Survival and predictors of death in dialysed diabetic patients

Summary

The objective of this study was to examine diabetic patients at the time of admission to maintenance haemodialysis and to follow them for 36 months in order to define predictors of cardiovascular and non-cardiovascular death. This prospective study comprised all consecutive diabetic patients admitted to 28 German dialysis centres between January 1985 and October 1987; 196 patients were examined, 67 Type 1 (insulin-dependent) diabetic (43 male, 24 female; median age 49 years, range 22–73) and 129 Type 2 (non-insulin-dependent) diabetic patients (54 male, 75 female; 64 years, range 37–82).

Outcome measures were death, i.e. myocardial infarction, sudden death, cardiac death of other causes, stroke and noncardiovascular death. Actuarial survival 36 months after the beginning of dialysis was similar in Type 1 (40%) and Type 2 diabetic patients (43%) despite the age difference. Causes of death were myocardial infarction (18%), sudden death (18%), other cardiac causes (18%); stroke (6%); septicaemia (17%) mostly originating from diabetic foot problems; and interruption of therapy. Survival rates and the proportion dying from cardiac causes were similar in patients with diabetic nephropathy or with other primary chronic renal disease and coincidental diabetes. On dialysis, de novo amaurosis or de novo amputation was not observed in any patient. The strongest predictor of myocardial infarction or sudden death was serum lipids on admission. Duration of hypertension, blood pressure at the time of admission to dialysis, left ventricular hypertrophy or end-diastolic diameter by echocardiography, Sokolow index and average predialysis blood pressure, smoking, interdialytic weight gain and type of dialysis were not predictive of cardiovascular death or death by all causes. Patients with myocardial infarction were more frequently male (70% of myocardial infarction), tended to be younger, more frequently had a history of myocardial infarction (relative risk 3.0) and more frequently had angina pectoris, proliferative retinopathy (relative risk 2.8) or somatosensory polyneuropathy (relative risk 3.0). Patients dying from myocardial infarction or other cardiac causes had more frequent episodes of intradialytic hypotension and tended to be less frequently on beta blocker treatment.

We conclude that cardiac death accounts for most fatalities of diabetic patients on dialysis. Some, but not all, classic risk factors are predictive of cardiac death.