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Cejka D, Wakolbinger-Habel R, Zitt E, Fahrleitner-Pammer A, Amrein K, Dimai HP, Muschitz C. [Diagnosis and treatment of osteoporosis in patients with chronic kidney disease : Joint guidelines of the Austrian Society for Bone and Mineral Research (ÖGKM), the Austrian Society of Physical and Rehabilitation Medicine (ÖGPMR) and the Austrian Society of Nephrology (ÖGN)]. Wien Med Wochenschr 2023; 173:299-318. [PMID: 36542221 PMCID: PMC10516794 DOI: 10.1007/s10354-022-00989-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 11/09/2022] [Indexed: 12/24/2022]
Abstract
DEFINITION AND EPIDEMIOLOGY Chronic kidney disease (CKD): abnormalities of kidney structure or function, present for over 3 months. Staging of CKD is based on GFR and albuminuria (not graded). Osteoporosis: compromised bone strength (low bone mass, disturbance of microarchitecture) predisposing to fracture. By definition, osteoporosis is diagnosed if the bone mineral density T‑score is ≤ -2.5. Furthermore, osteoporosis is diagnosed if a low-trauma (inadequate trauma) fracture occurs, irrespective of the measured T‑score (not graded). The prevalence of osteoporosis, osteoporotic fractures and CKD is increasing worldwide (not graded). PATHOPHYSIOLOGY, DIAGNOSIS AND TREATMENT OF CHRONIC KIDNEY DISEASE-MINERAL AND BONE DISORDER (CKD-MBD): Definition of CKD-MBD: a systemic disorder of mineral and bone metabolism due to CKD manifested by either one or a combination of the following: abnormalities of calcium, phosphorus, PTH, or vitamin D metabolism; renal osteodystrophy; vascular calcification (not graded). Increased, normal or decreased bone turnover can be found in renal osteodystrophy (not graded). Depending on CKD stage, routine monitoring of calcium, phosphorus, alkaline phosphatase, PTH and 25-OH-vitamin D is recommended (2C). Recommendations for treatment of CKD-MBD: Avoid hypercalcemia (1C). In cases of hyperphosphatemia, lower phosphorus towards normal range (2C). Keep PTH within or slightly above normal range (2D). Vitamin D deficiency should be avoided and treated when diagnosed (1C). DIAGNOSIS AND RISK STRATIFICATION OF OSTEOPOROSIS IN CKD Densitometry (using dual X‑ray absorptiometry, DXA): low T‑score correlates with increased fracture risk across all stages of CKD (not graded). A decrease of the T‑score by 1 unit approximately doubles the risk for osteoporotic fracture (not graded). A T-score ≥ -2.5 does not exclude osteoporosis (not graded). Bone mineral density of the lumbar spine measured by DXA can be increased and therefore should not be used for the diagnosis or monitoring of osteoporosis in the presence of aortic calcification, osteophytes or vertebral fracture (not graded). FRAX can be used to aid fracture risk estimation in all stages of CKD (1C). Bone turnover markers can be measured in individual cases to monitor treatment (2D). Bone biopsy may be considered in individual cases, especially in patients with CKD G5 (eGFR < 15 ml/min/1.73 m2) or CKD 5D (dialysis). SPECIFIC TREATMENT OF OSTEOPOROSIS IN PATIENTS WITH CKD Hypocalcemia should be treated and serum calcium normalized before initiating osteoporosis therapy (1C). CKD G1-G2 (eGFR ≥ 60 ml/min/1.73 m2): treat osteoporosis as recommended for the general population (1A). CKD G3-G5D (eGFR < 60 ml/min/1.73 m2 to dialysis): treat CKD-MBD first before initiating osteoporosis treatment (2C). CKD G3 (eGFR 30-59 ml/min/1.73 m2) with PTH within normal limits and osteoporotic fracture and/or high fracture risk according to FRAX: treat osteoporosis as recommended for the general population (2B). CKD G4-5 (eGFR < 30 ml/min/1.73 m2) with osteoporotic fracture (secondary prevention): Individualized treatment of osteoporosis is recommended (2C). CKD G4-5 (eGFR < 30 ml/min/1.73 m2) and high fracture risk (e.g. FRAX score > 20% for a major osteoporotic fracture or > 5% for hip fracture) but without prevalent osteoporotic fracture (primary prevention): treatment of osteoporosis may be considered and initiated individually (2D). CKD G4-5D (eGFR < 30 ml/min/1.73 m2 to dialysis): Calcium should be measured 1-2 weeks after initiation of antiresorptive therapy (1C). PHYSICAL MEDICINE AND REHABILITATION Resistance training prioritizing major muscle groups thrice weekly (1B). Aerobic exercise training for 40 min four times per week (1B). Coordination and balance exercises thrice weekly (1B). Flexibility exercise 3-7 times per week (1B).
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Affiliation(s)
- Daniel Cejka
- Abteilung für Innere Medizin III, Nieren- und Hochdruckerkrankungen, Transplantationsmedizin, Rheumatologie, Akutgeriatrie, Ordensklinikum Linz – Krankenhaus der Elisabethinen, Fadingerstr. 1, 4020 Linz, Österreich
| | - Robert Wakolbinger-Habel
- Department of Physical and Rehabilitation Medicine (PRM), Vienna Healthcare Group – Clinic Donaustadt, Langobardenstr. 122, 1220 Wien, Österreich
| | - Emanuel Zitt
- Department of Internal Medicine 3 (Nephrology and Dialysis), Feldkirch Academic Teaching Hospital, Feldkirch, Österreich
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Feldkirch, Österreich
- Agency for Preventive and Social Medicine (aks), Bregenz, Österreich
| | - Astrid Fahrleitner-Pammer
- Division of Endocrinology and Diabetology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Österreich
| | - Karin Amrein
- Division of Endocrinology and Diabetology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Österreich
| | - Hans Peter Dimai
- Division of Endocrinology and Diabetology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Österreich
| | - Christian Muschitz
- Medical Department II – VINFORCE, St. Vincent Hospital Vienna (Barmherzige Schwestern Krankenhaus Wien), Stumpergasse 13, 1060 Wien, Österreich
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ter Meulen KJ, Ye X, Wang Y, Usvyat LA, van der Sande FM, Konings CJ, Kotanko P, Kooman JP, Maddux FW. Variability of Serum Phosphate in Incident Hemodialysis Patients: Association with All-Cause Mortality. KIDNEY360 2023; 4:374-380. [PMID: 36918167 PMCID: PMC10103252 DOI: 10.34067/kid.0000000000000062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 12/20/2022] [Indexed: 03/15/2023]
Abstract
Key Points An increase in serum phosphate variability is an independent risk factor of mortality. The effects of a positive directional range (DR) is most pronounced in patients with high serum phosphate levels whereas the effects of a negative DR is most pronounced in patients with low serum phosphate and/or serum albumin. Background In maintenance hemodialysis (HD) patients, previous studies have shown that serum phosphate levels have a bidirectional relation to outcome. Less is known about the relation between temporal dynamics of serum phosphate in relation to outcome. We aimed to further explore the relation between serum phosphate variability and all-cause mortality. Methods All adult incident HD patients treated in US Fresenius Kidney Care clinics between January 2010 and October 2018 were included. Baseline period was defined as 6 months after initiation of HD and months 7–18 as follow-up period. All-cause mortality was recorded during the follow-up period. The primary metric of variability used was directional range (DR) that is the difference between the largest and smallest values within a time period; DR was positive when the smallest value preceded the largest and negative otherwise. Cox proportional hazards models with spline terms were applied to explore the association between phosphate, DR, and all-cause mortality. In addition, tensor product smoothing splines were computed to further elucidate the interactions of phosphate, DR, and all-cause mortality. Results We included 302,613 patients. Baseline phosphate was 5.1±1.2 mg/dl, and mean DR was +0.6±3.3 mg/dl. Across different levels of phosphate, higher levels of DR of phosphate were associated with higher risk of all-cause mortality. In patients with lower levels of phosphate and serum albumin, the effect of a negative DR was most pronounced, whereas in patients with higher phosphate levels, a positive DR was related to increased mortality. Conclusions Higher variability of serum phosphate is related to mortality at all levels of phosphate, especially in lower levels with a negative DR and in low serum albumin levels. This could possibly reflect dietary intake in patients who are already inflamed or malnourished, where a further reduction in serum phosphate should prompt for nutritional evaluation.
