Interleukin 6 is a better predictor of 5-year cardiovascular mortality than high-sensitivity C-reactive protein in hemodialysis patients using reused low-flux dialyzers

IL-6 inhibition with clazakizumab in patients receiving maintenance dialysis: a randomized phase 2b trial

Inflammation mediated by interleukin-6 (IL-6) is strongly associated with cardiovascular risk. Here we evaluated clazakizumab, a monoclonal antibody targeting the IL-6 ligand, in a phase 2b dose-finding study. Adults with cardiovascular disease and/or diabetes receiving maintenance dialysis with high-sensitivity C-reactive protein (hs-CRP) ≥ 2 mg l-1 at baseline were randomized to receive clazakizumab (2.5 mg, 5 mg or 10 mg, n = 32 per dose group) or placebo (n = 31) every 4 weeks. The primary endpoint was the change from baseline in hs-CRP to week 12, expressed as the geometric mean ratio. Clazakizumab treatment signficantly reduced serum hs-CRP concentrations at week 12 by 86%, 90% and 92% relative to placebo in patients randomized to 2.5 mg, 5 mg or 10 mg clazakizumab, respectively (all P < 0.0001), meeting the primary outcome. With regard to secondary endpoints, clazakizumab treatment reduced serum fibrinogen, amyloid A, secretory phospholipase A2, and lipoprotein(a) concentrations, as well as increased mean serum albumin concentrations at 12 weeks, relative to placebo. The proportion of patients who achieved hs-CRP < 2.0 mg l-1 was 79%, 82% and 79% in the 2.5 mg, 5 mg and 10 mg clazakizumab groups, respectively, compared with 0% of placebo-treated patients. With regard to safety, no cases of sustained grade 3 or 4 thrombocytopenia or neutropenia were observed. Serious infections were seen with similar frequency in the placebo, clazakizumab 2.5 mg and clazakizumab 5 mg groups, but were numerically more frequent in the clazakizumab 10 mg group. The results of this trial indicate that in patients receiving maintenance dialysis, clazakizumab reduced inflammatory biomarkers associated with cardiovascular events. ClinicalTrials.gov registration: NCT05485961 .

Exploring the relation between Interleukin-6 and high-sensitive cardiac troponin T in asymptomatic hemodialysis patient: A cross-sectional study

BACKGROUND

High-sensitive cardiac troponin T (h-cTnT), which serves as a marker for myocardial damage, has also been linked to adverse outcomes in asymptomatic hemodialysis patients. This study aims to explore the correlation between interleukin-6 (IL-6) and h-cTnT in asymptomatic hemodialysis patients to unravel the relationship between inflammation and cardiovascular risk.

METHODS

A cross-sectional study involving 81 patients was conducted from November 2022 to March 2023 at An-Najah National University Hospital in Palestine. We gathered clinical data, including comorbidities, and obtained blood samples for measuring IL-6 and h-cTnT levels. We performed statistical analyses, including correlation tests and linear regression, to assess the associations between these variables.

RESULTS

The study revealed a notable increase in both h-cTnT and IL-6 levels, and a significant correlation between the two (rho = 0.463, P<0.001) in asymptomatic hemodialysis patients. Likewise, h-cTnT levels displayed positive correlations with age (rho = 0.519, P<0.001) and negative correlations with albumin (rho = -0.297, p = 0.007) and transferrin saturation (rho = -0.227, P = 0.042). IL-6 levels exhibited correlations with age (rho = 0.422, P<0.001), albumin (rho = -0.389, P<0.001), iron (rho = -0.382, P<0.001), and transferrin saturation (rho = -0.362, P = 0.001). Notably, higher h-cTnT levels were associated with diabetes, hypertension, a history of coronary artery disease, cerebrovascular accidents, older age, and male gender.

CONCLUSION

This study underscores the significant association between the inflammatory marker IL-6 and h-cTnT in asymptomatic hemodialysis patients, suggesting that inflammation may play an essential role in the elevation of h-cTnT levels. This association may have implications for predicting cardiovascular events and guiding interventions to reduce cardiovascular disease morbidity and mortality in hemodialysis patients.

