Mortality In Incident Hemodialysis Patients Research Articles

Geriatric Nutritional Risk Index and First-Year Mortality in Incident Hemodialysis Patients.

The Geriatric Nutritional Risk Index is a simple nutritional screening method, and this study aimed to investigate the association between the initial Geriatric Nutritional Risk Index and all-cause mortality in incident patients in the first year after the initiation of hemodialysis. This study is a retrospective cohort study and used the Korean Renal Data System database. Patients who were eligible for Geriatric Nutritional Risk Index assessment and underwent hemodialysis from January 2016 to December 2019 were included. The primary outcome was all-cause mortality, and outcome evaluation was performed in December 2020. A Cox proportional hazard model was used to analyze the association between the Geriatric Nutritional Risk Index and mortality. A total of 10,545 patients were included, and the mean age was 63.9 ± 3.7 years. The patients were divided into four groups by the quartile of the Geriatric Nutritional Risk Index with a mean value of 96.2 ± 8.2. During the study period, 545 (5.2%) deaths occurred. The surviving patients had higher Geriatric Nutritional Risk Index values than ones who died in the first year of hemodialysis initiation (96.6 ± 7.5 vs. 88.2 ± 9.3, p < 0.001). Quartile 1 (Geriatric Nutritional Risk Index < 91.8) showed a significantly increased risk of all-cause (Hazard Ratio: 2.56; 95% Confidence Interval: 2.13-3.09; p < 0.001) and cardiovascular mortality (Hazard Ratio: 22.29; 95% Confidence Interval: 1.71- 3.08; p < 0.001) at the first year in comparison with Quartile 4 (Geriatric Nutritional Risk Index ≥ 101.3). In areas under the receiver-operating characteristic curves of all-cause mortality, the Geriatric Nutritional Risk Index model improved predictive values, compared to the baseline model. The area with the Geriatric Nutritional Risk Index model was significantly higher than the one with a model including albumin or body mass index (p < 0.001). These findings suggest that a low Geriatric Nutritional Risk Index (<91.8) is associated with first-year all-cause and cardiovascular mortality in patients who start hemodialysis and may be a useful and reproducible tool for assessing prognoses in this population.

Dynamic Predictions of All-Cause Mortality in Incident Hemodialysis Patients with Extended Joint Models Adjusting for Albumin Trajectory and Competing Risks

Dynamic Predictions of All-Cause Mortality in Incident Hemodialysis Patients with Extended Joint Models Adjusting for Albumin Trajectory and Competing Risks

The effect of early conversion from central venous catheter to arteriovenous fistula on hospitalization and mortality in incident haemodialysis patients.

Controversy remains as to whether initiating haemodialysis (HD) with a central venous catheter (CVC) and vascular access conversion are associated with the risk of morbidity and mortality in incident HD patients. At our dialysis centre, the vascular access strategy is to create an arteriovenous fistula (AVF) early and use the AVF to initiate HD. In emergency situations, HD is initiated with a CVC and subsequent conversion from a CVC to an AVF as soon as possible. The effects of early AVF conversion on hospitalization and mortality were analysed. At HD initiation, 35.42% used AVF, 15.63% used CVC with immature AVF and 48.96% used CVC, and all patients were able to convert from CVC to AVF within approximately 3 months. Compared to starting HD using an AVF, using a CVC was associated with access-related hospitalizations at 2 years, regardless of whether an AVF was created before (incidence rate ratio (IRR) = 3.02, 95% CI 0.89-10.24, p = 0.03) or after (IRR = 4.10, 95% CI 1.55-10.85, p < 0.01) HD initiation. The Kaplan-Meier method showed that the 2-year survival probability was not statistically significant between the three groups (log-rank χ2 = 0.165, p = 0.921). Multivariate Cox proportional hazards regression showed that starting HD with a CVC was not associated with mortality at 2 years (p > 0.05). In this cohort, initiating HD with a CVC was associated with more access-related hospitalizations. Under the impact of an early AVF conversion strategy, despite initiating HD with a CVC, subsequent conversion from a CVC to an AVF within approximately 3 months had no impact on all-cause mortality in incident HD patients.

