ESRD-induced dyslipidemia-Should management of lipid disorders differ in dialysis 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.

The Decrease in Serum Total Cholesterol and Low-Density Lipoprotein (LDL) Concentrations With the Initiation of Hemodialysis Despite a Concomitant Increase in Serum Albumin Concentrations

Background and objective Hemodialysis patients often have lower serum low-density lipoprotein (LDL) and total cholesterol concentrations compared to the general population. It is unclear if this is due to a persistent decline in the values due to kidney disease or if the hemodialysis itself is contributing to the lower values. It is often assumed that malnutrition and anorexia are the main causes of the low lipid concentration in hemodialysis patients. In this study, we aimed to determine the association between hemodialysis initiation and serum lipid and albumin concentrations. Methodology The medical records of all patients initiating hemodialysis over an 11-year period at a single center were retrospectively reviewed. The data of 145 patients who had all the required lab values available were ultimately included in the study. Serum lipid levels at the initiation of hemodialysis were compared to values obtained mostly 6-18 months later. In order to determine if poor nutritional status is the reason for the decline in serum lipid levels, the serum albumin concentration at the initiation of hemodialysis was compared to that obtained during follow-up labs. Results We observed that serum cholesterol concentration declined from an average of 147 mg/dL to 137 mg/dL, while LDL decreased from an average of 78 mg/dL to 68 mg/dL, and serum albumin concentration increased from 3.4 g/dL to 3.8 g/dL after an average follow-up period of 10.8 months. Conclusions Based on our findings, the decline in serum LDL and total cholesterol concentrations with the initiation of hemodialysis may not be attributed to poor nutritional intake.

Use of the systemic inflammation response index (SIRI) as a novel prognostic marker for patients on peritoneal dialysis

Background

The systemic inflammatory response index (SIRI), a novel inflammation maker, has proven to be associated with prognostic outcomes in various diseases. However, few studies have been conducted assessing how SIRI may influence outcomes of patients on peritoneal dialysis (PD). Herein, we assessed the predictive value of SIRI on mortality all-cause mortality, including cardiovascular disease (CVD) in PD patients.

Methods

A total of 646 PD patients were enrolled in this study. PD patients received regular PD treatments at the Zhujiang Hospital from 1 January 2011 to 31 December 2018. SIRI values could be computed as follows: neutrophil count × monocyte count/lymphocyte count. Patients were divided into two groups according to the median level of SIRI. Cox regression analysis and Kaplan–Meier methods were applied to analyze the relationship between SIRI and mortality outcomes in PD patients.

Results

During the median 31-month follow-up period, 97 (15.0%) PD patients died from all-causes, and 47 (49.0%) died of CVD. Kaplan–Meier analyses revealed that a high SIRI corresponded to the high mortality of all-cause deaths, including CVD (both p < 0.001) in patients on PD. After adjusting for potential confounders, the higher SIRI level was significantly associated with an increased all-cause mortality (HR: 2.007, 95% CI: 1.304–3.088, p = 0.002) and cardiovascular mortality (HR: 2.847, 95% CI: 1.445–5.608, p = 0.002).

Conclusions

SIRI was a promising predictor of mortality in PD patients, with a higher SIRI corresponding to increased risk of mortality.

The Correlation between Serum Sclerostin Level and Arterial Stiffness in Peritoneal Dialysis Patients

Objective

To study the correlation between serum sclerostin (SO) and arterial stiffness in peritoneal dialysis (PD) patients.

Methods

The study included 50 Parkinson's disease (PD) patients on continuous ambulatory peritoneal dialysis (CAPD) for more than 6 months at the nephrology department of our hospital. Without regard for age, the eligible patients were assigned to a low PWV group and a high PWV group with brachial-ankle pulse wave velocity (Ba PWV) of 1400 cm/s as the cutoff value. Patient characteristics such as age, gender, height, weight, BMI, smoking history, dialysis age, systolic blood pressure (SBP), diastolic blood pressure (DBP), urea clearance index (Kt/V), residual renal function (RRF), and diabetes mellitus (DM) were analyzed. Biochemical indices for analysis include hemoglobin (Hb), albumin (ALB), total cholesterol (TC), urea nitrogen (BUN), creatinine (CREA), triglyceride (TG), uric acid (UA), parathyroid hormone (PTH), blood phosphorus(P), fasting blood glucose (GLU), corrective calcium (Ca), calcium-phosphorus product, low-density lipoprotein (LDL-C), high-density lipoprotein (HDL-C), SO, and arterial stiffness.

