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INTRODUCTION AND AIMS: Little is known about how different strategies used by hemodialysis (HD) patients to cope with their disease might affect their health status. Our objective was to estimate the effects of 4 coping strategies on quality of life (QoL) and mortality. We hypothesized that active engagement coping would lead to better patient outcomes than would avoidance or disengagement. METHOD(S): Coping strategies were reported by 2,339 HD patients from the US, UK, Australia/New Zealand, Canada, Germany and Sweden in DOPPS 4 (2009-11), using the Coping Strategies Inventory-Short Form (CSI-SF) previously validated for HD patients in these countries. The CSI-SF contains 4 subscales: problem-focused engagement & disengagement (PFE & PFD); and emotion-focused engagement & disengagement (EFE & EFD). Cox or linear regression were used to estimate the associations of each coping strategy (by quartile) with all-cause mortality during follow-up and 6 cross-sectional patient-reported outcomes (3 KDQoL kidney-disease measures with higher scores reflecting less impact on patients' lives (Effects, Burdens, Symptoms); 2 SF-12 scores (MCS, PCS) reflecting better functional status; and a CES-D score reflecting more depression symptoms), adjusting for age, sex, vintage, BMI, catheter use, 13 comorbidities, and country. RESULT(S): PFE was positively associated with less kidney-disease burden and effect scores and better mental and physical function scores, and it was inversely associated with depression symptoms. EFE was not associated with any QoL outcomes (Figure 1). In contrast, disengagement strategies (PFD & EFD) were inversely associated with the kidney-disease and functional-status scores, and they were positively associated with depression symptoms. Compared to patients in the lowest PFE quartile (Q1), the hazard ratio for mortality (95% CI) was 0.73 (0.55, 0.98) for patients in Q2, 0.67 (0.49,0.93) for patients in Q3, and 0.74 (0.53, 1.03) for patients in Q4. Little ass

Background Survival and quality of life for patients on hemodialysis therapy remain poor despite substantial research efforts. Existing trials often report surrogate outcomes that may not be relevant to patients and clinicians. The aim of this project was to generate a consensus-based prioritized list of core outcomes for trials in hemodialysis. Study Design In a Delphi survey, participants rated the importance of outcomes using a 9-point Likert scale in round 1 and then re-rated outcomes in rounds 2 and 3 after reviewing other respondents’ scores. For each outcome, the median, mean, and proportion rating as 7 to 9 (critically important) were calculated. Setting & Participants 1,181 participants (202 [17%] patients/caregivers, 979 health professionals) from 73 countries completed round 1, with 838 (71%) completing round 3. Outcomes & Measurements Outcomes included in the potential core outcome set met the following criteria for both patients/caregivers and health professionals: median score ≥ 8, mean score ≥ 7.5, proportion rating the outcome as critically important ≥ 75%, and median score in the forced ranking question < 10. Results Patients/caregivers rated 4 outcomes higher than health professionals: ability to travel, dialysis-free time, dialysis adequacy, and washed out after dialysis (mean differences of 0.9, 0.5, 0.3, and 0.2, respectively). Health professionals gave a higher rating for mortality, hospitalization, decrease in blood pressure, vascular access complications, depression, cardiovascular disease, target weight, infection, and potassium (mean differences of 1.0, 1.0, 1.0, 0.9, 0.9, 0.8, 0.7, 0.4, and 0.4, respectively). Limitations The Delphi survey was conducted online in English and excludes participants without access to a computer and internet connection. Conclusions Patients/caregivers gave higher priority to lifestyle-related outcomes than health professionals. The prioritized outcomes for both groups were vascular access problems, dialysis ad