Risk Factors Affecting 5-Year Mortality in Incident Hemodialysis Patients in the Black Sea Region of Turkiye

Risk Factors Affecting 5-Year Mortality in Incident Hemodialysis Patients in the Black Sea Region of Turkiye

Trend and determinants of mortality in incident hemodialysis patients of the Lazio region

Background. In the last decades some studies observed a moderate progressive decrease in short-term mortality in incident hemodialysis patients. The aim of the study is to analyse the mortality trends in patients starting hemodialysis using the Lazio Regional Dialysis and Transplant Registry.Methods. Patients who started chronic hemodialysis between 2008 and 2016 were included. Annual 1-year and 3-year Crude Mortality Rate*100 Person Years (CMR*100PY) overall, by gender and age classes were calculated. Cumulative survival estimates at 1 year and 3 years since the date of starting hemodialysis were presented as Kaplan-Meier curves for the three periods and compared using the log-rank test. The association between periods of incidence in hemodialysis and 1-year and 3-year mortality were investigated by means of unadjusted and adjusted Cox regression models. Potential determinants of both mortality outcomes were also investigated.Results. Among 6,997 hemodialysis patients (64.5% males, 66.1% over 65 years old) 923 died within 1 year and 2,253 within 3 years form incidence; CMR*100PY were 14.1 (95%CI: 13.2–15.0) and 13.7 (95%CI: 13.2–14.3), respectively; both remained unchanged over the years. Even after stratification by gender and age classes no significant changes emerged. Kaplan-Meier mortality curves did not show any statistically significant differences in survival at 1 year and 3 years from hemodialysis incidence across periods. No statistically significant associations were found between periods and 1-year and 3-year mortality. Factors associated with a greater increase in mortality are: being over 65 years, born in Italy, not being self-sufficient, having systemic versus undetermined nephropathy, having heart disease, peripheral vascular disease, cancer, liver disease, dementia and psychiatric illness, and receiving dialysis by catheter rather than fistula.Conclusions. The study shows that the mortality rate in patients with end-stage renal disease starting hemodialysis in the Lazio region was stable over 9 years.

C-reactive protein-to-albumin ratio and six-month mortality in incident hemodialysis patients

Background The first few months of hemodialysis (HD) are associated with a higher risk of mortality. Protein-energy malnutrition is a demonstrated major risk factor for mortality in this population. The C-Reactive Protein to Albumin ratio (CAR) has also been associated with increased mortality risk. The aim of this study was to determine the predictive value of CAR for six-month mortality in incident HD patients. Methods Retrospective analysis of incident HD patients between January 2014 and December 2019. CAR was calculated at the start of HD. We analyzed six-month mortality. A Cox regression was performed to predict six-month mortality and the discriminatory ability of CAR was determined using the receiver operating characteristic (ROC) curve. Results A total of 787 patients were analyzed (mean age 68.34 ± 15.5 years and 60.6% male). The 6-month mortality was 13.8% (n = 109). Patients who died were significantly older (p < 0.001), had more cardiovascular disease (p = 0.010), had central venous catheter at the start of HD (p < 0.001), lower parathyroid hormone (PTH) level (p = 0.014) and higher CAR (p = 0.015). The AUC for mortality prediction was 0.706 (95% CI (0.65–0.76), p < 0.001). The optimal CAR cutoff was ≥0.5, HR 5.36 (95% CI 3.21–8.96, p < 0.001). Conclusion We demonstrated that higher CAR was significantly associated with a higher mortality risk in the first six months of HD, highlighting the prognostic importance of malnutrition and inflammation in patients starting chronic HD.

High Ultrafiltration Rate Is Associated with Increased All-Cause Mortality in Incident Hemodialysis Patients with a High Cardiothoracic Ratio.

