Risk factors for mortality in patients undergoing peritoneal dialysis: a systematic review and meta-analysis

Figures & data

Figure 1. Flow diagram of the trail selection process.

Figure 2. Forest plots for the hazard risk (HR) between risk factors and all-cause mortality in PD patients (a) age (per 1 year increase); (b) cardiovascular disease; (c) diabetes mellitus; (d) hypersensitive-C reaction protein (mg/l); (e) hemoglobin (g/dl); (f) albumin (mg/dl); (g) high body mass index; (h) low body mass index; (i) alkaline phosphatases (U/l); (j) magnesium (high vs low); (k) uric acid (high vs low); (l) potassium (low vs high); (m) early on-set of peritonitis; (n) peritoneal transport status (high vs low)).

Figure 3. Forest plots for the hazard risk (HR) between risk factors and cardiovascular mortality in PD patients (a) age (per 1 year increase); (b) diabetes mellitus; (c) cardiovascular disease; (d) albumin (mg/dl); (e) hemoglobin (g/dl); (f) uric acid (high vs low); (g) potassium (low vs high); (h) alkaline phosphatases (U/l)).

Table 1. Baseline of characteristics of studies of systematic review and meta-analysis.

Study	Country	Type	Sample size	Mean age (year)	Percentage Male (%)	Percentage DM (%)	Follow-up duration (month)	Reported outcome	Adjusted factors
Ye H 2017 [15]	China	Retrospec-tive	1321	48.1 ± 15.3	58.7	23.5	34 (21–48）	All-cause and cardiovas-cular mortality	age, sex, DM, CVD, ALB, 24 h urine output, Hb, P
Xiang S 2019 [16]	China	Retrospec-tive	9405	52.5 ± 14.6	54.9	12.2	34.5 ± 23.2	All-cause and cardiovas-cular mortality	DM, CVD, Ca, RRF, Hb, Cr, ALB, PTH, potassium, natrium, P, fasting plasma glucose
Xue Y 2019 [17]	China	Retrospec-tive	748		50.1		6.23 (2.423– 11.652)	All-cause and cardiovas-cular mortality	age, Cr, urea, ALB, Hb, Ca, DM, P, DBP, CHD, eGFR
Hwang SD 2019 [18]	Korea	Retrospec-tive	6071	65.8 ± 13.7	57.5	36.1	90.96 ± 54.34	All-cause mortality	age, sex, DM, ALB, Hb, SBP, DBP, PNA, cholesterol, total body water, urine duration, Kt/Vurea week total, Cr clearance weekly
Lai KJ 2018 [19]	China	Retrospec-tive	492	53.5 ± 15.3	48	34.6	36.4	All-cause and cardiovas-cular mortality	age, sex, BMI, smoking, medication, comorbidi-ties, PD related parameters, laboratory data
Jung HY 2018 [20]	Korea	Prospective	953	57.2 ± 12.8	58.6	45	36.0 ± 16.2	All-cause and cardiovas-cular mortality	age, sex, BMI, SBP, DBP, DM, smoking, myocardial infarction, LDL, HDL, total cholesterol, dialysis vintage
Liu Y 2017 [21]	China	Retrospec-tive	667		42.9	24.7	32.64	All-cause and cardiovas-cular mortality	age, sex, 24 h urinary output, Hb, ALB, Ca, AST, P, ALT, PTH
Rhee CM 2014 [22]	USA	Retrospec-tive	9244	54 ± 15	52	49	32.4 (15.6–51.6)	All-cause mortality	age, sex, race, DM, BMI, CVD, smoking, ferritin, dialysis vintage, primary insurance, marital status
Liu X 2014 [23]	China	Retrospec-tive	1021	47.5 ± 15.5	59.1	22.8	31 (19–45)	All-cause and cardiovas-cular mortality	age, sex, 24 h urinary output, BP, ALB, Hb, comorbidity score, ALT, AST, P, Ca, iPTH, phosphate binders use
