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Clinical Nutrition

Unraveling the relationship between mortality, hyponatremia, inflammation and malnutrition in hemodialysis patients: results from the international MONDO initiative

European Journal of Clinical Nutrition volume 70, pages 779–784 (2016)Cite this article

Subjects

Abstract

Background/Objectives:

Hyponatremia is a risk factor for mortality in hemodialysis (HD) patients. It is not well known to which extent the comorbidities, malnutrition, fluid status imbalance and inflammation are related to hyponatremia and affect outcomes.

Subjects/Methods:

We studied 8883 patients from the European subset of the international MONitoring Dialysis Outcomes initiative. Nutritional and fluid statuses were assessed by bioimpedance spectroscopy. Fluid depletion was defined as overhydration⩽−1.1 l and fluid overload as overhydration>+1.1 l, respectively. Malnutrition was defined as a lean tissue index below the 10th percentile of age- and gender-matched healthy controls. Hyponatremia and inflammation were defined as serum sodium levels <135 mEq/l and C-reactive protein levels>6.0 mg/l, respectively. We used logistic regression to test for predictors of hyponatremia and Cox proportional hazards analysis to assess the association with all-cause mortality.

Results:

Hyponatremia was predicted by the presence of malnutrition (odds ratio (OR)=1.49 (95% confidence interval (CI)=1.30–1.70), inflammation (OR=1.44 (95% CI=1.26–1.64)) and fluid overload ((>+1.1 l to +2.5 l) OR=0.73 (95% CI=0.62–0.85)) but not by fluid depletion (OR=1.34 (95% CI=0.92–1.96)). Malnutrition, inflammation, fluid overload, fluid depletion and hyponatremia (hazard ratio=1.70 (95% CI=1.46–1.99)) were independent predictors for all-cause mortality.

Conclusions:

In HD patients, hyponatremia is associated with malnutrition, inflammation and fluid overload. Hyponatremia maintained predictive for all-cause mortality after adjustment for malnutrition, inflammation and fluid status abnormalities. The presence of hyponatremia may assist in identifying HD patients at increased risk of death.

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Author information

Author notes

  1. M J E Dekker and D Marcelli: These authors contributed equally to this work.

Authors and Affiliations

  1. Division of Nephrology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands

    M J E Dekker, K M Leunissen, F M van der Sande & J P Kooman

  2. Catharina Hospital, Eindhoven, The Netherlands

    M J E Dekker & C J A M Konings

  3. Fresenius Medical Care, Bad Homburg, Germany

    D Marcelli, B Canaud & P Carioni

  4. Renal Research Institute, New York, NY, USA

    N W Levin, V Maheshwari, J G Raimann, L A Usvyat & P Kotanko

  5. Icahn School of Medicine at Mount Sinai Health System, Waltham, MA, USA

    N W Levin

  6. Fresenius Medical Care North America, Waltham, MA, USA

    L A Usvyat

  7. Mount Sinai Hospital, New York, NY, USA

    P Kotanko

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Correspondence to M J E Dekker.

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Competing interests

DM, BC, PC and LAU are employees of Fresenius Medical Care and may hold stock in the company. PK and NWL hold stock in Fresenius Medical Care. The remaining authors declare no conflict of interest.

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Author contributions

DM, JPK and LAU conceived the idea; LAU performed the statistical analyses; MD, DM and JPK wrote the paper. MD had primary responsibility for final content; BC, PC, CJAMK, KML, NWL, JGR, FMvdS and PK revised the manuscript. All authors critically revised the manuscript for intellectual content and approved the final version of the manuscript.

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Dekker, M., Marcelli, D., Canaud, B. et al. Unraveling the relationship between mortality, hyponatremia, inflammation and malnutrition in hemodialysis patients: results from the international MONDO initiative. Eur J Clin Nutr 70, 779–784 (2016). https://doi.org/10.1038/ejcn.2016.49

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