American Journal of Kidney Diseases

Associates of Mortality and Hospitalization in Hemodialysis: Potentially Actionable Laboratory Variables and Vascular Access

Published:October 20, 2008DOI:


      To determine the most significant potentially actionable clinical variables associated with mortality and hospitalization risk in hemodialysis (HD) patients.

      Study Design

      Cohort study.

      Setting & Participants

      Adult maintenance HD patients in the Fresenius Medical Care, North America database as of January 1, 2004, with baseline information from October 1, 2003, to December 31, 2003, comprising approximately 26% of the US HD population.


      Case-mix (age, sex, race, diabetes, vintage, and body surface area), vascular access, and laboratory (albumin, equilibrated Kt/V, hemoglobin, calcium, phosphorus, creatinine, bicarbonate, biointact parathyroid hormone, transferrin saturation, and white blood cell count) variables.


      1-year mortality and hospitalization risk from January 1 to December 31, 2004.


      Cox proportional hazards models for death and hospitalization.


      The cohort (N = 78,420) had a mean age of 61.4 ± 15.0 years, 47% were women, 49% were white, 41% were black race (10% defined as “other”), and 52% had diabetes. The top 5 actionable variables were the same for mortality and hospitalization. Final case-mix plus laboratory–adjusted hazard ratios for these top 5 actionable variables indicate 177% increased risk of death and 67% increased risk of hospitalization per 1-g/dL decrease in albumin level, 39% and 45% greater risk with catheters compared with fistulas, 18% and 9% greater risk per 1-mg/dL greater phosphorus level, 11% and 9% lower risk per 1-g/dL greater hemoglobin level, and 5% and 2% greater risk per 0.1-unit decrease in equilibrated Kt/V, respectively (all P < 0.0001).


      Observational cross-sectional study with limited comorbidity adjustment (for diabetes).


      The same variables are associated with both mortality and hospitalization in HD patients. The top 5 potentially actionable variables are readily identifiable, with albumin level and catheter use the most prominent, and all 5 are appropriate targets for improvement.