Background Survival and quality of life for patients on hemodialysis therapy remain poor despite substantial research efforts. Existing trials often report surrogate outcomes that may not be relevant to patients and clinicians. The aim of this project was to generate a consensus-based prioritized list of core outcomes for trials in hemodialysis. Study Design In a Delphi survey, participants rated the importance of outcomes using a 9-point Likert scale in round 1 and then re-rated outcomes in rounds 2 and 3 after reviewing other respondents' scores. For each outcome, the median, mean, and proportion rating as 7 to 9 (critically important) were calculated. Setting & Participants 1,181 participants (202 [17%] patients/caregivers, 979 health professionals) from 73 countries completed round 1, with 838 (71%) completing round 3. Outcomes & Measurements Outcomes included in the potential core outcome set met the following criteria for both patients/caregivers and health professionals: median score >= 8, mean score >= 7.5, proportion rating the outcome as critically important >= 75%, and median score in the forced ranking question < 10. Results Patients/caregivers rated 4 outcomes higher than health professionals: ability to travel, dialysis-free time, dialysis adequacy, and washed out after dialysis (mean differences of 0.9, 0.5, 0.3, and 0.2, respectively). Health professionals gave a higher rating for mortality, hospitalization, decrease in blood pressure, vascular access complications, depression, cardiovascular disease, target weight, infection, and potassium (mean differences of 1.0, 1.0, 1.0, 0.9, 0.9, 0.8, 0.7, 0.4, and 0.4, respectively). Limitations The Delphi survey was conducted online in English and excludes participants without access to a computer and internet connection. Conclusions Patients/caregivers gave higher priority to lifestyle-related outcomes than health professionals. The prioritized outcomes for both groups were vascular access problems, dialysis

INTRODUCTION AND AIMS: Little is known about how different strategies used by hemodialysis (HD) patients to cope with their disease might affect their health status. Our objective was to estimate the effects of 4 coping strategies on quality of life (QoL) and mortality. We hypothesized that active engagement coping would lead to better patient outcomes than would avoidance or disengagement. METHOD(S): Coping strategies were reported by 2,339 HD patients from the US, UK, Australia/New Zealand, Canada, Germany and Sweden in DOPPS 4 (2009-11), using the Coping Strategies Inventory-Short Form (CSI-SF) previously validated for HD patients in these countries. The CSI-SF contains 4 subscales: problem-focused engagement & disengagement (PFE & PFD); and emotion-focused engagement & disengagement (EFE & EFD). Cox or linear regression were used to estimate the associations of each coping strategy (by quartile) with all-cause mortality during follow-up and 6 cross-sectional patient-reported outcomes (3 KDQoL kidney-disease measures with higher scores reflecting less impact on patients' lives (Effects, Burdens, Symptoms); 2 SF-12 scores (MCS, PCS) reflecting better functional status; and a CES-D score reflecting more depression symptoms), adjusting for age, sex, vintage, BMI, catheter use, 13 comorbidities, and country. RESULT(S): PFE was positively associated with less kidney-disease burden and effect scores and better mental and physical function scores, and it was inversely associated with depression symptoms. EFE was not associated with any QoL outcomes (Figure 1). In contrast, disengagement strategies (PFD & EFD) were inversely associated with the kidney-disease and functional-status scores, and they were positively associated with depression symptoms. Compared to patients in the lowest PFE quartile (Q1), the hazard ratio for mortality (95% CI) was 0.73 (0.55, 0.98) for patients in Q2, 0.67 (0.49,0.93) for patients in Q3, and 0.74 (0.53, 1.03) for patients in Q4. Little ass

Aim: To generate a consensus-based, prioritized list of core outcomes for trials in haemodialysis. Background(s): Survival and quality of life for patients on haemodialysis remain poor despite substantial research efforts. Existing trials often report surrogate outcomes that may not be relevant to patients and clinicians. A core outcome set that reflects stakeholder priorities would improve the relevance, efficiency, and comparability of haemodialysis trials. Method(s): In an online Delphi survey, participants rated the importance of outcomes using a 9-point Likert scale. In Round 2 and 3, participants reviewed the scores and comments of other respondents and re-rated the outcomes. For each outcome, we calculated the median, mean, and proportion rating 7-9 ("critically important"). Result(s): 1,181 participants (202 [17%] patients/caregivers, 979 health professionals) from 73 countries completed Round 1 and 838 (150 [18%] patients/caregivers) completed Round 3 (71% response rate). Outcomes achieving consensus as high priorities across both groups were: vascular access complications, cardiovascular disease, mortality, dialysis adequacy and fatigue. Patients/caregivers rated four outcomes higher than health professionals: ability to travel (mean difference 0.9), dialysis- free time (0.5), dialysis adequacy (0.3), and washed out after dialysis (0.2). Health professionals rated 11 outcomes higher: mortality (1.0), hospitalization (1.0), drop in blood pressure (1.0), vascular access complications (0.9), depression (0.9), cardiovascular disease (0.8), target weight (0.7), infection (0.4), potassium (0.4), ability to work (0.3), and pain (0.3). Conclusion(s): The top stakeholder prioritized outcomes were vascular access problems, cardiovascular disease, mortality, dialysis adequacy and fatigue. Patients/caregivers gave higher priority to lifestyle-related outcomes than health professionals. This prioritized set of outcomes can inform the establishment of a core outcome set