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Affiliation(s)
- Karlien J. ter Meulen
- Maastricht University Medical Center, Maastricht, The Netherlands
- Catharina Hospital, Eindhoven, The Netherlands
| | - Xiaoling Ye
- Renal Research Institute, New York, New York
| | - Yuedong Wang
- Department of Statistics and Applied Probability, University of California–Santa Barbara, Santa Barbara, California
| | - Len A. Usvyat
- Global Medical Office, Fresenius Medical Care, Waltham, Massachusetts
| | | | | | - Peter Kotanko
- Renal Research Institute, New York, New York
- Icahn School of Medicine at Mount Sinai Hospital, New York, New York
| | - Jeroen P. Kooman
- Maastricht University Medical Center, Maastricht, The Netherlands
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Schwaiger JP, Kollerits B, Steinbrenner I, Weissensteiner H, Schönherr S, Forer L, Kotsis F, Lamina C, Schneider MP, Schultheiss UT, Wanner C, Köttgen A, Eckardt KU, Kronenberg F. Apolipoprotein A-IV concentrations and clinical outcomes in a large chronic kidney disease cohort: Results from the GCKD study. J Intern Med 2022; 291:622-636. [PMID: 34914850 PMCID: PMC9305919 DOI: 10.1111/joim.13437] [Citation(s) in RCA: 2] [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] [Indexed: 01/07/2023]
Abstract
BACKGROUND Chronic kidney disease (CKD) represents a chronic proinflammatory state and is associated with very high cardiovascular risk. Apolipoprotein A-IV (apoA-IV) has antiatherogenic, antioxidative, anti-inflammatory and antithrombotic properties and levels increase significantly during the course of CKD. OBJECTIVES We aimed to investigate the association between apoA-IV and all-cause mortality and cardiovascular outcomes in the German Chronic Kidney Disease study. METHODS This was a prospective cohort study including 5141 Caucasian patients with available apoA-IV measurements and CKD. The majority of the patients had an estimated glomerular filtration rate (eGFR) of 30-60 ml/min/1.73m2 or an eGFR >60 ml/min/1.73m2 in the presence of overt proteinuria. Median follow-up was 6.5 years. The association of apoA-IV with comorbidities at baseline and endpoints during follow-up was modelled adjusting for major confounders. RESULTS Mean apoA-IV concentrations of the entire cohort were 28.9 ± 9.8 mg/dl. Patients in the highest apoA-IV quartile had the lowest high-sensitivity C-reactive protein values despite the highest prevalence of diabetes, albuminuria and the lowest eGFR. Each 10 mg/dl higher apoA-IV translated into lower odds of prevalent cardiovascular disease (1289 cases, odds ratio = 0.80, 95% confidence interval [CI] 0.72-0.86, p = 0.0000003). During follow-up, each 10 mg/dl higher apoA-IV was significantly associated with a lower risk for all-cause mortality (600 cases, hazard ratio [HR] = 0.81, 95% CI 0.73-0.89, p = 0.00004), incident major adverse cardiovascular events (506 cases, HR = 0.88, 95% CI 0.79-0.99, p = 0.03) and death or hospitalizations due to heart failure (346 cases, HR = 0.84, 95% CI 0.73-0.96, p = 0.01). CONCLUSIONS These data support a link between elevated apoA-IV concentrations and reduced inflammation in moderate CKD. ApoA-IV appears to be an independent risk marker for reduced all-cause mortality, cardiovascular events and heart failure in a large cohort of patients with CKD.
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Affiliation(s)
- Johannes P Schwaiger
- Institute of Genetic Epidemiology, Medical University of Innsbruck, Innsbruck, Austria.,Department of Internal Medicine, Landeskrankenhaus Hall i.T., Hall in Tirol, Austria
| | - Barbara Kollerits
- Institute of Genetic Epidemiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Inga Steinbrenner
- Institute of Genetic Epidemiology, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Hansi Weissensteiner
- Institute of Genetic Epidemiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Sebastian Schönherr
- Institute of Genetic Epidemiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Lukas Forer
- Institute of Genetic Epidemiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Fruzsina Kotsis
- Institute of Genetic Epidemiology, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany.,Department of Medicine IV - Nephrology and Primary Care, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Claudia Lamina
- Institute of Genetic Epidemiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Markus P Schneider
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Ulla T Schultheiss
- Institute of Genetic Epidemiology, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany.,Department of Medicine IV - Nephrology and Primary Care, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Christoph Wanner
- Division of Nephrology, Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Anna Köttgen
- Institute of Genetic Epidemiology, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Kai-Uwe Eckardt
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.,Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Florian Kronenberg
- Institute of Genetic Epidemiology, Medical University of Innsbruck, Innsbruck, Austria
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- Institute of Genetic Epidemiology, Medical University of Innsbruck, Innsbruck, Austria
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Huang N, Li H, Fan L, Zhou Q, Fu D, Guo L, Yi C, Yu X, Mao H. Serum Phosphorus and Albumin in Patients Undergoing Peritoneal Dialysis: Interaction and Association With Mortality. Front Med (Lausanne) 2021; 8:760394. [PMID: 34926505 PMCID: PMC8672136 DOI: 10.3389/fmed.2021.760394] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 10/29/2021] [Indexed: 12/13/2022] Open
Abstract
Hyperphosphatemia and hypoalbuminemia confer worse clinical outcomes, whether these risk factors interact to predispose to mortality is unclear. In this prospective cohort study, 2,118 patients undergoing incident continuous ambulatory peritoneal dialysis (CAPD) were enrolled and categorized into four groups based on the changing point regarding mortality at 1.5 mmol/L for serum phosphorus and 35 g/L for serum albumin. Risks of all-cause and cardiovascular mortality were examined independently and interactively in overall and subgroups. There was no association between serum phosphorus with all-cause and cardiovascular mortality, but significant interactions (p = 0.02) between phosphorus and albumin existed in overall population. Patients in subgroup with high phosphorus and low albumin were at greater risk of all-cause (HR 1.95, 95%CI 1.27–2.98, p = 0.002) but not cardiovascular mortality (HR 0.37, 95%CI 0.10–1.33, p = 0.13), as compared to those with low phosphorus and high albumin. In contrast, patients with both low parameters had a higher risk of all-cause (HR 1.75, 95%CI 1.22–2.50, p = 0.002) and cardiovascular mortality (HR 1.92, 95%CI 1.07–3.45, p = 0.03). Notably, an elevated risk of both all-cause and cardiovascular mortality was observed in those with low serum albumin, irrespective of phosphorus levels, suggesting low albumin may be useful to identify a higher-risk subgroup of patients undergoing CAPD with different serum phosphorus levels.
