Hypocholesterolemia is a significant predictor of death in a cohort of chronic hemodialysis patients

Relationship of serum total cholesterol and triglyceride with risk of mortality in maintenance hemodialysis patients: a multicenter prospective cohort study

OBJECTIVE

The relationship between serum total cholesterol (TC) and triglyceride (TG) levels and mortality in maintenance hemodialysis (MHD) patients remains inconsistent. We aimed to explore the individual and combined association of TC and TG levels with the risk of mortality in Chinese MHD patients.

METHODS

1036 MHD patients were enrolled in this multicenter, prospective cohort study. The serum levels of total cholesterol and triglycerides were measured at baseline. The primary outcome was all-cause mortality and secondary outcome was cardiovascular disease (CVD) mortality.

RESULTS

During a median follow-up duration of 4.4 years (IQR= 2.0-7.9 years), 549 (53.0%) patients died, and 297 (28.7%) deaths were attributed to CVD. Compared with patients with TC levels in the first three quartiles (<182.5 mg/dL), a significantly higher risk of all-cause mortality was found in participants with TC in the fourth quartile (hazard ratio [HR], 1.43; 95% confidence interval [CI], 1.17-1.76). However, a significantly lower risk of all-cause mortality was observed in participants with TG in the fourth quartile (≥193.9 mg/dL) (HR, 0.78; 95%CI: 0.63-0.98), compared with participants with TG in the first three quartiles. Similar trends were observed in CVD mortality. When analyzed jointly, patients with lower TC (<182.5 mg/dL) and higher TG (≥193.9 mg/dL) levels had the lowest risk of all-cause mortality and CVD mortality.Conclusions: In MHD patients in southern China, higher TC levels were associated with higher risk of mortality, while higher TG levels were related to lower risk of mortality. Patients with lower TC and higher TG levels had the best survival prognosis.

Association between the triglyceride to high-density lipoprotein cholesterol ratio and mortality in Chinese maintenance haemodialysis patients: a retrospective cohort study

OBJECTIVE

To investigate the relationship between the triglyceride to high-density lipoprotein cholesterol (TG/HDL-C) ratio and all-cause and cardiovascular (CV) mortality in Chinese haemodialysis (HD) patients.

DESIGN

Retrospective cohort study.

SETTING

Patients from June 2015 to September 2016 and followed through September 2021 were categorised into quartiles according to the follow-up averaged TG/HDL-C ratio. The association between TG/HDL-C and mortality was examined by univariate and multivariate time-varying Cox regression analyses. The C-index was used to assess the predictive accuracy of the Cox regression models.

PARTICIPANTS

A total of 534 maintenance HD patients were enrolled.

PRIMARY AND SECONDARY OUTCOME MEASURES

The outcomes were all-cause death and CV mortality.

RESULTS

During the median follow-up of 61 months, 207 patients died, with 94 (45.4%) classified as CV death. After adjusting for confounders, multivariate time-varying Cox regression analysis showed that the quartile 4 group (TG/HDL-C ≥2.64) was associated with decreased all-cause mortality (adjusted HR 0.51, 95% CI 0.33-0.77, p=0.001) and CV mortality (adjusted HR 0.31; 95% CI 0.16 to 0.62; p=0.001) in maintenance HD patients. Model 1 of all-cause mortality achieved a C-index of 0.72 (95% CI 0.68 to 0.75), and model 2 achieved a C-index of 0.77 (95% CI 0.73 to 0.82). The C-index for model 1 in CV mortality was 0.74 (95% CI 0.70 to 0.77), and the C-index for model 2 was 0.80 (95% CI 0.75 to 0.84).

CONCLUSIONS

High TG/HDL-C was associated with decreased all-cause and CV mortality in HD patients.

Lipoprotein-associated phospholipase A2 predicts cardiovascular death in patients on maintenance hemodialysis: a 7-year prospective cohort study

BACKGROUND

Cardiovascular diseases (CVD) is the leading cause of death among maintenance hemodialysis patients, with dyslipidemia being a prevalent complication. The paradoxical relationship between cardiovascular outcomes and established lipid risk markers, such as low-density lipoprotein cholesterol (LDL-C), complicates lipid management in this population. This study investigated Lipoprotein-associated phospholipase A2 (Lp-PLA2), an emerging biomarker known for its proinflammatory and proatherogenic properties, as a potential cardiovascular prognostic marker in this cohort. In this context, the association between Lp-PLA2 levels and cardiovascular outcomes was evaluated, with the aim to facilitate more accurate stratification and identification of high-risk individuals.

METHODS

From August 2013 to January 2014, 361 hemodialysis patients were prospectively enrolled. Lp-PLA2 activity and laboratory measures at baseline were quantified. Comorbidities and medications were recorded. All patients were followed until the end of April, 2022. The individual and combined effects of Lp-PLA2 activity and LDL-C on patient outcomes were examined. The association between Lp-PLA2 activity and all-cause mortality, cardiovascular mortality, and major adverse cardiovascular events (MACEs) was analyzed.

RESULTS

The median Lp-PLA2 activity was 481.2 U/L. In subjects with Lp-PLA2 activity over 481.2 U/L, significantly higher total cholesterol (4.89 vs. 3.98 mmol/L; P < 0.001), LDL-C (3.06 vs. 2.22 mmol/L; P < 0.001), and apolipoprotein B (0.95 vs. 0.75 mmol/L; P < 0.001) were observed. Over a median follow-up of 78.1 months, 182 patients died, with 77 cases identified as cardiovascular death, 88 MACEs happened. Cardiovascular mortality and MACEs, but not all-cause mortality, were significantly increased in the high Lp-PLA2 group. Cox regression analyses showed that high Lp-PLA2 activity was associated with cardiovascular mortality and MACE occurrence. After comprehensive adjustment, high Lp-PLA2 activity was independently associated with cardiovascular mortality(as a dichotomous variable: HR:2.57, 95%CI:1.58,4.18, P < 0.001; as a continuous variable: HR:1.25, 95%CI:1.10,1.41, P = 0.001) and MACEs(as a dichotomous variable: HR:2.17, 95%CI:1.39,3.40, P = 0.001; as a continuous variable: HR:1.20, 95%CI:1.07,1.36, P = 0.002). When participants were grouped by median Lp-PLA2 activity and LDL-C values, those with high Lp-PLA2 and low LDL-C had the highest CV mortality. The addition of Lp-PLA2 significantly improved reclassification (as a dichotomous variable NRI = 42.51%, 95%CI: 5.0%,61.33%; as a continuous variable, NRI = 33.32%, 95% CI: 7.47%,56.21%).

CONCLUSIONS

High Lp-PLA2 activity is an independent risk factor for cardiovascular mortality and MACEs occurrence in patients on hemodialysis. The combined measures of Lp-PLA2 and LDL-C help to identify individuals with a higher risk of cardiovascular death.

Machine Learning Model for Predicting Mortality Risk in Patients With Complex Chronic Conditions: Retrospective Analysis

Background

The health care system is undergoing a shift toward a more patient-centered approach for individuals with chronic and complex conditions, which presents a series of challenges, such as predicting hospital needs and optimizing resources. At the same time, the exponential increase in health data availability has made it possible to apply advanced statistics and artificial intelligence techniques to develop decision-support systems and improve resource planning, diagnosis, and patient screening. These methods are key to automating the analysis of large volumes of medical data and reducing professional workloads.

Objective

This article aims to present a machine learning model and a case study in a cohort of patients with highly complex conditions. The object was to predict mortality within the following 4 years and early mortality over 6 months following diagnosis. The method used easily accessible variables and health care resource utilization information.

Methods

A classification algorithm was selected among 6 models implemented and evaluated using a stratified cross-validation strategy with k=10 and a 70/30 train-test split. The evaluation metrics used included accuracy, recall, precision, F1-score, and area under the receiver operating characteristic (AUROC) curve.

Results

The model predicted patient death with an 87% accuracy, recall of 87%, precision of 82%, F1-score of 84%, and area under the curve (AUC) of 0.88 using the best model, the Extreme Gradient Boosting (XGBoost) classifier. The results were worse when predicting premature deaths (following 6 months) with an 83% accuracy (recall=55%, precision=64% F1-score=57%, and AUC=0.88) using the Gradient Boosting (GRBoost) classifier.

Conclusions

This study showcases encouraging outcomes in forecasting mortality among patients with intricate and persistent health conditions. The employed variables are conveniently accessible, and the incorporation of health care resource utilization information of the patient, which has not been employed by current state-of-the-art approaches, displays promising predictive power. The proposed prediction model is designed to efficiently identify cases that need customized care and proactively anticipate the demand for critical resources by health care providers.

Effect of low-density lipoprotein level and mortality in older incident statin-naïve hemodialysis patients

BACKGROUND

This study aimed to analyze low-density lipoprotein cholesterol (LDL-C) levels and their relationship with mortality in order to identify the appropriate lipid profile for older Korean hemodialysis patients.

METHODS

We enrolled a total of 2,732 incident hemodialysis patients aged > 70 years from a retrospective cohort of the Korean Society of Geriatric Nephrology from 2010 Jan to 2017 Dec, which included 17 academic hospitals in South Korea. Of these patients, 1,709 were statin-naïve, and 1,014 were analyzed after excluding those with missing LDL-C level data. We used multivariate Cox regression analysis to select risk factors from 20 clinical variables among the LDL-C groups.

RESULTS

The mean age of the entire patient population was 78 years, with no significant differences in age between quartiles Q1 to Q4. However, the proportion of males decreased as the quartiles progressed towards Q4 (p < 0.001). The multivariate Cox regression analysis, which included all participants, showed that low LDL-C levels were associated with all-cause mortality. In the final model, compared to Q1, the hazard ratios (95% confidence interval) were 0.77 (0.620-0.972; p = 0.027), 0.85 (0.676-1.069; p = 0.166), and 0.65 (0.519-0.824; p < 0.001) for Q2, Q3, and Q4, respectively, after adjusting for covariates, such as conventional and age-specific risk factors. The final model demonstrated that all-cause mortality increased as LDL-C levels decreased, as confirmed by a restrictive cubic spline plot.