Aim: To generate a consensus-based, prioritized list of core outcomes for trials in haemodialysis. Background(s): Survival and quality of life for patients on haemodialysis remain poor despite substantial research efforts. Existing trials often report surrogate outcomes that may not be relevant to patients and clinicians. A core outcome set that reflects stakeholder priorities would improve the relevance, efficiency, and comparability of haemodialysis trials. Method(s): In an online Delphi survey, participants rated the importance of outcomes using a 9-point Likert scale. In Round 2 and 3, participants reviewed the scores and comments of other respondents and re-rated the outcomes. For each outcome, we calculated the median, mean, and proportion rating 7-9 ("critically important"). Result(s): 1,181 participants (202 [17%] patients/caregivers, 979 health professionals) from 73 countries completed Round 1 and 838 (150 [18%] patients/caregivers) completed Round 3 (71% response rate). Outcomes achieving consensus as high priorities across both groups were: vascular access complications, cardiovascular disease, mortality, dialysis adequacy and fatigue. Patients/caregivers rated four outcomes higher than health professionals: ability to travel (mean difference 0.9), dialysis- free time (0.5), dialysis adequacy (0.3), and washed out after dialysis (0.2). Health professionals rated 11 outcomes higher: mortality (1.0), hospitalization (1.0), drop in blood pressure (1.0), vascular access complications (0.9), depression (0.9), cardiovascular disease (0.8), target weight (0.7), infection (0.4), potassium (0.4), ability to work (0.3), and pain (0.3). Conclusion(s): The top stakeholder prioritized outcomes were vascular access problems, cardiovascular disease, mortality, dialysis adequacy and fatigue. Patients/caregivers gave higher priority to lifestyle-related outcomes than health professionals. This prioritized set of outcomes can inform the establishment of a core outcome set

Altered bone structure and function contribute to the high rates of fractures in dialysis patients compared to the general population. Fracture events may increase the risk of subsequent adverse clinical outcomes. Here we assessed the incidence of post-fracture morbidity and mortality in an international cohort of 34,579 in-center hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study (DOPPS). We estimated country-specific rates of fractures requiring a hospital admission and associated length of stay in the hospital. Incidence rates of death and of a composite event of death/rehospitalization were estimated for 1 year after fracture. Overall, 3% of participants experienced a fracture. Fracture incidence varied across countries, from 12 events/1000 patient-years (PY) in JPN to 45/1000 PY in BEL. In all countries, fracture rates were higher in the hemodialysis group compared to those reported for the general population. Median length of stay ranged from 7 to 37 days in the United States and JPN, respectively. In most countries, postfracture mortality rates exceeded 500/1000 PY and death/rehospitalization rates exceeded 1500/1000 PY. Fracture patients had higher unadjusted rates of death (3.7-fold) and death/rehospitalization (4.0-fold) compared to the overall DOPPS population. Mortality and hospitalization rates were highest in the first month after the fracture and declined thereafter. Thus, the high frequency of fractures and increased adverse outcomes following a fracture pose a significant health burden for dialysis patients. Fracture prevention strategies should be identified and applied broadly in nephrology practices © 2013 International Society of Nephrology.