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Affiliation(s)
- Naya Huang
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Key Laboratory of Nephrology, Ministry of Health of China, Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
| | - Huiyan Li
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Key Laboratory of Nephrology, Ministry of Health of China, Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
| | - Li Fan
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Key Laboratory of Nephrology, Ministry of Health of China, Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
| | - Qian Zhou
- Department of Medical Statistics, Clinical Trials Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Dongying Fu
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Key Laboratory of Nephrology, Ministry of Health of China, Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
| | - Lin Guo
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Key Laboratory of Nephrology, Ministry of Health of China, Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
| | - Chunyan Yi
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Key Laboratory of Nephrology, Ministry of Health of China, Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
| | - Xueqing Yu
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Key Laboratory of Nephrology, Ministry of Health of China, Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China.,Department of Nephrology, Guangdong Provincial People's Hospital, Guangzhou, China
| | - Haiping Mao
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Key Laboratory of Nephrology, Ministry of Health of China, Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
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Boz G, Uludag K. Serum Albumin Trends in Relation With Prognosis of Individuals Receiving Hemodialysis Therapy. Cureus 2021; 13:e19958. [PMID: 34984121 PMCID: PMC8714045 DOI: 10.7759/cureus.19958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2021] [Indexed: 11/20/2022] Open
Abstract
Introduction Hypoalbuminemia 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. Methods Retrospective 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. Results Mean (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. Conclusion These 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.
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Moromizato T, Kohagura K, Tokuyama K, Shiohira Y, Toma S, Uehara H, Arima H, Ueda S, Iseki K. Predictors of Survival in Chronic Hemodialysis Patients: A 10-Year Longitudinal Follow-Up Analysis. Am J Nephrol 2021; 52:108-118. [PMID: 33756478 DOI: 10.1159/000513951] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 12/18/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Risk factors of mortality in chronic hemodialysis patients have not yet been sufficiently evaluated. In particular, chronological transits and interactions of the impact of risk factors have rarely been described. METHODS This study is a post hoc analysis of the participants in the Olme-sartan Clinical Trial in Okinawan Patients under OKIDS (OCTOPUS) study conducted between June 2006 and June 2011. We additionally followed up on the prognosis of the participants until July 31, 2018. Standardized univariable and multivariable Cox regression analyses were used to evaluate the influences of the participants' baseline characteristics on all-cause mortality. We also evaluated chronological changes in the impacts of risk factors, interactions among predictors, and the influence of missing values using sensitivity analyses. RESULTS Of the 469 original trial participants, 461 participants were evaluated. The median time of follow-up was 10.2 years. A total of 211 (45.8%) participants were deceased. The leading causes of death were infection (n = 72, 34.1%) and cardiovascular disease (n = 66, 31.3%). Univariate and multivariate Cox regression analyses revealed that the impact of diabetes mellitus, history of coronary intervention, and hypoalbuminemia were significant risk factors for mortality during the whole follow-up period. During the early follow-up period (≤3 years), standardized univariate Cox regression analyses revealed that history of amputation (hazard ratio [HR] = 4.61, p < 0.001), lower dry weight, higher cardiothoracic ratio, and lower potassium levels were statistically significant risks. In those who survived for longer than 3 years, a history of stroke (HR = 1.73, p = 0.006), higher systolic blood pressure, lower serum sodium levels, and higher levels of hemoglobin, and serum phosphate were significant risks. We also observed a stable interaction between the impacts of serum phosphate and albumin on all-cause mortality. CONCLUSION In chronic hemodialysis patients, targets to improve the short-term prognosis and long-term prognosis are not equivalent. Hyperphosphatemia was a significant risk factor for the all-cause mortality among patients with normal serum albumin levels but not among patients with compromised albumin levels.
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Affiliation(s)
- Takuhiro Moromizato
- Renal and Rheumatology Division, Internal Medicine Department, Okinawa Nanbu Prefectural Medical Center and Children's Medical Center, Okinawa, Japan,
| | - Kentaro Kohagura
- Renal Division and Blood Purification Center, University of the Ryukyus, Okinawa, Japan
- OCTOPUS Group, Okinawa Dialysis and Transplant Association, Okinawa, Japan
| | - Kiyoyuki Tokuyama
- OCTOPUS Group, Okinawa Dialysis and Transplant Association, Okinawa, Japan
- Tokuyama Clinic, Okinawa, Japan
| | - Yoshiki Shiohira
- OCTOPUS Group, Okinawa Dialysis and Transplant Association, Okinawa, Japan
- Renal and Rheumatology Division, Internal Medicine Department, Tomishiro Central Hospital, Okinawa, Japan
| | - Shigeki Toma
- OCTOPUS Group, Okinawa Dialysis and Transplant Association, Okinawa, Japan
- Toma Clinic, Okinawa, Japan
| | - Hajime Uehara
- OCTOPUS Group, Okinawa Dialysis and Transplant Association, Okinawa, Japan
- Blood Purification Center, Okinawa Prefectural Chubu Hospital, Okinawa, Japan
| | - Hisatomi Arima
- OCTOPUS Group, Okinawa Dialysis and Transplant Association, Okinawa, Japan
- Department of Preventive Medicine and Public Health, Fukuoka University, Fukuoka, Japan
| | - Shinichiro Ueda
- OCTOPUS Group, Okinawa Dialysis and Transplant Association, Okinawa, Japan
- Clinical Pharmacology Division, University of the Ryukyus, Okinawa, Japan
| | - Kunitoshi Iseki
- OCTOPUS Group, Okinawa Dialysis and Transplant Association, Okinawa, Japan
- Clinical Research Support Center, Nakamura Clinic, Okinawa, Japan
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Kalantar-Zadeh K, Ficociello LH, Bazzanella J, Mullon C, Anger MS. Slipping Through the Pores: Hypoalbuminemia and Albumin Loss During Hemodialysis. Int J Nephrol Renovasc Dis 2021; 14:11-21. [PMID: 33505168 PMCID: PMC7829597 DOI: 10.2147/ijnrd.s291348] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 12/30/2020] [Indexed: 12/12/2022] Open
Abstract
Hypoalbuminemia results when compensatory mechanisms are unable to keep pace with derangements in catabolism/loss and/or decreased synthesis of albumin. Across many disease states, including chronic kidney disease (CKD), hypoalbuminemia is a well-established, independent risk factor for adverse outcomes, including mortality. In the setting of CKD, reduced serum albumin concentrations are often a manifestation of protein-energy wasting, a state of metabolic and nutritional alterations resulting in reduced protein and energy stores. The progression of CKD to kidney failure and the initiation of maintenance hemodialysis (HD) further predisposes an already at-risk population toward hypoalbuminemia such that approximately 60% of HD patients have albumin concentrations <4.0 g/dl. Albumin loss into the dialysate through the dialyzer appears to be a potentially modifiable cause of hypoalbuminemia in some patients. A group of newer dialyzers for maintenance HD-sometimes termed protein-leaking or medium cut-off membranes-aim to improve clearance of middle molecules (vs high flux dialyzers) but are associated with increased albumin losses. In this article, we will examine the impact of dialyzer selection on albumin losses during conventional HD, including the clinical relevance of such losses on serum albumin levels. Data on the clinical relevance of albumin losses during dialysis and current gaps in the evidence base are also discussed.
