This study confirms that hypertension is a risk factor for mortality in HD patients, and shows the importance of the length of the follow-up time to demonstrate this relationship. The low frequency of a cardiac cause in the early death group suggests that the association between hypotension and mortality in HD patients is not related to cardiovascular causes, and only reflects the association between hypotension and other severe medical conditions.
The Cox stepwise logistic regression model was applied to analyze 22 factors potentially affecting morbidity and mortality (MM) in a cohort of 104 patients on chronic hemodialysis (CHD). Two groups of predictor variables were considered: patients' characteristics at the start of the study, and treatment-related factors recorded throughout the observation period. End points were either failure (death or admission to a hospital) or success. Patients were followed for 24 months. Thirty-nine patients were hospitalized and seven died in the interval. The two leading causes of failure were cardiovascular and infectious complications. Variables significantly associated with the result were: cardiac status (score greater than 2, beta = 1.16), mean predialysis blood pressure (greater than 115 mm Hg, beta = 0.94), total dialysis dose (greater than 0.90, beta = -0.59) and age (greater than 55 years, beta = 0.51). The probability of failure was 0.13 for patients who presented the four variables in the lowest risk class. This increased to a maximum of 0.60 with one risk factor, to 0.91 with two risk factors, and to 0.99 with three or more risk factors. We conclude that, given the conditions for this study, two treatment-related variables of CHD (mean predialysis blood pressure and total dialysis dose) are MM factors even when simultaneously analyzed with other well-established predictors (cardiac status and age). Mean arterial pressure (MAP) is the most important CHD treatment-related MM predictor.
Importance of blood pressure control in hemodialysis patient patients, however, the relationship between blood pressurvival. sure (BP) and mortality is controversial. Several studies Background. In the general population, hypertension is the have reported that hypertension is a risk factor for morleading cause of cardiovascular mortality. In dialysis patients, tality [8-11]. Other studies have suggested that hypertenhowever, the relationship between blood pressure (BP) and sion may not have a major adverse effect on mortality mortality is controversial. We analyzed this relationship in hemodialysis (HD) patients. of hemodialysis (HD) patients [12-16]. It has been also Methods. The study population included 405 patients who observed that low BP is associated with increased mortalhad survived at least two years on HD. The observation period ity [12, 14, 15], and some results suggest a U-curve relawas initiated at the beginning of the third year. Predialysis BP tionship between BP and CV mortality [14]. measurements of all the dialysis treatments performed during The present study analyzes the relationship between the second year of HD was collected as the baseline data. Mean systolic BP (SBP) and mean diastolic BP (DBP) were BP and mortality in HD patients, using the Cox proporcalculated. Demographic and comorbidity data were collected tional hazard regression model [17] and adjusting for at the start of the observation period (beginning of third year demographic and comorbidity variables. of HD). Mortality was analyzed at the end of the follow-up (death or December 31, 1998; total mortality), during the first two years of follow-up (years 3 and 4 of HD; early mortality) METHODS and after the second year of follow-up (Ն5 years of HD; late mortality). All of the 405 patients who survived at least two years Results. In the multivariate analysis, SBP and DBP were of HD therapy, and were treated in five centers in Montesignificantly associated with death. The adjusted total mortalit
In spite of the economic difficulties, very important efforts have been made to treat ESRD patients and gross mortality statistics in some countries are similar to those reported by other regional registries.
Criteria for selection of ESRD treatment modalities. The most strategy may be based, also, on clinical status, patient important renal replacement therapies (RRT) for end-stage age, patient preference, psychological stability, etiology renal disease (ESRD) patients are hemodialysis (HD), peritoof ESRD, comorbidity, suitable living-related donor, neal dialysis (PD) and renal transplantation (RT). Survival, economic factors and social circumstances. morbidity and quality of life are the main factors to select the best RRT modality for a particular patient. The outcome comparison suggest that RT is a better overall treatment for DIALYSIS VS. RENAL TRANSPLANTESRD patients. On the other hand, the studies that compared patient outcome for HD and PD have yielded conflicting re-Patient survival after RT is markedly better than that sults. Neither treatment modality is best suited for all patients.seen with either HD or PD [1][2][3][4]. However, some of the The choice should be analyzed for each particular patient conbenefits associated with transplantation are related to sidering his demographic and comorbid conditions. Diabetic patient selection, since dialysis patients with the most patients, patients with cardiovascular disease and elderly patients are high risk populations and they are discussed indepenserious comorbid conditions are not accepted for the dently. The frequency of treatment modalities in the different transplant waiting list and hence remain in the dialysis countries is not in accordance with the analysis of the advangroup. Some comparative studies of dialysis vs. RT surtages and disadvantages of each one. Non-medical reasons vival have considered that the transplant group is favored are important factors in dialysis modality selection. In our experience the expertise of the nephrologic team is the most by inclusion of these high-risk patients in the dialysis important one. RT, HD and PD should not be seen as competgroup [2, 3, 5, 6].ing therapeutic options, rather, they are complementary meth-We analyzed survival for ESRD patients on dialysis ods of dealing with uremia. An integrated approach combining vs. after transplantation, adjusting for the variables that HD, PD and RT is necessary to devise an individualized treatwere significantly and independently related with mortalment program permitting optimal long-term physical and psychological well being and adequate integration in the family ity [7]. This analysis concluded that, when the outcome and society.is adjusted to comorbid factors, there are no differences between RT recipients' and HD patients' survival in nondiabetic patients, while RT gives better survival than HD Technological and immunological developments within in diabetics patients. Overall survival was significantly the last two decades have evolved several renal replacehigher in RT recipients than in HD patients (P Ͻ 0.0001). ment therapy (RRT) options. The most important of However, treatment modality did not show a significant them in the treatment of end-stage renal disease (ESRD...
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