Temporal evolution of clinical parameters before death in dialysis patients: A new concept

Background: Chronic hemodialysis (HD) patients experience an appallingly high mortality in the range of 20% per year. Little is known on the dynamics of key clinical and laboratory variables in the weeks and months preceding death. In order to gain more insight into events preceding death, we embarked on a novel methodological approach which encompasses data analysis from the date of death backwards in time. Methods: The current study investigates the dynamics of postdialytic weight and serum albumin levels in the 24 months preceding death. We performed a retrospective analysis of 2,462 maintenance HD patients who died between July 1, 2005 and April 30, 2008. Patients' monthly serum albumin levels were extracted for the 24 months preceding the date of death. Similarly, the median weekly postdialysis weight was extracted for the 104 weeks prior to death. Data were analyzed with linear mixed models. Results: Both albumin levels and postdialytic body weight showed a significant decrease irrespective of gender and race in the 3 final months of life. The most pronounced decreases in postdialytic weight and albumin levels were observed in patients with infection as cause of death, the smallest changes occurred in subjects with cerebrovascular events. Conclusions: In their final 3 months of life, HD patients experience a marked decrease in body weight and serum albumin levels. A better understanding of dynamic patterns of key variables before death may be useful in developing processes which alert medical caregivers to patients at increased risk, in order to institute timely diagnostic and therapeutic interventions.