CONCLUSIONS

In older hemodialysis patients who had not previously received dyslipidemia treatment, elevated LDL-C levels were not associated with increased all-cause mortality. Intriguingly, lower LDL-C levels appear to be associated with an unfavorable effect on all-cause mortality among high-risk hemodialysis patients.

Impact of pretransplantation malnutrition risk on the clinical outcome and graft survival of kidney transplant patients

BACKGROUND

The prevalence of malnourished patients before transplantation and the influence of malnutrition on graft and patient outcomes remain underestimated, despite being associated with higher postoperative morbidity and mortality. This study aimed to develop an easy nutritional screening tool and evaluate the impact of nutritional status on clinical outcome, graft survival (GS) and mortality risk in kidney transplant patients (KTP).

METHODS

In this retrospective cohort study including 451 KTP, we developed a score by using anthropometric, clinical, and laboratory measures performed in the pretransplant evaluation. The patients were stratified into 3 groups according to the final score: G1 (0 or 1 point)=low risk, G2 (2 to 4 points)=moderate risk, and G3 (>5 points)=high risk of malnutrition. The patients were monitored after transplantation at least 1 to 10 years.

RESULTS

Stratifying the 451 patients based on the pretransplant risk score, G1, G2, and G3 were composed of 90, 292, and 69 patients, respectively. Patients from G1 maintained the lowest serum creatinine levels at hospital discharge when compared with others (p = 0.012). The incidence of infection in the patients from G3 was higher than patients from G1 and G2 (p = 0.030). G3 recipients showed worse GS than G1 patients (p = 0.044). G3 patients showed almost threefold higher risk for graft loss (HR 2.94, 95% CI 1.084-7.996).

CONCLUSIONS

KTP with higher malnutrition risk score were associated with worse outcomes and GS. The nutritional screening tool is easy to be used in clinical practice to evaluate the patient in preparation for kidney transplant.

Pathophysiological concepts and screening of cardiovascular disease in dialysis patients

Dialysis patients experience 10-20 times higher cardiovascular mortality than the general population. The high burden of both conventional and nontraditional risk factors attributable to loss of renal function can explain higher rates of cardiovascular disease (CVD) morbidity and death among dialysis patients. As renal function declines, uremic toxins accumulate in the blood and disrupt cell function, causing cardiovascular damage. Hemodialysis patients have many cardiovascular complications, including sudden cardiac death. Peritoneal dialysis puts dialysis patients with end-stage renal disease at increased risk of CVD complications and emergency hospitalization. The current standard of care in this population is based on observational data, which has a high potential for bias due to the paucity of dedicated randomized clinical trials. Furthermore, guidelines lack specific guidelines for these patients, often inferring them from non-dialysis patient trials. A crucial step in the prevention and treatment of CVD would be to gain better knowledge of the influence of these predisposing risk factors. This review highlights the current evidence regarding the influence of advanced chronic disease on the cardiovascular system in patients undergoing renal dialysis.

The Clinical Significance of LDL-Cholesterol on the Outcomes of Hemodialysis Patients with Acute Coronary Syndrome

Background and objectives: Dyslipidemia is one of the most important modifiable risk factors in the pathogenesis of cardiovascular disease in the general population, but its importance in the hemodialysis (HD) population is uncertain. Materials and Methods: This retrospective cohort study includes HD patients hospitalized due to acute coronary syndrome (ACS) in the period 2015-2020 with lipid profile data during ACS. A control group with preserved kidney function was matched. Risk factors for 30-day and 1-year mortality were assessed. Results: Among 349 patients included in the analysis, 246 were HD-dependent ("HD group"). HD group patients had higher prevalence of diabetes, hypertension, and heart disease than the control group. At ACS hospitalization, lipid profile and chronic statin treatment were comparable between groups. Odds ratios for 30-day mortality in HD vs. control group was 5.2 (95% CI 1.8-15; p = 0.002) and for 1-year, 3.4 (95% CI 1.9-6.1; p <0.001). LDL and LDL < 70 did not change 30-day and 1-year mortality rates in the HD group (p = 0.995, 0.823, respectively). However, survival after ACS in HD patients correlated positively with nutritional parameters such as serum albumin (r = 0.368, p < 0.001) and total cholesterol (r = 0.185, p < 0.001), and inversely with the inflammatory markers C-reactive protein (CRP; r = -0.348, p < 0.001) and neutrophils-to-lymphocytes ratio (NLR; r = -0.181, p = 0.019). Multivariate analysis demonstrated that heart failure was the only significant predictor of 1-year mortality (OR 2.8, p = 0.002). LDL < 70 mg/dL at ACS hospitalization did not predict 1-year mortality in the HD group. Conclusions: Despite comparable lipid profiles and statin treatment before and after ACS hospitalization, mortality rates were significantly higher among HD group. While malnutrition-inflammation markers were associated with survival of dialysis patients after ACS, LDL cholesterol was not. Thus, our study results emphasize that better nutritional status and less inflammation are associated with improved survival among HD patients.

Statins in Chronic Kidney Disease-Effects on Atherosclerosis and Cellular Senescence

Chronic kidney disease (CKD) is a serious health problem that can affect various systems in the human body. Renal failure promotes mechanisms of premature cellular aging and also features of generalized inflammation in the body, which translates into a close relationship between kidney dysfunction and cardiovascular disease (CVD). As kidney function deteriorates, cardiovascular risk and mortality increase in this group of patients. Oxidative stress and inflammation are two closely related processes that initiate a vicious cycle by activating each other. Together with aging, they represent the key factors that cause and exacerbate CVD in CKD. Patients with CKD are particularly vulnerable to the accumulation of aging endothelial cells, vascular smooth muscle and macrophages, increasing the risk of atherosclerosis. Several mechanisms are known that can lead to the progression of the aforementioned problems, such as the accumulation of uremic toxins, persistent inflammation, impaired lipid and electrolyte metabolism, nitric oxide (NO) deficiency, the increased production of reactive oxygen species (ROS) and damage to deoxyribonucleic acid (DNA) and mitochondria. According to research, we can distinguish a group of drugs that effectively counteract the negative effects of CKD-statins. This is a group of drugs that inhibit 3-hydroxy-3-methylglutaryl-coenzyme-A (HMG-CoA) reductase and affect a number of cellular processes and pathways, resulting in the overall slowing of atherosclerosis and cellular aging.

Total cholesterol and mortality in peritoneal dialysis: a retrospective cohort study

BACKGROUND

Total cholesterol is inversely associated with mortality in dialysis patients, which seems implausible in real-world clinical practice. May there be an optimal range of total cholesterol associated with a lower mortality risk? We aimed to evaluate the optimal range for peritoneal dialysis (PD) patients.

METHODS

We conducted a retrospective real-world cohort study of 3565 incident PD patients from five PD centers between January 1, 2005, and May 31, 2020. Baseline variables were collected within one week before the start of PD. The associations between total cholesterol and mortality were examined using cause-specific hazard models.

RESULTS

820 (23.0%) patients died, including 415 cardiovascular deaths, during the follow-up period. Restricted spline plots showed a U-curved association of total cholesterol with mortality. Compared with the reference range (4.10-4.50 mmol/L), high levels of total cholesterol (> 4.50 mmol/L) were associated with increased risks of all-cause (hazard ratio [HR] 1.35, 95% confidence index [CI] 1.08-1.67) and cardiovascular mortality (HR 1.38, 95% CI 1.09-1.87). Similarly, compared with the reference range, low levels of total cholesterol (< 4.10mmol/L) were also associated with high risks of all-cause (HR 1.62, 95% CI 1.31-1.95) and cardiovascular mortality (HR 1.72, 95% CI 1.27-2.34).

CONCLUSION

Total cholesterol levels at the start of PD between 4.10 and 4.50 mmol/L (158.5 to 174.0 mg/dL), an optimal range, were associated with lower risks of death than higher or lower levels, resulting in a U-shaped association.

Low cholesterol states: clinical implications and management

INTRODUCTION

Hypocholesterolemia results from genetic - both monogenic and polygenic - and non-genetic causes and can sometimes be a source of clinical concern. We review etiologies and sequelae of hypocholesterolemia and therapeutics inspired from genetic hypocholesterolemia.

AREAS COVERED

Monogenic hypocholesterolemia disorders caused by the complete absence of apolipoprotein (apo) B-containing lipoproteins (abetalipoproteinemia and homozygous hypobetalipoproteinemia) or an isolated absence of apo B-48 lipoproteinemia (chylomicron retention disease) lead to clinical sequelae. These include gastrointestinal disturbances and severe vitamin deficiencies that affect multiple body systems, i.e. neurological, musculoskeletal, ophthalmological, and hematological. Monogenic hypocholesterolemia disorders with reduced but not absent levels of apo B lipoproteins have a milder clinical presentation and patients are protected against atherosclerotic cardiovascular disease. Patients with heterozygous hypobetalipoproteinemia have somewhat increased risk of hepatic disease, while patients with PCSK9 deficiency, ANGPTL3 deficiency, and polygenic hypocholesterolemia typically have anunremarkable clinical presentation.

EXPERT OPINION

In patients with severe monogenic hypocholesterolemia, early initiation of high-dose vitamin therapy and a low-fat diet are essential for optimal prognosis. The molecular basis of monogenic hypocholesterolemia has inspired novel therapeutics to help patients with the opposite phenotype - i.e. elevated apo B-containing lipoproteins. In particular, inhibitors of PCSK9 and ANGPTL3 show important clinical impact.

Improvement of clinical outcomes in patients undergoing peritoneal dialysis using hydroxymethylglutaryl-CoA reductase inhibitors: A systematic review and meta-analysis

BACKGROUND

It is unclear whether hydroxymethylglutaryl-CoA reductase inhibitor (statin) therapy decreases the risk of mortality and cardiovascular disease (CVD) in patients undergoing peritoneal dialysis (PD).

METHODS

We performed a literature search of PubMed, Cochrane Library, Embase, and other databases for research publications up to June 2022. The outcomes of interest were fatal and nonfatal CVDs, all-cause mortality, and changes in the biochemical profiles. Hazard ratios (HRs) with 95% confidence intervals (CIs) were pooled and synthesized using a random-effects model. The certainty of the evidence was determined using Grading of Recommendations, Assessment, Development, and Evaluation.

