Fasting glucose levels in predicting 1-year all-cause mortality in patients who do not have diabetes and are on maintenance hemodialysis

Chronic inflammation and malnutrition relate to increased risks for cardiovascular death. This study compared fasting glucose levels (FGL) and impaired fasting glucose (IFG) with malnutrition and inflammation in nondiabetic maintenance hemodialysis (MHD) patients to investigate the adverse affects and risks for mortality. In total, 693 MHD patients were enrolled in this study and followed up for 1 yr. Geographic, hematologic, biochemical, and dialysis-related data were collected. According to 1997 and 2003 definitions, all patients were classified into three groups: Diabetic, nondiabetic with IFG, and nondiabetic with normal FGL. More diabetic and nondiabetic with IFG group patients were malnourished (chi(2) = 24.55, P < 0.0001) and had inflammatory changes (chi(2) = 9.32, P = 0.0095) than those with normal FGL. The IFG group had higher high-sensitivity C-reactive protein and ferritin and lower serum albumin, creatinine levels, and normalized protein catabolic rate than the normal FGL group. Age and parameters of nutrition and inflammation were associated with FGL. Stepwise multiple regression analysis demonstrated that FGL were negatively associated with serum albumin (P = 0.0026) and positively correlated with Log high-sensitivity C-reactive protein (P = 0.0004) in nondiabetic MHD patients. In addition, after 1 yr of follow-up, Cox multivariate analysis demonstrated that, after adjustment for other significant related factors, FGL (relative risk 1.049; 95% confidence interval 1.007 to 1.093; P = 0.0232) or presence of IFG (relative risk 3.798; 95% confidence interval 1.168 to 12.344; P = 0.0265) was a significant risk factor for 1-yr all-cause mortality of these patients. On the basis of these findings, basal FGL or presence of IFG, a preventive and treatable status, plays an important role in inflammation, malnutrition, and short-term mortality of nondiabetic MHD patients.     

Increased pasma S-nitrosothiol concentrations predict cardiovascular outcomes among patients with end-stage renal disease: a prospective study

The plasma concentrations of S-nitrosothiols, which are circulating nitric oxide metabolites with potential biologic activity, are increased among patients undergoing chronic hemodialysis (HD). However, the ability of S-nitrosothiols to release nitric oxide at physiologically relevant sites may be reduced among HD patients, because of impaired availability and/or activity of factors involved in S-nitrosothiol breakdown. The resultant lack of S-nitrosothiol bioavailability could contribute to the high cardiovascular risk for such patients. A possible relationship between plasma S-nitrosothiol levels and cardiac outcomes, as well as all-cause mortality rates, was investigated in a cohort of 250 chronic HD patients and who were undergoing regular dialysis three times per week were monitored for 1 yr. During that follow-up period, major cardiac events and all-cause deaths were prospectively recorded. At baseline, high plasma S-nitrosothiol levels (>2 micro M, corresponding to the top quartile of all measured values) were independently associated with pulse pressure in an adjusted multivariate analysis (odds ratio, 1.03; 95% confidence interval, 1.01 to 1.05; P = 0.007). During the follow-up period, 36 patients died (16 as a result of cardiac causes) and 33 patients experienced major adverse cardiac events. In an adjusted Cox proportional-hazards model, high plasma S-nitrosothiol concentrations (i.e., the top quartile versus the three other quartiles) were an independent predictor of cardiac events (hazard ratio, 3.30; 95% confidence interval, 1.61 to 6.76; P = 0.001) but not of all-cause death. Therefore, among chronic HD patients, markedly elevated plasma S-nitrosothiol levels are associated with pulse pressure and predict cardiovascular outcomes. These findings support the hypothesis that impaired S-nitrosothiol bioavailability in uremia is an important factor for the excessive cardiovascular risk among HD patients.     