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Affiliation(s)
- Kamyar Kalantar-Zadeh
- Division of Nephrology, Hypertension and Kidney Transplantation, University of California, Irvine, School of Medicine, Orange, CA, USA
- Department of Epidemiology, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
- Los Angeles Biomedical Research Institute at Harbor–UCLA, Torrance, CA, USA
| | | | | | - Claudy Mullon
- Fresenius Medical Care Renal Therapies Group, Waltham, MA, USA
| | - Michael S Anger
- Fresenius Medical Care Renal Therapies Group, Waltham, MA, USA
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TAPAK LEILI, SHEIKH VIDA, JENABI ENSIYEH, KHAZAEI SALMAN. Predictors of mortality among hemodialysis patients in Hamadan province using random survival forests. JOURNAL OF PREVENTIVE MEDICINE AND HYGIENE 2020; 61:E482-E488. [PMID: 33150237 PMCID: PMC7595073 DOI: 10.15167/2421-4248/jpmh2020.61.3.1421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 06/24/2020] [Indexed: 11/16/2022]
Abstract
Background Hemodialysis patients are at a high risk for morbidity and mortality. This study aimed to find the predictors of mortality and survival in hemodialysis patients in Hamadan province of Iran. Methods A number of 785 patients during the entire 10 years were enrolled into this historical cohort study. Data were gathered by a checklist of hospital records. The survival time was the time between the start of hemodialysis treatment to patient’s death as the end point. Random survival forests (RSF) method was used to identify the main predictors of survival among the patients. Results The median survival time was 613 days. The number of 376 deaths was occurred. The three most important predictors of survival were hemoglobin, CRP and albumin. RSF method predicted survival better than the conventional Cox-proportional hazards model (out-of-bag C-index of 0.808 for RSF vs. 0.727 for Cox model). Conclusions We found that positivity of CRP, low serum albumin and low serum hemoglobin were the top three most important predictors of low survival for HD patients
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Affiliation(s)
- LEILI TAPAK
- Department of Biostatistics, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran
- Modeling of Non-communicable diseases research center, Hamadan University of Medical Sciences, Hamadan, Iran
| | - VIDA SHEIKH
- Clinical Research Development Unit of Shahid Beheshti Hospital, Hamadan University of Medical Sciences, Hamadan, Iran
| | - ENSIYEH JENABI
- Autism Spectrum disorders Research Center, Hamadan University of Medical Sciences, Hamadan, Iran
| | - SALMAN KHAZAEI
- Research Center for Health Sciences, Hamadan University of Medical Sciences, Hamadan, Iran
- Correspondence: Salman Khazaei, Research Center for Health Sciences, Hamadan University of Medical Sciences, Hamadan, Iran - E-mail:
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Hidden Hypocalcemia as a Risk Factor for Cardiovascular Events and All-Cause Mortality among Patients Undergoing Incident Hemodialysis. Sci Rep 2020; 10:4418. [PMID: 32157180 PMCID: PMC7064591 DOI: 10.1038/s41598-020-61459-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 02/26/2020] [Indexed: 12/16/2022] Open
Abstract
Lower corrected calcium (cCa) levels are associated with a better prognosis among incident dialysis patients. However, cCa frequently overestimates ionized calcium (iCa) levels. The prognostic importance of the true calcium status defined by iCa remains to be revealed. We conducted a retrospective cohort study of incident hemodialysis patients. We collected data of iCa levels immediately before the first dialysis. We divided patients into three categories: apparent hypocalcemia (low iCa; <1.15 mmol/L and low cCa; <8.4 mg/dL), hidden hypocalcemia (low iCa despite normal or high cCa), and normocalcemia (normal iCa). The primary outcome was the composite of all-cause death and cardiovascular diseases after hospital discharge. Among the enrolled 332 patients, 75% of the patients showed true hypocalcemia, defined as iCa <1.15 mmol/L, 61% of whom showed hidden hypocalcemia. In multivariate Cox models including other potential risk factors, true hypocalcemia was a significant risk factor (hazard ratio [HR], 2.34; 95% confidence interval [CI], 1.03–5.34), whereas hypocalcemia defined as corrected calcium <8.4 mg/dL was not. Furthermore, hidden hypocalcemia was significantly associated with an increased risk of the outcome compared with normocalcemia (HR, 2.56; 95% CI, 1.11–5.94), while apparent hypocalcemia was not. Patients with hidden hypocalcemia were less likely to receive interventions to correct hypocalcemia, such as increased doses of active vitamin D or administration of calcium carbonate, than patients with apparent hypocalcemia (odds ratio, 0.45; 95% CI, 0.23–0.89). Hidden hypocalcemia was a strong predictor of death and cardiovascular events, suggesting the importance of measuring iCa.
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Ye X, Kooman JP, van der Sande FM, Raimann JG, Usvyat LA, Wang Y, Maddux FW, Kotanko P. Relationship between serum phosphate levels and survival in chronic hemodialysis patients: interactions with age, malnutrition and inflammation. Clin Kidney J 2019; 14:348-357. [PMID: 33564438 PMCID: PMC7857835 DOI: 10.1093/ckj/sfz143] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 09/10/2019] [Indexed: 12/14/2022] Open
Abstract
Background Evidence indicates that the inverse relationships between phosphate levels and mortality maybe modified by age. Furthermore, malnutrition and inflammation could strengthen the risk associated with phosphate abnormalities. This study aimed to assess the associations between phosphate levels and mortality while accounting for the interactions with age and parameters associated with malnutrition and inflammation in hemodialysis (HD) patients. Methods Adult HD patients (n = 245 853) treated in Fresenius Medical Care North America clinics from January 2010 to October 2018 were enrolled. Baseline was defined as Months 4-6 on dialysis, with the subsequent 12 months as the follow-up period. Univariate and multivariate Cox proportional hazard models with spline terms were applied to study the nonlinear relationships between serum phosphate levels and mortality. The interactions of phosphate levels with albumin, creatinine, normalized protein catabolic rate (nPCR) and neutrophil-lymphocyte ratio (NLR) were assessed with smoothing spline analysis of variance Cox proportional hazard models. Results Older patients tended to have lower levels of serum phosphate, albumin, creatinine and nPCR. Additionally, both low (<4.0 mg/dL) and high (>5.5 mg/dL) phosphate levels were associated with higher risk of mortality across all age strata. The U-shaped relationships between phosphate levels and outcome persisted even for patients with low or high levels of serum albumin, creatinine, nPCR and NLR, respectively. Conclusion The consistent U-shaped relationships between serum phosphate and mortality across age strata and levels of inflammatory and nutritional status should prompt the search for underlying causes and potentially nutritional intervention in clinical practice.
