Life Expectancy With Chronic Kidney Disease: An Educational Review
Life Expectancy With Chronic Kidney Disease: An Educational Review
Life Expectancy With Chronic Kidney Disease: An Educational Review
DOI 10.1007/s00467-016-3383-8
EDUCATIONAL REVIEW
Received: 26 October 2015 / Revised: 28 March 2016 / Accepted: 29 March 2016 / Published online: 26 April 2016
# The Author(s) 2016. This article is published with open access at Springerlink.com
Abstract Can renal prognosis and life expectancy be accu- one sees a new patient, a 19-year-old youth with a serum
rately predicted? Increasingly, the answer is yes. The natural creatinine level of 200 μmol/l, can one predict his likely renal
history of different forms of renal disease is becoming clearer; prognosis and his life expectancy? The answer is yes, and this
the degree of reduction in glomerular filtration rate (GFR) and is frequently done when the question is posed in a medico-
the magnitude of proteinuria are strong predictors of renal legal context; however, is the answer accurate?
outcome. Actuarial data on life expectancy from the start of We know that life expectancy is much reduced with end-
renal replacement therapy are available from renal registries stage renal failure—but what about the different degrees or
such as the U.S. Renal Data System (USRDS), and the stages of renal failure? For this review I have searched the
UK Renal Registry. Recently, similar data have become avail- adult and paediatric literature for papers cited in PubMed
able for patients with chronic kidney disease. Data collected and Google Scholar that might contain data on life expectancy
from a large population-based registry in Alberta, Canada and with CKD, or for series that have followed patients with CKD
stratified for different levels of estimated GFR (eGFR) have from childhood to end-stage kidney disease (ESKD) and
shown that the reduction in life expectancy with kidney failure through to renal replacement therapy (RRT). I summarise
is not a uremic event associated with starting dialysis but a the evidence on the prediction of renal prognosis, describe
continuous process that is evident from an eGFR of ≤60 important new data from Canada that for the first time looks
ml/min. Nevertheless, despite the poor prognosis of the last at life expectancy with different stages of CKD and cite the
stages of renal failure, progress in the treatment and manage- U.S. Renal Data System (USRDS) and UK renal registries
ment of these patients and, in particular, of their cardiovascu- that report annual data regarding life expectancy with RRT.
lar risk factors continues to improve long-term outcome.
tubular disease, and I am assuming that this disease will have min/1.73 m 2 cannot be considered as a Bnorm al
been picked up during the history, examination and other basic population^ as patients having their creatinine measured
investigations. are likely to be less well than the general population
Patients with inexorably progressive renal failure tend (who would not have a creatinine measure) and therefore
to deteriorate at a rate proportional to their proteinuria [6], have a lower life expectancy.
but generally speaking the more proteinuria, the more the From Table 1 it can be seen that for the first three age
rate of progression can be slowed by angiotensin groups (30–34, 35–39, 40–44 years), life expectancy falls by
converting enzyme inhibitors (ACEIs) and good control approximately 20 % with an eGFR of 45–59 ml/min/1.73 m2,
of blood pressure [2, 7–9]. by approximately 50 % with an eGFR of 30–44 ml/min/
Patients with small asymmetric kidneys (renal 1.73 m2 and by approximately 65 % with an eGFR of 15–
hypodysplasia—often described in the UK as reflux nephrop- 29 ml/min/1.73 m2, when compared with those with an eGFR
athy) tend to deteriorate at the slowest rates, and this is rarely of ≥60 ml/min/1.73 m2 (note: these figures are calculated from
greater than an estimated glomerular filtration ration (eGFR) the first three age groups, i.e. 30, 35 and 40 years, respective-
of 3–4 ml/min/1.73 m2/year [3, 7]. Studies by of our own ly). Thus, the GFR of our patient now age 30 would be ap-
group have shown that controlling blood pressure and reduc- proximately 19 ml/min/1.73 m2 (eGFR decline of 1.5 ml/min/
ing proteinuria with an ACEI should reduce the rate of loss 1.73 m2) and that at this level of function his life expectancy is
down to around 1.5 ml/min/1.73 m2/year [2, 7]. reduced by 70 % from 50.6 to 15 years.
