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.     

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.     

Relationship between coronary artery calcification and outcomes in maintenance hemodialysis patients

Objective To evaluate the relationship between coronary artery calcification (CAC) and outcomes in maintenance hemodialysis (MHD) patients. Methods Eighty-six patients who were on MHD between October 2014 and May 2015 in the blood purification center of our hospital were enrolled prospectively. CAC was measured and scored by multiple slice computed tomography (MSCT). According to the CAC score (CACs), the patients were divided into mild CAC (CACs＜100) group and severe CAC (CACs≥100) group. Kaplan-Meier analysis was performed to analyze the survival rates of the two groups, and a COX proportional hazards regression model was used to estimate the risk factors of all-cause mortality and cardiovascular disease mortality in MHD patients. Results Severe CAC (CACs≥100) was present in 62.8% (54/86) patients. The median of follow-up duration was 28.9(23.8, 29.4) months. During the follow up, 2(6.3%) patients in CACs＜100 group and 18 (33.3%) patients in CACs≥100 group died. Kaplan-Meier survival analysis demonstrated that patients in CACs≥100 group had higher all-cause mortality and cardiovascular mortality as compared with patients in CACs＜100 group (P=0.007, P=0.030). Multivariate COX regression analysis demonstrated that CACs≥100 (HR=7.687, 95%CI 1.697-34.819, P=0.008) and low single-pool Kt/V (HR=0.092, 95%CI 0.020-0.421, P=0.002) were independent risk factors for all-cause mortality. Old age (HR=1.192, 95%CI 1.100-1.291, P＜0.001), short duration of dialysis (HR=0.598, 95%CI 0.445-0.804, P=0.001), low 25-hydroxy vitamin D3 (HR=0.461, 95%CI 0.326-0.630, P＜0.001), and low total cholesterol (HR=0.405, 95%CI 0.213-0.772, P=0.006) were independent risk factors for cardiovascular disease mortality. Conclusions The CACs is significantly related with overall survival in MHD patients. Large multicenter prospective studies are to be evaluated the association between CACs and long-term survival in MHD patients.     

The study of cardiovascular disease and survival among maintenance hemodialysis patients

Objective To evaluate the associated factors about cardiovascular disease and survival among maintenance hemodialysis patients. Methods The newly diagnosed patients with ESRD in the 44th hospital of People's Liberation Army and Changzheng hospital during the period of 2008-2012 were analyzed retrospectively. The baseline variables and laboratory results were collected. Cardiovascular disease and survival were recorded. Logistic regression and multivariate COX regression were used to detect the relative factors. Results A total of 158 patients were included in the study. The mean age was 54.61±16.98. Cardiovascular complications were recorded in 40 cases. Heart and coronary artery disease were recorded 24 cases, strokes were recorded in 16 cases. Cox proportional hazards regression model showed thatage (HR=1.051, 95%CI:1.023-1.081), male (HR=6.025, 95%CI:2.571-14.121), increased neutrophile granulocyte(%) (HR=1.073, 95%CI:1.028-1.121), increased LDL (HR=1.562, 95%CI:1.058-2.305), high calcium concentration dialysate (HR=5.025, 95%CI:1.163-21.739) were risk factors for cardiovascular disease. Compared to conventional hemodialysis, in-center nocturnal hemodialysis was a protective factor (HR=0.288, 95%CI:0.090-0.924). In our study, 7 patients died. After adjusted to multiple variances, we found diabetes was a risk factor for survival (HR=15.385, 95%CI：1.692-145.851). Compared to conventional hemodialysis, hemodiafiltration may reduce the risk of CVD(HR=0.145, 95%CI:0.021-1.016, P=0.052). Conclusions To maintenance hemodialysis patients, age, male gender, the percent of neutrophile granulocyte, LDL, high calcium concentration dialysate are risk factors for CVD. In-center nocturnal hemodialysis reduces the risk ofCVD. Diabetes increase the risk of death, while hemodiafiltration may reduce the risk of death.     