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Affiliation(s)
- Xiaoling Ye
- Research Department, Renal Research Institute, New York, NY, USA
| | - Jeroen P Kooman
- Nephrology Department, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Frank M van der Sande
- Nephrology Department, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Jochen G Raimann
- Research Department, Renal Research Institute, New York, NY, USA
| | - Len A Usvyat
- Research Department, Renal Research Institute, New York, NY, USA.,Global Medical Office, Fresenius Medical Care, Waltham, MA, USA
| | - Yuedong Wang
- Department of Statistics and Applied Probability, University of California-Santa Barbara, Santa Barbara, CA, USA
| | | | - Peter Kotanko
- Research Department, Renal Research Institute, New York, NY, USA.,Department of Nephrology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Kalantar-Zadeh K, Ficociello LH, Parameswaran V, Athienites NV, Mullon C, Kossmann RJ, Coyne DW. Changes in serum albumin and other nutritional markers when using sucroferric oxyhydroxide as phosphate binder among hemodialysis patients: a historical cohort study. BMC Nephrol 2019; 20:396. [PMID: 31664928 PMCID: PMC6820926 DOI: 10.1186/s12882-019-1582-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 10/03/2019] [Indexed: 12/16/2022] Open
Abstract
Background Elevated serum phosphorus concentrations are common among maintenance hemodialysis patients. Protein is a major source of dietary phosphate, but restriction of protein intake can result in hypoalbuminemia and protein-energy wasting. We hypothesized that sucroferric oxyhydroxide (SO), a potent phosphate binder with a low pill burden, may reduce serum phosphorus levels in hemodialysis patients with hypoalbuminemia without adversely impacting albumin levels or dietary intake of protein. Methods We retrospectively examined de-identified data from 79 adult, in-center hemodialysis patients with baseline hypoalbuminemia (≤ 3.5 g/dL) switched to SO as part of routine clinical care for at least 1 year. Temporal changes (3-month intervals from baseline through Q4) in phosphate binder pill burden, serum phosphorous levels, nutritional markers, and equilibrated Kt/V were analyzed. Data from a matched reference group of non-hypoalbuminemic patients (N = 79) switched to SO were also examined. Results SO therapy was associated with a mean reduction of 45.7 and 45.1% in daily phosphate binder pill burden, and a mean reduction of 0.4 mg/dL and 0.51 mg/dL in serum phosphorus levels for the hypoalbuminemic and non-hypoalbuminemic patients, respectively. Hypoalbuminemic patients demonstrated significant increases in mean serum albumin levels from 3.50 mg/dL at baseline to 3.69, 3.74, 3.70, and 3.69 mg/dL during Q1 through Q4, respectively (P < 0.0001), whereas serum albumin levels remained unchanged in the non-hypoalbuminemic group. Conclusions Both hypoalbuminemic and non-hypoalbuminemic patients switching to SO exhibited significant reductions in serum phosphorus concentrations and daily phosphate binder pill burden. Among hypoalbuminemic patients, the initiation of SO therapy was also associated with increases in serum albumin, suggesting therapy may have allowed patients to increase their dietary intake of protein.
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Affiliation(s)
| | | | | | | | - Claudy Mullon
- Fresenius Medical Care Renal Therapies Group, Waltham, MA, USA
| | | | - Daniel W Coyne
- Washington University School of Medicine, 660 S. Euclid Ave., CB 8129, St. Louis, MO, 63110, USA.
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Dysregulated Phosphate Metabolism, Periodontal Disease, and Cancer: Possible Global Health Implications. Dent J (Basel) 2019; 7:dj7010018. [PMID: 30754693 PMCID: PMC6473307 DOI: 10.3390/dj7010018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 01/31/2019] [Accepted: 02/06/2019] [Indexed: 01/08/2023] Open
Abstract
An association between periodontal disease and cancer has been established in recent studies, but no common etiology has been identified in the hopes of reducing the global burden of these non-communicable diseases. This perspective article hypothesizes that the determinant mediating the association of periodontal disease with cancer is dysregulated phosphate metabolism. Phosphate, an essential dietary micronutrient, is dysregulated in chronic kidney disease, and both cancer and periodontal disease are associated with chronic kidney disease. Reviewed evidence includes the association between phosphate toxicity and cancer development, and the association between periodontal disease and chronic kidney disease-mineral and bone disorder includes conditions such as ectopic calcification and bone resorption, which may be indirectly related to periodontal disease. Dental calculus in periodontal disease contains calcium phosphate crystals that are deposited from excess calcium and phosphate in saliva. Alveolar bone resorption may be linked systemically to release of parathyroid hormone in response to hypocalcemia induced by hyperphosphatemia. More research is needed to examine the role of dysregulated phosphate metabolism in periodontal disease.
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Fukuma S, Ikenoue T, Akizawa T, Fukuhara S. Impact of nutritional index on the association between phosphorus concentrations and mortality in haemodialysis patients: a cohort study from dialysis outcomes and practice pattern study in Japan. BMJ Open 2017; 7:e016682. [PMID: 28790041 PMCID: PMC5629681 DOI: 10.1136/bmjopen-2017-016682] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVES While maintenance of both phosphorus concentration and nutritional status is a major concern in managing haemodialysis patients, the interaction between these parameters is not well understood. The aim of this study was to assess whether or not nutritional index influences the association between phosphorus concentration and all-cause mortality. DESIGN A cohort study. SETTING The Dialysis Outcomes and Practice Pattern Study, which included 99 representative dialysis facilities in Japan between 1997 and 2010. PARTICIPANTS A total of 6230 adult haemodialysis patients who had spent at least 6 months on haemodialysis. MAIN PREDICTORS Six categories based on time-averaged factors of the geriatric nutritional risk index (GNRI; the lowest two and highest tertiles) and phosphorus concentration (<3.5, 3.5 to <6 and ≥6 mg/dL). PRIMARY OUTCOME MEASURE All-cause mortality rate. ANALYSIS Time-dependent Cox regression adjusting for potential confounders. RESULTS During the follow-up period (12 294 person-years), we noted 561 deaths (4.6 per 100 person-years), and both high phosphorus concentrations and low-middle GNRI were separately associated with all-cause mortality. The harmful effect of high phosphorus concentrations on all-cause mortality was stronger in patients with high GNRI than in those with low-middle GNRI. On the other hand, the harmful effect of low phosphorus concentrations was stronger in those with low-middle GNRI than in those with high GNRI. Relative excess risk due to interaction (RERI) between high phosphorus concentrations and low-middle GNRI was -0.57, indicating an antagonistic interaction. We also observed a significant statistical multiplicative interaction between phosphorus concentrations and GNRI (p=0.05 by likelihood ratio test). CONCLUSIONS The association between time-averaged serum phosphorus concentration and all-cause mortality differs across the nutritional index. Accordingly, nutritional index should be considered when the impact of phosphorus concentration on mortality in haemodialysis patients is evaluated.
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Affiliation(s)
- Shingo Fukuma
- Department of Healthcare Epidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
- Center for Innovative Research for Communities and Clinical Excellence (CIRC2LE), Fukushima Medical University, Fukushima, Japan
- Institute for Health Outcomes and Process Evaluation Research (iHope International), Kyoto, Japan
| | - Tatsuyoshi Ikenoue
- Department of Healthcare Epidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - Tadao Akizawa
- Department of Medicine, Division of Nephrology, Showa University School of Medicine, Tokyo, Japan
| | - Shunichi Fukuhara
- Department of Healthcare Epidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
- Center for Innovative Research for Communities and Clinical Excellence (CIRC2LE), Fukushima Medical University, Fukushima, Japan
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Bhandari SK, Liu ILA, Kujubu DA, Huynh T, Behayaa H, Kovesdy CP, Kalantar-Zadeh K, Jacobsen SJ, Sim JJ. Use of Phosphorus Binders among Non-Dialysis Chronic Kidney Disease Patients and Mortality Outcomes. Am J Nephrol 2017; 45:431-441. [PMID: 28445887 DOI: 10.1159/000474959] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 03/27/2017] [Indexed: 01/21/2023]
Abstract
BACKGROUND Whether the benefits of phosphorus binders extend to those without end stage renal disease is uncertain. Among a large diverse non-dialysis chronic kidney disease (CKD) population with hyperphosphatemia, we sought to evaluate phosphorus binder use and compare mortality risk between patients prescribed and not prescribed binders. METHODS A retrospective cohort study within an integrated health system (January 1, 1998 - December 31, 2012) among CKD patients (age ≥18) was performed. Non-dialysis CKD patients with 2 separate estimated glomerular filtrate rate (eGFR) <30 mL/min/1.73 m2 and serum phosphorus ≥5.0 mg/dL within 180 days of eGFR were included. Multivariable cox proportional hazards and inverse probability of treatment-weighted models were used to estimate mortality hazard ratios (HRs) for patients who received phosphorus binders compared to no binders. RESULTS Among 10,165 study patients, 2,733 subjects (27%) received phosphorus binders. Compared to the no-phosphorus-binder group, the binder group had mortality HRs (95% CI) of 0.86 (0.79-0.94) and 0.86 (0.80-0.93) using traditional multivariable and inverse probability of treatment-weighted models respectively. Sensitivity analyses removing patients who were prescribed binders >180 days after index date revealed no difference in mortality between those with binders and with no binders. CONCLUSION Our findings from a real-world clinical environment revealed that 27% of hyperphosphatemic non-dialysis CKD patients were prescribed binders. They also had lower risk of mortality compared to those not prescribed phosphorus binders. However, the lower mortality risk was not observed when we accounted for immortal time bias. Whether phosphorus binder use in CKD improves survival remains to be determined.
