Mortality In Incident Dialysis Patients Research Articles

#1469 Predicting mortality risk in incident dialysis patients using clinical predictors and patient-reported predictors

Abstract Background and Aims Prognostic prediction models can be used to identify dialysis patients that are at high risk of dying. By doing so, vulnerable patients can be monitored more closely and treatment can be intensified where needed. In addition, individualized predictions can help inform patients about their prognosis. Traditionally, prognostic models primarily rely on known clinical predictors such as age, comorbidities and laboratory markers. Although it is still unchartered territory in the field of nephrology, studies in other fields have shown that patient-reported predictors, like pain and fatigue, can be of use as predictors of survival. Predictive performance of current prognostic models for mortality risk amongst dialysis patients is subpar and we hypothesized that the addition of patient-reported predictors may improve predictions. Therefore, we aimed to develop a novel prognostic model for the prediction of two-year mortality in patients starting dialysis using both clinical predictors and patient-reported predictors. Method Data from the Netherlands Cooperative Study on the Adequacy of Dialysis (NECOSAD) were used to develop two prognostic models for the prediction of 2-year all-cause mortality in incident dialysis patients: a base model consisting of clinical predictors and an updated model containing additional patient-reported predictors. Missing data were handled using a tenfold multiple imputation with fully conditional specification. The imputation model included all candidate predictors as well as the outcome variable of 2-year mortality. Predictors for the base model were selected based on existing mortality models and clinical expertise. Patient-reported predictors to add to the base model were chosen based on availability in NECOSAD, clinical expertise and literature describing patient-reported predictors. The models were developed using multivariate logistic regression and their discriminative abilities were assessed by calculating the area under the curve (AUC). Results A total of 1956 patients from NECOSAD were used for the analyses. Of these, 447 (22.9%) died within two years after baseline (3 months after dialysis initiation). The base model contained the following predictors: age, sex, serum albumin, C-reactive protein, diabetes mellitus, hemoglobin, residual kidney function (GFR at 3 months), body mass index, cardiovascular disease, dialysis modality, malignancy and primary kidney disease. The discriminative abilities of the base model were moderate with a AUC of 0.79 (95% CI: 0.77-0.82). The base model was updated using the following patient-reported predictors: mental component score, physical component score, general health perception, number of symptoms, symptom burden (measured with the KDQOL instrument) depressive symptoms, fatigue and pain. The addition of the patient-reported predictors marginally improved the predictive performance of the model achieving an AUC of 0.81 (95% CI: 0.79-0.84). Conclusion The base model including clinical predictors was enhanced slightly by the addition of patient-reported predictors.

Clinical frailty assessment might be associated with mortality in incident dialysis patients

Frailty is associated with mortality in maintenance dialysis patients. For incident dialysis patients, we used the clinical frailty scale (CFS) to investigate frailty as related to mortality or hospitalization within 2 years. We retrospectively reviewed the medical records of patients initiating hemodialysis or peritoneal dialysis during 2016–2018. Based on those records, two dialysis nurses independently used a 9-point CFS (1 = “Very fit” to 9 = “Terminally ill”) to assess each patient’s frailty at dialysis initiation. Patients with a mean CFS value of 5 or higher were classified into the frail group. The 2-year survival rates or hospitalization-free rates after the initiation of dialysis were compared between the frail (mean CFS score ≥ 5) and non-frail (mean CFS score < 5) groups. The analysis included 155 incident dialysis patients with mean age of 66.7 ± 14.1 (71% male). Frailty was inferred for 39 (25%) patients at dialysis initiation. Kaplan–Meier analyses showed that the survival rate and hospitalization-free rate within 2 years were significantly lower in the frail group than in the non-frail group (p < 0.01). Cox proportional hazards regression analyses revealed the CFS score as associated with the occurrence of a composite outcome, independently of age (hazard ratio 1.34, 95% confidence interval 1.04–1.72). Frailty assessment based on clinical judgment using CFS might predict adverse outcomes in dialysis-initiated patients.

