = 7.246; 95%CI: 3.359; 15.630) remained independently associated with the risk of mortality. At the end of the follow-up period, factors such as not being married (HR = 1.337, 95%CI: 1.019; 1.756), not being transplanted (HR = 7.341, 95%CI: 3.829; 14.075) and having a worse nutritional status (HR = 1.363, 95%CI: 1.002; 1.853) remained independently associated with an increased risk of mortality, whereas a high schooling level (10 to 12 years, HR = 0.578, 95%CI: 0.344; 0.972; and over 12 years, HR = 0.561, 95%CI: 0.329; 0.956) and a better SF-36 physical functioning score (HR = 0.992, 95%CI: 0.987; 0.998) were protective factors associated with survival. The survival of patients with CKF is associated with factors not restricted to the clinical spectrum. The following factors were associated with high mortality: not being married, low schooling level, a limited social routine, a longer time on dialysis, worse nutritional status, and worse physical functioning.

Keywords:
Survival; Mortality; Quality of Life; Chronic Kidney Failure; Renal Replacement Therapy

Variables	Total population (n = 712)	Survivors (n = 226)	Non-survivors (n = 444)	p-value
Sociodemographic variables
Age [mean±SD]	53.9±15.2	45.0±13.3	58.7±13.8	< 0.01
Sex (female) [n (%)]	301 (42.3)	107 (47.3)	179 (40.3)	0.82
Skin color (brown/black) [n (%)]	406 (57.7)	139 (61.5)	241 (55.3)	0.27
Married/de facto relationship [n (%)]	411 (57.7)	140 (61.9)	242 (54.5)	0.06
Religion (yes) [n (%)]	659 (92.7)	210 (92.9)	409 (92.3)	0.78
Schooling (years) [n (%)]
Illiterate	61 (8.6)	11 (4.9)	47 (10.7)	< 0.01
Up to 9	418 (59.1)	127 (56.2)	268 (61.0)
10 to 12	154 (21.8)	64 (28.3)	79 (18.0)
Over 12	74 (10.5)	24 (10.6)	45 (10.3)
Has a job	95 (13.3)	42 (18.6)	46 (10.4)	< 0.01
Number of monthly minimum wages [mean±SD]	3.9±5.5	1.9 (1.2; 3.9)	2.1 (1.3; 4.0)	0.13
Source of income [n (%)]
Work	81 (13.6)	33 (18.4)	42 (11.0)	0.01
Benefits	506 (84.8)	146 (81.6)	332 (86.9)
Others	10 (1.7)	0	8 (2.1)
Clinical variables
Baseline time on dialysis (months) [mean±SD]	13.9±8.4	14.4±8.2	13.0 (7.0; 21,0)	0.47
Total time on dialysis (months) [mean±SD]	68.0±37.7	91.9±39.5	51.0 (32,0; 79.0)	< 0.01
Total time on transplant (months) [mean±SD]	69.2±86.7	66.6±31.1	11.0 (2.0; 72.0)	< 0.01
Transplant (yes) [n (%)]	109 (16.8)	94 (42.9)	13 (3.1)	< 0.01
Renal graft loss (yes) [n (%)]	18 (17.3)	13 (14.0)	5 (50.0)	< 0.01
CCI [mean±SD]	3.3±1.7	2.0 (2.0; 3.0)	3.0 (2.0; 4.0)	< 0.01
Medications prescribed [mean±SD]	5.9±4.3	5.0 (4.0; 7.0)	6.0 (4.0; 8.0)	0.17
GSA (well nourished) [n (%)]	560 (78.7)	194 (85.8)	331 (74.5)	< 0.01
Habits
Recreational activities * (no) [n (%)]	502 (70.5)	182 (80.5)	291 (65.5)	< 0.01
Social group * (no) [n (%)]	203 (28.6)	76 (33.6)	112 (25.3)	0.02
SF-36 scores
Physical components [mean±SD]	40.8±9.9	42.6±9.2	39.7±10.1	< 0.01
Physical functioning	54.6±29.9	70.0 (50.0; 90.0)	45.0 (20.0;70.0)	< 0.01
Role physical	40.0±39.9	50.0 (0.0; 100)	25.0 (0.0; 75.0)	< 0.01
Bodily pain	67.0±29.6	72.0 (51.0; 100)	62.0 (41,0; 100)	0.01
General health status	59.3±22.7	61.5±20.3	60.0 (40.0; 77.0)	0.09
Mental components [mean±SD]	49.4±12.5	53.0 (43.4; 58.5)	51.5 (39.6; 60.1)	0.44
Vitality	62.4±25.1	70.0 (50.0; 77.0)	65.0 (40.0; 80.0)	0.05
Social functioning	71.2±27.9	75.0 (55.0; 80.0)	75.0 (50.0; 100)	< 0.01
Emotional role	59.8±41.9	66.6 (33.3; 100)	66.6 (66.6; 100)	0.09
Mental health	71.5±23.3	80.0 (60.0; 92.0)	76.0 (54.0; 88.0)	0.11

