终末期糖尿病肾病血液透析患者危险因素分析

目的 :探讨影响终末期糖尿病肾病 (DN)血液透析患者生活质量及长期存活的各种危险因素及防治方法。方法 :选择 5 0例终末期糖尿病肾病血透患者和同期 6 0例相同年龄段非糖尿病血透患者 ,分别观察死亡原因、存活率、并发症、内瘘使用情况及血生化改变。结果 :①糖尿病肾病组 1年和 2年存活率分别为 80 %和 72 %。主要死因是心血管病变 ,其次是感染。②首次透析时的肌酐值与病死率成正比。③影响透析效果的主要并发症是心血管病变 (84% )、高血压 (90 % )、透析低血压 (32 % )、感染 (5 0 % ) ,与非糖尿病肾病组比较有显著性差异。结论 :糖尿病肾病终末期患者较非糖尿病患者应更早进行血透 ,血肌酐 >5 0 0 μmol/L即应透析 ,控制两次透析期间的体重增加<2 .5kg ,减少透析时血糖波动 ,防治并发症是减少危险因素 ,提高存活率及生活质量的关键。     

高通量透析对老年维持性血液透析患者住院率及死亡率的影响

目的探讨高通量血液透析对老年维持性血液透析患者住院率及死亡率的影响。方法行高通量透析且透析龄超过3个月的维持性血液透析患者141例,按年龄分为两组:年龄≥65岁的老年组(79例)和年龄<65岁的非老年组(62例),血液透析频率为3次/w,4 h/次,回顾性分析研究对象在此期间的住院情况和死亡情况,并进行原因分析。结果老年组住院例数较非老年组明显增高(P<0.01),年住院率较非老年组亦明显升高(P<0.05)。心血管事件、脑血管事件、呼吸道感染及血管通路是老年血液透析患者住院的前4位原因,老年组年死亡率为164.55人次/1 000患者年。心血管事件是老年透析患者死亡的最主要原因。结论老年组高通量血液透析患者的住院例数、住院率及死亡率较非老年组患者明显增高,心血管事件是老年组血液透析患者住院及死亡的最主要原因。     

维持性血液透析住院患者临床特征分析

目的探讨维持性血液透析因并发症或合并症住院患者的临床特征,为降低该类患者的住院率和死亡率提供理论依据。方法回顾性分析133例维持性血液透析因各类并发症或合并症住院患者的临床资料,根据性别、年龄、透析龄进行分组,比较组间临床特征差异。结果133例患者中,住院病因前3位分别是感染性疾病、心脑血管疾病和动静脉内瘘失功。≥60岁者心脑血管病、恶性肿瘤发生率及死亡率显著增高。透析龄〉60个月者心脑血管疾病及继发性甲状旁腺功能亢进症发生率显著增高。死亡原因前3位分别是肺部感染、心脑血管疾病和恶性肿瘤。结论肺部感染和心脑血管疾病是维持性血液透析患者常见的住院病因及死亡原因;年龄和透析龄可能对心脑血管疾病发生率及死亡率具有一定影响。     

高龄尿毒症患者维持性血液透析的临床分析

目的 探讨高龄尿毒症患者维持性血液透析的可行性和有效性.方法 回顾性总结和分析血液透析治疗37例75岁以上慢性肾衰竭患者的临床效果及死亡原因.结果 血透能有效延长75岁以上尿毒症患者的生命,其死亡原因主要为心血管疾病,其次是感染.存活期≥12月与＜12月的患者比较,开始透析前年龄越小,内生肌酐清除率和血浆蛋白水平越高;贫血程度较轻,而透析期间的营养状况越好;透析更充分,心血管并发症和感染越少.均有统计学差异(P＜0.05).结论 分析表明透析前年龄、原发病为糖尿病、透析中发生心血管并发症或感染、血浆白蛋白水平、贫血纠正程度等是高龄血液透析患者死亡的独立危险因素;血液透析是治疗高龄(≥75岁)尿毒症患者的有效手段.     

