Nephrology Dialysis Transplantation, Vol 12, Issue 12 2603-2611, Copyright © 1997 by Oxford University Press
M Koch, B Kutkuhn, B Grabensee and E Ritz
Background: diabetic patients with end-stage renal
failure (ESRD) have a high cardiovascular morbidity and mortality. The
underlying mechanisms are not completely elucidated. The aim of our study
was to define predictors of death in diabetic patients with end-stage renal
disease. Patients and methods: We preformed a
prospective study in 35 dialysis centres in Germany between 1985 and 1994.
To evaluate predictors and risk factors in this population we examined 412
diabetic patients at the time of admission to dialysis treatment
(peritoneal dialysis (PD) or haemodialysis (HD)). Classification of the
type of diabetes was done according the criteria of the National Diabetes
Data Group [1,2]. Items assessed at the time of admission were coronary
artery disease (CAD), peripheral occlusive disease (POD), and stroke. CAD
was defined as a history of myocardial infarction with the corresponding
changes in the ECG or luminal narrowing by more than 50% in at least one
coronary artery upon coronarangiography; POD was defined as claudication
and/or brachial-tibial ratio (BTR) less than 0.9 or a history of
amputation. Assessment of the nutritional state comprised body mass index,
skinfold thickness of the upper arm and lateral thorax area, and urea
concentration. Cholesterol, HDL, LDL, apolipoprotein A (ApoA-I) and B
(ApoB), triglycerides, lipoprotein (a) (Lp(a)), and fibrinogen were
measured. As an index of disturbed cardiac innervation beat-to-beat
variation was measured. Outcome measurements were causes of death (i.e.
cardiac and non-cardiac) and time of survival.
Results: One hundred and eighty of 412 (44%) patients
died during the observation period Patients who died were older
(61±12 versus 53±15 years P
lt;0.0001), had lower skin fold thickness (13.1±6.0
versus 15.1±7.2 mm P <0.04), lower
ApoA-I (100±35 versus 111±32
mg/dl P <0.005) and higher fibrinogen (515±156
versus 451±155 mg/dl P <0.02). Type
II diabetic patients had a lower mean survival time than type I (34
versus 66 months P <0.0006). The mode of renal
replacement therapy (PD or HD) had no adverse effect on survival time.
Survivors less frequently had a history of CAD, POD and stroke than
non-survivors. In multivariate analysis ApoA-I, fibrinogen ,age and stroke
were independent predictors of cardiac and non-cardiac death in diabetic
patients with end-stage renal failure. Lipid values and nutritional state
did not independently predict the overall and cardiovascular mortality.
Conclusion: This study in dialysed diabetic patients
identified several predictors of death, some of which are susceptible to
intervention. Key words: cardiovascular risk factors;
chronic ambulatory peritoneal dialysis, diabetes, end-stage renal failure;
haemodialysis; survival; vascular diseases
ORIGINAL ARTICLES
Apolipoprotein A, fibrinogen, age, and history of stroke are predictors of death in dialysed diabetic patients: a prospective study in 412 subjects
Clinic of Nephrology and Rheumatology, Heinrich Heine University Dusseldorf, Germany; Department of Internal Medicine, Ruprecht Karl University Heidelberg, Germany; Corresponding author at: Heinrich Heine University, PO Box 101007, D-40001 Dusseldorf, Germany
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