Relationship between abdominal aortic calcification and outcomes in maintenance hemodialysis patients

Objective To investigate the relationship between abdominal aortic calcification (AAC) and outcomes in maintenance hemodialysis (MHD) patients. Methods One hundred and seventy MHD patients in the dialysis center of the Second Hospital of Tianjin Medical University from June 2014 and October 2014 were enrolled prospectively. Abdominal aortic calcification (AAC) was measured using AAC score (AACS) by abdominal lateral plain radiography. According to the AACS, the patients were divided into mild AAC (AACS＜5) group and severe AAC (AACS≥5) group for comparison, and Kaplan-Meier analysis was used to compare their survival rates. Multivariable COX regression models were used to determine the risk factors of all - cause mortality and cardiovascular disease mortality in MHD patients. Results Severe AAC (AACS≥5) was present in 28.2% (48/170) patients. The median follow-up duration was 25.6 (22.0, 26.0) months. During the follow-up, 6 patients (4.9%) in AACS＜5 group and 14 patients (29.2%) in AACS≥5 group died. Kaplan-Meier analysis showed that patients in AACS≥5 group had higher all-cause mortality rate and cardiovascular disease mortality rate as compared with patients in AACS＜5 group (χ2=9.746,P=0.002; χ2=9.697,P=0.002). Multivariate COX regression analysis demonstrated that high AACS (HR=4.373, 95%CI 1.562-7.246, P=0.005) and hypoproteinemia (HR=0.886, 95% CI 0.797 - 0.985, P=0.025) were independent risk factors for all-cause mortality, while hypoproteinemia (HR=0.829, 95%CI 0.718-0.956, P=0.010) and low 1,25(OH)D3 (HR=0.769, 95% CI 0.627 - 0.944, P=0.012) were independent risk factors for cardiovascular disease mortality. Conclusions AAC is significantly associated with overall survival in MHD patients. To further evaluate the relationship between AAC and outcomes in MHD patients, multi-center and long term follow up studies of large sample size are necessary.     

Serum phosphorus variation is associated with mortality in maintenance hemodialysis patients

Objective To investigate the relationship between serum phosphorus variability and mortality in maintenance hemodialysis (MHD) patients. Methods A total of 502 MHD cases from Renji hospital hemodialysis center were registered in Shanghai Registry Network from January 2007 to April 2015. They were recruited with general information, laboratory results and outcomes. According to their median of coefficient of variation (CV) of blood phosphorus, the patients were divided into high variation group (CV≥0.226 mmol/L) and low variation group (CV＜0.226 mmol/L). The relationship of serum phosphorus CV with all-cause mortality and cardiovascular disease mortality was assessed respectively. Results The average age was (63.9±14.6) years, the median dialysis age was 82.0 (43.0, 139.0) months, 118 patients (23.5%) died for all cause and 64 patients (12.7%) died for cardiovascular disease. Compared with patients in low phosphorus variation group, patients had a higher all-cause mortality in high phosphorus variation group (27.7% vs 19.3%, P=0.028). Higher cardiovascular disease mortality was observed in high variation group as well, but this difference was no statistical significant (15.4% vs 10.0%, P=0.082). COX regression analysis showed that ＞60 years of age (HR=2.762, 95%CI 1.707-4.468, P＜0.001), low hemoglobin (HR=0.466, 95%CI 0.317-0.686, P＜0.001), low albumin (HR=0.555, 95%CI 0.366-0.840, P=0.005), high CV of phosphorus (HR=1.479, 95%CI 1.023-2.139, P=0.037) were independent risk factors for all-cause mortality. Moreover, ＞60 years of age (HR=2.666, 95%CI 1.469-4.837, P=0.001), low hemoglobin (HR=0.480, 95%CI 0.238-0.801, P=0.005), and high CV of phosphorus (HR=1.655, 95%CI 1.003-2.729, P=0.049) were independent risk factors for cardiovascular disease mortality. There was no significant statistical difference between patients phosphorus on target and patients phosphorus below target in all-cause disease mortality (P=0.065) and cardiovascular disease mortality (P=0.425). High variation group whose phosphorus on target had higher all-cause mortality and cardiovascular disease mortality than those in low variation group (29.2% vs 16.9%, P=0.047; 15.0% vs 6.0%, P=0.033). Kaplan-Meier method showed that patients with high phosphorus variation had higher all-cause (P=0.023) and cardiovascular disease mortality (P=0.047) than patients with low phosphorus variation. Conclusions The high CV of phosphorus is independently correlated with all-cause and cardiovascular disease mortality. Patients with standard-reaching phosphorus in the low variation group have a lower mortality. A serum phosphorus level sustainably reaching the standard may improve the survival in MHD patients.     

Effects of abdominal aortic calcification progression on outcomes in maintenance hemodialysis patients

Objective To investigate the effects of abdominal aortic calcification (AAC) progression on outcomes in maintenance hemodialysis (MHD) patients. Methods Patients who were on MHD between Jun. 2014 and Oct. 2014 in the dialysis center of the Second Hospital of Tianjin Medical University and finished the AAC examination at baseline and two years later were included prospectively. The progression of AAC by AAC score (AACs) at baseline and two years later was evaluated. According to the change of AACs, the patients were divided into rapid AAC progression group and non-rapid AAC progression group. The effect of AAC progression on outcomes in MHD patients in the follow-up period was investigated. Kaplan-Meier analysis was used to compare their survival rates. Multivariable Cox regression model was used to determine the risk factors of all-cause mortality, cardiovascular mortality and cardiovascular events. Results A total of 111 MHD patients were included, including 51 males and 60 females, aged (52.24±12.69) years. Baseline AAC prevalence was 45.9% (51/111), and median AACs was 0 (0, 5); After 2 years, the prevalence of AAC was 78.4% (87/111), and the median AACs was 6 (2, 11). There were 54 cases in the AAC rapid progression group (AACs change value＞2) and 57 cases in the non-rapid AAC progression group (AACs change value≤2). The median follow-up duration was 27.9(27.1, 28.0) months. Kaplan-Meier analysis showed that patients in rapid AAC progression group had a higher risk of mortality as compared to patients in non-rapid AAC progression group (Log-rank χ2=5.695, P=0.017). Multivariate Cox regression analysis demonstrated that high baseline AACs (HR=1.135, 95%CI 1.001-1.286, P=0.048), hypoalbuminemia (HR=0.789, 95%CI 0.640-0.972, P=0.026) were independent risk factors for all-cause mortality in MHD patients. High baseline AACs (HR=1.187, 95%CI 1.038-1.356, P=0.012), low spKt/V (HR=0.103, 95%CI 0.013-0.801, P=0.030) were independent risk factors for cardiovascular mortality in MHD patients. Low spKt/V (HR=0.018, 95%CI 0.003-0.115, P＜0.001), hypoalbuminemia (HR=0.736, 95%CI 0.608-0.890, P=0.002) were independent risk factors for cardiovascular events in MHD patients. Conclusions Abdominal aortic calcification progression may increase the risk of cardiovascular events and death in MHD patients. Severity of AAC, adequacy of dialysis, and nutritional status are predictors of outcomes in MHD patients.     