Estimating the association between systemic Interleukin-6 and mortality in the dialysis population. Re-analysis of the global fluid study, systematic review and meta-analysis

BACKGROUND

Systemic inflammation, measured as circulating Interleukin-6 (IL-6) levels, is associated with cardiovascular and all-cause mortality in chronic kidney disease. However, this has not been convincingly demonstrated in a systematic review or a meta-analysis in the dialysis population. We provide such evidence, including a re-analysis of the GLOBAL Fluid Study.

METHODS

Mortality in the GLOBAL fluid study was re-analysed using Cox proportional hazards regression with IL-6 levels as a covariate using a continuous non-logarithmic scale. Literature searches of the association of IL-6 levels with mortality were conducted on MEDLINE, EMBASE, PyschINFO and CENTRAL. All studies were assessed for risk of bias using the QUIPS tool. To calculate a pooled effect size, studies were grouped by use of IL-6 scale and included in the meta-analysis if IL-6 was analysed as a continuous linear covariate, either per unit or per 10 pg/ml, in both unadjusted or adjusted for other patient characteristics (e.g. age, comorbidity) models. Funnel plot was used to identify potential publication bias.

RESULTS

Of 1886 citations identified from the electronic search, 60 were included in the qualitative analyses, and 12 had sufficient information to proceed to meta-analysis after full paper screening. Random effects meta-analysis of 11 articles yielded a pooled hazard ratio (HR) per pg/ml of 1.03, (95% CI 1.01, 1.03), [Formula: see text]= 81%. When the analysis was confined to seven articles reporting a non-adjusted HR the result was similar: 1.03, per pg/ml (95% CI: 1.03, 1.06), [Formula: see text]=92%. Most of the heterogeneity could be attributed to three of the included studies. Publication bias could not be determined due to the limited number of studies.

CONCLUSION

This systematic review confirms the adverse association between systemic IL-6 levels and survival in people treated with dialysis. The heterogeneity that we observed may reflect differences in study case mix.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO - CRD42020214198.

Interleukin-6 levels can be used to estimate cardiovascular and all-cause mortality risk in dialysis patients: A meta-analysis and a systematic review

BACKGROUND

Although previous studies have explored the correlation of interleukin (IL)-6 with mortality risk in dialysis patients, the findings have been conflicting. Hence, this meta-analysis aimed to comprehensively assess the use of IL-6 measurement for estimating cardiovascular mortality and all-cause mortality in dialysis patients.

METHODS

The Embase, PubMed, Web of Science, and MEDLINE databases were searched to identify relevant studies. After screening out the eligible studies, the data were extracted.

RESULTS

Twenty-eight eligible studies with 8370 dialysis patients were included. Pooled analyses revealed that higher IL-6 levels were related to increased cardiovascular mortality risk (hazard ratio [HR] = 1.55, 95% confidence interval [CI]: 1.20-1.90) and all-cause mortality risk (HR = 1.11, 95% CI: 1.05-1.17) in dialysis patients. Further subgroup analyses suggested that higher IL-6 levels were associated with elevated cardiovascular mortality in hemodialysis patients (HR = 1.59, 95% CI: 1.36-1.81) but not in peritoneal dialysis patients (HR = 1.56, 95% CI: 0.46-2.67). Moreover, sensitivity analyses indicated that the results were robust. Egger's test revealed potential publication bias among studies exploring the correlation of IL-6 levels with cardiovascular mortality (p = .004) and all-cause mortality (p < .001); however, publication bias was not observed when using Begg's test (both p > .05).

CONCLUSIONS

This meta-analysis reveals that higher IL-6 levels could indicate higher risks of cardiovascular mortality and all-cause mortality in dialysis patients. These findings suggest that monitoring IL-6 cytokine may help to enhance dialysis management and improve the general prognosis of patients.

Interleukin6 prediction of mortality in critically ill COVID19 patients: A prospective observational cohort study

OBJECTIVE

The aim of this study is to explore the role of IL6 in predicting outcome in critically ill COVID-19 patients. Design Prospective observational cohort study. Setting 20-bed respiratory medical intensive care unit of Abderrahmen Mami Teaching Hospital between September and December 2020.

METHODS

We included all critically ill patients diagnosed with COVID-19 managed in ICU. IL6 was measured during the first 24 hours of hospitalization.