RESULTS

Nine studies, including 2,933 patients undergoing PD, were included. Among them, three studies, including 2,099 patients, reported all-cause mortality, and three, including 1,571 patients, reported CVDs. In these patients, pooling results of two observational studies (very low-certainty evidence) showed that statin therapy significantly reduced CVDs (HR = 0.67; 95% CI = 0.54-0.84; p = 0.0004). Moreover, statin therapy was associated with significantly reduced low-density lipoprotein cholesterol, total cholesterol, and C-reactive protein levels (very low certainty of evidence). However, the effects of statin therapy on triglyceride, high-density lipoprotein, and albumin levels were not statistically significant.

CONCLUSION

Although statin therapy was associated with significantly reduced low-density lipoprotein cholesterol, total cholesterol, and C-reactive protein levels, the probable beneficial effect of statins on CVD risk in patients undergoing PD could not be concluded firmly. Additional high-quality studies are required to assess the potential beneficial effects of statin therapy in PD patients.

Timed-averaged blood pressure showed a J-curve association with stroke in elderly chronic kidney disease patients

BACKGROUND

The risk factors for stroke in elderly patients with chronic kidney disease (CKD) are not well understood. This study aimed to explore the influence of systolic blood pressure (SBP) on the risk of stroke in a large cohort of elderly patients with stage 3-5 CKD.

METHODS

We retrospectively identified 665 patients hospitalized in Beijing Friendship Hospital from January 2000 to December 2021. Patients were followed up until the occurrence of stroke or death. Multivariate logistic regression analysis and Cox proportional hazard models were used to analyze the risk factors for stroke according to the presence or absence of CKD. The association between CKD and stroke was further evaluated regarding the role of SBP in the hypertensive population.

RESULTS

In individuals with CKD, a J-shaped relationship was observed between SBP levels and the risk of stroke. Participants with CKD and an SBP less than 125 mmHg had a significantly higher cumulative stroke survival rate than those whose SBP was between 125 and 139 mmHg. The cumulative stroke survival rate increased progressively for those with SBP higher than 140 mmHg. This J-shaped relationship was not found in patients without CKD.

CONCLUSION

In elderly patients with CKD, those with the lowest BP are at increased risk for incident stroke. This phenomenon could be different from that in the general population.

Clinical frailty assessment might be associated with mortality in incident dialysis patients

Frailty is associated with mortality in maintenance dialysis patients. For incident dialysis patients, we used the clinical frailty scale (CFS) to investigate frailty as related to mortality or hospitalization within 2 years. We retrospectively reviewed the medical records of patients initiating hemodialysis or peritoneal dialysis during 2016-2018. Based on those records, two dialysis nurses independently used a 9-point CFS (1 = "Very fit" to 9 = "Terminally ill") to assess each patient's frailty at dialysis initiation. Patients with a mean CFS value of 5 or higher were classified into the frail group. The 2-year survival rates or hospitalization-free rates after the initiation of dialysis were compared between the frail (mean CFS score ≥ 5) and non-frail (mean CFS score < 5) groups. The analysis included 155 incident dialysis patients with mean age of 66.7 ± 14.1 (71% male). Frailty was inferred for 39 (25%) patients at dialysis initiation. Kaplan-Meier analyses showed that the survival rate and hospitalization-free rate within 2 years were significantly lower in the frail group than in the non-frail group (p < 0.01). Cox proportional hazards regression analyses revealed the CFS score as associated with the occurrence of a composite outcome, independently of age (hazard ratio 1.34, 95% confidence interval 1.04-1.72). Frailty assessment based on clinical judgment using CFS might predict adverse outcomes in dialysis-initiated patients.

Energy Homeostasis Gene Nucleotide Variants and Survival of Hemodialysis Patients-A Genetic Cohort Study

Background: Patients undergoing hemodialysis (HD) therapy have an increased risk of death compared to the general population. We investigated whether selected single nucleotide variants (SNVs) involved in glucose and lipid metabolism are associated with mortality risk in HD patients. Methods: The study included 805 HD patients tested for 11 SNVs in FOXO3, IGFBP3, FABP1, PCSK9, ANGPTL6, and DOCK6 using HRM analysis and TaqMan assays. FOXO3, IGFBP3, L-FABP, PCSK9, ANGPTL6, and ANGPTL8 plasma concentrations were measured by ELISA in 86 individuals. The Kaplan–Meier method and Cox proportional hazards models were used for survival analyses. Results: We found out that the carriers of a C allele in ANGPTL6 rs8112063 had an increased risk of all-cause, cardiovascular, and cardiac mortality. In addition, the C allele of DOCK6 rs737337 was associated with all-cause and cardiac mortality. The G allele of DOCK6 rs17699089 was correlated with the mortality risk of patients initiating HD therapy. The T allele of FOXO3 rs4946936 was negatively associated with cardiac and cardiovascular mortality in HD patients. We observed no association between the tested proteins’ circulating levels and the survival of HD patients. Conclusions: The ANGPTL6 rs8112063, FOXO3 rs4946936, DOCK6 rs737337, and rs17699089 nucleotide variants are predictors of survival in patients undergoing HD.

Role of predictable biomarkers in early detection of cardiovascular events in Chronic Kidney Disease III and IV

This comes about because of a lack of predicted biomarkers in the risk analysis of CVD events in chronic kidney disease (CKD) patients. The present study aimed to determine the clinical utility of independent, predictable biomarkers such as serum creatinine, estimated Glomerular Filtration Rate (eGFR), high sensitive C-Reactive protein (hsCRP), fibrinogen and lipid profile as early predictors of CVD in CKD at stage III/IV.

Methods. This is a case-control study that includes a sample size of 100 patients of cases and 100 patients of controls who were recruited from November 2020 to April 2021, from the Nephrology department of the Visakhapatnam tertiary care teaching hospital, and present with chronic kidney disease – stage III/IV. The subjects’ general conditions (age, gender, height, weight, systolic blood pressure, diastolic blood pressure, and smoking history); underlying diseases (coronary heart disease and diabetes mellitus) were recorded. Fasting venous blood samples were collected under aseptic conditions from the study group after taking informed consent. The measurement of serum creatinine was performed by modification of kinetic Jaffe reaction. The Cockcroft-Gault equation was used to calculate eGFR in both cases and controls. CRP testing was done with a Cobas C311 analyzer, using immunoturbidimetric assay. The Fibroquant kit from Tulip was employed to measure fibrinogen levels in blood samples, and enzymatic methods were applied for lipid profile analysis.

Results. In this study, higher mean values of hsCRP (34.28 mg/dl), increased serum creatinine levels (2.876 mg/dl), reduced eGFR (28.37 mls/min), high levels of serum fibrinogen (291.6 mg/dl), and cholesterol (214.5 mg/dl), HDL (28.34 mg/dl), TG (162.1 mg/dl), VLDL (32.41 mg/dl) and LDL (153.77 mg/dl) were found to be independent predictors of assessment of CV events in patients with CKD stages III and IV as determined by Chi-square test.

Conclusion. A prompt and accurate assessment of cardiovascular risk in CKD patients would enable more aggressive and focused treatment of the individuals who are most in need of preventive interventions to decrease incident rates.

Interaction between the stage of chronic kidney disease and diabetes mellitus as factors associated with mortality in chronic kidney disease patients: An external cohort study

INTRODUCTION

Diabetic kidney disease is the main cause of chronic kidney disease (CKD) worldwide. Both CKD and diabetes mellitus (DMT2) are important risk factors for mortality. However, it is still unknown if the risk of death is modified by the simultaneous presence of these diseases.

OBJECTIVE

To evaluate the presence of an interaction between DMT2 and CKD for mortality in a representative population of a Latin American country.

METHODS

It is an analytical cohort study of patients with CKD, who were followed for 4 years (between 2004 and 2009). We calculated the incidence rate, progression, survival (using Kaplan-Meier curves), interaction (on the additive and multiplicative scales) and impact of the different stages of CKD in patients with and without DMT2 (using a cox proportional hazards model).

RESULTS

In this population of 5663 individuals, both DMT2 and CKD are risk factors for mortality (p<0.001). We found a statistically significant difference in mortality between individuals with and without DMT2, who also had CKD stages 3-4 -5 (Log-rank p=0.0076). Additionally, we found a statistically significant interaction for mortality in both the additive and multiplicative scales between DMT2 and CKD (p=0.005). DMT2 was found to be a risk factor for mortality (Hazard Ratio 1.61 p<0.001), but in individuals with DMT2, the only risks significantly associated with mortality, were age, dyslipidemia and nephroprotective drugs. CONCLUSIóN: The interaction between CKD and DMT2 negatively modifies the risk of death of both diseases. This means that when the two diseases are present, the risk of mortality is lower than expected.

The Association of Controlling Nutritional Status Score and Prognostic Nutritional Index with Cardiovascular Diseases: the Fukuoka Kidney Disease Registry Study

AIM

The Controlling Nutritional Status (CONUT) score and the Prognostic Nutritional Index (PNI) reflect the immunonutritional status of patients. However, the associations of these two indices with cardiovascular disease (CVD) have not been characterized in patients with chronic kidney disease (CKD). Therefore, the current study aimed to determine whether the CONUT score or PNI was associated with prior CVD in patients with CKD.

METHODS

A cross-sectional study of 2,751 patients with CKD who were not on dialysis was performed. The patients were grouped into tertiles (T1-T3) of PNI and placed into three groups following their CONUT score: low- (CONUT score, 0), mild- (CONUT score, 1-2), and moderate-to-high- (CONUT score, ≥ 3) risk groups.

RESULTS

Prior CVD was present in 655 (24%) of the participants. Multivariable logistic regression analyses, with adjustment for potential confounders, showed that high CONUT score was associated with prior CVD than the low score (mild-risk group: odds ratio [OR]=1.35, 95% confidence interval [CI]=1.04-1.76; moderate-to-high-risk group: OR=1.66, 95% CI=1.19-2.30). In addition, the lower PNI tertiles were independently associated with prior CVD compared with T3 of PNI (T1: OR=1.45, 95% CI=1.09-1.92; T2: OR=1.32, 95% CI=1.01-1.72).

