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Yang Z, Tian Y, Zhou T, Zhu Y, Zhang P, Chen J, Li J. Time-series deep survival prediction for hemodialysis patients using an attention-based Bi-GRU network. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2021; 212:106458. [PMID: 34736175 DOI: 10.1016/j.cmpb.2021.106458] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 10/03/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND AND OBJECTIVE The number of end-stage renal disease (ESRD) patients treated with hemodialysis (HD) has significantly increased, but the prognosis remains poor. Time-series features have been included in only a few studies to predict HD patient survival, and how to utilize such features effectively remains unclear. This article aims to develop a more accurate, interpretable, and clinically practical personalized survival prediction model for HD patients. METHODS This study proposed and evaluated an attention-based Bi-GRU network using time-series features for survival prediction. A distance-based loss function was proposed to improve performance. We used data from 1232 ESRD patients who received regular hemodialysis treatment for ≥ 3 months from 2007 to 2016 at the First Affiliated Hospital of Zhejiang University. The proposed model was compared with representative sequence modeling deep learning architectures and existing survival analysis methods in terms of the C-index and IBS value. Post hoc tests were used to test statistical significance. The attention map was used to assess feature importance over time. The impact of time-series changes on survival was investigated after controlling initial values (using BMI as an example). RESULTS The proposed method outperformed other sequence modeling architectures and the state-of-the-art survival analysis approaches in terms of the C-index and the integrated Brier score (IBS) value. Our method achieved a C-index of 0.7680 (95% confidence intervals [CI]: 0.7645, 0.7716) and an IBS of 0.1302 (95% confidence intervals [CI]: 0.1292, 0.1313), showing an improvement of up to 5.4% in terms of the C-index and a decrease of 3.2% in terms of the IBS value. The addition of the distance-based loss function improved the performance. The predicted risk and actual risk levels closely agreed. This study also found that even after controlling the initial body mass index (BMI) values, different 3-month BMI trends could produce different survival outcomes. CONCLUSIONS This study proposed a more effective and interpretable method to use time-series information in survival analysis. The proposed method may help promote personalized medicine and improve patient prognosis.
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Affiliation(s)
- Ziyue Yang
- Engineering Research Center of EMR and Intelligent Expert System, Ministry of Education, College of Biomedical Engineering and Instrument Science, Zhejiang University, No. 38 Zheda Road, Hangzhou 310027, China
| | - Yu Tian
- Engineering Research Center of EMR and Intelligent Expert System, Ministry of Education, College of Biomedical Engineering and Instrument Science, Zhejiang University, No. 38 Zheda Road, Hangzhou 310027, China
| | - Tianshu Zhou
- Research Center for Healthcare Data Science, Zhejiang Lab, Hangzhou, China
| | - Yilin Zhu
- Kidney Disease Center, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Ping Zhang
- Kidney Disease Center, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Jianghua Chen
- Kidney Disease Center, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Jingsong Li
- Engineering Research Center of EMR and Intelligent Expert System, Ministry of Education, College of Biomedical Engineering and Instrument Science, Zhejiang University, No. 38 Zheda Road, Hangzhou 310027, China; Research Center for Healthcare Data Science, Zhejiang Lab, Hangzhou, China.
