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Chan GCK, Fung WWS, Szeto CC, Ng JKC. From MIA to FIFA: The vicious matrix of frailty, inflammation, fluid overload and atherosclerosis in peritoneal dialysis. Nephrology (Carlton) 2023; 28:215-226. [PMID: 36807408 DOI: 10.1111/nep.14150] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 01/25/2023] [Accepted: 02/14/2023] [Indexed: 02/20/2023]
Abstract
Cardiovascular disease (CVD) is a major cause of mortality and morbidity in peritoneal dialysis (PD) patients. Two decades ago, the common co-existence of malnutrition and systemic inflammation PD patients with atherosclerosis and CVD led to the proposed terminology of 'malnutrition-inflammation-atherosclerosis (MIA) syndrome'. Although the importance of malnutrition is well accepted, frailty represents a more comprehensive assessment of the physical and functional capability of the patient and encompasses the contributions of sarcopenia (a key component of malnutrition), obesity, cardiopulmonary as well as neuropsychiatric impairment. In recent years, it is also increasingly recognized that fluid overload is not only the consequence but also play an important role in the pathogenesis of CVD. Moreover, fluid overload is closely linked with the systemic inflammatory status, presumably by gut oedema, gastrointestinal epithelial barrier dysfunction and leakage of bacterial fragments to the systemic circulation. There are now a wealth of published evidence to show intricate relations between frailty, inflammation, fluid overload and atherosclerotic disease in patients with chronic kidney disease (CKD) and those on PD, a phenomenon that we propose the term 'FIFA complex'. In this system, frailty and atherosclerotic disease may be regarded as two patient-oriented outcomes, while inflammation and fluid overload are two inter-connected pathogenic processes. However, there remain limited data on how the treatment of one component affect the others. It is also important to define how treatment of fluid overload affect the systemic inflammatory status and to develop effective anti-inflammatory strategies that could alleviate atherosclerotic disease and frailty.
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Affiliation(s)
- Gordon Chun-Kau Chan
- Carol & Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Winston Wing-Shing Fung
- Carol & Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Cheuk-Chun Szeto
- Carol & Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
- Li Ka Shing Institute of Health Sciences (LiHS), Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Jack Kit-Chung Ng
- Carol & Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
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Luo Y, Li Z, Ge P, Guo H, Li L, Zhang G, Xu C, Chen H. Comprehensive Mechanism, Novel Markers and Multidisciplinary Treatment of Severe Acute Pancreatitis-Associated Cardiac Injury - A Narrative Review. J Inflamm Res 2021; 14:3145-3169. [PMID: 34285540 PMCID: PMC8286248 DOI: 10.2147/jir.s310990] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 06/15/2021] [Indexed: 12/12/2022] Open
Abstract
Acute pancreatitis (AP) is one of the common acute abdominal inflammatory diseases in clinic with acute onset and rapid progress. About 20% of the patients will eventually develop into severe acute pancreatitis (SAP) characterized by a large number of inflammatory cells infiltration, gland flocculus flaky necrosis and hemorrhage, finally inducing systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS). Pancreatic enzyme activation, intestinal endotoxemia (IETM), cytokine activation, microcirculation disturbance, autonomic nerve dysfunction and autophagy dysregulation all play an essential role in the occurrence and progression of SAP. Organ dysfunction is the main cause of early death in SAP. Acute kidney injury (AKI) and acute lung injury (ALI) are common, while cardiac injury (CI) is not, but the case fatality risk is high. Many basic studies have observed obvious ultrastructure change of heart in SAP, including myocardial edema, cardiac hypertrophy, myocardial interstitial collagen deposition. Moreover, in clinical practice, patients with SAP often presented various abnormal electrocardiogram (ECG) and cardiac function. Cases complicated with acute myocardial infarction and pericardial tamponade have also been reported and even result in stress cardiomyopathy. Due to the molecular mechanisms underlying SAP-associated cardiac injury (SACI) remain poorly understood, and there is no complete, unified treatment and sovereign remedy at present, this article reviews reports referring to the pathogenesis, potential markers and treatment methods of SACI in recent years, in order to improve the understanding of cardiac injury in severe pancreatitis.