First-year mortality in incident dialysis patients: results of the Peridialysis study

BackgroundControversy surrounds which factors are important for predicting early mortality after dialysis initiation (DI). We investigated associations of predialysis course and circumstances affecting planning and execution of DI with mortality following DI.MethodsAmong 1580 patients participating in the Peridialysis study, a study of causes and timing of DI, we registered features of predialysis course, clinical and biochemical data at DI, incidence of unplanned suboptimal DI, contraindications to peritoneal dialysis (PD) or hemodialysis (HD), and modality preference, actual choice, and cause of modality choice. Patients were followed for 12 months or until transplantation. A flexible parametric model was used to identify independent factors associated with all-cause mortality.ResultsFirst-year mortality was 19.33%. Independent factors predicting death were high age, comorbidity, clinical contraindications to PD or HD, suboptimal DI, high eGFR, low serum albumin, hyperphosphatemia, high C-reactive protein, signs of overhydration and cerebral symptoms at DI. Among 1061 (67.2%) patients who could select dialysis modality based on personal choice, 654 (61.6%) chose PD, 368 (34.7%) center HD and 39 (3.7%) home HD. The 12-months survival did not differ significantly between patients receiving PD and in-center HD.ConclusionsFirst-year mortality in incident dialysis patients was in addition to high age and comorbidity, associated with clinical contraindications to PD or HD, clinical symptoms, hyperphosphatemia, inflammation, and suboptimal DI. In patients with a “free” choice of dialysis modality based on their personal preferences, PD and in-center HD led to broadly similar short-term outcomes.

Adipokines and coronary artery calcification in incident dialysis participants.

Adipokines have been associated with increased risk of cardiovascular disease. Our aim was to determine if adipokine levels are associated with coronary artery calcification (CAC) as well as all-cause mortality in incident dialysis patients. In patients new to dialysis, we prospectively investigated the association of adiponectin, leptin and resistin with coronary artery calcification measured by ECG-gated computer tomography. Participants were recruited a median of two months after starting dialysis. The mean age was 50.0 (12.6) years and 31.1% were women. About 42% percent had BMI > 30. Higher adiponectin levels were inversely associated with CAC progression as change in Agatston score [-155.1 (-267.9, -42.2), p = 0.008] or change in CAC volumes between scans [-2.8 (-4.9, -0.6), p = 0.01]. Higher leptin levels were associated with CAC progression [110.4 (34.3-186.6), p = 0.005]. Decreased leptin [HR 0.5 (0.3-0.9), p = 0.05] was associated with all-cause mortality in adjusted models. There was no significant association between all-cause mortality and adiponectin [1.4 (0.6-3.4), p = 0.4] or resistin [HR 1.7 (0.5-5.0), p = 0.4]. High adiponectin protects against CAC progression, but is not associated with increased all-cause mortality. Higher leptin, as well as higher leptin to adiponectin ratio, is associated with CAC progression. Lower leptin levels were associated with all-cause mortality. The association of adipokines and cardiovascular disease in individuals on dialysis is complex and requires further study.

Adipose and serum zinc alpha-2-glycoprotein (ZAG) expressions predict longitudinal change of adiposity, wasting and predict survival in dialysis patients