Effects of serum magnesium level on mortality in maintenance hemodialysis patients

Objective To investigate the effects of serum magnesium level on all-cause mortality and cardiovascular and cerebrovascular diseases mortality in maintenance hemodialysis (MHD) patients. Methods Clinical data of MHD patients in Shaoxing People's Hospital from June 1, 2016 to June 30, 2018 were collected retrospectively. The patients were divided into low magnesium group (serum magnesium≤0.96 mmol/L), medium magnesium group (serum magnesium 0.97-1.07 mmol/L) and high magnesium group (serum magnesium≥1.08 mmol/L) according to the tertile of mean serum magnesium level. The differences of clinical data and laboratory results were compared among the three groups. Kaplan-Meier method was used to draw the survival curves, and log-rank test was used to compare the survival rate differences. Multivariate Cox regression was used to analyze the relationship between serum magnesium and all-cause mortality and cardiovascular and cerebrovascular diseases mortality in MHD patients. Results A total of 332 patients [194 males (58.4%)] were included in this study, with a median age of 63(51, 72) years and a median follow-up time of 36(20, 45) months. Kaplan-Meier survival analysis showed that the all-cause survival rate and cardiovascular and cerebrovascular diseases survival rate in the low magnesium group were lower than those in the medium magnesium group and the high magnesium group (Log-rank χ2=36.286, P＜0.001; Log-rank χ2=20.145, P＜0.001; respectively). After adjusting for multiple confounding factors, the results of multivariate Cox regression analysis suggested that low serum magnesium was an independent risk factor for all-cause death and cardiovascular and cerebrovascular diseases death in MHD patients. The risk of all-cause death and cardiovascular and cerebrovascular diseases death in the low magnesium group were significantly higher than those in the high magnesium group (HR=2.925, 95%CI 1.352-6.330, P=0.006; HR=3.821, 95% CI 1.394-10.473, P=0.009; respectively). Conclusions Hypomagnesemia may be an independent risk factor for all-cause death and cardiovascular and cerebrovascular diseases death in MHD patients. Low serum magnesium level increases the risk of all-cause death and cardiovascular and cerebrovascular diseases in MHD patients.     

Effect of serum uric acid level on prognosis in maintenance hemodialysis patients

Objective To analyze the relationship between serum uric acid (SUA) level and clinical indicators in maintenance hemodialysis (MHD) patients, and explore its influence on all-cause mortality and cardiovascular mortality. Methods This study was a retrospective cohort study. Patients who received MHD from the blood purification center of the Third Affiliated Hospital of Sun Yat-sen University from January 1, 2011 to December 30, 2015 were enrolled in the queue. They were divided into 3 groups according to the first and third quantile of the SUA level quartiles, and the baseline data of clinical and laboratory examinations were compared. The correlation between SUA level and clinical indicators was analyzed by Pearson correlation coefficient. Kaplan-Meier method and Cox proportional hazard regression model were used to examine the association between SUA and all-cause mortality and cardiovascular mortality in MHD patients. Results A total of 201 patients were enrolled in the study. The age of the patients was (56.9±16.7) years and the baseline SUA level was (531.1±137.9) μmol/L. Patients were divided into 3 groups with the first quantile (442 μmol/L) and the third quantile (620 μmol/L) of the SUA quartiles as the boundary points: group 1 (SUA＜442 μmol/L, n=52), group 2 (SUA 442-620 μmol/L, n=101) and group 3 (SUA＞620 μmol/L, n=48). The results showed that the patients in group 1 were older and had more proportion of patients with diabetes mellitus and cardiovascular diseases than those in group 3 (all P＜0.05). Compared to group 3, the serum albumin, serum phosphorus and serum creatinine were lower in group 1, while the hypersensitive C-reactive protein was higher (all P＜0.05). Pearson correlation analysis showed that SUA level was positively correlated with albumin (r=0.135, P=0.047), blood phosphorus (r=0.269, P＜0.001) and serum creatinine (r=0.333, P＜0.001), and negatively correlated with hypersensitive C-reactive protein (r=-0.216, P=0.002). After a median follow-up of 49.8 months, 66(32.8%) all-cause deaths and 32(15.9%) cardiovascular deaths were recorded. Kaplan-Meier method showed that with the decrease of SUA, all-cause mortality (Log-rank χ2=18.27, P＜0.001) and cardiovascular mortality (Log-rank χ2=15.04, P=0.001) increased. After adjusting for age, gender, comorbidity and other factors using the Cox proportional hazards model, the all-cause mortality and cardiovascular mortality decreased by 20.1% (HR=0.799, 95% CI 0.651-0.980, P=0.031) and 29.6% (HR=0.704, 95% CI 0.524-0.946, P=0.020) for each 100 μmol/L increase in baseline SUA. Compared to group 1, all-cause mortality (HR=0.332, 95%CI 0.142-0.774, P=0.011) and cardiovascular mortality (HR=0.140, 95%CI 0.030-0.657, P=0.013) were lower in the group 3. Conclusion Low SUA level increases the risk of all-cause mortality and cardiovascular mortality in MHD patients.     

