Patients with late-stage chronic kidney disease (CKD) who have low serum albumin levels prior to development of end-stage renal disease (ESRD) have an increased risk of death within 1 year after transitioning to dialysis, according to a new study.

Compared with patients with serum albumin levels of 4.0 g/dL or higher (reference) prior to dialysis, those with the lowest levels (below 2.8 g/dL) had a statistically significant 2-fold increased risk of death from any cause in 1 year after initiating dialysis, in a fully adjusted model, Elani Streja, MD, PhD, of the University of California Irvine, and colleagues reported in the Journal of Renal Nutrition. They also had a statistically significant 2.1- and 2.6-fold higher risk of cardiovascular- and infection-related mortality, respectively.

Patients who experienced declining serum albumin levels in the pre-ESRD period also had worse 1-year mortality following transition to dialysis. Each 0.5 g/dL decline per year was associated with a statistically significant 55% increased risk of death in a fully adjusted model. Furthermore, serum albumin levels below 2.8 g/dL were associated with a 50% increased risk of hospitalization within 1 year of transitioning to dialysis.

The findings are from a retrospective cohort study that included 29,124 US veterans with advanced CKD transitioning to ESRD. The cohort had a mean age of 67 years. They evaluated the association of pre-ESRD (91 days before transition) serum albumin with 1-year post-ESRD all-cause and cardiovascular- and infection-related mortality. During the 1-year after transition to dialysis, 6236 patients died, for a crude mortality rate of 25.6 deaths per 100 person-years, 468 patients received kidney transplants, and 2027 were lost to follow-up.

“To the best of our knowledge, this is the first study examining the association of serum albumin concentrations and its change in advanced CKD patients with early outcomes after transitioning to ESRD,” the authors wrote.

Study strengths include the large sample size and capture of comprehensive data on comorbidity status in the pre-ESRD period, the authors noted. In addition, the investigators were able to calculate serum albumin changes prior to dialysis initiation because they had repeated serum albumin measurements available. Dr Streja’s team also pointed out study limitations. The study included patients using the Veterans Affairs health system and its laboratory services in the year prior to starting dialysis. Consequently, study findings may not be generalizable to other populations. Furthermore, their study might be susceptible to survivor bias because they were only able to look at patients who survived the late-stage CKD to post-ESRD transition period. “Because of the design of our cohort, we were unable to examine CKD patients who died before transitioning to ESRD, which may limit generalizability,” they wrote. “Thus, our study cohort may consist of a ‘relatively healthy’ subset of late CKD patients.”


Hsiung JT, Kleine CE, Naderi N, et al. Association of pre-end-stage renal disease serum albumin with post-end-stage renal disease outcomes among patients transitioning to dialysis. J Ren Nutr. 2019;29:310-321.

doi: 10.1053/j.jrn.2018.09.004