Plasma osteoprotegerin is associated with mortality in hemodialysis patients

Expression of bone proteins resulting from transdifferentiation of vascular smooth muscle cells into osteoblasts suggests that vascular calcifications are a bioactive process. Regulating molecules such as osteoprotegerin (OPG) and receptor activator of NF-kappaB ligand (RANKL) could play a key role in bone-vascular calcification imbalance. This study investigated the contribution of these proteins as well as mineral metabolism disorders in hemodialysis (HD) patient outcome. A total of 185 HD patients were followed up prospectively for 2 yr. In addition to clinical characteristics, mineral metabolism markers as well as OPG and soluble RANKL (sRANKL) were measured at baseline. After 2 yr, survival rates were described with Kaplan-Meier and compared with Cox regression analyses; 50 patients died (27 from cardiovascular diseases). Calcium, phosphate, and calcium x phosphate product were not associated with mortality. Both hyperparathyroidism (parathyroid hormone > or =300 pg/ml) and hypoparathyroidism (parathyroid hormone <150 pg/ml) were poorly associated with all-cause and cardiovascular mortality. By contrast, elevated OPG levels predicted all-cause (relative risk [RR] 2.67; 95% confidence interval [CI] 1.32 to 5.41; P = 0.006) and cardiovascular mortality (RR 3.15; 95% CI 1.14 to 8.69; P = 0.03). Low levels of sRANKL were associated with a protective effect for all-cause mortality (RR 0.45; 95% CI 0.21 to 0.94; P = 0.03). The association of OPG with all-cause mortality was stronger in patients with C-reactive protein > or =12.52 mg/L. In this condition, both highest (RR 5.68; 95% CI 1.48 to 22.73; P = 0.01) and lowest tertiles (RR 5.37; 95% CI 147 to 1968; P = 0.01) significantly predicted poor outcome. These results show that regulating-bone molecules, especially OPG, are strong predictors of mortality in HD patients, suggesting that OPG is a vascular risk factor, in particular in patients who have high C-reactive protein levels. OPG determination therefore should be added to the biologic follow-up of these patients.     

Obesity in Diabetic Patients Undergoing Coronary Artery Bypass Graft Surgery Is Associated with Increased Postoperative Morbidity

Background: Despite the fact that obesity is a known risk factor for cardiovascular disease, many studies have failed to demonstrate that obesity is independently associated with an increased risk of cardiovascular morbidity and mortality in nondiabetic patients undergoing coronary artery bypass graft surgery. The authors investigated the influence of obesity on adverse postoperative outcomes in diabetic and nondiabetic patients after primary coronary artery bypass surgery.

Methods: A retrospective cohort study of patients undergoing primary coronary artery bypass surgery (n = 9,862) between January 1995 and December 2004 at the Texas Heart Institute was performed. Diabetic (n = 3,374) and nondiabetic patients (n = 6,488) were classified into five groups, according to their body mass index: normal weight (n = 2,148), overweight (n = 4,257), mild obesity (n = 2,298), moderate obesity (n = 785), or morbid obesity (n = 338). Multivariate, stepwise logistic regression was performed controlling for patient demographics, medical history, and preoperative medications to determine whether obesity was independently associated with an increased risk of adverse postoperative outcomes.

Results: Obesity in nondiabetic patients was not independently associated with an increased risk of adverse postoperative outcomes. In contrast, obesity in diabetic patients was independently associated with a significantly increased risk of postoperative respiratory failure (odds ratio [OR], 2.26; 95% confidence interval [CI], 1.41-3.61; P < 0.001), ventricular tachycardia (OR, 2.27; 95% CI, 1.18-4.35; P < 0.02), atrial fibrillation (OR, 1.56; 95% CI, 1.03-2.38; P < 0.04), atrial flutter (OR, 2.38; 95% CI, 1.29-4.40; P < 0.01), renal insufficiency (OR, 1.66; 95% CI, 1.10-3.41; P < 0.03), and leg wound infection (OR, 5.34; 95% CI, 2.27-12.54; P < 0.001). Obesity in diabetic patients was not independently associated with an increased risk of mortality, stroke, myocardial infarction, sepsis, or sternal wound infection.     