Prognostic value of red cell distribution width in maintenance hemodialysis patients

Objective To investigate the relationship of red cell distribution width (RDW) with all-cause mortality and cardiovascular disease (CVD) mortality in patients undergoing maintenance hemodialysis (MHD). Methods A retrospective analysis was performed in patients who initiated MHD from January 2008 to September 2017 in the hemodialysis center of the Second Affiliated Hospital of Soochow University. Basic data on demographic, dialysis and laboratory were collected, and echocardiography indicators and clinical outcomes were recorded. Patients were divided into four groups according to the quartile of RDW level. Kaplan-Meier survival analysis was used to compare the difference of survival rate among the groups. Cox regression analysis was used to analyze the risk factors of all-cause and CVD-related mortality, and predictive value of RDW for all-cause and CVD-related death in hemodialysis patients. Results A total of 268 MHD patients were enrolled in this study with age of (60.9±15.8) years and dialysis duration of (58.1±9.1) months, including 159 males(59.3%). Kaplan-Meier survival analysis showed that the 1-year overall survival rates of Q1 group (RDW≤13.8%, n=61), Q2 group (RDW 13.9%-14.6%, n=66), Q3 group (RDW 14.7%-15.6%, n=73) and Q4 group (RDW≥15.7%, n=68) were 96.8%, 95.1%, 93.1% and 85.7% respectively; 3-year overall survival rates were 88.5%, 87.5%, 59.2% and 51.8% respectively; 5-year overall survival rates were 71.5%, 65.4%, 33.6% and 17.7% respectively; The difference between the groups was statistically significant (all P＜0.01). The 1-year CVD survival rates were 98.4%, 96.6%, 95.8% and 92.4% respectively; 3-year CVD survival rates were 94.8%, 92.5%, 84.4% and 70.4% respectively; 5-year CVD survival rates were 86.9%, 81.3%, 65.6% and 51.3% respectively; The difference between the groups was statistically significant (all P＜0.01). Multivariate Cox regression analysis showed that RDW≥15.7% was an independent risk factor for all-cause and CVD-related mortality in MHD patients. The risk of all-cause mortality in Q4 group was 3.098 times higher than that in Q1 group (95%CI 1.072-8.950, P=0.037) and the risk of CVD-related mortality was 2.661 times (95%CI 1.111-8.342, P=0.048). Receiver operating characteristic curve (ROC) showed that RDW=14.85% was the best cut-off point for predicting the all-cause mortality in HD patients (P＜0.01), RDW=15.45% was the best cut-off point for predicting the cardiovascular disease mortality (P＜0.01), and RDW=14.45% had a higher 5-year survival rate (P＜0.01). Conclusion RDW can independently predict all-cause and CVD-related mortality risk in hemodialysis patients, and it has important value for prognosis.     

骨硬化蛋白与维持性血液透析患者冠状动脉钙化的关系

Objective To evaluate the potential association of serum sclerostin with the development of coronary artery calcifications(CAC)in maintenance hemodialysis (MHD) patients. Methods Ninety-two patients who were on MHD between Jan 2014 and Jan 2015 in the dialysis center were enrolled prospectively. Serum sclerostin was tested. CAC was measured by multi-slice computed tomography (MSCT) scanning, and the CAC score (CACs) was calculated. Logistic regression analysis was used to determine the risk factor of CAC in MHD patients. The diagnostic value of serum sclerostin for CAC was assessed using receiver operator characteristic curve (ROC). Results CAC (Agatston score>100) was present in 65.2% (60/92) patients, the median CAC score was 446 (26, 1 000). The median of serum sclerostin levels was 37.05 (29.99, 49.04) ng/L. The serum sclerostin levels were significantly elevated in the group of CACs＞400 compared to that in the group of CACs＜100 [40.71(36.69, 74.21) ng/L vs 28.16 (25.27, 33.64) ng/L, P＜0.05]. Multivariate logistic regression analysis showed that serum sclerostin level was independent risk factor for CAC (OR=1.292, 95%CI 1.017-1.641, P＜0.05). The area under the ROC curve (AUC) of serum sclerostin for CAC was 0.846 (95%CI 0.717-0.975, P=0.001), sensitivity was 0.826, and specificity was 0.769 for a cutoff value of 35.165 ng/L. Conclusions Serum sclerostin level is associated with CAC. Serum sclerostin level may have a diagnostic value for CAC in MHD patients.     

Association of serum FGF23 with abdominal aortic calcification and outcomes in maintenance hemodialysis patients

Objective To explore the association of fibroblast growth factor-23 (FGF23) with abdominal aortic calcification(AAC) and adverse outcomes in maintenance hemodialysis patients. Methods One hundred and fourteen cases of MHD patients were collected prospectively. Serum intact FGF23 was detected by ELISA. Abdomen lateral plain was used as a criteria to determine the abdominal aortic calcification and the abdominal aortic calcification score was counted. Logistic regression analysis was used to determine the risk factors of AAC. Kaplan-Meier analysis was applied to compare the survival rate among different groups and COX regression analysis was used to determine the association of FGF23 and mortality in MHD patients. Results Seventy-six patients present abdominal aortic calcification. The median of AACS was 4.0(0.0, 11.0). The median level of FGF23 was 7277.4(2535.0, 9990.8) pg/ml. The median follow-up duration was 72.0(67.8, 72.8) months. During the follow-up, 22 patients (19.3%) died of all-cause death and 17 cases (14.9%) died of cardiovascular diseases. Serum FGF23 level was positively correlated with AAC (r=0.285, P=0.002). Logistic regression analysis showed that longer age (OR=1.059, 95%CI: 1.020-1.100, P=0.003) and dialysis vintage (OR=1.009, 95%CI 1.000-1.017, P=0.039), smoking history (OR=3.010, 95%CI 1.177-7.696, P=0.021) and higher FGF23 level(OR=2.831, 95%CI 1.010-7.937, P=0.048) were independent risk factors of moderate to severe AAC in MHD patients. Kaplan-Meier survival curves showed that the patients with AACS≥5 had significantly higher all-cause mortality(P=0.028) and CVD mortality (P=0.035) than those with AACS＜5. However, the Kaplan-Meier analysis showed no significant difference regarding the level of serum FGF23 with the all-cause and CVD mortality. Cox regression demonstrated that FGF23 was not associated with increased mortality risk, neither in crude nor in multivariate adjusted models. Conclusions Abdominal aortic calcification had a high prevalence in MHD patients. The all-cause and CVD mortality was higher in patients with moderate to severe AAC. FGF23 was an independent risk factor of moderate to severe AAC, but it can't yet be a predictor for the all-cause and CVD mortality of MHD patients.     

