Serum Albumin as a Predictor of Mortality in Peritoneal Dialysis: Comparisons With Hemodialysis

Background: Serum albumin level predicts mortality in dialysis patients and is used to assess their health status and the quality of delivered care. Whether the threshold level of serum albumin at which mortality risk increases in peritoneal dialysis (PD) patients is the same as for hemodialysis (HD) patients has not been studied. Study Design: Observational cohort study of dialysis patients undertaken to determine the survival-predictability of serum albumin level in PD patients and compare it with that in HD patients. Setting & Participants: 130,052 dialysis patients (PD, 12,171; HD, 117,851) who received treatment in any of the 580 dialysis units owned by DaVita Inc between July 1, 2001, through June 30, 2006, followed up through June 30, 2007. Predictor: Baseline and time-averaged serum albumin level (assayed using bromcresol green) and change in serum albumin level over 6 months. Outcome Measures: All-cause, cardiovascular, and infection-related mortality. Results: PD patients with baseline serum albumin level < 3.0 g/dL had a more than 3-fold higher adjusted risk of all-cause and cardiovascular mortality and 3.4-fold higher risk of infection-related mortality (reference group: serum albumin, 4.00-4.19 g/dL). Adjusted all-cause mortality was significantly lower in PD patients with a >= 0.3-g/dL increase in serum albumin level over 6 months and significantly higher in those for whom it decreased by >= 0.2 g/dL (reference group: serum albumin change, +0.1 to -0.1 g/dL). A significant increase in death risk was evident for HD patients with serum albumin level < 4.0 g/dL, but at < 3.8 g/dL for PD patients. For each albumin category, overall death risk for PD patients was lower than for HD patients (reference group: HD patients with serum albumin of 4.00-4.19 g/dL). Limitations: Study can identify associations only without attribution of causality and residual confounding cannot be excluded. Conclusions: Serum albumin predicts all-cause, cardiovascular, and infection-related mortality in both PD and HD patients. However, the threshold at which risk of death increases varies by dialysis modality, and this difference should be considered by agencies or organizations that set quality standards. Am J Kidney Dis. 58(3): 418-428. (C) 2011 by the National Kidney Foundation, Inc.