There were limited data on adipose and serum zinc alpha-2-glycoprotein (ZAG) expression and its association with body composition in patients with advanced chronic kidney disease (CKD). This study aimed to quantify adipose and serum ZAG expression and evaluate their association with body composition and its longitudinal change, together with mortality in incident dialysis patients. We performed a single-center prospective cohort study. Patients who were planned for peritoneal dialysis were recruited. ZAG levels were measured from serum sample, subcutaneous and pre-peritoneal fat tissue obtained during peritoneal dialysis catheter insertion. Body composition and functional state were evaluated by bioimpedance spectroscopy and Clinical Frailty Scale respectively at baseline and were repeated 1 year later. Primary outcome was 2-year survival. Secondary outcomes were longitudinal changes of body composition. At baseline, the average adipose and serum ZAG expression was 13.4 ± 130.0-fold and 74.7 ± 20.9 µg/ml respectively. Both adipose and serum ZAG expressions independently predicted adipose tissue mass (ATM) (p = 0.001, p = 0.008, respectively). At 1 year, ATM increased by 3.3 ± 7.4 kg (p < 0.001) while lean tissue mass (LTM) remained similar (p = 0.5). Adipose but not serum ZAG level predicted change in ATM (p = 0.007) and LTM (p = 0.01). Serum ZAG level predicted overall survival (p = 0.005) and risk of infection-related death (p = 0.045) after adjusting for confounders. In conclusion, adipose and serum ZAG levels negatively correlated with adiposity and predicted its longitudinal change of fat and lean tissue mass, whilst serum ZAG predicted survival independent of body mass in advanced CKD patient.

Validation of a United Kingdom Model to Predict Mortality in Incident Dialysis Patients in the Dialysis Outcomes and Practice Patterns Study Cohort: Introduction of a Clinical Risk Score

Patients with kidney failure represent a heterogeneous group, in which many factors, including age, the cause of kidney disease, comorbidities, and so forth, result in a wide variation of mortality risk.1 A number of predictive models are available to assess the patient’s individual risk of mortality at the time of dialysis initiation.2 However, few are applicable to patients treated with hemodialysis (HD) and peritoneal dialysis, many include nonroutinely available variables, and most importantly, few have been externally validated in independent cohorts, thus leaving their applicability and validity in clinical practice unanswered.

Effect of Nephrology Care on Mortality in Incident Dialysis Patients: A Population-Based Cohort Study.

Long-term and continuous nephrology care effects on post-dialysis mortality remain unclear. This study aims to systematically explore the causal effect of nephrology care on mortality for patients with dialysis initiation. We conducted a retrospective cohort study to include incident patients with dialysis for ≥ 3 months in Taiwan from 2004 through 2011. The continuous nephrology care of incident patients in the three years before their dialysis was measured every six months. Continuous nephrology care was determined by 0–6, 0–12, …, 0–36 months and their counterparts; and none, intermittent, 0–6 months, …, and 0–36 months. Simple and weighted hazards ratio (HR) and 95% confidence interval (CI) for one-year mortality were estimated after propensity score (PS) matching. We included a total of 44,698 patients (mean age 63.3 ± 14.2, male 51.9%). Receiving ≥ 1 year predialysis nephrology care was associated with a 22% lower post-dialysis mortality hazard. No different effects were found (ranges of PS matching HR: 0.77–0.80) when comparing the defined duration of nephrology care with their counterparts. Stepped survival benefits were newly identified in the intermittent care, which had slightly lower HRs (weighted HR: 0.88, 95% CI: 0.79–0.97), followed by reviving care over six months to two years (ranges of weighted HR: 0.60–0.65), and reviving care over two years (ranges of weighted HR: 0.48–0.52). There was no existing critical period of nephrology care effect on post-dialysis, but there were extra survival benefits when extending nephrology care to >2 years, which suggests that continuous and long-term care during pre-dialysis/chronic kidney disease phase is required.

Adipose expression of miR-130b and miR-17-5p with wasting, cardiovascular event and mortality in advanced chronic kidney disease patients.

