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Serum Creatinine Level, a Surrogate of Muscle Mass, Predicts Mortality in Peritoneal Dialysis Patients

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Serum Creatinine Level, a Surrogate of Muscle Mass, Predicts Mortality in Peritoneal Dialysis Patients Nephrol Dial Transplant (2013) 28: 2146–2155 doi: 10.1093/ndt/gft213 Advance Access publication 5 June 2013 Serum creatinine level, a surrogate of muscle mass, predicts mortality in peritoneal dialysis patients 1 Jongha Park1,2, Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University 3 Rajnish Mehrotra , of California Irvine, School of Medicine, Orange, CA, USA, Connie M. Rhee1,4, 2Division of Nephrology, Ulsan University Hospital, University of Miklos Z. Molnar1,5,6, Ulsan College of Medicine, Ulsan, Republic of Korea, 3Harborview Medical Center, University of Washington, Seattle, WA, 1,7 Lilia R. Lukowsky , USA, Sapna S. Patel1,8, 4Division of Nephrology, Brigham and Women’s Hospital, Boston, MA, USA, Allen R. Nissenson9, 5Institute of Pathophysiology, Semmelweis University, Budapest, 7,8,10 Joel D. Kopple , Hungary, Csaba P. Kovesdy11,12 6Division of Nephrology, University Health Network, University of Toronto, Toronto, ON, Canada, and Kamyar Kalantar-Zadeh1,7 7UCLA Fielding School of Public Health, Los Angeles, CA, USA, 8Division of Nephrology and Hypertension, Harbor-UCLA Medical Center, Torrance, CA, USA, 9DaVita Inc., El Segundo, CA, USA, 10David Geffen School of Medicine at UCLA, Los Angeles, CA, USA, 11Division of Nephrology, Memphis Veterans Affairs Medical Center, ORIGINAL ARTICLE Memphis, TN, USA and 12Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA Correspondence and offprint requests to: Keywords: creatinine, malnutrition, mortality, muscle, perito- Kamyar Kalantar-Zadeh; E-mail: [email protected] neal dialysis {HR 1.36 [95% confidence interval (95% CI) 1.19–1.55] and ABSTRACT 1.19 (1.08–1.31), respectively} whereas patients with serum Cr levels of 10.0–11.9 mg/dL, 12.0–13.9 mg/dL and ≥14.0 Background. In hemodialysis patients, higher serum creati- mg/dL had lower risks of death (HR 0.88 [95% CI 0.79– nine (Cr) concentration represents larger muscle mass and 0.97], 0.71 [0.62–0.81] and 0.64 [0.55–0.75], respectively) in predicts greater survival. However, this association remains the fully adjusted model. Decrease in serum Cr level over uncertain in peritoneal dialysis (PD) patients. 1.0 mg/dL during the 3 months predicted an increased risk Methods. In a cohort of 10 896 PD patients enrolled from of death additionally. The serum Cr–mortality association 1 July 2001 to 30 June 2006, the association of baseline serum ≥ fi was robust in patients with PD treatment duration of 12 Cr level and change during the rst 3 months after enrollment months, but was not observed in those with PD duration of with all-cause mortality was examined. <3 months. Results. The cohort mean ± SD age was 55 ± 15 years old Conclusions. Muscle mass reflected in serum Cr level may be andincluded52%women,24% African-Americans and associated with survival even in PD patients. However, the 48% diabetics. Compared with patients with serum Cr serum Cr–mortality association is attenuated in the early levels of 8.0–9.9 mg/dL, patients with serum Cr levels of – period of PD treatment, suggesting competing effect of muscle <4.0 mg/dL and 4.0 5.9 mg/dL had higher risks of death mass versus residual renal function on mortality. 2146 © The Author 2013. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. described in previous studies [33, 34]. The first (baseline) INTRODUCTION quarter for each patient was the calendar quarter in which the patient’s dialysis duration was >90 days. Dialysis modality Serum creatinine (Cr) is typically used to estimate glomerular fi (PD versus HD) was ascertained according to the type of ltration rate (GFR) during a steady state of renal function. treatment patients were receiving at the time of entry into However, serum Cr originates from creatine, 95% of which is fl cohort. The follow-up time began on the date of entry into located in muscle [1, 2]. Although in uenced by both muscle the cohort. Patients were censored at the time of death, renal mass and GFR, serum Cr level may be used as a surrogate of transplantation, departure from DaVita facilities or end of muscle mass in end-stage renal disease (ESRD) patients – the study period (30 June 2007). The study was approved by among whom there is a balanced distribution of low GFRs [3 the Harbor-UCLA Medical Center Institutional Review 10]. In hemodialysis (HD) patients, increased serum Cr level Board with exemption of the requirement for a written has been associated with greater survival, whereas lower serum consent form. Cr level has been associated with increased mortality [10–13]. fi These ndings suggest that low serum Cr level as a proxy of Demographic and clinical