老年维持性血液透析患者第1年内的生存状况影响因素分析

目的分析老年维持性血液透析(MHD)患者在开始透析第1年的生存状况,并探讨其影响因素。方法选取2010年6月1日至2013年12月31日新入北京老年医院血液净化中心开始血液透析治疗的老年终末期肾病患者56例,所有患者随访观察1年,并收集其临床资料。根据是否死亡分为死亡组和存活组,先进行组间比较,再采用多因素logistic回归分析死亡危险因素。结果随访观察1年后,56例患者中死亡22例,我院继续透析30例,分别归入死亡组和存活组,第1年内死亡率达39.3%,前3个月死亡率达17.9%;两组患者在合并糖尿病、合并充血性心力衰竭、C-G公式的估算肾小球滤过率、血清白蛋白、C-反应蛋白、主观全面评估(SGA)法评分等比较,差异均有统计学意义(P0.05);多因素logistic回归分析显示,原发病为糖尿病肾病、进入透析时合并充血性心力衰竭、透始肾小球滤过率、透始血清白蛋白、透始C-反应蛋白、透始SGA评分为老年MHD患者进入透析第1年内死亡的危险因素,透始合并心力衰竭为最危险因素;死亡原因主要为心血管疾病(54.5%)和脑血管病(22.7%)。结论老年终末期肾病患者是新入MHD患者的主要人群,其开始透析后1年内特别是3个月内死亡风险最高,心血管疾病为死亡的首要原因。关注并积极控制患者的死亡危险因素可能有助于提高老年MHD患者的早期生存率。     

银杏达莫注射液治疗糖尿病肾病临床观察

<正>糖尿病肾病(DN)是糖尿病最常见、最严重的微血管并发症,危害性大,是糖尿病主要死亡原因之一。在西方国家已成为终末期肾病的首要原因,而在我国接受透析治疗的终末期肾病患者中,糖尿病肾病所占的比例也增至15%。因此加强糖尿病肾病早期防治尤为重要。我们使用银杏达莫注射液治疗     

影响2型糖尿病肾衰患者早期血液透析死亡的危险因素

目的探讨影响2型糖尿病肾衰患者早期血液透析死亡的危险因素,以改善预后。方法通过对我院62例2型糖尿病肾衰竭行血液透析患者临床资料的回顾性研究,应用二值多元logistic回归对导致患者死亡的危险因素进行分析。结果心衰、低蛋白、低胆固醇血症、透析时的内生肌酐清除率水平、透析前高血压年数、低血红蛋白等是与病死率相关的危险因素(P<0.05),透析中并发症(高血压、低血压、消化道出血、低血糖)、高龄、感染、慢性病数目与病死率无关。结论心衰、低蛋白、低胆固醇血症、透析时的内生肌酐清除率水平、透析前高血压年数、低血红蛋白等因素是影响DM肾衰早期血液透析患者死亡率的原因,与预后有关。     

糖尿病终末期肾病患者透析方式的探讨

目的比较腹膜透析（PD）及血液透析（HD）对糖尿病终末期肾病患者长期预后的影响,以便为临床选取适当治疗方法提供参考。方法将131例糖尿病终末期肾病患者分为HD组（58例）和PD组（73例）,比较两组患者的血液生化指标、生存率和死亡原因。结果两组患者年龄比较无显著性差异,但大于65岁的老年糖尿病患者PD组明显增多（P〈0．01）。透析第1、第2年两组患者死亡率比较无显著性差异,第3、4年PD组死亡率大幅上升,显著高于HD组（P〈0．01）。HD组18例死亡患者中,年龄大于65岁者4例（22．2％）;PD组29例死亡患者中,年龄大于65岁者17例（58．6％）,两组比较有显著性差异（P〈0．01）。HD组死亡主要原因为脑血管病变（占38．9％）,PD组死亡主要原因为感染（占34．5％）。PD组空腹血糖、甘油三酯、胆固醇均高于HD组,两组比较差异有显著性（P〈0．01）。PD组患者血浆白蛋白、血钾明显低于HD组（P〈0．01）。结论糖尿病终末期肾病患者适于PD,但PD组患者2年以上远期生存率明显低于HD组,尤其是大于65岁高龄糖尿病患者PD死亡率明显上升。腹膜透析相对于血液透析仍存在局限性。     

