title: Independent and joint associations of nutritional status indicators with mortality risk among chronic hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study (DOPPS).
abstract: OBJECTIVE
  To consider the Kidney Disease Outcomes Quality Initiative recommendation of using multiple nutritional measurements for patients on maintenance dialysis, we explored data for independent and joint associations of nutritional indicators with mortality risk among maintenance hemodialysis patients treated in 12 countries.
  
  
  METHODS
  Dialysis units in seven European countries, the United States, Canada, Australia, New Zealand, and Japan.
  
  
  RESULTS
  Mortality risk.
  
  
  METHODS
  We conducted a prospective cohort study of 40,950 patients from phases I to III of the Dialysis Outcomes and Practice Patterns Study (1996-2008). Independent and joint effects (interactions) of nutritional indicators (serum creatinine, serum albumin, normalized protein catabolic rate, body mass index [BMI]) on mortality risk were assessed by Cox regression with adjustments for demographics, years on dialysis, and comorbidities.
  
  
  RESULTS
  Important variations in nutritional indicators were seen by country and patient characteristics. Poorer nutritional status assessed by each indicator was independently associated with higher mortality risk across regions. Significant multiplicative interactions (each p < or = 0.01) between indicators were also observed. For example, by using patients with serum creatinine 7.5-10.5 mg/dL and BMI 21-25 kg/m(2) as referent, BMI <21 kg/m(2) was associated with lower mortality risk among patients with creatinine >10.5 mg/dL (relative risk = 0.68) but with higher mortality risk among those with creatinine <7.5 mg/dL (relative risk = 1.38). The association of lower albumin concentration with higher mortality risk was stronger for patients with lower BMI or lower creatinine.
  
  
  CONCLUSIONS
  The joint effects of nutritional indicators on mortality indicate the need to use multiple measurements when assessing the nutritional status of hemodialysis patients.
authors.affiliation: Department of Medicine, Federal University of Bahia, Salvador, BA CEP: 40110-100, Brazil. aaslopes@ufba.br
authors.forename: Antonio Alberto
authors.initials: AA
authors.lastname: Lopes
authors.forename: Jennifer L
authors.initials: JL
authors.lastname: Bragg-Gresham
authors.forename: Stacey J
authors.initials: SJ
authors.lastname: Elder
authors.forename: Nancy
authors.initials: N
authors.lastname: Ginsberg
authors.forename: David A
authors.initials: DA
authors.lastname: Goodkin
authors.forename: Trinh
authors.initials: T
authors.lastname: Pifer
authors.forename: Norbert
authors.initials: N
authors.lastname: Lameire
authors.forename: Mark R
authors.initials: MR
authors.lastname: Marshall
authors.forename: Yasushi
authors.initials: Y
authors.lastname: Asano
authors.forename: Tadao
authors.initials: T
authors.lastname: Akizawa
authors.forename: Ronald L
authors.initials: RL
authors.lastname: Pisoni
authors.forename: Eric W
authors.initials: EW
authors.lastname: Young
authors.forename: Friedrich K
authors.initials: FK
authors.lastname: Port
mesh_terms: D015415:Biomarkers / Q000097:blood; D015992:Body Mass Index; D015331:Cohort Studies; D015897:Comorbidity; D003404:Creatinine / Q000097:blood; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000401:mortality* / Q000628:therapy*; D016015:Logistic Models; D008297:Male; D044342:Malnutrition / Q000209:etiology / Q000401:mortality*; D008875:Middle Aged; D015999:Multivariate Analysis; D009752:Nutritional Status; D011446:Prospective Studies; D006435:Renal Dialysis / Q000009:adverse effects / Q000401:mortality*; D012307:Risk Factors; D012709:Serum Albumin / Q000378:metabolism; D016896:Treatment Outcome; D015431:Weight Loss
chemical_list: D015415:Biomarkers; D012709:Serum Albumin; D003404:Creatinine