RESULTS

71 patients were included with mean age of 64 ± 12 years, gender ratio of 22. Most patients had comorbidities, including hypertension (n = 32, 45%), obesity (n = 32, 45%) and diabetes (n = 29, 41%). Dexamethasone 6 mg twice a day was initiated as treatment for all patients. Thirty patients (42%) needed high flow oxygenation; 59 (83%) underwent non-invasive ventilation for a median duration 2 [1-5] days. Invasive mechanical ventilation was required in 44 (62%) patients with a median initiation delay of 1 [0-4] days. Median ICU length of stay was 11 [7-17] days and overall mortality was 61%. During the first 24 hours, median IL6 was 34.4 [12.5-106] pg/ml. Multivariate analysis shows that IL-6 ≥ 20 pg/ml, CPK < 107 UI/L, AST < 30 UI/L and invasive ventilation requirement are independent risk factors for mortality.

CONCLUSIONS

IL-6 is a strong mortality predictor among critically ill COVID19 patients. Since IL-6 antagonist agents are costly, this finding may help physicians to consider patients who should benefit from that treatment.

Inflammation and Cardiovascular Disease Associated With Hemodialysis for End-Stage Renal Disease

Chronic kidney disease (CKD) and cardiac insufficiency often co-exist, particularly in uremic patients on hemodialysis (HD). The occurrence of abnormal renal function in patients with cardiac insufficiency is often indicative of a poor prognosis. It has long been established that in patients with cardiac insufficiency, poorer renal function tends to indicate poorer cardiac mechanics, including left atrial reserve strain, left ventricular longitudinal strain, and right ventricular free wall strain (Unger et al., Eur J Heart Fail, 2016, 18(1), 103–12). Similarly, patients with chronic kidney disease, particularly uremic patients on HD, often have cardiovascular complications in addition to abnormal endothelial function with volume overload, persistent inflammatory states, calcium overload, and imbalances in redox responses. Cardiac insufficiency due to uremia is therefore mainly due to multifaceted non-specific pathological changes rather than pure renal insufficiency. Several studies have shown that the risk of adverse cardiovascular events is greatly increased and persistent in all patients treated with HD, especially in those who have just started HD treatment. Inflammation, as an important intersection between CKD and cardiovascular disease, is involved in the development of cardiovascular complications in patients with CKD and is indicative of prognosis (Chan et al., Eur Heart J, 2021, 42(13), 1244–1253). Therefore, only by understanding the mechanisms underlying the sequential development of inflammation in CKD patients and breaking the vicious circle between inflammation-mediated renal and cardiac insufficiency is it possible to improve the prognosis of patients with end-stage renal disease (ESRD). This review highlights the mechanisms of inflammation and the oxidative stress that co-exists with inflammation in uremic patients on dialysis, as well as the mechanisms of cardiovascular complications in the inflammatory state, and provides clinical recommendations for the anti-inflammatory treatment of cardiovascular complications in such patients.

Evaluation of demographic and clinical risk factors for high interdialytic weight gain

Xerostomia and hyposalivation are highly prevalent in hemodialysis (HD) patients and this is effective in increased fluid intake. The aim of this study is to determine the demographic and clinical risk factors associated with high interdialytic weight gain (IDWG) in nondiabetic HD patients. In total, 52 eligible HD patients were recruited in this cross-sectional study. Patients were divided into two groups according to % IDWG: Group 1: High IDWG (≥3%) and Group 2: normal IDWG (<3%). Plasma osmolarity (POsm), unstimulated salivary flow rate (USFR), xerostomia inventory (XI), and dialysis thirst inventory (DTI) were evaluated. The mean age of the patients was 53.7 ± 15.7 years. The prevalence of xerostomia was 53.8%, and hyposalivation was in 40.3% in the patients. High IDWG was positively correlated with XI and DTI while it was negatively correlated with POsm and USFR. The area under the receiver-operating characteristics curve for POsm for high IDWG was 0.661, with sensitivity of 63.8% and specificity of 72.7% for a cut-off point of 297.4 mOsm/L. Logistic regression analysis showed that advanced age odds ratio (OR: 1.215, p = 0.019), pill burden (OR: 1.162, p = 0.031), C-reactive protein (CRP; OR: 1.308, p = 0.042), and low POsm (OR: 0.768, p = 0.046) were independently related to high IDWG. The prevalence of xerostomia and thirst was higher in HD patients with high IDWG compared to the normal IDWG group. Age, CRP, low POsm, and pill burden were independently associated with high IDWG.

