Serum Ferritin Levels Predict All-Cause and Infection-Cause 1-Year Mortality in Diabetic Patients on Maintenance Hemodialysis

Serum ferritin and neutrophil-to-lymphocyte ratio predict all-cause mortality in patients receiving maintenance hemodialysis: a prospective study

Introduction: Maintenance hemodialysis is an effective treatment for end-stage renal disease patients. A critical factor contributing to the deterioration and death of maintenance hemodialysis patients is inflammation. Therefore, we focused on two inflammatory markers, serum ferritin and neutrophil-to-lymphocyte ratio, to speculate whether they could predict the prognosis of maintenance hemodialysis patients. Patients and methods: We followed 168 patients with maintenance hemodialysis from July 2019 to July 2022 with the endpoint of all-cause death or follow-up completion. Receiver operating characteristic curves were plotted to assess the values of serum ferritin, neutrophil-to-lymphocyte ratio and serum ferritin combined with neutrophil-to-lymphocyte ratio to predict the outcomes of maintenance hemodialysis patients. Kaplan-Meier survival curves were constructed to compare survival rates over time. Results: Receiver operating characteristic curves demonstrated that the best cut-off value of serum ferritin for predicting the prognosis of maintenance hemodialysis patients was 346.05 μg/L, and that of neutrophil-to-lymphocyte ratio was 3.225. Furthermore, a combination of both had a more excellent predicting value than either index (p < 0.05). Kaplan-Meier survival curve analyses revealed that low serum ferritin levels and low neutrophil-to-lymphocyte ratio had a higher probability of survival than high ferritin levels and high neutrophil-to-lymphocyte ratio, separately. Conclusion: Elevated serum ferritin and neutrophil-to-lymphocyte ratio are closely related to all-cause mortality among maintenance hemodialysis patients, for which they may be predictors of all-cause mortality. Additionally, the combination of the two has a much higher predictor value for the prognosis of maintenance hemodialysis patients.

Investigating the relationship between erythropoiesis-stimulating agents and mortality in hemodialysis patients: A systematic review and meta-analysis

BACKGROUND

In recent years, various studies have been conducted to investigate the relationship between erythropoiesis-stimulating agents (ESAs) and mortality in hemodialysis patients, who showed contradictory results. Therefore, this study aimed to investigate the relationship between ESAs and mortality in hemodialysis patients.

METHODS

The current study is a systematic review and meta-analysis based on observational and interventional studies published in the Web of Science, Cochrane Library, Science Direct, PubMed, Scopus, and Google Scholar databases between 1980 and the end of 2022. Jadad scale checklist and Newcastle Ottawa scale were used to evaluate the quality of articles. The study data were analyzed using Stata 15 software.

RESULTS

In the initial search, 3933 articles were extracted, and by screening and considering the research criteria, 68 studies were finally included in the meta-analysis. According to the meta-analysis results, the risk ratio (RR) of overall mortality in hemodialysis patients receiving ESAs was equal to 1.19 (95% CI: 1.16-1.23, P ≤ 0.001). The RR of mortality in patients aged 60 years and under was equal to 1.33 (1.15-1.55, P ≤ 0.001), in the age group over 60 years was equal to 1.13 (1.10-1.16, P ≤ 0.001), in randomized clinical trial studies was equal to 1.06 (0.80-1.40, P = 0.701), in cohort studies was equal to 1.20 (1.16-1.25, P ≤ 0.001), in American countries was equal to 1.19 (1.10-1.29, P ≤ 0.001), in Asian countries was equal to 1.15 (1.10-1.19, P ≤ 0.001), and in European countries was equal to 1.18 (1.05-1.34, P = 0.007).

CONCLUSION

The results of the study show that receiving ESAs is associated with a 19% increase in the risk of overall mortality in hemodialysis patients.

Dietary Factors and All-Cause Mortality in Individuals With Type 2 Diabetes: A Systematic Review and Meta-analysis of Prospective Observational Studies

BACKGROUND

Type 2 diabetes is a major health concern associated with mortality. Diet may influence the progression of diabetes; however, systematic reviews are lacking.

PURPOSE

This study systematically summarized the evidence on diet and all-cause mortality in individuals with type 2 diabetes.

DATA SOURCES

PubMed and Web of Science were searched until June 2022.

STUDY SELECTION

Prospective observational studies investigating dietary factors in association with all-cause mortality in individuals with type 2 diabetes were selected.