CONCLUSIONS

Both CONUT score and PNI were found to be independently associated with prior CVD in patients with CKD in the present cross-sectional study. A longitudinal study is needed to elucidate whether these two indices are associated with subsequent cardiovascular events.

Albumin to Total Cholesterol Ratio and Mortality in Peritoneal Dialysis

Background

Serum albumin and total cholesterol are associated with mortality. In clinical practice, evaluating the association of combining album and total cholesterol with mortality may be more reasonable. Thus, we examined the association between serum albumin to total cholesterol ratio and mortality in peritoneal dialysis (PD) patients.

Methods

We conducted a retrospective cohort study of 3447 incident continuous ambulatory peritoneal dialysis (CAPD) patients from five PD centers in China from 1 January 2005 and 31 May 2020. The association between albumin to total cholesterol ratio and mortality was evaluated.

Results

With a median follow-up of 39.3 months, 762 (22.1%) all-cause deaths occurred, including 382 (11.1%) cardiovascular deaths. As compared with a serum albumin to total cholesterol ratio of 0.77–0.82 (reference range), a higher ratio (>0.82) was associated with increased risks of all-cause mortality[hazards ratio (HR), 1.54; 95% confidence interval (CI), 1.16–2.05, E-value = 2.45] and cardiovascular mortality (HR, 2.10; 95% CI, 1.35–3.29, E-value = 3.62). A lower ratio (<0.77) was also associated with increased risks of all-cause mortality (HR, 1.46; 95% CI, 1.10–1.94, E-value = 2.28) and cardiovascular mortality (HR, 1.78; 95% CI, 1.14–2.78, E-value = 2.96) compared with the reference. No interaction was observed in subgroup analyses of age, sex, diabetes mellitus, hypertension, prior cardiovascular disease, and hyperlipidemia, and malnutrition (serum albumin <3.6 g/dL).

Conclusion

An albumin to total cholesterol ratio before the start of PD between 0.77 and 0.82 was associated with a lower risk of death than a higher or lower ratio, resulting in a U-curve association. Therefore, serum albumin to total cholesterol ratio, as an inexpensive and readily available biochemical biomarker, may further improve the stratification risk of mortality in PD patients.

Prevalence and Correlates of Cardiovascular Calcification and Its Prognostic Effects Among Patients With Chronic Kidney Disease: Results From the C-STRIDE Study

Background and Aims: The purpose of this study was to identify the characteristics and risk factors for cardiovascular calcification, and its relationship to prognosis, in patients with chronic kidney disease (CKD) stages 1–4.

Methods: Cardiovascular calcification was evaluated at baseline by lateral abdominal radiography to detect abdominal aortic calcifications (AAC), and by echocardiogram to detect cardiac valvular calcifications (CVC), respectively. Demographic and laboratory data were collected and analyzed. Univariate and multivariable logistic regression model was used to explore the factors associated with the indicators of cardiovascular calcification, while Cox proportional hazards regression was used to examine the association between AAC/CVC and incidence of cardiovascular events and all-cause mortality.

Results: A subgroup of 2,235 patients with measurement of AAC in the C-STRIDE study and a subgroup of 2,756 patients with CVC were included in the analysis. AAC was present in 206 patients (9.22%) and CVC was present in 163 patients (5.91%). Age, gender, history of cardiovascular diseases, smoking, hypertension, diabetes, levels of hemoglobin, low-density lipoprotein cholesterol, and uric acid were associated with prevalence of AAC, while only age, history of cardiovascular diseases, levels of serum albumin and low-density lipoprotein cholesterol were associated with prevalence of CVC (all p < 0.05).Survival analyses showed that cardiovascular events and all-cause mortality were significantly greater in patients with AACor with CVC (all p-values for log-rank tests <0.05). After adjustment for age, sex and estimated glomerular filtration rate (eGFR), AAC was associated with increased risk of all-cause mortality (hazard ratio = 1.67[95% confidence interval: 0.99, 2.79]), while CVC associated with that of cardiovascular events only among patients with comparatively normal eGFR (≥45 ml/min/1.73m²) (hazard ratio = 1.99 [0.98, 4.03]).

Conclusion: Demographic and traditional cardiovascular risk factors were associated with cardiovascular calcification, especially AAC. AAC may be associated with risk of death for patients CKD of any severity, while CVC as a possible risk factor for cardiovascular disease only among those with mild to moderate CKD. Assessments of vascular calcification are need to be advanced to patients in the early and middle stages of chronic kidney disease and to initiate appropriate preventive measures earlier.

Associations between dietary patterns and stages of chronic kidney disease

BACKGROUND

Studies have revealed that patients with chronic kidney disease (CKD) have dietary patterns different from those of the general population. However, no studies have compared the dietary patterns of between patients with early-stages (stages 1-3a) and late-stages (stages 3b-5) of CKD. Our objective was to investigate the associations between dietary patterns in early and late-stage CKD.

METHODS

We analyzed 4480 participants with CKD at various stages based on the data recorded between 2007 and 2016 from the database of the American National Health and Nutrition Examination Survey.

RESULTS

In total, 3683 and 797 participants had early and late-stage CKD, respectively. Through principal components analysis, the dietary intake dimension was reduced from 63 variables to 3 dietary patterns. We adopted logistic regression for analysis. The three dietary patterns are as follows: (1) saturated fatty acids and mono-unsaturated fatty acids (MUFA); (2) vitamins and minerals; and (3) cholesterols and polyunsaturated fatty acids (PUFA). These 3 patterns explained > 50% of dietary nutrient intake. Results indicated that among participants with dietary patterns 2 (vitamins and minerals) and 3 (cholesterols and PUFA), those with low intakes were more likely to have late-stage CKD. The odds ratios for patterns 2 and 3 were 1.74 (95% CI: 1.21-2.50) and 1.66 (95% CI: 1.13-2.43), respectively.

CONCLUSIONS

This study revealed that intakes of vitamins and minerals and cholesterols and PUFA were associated with the stages of CKD.

Evolution of Quality of Life in Chronic Kidney Disease Stage 4-5 Patients Transitioning to Dialysis and Transplantation

INTRODUCTION

Chronic kidney disease (CKD) has a profound effect on patients' health-related quality of life (QoL). Longitudinal studies on QoL in CKD are scarce and have explored selected patients on renal replacement therapy (RRT). We studied the evolution of QoL in patients with advanced CKD transitioning to dialysis and transplantation in a prospective follow-up study.

METHODS

A total of 100 participants of the Chronic Arterial Disease, Quality of Life, and Mortality in Chronic Kidney Injury (CADKID) study were enrolled in the study. Kidney Disease Quality of Life Short Form, biochemistry, and echocardiography were obtained at baseline and after a median interval of 33 (range 12-85) months.

RESULTS

At the time of the follow-up QoL assessment, 32 patients were not receiving RRT, 30 were on hemodialysis (HD), 19 on peritoneal dialysis (PD), and 19 had received a kidney transplant. Among kidney transplant recipients (KTRs), "Burden of Kidney Disease" and "General Health" domains improved compared to patients who initiated HD (p < 0.0001 and p = 0.007, respectively), PD (p = 0.0005 and p = 0.03, respectively), or remained in predialysis care (p = 0.009 and p = 0.003, respectively) while "Effects of Kidney Disease" improved compared to those who started HD (p = 0.004) or PD (p = 0.002). The change in Short Form-36 (SF-36) Physical Component Summary was not different between patients on different treatment modalities. Higher plasma albumin and cholesterol levels were associated with improved QoL in "Symptoms/Problems" (r = 0.28, p = 0.005, and r = 0.30, p = 0.004, respectively) and "Effects of Kidney Disease" (r = 0.27, p = 0.008, and r = 0.24, p = 0.03, respectively).

CONCLUSION

QoL improved in KTRs in kidney disease-specific domains compared to patients initiating dialysis or those without RRT. Plasma albumin and lipids were associated with QoL over time.

Impact of Hemodialysis on Clinical Outcomes in Patients Undergoing Lower Extremity Bypass Surgery for Peripheral Artery Disease-10-year Follow-Up Study

We investigated the clinical impact of hemodialysis on long-term outcomes of bypass surgery in patients with peripheral artery disease. We evaluated 660 consecutive patients who underwent successful bypass surgery (392 hemodialysis and 268 non-hemodialysis). The endpoint was amputation-free survival (AFS). To minimize differences in clinical characteristics between the 2 groups, propensity score matching was performed. The AFS rates for 10-year follow-up were 39.3% and 67.7% in hemodialysis and non-hemodialysis patients [hazard ratio (HR) 2.21, 95% confidence interval (CI) 1.65-3.01, P < .0001]. Cumulative incidence of amputation was higher in the hemodialysis group than in the non-hemodialysis group [(19.4 vs 8.4%, HR 2.15, 95% CI 1.29-3.74, P = .0027). In a matched cohort (n = 210 each), AFS was still lower in the hemodialysis patients (53.1 vs 66.3%, HR 1.94, 95% CI 1.36-2.82, P = .0003). However, there was no significant difference in amputation rate between the groups (10.5 vs 10.6%, HR .97, 95% CI 0.49-1.87, P = .93). In a sub-analysis of patients with critical limb ischemia, similar results were obtained. The 10-year AFS was consistently lower in the hemodialysis group than in the non-hemodialysis group. However, the amputation rate was comparable between the groups when matched for the differences in clinical characteristics.

Time-dependent lipid profile inversely associates with mortality in hemodialysis patients - independent of inflammation/malnutrition

BACKGROUND

Patients with end-stage kidney disease have an extremely high cardiovascular mortality rate, but there is a paradoxical relationship between lipid profile and survival in haemodialysis patients. To investigate whether inflammation/malnutrition confounds the associations between lipids and mortality, we studied a full lipid profile comprising of five clinically well-established lipid parameters and its associations with mortality in a large, multinational European cohort with a median follow-up >3 years.

METHODS

The association between quartiles of total, high-density lipoprotein (HDL), non-HDL, low-density lipoprotein (LDL) cholesterol, as well as triglyceride, levels and the end-points of all-cause, cardiovascular and non-cardiovascular mortality was assessed in a cohort of 5,382 incident, adult haemodialysis patients from >250 Fresenius Medical Care dialysis centres out of 14 participating countries using baseline and time-dependent Cox models. Analyses were fully adjusted and stratified for inflammation/malnutrition status and other patient-level variables.