      Index Words

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        • Lowrie E.G.
        • Lew N.L.
        Death risk in hemodialysis patients: The predictive value of commonly measured variables and an evaluation of death rate differences between facilities.
        Am J Kidney Dis. 1990; 15: 458-482
        • Lacson Jr, E.
        • Teng M.
        • Lazarus J.M.
        • Lew N.
        • Lowrie E.
        • Owen W.
        Limitations of the facility-specific standardized mortality ratio for profiling health care quality in dialysis.
        Am J Kidney Dis. 2001; 37: 267-275
        • Lowrie E.G.
        • Teng M.
        • Lacson E.
        • Lew N.
        • Lazarus J.M.
        • Owen W.F.
        Association between prevalent care process measures and facility-specific mortality rates.
        Kidney Int. 2001; 60: 1917-1929
        • Lacson Jr, E.
        • Ofsthun N.
        • Lazarus J.M.
        Effect of variability in anemia management on hemoglobin outcomes in ESRD.
        Am J Kidney Dis. 2003; 41: 111-124
        • Lacson E.
        • Teng M.
        • Ong J.
        • Vienneau L.
        • Ofsthun N.
        • Lazarus J.M.
        Antibody response to Engerix-B and Recombivax-HB hepatitis B vaccination in end-stage renal disease.
        Hemodialysis Int. 2005; 9: 367-375
        • Li Z.
        • Lacson Jr, E.
        • Lowrie E.G.
        • et al.
        The epidemiology of systolic blood pressure and death risk in hemodialysis patients.
        Am J Kidney Dis. 2006; 48: 606-615
        • Lowrie E.G.
        • Li Z.
        • Ofsthun N.J.
        • Lazarus J.M.
        Evaluating a new method to judge dialysis treatment using online measurements of ionic clearance.
        Kidney Int. 2006; 70: 211-217
        • Mishler R.
        • Sands J.J.
        • Ofsthun N.J.
        • Teng M.
        • Schon D.
        • Lazarus J.M.
        Dedicated outpatient vascular access center decreases hospitalization and missed outpatient dialysis treatments.
        Kidney Int. 2006; 69: 393-398
        • Williams M.E.
        • Lacson Jr, E.
        • Teng M.
        • Ofsthun N.
        • Lazarus J.M.
        Hemodialyzed type I and type II diabetic patients in the US: Characteristics, glycemic control, and survival.
        Kidney Int. 2006; 70: 1503-1509
        • Lowrie E.G.
        • Zhu X.
        • Lew N.L.
        Primary associates of mortality among dialysis patients: Trends and reassessment of Kt/V and urea reduction ratio as outcome-based measures of dialysis dose.
        Am J Kidney Dis. 1998; 32: S16-S31
        • Leavey S.F.
        • Strawderman R.L.
        • Jones C.A.
        • Port F.K.
        • Held P.J.
        Simple nutritional indicators as independent predictors of mortality in hemodialysis patients.
        Am J Kidney Dis. 1998; 31: 997-1006
        • Lowrie E.G.
        • Huang W.
        • Lew N.L.
        • Liu Y.
        The relative contribution of measured variables to death risk among hemodialysis patients.
        in: Friedman E. Death on Hemodialysis: Preventable or Inevitable? Kluwer Academic Publishers, Hingham, MA1994: 121-141
        • Smye S.W.
        • Tattersall J.E.
        • Will E.J.
        Modeling the postdialysis rebound: The reconciliation of current formulas.
        ASAIO J. 1999; 45: 562-567
        • National Kidney Foundation
        KDOQI Clinical Practice Guidelines for Hemodialysis Adequacy: Update 2006.
        Am J Kidney Dis. 2006; 48: S2-S90
        • Pankratz V.S.
        • de Andrade M.
        • Therneau T.M.
        Random-effects Cox proportional hazards model: General variance components methods for time-to-event data.
        Genet Epidemiol. 2005; 28: 97-109
        • Geiss L.S.
        • Pan L.
        • Cadwell B.
        • Gregg E.W.
        • Benjamin S.M.
        • Engelgau M.M.
        Changes in incidence of diabetes in U.S. adults, 1997-2003.
        Am J Prev Med. 2006; 30: 371-377
        • Drey N.
        • Roderick P.
        • Mullee M.
        • Rogerson M.
        A population-based study of the incidence and outcomes of diagnosed chronic kidney disease.
        Am J Kidney Dis. 2003; 42: 677-684
        • Eriksen B.O.
        • Ingebretsen O.C.
        The progression of chronic kidney disease: A 10-year population-based study of the effects of gender and age.
        Kidney Int. 2006; 69: 375-382
        • Evans M.
        • Fryzek J.P.
        • Elinder C.G.
        • et al.
        The natural history of chronic renal failure: Results from an unselected, population-based, inception cohort in Sweden.
        Am J Kidney Dis. 2005; 46: 863-870
        • National Kidney Foundation
        DOQI Clinical Practice Guidelines for Hemodialysis Adequacy.
        Am J Kidney Dis. 1997; 30: S15-S66
        • National Kidney Foundation
        KDOQI Clinical Practice Guidelines for Nutrition in Chronic Renal Failure.
        Am J Kidney Dis. 2000; 35: S1-S140
        • Sehgal A.R.
        Impact of quality improvement efforts on race and sex disparities in hemodialysis.
        JAMA. 2003; 289: 996-1000
        • Bloembergen W.E.
        • Port F.K.
        • Mauger E.A.
        • Wolfe R.A.
        Causes of death in dialysis patients: Racial and gender differences.
        J Am Soc Nephrol. 1994; 5: 1231-1242
        • Owen Jr, W.F.
        • Lew N.L.
        • Liu Y.
        • Lowrie E.G.
        • Lazarus J.M.
        The urea reduction ratio and serum albumin concentration as predictors of mortality in patients undergoing hemodialysis.
