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Serum biochemical measures suggestive of undernutrition have been reported to correlate with 1-yr mortality risk in prevalent groups of hemodialysis patients. The predictive power of these variables has not been reported in newly diagnosed patients or in patients whose dialysis prescription is guided by urea kinetics. The relationship of these predictors to mortality over periods of longer than 1 yr is also unreported. Therefore, the survival of 184 hemodialysis patients was examined for up to 44 months (1987 to 1991) with the Cox proportional hazards model. Baseline demographic, clinical, and biochemical parameters were used as independent variables. To adjust for bias in patient selection, the survival of patients with 12 months or less of prior dialysis at the time of enrollment ("new cases") was analyzed separately from that of patients with more than 1 yr of prior treatment ("long-standing cases"). Serum albumin was less than 3.5 g/dL in 31% of new cases and in 12% of long-standing cases. Adjusting for the other variables, low serum albumin was the strongest mortality risk predictor in both new and long-standing cases. Low serum cholesterol was an independent risk predictor in both groups. Diabetes and race were not significant predictors. Mean age at enrollment was nearly a decade higher for nonsurvivors than for survivors, in both new and long-standing groups. Yet, age was not an independent risk predictor in the Cox model for the new group because of an unexpectedly high death rate among young black men. Female gender, which was confounded by increased age, took the place of age in the model for the new group. For each model, there was good agreement between observed and predicted mortality for up to 24 months. To assess the influence of dialysis treatment time and dose (measured as pre-to-post treatment urea ratio) on risk, survival was examined in a subset of 139 patients monitored for up to 22 months, from 1989 to 1991, a period when the urea ratio was used routinely. Adjusting for the other variables, low serum albumin and cholesterol again independently increased risk. The urea ratio was also a significant independent predictor. The pattern of mortality by urea ratio was U shaped, with minimum risk for values between 2.5 and 3.4 Treatment time did not influence risk. It was concluded that baseline serum values of albumin and cholesterol strongly influence survival for up to 2 yr in new and long-standing hemodialysis patients.(ABSTRACT TRUNCATED AT 400 WORDS)
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PMID:Predictors of mortality in hemodialysis patients. 850 18

The incidence, causes, and consequences of hypoalbuminemia after renal transplantation are not well defined. We examined clinical correlates of serum albumin measured at 3 months, 6 months, 1 year, and annually thereafter in 706 renal transplant recipients who survived at least 6 months with a functioning allograft. Follow-up was 7.0 +/- 4.2 years. Hypoalbuminemia (< or = 3.5 g/dL) was most common at 3 months (31%, n = 692), least common at 1 year (12%, n = 656), and then became increasingly common among survivors, for example, 14% (n = 466) at 4 years, 20% (n = 204) at 8 years, and 29% (n = 77) at 12 years after transplantation. By multiple linear regression, variables that correlated (P < 0.05) with lower serum albumin at 3, 6, 12, and 24 months included age, diabetes, proteinuria, and cytomegalovirus infection. Other independent correlates on at least one of these occasions included renal function and chronic disease (malignancy, liver disease, and cardiovascular disease). Serum albumin, as a time-averaged and time-dependent covariate, was a strong independent risk factor for death using Cox proportional hazards analysis (relative risk for each g/dL increment, 0.26; 95% confidence interval, 0.16 to 0.44 [1.00 = no risk]). The effects of albumin on mortality were independent of age, diabetes, serum lipids, renal function, chronic liver disease, malignancies, and cardiovascular disease. The effects of albumin on mortality were evident even when the analysis was restricted to patients dying several years after albumin was measured. Thus, hypoalbuminemia is common and serum albumin is a strong independent risk factor for all-cause mortality after renal transplantation.
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PMID:Serum albumin and mortality after renal transplantation. 854 25

