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Background: Since protein-calorie malnutrition is a common factor influencing morbidity and mortality of haemodialysis patients, assessing their nutritional status is important. The aim of this study was to investigate the predictive value of anthropometric parameters on mortality and their interrelationship., Methods: The study included a cohort of 242 patients. The analysis involved baseline data obtained during the first calendar year after the patients entered the study (1994-2001) and repeated measurements for up to 132 months of follow-up (until 2004). Anthropometric measurements were made during the winter season and included skinfolds, mid-arm circumference (MAC), body height and weight. The percentage of body fat (%fat) was calculated from triceps (TSF), biceps, subscapular and suprailiac skinfolds (Disease Outcomes Quality Initiative (DOQI) guidelines) and mid-arm muscle circumference (MAMC) from MAC and TSF. Body mass index (BMI), Kt/V, normalized protein catabolic rate (NPCR) and cardiovascular co-morbidity were also determined and laboratory analyses undertaken., Results: Strong correlations were found among the anthropometric parameters. Extended Cox regression analysis selected %fat, MAC, MAMC and TSF in addition to age, ischaemic heart disease, congestive heart failure, Kt/V, haemoglobin, creatinine, albumin and NPCR as potential predictors of mortality. The same anthropometric parameters were found to be independent mortality predictors in corresponding models. The most predictive anthropometric factor was MAC. BMI was not a risk factor., Conclusion: Percentage of body fat, MAC, MAMC and TSF were independent predictors of mortality of haemodialysis patients, and MAC was the most predictive one.

The most frequent cause of death in hemodialysis patients is cardiovascular disease with chronic inflammation being an epidemiologically proved risk factor. Many studies have shown C-reactive protein (CRP) as the strongest predictor of long-term mortality of hemodialysis patients, while other reports have indicated acute phase proteins as potential predictors of the mortality. The present study therefore aimed to evaluate the prevalence of chronic inflammation in hemodialysis patients and the role of acute phase proteins together with lipids and divalent ions for predicting mortality in hemodialysis patients. Chronic inflammation was defined, based on the serum level of high sensitive CRP > 8.4 mg/L and/or serum amyloid-A (SAA) > 8.9 mg/L. Acute phase proteins are defined as one whose plasma concentration increase (positive) or decreases (negative) by at least 25% during inflammation. High sensitive CRP and SAA were positive acute phase proteins measured, while albumin and fetuin-A, a calcification inhibitor, were selected as negative acute phase proteins. This prospective 36-month follow-up study included 130 patients (60 males and 70 females, aged 55.1 +/- 12.9 years) maintained by hemodialysis for 107.2 +/- 54.72 months at a Nephrology Clinic in Belgrade. The prevalence of chronic inflammation was 35.4% (46 patients). During the follow-up period, 24 patients (18.5%) died and 2 patients received transplants. In multivariate analysis, potential independent predictors of mortality in hemodialysis patients are hyperphosphatemia, hypoalbuminemia, and high SAA. Considering that assays for SAA are widely used, we propose that SAA is the best predictor for outcomes of end-stage renal disease.

The aims of the present study were to determine the prevalence of depression in our dialysis patients, to detect the most powerful variables associated with depression, and to determine the role of depression in prediction of mortality. The prospective follow-up study of 128 patients (77 HD and 51 CAPD, 65 male, aged 53.8 +/- 13.5 years, dialysis duration 64.7 +/- 64.8 months) was carried out over 36 months. Depression by the Beck Depression Inventory-BDI-II score, laboratory parameters (hemoglobin, serum albumin and creatinine concentration), immunological status (cytokines and hsCRP), comorbidity by Index of Physical Impairment (IPI) and adequacy of dialysis by Kt/V were monitored. The overall prevalence of depression in the dialysis patients (BDI score > or = 14) was 45.3%, and 28.2%, respectively, for moderate and severe depression (BDI > or = 20). The most powerful variable associated with depression was IL-6, but associations with albumin, hemoglobin, creatinine and IPI score were also found. During the follow-up period 36 patients died, 7 patients left the cohort and 2 patients were transplanted. If IPI score was not included in the multivariate Cox analysis, the BDI score remained one of the best predictors of mortality along with albumin. In conclusion, because of the close association of depression with inflammation, malnutrition, and cardiovascular mortality, it could be speculated that depression is one branch of the MIA (malnutrition, inflammation, atherosclerosis) syndrome.

