Fivefold increased risk observed in hemodialysis patients with moderate to severe disease

Hemodialysis patients with moderate to severe periodontal disease are five times more likely to die from cardiovascular disease (CVD) compared with those with mild or no periodontal disease, according to researchers.

The findings are based on a retrospective study of 168 HD patients conducted by Abhijit V. Kshirsagar, MD, of the University of North Carolina Kidney Center in Chapel Hill, and colleagues.

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Of the 168 patients, 100 had mild or no periodontal disease and 68 had moderate to severe disease, defined as two or more teeth with at least 6 mm of inter-proximal attachment loss. Baseline demographics and medical characteristics were similar between the two groups, except that the group with moderate to severe periodontal disease had a lower proportion of male patients than the group with mild or no disease (34% vs. 54%).

Twenty-two deaths—14 from CVD—occurred during an 18-month follow-up period, the investigators reported in Kidney International (2009;75:746-751). Of the 14-CVD-related deaths, 11 occurred in the moderate-to-severe periodontal disease group and three occurred in the mild or no periodontal disease group.

Ten of the 14 CVD-related deaths were from cardiac arrest. Two patients died from a hemorrhagic stroke and one each died from cardiomyopathy and pericarditis. After adjusting for age, dialysis vintage, smoking status, cause of end-stage renal disease, and other confounders, moderate to severe periodontal disease was associated with a fivefold increased risk of CVD-related death. The investigators observed no significant difference in all-cause mortality.

In their discussion of study limitations, the authors noted that their sample size was modest and the number of deaths was small. In addition, they did not have baseline measurements of the burden of CVD.

“Thus, the observed findings may have been confounded by the presence of variable degrees of occult CVD,” they wrote. Another limitation was the lack of complete information on socioeconomic status (SES) or nutrition. “It has been proposed that the observed association between periodontal disease and CVD is confounded by SES, diet, and access to dental care.”

In an accompanying editorial (pp. 672-674), François Madore, MD, of Hôpital du Sacre-Coeur de Montréal, noted that the new study findings “suggest that part of the unexplained CVD burden among ESRD patients may be linked to periodontal disease.

In addition, this study raises the possibility that eventual treatment of periodontal disease may improve CVD morbidity and mortality among ESRD patients.” He pointed out, however, that a causal relationship between CVD and periodontal disease has yet to be firmly established.