Visceral Adiposity & CV Events in Hemodialysis Patients
Visceral Adiposity & CV Events in Hemodialysis Patients
The basic characteristics of all participants are summarized in Table 1. Generally, the patients in VAI tertile 3 had a higher percentage of history of DM, hypertension and concurrent CV disease. In addition, BMI, WC, WHtR, lipid profiles, hs-CRP and GNRI levels were higher in the tertile 3 patients.
During the follow-up period (median 4.2 years, range 0.3–6.8 years), 219 patients reached the composite outcome; 120 patients died and 162 experienced CV events. In the 162 patients with CV events, 15 had intracranial hemorrhage, 48 had ischemic stroke, 70 had coronary artery disease (either non-fatal acute myocardial infarct or coronary re-vascularization), 20 had peripheral arterial occlusion disease, and 9 were hospitalized for de-compensated heart failure.
In the unadjusted Cox regression model, the patients in VAI tertile 2 (HR, 1.6; 1.13–2.26) and VAI tertile 3 (HR, 2.12; 1.51–2.98) had more composite outcomes. In addition, the patients in VAI tertile 2 (HR, 1.91; 1.26–2.91) and VAI tertile 3 (HR, 2.68; 1.78–4.03) also had more CV outcomes, and the patients in VAI tertile 3 had the worst all-cause mortality (HR, 1.74; 1.11–2.74). Similarly, WC and WHtR also predicted composite and CV outcomes; however, WC and WHtR did not predict all-cause mortality.
In the multivariate adjusted model (Table 2), VAI was a good predictor of composite and CV outcomes. The patients in VAI tertile 3 had 65% and 80% higher risk of having composite and CV outcomes, and the patients in tertile 2 had 52% and 70% higher risk of composite and CV outcomes. However, after adjusting for multiple outcome-related factors, the patients in VAI tertile 3 had a marginally higher risk of mortality (HR, 1.49; 1.0–2.5, P = 0.06). Similarly, a 10-cm larger WC was associated with a 29% and 36% higher risk, and a 0.01 unit increase in WHtR was associated with 5% and 6% higher risk for composite and CV outcomes after multivariate adjustments. However, WC and WHtR did not predict all-cause mortality after adjustments (Table 2).
We used the stepwise forward likelihood ratio method in the adjusted multivariate model (Table 3), and found that VAI was a good predictor of composite and CV outcomes. However, WC and WHtR did not predict composite outcome, CV outcome or all-cause mortality, and the VAI and WHtR were also not good predictors of all-cause mortality.
The AUC for the VAI, WC and WHtR versus outcomes are shown in Table 4. VAI, WC and WHtR had similar predictive performance for all aspects of outcome analysis at the fourth, fifth and sixth years of follow-up.
In men, the VAI (VAI 3 versus VAI 1, HR, 2.95; 1.3–6.69 and VAI 2 versus VAI 1, HR, 2.25; 1.15–4.39), WC (HR, 1.51; 1.13–2.03, every 10 cm increase) and WHtR (HR, 1.09; 1.03–1.16, every 0.01 unit increase) all predicted all-cause mortality. However, in women, the VAI, WC and WHtR did not predict all-cause mortality. The VAI predicted all-cause mortality in patients with better nutritional status (GNRI ≥ 103.6) but not in patients with worse nutritional status (GNRI < 103.6) (Figure 1). However, WC did not predict all-cause mortality in either the patients with better (GNRI ≥ 103.6, HR = 1.12; 0.67–2.45, every 10 cm increase) or worse (GNRI < 103.6, HR = 1.03; 0.58–2.55) nutritional status. Similarly, WHtR did not predict all-cause mortality in either patients with better (HR = 1.06; 0.55–1.7, every 0.01 unit increase) or worse (HR = 1.01; 0.38–3.55, every 0.01 unit increase) nutritional status.
(Enlarge Image)
Figure 1.
Relationship between visceral adiposity index (VAI) tertiles and all-cause mortality in hemodialysis patients with different nutritional status. The VAI predicted all-cause mortality in patients with a better nutritional status (GNRI ≥ 103.6) but not in those with a worse nutritional status (GNRI < 103.6). Analysis were adjusted for gender, age, hemodialysis vintage, presence of diabetes, hypertension and concurrent cardiovascular disease, hemoglobin, intact parathyroid hormone, high sensitive C-reactive protein and calcium phosphate product.
Results
Basic Characteristics of all Participants and by VAI Tertiles
The basic characteristics of all participants are summarized in Table 1. Generally, the patients in VAI tertile 3 had a higher percentage of history of DM, hypertension and concurrent CV disease. In addition, BMI, WC, WHtR, lipid profiles, hs-CRP and GNRI levels were higher in the tertile 3 patients.