Altered bone structure and function contribute to the high rates of fractures in dialysis patients compared to the general population. Fracture events may increase the risk of subsequent adverse clinical outcomes. Here we assessed the incidence of post-fracture morbidity and mortality in an international cohort of 34,579 in-center hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study (DOPPS). We estimated country-specific rates of fractures requiring a hospital admission and associated length of stay in the hospital. Incidence rates of death and of a composite event of death/rehospitalization were estimated for 1 year after fracture. Overall, 3% of participants experienced a fracture. Fracture incidence varied across countries, from 12 events/1000 patient-years (PY) in JPN to 45/1000 PY in BEL. In all countries, fracture rates were higher in the hemodialysis group compared to those reported for the general population. Median length of stay ranged from 7 to 37 days in the United States and JPN, respectively. In most countries, postfracture mortality rates exceeded 500/1000 PY and death/rehospitalization rates exceeded 1500/1000 PY. Fracture patients had higher unadjusted rates of death (3.7-fold) and death/rehospitalization (4.0-fold) compared to the overall DOPPS population. Mortality and hospitalization rates were highest in the first month after the fracture and declined thereafter. Thus, the high frequency of fractures and increased adverse outcomes following a fracture pose a significant health burden for dialysis patients. Fracture prevention strategies should be identified and applied broadly in nephrology practices © 2013 International Society of Nephrology.

Introduction and Aims:We measured the involvement of in-center patients in their dialysis treatment and assessed cross-sectional associations with measures of health-related quality of life in the Dialysis Outcomes and Practice Patterns Study (DOPPS). Method(s): Data on self-care activities (listed in Table 1) were available in DOPPS phase 4 (2009-11). Descriptive analyses included 5657 patients in 8 countries with >2% of patients reporting >=1 activity. 3242 of these patients reported the physical (PCS) and mental (MCS) component summary of the KDQoL-36TM. Linear mixed models adjusted for many potential confounders, including country, estimated the effects of self-care activities on PCS and MCS. Result(s): The % of patients who performed >=1 self-care activity was 9% overall and highest in Australia/New Zealand and Sweden (16% each, Table 1). The activity most commonly performed was setting up the machine/dialyzer (7%). Facility % of patients who performed >=1 self-care activity was 0% in 39% of facilities, with median 4% (IQR: 0%, 12%) and 95th percentile 36%. Patients performing >=1 self-care activity were younger (51 vs 66 yrs), had longer vintage (6.2 vs 3.6 yrs), lower catheter use (23% vs 36%), higher albumin (3.9 vs 3.6 g/dL), higher creatinine (9.3 vs 7.5 mg/dL), longer session length, (256 vs 238 min), and fewer comorbidities than patients performing none of the 4 activities. For patients performing >=1 self-care activity: crude mean PCS (39.2 vs 34.9) and MCS (47.9 vs 45.3) were higher, and after covariate adjustment, mean PCS was 1.6 points higher (95% CI: 0.3, 2.8) and mean MCS was 2.2 points higher (95% CI: 0.7, 3.7). Conclusion(s): Greater patient involvement in the routine tasks of hemodialysis is associated with better physical and mental quality of life; however, methodological limitations limit causal inference. Marked variation in up-take of self-care is likely to represent facility preferences for empowering patients. The impact and safety of th

Introduction and Aims:We measured the involvement of in-center patients in their dialysis treatment and assessed cross-sectional associations with measures of health-related quality of life in the Dialysis Outcomes and Practice Patterns Study (DOPPS). Method(s): Data on self-care activities (listed in Table 1) were available in DOPPS phase 4 (2009-11). Descriptive analyses included 5657 patients in 8 countries with >2% of patients reporting >=1 activity. 3242 of these patients reported the physical (PCS) and mental (MCS) component summary of the KDQoL-36TM. Linear mixed models adjusted for many potential confounders, including country, estimated the effects of self-care activities on PCS and MCS. Result(s): The % of patients who performed >=1 self-care activity was 9% overall and highest in Australia/New Zealand and Sweden (16% each, Table 1). The activity most commonly performed was setting up the machine/dialyzer (7%). Facility % of patients who performed >=1 self-care activity was 0% in 39% of facilities, with median 4% (IQR: 0%, 12%) and 95th percentile 36%. Patients performing >=1 self-care activity were younger (51 vs 66 yrs), had longer vintage (6.2 vs 3.6 yrs), lower catheter use (23% vs 36%), higher albumin (3.9 vs 3.6 g/dL), higher creatinine (9.3 vs 7.5 mg/dL), longer session length, (256 vs 238 min), and fewer comorbidities than patients performing none of the 4 activities. For patients performing >=1 self-care activity: crude mean PCS (39.2 vs 34.9) and MCS (47.9 vs 45.3) were higher, and after covariate adjustment, mean PCS was 1.6 points higher (95% CI: 0.3, 2.8) and mean MCS was 2.2 points higher (95% CI: 0.7, 3.7). Conclusion(s): Greater patient involvement in the routine tasks of hemodialysis is associated with better physical and mental quality of life; however, methodological limitations limit causal inference. Marked variation in up-take of self-care is likely to represent facility preferences for empowering patients. The impact and safety of th

