End-stage renal disease (ESRD) is the final, irreversible stage of chronic kidney failure, where the kidneys can no longer filter waste products and excess fluid from the blood. Life-sustaining treatment, known as renal replacement therapy, becomes necessary. Dialysis, including in-center hemodialysis and home-based peritoneal dialysis, performs the work of the failed kidneys. While dialysis is a life-extending intervention, it is important to understand the overall health context of the population requiring this therapy.
Understanding Mortality Metrics for Dialysis Patients
The question of death “during dialysis” refers either to acute death while connected to the machine or the overall yearly mortality rate for patients receiving maintenance treatment. Acute death during a specific session is rare, often due to severe cardiovascular events like cardiac arrest. The more relevant measure is the annual all-cause mortality rate across the entire ESRD population undergoing treatment. This population carries an inherently high risk because kidney failure results from years of cumulative damage from severe, pre-existing health issues. For statistical purposes, “dialysis death” refers to any death of a patient receiving maintenance renal replacement therapy, regardless of location.
Current Annual Mortality Rates
The annual mortality rate for individuals with ESRD receiving maintenance dialysis is substantially higher than the general population. Recent data indicate the adjusted mortality rate is approximately 187.7 deaths per 1,000 person-years, illustrating the serious nature of the underlying disease. The five-year survival rate for patients undergoing long-term dialysis in the United States is estimated to be around 35%. This figure drops to approximately 25% for patients whose kidney failure is caused by diabetes. The highest period of risk for death is immediately after starting treatment, with mortality rates significantly elevated within the first 90 days of initiating dialysis.
Leading Medical Causes of Death
The vast majority of deaths among dialysis patients are caused by underlying chronic diseases, not the procedure itself. Cardiovascular disease (CVD) is the leading cause of death, accounting for between 30% and 47% of all recorded deaths, including heart attack, stroke, and heart failure. The physiological link between ESRD and CVD is strong, often termed “cardiorenal syndrome.” Kidney failure causes chronic inflammation, fluid overload, and imbalances that contribute to the hardening and calcification of blood vessels and heart muscle. Sudden cardiac death, often due to fatal arrhythmias, is a major component of these cardiovascular deaths.
Other Major Causes
Infection and sepsis represent the second most frequent cause of death, contributing to 10% to over 36% of fatalities. Dialysis patients are immunocompromised and susceptible to severe infections, often originating from vascular access sites required for hemodialysis. These infections can rapidly progress to life-threatening sepsis. Malnutrition and frailty are also contributing factors. Furthermore, over 12% of deaths are attributed to the patient or family choosing to withdraw from dialysis treatment, which is more common among older patients facing a severely diminished quality of life.
Variations Based on Dialysis Modality and Patient Factors
The commonness of death is highly individualized, influenced by the type of dialysis chosen and the patient’s specific health profile. The two primary modalities are in-center hemodialysis (HD) and home-based peritoneal dialysis (PD). While early studies suggested a survival advantage for PD, recent analyses show that overall adjusted mortality outcomes for both are largely similar. Comparing the two is challenging due to selection bias, as healthier patients are often chosen for home therapies like PD.
Patient Risk Factors
Patient-specific factors are the most powerful predictors of mortality risk. Age is a major determinant, with survival rates declining significantly as the patient’s age increases. The presence and severity of comorbidities are often more telling than age alone. Patients with pre-existing conditions like diabetes, congestive heart failure, or a history of myocardial infarction face a substantially higher risk of death, especially early in treatment. Mortality rates also vary based on sex and race, with men generally having higher rates than women.