Body mass index and mortality in patients on maintenance hemodialysis: a meta-analysis

Purpose

In patients undergoing maintenance hemodialysis (MHD), increasing numbers of studies have reported a reduced mortality in patients with an increased body mass index (BMI). This article provides a meta-analysis on the assessment of the relationship between BMI and mortality in MHD patients.

Methods

A systemic literature review was conducted to identify studies that examined all-cause mortality, with or without cardiovascular events, on the basis of bodyweight or obesity measures in MHD population published before October 2012.

Results

Eight observational studies with a total of 190,163 patients were included. Compared to the individuals with a normal BMI, overweight patients and obese patients were associated with lower all-cause mortality [relative risk (RR) 0.86, 95 % confidence interval (CI) 0.84–0.88; RR 0.77, 95 % CI 0.75–0.78, respectively] and cardiovascular mortality (RR 0.86; 95 % CI 0.81–0.91; RR 0.78, 95 % CI 0.73–0.83, respectively). Underweight patients had relatively higher all-cause and cardiovascular mortality (RR 1.22, 95 % CI 1.20–1.25; RR 1.19, 95 % CI 1.11–1.28, respectively). In an obesity-stratified analysis, the patients with moderate or severe obesity presented a strongly decreased all-cause mortality risk (RR 0.64, 95 % CI 0.61–0.68) and cardiovascular mortality risk (RR 0.63, 95 % CI 0.53–0.75) compared to patients with mild obesity (RR 0.74, 95 % CI 0.71–0.77; RR 0.81, 95 % CI 0.75–0.87, respectively).

Conclusions

These findings show that overweight and obese patients have lower all-cause and cardiovascular mortality rates in patients undergoing MHD. Body weight management and optimized nutritional and metabolic support should help to reduce the high mortality rates that are prevalent in the hemodialysis population.     

Obesity in diabetic patients undergoing coronary artery bypass graft surgery is associated with increased postoperative morbidity

BACKGROUND: Despite the fact that obesity is a known risk factor for cardiovascular disease, many studies have failed to demonstrate that obesity is independently associated with an increased risk of cardiovascular morbidity and mortality in nondiabetic patients undergoing coronary artery bypass graft surgery. The authors investigated the influence of obesity on adverse postoperative outcomes in diabetic and nondiabetic patients after primary coronary artery bypass surgery. METHODS: A retrospective cohort study of patients undergoing primary coronary artery bypass surgery (n = 9,862) between January 1995 and December 2004 at the Texas Heart Institute was performed. Diabetic (n = 3,374) and nondiabetic patients (n = 6,488) were classified into five groups, according to their body mass index: normal weight (n = 2,148), overweight (n = 4,257), mild obesity (n = 2,298), moderate obesity (n = 785), or morbid obesity (n = 338). Multivariate, stepwise logistic regression was performed controlling for patient demographics, medical history, and preoperative medications to determine whether obesity was independently associated with an increased risk of adverse postoperative outcomes. RESULTS: Obesity in nondiabetic patients was not independently associated with an increased risk of adverse postoperative outcomes. In contrast, obesity in diabetic patients was independently associated with a significantly increased risk of postoperative respiratory failure (odds ratio [OR], 2.26; 95% confidence interval [CI], 1.41-3.61; P < 0.001), ventricular tachycardia (OR, 2.27; 95% CI, 1.18-4.35; P < 0.02), atrial fibrillation (OR, 1.56; 95% CI, 1.03-2.38; P < 0.04), atrial flutter (OR, 2.38; 95% CI, 1.29-4.40; P < 0.01), renal insufficiency (OR, 1.66; 95% CI, 1.10-3.41; P < 0.03), and leg wound infection (OR, 5.34; 95% CI, 2.27-12.54; P < 0.001). Obesity in diabetic patients was not independently associated with an increased risk of mortality, stroke, myocardial infarction, sepsis, or sternal wound infection. CONCLUSION: Obesity in diabetic patients is an independent predictor of worsened postoperative outcomes after primary coronary artery bypass graft surgery.     