measures low muscle mass and protein-energy wasting (PEW) may be Data from the DaVita database was merged with data from associated with adverse outcomes in HD patients [6, 14–17]. the US Renal Data System (USRDS). Information regarding However, in studies of peritoneal dialysis (PD) patients, the date of the first dialysis treatment, race/ethnicity, marital there have been variable associations between serum Cr level status, insurance and comorbidities was obtained from the and mortality [18–20]. One reason for this may be that, com- USRDS. Race/ethnicity was reported as one of the three mu- pared with HD patients, PD patients have greater preservation tually exclusive categories: non-Hispanic whites, non-Hispanic of residual GFR [21–24] which is independently associated African-Americans and Hispanics. In this report, the former with mortality [25–27] as well as serum Cr level [28, 29]. In two groups are referred to Caucasians and African-Americans, PD patients, total Cr clearance (peritoneal dialytic + renal Cr respectively. The following 10 baseline comorbidities were clearance) may be a greater determinant of serum Cr level considered: diabetes mellitus, hypertension, ischemic heart than muscle mass and, in this scenario, higher serum Cr level disease, congestive heart failure, cerebrovascular disease, per- ORIGINAL ARTICLE (i.e. a proxy of lower Cr clearance) would relate to increased ipheral vascular disease, chronic obstructive pulmonary mortality. In contrast, muscle mass may have a greater influ- disease, malignancy, non-ambulatory state and current ence on serum Cr level and, in this scenario, higher serum Cr smoking. The presence of diabetes mellitus was ascertained level (i.e. proxy of larger muscle mass) would relate to greater using data from the DaVita database. Dialysis duration was survival. In a recent study of PD patients, higher estimated defined as the time between the first day of dialysis treatment GFR by the Modification of Diet in Renal Disease (MDRD) and the first day that the patient entered the cohort. Body equation [30, 31] was associated with increased mortality, but weight averaged over 13 weeks during the first (baseline) measured GFR was not related to mortality [32]. These data quarter was used to calculate body mass index (BMI). suggest that, in PD patients, serum Cr level may in fact be a surrogate of muscle mass, and that low muscle mass is associ- ated with worse outcomes in this context. Laboratory measures We thus hypothesized that elevated serum Cr level as a All laboratory values were typically measured on a monthly proxy of large muscle mass may be associated with better out- basis by automated and standardized methods. Blood samples comes in PD patients. In a large and contemporary cohort of were transported to the central laboratory center (DaVita Lab- PD patients, we examined the association of baseline serum Cr oratory, Deland, FL) within 24 h. To minimize effects of short- level and change in serum Cr level during the first 3 months term variations, all repeated measures for each patient during after enrollment with all-cause mortality. In addition, we the first quarter were averaged, and the summary estimates examined effect modification of PD treatment duration on the were used in all models. Change in serum Cr level (ΔCr) was serum Cr–mortality association by conducting stratified ana- calculated as the mean serum Cr during the second quarter lyses. minus the mean serum Cr during the first quarter. Statistical analysis MATERIALS AND METHODS Cox proportional hazards models were used to determine the relationship of baseline serum Cr level (mean serum Patients Cr concentration during the first quarter) and ΔCr level We retrospectively examined data from all patients receiv- with all-cause mortality. We divided serum Cr levels into ing PD treatment from 1 July 2001 to 30 June 2006 (i.e. for 20 seven categories (<4.0, 4.0–5.9, 6.0–7.9, 8.0–9.9, 10.0–11.9, consecutive calendar quarters) in a large US dialysis organiz- 12.0–13.9, ≥14.0 mg/dL) apriori. ΔCr levels were divided ation, DaVita, Inc. As the dialysis population is a dynamic into <−1.0, −1.0 to 1.0 and >1.0 mg/dL. For the stratified cohort with a high turnover rate, a non-concurrent cohort analyses, PD duration was divided into <3, 3 to <12 and was created to include all existing maintenance dialysis ≥12 months. patients from the first quarter (q1) and all new patients from For each analysis, three levels of multivariable adjustment subsequent quarters (q2 through q20), which has been were examined: (i) unadjusted models that included the main 2147 Serum creatinine and mortality in PD ORIGINAL ARTICLE J. Park et al . Table 1. Baseline characteristics according to serum creatinine level (n = 10 896) Variables Serum creatinine (mg/dL) <4.0 4.0–5.9 6.0–7.9 8.0–9.9 10.0–11.9 12.0–13.9 ≥14.0 P-value
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