title: Association of fluid overload with cardiovascular morbidity and all-cause mortality in stages 4 and 5 CKD.
abstract: OBJECTIVE
  Fluid overload is a common characteristic associated with renal progression in CKD. Additionally, fluid overload is an independent predictor of all-cause or cardiovascular mortality in patients on dialysis, but its influence on patients not on dialysis is uncertain. The aim of the study was to assess the relationship between the severity of fluid status and clinical outcomes in an advanced CKD cohort.
  
  
  METHODS
  In total, 478 predialysis patients with stages 4 and 5 CKD in the integrated CKD care program were enrolled from January of 2011 to December of 2011 and followed-up until August of 2013. The clinical outcomes included cardiovascular morbidity and all-cause mortality. The relative hydration status (overhydration/extracellular water) was used as the presentation of the severity of fluid status and measured using a body composition monitor. Overhydration/extracellular water >7% was defined as fluid overload.
  
  
  RESULTS
  Over a median follow-up period of 23.2 (12.6-26.4) months, 66 (13.8%) patients reached all-cause mortality or cardiovascular morbidity. The adjusted hazard ratio of the combined outcome of all-cause mortality or cardiovascular morbidity for every 1% higher overhydration/extracellular water was 1.08 (95% confidence interval, 1.04 to 1.12; P<0.001). The adjusted overhydration/extracellular water for the combined outcome of all-cause mortality or cardiovascular morbidity in participants with overhydration/extracellular water ≥7% compared with those with overhydration/extracellular water <7% was 1.93 (95% confidence interval, 1.01 to 3.69; P=0.04). In subgroup analysis, higher overhydration/extracellular water was consistently associated with increased risk for the combined outcome independent of diabetes, cardiovascular disease, and serum albumin. There was no significant interaction between all subgroups.
  
  
  CONCLUSIONS
  These findings suggest that fluid overload is an independent risk factor of the combined outcome of all-cause mortality or cardiovascular morbidity in patients with advanced CKD.
authors.affiliation: Graduate Institute of Clinical Medicine and Division of Nephrology and Faculty of Renal Care, Kaohsiung Medical University, Kaohsiung, Taiwan;
authors.forename: Yi-Chun
authors.initials: YC
authors.lastname: Tsai
authors.affiliation: Division of Nephrology and Faculty of Renal Care, Kaohsiung Medical University, Kaohsiung, Taiwan;
authors.forename: Yi-Wen
authors.initials: YW
authors.lastname: Chiu
authors.affiliation: Division of Nephrology and Faculty of Renal Care, Kaohsiung Medical University, Kaohsiung, Taiwan;
authors.forename: Jer-Chia
authors.initials: JC
authors.lastname: Tsai
authors.affiliation: Division of Nephrology and Faculty of Renal Care, Kaohsiung Medical University, Kaohsiung, Taiwan;
authors.forename: Hung-Tien
authors.initials: HT
authors.lastname: Kuo
authors.affiliation: Division of Nephrology and Faculty of Renal Care, Kaohsiung Medical University, Kaohsiung, Taiwan;
authors.forename: Chi-Chih
authors.initials: CC
authors.lastname: Hung
authors.affiliation: Graduate Institute of Clinical Medicine and Division of Nephrology and Faculty of Renal Care, Kaohsiung Medical University, Kaohsiung, Taiwan; Institute of Population Sciences, National Health Research Institutes, Miaoli, Taiwan.
authors.forename: Shang-Jyh
authors.initials: SJ
authors.lastname: Hwang
authors.affiliation: Department of Nursing, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; and.
authors.forename: Tzu-Hui
authors.initials: TH
authors.lastname: Chen
authors.affiliation: Graduate Institute of Clinical Medicine and Division of Nephrology and Faculty of Renal Care, Kaohsiung Medical University, Kaohsiung, Taiwan; mechku@cc.kmu.edu.tw.
authors.forename: Mei-Chuan
authors.initials: MC
authors.lastname: Kuo
authors.affiliation: Division of Nephrology and Faculty of Renal Care, Kaohsiung Medical University, Kaohsiung, Taiwan;
authors.forename: Hung-Chun
authors.initials: HC
authors.lastname: Chen
mesh_terms: D000368:Aged; D001823:Body Composition; D002318:Cardiovascular Diseases / Q000175:diagnosis / Q000401:mortality*; D002423:Cause of Death; D018450:Disease Progression; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D051436:Renal Insufficiency, Chronic / Q000150:complications / Q000175:diagnosis / Q000401:mortality* / Q000503:physiopathology; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D013624:Taiwan / Q000453:epidemiology; D013997:Time Factors; D014882:Water-Electrolyte Balance; D014883:Water-Electrolyte Imbalance / Q000175:diagnosis / Q000401:mortality* / Q000503:physiopathology
keywords: CKD; cardiovascular disease; mortality