No abstract

This study expands our understanding of the relationship between altered mineral metabolism and outcomes and identifies several potential opportunities for improved practice in this area.

Mortality risk among hemodialysis (HD) patients may be highest soon after initiation of HD. A period of elevated mortality risk was identified among US incident HD patients, and which patient characteristics predict death during this period and throughout the first year was examined using data from the Dialysis Outcomes and Practice Patterns Study (DOPPS; 1996 through 2004). A retrospective cohort study design was used to identify mortality risk factors. All patient information was collected at enrollment. Life-table analyses and discrete logistic regression were used to identify a period of elevated mortality risk. Cox regression was used to estimate adjusted hazard ratios (HR) measuring associations between patient characteristics and mortality and to examine whether these associations changed during the first year of HD. (1), and a higher mortality rate within the first year after initiation of HD has been described (2). Identifying the period of highest risk for death after initiation of HD and factors that are associated with this higher risk are important to the care of patients who are new to HD (incident). Observational studies among prevalent HD patients have identified patient characteristics that are associated with greater mortality risk, including white race, older age, low serum albumin levels, low and elevated serum phosphorus levels, anemia, and cardiovascular disease (traditional risk factors) (3-14), as well as other nontraditional risk factors, including C-reactive protein and IL-6 levels (15,16). Studies also have supported the importance of early nephrology referral in the predialysis period for reducing mortality after HD initiation (17)(18)(19). Because these studies typically have included prevalent rather than incident patients, only limited information is available concerning mortality rates and factors that influence mortality immediately after HD initiation. One reason for this may be the 90-d Medicare entitlement period (coordination of benefits) during which coverage is not guaranteed (1). The few studies that have assessed mortality rates or risk predictors in the period immediately after HD initiation (2,20 -24) suggest an elevated mortality risk in the first 90 d, but it is unclear whether that elevation is limited to the first 90 d. One population-based study (2) found that 6% of HD patients died within the first 90 d, accounting for nearly 35% of deaths within the first year.Studies that quantify mortality rates and identify mortality predictors among incident HD populations are useful for understanding the influence of predialysis care and length of time on dialysis. Data from the 2004 Annual Dialysis Report (1) indicate higher mortality rates for patients who have received HD for Ͼ5 yr as compared with Ͻ2 yr, suggesting that length of time on HD modifies mortality risk. Most patients begin HD

The available data on bone fractures in hemodialysis (HD) patients are limited to results of a few studies of subgroups of patients in the United States. This study describes the prevalence of hip fractures and the incidence and risk factors associated with hip and other fractures in representative groups of HD facilities (n=320) and patients (n=12 782) from the 12 countries in the second phase of the Dialysis Outcomes and Practice Patterns Study (2002-2004). Among prevalent patients, 2.6% had a prior hip fracture. The incidence of fractures was 8.9 per 1000 patient years for new hip fractures and 25.6 per 1000 for any new fracture. Older age (relative risk (RR)(HIP)=1.91, RR(ANY)=1.33, P<0.0001), female sex (RR(HIP)=1.41, P=0.02; RR(ANY)=1.59, P<0.0001), prior kidney transplant (RR(HIP)=2.35, P=0.04; RR(ANY)=1.76, P=0.007), and low serum albumin (RR(HIP)=1.85, RR(ANY)=1.45, per 1 g/dl lower, P<0.0001) were predictive of new fractures. Elevated risk of new hip fracture was observed for selective serotonin reuptake inhibitors and combination narcotic medications (RR=1.63, RR=1.74, respectively, P<0.05). Several medications were associated with risk of any new fracture: narcotic pain medications (RR=1.67, P=0.02), benzodiazepines (RR=1.31, P=0.03), adrenal cortical steroids (RR=1.40, P<0.05), and combination narcotic medications (RR=1.72, P=0.001). Parathyroid hormone (PTH) levels >900 pg/ml were associated with an elevated risk of any new fracture (RR=1.72, P<0.05) versus PTH 150-300. The results suggest that greater selectivity in prescribing several classes of psychoactive drugs and more efficient treatment of secondary hyperparathyroidism may help reduce the burden of fractures in HD patients.