Blood Pressure Control and Antihypertensive Treatment among Hemodialysis Patients-Retrospective Single Center Experience

Background and Objectives: Hypertension affects at least 80% of hemodialysis patients. Inappropriate control of blood pressure is mentioned as one of the essential cardiovascular risk factors associated with development of cardiovascular events in dialysis populations. The aim of the cross-sectional, retrospective study was the evaluation of the antihypertensive treatment schedule and control of blood pressure in relation to the guidelines in the group of hemodialysis patients. Additionally, we assessed the level of decrease in blood pressure by each group of hypotensive agents. Materials and Methods: 222 patients hemodialyzed in a single Dialysis Unit in three distinct periods of time—2006, 2011, and 2016—with a diagnosis of hypertension were enrolled in the study. The analysis of the antihypertensive treatment was based on the medical files and it consisted of a comparison of the mean blood pressure results reported during the six consecutive hemodialysis sessions. Results: The mean values of blood pressure before hemodialysis were as follows: 134/77, 130/74, and 140/76 mmHg, after hemodialysis 124/74, 126/73, and 139/77 mmHg in 2006, 2011, and 2016 respectively. The goal of predialysis blood pressure control (<140/90) was achieved by up to 64.3% of participants in 2006 as compared to 49.4% in 2016. Additionally, the postdialysis goal (<130/90) reached 57.1% of the study population in 2006 as compared to 27.1% of patients in 2016. The differences in percentage of patients using single, double, triple, and multidrug therapy during observation were not statistically significant. The most often used drugs were ß-blockers, diuretics, and calcium channel blockers in all points of the study. Blockades of the renin–angiotensin–aldosterone system in 2006 and calcium channel blockers in 2011 and 2016 were the drugs with highest impact on lowering blood pressure. Conclusions: The goal of predialysis or postdialysis blood pressure control was achieved in a lower percentage of patients during the period of the study. Blockade of renin–angiotensin–aldosterone system and calcium channel blockers decrease the blood pressure significantly. It is necessary to achieve better control of blood pressure in prevention of cardiovascular incidents.

The association between self-management ability and malnutrition-inflammation-atherosclerosis syndrome in peritoneal dialysis patients: a cross-sectional study

BACKGROUND

The relationship between malnutrition-inflammation-atherosclerosis syndrome (MIAS) and self-management ability has not been previously revealed even though both play an important role in the management of peritoneal dialysis (PD) patients.

METHODS

In total, 93 patients were enrolled in this study. A self-management questionnaire was used for the evaluation of self-management ability. The identification of MIAS was based on one or more of the following three conditions: C-reactive protein (CRP)≥10 mg/L, malnutrition-inflammation score (MIS)> 7, and the presence of atherosclerosis-related medical records. The possible association between different self-management abilities and MIAS was analyzed with a Spearman correlation analysis.

RESULTS

There were 40 (43.0%) patients in the atherosclerosis group, and 38 (40.9%), 38 (40.9%), 10 (10.8%), and 7 (7.5%) patients in the MIAS0, MIAS1, MIAS2, and MIAS3 groups, respectively. The group with a score above the mean score of the Dialysis Effect Evaluation and Monitoring dimension had a fewer number of hospitalizations, higher albumin levels, lower MIS scores, a lower level of IL-6, and a lower number of MIAS factors. The Pearson and Spearman correlation analyses also revealed that this dimension was negatively correlated with the MIAS, MIS, IL-6, BNP, number of hospitalizations, and age and positively associated with albumin and prealbumin.

CONCLUSION

The Dialysis Effect Evaluation and Monitoring dimension of the self-management scale for PD patients is closely linked to the MIAS, and a better dialysis effect evaluation and monitoring capacity results in a decreased likelihood of exposure to malnutrition and inflammation.

TRIAL REGISTRATION

Chinese Clinical Trial Registry: ChiCTR2000035525 ( http://www.chictr.org.cn/showproj.aspx?proj=58110 ), registered August 13, 2020.