Background: It is well known that serum urea concentration is not a good predictor of mortality in hemodialysis patients. On the other hand, urea kinetic modeling has been very successfully used to measure dialysis dose by the Kt/V index, which was found to be a good predictor of mortality. Could there be a relation between urea and mortality, but in some more complex way?, Methods: This is a post-hoc analysis of a single center observation study that included 242 patients and an 11-year observation period. Mortality rates between the quartiles of serum urea levels were examined by a 2 x 4 table with the chi(2) test. Both univariate and multivariate survival analyses were performed with standard and segmented extended Cox regression., Results: The relation between mean urea in the baseline period and mortality showed an irregular U-shaped curve. The lowest mortality was observed in the third quartile (28 to 31 mmol/L). The relation between mean urea in the whole observation period and mortality was a J-shaped curve. The lowest mortality was in the second quartile (25-27 mmol/L). Urea was not a predictor of mortality in the whole cohort, but low-urea (binary) and high-urea (binary) were independent predictors of mortality in the corresponding models using standard or extended Cox regression., Conclusion: This study revealed a complex relationship between urea and mortality in hemodialysis patients. Patients with low or high urea levels exhibited higher mortality than those with medium levels, while both low and high levels of urea were independent predictors of all-cause mortality.

The aim of the study was to examine the influence of improved treatment of hemodialysis (HD) patients on their health-related quality of life (HrQoL) and to assess the predictive value of HrQoL dimensions on patient outcome. The prospective cohort study involved 102 HD patients, and their clinical and laboratory parameters and HD adequacy indices were followed from 2001 to 2007. HrQoL was measured using KDQOL-SF Version 1.3 in 2001, 2004, and 2007. During a six-year period, quality of HD and anemia treatment improved and resulted in significant increase of mean Kt/V (1.2-1.56) and hemoglobin levels (86.5-115.6 g/L). All four HrQoL dimensions (i.e., physical, mental health, kidney disease target issues, and patient satisfaction) remained unchanged, but significant improvement in several HrQoL physical health domains and the effects of kidney disease domain was found. Mortality rate decreased from 18.6% to 7.14% per year. Age was associated positively, but kidney disease target issue score negatively, with patient death. Improved HD adequacy and anemia treatment in HD patients were followed with maintenance of all four HrQoL dimensions unchanged over six years. Moreover, an improvement in several physical health domains and the effects of kidney disease domain was found. Age and kidney disease target issue appeared as significant predictors of patients' death.

Background: A number of studies have reported lower mortality of overweight hemodialysis patients. This post hoc analysis of an observational prospective single-center study was aimed at elucidating whether both being overweight and surviving longer could result from changes in the hemodialysis modality., Methods: The study included a cohort of 242 patients who were gradually switched from cuprophane membrane and acetate dialysis to polysulfone (including high-flux) membranes and bicarbonate dialysis. The analysis involved 12 months of baseline data obtained during the first calendar year after the patients entered the study (1994-2001) and repeated measurements for up to 132 months of follow-up (until 2004). Anthropometric measurements were made during the winter season and the percentage of body fat (%fat) was calculated from triceps, biceps, subscapular, and suprailiac skinfolds (K/DOQI guidelines).Kt/V, normalized protein catabolic rate, and cardiovascular comorbidity were also determined and laboratory analyses undertaken., Results: Significant correlations were found between %fat and bicarbonate dialysate as well as polysulfone membrane and high-flux membrane. The linear mixed model showed dependence of %fat on polysulfone and high-flux membrane (p<0.01) Multivariate Cox regression (time-dependent covariates) found %fat to be an independent factor for longer survival, in addition to polysulfone and high-flux membranes., Conclusion: Changes in hemodialysis modality were followed by both higher body fat percentage and patient survival. The reverse epidemiology of overweight patients might be at least partially the result of the influence of nonnutritional factors, such as a change in hemodialysis modality (introducing biocompatible high-flux and low-flux membranes and bicarbonate dialysis).

Background: The electrophysiological aspects of uremic neuropathy have been studied extensively, but never for prediction of mortality. In order to assess the parameters of nerve conduction study (NCS) as predictors of mortality in hemodialysis patients, a post hoc analysis of a prospective observation study was made., Methods: We examined conventional electrophysiological parameters (motor nerve conduction velocity [MCV], terminal latency [TL], and F wave latency of the peroneal nerve, as well as sensory nerve conduction velocity [SCV] of the sural nerve) in 75 nondiabetic patients. Hemodialysis modality (bicarbonate dialysis and biocompatible membranes), Kt/V, comorbidity (ischemic heart disease and congestive heart failure), and clinical and laboratory parameters were also evaluated. Survival was analyzed using the Cox proportional hazard model., Results: SCV was significantly higher (t-test, p < 0.01) in the group of patients treated with polysulfone compared to those using cuprophane membranes. On the other hand, MCV significantly correlated with Kt/V (Pearson, r = 0.388; p < 0.01). Multivariate Cox regression revealed only MCV as a significant predictor of mortality in this group of hemodialysis patients (HR = 0.92; CI (0.86-0.99); p < 0.05)., Conclusion: Only MCV was a significant mortality risk predictor among NCS parameters. This parameter correlates significantly with dialysis dose. SCV was related to the use of biocompatible membranes, indicating the complexity of polyneuropathy in dialysis patients.