DATA SYNTHESIS

We identified 107 studies. Moderate certainty of evidence was found for inverse associations of higher intakes of fish (summary risk ratios per serving/week: 0.95; 95% CI 0.92, 0.99; n = 6 studies), whole grain (per 20 g/day: 0.84; 95% CI 0.71, 0.99; n = 2), fiber (per 5 g/day: 0.86; 95% CI 0.81, 0.91; n = 3), and n-3 polyunsaturated fatty acids (per 0.1 g/day: 0.87; 95% CI 0.82, 0.92; n = 2) and mortality. There was low certainty of evidence for inverse associations of vegetable consumption (per 100 g/day: 0.88; 95% CI 0.82, 0.94; n = 2), plant protein (per 10 g/day: 0.91; 95% CI 0.87, 0.96; n = 3), and for positive associations of egg consumption (per 10 g/day: 1.05; 95% CI 1.03, 1.08; n = 7) and cholesterol intake (per 300 mg/day: 1.19; 95% CI 1.13, 1.26; n = 2). For other dietary factors, evidence was uncertain or no association was observed.

CONCLUSIONS

Higher intake of fish, whole grain, fiber, and n-3 polyunsaturated fatty acids were inversely associated with all-cause mortality in individuals with type 2 diabetes. There is limited evidence for other dietary factors, and, thus, more research is needed.

Role of Serum Ferritin in Predicting Outcomes of COVID-19 Infection Among Sickle Cell Disease Patients: A Systematic Review and Meta-Analysis

Patients with sickle cell disease (SCD) are at higher risk of getting severe COVID-19 infection. This systematic review and meta-analysis aimed to determine the role of serum ferritin in predicting ICU admission and mortality among patients with SCD following COVID-19 infection. A systematic search was conducted in PubMed, Scopus, Web of Science, Embase, WHO COVID-19 database, ProQuest, and Cochrane Library for articles published between 1st December 2019 to 31st November 2021. Methodological quality was assessed using the Joanna Briggs Institute (JBI) critical appraisal checklists. Eleven articles (7 cohorts and 4 case series) were included in this review. Pooled mean serum ferritin level on admission was 1581.62 ng/mL while pooled proportion of ICU admission and mortality were 0.10 (95% CI 0.06; 0.16, prediction interval 0.04; 0.23, p = 0.29, I 2 = 17%) and 0.07 (95% CI 0.05; 0.11, prediction interval 0.04; 0.12, p = 0.68, I 2 = 0%) respectively. Meta-regression showed that serum ferritin did not predict for both ICU admission (regression coefficient = 0.0001, p = 0.3523) and mortality (regression coefficient = 0.0001, p = 0.4029). Our analyses showed that serum ferritin may not be a useful marker to predict the outcomes of COVID-19 infection among patients with SCD. More data are required to identify a reliable tool to identify patients with SCD who are at risk of getting severe COVID-19 infection.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=287792, PROSPERO Registration: CRD42021287792.

Description of the Etiologies, Clinical Characteristics, and Outcomes in Patients with Hyperferritinemia in a Colombian Tertiary Hospital

BACKGROUND

This study analyzes the clinical characteristics, outcomes, and conditions associated with hyperferritinemia (≥5000 ng/mL) in a high-complexity center in Colombia.

METHODS

This retrospective and descriptive study was performed between 2011 and 2020, at the Fundación Valle del Lili, Cali, Colombia, by reviewing medical charts from patients who had serum ferritin measurements equal to or greater than 5000 ng/mL.

RESULTS

We found 350 reports of ferritin values ≥5000 ng/mL, corresponding to 317 patients, with a median ferritin value of 8789 (6001-15 373)  ng/mL. The most frequent etiologies were infection (n = 198, 56.57%), hematologic disorders (n = 104, 29.71%), and blood transfusion (n = 98, 28.00%). These last 2 etiologies cooccurred in 37 (10.57%) cases. The main clinical signs accompanying hyperferritinemia were fever in 199 (56.86%) cases, multiorgan involvement in 125 (35.71%), and hepatomegaly in 95 (27.14%) cases. Ninety-four (29.65%) patients died in the hospital, and 11 (3.47%) died within 30 days after medical discharge, mainly due to infection (n = 51, 48.57%). Intrahospital mortality was associated with significantly higher ferritin levels (10 846, IQR: 6425-23 459) than survival (8452, IQR: 5980-13 932) (P = 0.018).

CONCLUSIONS

Hyperferritinemia is related to many underlying causes, with infection being the principal cause in our cohort, followed by hematologic disorders. Additionally, in-hospital mortality was related to higher ferritin levels.

The Relationship between Serum Ferritin Levels and 5-Year All-Cause Mortality in Hemodialysis Patients

INTRODUCTION

The effect of high serum ferritin levels on long-term mortality in hemodialysis patients is unknown. The relationship between serum ferritin levels and 5-year all-cause mortality in hemodialysis patients was investigated in this study.

