Tania Vashistha1, Rajnish Mehrotra2, Jongha Park3, Elani Streja1, Ramnath Dukkipati4, Allen R Nissenson5, Jennie Z Ma6, Csaba P Kovesdy7, Kamyar Kalantar-Zadeh8. 1. Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA. 2. Division of Nephrology, University of Washington, Seattle, WA. 3. Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA; Division of Nephrology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea. 4. Division of Nephrology and Hypertension, Harbor-UCLA Medical Center, Torrance. 5. DaVita Inc, El Segundo, CA. 6. Department of Public Health Sciences, University of Virginia, Charlottesville, VA. 7. Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN; Division of Nephrology, Memphis VA Medical Center, Memphis, TN. 8. Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA; Fielding School of Public Health at UCLA, Los Angeles, CA. Electronic address: kkz@uci.edu.
Abstract
BACKGROUND: In contrast to the general population, higher body mass index (BMI) is associated with greater survival in patients receiving hemodialysis (HD; "obesity paradox"). We hypothesized that this paradoxical association between BMI and death may be modified by age and dialysis vintage. STUDY DESIGN: Retrospective observational study using a large HD patient cohort. SETTING & PARTICIPANTS: 123,383 maintenance HD patients treated in DaVita dialysis clinics between July 1, 2001, and June 30, 2006, with follow-up through September 30, 2009. PREDICTORS: Age, dialysis vintage, and time-averaged BMI. Time-averaged BMI was divided into 6 subgroups; <18.5, 18.5-<23.0, 23.0-<25.0, 25.0-<30.0, 30.0-<35.0, and ≥35.0kg/m(2). BMI category of 23-<25kg/m(2) was used as the reference category. OUTCOMES: All-cause, cardiovascular, and infection-related mortality. RESULTS: Mean BMI of study participants was 27±7kg/m(2). Time-averaged BMI was <18.5 and ≥35kg/m(2) in 5% and 11% of patients, respectively. With progressively higher time-averaged BMI, there was progressively lower all-cause, cardiovascular, and infection-related mortality in patients younger than 65 years. In those 65 years or older, even though overweight/obese patients had lower mortality compared with underweight/normal-weight patients, sequential increases in time-averaged BMI > 25kg/m(2) added no additional benefit. Based on dialysis vintage, incident HD patients had greater all-cause and cardiovascular survival benefit with a higher time-averaged BMI compared with the longer term HD patients. LIMITATIONS: Causality cannot be determined, and residual confounding cannot be excluded given the observational study design. CONCLUSIONS: Higher BMI is associated with lower death risk across all age and dialysis vintage groups. This benefit is more pronounced in incident HD patients and those younger than 65 years. Given the robustness of the survival advantage of higher BMI, examining interventions to maintain or even increase dry weight in HD patients irrespective of age and vintage are warranted.
BACKGROUND: In contrast to the general population, higher body mass index (BMI) is associated with greater survival in patients receiving hemodialysis (HD; "obesity paradox"). We hypothesized that this paradoxical association between BMI and death may be modified by age and dialysis vintage. STUDY DESIGN: Retrospective observational study using a large HDpatient cohort. SETTING & PARTICIPANTS: 123,383 maintenance HDpatients treated in DaVita dialysis clinics between July 1, 2001, and June 30, 2006, with follow-up through September 30, 2009. PREDICTORS: Age, dialysis vintage, and time-averaged BMI. Time-averaged BMI was divided into 6 subgroups; <18.5, 18.5-<23.0, 23.0-<25.0, 25.0-<30.0, 30.0-<35.0, and ≥35.0kg/m(2). BMI category of 23-<25kg/m(2) was used as the reference category. OUTCOMES: All-cause, cardiovascular, and infection-related mortality. RESULTS: Mean BMI of study participants was 27±7kg/m(2). Time-averaged BMI was <18.5 and ≥35kg/m(2) in 5% and 11% of patients, respectively. With progressively higher time-averaged BMI, there was progressively lower all-cause, cardiovascular, and infection-related mortality in patients younger than 65 years. In those 65 years or older, even though overweight/obesepatients had lower mortality compared with underweight/normal-weight patients, sequential increases in time-averaged BMI > 25kg/m(2) added no additional benefit. Based on dialysis vintage, incident HDpatients had greater all-cause and cardiovascular survival benefit with a higher time-averaged BMI compared with the longer term HDpatients. LIMITATIONS: Causality cannot be determined, and residual confounding cannot be excluded given the observational study design. CONCLUSIONS: Higher BMI is associated with lower death risk across all age and dialysis vintage groups. This benefit is more pronounced in incident HDpatients and those younger than 65 years. Given the robustness of the survival advantage of higher BMI, examining interventions to maintain or even increase dry weight in HDpatients irrespective of age and vintage are warranted.
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