Value of handgrip strength in predicting the mortality of hemodialysis patients

Objective To analyze the risk factors of mortality among patients treated by maintenance hemodialysis (MHD), and identify whether handgrip strength (HGS) or other nutrient markers could predict the mortality independently. Methods One hundred and eight patients receiving regular MHD in Peking Union Medical College Hospital from July to September, 2008 were involved. Baseline data including clinical data, nutrient data such as subjective global assessment, anthropometrics and biochemical measurement were collected. After being followed for 72 months, the patients' mortality and morbidity of cardiovascular event were recorded. Cox regression model was used to estimate the risk factors of mortality. Results The average age of 108 MHD patients was (57.6±13.0) years. During the 6-years following up, 35 patients died (32.4%), of whom 62.9% died of cardiovascular events. Among variables, patients’ age, residual urine volume, serum creatinine level, prealbumin level and mean leg circumference were risk factors for all-cause mortality. The patient with lower HGS bore higher risk for all-cause mortality (HR=2.842, 95%CI 1.390-5.811) and cardiovascular death (HR=2.826, 95%CI 1.150-6.947). After adjusting gender, age, history of cardiovascular disease and diabetes, body mass index (BMI), dialysis vintage, Kt/V, nPCR and prealbumin, lower handgrip strength was still an independent risk factor of all-cause mortality (HR=2.505, 95%CI 1.112-5.642). In prediction for all-cause mortality by HGS, the area under the receiver operating characteristic curve(ROC) were 0.705 and 0.682 among men and women respectively. Conclusion Lower handgrip strength can predict mortality of maintenance hemodialysis patients independently.     

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.     

Prognostic analysis of aged end-stage renal disease patients receiving hemodialysis and peritoneal dialysis

Objective To compare the survival rates of elderly hemodialysis (HD) and peritoneal dialysis (PD) patients and identify their independent prognostic predictors. Methods Patients aging ＞60 years old who initiated dialysis between January 1, 2008 and December 31, 2014 were included. Propensity score method (PSM) was applied to adjust for selection bias. Kaplan-Meier method was used to obtain survival curves and a Cox regression model was used to evaluate risk factors for mortality. Results 447 eligible patients with maintenance dialysis were identified, 236 with hemodialysis and 211 with peritoneal dialysis. 174 pairs of patients were matched, with the baseline data [age, gender, Charlson comorbidity index (CCI) and the primary disease] between two groups showing no significant difference (P＞0.05). Cardiovascular events, cerebrovascular events and infection were major causes of death in both groups and there was no significant difference in the causes of death between two groups (P＞0.05). The overall survival rates at 1 and 5 year were 93.6% and 63.4% respectively in HD group, 91.9% and 61.5% in PD group. The differences of total survival rates between HD and PD patients were not significant (P＞0.05). Cox regression analysis showed age(≥80 year) (P＜0.001, HR=1.058, 95%CI 1.028-1.088), diabetic nephropathy (P=0.001, HR=2.161, 95%CI 1.384-3.373), CCI≥5 (P=0.007, HR=1.935, 95%CI 1.201-3.117) were independent prognostic risk predictors in HD patients; age(≥80 year) (P=0.022, HR=1.043, 95%CI 1.006-1.081), serum albumin level ＜ 35 g/L (P=0.025, HR=1.776, 95%CI 1.075-2.934), and prealbumin (P=0.012, HR=0.968, 95%CI 0.944-0.993) were independent prognostic predictors in PD patients. Conclusions The differences of total survival rates between aged HD and PD patients are not significant. Age, diabetic nephropathy, CCI≥5 and age, serum albumin＜35 g/L, prealbumin＞30 g/L respectively influence the survival of elderly HD and PD 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.     

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.     

Effects of different vascular access types on new atrial fibrillation in maintenance hemodialysis patients： a prospective cohort study

