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      Disappearance of Association in Diabetic Patients on Hemodialysis between Anemia and Mortality Risk: The Japan Dialysis Outcomes and Practice Pattern Study

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          Abstract

          We previously demonstrated that anemia was not associated with mortality in hemodialysis patients with cardiovascular disease (CVD). Since diabetes mellitus (DM) accelerates CVD, the influence of DM on the relationship between anemia and mortality was examined using the data obtained from 1,385 DM patients and 2,583 non-DM hemodialysis patients recruited into the Dialysis Outcomes Practice Pattern Study in Japan (J-DOPPS). When all patients were stratified into four groups on their hematocrit levels, mortality rate was significantly and steadily lower in the subgroups with the higher levels of hematocrit by the Kaplan-Meier method (p = 0.0003 by log-rank test). When DM and non-DM patients were analyzed separately, a significant association of lower hematocrit levels with higher mortality disappeared in DM patients (p = 0.6280), in contrast with its retention in non-DM counterparts (p < 0.0001). Multivariable-adjusted Cox proportional hazards models demonstrated a significant association between hematocrit with all-cause mortality in non-DM patients after adjustment for age, gender, BMI, hemodialysis duration, SBP, DBP, albumin, total cholesterol, calcium, phosphorus, and intact PTH (p = 0.046), whereas this association disappeared in DM patients in the same model (p = 0.583). In conclusion, these results suggested that the association between anemia and higher mortality disappeared in DM hemodialysis patients, in contrast with non-DM counterparts.

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          Graphical methods for assessing violations of the proportional hazards assumption in Cox regression.

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          A major assumption of the Cox proportional hazards model is that the effect of a given covariate does not change over time. If this assumption is violated, the simple Cox model is invalid, and more sophisticated analyses are required. This paper describes eight graphical methods for detecting violations of the proportional hazards assumption and demonstrates each on three published datasets with a single binary covariate. I discuss the relative merits of these methods. Smoothed plots of the scaled Schoenfeld residuals are recommended for assessing PH violations because they provide precise usable information about the time dependence of the covariate effects.
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              Physical exercise among participants in the Dialysis Outcomes and Practice Patterns Study (DOPPS): correlates and associated outcomes.

              Levels of physical exercise among haemodialysis patients are low. Increased physical activity in this population has been associated with improved health-related quality of life (HRQoL) and survival. However, results of previous studies may not be applicable to the haemodialysis population as a whole. The present study provides the first description of international patterns of exercise frequency and its association with exercise programmes and clinical outcomes among participants in the Dialysis Outcomes and Practice Patterns Study (DOPPS). Data from a cross section of 20,920 DOPPS participants in 12 countries between 1996 and 2004 were analysed. Regular exercise was defined as exercise frequency equal to or more than once/week based on patient self-report. Linear mixed models and logistic regression assessed associations of exercise frequency with HRQoL and other psychosocial variables. Mortality risk was calculated in Cox proportional hazard models using patient-level (patient self-reported exercise frequency) and facility-level (the dialysis facility percentage of regular exercisers) predictors. Regular exercise frequency varied widely across countries and across dialysis facilities within a country. Overall, 47.4% of participants were categorized as regular exercisers. The odds of regular exercise was 38% higher for patients from facilities offering exercise programmes (adjusted odds ratio = 1.38 [95% confidence interval: 1.03-1.84]; P = 0.03). Regular exercisers had higher HRQoL, physical functioning and sleep quality scores; reported fewer limitations in physical activities; and were less bothered by bodily pain or lack of appetite (P
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                Author and article information

                Journal
                NEC
                Nephron Clin Pract
                10.1159/issn.1660-2110
                Nephron Clinical Practice
                S. Karger AG
                1660-2110
                2012
                May 2012
                22 February 2012
                : 120
                : 2
                : c91-c100
                Affiliations
                aDepartment of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, bDepartment of Epidemiology and Healthcare Research, Kyoto University Graduate School of Medicine and Public Health, Kyoto, cDepartment of Blood Purification and Internal Medicine, Kidney Center, Tokyo Women’s Medical University, Tokyo, dDivision of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, eDivision of Nephrology and Metabolism, Department of Medicine, Tokai University School of Medicine, Kanagawa, and fNational Graduate Institute for Policy Studies, Tokyo, Japan
                Author notes
                *Masaaki Inaba, MD, Department of Metabolism, Endocrinology and Molecular Medicine, Internal Medicine, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka 545-8585 (Japan), Tel. +81 6 6645 3806, E-Mail inaba-m@med.osaka-cu.ac.jp
                Article
                335979 Nephron Clin Pract 2012;120:c91–c100
                10.1159/000335979
                22377677
                8c20214c-fb41-442f-9adb-e9db149cce74
                © 2012 S. Karger AG, Basel

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                History
                : 14 September 2011
                : 16 December 2011
                Page count
                Figures: 2, Tables: 4, Pages: 10
                Categories
                Original Paper

                Cardiovascular Medicine,Nephrology
                Diabetes,Hemodialysis,Anemia,Mortality
                Cardiovascular Medicine, Nephrology
                Diabetes, Hemodialysis, Anemia, Mortality

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