A high ultrafiltration rate (UFR) is associated with increased mortality in hemodialysis patients. However, whether a high UFR itself or heart failure with fluid overload followed by a high UFR causes mortality remains unknown. In this study, 2615 incident hemodialysis patients were categorized according to their initial cardiothoracic ratios (CTRs) to assess whether UFR was associated with mortality in patients with high or low CTRs. In total, 1317 patients (50.4%) were women and 1261 (48.2%) were diabetic. During 2246 (1087-3596) days of follow-up, 1247 (47.7%) cases of all-cause mortality were noted. UFR quintiles 4 and 5 were associated with higher risks of all-cause mortality than UFR quintile 2 in fully adjusted Cox regression analysis. As the UFR increased by 1 mL/kg/h, the risk of all-cause mortality increased 1.6%. Subgroup analysis revealed that in UFR quintile 5, hazard ratios (HRs) for all-cause mortality were 1.91, 1.48, 1.22, and 1.10 for CTRs of &gt;55%, 50-55%, 45-50%, and &lt;45%, respectively. HRs for all-cause mortality were higher in women and patients with high body weight. Thus, high UFRs may be associated with increased all-cause mortality in incident hemodialysis patients with a high CTR, but not in those with a low CTR.

The association between body mass index and all-cause mortality in Japanese patients with incident hemodialysis.

A higher body mass index (BMI) has been associated with better survival among chronic kidney disease patients in some reports. However, more research is required to determine the associations between BMI and mortality in incident hemodialysis patients. Therefore, this study aimed to investigate the association between mortality and BMI measured at the first hemodialysis session and 2 weeks after hemodialysis initiation in Japanese patients with incident hemodialysis. We retrospectively enrolled 266 adult patients with incident hemodialysis who were treated at our hospital between May 2013 and June 2019. The data on BMI was obtained at the first hemodialysis session and 2 weeks after hemodialysis initiation. Patients were divided into tertiles based on BMI [<18.5 (low), 18.5-23.9 (normal), and ≥24 (high) kg/m2]. The normal group was used as the reference group. The primary outcome was all-cause mortality. The mean age of patient was 68.9 ± 12.0 years, and the BMI was 23.3 ± 4.24 kg/m2 at the first hemodialysis session. The body mass index was 22.0 ± 3.80 kg/m2 at 2 weeks after hemodialysis initiation. During a mean follow-up of 3.89 ± 2.12 years, 80 (30.1%) deaths occurred. In multivariate analyses, low BMI at the first hemodialysis session was significantly associated with worse all-cause mortality (hazard ratio, 2.39; 95% confidence interval, 1.13-5.03). At 2 weeks after hemodialysis initiation, high BMI was significantly associated with better all-cause mortality (hazard ratio, 0.38; 95% confidence interval, 0.18-0.81). At 2 weeks after HD initiation, high BMI was associated with lower mortality in Japanese patients with incident hemodialysis.

MO818: PTH Levels and Mortality in Incident Haemodialysis Patients

Abstract BACKGROUND AND AIMS Serum intact parathyroid hormone (iPTH) is associated with the prognosis of haemodialysis (HD) patients; however, its optimal range for reducing mortality remains unknown. The aim of this study was to assess the association between different serum iPTH levels and mortality in incident HD patients. METHOD We conducted a retrospective single-centre study of incident HD patients between January 2013 and 2020. According to the iPTH level measured at baseline, patients were categorized into four groups: &amp;lt;150 pg/mL, 150–300 pg/mL, 301–600 pg/mL and &amp;gt;600 pg/mL. Clinical, analytical and demographic data were compared among groups. All-cause mortality over a mean follow-up of 3.2 years was assessed using standard survival methods. Statistical analysis was performed using SPSS (Version 23 for Mac OSX). RESULTS The mean age of 149 patients was 74.14 ± 14.17 years, 95 (63.8%) were male, 75 (50.3%) were diabetic, 85 (57%) had congestive heart failure (CHF) and 110 (73.9%) had hypertension. A total of 46 patients (30.9%) were treated with vitamin D analogues, 2 (1.3%) with calcimimetics and 25 (16.8%) with oral phosphate binders. A total of 57 (38.3%) patients had iPTH &amp;lt; 150 pg/mL, 44 (29.5%) 150–300 pg/mL, 35 (23.5%) 301–600 pg/mL and 13 (8.7%) &amp;gt; 600 pg/mL. There were no age, gender, comorbidity or HD modality differences among groups. Patients with iPTH &amp;lt; 150 pg/mL had higher c-reactive protein (CRP) (P = .042), higher serum bicarbonate (P = .020), lower albumin (P = .001), lower serum phosphate (P = .009) and lower bone-specific alkaline phosphatase (BAP) (P = .008). During the study follow-up period, 82 patients (55%) died. Multivariate Cox regression showed that patients with iPTH &amp;lt; 150 pg/mL had an increased risk of all-cause mortality when compared with those with iPTH 301–600 pg/mL {HR: 0.59, [95% confidence interval (95% CI) 0.36–0.96]; P = .035} and iPTH &amp;gt; 600 pg/mL [HR: 0.36, 95% CI 0.19–0.70; P = .02] in both unadjusted and adjusted models for age, albumin, diabetes, CHF and hypertension. No significant difference was found between iPTH &amp;lt; 150 pg/mL and iPTH 150–300 pg/mL groups. When the reference was changed to iPTH &amp;gt; 600 pg/mL, patients in this group had a decreased mortality risk when compared with those with iPTH &amp;lt; 150 pg/mL (HR: 2.75, 95% CI 1.43–5.29; P = .02) and iPTH 150–300 pg/mL (HR: 2.23, 95% CI 1.14–4.36; P = .02), but not iPTH 300–600 pg/mL. CONCLUSION In our study, the baseline iPTH level was associated with all-cause mortality in incident HD patients. Our results suggest that the optimal serum iPTH level conferring the lowest mortality risk is &amp;gt; 300 pg/mL in this group of patients.

