Published Online
on January 26, 2009

A more recent version of this article appeared on February 10, 2009

This Article Full Text (PDF) Data Supplement All Versions of this Article: 119/5/671    most recent CIRCULATIONAHA.108.807362v1 Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kalantar-Zadeh, K. Articles by Fonarow, G. C. Search for Related Content PubMed PubMed Citation Articles by Kalantar-Zadeh, K. Articles by Fonarow, G. C. Pubmed/NCBI databases Medline Plus Health Information Dialysis Heart Failure Kidney Failure Related Collections Cardio-renal physiology/pathophysiology Other heart failure Congestive

Submitted on July 15, 2008
Accepted on December 1, 2008

Fluid Retention Is Associated With Cardiovascular Mortality in Patients Undergoing Long-Term Hemodialysis

Kamyar Kalantar-Zadeh MD, MPH, PhD^*, Deborah L. Regidor MPH, PhD, Csaba P. Kovesdy MD, David Van Wyck MD, Suphamai Bunnapradist MD, Tamara B. Horwich MD, and Gregg C. Fonarow MD

From Harold Simmons Center for Kidney Disease Research and Epidemiology (K.K.-Z., D.L.R.), Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, Calif; Department of Epidemiology (K.K.-Z., D.L.R.), UCLA School of Public Health, Los Angeles, Calif; David Geffen School of Medicine at UCLA (K.K.-Z., S.B., T.B.H., G.C.F.), Los Angeles, Calif; Salem VA Medical Center (C.P.K.), Salem, Va; DaVita Inc (D.V.W.), El Segundo, Calif; Arizona Center on Aging (D.V.W.), Arizona Health Sciences Center, Tucson, Ariz; UCLA Kidney Transplant Center (S.B.), Los Angeles, Calif; and Ahmanson-UCLA Cardiomyopathy Center (T.B.H., G.C.F.), UCLA Division of Cardiology, Los Angeles, Calif.

^* To whom correspondence should be addressed. E-mail: kamkal{at}ucla.edu.

Background—Patients with chronic kidney disease (stage 5) who undergo hemodialysis treatment have similarities to heart failure patients in that both populations retain fluid frequently and have excessively high mortality. Volume overload in heart failure is associated with worse outcomes. We hypothesized that in hemodialysis patients, greater interdialytic fluid gain is associated with poor all-cause and cardiovascular survival.

Methods and Results—We examined 2-year (July 2001 to June 2003) mortality in 34 107 hemodialysis patients across the United States who had an average weight gain of at least 0.5 kg above their end-dialysis dry weight by the time the subsequent hemodialysis treatment started. The 3-month averaged interdialytic weight gain was divided into 8 categories of 0.5-kg increments (up to 4.0 kg). Eighty-six percent of patients gained >1.5 kg between 2 dialysis sessions. In unadjusted analyses, higher weight gain was associated with better nutritional status (higher protein intake, serum albumin, and body mass index) and tended to be linked to greater survival. However, after multivariate adjustment for demographics (case mix) and surrogates of malnutrition-inflammation complex, higher weight-gain increments were associated with increased risk of all-cause and cardiovascular death. The hazard ratios (95% confidence intervals) of cardiovascular death for weight gain <1.0 kg and 4.0 kg (compared with 1.5 to 2.0 kg as the reference) were 0.67 (0.58 to 0.76) and 1.25 (1.12 to 1.39), respectively.

Conclusions—In hemodialysis patients, greater fluid retention between 2 subsequent hemodialysis treatment sessions is associated with higher risk of all-cause and cardiovascular death. The mechanisms by which fluid retention influences cardiovascular survival in hemodialysis may be similar to those in patients with heart failure and warrant further research.

Key words: renal dialysis • heart failure • ultrafiltration • cardiovascular death • obesity

This article has been cited by other articles:

				N. Lameire, W. Van Biesen, and R. Vanholder Did 20 Years of Technological Innovations in Hemodialysis Contribute to Better Patient Outcomes? Clin. J. Am. Soc. Nephrol., December 1, 2009; 4(Supplement_1): S30 - S40. [Abstract] [Full Text] [PDF]

				C. Chan, C. McIntyre, D. Smith, P. Spanel, and S. J. Davies Combining Near-Subject Absolute and Relative Measures of Longitudinal Hydration in Hemodialysis Clin. J. Am. Soc. Nephrol., November 1, 2009; 4(11): 1791 - 1798. [Abstract] [Full Text] [PDF]

				G. Tripepi, F. Mattace-Raso, F. Mallamaci, F. A. Benedetto, J. Witteman, L. Malatino, and C. Zoccali Biomarkers of Left Atrial Volume: A Longitudinal Study in Patients With End Stage Renal Disease Hypertension, October 1, 2009; 54(4): 818 - 824. [Abstract] [Full Text] [PDF]

				A. Ganguli, T. I. Kassimatis, P. A. Konstantinopoulos, J. M. F. de Oliveira, B. Fellstrom, A. Jardine, H. Holdaas, and the AURORA Executive Steering Committee Rosuvastatin in patients undergoing hemodialysis. N. Engl. J. Med., July 2, 2009; 361(1): 93 - 94. [Full Text] [PDF]