title: Sex differences in the impact of diabetes on mortality in chronic dialysis patients.
abstract: BACKGROUND
  Although females have a survival advantage in the general population, women undergoing dialysis have similar mortality to men. Because the reasons for this difference are unknown, we hypothesized that sex differences in cardiovascular disease (CVD) risk profile exist at dialysis initiation and that the association of such risk factors with mortality differs between sexes.
  
  
  METHODS
  This study was a prospective observational cohort study (NECOSAD) of incident dialysis patients with 5 years of follow-up where we calculated male:female odds ratios (OR) and relative risks of mortality (hazard ratio, HR) for the presence of CVD risk factors at the start of dialysis. We also examined the presence of interaction between sex and CVD risk factors in their association with mortality.
  
  
  RESULTS
  In 1577 patients (61% men, 60 ± 15 years), men presented more CVD co-morbidity [OR: 1.88 (95% CI: 1.51, 2.35)] but less diabetes mellitus (OR: 0.70 [0.55, 0.89]) than women. Both sexes presented equal survival [HR 0.98 (0.83, 1.16)]. Women with diabetes had a higher mortality risk [HR 2.93 (2.27, 3.79)] than their male counterparts [HR 1.99 (1.52, 2.59)], showing an interaction effect between sex and diabetes [relative excess risk due to interaction 1.18 (0.37, 2.00)].
  
  
  CONCLUSIONS
  Despite a lower prevalence of CVD, women starting dialysis had the same mortality risk as men. The mortality risk was strikingly higher in diabetic women than diabetic men. This excess mortality may help explain why dialysis cancels out the female survival advantage. Our study identifies a high-risk group of patients that may warrant further investigation and intensified therapeutic care.
authors.affiliation: Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden. juan.jesus.carrero@ki.se
authors.forename: Juan J
authors.initials: JJ
authors.lastname: Carrero
authors.forename: Renée
authors.initials: R
authors.lastname: de Mutsert
authors.forename: Jonas
authors.initials: J
authors.lastname: Axelsson
authors.forename: Olaf M
authors.initials: OM
authors.lastname: Dekkers
authors.forename: Kitty J
authors.initials: KJ
authors.lastname: Jager
authors.forename: Elisabeth W
authors.initials: EW
authors.lastname: Boeschoten
authors.forename: Raymond T
authors.initials: RT
authors.lastname: Krediet
authors.forename: Friedo W
authors.initials: FW
authors.lastname: Dekker
mesh_terms: D002318:Cardiovascular Diseases / Q000209:etiology; D002908:Chronic Disease; D015331:Cohort Studies; D048909:Diabetes Complications / Q000401:mortality*; D003920:Diabetes Mellitus / Q000401:mortality*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007676:Kidney Failure, Chronic / Q000150:complications* / Q000401:mortality / Q000628:therapy; D016030:Kidney Transplantation; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D006435:Renal Dialysis; D012307:Risk Factors; D012737:Sex Factors; D015996:Survival Rate; D016896:Treatment Outcome