A high dropout rate is a major problem of continuous ambulatory peritoneal dialysis (CAPD) treatment. Serum albumin is both a significant parameter of dropout in CAPD and a predictor of peritoneal transport category based on the peritoneal equilibration test (PET). High flux peritoneal membrane (HFPM) may lose more protein in the dialysate. We examined the effect of HFPM on the survival of treatment of CAPD. The study was composed of 171 adult patients who had standard PET. The peritoneal transport category was based on their first PET after starting CAPD. The HFPM was defined as the dialysate-to-plasma creatinine concentration ratio (D/P) of more than one standard deviation of the mean (0.702 +/- 0.114; D/P > 0.816). Twenty-two patients had HFPM. The other 149 patients were categorized as the non-high flux group. The high flux group had a significantly lower serum albumin at PET (3.07 +/- 0.15 vs 3.68 +/- 0.05 g/dL, respectively p < 0.0001) and lower mean serum albumin during treatment than the non-high flux group (3.40 +/- 0.20 vs 3.70 +/- 0.04 g/dL, respectively, p = 0.020), and lower net drainage volume (p = 0.0007), but age, diabetes, total Kt/V, and total normalized weekly creatinine clearance were not different between groups. The risk of dropout was higher in the high flux group (p = 0.0127, Cox-Mantel log rank test), and the risk increased, especially after 1.5 years of treatment. Corrected for other risk factors, patients who had HFPM have two times the risk of dropout compared to the non-high flux groups (p = 0.0401, Cox proportional hazards model).
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PMID:High flux peritoneal membrane is a risk factor in survival of CAPD treatment. 886 83

Thirty-four children were followed up prospectively for 5 years from the onset of diabetes regarding serum magnesium, zinc and some proteins. Serum magnesium decreased to significantly lower values (0.76 +/- 0.05 mmol l-1) than those in matched controls after 2 and 5 years, with the lowest mean values in diabetic girls. Serum zinc concentration was higher in the diabetic group than in the control children, and again the diabetic girls differed most from the controls. Serum prealbumin was significantly lower in the diabetic patients after 2 and 5 years than in the controls. Serum albumin was also slightly reduced in the diabetic patients, while orosomucoid was normal. These data indicate chronic magnesium deficiency and insufficient liver synthesis of certain serum proteins in diabetic children.
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PMID:Serum magnesium and protein concentrations during the first five years of insulin-dependent diabetes in children. 905 31

The records of 734 peritoneal dialysis (PD) patients trained at our center between January 1983 and December 1991 were reviewed, and those who had been on PD more than 5 years were selected to study the characteristics common to long-term survivors. We obtained the following results: 22 patients (3%) remained on PD for more than 5 years and 6 patients for more than 8 years (0.8%). Of these, 59.1% were males and 55% white with a mean age of 41.3 +/- 15.1 years and weight 71.1 +/- 14.7 kg. The causes of end-stage renal disease (ESRD) were: diabetes 31.8%, glomerulonephritis 36.4%, and nephrosclerosis 22.7%. The average peritonitis rate was 0.46 episodes/year and hospitalization 4.13 +/- 3.70 days/ year. After 3 years of PD all patients were essentially anuric. The mean 4-hour D/Purea = 0.94 +/- 0.01 and D/Pcreatinine = 0.68 +/- 0.03. Weekly Kpt/Vurea improved from 1.61 to 1.82, Kcreatinine from 40 to 45 L/1.73 m2, and dialysate volume from 11.6 to 14.1 L/day. The normalized catabolic protein rate (NPCR) remained stable at 0.7 g/kg/day. Serum albumin concentrations (SACs) averaged 3.5 g/dL and did not show a trend with time. Weights revealed marked variation with a mean group gain of 3.4 +/- 0.85 kg. Social support was excellent in 19 patients, and 20 were very compliant. Thirteen patients remain on PD, 4 expired, 1 received a transplant, and 4 transferred to hemodialysis. In conclusion, PD can maintain life for prolonged periods of time in the absence of renal function. Longterm survivors are typically of average size, enjoy stable and average peritoneal transport, good social support, remain compliant with therapy, and experience infrequent peritonitis. New PD modalities capable of delivering higher doses and adjustment of prescription based on residual renal function, peritoneal transport, and metabolic needs should increase the proportion of long-term survivors.
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PMID:Characteristics of long-term peritoneal dialysis patients. 936 Jun 60