Variables	1-year follow-up (n = 670)		5-year follow-up (n = 264)		9-year follow-up (n = 129)
	HR (95%CI)	p-value	HR (95%CI)	p-value	HR (95%CI)	p-value
Sociodemographic variables
Age	1.024 (1.004; 1.044)	0.01	1.034 (1.026; 1.042)	< 0.01	1.038 (1.031; 1.045)	< 0.01
Sex (female)	1.100 (0.634; 1.909)	0.73	0.923 (0.738; 1.156)	0.48	0.871 (0.720; 1.052)	0.15
Skin color (brown/black)	1.175 (0.456; 3.029)	0.73	1.159 (0.799; 1.681)	0.43	1.077 (0.784; 1.479)	0.64
Married/de facto relationship (no)	1.393 (0.804; 2.412)	0.23	1.170 (0.940; 1.461)	0.15	1.213 (1.006; 1.462)	0.04
Religion (no)	1.060 (0.382; 2.943)	0.91	1.119 (0.749; 1.671)	0.58	1.074 (0.757; 1.524)	0.69
Schooling (years)
Over 12 (reference)
Illiterate	1.202 (0.388; 3.728)	0.74	1.721 (1.081; 2.741)	0.02	1.648 (1.094; 2.482)	0.01
Up to 9	0.995 (0.418; 2.371)	0.99	1.028 (0.707; 1.496)	0.88	1.061 (0.773; 1,453)	0.71
10 to 12	0.399 (0.122; 1.306)	0.12	0.708 (0.455; 1.101)	0.12	0.753 (0.522; 1.087)	0.13
Has a job (no)	1.853 (0.668; 5.143)	0.23	1.480 (1.032; 2.123)	0.03	1.581 (1.165; 2.145)	< 0.01
Monthly minimum wages (n)	1.012 (0.957; 1.069)	0.68	1.012 (0.990; 1.034)	0.29	1.016 (0.997; 1.034)	< 0.01
Clinical variables
Transplant (no)	27.185 (1.185; 63.430)	0.03	10.545 (5.223; 21.291)	< 0.01	11.177 (6.427; 19.439)	< 0.01
CCI	1.091 (0.973; 1.224)	0.13	1.092 (1.046; 1.141)	< 0.01	1.078 (1.038; 1.118)	< 0.01
Number of prescribed medications	0.996 (0.927; 1.070)	0.91	0.993 (0.965; 1.023)	0.65	1.008 (0.992; 1.025)	0.30
GSA (malnourished)	1.521 (0.833; 2.779)	0.17	1.667 (1.301; 2.134)	< 0.01	1.612 (1.302; 1.997)	< 0.01
Habits
Recreational activities * (no)	1.727 (0.989; 3.016)	0.05	1.781 (1.418; 2.235)	< 0.01	1.643 (1.351; 2.001)	< 0.01
Social group * (no)	1.293 (0.677; 2.470)	0.43	1.261 (0.975; 1.631)	0.07	1.281 (1.034; 1.588)	0.02
SF-36
Physical components	0.962 (0.935; 0.990)	< 0.01	0.971 (0.959; 0.982)	< 0.01	0.977 (0.967; 0.986)	< 0.01
Physical functioning	0.982 (0.973; 0.992)	< 0.01	0.985 (0.981; 0.989)	< 0.01	0.985 (0.982; 0.989)	< 0.01
Role physical	0.995 (0.988; 1.002)	0.16	0.995 (0.992; 0.998)	< 0.01	0.996 (0.993; 0.998)	< 0.01
Bodily pain	0.989 (0.980; 0.999)	0.02	0.992 (0.988; 0.996)	< 0.01	0.994 (0.991; 0.997)	< 0.01
General health status	0.994 (0.982; 1.006)	0.29	0.995 (0.991; 1.001)	0.03	0.995 (0.991; 0.999)	0.02
Mental components	0.997 (0.975; 1.019)	< 0.01	0.996 (0.987; 1.005)	0.34	0.996 (0.988; 1.003)	0.28
Vitality	0.992 (0.981; 1.003)	0.15	0.994 (0.991; 0.998)	< 0.01	0.995 (0.991; 0.998)	< 0.01
Social functioning	0.997 (0.988; 1.007)	0.55	0.995 (0.991; 0.998)	< 0.01	0.995 (0.992; 0.998)	< 0.01
Role emotional	0.998 (0.992; 1.005)	0.58	0.997 (0.995; 1.001)	0.04	0.998 (0.996; 1.001)	0.07
Health mental	0.992 (0.981; 1.003)	0.14	0.996 (0.991; 1.002)	0.06	0.995 (0.992; 0.999)	0.02

Models	ß	HR	95%CI	p-value
1-year follow-up	-	-	-	-
5-year follow-up
Married/de facto relationship (no)	0.254	1.289	1.001; 1.660	0.04
Recreational activities * (no)	0.278	1.321	1.010; 1.727	0.04
Transplant (no)	1.980	7.246	3.359; 15.630	< 0.01
9-year follow-up
Married/de facto relationship (no)	0.291	1.337	1.019; 1.756	0.03
Schooling (years)
Illiterate (reference)
Up to 9	-0.585	0.557	0.284; 1.091	0.08
10 to 12	-0.547	0.578	0.344; 0.972	0.03
Over 12	-0.578	0.561	0.329; 0.956	0.03
Transplant (no)	1.993	7.341	3.829; 14.075	< 0.01
GSA (malnourished)	0.309	1.363	1.002; 1.853	0.04
Physical functioning (SF-36)	-0.008	0.992	0.987; 0.998	< 0.01

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[1] Correspondência
D. C. S. Brito Departamento de Medicina Preventiva e Social, Faculdade de Medicina, Universidade Federal de Minas Gerais. Av. Alfredo Balena 190, sala 706, Belo Horizonte, MG 30130-100, Brazil. danielacbrito@hotmail.com