RESULTS

Time-dependent quartiles of total, HDL, non-HDL and LDL cholesterol were inversely associated with the hazard for all-cause, cardiovascular and non-cardiovascular mortality. Compared with the lowest quartile of the respective lipid parameter, hazard ratios of other quartiles were <0.86. Similar, albeit weaker, associations were found with baseline lipid profile and mortality. Neither time-dependent nor baseline associations between lipid profile and mortality were affected by inflammation/malnutrition, statin use or geography.

CONCLUSIONS

Baseline and time-dependent lipid profile are inversely associated with mortality in a large, multicentre cohort of incident haemodialysis patients. Inflammation/malnutrition is not a confounder nor effect modificator of the associations between lipid profile and mortality in European haemodialysis patients.

Interaction between the stage of chronic kidney disease and diabetes mellitus as factors associated with mortality in chronic kidney disease patients: An external cohort study

INTRODUCTION

Diabetic kidney disease is the main cause of chronic kidney disease (CKD) worldwide. Both CKD and diabetes mellitus (DMT2) are important risk factors for mortality. However, it is still unknown if the risk of death is modified by the simultaneous presence of these diseases.

OBJECTIVE

To evaluate the presence of an interaction between DMT2 and CKD for mortality in a representative population of a Latin American country.

METHODS

It is an analytical cohort study of patients with CKD, who were followed for 4 years (between 2004 and 2009). We calculated the incidence rate, progression, survival (using Kaplan-Meier curves), interaction (on the additive and multiplicative scales) and impact of the different stages of CKD in patients with and without DMT2 (using a cox proportional hazards model).

RESULTS

In this population of 5663 individuals, both DMT2 and CKD are risk factors for mortality (P < 0.001). We found a statistically significant difference in mortality between individuals with and without DMT2, who also had CKD stages 3 - 4 - 5 (Log-rank P = 0.0076). Additionally, we found a statistically significant interaction for mortality in both the additive and multiplicative scales between DMT2 and CKD (P = 0.005). DMT2 was found to be a risk factor for mortality (Hazard Ratio 1.61 P < 0.001), but in individuals with DMT2, the only risks significantly associated with mortality, were age, dyslipidemia and nephroprotective drugs. CONCLUSIóN: The interaction between CKD and DMT2 negatively modifies the risk of death of both diseases. This means that when the two diseases are present, the risk of mortality is lower than expected.

Association of the nutritional risk index for Japanese hemodialysis patients with long-term mortality: The Q-Cohort Study

BACKGROUND

Protein-energy wasting (PEW) is a risk factor for mortality in patients undergoing hemodialysis. Recently, a nutritional risk index for Japanese hemodialysis patients (NRI-JH) has been proposed as a surrogate index of PEW. However, no study has determined the association of the NRI-JH with long-term mortality in patients undergoing hemodialysis. Furthermore, the validity of the NRI-JH has not been confirmed.

METHODS

In total, 3046 patients undergoing hemodialysis and registered in the Q-Cohort Study were followed up for 10 years. The NRI-JH was calculated on the basis of body mass index and serum levels of albumin, total cholesterol, and creatinine. The patients were divided into four groups according to the NRI-JH scores: 0-3 (G1, n = 1343), 4-7 (G2, n = 1136), 8-10 (G3, n = 321), and 11-13 (G4, n = 246). We examined the association between the NRI-JH and the 4-year and 10-year risks of all-cause, cardiovascular, and infection-related deaths using the Cox proportional hazards model.

RESULTS

During the follow-up period, 647 patients died during the first 4 years, and 1503 patients died within 10 years. The 4-year prognosis was analyzed and compared with the lowest NRI-JH score group. Multivariable-adjusted hazard ratios (95% confidence intervals) for all-cause death were 1.93 (1.57-2.38), 2.68 (2.05-3.50), and 3.16 (2.40-4.16) in the G2, G3, and G4 groups, respectively. Similarly, a higher NRI-JH score was associated with an increased risk of cardiovascular and infection-related deaths.

CONCLUSION

A higher NRI-JH score was associated with an increased risk of long-term mortality in patients undergoing maintenance hemodialysis.

TRIAL REGISTRATION

The study protocol was registered in the University Hospital Medical Information Network (UMIN) clinical trial registry (UMIN ID: 000000556).

Non-high-density lipoprotein cholesterol and mortality among peritoneal dialysis patients

BACKGROUND

The association between non-high-density lipoprotein cholesterol (non-HDL-C) and mortality in patients undergoing peritoneal dialysis (PD) is unclear.

OBJECTIVE

The aim of this study was to evaluate the association of non-HDL-C with cardiovascular (CV) and all-cause mortality in PD patients.

METHODS

We conducted a prospective cohort study. A total of 1,616 incident PD patients from a single PD center in South China were followed for a median of 47.6 months. The independent association of non-HDL-C with CV and all-cause mortality was evaluated by a Cox regression analysis.

RESULTS

During the follow-up period, 508 (31.4%) patients died, of which 249 (49.0%) were due to CV events. Atherosclerotic CV mortality accounted for 59.8% of CV mortality. In multivariable models, for 1-SD increase in non-HDL-C level, the hazard ratios (HRs) for CV and all-cause mortality were 1.52  [95% confidence interval (CI), 1.32-1.75; P < 0.001)] and 1.24 (95% CI, 1.12-1.39; P < 0.001), respectively. Furthermore, non-HDL-C was positively associated with atherosclerotic CV mortality (HR, 1.29; 95% CI, 1.09-1.52; P = 0.004) but not associated with nonatherosclerotic CV mortality (HR, 0.79; 95% CI, 0.59-1.05; P = 0.108). The quartile analyses showed a similar pattern to the continuous variable analyses of non-HDL-C levels for CV and all-cause mortality but did not demonstrate statistical significance for atherosclerotic or nonatherosclerotic CV mortality.

CONCLUSION

An elevated non-HDL-C level was independently associated with an increased risk of CV mortality, especially atherosclerotic CV mortality, and all-cause mortality in incident PD patients.

The Association between Baseline Serum Lipids and Mortality in Peritoneal Dialysis Patients

INTRODUCTION

Lipid disturbances are common in ESRD patients. In peritoneal dialysis (PD) patients, dyslipidemia is even more common. This study aimed to examine whether serum lipids were associated with prognosis of PD patients.

METHODS

Patients from a multicenter retrospective cohort were used for the present study. The primary endpoint was all-cause mortality. Cox regression was used to analyze the association between serum lipids including total cholesterol, low-density lipoprotein (LDL), high-density lipoprotein, and triglycerides and the prognosis.

RESULTS

The results showed that lower total cholesterol and LDL levels at the initiation of PD predicted higher all-cause mortality in PD patients. Multivariate analysis reveal that the association disappeared after adjusting for age, gender, albumin, prealbumin, protein catabolic rate normalized to body weight, C-reactive protein, and residual renal function. Further analysis showed that patients with lower total cholesterol/LDL had a higher mortality only during the first 24 months of follow-up. In the patients who survived >2 years after PD, lower total cholesterol/LDL was not associated with higher long-term all-cause mortality any more.

CONCLUSION

Lower total cholesterol/LDL levels at the initiation of PD were associated with overall mortality in PD patients. The association could be potentially modified by malnutrition, inflammation, and residual renal function or disappeared after 24 months.

Hypocholesterolemia is a risk factor for reduced systemic vascular resistance reactivity during hemodialysis

Intradialytic hypotension (IDH) is associated with high mortality. Peripheral vascular resistance and circulating blood volume are important factors in IDH; however, the effects of hemodialysis (HD) on vascular resistance in IDH remain unclear. We herein performed a retrospective observational cohort study to investigate changes in and factors related to vascular resistance during HD. A total of 101 HD patients were divided into two groups (Decreased blood pressure (BP) during HD group: N = 19, Nondecreased BP group: N = 82), and cardiac output was measured with electrical velocimetry (AESCLON) for 3 h. The systemic vascular resistance index (SVRI) was significantly decreased in the Decreased BP group, while the cardiac index was similar in both groups. A multivariate regression analysis identified hypocholesterolemia as a predictor of reduced vascular resistance reactivity during HD. Furthermore, a correlation was found between changes in the SVRI and cholesterol levels in patients with a higher Geriatric Nutritional Risk Index (GNRI) but not in those with a lower GNRI. The present results suggest that hypocholesterolemia contributes to reducing systematic vascular resistance reactivity during HD, which is an important predictor of a reduction in BP during HD. The relationship between hypocholesterolemia and vascular resistance may involve mechanisms other than malnutrition.

Dietary intake, anthropometric measurements, biochemistry profile and their associations with chronic kidney disease and diabetes mellitus

The chronic kidney disease (CKD) and diabetes mellitus (DM) are considered a serious public health problem. The objective was investigating the association of DM with the anthropometric measures, biochemical profile and dietary intake in patients with CKD. Is a cross-sectional study done in 2017, with 51 patients previously diagnosed with CKD. We collect socio-demographic, lifestyle variables, anthropometric measurements, biochemical profile and dietary intake. We using the Kolmogorov–Smirnov test, followed by Pearson's χ² test and Student's t test. Data were analysed using several multivariable logistic regression models, including the socio-demographic, anthropometric, dietary intake and biochemical variable. Variables with P ≤ 0⋅20 in the univariate analyses were selected and kept in the block in the simple and multiple logistic regression analysis, to determine the differences between the categories and the factors associated with the presence of DM or not, remaining in the model final, only the significant variables (P ≤ 0⋅05). Each variable was adjusted for all other variables included in the univariate analysis. The strength of the association was assessed by the odds ratio and 95% confidence intervals (CI). The multivariate logistic regression analysis evidenced that the increase of 1 cm in waist circumference and 1 mg/dl in VLDL-c values increases the chance of DM, respectively, by 8⋅4% (OR 1⋅076; P 0⋅05) and 8⋅8% (OR 1⋅102; P 0⋅01). In contrast, an increase of 1 mg/dl in total cholesterol decreases the chance of developing DM by 3⋅1% (OR 0⋅965; P 0⋅01), that is, it becomes a protective factor. The present study identified the associations between overweight, dietary intake and biochemical tests.

