Anemia and hypoalbuminemia at initiation of hemodialysis as risk factor for survival of dialysis patients

Abstract

Objective: To determine the survival of patients undergoing chronic maintenance hemodialysis by determining the relative risk (RR) of anemia and hypoalbuminemia at initiation of dialysis on survival.

Study design: Cohort study.

Place and duration of study: Hemodialysis Unit of Shalamar Hospital, Lahore, from June 2003 to October 2006.

Methodology: This study was conducted on all patients of end stage renal disease who presented in Accident/Emergency Department of the hospital for the first time or received calls from other departments in getting dialysis. Patients with acute renal failure and those lost to follow-up were excluded from the study. At presentation, a history and examination was done and recorded. At the same time a blood sample was sent for routine hematological parameters (hemoglobin, total leucocyte count (TLC), biochemical (urea, creatinine, serum potassium and albumin) and viral markers (anti-HCV and HbsAg). Patients were followed up for outcomes. The outcomes of the study were continued dialysis, death and renal transplant. Kaplan-Meier and log Rank tests were used for determining survival. Relative risk was assessed on medical 9.2.

Results: One hundred and eighty five patients were studied including 99 (52.8%) males and 86 (47.2%) females. Major causes of renal failure were Diabetes mellitus in 125 (67.6%), chronic glomerulonephrotis in 31 (16.8%) and hypertension in 18 (9.7%). Most of the patients - 105 (60%) were euvolemic. Sixty percent of patients had very high urea (> 200 mg/dl) and creatinine (> 8.0 mg/dl). The mortality of haemodialysis patients was seventy four percent per 100 patients per year, 62.24% being in the initial 6 months. One hundred and sixty four patients (91.1%) were anemic (hemoglobin < 11 gm/dl) and 124 (67%) were hypoalbuminemic (serum albumin < 4 gm/dl) on first presentation. Patients with group 1 have hemoglobin less than 11 gm/dl (7.83 + or - 1.51), group 2 had hemoglobin of equal to more than 11 gm/dl (11.56 + or - 0.64) which was statistically significant (t = - 9.54, p= 0.000). The survival freedom in group 2 (Hb > 11 gm/dl) was higher than group 1 (Hb < 11 gm/dl) which is statistical significant (p = 0.023). On the basis of serum albumin (S.Alb), patients were divided into two groups i.e S.Alb less than 4 (3.15 + or - 0.38 gm/dl) was group 1, and more than or equal to 4 (4.23 + or - 0.28 gm/dl) was group 2, which were statistically significant (t = - 11.58, p < 0.001). The overall survival time was significantly shorter in group 1 patients than group 2 (p = 0.037). RR for low albumin was 1.27 and for low hemoglobin, it was 1.30.

Conclusion: Mortality of haemodialysis patients was seventy four percent per 100 patients per year. Amongst these 62.24% were in the initial 6 months. The mean survival time was 296 days. Patients with very low hemoglobin and albumin are at more risk for early deaths than patients with normal hemoglobin and albumin on first presentation for dialysis.