High Ferritin Level and Malnutrition Predict High Risk of Infection-Related Hospitalization in Incident Dialysis Patients: A Japanese Prospective Cohort Study

Kato, Shinichi; Lindholm, Bengt; Tsuruta, Yoshinari; Nakauchi, Kana; Yasuda, Kaoru; Sugiura, Sachiyo; Morozumi, Kunio; Tsuboi, Naotake; Maruyama, Shoichi

doi:10.1159/000445424

Cited by 13 publications

(14 citation statements)

References 27 publications

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“… 30 - 32 Characteristics previously found to be associated with hospitalizations, such as frailty, serum ferritin, and serum sodium, were not examined. 33 - 36 Data on patient adherence with prescribed treatments and individual dialysis prescriptions were also not available. The outcome of infection-related hospitalization was determined using diagnostic codes with uncertain validity.…”

Section: Discussionmentioning

confidence: 99%

Hospitalizations in Dialysis Patients in Canada: A National Cohort Study

Molnar

Moist

Klarenbach

et al. 2018

Can J Kidney Health Dis

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Background:Hospitalizations of chronic dialysis patients have not been previously studied at a national level in Canada. Understanding the scope and variables associated with hospitalizations will inform measures for improvement.Objective:To describe the risk of all-cause and infection-related hospitalizations in patients on dialysis.Design:Retrospective cohort study using health care administrative databases.Setting:Provinces and territories across Canada (excluding Manitoba and Quebec).Patients:Incident chronic dialysis patients with a dialysis start date between January 1, 2005, and March 31, 2014. Patients with a prior history of kidney transplantation were excluded.Measurements:Patient characteristics were recorded at baseline. Dialysis modality was treated as a time-varying covariate. The primary outcomes of interest were all-cause and dialysis-specific infection-related hospitalizations.Methods:Crude rates for all-cause hospitalization and infection-related hospitalization were determined per patient year (PPY) at 7 and 30 days, and at 3, 6, and 12 months postdialysis initiation. A stratified, gamma-distributed frailty model was used to assess repeat hospital admissions and to determine the inter-recurrence dependence of hospitalizations within individuals, as well as the hazard ratio (HR) attributed to each covariate of interest.Results:A total of 38 369 incident chronic dialysis patients were included: 38 088 adults and 281 pediatric patients (age less than 18 years). There were 112 374 hospitalizations, of which 11.5% were infection-related hospitalizations. The all-cause hospitalization rate was similar for all adult age groups (age 65 years and older: 1.40, 1.35, and 1.18 admissions PPY at 7 days, 30 days, and 6 months, respectively). The all-cause hospitalization rate was higher for pediatric patients (1.67, 2.48, and 2.47 admissions PPY at 7 days, 30 days, and 6 months, respectively; adjusted HR: 2.73, 95% confidence interval [CI]: 2.37-3.15, referent age group: 45-64 years). Within the first 7 days after dialysis initiation, patients on peritoneal dialysis had a higher risk of all-cause hospitalization (HR: 1.27, 95% CI: 1.07-1.50) and infection-related hospitalization (HR: 2.05, 95% CI: 1.19-3.55) compared with patients on hemodialysis. Beyond 7 days, the risk did not differ significantly by dialysis modality. Female sex and Indigenous race were significant risk factors for all-cause hospitalization.Limitations:The cohort had too few home hemodialysis patients to examine this subgroup. The outcome of infection-related hospitalization was determined using diagnostic codes. Dialysis patients from Manitoba and Quebec were not included.Conclusions:In Canada, the rates of hospitalization were not influenced by dialysis modality beyond the initial 7-day period following dialysis initiation; however, the rate of hospitalization in pediatric patients was higher than in adults at every time frame examined.

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Section: Discussionmentioning

confidence: 99%

Hospitalizations in Dialysis Patients in Canada: A National Cohort Study

Molnar

Moist

Klarenbach

et al. 2018

Can J Kidney Health Dis

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“…In recent years, there is a trend for decreasing the use of ESA and increasing the use of IIT for CKD patients in the US [ 109 ]. Like CRP [ 15 , 62 ], serum ferritin levels and the doses of IV iron used were generally higher in HD patients of Western countries than in those of Japan [ 193 , 194 ]. Serum ferritin levels were increased in HD patients of Canada, Europe and the US from 1997 to 2011, compared to those of Japan [ 195 ].…”

