Tentori F et al. (2007) Which targets in clinical practice guidelines are associated with improved survival in a large dialysis organization? J Am Soc Nephrol 18: 2377–2384

New research has revealed a marked reduction in mortality rates among hemodialysis patients who meet K/DOQI targets for several clinical parameters. Mortality was increased, however, in patients whose blood pressure was within the recommended range.

This retrospective study included 13,792 hemodialysis patients followed until death, kidney transplantation, switch to peritoneal dialysis, prolonged absence from the clinic, or end of follow-up in 2005. Mean duration of follow-up was 569 days. Few patients met recommended targets at baseline.

The results revealed a significant improvement in the survival of patients whose dialysis dosage, hematocrit, serum albumin, calcium and phosphorus levels, and parathyroid hormone concentration met targets (P ≤0.0001), with serum albumin level (≥4 g/dl) having the greatest positive effect (hazard ratio [HR] for death 0.27, 95% CI 0.24–0.31). The small proportion of patients who simultaneously met all six targets had an 89% reduction in mortality (HR 0.11, 95% CI 0.06–0.19). By contrast, those whose blood pressure fell below the recommended upper limit of 140/90 mmHg were significantly more likely to die (HR 1.90, 95% CI 1.73–2.10).

These findings underline the importance of adhering to clinical practice guidelines, as well as the problems inherent in extrapolating targets (e.g. those for blood pressure levels) from the general population to people receiving dialysis. The authors call for prospective randomized controlled trials to determine the optimum blood pressure for patients on hemodialysis.