终末期糖尿病肾病患者持续性非卧床腹膜透析与血液透…

目的：研究糖尿病终末期肾病（ＥＳＲＤ）患者的透析治疗，选择血液透析（ＨＤ）好还是持续性非卧床腹膜透析（ＣＡＰＤ）好。 方法：观察了８例接受透析治疗的糖尿病ＥＳＲＤ患者，其中５２例进行ＨＤ治疗，１６例进行ＣＡＰＤ治疗。对比两组患者透析前后的血液生化指标、生存率、死亡原因、血糖的控制、透析后主要并发症。 结果：６０岁以下ＨＤ或ＣＡＰＤ治疗患者３年生存率均达７５％以上。但透析前合并有高血压、心脏肥大、冠     

维持性血液透析患者死亡原因及相关危险因素分析

目的 探讨维持性血液透析患者死亡原因和相关危险因素.方法 选择2003-01～2007-12在该院肾内科血液净化中心治疗的122例维持性血液透析患者的临床和血液透析资料进行回顾性分析.结果 122例患者中,死亡56例,占45.9%,其中因心血管病死亡31例(55.38%),严重感染9例(16.07%),脑血管病7例(12.50%),全身衰竭6例(10.71%),消化道出血3例(5.36%).其他如贫血、高血压、糖尿病、营养不良、低血压和高钾血症等也是与血液透析死亡密切相关的危险因素.结论 心血管病和严重感染是维持性血液透析患者死亡的主要原因.充分透析,积极控制相关的危险因素,防治并发症可降低病死率并提高生存质量.     

Hospital outcome of acute myocardial infarction in patients with and without diabetes mellitus.

AIMS: To assess hospital mortality and morbidity in diabetic and non-diabetic patients with acute myocardial infarction and to compare the results between the two groups. METHODS: All patients admitted in 1999 to the intensive care unit of the Schwabing City Hospital with diagnosis of acute myocardial infarction were assessed for hospital mortality and co-morbidity. RESULTS: Three hundred and thirty patients with acute myocardial infarction were admitted. Of those, 126 (38%) were diabetic and 204 (62%) were non-diabetic patients. Mortality within 24 h after admission was 13.5% in diabetic patients and 5.4% in non-diabetic patients (P<0.01). Mortality during entire hospitalization was higher in diabetic than in non-diabetic patients (29.4% vs. 16.2%; P=0.004). Diabetic patients were resuscitated more frequently than non-diabetic patients (24% vs. 11%, P<0.01). In diabetic patients, heart rate at admission was increased (91 +/- 27 vs. 82 +/- 23/min; P<0.01) and presence of angina pectoris was reported less frequently (59% (n=72) vs. 82% (n=167); P<0.001). Preceding myocardial infarction, microalbuminuria, peripheral artery disease and arterial hypertension were more frequent in diabetic than in non-diabetic patients. Diabetic patients demonstrated higher C-reactive protein (CRP) levels than non-diabetic patients (91.4 +/- 78.2 mg/l vs. 45.2 +/- 62.4 mg/l; P<0.001). CONCLUSIONS: In diabetic patients with acute myocardial infarction, early hospital mortality is increased and signs of cardiac autonomic dysfunction and microangiopathy are detected more frequently than in non-diabetic patients. The need for advanced treatment strategies early in the course of diabetic patients with myocardial infarction is emphasized.     

Outcome of Unstable Angina in Patients with Diabetes Mellitus

This prospective hospital-based, case–control study compares the outcome of unstable angina in non-insulin dependent diabetic patients and non-diabetic control subjects. One hundred and sixty-two diabetic patients and 162 non-diabetic control patients with unstable angina were entered into the study. The 3-month mortality was 8.6 % (95 % confidence interval, CI = 4.4–12.9 %) in diabetic patients and 2.5 % (CI = 0.1–4.9 %) in control patients (p = 0.014). The 1-year mortality was 16.7 % (CI = 10.9 %–22.4 %) in diabetic patients and 8.6 % (CI = 4.4 %–12.9 %) in non-diabetic patients (p = 0.029). Diabetic patients received beta-blockade and underwent coronary angiography and angioplasty less frequently than controls; the frequency of unstable angina, of acute myocardial infarction, and of coronary artery bypass grafting was similar in both groups at 1 year of follow-up. It is concluded that diabetic patients with unstable angina have a higher mortality than non-diabetic patients and that this difference is largely accounted for by early (first 3 months) mortality. © 1997 by John Wiley & Sons, Ltd.     

