A Retrospective Cohort Study of hemodialysis optimization in elderly renal patients with diabetic nephropathy
DOI:
https://doi.org/10.5281/zenodo.22813087Keywords:
hemodialysis, diabetic nephropathy, elderly, dialysis adequacy, frailtyAbstract
Background: Diabetic nephropathy is the leading cause of end-stage renal disease among elderly patients starting hemodialysis, and this subgroup carries a disproportionate burden of frailty, cardiovascular disease, and vascular access dysfunction.
Objective: To describe five-year survival among elderly hemodialysis patients with diabetic nephropathy and identify which components of dialysis adequacy, vascular access, glycemic control, and comorbidity burden are independently associated with mortality.
Methods: We retrospectively studied 412 patients aged 65 years or older who initiated in-center hemodialysis for diabetic nephropathy at our affiliated units between 2019 and 2020, followed through 2025. Survival was estimated by the Kaplan-Meier method and independent predictors of mortality were identified by multivariable Cox regression.
Results: Over a median follow-up of 4.1 years, 187 patients (45.4%) died. Five-year survival ranged from 38.9% in the lowest Kt/V tertile to 63.8% in the highest (log-rank p<0.001). Catheter access at initiation, frailty, both the lowest and highest glycated hemoglobin categories, and low serum albumin were each independently associated with higher mortality after adjustment.
Conclusions: Dialysis adequacy, vascular access planning, individualized glycemic targets, frailty, and nutritional status each independently predicted survival in this population, supporting a bundled rather than single-parameter approach to hemodialysis optimization in elderly diabetic nephropathy patients.
References
Collins, A.J., Kasiske, B., Herzog, C., Chavers, B., Foley, R., Gilbertson, D., et al. (2002) United States Renal Data System 2001 annual data report: atlas of end-stage renal disease in the United States. American Journal of Kidney Diseases, 39(4 Suppl 1): A1-A2. DOI: 10.1053/ajkd.2002.32763
Ritz, E., Orth, S.R. (1999) Nephropathy in patients with type 2 diabetes mellitus. New England Journal of Medicine, 341(15): 1127-1133. DOI: 10.1056/NEJM199910073411506
Lewis, E.J., Hunsicker, L.G., Bain, R.P., Rohde, R.D. (1993) The effect of angiotensin-converting-enzyme inhibition on diabetic nephropathy. New England Journal of Medicine, 329(20): 1456-1462. DOI: 10.1056/NEJM199311113292004
Brenner, B.M., Cooper, M.E., de Zeeuw, D., Keane, W.F., Mitch, W.E., Parving, H.H., et al. (2001) Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. New England Journal of Medicine, 345(12): 861-869. DOI: 10.1056/NEJMoa011161
Lewis, E.J., Hunsicker, L.G., Clarke, W.R., Berl, T., Pohl, M.A., Lewis, J.B., et al. (2001) Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. New England Journal of Medicine, 345(12): 851-860. DOI: 10.1056/NEJMoa011303
Perkovic, V., Jardine, M.J., Neal, B., Bompoint, S., Heerspink, H.J.L., Charytan, D.M., et al. (2019) Canagliflozin and renal outcomes in type 2 diabetes and nephropathy. New England Journal of Medicine, 380(24): 2295-2306. DOI: 10.1056/NEJMoa1811744
EMPA-KIDNEY Collaborative Group. (2023) Empagliflozin in patients with chronic kidney disease. New England Journal of Medicine, 388(2): 117-127. DOI: 10.1056/NEJMoa2204233
Kurella Tamura, M., Covinsky, K.E., Chertow, G.M., Yaffe, K., Landefeld, C.S., McCulloch, C.E. (2009) Functional status of elderly adults before and after initiation of dialysis. New England Journal of Medicine, 361(16): 1539-1547. DOI: 10.1056/NEJMoa0904655
