Relative contribution of residual renal function and different measures of adequacy to survival in hemodialysis patients: An analysis of the Netherlands Cooperative Study on the Adequacy of Dialysis (NECOSAD)-2

A high delivered Kt/V-urea (dKt/V-urea) is advocated in the U.S. National Kidney Foundation Dialysis Outcomes Quality Initiative guidelines on hemodialysis (HD) adequacy, irrespective of the presence of residual renal function. The contribution of treatment adequacy and residual renal function to patient survival was investigated. The Netherlands Cooperative Study on the Adequacy of Dialysis is a prospective multicenter study that includes incident ESRD patients older than 18 yr. The longitudinal data on residual renal function and dialysis adequacy of patients who were treated with HD 3 mo after the initiation of dialysis (n = 740) were analyzed. The mean renal Kt/V-urea, (rKt/V-urea) at 3 mo was 0.7/wk (SD 0.6) and the dKt/V-urea at 3 mo was 2.7/wk (SD 0.8). Both components of urea clearance were associated with a better survival (for each increase of 1/wk in rKt/V-urea, relative risk of death = 0.44 [P < 0.0001]; dKt/V-urea, relative risk of death = 0.76 [P < 0.01]). However, the effect of dKt/V-urea on mortality was strongly dependent on the presence of rKt/V-urea, low values for dKt/V-urea of <2.9/wk being associated with a significantly higher mortality in anuric patients only. Furthermore, an excess of ultrafiltration in relation to interdialytic weight gain was associated with an increase in mortality independent of dKt/V-urea. In conclusion, residual renal clearance seems to be an important predictor of survival in HD patients, and the dKt/V-urea should be tuned appropriately to the presence of renal function. Further studies are required to substantiate the important role of fluid balance in HD adequacy.