Recent studies give contradictory data regarding the role of hyperhomocysteinemia (hyperHcy) in cardiovascular (CV) morbidity and mortality in hemodialysis (HD) patients. The aims of the present study were to detect the most powerful variables associated with hyperHcy as well as to evaluate the relationship between hyperHcy and CV morbidity and mortality. The prospective follow-up study of 113 patients (52 males, aged 55.2+/-13.1 years) maintained by HD for 81.9+/-56.9 months at our Institute was carried out over 55 months. Fifty-seven (50.4%) of the examined patients were supplemented with water-soluble vitamins including folic acid and vitamin B complex pills or ampoules. Total serum Hcy level was determined by high-performance liquid chromatography, while serum folic acid and vitamin B(12) were measured by radioimmunoassay. The multivariate analysis showed HD duration (r=0.608; P=0.02) and folic acid serum level (r=-0.580; P=0.03) to be significant predictors of serum tHcy concentration. The multivariate Cox regression analysis of CV mortality revealed diabetes mellitus and heart failure as the most powerful positive predictors, while creatinine, albumin and vitamins intake therapy were negative predictors of CV mortality. Long-term supplementation with the usual doses of vitamins is followed with increased survival in hemodialysis patients. Although total serum Hcy level was not found to be a predictor of overall and CV mortality, the role of hyperHcy. as risk factor for CVD cannot be excluded in hemodialysis patients.

Background: Acute renal failure (ARF) requiring hemodialysis (HD) treatment is related to high mortality. The aim of this study was to analyze the influence of age, disease severity, and catabolism intensity on ARF outcome in patients requiring HD treatment during a 15-year period (1987-2001)., Methods: The retrospective, single-center study included 583 patients, 428 male, 155 female, age 49+/-15 years, treated by intermittent HD using cuprophane membranes with surface area of 1.3 m2. Liano's Acute Tubular Necrosis Individual Severity Score (ATNISS) score and Hypercatabolism Depuration Score (HDS) score were calculated to estimate disease severity and catabolism intensity in ARF patients., Results: Average age of patients significantly increased during the 15-year period for more than one decade (44 to 55 years; p=0.0359), especially during the last five-year period (47+/-14.5 vs. 53+/-14.7, p=0.00015). Disease severity showed significant increase comparing periods 1992-1996 and 1997-2001 (ATNISS 0.385+/-0.197 vs. 0.437+/-0.208; p=0.00137), while catabolism intensity during these periods was similar (HDS 0.569+/-0.145 vs. 0.582+/-0.127; p=0.357). Despite the older and more severely ill population of ARF patients, mortality showed a sustained decrease during the 15-year period. Mortality in the period from 1987 to 1991 (49/83; 59%) was similar with the period 1992-1996 (chi2=0.44, p=0.5081), but significantly higher than in the period 1997-2001 (114/250; 45.6%; chi2=3.98, p = 0.0471)., Conclusion: The results showed an improvement in the outcome of patients with ARF requiring HD treatment, despite increasing age, disease severity, and use of bioincompatible membranes.

In recent years the percentage of diabetic patients on haemodialysis has increased. Considering the high frequency of intradialytic hypotensive and hypoglycaemic episodes experienced by these patients, it was the aim of the present study to evaluate the influence of different dialysate glucose concentrations (5.5 mmol/L or 11 mmol/L) on blood pressure and glycaemic regulation, using special dialysis equipment - the GENIUS System. This cross-over, prospective and randomised study, total duration 14 weeks, included 20 diabetic patients on maintenance haemodialysis. Group 1: 9 patients dialysed using dialysate with a glucose concentration of 5.5 mmol/L and after 7 weeks switched to dialysate with a glucose concentration of 11 mmol/L. Group 2: vice versa. Results show a statistically higher number of patients with hypoglycaemic and hypotensive episodes using dialysate with a 5.5 mmol/L glucose concentration. Also, mean serum glucose values were higher during haemodialysis sessions with a glucose dialysate concentration of 11 mmol/L. There were no statistical differences between the groups in laboratory values, HbA1C, insulin doses or in anthropometric parameters. Our results suggest that fewer diabetic patients undergoing haemodialysis using a higher dialysate glucose concentration of 11 mmol/L have hypoglycaemic and hypotensive episodes. Since this dialysate glucose concentration had no influence on lipid or hepatic metabolism, anthropometric parameters and especially HbA/1C values in this short-term study, the long term examination of its effects is warranted.