Abstract
Serum albumin is a marker of malnutrition and inflammation and has been demonstrated as a strong predictor of mortality in chronic kidney disease (CKD) and end-stage renal disease (ESRD) patients. Yet, whether serum albumin levels in late-stage CKD are associated with adverse outcomes after the transition to ESRD is unknown. We hypothesize that lower levels and a decline in serum albumin in late-stage CKD are associated with higher risk of mortality and hospitalization rates 1year after transition to ESRD. This retrospective cohort study included 29,124 US veterans with advanced CKD transitioning to ESRD between 2007 and2015. We evaluated the association of pre-ESRD (91days before transition) serum albumin with 12-month post-ESRD all-cause, cardiovascular, and infection-related mortalities and hospitalization rates as well as the association of 1-year pre-ESRD albumin slope and 12-month post-ESRD mortality using hierarchical multivariable adjustments. There was a negative linear association between serum albumin and all-cause mortality, such that risk doubled (hazard ratio [HR]: 2.07, 95% confidence interval [CI]: 1.87, 2.28) for patients with the lowest serum albumin <2.8g/dL (ref: ≥4.0g/dL) after full adjustment. A consistent relationship was observed between serum albumin and cardiovascular and infection-related mortality, and hospitalization outcomes. An increase in serum albumin of >0.25g/dL/year was associated with reduced mortality risk (HR: 0.76, 95% CI: 0.63, 0.91) compared with a slight decline in albumin (ref: >-0.25 to 0g/dL/year), whereas a decline more than 0.5g/dL/year was associated with a 55% higher risk in mortality (HR: 1.55, 95% CI: 1.43, 1.68) in fully adjusted models. Lower pre-ESRD serum albumin was associated with higher post-ESRD all-cause, cardiovascular, and infection-related mortalities and hospitalization rates. Declining serum albumin levels in the pre-ESRD period were also associated with worse 12-month post-ESRD mortality.
Highlights
An increase in serum albumin of >0.25 g/dL/year was associated with reduced mortality risk (HR: 0.76, 95% CI: 0.63, 0.91) compared with a slight decline in albumin, whereas a decline more than 0.5 g/dL/year was associated with a 55% higher risk in mortality (HR: 1.55, 95% CI: 1.43, 1.68) in fully adjusted models
Lower pre-end-stage renal disease (ESRD) serum albumin was associated with higher post-ESRD allcause, cardiovascular, and infection-related mortalities and hospitalization rates
PROTEIN–ENERGY WASTING (PEW), a condition characterized by metabolic and nutritional changes leading to depleted stores of protein and energy, has been considered as one of the strongest indicators of death in chronic kidney disease (CKD) and maintenance hemodialysis patients.[1,2,3]
Summary
PROTEIN–ENERGY WASTING (PEW), a condition characterized by metabolic and nutritional changes leading to depleted stores of protein and energy, has been considered as one of the strongest indicators of death in chronic kidney disease (CKD) and maintenance hemodialysis patients.[1,2,3] Serum albumin is a protein synthesized by the liver, whose synthesis and thereby serum levels are impacted by conditions related to both nutrition (protein intake) and inflammation.[4,5,6] Many studies have indicated hypoalbuminemia in CKD and end-stage renal disease (ESRD) patients as a strong indicator of PEW.[1,3,7] Lower serum albumin levels have been associated with higher all-cause and cardiovascular (CV) death risk in nondialysis-dependent CKD patients.[8,9,10,11] In maintenance hemodialysis patients, low baseline serum albumin is a potent predictor of adverse outcomes such as lower health-related quality of life and higher hospitalization rates and death risk.[12,13,14,15,16] In chronic dialysis patients, in addition to the mortality–predictability of serum albumin measured at a single point in time, time-varying hypoalbuminemia independently predicts all-cause and CV mortalities.[12] studies examining change in serum albumin in ESRD patients found that declining albumin levels in ESRD were associated with higher mortality, whereas increasing levels reduced this risk.[12,17,18,19]
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