METHODS

A total of 173 prevalent hemodialysis patients were included in this study. The patients were followed for up to 5 years and divided into 3 groups according to time-averaged serum ferritin levels (group 1: serum ferritin <800 ng/mL, group 2: serum ferritin 800-1,500 ng/mL, and group 3: serum ferritin >1,500 ng/mL). Along with the serum ferritin levels, other clinical and laboratory variables that may affect mortality were also included in the Cox proportional-hazards regression analysis.

RESULTS

Eighty-one (47%) patients died during the 5-year follow-up period. The median follow-up time was 38 (17.5-60) months. The 5-year survival rates of groups 1, 2, and 3 were 44, 64, and 27%, respectively. In group 3, the survival was lower than in groups 1 and 2 (log-rank test, p = 0.002). In group 1, the mortality was significantly lower than in group 3 (HR [95% CI]: 0.16 [0.05-0.49]; p = 0.001). In group 2, the mortality was also lower than in group 3 (HR [95% CI]: 0.32 [0.12-0.88]; p = 0.026). No significant difference in mortality between groups 1 and 2 was found (HR [95% CI]: 0.49 [0.23-1.04]; p = 0.063).

CONCLUSION

Time-averaged serum ferritin levels >1,500 ng/mL in hemodialysis patients are associated with an increased 5-year all-cause mortality risk.

Evaluation of Ferritin and Transferrin Ratio as a Prognostic Marker for Hepatocellular Carcinoma

PURPOSE OF THE STUDY

Hepatocellular carcinoma (HCC) has tripled in incidence over the past 20 years and now ranks as the third leading cause of mortality attributed to cancer. Underlying pathophysiology is sustained hepatic inflammation which results in hepatocellular dysplasia and thus an environment prone to HCC. Considering the essential role of inflammation in the pathogenesis of HCC, we evaluated the prognostic utility of ferritin-transferrin ratio (FTR) in HCC.

METHODS

We retrospectively reviewed the electronic medical records of patients with HCC (diagnosed on radiographic criteria and/or biopsy) from 2000 through 2015. We collected data regarding the patient demographics, laboratory investigations at the time of HCC diagnosis and prior to the initiation of treatment. Overall survival was calculated from the time of diagnosis, cases were censored at the date of last follow-up, if date of death was not known. Kaplan-Meier curves were estimated to evaluate the prognostic significance of FTR. Receiver operating characteristics (ROC) curve was plotted for FTR to predict mortality and identify cut-off value by optimized Youden's index.

RESULTS

Among the 176 patients identified by initial screening, 116 patients were eventually included for analysis. Overall median survival was 11.9 months. FTR, of note, was significantly lower in alive (6.9, p < 0.001). In univariate analysis, alfa-fetoprotein (AFP), aspartate aminotransferase (AST), serum ferritin (SF), transferrin (TFS), and FTR were significantly associated with mortality. On multivariate analysis for mortality, FTR, AFP, and epidemiologic factors predictive of mortality including male gender and advanced HCC were significant.

CONCLUSION

The ferritin-transferrin ratio (FTR), calculated at the time of HCC diagnosis could predict mortality in our cohort of patients. With an optimal cut-off of 7.7 for FTR were stratified into high- and low-risk groups. The hazard ratio between the two groups was 2.36 (p < 0.003). Future studies with longitudinal follow-up of FTR at intervals and important time points (e.g., perioperative) might provide more insights to its prognostic value.

Impact of Inflammation on Ferritin, Hepcidin and the Management of Iron Deficiency Anemia in Chronic Kidney Disease

Iron deficiency anemia (IDA) is a major problem in chronic kidney disease (CKD), causing increased mortality. Ferritin stores iron, representing iron status. Hepcidin binds to ferroportin, thereby inhibiting iron absorption/efflux. Inflammation in CKD increases ferritin and hepcidin independent of iron status, which reduce iron availability. While intravenous iron therapy (IIT) is superior to oral iron therapy (OIT) in CKD patients with inflammation, OIT is as effective as IIT in those without. Inflammation reduces predictive values of ferritin and hepcidin for iron status and responsiveness to iron therapy. Upper limit of ferritin to predict iron overload is higher in CKD patients with inflammation than in those without. However, magnetic resonance imaging studies show lower cutoff levels of serum ferritin to predict iron overload in dialysis patients with apparent inflammation than upper limit of ferritin proposed by international guidelines. Compared to CKD patients with inflammation, optimal ferritin levels for IDA are lower in those without, requiring reduced iron dose and leading to decreased mortality. The management of IDA should differ between CKD patients with and without inflammation and include minimization of inflammation. Further studies are needed to determine the impact of inflammation on ferritin, hepcidin and therapeutic strategy for IDA in CKD.

