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. 2017 Aug;28(8):2491-2497.
doi: 10.1681/ASN.2016121341. Epub 2017 May 4.

Chronic Fluid Overload and Mortality in ESRD

Carmine Zoccali  1 , Ulrich Moissl  2 , Charles Chazot  3 , Francesca Mallamaci  4 , Giovanni Tripepi  4 , Otto Arkossy  5 , Peter Wabel  2 , Stefano Stuard  6
Affiliations

Chronic Fluid Overload and Mortality in ESRD

Carmine Zoccali et al. J Am Soc Nephrol. 2017 Aug.

Abstract

Sustained fluid overload (FO) is considered a major cause of hypertension, heart failure, and mortality in patients with ESRD on maintenance hemodialysis. However, there has not been a cohort study investigating the relationship between chronic exposure to FO and mortality in this population. We studied the relationship of baseline and cumulative FO exposure over 1 year with mortality in 39,566 patients with incident ESRD in a large dialysis network in 26 countries using whole-body bioimpedance spectroscopy to assess fluid status. Analyses were applied across three discrete systolic BP (syst-BP) categories (<130, 130-160, and >160 mmHg), with nonoverhydrated patients with syst-BP=130-160 mmHg as the reference category; >200,000 FO measurements were performed over follow-up. Baseline FO value predicted excess risk of mortality across syst-BP categories (<130 mmHg: hazard ratio [HR], 1.51; 95% confidence interval [95% CI], 1.38 to 1.65; 130-160 mmHg: HR, 1.25; 95% CI, 1.16 to 1.36; >160 mmHg: HR, 1.30; 95% CI, 1.19 to 1.42; all P<0.001). However, cumulative 1-year FO exposure predicted a higher death risk (P<0.001) across all syst-BP categories (<130 mmHg: HR, 1.94; 95% CI, 1.68 to 2.23; 130-160 mmHg: HR, 1.51; 95% CI, 1.35 to 1.69; >160 mmHg: HR, 1.62; 95% CI, 1.39 to 1.90). In conclusion, chronic exposure to FO in ESRD is a strong risk factor for death across discrete BP categories. Whether treatment policies that account for fluid status monitoring are preferable to policies that account solely for predialysis BP measurements remains to be tested in a clinical trial.

Keywords: ESRD; Epidemiology and outcomes; VOLUME EXPANSION; blood pressure; hemodialysis; mortality risk.

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Figures

Figure 1.
Figure 1.
Flow diagram of the study cohort.
Figure 2.
Figure 2.
Distribution of FO and systolic BP in the study population at baseline. The vertical lines identify (left panel) the upper limit of the normal range of FO and (right panel) the reference population for systolic BP (130–160 mmHg).
Figure 3.
Figure 3.
Relationship between (left panel) baseline and (right panel) 1-year cumulative systolic BP and mortality. Data are adjusted for the full list of variables in Table 1.
Figure 4.
Figure 4.
(Left panel) Baseline and (right panel) 1-year cumulative FO and mortality in patients stratified by predialysis systolic BP. Data are adjusted for the full list of variables in Table 1. Data are HR and 95% CIs. Fluid-overloaded patients had a significantly higher risk of death compared with nonoverloaded patients across all BP strata (all P<0.001).
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