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Serum albumin as a predictor of mortality in peritoneal dialysis: comparisons with hemodialysis.

ABSTRACT: Serum albumin level predicts mortality in dialysis patients and is used to assess their health status and the quality of delivered care. Whether the threshold level of serum albumin at which mortality risk increases in peritoneal dialysis (PD) patients is the same as for hemodialysis (HD) patients has not been studied.Observational cohort study of dialysis patients undertaken to determine the survival-predictability of serum albumin level in PD patients and compare it with that in HD patients.130,052 dialysis patients (PD, 12,171; HD, 117,851) who received treatment in any of the 580 dialysis units owned by DaVita Inc between July 1, 2001, through June 30, 2006, followed up through June 30, 2007.Baseline and time-averaged serum albumin level (assayed using bromcresol green) and change in serum albumin level over 6 months.All-cause, cardiovascular, and infection-related mortality.PD patients with baseline serum albumin level <3.0 g/dL had a more than 3-fold higher adjusted risk of all-cause and cardiovascular mortality and 3.4-fold higher risk of infection-related mortality (reference group: serum albumin, 4.00-4.19 g/dL). Adjusted all-cause mortality was significantly lower in PD patients with a ?0.3-g/dL increase in serum albumin level over 6 months and significantly higher in those for whom it decreased by ?0.2 g/dL (reference group: serum albumin change, +0.1 to -0.1 g/dL). A significant increase in death risk was evident for HD patients with serum albumin level <4.0 g/dL, but at <3.8 g/dL for PD patients. For each albumin category, overall death risk for PD patients was lower than for HD patients (reference group: HD patients with serum albumin of 4.00-4.19 g/dL).Study can identify associations only without attribution of causality and residual confounding cannot be excluded.Serum albumin predicts all-cause, cardiovascular, and infection-related mortality in both PD and HD patients. However, the threshold at which risk of death increases varies by dialysis modality, and this difference should be considered by agencies or organizations that set quality standards.

SUBMITTER: Mehrotra R

PROVIDER: S-EPMC3159826 | biostudies-literature | 2011 Sep

REPOSITORIES: biostudies-literature

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Serum albumin as a predictor of mortality in peritoneal dialysis: comparisons with hemodialysis.

Mehrotra Rajnish R Duong Uyen U Jiwakanon Sirin S Kovesdy Csaba P CP Moran John J Kopple Joel D JD Kalantar-Zadeh Kamyar K

American journal of kidney diseases : the official journal of the National Kidney Foundation 20110520 3

<h4>Background</h4>Serum albumin level predicts mortality in dialysis patients and is used to assess their health status and the quality of delivered care. Whether the threshold level of serum albumin at which mortality risk increases in peritoneal dialysis (PD) patients is the same as for hemodialysis (HD) patients has not been studied.<h4>Study design</h4>Observational cohort study of dialysis patients undertaken to determine the survival-predictability of serum albumin level in PD patients an ...[more]

PMID: 21601335

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Project description:BackgroundPeritoneal dialysis (PD) is an easily implementable dialysis modality in end-stage renal disease (ESRD). PD may improve access to renal replacement therapy in low- and middle-income countries; however, these countries have a higher prevalence of protein-energy wasting in patients and poorer socioeconomic conditions. We evaluated the effects of HIV infection on serum albumin levels in ESRD patients starting continuous ambulatory PD (CAPD) and mortality outcomes.MethodsWe conducted a single-center prospective cohort study of consecutive incident CAPD patients recruited from two hospitals in Durban, South Africa, from September 2012 to February 2015. Seventy HIV-negative and 70 HIV-positive ESRD patients were followed monthly for serum albumin levels and mortality events during the first 18 months of CAPD therapy.ResultsThe HIV-positive cohort recorded 28 deaths (40%) among patients with a functional CAPD catheter at 18 months and 13 deaths (18.6%) in the HIV-negative cohort (p = 0.005). The mean serum albumin levels were lower in the HIV-positive cohort than in the HIV-negative cohort during the 18-month follow-up. The mean difference in serum albumin levels between the two cohorts was 4.24 g/L (95% confidence interval [CI] 2.02-6.46, p<0.001) at baseline and 3.99 g/L (95% CI 1.19-6.79, p = 0.006) at 18 months. HIV-positive status (adjusted regression coefficient -2.84, CI -5.00--0.67, p = 0.011), diabetes (adjusted coefficient -2.85; CI, -5.58--0.12; p = 0.041), and serum C-reactive protein and blood hemoglobin levels were independent predictors of serum albumin levels on multivariable linear regression. Baseline serum albumin <25 g/L (subdistribution-hazard ratio [SHR] 13.06, 95% CI 3.09-55.14, p<0.001) and CD4+ cell count <200 cells/?L (SHR 3.2, CI 1.38-7.45, p = 0.007) were independent predictors of mortality in our competing risk model.ConclusionsHIV infection can adversely affect serum albumin levels in ESRD patients managed with CAPD, while low baseline serum albumin levels and impaired immunity reliably predict mortality.

