First, cause-specific death was not available in this study. Second, RKF measurement is not accurate given the use of CLurea and not the average of renal urea and creatinine clearances and the difficulties in complete collection of urine samples and its punctuality in patient daily life. The use of factor 0.9 for predialysis serum urea nitrogen for renal CLurea calculation might have also induced errors to some extent. Nevertheless, the population-level associations with clinical outcomes can be estimated from an adequate number of subjects if such errors are not associated with the outcome. Third, available RKF measures may not be representative of those in the entire hemodialysis population, because patients on dialysis with limited or no RKF are less likely to have undergone urine collections, especially at 1 year after hemodialysis initiation. This potential selection bias might have resulted in missing patients who lost RKF during the first 1 year of dialysis, and thus, the mortality risk of RKF decline might be underestimated. Additionally, although we adjusted for only baseline patient characteristics and not those at year 1 to avoid overadjustment, RKF decline could also be an intermediary between adverse events (e.g., cardiovascular events and infection) during the first year of dialysis and subsequent mortality. Indeed, the mortality risk of RKF decline was attenuated to some extent after adjusting for body mass index and laboratory variables at both baseline and 1 year, but it still remained significant (data not shown). Although it is hard to estimate the net effect of the former and the latter limitations, our results met seven of nine of the criteria by Hill 38 (i.e., temporal relationship, strength, dose-response relationship, consistency, biologic plausibility, coherence, and reasoning by analogy), suggesting a possible causal relationship between RKF decline and all-cause death in patients on hemodialysis.
In conclusion, decline in RKF, both renal CLurea and urine volume separately, shows a graded association with higher mortality among incident hemodialysis patients. Future trials are warranted to test the clinical benefits of RKF preservation strategies, including maintaining diuretic use and the incremental hemodialysis regimen.
We retrospectively extracted, discreet, and you can tested analysis regarding all the incident hemodialysis customers have been age ?18 years of age and you will obtained hemodialysis solution to ?60 straight months within the business work of the a giant dialysis providers (DaVita, Inc.) in the usa off . 39 People have been used up to , in addition to go after-right up time is actually split up into patient-home (91-big date symptoms off go out of earliest dialysis). For every single diligent-quarter, people was basically assigned the regular hemodialysis modality whenever they didn’t discover service besides thrice a week hemodialysis (i.e., peritoneal dialysis, less frequent for the–cardiovascular system hemodialysis, home hemodialysis, regular during the–center hemodialysis, otherwise letter;cardio hemodialysis) for around forty five weeks from inside the diligent-one-fourth.
To examine RKF and the changes during the first 1 year of hemodialysis, we used all incident in–center hemodialysis patients between 2007 and 2010 who were alive at year 1 and had measured renal CLurea at the start of dialysis and year 1. First, we excluded patients who were censored or ever treated with peritoneal dialysis, nocturnal hemodialysis, or home hemodialysis during the first 1 year of dialysis. Second, we identified 22,895 incident hemodialysis patients with baseline CLurea data from 67,311 patients who were assigned only conventional hemodialysis for the first four patient-quarters. Among them, 6538 patients also had RKF measurements at the fifth patient-quarter (i.e., the first 91-day period of the second year of dialysis) and were included in this study (details in Supplemental Figure 5). This study was approved by the Institutional Review Committees of the Los Angeles Biomedical Research Institute at Chicago escort service Harbor–University of California, Los Angeles; the University of California, Irvine Medical Center; and the University of Washington.