There are limited data on the association of adipose microRNA expression with body composition and adverse clinical outcomes in patients with advanced chronic kidney disease (CKD). We aimed to evaluate the association of adipose miR-130b and miR-17-5p expressions with body composition, functional state, cardiovascular outcome and mortality in incident dialysis patients. We performed a single-center prospective cohort study. Patients who were planned for peritoneal dialysis were recruited. miR-130b and miR-17-5p expressions were measured from subcutaneous and pre-peritoneal fat tissue obtained during peritoneal dialysis catheter insertion. Body composition and physical function were assessed by bioimpedance spectroscopy and Clinical Frailty Scale. Primary outcome was 2-year survival. Secondary outcomes were 2-year technique survival and major adverse cardiovascular event (MACE) rate. Adipose expression of miR-130b and miR-17-5p correlated with parameters of muscle mass including intracellular water (miR-130b: r=0.191, P=0.02; miR-17-5p: r=0.211, P=0.013) and lean tissue mass (miR-17-5p: r=0.176, P=0.04; miR-17-5p: r=0.176, P=0.004). miR-130b expression predicted frailty significantly (P=0.017). Adipose miR-17-5p expression predicted 2-year all-cause survival (P=0.020) and technique survival (P=0.036), while miR-130b expression predicted incidence of MACE (P=0.015). Adipose miR-130b and miR-17-5p expressions correlated with body composition parameters, frailty, and predicted cardiovascular events and mortality in advanced CKD patients.

IL-6 Is Associated with Progression of Coronary Artery Calcification and Mortality in Incident Dialysis Patients

Introduction: Inflammation is important in the pathogenesis of atherosclerosis. Elevated interleukin-6 (IL-6) is associated with cardiovascular events and also predicts mortality in individuals with CKD. Our goal was to determine the association between IL-6, FGF23, and high-sensitivity C-reactive protein (hsCRP) on coronary artery calcification (CAC) progression and mortality in incident dialysis patients without prior coronary events. Methods: A prospective cohort of incident adult dialysis participants had CAC measured by ECG-triggered multislice CT scans at baseline and at least 12 months later. Lipids, mineral metabolism markers, FGF23, and inflammatory markers, such as IL-6 and hsCRP, were measured at the baseline visit. Results: Participants in the high IL-6 tertile had the highest baseline CAC score (133.25 [10.35–466.15]) compared to the low (0.25 [0–212.2]) and intermediate (29.55 [0–182.85]) tertiles. Almost half of the participants with high IL-6 (15 of 32 [46.9%]) experienced progression of CAC compared to participants with low (8 of 32 [25%]) and intermediate (9 of 32 [28.1%]) (p = 0.05) IL-6 levels. Each log increase in IL-6 was associated with increase in death (hazard ratio 2.2, 95% CI: 1.2–3.8; p = 0.01). After adjusting for smoking, age, gender, race, diabetes, phosphate, and baseline calcium score, IL-6 (log) was associated with 2.2 times (95% CI: 1.1–4.6; p = 0.03) increase in death. Conclusion: IL-6 is associated with progression of CAC and mortality in incident dialysis patients.

Associations of Serum Insulin-Like Growth Factor 1 with New Cardiovascular Events and Subsequent Death in Hemodialysis Patients: The DREAM Cohort.

Aim: Patients with chronic kidney disease (CKD) have elevated risk of death from cardiovascular disease (CVD). A low serum insulin-like growth factor 1 (IGF-1) level is known to predict higher risk for all-cause mortality in incident dialysis patients, although it is unknown whether IGF-1 predicts cardiovascular outcomes. Methods: This was a prospective cohort study of maintenance hemodialysis patients followed up for 5 years. Serum IGF-1 levels were measured at baseline, and patients were divided into IGF-1 tertiles. The key outcomes were all-cause mortality, a composite of new CVD, and death after new CVD events. Additional outcomes were hospitalization for infection and subsequent death. Association was analyzed using Cox proportional hazards models. Results: In the 516 patients that were analyzed, we identified 106 all-cause deaths, 190 new CVD events, and 61 subsequent deaths. In addition, there were 169 hospitalizations for infection and 47 subsequent deaths. The risk of all-cause death was the highest in the lowest IGF-1 tertile, and this association remained significant in multivariable-adjusted models. Regarding CVD outcomes, IGF-1 was not associated with new CVD events but significantly associated with subsequent death in adjusted models. Similarly, IGF-1 was not an independent predictor of hospitalization for infection, but it predicted subsequent death. Conclusions: A low IGF-1 level was not a significant predictor of new CVD events but an independent predictor of subsequent death in hemodialysis patients. Since similar associations with infection outcomes were observed, IGF-1 may be a biomarker of fragility or frailty in this population.

