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Registration on the renal transplantation waiting list and mortality on dialysis: an analysis of the French REIN registry using a multi-state model.

Beuscart JB, Pagniez D, Boulanger E, Duhamel A - J Epidemiol (2014)

Bottom Line: Of the 2954 deaths observed in the entire cohort during follow-up, 2921 (98.9%) were observed in the not wait-listed group compared with only 33 (1.1%) in the wait-listed group.The risk factors for death identified for not wait-listed patients were not found to be significant risk factors for wait-listed patients, with the exception of age.Patients who were not wait-listed had a much higher risk of death, regardless of co-morbidities associated with being wait-listed, and did not share the same risk factors of death as wait-listed patients.

View Article: PubMed Central - PubMed

Affiliation: Department of Biostatistics, EA2694, Lille School of Medicine, Lille2 University.

ABSTRACT

Background: Access to the renal transplantation (RT) waiting list depends on factors related to lower mortality rates and often occurs after dialysis initiation. The aim of the study was to use a flexible regression model to determine if registration on the RT waiting list is associated with mortality on dialysis, independent of the comorbidities associated with such registration.

Methods: Data from the French REIN registry on 7138 incident hemodialysis (HD) patients were analyzed. A multi-state model including four states ('HD, not wait-listed', 'HD, wait-listed', 'death', and 'RT') was used to estimate the effect of being wait-listed on the probability of death.

Results: During the study, 1392 (19.5%) patients were wait-listed. Of the 2954 deaths observed in the entire cohort during follow-up, 2921 (98.9%) were observed in the not wait-listed group compared with only 33 (1.1%) in the wait-listed group. In the multivariable analysis, the adjusted hazard ratio for death associated with non-registration on the waiting list was 3.52 (95% CI, 1.70-7.30). The risk factors for death identified for not wait-listed patients were not found to be significant risk factors for wait-listed patients, with the exception of age.

Conclusions: The use of a multi-state model allowed a flexible analysis of mortality on dialysis. Patients who were not wait-listed had a much higher risk of death, regardless of co-morbidities associated with being wait-listed, and did not share the same risk factors of death as wait-listed patients. Registration on the waiting list should therefore be taken into account in survival analysis of patients on dialysis.

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Related in: MedlinePlus

Multi-state model used in the study. All patients start treatment on hemodialysis (HD), and are considered as not wait-listed. Then they may die during HD (transition 1 → 3) or be put on the waiting list (transition 1 → 2). Once on the waiting list, patients may die during HD (transition 2 → 3) or undergo a renal transplantation (RT, transition 2 → 4). Follow-up stops after RT because patients are no longer on dialysis, and the risk factors for death are therefore different from those for dialysis patients.
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fig01: Multi-state model used in the study. All patients start treatment on hemodialysis (HD), and are considered as not wait-listed. Then they may die during HD (transition 1 → 3) or be put on the waiting list (transition 1 → 2). Once on the waiting list, patients may die during HD (transition 2 → 3) or undergo a renal transplantation (RT, transition 2 → 4). Follow-up stops after RT because patients are no longer on dialysis, and the risk factors for death are therefore different from those for dialysis patients.

Mentions: A multi-state model including the four following states was applied: 1) ‘HD, not wait-listed’, ie, HD patients who were not registered on the RT waiting list; 2) ‘HD, wait-listed’, ie, HD patients who were registered on the RT waiting list; 3) ‘death’; and 4) ‘kidney transplantation’. Usually, a multi-state process is assumed to be a time-inhomogeneous Markov process18; this means that the future state of the process only depends on the current state and the elapsed time since the time of origin. As this model required the presence of a unique initial state, all patients were considered as ‘HD, not wait-listed’ at the onset; for patients who were already wait-listed at the initiation of HD, registration was set at day one. Death and RT were absorbent states, while being wait-listed was a transient state. Consequently, four transitions were possible, which are detailed in Figure 1.


