Peripheral artery disease at the time of dialysis initiation and mortality: a prospective observational multicenter study

Objectives Patients with peripheral artery disease (PAD) are reported to have a poorer prognosis than those without PAD. PAD is sometimes found at dialysis initiation, but its influence on the prognosis in these patients has not been investigated. We aimed to compare the mortality rate between patients with PAD at the time of dialysis initiation and those without PAD.Design We undertook an observational prospective multicenter study of patients starting dialysis treatment. Data were collected on patients’ sex, age, presence of PAD, medication, medical history and clinical and laboratory data.Setting Seventeen centers participated in the Aichi Cohort Study of Prognosis in Patients Newly Initiated into Dialysis.Participants A total of 1524 patients with chronic kidney disease started dialysis from October 2011 to September 2013. The patients were followed-up until March 2015. During this time, there were two patients who lost the follow-up.Primary and secondary outcome measures The primary outcome was defined as all-cause mortality. The secondary outcomes were defined as each cause of mortality.Results This study included 1030 men and 492 women with a mean age of 67.50±13.10 years. Of these, 71 had PAD and 1451 did not have PAD. After a median follow-up of 814.5 days, 33.80% of the former group and 17.00% of the latter group had died in March 2015 (p=0.001). After adjusting for confounding factors, PAD at dialysis initiation remained an independent risk factor for mortality (p<0.01).Conclusions Patients with PAD at the time of dialysis initiation had a poorer prognosis than patients without PAD. Therefore, the presence of PAD in patients starting dialysis should be considered for their monitoring and follow-up

Relationship between mortality and Geriatric Nutritional Risk Index (GNRI) at the time of dialysis initiation: a prospective multicenter cohort study

Abstract Background The Geriatric Nutritional Risk Index (GNRI) is a nutritional screening method primarily developed for elderly people; it is also reported to be useful for predicting mortality in patients on maintenance dialysis. However, it is unclear whether it is useful at the time of dialysis initiation, which is accompanied by large weight fluctuations and unstable nutritional status. Methods The study included 1524 patients with chronic kidney disease who commenced dialysis therapy at 17 centers. Patients commenced dialysis between October 2011 and September 2013 and were followed up until March 2015. Results We analyzed 1489 patients whose GNRI could be calculated and whose prognosis was clear. The mean GNRI was 87.60 (median 87.86). We divided patients based on the median value into a high (H) and low (L) group. The H group included 728 patients (mean GNRI 95.2 ± 4.9, mean age 65.8 ± 13.2 years, 69.3% men), and the L group included 761 patients (mean GNRI 80.3 ± 6.1, mean age 69.1 ± 12.8 years, 66.0% men). Mortality was significantly higher in the L group (L, 22.2% vs. H, 12.6%, P < 0.001). The rates of infection-associated death in the L group was significantly higher (L, 5.5% vs. H, 1.9%, P < 0.001), although no significant difference was observed regarding cardiovascular disease-associated death (L, 7.6% vs. H, 5.2%, P = 0.059) and malignancy-associated death (L, 3.0% vs. H, 3.0%, P = 1.000). Multivariate analysis showed an association between GNRI and all-cause mortality (HR 0.9852, 95%CI 0.9707–0.9999, P = 0.049) and infection-associated death (HR 0.9484, 95%CI 0.9191–0.9786, P < 0.001). Conclusions GNRI is useful for predicting mortality even at the time of dialysis initiation. Among the causes of death, GNRI was strongly associated with infection-associated death

Evaluation of the Relationship between the Serum Alkaline Phosphatase Level at Dialysis Initiation and All-Cause Mortality: A Multicenter, Prospective Study

Background/Aim: High serum alkaline phosphatase (ALP) levels predict mortality independent of bone metabolism parameters and liver function test results in patients on hemodialysis. The relationship between serum ALP at dialysis initiation and mortality during maintenance dialysis is unknown; therefore, we aimed to identify an association. Methods: This multicenter, prospective cohort study analyzed 1,213 patients registered in the Aichi Cohort Study of Prognosis in Patients Newly Initiated into Dialysis from October 2011 to September 2013. Patients were divided into 2 groups based on serum ALP levels. All-cause mortality and incidences of cardiovascular events after dialysis initiation were compared using the log-rank test and multivariate Cox proportional hazard regression analysis. We performed stratified analysis based on parathyroid hormone (PTH) levels. Results: During the follow-up, 109 (18.0%) and 86 (14.1%) patients died in the high ALP group (232 ≥IU/L; High ALP group) and low ALP group (232 &#x3c;IU/L; Low ALP group), respectively. All-cause mortality was significantly higher in the High ALP group than in the Low ALP group (p = 0.014). The serum ALP level was significantly correlated with the all-cause mortality rate (hazard ratio = 1.17 per 100 IU/L increase of ALP, 95% confidence interval: 1.11–1.24, p &#x3c; 0.001). The all-cause mortality rate was significantly higher in the High ALP group among patients with low (&#x3c;150 pg/mL) or normal (150–300 pg/mL) PTH levels (p = 0.012 and p = 0.005, respectively) than in the Low ALP group; there was no significant difference among patients with a high (≥300 pg/mL) PTH level (p = 1.000). Conclusion: The serum ALP level at dialysis initiation is associated with all-cause mortality during maintenance dialysis

Effects of iron-based phosphate binders on mortality and cardiovascular events in patients receiving maintenance dialysis