Erectile dysfunction and coronary artery calcification in incident dialysis patients.

Erectile dysfunction, which has been associated with mortality in the general population, is common in individuals on hemodialysis. Our aim was to determine the relationship between erectile dysfunction, coronary artery calcification and mortality in incident hemodialysis patients. A prospective cohort of incident adult dialysis patients with no history of coronary artery disease underwent coronary artery calcification measurement by ECG-triggered multi-slice computed tomography (MSCT) scan at baseline and at least 12months later. Erectile dysfunction was determined using the 15-item validated International Index of Erectile Function (IIEF-15) questionnaire. Erectile dysfunction was prevalent in 83% of patients, with 43% classified as severe erectile dysfunction, 22.4% as moderate erectile dysfunction, and 17.2% as mild erectile dysfunction. The median (IQR) coronary artery calcification score was 43.4 (0.25-353.8) for those with erectile dysfunction and 0 (0-0) for those without erectile dysfunction (p = 0.007). More than half (55.6%) of the patients with erectile dysfunction experienced progression of coronary artery calcification compared to 14.3% of patients without erectile dysfunction (p = 0.05). Mortality was 21% during an average follow-up of 5.2 (1.3) years. Twenty-three percent of patients with erectile dysfunction died compared to 10% of people without erectile dysfunction (p = 0.4). Erectile dysfunction was not significantly associated with mortality [HR 1.2 (1.3), p = 0.87]. Erectile dysfunction is common in individuals who startdialysis. It issignificantly associated with an increased coronary artery calcification score, however, it isnot associated with increased mortality in incident dialysis patients with no history of coronary artery disease.

Association of lactate dehydrogenase with mortality in incident hemodialysis patients.

Lactate dehydrogenase (LDH) plays a role in the glucose metabolism of the human body. Higher LDH levels have been linked to mortality in various cancer types; however, the relationship between LDH and survival in incident hemodialysis (HD) patients has not yet been examined. We hypothesized that higher LDH level is associated with higher death risk in these patients. We examined the association of baseline and time-varying serum LDH with all-cause, cardiovascular and infection-related mortality among 109 632 adult incident HD patients receiving care from a large dialysis organization in the USA during January 2007 to December 2011. Baseline and time-varying survival models were adjusted for demographic variables and available clinical and laboratory surrogates of malnutrition-inflammation complex syndrome. There was a linear association between baseline serum LDH levels and all-cause, cardiovascular and infection-related mortality in both baseline and time-varying models, except for time-varying infection-related mortality. Adjustment for markers of inflammation and malnutrition attenuated the association in all models. In fully adjusted models, baseline LDH levels ≥360 U/L were associated with the highest risk of all-cause mortality (hazard ratios = 1.19, 95% confidence interval 1.14-1.25). In time-varying models, LDH >280 U/L was associated with higher death risk in all three hierarchical models for all-cause and cardiovascular mortality. Higher LDH level >280 U/L was incrementally associated with higher all-cause and cardiovascular mortality in incident dialysis patients, whereas LDH <240 U/L was associated with better survival. These findings suggest that the assessment of metabolic functions and monitoring for comorbidities may confer survival benefit to dialysis patients.