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Iseri K, Carrero JJ, Evans M, Felländer-Tsai L, Berg HE, Runesson B, Stenvinkel P, Lindholm B, Qureshi AR. Incidence of Fractures Before and After Dialysis Initiation. J Bone Miner Res 2020; 35:2372-2380. [PMID: 32717115 PMCID: PMC7757394 DOI: 10.1002/jbmr.4141] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 07/13/2020] [Accepted: 07/19/2020] [Indexed: 12/22/2022]
Abstract
Fractures are common in dialysis patients, but little is known about the trajectory of incidence rates of different types of fractures before and after dialysis initiation. To address this, we investigated the incidence of major fractures before and after dialysis initiation. We performed a retrospective statistical analysis using the Swedish Renal Registry of 9041 incident dialysis patients (median age 67 years, 67% men) starting dialysis 2005 through 2015 to identify major fractures (hip, spine, humerus, and forearm) occurring during the dialysis transition period from 1 year before until 1 year after dialysis initiation. Using flexible parametric hazard models and the Fine-Gray model, we estimated adjusted fracture incidence rates and predictors of major fractures. We identified 361 cases with primary diagnosis of major fracture, of which 196 (54%) were hip fractures. The crude incidence rate of major fractures before dialysis initiation was 17 per 1000 patient-years (n = 157) and after dialysis initiation it was 24 per 1000 patient-years (n = 204). The adjusted incidence rate of major fractures began to increase 6 months before dialysis initiation, and then stabilized at a higher rate after 1 year. The adjusted incidence rate of hip fractures started to increase sharply 3 months before dialysis initiation, peaked at initiation, and declined thereafter. In contrast, the adjusted incidence rate of non-hip fractures was stable during the transition period and gradually increased over time. Higher age, female sex, and history of previous major fractures were associated with increased fracture incidence both before and after dialysis initiation. We conclude that the incidence of major fractures, especially hip fractures, start to rise 6 months before initiation of dialysis therapy, indicating that heightened surveillance with implementation of preventive measures to avoid fractures is warranted during the transition period to dialysis. © 2020 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Ken Iseri
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.,Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Juan Jesús Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Marie Evans
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Li Felländer-Tsai
- Division of Orthopaedics and Biotechnology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Hans E Berg
- Division of Orthopaedics and Biotechnology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Björn Runesson
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Peter Stenvinkel
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Bengt Lindholm
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Abdul Rashid Qureshi
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
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Harhay MN, Ranganna K, Boyle SM, Brown AM, Bajakian T, Levin Mizrahi LB, Xiao G, Guy S, Malat G, Segev DL, Reich D, McAdams-DeMarco M. Association Between Weight Loss Before Deceased Donor Kidney Transplantation and Posttransplantation Outcomes. Am J Kidney Dis 2019; 74:361-372. [PMID: 31126666 PMCID: PMC6708783 DOI: 10.1053/j.ajkd.2019.03.418] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 03/07/2019] [Indexed: 12/25/2022]
Abstract
RATIONALE & OBJECTIVE There is debate on whether weight loss, a hallmark of frailty, signals higher risk for adverse outcomes among recipients of deceased donor kidney transplantation (DDKT). STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS Using national Organ Procurement and Transplantation Network data, we included all DDKT recipients in the United States between December 4, 2004, and December 3, 2014, who were adults (aged ≥ 18 years) when listed for DDKT. EXPOSURES Relative pre-DDKT weight change as a continuous predictor and categorized as <5% weight change from listing to DDKT, ≥5% to <10% weight loss, ≥10% weight loss, ≥5% to <10% weight gain, and ≥10% weight gain. OUTCOMES We examined 3 post-DDKT outcomes: (1) transplant hospitalization length of stay (LOS) in days, (2) all-cause graft failure, and (3) mortality. ANALYTIC APPROACH Unadjusted fractional polynomial methods, multivariable log-gamma models, and multivariable Cox proportional hazards models. RESULTS Among 94,465 recipients of DDKT, median pre-DDKT weight change was 0 (interquartile range, -3.5 to +3.9) kg. There were nonlinear unadjusted associations between relative pre-DDKT weight loss and longer transplant hospitalization LOS, higher all-cause graft loss, and higher mortality. Compared with recipients with <5% pre-DDKT weight change (n = 49,366; 52%), recipients who lost ≥10% of their listing weight (n = 10,614; 11%) had 0.66 (95% CI, 0.23-1.09) days longer average transplant hospitalization LOS (P = 0.003), 1.11-fold higher graft loss (adjusted HR [aHR], 1.11; 95% CI, 1.06-1.17; P < 0.001), and 1.18-fold higher mortality (aHR, 1.18; 95% CI, 1.11-1.25; P < 0.001) independent of recipient, donor, and transplant factors. Pre-DDKT dialysis exposure, listing body mass index category, and waiting time modified the association of pre-DDKT weight change with hospital LOS (interaction P < 0.10), but not with all-cause graft loss and mortality. LIMITATIONS Unmeasured confounders and inability to identify volitional weight change. Also, the higher significance level set to increase the power of detecting interactions with the fixed sample size may have resulted in increased risk for type 1 error. CONCLUSIONS DDKT recipients with ≥10% pre-DDKT weight loss are at increased risk for adverse outcomes and may benefit from augmented support post-DDKT.