Abstract Phosphate binders are the main treatment for hyperphosphatemia in patients with chronic kidney disease, and iron-based phosphate binders have been used with increasing frequency in recent years. This study examined the association of the use of iron-based, rather than non-iron-based, phosphate binders with the incidence of cardiovascular events, in a real-world setting. We used data from a cohort comprising representative adult patients on maintenance hemodialysis in Japan. The exposure of interest was the time-varying use of phosphate binders, classified into “iron-based”, “only non-iron-based”, and “no use”. The primary outcome was a composite of cardiovascular events and all-cause deaths. A marginal structural Cox regression model was used to deal with possible time-dependent confounding. Of the 2247 patients from 58 hemodialysis facilities, iron-based and only non-iron-based phosphate binders were used in 328 (15%) and 1360 (61%), respectively, at baseline. Hazard ratios (95% confidence intervals) for iron-based and non-iron-based phosphate binders versus no use of phosphate binders were 0.35 (0.24, 0.52) and 0.44 (0.33, 0.58), respectively. The hazard ratio for iron-based relative to non-iron-based phosphate binders was 0.81 (0.58, 1.13), which was not statistically significant. Further studies are warranted to elucidate whether the use of iron-based phosphate binders reduces the event rate

Lower levels of proteinuria are associated with elevated mortality in incident dialysis patients.

IntroductionProteinuria is a potent predictor of adverse events in general, although a few large studies have reported a J-shaped association between proteinuria and mortality in individuals with glomerular filtration rate MethodsAmong 1,380 Japanese patients who initiated dialysis, we quantified the association of pre-dialysis dipstick proteinuria (negative/trace, 1+, 2+, and ≥3+) with mortality using Cox models adjusting for potential confounders, such as age, gender, clinical history of hypertension, diabetes, and cardiovascular disease.ResultsMean age of study participants was 67.4 (SD 13.0) years, and 67.6% were men. The most common dipstick proteinuria category was ≥3+ (55.4%), followed by 2+ (31.2%), 1+ (9.9%), and negative or trace (3.5%). Patients with lower proteinuria level were older than those with higher proteinuria. Lower proteinuria was significantly associated with a higher risk of all-cause mortality, even after accounting for potential confounders (p for trend ConclusionsIn incident dialysis patients, pre-dialysis proteinuria was inversely associated with mortality risk. Although future studies are needed to identify mechanisms, our findings suggest the need to carefully interpret proteinuria in patients with incident dialysis

Increasing tendency of urine protein is a risk factor for rapid eGFR decline in patients with CKD: A machine learning-based prediction model by using a big database.

Artificial intelligence is increasingly being adopted in medical fields to predict various outcomes. In particular, chronic kidney disease (CKD) is problematic because it often progresses to end-stage kidney disease. However, the trajectories of kidney function depend on individual patients. In this study, we propose a machine learning-based model to predict the rapid decline in kidney function among CKD patients by using a big hospital database constructed from the information of 118,584 patients derived from the electronic medical records system. The database included the estimated glomerular filtration rate (eGFR) of each patient, recorded at least twice over a period of 90 days. The data of 19,894 patients (16.8%) were observed to satisfy the CKD criteria. We characterized the rapid decline of kidney function by a decline of 30% or more in the eGFR within a period of two years and classified the available patients into two groups-those exhibiting rapid eGFR decline and those exhibiting non-rapid eGFR decline. Following this, we constructed predictive models based on two machine learning algorithms. Longitudinal laboratory data including urine protein, blood pressure, and hemoglobin were used as covariates. We used longitudinal statistics with a baseline corresponding to 90-, 180-, and 360-day windows prior to the baseline point. The longitudinal statistics included the exponentially smoothed average (ESA), where the weight was defined to be 0.9*(t/b), where t denotes the number of days prior to the baseline point and b denotes the decay parameter. In this study, b was taken to be 7 (7-day ESA). We used logistic regression (LR) and random forest (RF) algorithms based on Python code with scikit-learn library (https://scikit-learn.org/) for model creation. The areas under the curve for LR and RF were 0.71 and 0.73, respectively. The 7-day ESA of urine protein ranked within the first two places in terms of importance according to both models. Further, other features related to urine protein were likely to rank higher than the rest. The LR and RF models revealed that the degree of urine protein, especially if it exhibited an increasing tendency, served as a prominent risk factor associated with rapid eGFR decline

Unfavorable effects of history of volume overload and late referral to a nephrologist on mortality in patients initiating dialysis: a multicenter prospective cohort study in Japan

Abstract Background Patients with late referral and positive history of volume overload may have a poor prognosis after initiating dialysis due to insufficient and/or inadequate management of complications of renal failure and the lack of better dialysis preparation. Little is known about the influence of the relationship between history of volume overload and late referral on prognosis. Methods We analyzed 1475 patients who had initiated dialysis for the first time from October 2011 to September 2013. late referral was defined as referral to a nephrologist < 3 months before dialysis initiation. The major outcomes were all-cause death and deaths due to cardiovascular diseases (CVD). The impact of late referral and history of volume overload on all-cause mortality was assessed by Cox proportional hazards models. Results Among 1475 patients, the mean patient age was 67.5 years. During the median follow-up of 2.2 years, 260 deaths occurred; 99 were due to CVD. Cox proportional hazards models demonstrated that late referral (adjusted hazard ratio [HR], 1.35; 95% confidence interval [CI], 1.00–1.82) and history of volume overload (adjusted HR, 1.39; 95% CI, 1.06–1.81) were risk factors for all-cause mortality. Furthermore, late referral coexisting was associated with a history of volume overload increased mortality (adjusted HR, 2.10; 95% CI, 1.39–3.16 versus absence of late referral without history of volume overload) after adjusting for age, sex, diabetes, atherosclerotic disease, and laboratory values. Conclusions Both late referral and history of volume overload were associated with increased risks of all-cause mortality. Trial registration University Hospital Medical Information Network (UMIN000007096). Registered 18 January 2012, retrospectively registered. https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000008349