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      Morbidity and Mortality on Maintenance Haemodialysis

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          Despite the many technical advances in medical care and dialysis delivery, mortality and morbidity remain high in end-stage renal disease (ESRD) patients. A number of factors seem to contribute. Cardiovascular diseases are the leading cause of death: volume overload, anaemia, hypertension, arteriovenous fistula, uraemia-related myocardial cell injury all contribute to the development of ischaemic heart disease and congestive heart failure. The underlying disease is determinant for prognosis, with diabetics displaying an excess cardiovascular mortality. Elderly are also more likely to experience intercurrent medical conditions, vascular disease and diabetes, thus increasing the risk of death. Protein-energy malnutrition and wasting also contribute to the higher mortality in renal replacement therapy. Although nowadays high-risk patients are dialysed too, the rate of acceptance of ESRD patients still varies widely in different countries, possibly because of hidden selection criteria. The patients in the registries with a higher acceptance rate are more likely to be affected by co-morbid conditions and greater disease severity; the assessment of these co-morbid conditions is extremely important when comparing outcomes in different haemodialysis populations. Dialysis adequacy, obtained by means of longer duration of the treatment, is also of paramount importance; it allows minimizing the clinical effects of ultrafiltration and ensure that correct dry weight is reached. This means decreasing the incidence of intradialytic hypotensive episodes, but also improving blood pressure control, a strong predictor of survival. Family and social support, together with adequate medical care, greatly affect the quality of life of patients and can improve compliance to dialysis, diet and drugs and therefore survival.

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          The urea reduction ratio and serum albumin concentration as predictors of mortality in patients undergoing hemodialysis.

          Among patients with end-stage renal disease who are treated with hemodialysis, solute clearance during dialysis and nutritional adequacy are determinants of mortality. We determined the effects of reductions in blood urea nitrogen concentrations during dialysis and changes in serum albumin concentrations, as an indicator of nutritional status, on mortality in a large group of patients treated with hemodialysis. We analyzed retrospectively the demographic characteristics, mortality rate, duration of hemodialysis, serum albumin concentration, and urea reduction ratio (defined as the percent reduction in blood urea nitrogen concentration during a single dialysis treatment) in 13,473 patients treated from October 1, 1990, through March 31, 1991. The risk of death was determined as a function of the urea reduction ratio and serum albumin concentration. As compared with patients with urea reduction ratios of 65 to 69 percent, patients with values below 60 percent had a higher risk of death during follow-up (odds ratio, 1.28 for urea reduction ratios of 55 to 59 percent and 1.39 for ratios below 55 percent). Fifty-five percent of the patients had urea reduction ratios below 60 percent. The duration of dialysis was not predictive of mortality. The serum albumin concentration was a more powerful (21 times greater) predictor of death than the urea reduction ratio, and 60 percent of the patients had serum albumin concentrations predictive of an increased risk of death (values below 4.0 g per deciliter). The odds ratio for death was 1.48 for serum albumin concentrations of 3.5 to 3.9 g per deciliter and 3.13 for concentrations of 3.0 to 3.4 g per deciliter. Diabetic patients had lower serum albumin concentrations and urea reduction ratios than nondiabetic patients. Low urea reduction ratios during dialysis are associated with increased odds ratios for death. These risks are worsened by inadequate nutrition.
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            Interaction between hypertension and other cardiovascular risk factors in survival of hemodialyzed patients.

            The interaction of hypertension with other cardiovascular risk factors, namely hypercholesterolemia, smoking, and past history of cardiovascular complications, was examined. One hundred and ninety-five hemodialysis patients were followed up for 54.2 +/- 2.3 months, among whom 66 died. In patients with cardiovascular complications, such as ischemic heart disease, cerebrovascular accident, or atherosclerotic obliteration of peripheral arteries, and in patients older than 70 years, blood pressure had no significant effect on the already poor survival. On the other hand, in patients with hypercholesterolemia (> or = 220 mg/dL) and in smokers, elevated systolic blood pressure made the survival significantly worse. These results suggest an interaction between hypertension and other cardiovascular risk factors in hemodialysis patients.
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              Effect of age and diagnosis on survival of older patients beginning chronic dialysis.

              To assess the survival of elderly patients in the United States beginning chronic dialysis for end-stage renal disease caused by diabetes mellitus, hypertension, glomerulonephritis, polycystic kidney disease, and other causes. A secondary analysis of data obtained from the Health Care Financing Administration. All Medicare end-stage renal disease patients 55 years of age or older (n = 95,394) who began chronic dialysis treatment in the US between 1982 and 1987. The 1-, 3-, and 5-year survival rates for each of six age strata and, within each strata, for each of the four most frequent causes of renal failure. Survival rates of dialysis patients fell precipitously, and much more rapidly for the study group than for the general population, as a function of advancing age. Older patients with diabetic nephropathy fared particularly badly, such that no patients with diabetic nephropathy aged 85 years or more survived 5 years. Mortality rates of patients older than 55 years beginning chronic dialysis treatment increased dramatically as age at initiation of dialysis increased. Clinically meaningful survival data should prove useful to persons making decisions about the initiation of chronic dialysis.

                Author and article information

                S. Karger AG
                December 1998
                07 December 1998
                : 80
                : 4
                : 380-400
                Department of Nephrology and Dialysis, Ospedale di Lecco, Italy
                45210 Nephron 1998;80:380–400
                © 1998 S. Karger AG, Basel

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                Page count
                Figures: 1, Tables: 1, References: 115, Pages: 21
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                Nephrology Grand Rounds. Clinical Issues in Nephrology<br>Section Editors: Prof. E. Ritz and Dr. M. Zeier, Heidelberg


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