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Affiliation(s)
- Meera Nair Harhay
- Division of Nephrology and Hypertension, Department of Medicine, Drexel University College of Medicine, Philadelphia, PA; Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, PA.
| | - Karthik Ranganna
- Division of Nephrology and Hypertension, Department of Medicine, Drexel University College of Medicine, Philadelphia, PA
| | - Suzanne M Boyle
- Division of Nephrology and Hypertension, Department of Medicine, Drexel University College of Medicine, Philadelphia, PA
| | - Antonia M Brown
- Division of Nephrology and Hypertension, Department of Medicine, Drexel University College of Medicine, Philadelphia, PA
| | - Thalia Bajakian
- Division of Nephrology and Hypertension, Department of Medicine, Drexel University College of Medicine, Philadelphia, PA
| | - Lissa B Levin Mizrahi
- Division of Nephrology and Hypertension, Department of Medicine, Drexel University College of Medicine, Philadelphia, PA
| | - Gary Xiao
- Division of Multiorgan Transplantation, Department of Surgery, Drexel University College of Medicine, Philadelphia, PA
| | - Stephen Guy
- Division of Multiorgan Transplantation, Department of Surgery, Drexel University College of Medicine, Philadelphia, PA
| | - Gregory Malat
- Division of Multiorgan Transplantation, Department of Surgery, Drexel University College of Medicine, Philadelphia, PA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - David Reich
- Division of Multiorgan Transplantation, Department of Surgery, Drexel University College of Medicine, Philadelphia, PA
| | - Mara McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Kopple JD, Fouque D. Pro: The rationale for dietary therapy for patients with advanced chronic kidney disease. Nephrol Dial Transplant 2019; 33:373-378. [PMID: 29471458 DOI: 10.1093/ndt/gfx333] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 07/27/2017] [Indexed: 01/09/2023] Open
Abstract
Dietary treatment offers many benefits to patients with advanced chronic kidney disease (CKD) who are approaching the need for renal replacement therapy. A large number of these benefits are independent of whether diets slow the rate of progression of CKD. These diets are low in protein and many minerals, and provide adequate energy for the CKD patient. The diets can reduce accumulation of potentially toxic metabolic products derived from protein and amino acid degradation, maintain a healthier balance of body water, sodium, potassium, phosphorus, calcium and other minerals, and prevent or improve protein-energy wasting. Such diets may enable patients to safely delay the onset of chronic dialysis therapy or kidney transplantation. Dietary therapy may also augment the effectiveness of infrequent or incremental dialysis by maintaining healthier metabolic and clinical status and may enable some end-stage renal disease patients to avoid the need for temporary placement of hemodialysis catheters while their arterial venous fistulae or grafts mature. The anxiety that many advanced CKD patients commonly experience with regard to starting dialysis may incentivize them to accept and adhere to dietary therapy.
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Affiliation(s)
- Joel D Kopple
- Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, the David Geffen School of Medicine at UCLA and the UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Denis Fouque
- Department of Nephrology, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
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Bansal S, Wei G, Boucher RE, Beddhu S. Self-reported Intentional Weight Loss and Risk of Death in Moderate Chronic Kidney Disease in the United States. J Ren Nutr 2018; 28:422-427. [PMID: 30077396 DOI: 10.1053/j.jrn.2018.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 03/27/2018] [Accepted: 04/02/2018] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE We hypothesized that intentional weight loss is associated with lower mortality risk, whereas unintentional weight loss is associated with higher mortality risk in chronic kidney disease (CKD). DESIGN AND METHODS We examined this hypothesis in 872 participants with age >20 years, body mass index ≥ 25 kg/m2 and CKD from 1999-2004 National Health and Nutrition Examination Survey who reported their 1 year prior and current weights and the intent to lose weight. We examined the association of self-reported intentional versus unintentional weight loss with all-cause mortality. Participants with no intent to lose weight and no change in weight were the reference group. A multivariable Cox regression model was used to relate mortality with intentional and unintentional weight losses after adjustment for demographics and comorbidity. RESULTS There were 446 deaths over 6271 years of follow-up. Compared to the reference group, intentional weight loss of 5% to <10% (hazard ratio (HR) 1.22, 95% confidence interval (CI): 0.74-1.99), intentional weight loss of ≥10% (HR 1.53, 95% CI: 0.75-3.12), and unintentional weight loss of 5% to <10% (HR 1.11, 95% CI: 0.71-1.75) were not associated with mortality; however, unintentional weight loss of ≥10% (HR 1.66, 95% CI: 1.06-2.58) was significantly associated with higher risk of mortality. Retrospective design and self-reported weight loss were the limitations. CONCLUSIONS Intentional weight loss in CKD participants was not associated with lower mortality risk. This might reflect residual confounding. Mechanistic and interventional studies are warranted to determine the effects of intentional weight loss in CKD.
