Risk Factors For All-cause Mortality In Patients With Car-Diorenal Anemia Syndrome

Objective:To investigate the risk factors for all-cause mortality in patients with cardiorenal anemia syndrome(CRAS).Methods:1.A total of 820 patients who met the inclusion and exclusion criteria for CRAS from August 2012 to August 2021 were selected.The basic data,personal history,past medical history,laboratory indicators,echocardiographic indicators and treatment plan of the patients were collected,and the patients were followed up.The endpoint event was all-cause death..The endpoint event was all-cause death.2.The general condition,clinical features,laboratory indicators and cardiac ultrasound indicators of patients with CRAS were analyzed;Multivariate Cox proportional hazard regression was used to analyze independent risk factors for allcause death in patients with CRAS.3.Patients with CRAS were grouped according to some independent risk factors screened out.This includes the New York Heart Association(NYHA)cardiac function grades,serum Albumin(ALB),blood Uric Acid(UA),blood sodium(Na)levels,The differences of general conditions,clinical features,laboratory and echocardiographic indexes among different groups were compared.Results:1.A total of 820 patients with CRAS were enrolled in this study,including 502 males and 318 females,with a median age of 65 years.According to NYHA classification,124 cases(15.1%)were in class Ⅱ,492 cases(60.0%)in class Ⅲ,and 204 cases(24.9%)in class Ⅳ.A total of 670 patients(81.7%)were in chronic kidney disease(CKD)stage 5,and 386 patients(47.1%)received hemodialysis.By the end of follow-up on July 31,2022,416 of 820 patients(50.7%)died,the median survival time was 47.0 months,and the median follow-up time was 54.0 months.Among the 416 patients who died,186(44.7%)died of unknown causes and 230(55.3%)died of definite causes.Among the patients with clear causes of death,cardiovascular death was the most common cause of death(67.0%).2.Multivariate COX regression analysis showed that every 10 years increase in age(HR=1.433,95%CI:1.331-1.542,P=0.000),smoking(HR=1.300,95%CI:1.014-1.667,P=0.039),a history of cardiovascular disease(HR=1.368,95%CI:1.089-1.718,P=0.007),each higher NYHA class(HR=1.303,95%CI:1.115-1.523,P=0.001),hypoalbuminemia(HR=1.296,95%CI:1.065-1.577,P=0.010),hyperuricemia(HR=1.308,95%CI:1.051-1.626,P=0.016),and hyponatremia(HR=1.323,95%CI:1.062-1.647,P=0.012)were the independent risk factors for all-cause mortality of CRAS.3.According to serum ALB level,CRAS patients were divided into normal serum ALB group(ALB≥35g/L)and hypoalbuminemia group(ALB<35g/L).Compared with the normal serum ALB group,the patients in the hypoalbuminemia group were younger[63(48,75)years vs 66(52,75)years],with more diabetic nephropathy(42.2%vs 28.9%)and less chronic glomerulonephritis(29.1%vs 36.8%).Lower hemoglobin[83(71,95)g/L vs 93(81,107)g/L],lower kalium[4.55(4.01,5.08)mmol/L vs 4.75(4.21,5.37)mmol/L],higher platelet count[169(126,229)×109/L vs 161(119,203)×109/L],higher blood chloride[104(99,107)mmol/L vs 101(96,105)mmol/L],and higher blood chloride[104(99,107)mmol/L vs 101(96,105)mmol/L],higher serum phosphorus[1.75(1.43,2.13)mmol/L vs 1.61(1.33,1.95)mmol/L],higher blood urea nitrogen[22.72(17.08,30.37)mmol/L vs 21.29(15.55,29.35)mmol/L],more patients received diuretics(63.4%vs 50.9%)and anemia correction treatment(75.4%vs 64.3%)in the hypoalbuminemia group.The difference was statistically significant(P<0.05).4.According to the serum UA level,the CRAS patients