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Affiliation(s)
- YaLan Luo
- Institute (College) of Integrative Medicine, Dalian Medical University, Dalian, Liaoning, People's Republic of China.,Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, People's Republic of China.,Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, People's Republic of China
| | - ZhaoXia Li
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, People's Republic of China
| | - Peng Ge
- Institute (College) of Integrative Medicine, Dalian Medical University, Dalian, Liaoning, People's Republic of China.,Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, People's Republic of China.,Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, People's Republic of China
| | - HaoYa Guo
- Institute (College) of Integrative Medicine, Dalian Medical University, Dalian, Liaoning, People's Republic of China.,Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, People's Republic of China.,Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, People's Republic of China
| | - Lei Li
- Department of Vascular Surgery, The Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, People's Republic of China
| | - GuiXin Zhang
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, People's Republic of China
| | - CaiMing Xu
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, People's Republic of China
| | - HaiLong Chen
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, People's Republic of China
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Erthal Leinig C, Pecoits-Filho R, Kunii L, Claro LM, Merlin J, Almeida NRD, Carvalho CRDS, Moraes TPD. Low-Fiber Intake Is Associated With High Production of Intraperitoneal Inflammation Biomarkers. J Ren Nutr 2019; 29:322-327. [PMID: 30642655 DOI: 10.1053/j.jrn.2018.10.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 09/20/2018] [Accepted: 10/20/2018] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE Fiber intake influences disturbances in the gastrointestinal tract and is associated with systemic inflammation in the general population. Systemic and intraperitoneal inflammation play an important role in defining outcomes in peritoneal dialysis (PD), but the relationship between dietary fiber intake and inflammatory biomarkers has not yet been reported in the population on PD. The objective of the present study is to analyze whether or not fiber intake in patients on PD is associated with serum and intraperitoneal levels of inflammatory biomarkers. DESIGN AND METHODS Adult and clinically stable PD patients were included in this observational and cross-sectional study. Fiber intake was assessed by means of a dietary survey and calculated using the DietPro program 5.6i. The population was divided into two groups according to the median fiber intake. We investigated interleukin (IL)-1β, IL-6, tumor necrosis factor-α, monocyte chemoattractant protein-1 (MCP-1), B-cell-activating factor, and plasminogen-activator inhibitor-1 in both serum and peritoneal fluid. The latter was determined after a dwell time of 4 hours. RESULTS Fifty-two patients (42% men; aged 53 ± 14 years, 36% diabetics) were evaluated. Low intake of dietary fiber was found in 90% of patients, with a median of 12.2 g per day (3.4-33.3). The group with the highest fiber intake presented lower intraperitoneal levels of IL-6, IL-8, and MCP-1. In contrast, only MCP-1 was lower in the serum of those who consumed more fiber. All the associations remained significant after adjustment for confounders with plasminogen-activator inhibitor-1 included. CONCLUSIONS Patients on PD frequently present inadequate dietary fiber intake, which appears to have an association with the inflammatory response, particularly in the intraperitoneal component. Further prospective studies, evaluating whether or not a dietetic intervention with a focus on fiber intake affects these biomarkers and clinical outcomes, are essential to determine causality and clinical relevance.
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Affiliation(s)
- Cyntia Erthal Leinig
- School of Medicine, Pontifical Catholic University of Paraná (PUCPR), Curitiba, Brazil.
| | - Roberto Pecoits-Filho
- School of Medicine, Pontifical Catholic University of Paraná (PUCPR), Curitiba, Brazil
| | - Luiz Kunii
- State University of Londrina, Londrina, Brazil; Pontifical Catholic University of Paraná (PUCPR), Londrina, Brazil
| | - Ligia Maria Claro
- School of Medicine, Pontifical Catholic University of Paraná (PUCPR), Curitiba, Brazil
| | - Julio Merlin
- School of Medicine, Pontifical Catholic University of Paraná (PUCPR), Curitiba, Brazil
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Dekker MJE, van der Sande FM, van den Berghe F, Leunissen KML, Kooman JP. Fluid Overload and Inflammation Axis. Blood Purif 2018; 45:159-165. [PMID: 29478061 DOI: 10.1159/000485153] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Extracellular fluid overload (FO), which is assessed using bioimpedance technologies, is an important predictor of outcome in dialysis patients and in patients with early stages of chronic kidney disease. While traditional cardiovascular abnormalities are assumed to mediate this risk, recently also, the importance of noncardiovascular factors, such as systemic inflammation and malnutrition has been shown. While both FO and inflammation are independent risk factors for mortality, recent studies have shown that their combined presence can lead to a cumulative risk profile. From a pathophysiologic viewpoint, FO and inflammation can also be mutually reinforcing. Inflammation could contribute to FO by hypoalbuminemia, capillary leakage, and a (unnoticed) decline in lean and/or fat tissue mass resulting in incorrect estimation of dry weight. Reciprocally, FO could lead to inflammation by the translocation of endotoxins through a congested bowel wall or by a proinflammatory effect of tissue sodium. The relative importance of these putative factors is, however, not clear yet and epidemiological studies have shown no clear temporal direction regarding the relationship between FO and inflammation. FO and inflammation appear to be part of (dynamic) clusters of risk factors, including malnutrition and hyponatremia. Technology-guided fluid management of the often vulnerable dialysis patient with FO and inflammation cannot yet be based on evidence from randomized controlled trials, in which these specific patients were in general not included. In the absence of those trials, treatment should be based on identifying actionable causes of inflammation and on the judicious removal of excess volume based on frequent clinical reassessment.
