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BACKGROUND: We developed machine learning models to understand the predictors of shorter-, intermediate-, and longer-term mortality among hemodialysis (HD) patients affected by COVID-19 in four countries in the Americas. METHODS: We used data from adult HD patients treated at regional institutions of a global provider in Latin America (LatAm) and North America who contracted COVID-19 in 2020 before SARS-CoV-2 vaccines were available. Using 93 commonly captured variables, we developed machine learning models that predicted the likelihood of death overall, as well as during 0-14, 15-30, > 30 days after COVID-19 presentation and identified the importance of predictors. XGBoost models were built in parallel using the same programming with a 60%:20%:20% random split for training, validation, & testing data for the datasets from LatAm (Argentina, Columbia, Ecuador) and North America (United States) countries. RESULTS: Among HD patients with COVID-19, 28.8% (1,001/3,473) died in LatAm and 20.5% (4,426/21,624) died in North America. Mortality occurred earlier in LatAm versus North America; 15.0% and 7.3% of patients died within 0-14 days, 7.9% and 4.6% of patients died within 15-30 days, and 5.9% and 8.6% of patients died > 30 days after COVID-19 presentation, respectively. Area under curve ranged from 0.73 to 0.83 across prediction models in both regions. Top predictors of death after COVID-19 consistently included older age, longer vintage, markers of poor nutrition and more inflammation in both regions at all timepoints. Unique patient attributes (higher BMI, male sex) were top predictors of mortality during 0-14 and 15-30 days after COVID-19, yet not mortality > 30 days after presentation. CONCLUSIONS: Findings showed distinct profiles of mortality in COVID-19 in LatAm and North America throughout 2020. Mortality rate was higher within 0-14 and 15-30 days after COVID-19 in LatAm, while mortality rate was higher in North America > 30 days after presentation. Nonetheless, a remarkable proportion of HD patients died > 30 days after COVID-19 presentation in both regions. We were able to develop a series of suitable prognostic prediction models and establish the top predictors of death in COVID-19 during shorter-, intermediate-, and longer-term follow up periods.
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COVID-19 , Adulto , Humanos , Masculino , Vacinas contra COVID-19 , Aprendizado de Máquina , América do Norte/epidemiologia , Diálise Renal , SARS-CoV-2 , FemininoRESUMO
OBJECTIVES: Sarcopenia is the loss of skeletal muscle mass and function that occurs with aging that can lead to greater morbidity and mortality. Chronic kidney disease and hemodialysis (HD) favors the development of sarcopenia. We studied the prevalence of sarcopenia and its components using European Working Group on Sarcopenia in Elderly People 2 proposed criteria and risk factors for its development in HD patients. METHODS: In 100 adult HD patients, we evaluated: hand grip strength (HGS), muscle mass by dual energy X-ray absorptiometry and physical performance (gait-speed and sit-stand test). RESULTS: Sixty patients were male and 40 were female; mean age 55.6 years. Prevalence of sarcopenia was 16% (11.1% in males and 25% in females; P = 0.05); 7% had severe sarcopenia. Prevalence of low HGS was 33% in males and 28% in females; low muscle mass was 30% in males but 70% in females and low physical performance 23% in males and 45% in females. Falls were reported by 23 patients. Patients with lower HGS had a higher prevalence of falls in the last year (40% two or more falls; P = 0.03). Only females with sarcopenia had lower bone mineral content. Neither age, body mass index, time on dialysis, or prevalence of diabetes predicted sarcopenia. CONCLUSIONS: A significant proportion of dialysis patients had sarcopenia, more frequent in females. Low HGS was associated with a higher prevalence of falls. Only females with sarcopenia had lower bone mineral content.