Section: Safety Issues Of Iron Therapymentioning

confidence: 99%

Impact of Inflammation on Ferritin, Hepcidin and the Management of Iron Deficiency Anemia in Chronic Kidney Disease

2018

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Iron deficiency anemia (IDA) is a major problem in chronic kidney disease (CKD), causing increased mortality. Ferritin stores iron, representing iron status. Hepcidin binds to ferroportin, thereby inhibiting iron absorption/efflux. Inflammation in CKD increases ferritin and hepcidin independent of iron status, which reduce iron availability. While intravenous iron therapy (IIT) is superior to oral iron therapy (OIT) in CKD patients with inflammation, OIT is as effective as IIT in those without. Inflammation reduces predictive values of ferritin and hepcidin for iron status and responsiveness to iron therapy. Upper limit of ferritin to predict iron overload is higher in CKD patients with inflammation than in those without. However, magnetic resonance imaging studies show lower cutoff levels of serum ferritin to predict iron overload in dialysis patients with apparent inflammation than upper limit of ferritin proposed by international guidelines. Compared to CKD patients with inflammation, optimal ferritin levels for IDA are lower in those without, requiring reduced iron dose and leading to decreased mortality. The management of IDA should differ between CKD patients with and without inflammation and include minimization of inflammation. Further studies are needed to determine the impact of inflammation on ferritin, hepcidin and therapeutic strategy for IDA in CKD.

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“…This study is based on analysis of data from an ongoing prospective cohort study, approved by the ethics committee of Nagoya University Graduate School of Medicine, details of which has been described in reports based on this cohort. [6][7][8] Informed consent for participation was obtained from all patients. We excluded patients >75 years of age and those with acute infectious disease or severe liver dysfunction because the purpose of the cohort was to elucidate risk factors due to uremia.…”

Section: Study Design and Patientsmentioning

confidence: 99%

Inter-leg systolic blood pressure difference predicts cardiovascular events and mortality in incident hemodialysis patients

et al. 2019

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Background: High inter-arm blood pressure difference, a marker of vascular disease, may be difficult to assess in hemodialysis patients with arm arteriovenous fistulae. We investigated if high inter-leg systolic blood pressure difference associates with cardiovascular events and increased mortality in hemodialysis patients. Methods: Among 118 incident Japanese dialysis patients, bilateral leg blood pressure, arm blood pressure, brachial–ankle pulse wave velocity, and ankle–brachial index were measured, and the relative risk associated with inter-leg systolic blood pressure difference and other indices of vascular status was analyzed. Results: During follow-up (median, 46 months), 18 deaths and 75 cardiovascular events occurred in 38 patients. Kaplan–Meier curves showed that higher inter-leg systolic blood pressure difference was associated with overall (log-rank 9.35, p = 0.002) and cardiovascular (log-rank 5.81, p = 0.02) mortality. The period from the start of dialysis therapy to the first cardiovascular event was shorter as inter-leg systolic blood pressure difference increased (log-rank 23.7, p < 0.0001). In Cox hazard models, inter-leg systolic blood pressure difference greater than median independently predicted deaths (relative risk, 3.8; 95% confidence interval, 1.3–13.9) and cardiovascular events (relative risk, 3.9; 95% confidence interval, 1.9–9.21) after adjustments for age, sex, nutritional status, and diabetes, whereas other indices were not related to the risks. For well-nourished, moderately malnourished, and severely malnourished patients, the cumulative number of cardiovascular events in the high–inter-leg systolic blood pressure difference patients were 4.96, 31.44, and 55.18 events per 100 patient-years. Conclusions: Higher inter-leg systolic blood pressure difference associated with increased risk of mortality and cardiovascular events suggesting that wider application of inter-leg systolic blood pressure difference measurements may be warranted in hemodialysis patients.

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High Ferritin Level and Malnutrition Predict High Risk of Infection-Related Hospitalization in Incident Dialysis Patients: A Japanese Prospective Cohort Study

Cited by 13 publications

References 27 publications

Hospitalizations in Dialysis Patients in Canada: A National Cohort Study

Hospitalizations in Dialysis Patients in Canada: A National Cohort Study

Impact of Inflammation on Ferritin, Hepcidin and the Management of Iron Deficiency Anemia in Chronic Kidney Disease

Inter-leg systolic blood pressure difference predicts cardiovascular events and mortality in incident hemodialysis patients

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