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Our study aimed to validate heart rate turbulence as a long-term predictor of mortality in this vulnerable cohort.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Heart rate turbulence is a non-invasive, 24\u00a0h electrocardiography-Holter-based assessment of cardiovascular autonomic responses. Hemodialysis patients of the \u201crISk strAtification in end-stage Renal disease\u201d (ISAR) study, a prospective, multicenter observational study, were followed up for six years. Mortality hazard, and correlations between clinical\u00a0characteristics and\u00a0mortality, were assessed using Cox regression models.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Heart rate turbulence measurement at baseline was available in 290 hemodialysis patients, 99 (34%) with diabetes mellitus. In a multivariable analysis, abnormal heart rate turbulence was associated with a 2.1-fold (95% CI: 1.4\u20133.2;\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.001) increased risk for all-cause and 3.1-fold (95% CI: 1.5\u20136.2;\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.001) increased risk for cardiovascular mortality. The co-occurrence of abnormal heart rate turbulence and diabetes mellitus represented the strongest risk constellation, increasing all-cause mortality risk to a hazard ratio of 5.8 (95% CI: 3.3\u201410.4;\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.001) and cardiovascular mortality risk to 6.1 (95% CI: 2.5\u201415.1;\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.001). This association with mortality risk remained significant after multivariate adjustment. The interaction term between the two comorbidities indicated an approximately additive effect on mortality risk.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Heart rate turbulence significantly contributed to the prediction of long-term mortality risk in hemodialysis patients. Diabetes mellitus is a major driver of cardiovascular autonomic dysfunction, which plays a crucial role in mortality among dialysis patients. Heart rate turbulence measurement identifies high-risk patients in the dialysis setting, enhancing\u00a0precision in risk prediction\u00a0and stratification, and allowing an\u00a0opportunity for personalized monitoring and prevention.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Graphical abstract<\/jats:title>\n                  <\/jats:sec>","DOI":"10.1007\/s40620-025-02357-8","type":"journal-article","created":{"date-parts":[[2025,7,15]],"date-time":"2025-07-15T15:33:40Z","timestamp":1752593620000},"page":"2261-2272","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Long-term prediction of mortality by heart rate turbulence in hemodialysis patients and the impact of diabetes mellitus\u2013a longitudinal observational study"],"prefix":"10.1093","volume":"38","author":[{"given":"Nora","family":"Hannane","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Christopher C.","family":"Mayer","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Julia","family":"Matschkal","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Felix","family":"Bormann","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Axel","family":"Krieter","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"J\u00fcrgen R.","family":"Braun","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Claudius","family":"K\u00fcchle","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Lutz","family":"Renders","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Roman","family":"G\u00fcnthner","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Georg","family":"Schmidt","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alexander","family":"M\u00fcller","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Siegfried","family":"Wassertheurer","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Uwe","family":"Heemann","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Bernhard","family":"Haller","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Marek","family":"Malik","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Christoph","family":"Schmaderer","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8527-0699","authenticated-orcid":false,"given":"Matthias Christoph","family":"Braunisch","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"286","published-online":{"date-parts":[[2025,7,15]]},"reference":[{"issue":"43","key":"2357_CR1","doi-asserted-by":"publisher","first-page":"1165","DOI":"10.15585\/mmwr.mm6643a2","volume":"66","author":"NR Burrows","year":"2017","unstructured":"Burrows NR, Hora I, Geiss LS et al (2017) Incidence of end-stage renal disease attributed to diabetes among persons with diagnosed diabetes - United States and Puerto Rico, 2000\u20132014. 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MB reports travel support from Lilly Germany and consulting fees from Samsung Bioepis, Takeda Pharma, and Boehringer Ingelheim unrelated to the project.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Conflict of interest"}},{"value":"This prospective longitudinal clinical study was reviewed and approved by the Medical Ethics Committee of the Klinikum Rechts der Isar of the Technical University of Munich and the Bavarian State Board of Physicians.\u00a0The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethical approval"}},{"value":"All patients\/participants provided written informed consent to participate in this study.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Informed consent to participate"}}]}}