Effects of serum uric acid level on all-cause death and cardiovascular death in patients of maintaining peritoneal dialysis

Objective To investigate the effects of serum uric acid (SUA) on all-cause death and cardiovascular death in patients of maintaining peritoneal dialysis (PD). Methods One thousand and sixty-three PD patients in the First Affiliated Hospital of Zhejiang University Medical College were included. The SUA levels at 6 months after PD start were measured. Patients with SUA≥420 μmol/L were grouped in hyperuricemia group (492 cases) and patients with SUA＜420 μmol/L were grouped in normal uric acid group (571 cases). The effects on all-cause mortality and cardiovascular mortality were retrospectively analyzed. Results The median age of the patients was 51(41, 62) years; 557 cases were male (52.40%); the median follow-up time was 33(20, 54) months (6-96 months); 167 cases (15.71%) died during the follow-up period, including 64 cases (6.02%) with cardiovascular causes. The mortality in hyperuricemia group was 19.11%(94/492) and the cardiovascular mortality was 7.93%(39/492), both rates were higher than those in normal uric acid group, and the differences were statistically significant (P=0.005, P=0.015, respectively). Hyperuricemia (SUA≥420 μmol/L) at 6 months after PD start (HR=1.572, 95%CI 1.155-2.141, P=0.004), high uric acid level (continuous variable) at 6 months after PD start (HR=1.002, 95%CI 1.001-1.004, P=0.008), and age≥65 years (HR=3.571, 95%CI 2.556-4.990, P＜0.001), serum albumin≤30 g/L (HR=1.907, 95%CI 1.278-2.845, P=0.002), high Charlson comorbidity index (HR=1.209, 95%CI 1.032-1.417, P=0.019) at the beginning of PD start were independent risk factors for all-causes death in PD patients. Hyperuricemia (SUA≥420 μmol/L) at 6 months after PD start (HR=1.734, 95%CI 1.033-2.912, P=0.037) and age≥65 years (HR=1.761, 95%CI 1.024-3.209, P=0.041), with diabetes (HR=2.775, 95%CI 1.358-5.671, P=0.005) at the beginning of PD start were independent risk factors for cardiovascular death in PD patients. Conclusions SUA at 6 months after PD is an independent risk factor for all-cause death and cardiovascular death in PD patients.     

Risk factors for mortality in diabetic peritoneal dialysis patients

Objective To investigate the risk factors of all-cause mortality in diabetic patients on peritoneal dialysis (PD). Methods As a single-center retrospective cohort study, all incident PD patients who were catheterized at the First Affiliated Hospital of Nanchang University between November 1, 2005 and February 28, 2017 were included. Patients were divided into diabetes mellitus group (DM group) and non-diabetes mellitus group (NDM group). Outcomes were analyzed by Kaplan-Meier method. Multivariate Cox proportional hazards models were utilized to assess the risk factors of all-cause mortality. Results A total of 977 patients were enrolled. Compared with NDM group, patients in DM group were older (47.5±14.4 vs 59.3±11.3, P＜0.01), had more cardiovascular disease (CVD) (7.5% vs 20.3%, P＜0.01), higher levels of serum hemoglobin (78.2±17.2 vs 82.3±14.6 g/L, P＜0.01) , and lower levels of serum albumin (36.1±5.0 vs 32.7±5.6 g/L, P＜0.01). The one-, three- and five-year patient survival rates of DM and NDM group were 89.7%, 56.0%, 31.9% and 94.7%, 81.3%, 67.4%, respectively.Survival rate was significantly lower in DM group than in NDM group ( χ2=63.51, P＜0.01). Stratified analysis showed that DM group had significant lower survival rate than NDM group in patients younger than 70 years old ( χ2= 73.35, P＜0.01), while survival rate was similar between the two groups patients older than 70 years old ( χ2= 0.003, P=0.96). Multivariate Cox proportional hazards model analysis showed that DM (HR: 1.74, 95%CI: 1.27-2.38, P＜0.01), age (HR: 1.05, 95%CI: 1.04-1.06, P＜0.01), leukocyte (HR: 1.06, 95%CI: 1.00-1.12, P=0.04) and triglyceride (HR: 1.19, 95%CI: 1.07-1.32, P＜0.01) were all independent risk factors for all-cause mortality of PD patients. However, age (HR: 1.05, 95%CI: 1.04-1.07, P＜0.01) and alkaline phosphatase (HR: 1.01, 95%CI: 1.00-1.01, P=0.02) were independent risk factors for all-cause mortality of diabetic patients. Conclusions Long-term survival rate was lower in diabetic PD patients than in non-diabetic PD patients. DM, age, leukocyte and triglyceride were independent risk factors of mortality in PD patients. Age and alkaline phosphatase were independent risk factors of mortality in diabetic patients.     

