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Aldosterone and mortality in hemodialysis patients: role of volume overload.

Hung SC, Lin YP, Huang HL, Pu HF, Tarng DC - PLoS ONE (2013)

Bottom Line: Elevated aldosterone is associated with increased mortality in the general population.During a median follow-up of 54 months, 83 deaths and 70 cardiovascular events occurred.Cox multivariate analysis showed that by using the low aldosterone as the reference, high aldosterone was inversely associated with decreased hazard ratios for mortality (0.49; 95% confidence interval, 0.25-0.76) and first cardiovascular event (0.70; 95% confidence interval, 0.33-0.78) in the presence of volume overload.

View Article: PubMed Central - PubMed

Affiliation: Division of Nephrology, Buddhist Tzu Chi General Hospital, Taipei Branch, Taipei, Taiwan.

ABSTRACT

Background: Elevated aldosterone is associated with increased mortality in the general population. In patients on dialysis, however, the association is reversed. This paradox may be explained by volume overload, which is associated with lower aldosterone and higher mortality.

Methods: We evaluated the relationship between aldosterone and outcomes in a prospective cohort of 328 hemodialysis patients stratified by the presence or absence of volume overload (defined as extracellular water/total body water >48%, as measured with bioimpedance). Baseline plasma aldosterone was measured before dialysis and categorized as low (<140 pg/mL), middle (140 to 280 pg/mL) and high (>280 pg/mL).

Results: Overall, 36% (n = 119) of the hemodialysis patients had evidence of volume overload. Baseline aldosterone was significantly lower in the presence of volume overload than in its absence. During a median follow-up of 54 months, 83 deaths and 70 cardiovascular events occurred. Cox multivariate analysis showed that by using the low aldosterone as the reference, high aldosterone was inversely associated with decreased hazard ratios for mortality (0.49; 95% confidence interval, 0.25-0.76) and first cardiovascular event (0.70; 95% confidence interval, 0.33-0.78) in the presence of volume overload. In contrast, high aldosterone was associated with an increased risk for mortality (1.97; 95% confidence interval, 1.69-3.75) and first cardiovascular event (2.01; 95% confidence interval, 1.28-4.15) in the absence of volume overload.

Conclusions: The inverse association of aldosterone with adverse outcomes in hemodialysis patients is due to the confounding effect of volume overload. These findings support treatment of hyperaldosteronemia in hemodialysis patients who have achieved strict volume control.

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Kaplan-Meier mortality curves according to aldosterone tertile, modified by volume status.All-cause mortality in relation to plasma aldosterone levels at baseline modified by the ratio of extracellular water to total body water (ECW/TBW) >48% (A) and ≤48% (B) among hemodialysis patients.
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pone-0057511-g003: Kaplan-Meier mortality curves according to aldosterone tertile, modified by volume status.All-cause mortality in relation to plasma aldosterone levels at baseline modified by the ratio of extracellular water to total body water (ECW/TBW) >48% (A) and ≤48% (B) among hemodialysis patients.

Mentions: During the follow-up period, 16 patients received kidney transplants, and 4 patients transitioned to peritoneal dialysis. Thirty-three patients who were transferred to other dialysis units were followed up using questionnaire forms completed by the attending physicians at the units. At the end of the follow-up period, 225 patients were confirmed to be alive on hemodialysis treatment, and 83 patients died while being treated; 37 (44.6%) of these deaths were due to CVD-related causes. There were 70 CV events in the median follow-up period of 54 months (IQR: 27–107 months). In unadjusted analysis, lower aldosterone levels were associated with higher mortality in the overall cohort (P for trend = 0.006) (Fig. 2) and in the presence of volume overload (P for trend = 0.001) (Fig. 3A), respectively. However, in the absence of volume overload, the association was reversed, with higher aldosterone levels associated with higher mortality (P for trend = 0.042) (Fig. 3B).