Project description:Peritoneal dialysis (PD) is a frequently used and growing therapy for end-stage renal diseases (ESRD). Survival analysis of PD patients is an ongoing research topic in the field of nephrology. Several biochemical parameters (e.g., serum albumin, creatinine, and blood urea nitrogen) are measured repeatedly in the follow-up period; however, baseline or averaged values are primarily associated with mortality. Although this strategy is not incorrect, it leads to information loss, resulting in erroneous conclusions and biased estimates. This retrospective study used the trajectory of common renal function indexes in PD patients and mainly investigated the association between serum albumin change and mortality. Furthermore, we considered patient-specific variability in serum albumin change and obtained personalized dynamic risk predictions for selected patients at different follow-up thresholds to investigate the effect of serum albumin trajectories on patient-specific mortality. We included 417 patients from the Erciyes University Nephrology Department whose data were retrospectively collected using medical records. A joint modeling approach for longitudinal and survival data was used to investigate the relationship between serum albumin trajectory and mortality of PD patients. Results showed that averaged serum albumin levels were not associated with mortality. However, serum albumin change was significantly and inversely associated with mortality (HR: 2.43, 95% CI: 1.48 to 4.16). Risk of death was positively associated with peritonitis rate, hemodialysis history, and the total number of comorbid and renal diseases with hazard ratios 1.74, 3.21, and 1.41. There was also significant variability between patients. The personalized risk predictions showed that overall survival estimates were not representative for all patients. Using the patient-specific trajectories provided better survival predictions within the follow-up period as more data become available in serum albumin levels. In conclusion, using the trajectory of risk predictors via an appropriate statistical method provided better predictive accuracy and prevented biased findings. We also showed that personalized risk predictions were much informative than overall estimations in the presence of significant patient variability. Furthermore, personalized estimations may play an essential role in monitoring and managing patients during the follow-up period.

Project description:BACKGROUND:Vascular calcification is seen in most patients on dialysis and is strongly associated with cardiovascular mortality. Vascular calcification is promoted by phosphate, which generally reaches higher levels in hemodialysis than in peritoneal dialysis. However, whether vascular calcification develops less in peritoneal dialysis than in hemodialysis is currently unknown. Therefore, we compared coronary artery calcification (CAC), its progression, and calcification biomarkers between patients on hemodialysis and peritoneal dialysis. METHODS:We measured CAC in 134 patients who had been treated exclusively with hemodialysis (n = 94) or peritoneal dialysis (n = 40) and were transplantation candidates. In 57 of them (34 on hemodialysis and 23 on peritoneal dialysis), we also measured CAC progression annually up to 3 years and the inactive species of desphospho-uncarboxylated matrix Gla protein (dp-ucMGP), fetuin-A, osteoprotegerin. We compared CAC cross-sectionally with Tobit regression. CAC progression was compared in 2 ways: with linear mixed models as the difference in square root transformed volume score per year (?CAC SQRV) and with Tobit mixed models. We adjusted for potential confounders. RESULTS:In the cross-sectional cohort, CAC volume scores were 92 mm3 in hemodialysis and 492 mm3 in peritoneal dialysis (adjusted difference 436 mm3; 95% CI -47 to 919; p = 0.08). In the longitudinal cohort, peritoneal dialysis was associated with significantly more CAC progression defined as ?CAC SQRV (adjusted difference 1.20; 95% CI 0.09 to 2.31; p = 0.03), but not with Tobit mixed models (adjusted difference in CAC score increase per year 106 mm3; 95% CI -140 to 352; p = 0.40). Peritoneal dialysis was associated with higher osteoprotegerin (adjusted p = 0.02) but not with dp-ucMGP or fetuin-A. CONCLUSIONS:Peritoneal dialysis is not associated with less CAC or CAC progression than hemodialysis, and perhaps with even more progression. This indicates that vascular calcification does not develop less in peritoneal dialysis than in hemodialysis.

Dataset Information

Serum albumin as a predictor of mortality in peritoneal dialysis: comparisons with hemodialysis.

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Serum albumin as a predictor of mortality in peritoneal dialysis: comparisons with hemodialysis.

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