Period prevalence and mortality rates associated with hypocholesterolaemia in dogs and cats: 1,375 cases

To determine the period prevalence of hypocholesterolaemia and the associated mortality rates in dogs and cats at a university teaching hospital. The secondary aim was to identify disease processes associated with hypocholesterolaemia.

MATERIALS AND METHODS

Medical records over a 5-year period were reviewed to determine the severity of hypocholesterolaemia and its associated mortality rate. Medical records of animals with moderate to severe hypocholesterolaemia (<2.59 mmol/L in dogs, <1.81 mmol/L in cats) were analysed further. Animals with hospital-acquired hypocholesterolaemia were identified.

RESULTS

Among 16,977 dogs and 3,788 cats that had at least one cholesterol measurement, the period prevalence of hypocholesterolaemia was 7.0% in dogs and 4.7% in cats. The mortality rate of hypocholesteraemic dogs and cats was 12% in both species which was significantly higher than that of animals with normal serum cholesterol. The degree of hypocholesterolaemia was significantly associated with mortality. Dogs, but not cats, with hospital-acquired hypocholesterolaemia had a higher mortality rate than those presenting with hypocholesterolaemia. Disease of hepatic, gastrointestinal and lymphoreticular systems were most commonly associated with hypocholesterolaemia, and infectious and neoplastic disease were the most commonly associated pathophysiologic processes in both species. Lymphoma was over-represented in dogs with neoplasia.

CLINICAL SIGNIFICANCE

Hypocholesterolaemia is not a frequent abnormality but was associated with mortality in this study and may be a negative prognostic indicator. It is not known if hypocholesterolaemia is simply a marker for disease severity, or if it is has active physiologic effects contributing to poor outcomes.

Characterizing Comorbidity in Dialysis Patients: Principles of Measurement and Applications in Risk Adjustment and Patient Care

Comorbid conditions are highly prevalent in dialysis patients and are significant predictors of mortality and other adverse outcomes. Accordingly, it is important to account for differences in comorbid illness burden among groups of dialysis patients being compared. At present, there is no consensus on what conditions matter, how each should be defined, and what weights each carries when defining an individual's risk or case-mix severity. A number of comorbidity instruments, generic or disease specific, have been employed in dialysis populations. They differ by the representation and definition of conditions as well as instrument scoring. No instrument has been found to be superior to another in terms of predictive accuracy for mortality, and accuracy across the board is low. Further studies are needed to determine whether improvements would be found with the use of more specifically defined items and through assignment of item weights based on relationships for outcomes specifically in a dialysis population. The roles of other factors in risk prediction, such as markers of nutritional status, inflammation, or other physiological parameters, relative to comorbid conditions also need to be defined. Outcomes other than mortality are likely to identify different factors and/or different relationships than those noted for mortality, which also require study.

Comorbidity is important for risk adjusting comparative analyses in nonrandomized trials and quality of care assessments and may, in future, influence payment for dialysis services. Efforts to improve the management of comorbid illnesses are needed. Comorbid conditions must be documented accurately and uniformly in all dialysis patients to enable these applications.

Contribution of Early Failure to Outcome on Peritoneal Dialysis

Background

The technique failure rate on peritoneal dialysis (PD) remains high despite technical progress. There are no data concerning the contribution of early failure to outcome on PD.

Aim

To analyze the importance of early treatment failure in PD and to compare early with late failures with respect to reasons and predictors of risk for failure.

Methods

We performed a retrospective study of all patients admitted for PD from October 1983 to June 2005. The end point was PD failure-free survival. Differences between reasons for failure with respect to early (within 6 months) and late failure were analyzed. Multivariate associations of baseline covariates with early and late failure were investigated.

Results

We included 279 patients. 153 (55%) patients experienced PD failure: 97 (63%) of them had technique failure; 56 (37%) patients died due to non-PD-related causes. 29% ( n = 44) of all PD failures and 40% ( n = 39) of all technique failures occurred within 6 months. Catheter and psychosocial problems contributed more often to early than to late failure, whereas infections, leakages, and hernias contributed equally to early and late failure. Death was the predominant reason for late failure. Female sex was a risk factor for early failure and older age a risk factor for late failure. Higher cholesterol levels were associated with a decreased risk for both early and late failure.

Conclusion

The contribution of early failure to outcome on PD is important, as one third of all PD failures and 40% of all technique failures may occur within the first 6 months, as shown in our study. Due to the retrospective nature and the single-center character, the results cannot be generalized. However, it is important to enhance recognition of patients at high risk for early PD failure prior to initiation of PD, in order to avoid unnecessary surgical interventions and medical complications, and for rational resource allocation.

Statins for Treatment of Dyslipidemia in Chronic Kidney Disease

Dyslipidemia is a potent cardiovascular (CV) risk factor in the general population. Elevated low-density lipoprotein cholesterol (LDL-C) and/or low high-density lipoprotein (HDL-C) are well-established CV risk factors, but more precise determinants of risk include increased apoprotein B (ApoB), lipoprotein(a) [Lp(a)], intermediate and very low-density lipoprotein (IDL-C, VLDL-C; “remnant particles”), and small dense LDL particles. Lipoprotein metabolism is altered in association with declining glomerular filtration rate such that patients with non dialysis-dependent chronic kidney disease (CKD) have lower levels of HDL-C, higher triglyceride, ApoB, remnant IDL-C, remnant VLDL-C, and Lp(a), and a greater proportion of oxidized LDL-C. Similar abnormalities are prevalent in hemodialysis (HD) patients, who often manifest proatherogenic changes in LDL-C in the absence of increased levels. Patients treated with peritoneal dialysis (PD) have a similar but more severe dyslipidemia compared to HD patients due to stimulation of hepatic lipoprotein synthesis by glucose absorption from dialysate, increased insulin levels, and selective protein loss in the dialysate analogous to the nephrotic syndrome. In the dialysis-dependent CKD population, total cholesterol is directly associated with increased mortality after controlling for the presence of malnutrition–inflammation.

Treatment with statins reduces CV mortality in the general population by approximately one third, irrespective of baseline LDL-C or prior CV events. Statins have similar, if not greater, efficacy in altering the lipid profile in patients with dialysis-dependent CKD (HD and PD) compared to those with normal renal function, and are well tolerated in CKD patients at moderate doses (≤ 20 mg/day atorvastatin or simvastatin). Statins reduce C-reactive protein as well as lipid moieties such as ApoB, remnants IDL and VLDL-C, and oxidized and small dense LDL-C fraction. Large observational studies demonstrate that statin treatment is independently associated with a 30% – 50% mortality reduction in patients with dialysis-dependent CKD (similar between HD- and PD-treated patients). One recent randomized controlled trial evaluated the ability of statin treatment to reduce mortality in type II diabetics treated with HD (“4D”); the primary end point of death from cardiac cause, myocardial infarction, and stroke was not significantly reduced. However, results of this trial may not apply to other end-stage renal disease populations. Two ongoing randomized controlled trials (SHARP and AURORA) are underway evaluating the effect of statins on CV events and death in patients with CKD (including patients treated with HD and PD). Recruitment to future trials should be given a high priority by nephrologists and, until more data are available, consideration should be given to following published guidelines for the treatment of dyslipidemia in CKD. Additional consideration could be given to treating all dialysis patients felt to be at risk of CV disease (irrespective of cholesterol level), given the safety and potential efficacy of statins. This is especially relevant in patients treated with PD, given their more atherogenic lipid profile and the lack of randomized controlled trials in this population.

Higher Cholesterol Level Predicts Cardiovascular Event and Inversely Associates With Mortality in Hemodialysis Patients: 10-Year Outcomes of the Q-Cohort Study

The prevalence of atherosclerotic diseases is higher in hemodialysis patients. The aim of the current study was to investigate associations between cholesterol level and the incidences of cardiovascular disease (CVD) and mortality in hemodialysis patients. A total of 3517 participants undergoing maintenance hemodialysis were followed up for 10 years. Total cholesterol (TC) level was divided into quartile in baseline data. The multivariate analyses were calculated by a Cox proportional hazards model. The incidences of ischemic heart disease (IHD), peripheral artery disease (PAD), and CVD were significantly positively associated with higher cholesterol levels after adjustment for confounding factors (P < 0.01, P = 0.04, and P < 0.01, respectively). Furthermore, the incidences of cancer-associated mortality and all-cause mortality were significantly positively associated with lower cholesterol levels after adjustment for confounding factors (both P < 0.01). The lowest TC level at all-cause mortality risk was 179 mg/dL. From these results, higher TC predicts IHD, PAD, and CVD events, and lower TC predicts cancer-associated mortality and all-cause mortality in patients undergoing maintenance hemodialysis.

Cholesterol Disturbances and the Role of Proper Nutrition in CKD Patients

Chronic kidney disease (CKD) is a widespread disease with increasing prevalence in the modern society. Lipid disturbances are common in this group of patients. In most patients with CKD atherogenic dyslipidemia is observed. Dyslipidemia in patients with renal diseases increases the risk of cardiovascular diseases and it accelerates the progression of chronic kidney disease to its end stage. The amelioration of dyslipidemia and the lowering of oxidative stress, inflammatory processes, insulin sensitivity and remnant lipoproteins levels may lead to the reduction in cardiovascular burden. Nutritional interventions can strengthen the beneficial effect of treatment and they play an important role in the preservation of overall well-being of the patients with CKD since the aim of appropriate diet is to reduce the risk of cardiovascular events, prevent malnutrition, and hamper the progression of kidney disease. The management of dyslipidemia, regardless of the presence of chronic kidney disease, should be initiated by the introduction of therapeutic lifestyle changes. The introduction of diet change was shown to exert beneficial effect on the lipid level lowering that reaches beyond pharmacological therapy. Currently available evidence give the impression that data on dietary interventions in CKD patients is not sufficient to make any clinical practice guidelines and is of low quality.

