Association of remnant cholesterol with cardiovascular mortality among maintenance hemodialysis patients: a retrospective cohort study

Remnant cholesterol (RC) is increasingly acknowledged as a significant causal contributor to cardiovascular disease (CVD) and associated mortality. Nonetheless, the link between RC and both all-cause mortality and CVD mortality in patients undergoing maintenance hemodialysis (MHD) remains poorly characterized. This study aims to investigate the association between RC and the risk of all-cause and CVD mortality in MHD patients. This study enrolled 346 MHD patients from 2010 to 2025 at Peking University Third Hospital. Based on the median RC value, patients were stratified into high RC (RC ≥ 0.72 mmol/L) and low RC (RC < 0.72 mmol/L) groups. Firth-penalized Cox regression was used to assess the association between RC and all-cause and CVD mortality. During a median follow-up of 6.3 years (interquartile range 3.6 to 10.5), we observed 118 all-cause deaths, including 64 CVD deaths. CVD mortality rate was higher in the high-RC group than in the low-RC group (4.68 vs. 0.29 per 100 person-years; p < 0.001). Kaplan-Meier survival analysis indicated a significant difference in CVD mortality between the two groups as determined by the log-rank test ( p < 0.0001). Each 1 mmol/L increase in RC was associated with an increased risk of CVD mortality (HR, 2.16; 95% CI, 1.31–3.37; p = 0.004). Conversely, elevated RC was not associated with all-cause mortality. Elevated RC was significantly associated with CVD mortality in MHD patients. These findings support further evaluation of RC as a potential cardiovascular risk marker in this population.