Jassal, S.V., Chiu, E., Hladunewich, M. (2007) Loss of independence in patients starting dialysis at 80 years of age or older. New England Journal of Medicine, 361(16): 1612-1613. DOI: 10.1056/NEJMc0905289
Johansen, K.L., Chertow, G.M., Jin, C., Kutner, N.G. (2007) Significance of frailty among dialysis patients. Journal of the American Society of Nephrology, 18(11): 2960-2967. DOI: 10.1681/ASN.2007020221
Miskulin, D.C., Athienites, N.V., Yan, G., Martin, A.A., Ojo, A.O., Kutner, N.G., et al. (2001) Comorbidity assessment using the Index of Coexistent Disease in a chronic hemodialysis population. Kidney International, 60(4): 1498-1510. DOI: 10.1046/j.1523-1755.2001.00954.x
Murray, A.M., Tupper, D.E., Knopman, D.S., Gilbertson, D.T., Pederson, S.L., Li, S., et al. (2006) Cognitive impairment in hemodialysis patients is common. Neurology, 67(2): 216-223. DOI: 10.1212/01.wnl.0000225182.15532.40
Allon, M., Robbin, M.L. (2002) Increasing arteriovenous fistulas in hemodialysis patients: problems and solutions. Kidney International, 62(4): 1109-1124. DOI: 10.1046/j.1523-1755.2002.00540.x
Chou, J.A., Kalantar-Zadeh, K., Mathew, A.T. (2017) A brief review of intradialytic hypotension with a focus on survival. Seminars in Dialysis, 30(6): 473-480. DOI: 10.1111/sdi.12627
Goodman, W.G., Goldin, J., Kuizon, B.D., Yoon, C., Gales, B., Sider, D., et al. (2000) Coronary-artery calcification in young adults with end-stage renal disease who are undergoing dialysis. New England Journal of Medicine, 342(20): 1478-1483. DOI: 10.1056/NEJM200005183422003
Foley, R.N., Parfrey, P.S., Sarnak, M.J. (1998) Clinical epidemiology of cardiovascular disease in chronic renal disease. American Journal of Kidney Diseases, 32(5 Suppl 3): S112-S119. DOI: 10.1053/ajkd.1998.v32.pm9820470
Eknoyan, G., Beck, G.J., Cheung, A.K., Daugirdas, J.T., Greene, T., Kusek, J.W., et al. (2002) Effect of dialysis dose and membrane flux in maintenance hemodialysis. New England Journal of Medicine, 347(25): 2010-2019. DOI: 10.1056/NEJMoa021583
Owen, W.F., Lew, N.L., Liu, Y., Lowrie, E.G., Lazarus, J.M. (1993) The urea reduction ratio and serum albumin concentration as predictors of mortality in patients undergoing hemodialysis. New England Journal of Medicine, 329(14): 1001-1006. DOI: 10.1056/NEJM199309303291404
Daugirdas, J.T. (1993) Second generation logarithmic estimates of single-pool variable volume Kt/V: an analysis of error. Journal of the American Society of Nephrology, 4(5): 1205-1213. DOI: 10.1681/ASN.V451205
FHN Trial Group. (2010) In-center hemodialysis six times per week versus three times per week. New England Journal of Medicine, 363(24): 2287-2300. DOI: 10.1056/NEJMoa1001593
Termorshuizen, F., Dekker, F.W., van Manen, J.G., Korevaar, J.C., Boeschoten, E.W., Krediet, R.T. (2004) Relative contribution of residual renal function and different measures of adequacy to survival in hemodialysis patients: an analysis of the Netherlands Cooperative Study on the Adequacy of Dialysis (NECOSAD)-2. Journal of the American Society of Nephrology, 15(4): 1061-1070. DOI: 10.1097/01.ASN.0000117976.29592.93
Obi, Y., Rhee, C.M., Mathew, A.T., Shah, G., Streja, E., Brunelli, S.M., et al. (2016) Residual kidney function decline and mortality in incident hemodialysis patients. Journal of the American Society of Nephrology, 27(12): 3758-3768. DOI: 10.1681/ASN.2015101142
Besarab, A., Bolton, W.K., Browne, J.K., Egrie, J.C., Nissenson, A.R., Okamoto, D.M., et al. (1998) The effects of normal as compared with low hematocrit values in patients with cardiac disease who are receiving hemodialysis and epoetin. New England Journal of Medicine, 339(9): 584-590. DOI: 10.1056/NEJM199808273390903