Lipotoxicity in Kidney, Heart, and Skeletal Muscle Dysfunction

Dyslipidemia is a common nutritional and metabolic disorder in patients with chronic kidney disease. Accumulating evidence supports the hypothesis that prolonged metabolic imbalance of lipids leads to ectopic fat distribution in the peripheral organs (lipotoxicity), including the kidney, heart, and skeletal muscle, which accelerates peripheral inflammation and afflictions. Thus, lipotoxicity may partly explain progression of renal dysfunction and even extrarenal complications, including renal anemia, heart failure, and sarcopenia. Additionally, endoplasmic reticulum stress activated by the unfolded protein response pathway plays a pivotal role in lipotoxicity by modulating the expression of key enzymes in lipid synthesis and oxidation. Here, we review the molecular mechanisms underlying lipid deposition and resultant tissue damage in the kidney, heart, and skeletal muscle, with the goal of illuminating the nutritional aspects of these pathologies.

Proprotein convertase subtilisin/kexin type 9 and mortality in patients starting hemodialysis

BACKGROUND

Cardiovascular events are the leading cause of death in end stage renal disease (ESRD), but traditional markers of dyslipidemia are not clearly associated with cardiovascular risk in this population. Proprotein Convertase Subtilsin/Kexin type 9 (PCSK-9) could be of interest as a novel cardiovascular risk marker in ESRD due to the emergence of lipid lowering therapy based on PCSK-9 inhibition. The aim of the present study was to investigate if the convertase PCSK-9 is a potential risk marker for mortality among patients starting haemodialysis treatment.

MATERIALS AND METHODS

This is a cohort study of 265 patients starting haemodialysis between 1991-2009, with 3 years follow-up. The association between baseline PCSK-9 levels and mortality was assessed using Cox proportional hazards- and quantile regression models, with adjustment for potential confounders.

RESULTS

PCSK-9 levels at initiation of haemodialysis were associated to mortality in multivariable adjusted analysis. PCSK-9 levels exhibited an U-shaped association to mortality. Inclusion of the quadratic term of PCSK-9 in regression modelling optimized model performance. At baseline, PCSK-9 levels had positive correlations to Davies comorbidity score, haemoglobin and C-reactive protein while negative correlations were found for high-density lipoprotein and total cholesterol. PCSK-9 levels were higher in statin users and patients with a history of cardiovascular disease.

CONCLUSIONS

This study shows, for the first time, that the level of PCSK-9 is associated with all-cause mortality in haemodialysis patients, independently of a number of potential confounders.

Cystic fibrosis dyslipidaemia: A cross-sectional study

BACKGROUND

The interest in cystic fibrosis (CF) dyslipidaemia as a potential risk factor for cardiovascular disease is increasing with patients' survival. This study aimed to investigate CF dyslipidaemia, its clinical correlates and links to oxidized low-density lipoprotein (oxLDL), adiponectin, and apolipoprotein E (APOE).

METHODS

This cross-sectional study assessed clinical characteristics of CF, as well as the serum lipid profile, oxLDL, adiponectin, and APOE.

RESULTS

In total, 108 CF subjects were enrolled in this study, with a median age of 22 years, BMI of 20.5 kg/m², FEV1% of 61%, of which 81% were pancreatic insufficient (PI). Healthy subjects (HS; n = 51) were in similar age. Hypocholesterolaemia occurred in 31% of CF subjects and in no HS. Hypertriglyceridaemia concerned 21% of patients (HS: 8%, p = .04), and low HDL-C 45% (HS: 6%, p < .0001). At least one of these three CF dyslipidaemia disturbances was present in 62% of CF subjects, but there were no significant differences in oxLDL, oxLDL/LDL-C ratio, adiponectin, and APOE between CF and HS groups. PI was independently associated with low total cholesterol, LDL-C, and non-high density lipoprotein cholesterol, with age and sex also modifying lipid levels. In CF (n = 42), triglycerides did not correlate with serum tumour necrosis factor α (TNF-α).

CONCLUSIONS

CF dyslipidaemia is highly prevalent and heterogenous. The lipid profile weakly associates with the clinical characteristics of CF as well as oxLDL, adiponectin, and APOE. Further research is needed, especially regarding HDL function in CF, the causes of hypertriglyceridaemia, and the value of essential fatty acid supplementation for CF dyslipidaemia.

Risk factors for peptic ulcer disease in patients with end-stage renal disease receiving dialysis

Background

Compared to the general population, patients with end-stage renal disease have more gastrointestinal symptoms and a higher prevalence of peptic ulcer. Risk factors for peptic ulcer disease in patients with end-stage renal disease, however, remain poorly defined. This study aims to better identify those risk factors.

Methods

We analyzed 577 patients with end-stage renal disease from 2004 to 2016. We excluded patients with life-threatening conditions. All patients underwent upper endoscopy. We analyzed patient medical records, medication history, and endoscopic findings. Independent sample t test, chi-square test, Fisher’s exact test, and multiple logistic regression analysis were used in statistical analyses.

Results

Of the 577 patients with end-stage renal disease, 174 had peptic ulcer disease (gastric or duodenal ulcer). Patients on hemodialysis had a higher prevalence of peptic ulcer disease than those on peritoneal dialysis. Patients with peptic ulcer disease had lower serum albumin level and higher blood urea nitrogen level than those without peptic ulcer disease. Positive scores on two or more nutritional indices (albumin, serum cholesterol, uric acid, and creatinine levels) were associated with peptic ulcer disease in end-stage renal disease.

Conclusion

Hemodialysis, hypoalbuminemia, and multiple malnutrition indices were associated with the prevalence of peptic ulcer disease in patients with end-stage renal disease receiving dialysis.

A new nutritional risk index for predicting mortality in hemodialysis patients: Nationwide cohort study

Background

Protein energy wasting (PEW) is a risk factor for death. However, the cutoff vales for PEW are not optimized for early identification of hemodialysis patients with malnutrition. We evaluated the prognosis of Japanese maintenance hemodialysis patients using nutritional indices optimized for them.

Materials and methods

We analyzed data from a nation-wide prospective cohort study of the Japanese Society for Dialysis Therapy Renal Data Registry to develop and validate a nutritional risk index (n = 48349, 48349, respectively). The association of nutritional factors with one-year death was tested using Cox proportional hazards models. Their cutoff levels were determined from the hazard ratios or receiver operating characteristic curves. Then, risk index was developed using scoring models.

Results

Male was 61.4%; average age, 65.7±12.2 years; and diabetes mellitus, 32.8%. Four clinical factors were retained in the final model: low BMI (<20kg/m²), yes = 3, no = 0; low serum albumin level (young <3.7g/dL; old <3.5g/dL), yes = 4, no = 0; abnormal serum total cholesterol level, low (<130mg/dL) = 1, high (220≥mg/dL) = 2, no = 0; low serum creatinine level (young female, <9.7mg/dL; old female, <8.0mg/dL; young male, <11.6mg/dL; old male, <9.7mg/dL), yes = 4, no = 0. In the validation dataset, medium- and high-risk groups (total score 8 to 10; 11 or more) showed a higher risk of all-cause death than the low-risk group (0 to 7): medium-risk group (10.5%), hazard ratio adjusted for baseline characteristics 1.96 (95% confidence interval 1.77, 2.16); high-risk group (8.2%), 3.91 (3.57, 4.29). The medium- and high-risk groups also showed a higher risk of cardiovascular disease- and infection-caused deaths than the low-risk group.

Conclusion

We developed a new nutritional risk index for hemodialysis patients, which may detect patients with malnutrition with a high-risk of death.

Serum Lipids and Risk of Rapid Renal Function Decline in Treated Hypertensive Adults With Normal Renal Function

BACKGROUND

We aim to evaluate the effect of different lipids parameters, including triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), the TG to HDL-C (TG:HDL-C) ratio, total cholesterol (TC), and low-density lipoprotein cholesterol (LDL-C), on the risk of rapid renal function decline and examine any possible effect modifiers in general hypertensive patients with normal renal function.

METHODS

A total of 12,549 hypertensive patients with estimated glomerular filtration rate (eGFR) ≥60 ml/min/1.73 m2 in the renal sub-study of the China Stroke Primary Prevention Trial were included in the analyses. The primary outcome was rapid renal function decline, defined as an average decline in eGFR ≥ 5 ml/min/1.73 m2 per year.

RESULTS

The median treatment duration was 4.4 years. After the full adjustment for TC, TG, HDL-C, and other major covariates, a significantly higher risk of rapid renal function decline was found in participants with higher TG [≥150 vs. <150 mg/dl, 7.7% vs. 5.5%; odds ratios (OR): 1.27; 95% confidence interval (CI): 1.06-1.51], higher TG:HDL-C ratio [≥2.7 (median) vs. <2.7, 7.7% vs. 5.0%; OR: 1.39; 95% CI: 1.14-1.71), lower TC (≥200 vs. <200 mg/dl, 6.0% vs. 7.0%; OR: 0.79; 95% CI: 0.67-0.93), or lower LDL-C levels (≥130 vs. <130 mg/dl, 6.1% vs. 7.0%; OR: 0.79; 95% CI: 0.67-0.94). Moreover, the increased risk of the primary outcome associated with elevated TG was particularly evident among individuals with lower total homocysteine levels [<12.4 (median) vs. ≥ 12.4 μmol/l, P interaction = 0.036].

CONCLUSIONS

Higher TG and TG:HDL-C ratio were independent risk factors for rapid renal function decline in hypertensive adults with normal renal function.

Hypolipidemic Therapy and Chronic Kidney Disease: Effects on Cardiovascular Risks and Renal Dysfunction

Steady increase in the prevalence of chronic kidney disease (CKD) is a serious public health problem, since CKD potentially leads to the development of end-stage renal disease (ESRD) that requires high-cost replacement therapy and is closely associated with increased risk of developing cardiovascular diseases (CVD), which are the cause of death in most patients. Progression of renal dysfunction and development of CVD are significantly affected by hyper- and dyslipidemia. This review contains results of studies evaluating the effect of hypolipidemic therapy on reduction of cardiovascular risk and slowdown of renal dysfunction in patients with CKD at pre-dialysis and dialysis stages of renal failure, as well as in patients with kidney transplant. In addition, recommendations on nutrition and new therapeutic approaches to lipid-lowering therapy in patients with CKD, as well as prospects for the usage of new hypolipidemic drugs are also presented.