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Affiliation(s)
- Simran K Bhandari
- Division of Nephrology and Hypertension, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
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Piccoli GB, Moio MR, Fois A, Sofronie A, Gendrot L, Cabiddu G, D'Alessandro C, Cupisti A. The Diet and Haemodialysis Dyad: Three Eras, Four Open Questions and Four Paradoxes. A Narrative Review, Towards a Personalized, Patient-Centered Approach. Nutrients 2017; 9:E372. [PMID: 28394304 PMCID: PMC5409711 DOI: 10.3390/nu9040372] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 03/17/2017] [Accepted: 03/31/2017] [Indexed: 12/25/2022] Open
Abstract
The history of dialysis and diet can be viewed as a series of battles waged against potential threats to patients' lives. In the early years of dialysis, potassium was identified as "the killer", and the lists patients were given of forbidden foods included most plant-derived nourishment. As soon as dialysis became more efficient and survival increased, hyperphosphatemia, was identified as the enemy, generating an even longer list of banned aliments. Conversely, the "third era" finds us combating protein-energy wasting. This review discusses four questions and four paradoxes, regarding the diet-dialysis dyad: are the "magic numbers" of nutritional requirements (calories: 30-35 kcal/kg; proteins > 1.2 g/kg) still valid? Are the guidelines based on the metabolic needs of patients on "conventional" thrice-weekly bicarbonate dialysis applicable to different dialysis schedules, including daily dialysis or haemodiafiltration? The quantity of phosphate and potassium contained in processed and preserved foods may be significantly different from those in untreated foods: what are we eating? Is malnutrition one condition or a combination of conditions? The paradoxes: obesity is associated with higher survival in dialysis, losing weight is associated with mortality, but high BMI is a contraindication for kidney transplantation; it is difficult to limit phosphate intake when a patient is on a high-protein diet, such as the ones usually prescribed on dialysis; low serum albumin is associated with low dialysis efficiency and reduced survival, but on haemodiafiltration, high efficiency is coupled with albumin losses; banning plant derived food may limit consumption of "vascular healthy" food in a vulnerable population. Tailored approaches and agreed practices are needed so that we can identify attainable goals and pursue them in our fragile haemodialysis populations.
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Affiliation(s)
- Giorgina Barbara Piccoli
- Dipartimento di Scienze Cliniche e Biologiche, University of Torino, 10100 Torino, Italy.
- Nephrologie, Centre Hospitalier le Mans, Avenue Roubillard, 72000 Le Mans, France.
| | - Maria Rita Moio
- Nephrologie, Centre Hospitalier le Mans, Avenue Roubillard, 72000 Le Mans, France.
| | - Antioco Fois
- Nefrologia, Ospedale Brotzu, 09100 Cagliari, Italy.
| | - Andreea Sofronie
- Nephrologie, Centre Hospitalier le Mans, Avenue Roubillard, 72000 Le Mans, France.
| | - Lurlinys Gendrot
- Nephrologie, Centre Hospitalier le Mans, Avenue Roubillard, 72000 Le Mans, France.
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Lopes MB, Silva LF, Lopes GB, Penalva MA, Matos CM, Robinson BM, Lopes AA. Additional Contribution of the Malnutrition–Inflammation Score to Predict Mortality and Patient-Reported Outcomes as Compared With Its Components in a Cohort of African Descent Hemodialysis Patients. J Ren Nutr 2017; 27:45-52. [DOI: 10.1053/j.jrn.2016.08.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 08/08/2016] [Accepted: 08/12/2016] [Indexed: 12/24/2022] Open
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Kirushnan BB, Rao BS, Annigeri R, Balasubramanian S, Seshadri R, Prakash KC, Vivek V. Impact of Malnutrition, Inflammation, and Atherosclerosis on the Outcome in Hemodialysis Patients. Indian J Nephrol 2017; 27:277-283. [PMID: 28761229 PMCID: PMC5514823 DOI: 10.4103/0971-4065.202830] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Malnutrition, inflammation, and atherosclerosis are significant problems in patients on hemodialysis. A prospective, observational study in 100 hemodialysis patients for 2 years was conducted. The primary outcomes were hospitalizations and mortality at the end of 2 years. The mean age was 61 ± 11.3 years and 69% were male. Seven patients did not complete the study (five underwent transplant and two were shifted to other units). Serum albumin was significantly lower in malnourished patients at 6 months from the beginning of the study period (3.58 vs. 3.79 g/dl, P = 0.001). Malnutrition based on subjective global assessment (SGA) was seen in 30 (32%) patients: mild to moderate in 27 (29%) and severe in 3 (3%). Inflammation was seen in 73 (78.5%) patients and intimal-medial thickness of >1.1 mm indicating significant atherosclerosis was seen in 73 (78.5%) patients. Modified SGA score and malnutrition-inflammation score (MIS) were significantly more in the malnourished group. Statistically significant association was seen between hospitalization and mortality in the malnourished population, and the odds ratio of death in malnourished patients was 9.83 (95% confidence interval: 2.8-34.3, P < 0.001). There was a moderate correlation between malnutrition assessed by modified SGA and MIS score (r = 0.54, P < 0.001). Mortality rate was 37% in patients with mild to moderate and 67% in severe malnutrition. Hospital admission was seen in 43 (46%) patients and was significantly more common in malnourished compared to well-nourished patients (77% vs. 32%, P < 0.001). Multiple logistic regression analysis showed that malnutrition by Modified SGA was the only significant variable associated with mortality at 2 years, and addition of MIS score did not improve the predictive ability of the model to modified SGA. We recommend the use of modified SGA and serial serum albumin to monitor nutrition in hemodialysis patients.