Association of serum soluble Klotho with episode of nonfatal cardiovascular disease and mortality in maintenance hemodialysis patients

Objective To explore the association of serum soluble Klotho (sKlotho) with nonfatal cardiovascular disease (CVD) and all-cause/CVD mortality in maintenance hemodialysis (MHD) patients. Methods A total of 132 MHD patients admitted during October 2011 were enrolled. Serum sKlotho was measured by ELISA. Demographic data, including age, gender and comorbid conditions, were obtained from their medical histories, and parameters including calcium, phosphorus and albumin were assessed. The occurrence time of nonfatal CVD and all-cause mortality were recorded during the 60 months follow-up. MHD patients were categorized into four groups according to the quartiles of sKlotho: group Ⅰ (sKlotho＜361.34 ng/L), group Ⅱ (361.34 ng/L≤sKlotho＜398.81 ng/L), group Ⅲ (398.81 ng/L≤sKlotho＜445.99 ng/L) and group Ⅳ (sKlotho≥445.99 ng/L). Spearman correlation analysis and binary Logistic regression analysis were used to test the association between sKlotho and nonfatal CVD events. The impacts of sKlotho on all-cause mortality and CVD mortality were assessed by Kaplan-Meier method with log-rank test. Cox regression model was applied to evaluate the effect of sKlotho on MHD patients outcomes. Results All 132 MHD patients had sKlotho ranging from 304.02 ng/L to 550.62 ng/L. And 87 patients suffered from nonfatal CVD, with 192 episodes of nonfatal CVD during the follow-up period. The sKlotho had negative correlations with coronary artery disease (r=-0.286, P=0.001), congestive heart failure (r=-0.190, P=0.029), cerebrovascular accident (r=-0.240, P=0.006) and peripheral arterial occlusion (r=-0.243, P=0.005). The sKlotho were risk factors of coronary artery disease (OR=0.989, P=0.023) and peripheral artery occlusion (OR=0.988, P=0.046). 35 patients died in the follow-up period, including 27 death from CVD. The all-cause mortality and CVD mortality rates were significantly different among four groups (P=0.036, P=0.047). Survival rates of all-cause death and CVD death varied among four groups (χ2=8.076, P=0.044; χ2=7.866, P=0.049). Patients in group Ⅳhad higher survival rates of all-cause death and CVD death than those in group Ⅰ and group Ⅱ (all P＜0.05). Multivariate Cox regression analyses revealed diabetes and age were independent risk factors for all-cause mortality and CVD mortality (all P＜0.05), but sKlotho was not associated with the poor prognosis (HR=0.996, P=0.256; HR=0.996, P=0.287). Conclusions Patients with lower sKlotho have worse nonfatal CVD ratio, especially coronary artery disease and peripheral arterial occlusion. Reduced serum sKlotho is associated with all-cause and CVD mortality, but sKlotho is still not a predictive indicator of prognosis of MHD patients.     

Associations between home blood pressure and mortality in peritoneal dialysis

Objective To investigate the association between the home blood pressure (BP) and morality in peritoneal dialysis (PD). Methods PD patients from the First Affiliated Hospital of Zhejiang University from January 1, 2008 to June 30, 2016 were studied. Over the first 6 months PD therapy, systolic SB (SBP) and diastolic BP (DBP) averaged as 5 (＜120 to≥150 mmHg in 10 mmHg increments) and 4 (＜70 to≥90 mmHg in 10 mmHg increments) categories, respectively, as well as continuous measures. All-cause and cardiovascular mortality were assessed by using Cox regression models adjusted for demographics, laboratory measurements, comorbid conditions and antihypertensive medications. The relationships between home BP and all-cause and cardiovascular mortality were assessed by restricted cubic spline regression model. Results A total of 1663 PD patients were included with a median follow-up of 29.9 months, in which 737 patients (44.3%) were female. The SBP and DBP were (135.2±15.8) mmHg and (83.1±10.5) mmHg, respectively. Two hundred and twenty-one PD patients died during the study period, of which 102 patients (46.2%) died of cardiac-cerebral vascular events. With 130≤SBP＜140 mmHg as a refernece, SBP≥150 mmHg (HR=1.83, 95%CI 1.19-2.82, P=0.005) and SBP＜120 mmHg (HR=2.05, 95%CI 1.29-3.27, P＜0.001) were associated with significantly higher risks of all-cause morality, but not cardiovascular morality. With 80≤DBP＜90 mmHg as a refernece, patients with DBP≥90 mmHg exhibited significantly higher risks of all-cause mortality (HR=1.80, 95%CI 1.21-2.68, P=0.009). SBP presented a U-shaped association with all-cause mortality. DBP presented a J-shaped association with all-cause mortality. Conclusions Higher SBP, lower SBP and higher DBP are associated with higher risks of all-cause mortality in PD patients. However, neither SBP nor DBP is observed statistically significant relationship with the risk of cardiovascular mortality. Further prospective and randomized clinical trials are needed to determine the optimal BP targets and improve the management of hypertension in PD patients.     

Association between serum soluble Klotho level and outcome in patients on maintenance hemodialysis

Objective To determine the relationship between serum soluble Klotho (sKL) level and adverse outcome in maintenance hemodialysis (MHD) patients. Methods One hundred and twenty nine cases of MHD patients were collected prospectively. Serum sKL was detected by ELISA. Abdomen lateral plain was used as a criterion to determine the abdominal aortic calcification. The abdominal aortic calcification score (AAC) was calculated. Cox regression analysis was used to determine the risk factor of cardiovascular death (CVD) in MHD patients. Kaplan-Meier showed the relationship between sKL and CVD in MHD patients. Results There were 27 cases (20.9%) of all-cause death and 19 cases (14.7%) of cardiovascular death. The median sKL was 612.6(379.2-816.6) ng/L, and log[iPTH] was an independent factor of sKL concentration. Low sKL had high AAC and CVD death rate. Kaplan-Meier method showed that the all-cause death rate was similar between two groups, and CVD death rate increased significantly in low sKL patients (P=0.036). Cox regression indicated that lower sKL level was associated with high CVD death rate [OR=0.352, 95%CI(0.127- 0.977), P=0.045].After adjustment for the general condition, biochemical indicators, the relationship still existed [OR=0.331, 95% CI (0.117-0.933), P=0.037]. In no or mild vascular calcification patients (AAC≤4), compared with high sKL patients, low sKL patients had no significant difference rate in all-cause mortality. The CVD mortality was significantly higher in high sKL (P=0.035) compared with low sKL. In severe calcification group (AAC＞4),all-cause death and CVD death rates were similar between different sKL groups (P=0.991 and 0.522, respectively). Conclusions Lower sKL has the high CVD death rate and sKL level decreasing is an independent risk factor for CVD death in MHD patients. The lower sKL concentration in MHD patients with no or mild calcification may predict CVD mortality. This study suggests that sKL levels may be helpful in predicting the outcome of patients with MHD.     