Optimal Serum Ferritin Levels for Iron Deficiency Anemia during Oral Iron Therapy (OIT) in Japanese Hemodialysis Patients with Minor Inflammation and Benefit of Intravenous Iron Therapy for OIT-Nonresponders

Background: We determined optimal serum ferritin for oral iron therapy (OIT) in hemodialysis (HD) patients with iron deficiency anemia (IDA)/minor inflammation, and benefit of intravenous iron therapy (IIT) for OIT-nonresponders. Methods: Inclusion criteria were IDA (Hb <120 g/L, serum ferritin <227.4 pmol/L). Exclusion criteria were inflammation (C-reactive protein (CRP) ≥ 5 mg/L), bleeding, or cancer. IIT was withheld >3 months before the study. ΔHb ≥ 20 g/L above baseline or maintaining target Hb (tHB; 120-130 g/L) was considered responsive. Fifty-one patients received OIT (ferrous fumarate, 50 mg/day) for 3 months; this continued in OIT-responders but was switched to IIT (saccharated ferric oxide, 40 mg/week) in OIT-nonresponders for 4 months. All received continuous erythropoietin receptor activator (CERA). Hb, ferritin, hepcidin-25, and CERA dose were measured. Results: Demographics before OIT were similar between OIT-responders and OIT-nonresponders except low Hb and high triglycerides in OIT-nonresponders. Thirty-nine were OIT-responders with reduced CERA dose. Hb rose with a peak at 5 months. Ferritin and hepcidin-25 continuously increased. Hb positively correlated with ferritin in OIT-responders (r = 0.913, p = 0.03) till 5 months after OIT. The correlation equation estimated optimal ferritin of 30-40 ng/mL using tHb (120-130 g/L). Seven OIT-nonresponders were IIT-responders. Conclusions: Optimal serum ferritin for OIT is 67.4-89.9 pmol/L in HD patients with IDA/minor inflammation. IIT may be a second line of treatment for OIT-nonreponders.

Total and cause-specific mortality by moderately and markedly increased ferritin concentrations: general population study and metaanalysis

BACKGROUND

Previous population-based studies of plasma ferritin concentration have not revealed a relationship with total mortality. We tested the possible association of increased ferritin concentrations with increased risk of total and cause-specific mortality in the general population.

METHODS

We examined total and cause-specific mortality according to baseline plasma ferritin concentrations in a Danish population-based study (the Copenhagen City Heart Study) of 8988 individuals, 6364 of whom died (median follow-up 23 years). We also included a metaanalysis of total mortality comprising population-based studies according to ferritin quartiles or tertiles.

RESULTS

Multifactorially adjusted hazard ratios (HRs) for total mortality for individuals with ferritin ≥200 vs <200 μg/L were 1.1 (95% CI 1.1-1.2; P = 0.0008) overall, 1.1 (1.0-1.2; P = 0.02) in men, and 1.2 (1.0-1.3; P = 0.03) in women. Stepwise increasing concentrations of ferritin were associated with a stepwise increased risk of premature death overall (log rank, P = 2 × 10(-22)), with median survival of 55 years at ferritin concentrations ≥600 μg/L, 72 years at 400-599 μg/L, 76 years at 200-399 μg/L, and 79 years at ferritin <200 μg/L. The corresponding HR for total overall mortality for ferritin ≥600 vs <200 μg/L was 1.5 (1.2-1.8; P = 0.00008). Corresponding adjusted HRs for ferritin ≥600 vs <200 μg/L were 1.6 (1.1-2.3; P = 0.01) for cancer mortality, 2.9 (1.7-5.0; P = 0.0001) for endocrinological mortality, and 1.5 (1.1-2.0; P = 0.01) for cardiovascular mortality. The metaanalysis random effects odds ratio for total mortality for ferritin upper vs reference quartile or tertile was 1.0 (0.9-1.1; P = 0.3) (P heterogeneity = 0.5).

CONCLUSIONS

Moderately to markedly increased ferritin concentrations represent a biological biomarker predictive of early death in a dose-dependent linear manner in the general population.

Ferritin as a predictor of decline in residual renal function in peritoneal dialysis patients

AIMS

Inflammation is an important factor in renal injury. Ferritin, an inflammatory marker, is considered an independent predictor of rapid renal progression in patients with chronic kidney disease. However, the relationship between ferritin and residual renal function (RRF) in patients undergoing peritoneal dialysis (PD) remains unclear.

METHODS

We reviewed the medical records of patients who started PD between June 2001 and March 2012 at Soonchunhyang University Bucheon Hospital, Korea. A total of 123 patients were enrolled in the study. At 1 month after the initiation of PD, RRF was determined by a 24-hour urine collection and measured every 6 months thereafter. Clinical and biochemical data at the time of the initial 24-hour urine collection were considered as baseline.

