Comorbidity burden at dialysis initiation and mortality: A cohort study

Background: A high level of comorbidity at dialysis initiation is associated with an increased risk of death. However, contemporary assessments of the validity and prognostic value of comorbidity indices are lacking. Objectives: To assess the validity of two comorbidity indices and to determine if a high degree of comorbidity is associated with mortality among dialysis patients. Design: Cohort study. Setting: QEII Health Sciences Centre (Halifax, Nova Scotia, Canada). Patients: Incident, chronic dialysis patients between 01 Jan 2006 and 01 Jul 2013. Measurements: Exposure: The Charlson Comorbidity Index (CCI) and End-Stage Renal Disease Comorbidity Index (ESRD-CI) were used to classify individual comorbid conditions into an overall score. Comorbidities were classified using patient charts and electronic records. Outcome: All-cause mortality. Confounders: Patient demographics, dialysis access, cause of ESRD and baseline laboratory data. Methods: Regression coefficients were estimated on the CCI and ESRD-CI. Discrimination for death was assessed using Harrell's c-index. Adjusted Cox proportional hazard models were used to calculate relative hazards and 95% confidence intervals for each category of the CCI and ESRD-CI. Results: The cohort consisted of 771 ESRD patients from 01 Jan 2006 to 01 Jul 2013. Most were male (62%) and Caucasian (91%). The cohort had a high proportion of diabetes (48%), history of previous myocardial infarction (31%) and heart failure (22%). Regression coefficients on the CCI and ESRD-CI were 0.55 and 0.52, respectively. The c-index, for the prediction of death, was 0.61 for the CCI and 0.63 for the ESRD-CI. ESRD-CI scores of 4, 5 and ≥6 were associated with a similar mortality risk (adjusted relative hazard of 1.95, 1.89 and 1.99, respectively). There was a small increased mortality risk for CCI scores of 4, 5 and ≥6 (adjusted relative hazard of 1.86, 2.38 and 2.71, respectively). Limitations: Classification of comorbidities for each patient was determined by clinical impression. Conclusions: The CCI and ESRD-CI have a limited ability to discriminate mortality risk for incident dialysis patients. Acknowledging the frequency with which they are used, this study emphasizes the need to re-examine the usefulness of previously derived comorbidity indices in contemporary dialysis cohorts.