Analysis of early mortality and related risk factors in maintenance hemodialysis patients

Objective To analyze the early mortality and related risk factors of new hemodialysis patients in Zhejiang province, and provide basis for reducing the death risk of hemodialysis patients. Methods The early mortality and related factors of new hemodialysis patients from January 1, 2010 to June 30, 2018 were retrospectively analyzed using the database of Zhejiang province hemodialysis registration. The early mortality was defined as death within 90 days of dialysis. Cox regression model was used to analyze the related risk factors of the early mortality in hemodialysis patients. Results The mortality was the highest in the first month after dialysis (46.40/100 person year), and gradually stabilized after three months. The early mortality was 25.33/100 person year. The mortality within 120 days and 360 days were 21.40/100 person year and 11.37/100 person year, respectively. The elderly (≥65 years old, HR=1.981, 95%CI 1.319-2.977, P＜0.001), primary tumor (HR=3.308, 95%CI 1.137-5.624, P=0.028), combined with tumors (not including the primary tumor, HR=2.327, 95%CI 1.200-4.513, P=0.012), temporary catheter (the initial dialysis pathway, HR=3.632, 95%CI 1.806-7.307, P＜0.001), lower albumin (＜30 g/L, HR=2.181, 95%CI 1.459-3.260, P＜0.001), lower hemoglobin (every 0.01 g/L increase, HR=0.861, 95%CI 0.793-0.935, P=0.001), lower high density lipoprotein (＜0.7 mmol/L, HR=1.796, 95%CI 1.068-3.019, P=0.027) and higher C reactive protein (≥40 mg/L, HR=1.889, 95%CI 1.185-3.012, P=0.008) were the risk factors of early death for hemodialysis patients. Conclusions The early mortality of hemodialysis patients is high after dialysis, and gradually stable after 3 months. The elderly, primary tumor, combined with tumors, the initial dialysis pathway, lower albumin, lower hemoglobin, lower high density lipoprotein and higher C reactive protein are the risk factors of early death for hemodialysis patients.     

Risk factor analysis of pneumonia in maintenance hemodialysis patients

Objective To investigate the risk factors of pneumonia in maintenance hemodialysis (MHD) patients. Methods The clinical data of patients undergoing dialysis longer than three months at the Hemodialysis Center of West China Hospital of Sichuan University from July 2013 to July 2018 were retrospectively analyzed. The patients were divided into pneumonia group and non- pneumonia group. Follow-up time started from admission to the beginning of hemodialysis. All patients were followed until the patient died, or withdrawn from hemodialysis, or transferred to another center, or until the study deadline (April 2019). Baseline clinical data were compared between the two groups, and the differences in clinical data between the pneumonia group and the baseline were also analyzed. Risk factors for pneumonia in hemodialysis patients was analyzed by binary logistic regression. Kaplan-Meier curve was used to compare the survival prognosis of the two groups, and the Log-rank method was used for significant test. A multivariate Cox proportional hazard model was used to analyze risk factors for MHD patients' death. Results (1) A total of 311 patients were enrolled in the study, in which 178 (57.2%) of the patients were male, and 75(24.1%) of the patients had pneumonia. Compared with non-pneumonia group, the pneumonia group patients were older (P=0.002), had higher level of white blood cells (P=0.001) and lower level of serum creatinine (P=0.003), albumin (P=0.001), and serum magnesium (P=0.039). There were also statistically significant differences between the two groups in the proportion of females and underlying diseases (all P＜0.05). (2) The time of pneumonia occurred from the initial time of dialysis was (10.69±9.82) months. Compared with baseline values, decreased hemoglobin and albumin level were found (both P＜0.01). (3) Logistic regression analysis showed male patients had lower risk of pneumonia than female patients (OR=0.438, 95%CI 0.242-0.795, P=0.007). For every 1 g/L increase in albumin, the risk of pneumonia was reduced by 6.4% (OR=0.936, 95%CI 0.885-0.991, P=0.022). Kaplan-Meier survival curve analysis showed that the difference in 5-year cumulative survival rate between pneumonia group and non-pneumonia group was statistically significant ( 60.6% vs 84.4%, χ2=16.647, P＜0.001). (4) Multivariate Cox regression analysis showed that long dialysis time (HR=0.870, 95%CI 0.832-0.909, P＜0.001) and high serum albumin level (HR=0.898, 95%CI 0.845-0.955, P=0.001) were protective factors in patients with MHD. Pneumonia (HR=3.008, 95%CI 1.423-6.359, P=0.004) was an independent risk factor for death in MHD patients. Conclusions Hemoglobin and albumin level are reduced in MHD patients with pneumonia. Low albumin level is a risk factor for pneumonia in patients. MHD patients with pneumonia have a lower survival time than those without pneumonia.     