Results

There were 9 males and 16 females in the low PWV group and 12 males and 13 females in the high PWV group. Statistical significance was absent in patient characteristics despite more males in the high PWV group (P=0.055). The low PWV group had significantly lower mean age, SBP, SO, and PWV level, fewer diabetic patients, and higher CREA than the control group. Analysis of PWV-related factors showed that PWV was positively correlated with age, P, Ca, GLU, SBP, PTH, and SO while negatively correlated with CREA. Multiple stepwise regression analysis showed that age, SO, and SBP demonstrated great potential to predict PWV (P < 0.05).

Conclusion

The degree of vascular sclerosis is highly correlated with SO level in Parkinson's disease patients, which might provide a theoretical basis for the evaluation of cardiovascular illness in Parkinson's disease patients. High serum sclerostin level is a risk factor for deteriorated arterial stiffness. Given the limited sample size, the relevant results require further validation by expanding the sample size.

Classification Algorithms for Brain Magnetic Resonance Imaging Images of Patients with End-Stage Renal Disease and Depression

This study was aimed to explore the relationship between depression and brain function in patients with end-stage renal disease (ESRD) complicated with depression based on brain magnetic resonance imaging (MRI) image classification algorithms. 30 people in the healthy control group and 70 people in the observation group were selected as the research objects. First, the preprocessing algorithms were applied on MRI images. With the depression classification algorithm based on deep learning, the features were extracted from the capsule network to construct a classification network, and the network structure was compared to obtain the difference in the distribution of brain lesions. Different classifiers and degree centrality, functional connection, low-frequency amplitude ratio, and low-frequency amplitude were selected to analyze the effectiveness of features. In the deep learning method, the neural network model was constructed, and feature extraction and classification network were carried out. The classification layer was based on the capsule network. The results showed that the correct rate of the deep learning feature extraction network structure combined with the capsule network classification was 82.47%, the recall rate was 83.69%, and the accuracy was 88.79%, showing that the capsule network can improve the heterogeneity of depression. The combination of fractional amplitude of low-frequency fluctuation (fALFF), DC, and amplitude of low-frequency fluctuation (ALFF) can achieve the accuracy of 100%. In summary, MRI images showed that patients with depression may have neurological abnormalities in the white matter area. In this study, the classification algorithm based on brain MRI images can effectively improve the classification performance.

Diffusion Tensor Imaging Features of Watershed Segmentation Algorithm for Analysis of the Relationship between Depression and Brain Nerve Function of Patients with End-Stage Renal Disease

The aim of this research was to explore the relationship between depression and brain nerve function in patients with end-stage renal disease (ESRD) and long-term maintenance hemodialysis (MHD) based on watershed segmentation algorithm using diffusion tensor imaging (DTI) technology. A total of 29 ESRD patients with depression who received MHD treatment in the hemodialysis center of hospital were included as the research subjects (case group). A total of 29 healthy volunteers were recruited as the control group, and a total of 29 ESRD patients with depression and brain lesions were recruited as the control group (HC group). Within 24 h after hemodialysis, the blood biochemical indexes were collected before this DTI examination. All participants completed the neuropsychological scale (MoCA, TMT A, DST, SAS, and SDS) test. The original DTI data of all subjects were collected and processed based on watershed segmentation algorithm, and the results of automatic segmentation according to the image were evaluated as DSC = 0.9446, MPA = 0.9352, and IOU = 0.8911. Finally, the average value of imaging brain neuropathy in patients with depression in the department of nephrology was obtained. The differences in neuropsychological scale scores (PSQI, MoCA, TMTA, DST, SAS, and SDS) between the two groups were statistically significant (P < 0.05). The differences of FA values in all the white matter partitions of Fu organs, except the cingulum of hippocampus (CgH) between the two groups, were statistically significant (P < 0.05). ESRD and DTI quantitative detection under the guidance of watershed segmentation algorithm in MHD patients showed that ESRD patients can be early identified, so as to carry out psychological nursing as soon as possible to reduce the occurrence of depression, and then protect the brain nerve to reduce brain neuropathy.