Standard total pancreatectomy (TP) combined with gastric resection often results in uncontrollable diabetes and malnutrition. Pylorus-preserving total pancreatectomy (PPTP) and standard TP for pancreatic cancer were compared in terms of operative outcomes, nutritional recovery, and long-term survival. Twenty-four patients with pancreatic ductal adenocarcinoma (n = 14) or intraductal papillary mucinous carcinoma (N = 10) underwent PPTP (n = 10) or standard TP (n = 14). There were no significant differences in age, gender, or tumor type or stage between the PPTP and standard TP groups. Early (within 30 days of surgery) morbidity and mortality rates were 20% and 0% for PPTP and 29% and 7% for standard TP, respectively. Delayed gastric emptying occurred in 2 patients in each group. The incidence of late complications, including uncontrollable diabetes, diarrhea, and malnutrition, tended to be lower after PPTP (30%) than after standard TP (69%). Serum albumin and body weight at 6 months after surgery were significantly higher in the PPTP than in the standard TP group. Regardless of the tumor type, long-term survival did not differ significantly between patients receiving PPTP and those with standard TP. PPTP for pancreatic cancer improves nutritional recovery, without compromising long-term survival, compared with standard TP.
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PMID:Pylorus-preserving total pancreatectomy for pancreatic cancer. 1059 6

Hypoalbuminemia in end-stage renal disease is a marker of high morbidity and mortality. In some patients, the cause of low serum albumin levels is easily identified and therefore treatable, but in many patients, the cause is not clear. We studied the effect of changing the dialysis membrane from a bioincompatible to a biocompatible membrane on serum albumin level. Stable hemodialysis patients dialyzed with cuprammonium membranes who had serum albumin levels less than 3.5 g/dL were switched to the more biocompatible membrane, polysulfone. Serum albumin levels increased from 3.22 +/- 0.037 to 3.35 +/- 0.038 g/dL (mean +/- SE; P < 0.002). The increase was seen in patients both with and without diabetes. Thus, dialyzer membrane may affect serum albumin levels and should be considered in the differential diagnosis of hypoalbuminemia in patients undergoing hemodialysis with bioincompatible membranes. Membrane choice may have an important effect on the outcome of morbidity and mortality of hemodialysis patients.
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PMID:Effect of biocompatibility of hemodialysis membranes on serum albumin levels. 1115 97

A 72-year-old woman with diabetic nephropathy was hospitalized with peripheral edema in the extremities and weight increase. After diuretics and human serum albumin administration, her condition improved. From the 15th day she had run a subfever and her breathing was diminished in the left lower lung field. A plain chest X-ray film showed pleural effusion over the left lung field. The fluid was exudative. Fluid cultures were negative. A tuberculin reaction was negative. Polymerase chain reaction method disclosed mycobacterium avium complex, indicating rare pleuritis due to mycobacterium avium complex. Eighteen days after chemotherapy, pleural effusion disappeared. Although her hemoglobin A1c (HbA1c) levels were maintained from 6.0 to 6.5% over 4 years, urinary albumin excretion levels and serum creatinine levels increased, indicating deteriorating diabetic nephropathy. Serum albumin levels remained low (3.3-3.6 g/dl). Malnutrition, impaired cellular immunity and apparently abnormal microvascular circulation due to diabetes mellitus may consequently have induced pleuritis due to mycobacterium avium complex.
Diabetes Res Clin Pract 2000 May
PMID:Mycobacterium avium complex pleuritis accompanied by diabetes mellitus. 1080 46

