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 Irving escort service (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.
Clients
We retrospectively removed, delicate, and you will checked out studies of most of the event hemodialysis customers who had been decades ?18 yrs old and you can obtained hemodialysis means to fix ?60 straight days when you look at the institution operated because of the a massive dialysis team (DaVita, Inc.) in america away from . 39 Customers was in fact observed up to , as well as the go after-right up go out try put into diligent-home (91-date periods away from time regarding very first dialysis). For each diligent-quarter, customers was assigned the conventional hemodialysis modality when they did not receive services besides thrice per week hemodialysis (we.elizabeth., peritoneal dialysis, less common into the–cardio hemodialysis, domestic hemodialysis, regular into the–cardio hemodialysis, otherwise letter;cardiovascular system hemodialysis) for around forty-five months when you look at the diligent-one-fourth.
To the point Strategies
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 Harbor–University of California, Los Angeles; the University of California, Irvine Medical Center; and the University of Washington.