MO847: C-Reactive Protein to Albumin Ratio and 6-Month Mortality in Incident Haemodialysis Patients

Abstract BACKGROUND AND AIMS The prevalence of chronic kidney disease (CKD) is growing worldwide and ranges from 8% to 16%. Mortality rates are higher in the first few months of haemodialysis (HD). Protein-energy malnutrition has been demonstrated to be a major risk factor for mortality in this population. The C-Reactive Protein to Albumin ratio (CAR) has been associated with increased mortality risk. We aimed to evaluate if CAR could be used to predict 6-month mortality in incident HD patients. METHOD Retrospective analysis of CKD patients who initiated chronic HD between January of 2014 and December of 2019 in a tertiary-care hospital in Portugal. CAR was calculated at HD start. We analyzed 6-month mortality. Variables were submitted to univariate and multivariate analysis to determine factors predictive of 6-month mortality after HD start. We assessed the logistic regression method of the CAR to predict 6-month mortality and the discriminatory ability was determined using the receiver operating characteristic (ROC) curve. RESULTS A total of 787 patients were analyzed (mean age 68.34 ± 15.5 years and 60.6% male). The 6-month mortality was 13.8% (n = 109). Patients who died were significantly older [76.50 ± 11.39 versus 67.29 ± 15.52 years; P &amp;lt; 0.001, OR: 1.055 (1.035–1.074); P &amp;lt; 0.001, aOR: 1.058 (1.030–1.086); P &amp;lt; 0.001], had more frequently cardiovascular disease [65.1% versus 46.1%; P &amp;lt; 0.001, OR: 2.192 (1.437–3.342); P &amp;lt; 0.001, aOR: 2.210 (1.210–4.037); P = 0.010], central venous catheter at HD start [83.5% versus 58.3%; P &amp;lt; 0.001, OR: 3.622 (2.136–6.142); P &amp;lt; 0.001, aOR: 3.090 (1.584–6.026); P &amp;lt; 0.001], lower PTH [229.44 ± 170.50 versus 365.95 ± 415.80; P = 0.006, OR: 0.998 (0.996–0.999); P &amp;lt; 0.001, aOR: 0.998 (0.997–1.000); P = 0.014] and higher CAR [2.85 ± 3.85 versus 1.36 ± 2.44; P &amp;lt; 0.001, OR: 1.159 (1.086–1.236); P &amp;lt; 0.001, aOR: 1.126 (1.023–1.239); P = 0.015]. The AUC for mortality prediction was of 0.706 [95% confidence interval (0.65–0.76); P &amp;lt; 0.001]. The optimal CAR cut-off was &amp;gt;0.5, with an odds ratio of 5.362 (95% CI 3.208–8.963; P &amp;lt; 0.001). CONCLUSION In our study, we demonstrated that higher CAR was independently associated with a higher mortality rate in the first 6 months of starting HD, highlighting the prognostic importance of malnutrition and inflammation in patients starting chronic HD.

