Background-Equations to estimate glomerular filtration rate (GFR) are routinely used to assess kidney function. Current equations have limited precision and systematically underestimate measured GFR at higher levels.

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Limited data are available on the independent associations of estimated glomerular filtration rate (eGFR) and albuminuria with mortality and end stage renal disease (ESRD) among individuals with chronic kidney disease (CKD). We conducted a collaborative meta-analysis of 21,688 participants selected for CKD from 13 cohorts. After adjustment for potential confounders and albuminuria, a 15 mL/min/1.73 m2 lower eGFR below 45 mL/min/1.73 m2 was significantly associated with mortality (pooled hazard ratio [HR] 1.47 [95% CI: 1.22–1.79]), and ESRD (pooled HR 6.24 [95% CI: 4.84–8.05]). There was significant heterogeneity between studies for both HR estimates. After adjustment for risk factors and eGFR, an eight-fold higher albumin:creatinine ratio (ACR) or protein:creatinine ratio (PCR) was significantly associated with mortality (pooled HR 1.40 [95% CI: 1.27–1.55]), without evidence of significant heterogeneity. An eight-fold higher ACR or PCR was also strongly associated with ESRD (pooled HR 3.04 [95% CI: 2.27–4.08]), with significant heterogeneity between HR estimates. Lower eGFR and more severe albuminuria independently predict mortality and ESRD among individuals selected for CKD. The associations are stronger for ESRD than for mortality. The observed associations are consistent with CKD classification based on eGFR stages, and suggest that albuminuria provides additional prognostic information among individuals with CKD.

Both high CRP and low albumin, measured in CKD stages 3 and 4, are independent risk factors for all-cause mortality. High CRP, but not serum albumin, is a risk factor for cardiovascular mortality. These results suggest that high CRP and hypoalbuminemia provide prognostic information independent of each other in CKD.

Physical inactivity is associated with increased mortality in CKD and non-CKD populations. As in the non-CKD population, increased physical activity might have a survival benefit in the CKD population.

Adiponectin is presumed to possess antiatherogenic and cardioprotective properties. Limited data exist on the relationship between adiponectin and mortality in the earlier stages of chronic kidney disease. The Modification of Diet in Renal Disease study was a randomized, controlled trial that was conducted between 1989 and 1993. Adiponectin was measured in frozen samples that were obtained at baseline (N ‫؍‬ 820). Survival status and cause of death, up to December 31, 2000, were obtained from the National Death Index. Multivariable Cox models were used to examine the relationship of adiponectin with all-cause and cardiovascular mortality. Mean ؎ SD age was 52 ؎ 12 yr, and mean ؎ SD glomerular filtration rate (GFR) rate was 33 ؎ 12 ml/min per 1.73 m 2 . Eighty-five percent of participants were white, and 60% were male. Mean ؎ SD adiponectin was 12.8 ؎ 8.0 g/ml. Triglycerides, insulin resistance, glucose, body mass index, GFR, C-reactive protein, and albumin were inversely related and proteinuria and HDL cholesterol were directly related to adiponectin. During the 10-year follow-up period, 201 (25%) participants died of any cause, and 122 (15%) from cardiovascular disease. In multivariable adjusted Cox models, a 1-g/ml increase in adiponectin was associated with a 3% (hazard ratio 1.03; 95% confidence interval 1.01 to 1.05; P ‫؍‬ 0.02) increased risk for all-cause and 6% (hazard ratio 1.06; 95% confidence interval 1.03 to 1.09; P < 0.001) increased risk for cardiovascular mortality. High, rather than low, adiponectin is associated with increased mortality in this cohort of patients with chronic kidney disease stages 3 to 4. Further studies are necessary to confirm this association and to elucidate the underlying mechanisms. A diponectin is an adipocyte-derived peptide that may possess antiatherogenic properties (1,2). Obesity (3), coronary artery disease (4 -6), and diabetes (7) are characterized by low adiponectin levels, suggesting an inverse association with cardiovascular disease (CVD) risk. Whereas prospective studies in diabetic and nondiabetic men have demonstrated an inverse relationship between adiponectin levels and risk for CVD events (5,6), this association was not found in women (8) and in a population-based cohort of American Indians (9). On the contrary, in a few studies, high rather than low adiponectin levels were associated with adverse outcomes in patients with type 1 diabetes (10,11) and heart failure (12).Kidney function is an important determinant of circulating levels of adiponectin (13,14), and levels of this protein are markedly elevated in kidney failure (15). Data on the relationship between adiponectin and outcomes in patients with chronic kidney disease (CKD) are sparse. Low adiponectin levels were associated with increased risk for CVD events in one study of hemodialysis patients (15). Similarly, there was an inverse correlation between adiponectin levels and incident CVD in univariate analyses in a small cohort of patients in the earlier stages of CKD (13). Using data from the random...

Abstract. Among the 1846 patients in the HEMO Study, chronic high-flux dialysis did not significantly affect the primary outcome of the all-cause mortality (ACM) rate or the main secondary composite outcomes, including the rates of first cardiac hospitalization or ACM, first infectious hospitalization or ACM, first 15% decrease in serum albumin levels or ACM, or all non-vascular access-related hospitalizations. The high-flux intervention, however, seemed to be associated with reduced risks of specific cardiac-related events. The relative risks (RR) for the high-flux arm, compared with the low-flux arm, were 0.80 [95% confidence interval (CI), 0.65 to 0.99] for cardiac death and 0.87 (95% CI, 0.76 to 1.00) for the composite of first cardiac hospitalization or cardiac death. Also, the effect of high-flux dialysis on ACM seemed to vary, depending on the duration of prior dialysis. This report presents secondary analyses to further explore the relationship between the flux intervention and the duration of dialysis with respect to various outcomes. The patients were stratified into a short-duration group and a long-duration group, on the basis of the mean duration of dialysis of 3.7 yr before randomization. In the subgroup that had been on dialysis for Ͼ3.7 yr, randomization to high-flux dialysis was associated with lower risks of ACM (RR, 0.68; 95% CI, 0.53 to 0.86; P ϭ 0.001), the composite of first albumin level decrease or ACM (RR, 0.74; 95% CI, 0.60 to 0.91; P ϭ 0.005), and cardiac deaths (RR, 0.63; 95% CI, 0.43 to 0.92; P ϭ 0.016), compared with low-flux dialysis. No significant differences were observed in outcomes related to infection for either duration subgroup, however, and the trends for beneficial effects of high-flux dialysis on ACM rates were considerably weakened when the years of dialysis during the follow-up phase were combined with the prestudy years of dialysis in the analysis. For the subgroup of patients with Ͻ3.7 yr of dialysis before the study, assignment to high-flux dialysis had no significant effect on any of the examined clinical outcomes. These data suggest that high-flux dialysis might have a beneficial effect on cardiac outcomes. Because these results are derived from multiple statistical comparisons, however, they must be interpreted with caution. The subgroup results that demonstrate that patients with different durations of dialysis are affected differently by high-flux dialysis are interesting and require further study for confirmation.The annual mortality rate among patients undergoing maintenance hemodialysis is approximately 18%, with cardiovascular events being the most common cause of death. Morbidity is also substantial, with an average of 1.94 hospitalizations and approximately 14 d of hospitalization each year (1). The HEMO Study was a randomized, prospective, clinical trial designed to examine the effects on clinical outcomes of two treatment parameters, i.e., hemodialysis dose based on the clearance of urea (molecular mass, 60 D) and membrane porosity or flux, which serves...