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.     

Survival differences between peritoneal dialysis and hemodialysis among "large" ESRD patients in the United States

BACKGROUND: It has been hypothesized that peritoneal dialysis compared to hemodialysis may be less effective in large patients with end-stage renal disease (ESRD). METHODS: We tested this hypothesis in a cohort of 134,728 new ESRD patients who were initiated on dialysis from May 1, 1995 to July 31, 1997 using data from United States Renal Data System (USRDS). Cox regression models evaluated the association of body mass index (BMI) in quintiles (8.8-20.9, 20.9-23.5, 23.5-26.1, 26.1-30.0, 30.0-75.2 kg/m(2)) with mortality over 2 years in peritoneal dialysis and hemodialysis patients separately, while time-dependent models evaluated the relative risk (RR) of death by modality for each BMI quintile. RESULTS: For hemodialysis, the adjusted RR of death was greatest for patients with BMI 30.0 (RR = 0.97, 95% CI 0.96-0.99 for diabetic and RR = 0.97, 95% CI 0.95-0.98 for nondiabetic patients) compared with the referent (23.5-26.1; RR = 1.00). For peritoneal dialysis, the RR of death was also higher for patients with a BMI <20.9 (RR = 1.20, 95% CI 1.00-1.43 for diabetic and RR = 1.39, 95% CI 1.19-1.64 for nondiabetic patients) but no survival advantage was associated with higher BMI values. The RR of death (peritoneal dialysis/hemodialysis) for each BMI quintile was 0.99, 1.12, 1.26 (P < 0.01), 1.15 (P < 0.01), and 1.44 (P < 0.0001) for diabetic and were 1.07, 1.01, 0.96, 1.04, and 1.22 (P < 0.01) for nondiabetic patients, respectively. CONCLUSION: We conclude that body size modifies the impact of dialysis modality on mortality risk among new ESRD patients in the United States. The selection of hemodialysis over peritoneal dialysis was associated with a survival advantage in patients with large body habitus.     

Serum uric acid levels show a 'J-shaped' association with all-cause mortality in haemodialysis patients.

BACKGROUND: Although elevated serum levels of uric acid are common in patients with kidney disease or in those receiving maintenance dialysis therapy, the clinical impact of uric acid on mortality in haemodialysis (HD) patients remains unclear. This work was designed to explore the predictive value of serum uric acid levels on all-cause mortality of HD patients. METHODS: We retrospectively analysed mortality rates in 146 chronic HD patients that were treated with HD three times per week at our HD unit for a period of one full year. The analysed parameters included demographic characteristics, aetiology of end-stage renal disease, co-morbid conditions, duration (at least 1 year) and delivered dose of HD, normalized protein catabolic rate, serum albumin concentration, haematocrit, serum uric acid (UA) levels and other laboratory parameters. A multivariate Cox proportional hazards model, which included adjustment for the above factors, was applied to identify the predictive value of UA levels on patient mortality. RESULTS: A Cox proportional hazards model revealed that decreased serum albumin, underlying diabetic nephropathy (DMN) and UA groups (< or =20th, 20-80th and > or =80th percentiles; P = 0.016) were all significant, independent predictors of all-cause mortality in HD patients. The hazard ratios of death were: serum albumin (per 0.5 g/dl decrease), 3.10 [95% confidence interval (95% CI), 1.80-5.34, P < 0.001]; DMN (vs non-DMN), 3.47 (95% CI, 1.25-9.59, P = 0.017); and UA groups (vs 20th to 80th percentile): < or =20th percentile, 2.98 (95% CI, 0.82-10.90, P = 0.099); > or = 80th percentile, 5.67 (95% CI, 1.71-18.78, P = 0.004). CONCLUSIONS: These preliminary observations suggest that HD patients in the lowest and highest quintiles of UA levels would face higher risk of mortality. Further studies with larger sample sizes will be needed to confirm these findings.     