Early mortality in incident hemodialysis patients – A retrospective case-control study

Introduction: Chronic kidney disease has significant morbidity and mortality worldwide. Various studies have demonstrated that incident patients experience a higher mortality rate within the first 3 months of dialysis. Methods: A single-center retrospective case-control study (1:3) was performed to determine early (&lt;90 days) mortality rate and associated risk factors in incident hemodialysis patients from January 2013 to December 2018. We compared variables between survivors and non-survivors at 90 days after initiation of hemodialysis. Multivariate logistic regression was used to calculate the adjusted odds ratio with 95% confidence intervals for the variables associated with early mortality and a predictive model was developed. Results: From a total of 626 incident hemodialysis patients, 48 (7.7%) died before 90 days of treatment. Non-survivors were older [OR 1.07 (1.03-1.11)], had higher rates of non-recovering acute kidney injury [OR 7.91 (3.63- 17.24)], emergency start of hemodialysis [OR 4.31 (2.15-8.62)], congestive heart failure [OR 5.68 (2.81-11.48)], ischemic cardiomyopathy [OR 4.50 (2.25-8.99)], chronic obstructive pulmonary disease [OR 3.60 (1.44-8.95)], Charlson comorbidity index [OR 1.47 (1.27-1.70)] and dependence of assistance in daily living activities [OR 3.46 (1.76-6.82)]. Patients were less likely to have 90-day mortality if they had nephrologist appointments at least 90 days prior to end-stage renal disease [OR 0.25, 95% CI (0.13-0.50); p&lt;0.001] or a higher serum albumin [OR 0.34, 95% CI (0.19-0.62); p&lt;0.001]. Multivariate analysis risk factors independently associated with early mortality were older age [aOR 1.06 (1-01-1.10), p=0.022], acute kidney injury as cause of end-stage renal disease [aOR 12.62 (4.50-35.40), p&lt;0.001], congestive heart failure [aOR 3.79 (1.58-9.11), p=0.003], and Charlson comorbidity index [aOR 1.30 (1.09-1.56), p=0.005]. The model showed very good discriminative ability [AUROC (95% CI) 0.88 (0.83-0.94)]. Conclusion: Early mortality occurred in 7.7% of our population. Our model could be used to identify patients at higher risk of death during the first 90 days of hemodialysis and aid informed decision-making regarding end-stage renal disease treatment options.

Utility of CHA2DS2-VASc Score to Predict Mid-Term Clinical Outcomes in Hemodialysis Patients

Background: The CHA₂DS₂-VASc score has been widely used to predict stroke in patients with atrial fibrillation (AF). Recently, it was reported that the CHA₂DS₂-VASc score helps predict cardiovascular disease (CVD) or all-cause mortality in patients with or without AF. However, few reports have examined the association between this score and mortality in hemodialysis (HD) patients. Methods: We analyzed 557 consecutive patients who initiated HD at our facilities between February 2005 and October 2017. The CHA₂DS₂-VASc score was calculated at the time of initiation of HD. Patients were then categorized into three groups according to their CHA₂DS₂-VASc scores: 0–1 (low), 2–3 (intermediate), and 4–9 (high). Multivariate Cox proportional hazards analysis was used to assess independent risk factors for 3-year all-cause mortality. Results: During the 3-year follow-up period, 153 (27.5%) patients died (cardiovascular death: n = 88). According to multivariate analysis, serum albumin (hazard ratio [HR] 0.60, 95% confidence interval [CI] 0.43–0.85, p = 0.003), creatinine (HR 0.91, 95% CI 0.84–0.99, p = 0.049), and CHA₂DS₂-VASc score (HR 1.33, 95% CI 1.20–1.46, p < 0.001) were associated with 3-year all-cause mortality. Compared with patients in the low CHA₂DS₂-VASc score group, those in the intermediate- and high-score groups had a higher risk for all-cause and CVD mortality (all-cause mortality: HR 1.77, 95% CI 1.23–2.55, p = 0.002 and HR 2.94, 95% CI 1.90–4.53, p < 0.001, respectively; CVD mortality: HR 1.82, 95% CI 1.27–2.59, p = 0.001 and HR 2.85, 95% CI 1.88–4.31, p < 0.001, respectively). Conclusion: The CHA₂DS₂-VASc score is a valuable predictor of 3-year all-cause and CVD mortality in incident HD patients.

