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      Association between Ultrafiltration Rate and Clinical Outcome Is Modified by Muscle Mass in Hemodialysis Patients

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          Background: The association between ultrafiltration rate (UFR) and mortality may be affected by the muscle mass or volume status in hemodialysis (HD) patients. However, there is an absence of data regarding this association. Methods: We performed an observational study on patients (≥18 years old) who had been on HD for at least 3 months. A body composition monitor (BCM) was used for baseline bioimpedance analysis measurement. The primary composite outcome was defined as the time to death or the first cardiovascular event. Results: The median (interquartile range) UFR, volume excess measured by the BCM, and lean tissue index (LTI) (calculated as lean tissue mass/height<sup>2</sup>) were 11.4 (8.0–15.0) mL/h/kg, 2.4 (1.4–4.1) L, and 12.5 (10.4–14.4) kg/m<sup>2</sup>, respectively. During 284 person-years of follow-up, the primary outcome occurred in 44 of the 167 patients (26%). Higher UFR was associated with an increased outcome of death or cardiovascular event; the adjusted hazard ratio (HR) was 1.044 (95% confidence interval [CI]: 1.006–1.083). This association remained consistent even after adjusting for volume excess. However, the association between UFR and the primary outcome was modified by LTI ( p<sub>interaction</sub> = 0.027); the association was significant in patients with LTI < 12.5 kg/m<sup>2</sup>, and the HR (95% CI) was 1.050 (1.001–1.102). Conclusion: Higher UFR was associated with an increased risk of a composite outcome of death or cardiovascular event regardless of volume status in HD patients. However, muscle mass may modify the association between higher UFR and increased risk of a composite outcome.

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          Fluid retention is associated with cardiovascular mortality in patients undergoing long-term hemodialysis.

          Patients with chronic kidney disease (stage 5) who undergo hemodialysis treatment have similarities to heart failure patients in that both populations retain fluid frequently and have excessively high mortality. Volume overload in heart failure is associated with worse outcomes. We hypothesized that in hemodialysis patients, greater interdialytic fluid gain is associated with poor all-cause and cardiovascular survival. We examined 2-year (July 2001 to June 2003) mortality in 34,107 hemodialysis patients across the United States who had an average weight gain of at least 0.5 kg above their end-dialysis dry weight by the time the subsequent hemodialysis treatment started. The 3-month averaged interdialytic weight gain was divided into 8 categories of 0.5-kg increments (up to > or =4.0 kg). Eighty-six percent of patients gained >1.5 kg between 2 dialysis sessions. In unadjusted analyses, higher weight gain was associated with better nutritional status (higher protein intake, serum albumin, and body mass index) and tended to be linked to greater survival. However, after multivariate adjustment for demographics (case mix) and surrogates of malnutrition-inflammation complex, higher weight-gain increments were associated with increased risk of all-cause and cardiovascular death. The hazard ratios (95% confidence intervals) of cardiovascular death for weight gain or =4.0 kg (compared with 1.5 to 2.0 kg as the reference) were 0.67 (0.58 to 0.76) and 1.25 (1.12 to 1.39), respectively. In hemodialysis patients, greater fluid retention between 2 subsequent hemodialysis treatment sessions is associated with higher risk of all-cause and cardiovascular death. The mechanisms by which fluid retention influences cardiovascular survival in hemodialysis may be similar to those in patients with heart failure and warrant further research.
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            Is Open Access

            Lean body mass index prognostic value for cardiovascular events in patients with coronary artery disease

            Objective Little is known about the relationship between body composition indicators, including body mass index (BMI), fat mass index (FMI) and lean BMI (LBMI), and adverse outcomes after percutaneous coronary intervention (PCI) in Asian populations. The aim of this study was to clarify this relationship. Methods The SHINANO registry is a prospective, observational, multicenter cohort registry that enrolled 1923 consecutive patients with coronary heart disease (CHD) from August 2012 to July 2013; 66 patients were excluded because of missing data. We evaluated 1857 patients with CHD who underwent PCI (aged 70±11 years; 23% women; BMI 23.8±3.5 kg/m2; LBMI 18.3±1.8 kg/m2; FMI 5.4±2.2 kg/m2). Patients were divided into three groups, based on BMI, LBMI and FMI tertiles, to assess the prognostic value of the three indicators. The primary endpoint was major adverse cardiac events (MACE), including all cause death, non-fatal myocardial infarction and ischaemic stroke at 1 year. Results Over a 1 year follow-up period (1776 patients, 95.6%), the cumulative MACE incidence was 8.7% (161 cases). Using Kaplan–Meier analysis, the MACE incidence was significantly higher in patients with lower BMI values (13.4–22.2 kg/m2) (p=0.002) and lower LBMI values (11.6–17.6 kg/m2) (p<0.001); this trend was not observed for FMI. Multivariate Cox regression analysis showed that lower LBMI but not lower BMI values were predictive of a higher MACE incidence (HR 1.55; 95% CI 1.05 to 2.30). Conclusions Lower LBMI values are associated with adverse outcomes in an Asian population with CHD undergoing PCI. LBMI is a better predictor of MACE than BMI or FMI. Clinical trial registration UMIN-ID; 000010070.
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              Association of Ultrafiltration Rate with Mortality in Incident Hemodialysis Patients

              Background/Aims: Ultrafiltration rate (UFR) appears to be associated with mortality in prevalent hemodialysis (HD) patients. However, the association of UFR with mortality in incident HD patients remains unknown. Methods: We examined a US cohort of 110,880 patients who initiated HD from 2007 to 2011. Baseline UFR was divided into 5 groups (<4, 4 to <6, 6 to <8, 8 to <10, and ≥10 mL/h/kg body weight [BW]). We examined predictors of higher baseline UFR using logistic regression and the association of baseline UFR and all-cause and cardiovascular (CV) mortality using Cox proportional hazard models with adjustments for demographics, comorbidities, and markers of malnutrition-inflammation-cachexia syndrome. Results: Patients were 63 ± 15 years, with 43% women, 32% African Americans, and had a mean baseline UFR of 7.5 ± 3.1 mL/h/kg BW. In the fully adjusted logistic regression models, factors associated with higher UFR (≥7.5 mL/h/kg BW) included Hispanic ethnicity, diabetes, and higher dietary protein intake. There was a linear association between UFR and all-cause and CV mortality, where UFR ≥10 mL/h/kg BW (reference UFR 6–<8 mL/h/kg BW) conferred the highest risk in both unadjusted (HR 1.15 [95% CI 1.10–1.19]) and adjusted models (HR 1.23 [95% CI 1.16–1.31]). The linear association with all-cause mortality remained consistent across strata of age, urine volume, and treatment time. Conclusions: Higher UFR is independently associated with higher all-cause and CV mortality in incident HD patients. Clinical trials are warranted to examine the effects of lowering UFR on outcomes.

                Author and article information

                S. Karger AG
                September 2020
                28 July 2020
                : 144
                : 9
                : 447-452
                Division of Nephrology, Department of Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
                Author notes
                *Yu-Ji Lee, Division of Nephrology, Department of Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, 158, Paryong-ro, Masanhoewon-gu, Changwon 51353 (Republic of Korea),
                509350 Nephron 2020;144:447–452
                © 2020 S. Karger AG, Basel

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                Page count
                Figures: 1, Tables: 2, Pages: 6
                Clinical Practice: Research Article


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