Registration on the renal transplantation waiting list and mortality on dialysis: an analysis of the French REIN registry using a multi-state model.

Beuscart JB, Pagniez D, Boulanger E, Duhamel A - J Epidemiol (2014)

Multi-state model used in the study. All patients start treatment on hemodialysis (HD), and are considered as not wait-listed. Then they may die during HD (transition 1 → 3) or be put on the waiting list (transition 1 → 2). Once on the waiting list, patients may die during HD (transition 2 → 3) or undergo a renal transplantation (RT, transition 2 → 4). Follow-up stops after RT because patients are no longer on dialysis, and the risk factors for death are therefore different from those for dialysis patients.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4310874&req=5

fig01: Multi-state model used in the study. All patients start treatment on hemodialysis (HD), and are considered as not wait-listed. Then they may die during HD (transition 1 → 3) or be put on the waiting list (transition 1 → 2). Once on the waiting list, patients may die during HD (transition 2 → 3) or undergo a renal transplantation (RT, transition 2 → 4). Follow-up stops after RT because patients are no longer on dialysis, and the risk factors for death are therefore different from those for dialysis patients.
Mentions: A multi-state model including the four following states was applied: 1) ‘HD, not wait-listed’, ie, HD patients who were not registered on the RT waiting list; 2) ‘HD, wait-listed’, ie, HD patients who were registered on the RT waiting list; 3) ‘death’; and 4) ‘kidney transplantation’. Usually, a multi-state process is assumed to be a time-inhomogeneous Markov process18; this means that the future state of the process only depends on the current state and the elapsed time since the time of origin. As this model required the presence of a unique initial state, all patients were considered as ‘HD, not wait-listed’ at the onset; for patients who were already wait-listed at the initiation of HD, registration was set at day one. Death and RT were absorbent states, while being wait-listed was a transient state. Consequently, four transitions were possible, which are detailed in Figure 1.

Bottom Line: Of the 2954 deaths observed in the entire cohort during follow-up, 2921 (98.9%) were observed in the not wait-listed group compared with only 33 (1.1%) in the wait-listed group.The risk factors for death identified for not wait-listed patients were not found to be significant risk factors for wait-listed patients, with the exception of age.Patients who were not wait-listed had a much higher risk of death, regardless of co-morbidities associated with being wait-listed, and did not share the same risk factors of death as wait-listed patients.

View Article: PubMed Central - PubMed

Affiliation: Department of Biostatistics, EA2694, Lille School of Medicine, Lille2 University.

ABSTRACT

Background: Access to the renal transplantation (RT) waiting list depends on factors related to lower mortality rates and often occurs after dialysis initiation. The aim of the study was to use a flexible regression model to determine if registration on the RT waiting list is associated with mortality on dialysis, independent of the comorbidities associated with such registration.

Methods: Data from the French REIN registry on 7138 incident hemodialysis (HD) patients were analyzed. A multi-state model including four states ('HD, not wait-listed', 'HD, wait-listed', 'death', and 'RT') was used to estimate the effect of being wait-listed on the probability of death.

Results: During the study, 1392 (19.5%) patients were wait-listed. Of the 2954 deaths observed in the entire cohort during follow-up, 2921 (98.9%) were observed in the not wait-listed group compared with only 33 (1.1%) in the wait-listed group. In the multivariable analysis, the adjusted hazard ratio for death associated with non-registration on the waiting list was 3.52 (95% CI, 1.70-7.30). The risk factors for death identified for not wait-listed patients were not found to be significant risk factors for wait-listed patients, with the exception of age.

Conclusions: The use of a multi-state model allowed a flexible analysis of mortality on dialysis. Patients who were not wait-listed had a much higher risk of death, regardless of co-morbidities associated with being wait-listed, and did not share the same risk factors of death as wait-listed patients. Registration on the waiting list should therefore be taken into account in survival analysis of patients on dialysis.

Show MeSH
Related in: MedlinePlus