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Affiliation(s)
- B B Kirushnan
- Department of Nephrology, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - B Subba Rao
- Department of Nephrology, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - R Annigeri
- Department of Nephrology, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - S Balasubramanian
- Department of Nephrology, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - R Seshadri
- Department of Nephrology, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - K C Prakash
- Department of Nephrology, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - V Vivek
- Department of Nephrology, Apollo Hospitals, Chennai, Tamil Nadu, India
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Gadalean F, Lighezan D, Stoian D, Schiller O, Timar R, Timar B, Bob F, Donciu MD, Munteanu M, Mihaescu A, Covic A, Schiller A. The Survival of Roma Minority Patients on Chronic Hemodialysis Therapy - A Romanian Multicenter Survey. PLoS One 2016; 11:e0155271. [PMID: 27196564 PMCID: PMC4873236 DOI: 10.1371/journal.pone.0155271] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 04/26/2016] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE The Roma minority represents the largest ethnic group in Central and South-East European countries. Data regarding the mortality in Roma hemodialysis subjects are limited. We evaluated the 3 year mortality of ESRD Roma patients treated with hemodialysis (HD). STUDY DESIGN AND SETTING Our prospective cohort study included 600 ESRD patients on HD therapy recruited from 7 HD centers, from the main geographical regions of Romania. The median age of the patients was 56 (19) years, 332 (55.3%) being males, 51 (8.5%) having Roma ethnicity. RESULTS Roma ESRD patients initiate dialysis at a younger age, 47.8 years vs. 52.3 years (P = 0.017), present higher serum albumin (P = 0.013) and higher serum phosphate levels (P = 0.021). In the Roma group, the overall 3 year mortality was higher when compared to Caucasians (33.3% vs. 24.8%). The multivariate survival analysis revealed that being of Roma ethnicity is an independent risk factor for mortality (HR = 1.74; 95% CI = 1.04-2.91; P = 0.035). CONCLUSIONS Roma patients with ESRD initiate HD therapy at a younger age as compared to Caucasians. They have a higher 3 year mortality rate and are dying at a younger age. Roma ethnicity represents an independent risk factor for mortality in our cohort.
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Affiliation(s)
- Florica Gadalean
- Department of Nephrology, ‘Victor Babes’ University of Medicine and Pharmacy, County Emergency Hospital, Timisoara, Romania
| | - Daniel Lighezan
- Department of Internal Medicine, ‘Victor Babes’ University of Medicine and Pharmacy, Municipal Clinical Emergency Hospital, Timisoara, Romania
| | - Dana Stoian
- Department of Obstetrics and Gynecology, ‘Victor Babes’ University of Medicine and Pharmacy, Municipal Hospital, Timisoara, Romania
| | - Oana Schiller
- B Braun Avitum Dialysis Center Timisoara, Timisoara, Romania
| | - Romulus Timar
- Department of Diabetes and Metabolic Diseases, ‘Victor Babes’ University of Medicine and Pharmacy, County Emergency Hospital, Timisoara, Romania
| | - Bogdan Timar
- Department of Medical Informatics and Biostatistics, ‘Victor Babes’ University of Medicine and Pharmacy, County Emergency Hospital, Timisoara, Romania
| | - Flaviu Bob
- Department of Nephrology, ‘Victor Babes’ University of Medicine and Pharmacy, County Emergency Hospital, Timisoara, Romania
| | - Mihaela Dora Donciu
- Department of Nephrology and Internal Medicine, University of Medicine “Gr. T. Popa” Iasi, Hospital “C. I. Parhon” Iasi, Iasi, Romania
| | - Mircea Munteanu
- Department of Diabetes and Metabolic Diseases, ‘Victor Babes’ University of Medicine and Pharmacy, County Emergency Hospital, Timisoara, Romania
| | - Adelina Mihaescu
- Department of Nephrology, ‘Victor Babes’ University of Medicine and Pharmacy, County Emergency Hospital, Timisoara, Romania
| | - Adrian Covic
- Department of Nephrology and Internal Medicine, University of Medicine “Gr. T. Popa” Iasi, Hospital “C. I. Parhon” Iasi, Iasi, Romania
| | - Adalbert Schiller
- Department of Nephrology, ‘Victor Babes’ University of Medicine and Pharmacy, County Emergency Hospital, Timisoara, Romania
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Zitt E, Sturm G, Kronenberg F, Neyer U, Knoll F, Lhotta K, Weiss G. Iron supplementation and mortality in incident dialysis patients: an observational study. PLoS One 2014; 9:e114144. [PMID: 25462819 PMCID: PMC4252084 DOI: 10.1371/journal.pone.0114144] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 11/03/2014] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Studies on the association between iron supplementation and mortality in dialysis patients are rare and conflicting. METHODS In our observational single-center cohort study (INVOR study) we prospectively studied 235 incident dialysis patients. Time-dependent Cox proportional hazards models using all measured laboratory values for up to 7.6 years were applied to study the association between iron supplementation and all-cause mortality, cardiovascular and sepsis-related mortality. Furthermore, the time-dependent association of ferritin levels with mortality in patients with normal C-reactive protein (CRP) levels (<0.5 mg/dL) and elevated CRP levels (≧0.5 mg/dL) was evaluated by using non-linear P-splines to allow flexible modeling of the association. RESULTS One hundred and ninety-one (81.3%) patients received intravenous iron, 13 (5.5%) patients oral iron, whereas 31 (13.2%) patients were never supplemented with iron throughout the observation period. Eighty-two (35%) patients died during a median follow-up of 34 months, 38 patients due to cardiovascular events and 21 patients from sepsis. Baseline CRP levels were not different between patients with and without iron supplementation. However, baseline serum ferritin levels were lower in patients receiving iron during follow up (median 93 vs 251 ng/mL, p<0.001). Iron supplementation was associated with a significantly reduced all-cause mortality [HR (95%CI): 0.22 (0.08-0.58); p = 0.002] and a reduced cardiovascular and sepsis-related mortality [HR (95%CI): 0.31 (0.09-1.04); p = 0.06]. Increasing ferritin concentrations in patients with normal CRP were associated with a decreasing mortality, whereas in patients with elevated CRP values ferritin levels>800 ng/mL were linked with increased mortality. CONCLUSIONS Iron supplementation is associated with reduced all-cause mortality in incident dialysis patients. While serum ferritin levels up to 800 ng/mL appear to be safe, higher ferritin levels are associated with increased mortality in the setting of concomitant inflammation.
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Affiliation(s)
- Emanuel Zitt
- Department of Nephrology and Dialysis, Feldkirch Academic Teaching Hospital, Feldkirch, Austria
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Feldkirch, Austria
| | - Gisela Sturm
- Department of Dermatology and Venereology, Innsbruck Medical University, Innsbruck, Austria
- Division of Genetic Epidemiology, Department of Medical Genetics, Molecular and Clinical Pharmacology, Innsbruck Medical University, Innsbruck, Austria
| | - Florian Kronenberg
- Division of Genetic Epidemiology, Department of Medical Genetics, Molecular and Clinical Pharmacology, Innsbruck Medical University, Innsbruck, Austria
| | - Ulrich Neyer
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Feldkirch, Austria
| | - Florian Knoll
- Department of Nephrology and Dialysis, Feldkirch Academic Teaching Hospital, Feldkirch, Austria
| | - Karl Lhotta
- Department of Nephrology and Dialysis, Feldkirch Academic Teaching Hospital, Feldkirch, Austria
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Feldkirch, Austria
- * E-mail: (KL); (GW)
| | - Günter Weiss
- Department of Internal Medicine VI (Infectious Diseases, Immunology, Rheumatology, Pneumology), Innsbruck Medical University, Innsbruck, Austria
- * E-mail: (KL); (GW)
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Huang N, Chen J, Fan L, Zhou Q, Xu Q, Xu R, Xiong L, Yu X, Mao H. High peritoneal transport status was not associated with mortality in peritoneal dialysis patients with diabetes. PLoS One 2014; 9:e110445. [PMID: 25329459 PMCID: PMC4199757 DOI: 10.1371/journal.pone.0110445] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 09/12/2014] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Continuous ambulatory peritoneal dialysis (CAPD) patients with diabetes are at increased risk of mortality and high peritoneal transporters appear to contribute to poor survival. However, little is known about the combined impacts of high peritoneal transporters and diabetes on mortality. METHODS This was a prospective observational cohort study. 776 incident CAPD patients were enrolled. Unadjusted and adjusted Cox proportional regression models were used to evaluate the association and interaction of peritoneal transport and diabetic status with mortality. RESULTS In the entire cohort, high peritoneal transport status was associated with an increased risk of all-cause mortality in unadjusted model [hazard ratio (HR) 2.35, 95% confidence interval (CI) 1.30 to 4.25, P = 0.01], but this association was not significant in multivariable model. There was an interaction between peritoneal membrane transport status and diabetes (P = 0.028). Subgroup analyses showed that compared to low and low average transporters, high transporters was associated with a higher risk of all-cause mortality (adjusted HR 1.78, 95% CI 1.07 to 4.70, P = 0.04) in CAPD patients without diabetes, but not in those with diabetes (adjusted HR 0.79, 95%CI 0.33 to 1.89, P = 0.59). Results were similar when transport status was assessed as a continuous variable. CONCLUSIONS The association between high peritoneal transport and all-cause mortality was likely to vary with diabetes status. High peritoneal transport was associated with an elevated risk of death among CAPD patients without diabetes, but not in those with diabetes.