Li W 2017 [24]	China	Retrospec-tive	1228	46.96 ± 14.9	61.2	25.5	35 (18.7–52.3)	All-cause and cardiovas-cular mortality	age, sex, BMI, DM, CVD, Hb, ALB, TG, uric acid, MAP, rGFR
Lee S 2017 [25]	Korea	Prospective	1152	54 (45–64)	56.5	34.8	52.8 ± 20.4	All-cause mortality	age, sex, MCCI, BMI, ALB, ALP, Ca, P, SGA, uric acid
Kim YK 2014 [26]	Korea	Prospective	900	56 ± 12	57	32	24 (14 − 27)	All-cause mortality	age, sex, DM, Davies comorbidity score
Prasad N 2014 [27]	India	Prospective	328	52.6 ± 12.6	73.8	53.7	20.0 ± 14.3	All-cause mortality	age, SGA, DM, ALB, comorbidities, rGFR
Tian Y 2016 [28]	China	Retrospec-tive	294	50.8 ± 14.0	62.2	14.3	33.3 (17.3–52.8)	All-cause mortality	age, time to first peritonitis, cholesterol, DM, eGFR, ALB, CCI score
Feng S 2016 [29]	China	Retrospec-tive	189	57.5 ± 15.9	56.1	51.3		All-cause mortality	age, DM, ALB, CRP, RRF
Liu X 2016 [30]	China	Retrospec-tive	1778	47.4 ± 15.6	59.5	25.3	35 (17–56)	All-cause and cardiovas-cular mortality	age, sex, PD inception
Yang X 2016 [9]	China	Retrospec-tive	10692	56 ± 16	55	40	13 (7–23)	All-cause mortality	age, sex, DM, race, primary insurance, geographic location, ESRD reason, prior transplant, comorbidities, laboratory
Cai K 2016 [10]	China	Retrospec-tive	253	58 ± 16	55.3	22.9	29 (4–120)	All-cause and cardiovas-cular mortality	age, sex, DM, rGFR, MAP, urinary output, sodium, Cr clearance, malnutrition, bone disorder-related factors
Wu X 2016 [31]	China	Retrospec-tive	1068	48.0 ± 15.4	58.8	23.1	21.7 ± 14.1	All-cause mortality	age, heart disease, DM, stroke, MAP, Hb, ALB, hs-CRP, time to first peritonitis
Xiong L 2015 [32]	China	Retrospec-tive	1263	47.8 ± 15.0	58.6	24.1	25.3 (3.03– 82.07)	All-cause and cardiovas-cular mortality	age, sex, DM, CVD, MAP, Hb, ALB, hs-CRP, TG, rGFR, Kt/Vurea, total cholesterol
Xu Q 2014 [12]	China	Retrospec-tive	886	48.5 ± 15.4	57.1	23.9	31 (0.5–81.0)	All-cause and cardiovas-cular mortality	age, sex, BMI, DM, Hb, ALB, CCI, hs-CRP
Dong J 2014 [33]	China	Retrospec-tive	2264	58.1 ± 15.5	49.1	37.7	26.5 (13.6–43.6)	All-cause and cardiovas-cular mortality	age, sex, RRF, ALB, Hb, P, CRP, CVD, DM, MAP, BMI, LDL
Torlen K 2012 [34]	Sweden	Retrospec-tive	10468	56 ± 16	53	49	27	All-cause and cardiovas-cular mortality	age, sex, DM, race, dialysis vintage, Hb, primary insurance, marital status, BMI, smoking, CVD, cancer, ferritin, ALP, WBC, ALB, Cr, Ca, P, PTH, total iron binding capacity
Angela 2003 [35]	China	Prospective	246	55 ± 12	52	31	24 (2–34)	All-cause and cardiovas-cular mortality	age, weight, height, BMI, CVD, DBP, LV mass index, LV end-diastolic diameter, LV ejection fraction, LV fractional shortening
Guan JC 2015 [36]	China	Retrospec-tive	102		57.8		22.6	All-cause mortality	age, ALB, Hb, glycated Hb A1c, clearance of Cr, RRF, PNA
Rumpsfe-ld M 2006 [37]	Australia	Retrospec-tive	3702	59.4 ± 14.8	53.9	38.1		All-cause mortality	age, sex, race, smoking, BMI, weekly Kt/V, RRF, vintage year, PD modality, hyperten-sion,chronic lung disease, DM, coronary artery disease, peripheral vascular disease, cerebrovas-cular disease

