Early Mortality Rates After Commencement of Maintenance Hemodialysis: A Systematic Review and Meta-Analysis

Mortality rates are reported to be high soon after the commencement of maintenance HD for ESRD. Our aim was to estimate early mortality rates (deaths within 180 days of starting therapy), through a systematic review of literature, in this patient population. Medline and EMBASE were searched for publications between 1 January 1985 and 31 December 2017. Observational studies reporting deaths involving adults commencing HD were included. The Quality in Prognosis Studies tool was used to assess risk of bias in studies. Crude mortality rates (expressed in 100 person-years) and age-standardized mortality ratios (SMR) were calculated. Meta-analyses of these rates were conducted for studies with lowest risk of bias (i.e. highest quality). In total, 32 studies were included (combined population: 1 083 264) representing 283 277 person-years of observation; median follow-up: 90 days. Mortality rates ranged between 12.8 and 55.6 per 100 person-years. Cardiovascular causes accounted for the majority of early deaths. Meta-analysis of high-quality studies showed an overall crude mortality rate of 32.6 per 100 person-years (95% CI 32.4-32.8). This equates to 16.3% mortality in first 180 days of starting HD. Six high-quality studies contained sufficient data for calculation of SMR. Meta-analysis of SMRs showed that patients starting HD therapy sustain 8.8 times higher mortality rates compared to the general population. We have combined the results of high-quality studies to produce new estimates of early mortality rates after commencement of HD therapy. This information can help relay more reliable prognostic information to this patient population.