Comparative Analysis of Patency,Limb Salvage and Survival in Diabetic and Non-diabetic Patients Undergoing Infrainguinal Bypass Surgery

In 92 diabetic and 175 non-diabetic patients undergoing 336 femoropopliteal or femorodistal bypass procedures, 1- and 3-year cumulative life-table patency, limb salvage, and survival rates were comparatively analysed. The peroperative mortality rate was significantly higher in diabetic patients (5% compared to 1.4%, p < 0.001). The cumulative graft patency rates were 61% at 12 months and 46% at 36 months in diabetic patients compared to 64 and 52% in non-diabetic patients. Significantly better patency rates were observed in limbs with good runoff compared to limbs with poor runoff in both groups. The limb salvage rates at 3 years were 70% in diabetic patients and 62% in non-diabetic patients. The survival rate at 3 years was significantly lower in diabetic patients, 62% compared to 86% in non-diabetic patients. Diabetic patients with poor runoff demonstrated a significantly lower survival rate after 36 months compared to diabetic patients with good runoff (48% and 74%, respectively). The results of this study demonstrate that the early and intermediate patency and limb salvage rates are similar in diabetic and non-diabetic patients. On the other hand the survival rate in diabetic patients, especially in those with poor distal runoff, is significantly lower than non-diabetic patients.     

Influence of diabetes mellitus on the clinical manifestations and prognosis of infective endocarditis: a report from the International Collaboration on Endocarditis-Merged Database

The purpose of this investigation was to study the influence of diabetes mellitus (DM) on outcomes of infective endocarditis (IE). Outcomes were compared between 150 diabetic and 905 non-diabetic patients with IE from the International Collaboration on Endocarditis Merged Database. Compared to non-diabetic patients, diabetic patients were older (median age 63 vs 57 y, p<0.001), were more often female (42.0% vs 31.9%, p=0.01), more often had comorbidities (41.5% vs 26.7%, p<0.001), and were more likely to be dialysis dependent (12.7% vs 4.0%, p<0.001). S. aureus was isolated more often (30.7% vs 21.7%, p=0.02), and microorganisms from the viridans Streptococcus group less often (16.7% vs 28.2%, p = 0.001) in the diabetic group. There was no difference with respect to the presence of congestive heart failure, embolism, intra-cardiac abscess, new valvular regurgitation, or valvular vegetation. Diabetic patients underwent surgical intervention less frequently (32.0% vs 44.9%, p = 0.003), and had higher overall in-hospital mortality (30.3% vs 18.6%, p = 0.001). On multivariable analysis, DM was an independent predictor of mortality (odds ratio (OR) = 1.71, 95% confidence interval (CI) 1.08-2.70), especially in male patients, as diabetic males had higher mortality than non-diabetic males (OR 2.18, CI 1.08-4.35). DM is an independent predictor of in-hospital mortality among patients hospitalized with IE.     

Cardiac disease in diabetic end-stage renal disease

Summary Little is known about the epidemiology of cardiac disease in diabetic end-stage renal disease. We therefore prospectively followed a cohort of 433 patients who survived 6 months after the inception of dialysis therapy for an average of 41 months. Clinical and echocardiographic data were collected yearly. At baseline, diabetic patients (n = 116) had more echocardiographic concentric left ventricular hypertrophy (50 vs 38 %, p = 0.04), clinically diagnosed ischaemic heart disease (32 vs 18 %, p = 0.003) and cardiac failure (48 vs 24 %, p < 0.00 001) than non-diabetic patients (n = 317). After adjusting for age and sex, diabetic patients had similar rates of progression of echocardiographic disorders, and de novo cardiac failure, but higher rates of de novo clinically diagnosed ischaemic heart disease (RR 3.2, p = 0.0002), overall mortality (RR 2.3, p < 0.0001) and cardiovascular mortality (RR 2.6, p < 0.0001) than non-diabetic patients. Mortality was higher in diabetic patients following admission for clinically diagnosed ischaemic heart disease (RR 1.7, p = 0.05) and cardiac failure (RR 2.2, p = 0.0003). Among diabetic patients older age, left ventricular hypertrophy, smoking, clinically diagnosed ischaemic heart disease, cardiac failure and hypoalbuminaemia were independently associated with mortality. The excessive cardiac morbidity and mortality of diabetic patients seem to be mediated via ischaemic disease, rather than progression of cardiomyopathy while on dialysis therapy. Potentially remediable risk factors include smoking, left ventricular hypertrophy, and hypoalbuminaemia. [Diabetologia (1997) 40: 1307–1312] Received: 25 March 1997 and in final revised form: 23 June 1997     