Serum Albumin Trends in Relation With Prognosis of Individuals Receiving Hemodialysis Therapy.

IntroductionHypoalbuminemia is recognized as an indication of protein-energy depletion in several disease states. According to many studies, hemodialysis (HD) patients who have decreased baseline serum albumin levels exhibit a poor prognosis. However, serum albumin does not stay at a constant level with the progress of the disease, considering that only a baseline value may not precisely reflect prognostic value. The study objective was to ascertain whether there is a link between serum albumin trajectories and all-cause mortality in incident HD patients. MethodsRetrospective cohort analysis was conducted in the HD unit at the University of Health Sciences, Kayseri Training and Research Hospital, Nephrology Clinic between June 19, 2010, and December 29, 2017. A total of 408 individuals aged 18 years or older, who had at least one measurement of serum albumin at baseline, were enrolled. The outcome was all-cause death. Time-dependent Cox regression and joint model were used to investigate the associations between serum albumin trend in time and the risk of all-cause mortality.ResultsMean (SD) age was 62.17 (12.33) years, and 50.7% were male. At baseline, the mean (SD) albumin level was 3.59 (0.27). A faster decrease (per 1-SD increase in negative slope) in serum albumin levels was associated with increased risk of all-cause mortality (HR, 1.63; 95% CI, 1.08-2.84; p=0.023) in a fully adjusted joint model with slope parameterization. Also, an annual 1-SD increase in albumin level declined the hazard of all-cause mortality by 22% (HR, 0.78; 95% CI, 0.66-0.92; p=0.008) in a fully adjusted joint model with value parameterization. Similar results were obtained from time-dependent Cox models.ConclusionThese findings suggest that longitudinal albumin evaluation, including the rate of change as a slope parameter, may be valuable for risk stratification of patients receiving HD.

Longitudinal effects of modified creatinine index on all-cause mortality in individuals receiving hemodialysis treatment.

BACKGROUND: The modified creatinine index (mCI), as a surrogate marker of muscle mass, has been associated with poor outcomes in patients undergoing hemodialysis. However, a single assessment may not reflect the clinical significance before an adverse clinical endpoint.OBJECTIVE: Analyze mCI trajectories and their association with all-cause mortality in incident hemodialysis patients.DESIGN: Retrospective observational cohort.SETTING: Outpatient dialysis facility.PATIENTS AND METHODS: We followed a cohort of patients who underwent maintenance hemodialysis treatment at least three times weekly for at least three months from 19 June 2010 to 29 December 2017. Clinical and laboratory features were measured at baseline. Longitudinal changes in the mCI were modeled using a joint longitudinal and survival model adjusted for baseline covariates and body mass index trajectories.MAIN OUTCOME MEASURE: All-cause mortality.SAMPLE SIZE: 408 with 208 males (50.7%).RESULTS: The mean (SD) age was 62.2 (12.3) years. The mCI changes were evaluated for a median (interquartile range) follow-up of 2.16 (1.13, 3.73) years. Forty-six percent (n=188) of patients reached the endpoint. A steeper slope (per 0.1 unit increase in the decrease rate) in modified creatinine index was associated with increased risk of all-cause mortality (HR, 1.04; 95% CI, 1.02–1.07; P=.011). In addition, an annual 1 mg/kg/day decrease in modified creatinine index level increased the hazard of all-cause mortality by 4% (HR, 1.04; 95% CI, 1.02–1.07; P=.001).LIMITATIONS: Residual kidney function was not observed in the data. Setting was single center and thus results may not be generalizable to other populations.CONCLUSION: All-cause death was significantly associated with loss of muscle mass over time. Longitudinal trajectories of nutritional markers may predict the clinical outcomes in patients undergoing hemodialysis. This may also be valuable for individual risk stratification. Furthermore, early management may provide an opportunity to improve patient survival.CONFLICT OF INTEREST: None.