P1389MAJOR OSTEOPOROTIC FRACTURES AFTER INITIATION OF DIALYSIS: INCIDENCE, PREDICTORS AND ASSOCIATION WITH MORTALITY

Abstract Background and Aims Major osteoporotic fractures (MOF) are common in dialysis patients. We investigated incidence, predictors and clinical outcomes associated with first MOF occurring after initiation of dialysis (MOFfirst). Method In Swedish Renal Registry of 9714 incident (2005 -2016) dialysis patients (median age 68 years, 67% men), we identified all MOFfirst in hip, spine, humerus and forearm. Using flexible parametric hazard models and Fine-Gray analysis, we estimated incidence, mortality rates and predictors of MOFfirst, and, in time-dependent analysis, risk of all-cause and cardiovascular disease (CVD) mortality following MOFfirst. Results During median follow-up of 2.2 years, the crude incidence rate of MOFfirst (n=835) was 24/1000 patient-years (pt-yrs) and that of hip fractures (n=470) 13/1000 pt-yrs. The multivariate-adjusted fracture incidence rates increased gradually after dialysis initiation and were 47% higher among women. Female sex, higher age, presence of comorbidities, and previous history of MOF (MOFprevious) were associated with increased risk for MOFfirst, whereas peritoneal dialysis as compared to hemodialysis was associated with decreased fracture risk. The adjusted fracture incidence rate of MOFfirst during the first 90 days following dialysis initiation was higher in patients with MOFprevious than in those without MOFprevious. MOFfirst independently predicted increased all-cause mortality (sub-distribution hazard ratio, sHR, 1.67(95%CI 1.47-1.91) and CVD-related mortality (sHR 1.49 (95%CI 1.22-1.84). Adjusted mortality rate following hip fractures was higher than for other types of MOF. Spline curves showed that mortality following MOFfirst was highest during the first 6 months of follow-up. Conclusion Major osteoporotic fractures are common and associated with increased mortality in incident dialysis patients.

Major fractures after initiation of dialysis: Incidence, predictors and association with mortality.

Major fractures (MF) are common in dialysis patients. We investigated incidence, predictors and clinical outcomes associated with first MF occurring after initiation of dialysis (MFfirst). In Swedish Renal Registry of 9714 incident (2005-2016) dialysis patients (age 68years, 67% men), we identified all MFfirst in hip, spine, humerus and forearm. Using flexible parametric hazard models and Fine-Gray analysis, we estimated incidence, mortality rates and predictors of MFfirst, and, in time-dependent analysis, risk of all-cause and cardiovascular disease (CVD) mortality following MFfirst. During median follow-up of 2.2years, the crude incidence rate of MFfirst (n=835) was 23.7/1000 patient-years and that of hip fractures (n=470) 13.3/1000 patient-years. The multivariate-adjusted fracture incidence rates increased gradually after dialysis initiation and were 47% higher among women. Female sex, higher age, comorbidity, and previous history of MF (MFprevious) were associated with increased risk for MFfirst, whereas peritoneal dialysis as compared to hemodialysis was associated with decreased risk. The adjusted fracture incidence rate of MFfirst during the first 90days following dialysis initiation was higher in patients with MFprevious than in those without MFprevious. MFfirst independently predicted increased all-cause (sub-distribution hazard ratio, SHR, 1.67(95%CI 1.47-1.91)) and CVD (SHR 1.49 (95%CI 1.22-1.84)) mortality. Adjusted mortality rate following hip fractures was higher than for other types of MF. Spline curves showed that mortality following MFfirst was highest during the first 6months of follow-up. MF are common and associated with increased mortality in incident dialysis patients.

Extreme hyperuricemia is a risk factor for infection-related deaths in incident dialysis patients: a multicenter prospective cohort study

Introduction There are few studies on the association between serum uric acid (UA) level and mortality in incident dialysis patients. We aimed to clarify whether the serum UA level at dialysis initiation is associated with mortality during maintenance dialysis. Methods We enrolled 1486 incident dialysis patients who participated in a previous multicenter prospective cohort study in Japan. We classified the patients into the following five groups according to their serum UA levels at dialysis initiation: G1 with a serum UA level <6 mg/dL; G2, 6.0–8.0 mg/dL; G3, 8.0–10.0 mg/dL; G4, 10.0–12.0 mg/dL; and G5, ≥12.0 mg/dL. We created three models (Model 1: adjusted for age and sex, Model 2: adjusted for Model 1 + 12 variables, and Model 3: stepwise regression adjusted for Model 2 + 13 variables) and performed a multivariate Cox proportional hazard regression analysis to examine the association between the serum UA level and outcomes, including infection-related mortality. Results Hazard ratios (HRs) were calculated relative to the G2, because the all-cause mortality rate was the lowest in G2. For Models 1 and 2, the all-cause mortality rate was significantly higher in G5 than in G2 (HR: 1.63, 95% confidence interval [CI]: 1.14–2.33 and HR: 1.78, 95% CI: 1.19–2.68, respectively). For Models 1, 2, and 3, the infection-related mortality rate was significantly higher in G5 than in G2 (HR: 2.75, 95% CI: 1.37–5.54, HR: 3.09, 95% CI: 1.45–6.59, HR: 3.37, and 95% CI: 1.24–9.15, respectively). Conclusions Extreme hyperuricemia (serum UA level ≥12.0 mg/dL) at dialysis initiation is a risk factor for infection-related deaths.