Thirty-six patients on peritoneal dialysis (PD) for more than ten years in six North American centers were analyzed retrospectively. In the six centers, the percentage of patients surviving for more than ten years varied between 0.8% and 7.3%. The study group included 27 females and 9 males aged 38.6 +/- 14.2 years [mean +/- standard deviation (SD)] at the start of treatment. Of the 36 patients, 28 were Caucasian. The most common cause of end-stage renal disease (ESRD), present in 12 patients, was chronic glomerulonephritis. Only 4 patients had diabetes. At the beginning of the study, 19 patients had hypertension (the most common comorbid condition); 11 had no comorbid conditions at the start. Creatinine clearance at the start was 4.12 +/- 3.5 mL per minute, and the mean duration to anuria was 51 +/- 25 months. Mean initial body weight was 55 +/- 9 kg, and mean body surface area was 1.5 +/- 0.2 m2. Serum albumin levels showed an increase from 33.8 +/- 3.6 g/L at the start of the study to 38.2 +/- 3.9 g/L at the end. Hospitalization rate was low at 0.5 +/- 0.3 admissions per patient-year, and duration of hospitalization was 4.8 +/- 3.7 days per patient-year. Peritonitis was the most common cause of hospitalization. The mean peritonitis rate was 1 episode every 52 +/- 48 patient-months. There were 36 catheter changes in 18 patients; 16 patients had a single PD catheter throughout the period of study. Autonomous hyperparathyroidism was the most common long-term complication. At the end of the study period, 11 patients were still on PD, 9 had died, 5 had been transferred to hemodialysis (HD), 1 was alive with a functioning allograft, and 1 was lost to follow-up. We conclude that patients who survive longer than ten years on PD are most likely to be young Caucasian females, small in body size, who are non diabetic, with few comorbid conditions. These long-term survivors have few hospitalizations, and their peritonitis rate is low. In this group of patients, severe autonomous hyperparathyroidism is the most common long-term complication.
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PMID:Patients on chronic peritoneal dialysis for ten years or more in North America. 1091 58

The mortality rate on hemodialysis therapy remains unacceptably high, and it is worse in whites than blacks. Substantially elevated serum aluminum levels have been shown to predict mortality on hemodialysis. However, whether this is a factor in the race-dependent survival difference on hemodialysis therapy is presently unknown. To determine the relevance of serum aluminum level on race-dependent survival disparity on chronic hemodialysis therapy, 1-year survival of 118 whites was prospectively compared with 473 age- and sex-matched blacks. The variables predictive for survival, including serum aluminum level, were defined separately in whites and blacks using Cox univariate and multivariate analyses. The 1-year mortality rate was significantly greater in whites than blacks (18% versus 12%; P: < 0.001). Serum albumin level, body mass index (BMI), and creatinine level had a positive influence, whereas age had a negative influence on survival in both groups in the univariate analysis. The mean serum aluminum level was significantly greater in whites (n = 118) than blacks (n = 473; 20 +/- 2.3 versus 14 +/- 0.6 [SE] ng/mL; P: = 0.0009) and was not caused by increased duration on dialysis, increased prescription of aluminum-containing phosphate binders, or reduced delivered dose of dialysis. Unlike the blacks, serum aluminum levels had a significant negative influence on the survival of whites, and this persisted in multivariate analysis after controlling for age, sex, diabetes, albumin level, creatinine level, and BMI (relative risk, 1.013; 95% confidence interval, 1.004 to 1.023; P: < 0.007). In summary, this study suggests that whites undergoing hemodialysis may have greater serum aluminum levels than blacks, which might contribute to the whites' greater rate of mortality. Because hyperaluminemia is a modifiable risk factor, studies are required to verify our findings, explore the mechanism of elevated aluminum levels in whites, and test the hypothesis that reducing serum aluminum levels in whites may improve their survival.
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PMID:Race-dependent survival disparity on hemodialysis: higher serum aluminum as an independent risk factor for higher mortality in whites. 1109 39


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