Improvements in six aspects of quality of care of incident hemodialysis patients \u2013 a real-world experience

BackgroundThe transition from chronic kidney disease stage 5 to initiation of hemodialysis has gained increased attention in recent years as this period is one of high risk for patients with an annual mortality rate exceeding 20%. Morbidity and mortality in incident hemodialysis patients are partially attributed to failure to attain guideline-based targets. This study focuses on improvements in six aspects of quality of dialysis care (adequacy, anemia, nutrition, chronic kidney disease-mineral bone disorder (CKD-MBD), blood pressure and vascular access) aligning with KDIGO guidelines, during the first 6 months of hemodialysis.MethodsWe analyzed patient demographics, practice patterns and laboratory data in all 3 462 patients (mean age 65.9 years, 41% females) on hemodialysis (incident <90 days on hemodialysis, n=603, prevalent ≥90 days on hemodialysis, mean 55 months, n=2 859) from all 56 DaVita centers in Poland (51 centers) and Portugal (5 centers). 80% of patients had hemodialysis and 20% hemodiafiltration. Statistical analyses included unpaired and paired Students t-test, Chi-2 analyses, McNemar test and logistic regression analysis.ResultsIncident patients had lower Kt/V (1.4 vs 1.7, p<0.001), lower serum albumin (37 vs 40 g/l, p=0.001), lower Hb (9.9 vs 11.0 g/dl, p<0.001), lower TSAT (26 vs 31%, p<0.001), lower iPTH (372 vs 496 pg/ml, p<0.001), more often a central venous catheter (68 vs 26%, p<0.001), less often an AV fistula (34 vs 70 %, p<0.001) compared with all prevalent patients. Significantly more prevalent patients achieved international treatment targets.Improvements in quality of care was also analyzed in a subgroup of 258 incident patients who were followed prospectively for 6 months. We observed significant improvements in Kt/V (p<0.001), albumin (p<0.001), Hb (p<0.001) transferrin saturation (TSAT, p<0.001), iPTH (p=0.005) and an increased use of AV fistula (p<0.001). Furthermore, logistic regression analyses identified treatment time and TSAT as major factors influencing the attainment of adequacy and anemia treatment targets.ConclusionThis large real-world European multicenter analysis of representative incident hemodialysis patients indicates that the use of medical protocols and medical targets assures significant improvements in quality of care, which may correspond to better outcomes. A selection bias of survivors with less comorbidities in prevalent patients may have influenced the results.

Association of serum globulin with all-cause mortality in incident hemodialysis patients.

Serum globulin is a major component of total protein and can be elevated in inflammatory disease states. While inflammation is common in hemodialysis patients and associated with mortality and morbidity, the association between serum globulin and mortality has never been examined in hemodialysis patients. In a retrospective cohort of 104 164 incident hemodialysis patients treated by a large dialysis organization from 2007 to 2011, we explored the association between baseline serum globulin, albumin: globulin (A:G) ratio and serum protein levels and all-cause, cardiovascular and infection-related mortality with adjustments for demographic variables and laboratory markers of malnutrition and inflammation using Cox proportional hazards models. Patients with a globulin concentration >3.8g/dL had a higher all-cause and infection-related mortality risk {hazard ratio [HR] 1.11 [95% confidence interval (CI) 1.06-1.16] and HR 1.28 [95% CI 1.09-1.51], respectively} in the fully adjusted model when compared with the reference group of 3.0-<3.2g/dL. In addition, patients with an A:G ratio <0.75had a 45% higher all-cause mortality hazard [HR 1.45 (95% CI 1.38-1.52)] and patients with total serum protein <5.5g/dLhad a 34% higher risk of death [1.34 (95% CI 1.27-1.42)] when compared with the reference (A:G ratio 1.05-<1.15 and total serum protein 6.5-<7g/dL). Among incident hemodialysis patients, a higher globulin level was associated with a higher mortality risk independent of other markers of malnutrition and inflammation, including albumin. A lower A:G ratio and serum protein was also associated with a higher mortality hazard. The mechanisms that contribute to elevated serum globulin should be further explored.