Aldosterone and mortality in hemodialysis patients: role of volume overload.

Hung SC, Lin YP, Huang HL, Pu HF, Tarng DC - PLoS ONE (2013)

Kaplan-Meier mortality curves according to aldosterone tertile, modified by volume status.All-cause mortality in relation to plasma aldosterone levels at baseline modified by the ratio of extracellular water to total body water (ECW/TBW) >48% (A) and ≤48% (B) among hemodialysis patients.
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC3585342&req=5

pone-0057511-g003: Kaplan-Meier mortality curves according to aldosterone tertile, modified by volume status.All-cause mortality in relation to plasma aldosterone levels at baseline modified by the ratio of extracellular water to total body water (ECW/TBW) >48% (A) and ≤48% (B) among hemodialysis patients.
Mentions: During the follow-up period, 16 patients received kidney transplants, and 4 patients transitioned to peritoneal dialysis. Thirty-three patients who were transferred to other dialysis units were followed up using questionnaire forms completed by the attending physicians at the units. At the end of the follow-up period, 225 patients were confirmed to be alive on hemodialysis treatment, and 83 patients died while being treated; 37 (44.6%) of these deaths were due to CVD-related causes. There were 70 CV events in the median follow-up period of 54 months (IQR: 27–107 months). In unadjusted analysis, lower aldosterone levels were associated with higher mortality in the overall cohort (P for trend = 0.006) (Fig. 2) and in the presence of volume overload (P for trend = 0.001) (Fig. 3A), respectively. However, in the absence of volume overload, the association was reversed, with higher aldosterone levels associated with higher mortality (P for trend = 0.042) (Fig. 3B).

Bottom Line: Elevated aldosterone is associated with increased mortality in the general population.During a median follow-up of 54 months, 83 deaths and 70 cardiovascular events occurred.Cox multivariate analysis showed that by using the low aldosterone as the reference, high aldosterone was inversely associated with decreased hazard ratios for mortality (0.49; 95% confidence interval, 0.25-0.76) and first cardiovascular event (0.70; 95% confidence interval, 0.33-0.78) in the presence of volume overload.

View Article: PubMed Central - PubMed

Affiliation: Division of Nephrology, Buddhist Tzu Chi General Hospital, Taipei Branch, Taipei, Taiwan.

ABSTRACT

Background: Elevated aldosterone is associated with increased mortality in the general population. In patients on dialysis, however, the association is reversed. This paradox may be explained by volume overload, which is associated with lower aldosterone and higher mortality.

Methods: We evaluated the relationship between aldosterone and outcomes in a prospective cohort of 328 hemodialysis patients stratified by the presence or absence of volume overload (defined as extracellular water/total body water >48%, as measured with bioimpedance). Baseline plasma aldosterone was measured before dialysis and categorized as low (<140 pg/mL), middle (140 to 280 pg/mL) and high (>280 pg/mL).

Results: Overall, 36% (n = 119) of the hemodialysis patients had evidence of volume overload. Baseline aldosterone was significantly lower in the presence of volume overload than in its absence. During a median follow-up of 54 months, 83 deaths and 70 cardiovascular events occurred. Cox multivariate analysis showed that by using the low aldosterone as the reference, high aldosterone was inversely associated with decreased hazard ratios for mortality (0.49; 95% confidence interval, 0.25-0.76) and first cardiovascular event (0.70; 95% confidence interval, 0.33-0.78) in the presence of volume overload. In contrast, high aldosterone was associated with an increased risk for mortality (1.97; 95% confidence interval, 1.69-3.75) and first cardiovascular event (2.01; 95% confidence interval, 1.28-4.15) in the absence of volume overload.

Conclusions: The inverse association of aldosterone with adverse outcomes in hemodialysis patients is due to the confounding effect of volume overload. These findings support treatment of hyperaldosteronemia in hemodialysis patients who have achieved strict volume control.

Show MeSH
Related in: MedlinePlus