The influence of patient- and facility-specific factors on nutritional status and survival in hemodialysis☆
Abstract
Background
Parameters of nutritional status, including serum albumin, serum creatinine, and body mass index (BMI), are powerful predictors of mortality and hospitalization in patients with end stage renal disease (ESRD). Patient-specific characteristics and facility-related practice patterns modify certain parameters of nutritional status. We aimed to determine whether patient and facility characteristics modify the risk profiles associated with malnutrition in hemodialysis patients.
Methods
We analyzed data on 5,234 prevalent hemodialysis patients from the Dialysis Morbidity and Mortality Study (DMMS) Wave 1 for whom information on demographic, clinical, nutritional, and facility-related characteristics were available. We evaluated the associations among facility characteristics and serum albumin, serum creatinine, and BMI, adjusting for the effects of age, sex, race/ethnicity, diabetes, and dialysis vintage. We determined correlates of mortality and hospitalization, focusing on nutritional parameters, facility effects, and the interactions among patient-specific and facility-specific characteristics, albumin, creatinine, and BMI.
Results
Serum albumin was lower with older age, diabetes, nonblack race, and hemodialysis using a catheter. Serum albumin was higher with annual vascular access surveillance, higher BMI among women, higher urea reduction ratio, among patients in whom dialyzers were reprocessed (particularly with bleach), among dialysis units in which water purification was used, and when vascular access blood flow rates were ≥350 mL/min. Overall survival was decreased with lower albumin, creatinine, and BMI. There were interactions among albumin, age, and vintage. Whereas lower serum albumin concentrations consistently were associated with an increased risk of death, the differences were attenuated among older patients and accentuated among patients of longer vintage.
Conclusion
Some facility-specific factors are associated with nutritional parameters including serum albumin, serum creatinine, and BMI. The associations of nutritional parameters with mortality and hospitalization vary by age, sex, and vintage but not by facility-specific factors, including those associated with the nutritional parameters themselves.
★Division of Nephrology, Department of Medicine, University of California Davis, Davis, CA, USA
†Department of Statistics, University of California Davis, Davis, CA, USA
‡Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
§Division of Nephrology, Departments of Medicine and Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
Address reprint requests to Glenn M. Chertow, MD, MPH, University of California San Francisco, Department of Medicine Research, UCSF Laurel Heights Suite 430, 3333 California Street, San Francisco, CA 94118-1211 USA
☆ Supported by contract N01-DK-1-2450 from the National Institutes of Health, National Institute of Diabetes, Digestive, and Kidney Diseases.
ABSTRACT