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.

Prognostic Machine Learning Models for First-Year Mortality in Incident Hemodialysis Patients: Development and Validation Study.

BackgroundThe first-year survival rate among patients undergoing hemodialysis remains poor. Current mortality risk scores for patients undergoing hemodialysis employ regression techniques and have limited applicability and robustness.ObjectiveWe aimed to develop a machine learning model utilizing clinical factors to predict first-year mortality in patients undergoing hemodialysis that could assist physicians in classifying high-risk patients.MethodsTraining and testing cohorts consisted of 5351 patients from a single center and 5828 patients from 97 renal centers undergoing hemodialysis (incident only). The outcome was all-cause mortality during the first year of dialysis. Extreme gradient boosting was used for algorithm training and validation. Two models were established based on the data obtained at dialysis initiation (model 1) and data 0-3 months after dialysis initiation (model 2), and 10-fold cross-validation was applied to each model. The area under the curve (AUC), sensitivity (recall), specificity, precision, balanced accuracy, and F1 score were used to assess the predictive ability of the models.ResultsIn the training and testing cohorts, 585 (10.93%) and 764 (13.11%) patients, respectively, died during the first-year follow-up. Of 42 candidate features, the 15 most important features were selected. The performance of model 1 (AUC 0.83, 95% CI 0.78-0.84) was similar to that of model 2 (AUC 0.85, 95% CI 0.81-0.86).ConclusionsWe developed and validated 2 machine learning models to predict first-year mortality in patients undergoing hemodialysis. Both models could be used to stratify high-risk patients at the early stages of dialysis.

Serum-to-Dialysate Calcium Gradient and Its Association with Mortality in Incident Hemodialysis Patients

Serum-to-Dialysate Calcium Gradient and Its Association with Mortality in Incident Hemodialysis Patients

Associations of Serum Calciprotein Particle Size and Transformation Time With Arterial Calcification, Arterial Stiffness, and Mortality in Incident Hemodialysis Patients

Characteristics of the transformation of primary to secondary calciprotein particles (CPPs) in serum, including the size of secondary CPP (CPP2) aggregates and the time of transformation (T50), may be markers for arterial calcification in patients undergoing hemodialysis (HD). We examined the associations of CPP2 aggregate size and T50 with arterial calcification in incident HD patients. Prospective cohort study. Incident HD patients (n=402with available CPP2 measures and n=388with available T50 measures) from the Predictors of Arrhythmic and Cardiovascular Risk in End-Stage Renal Disease (PACE) Study PREDICTORS: Serum CPP2 size and T50 at baseline. Primary outcomes were baseline coronary artery and thoracic aorta calcifications. Exploratory outcomes included baseline arterial stiffness, measured by pulse wave velocity (PWV) and ankle brachial index, and longitudinally, repeat measures of PWV and all-cause mortality. Tobit regression, multiple linear regression, Poisson regression, linear mixed-effects regression, and Cox proportional hazards regression. Mean age was 55±13 years, 41% were women, 71% were Black, and 57% had diabetes mellitus. Baseline CPP2 size and T50 were correlated with baseline fetuin A level (r=-0.59 for CPP2 and 0.44 for T50; P<0.001 for both), but neither was associated with baseline measures of arterial calcification or arterial stiffness. Baseline CPP2 size and T50 were not associated with repeat measures of PWV. During a median follow-up of 3.5 (IQR, 1.7-6.2) years, larger CPP2 was associated with higher risk for mortality (HR, 1.17 [95% CI, 1.05-1.31] per 100nm larger CPP2 size) after adjusting for demographics and comorbid conditions, but there was no association between baseline T50 and risk for mortality. Possible imprecision in assays, small sample size, limited generalizability to incident HD populations with different racial composition, and residual confounding. In incident HD patients, neither CPP2 size nor T50 was associated with prevalent arterial calcification and stiffness. Larger CPP2 was associated with risk for mortality, but this finding needs to be confirmed in future studies.