RESULTS

The RRF reduction rate was significantly greater in patients with high ferritin (ferritin ≥ 250 ng/mL) compared with those with low ferritin (ferritin < 250 ng/mL; -1.71 ± 1.36 mL/min/yr/1.73 m(2) vs. -0.84 ± 1.63 mL/min/yr/1.73 m(2), respectively; p = 0.007). Pearson correlation analysis revealed a significant negative correlation between the baseline serum ferritin level and the RRF reduction rate (r = -0.219, p = 0.015). Using multiple linear regression analysis and adjusting for other risk factors, baseline serum ferritin was an independent factor for the RRF reduction rate (β = -0.002, p = 0.002).

CONCLUSIONS

In this study we showed that a higher ferritin level was significantly associated with a more rapid RRF decline in patients undergoing PD.

Association between hemoglobin variability, serum ferritin levels, and adverse events/mortality in maintenance hemodialysis patients

In recent times, therapy for renal anemia has changed dramatically in that iron administration has increased and doses of erythropoiesis-stimulating agents (ESAs) have decreased. Here we used a prospective, observational, multicenter design and measured the serum ferritin and hemoglobin levels every 3 months for 2 years in 1086 patients on maintenance hemodialysis therapy. The associations of adverse events with fluctuations in ferritin and hemoglobin levels and ESA and iron doses were measured using a Cox proportional hazards model for time-dependent variables. The risks of cerebrovascular and cardiovascular disease (CCVD), infection, and hospitalization were higher among patients who failed to maintain a target-range hemoglobin level and who exhibited high-amplitude fluctuations in hemoglobin compared with patients who maintained a target-range hemoglobin level. Patients with a higher compared with a lower ferritin level had an elevated risk of CCVD and infectious disease. Moreover, the risk of death was significantly higher among patients with high-amplitude ferritin fluctuations compared with those with a low ferritin level. The risks of CCVD, infection, and hospitalization were significantly higher among patients who were treated with high weekly doses of intravenous iron compared with no intravenous iron. Thus, there is a high risk of death and/or adverse events in patients with hemoglobin levels outside the target range, in those with high-amplitude hemoglobin fluctuations, in those with consistently high serum ferritin levels, and in those with high-amplitude ferritin fluctuations.

Serum ferritin concentration predicts mortality in patients with hepatitis B virus-related acute on chronic liver failure

BACKGROUND AND AIMS

This study was designed to investigate the association between serum ferritin concentration (SF) and hepatitis B virus infected patients with acute-on-chronic liver failure (AoCLF). In addition, we analyzed whether SF levels are associated with mortality in AoCLF patients.

METHODS

One hundred and seventeen patients, including 46 patients with chronic hepatitis B (CHB), 71 with AoCLF, and 55 healthy controls (HCs) were enrolled in this study. All patients were followed for 4 months. In all subjects, a blood sample was collected at admission to examine liver function, renal function, international normalized ratio, and SF levels. A total of six clinical chemistry and biochemical variables (e.g., model for end-stage liver disease [MELD] score, age, levels of SF, total protein, albumin, and alanine aminotransferase) were measured and analyzed for their association with outcomes by using Cox proportional hazards and multiple regression models.

RESULTS

AoCLF patients had significantly higher SF levels at admission compared to HCs and CHB (all p = 0.001). Elevated SF levels were associated with increased severity of liver disease and 3-month mortality rate. Multivariate analysis demonstrated that SF levels and MELD score were independent predictors for mortality (both p <0.001).

CONCLUSION

The SF measured at admission may serve as an independent predictor for 3-month mortality rate in AoCLF patients.

Total and cause-specific mortality by elevated transferrin saturation and hemochromatosis genotype in individuals with diabetes: two general population studies

OBJECTIVE

Mortality is increased in patients with hereditary hemochromatosis, in individuals from the general population with increased transferrin saturation (TS), and also in patients with type 1 diabetes and increased TS from a highly specialized diabetes clinic. Thus, we have recommended targeted screening for TS in specialized diabetes clinics. Whether mortality is also increased in individuals from the general population with diabetes and increased TS is unknown.

RESEARCH DESIGN AND METHODS

In two Danish population studies (N = 84,865), we examined mortality according to baseline levels of TS and hemochromatosis genotype (HFE) G → A substitution at nucleotide 845 in codon 282 (C282Y/C282Y) in individuals with diabetes (type 1, N = 118; type 2, N = 3,228; total, N = 3,346).

