Advances in Peritoneal Dialysis, Vol.
28, 2012
Morrell M. Avram, Neal Mittman, Paul A. Fein, Samuel
Agahiu, William Hartman, Neil Chattopadhyay, Betty Matza
The relationship between dialysis vintage (length of
time on dialysis), body composition, and survival has
been reported in hemodialysis patients. In the present
study, we examined the association of dialysis vintage
with body composition and survival in peritoneal
dialysis (PD) patients.
At enrollment, body composition in 65 PD patients
was determined by bioelectrical impedance analysis.
Patients (mean age at enrollment: 54 years) were
followed for up to 11 years maximum. At enrollment,
the mean, median, and maximum dialysis vintages
were 51, 34, and 261 months respectively. After adjust-
ing for age, race, sex, and diabetes status, dialysis
vintage was indirectly correlated (partial correlation
coefficients) with body weight (r= 0.40, p= 0.001),
body mass index (r= 0.40, p= 0.002), body surface
area (r= 0.39, p= 0.002), body cell mass (r= 0.39, others, survive for 3 years or longer (4).
p= 0.002), total body fat weight (r= 0.30, p= 0.02),
and fat percentage of body weight (r= 0.31, p= 0.018),
and directly correlated with extracellular mass to
body cell mass ratio (r= 0.27, p= 0.039). The ob-
served cumulative survival was significantly higher
(p= 0.007) in patients with a dialysis vintage at en-
rollment of 35 months or less, than in patients with
dialysis vintage at enrollment of more than 35 months.
In the multivariate Cox regression analysis, adjusting
for age, race, sex, and diabetes, dialysis vintage at
enrollment remained an independent predictor of
mortality (relative risk: 1.010; p= 0.002). Increase
in relative risk of death with increasing dialysis vin-
tage may be partly explained by the association of
vintage with unfavorable changes in body composi-
tion and the nutrition status of patients over time.
From: Avram Division of Nephrology, SUNY Downstate
Medical Center UHB at Long Island College Hospital,
Brooklyn, New York, U.S.A.
Dialysis Vintage,
Body Composition, and
Survival in Peritoneal
Dialysis Patients
Key words
Dialysis vintage, bioelectrical impedance analysis,
BIA, survival, nutrition
Introduction
The term dialysis vintage means the length of time
in months or years that end-stage renal disease patients
spend on dialysis. We and other authors have reported
that the characteristics of patients with a long dialysis
vintage are different from those of patients with a short
vintage. In peritoneal dialysis (PD) patients, younger
age and nondiabetic status have been associated with
prolonged survival (13). Abraham et al. reported that
nondiabetic patients, those with average transport,
those who are nonsmoking with a reasonable nutrition
status, and those with a low peritonitis rate, among
Nutrition status is an important predictor of out-
comes in PD patients. Lower values for serum markers
of nutrition are associated with higher mortality in PD
patients (1,57). Enrollment values for markers such
as albumin and creatinine were significantly higher in
PD patients on dialysis for more than 10 years than in
those on dialysis for less than 5 years (1). Compared
with patients who survived less than 3 years on PD,
those who survived 3 years or longer had higher serum
albumin (4).
Body composition is closely related to nutrition
indicators and chronic illnesses in dialysis patients
(8). Bioelectrical impedance analysis (BIA) has been
recognized as a simple, noninvasive technique for the
determination of body composition and fluid status in
PD patients (9). We and other authors have investi-
gated the relationship of BIA-derived body composi-
tion parameters with nutrition markers and morbidity
and mortality in PD patients (10,11).
The relationship between dialysis vintage, body
composition, and survival has been reported in patients
Avram et al. 145

on hemodialysis. In hemodialysis patients, dialysis p= 0.03), total fat weight (r= 0.29, p= 0.02), and
vintage is directly related to unfavorable changes in fat% body weight (r= 0.26, p= 0.04). TableI shows
nutrition status, including body weight and body com- correlations between enrollment dialysis vintage and
position (12). That relationship remains to be studied body composition parameters adjusted for age, race,
in PD patients. In the present work, we examined the sex, and diabetes. Dialysis vintage was inversely
association of dialysis vintage at enrollment with body correlated with body weight (r= 0.40, p= 0.001),
composition and survival in PD patients. BMI (r= 0.40, p= 0.002), body surface area
(r= 0.39, p= 0.002), total body fat (r= 0.30,
Methods p= 0.02), fat% body weight (r= 0.31, p= 0.018),
From November 2000 to May 2008, our study enrolled and BCM (r= 0.39, p= 0.002), and directly cor-
65 PD patients, who were then followed until Septem- related with ECM/BCM ratio (r= 0.27, p= 0.039).
ber 2011 (up to 11 years maximum). On enrollment, The patients were allocated to two equal groups
demographic, clinical, and biochemical data were based on median dialysis vintage at enrollment. At
recorded. The BIA measurements were performed us- 11 years of observation, the cumulative observed
ing an impedance plethysmograph (800mA, 50kHz). survival (KaplanMeier) of patients with a dialysis
The resulting electrical impedance, resistance, and vintage at enrollment of 35 months or less (n= 33) was
reactance values were used in a computerized cal- significantly higher (p= 0.007) than that of patients
culation of body composition parameters including with dialysis vintage of more than 35 months (n= 32).
