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Background: People with end-stage kidney disease treated with dialysis experience high rates of premature death that are at least 30-fold that of the general population, and have markedly impaired quality of life. Despite this, interventions that lower risk factors for mortality (including antiplatelet agents, epoetins, lipid lowering, vitamin D compounds, or dialysis dose) have not been shown to improve clinical outcomes for this population. Although mortality outcomes may be improving overall, additional modifiable determinants of health in people treated with dialysis need to be identified and evaluated. Oral disease is highly prevalent in the general population and represents a potential and preventable cause of poor health in dialysis patients. Oral disease may be increased in patients treated with dialysis due to their lower uptake of public dental services, as well as increased malnutrition and inflammation, although available exploratory data are limited by small sample sizes and few studies evaluating links between oral health and clinical outcomes for this group, including mortality and cardiovascular disease. Recent data suggest periodontitis may be associated with mortality in dialysis patients and well-designed, larger studies are now required., Methods/design: The ORAL Diseases in hemodialysis (ORAL-D) study is a multinational, prospective (minimum follow-up 12 months) study. Participants comprise consecutive adults treated with long-term in-center hemodialysis. Between July 2010 and February 2012, we recruited 4500 dialysis patients from randomly selected outpatient dialysis clinics in Europe within a collaborative network of dialysis clinics administered by a dialysis provider, Diaverum, in Europe (France, Hungary, Italy, Poland, Portugal, and Spain) and South America (Argentina). At baseline, dental surgeons with training in periodontology systematically assessed the prevalence and characteristics of oral disease (dental, periodontal, mucosal, and salivary) in all participants. Oral hygiene habits and thirst were evaluated using self-administered questionnaires. Data for hospitalizations and mortality (total and cause-specific) according to baseline oral health status will be collected once a year until 2022., Discussion: This large study will estimate the prevalence, characteristics and correlations of oral disease and clinical outcomes (mortality and hospitalization) in adults treated with dialysis. We will further evaluate any association between periodontitis and risk of premature death in dialysis patients that has been suggested by existing research. The results from this study should provide powerful new data to guide strategies for future interventional studies for preventative and curative oral disease strategies in adults who have end-stage kidney disease.

A substantial amount of recent data suggests that even mild renal impairment is associated with a high risk of cardiovascular disease and exposes to a high risk of cardiovascular mortality in the case of an acute cardiovascular event. This relationship is consistent in all ranges of age including elderly subjects aged 65 years or above. The mechanisms behind this "renal-cardiovascular" association are probably intricated and include the high prevalence of traditional risk factors and the underutilisation of cardiovascular therapeutics and interventions in this population. On the other hand renal vascular damage may reflect the degree of systemic vascular damage. Alike proteinuria and microalbuminuria, renal insufficiency is a major independent cardiovascular risk factor, of the same magnitude as that confered by diabetes or symptomatic coronary disease. The risk increases continuously as the estimated glomerular filtration rate decreases below 60 mL/min, concerning at least 7% of all subjects aged 60 to 69 years and 25% above 70 years. Validated strategies for lowering the cardiovascular risk should be implemented to improve the prognosis in this high-risk population.