Apolipoprotein A, fibrinogen, age, and history of stroke are predictors of death in dialysed diabetic patients: a prospective study in 412 subjects

Background: diabetic patients with end-stage renalfailure (ESRD) have a high cardiovascular morbidity and mortality. Theunderlying mechanisms are not completely elucidated. The aim of our studywas to define predictors of death in diabetic patients with end-stage renaldisease. Patients and methods: We preformed aprospective study in 35 dialysis centres in Germany between 1985 and 1994.To evaluate predictors and risk factors in this population we examined 412diabetic patients at the time of admission to dialysis treatment(peritoneal dialysis (PD) or haemodialysis (HD)). Classification of thetype of diabetes was done according the criteria of the National DiabetesData Group [1,2]. Items assessed at the time of admission were coronaryartery disease (CAD), peripheral occlusive disease (POD), and stroke. CADwas defined as a history of myocardial infarction with the correspondingchanges in the ECG or luminal narrowing by more than 50% in at least onecoronary artery upon coronarangiography; POD was defined as claudicationand/or brachial-tibial ratio (BTR) less than 0.9 or a history ofamputation. Assessment of the nutritional state comprised body mass index,skinfold thickness of the upper arm and lateral thorax area, and ureaconcentration. Cholesterol, HDL, LDL, apolipoprotein A (ApoA-I) and B(ApoB), triglycerides, lipoprotein (a) (Lp(a)), and fibrinogen weremeasured. As an index of disturbed cardiac innervation beat-to-beatvariation was measured. Outcome measurements were causes of death (i.e.cardiac and non-cardiac) and time of survival.Results: One hundred and eighty of 412 (44%) patientsdied during the observation period Patients who died were older(61±12 versus 53±15 years Plt;0.0001), had lower skin fold thickness (13.1±6.0versus 15.1±7.2 mm P <0.04), lowerApoA-I (100±35 versus 111±32mg/dl P <0.005) and higher fibrinogen (515±156versus 451±155 mg/dl P <0.02). TypeII diabetic patients had a lower mean survival time than type I (34versus 66 months P <0.0006). The mode of renalreplacement therapy (PD or HD) had no adverse effect on survival time.Survivors less frequently had a history of CAD, POD and stroke thannon-survivors. In multivariate analysis ApoA-I, fibrinogen ,age and strokewere independent predictors of cardiac and non-cardiac death in diabeticpatients with end-stage renal failure. Lipid values and nutritional statedid not independently predict the overall and cardiovascular mortality.Conclusion: This study in dialysed diabetic patientsidentified several predictors of death, some of which are susceptible tointervention.