The Interdialytic Creatinine Rise is a novel marker of volume overload and mortality risk in hemodialysis patients

Abstract

Background: Volume overload poses a major risk in hemodialysis patients but simple detection methods are lacking. We propose a novel marker, the Interdialytic Creatinine Rise (IDCR), readily calculated as the change in serum creatinine over time (in mg/dL/h), to assess volume overload and predict mortality risk in hemodialysis patients. Methods: First, we calculated IDCR changes with volume in a prospective cohort of 35 hospitalized hemodialysis patients awaiting hemodialysis and 33 hospitalized patients undergoing hemodialysis every other day. Second, in a prospective cohort of 25 outpatients, IDCR cutoff values associated with hypervolemia were determined between two treatments and compared with simultaneous volume assessments by their nephrologist. Third, IDCR as a mortality predictor was studied using survival analysis in a longitudinal retrospective cohort study of 39 maintenance hemodialysis patients followed from 2012 until death or 2017. Results: IDCR decreased by - 0.014 mg/dL/h each day (95%CI - 0.017,- 0.010; p < 0.001) without dialysis due to fluid volume gain and increased by 0.013 mg/dL/h (95%CI 0.008,0.017; p < 0.001) from before to after each successive hemodialysis due to fluid removal. Choosing an IDCR cutoff value of ≤0.1 had sensitivity of 82% and specificity of 79% in diagnosing volume overload with the area under the ROC curve of 0.78 (95%CI 0.59,0.97). The hazard ratio of death for each 0.01 decrease in IDCR was 1.64 (95%CI 1.31,2.07; p < 0.001). If IDCR decreased to less than 0.05 mg/dL/h, the median survival was 32 days and the odds ratio of death within 2 months was 38 (95%CI 8, 131; p < 0.001). Conclusions: In this pilot study, IDCR is shown to be a novel metric that decreases with fluid retention and increases after fluid removal. IDCR can assist clinicians in detection or exclusion of volume overload in hemodialysis patients and provide prognostic value in identifying those at high risk for death.