        N Engl J Med. 1993; 329: 1001-1006
        • Kalantar-Zadeh K.
        • Kilpatrick R.D.
        • Kuwae N.
        • et al.
        Revisiting mortality predictability of serum albumin in the dialysis population: Time dependency, longitudinal changes and population-attributable fraction.
        Nephrol Dial Transplant. 2005; 20: 1880-1888
        • Lacson Jr, E.
        • Ikizler T.A.
        • Lazarus J.M.
        • Teng M.
        • Hakim R.M.
        Potential impact of nutritional intervention on ESRD hospitalization, death and treatment costs.
        J Ren Nutr. 2007; 17: 363-371
        • Peters V.J.
        • Clemons G.
        • Augustine B.
        “Fistula First” as a CMS breakthrough initiative: Improving vascular access through collaboration.
        Nephrol Nurs J. 2005; 32: 686-687
        • Lacson Jr, E.
        • Lazarus J.M.
        • Himmelfarb J.
        • Ikizler T.A.
        • Hakim R.M.
        Balancing Fistula First with Catheters Last.
        Am J Kidney Dis. 2007; 50: 379-395
        • Konner K.
        Should nephrologists be in charge?.
        Contrib Nephrol. 2005; 149: 121-130
        • Block G.A.
        • Klassen P.S.
        • Lazarus J.M.
        • Ofsthun N.
        • Lowrie E.G.
        • Chertow G.M.
        Mineral metabolism, mortality, and morbidity in maintenance hemodialysis.
        J Am Soc Nephrol. 2004; 15: 2208-2218
        • Teng M.
        • Wolf M.
        • Ofsthun M.N.
        • et al.
        Activated injectable vitamin D and hemodialysis survival: A historical cohort study.
        J Am Soc Nephrol. 2005; 16: 1115-1125
        • Cheng S.
        • Coyne D.
        Vitamin D and outcomes in chronic kidney disease.
        Curr Opin Nephrol Hypertens. 2007; 16: 77-82
        • Kalantar-Zadeh K.
        • Kuwae N.
        • Regidor D.L.
        • et al.
        Survival predictability of time-varying indicators of bone disease in maintenance hemodialysis patients.
        Kidney Int. 2006; 70: 771-780
        • Wolf M.
        • Shah A.
        • Gutierrez O.
        • et al.
        Vitamin D levels and early mortality among incident hemodialysis patients.
        Kidney Int. 2007; 72: 1004-1013
        • National Kidney Foundation
        II. KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Anemia in Chronic Kidney Disease in Adults.
        Am J Kidney Dis. 2006; 47: S16-S85
        • National Kidney Foundation
        K/DOQI Clinical Practice Guidelines for Cardiovascular Disease in Dialysis Patients.
        Am J Kidney Dis. 2005; 45: S1-S153
        • Eknoyan G.
        • Beck G.J.
        • Cheung A.K.
        • et al.
        Effect of dialysis dose and membrane flux in maintenance hemodialysis.
        N Engl J Med. 2002; 347: 2010-2019
        • Besarab A.
        • Bolton W.K.
        • Browne J.K.
        • et al.
        The effects of normal as compared with low hematocrit values in patients with cardiac disease who are receiving hemodialysis and epoetin.
        N Engl J Med. 1998; 339: 584-590
        • Port F.K.
        • Pisoni R.L.
        • Bragg-Gresham J.L.
        • et al.
        DOPPS estimates of patient life years attributable to modifiable hemodialysis practices in the United States.
        Blood Purif. 2004; 22: 175-180
        • Rocco M.V.
        • Frankenfield D.L.
        • Hopson S.D.
        • McClellan W.M.
        Relationship between clinical performance measures and outcomes among patients receiving long-term hemodialysis.
        Ann Intern Med. 2006; 145: 512-519
        • Tentori F.
        • Hunt W.C.
        • Rohrscheib M.
        • et al.
        Which targets in clinical practice guidelines are associated with improved survival in a large dialysis organization?.
        J Am Soc Nephrol. 2007; 18: 2377-2384
        • Cano N.J.
        • Fouque D.
        • Roth H.
        • et al.
        Intradialytic parenteral nutrition does not improve survival in malnourished hemodialysis patients: A 2-year multicenter, prospective, randomized study.
        J Am Soc Nephrol. 2007; 18: 2583-2591
        • Kovesdy C.P.
        • Trivedi B.K.
        • Kalantar-Zadeh K.
        • Anderson J.E.
        Association of anemia with outcomes in men with moderate and severe chronic kidney disease.
        Kidney Int. 2006; 69: 560-564
        • Li S.
        • Foley R.N.
        • Collins A.J.
        Anemia and cardiovascular disease, hospitalization, end stage renal disease, and death in older patients with chronic kidney disease.
        Int Urol Nephrol. 2005; 37: 395-402
        • Singh A.K.
        • Szczech L.
        • Tang K.L.
        • et al.
        Correction of anemia with epoetin alfa in chronic kidney disease.
        N Engl J Med. 2006; 355: 2085-2098
        • Drueke T.B.
        • Locatelli F.
        • Clyne N.
        • et al.
        Normalization of hemoglobin level in patients with chronic kidney disease and anemia.
        N Engl J Med. 2006; 355: 2071-2084
        • Concato J.
        • Shah N.
        • Horwitz R.I.
        Randomized, controlled trials, observational studies, and the hierarchy of research designs.
        N Engl J Med. 2000; 342: 1887-1892
        • Benson K.
        • Hartz A.J.
        A comparison of observational studies and randomized, controlled trials.
        N Engl J Med. 2000; 342: 1878-1886
        • Levin A.
        Understanding recent haemoglobin trials in CKD: Methods and lesson learned from CREATE and CHOIR.
        Nephrol Dial Transplant. 2007; 22: 309-312