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BACKGROUND: Seasonal mortality differences have been reported in US hemodialysis (HD) patients. Here we examine the effect of seasons on mortality, clinical and laboratory parameters on a global scale. METHODS: Databases from the international Monitoring Dialysis Outcomes (MONDO) consortium were queried to identify patients who received in-center HD for at least 1 year. Clinics were stratified by hemisphere and climate zone (tropical or temperate). We recorded mortality and computed averages of pre-dialysis systolic blood pressure (pre-SBP), interdialytic weight gain (IDWG), serum albumin, and log C-reactive protein (CRP). We explored seasonal effects using cosinor analysis and adjusted linear mixed models globally, and after stratification. RESULTS: Data from 87,399 patients were included (northern temperate: 63,671; northern tropical: 7,159; southern temperate: 13,917; southern tropical: 2,652 patients). Globally, mortality was highest in winter. Following stratification, mortality was significantly lower in spring and summer compared to winter in temperate, but not in tropical zones. Globally, pre-SBP and IDWG were lower in summer and spring as compared to winter, although less pronounced in tropical zones. Except for southern temperate zone, serum albumin levels were higher in winter. CRP levels were highest in winter. CONCLUSION: Significant global seasonal variations in mortality, pre-SBP, IDWG, albumin and CRP were observed. Seasonal variations in mortality were most pronounced in temperate climate zones.
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Diálise Renal/mortalidade , Estações do Ano , Clima Tropical , Adulto , Idoso , Ásia/epidemiologia , Pressão Sanguínea , Proteína C-Reativa/metabolismo , Europa (Continente)/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , América do Norte/epidemiologia , Oceania/epidemiologia , Sistema de Registros , Albumina Sérica/metabolismo , América do Sul/epidemiologia , Aumento de PesoRESUMO
The aims of this study were to analyse body composition, to detect the presence of undernutrition, and to establish a relationship between undernutrition and the biological markers routinely used as indicators of nutritional status in hemodialysis (HD) patients (pts). We used a body composition monitor (BCM) that expresses body weight in terms of lean tissue mass (LTM) and fat tissue mass (FTM) independent of hydration status. From nine HD units, 934 pts were included. Undernutrition was defined as having a lean tissue index (LTI = LTM/height(2)) below the 10th percentile of a reference population. Biochemical markers and parameters delivered by BCM were used to compare low LTI and normal LTI groups. Undernutrition prevalence was 58.8% of the population studied. Low LTI pts were older, were significantly more frequently overhydrated, and had been on HD for a longer period of time than the normal LTI group. FTI (FTI = FTM/ height(2)) was significantly higher in low LTI pts and increased according to BMI. LTI was not influenced by different BMI levels. Albumin and C-reactive protein correlated inversely (r = -0.28). However neither of them was statistically different when considering undernourished and normal LTI pts. Our BCM study was able to show a high prevalence of undernutrition, as expressed by low LTI. In our study, BMI and other common markers, such as albumin, failed to predict malnutrition as determined by BCM.
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Reports from a United States cohort of chronic hemodialysis patients suggested that weight loss, a decline in pre-dialysis systolic blood pressure, and decreased serum albumin may precede death. However, no comparative studies have been reported in such patients from other countries. Here we analyzed dynamic changes in these parameters in hemodialysis patients and included 3593 individuals from 5 Asian countries; 35,146 from 18 European countries; 8649 from Argentina; and 4742 from the United States. In surviving prevalent patients, these variables appeared to have notably different dynamics than in patients who died. While in all populations the interdialytic weight gain, systolic blood pressure, and serum albumin levels were stable in surviving patients, these indicators declined starting more than a year ahead in those who died with the dynamics similar irrespective of gender and geographic region. In European patients, C-reactive protein levels were available on a routine basis and indicated that levels of this acute-phase protein were low and stable in surviving patients but rose sharply before death. Thus, relevant fundamental biological processes start many months before death in the majority of chronic hemodialysis patients. Longitudinal monitoring of these dynamics may help to identify patients at risk and aid the development of an alert system to initiate timely interventions to improve outcomes.