Hb: hemoglobulin; PTH: parathyroid hormone; DM: diabetes mellitus; RRF: residual renal function; ALB: albumin; hs-CRP: hypersensitive C-reactive protein; CVD: cardiovascular disease; TG: total triglyceride; WBC: white blood cell; LDL: low density lipoprotein; HDL: high density lipoprotein; BMI: body mass index; BP: blood pressure; SBP: systolic blood pressure; DBP: diastolic blood pressure; Ca: calcium; Cr: creatinine; eGFR: estimated glomerular filtration rate; rGFR: residual glomerular filtration rate; MAP: mean arterial pressure; SGA: subjective global assessment; PNA: protein equivalent of total nitrogen appearance; MCCI, modified Charlson comorbidity index.

Table 2. Factors influencing the risk of all-cause mortality in PD patients.

Risk factors	HR (95% CI)	p Value	p Value for heterogeneity (p, I^2)
Age (per 1 year increase)	1.04 (1.04–1.05)	p < 0.00001***	p = 0.30 I^2=17%
CVD	1.72 (1.17–2.52)	p = 0.006**	p < 0.0001 I^2=87%
DM	1.58 (1.41–1.78)	p < 0.00001***	p = 0.09 I^2=46%
Hs-CRP (mg/l)	1.37 (1.04–1.82)	p = 0.03	p < 0.00001 I^2=94%
Hb (g/dl)	0.87 (0.83–0.90)	p < 0.00001***	p = 0.41 I^2=0%
ALB (mg/dl)	0.71 (0.42–1.21)	p = 0.21	p < 0.00001 I^2=93%
High BMI (kg/m^2)	1.17 (1.04–1.31)	p = 0.007	p = 0.40 I^2=0%
Low BMI (kg/m^2)	1.20 (0.83–1.73)	p = 0.34	p = 0.009 I^2=71%
ALP (U/l)	2.11 (1.86–2.39)	p < 0.00001***	p = 0.95 I^2=0%
Magnesium (high vs low)	0.19 (0.02–2.22)	p = 0.18	p = 0.03 I^2=73%
Uric acid (high vs low)	0.93 (0.48–1.79)	p = 0.83	p < 0.0001 I^2=91%
Potassium (low vs high)	1.25 (0.97–1.60)	p = 0.08	p = 0.10 I^2=56%
Early on-set of peritonitis	1.83 (1.26–2.64)	p = 0.001***	p = 0.41 I^2=0%
Peritoneal transport status (high vs low)	1.39 (1.10–1.76)	p = 0.006	p = 0.21 I^2=36%

HR: hazard ratio; CI: confidence interval; ALB: albumin; DM: diabetes mellitus; CVD: cardiovascular diseases; hs-CRP: hypersensitive C-reactive protein; Hb: hemoglobulin; ALP: alkaline phosphatases; GFR: glomerular filtration rate; BMI: body mass index.

**p < 0.01.

***p < 0.001.

Table 3. Factors influencing the risk of cardiovascular mortality in PD patients.

Risk factors	HR (95% CI)	p Value	p Value for heterogeneity (p, I^2)
Age (per 1 year increase)	1.04 (1.03-1.05)	p < 0.00001***	p = 0.67 I^2=0%
DM	1.60 (1.30-1.96)	p < 0.00001***	p = 0. 60 I^2=0%
CVD	2.12 (1.39-3.23)	p = 0.0005***	p = 0. 01 I^2=77%
ALB (g/dl)	0.79 (0.61-1.02)	p = 0.07	p = 0.93 I^2=0%
Hb (g/dl)	0.87 (0.81-0.94)	p = 0.0002***	p = 0.83 I^2=0%
Uric acid (high vs low)	0.74 (0.23-2.45)	p = 0.63	p = 0.009 I^2=85%
Potassium (low vs high)	1.46 (0.67-3.16)	p = 0.34	p = 0.03 I^2=79%
ALP (U/l)	2.39 (1.22-4.66)	p = 0.01**	p = 0.96 I^2=0%

HR: hazard ratio; CI: confidence interval; ALB: albumin; Hb: hemoglobulin; DM: diabetes mellitus; CVD: cardiovascular diseases; ALP: alkaline phosphatases.

**p < 0.01.

***p < 0.001.

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Data availability statement

The data of this study are available from the corresponding author.