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Affiliation(s)
- Shweta Bansal
- Renal section, South Texas Veterans Health Care System, San Antonio, Texas; Department of Medicine, University of Texas Health at San Antonio, San Antonio, Texas
| | - Guo Wei
- Renal section, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah
| | - Robert E Boucher
- Renal section, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah
| | - Srinivasan Beddhu
- Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah; Renal section, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah.
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Ku E, Kopple JD, Johansen KL, McCulloch CE, Go AS, Xie D, Lin F, Hamm LL, He J, Kusek JW, Navaneethan SD, Ricardo AC, Rincon-Choles H, Smogorzewski M, Hsu CY. Longitudinal Weight Change During CKD Progression and Its Association With Subsequent Mortality. Am J Kidney Dis 2018; 71:657-665. [PMID: 29217305 PMCID: PMC5915916 DOI: 10.1053/j.ajkd.2017.09.015] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 09/12/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND Few studies have investigated the changes in weight that may occur over time among adults with the progression of chronic kidney disease (CKD). Whether such weight changes are independently associated with death after the onset of end-stage renal disease has also not been rigorously examined. STUDY DESIGN Prospective cohort study. SETTING & PARTICIPANTS We studied 3,933 participants of the Chronic Renal Insufficiency Cohort (CRIC) Study, a longitudinal cohort of patients with CKD. We also performed similar analyses among 1,067 participants of the African American Study of Kidney Disease and Hypertension (AASK). PREDICTORS Estimated glomerular filtration rate (eGFR) and weight change during CKD. OUTCOME Weight and all-cause mortality after dialysis therapy initiation. RESULTS During a median follow-up of 5.7 years in CRIC, weight change was not linear. Weight was stable until cystatin C-based eGFR (eGFRcys) decreased to <35mL/min/1.73m2; thereafter, weight declined at a mean rate of 1.45 kg (95% CI, 1.19-1.70) for every 10 mL/min/1.73m2 decline in eGFRcys. Among the 770 CRIC participants who began hemodialysis or peritoneal dialysis therapy during follow-up, a >5% annualized weight loss after eGFR decreased to <35mL/min/1.73m2 was associated with a 54% higher risk for death after dialysis therapy initiation (95% CI, 1.17-2.03) compared with those with more stable weight (annualized weight changes within 5% of baseline) in adjusted analysis. Similar findings were observed in the AASK. LIMITATIONS Inclusion of research participants only; inability to distinguish intentional versus unintentional weight loss. CONCLUSIONS Significant weight loss began relatively early during the course of CKD and was associated with a substantially higher risk for death after dialysis therapy initiation. Further studies are needed to determine whether interventions to optimize weight and nutritional status before the initiation of dialysis therapy will improve outcomes after end-stage renal disease.
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Affiliation(s)
- Elaine Ku
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, CA; Division of Pediatric Nephrology, Department of Pediatrics, University of California, San Francisco, San Francisco, CA.
