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Volume 20, Issue 4, Pages 224-234 (July 2010)


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Independent and Joint Associations of Nutritional Status Indicators With Mortality Risk Among Chronic Hemodialysis Patients in the Dialysis Outcomes and Practice Patterns Study (DOPPS)

Antonio Alberto Lopes, MD, PhDCorresponding Author Informationemail address, Jennifer L. Bragg-Gresham, MS, Stacey J. Elder, MS, Nancy Ginsberg, RD, David A. Goodkin, MD, Trinh Pifer, MPH, Norbert Lameire, MD§, Mark R. Marshall, MBChB∗∗, Yasushi Asano, MD††, Tadao Akizawa, MD‡‡, Ronald L. Pisoni, PhD, MS, Eric W. Young, MD, MS§§, Friedrich K. Port, MD, MS

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

 Renal Research Institute, New York, NY 10128

§ Ghent University Hospital, Ghent, Belgium

∗∗ Middlemore Hospital, Auckland, New Zealand

†† Koga Red Cross Hospital, Koga, Ibaraki, Japan

‡‡ Showa University Hospital, Shingawa, Tokyo, Japan

§§ Veterans Affairs Ann Arbor Healthcare System/University of Michigan, Ann Arbor, MI 48105

Corresponding Author InformationAddress 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.

PII: S1051-2276(09)00280-5

doi:10.1053/j.jrn.2009.10.002


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