Hyperhomocysteinemia predicts cardiovascular outcomes in hemodialysis patients

BACKGROUND: We prospectively tested the prediction power of homocysteinemia for all-cause and cardiovascular outcomes in a cohort of 175 hemodialysis patients followed for 29 +/- 12 months. METHODS: Survival analysis was performed by the Cox's proportional hazard model and data were expressed as hazard ratio and 95% confidence interval (CI). RESULTS: During the follow-up period 51 patients died, 31 of them (61%) of cardiovascular causes and 16 patients developed non-fatal atherothrombotic complications. Plasma total homocysteine was an independent predictor of cardiovascular mortality (P=0.01). Combined analysis of fatal and non-fatal atherothrombotic events showed that homocysteine was a strong and independent predictor of these outcomes because the risk of these events was 8.2 times higher (95% CI 1.9 to 32.2) in patients in the third homocysteine tertile than in those in the first tertile (P=0.005). CONCLUSIONS: There is a clear association between hyperhomocysteinemia and incident cardiovascular mortality and atherothrombotic events in hemodialysis patients. Intervention studies are needed to determine whether the accumulation of this substance has a causal role in the pathogenesis of cardiovascular damage in patients undergoing hemodialysis.     

Iron administration and clinical outcomes in hemodialysis patients

To evaluate the impact of parenteral iron administration on the survival and rate of hospitalization of US hemodialysis patients, a nonconcurrent cohort study of 10,169 hemodialysis patients in the United States in 1994 was conducted. The main outcome measures were patient survival and rate of hospitalization. After adjusting for 23 demographic and comorbidity characteristics among 5833 patients included in multivariable analysis, bills for 10 vials showed a statistically significant elevated rate of death (adjusted RR = 1.11; 95% CI, 1.00 to 1.24; P = 0.05). Bills for 10 vials showed statistically significant elevated risk (adjusted RR = 1.12; 95% CI, 1.01 to 1.25; P = 0.03). Prescribing iron in quantities of 10 vials (1000 mg) of iron dextran over a period of 6 mo.     

Lessons learnt from the 4D trial

Renal dysfunction alters the pathogenesis of cardiovascular disease (CVD) profoundly conferring a very high-risk to the patients. Currently strategies are developed to combat CVD and clinical studies test a number of hypothesis. In this setting the results of the 4D study, comparing atorvastatin with placebo on cardiovascular outcomes in 1255 type 2 diabetic patients on maintenance hemodialysis, came as a great and unsuspected surprise. After a median follow-up of 4 years atorvastatin (20 mg/d) decreased the relative risk by 8% (95% confidence interval, 0.77-1.10; P=0.37) despite a high number of cardiovascular events and an overall 24% cardiovascular mortality. This indicates, that the risk in type 2 diabetic patients on hemodialysis origins from factors other than an atherogenic lipoprotein phenotype alone. Due to non-significant effects of atorvastatin on the primary endpoint and the different quality of such endpoints in dialysis patients as well as an unexplained higher rate of fatal strokes in atorvastatin treated patients we do not recommend to initiate statin treatment in patients with type 2 diabetes mellitus undergoing hemodialysis therapy at the present time. Statin therapy should be implemented earlier during the course of progressive vascular damage.     

Effects of sevelamer and calcium-based phosphate binders on mortality in hemodialysis patients: results of a randomized clinical trial.