Lower levels of proteinuria are associated with elevated mortality in incident dialysis patients.

IntroductionProteinuria is a potent predictor of adverse events in general, although a few large studies have reported a J-shaped association between proteinuria and mortality in individuals with glomerular filtration rate <30 ml/min/1.73m2. However, this association has not been specifically evaluated among incident dialysis patients.MethodsAmong 1,380 Japanese patients who initiated dialysis, we quantified the association of pre-dialysis dipstick proteinuria (negative/trace, 1+, 2+, and ≥3+) with mortality using Cox models adjusting for potential confounders, such as age, gender, clinical history of hypertension, diabetes, and cardiovascular disease.ResultsMean age of study participants was 67.4 (SD 13.0) years, and 67.6% were men. The most common dipstick proteinuria category was ≥3+ (55.4%), followed by 2+ (31.2%), 1+ (9.9%), and negative or trace (3.5%). Patients with lower proteinuria level were older than those with higher proteinuria. Lower proteinuria was significantly associated with a higher risk of all-cause mortality, even after accounting for potential confounders (p for trend <0.001). In those with negative/trace dipstick proteinuria compared to those with dipstick proteinuria ≥3+, the adjusted hazard ratio was 2.60 [95% CI: 1.62–4.17] in the fully adjusted model. Similar findings were observed when analyses were restricted to patients older than 70 years, and when cardiovascular mortality and non-cardiovascular mortality were analyzed separately.ConclusionsIn incident dialysis patients, pre-dialysis proteinuria was inversely associated with mortality risk. Although future studies are needed to identify mechanisms, our findings suggest the need to carefully interpret proteinuria in patients with incident dialysis.

Low parathyroid hormone level predicts infection-related mortality in incident dialysis patients: a prospective cohort study.

Background/AimsParathyroid hormone (PTH) is an important factor influencing immunologic dysfunction, but the effect of PTH level on infection-related outcomes remains unclear in incident dialysis.MethodsWe evaluated a multicenter prospective cohort study of 1,771 incident dialysis patients (1,260 hemodialysis and 511 peritoneal dialysis) in Korea. Patients were divided into three groups based on serum intact PTH (iPTH) level. The primary outcomes were all-cause and infection-related mortality and multivariate Cox regression analysis was performed to evaluate the role of iPTH in all-cause and infection-related mortality.ResultsDuring the follow-up period of 27.3 months, 175 patients (9.9%) died, and infection-related death represented 20% of all-cause mortality. Both all-cause mortality and infection-related mortality rates (p < 0.001 and p = 0.003, by logrank) were markedly higher in patients with serum iPTH < 150 pg/mL than in the other groups. Multivariate Cox regression analysis revealed that patients with serum iPTH < 150 pg/mL remained at higher risk for infection-related mortality than patients in the target range of 150 ≤ iPTH < 300 pg/mL, after adjusting for confounding variables (hazard ratio [HR], 2.52; 95% confidence interval, 1.06 to 5.99; p = 0.04). The HR of infection-related mortality in patients with serum iPTH < 150 pg/mL was significantly higher in patients with low serum phosphorus, low Ca × P product, low serum alkaline phosphatase and those older than 65 years.ConclusionsLow serum iPTH level is an independent predictor of infection-related mortality in incident dialysis patients.