Objective To investigate the effects and related risk factors of different vascular access types on new atrial fibrillation in maintenance hemodialysis (MHD) patients. Methods This was a single-center prospective cohort study. Patients who established long-term dialysis access and were voluntarily followed up in the Second Hospital of Tianjin Medical University from January 1, 2013 to June 30, 2013 were enrolled to follow-up for 5 years. Patients were divided into fistula group (patients with autogenous arteriovenous fistula) and catheter group (patients with tunneled cuffed internal jugular vein catheter). The incidences of new atrial fibrillation in the two groups were compared by Kaplan-Meier survival analysis. Cox regression analysis and receiver operator characteristic curve (ROC) were used to assess the risk factors of new atrial fibrillation. Results A total of 315 eligible patients were enrolled, including 150 males (47.62%). There were 189 patients (60.00%) in the fistula group, and 126 patients (40.00%) in the catheter group. Multivariate Cox regression analysis showed that older age (HR=1.021, 95%CI 1.003-1.040), arteriovenous fistula (HR=1.899, 95%CI 1.019-3.539), increased dialysis blood flow (HR=1.030, 95%CI 1.010-1.051) and left atrial diameter (HR=1.097, 95%CI 1.022-1.177) were independent risk factors for new atrial fibrillation in MHD patients (all P＜0.05). Kaplan-Meier survival analysis showed that the incidence of new atrial fibrillation in fistula group was higher than that in catheter group (Log-rank χ2=9.53,P=0.002). ROC curve analysis showed that age [the area under the curve (AUC)=0.608, P=0.008], arteriovenous fistula (AUC=0.594, P=0.021), dialysis blood flow (AUC=0.659, P＜0.001) and left atrial diameter (AUC=0.604, P=0.011) could predict the occurrence of new atrial fibrillation. Conclusions Older age, arteriovenous fistula, increased blood flow during dialysis and left atrial diameter are independent risk factors for new atrial fibrillation in MHD patients, which can predict the occurrence of atrial fibrillation. The incidence of new atrial fibrillation in patients with arteriovenous fistula is higher than that in patients with catheter.     

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.     

Association of intradialytic hypotension and 5-year mortality in maintaining hemodialysis patients

Objective To assess the risk factors of intradialytic-hypotension (IDH) and the prognosis of IDH among maintenance hemodialysis (MHD) patients for the prevention and treatment of IDH. Methods 276 MHD patients were enrolled during Jan. 2009 to Mar. 2009. Intradialytic blood pressure was monitored during a 3-month period. IDH was defined as an event characterized by a sudden drop in systolic BP more than 20 mmHg or in mean artery pressure (MAP) more than 10 mmHg associated with clinical events and need for interventions. Dialysis-related information was collected. Kaplan-Meier method, log-rank test, logistic regression and Cox regression analyses were performed to examine the association between IDH and survival, using a follow-up through 31 May 2014. Results A total of 276 patients were recruited. The incidence rate of IDH was 40.9%. 163 patients with no-IDH (＜1/10 hypotensive events/3 months) served as controls. 113 patients with IDH (≥1/10 hypotensive events/3 months) were identified among all 276 patients. Multivariate logistic regression analysis showed that age, ultrafiltration rate, gender, serum NT-proBNP, serum albumin and aortic rool inside dimension (AoRD) were associated with IDH among MHD patients. During the 5-year follow-up, 74 patients died, with a mortality rate 5.2 per 100 person-year. Kaplan-Meier survival curve showed significant difference of overall and CV mortality rates between 2 groups. The multivariate Cox regression model indicated that IDH increased the risk of death (HR=1.572, 95%CI 1.077-2.293, P=0.019). So did the rise of LVMI (HR=1.010, 95%CI 1.009-1.085, P=0.020). Conclusion Elderly, female, high ultrafiltration rate, high level of serum NT-proBNP, hypoalbuminemia and shorter AoRD are independent risk factors for IDH among MHD patients. LVMI can predict the outcome of MHD patients. Intradialytic hypotension is an independent risk factor for long-term mortality in MHD patients.     

The risk factors of mortality in peritoneal dialysis patients in different periods

