Maintaining work during the final 6 months prior to haemodialysis was associated with a better survival

 26% of patients had been employed 6 months prior to dialysis initiation – but this dropped to 15% when dialysis treatment was initiated.

This is the main result of a newly published study in CKJ. Additionally, the study showed that being made redundant increased mortality. Although no causal relationship can be drawn out of this retrospective study, Prof Alberto Ortiz, CKJ´s editor-in-chief concludes, “we should encourage our CKD patients to stay employed while on dialysis and support them to balance work and treatment.”

Employment is a key determinant of quality of life for all people, including haemodialysis patients [1, 2]. Employment offers social support and improves patients’ lifestyle, financial status, quality of life, and self-esteem, whilst unemployed people often face financial and social difficulties as well as physical and psychological problems. Unemployed people may spiral into a deep depression, sometimes accompanied by alcohol and drug abuse.

“Therefore it is important that patients with chronic kidney disease can maintain the work, especially when they reach the stage of end stage renal disease and are in need of dialysis treatment”, explains Professor Alberto Ortiz, editor-in chief of CKJ, in which an interesting study [3] has been published today. It analysed the employment status of 496,989 US patients initiating maintenance haemodialysis from 2006-2015 – with alarming results:

26% (n=129,622) of patients were employed 6 months prior to dialysis initiation – but this dropped to only 15% when dialysis treatment was initiated. It is not surprising that patients who were older and had more comorbidities were less likely to maintain employment, but there was also a social dimension: Females, Hispanic, African Americans, and people living in low-income zip codes lost their jobs more often.

The study showed that being made redundant was associated with mortality: Compared to those who were employed from 6 months prior to dialysis initiation, people who became unemployed in this phase had a significantly higher death rate (p<0.0001), even after adjustment for multiple co-variables. Conversely, those who continued to work were more likely to receive a transplant (p<0.0001).

Thus, maintaining employment during the final 6 months prior to haemodialysis was associated with protection against mortality and with higher rates of transplantation. “But of course we have to be careful with the interpretation of these data, because we are faced with a chicken-or-egg question. Was the survival benefit really due to the positive effect of work on body and mind of our patients – or did it simply show that those patients with lower survival rates were unemployed, because they had already been severely ill before the initiation of the dialysis treatment?” As the study authors explained in their paper, the limitations of thestudy include its retrospective design, which allowed only examination of associations between known variables, not causal relationships. Besides, data on important clinical and socioeconomic variables, such as residual renal function, depression, and nutritional status, which are also key factors that impact patients’ outcomes, were not included.

“Nevertheless, we know from the general population, that being unemployed impacts health negatively. Therefore, we should strive to offer opportunities to combine employment and dialysis to patients who are able to work, whenever it is possible. We should further strengthen peritoneal dialysis as well as home haemodialysis, which are often better dialysis modalities for patients who want to continue working. We should encourage our patients to stay employed while on dialysis and support them to balance job and treatment”, concludes Professor Ortiz.

[1] Curtin RB, Oberley ET, Sacksteder P, F et al. Differences between employed and nonemployee dialysis patients. Am J Kidney Dis 1996; 27 (4): 533-40

[2] Kutner NG, Zhang R, Huang Y, Johansen KL. Depressed mood, usual activity level, and continued employment after starting dialysis. Clin J Am Soc Nephrol 2010; 5 (11): 2040-5

[3] YuXin N, Witten B, Schatell D et al. Changes in Employment Status Prior to Initiation of Maintenance Hemodialysis in the United States, 2006-2015. CKJ 2019; 14 June.

With more than 7,000 active members, the ERA-EDTA is one of the biggest nephrology associations worldwide leading European nephrology and one of the most important European Medical Associations. It organises annual congresses and a Scientific Education Interactive Day (SEID), it produces guidelines, it collects data and performs epidemiological studies through its Registry. It supports fellowships and research projects. Its publications are NDT and CKJ (this last journal is Open Access). The ERA-EDTA also has an online Educational platform: the European Nephrology Portal (ENP) which includes NDT-Educational@ENP. The 2020 Congress will be held June 6-9 in Milan (Italy). Visit the booth to receive more information!

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