Prediction model for cardiovascular events or all-cause mortality in incident dialysis patients.

Some variables including age, comorbidity of diabetes, and so on at dialysis initiation are associated with patient prognosis. Cardiovascular (CV) events are a major cause of death, and adequate models that predict prognosis in dialysis patients are warranted. Therefore, we created models using some variables at dialysis initiation. We used a database of 1,520 consecutive dialysis patients (median age, 70 years; 492 women [32.4%]) from a multicenter prospective cohort study. We established the primary endpoint as a composite of the incidence of first CV events or all-cause death. A multivariable Cox proportional hazard regression model was used to construct a model. We considered a complex and a simple model. We used area under the receiver operating characteristic curve (AUROC) to assess and compare the predictive performances of the prediction models and evaluated the improvement in discrimination using the complex model versus the simple model using net reclassification improvement (NRI). We then assessed integrated discrimination improvement (IDI) to evaluate improvements in average sensitivity and specificity. Of 392 deaths, 152 were CV-related. Totally, 506 CV events occurred during the follow-up period (median 1,285 days). Finally, 692 patients reached the primary endpoint. Baseline data were set at dialysis initiation. AUROC for the primary endpoint was 0.737 (95% confidence interval [CI], 0.712–0.761) in the simple model and 0.765 (95% CI, 0.741–0.788) in the complex model. There were significant intergroup differences in NRI (0.44; 95% CI, 0.34–0.53; p < 0.001) and IDI (0.02; 95% CI, 0.02–0.03; p < 0.001). We prepared a Shiny R application for each model to automatically calculate the predicted occurrence probability (https://statacademy.shinyapps.io/App_inaguma_20190717/). The complex model made more accurate predictions than the simple model. However, the intergroup difference was not significant. Hence, the simple model was more useful than the complex model. The tool was useful in a real-world clinical setting because it required only routinely available variables. Moreover, we emphasized that the tool could predict the incidence of CV events or all-cause mortality for individual patients. In the future, we must confirm its external validity in other prospective cohorts.

Relationship between History of Ischemic Stroke and All-Cause Mortality in Incident Dialysis Patients

Background: Few studies have focused on the association between history of ischemic stroke at predialysis stage and mortality after dialysis initiation. Objective: To examine whether history of stroke in incident dialysis patients is associated with mortality, including all-cause and cardiovascular (CV)-related mortality. Methods: The study database was derived from the Aichi Cohort Study of Prognosis in Patients Newly Initiated into Dialysis, a multicenter, prospective, cohort analysis. We classified patients into 2 groups according to their history of ischemic stroke and compared their outcomes. Propensity scores (PSs) represented the probability of being assigned to a group with or without a history of ischemic stroke. We defined the following outcomes: all-cause mortality; CV-related mortality; non-CV-related mortality; infection-related mortality; and stroke event after dialysis initiation. Factors contributing to the outcomes were examined using stepwise multivariate Cox proportional hazards analysis. Results: All-cause mortality was significantly higher in the ischemic stroke group (log-rank test p < 0.001). All-cause, non-CV-related, and infection-related mortality and stroke event after dialysis initiation were significantly higher in the ischemic stroke group after PS matching (log-rank test: p < 0.001, <0.001, 0.002, and 0.002, respectively). History of ischemic stroke was associated with all-cause mortality in univariate analysis (hazard ratio [HR] 1.85, 95% CI 1.44–2.37). History of ischemic stroke before dialysis initiation was associated with all-cause mortality in multivariate analysis (HR 1.39, 95% CI 1.05–1.85). Conclusion: The present study revealed that history of ischemic stroke before dialysis initiation was associated with all-cause, non-CV-related, and infection-related mortality and stroke event after dialysis initiation during maintenance dialysis.

FP673A Clinical Risk Prediction Tool for Cardiovascular Events and Mortality in Incident Dialysis Patients

FP673A Clinical Risk Prediction Tool for Cardiovascular Events and Mortality in Incident Dialysis Patients