RESULTS

The cumulative survival rate was reduced in individuals with diabetes with TS ≥50% vs. <50% (log-rank; P < 0.0001), with median survival ages of 66 and 79 years, respectively. The hazard ratio (HR) for TS ≥50% vs. <50% was 2.0 (95% CI 1.3-2.8; P = 0.0004) for total mortality overall (and similar for men and women separately); 2.6 (1.3-5.4; P = 0.008) for neoplasms; and 3.4 (2.0-6.0; P = 0.00002) for endocrinological causes. A stepwise increased risk of total mortality was observed for stepwise increasing TS (log-rank test, P = 0.0001), with an HR for TS ≥70% vs. TS <20% of 4.8 (2.0-12; P = 0.0006). The HR for total mortality in individuals with diabetes for C282Y/C282Y versus wild type/wild type was 3.3 (1.04-10; P = 0.04), and for C282Y/C282Y and TS ≥50% versus wild type/wild type and TS <50% was 6.0 (1.5-24; P = 0.01). Six percent of these premature deaths can possibly be avoided by early screening for TS or HFE genotype.

CONCLUSIONS

Individuals with diabetes, ascertained in the general population, with increased TS or HFE genotype have a twofold to sixfold increased risk of premature death.

Iron and infection in hemodialysis patients

Intravenous iron is an important component of the treatment of anemia of end-stage renal disease (ESRD), but it is biologically plausible that iron could increase the risk of infection through impairment of neutrophil and T-cell function and promotion of microbial growth. Any such increase in risk would be particularly important because infection is a significant cause of mortality and morbidity in dialysis patients. The overall evidence favors an association between iron and infection in hemodialysis patients, but the optimal iron management strategy to minimize infection risk has yet to be identified. There is a need for further research on this topic, particularly in light of increased utilization of intravenous iron following implementation of the bundled ESRD reimbursement system.

Impact of living environment on 2-year mortality in elderly maintenance hemodialysis patients

Background

Studies on risk factors of mortality in elderly patients with hemodialysis usually focus on comorbidities, nutrition, and inflammation. Discussion on the correlation between living environment and mortality of these patients is limited.

Methods

A total of 256 elderly hemodialysis patients participated in this 2-year prospective observational study. The subjects were divided into 2 subgroups based on whether they were living in Taipei Basin (n = 63) or not (n = 193). Demographic, hematological, nutritional, inflammatory, biochemical, and dialysis-related data were obtained for cross-sectional analysis. Causes of death and mortality rates were also analyzed for each subgroup.

Results

Patients in the basin group had a higher incidence of combined protein-energy wasting and inflammation than those in the around basin group. At the end of the 2-year follow-up, 68 patients had died. Univariate binary logistic regression analysis revealed that a very advanced age, basin group, serum albumin levels, serum creatinine levels, non-anuria, and the complications of stroke and CAD were associated with 2-year mortality. Meanwhile, log high-sensitivity C-reactive protein (hs-CRP) levels were not associated with 2-year mortality. Multivariate Cox regression analysis revealed that basin group, serum albumin levels, and the complications of stroke and CAD were significant risk factors for 2-year mortality in these patients.

Conclusion

The results of this study indicate that factors such as living in the Taipei Basin with higher air pollutant levels in elderly hemodialysis patients is associated with protein-energy wasting and inflammation, as well as 2-year mortality. These findings suggest that among this population, living environment is as important as comorbidities and nutrition. Furthermore, air pollution should be getting more attention especially in the overcrowding Basin topography.

Serum iron parameters in the early post-transplant period and infection risk in kidney transplant recipients

BACKGROUND

The impact of iron metabolism on the risk of infectious complications has been demonstrated in various immunosuppressed populations. However, no previous studies have assessed this potential association in kidney transplant (KT) recipients.

METHODS

We prospectively analyzed 228 patients undergoing KT at our institution from November 2008 to February 2011. Serum iron parameters (iron level, ferritin, total iron-binding capacity, unsaturated iron-binding capacity, transferrin, and transferrin saturation) were assessed within the first 2 weeks after transplantation (median interval, 3 days; interquartile [Q1 -Q3 ] range, 1-6 days), and before the occurrence of the first infectious episode (median interval, 26 days; Q1 -Q3 range, 11-76 days). Primary outcome was the occurrence of any episode of infection during the first year. Multivariate-adjusted hazard ratios (aHRs) were estimated by Cox regression models.

RESULTS

Patients with ferritin level ≥ 500 ng/mL had higher incidence rates (per 1000 transplant-days) of overall infection (P = 0.017), bacterial infection (P = 0.002), and bloodstream infection (P = 0.011) during the first post-transplant year. One-year infection-free survival rate was lower in these recipients (26% vs. 41%; P = 0.004). On multivariate analysis, after adjusting for potential confounders, ferritin emerged as an independent predictor of overall infection (aHR [per unitary increment], 1.001; P = 0.006), and bacterial infection (aHR [per unitary increment], 1.001; P = 0.020).

