Association of the erythropoiesis-stimulating agent resistance index and the geriatric nutritional risk index with cardiovascular mortality in maintenance hemodialysis patients

Objective: Hyporesponsiveness to erythropoiesis-stimulating agent (ESA) may be associated with protein-energy wasting. We investigated the relationship of the ESA resistance index (ERI) and the geriatric nutritional risk index (GNRI) for cardiovascular mortality in hemodialysis (HD) patients. Methods: A total of 180 maintenance HD patients were enrolled. The patients were stratified by the GNRI of 91.2, a previously reported cut-off value, and the ERI of 13.7 (IU/week/kg/g/dL), a cut-off value for predicting cardiovascular-specific mortality, and they were classified into four groups (group 1[G1]: higher GNRI and lower ERI, G2: higher GNRI and higher ERI, G3: lower GNRI and lower ERI, G4: lower GNRI and higher ERI). Results: The ERI was independently associated with the GNRI (β = −0.271, p = 0.0005). During a median follow-up of 4.6 years, higher ERI and lower GNRI were independently associated with cardiovascular mortality, respectively (adjusted hazard ratio [aHR], 3.10; 95% confidence interval [CI], 1.31–7.34, and aHR, 6.64; 95%CI, 2.60–16.93, respectively). The 7-year survival rates were 96.1%, 70.3%, 77.3%, and 50.1% in G1, G2, G3, and G4, respectively. The aHR values for G4 versus G1 were 12.63 (95%CI, 3.58–44.59). With regards to model discrimination, adding the GNRI alone, the ERI alone, and both to the traditional risk model significantly improved the net reclassification improvement by 0.421, 0.662, and 0.671, respectively. Similar results were obtained for all-cause mortality. Conclusion: The ERI was independently associated with the GNRI, and could predict cardiovascular mortality in HD patients. Moreover, the combination of GNRI and ERI could improve the predictability for cardiovascular mortality.