Abstract
Diabetic patients undergoing maintenance dialysis (MD) have a particularly high mortality rate. Many of the risk factors for mortality have been identified in diabetics who die before reaching end stage renal disease (ESRD), i.e. before dialysis (BD). In addition, many risk factors for mortality have been identified in diabetics after dialysis onset (AD). However, whether in the BD period there are long-term risk factors for AD mortality in diabetics is unknown. We therefore investigated a new concept, i.e. that clinical and biochemical risk factors during the BD stage affect long-term AD mortality. We performed a population based retrospective cohort study, in diabetic CKD patients in a single center in south Israel who initiated MD between the years 2003 and 2015. Clinical and biochemical data 12 months BD and 6 months AD were collected and evaluated for association with mortality AD using Cox’s proportional-hazards model. BD parameters that were found to be significant were adjusted for significant parameters AD, thus generating a “combined” regression model in order to isolate the contribution of BD factors on long term mortality. Six hundred and fifty two diabetic MD patients were included in the final analysis. Four independent BD parameters were found in the multivariate model to significantly predict AD mortality: age, BMI (inversely), pulse pressure (U-shaped) and cardiovascular comorbidity. AD independent risk factors for mortality were age, BMI (inversely) and albumin (inversely). Of note, BD factors remained dominantly significant even after additionally adjusting for AD factors. No association was found between either BD HbA1C levels or BD proteinuria and AD mortality. In diabetics who reach ESRD, BD parameters can predict long term AD mortality. Thus, some of the factors affecting the poor survival of diabetic MD patients appear to begin already in the BD period.
Highlights
In 2009 Lamiere et al.[8] had introduced the hypothesis that the dismal after dialysis onset (AD) survival of the general maintenance dialysis (MD) population derives from before dialysis (BD) cardiovascular factors
Because this association found in the multivariate AD model became insignificant in the combined AD + BD model, we suggest that the obesity paradox in MD may begin already in the BD period
Because stages 3–5 in the general CKD population are widely heterogenous, our findings focus on diabetic BD with CKD stage 4 (Table S2) and suggest that the protective effect of obesity on AD mortality may begin already in the BD period
Summary
In 2009 Lamiere et al.[8] had introduced the hypothesis that the dismal AD survival of the general MD population derives from BD cardiovascular factors. In a mostly non-diabetic population the long-term follow up of the MDRD study[9] showed that strict blood pressure control during CKD did not prevent progression to ESRD, it had a beneficial effect on mortality AD. It appears that BD risk factors for AD mortality are less established in general and in diabetic MD patients in particular. To this end we analyzed BD and AD risk factors and compared their association with AD mortality
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