Background: Poor nutritional status and both hyper- and hypophosphatemia are associated with increased mortality in maintenance hemodialysis (HD) patients. We assessed associations of phosphate binder prescription with survival and indicators of nutritional status in maintenance HD patients. Study Design: Prospective cohort study (DOPPS [Dialysis Outcomes and Practice Patterns Study]), 1996-2008. Setting & Participants: 23,898 maintenance HD patients at 923 facilities in 12 countries. Predictors: Patient-level phosphate binder prescription and case-mix-adjusted facility percentage of phosphate binder prescription using an instrumental-variable analysis. Outcome(s): All-cause mortality. Result(s): Overall, 88% of patients were prescribed phosphate binders. Distributions of age, comorbid conditions, and other characteristics showed small differences between facilities with higher and lower percentages of phosphate binder prescription. Patient-level phosphate binder prescription was associated strongly at baseline with indicators of better nutrition, ie, higher values for serum creatinine, albumin, normalized protein catabolic rate, and body mass index and absence of cachectic appearance. Overall, patients prescribed phosphate binders had 25% lower mortality (HR, 0.75; 95% CI, 0.68-0.83) when adjusted for serum phosphorus level and other covariates; further adjustment for nutritional indicators attenuated this association (HR, 0.88; 95% CI, 0.80-0.97). However, this inverse association was observed for only patients with serum phosphorus levels <3.5 mg/dL. In the instrumental-variable analysis, case-mix-adjusted facility percentage of phosphate binder prescription (range, 23%-100%) was associated positively with better nutritional status and inversely with mortality (HR for 10% more phosphate binders, 0.93; 95% CI, 0.89-0.96). Further adjustment for nutritional indicators reduced this association to an HR of 0.95 (95% CI, 0.92-0.99). Limitation(s): Results were based o

Background: Abnormalities in serum calcium, phosphorus, and parathyroid hormone (PTH) concentrations are common in patients with chronic kidney disease and have been associated with increased morbidity and mortality. No clinical trials have been conducted to clearly identify categories of calcium, phosphorus, and PTH levels associated with the lowest mortality risk. Current clinical practice guidelines are based largely on expert opinions, and clinically relevant differences exist among guidelines across countries. We sought to describe international trends in calcium, phosphorus, and PTH levels during 10 years and identify mortality risk categories in the Dialysis Outcomes and Practice Patterns Study (DOPPS), an international study of hemodialysis practices and associated outcomes. Study Design: Prospective cohort study. Participant(s): 25,588 patients with end-stage renal disease on hemodialysis therapy for longer than 180 days at 925 facilities in DOPPS I (1996-2001), DOPPS II (2002-2004), or DOPPS III (2005-2007). Predictors: Serum calcium, albumin-corrected calcium (CaAlb), phosphorus, and PTH levels. Outcome(s): Adjusted hazard ratios for all-cause and cardiovascular mortality calculated using Cox models. Result(s): Distributions of mineral metabolism markers differed across DOPPS countries and phases, with lower calcium and phosphorus levels observed in the most recent phase of DOPPS. Survival models identified categories with the lowest mortality risk for calcium (8.6 to 10.0 mg/dL), CaAlb (7.6 to 9.5 mg/dL), phosphorus (3.6 to 5.0 mg/dL), and PTH (101 to 300 pg/mL). The greatest risk of mortality was found for calcium or CaAlb levels greater than 10.0 mg/dL, phosphorus levels greater than 7.0 mg/dL, and PTH levels greater than 600 pg/mL and in patients with combinations of high-risk categories of calcium, phosphorus, and PTH. Limitation(s): Because of the observational nature of DOPPS, this study can only indicate an association between mineral metabolism c