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Miler M, Nikolac N, Segulja D, Kackov Maslac S, Celap I, Altabas K, Sefer S, Simundic AM. Is peritoneal dialysis causing a measurable burden of inflammatory and endothelial injury on top of metabolic syndrome? J Endocrinol Invest 2017; 40:163-168. [PMID: 27600388 DOI: 10.1007/s40618-016-0540-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 08/25/2016] [Indexed: 12/13/2022]
Abstract
PURPOSE Low-grade chronic inflammation is present in patients on peritoneal dialysis (PD) and in metabolic syndrome (MS). Due to possible greater endothelial changes in dialyzed patients, inflammatory response and oxidative stress are probably stronger in patients on PD. The objective of the study was to investigate possible in between adipokines, inflammatory, endothelial and oxidative stress markers between MS patients and patients on PD. METHODS Concentrations of adipokines (leptin, resistin), inflammatory markers [interleukin-6 (IL-6), soluble tumor necrosis factor alpha receptor (sTNF-R), myeloperoxidase (MPO), monocyte chemoattractant protein 1 (MCP-1)] and endothelial markers [soluble intracellular adhesion molecule-1 (sICAM-1), soluble CD40 ligand (sCD40L)] were determined in 55 MS patients and 18 patients on PD, with flow cytometry, and visfatin concentration was measured with ELISA. Routine biochemistry parameters were measured on Beckman Coulter AU2700 analyzer. RESULTS Patients on PD have significantly higher concentration of: CRP [6.5 (3.7-12.1) versus 2.6 (1.3-4.0) mg/L, P < 0.001], IL-6 [13.83 (8.48-31.31) versus 2.05 (0.67-4.11) pg/mL, P < 0.001], MCP-1 [2172.28 (1563.84-2922.77) versus 1353.58 (1166.33-1961.70) pg/mL, P = 0.023], sTNF-R [18.25 (12.81-25.22) versus 1.23 (0.89-1.43) ng/mL, P < 0.001] and sICAM-1 [830.03 (599.21-967.02) versus 463.85 (315.25-751.71) ng/mL, P = 0.006] than subjects with MS. MS patients have higher concentrations of MPO [175.47 (120.15-231.67) versus 101.76 (53.55-186.06) ng/mL, P = 0.016] and visfatin [1.5 (0.9-2.3) versus 0.9 (0.6-1.6) ng/mL, P = 0.013]. CONCLUSION In patients on PD, inflammatory reaction is higher than in patients with MS. On the contrary, patients with MS have stronger oxidative stress response and adipose tissue activity caused probably by the chronic low level of inflammation and underlying metabolic disorders.
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Affiliation(s)
- M Miler
- University Department of Chemistry, Sestre Milosrdnice Medical School University Hospital, Zagreb, Croatia.
| | - N Nikolac
- University Department of Chemistry, Sestre Milosrdnice Medical School University Hospital, Zagreb, Croatia
| | - D Segulja
- Department of Laboratory Diagnostics, University Hospital Centre Zagreb, Zagreb, Croatia
| | - S Kackov Maslac
- Medical Biochemistry Laboratory, Policlinic Bonifarm, Zagreb, Croatia
| | - I Celap
- University Department of Chemistry, Sestre Milosrdnice Medical School University Hospital, Zagreb, Croatia
| | - K Altabas
- Department of Nephrology and Dialysis, Medical School University Hospital Sestre Milosrdnice, Zagreb, Croatia
| | - S Sefer
- Department of Nephrology and Dialysis, Medical School University Hospital Sestre Milosrdnice, Zagreb, Croatia
| | - A M Simundic
- Department of Medical Laboratory Diagnostics, University Hospital "Sveti Duh", Zagreb, Croatia
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