ESKD Is Often Not Identified as a Cause of Death in Death Certificates

Background: Many studies have found high error rates in death certificates, as most healthcare professionals have minimal to no training regarding how to complete this important task. A recent multicenter study demonstrated that most pathologists did not recognize end-stage kidney disease (ESKD) as either an underlying or contributing cause of death (COD) in autopsy reports of ESKD patients. Therefore, we conducted this study to determine whether a similar omission could be observed in the death certificates of ESKD patients. Methods: We identified 60 deceased patients with ESKD in our electronic medical record (EMR) between August 1, 2022 and January 30, 2024. Inclusion criteria were a diagnosis of ESKD, being on dialysis for at least 1 year, and a viewable death certificate in the EMR. Patients that were 18 years or younger or had any history of kidney transplant or malignancy were excluded. Results: The average age of patients was 62 years with sex equally split. Time on dialysis ranged from 1 to 20 years with a mean of at least 5.6 years. The common co-morbidities were hypertension (28/60, 47%), diabetes (28/60, 47%), heart disease including coronary artery disease, heart failure, and arrhythmias (35/60, 58%), and other cardiovascular disease including cerebrovascular disease and peripheral vascular disease (16/60, 27%). Cardiovascular causes were the most common immediate COD (27/60, 45%) followed by infection (13/60, 22%), ESKD (10/60, 17%), and hemorrhage (6/60, 10%). ESKD was listed as an immediate or proximate COD in 22 (37%) of 60 death certificates. The majority (41/60, 68%) of death certificates were completed by trainees, and the remaining 27% (16/60) were hospitalists, physician assistants, advanced practice nurses, or primary care physicians. Of the trainees, 29% (12/41) identified ESKD as a COD. Non-trainees identified ESKD as a COD in 8/19 (42%) of cases. Conclusion: The majority (63%) of providers failed to recognize ESKD as a cause of death in death certificates. The failure to identify ESKD as an underlying or contributing COD emphasizes the decreasing sense of urgency that is commonplace among healthcare providers ever since the advent of dialysis. This study identifies an important practice gap regarding the inaccurate completion of death certificates in the setting of ESKD, which shortchanges the nephrology community and their ESKD patients.