Predictors of early death during dialysis

The mortality among end-stage renal failure (ESRF) patients undergoing renal replacement therapy (RRT) remains high. An important proportion of these patients die shortly after the initiation of RRT. The present study aims to determine the best predictors for the early mortality in a group of 140 ESRF patients who initiated RRT between october 96 and december 99. The mean age of the study group was 61 +/- 13 years, and the mean follow-up time was 20 +/- 12 months. Diabetic nephropathy was the most prevalent etiology of renal failure (30%). The following data, collected immediately before the initiation of RRT, were included as independent variables: demographic and clinical characteristics, including the nutritional status established by the Subjective Global Assessment (SGA), follow-up time in the predialysis clinic (less or longer than 3 months), EPO therapy, vascular access, renal function (creatinine and urea clearances, and Kt/V urea), hematological and biochemical data including serum albumin, bicarbonate, transferrin, PTH and C-Reactive protein, as well as the protein catabolic rate and the percent of lean body mass normalized for ideal body weight, calculated from the 24 h total urine excretion of nitrogen and creatinine. The Cox proportional hazard regression model, stratified for an age over or less than 65 year, was utilized to determine the best predictors for the mortality during the study period. Sixty percent of patients had at least one comorbid condition, and 35% had cardiovascular diseases. Mild-moderate or severe malnutrition was observed in 48% of patients. The creatinine clearance and Kt/V urea before the initiation of RRT were: 9.50 +/- 2.64 ml/min/1.73 m2 and 1.47 +/- 0.44, respectively. Forty-one patients died during the study period (annual death rate: 17%). The best predictor of mortality was the nutritional status assessed by the SGA (OR: 2.32, IC 95% 1.54-3.48, p < 0.0001). In a second analysis in which the SGA was removed from the model, the previous history of cardiovascular diseases (OR: 2.07, CI 95%: 1.06-4.06, p = 0.032), and the percent of lean body mass/ideal weight (OR: 0.96; IC 95%: 0.93-0.99; p = 0.042), proved to be the best predictor of mortality. In conclusion, nutritional indices prior to the initiation of RRT, and the previous history of cardiovascular diseases were the best predictors of the early mortality in this unselected population on dialysis. Because nutritional status appeared to be a marker of the severity of the comorbid conditions, a better control of the number and severity of these comorbid conditions may be the best way for reducing the mortality in patients on RRT.     

Outcome of Patients with Diabetic Nephropathy after Kidney Transplantation

ABSTRACT During the period 1973–1983, 1014 patients with end stage renal failure received a kidney graft at the Helsinki University Central Hospital. As a consequence of diabetic nephropathy, 163 of them (16%) developed renal failure. Ten diabetic (6%) and 72 non-diabetic (9%) patients received grafts from a living donor. One-year patient survival did not differ between diabetic and non-diabetic patients (76% and 79%, respectively). From the second post-transplant year onwards patient survival was worse in diabetic than in non-diabetic patients. The two groups did not differ with respect to graft survival. Sixty-two diabetic patients (38%) died during the follow-up period, with myocardial infarction as the most common cause of death (31%), followed by infection (15%) and cerebral stroke (13%). Seven myocardial infarctions out of 19 occurred within three months of transplantation. However, significantly more fatal and non-fatal myocardial infarctions were observed in post-transplant patients who had returned to dialysis therapy than in patients with a functioning kidney graft. Blindness did not influence the outcome of transplantation. Nor did the transplantation significantly affect the course of this diabetic complication. In conclusion, although the early success rate of kidney transplantation in our study population was acceptable, the later outcome was poor, mainly due to advanced disease-related complications.     