| | - Joel D Kopple
- Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, and University of California, Los Angeles Schools of Medicine and Public Health, Los Angeles, CA
| | - Kirsten L Johansen
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, CA; Nephrology Section, San Francisco Veterans Affairs Medical Center, San Francisco, CA
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Alan S Go
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, CA; Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA; Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Dawei Xie
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Feng Lin
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - L Lee Hamm
- Department of Medicine, Tulane University School of Medicine, New Orleans, LA
| | - Jiang He
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA
| | - John W Kusek
- National Institute of Diabetes, Digestive, and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | | | - Ana C Ricardo
- Division of Nephrology, Department of Medicine, University of Illinois, Chicago, IL
| | - Hernan Rincon-Choles
- Glickman Urological and Kidney Institute, Department of Nephrology, Cleveland Clinic Foundation, Cleveland, OH
| | | | - Chi-Yuan Hsu
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, CA
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Kopple JD, Fouque D. Opponent's comments. Nephrol Dial Transplant 2018; 33:384-387. [PMID: 29165660 DOI: 10.1093/ndt/gfx294a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 08/18/2017] [Indexed: 11/14/2022] Open
Affiliation(s)
- Joel D Kopple
- Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, the David Geffen School of Medicine at UCLA and the UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Denis Fouque
- Department of Nephrology, Centre Hospitalier Lyon Sud, Univ Lyon, UCBL, Carmen, Pierre-Bénite, France
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Hanafusa N, Lodebo BT, Kopple JD. Current Uses of Dietary Therapy for Patients with Far-Advanced CKD. Clin J Am Soc Nephrol 2017; 12:1190-1195. [PMID: 28228464 PMCID: PMC5498353 DOI: 10.2215/cjn.09340916] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
For several decades, inquiry concerning dietary therapy for nondialyzed patients with CKD has focused mainly on its capability to retard progression of CKD. However, several studies published in recent years indicate that, independent of whether diet can delay progression of CKD, well designed low-protein diets may provide a number of benefits for people with advanced CKD who are close to requiring or actually in need of RRT. Dietary therapy may both maintain good nutritional status and safely delay the need for chronic dialysis in such patients, offering the possibility of improving quality of life and reducing health care costs. With the growing interest in incremental dialysis, dietary therapy may enable lower doses of dialysis to be safely and effectively used, even as GFR continues to decrease. Such combinations of dietary and incremental dialysis therapy might slow the rate of loss of residual GFR, possibly reduce mortality in patients with advanced CKD, improve quality of life, and also, reduce health care costs. The amount of evidence that supports these possibilities is limited, and more well designed, randomized clinical trials are clearly indicated.
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Affiliation(s)
- Norio Hanafusa
- Department of Blood Purification, Kidney Center, Tokyo Women’s Medical University, Tokyo, Japan
- Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor–UCLA Medical Center, Torrance, California
| | - Bereket Tessema Lodebo
- Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor–UCLA Medical Center, Torrance, California
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Joel D. Kopple
- Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor–UCLA Medical Center, Torrance, California
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California; and
- UCLA Fielding School of Public Health, Los Angeles, California
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Duranton F, Duny Y, Szwarc I, Deleuze S, Rouanet C, Selcer I, Maurice F, Rivory JP, Servel MF, Jover B, Brunet P, Daurès JP, Argilés À. Early changes in body weight and blood pressure are associated with mortality in incident dialysis patients. Clin Kidney J 2016; 9:287-94. [PMID: 26985382 PMCID: PMC4792627 DOI: 10.1093/ckj/sfv153] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 12/18/2015] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND While much research is devoted to identifying novel biomarkers, addressing the prognostic value of routinely measured clinical parameters is of great interest. We studied early blood pressure (BP) and body weight (BW) trajectories in incident haemodialysis patients and their association with all-cause mortality. METHODS In a cohort of 357 incident patients, we obtained all records of BP and BW during the first 90 days on dialysis (over 12 800 observations) and analysed trajectories using penalized B-splines and mixed linear regression models. Baseline comorbidities and all-cause mortality (median follow-up: 2.2 years) were obtained from the French Renal Epidemiology and Information Network (REIN) registry, and the association with mortality was assessed by Cox models adjusting for baseline comorbidities. RESULTS During the initial 90 days on dialysis, there were non-linear decreases in BP and BW, with milder slopes after 15 days [systolic BP (SBP)] or 30 days [diastolic BP (DBP) and BW]. SBP or DBP levels at dialysis initiation and changes in BW occurring in the first month or during the following 2 months were significantly associated with survival. In multivariate models adjusting for baseline comorbidities and prescriptions, higher SBP value and BW slopes were independently associated with a lower risk of mortality. Hazard ratios of mortality and 95% confidence intervals were 0.92 (0.85-0.99) for a 10 mmHg higher SBP and 0.76 (0.66-0.88) for a 1 kg/month higher BW change on Days 30-90. CONCLUSIONS BW loss in the first weeks on dialysis is a strong and independent predictor of mortality. Low BP is also associated with mortality and is probably the consequence of underlying cardiovascular diseases. These early markers appear to be valuable prognostic factors.