Background: Poor nutritional status and both hyper- and hypophosphatemia are associated with increased mortality in maintenance hemodialysis (HD) patients. We assessed associations of phosphate binder prescription with survival and indicators of nutritional status in maintenance HD patients. Study Design: Prospective cohort study (DOPPS [Dialysis Outcomes and Practice Patterns Study]), 1996-2008. Setting & Participants: 23,898 maintenance HD patients at 923 facilities in 12 countries. Predictors: Patient-level phosphate binder prescription and case-mix-adjusted facility percentage of phosphate binder prescription using an instrumental-variable analysis. Outcome(s): All-cause mortality. Result(s): Overall, 88% of patients were prescribed phosphate binders. Distributions of age, comorbid conditions, and other characteristics showed small differences between facilities with higher and lower percentages of phosphate binder prescription. Patient-level phosphate binder prescription was associated strongly at baseline with indicators of better nutrition, ie, higher values for serum creatinine, albumin, normalized protein catabolic rate, and body mass index and absence of cachectic appearance. Overall, patients prescribed phosphate binders had 25% lower mortality (HR, 0.75; 95% CI, 0.68-0.83) when adjusted for serum phosphorus level and other covariates; further adjustment for nutritional indicators attenuated this association (HR, 0.88; 95% CI, 0.80-0.97). However, this inverse association was observed for only patients with serum phosphorus levels <3.5 mg/dL. In the instrumental-variable analysis, case-mix-adjusted facility percentage of phosphate binder prescription (range, 23%-100%) was associated positively with better nutritional status and inversely with mortality (HR for 10% more phosphate binders, 0.93; 95% CI, 0.89-0.96). Further adjustment for nutritional indicators reduced this association to an HR of 0.95 (95% CI, 0.92-0.99). Limitation(s): Results were based o

KDOQI practice guidelines recommend predialysis blood pressure <140/90 mm Hg; however, most prior studies had found elevated mortality with low, not high, systolic blood pressure. This is possibly due to unmeasured confounders affecting systolic blood pressure and mortality. To lessen this bias, we analyzed 24,525 patients by Cox regression models adjusted for patient and facility characteristics. Compared with predialysis systolic blood pressure of 130-159 mm Hg, mortality was 13% higher in facilities with 20% more patients at systolic blood pressure of 110-129 mm Hg and 16% higher in facilities with 20% more patients at systolic blood pressure of >=160 mm Hg. For patient-level systolic blood pressure, mortality was elevated at low (>130 mm Hg), not high (>=180 mm Hg), systolic blood pressure. For predialysis diastolic blood pressure, mortality was lowest at 60-99 mm Hg, a wide range implying less chance to improve outcomes. Higher mortality at systolic blood pressure of <130 mm Hg is consistent with prior studies and may be due to excessive blood pressure lowering during dialysis. The lowest risk facility systolic blood pressure of 130-159 mm Hg indicates this range may be optimal, but may have been influenced by unmeasured facility practices. While additional study is needed, our findings contrast with KDOQI blood pressure targets, and provide guidance on optimal blood pressure range in the absence of definitive clinical trial data. © 2012 International Society of Nephrology.