Incidence of peripheral arteriosclerotic complications of the lower extremities in diabetic patients with chronic renal failure

Patients with diabetes mellitus are at high risk of arteriosclerotic complications. The same is true for those with chronic renal failure (CRF). The present study evaluated clinical factors on the occurrence of peripheral arterial diseases. The severity of peripheral arterial disease was defined as mild (plaque, calcifications) or severe (70% stenosis, obstructions) based upon ultrasonographical examination. Overall in diabetic patients, mild ultrasonographical findings such as plaque and calcification were observed in 25% (17/69) of predialysis patients and in 18% (7/38) of those on hemodialysis (HD). Severe arteriosclerotic findings such as stenosis and obstruction were seen in 42% (29/69) of predialysis patients and in 50% (19/38) of those on HD. The incidence is identical between predialysis patients and patients on HD, regardless of the severity of peripheral arterial diseases. In an attempt to compare diabetics with non-diabetics, the incidence of mild abnormal findings was found in 22% (24/107) of diabetics and in 30% (11/37) of non-diabetics. Similarly, the percentage of patients with severe arteriosclerotic findings was found in 45% (48/107) in diabetics and 11% (4/37) in non-diabetics. The incidence of the severe type findings in the diabetics is significantly more frequent than that in the non-diabetics (P < 0.01, by the chi(2) test). In non-diabetic predialysis patients, the incidence of mild arteriosclerotic findings was observed in 30% (7/23), and 29% (4/14) of non-diabetic patients on HD. Similarly, the percentage of severe type was 9% (2/23) in non-diabetic predialysis patients, and 14% (2/14) in non-diabetic patients on HD. These data are not only supportive of previous data that diabetes is a risk factor for arteriosclerosis, but also suggestive that, even before the initiation of dialysis, patients with CRF are already susceptible to arteriosclerotic assault of peripheral arterial complications.     

Long-term outcome in diabetic heart failure patients treated with cardiac resynchronization therapy

BACKGROUND: Diabetes mellitus is an independent risk factor for increased morbidity and mortality in heart failure (HF) patients. AIMS: To compare functional and structural improvement, as well as long-term outcome, between diabetic and non-diabetic HF patients treated with cardiac resynchronization therapy (CRT). METHODS: We compared response to CRT in 141 diabetic and 214 non-diabetic consecutive patients. Major events were; death from any cause, urgent heart transplantation and implantation of a left ventricular (LV) assist device. Frequencies of hospitalisation and defibrillator (CRT-D) discharges were also analyzed. RESULTS: CRT was able to significantly improve functional capacity, ventricular geometry and neurohumoral imbalance in both diabetic and non-diabetic patients over a median follow-up time of 34 months. Overall event-free survival was similar in diabetic and non-diabetic patients (HR 1.23, p=0.363), as was survival free from CRT-D interventions (HR 1.72; p=0.115) and hospitalisations (HR 1.12; p=0.500). On multivariable analysis, NYHA class IV (p=0.002), low LV ejection fraction (p=0.002), absence of beta-blocker therapy (p<0.001), impaired renal function (p=0.003), presence of an epicardial lead (p=0.025), but not diabetes (p=0.821) were associated with a poor outcome after CRT. CONCLUSIONS: Diabetic HF patients treated with CRT had a very favourable functional and survival outcome, which was comparable to non-diabetic patients.     

Mortality in diabetes mellitus: experience of a geographically defined population.

A population-based cohort study identified 915 deaths in 4186 patients with diabetes mellitus over a 5-year period. Ischaemic heart disease, cerebrovascular disease and malignant neoplasms were the major causes of death and accounted for 40%, 16%, and 14% of deaths, respectively, compared with 27%, 14%, and 25% of deaths in the non-diabetic population. Diabetic patients had a standardized mortality ratio (SMR) of 1.15 (95% Cl 1.08-1.22) (p less than 0.001). This excess risk of death was largely due to the excess death from ischaemic heart disease (SMR 1.55 (1.40-1.71); p less than 0.001) and the impact was greatest in middle-aged female patients. Stroke mortality was not significantly increased (SMR 1.09 (0.92-1.29)) while cancer mortality was reduced (SMR 0.75 (0.63-0.89); p less than 0.01). Death rates in diabetic male patients (SMR 1.04 (0.96-1.13)) did not differ significantly from those in non-diabetic male patients because the increased risk of ischaemic heart disease deaths (SMR 1.41 (1.22-1.62); p less than 0.001) was offset by the reduced risk of deaths from malignant neoplasms (SMR 0.65 (0.51-0.82); p less than 0.001). The reduction in cancer mortality did not reach statistical significance in diabetic women (SMR 0.82 (0.64-1.05)). Diabetic nephropathy and metabolic disasters were uncommon as causes of death.