BACKGROUND: Elevated serum phosphorus and calcium are associated with arterial calcification and mortality in dialysis patients. Sevelamer, a phosphate-binding polymer, attenuates the progression of arterial calcification; it is unknown whether this improves outcomes. PATIENTS AND INTERVENTIONS: A randomized comparison of sevelamer and calcium-based phosphate binders was performed in hemodialysis patients treated up to 45 months. The primary endpoint was mortality. Secondary endpoints included cause-specific mortality and hospitalization; 2103 patients were randomized, 2040 received treatment, and 1065 completed treatment. RESULTS: Overall mortality was not significantly reduced by sevelamer (adjusted relative risk = 0.92; 95% confidence interval, 0.78 to 1.09; log-rank P = .40). Among patients > or = 65 years of age, sevelamer reduced the risk of death (adjusted relative risk = 0.77; 95% confidence interval, 0.62 to 0.97; log-rank P = .02). Sevelamer patients had a trend toward fewer hospitalizations (P = .06) and fewer hospital days (P = .09). CONCLUSIONS: A statistically significant reduction in mortality in the overall study population was not observed. Sevelamer was associated with a survival benefit among patients > or = 65 years of age.     

Renal insufficiency and subsequent death resulting from cardiovascular disease in the United States

Several epidemiologic studies reported that persons with renal insufficiency might have increased cardiovascular disease-related mortality rates in select populations. The association between renal insufficiency and increased cardiovascular disease-related and all-cause mortality rates during 16 yr of follow-up monitoring was examined among participants who were 30 to 74 yr of age at the baseline examinations in 1976 to 1980, with urinary protein dipstick measurements (n = 8786) or serum creatinine levels of or=300 mg/dl and were 4.1, 8.6, and 20.5 deaths/1000 person-yr among participants with estimated GFR of >or=90, 70 to 89, and <70 ml/min, respectively. After adjustment for potential confounders, the relative hazards (and 95% confidence intervals) for cardiovascular disease-related death were 1.57 (0.99 to 2.48) and 1.77 (0.97 to 3.21) among subjects with urinary protein levels of 30 to 299 and >or=300 mg/dl, respectively, compared with <30 mg/dl (P trend = 0.02). The corresponding relative hazards for all-cause-related death were 1.64 (1.23 to 2.18) and 2.00 (1.13 to 3.55; P trend < 0.001). Compared with subjects with estimated GFR of >or=90 ml/min, those with estimated GFR of <70 ml/min exhibited higher relative risks of death from cardiovascular disease and all causes [1.68 (1.33 to 2.13) and 1.51 (1.19 to 1.91), respectively]. This study indicates that, in a representative sample of the United States general population, renal insufficiency is independently associated with increased cardiovascular disease-related and all-cause mortality rates.     

Increased plasma apolipoprotein(a) levels in IDDM patients with microalbuminuria

Patients with insulin-dependent diabetes mellitus (IDDM) have a significantly increased risk of macrovascular disease, particularly if they have persistent proteinuria. To determine whether altered levels of apolipoprotein(a) [apo(a)], the plasminogenlike glycoprotein of the potentially atherogenic lipoprotein(a); contribute to the increased risk of atherosclerosis, apo(a) levels were measured in 107 patients with IDDM and compared with nondiabetic control subjects and male elective coronary artery graft patients. Apo(a) levels were increased in diabetic patients with microalbuminuria (geometric mean 245 U/L, 95% confidence interval [CI] 142-427, n = 30) and albuminuria (mean 196 U/L, 95% CI 97-397, n = 18) with levels comparable to patients with coronary artery disease (mean 193 U/L, 95% CI 126-298, n = 40), which were higher than in the control group (mean 107 U/L, 95% CI 85-134, n = 140; P = 0.016). Apo(a) levels in diabetic patients without microalbuminuria (mean 86 U/L, 95% CI 63-116, n = 59) were comparable with the control population and less than in those with microalbuminuria (P less than 0.001) and albuminuria (P = 0.014). The elevated apo(a) levels found in patients with IDDM and increased urinary albumin loss may contribute to their heightened risk of macrovascular disease.     