CONCLUSION

Monitoring of serum iron parameters in the early post-transplant period may be useful in predicting the occurrence of infection in KT recipients, although further studies should be carried out to confirm this preliminary finding.

Total mortality by elevated transferrin saturation in patients with diabetes

OBJECTIVE

It is not known to what extent iron overload predicts prognosis in patients with diabetes after diagnosis or whether iron overload is a risk factor independent of the HFE genotype. We investigated total and cause-specific mortality according to increased transferrin saturation (≥ 50 vs. <50%), whether mortality is driven by the HFE genotype, and whether early measurement of transferrin saturation helps to predict mortality outcome.

RESEARCH DESIGN AND METHODS

Cohort 1 included patients with late-onset type 1 diabetes (n = 716) with a cross-sectional measurement of transferrin saturation and HFE genotype. Cohort 2 included consecutively recruited patients with any diabetes (n = 6,120), transferrin saturation measurement at referral, and HFE genotype if transferrin saturation was above 50%.

RESULTS

In cohort 1, the hazard ratio for total mortality was 2.3 (95% CI 1.3-3.9; P = 0.002) and for cause-specific mortality by neoplasms was 5.8 (2.4-14; P = 0.00007) in patients with transferrin saturation ≥ 50 vs. <50%. Excluding genotypes C282Y/C282Y and C282Y/H63D gave similar results. The hazard ratio for total mortality was 4.0 (1.2-13; P = 0.01) and for cause-specific mortality by neoplasms was 13 (3.6-49; P = 0.0001) in patients with C282Y/C282Y versus wild type. In cohort 2, total mortality was not different in patients with transferrin saturation ≥ 50 vs. <50%. In patients with late-onset type 1 diabetes and transferrin saturation ≥ 50%, the hazard ratio for total mortality was 0.4 (0.2-0.9; P = 0.03) in cohort 2 versus cohort 1.

CONCLUSIONS

Increased transferrin saturation and HFE genotype C282Y/C282Y predict total mortality in patients with late-onset type 1 diabetes, and increased transferrin saturation after diagnosis is an independent risk factor. Early measurement of transferrin saturation in these patients leading to early intervention improves life expectancy.

Education level is associated with mortality in male patients undergoing maintenance hemodialysis

BACKGROUND

Studies of the correlation between education levels and mortality in hemodialysis (HD) patients are rare. The aim of this multi-center study was to investigate the relationship between education levels and 3-year mortality rates in HD patients.

METHODS

A total of 935 HD patients from 3 HD centers participated in this 3-year prospective observational study. Education levels were categorized as either less than senior high school and above or equal to senior high school. The causes of death and mortality rates were also analyzed for each subgroup.

RESULTS

At the end of the 3-year follow-up period, 164 patients had died. In the male group, forward stepwise Cox regression analysis revealed that age, HD duration, hypertension, creatinine level, serum albumin level ≥3.6 g/dl, anuria, Kt/Vurea, and high education level were significant predictive factors for 3-year mortality rates.

CONCLUSION

This prospective observational study demonstrated that education level was associated with mortality in men undergoing HD.

Predictors of Failure of Catheter Salvage in Incident Hemodialysis Patients

Purpose

Catheter-related bloodstream infection is a frequent complication for patients who use catheter as dialysis access. This study was performed to identify the risk factors for failed catheter salvage.

Methods

We enrolled patients who received non-tunneled catheters as initial vascular access during a two-year period. Catheter salvage was attempted in all symptomatically mild patients. Patients were prospectively followed for 8 weeks starting from the day of infection. Risk factors for salvage failure were explored.

Results

A total of 77 bacteremia episodes occurred in 69 patient, with an infection rate of 1.61 per 1,000 catheter days. Salvage was successful in 73.4% of all episodes. We found that higher ferritin levels (greater vs. lower than 500 mg/l, (odds ratio (OR) 6.388, 95% confidence interval (CI) 2.073, 19.686), higher phosphate levels (greater vs. lower than 5.5 mg/dl, OR 4.084, 95% CI 1.391, 11.978) and shorter time intervals between catheterization and infection (within vs. beyond 3 weeks, OR 4.190, 95% CI 1.279, 13.725) predicted salvage failure.

Conclusions

Catheter salvage can be a reasonable initial strategy for symptomatically mild patients. We propose salvaging aggressively and waiting watchfully; however, clinical judgment is prior to any specific management protocol.

