All-cause and cause-specific mortality associated with diabetes in prevalent hemodialysis patients

Abdus Sattar,John A Kellum,Mark Unruh,Nizar Younas,Linda Fried,Lisa Weissfeld,Christos Argyropoulos

doi:10.1186/1471-2369-13-130

Abstract

BackgroundDiabetes is the most common risk factor for end-stage renal disease (ESRD) and has been associated with increased risk of death. In order to better understand the influence of diabetes on outcomes in hemodialysis, we examine the risk of death of diabetic participants in the HEMODIALYSIS (HEMO) study.MethodsIn the HEMO study, 823 (44.6%) participants were classified as diabetic. Using the Schoenfeld residual test, we found that diabetes violated the proportional hazards assumption. Based on this result, we fit two non-proportional hazard models: Cox’s time varying covariate model (Cox-TVC) that allows the hazard for diabetes to change linearly with time and Gray’s time-varying coefficient model.ResultsUsing the Cox-TVC, the hazard ratio (HR) for diabetes increased with each year of follow up (p = 0.02) for all cause mortality. Using Gray’s model, the HR for diabetes ranged from 1.41 to 2.21 (p <0.01). The HR for diabetes using Gray’s model exhibited a different pattern, being relatively stable at 1.5 for the first 3 years in the study and increasing afterwards.ConclusionRisk of death associated with diabetes in ESRD increases over time and suggests that an increasing risk of death among diabetes may be underappreciated when using conventional survival models.

Highlights

Diabetes is the most common risk factor for end-stage renal disease (ESRD) and has been associated with increased risk of death
Diabetic patients were more likely to be older, female, and have a higher body mass index (BMI), and were more likely to have tunneled dialysis catheters compared to non-diabetic participants
Villar et al analyzed the data from the ANZ Dialysis and Transplant Registry and assessed the risk factors for death using Cox regression demonstrating that the adjusted hazard ratio of death was 1.64 in type 1 diabetics and 1.13 in type 2 diabetics compared to non-diabetic patients with ESRD [3]

Summary

Introduction

Diabetes is the most common risk factor for end-stage renal disease (ESRD) and has been associated with increased risk of death. Diabetes is one of the leading causes of end stage renal disease in the U.S [1] and ESRD due to type 2 diabetes mellitus has been increasing worldwide [2,3]. In the case of diabetes, effects of the disease may accumulate over time resulting in a hazard function that is increasing at a greater rate over time than that in subjects without diabetes. Since diabetes is such a prevalent and

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