Background: Abnormalities in serum calcium, phosphorus, and parathyroid hormone (PTH) concentrations are common in patients with chronic kidney disease and have been associated with increased morbidity and mortality. No clinical trials have been conducted to clearly identify categories of calcium, phosphorus, and PTH levels associated with the lowest mortality risk. Current clinical practice guidelines are based largely on expert opinions, and clinically relevant differences exist among guidelines across countries. We sought to describe international trends in calcium, phosphorus, and PTH levels during 10 years and identify mortality risk categories in the Dialysis Outcomes and Practice Patterns Study (DOPPS), an international study of hemodialysis practices and associated outcomes. Study Design: Prospective cohort study. Participant(s): 25,588 patients with end-stage renal disease on hemodialysis therapy for longer than 180 days at 925 facilities in DOPPS I (1996-2001), DOPPS II (2002-2004), or DOPPS III (2005-2007). Predictors: Serum calcium, albumin-corrected calcium (CaAlb), phosphorus, and PTH levels. Outcome(s): Adjusted hazard ratios for all-cause and cardiovascular mortality calculated using Cox models. Result(s): Distributions of mineral metabolism markers differed across DOPPS countries and phases, with lower calcium and phosphorus levels observed in the most recent phase of DOPPS. Survival models identified categories with the lowest mortality risk for calcium (8.6 to 10.0 mg/dL), CaAlb (7.6 to 9.5 mg/dL), phosphorus (3.6 to 5.0 mg/dL), and PTH (101 to 300 pg/mL). The greatest risk of mortality was found for calcium or CaAlb levels greater than 10.0 mg/dL, phosphorus levels greater than 7.0 mg/dL, and PTH levels greater than 600 pg/mL and in patients with combinations of high-risk categories of calcium, phosphorus, and PTH. Limitation(s): Because of the observational nature of DOPPS, this study can only indicate an association between mineral metabolism c

Background: Poor nutritional status and both hyper- and hypophosphatemia are associated with increased mortality in maintenance hemodialysis (HD) patients. We assessed associations of phosphate binder prescription with survival and indicators of nutritional status in maintenance HD patients. Study Design: Prospective cohort study (DOPPS [Dialysis Outcomes and Practice Patterns Study]), 1996-2008. Setting & Participants: 23,898 maintenance HD patients at 923 facilities in 12 countries. Predictors: Patient-level phosphate binder prescription and case-mix-adjusted facility percentage of phosphate binder prescription using an instrumental-variable analysis. Outcome(s): All-cause mortality. Result(s): Overall, 88% of patients were prescribed phosphate binders. Distributions of age, comorbid conditions, and other characteristics showed small differences between facilities with higher and lower percentages of phosphate binder prescription. Patient-level phosphate binder prescription was associated strongly at baseline with indicators of better nutrition, ie, higher values for serum creatinine, albumin, normalized protein catabolic rate, and body mass index and absence of cachectic appearance. Overall, patients prescribed phosphate binders had 25% lower mortality (HR, 0.75; 95% CI, 0.68-0.83) when adjusted for serum phosphorus level and other covariates; further adjustment for nutritional indicators attenuated this association (HR, 0.88; 95% CI, 0.80-0.97). However, this inverse association was observed for only patients with serum phosphorus levels <3.5 mg/dL. In the instrumental-variable analysis, case-mix-adjusted facility percentage of phosphate binder prescription (range, 23%-100%) was associated positively with better nutritional status and inversely with mortality (HR for 10% more phosphate binders, 0.93; 95% CI, 0.89-0.96). Further adjustment for nutritional indicators reduced this association to an HR of 0.95 (95% CI, 0.92-0.99). Limitation(s): Results were based o

BackgroundLonger dialysis session length (treatment time, TT) has been associated with better survival among hemodialysis (HD) patients. The impact of TT on clinical markers that may contribute to this survival advantage is not well known.MethodsUsing data from the international Dialysis Outcomes and Practice Patterns Study, we assessed the association of TT with clinical outcomes using both standard regression analyses and instrumental variable approaches. The study included 37 414 patients on in-center HD three times per week with prescribed TT from 120 to 420 min.ResultsFacility mean TT ranged from 214 min in the USA to 256 min in Australia-New Zealand. Accounting for country effects, mortality risk was lower for patients with longer TT {hazard ratio for every 30 min: all-cause mortality: 0.94 [95 confidence interval (CI): 0.92-0.97], cardiovascular mortality: 0.95 (95 CI: 0.91-0.98) and sudden death: 0.93 (95 CI: 0.88-0.98)}. Patients with longer TT had lower pre- and post-dialysis systolic blood pressure, greater intradialytic weight loss, higher hemoglobin (for the same erythropoietin dose), serum albumin and potassium and lower serum phosphorus and white blood cell counts. Similar associations were found using the instrumental variable approach, although the positive associations of TT with weight loss and potassium were lost.ConclusionsFavorable levels of a variety of clinical markers may contribute to the better survival of patients receiving longer TT. These findings support longer TT prescription in the setting of in-center, three times per week HD. © The Author 2012. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.

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