Assuming that the 19-year-old patient with a serum creat- The excess mortality associated with renal failure is due
inine level of 200 μmol/l has an eGFR of 35 ml/min/1.73 m2 principally to the increased risk of cardiovascular disease.
and that he will need dialysis when his eGFR is around 10 An investigation of the causes of death associated with
ml/min/1.73 m2, then he should reach ESRD in approximately CKD in Alberta revealed that the major cause of death
17 years [(35 − 10) divided by 1.5 years]. If he were to lose was cardiovascular (including an increase in heart failure
function at the faster rate of 3 ml/min/year, this would be and valvular disease). The unadjusted proportion of pa-
8.3 years. tients who died from cardiovascular disease increased with
decreasing eGFR [21, 37, 41, and 44 % of patients with an
eGFR of ≥60 (with proteinuria), 45–59.9, 30–44.9, and
Life expectancy with CKD 15–29.9 ml/min/1.73 m2, respectively]. The proportion of
deaths from infection also increased but not those from
Life expectancy tables for people with CKD have been cancer [13].
created from a large population-based registry in Alberta, In a separate review using meta-analysis to examine the
Canada and stratified for different levels of eGFR [10]. influence of both reduced eGFR and albuminuria on car-
Data are calculated for men and women from 30 years of diovascular mortality the authors found that both lower
age to age 85 years by their levels of kidney function as eGFR (<60 ml/min/1.73 m 2 ) and higher albumin/
defined by eGFRs of ≥60, 45–59, 30–44 and 15–29 creatinine ratio (ACR ≥10 mg/g) were independent predic-
ml/min/1.73 m2 (see Table 1) [10]. These data show that tors of mortality risk in the general population [14].
life expectancy is progressively reduced with each age Adjusted hazard ratios (HRs) for all-cause mortality at
band of worse renal function. eGFRs of 60, 45 and 15 ml/min/1.73 m2 (vs. 95 ml/min/
Assuming our 19-year-old patient will be alive in 1.73 m2) were 1.18 [95 % confidence interval (CI) 1.05–
11 years, when he reaches 30 (the starting age of the 1.32], 1.57 (95 % CI 1.39–1.78) and 3.14 (95 % CI 2.39–
Canadian data), what can be expected? Looking at men 4.13), respectively. The ACR was associated with mortal-
age 30–34 years (see Table 1), the life expectancy for those ity risk linearly on the log-log scale without threshold ef-
with an eGFR of ≥60 ml/min/1.73 m2 is 39.1 years. This is fects. Adjusted HRs for all-cause mortality at ACRs of 10,
lower than expected and certainly much less than in the UK 30, and 300 mg/g (vs. 5 mg/g) were 1.20 (1.15–1.26), 1.63
database. For instance, data from the UK predict that a (1.50–1.77) and 2.22 (1.97–2.51), respectively. These data
normal, healthy white male aged 30 years in 2015 has a are derived from populations a higher mean age, but age
remaining expected lifetime of 50.7 years [11]. The equiv- was not an independent variable.