Glycosylated hemoglobin and mortality in patients with nondiabetic chronic kidney disease

In the general population, hyperglycemia in the absence of diabetes may be associated with increased risk for mortality. Hyperglycemia is prevalent in chronic kidney disease; however, the relationship between glycosylated hemoglobin (HbA(1c)) as a marker of chronic hyperglycemia and outcomes has not been studied in nondiabetic chronic kidney disease. HbA(1c) was measured at baseline in the randomized cohort of the Modification of Diet in Renal Disease Study (n = 840). Participants with diabetes (n = 43), fasting glucose levels >126 mg/dl (n = 20), or missing HbA(1c) levels (n = 9) were excluded. Survival status until December 2000 was obtained from the National Death Index. Death was classified as cardiovascular (CVD) when the primary cause was International Classification of Disease, Ninth Revision codes 390 to 459. Cox models were performed to assess the relationship of HbA(1c) with all-cause and CVD mortality. Mean (SD) age was 52 (12) years, and mean (SD) GFR was 32 (12) ml/min per 1.73 m(2). Eighty-six percent of participants were white, and 61% were male. Mean (SD) HbA(1c) was 5.6% (0.5). A total of 169 (22%) patients died, 96 (13%) from CVD. After adjustment for randomization assignments and demographic, CVD, and kidney disease factors, HbA(1c) was a predictor of all-cause mortality (hazard ratio per 1% increase 1.73; 95% confidence interval 1.24 to 2.41; P = 0.001). There was a trend toward statistical significance in the relationship between HbA(1c) and CVD mortality (hazard ratio per 1% increase 1.53; 95% confidence interval 0.96 to 2.43; P = 0.07). HbA(1c) is associated with increased mortality in nondiabetic kidney disease. Hyperglycemia may be a potential therapeutic target and HbA(1c) may be important as a risk stratification tool in this high-risk population.     

Effect of online hemodiafiltration on all-cause mortality and cardiovascular outcomes

In patients with ESRD, the effects of online hemodiafiltration on all-cause mortality and cardiovascular events are unclear. In this prospective study, we randomly assigned 714 chronic hemodialysis patients to online postdilution hemodiafiltration (n=358) or to continue low-flux hemodialysis (n=356). The primary outcome measure was all-cause mortality. The main secondary endpoint was a composite of major cardiovascular events, including death from cardiovascular causes, nonfatal myocardial infarction, nonfatal stroke, therapeutic coronary intervention, therapeutic carotid intervention, vascular intervention, or amputation. After a mean 3.0 years of follow-up (range, 0.4-6.6 years), we did not detect a significant difference between treatment groups with regard to all-cause mortality (121 versus 127 deaths per 1000 person-years in the online hemodiafiltration and low-flux hemodialysis groups, respectively; hazard ratio, 0.95; 95% confidence interval, 0.75-1.20). The incidences of cardiovascular events were 127 and 116 per 1000 person-years, respectively (hazard ratio, 1.07; 95% confidence interval, 0.83-1.39). Receiving high-volume hemodiafiltration during the trial associated with lower all-cause mortality, a finding that persisted after adjusting for potential confounders and dialysis facility. In conclusion, this trial did not detect a beneficial effect of hemodiafiltration on all-cause mortality and cardiovascular events compared with low-flux hemodialysis. On-treatment analysis suggests the possibility of a survival benefit among patients who receive high-volume hemodiafiltration, although this subgroup finding requires confirmation.     

