Lancet study finds 7 out of 10 dialysis patients in India survive beyond six months, rural mortality 32% higher

A study has established the benchmark for survival among dialysis patients in India for the first time, estimating the raw survival rate at 71 per cent, implying that about 7 of every 10 patients survive beyond six months. 

Of the total sample studied, 28 per cent patients (6,637 patients) receiving haemodialysis died within 10 months. The mortality rate in India is double the global rate, particularly in high-income Western countries and Japan, according to the Dialysis Outcomes and Practice Patterns study.

Dialysis is a medical treatment to help individuals with kidney failure filter waste and excess fluid from the blood. Globally, India had the highest number of patients receiving the treatment in 2018, with nearly 175,000 people. While incidences of kidney failure in India are rising, there is limited data on clinical outcomes. 

Read more: Edge of unreason

The paper was led by medical research institute George Institute of Global Health and is the largest study to investigate survival outcomes for patients receiving hemodialysis in terms of size and geographic scope. 

The researchers looked at 23,601 patients across 193 centres in 20 states, registered with a NephroPlus centre between April 1, 2014, and June 30, 2019. NephroPlus is the largest dialysis network in the country.  

The research period began 90 days after the patients commenced treatment at a centre. Of them, 29 per cent were women, with a median baseline age of 53 years.

About 83-97 per cent patients survived for 180 days across the centres, the study estimated after adjusting for both centre and patient-level factors. On average, survival was calculated at 90 per cent. 

“There was an inverse relationship between mortality and dialysis vintage, with those receiving dialysis for at least a year prior to joining a centre having a 17% lower rate of mortality than those who started dialysis less than 30 days before joining,” the researchers said.

Read more: COVID-19 cost: Dialysis takes a backseat

Some of the patients were followed up for 3 months, some were followed up for two years and some were followed up for four years, but the researchers chose 180 days because that is where they were able to get most data and therefore were able to standardise outcomes for most patients. The researchers are continuing to extend the period of follow-up.

Alongside establishing national standards for dialysis outcomes in India, the researchers took into account the multilevel effects of centre and patient-level characteristics on these outcomes. 

They found that survival rates were associated with the location of the centre as the mortality rate was 32 per cent higher in rural centres than in urban centres.

The paper published in The Lancet Regional Health-South East Asia noted that the mortality rate was higher for people who paid for their treatment out of pocket than those whose treatment was government-subsidised or covered by private insurance.

It further said the prevalence of diabetes and hypertension was high (37 per cent and 75 per cent, respectively) among the participants and higher mortality in patients who had diabetes was seen. Moreover, higher mortality was also observed in patients whose vascular access was anything other than an arteriovenous fistula or graft.

Age is a known risk factor for kidney failure and the cohort examined had  31 per cent of patients over the age of 60 versus 15 per cent of the patients observed previously. The diverse traits and outcome of the study demonstrate the need for more widespread data collection.

Read more: New guidelines for peritoneal dialysis services

Despite the growing burden of chronic kidney disease, there are a few studies available that are either single-centre with a small sample size or more than a decade old. The largest known study in India has 13,118 dialysis patients between 2008 and 2012, who received treatment through a publicly funded insurance scheme in Andhra Pradesh.

The earlier paper had found that 13 per cent of patients died within one year of beginning treatment. As the one-year mortality rate ranges between 10 per cent and 29 per cent in other states, the finding may not be generalisable to other states.

The latest one highlighted that among all procedures covered under the Ayushman Bharat scheme, the government spends the most money on dialysis procedures.

The number of patients on dialysis increased after the launch of the National Dialysis Service in 2016, which improved access to kidney replacement therapy and efforts to make dialysis affordable.

Professor Vivekanand Jha, executive director, the George Institute for Global Health India, in a statement, urged the government to consider extending the coverage under the National Dialysis Service to include support for the prevention of kidney disease and improved long-term management of major complications associated with dialysis, such as cardiovascular disease and mineral bone disease. 

“We also urge the pairing up of a dialysis registry with the national dialysis programme,” Jha stated.  

Read more: COVID-19 lockdown may have caused more deaths in Rajasthan in 2020 than reported: Study

Speaking to Down to Earth (DTE), Jha explained, “There are other factors also as we say that there are certain unmeasured factors. For example, certain patients may live far from a dialysis centre and they may have to spend a lot of money to reach it, which causes large out-of-pocket expenditures. That can compromise their ability to get better medical care which is number one.”

“The second factor is that although they are getting dialysis, we are not sure whether they are getting other ancillary medicines that are required for the care of kidney disease. Third, we are unsure whether they are getting good quality food, etc. We are not sure whether they have a current job or if their family can support them to the same amount as maybe some other families can do,” Jha told DTE.

“So those are unmeasured factors and one of our pleas is to try and measure those factors as much as possible,” Jha added.

Subscribe to Daily Newsletter :

SUPPORT US

We are a voice to you; you have been a support to us. Together we build journalism that is independent, credible and fearless. You can further help us by making a donation. This will mean a lot for our ability to bring you news, perspectives and analysis from the ground so that we can make change together.