were divided into normal UA group(UA≤420umol/L in men or UA ≤ 360umol/L in women)and hyperuricemia group(UA>420umol/L in men or UA>360umol/L in women).Compared with the normal UA group,the hyperuricemia group had more atrial fibrillation(14.9%vs 9.6%),more hypertensive nephropathy(25.1%vs 17.0%),and less diabetic nephropathy(32.0%vs 41.1%).Patients with hyperuricemia had lower hemoglobin[87(74,100)g/L vs 91(78,103)g/L]and lower carbon dioxide combining power[19.9(17.1,22.8)mmol/L vs 22.0(19.0,24.8)mmol/L].Lower parathyroid hormone level[208(98,377)pg/mL vs 226(118,443)pg/mL],higher blood chloride[103(98,107)mmol/L vs 101(97,105)mmol/L],higher blood phosphorus[1.75(1.43,2.13)mmol/L vs 1.61(1.33,1.95)mmol/L],higher blood urea nitrogen[24.1(18.2,32.4)mmol/L vs 18.1(13.4,23.7)mmol/L]in the hyperuricemia group.More patients were treated with digitalis(8.2%vs 3.3%),diuretics(63.6%vs 42.2%),and aldosterone receptor antagonists(13.8%vs 7.8%)in the hyperuricemia group.The difference was statistically significant(P<0.05).5.The patients with CRAS were divided into three groups according to the New York Heart Association(NYHA)classification:class Ⅱ,class Ⅲ and class Ⅳ.Compared to patients with NYHA class Ⅱ,patients with NYHA class Ⅲ were more likely to have atrial fibrillation(13.4%vs 4.8%)and higher neutrophil count[4.74(3.41,6.62)×109/L vs 4.24(3.33,5.77)×109/L],more patients received anticoagulants(4.7%vs 0.0%)and statins(29.9%vs 19.4%),and less patients received angiotensin receptor blockers(16.9%vs 28.2%).Patients with NYHA class Ⅳ were older[69(51,77)years vs 61(45,72)years],were more likely to have diabetes(51.0%vs 35.5%),and were more likely to have atrial fibrillation(17.6%vs 4.8%).Patients with NYHA class Ⅳ have higher neutrophil count[5.00(3.67,6.90)×109/L vs 4.24(3.33,5.77)× 109/L],and more patients received anticoagulants(6.4%vs 0.0%),statins(33.8%vs 19.4%),digitans(11.3%vs 4.0%)and aldosterone receptor antagonists(18.6%vs 6.5%).Compared with patients in NYHA class Ⅲ group,patients in NYHA class Ⅳ group were older[69(51,77)years vs 64(51,74)years],were more likely to have diabetes mellitus(51.0%vs 42.1%),and were more likely to receive treatment with digitalis(11.3%vs 5.3%),diuretics(64.7%vs 52.8%),aldosterone receptor antagonists(18.6%vs 10.4%)and anemia correction(63.7%vs 72.6%).The differences were statistically significant(P<0.05).6.CRAS patients were divided into normal serum Na group(135mmol/L ≤Na≤145mmol/L)and hyponatremia group(Na<135mmol/L)according to serum Na level.Compared with the normal Na group,patients with hyponatremia had higher white blood cells[7.02(5.17,9.14)× 109/L vs 6.37(4.95,8.22)×109/L]and higher neutrophils[5.2(13.81,7.43)×109/L vs 4.62(3.38,6.24)×109/L],lower serum albumin[34.6(30.4,38.8)g/L vs 36.3(32.2,40.3)g/L],and lower blood chlorine level(97±6.85mmol/L vs 103±5.48 mmol/L).Lower left ventricular end-diastolic diameter[53(48,58)mm vs 54(50,58)mm],lower ejection fraction[53(44,60)%vs 55(46,60)%],and fewer patients received calcium channel blockers(66.0%vs 79.6%)in patients with hyponatremia.The difference was statistically significant(P<0.05).Conclusions:1.Among CRS patients,the proportion of CRAS was 73%.2.Among the patients with definite causes of death,cardiovascular death accounted for 67%,which was the most common cause of death.3.Age(every 10 years increase),smoking,history of CVD.NYHA functional class(every level increase),hypoproteinemia,hyperuricemia,and hyponatremia were independent risk factors for all-cause mortality in CRAS.