Objective To explore the risk factors and characteristics in patients with peritoneal dialysis who died in different periods. Methods The clinical data of new peritoneal dialysis patients in the Department of Nephrology and Peritoneal Dialysis Center of the First Affiliated Hospital of Nanchang University from November 1, 2005 to February 28, 2017 was retrospectively analyzed. The patients were divided into two groups according to the time of death: those who died within one year and died after one year. The risk factors of mortality between the two groups were analyzed by Cox regression model. Results A total of 997 patients were enrolled and 244 patients died. There were 69 patients (28.3%) died within one year and 175 patients (71.7%) died after one year. Cardiovascular and cerebrovascular disease was the dominating reason of death in both groups, accounting for 59.4% (died within one year group) and 51.4% (died after one year group) respectively. Cox regression analysis showed that for died within one year group, old age (HR=1.035, 95%CI: 1.016-1.055, P＜0.001), low blood total calcium (HR=0.167, 95%CI: 0.053-0.529, P=0.002), low albumin (HR=0.899, 95%CI: 0.856-0.943, P＜0.001) and low apolipoprotein A1 (HR=0.274, 95%CI: 0.095-0.789, P=0.016) were risk factors associated with mortality. However, for died after one year group, old age (HR=1.053, 95%CI: 1.038-1.069, P＜0.001), combined with diabetes (HR=2.181, 95%CI: 1.445-3.291, P＜0.001) and hypertriglyceride (HR=1.204, 95%CI: 1.065-1.362, P=0.003) were risk factors associated with mortality. Conclusions The risk factors of mortality for peritoneal dialysis patients of different periods were not exactly the same. For died within one year patients, old age, low blood total calcium, low albumin and low apolipoprotein A1 were independent risk factors for mortality.However, for died after one year patients, old age, combined with diabetes, and high triglycerides were independent risk factors for mortality.     

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.     

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.     

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.     

Brain magnetic resonance and cognitive function changes in maintenance hemodialysis patients

Objective To investigate cerebrovascular lesions on maintenance hemodialysis (MHD) patients, including types of cerebrovascular disease, and cognitive function changes. Methods A cross-sectional study was applied. A total of 270 MHD patients at hemodialysis center of Peking Union Medical College Hospital were screened, and finally 117 cases were enrolled. Demographic information, aboratory data, MRI and MRA data were collected and assessed. Cognitive function was evaluated with C - MMSE (Chinese mini mental test examination) and C - MoCA (Chinese montreal cognitive assessment). The related factors were selected by Spearman correlation analysis, multiple linear regression and logistic regression analysis. Results The patients’average age was (56.0± 12.5) years, average hemodialysis age was (73.5±60.8) months. Only 5.1% patients had clinical history of cerebral infarction or hemorrhage. Pre - hemodialysis blood pressure was (142.7/80.3±18.2/12.9) mmHg, Post-hemodialysis blood pressure was (130.2/79.1±23.4/14.9) mmHg. A total of 18.8% patients had intra-hemodialysis hypotension, spKt/V was (1.45±0.25). MR results showed that 12.0% patients had cerebral artery stenosis, 5.1% patients had cortical infarcts, 39.3% patients had lacunar infarcts, 47.0% patients had microbleeds, 7.7% patients had chronic hematoma, 52.1% patients had abnormal brain whiter matter lesions (WMLs). In cognitive function evaluation, 20.9% patients had abnormal C-MMSE scores, but 65.2% patients had abnormal C-MoCA results. Multiple linear regression showed age (b=0.059, P＜0.01), dialysis age (b=0.005, P＜0.05) were associated with WMLs in MHD patients. Intra-hemodialysis hypotension was an independent risk factor of lacunar infarcts (b=2.123, P＜0.01) and microbleeds (b=3.531, P＜0.01). Low serum albumin level was an independent risk factor of cognitive decline (b=0.314, P＜0.05). Logistic regression analysis showed pre - hemodialysis systolic blood pressure was an independent risk factor of cortical infarcts [OR=1.088, 95%CI (1.018-1.152), P＜ 0.05]. Gender, dialysis age and pre - dialysis serum TCO2 level were related with chronic hematoma. Conclusions WMLs is related with dialysis voltage. Lacunar infarcts and mirobleeds are related with intra - hemodialysis hypotension. Lacunar infarcts, WMLs and nutritional status are contributed to decline of cognition in MHD patients.     