透析开始残余肾功能与维持性透析患者预后的关系

目的 评估终末期肾病患者透析开始残余肾功能与维持性透析预后的关系.方法 收集2005年1月1日至2009年9年30日新进入血透或腹透治疗的终末期肾病成年患者资料,随访至2010年3月31日.根据透析开始时估算肾小球滤过率(eGFR)分为≥10.5、8～＜10.5、6～＜8、＜6 ml· min-1·(1.73 m2)-1 4组.eGFR评估采用MDRD简化公式.终点事件为全因死亡和心脑血管死亡.结果 (1)共562例患者入选,透析开始中位eGFR为5.60(2.26～12.62) ml· min-1·(1.73 m2)-1;中位随访时间为17(0～58)个月 ;死亡141例,中位生存期为45.48(43.05 ～47.90)个月.随着透析开始eGFR下降,4组患者Scr、BUN、血尿酸(SUA)、血前白蛋白、血磷、血钙磷乘积、整段甲状旁腺激素(iPTH)、平均动脉压(MAP)逐渐升高 ;血红蛋白(Hb)、男性患者比例、并发糖尿病比例、Charison并发症指数≥5比例逐渐下降,差异均有统计学意义(均P＜ 0.05).随着透析开始eGFR下降,并发左室肥大比例有逐渐升高趋势,但差异无统计学意义.(2)Kaplan-Meier生存曲线显示4组患者总体生存率差异无统计学意义.Cox回归分析显示透析开始eGFR与透析预后无显著关系.对透析非早期(＞3个月)死亡患者进行Kaplan-Meier生存曲线分析,4组患者1年生存率差异无统计学意义.多因素Cox回归分析显示透析开始eGFR是透析1年生存预后的保护因素(HR =0.791,95％CI 0.669～0.935,P＜0.01).(3)以心脑血管死亡为终点事件,多因素Cox回归分析显示,透析开始eGFR是心脑血管生存预后(HR =0.868,95％CI 0.777～0.971,P＜0.05)和1年心脑血管生存预后(HR=0.937,95％CI 0.851～0.992,P＜0.05)的保护因素.(4)多因素Cox回归分析显示,透析开始eGFR增高1 ml·min-1·(1.73 m2)-1,腹膜透析患者死亡风险下降10％(HR=0.90,95％CI 0.81～0.99,P＜ 0.05).血液透析方式4组患者Kaplan-Meier生存率分析显示,差异有统计学意义(Log-rank检验,P=0.047),8～＜10.5组生存率最低,与6～＜8组、＜6组差异有统计学意义(Log-rank检验,P=0.033,P=0.005).多因素Cox回归分析并未显示透析开始eGFR与预后相关.多因素Cox回归分析提示透析开始eGFR增高1 ml·min-1·(1.73 m2)-1,慢性肾小球肾炎患者和慢性肾小球肾炎腹膜透析患者死亡风险分别降低16.6％(HR=0.834,95％CI 0.736～0.946,P＜0.01)和32.1％(HR=0.679,95％CI 0.535～0.862,P＜0.01).以心脑血管死亡为终点,多因素Cox回归分析显示透析开始eGFR增高1 ml·min-1·(1.73 m2)-1,慢性肾小球肾炎患者心脑血管死亡风险下降18.2％(HR=0.818,95％CI 0.669～0.999,P＜0.05).结论 本组患者透析时机明显晚于国际透析指南的标准.随着透析开始eGFR降低,并发症增多及程度加重.早期透析可能无法提高透析患者的总体生存率,但可能有助于改善患者心脑血管及1年总体生存预后和腹膜透析、慢性肾小球肾炎患者的预后.     

Association between body-mass index and survival in peritoneal dialysis patients

Objective To evaluate the association between body-mass index and prognosis in peritoneal dialysis (PD) patients. Methods In this observational study of a single nephrology unit in Shanghai East Hospital, 81 incident continuous ambulatory peritoneal dialysis(CAPD) patients were included from Jan 2008 to Dec 2013, whom were followed-up by 36 months or until death. The patients were classified as underweight (BMI＜18.5kg/m2); normal weight (18.5～23.9kg/m2); overweight (24～27.9kg/m2) and obese (BMI≥28kg/m2). The patients and technique survival rates were estimated by Kaplan-Meier analysis. Cox proportional hazards analyses were used to elucidate relationship between BMI and all-cause mortality and technique failure in PD patients. Results The overall survival rate was similar between normal and overweight groups (P=0.96), but significantly lower in underweight group and obese group (P＜0.01 respectively). The overall technical survival rate of obese group was lower compare with normal group (P＜0.01). The main cause of technical failure was peritonitis (81.3%). BMI was positively correlated with albumin (r=0.24, P＜0.05), hemoglobin (r=0.56, P＜0.01), glucose(r=0.23, P＜0.05) and cholesterol (r=0.41, P＜0.01), but negatively correlated with Kt/V (r=-0.36, P＜0.01) and Ccr(r=-0.34, P＜0.01). In adjusted Cox proportional hazard mode 3, obese was independently associated with all-cause mortality (HR: 5.93, 95%CI: 1.10～31.79). Obese and peritonitis were independently associated with technical failure (HR: 10.33, 95%CI: 1.04～78.02 and HR: 2.74, 95%CI: 1.17～6.40 respectively). Conclusions Underweight and obese CAPD patients have poorer outcome. Obese CAPD patients also have lower technical survival rate. Obesity was an independent risk factor for all-cause mortality in CAPD patients.     

Relationship between serum magnesium level and coronary artery calcification in maintenance hemodialysis patients

Objective To evaluate the relationship between serum magnesium and coronary artery calcification (CAC) and their associated factors. Methods 131 patients with chronic kidney disease on regular hemodialysis (HD) were recruited into this study from December 2014 to December 2015 in our center. Demographic and clinical data of selected patients were collected. Serum fibroblast growth factor 23 (FGF-23) level was quantified by enzyme linked immunosorbent assay(ELISA). Quantification of coronary artery calcification score (CACs) was determined by multi-slice spiral computed tomography (MSCT). The relationships between serum magnesium and FGF-23 level, CACs, demographic and clinical data were investigated. Results Patients were divided into low serum magnesium group, normal serum magnesium group and high serum magnesium group according to their serum magnesium levels. There were significant differences in the distribution of diabetes history, serum phosphorus, serum albumin, serum pre albumin, serum uric acid among these three groups(P＜0.05). A significant positive correlation was confirmed between serum magnesium level and serum albumin, serum pre albumin, serum phosphorus and serum uric acid by Pearson correlation analysis and Spearman correlation analysis (r=0.389, 0.234, 0.200, 0.234, P=0.000, 0.007, 0.022, 0.007, respectively). According to the degree of CAC, all maintenance hemodialysis (MHD) patients were divided into non-calcification group, low calcification group, moderate calcification group and high calcification group, and there were significant differences in the distribution of the age, serum phosphorus, serum magnesium, FGF-23 levels among these groups (P＜0.05) . Spearman correlation analysis showed that CACs was positively correlated with age, FGF-23, serum phosphorus (r=0.309, 0.277, 0.180, P=0.000, 0.001, 0.040, respectively), while negatively correlated with serum magnesium level (r=-0.238, P=0.006) in patients with MHD. The independent risk factors of CACs were aging, high level of FGF-23 in MHD patients by using ordinal logistic regression. However, Hypermagnesemia was a protective factor. Conclusions The history of diabetes, low serum albumin, phosphorus metabolism disorder and CAC are associated with hypomagnesemia in MHD patients. In MHD patients, aging as well as high level of FGF-23 are the risk factors of CAC, and hypermagnesemia is a protective factor of CAC.     