Pfeffer, M.A., Burdmann, E.A., Chen, C.Y., Cooper, M.E., de Zeeuw, D., Eckardt, K.U., et al. (2009) A trial of darbepoetin alfa in type 2 diabetes and chronic kidney disease. New England Journal of Medicine, 361(21): 2019-2032. DOI: 10.1056/NEJMoa0907845
Kalantar-Zadeh, K., Kopple, J.D., Regidor, D.L., Jing, J., Shinaberger, C.S., Aronovitz, J., et al. (2007) A1C and survival in maintenance hemodialysis patients. Diabetes Care, 30(5): 1049-1055. DOI: 10.2337/dc06-2127
Ricks, J., Molnar, M.Z., Kovesdy, C.P., Shah, A., Nissenson, A.R., Williams, M., et al. (2012) Glycemic control and cardiovascular mortality in hemodialysis patients with diabetes: a 6-year cohort study. Diabetes, 61(3): 708-715. DOI: 10.2337/db11-1015
Hedayati, S.S., Minhajuddin, A.T., Afshar, M., Toto, R.D., Trivedi, M.H., Rush, A.J. (2010) Association between major depressive episodes in patients with chronic kidney disease and initiation of dialysis, hospitalization, or death. JAMA, 303(19): 1946-1953. DOI: 10.1001/jama.2010.619
Mapes, D.L., Lopes, A.A., Satayathum, S., McCullough, K.P., Goodkin, D.A., Locatelli, F., et al. (2003) Health-related quality of life as a predictor of mortality and hospitalization: the Dialysis Outcomes and Practice Patterns Study (DOPPS). Kidney International, 64(1): 339-349. DOI: 10.1046/j.1523-1755.2003.00072.x
Kalantar-Zadeh, K., Kopple, J.D. (2001) Relative contributions of nutrition and inflammation to clinical outcomes in dialysis patients. American Journal of Kidney Diseases, 38(6): 1343-1350. DOI: 10.1053/ajkd.2001.29250
Kalantar-Zadeh, K., Kuwae, N., Wu, D.Y., Shantouf, R.S., Fouque, D., Anker, S.D., et al. (2006) Associations of body fat and its changes over time with quality of life and prospective mortality in hemodialysis patients. American Journal of Clinical Nutrition, 83(2): 202-210. DOI: 10.1093/ajcn/83.2.202
Kinchen, K.S., Sadler, J., Fink, N., Brookmeyer, R., Klag, M.J., Levey, A.S., et al. (2002) The timing of specialist evaluation in chronic kidney disease and mortality. Annals of Internal Medicine, 137(6): 479-486. DOI: 10.7326/0003-4819-137-6-200209170-00007
National Kidney Foundation. (2015) KDOQI clinical practice guideline for hemodialysis adequacy: 2015 update. American Journal of Kidney Diseases, 66(5): 884-930. DOI: 10.1053/j.ajkd.2015.07.015
Cohen, L.M., Germain, M.J., Poppel, D.M., Woods, A.L., Kjellstrand, C.M. (2000) Dialysis discontinuation and palliative care. American Journal of Kidney Diseases, 36(1): 140-144. DOI: 10.1053/ajkd.2000.8286
Wanner, C., Krane, V., Marz, W., Olschewski, M., Mann, J.F., Ruf, G., et al. (2005) Atorvastatin in patients with type 2 diabetes mellitus undergoing hemodialysis. New England Journal of Medicine, 353(3): 238-248. DOI: 10.1056/NEJMoa043545
Zager, P.G., Nikolic, J., Brown, R.H., Campbell, M.A., Hunt, W.C., Peterson, D., et al. (1998) "U" curve association of blood pressure and mortality in hemodialysis patients. Kidney International, 54(2): 561-569. DOI: 10.1046/j.1523-1755.1998.00005.x
Cooper, B.A., Branley, P., Bulfone, L., Collins, J.F., Craig, J.C., Fraenkel, M.B., et al. (2010) A randomized, controlled trial of early versus late initiation of dialysis. New England Journal of Medicine, 363(7): 609-619. DOI: 10.1056/NEJMoa1000552
Weinhandl, E.D., Foley, R.N., Gilbertson, D.T., Arneson, T.J., Snyder, J.J., Collins, A.J. (2010) Propensity-matched mortality comparison of incident hemodialysis and peritoneal dialysis patients. Journal of the American Society of Nephrology, 21(3): 499-506. DOI: 10.1681/ASN.2009060635
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