extracellular mass (ECM) and body cell mass (BCM) By univariate unadjusted Cox regression analysis,
using Cyprus (BIA-101, version 1.0: RJL/Akern increased dialysis vintage at enrollment was associ-
Systems, Clinton Township, MI, U.S.A.). The Long ated with increased risk of mortality (relative risk:
Island College Hospital Institutional Review Board 1.008; p= 0.008). In a multivariate Cox regression
approved this study protocol, and informed consent analysis with adjustment for age, sex, race, and diabe-
was obtained from each patient. tes status, dialysis vintage at enrollment as a continu-
ous variable was a significant independent predictor
Statistical analysis of mortality (relative risk: 1.010; p= 0.002). For each
Continuous variables are expressed as mean stan- month of increased dialysis vintage, the relative risk
dard deviation. Correlations are reported as Spearman of death increased significantly by 1%. Analyses with
rank correlation coefficients and partial correlation log-transformed dialysis vintage yielded similar re-
coefficients. Observed survival was computed by the sults. On multivariate Cox regression analysis, using
KaplanMeier method (13). A log-rank test was used
to assess differences between the survival curves. In-
table i Correlation between dialysis vintage and body composi-
dependent predictors of survival were determined by
tion parameters
Cox regression analysis. Calculations were performed
using SPSS for Windows (version 12.0.1: SPSS, Ar- Partial
monk, NY, U.S.A.). correlation p
Variable coefficienta Value
Results Body weight (lb.) 0.40 0.001
In our patient cohort [mean age: 54 years (range: 21
Body mass index (lb./in.2) 0.40 0.002
95 years); 56% women; 64% of African descent; 24%
diabetic], the mean, median, and maximum dialysis Body surface area (m2) 0.39 0.002
vintages at enrollment were 51, 34, and 261 months Fat weight (lb.) 0.30 0.02
respectively. Mean body mass index (BMI), total body Fat% body weight 0.31 0.018
fat, fat percentage (fat%) of body weight, phase angle, Body cell mass [BCM (lb.)] 0.39 0.002
and ECM/BCM ratio were 25.37 5.45lb./in.2, 45.32
ECM/BCM ratio 0.27 0.039
21lb., 26.86% 10.3%, 6.06 1.6degrees, and 1.21
0.2 respectively. Phase angle (degrees) 0.23 0.07
Using Spearman rank correlation, dialysis vin- a Adjusted
for age, sex, race, and diabetes.
tage was negatively correlated with BMI (r= 0.27, ECM= extracellular mass.
146 Dialysis Vintage and Body Composition in PD
dialysis vintage as a categorical variable and adjusting
for age, sex, race, and diabetes, the mortality risk was
more than doubled for patients with a dialysis vintage
at enrollment of more than 35 months compared with
patients with a dialysis vintage at enrollment of 35
months or less (relative risk: 2.37; p= 0.04).
Discussion
In the present study, we show that greater dialysis
vintage is associated with unfavorable changes in
body composition parameters. After adjustment
for age, race, sex, and diabetes status, an increase
in dialysis vintage was associated with lower body
weight, BMI, total fat weight, fat% body weight, and
BCM, and with a higher ECM/BCM ratio. Our results
accord with work by Chertow et al., who reported
that, when adjusted for age, race, sex, and diabetes,
body composition parameters such as body weight,
total body water, BCM, and phase angle tended to
be lower in hemodialysis patients after 2 years of
dialysis vintage (12). In our study, the relationship
between phase angle and dialysis vintage did not reach
statistical significance. In contrast, in hemodialysis
patients, the largest relative differences by vintage
were obtained for phase angle (12).
Our finding that body fat declines with increase
in dialysis vintage is interesting. Because we lack
longitudinal data, we cannot report the percentage of
our patients in whom body fat declined with increased
dialysis vintage. It has been reported that, after 12
months of dialysis, 53% of PD patients had gained
and 47% had lost body fat. Baseline BMI and hospi-
talizations during follow-up were the most important
factors associated with variability in change of body
fat (14). The ECM/BCM ratio has been reported to
be a highly sensitive index of malnutrition and a
marker for survival in PD patients (15). The higher
the ECM/BCM ratio, the poorer the nutrition status.
We observed an increase in ECM/BCM ratio with
increasing dialysis vintage, which implies poorer
nutrition status with increasing dialysis vintage in
our patients.
Although dialysis vintage has been associated
with survival in hemodialysis (12), little is known
about the relationship between dialysis vintage and
outcomes in PD patients. The relationship between
dialysis vintage and survival is difficult to explain
because of various confounding factors. Unfavor-
able changes in body composition parameters with
increasing dialysis vintage may be one of the fac-
tors contributing to the increasing risk of death in
PD patients.
Conclusions
End-stage renal disease is a wasting illness, as indi-
cated by unfavorable changes in body composition
over time with increasing dialysis vintage. Increase
in relative risk of death with increasing vintage may
be partly explained by the association of vintage with
declining body weight and BMI, depletion of body fat
and BCM, and increase in ECM/BCM ratio, implying
deteriorating nutrition status in patients over time.
Longitudinal studies with serial measurements of body
composition parameters are needed to better under-
stand the natural history of wasting in PD patients.
Disclosures
The authors have no financial conflicts of interest
to declare.
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Corresponding author:
Morrell M. Avram, md, Avram Division of Nephrol-
ogy, SUNY Downstate Medical Center UHB at
Long Island College Hospital, 339Hicks Street,
Brooklyn, New York 11201 U.S.A.
E-mail:
morrell.avram@Downstate.edu