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Affiliation(s)
- Flore Duranton
- RD – Néphrologie/EA7288, Université Montpellier, Montpellier, France
| | - Yohan Duny
- EA2415, Institut Universitaire de Recherche Clinique, Université Montpellier, Montpellier, France
| | - Ilan Szwarc
- Néphrologie Dialyse Saint Guilhem, Sète, France
| | | | | | | | | | | | | | - Bernard Jover
- EA7288, UFR Pharmacie, Université Montpellier, Montpellier, France
| | - Philippe Brunet
- Service de Néphrologie, CHU de La Conception, Université Aix – Marseille, Marseille, France
| | - Jean-Pierre Daurès
- EA2415, Institut Universitaire de Recherche Clinique, Université Montpellier, Montpellier, France
| | - Àngel Argilés
- RD – Néphrologie/EA7288, Université Montpellier, Montpellier, France
- Néphrologie Dialyse Saint Guilhem, Sète, France
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Villain C, Ecochard R, Genet L, Jean G, Kuentz F, Lataillade D, Legrand E, Moreau-Gaudry X, Fouque D. Impact of BMI Variations on Survival in Elderly Hemodialysis Patients. J Ren Nutr 2015; 25:488-93. [PMID: 26139338 DOI: 10.1053/j.jrn.2015.05.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 04/18/2015] [Accepted: 05/15/2015] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES In elderly hemodialysis patients, protein-energy wasting is associated with poor outcome; however, the association between body mass index (BMI) changes over time, and survival has been seldom studied in this particularly frail population. DESIGN AND METHODS This prospective study recruited 502 hemodialysis patients aged ≥75 years from the French cohort ARNOS and followed them from 2005 to 2009. BMI changes over time were modeled by individual linear regression models. Survival analyses used frailty Cox models. RESULTS The population average age was 80.9 years. Forty-one percent of the patients died during follow-up. A 1 kg/m(2) lower baseline BMI was associated with a 4% increase in the risk of death over the study period (hazard ratio [HR] 1.04, 95% confidence interval [1.01-1.08], P = .02). A 5% BMI loss per year was associated with a 52% increase in the risk of death (HR 1.52, 95% confidence interval [1.32-1.75], P < .001). In patients who lost weight (>5% BMI loss per year), the lower was the baseline BMI, the higher was the HR for death. There was a similar trend in the patients with stable weight (5% BMI loss-5% BMI gain per year). In patients who gained weight, the HR was unexpectedly higher than in those with stable weight. CONCLUSIONS In elderly hemodialysis patients, the impact of the BMI percent change on survival was stronger than that of the baseline BMI. Patients with stable weight had longer survivals than patients who lost or gained weight. Thus, in this population, BMI changes should be regularly assessed. Further studies should assess the safety of weight gain strategies.
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Affiliation(s)
- Cédric Villain
- Service de Biostatistique, Hospices Civils de Lyon, Lyon, France; Université de Lyon, Lyon, France; Université Lyon 1, Villeurbanne, France; CNRS, UMR5558, Equipe Biostatistique-Santé, Villeurbanne, France; Service de néphrologie-nutrition-dialyse, Centre Hospitalier Lyon Sud, Lyon, France.
| | - René Ecochard
- Service de Biostatistique, Hospices Civils de Lyon, Lyon, France; Université de Lyon, Lyon, France; Université Lyon 1, Villeurbanne, France; CNRS, UMR5558, Equipe Biostatistique-Santé, Villeurbanne, France
| | - Leslie Genet
- Service de néphrologie-nutrition-dialyse, Centre Hospitalier Lyon Sud, Lyon, France
| | | | | | | | - Eric Legrand
- Service de Néphrologie et Hémodialyse, Centre Hospitalier d'Ardèche Nord, Annonay, France
| | | | - Denis Fouque
- Université de Lyon, Lyon, France; Université Lyon 1, Villeurbanne, France; Service de néphrologie-nutrition-dialyse, Centre Hospitalier Lyon Sud, Lyon, France; INSERM CarMeN, CENS, Université Lyon 1, Villeurbanne, France
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11
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Affiliation(s)
- Juan Jesús Carrero
- Division of Renal Medicine and Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
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12
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Kovesdy CP, Kalantar-Zadeh K. Changes in body weight and subsequent mortality: are we any closer to knowing how to deal with obesity in ESRD? Clin J Am Soc Nephrol 2013; 8:1640-2. [PMID: 24009219 DOI: 10.2215/cjn.08260813] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Csaba P Kovesdy
- Division of Nephrology, Memphis Veterans Affairs Medical Center, Memphis, Tennessee;, †Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee;, ‡Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine Medical Center, Irvine, California;, §Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
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