Incidence of cognitive impairment and risk factors associated with prognosis in maintenance hemodialysis patients

Objective To investigate the incidence and prognosis of cognitive impairment and to find out the risk factors associated with the outcome for better understanding and preventing cognitive impairment in maintenance hemodialysis (MHD) patients. Methods The patients who met the criteria as below: MHD patients (≥3 months) in Renji Hospital, Shanghai Jiao Tong University School of Medicine from January 2000 to July 2014, ≥18 years old were enrolled and could carry on the montreal cognitive assessment (MoCA) of voluntary cooperation. According to the score of MoCA, all enrolled patients were divided into two groups: cognitive impairment (MoCA＜26) group and non-cognitive impairment (MoCA≥26) group. The follow-up period was 3 years. There were 130 males, and the incidence, demography data, medical history, hemodialysis data, laboratory examination and prognosis of cognitive impairment in hemodialysis patients were prospectively compared and analyzed. Logistic regression analysis was used to investigate the risk factors of cognitive impairment. Kaplan-Meier survival curve and Cox regression model were used for prognostic analysis. Results A total of 219 MHD patients were enrolled. The incidence of cognitive impairment in MHD patients was 51.6%. There were 130 males, and the ratio of male to female was 1.46∶1. Age was (60.07±12.44) years old and dialysis vintage was (100.79±70.23) months. Compared with non-cognitive impairment group (n=106), patients in cognitive impairment group (n=113) were older, and had higher proportion of education status＜12 years, history of diabetes and anuria (all P＜0.05); however, the post-dialysis systolic pressure, pre-dialysis diastolic pressure, post-dialysis diastolic pressure, platelet and spKt/V were lower (all P＜0.05). Multivariate logistic regression analysis showed that education status＜12 years (OR=3.428, 95%CI 1.919-6.125, P＜0.001), post-dialysis diastolic pressure＜73 mmHg (OR=2.234, 95%CI 1.253-3.984, P=0.006) and spKt/V＜1.72(OR=1.982, 95%CI 1.102-3.564, P=0.022) were the independent risk factors for cognitive impairment in MHD patients. The Kaplan-Meier survival curve analysis showed that the survival rate of patients with cognitive impairment was lower than that of non-cognitive impairment group in MHD patients during 3 years follow-up (χ2=3.977, P=0.046). Multivariate Cox regression analysis showed that cognitive impairment was an independent risk factor for death in MHD patients (RR=2.661, 95%CI 0.967-7.321, P=0.058). Conclusions Cognitive impairment is one of the common complications and an independent risk factor for death in MHD patients. The mortality is high in patients who suffer cognitive impairment. Education status ＜12 years, post-dialysis diastolic pressure＜73 mmHg and spKt/V＜1.72 are the independent risk factors for cognitive impairment in MHD patients.     

Association of serum magnesium with cardiovascular mortality and all-cause mortality in peritoneal dialysis patients

Objective To investigate the association of serum magnesium with cardiovascular disease (CVD) and all-cause mortality in peritoneal dialysis patients. Methods A retrospective study was performed in patients who initiated peritoneal dialysis from January 1, 2013 to July 31, 2019 in the Shaoxing People's Hospital. According to the standard of serum magnesium, the patients were divided into control group (Mg≥0.7 mmol/L) and low-magnesium group (Mg﹤0.7 mmol/L). The differences in baseline biochemical variables, comorbidities, medications, and clinical outcomes between the two groups were compared. Logistic regression was used to analyze the related factors of hypomagnesemia. Kaplan-Meier survival analysis and Fine-Gray model were used to compare the difference in cumulative survival rate between the two groups. Cox regression model and competitive risk model were used to analyze the risk factors of all-cause mortality and CVD mortality. Results A total of 381 peritoneal dialysis patients were enrolled in this study. Among them, 321 patients were in control group and 60 patients in low-magnesium group. The total median follow-up time was 27(15, 43) months. There were significant differences in serum albumin, magnesium, phosphorus, intact parathyroid hormone, low-density lipoprotein chloesterol, high sensitivity C-reactive protein and 4-hour dialysate-to-plasma creatinine (4 h D/Pcr) between the two groups. CVD was the main cause of death in patients on peritoneal dialysis. Multivariate logistic regression analysis showed that hypoalbuminemia (OR=0.901, 95%CI 0.831-0.976, P=0.011), hypophosphatemia (OR=0.217, 95%CI 0.080-0.591, P=0.003), higher hsCRP (OR=1.276, 95%CI 1.066-1.528, P=0.008), and higher 4 h D/Pcr (OR=1.395, 95%CI 1.014-1.919, P=0.041) were independent risk factors for patients with hypomagnesemia. Kaplan-Meier survival curve analysis showed the cumulative survival rate of patients in low-magnesium group was significantly lower than that of control group (Log-rank χ2=5.388, P=0.020). Fine-Gray model analysis showed the cumulative CVD survival rate of low-magnesium group was significantly lower than that of control group (Gray=6.915, P=0.009). Multivariate-corrected Cox regression model and competitive risk model analysis showed that higher serum magnesium level was a protective factor for all-cause mortality and CVD mortality when serum magnesium was used as a continuous variable (HR=0.137, 95%CI 0.020-0.946, P=0.044; SHR=0.037, 95%CI 0.002-0.636, P=0.023, respectively). Hypomagnesemia was an independent risk factor for all-cause mortality and CVD mortality when serum magnesium was used as categorical variable (HR=1.864, 95%CI 1.044-3.328, P=0.035; SHR=2.117, 95%CI 1.147-3.679, P=0.029, respectively). Conclusions Hypomagnesemia is susceptible to peritoneal dialysis patients with hypoalbuminemia, hypophosphatemia, higher hsCRP and higher peritoneal transport characteristics. Hypomagnesemia is an independent risk factor for CVD mortality and all-cause mortality in peritoneal dialysis patients.