alent figure for the USA suggests that for a 30- to 34-year- Thus, our patient, aged 19–36, even with an eGFR of
old male the expected life expectancy is 45.7 years [12] approximately 45 ml/min/1.73 m2, has an increased risk of
(see Table 2). The authors of this latter study explain that dying of around 57 % [risk ratio (RR) 1.57] compared with
this difference is attributed to the selective nature of their an eGFR of 95 ml/min/1.73 m2; similarly, with a ACR of
study cohort, which was limited to individuals who had 30 mg/g, our patient has an increased risk of dying of
outpatient serum creatinine measurements as part of rou- around 63 % (RR 1.63) compared with ACR of 5 mg/g
tine care. They write that those with an eGFR of >60 ml/ [14]. These figures correlate with life expectancy tables
Pediatr Nephrol (2017) 32:243–248 245
Values in table are presented as the mean life expectancy (in years), with the 95 % confidence interval in
parenthesis, according to age, gender and level of estimated glomerular filtration rate (eGFR)
a
Table is taken from Turin et al. [10] (used with permission)
[10] in which a 30-year male with an eGFR of 30–44 extrapolate that his life expectancy is reduced by around 50 %.
ml/min/1.73 m2 has a life expectancy reduced by approx- For a UK male aged 19 years, a life expectancy of 61.4 years
imately 50 % compared with a similar patient with an [11] is reduced to 30 years (age 49 years) [10].
eGFR of ≥60 ml/min/1.73 m2. Assuming that our patient would be around 36 years of age
To this equation we should also consider modification of when end-stage renal failure is reached, then one can use two
life expectancy by such factors as race, gender and socio- sources of actuarial information regarding future life
economic status [15, 16], as well as control of blood pressure expectancy:-
and hyperlipidemia [17]. All of these factors are being studied
in the ongoing Chronic Kidney Disease in Children (CKiD) 1) The USRDS Annual Report’s chapter on mortality and
Study. survival has actuarial tables which show data in 5-year
age bands [12] (Table 2). Thus, at 36 years of age, our
patient falls into the age band 35–39 years. This shows us
Predicting life expectancy at end-stage that a normal U.S. male of this age group can expect to
live a further 41 years. The same age group will live a
If our patient is well looked after for the next 17 years, I will further 12.5 years on dialysis and 30.8 years after a suc-
assume that he will not die before he reaches ESRD at the age cessful transplant. Of course, in reality, RRT life will tend
of 36 (age 19 + 17 years at a GFR decline rate of 1.5 ml/min/ to be a mixture of the two modes.
1.73 m2/year). However, we now know that this assumption 2) The UK Renal Registry annual report chapter on survival
cannot be made. As we have seen from the Canadian data, also has actuarial data in 5-year age bands [18]. However,
even at age 19 years with a GFR of 35 ml/min/1.73 m2, we can these show that the median life expectancy for patients
246 Pediatr Nephrol (2017) 32:243–248
Table 2 Expected remaining lifetime (years) by age, sex, and treatment from 7.2 years in 1996 to 11.5 years in 2013 (see Fig. 1).
modality of prevalent dialysis patients, prevalent transplant patients, and
Thus, one can anticipate that our current projections of life
the general U.S. population (2012) based on USRDS data and the
National Vital Statistics Reporta expectancy probably err on the pessimistic side of reality.
This is supported by a detailed analysis of paediatric outcome
ESRD patients, 2013 General U.S. population, 2012 over the period 1990–2010 [19].
Dialysis Transplant Male Female
starting RRT at the 90-day time point and for this age
group (35–39 years) is a further 13.5 years (dialysis and
transplant combined).
3) In comparison, the Canadian data show that at age 35
years with an eGFR of 15–29 ml/min/1.73 m2, the re-
maining life expectancy is +13.8 years [10].
Trends in life expectancy Fig. 1 Expected remaining lifetime (years) on dialysis for a 36-year-old
man 1996–2013. The data in this figure are taken from on-line archives of
United States Renal Data System (USRDS) 1996–2014[12] The
A review of annual reports from the USRDS in the period interpretation and reporting of these data are the responsibility of the
1996–2013 reveals that the life expectancy for a 36-year-old author and in no way should be seen as an official policy or
man on haemodialysis has improved steadily and linearly interpretation of the U.S. government
Pediatr Nephrol (2017) 32:243–248 247
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Conflict of interest The author declares no conflict of interest
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