Clinical Studies of Interventions to Mitigate Cardiovascular Risk in Peritoneal Dialysis Patients

Cardiovascular disease (CVD) is highly prevalent in the peritoneal dialysis (PD) population, affecting up to 60% of cohorts. CVD is the primary cause of death in up to 40% of PD patients in Australia, New Zealand, and the United States. Cardiovascular mortality rates are reported to be approximately 14 per 100 patient-years, which are 10- to 20-fold greater than those of age- and sex-matched controls. The excess risk of CVD is related to a combination of traditional risk factors (such as hypertension, dyslipidemia, obesity, smoking, sedentary lifestyle, and insulin resistance), nontraditional (kidney disease-related) risk factors (such as anemia, chronic volume overload, inflammation, malnutrition, hyperuricemia, and mineral and bone disorder), and PD-specific risk factors (such as dialysis solutions, glycation end products, hypokalemia, residual kidney function, and ultrafiltration failure). Interventions targeting these factors may mitigate cardiovascular risk, although high-level clinical evidence is lacking. This review summarizes the evidence relating to cardiovascular interventions targeting modifiable CVD risk factors in PD patients, as well as highlighting the key recommendations of the International Society for Peritoneal Dialysis Cardiovascular and Metabolic Guidelines.

Statins and Cardiovascular Disease Outcomes in Chronic Kidney Disease: Reaffirmation vs. Repudiation

Cardiovascular disease (CVD) burden is several-fold higher in patients with chronic kidney disease (CKD). Although statins have been shown to provide significant CVD benefits in both the general population and patients with CKD, this has not translated into survival advantage in patients with advanced CKD or on dialysis. It has been reported that CVD risk continues to escalate as CKD progresses to end-stage kidney disease (ESKD); however, the CVD risk reduction by statins appears to decline as patients' progress from the early to later stages of CKD. Statins have also been associated with a higher incidence of stroke in ESKD patients. Thus, the CVD benefits of statins in ESKD remain questionable.

Inverse Association Between Serum Non-High-Density Lipoprotein Cholesterol Levels and Mortality in Patients Undergoing Incident Hemodialysis

BACKGROUND

There is accumulating evidence that serum levels of non-high-density lipoprotein cholesterol (non-HDL-C) are a more accurate predictor of cardiovascular outcomes when compared with low-density lipoprotein cholesterol. However, we recently found that higher serum concentrations of triglycerides are associated with better outcomes in patients undergoing hemodialysis. Therefore, we hypothesized that the association of serum levels of non-HDL-C (which includes triglyceride-rich lipoproteins) with outcomes may also be different in patients undergoing hemodialysis when compared with other patient populations.

METHODS AND RESULTS

We studied the association of baseline and time-dependent serum levels of non-HDL-C with all-cause and cardiovascular mortality using Cox proportional hazard regression models in a nationally representative cohort of 50 118 patients undergoing incident hemodialysis from January 1, 2007, to December 31, 2011. In time-dependent models adjusted for case mix and surrogates of malnutrition and inflammation, a graded inverse association between non-HDL-C level and mortality was demonstrated with hazard ratios (95% confidence intervals) of the lowest (<60 mg/dL) and highest (≥160 mg/dL) categories: 1.88 (1.72-2.06) and 0.73 (0.64-0.83) for all-cause mortality and 2.07 (1.78-2.41) and 0.75 (0.60-0.93) for cardiovascular mortality, respectively (reference, 100-115 mg/dL). In analyses using baseline values, non-HDL-C levels <100 mg/dL were also associated with significantly higher mortality risk across all levels of adjustment. Similar associations were found when evaluating non-HDL/HDL cholesterol ratio and mortality, with the highest all-cause and cardiovascular mortality being observed in patients with decreased non-HDL/HDL-C ratio (<2.5).

CONCLUSIONS

Contrary to the general population, decrements in non-HDL-C and non-HDL/HDL cholesterol ratio were paradoxically associated with increased all-cause and cardiovascular mortality in patients undergoing incident hemodialysis. The underlying mechanisms responsible for these associations await further investigation.

Stage progression and need for renal replacement therapy in a renal protection programme in Colombia. A cohort study

BACKGROUND

Due to the global burden represented by chronic kidney disease (CKD), the World Health Organization encouraged the implementation of renal protection programmes (RPP) to affect its incidence through prevention and control measures.

OBJECTIVES

To assess the effectiveness of a Colombian RPP in terms of its effect on the stage progression of CKD and the need for renal replacement therapy (RRT).

METHODS

An analytical study that monitored 2cohorts of patients diagnosed with CKD. The study compares the behaviour of clinical and renal impairment indicators from patients exposed to a RPP with that of patients following conventional treatment (CT). The population of both intervention groups was considered when determining the sample size. The incidence rate was calculated as well as patient survival (Kaplan Meier). In addition, a multivariate analysis (Cox) was used to calculate the influence that exposure to the RPP had on the outcomes of the patients following the RPP and those following CT.

RESULTS

The patients exposed to the RPP took longer to advance to the next CKD stage and require RRT. The incidence rate for progression is higher for the patients following CT (0.050, IC 95%: 0.040-0.064) compared to those in the RPP (0.034, IC 95%: 0.030-0.039). The ratio of incidence rates was 1.480 (IC 95% 1.21-1.90). The hazard of progression was lower for the RPP (HR: 0.855, IC 95%: 0.74- 0.98), as was the hazard of requiring RRT (HR: 0.797, IC 95%: 0.606-1.049).

CONCLUSIONS

The RPP is a secondary prevention strategy against CKD which has an effect on the stage progression of CKD and the need for RRT. Early patient detection has a positive effect on the outcomes studied.

Inter-relation between Altered Nutritional Status and Clinical Outcomes in Patients with Acute Myocardial Infarction Admitted in a Tertiary Intensive Cardiac Care Unit

Background: The impact of nutritional status on the early outcome of subjects with acute myocardial infarction (AMI) is still not completely elucidated. This study aimed to assess the correlation between nutritional status, as expressed by the CONUT and PIN scores, and (1) clinical and laboratory characteristics, (2) complication rates, and (3) length of hospitalization, in patients with AMI.

Materials and methods: We included 56 consecutive patients with AMI who underwent primary percutaneous intervention and stenting. Evaluation of the nutritional status was comprised in the calculation of the CONUT and PNI scores. The study population was divided into 2 groups according to the calculated CONUT score, as follows: group 1 – CONUT score <3 points (normal to mildly impaired nutritional status) and group 2 – CONUT score ≥3 points (moderate to severe malnutrition). The primary end-point of the study was the rate of in-hospital complications (left ventricular free wall rupture, hemodynamic instability requiring inotropic medication, high-degree atrioventricular block, the need for temporary cardiostimulation, supraventricular and ventricular arrhythmias and in-hospital cardiac arrest). The secondary end-points included the duration of hospitalization and the length of stay in the intensive cardiac care unit.

Results: In total, 56 patients (44.64% with STEMI, 55.35% with NSTEMI) with a mean age of 61.96 ± 13.42 years, 58.92% males were included in the study. Group distribution was: group 1 – 76.78% (n = 43), group 2 – 23.21% (n = 23). There were no differences between the two groups regarding age, gender, cardiovascular risk factors, or comorbidities. PNI index in group 1 was 54.4 ± 10.4 and in group 2 41.1 ± 2.8, p <0.0001. Serum albumin was significantly lower in group 1 – 4.1 ± 0.3 vs. group 2 – 3.6 ± 0.3 (p <0.0001), similarly to total cholesterol levels (group 1 – 194.9 ± 41.5 vs. group 2 – 161.2 ± 58.2, p = 0.02). The complete blood cell count showed that group 2 presented lower levels of hematocrit (p = 0.003), hemoglobin (p = 0.002), and lymphocytes (p <0.0001) compared to group 1, but a significantly higher platelet count (p = 0.001), mean platelet volume (p = 0.03), neutrophil/lymphocyte (p <0.0001) and platelet/lymphocyte (p <0.0001) ratios, indicating enhanced blood thrombogenicity and inflammation. Regarding in-hospital complications, group 2 presented a higher rate of hemodynamic instability (group 1 – 11.6% vs. group 2 – 38.4%, p = 0.02). The overall hospitalization period was 7.7 ± 1.4 days in group 1 vs. 10.2 ± 4.8 days in group 2, p = 0.06; while the duration of stay in the intensive cardiac care unit was 2.6 ± 0.5 days in group 1 vs. 4.0 ± 2.5 days in group 2, p = 0.02.

Conclusions: This study proved that nutritional deficit in acute myocardial patients who undergo revascularization is associated with an increased rate of in-hospital complications and with a longer observation time in a tertiary intensive cardiac care unit.

Risk factors for heart valve calcification in chronic kidney disease

Cardiovascular disease (CVD) is a common cause of death in patients with chronic kidney disease (CKD). Aortic and mitral valve calcification (AVC and MVC, respectively) are critical indicators of CVD and all-cause mortality in CKD patients.We conducted a single center retrospective study of Chinese inpatients with CKD to identify risk factors associated with valve calcification (VC).Of 288 enrolled CKD patients, 22.9% had VC, all of which exhibited AVC, while 21.2% exhibited MVC. The VC group were significantly older than the non-VC group (70.42 ± 11.83 vs 56.47 ± 15.00, P < .001), and contained more patients with history of coronary artery disease (12.1% vs 4.5%, P = .025) or stroke (18.2% vs 5.4%, P < .001). Subjective global assessment scoring indicated that more VC patients were mid/severely malnourished. Levels of prealbumin, cholesterol (Ch), triglycerides, low-density lipoprotein (LDL), apolipoprotein E, ejection fraction, and fraction shortening were significantly lower, and blood C reactive protein, IL-6, left ventricular internal end diastole diameter measured in end diastole, and interventricular septum thickness (IVST) levels were significantly higher in the VC group. Bone metabolism did not differ significantly between the 2 groups. Multivariable logistic regression analysis indicated that age, blood Ch, and LDL levels were significantly associated with VC.Advanced age, increased IVST, hypocholesterolemia, and hyper-LDL cholesterolemia were key risk factors for VC in Han patients with CKD.