Independent and Joint Associations of Nutritional Status Indicators With Mortality Risk Among Chronic Hemodialysis Patients in the Dialysis Outcomes and Practice Patterns Study (DOPPS)
published online 11 January 2010.
Objective
To consider the Kidney Disease Outcomes Quality Initiative recommendation of using multiple nutritional measurements for patients on maintenance dialysis, we explored data for independent and joint associations of nutritional indicators with mortality risk among maintenance hemodialysis patients treated in 12 countries.
Setting
Dialysis units in seven European countries, the United States, Canada, Australia, New Zealand, and Japan.
Main Outcome
Mortality risk.
Methods
We conducted a prospective cohort study of 40,950 patients from phases I to III of the Dialysis Outcomes and Practice Patterns Study (1996–2008). Independent and joint effects (interactions) of nutritional indicators (serum creatinine, serum albumin, normalized protein catabolic rate, body mass index [BMI]) on mortality risk were assessed by Cox regression with adjustments for demographics, years on dialysis, and comorbidities.
Results
Important variations in nutritional indicators were seen by country and patient characteristics. Poorer nutritional status assessed by each indicator was independently associated with higher mortality risk across regions. Significant multiplicative interactions (each p ≤ 0.01) between indicators were also observed. For example, by using patients with serum creatinine 7.5–10.5 mg/dL and BMI 21–25 kg/m2 as referent, BMI <21 kg/m2 was associated with lower mortality risk among patients with creatinine >10.5 mg/dL (relative risk = 0.68) but with higher mortality risk among those with creatinine <7.5 mg/dL (relative risk = 1.38). The association of lower albumin concentration with higher mortality risk was stronger for patients with lower BMI or lower creatinine.
Conclusion
The joint effects of nutritional indicators on mortality indicate the need to use multiple measurements when assessing the nutritional status of hemodialysis patients.
∗Department of Medicine, Federal University of Bahia, Salvador, BA, Brazil
†Arbor Research Collaborative for Health, Ann Arbor, MI 48103
‡‡Showa University Hospital, Shingawa, Tokyo, Japan
§§Veterans Affairs Ann Arbor Healthcare System/University of Michigan, Ann Arbor, MI 48105
Address reprint requests to Dr. Antonio Alberto Lopes, Departamento de Medicina da Faculdade de Medicina da Universidade Federal da Bahia, Av. Reitor Miguel Calmon, s/n, Vale do Canela, Salvador, BA - CEP: 40110-100 Brazil.
The DOPPS is administered by Arbor Research Collaborative for Health. DOPPS I, II, and III have been supported by research grants from Amgen Inc. and Kyowa Hakko Kirin Co., Ltd. As of January 2009, the DOPPS is additionally funded by Genzyme Corp. Support is provided without restrictions on publications. Friedrich K. Port receives research funding for the DOPPS from Amgen Inc. and Kyowa Hakko Kirin Co Ltd. (additionally since 2009 from Genzyme Corp.). This manuscript was edited by Shauna Leighton, a medical editor employed by Arbor Research Collaborative for Health.
ABSTRACT