Composite Outcome, All-cause Mortality and Cardiovascular Events
During the follow-up period (median 4.2 years, range 0.3–6.8 years), 219 patients reached the composite outcome; 120 patients died and 162 experienced CV events. In the 162 patients with CV events, 15 had intracranial hemorrhage, 48 had ischemic stroke, 70 had coronary artery disease (either non-fatal acute myocardial infarct or coronary re-vascularization), 20 had peripheral arterial occlusion disease, and 9 were hospitalized for de-compensated heart failure.
In the unadjusted Cox regression model, the patients in VAI tertile 2 (HR, 1.6; 1.13–2.26) and VAI tertile 3 (HR, 2.12; 1.51–2.98) had more composite outcomes. In addition, the patients in VAI tertile 2 (HR, 1.91; 1.26–2.91) and VAI tertile 3 (HR, 2.68; 1.78–4.03) also had more CV outcomes, and the patients in VAI tertile 3 had the worst all-cause mortality (HR, 1.74; 1.11–2.74). Similarly, WC and WHtR also predicted composite and CV outcomes; however, WC and WHtR did not predict all-cause mortality.
In the multivariate adjusted model (Table 2), VAI was a good predictor of composite and CV outcomes. The patients in VAI tertile 3 had 65% and 80% higher risk of having composite and CV outcomes, and the patients in tertile 2 had 52% and 70% higher risk of composite and CV outcomes. However, after adjusting for multiple outcome-related factors, the patients in VAI tertile 3 had a marginally higher risk of mortality (HR, 1.49; 1.0–2.5, P = 0.06). Similarly, a 10-cm larger WC was associated with a 29% and 36% higher risk, and a 0.01 unit increase in WHtR was associated with 5% and 6% higher risk for composite and CV outcomes after multivariate adjustments. However, WC and WHtR did not predict all-cause mortality after adjustments (Table 2).
The Predictive Performance of the VAI, WC and WHtR on the Composite Outcomes, Cardiovascular Events And All-cause Mortality
We used the stepwise forward likelihood ratio method in the adjusted multivariate model (Table 3), and found that VAI was a good predictor of composite and CV outcomes. However, WC and WHtR did not predict composite outcome, CV outcome or all-cause mortality, and the VAI and WHtR were also not good predictors of all-cause mortality.
Time-dependent ROC Analysis of the VAI, WC and WHtR as Predictors of Composite Outcome, Cardiovascular Outcome and All-cause Mortality
The AUC for the VAI, WC and WHtR versus outcomes are shown in Table 4. VAI, WC and WHtR had similar predictive performance for all aspects of outcome analysis at the fourth, fifth and sixth years of follow-up.
Pre-specified Subgroup Analysis of the Impacts of the VAI, WC, and WHtR on All-cause Mortality
In men, the VAI (VAI 3 versus VAI 1, HR, 2.95; 1.3–6.69 and VAI 2 versus VAI 1, HR, 2.25; 1.15–4.39), WC (HR, 1.51; 1.13–2.03, every 10 cm increase) and WHtR (HR, 1.09; 1.03–1.16, every 0.01 unit increase) all predicted all-cause mortality. However, in women, the VAI, WC and WHtR did not predict all-cause mortality. The VAI predicted all-cause mortality in patients with better nutritional status (GNRI ≥ 103.6) but not in patients with worse nutritional status (GNRI < 103.6) (Figure 1). However, WC did not predict all-cause mortality in either the patients with better (GNRI ≥ 103.6, HR = 1.12; 0.67–2.45, every 10 cm increase) or worse (GNRI < 103.6, HR = 1.03; 0.58–2.55) nutritional status. Similarly, WHtR did not predict all-cause mortality in either patients with better (HR = 1.06; 0.55–1.7, every 0.01 unit increase) or worse (HR = 1.01; 0.38–3.55, every 0.01 unit increase) nutritional status.
(Enlarge Image)
Figure 1.
Relationship between visceral adiposity index (VAI) tertiles and all-cause mortality in hemodialysis patients with different nutritional status. The VAI predicted all-cause mortality in patients with a better nutritional status (GNRI ≥ 103.6) but not in those with a worse nutritional status (GNRI < 103.6). Analysis were adjusted for gender, age, hemodialysis vintage, presence of diabetes, hypertension and concurrent cardiovascular disease, hemoglobin, intact parathyroid hormone, high sensitive C-reactive protein and calcium phosphate product.
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