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Affiliation(s)
- Naya Huang
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Key Laboratory of Nephrology, Ministry of Health of China, Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, Guangdong, China
| | - Jiehui Chen
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Key Laboratory of Nephrology, Ministry of Health of China, Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, Guangdong, China
- Department of Nephrology, The Sixth People's Hospital of Shenzhen, Shenzhen, Guangdong, China
| | - Li Fan
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Key Laboratory of Nephrology, Ministry of Health of China, Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, Guangdong, China
| | - Qian Zhou
- Epidemiology Research Unit, Translational Medicine Research Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Qingdong Xu
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Key Laboratory of Nephrology, Ministry of Health of China, Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, Guangdong, China
| | - Ricong Xu
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Key Laboratory of Nephrology, Ministry of Health of China, Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, Guangdong, China
| | - Liping Xiong
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Key Laboratory of Nephrology, Ministry of Health of China, Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, Guangdong, China
| | - Xueqing Yu
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Key Laboratory of Nephrology, Ministry of Health of China, Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, Guangdong, China
| | - Haiping Mao
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Key Laboratory of Nephrology, Ministry of Health of China, Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, Guangdong, China
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Sridhar NR, Josyula S. Hypoalbuminemia in hemodialyzed end stage renal disease patients: risk factors and relationships--a 2 year single center study. BMC Nephrol 2013; 14:242. [PMID: 24499139 PMCID: PMC4029609 DOI: 10.1186/1471-2369-14-242] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2012] [Accepted: 10/23/2013] [Indexed: 11/24/2022] Open
Abstract
Background Malnutrition affects 1/3 of hemodialysis patients and associates with a higher risk of morbidity and mortality. Serum albumin is a marker of nutrition and inflammation, and predicts mortality, particularly when <3.8 g/dL. This study was performed to identify risk factors for hypoalbuminemia (<3.8 g/dL) and the particular temporal relationship and strength of association between protein intake (nPCR) and serum albumin when confounding variables are taken into account. Methods Demographic, clinical, and dialysis-related data of 57 ESRD patients on hemodialysis over 24 months in 6 temporal segments were analyzed with serum albumin as a continuous, and categorical outcome (with 3.8 g/dl as cut-off) variable , against 13 potential independent variables [4 demographic factors, 3 nutrition-related, and 5 morbidity-related parameters, and % urea reduction ratio (URR)]. The temporal relationships between albumin and nPCR were analyzed for the concurrent & 3 subsequent months in each temporal segment. Results The impact of nPCR on serum albumin (p < 0.05) was significant but with no discernible temporal relationship. Advancing age, longer vintage, female gender, diabetes mellitus, nPCR, serum phosphate and ferritin had significant correlation with albumin <3.8 g/dl (p < 0.05). Serum phosphate levels correlated positively, and fever, bacteremia, hospital stay and weight loss negatively, with mean serum albumin but did not negate the effect of nPCR. Regression analysis showed that mean albumin associated with nPCR, fever, hospital stay, bacteremia, dialysis vintage, age, sex, and diabetes mellitus; and that an albumin level of <3.8 g/dl associated with age, female sex, diabetes, lower nPCR, and higher ferritin. Conclusion Suggested target albumin levels were not met in elderly, female, and diabetic patients. The association of nPCR with albumin was not nullified by confounding demographic or morbidity-related factors. nPCR had no demonstrable temporal relationship with albumin.
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Affiliation(s)
- Nagaraja Rao Sridhar
- Department of Internal Medicine (Nephrology), Buffalo General Hospital, University at Buffalo, and Buffalo Medical Group, 85 High Street, Buffalo, New York, USA.
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Cannata-Andía JB, Fernández-Martín JL, Locatelli F, London G, Gorriz JL, Floege J, Ketteler M, Ferreira A, Covic A, Rutkowski B, Memmos D, Bos WJ, Teplan V, Nagy J, Tielemans C, Verbeelen D, Goldsmith D, Kramar R, Martin PY, Wüthrich RP, Pavlovic D, Benedik M, Sánchez JE, Martínez-Camblor P, Naves-Díaz M, Carrero JJ, Zoccali C. Use of phosphate-binding agents is associated with a lower risk of mortality. Kidney Int 2013; 84:998-1008. [PMID: 23823605 DOI: 10.1038/ki.2013.185] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Revised: 01/31/2013] [Accepted: 02/14/2013] [Indexed: 11/09/2022]
Abstract
Hyperphosphatemia has been associated with higher mortality risk in CKD 5 patients receiving dialysis. Here, we determined the association between the use of single and combined phosphate-binding agents and survival in 6797 patients of the COSMOS study: a 3-year follow-up, multicenter, open-cohort, observational prospective study carried out in 227 dialysis centers from 20 European countries. Patient phosphate-binding agent prescriptions (time-varying) and the case-mix-adjusted facility percentage of phosphate-binding agent prescriptions (instrumental variable) were used as predictors of the relative all-cause and cardiovascular mortality using Cox proportional hazard regression models. Three different multivariate models that included up to 24 variables were used for adjustments. After multivariate analysis, patients prescribed phosphate-binding agents showed a 29 and 22% lower all-cause and cardiovascular mortality risk, respectively. The survival advantage of phosphate-binding agent prescription remained statistically significant after propensity score matching analysis. A decrease of 8% in the relative risk of mortality was found for every 10% increase in the case-mix-adjusted facility prescription of phosphate-binding agents. All single and combined therapies with phosphate-binding agents, except aluminum salts, showed a beneficial association with survival. The findings made in the present association study need to be confirmed by randomized controlled trials to prove the observed beneficial effect of phosphate-binding agents on mortality.
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Affiliation(s)
- Jorge B Cannata-Andía
- Bone and Mineral Research Unit, Instituto Reina Sofía de Investigación, REDinREN del ISCIII, Hospital Universitario Central de Asturias, Universidad de Oviedo, Oviedo, Spain
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Gungor O, Kircelli F, Voroneanu L, Covic A, Ok E. Hormones and Arterial Stiffness in Patients with Chronic Kidney Disease. J Atheroscler Thromb 2013; 20:698-707. [DOI: 10.5551/jat.18580] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Visualizing interaction effects: a proposal for presentation and interpretation. J Clin Epidemiol 2012; 65:855-62. [DOI: 10.1016/j.jclinepi.2012.02.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Revised: 02/08/2012] [Accepted: 02/15/2012] [Indexed: 11/20/2022]
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