Ankle-brachial blood pressure index predicts all-cause and cardiovascular mortality in hemodialysis patients

A reduction in ankle-brachial BP index (ABPI) is associated with generalized atherosclerotic diseases and predicts cardiovascular mortality and morbidity in several patient populations. However, a large-scale analysis of ABPI is lacking for hemodialysis (HD) patients, and its use in this population is not fully validated. A cohort of 1010 Japanese patients undergoing chronic hemodialysis was studied between November 1999 and May 2002. Mean age at entry was 60.6 +/- 12.5 yr, and duration of follow-up was 22.3 +/- 5.6 mo. Patients were stratified into five groups (< 0.9, > or = 0.9 to < 1.0, > or = 1.0 to < 1.1, > or = 1.1 to < 1.3, and > or = 1.3) by ABPI measured at entry by an oscillometric method. The frequency distribution of ABPI was 16.5% of patients < 0.9, 8.6% of patients > or = 0.9 to < 1.0, 16.9% of patients 1.0 > or = to < 1.1, and 47.0% of patients > or 1.1 to < 1.3, whereas 10.9% of patients had an abnormally high ABPI (> or = 1.3). The relative risk of a history of diabetes mellitus (DM), cardiovascular, and cerebrovascular disease was significantly higher in patients with lower ABPI than those with ABPI > or = 1.1 to <1.3. During the study period, 77 cardiovascular and 41 noncardiovascular fatal events occurred. On the basis of Cox proportional hazards regression analysis, ABPI emerged as a strong independent predictor of all-cause and cardiovascular mortality. After adjustment for confounding variables, the hazard ratio (HR) for ABPI < 0.9 was 4.04 (95% confidence interval, 2.38 to 6.95) for all-cause mortality and 5.90 (2.83 to 12.29) for cardiovascular mortality. Even those with modest reductions in the ABPI (> or = 0.9 to <1.1) appeared to be at increased risk. Patients having abnormally high ABPI (> or = 1.3) also had poor prognosis (HR, 2.33 [1.11 to 4.89] and 3.04 [1.14 to 8.12] for all-cause and cardiovascular mortality, respectively). Thus, the present findings validate ABPI as a powerful and independent predictor for all-cause and cardiovascular mortality among hemodialysis patients.     

Mortality and morbidity after hepatic resection in patients undergoing hemodialysis: analysis of a national inpatient database in Japan

Background

Whether patients undergoing hemodialysis have greater risks of mortality and morbidity after hepatic resection remains unclear.

Prognostic efficacy of combined index of cardiac biomarkers for cardiovascular and all-cause mortality on hemodialysis patients

Objective To evaluate cardiac biomarkers as biological risk factors for cardiovascular and all-cause motality in HD patients. In addition, a multimarker approach including inflammatory index was performed to improve the cardiovascular and all-cause risk assessment of these patients. Methods The author measured Troponin-T (TnT), N-terminal pro brain natriuretic peptide (NT-proBNP) and high-sensitivity C-reactive protein (HsCRP), collected the clinical data at baseline(January 2012) in 229 HD patients in three hemodialysis centers in Haidian District of Beijing, recorded time and cause of death in the next 1000 days. Kaplan-Meier was used to calculate survival rate and impact factors of prognosis. Cox proportional hazard model was used to estimate significance of TnT, NT-proBNP and HsCRP and adjusted hazard ratios (HRs) of death. Results During the follow-up, 37 patients died, mainly from cardiac cause (54.05%, 20/37). Univariate analysis found old age, diabetes, cardiovascular disease, low serum albumin, CRP≥3 mg/L, TnT≥0.1 mg/L, NT-proBNP≥4381 ng/L were associated with prognosis. Elevated cTnT, NT-proBNP or HsCRP were all associated with increased cardiovascular and all-cause motality. Moreover, the combination of all parameters (NT-proBNP≥4381 ng/L and TnT≥0.1 mg/L and HsCRP≥3 mg/L) were dramatically associated with increased cardiovascular cause mortality (HR=25.25, P＜0.01) and all-cause mortality (HR=27.33, P＜0.01). The association were significant even after full adjustment for cardiovascular (HR=14.33, P＜0.01) and all-cause mortality (HR=11.54, P＜0.01) respectively. Conclusions A combined index of cardiovascular risk factors could provide supplementary risk stratification in HD patients for cardiovascular mortality and all-cause mortality, strongly supporting the annual routine determination of these biomarkers.