Left ventricular morphology and function in diabetic and nondiabetic hemodialyzed patients

Morbidity in end-stage renal disease (ESRD) diabetic patients is worse than in patients without diabetes mellitus (DM). This study aims to compare clinical, laboratory, and echocardiographic features between the ESRD patients with and without DM. Fifty-eight ESRD patients on dialysis were prospectively divided into two groups according to the presence of DM. Demographic, clinical, laboratory, and echocardiographic features (ejection fraction and wall motion score index) were compared between the two groups. Overall, 20 out of 58 patients (37.8%) with ESRD had DM. There were no significant differences between the patients with DM and those without DM when it comes to age (60.6 ± 10.6 vs. 59.0 ± 10.6 years, P = 0.665), ejection fraction (52.6% ± 12.8% vs. 54.2% ± 12.8%, P = 0.59), and wall motion score index (1.21 ± 0.3 vs.1.15 ± 0.3, P = 0.37). In multivariant analysis of the interventricular septum, posterior wall thickness and left atrium size correlated positively with DM. There was also no statistical difference in myocardial perfusion disturbances on real-time contrast echocardiography between the groups with and without DM (12 (60%) patients vs. 14 patients (36.8%), P = 0.079). Among diabetics 77.8% had significant atherosclerotic changes, while in the group without DM, only 38.1%, P = 0.01. From the laboratory parameters ferritin and high-sensitivity C-reactive protein levels were significantly higher in the group with DM, P = 0.014 and P = 0.026, respectively. Patients with ESRD and DM have significantly bigger left atrial size, thicker left ventricular walls, and higher serum ferritin and high-sensitivity C-reactive protein levels than the patients without DM. The aforementioned features may be possible risk factors for the development of adverse cardiac events in patients on hemodialysis.

Serum ferritin concentration and transferrin saturation before liver transplantation predict decreased long-term recipient survival

Serum ferritin (SF) concentration is a widely available parameter used to assess iron homeostasis. It has been described as a marker to identify high-risk patients awaiting liver transplantation (LT) but is also elevated in systemic immune-mediated diseases, metabolic syndrome, and in hemodialysis where it is associated with an inferior prognosis. This study analyzed whether SF is not only a predictor of liver-related mortality prior to LT but also an independent marker of survival following LT. In a dual-center, retrospective study, a cohort of 328 consecutive first-LT patients from Hannover Medical School, Germany (2003-2008, follow-up 1260 days), and 82 consecutive LT patients from Regensburg University Hospital, Germany (2003-2007, follow-up 1355 days) as validation cohort were analyzed. In patients exhibiting SF ≥365 μg/L versus <365 μg/L prior to LT, 1-, 3-, and 5-year post-LT survival was 73.3% versus 81.1%, 64.4% versus 77.3%, and 61.1% versus 74.4%, respectively (overall survival P = 0.0097), which was confirmed in the validation cohort (overall survival of 55% versus 83.3%, P = 0.005). Multivariate analyses identified SF ≥365 μg/L combined with transferrin saturation (TFS) <55%, hepatocellular carcinoma, and the survival after LT (SALT) score as independent risk factors for death. In patients with SF concentrations ≥365 μg/L and TFS <55%, overall survival was 54% versus 74.8% in the remaining group (P = 0.003). In the validation cohort, it was 28.6% versus 72% (P = 0.017), respectively.

CONCLUSION

SF concentration ≥365 μg/L in combination with TFS <55% before LT is an independent risk factor for mortality following LT. Lower TFS combined with elevated SF concentrations indicate that acute phase mechanisms beyond iron overload may play a prognostic role. SF concentration therefore not only predicts pre-LT mortality but also death following LT.

Serum ferritin predicts prognosis in hemodialysis patients: the Nishinomiya study

BACKGROUND

The mortality in end-stage renal disease patients with dialysis remains high. Serum ferritin is a useful surrogated marker of iron storage. It has not been elucidated whether the ferritin level can predict the prognosis of patients with dialysis but without obvious inflammation. To clarify whether the ferritin level is involved in the prognosis in dialyzed patients, we investigated the relation between ferritin level and mortality in hemodialyzed patients during long-term follow-up.

METHODS

Ninety stable hemodialyzed patients were enrolled and followed for 107 months. Serum ferritin and related factors (dialysis, nutrition, iron metabolism, inflammation and oxidative stress) were measured and used for statistical analysis. Survival analysis of death for ferritin as a predictive variable was performed.

RESULTS

A relatively high level of serum ferritin (> or =100 ng/ml) was associated with poor prognosis after adjustment for basic factors and C reactive protein (hazard ratio, 4.18). Hemoglobin-stratified Kaplan-Meier analysis showed that the prognosis for the high ferritin-low hemoglobin group was significantly poor.

CONCLUSION

This study suggests that the ferritin level is closely associated with high mortality in hemodialyzed patients. Further studies investigating the pathological role of iron storage on survival of hemodialyzed patients with large populations are needed.