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Pressão Sanguínea , Proteína C-Reativa/metabolismo , Diálise Renal/mortalidade , Insuficiência Renal Crônica/mortalidade , Insuficiência Renal Crônica/terapia , Albumina Sérica/metabolismo , Sístole , Aumento de Peso , Idoso , Argentina , Ásia , Biomarcadores/sangue , Bases de Dados Factuais , Progressão da Doença , Europa (Continente) , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Diálise Renal/efeitos adversos , Insuficiência Renal Crônica/sangue , Insuficiência Renal Crônica/diagnóstico , Insuficiência Renal Crônica/fisiopatologia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Albumina Sérica Humana , Fatores de Tempo , Resultado do Tratamento , Estados UnidosRESUMO
Brazil has the third largest contingent of patients on maintenance hemodialysis (HD) worldwide. However, little is known regarding survival rate and predictors of mortality risk in that population, which are the purposes of this study. A total of 3,082 patients incident on HD, from 2000 to 2004, at 25 dialysis facilities distributed among 7 out of 26 states of Brazil were followed-up until 2009. Patients were 52 ± 16 years-old, 57.8% men, and 20.4%, diabetics. The primary outcome was all causes of mortality. Data were censored at five years of follow-up. The global five-year survival rate was 58.2%. In the Cox proportional model, variables associated with risk of death were: age (hazard ratio - HR = 1.44 per decade, p < 0.0001), diabetes (HR = 1.51, p < 0.0001), serum albumin (HR = 0.76 per g/dL, p = 0.001), creatinine (HR = 0.92 per mg/dL, p < 0.0001), and phosphorus (HR = 1.06 per mg/dL, p = 0.04). The present results show that the mortality rate on HD in this Brazilian cohort was relatively low, but the population is younger and with a lower prevalence of diabetes than the ones reported for developed countries.
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Diálise Renal/mortalidade , Adulto , Brasil/epidemiologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Taxa de Sobrevida , Fatores de TempoRESUMO
O Brasil tem o terceiro maior contingente de pacientes em hemodiálise (HD) no mundo. Todavia, pouco conhece-se sobre a taxa de sobrevida e os preditores do risco de mortalidade nessa população, que são os objetivos deste estudo. Um total de 3.082 pacientes incidentes em HD, de 2000 a 2004, em 25 unidades de diálise distribuídas por 7 dos 26 estados do Brasil, foi acompanhado até 2009. Os pacientes tinham entre 52 ± 16 anos de idade, 57,8 por cento eram homens e 20,4 por cento, diabéticos. O desfecho primário foi de mortalidade por todas as causas. Os dados foram censurados aos cinco anos de seguimento. A taxa global de sobrevida em cinco anos foi de 58,2 por cento. No modelo proporcional de Cox, as variáveis associadas ao risco de óbito foram: a idade (risco relativo - RR = 1,44 por década; p < 0,0001), diabetes (RR = 1,51; p < 0,0001), albumina sérica (RR = 0,76 por g/dL; p = 0,001), creatinina (RR = 0,92 por mg/dL; p < 0,0001) e fósforo (RR = 1,06 por mg/dL; p = 0,04). Os resultados mostram que a taxa de mortalidade em HD nesta coorte brasileira foi relativamente baixa, mas a população é mais jovem e com prevalência de diabetes mais baixa do que aquela descrita nos países desenvolvidos.
Brazil has the third largest contingent of patients on maintenance hemodialysis (HD) worldwide. However, little is known regarding survival rate and predictors of mortality risk in that population, which are the purposes of this study. A total of 3,082 patients incident on HD, from 2000 to 2004, at 25 dialysis facilities distributed among 7 out of 26 states of Brazil were followed-up until 2009. Patients were 52 ± 16 years-old, 57.8 percent men, and 20.4 percent, diabetics. The primary outcome was all causes of mortality. Data were censored at five years of follow-up. The global five-year survival rate was 58.2 percent. In the Cox proportional model, variables associated with risk of death were: age (hazard ratio - HR = 1.44 per decade, p < 0.0001), diabetes (HR = 1.51, p < 0.0001), serum albumin (HR = 0.76 per g/dL, p = 0.001), creatinine (HR = 0.92 per mg/dL, p < 0.0001), and phosphorus (HR = 1.06 per mg/dL, p = 0.04). The present results show that the mortality rate on HD in this Brazilian cohort was relatively low, but the population is younger and with a lower prevalence of diabetes than the ones reported for developed countries.