Assessment of fluid and nutritional status using bioelectrical impedance methods in acute kidney injury patients requiring continuous renal replacement therapy

Objective To investigate the predictive value of nutritional and fluid status measured by bioelectrical impedance methods for the prognosis of acute kidney injury (AKI) patients undergoing continuous renal replacement therapy (CRRT). Methods Patients with severe AKI received CRRT in the First Affiliated Hospital of Nanjing Medical University from September 2016 to September 2018 were enrolled, and divided into death group and survival group according to 28-day survival. Cox regression was used to analyze the association between 28-day survival and lean tissue index (LTI), fat tissue index (FTI), the ratio of extracellular water (ECW) and body cell mass (BCM) (ECW/BCM), and overhydration (OH), respectively. Results A total of 156 patients were included, including 101 males and 55 females. The age was (62.7±15.4) years, with sequential organ failure assessment (SOFA) score of 9.9±3.9. The 28-day mortality rate was 46.2%. The pre-CRRT OH values in the 28-day survival group and death group were 2.95(1.80, 5.50) L and 4.20(2.95, 5.70) L(P=0.016), and ECW/BCM values were 1.00(0.76, 1.18) and 1.07(0.88, 1.25) (P=0.033), respectively. Univariate Cox regression analysis showed that pre-CRRT high OH values (HR=1.08, 95%CI 1.00-1.17, P=0.040) and high ECW/BCM values (HR=3.02, 95%CI 1.46-6.22, P=0.003) were associated with 28-day death. The changes of OH values (HR=0.83, 95%CI 0.72-0.95, P=0.008) and ECW/BCM values (HR=6.79, 95%CI 1.72-26.82, P=0.006) between pre-CRRT and the 7th day after CRRT initiation were significantly associated with 28-day mortality in patients who survived 7 days after CRRT initiation. After adjusting for age, gender, and SOFA scores, multivariate Cox regression analysis showed that the high OH value (HR=1.16, 95%CI 1.06-1.27, P=0.002) and the high ECW/BCM value (HR=2.80, 95%CI 1.30-6.06, P=0.003) before CRRT, the change of OH value (HR=0.82, 95%CI 0.72-0.95, P=0.008) and ECW/BCM value (HR=2.79, 95%CI 1.30-5.98, P=0.009) between the 7th day after CRRT initiation and pre-CRRT, were independently associated with 28-day death, while LTI (HR=0.93, 95%CI 0.86-1.02, P=0.113) and FTI (HR=0.98, 95%CI 0.92-1.04, P=0.475) before CRRT were uncorrelated with 28-day death. Conclusions In bioelectrical impedance analysis, the high OH value and high ECW/BCM value before CRRT are associated with 28-day mortality in patients with AKI, while the nutritional indicators LTI and FTI before CRRT are not significantly related. The correction of fluid overload by CRRT within 7 days may reduce the risk of 28-day mortality.     

自体动静脉内瘘使用寿命的影响因素

目的分析自体动静脉内瘘(arteriovenous fistula,AVF)使用的相关因素,为延长血液透析患者AVF使用寿命提供理论依据。方法采用回顾性调查研究,选取2004年10月至2017年6月在南昌大学第一附属医院行AVF手术并使用其进行维持性血液透析(maintenance hemodialysis,MHD)的患者为研究对象,探讨AVF使用寿命的影响因素。通过问卷调查、查阅医院病历系统和血液透析记录单等方式,记录患者的一般资料、透析资料和实验室指标。根据内瘘功能状态将患者分为失功组及通畅组,对比两组资料之间的差异。采用多因素Cox比例风险回归模型分析AVF使用寿命的影响因素,Kaplan-Meier方法绘制生存曲线。结果共纳入研究对象187例,内瘘失功组47例,通畅组140例,两组患者在糖尿病占比、血浆白蛋白水平、尿酸水平、甲状旁腺素(parathyroid hormone,PTH)水平之间的差异均有统计学意义(均P<0.05)。多因素Cox比例风险回归分析结果显示,糖尿病(HR=9.348,95%CI 3.507~24.918,P<0.001)和低白蛋白血症(HR=12.650,95%CI 2.925~54.714,P=0.001)是AVF使用寿命短的危险因素。Kaplan-Meier分析结果显示,合并糖尿病MHD患者AVF使用寿命明显短于未合并糖尿病的MHD患者(Log-rankχ2=13.191,P<0.001);低白蛋白血症的MHD患者AVF使用寿命明显短于无低白蛋白血症的MHD患者(Log-rankχ2=13.591,P<0.001)。结论糖尿病及低白蛋白血症是AVF使用寿命短的危险因素,应积极制定干预方案,延长AVF的使用寿命。     

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.