Current Understanding of the Relationship of HDL Composition, Structure and Function to Their Cardioprotective Properties in Chronic Kidney Disease

In the general population, the ability of high-density lipoproteins (HDLs) to promote cholesterol efflux is a predictor of cardiovascular events, independently of HDL cholesterol levels. Although patients with chronic kidney disease (CKD) have a high burden of cardiovascular morbidity and mortality, neither serum levels of HDL cholesterol, nor cholesterol efflux capacity associate with cardiovascular events. Important for the following discussion on the role of HDL in CKD is the notion that traditional atherosclerotic cardiovascular risk factors only partially account for this increased incidence of cardiovascular disease in CKD. As a potential explanation, across the spectrum of cardiovascular disease, the relative contribution of atherosclerotic cardiovascular disease becomes less important with advanced CKD. Impaired renal function directly affects the metabolism, composition and functionality of HDL particles. HDLs themselves are a heterogeneous population of particles with distinct sizes and protein composition, all of them affecting the functionality of HDL. Therefore, a more specific approach investigating the functional and compositional features of HDL subclasses might be a valuable strategy to decipher the potential link between HDL, cardiovascular disease and CKD. This review summarizes the current understanding of the relationship of HDL composition, metabolism and function to their cardio-protective properties in CKD, with a focus on CKD-induced changes in the HDL proteome and reverse cholesterol transport capacity. We also will highlight the gaps in the current knowledge regarding important aspects of HDL biology.

Lipid status association with 25-hydroxy vitamin D: Cross sectional study of end stage renal disease patients

Background

Some observational studies indicate an association of 25-hydroxy vitamin D (25(OH)D) insufficiency and atherogenic cholesterol concentrations. The aim of this study was to investigate relationship between 25(OH)D concentrations and lipid parameters in end stage renal disease (ESRD) patients, separately for predialysis, hemodialysis and peritoneal dialysis patients.

Methods

We have adjusted 25(OH)D concentrations for seasonal variability with cosinor analysis, and performed all further analysis using these corrected 25(OH)D concentrations. Concentrations of 25(OH)D and the lipid parameters were determined in 214 ESRD patients and 50 control group participants. The analysis included the measurement of 25(OH)D by HPLC, apolipoprotein (Apo) AI, ApoB and Lp(a) by nephelometry, total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C) and triglyceride (TG) by spectrophotometry and manually calculated ApoB/ApoAI and LDL-C/HDL-C ratio.

Results

ESRD patients with adjusted 25(OH)D concentrations of 50 nmol/L had significantly higher TC (P = 0.005) and ApoAI (P = 0.049). Significantly higher HDLC (P = 0.011) and ApoAI (P = 0.020) were found in hemodialysis patients with the 25(OH)D concentrations of 50 nmol/L. The other analyzed lipid parameters differed significantly between predialysis, hemodialysis and peritoneal dialysis patients with 25(OH)D concentrations of < 50 nmol/L.

Conclusions

Our study indicate the significant relationship between 25(OH)D repletion and optimal concentrations of lipid parameters in ESRD patients. Further research is necessary to explain whether joint evaluation of vitamin D status and lipid abnormalities could improve cardiovascular outcome in ESRD patients.

Effects of Statins on Lipid Profile of Kidney Transplant Recipients: A Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

To assess the benefits of statins on lipid profile in kidney transplant recipients via a meta-analysis.

METHODS

We systematically identified peer-reviewed clinical trials, review articles, and treatment guidelines from PubMed, Embase, the Cochrane Library, Wanfang, Chinese National Knowledge Infrastructure (CNKI), SinoMed (CBM), and Chongqing VIP databases from inception to April 2019. In the analysis, only randomized controlled clinical trials performed in human were included.

RESULTS

Eight articles were included in the analysis, involving 335 kidney transplant recipients who received statins and 350 kidney transplant patients as the control group. Results revealed that statins improved the lipid profile of kidney transplant recipients. Specifically, statin therapy significantly reduced total cholesterol and low-density lipoprotein cholesterol. However, it had no effects on high-density lipoprotein cholesterol and triglyceride levels.

CONCLUSIONS

The present study provides valuable knowledge on the potential benefits of statins in kidney transplant recipients. This meta-analysis shows that statin therapy modifies the lipid profile in this patient population.

Circulating Endocannabinoids and Mortality in Hemodialysis Patients

BACKGROUND

Mortality in patients with end-stage renal disease (ESRD) on maintenance hemodialysis (MHD) remains exceptionally high. While traditional risk factors such as obesity are paradoxically associated with better survival, nontraditional risk factors including cachexia increase the likelihood of poor outcomes. There is accumulating evidence that the endocannabinoid (ECB) system plays a major role in energy preservation and storage, factors which can prevent the deleterious effects of cachexia. Hence, in this study, we evaluated the association of circulating ECB levels with mortality in MHD patients.

METHODS

Serum concentrations of anandamide (AEA) and 2-arachidonoyl-sn-glycerol (2-AG), major ECB ligands, were measured in MHD patients. Their correlation with various clinical/laboratory indices and association with 12-month all-cause mortality were examined.

RESULTS

Serum 2-AG levels positively correlated with body mass index, serum triglycerides and body anthropometric measures. Meanwhile, serum AEA levels correlated positively with serum interleukin-6, and negatively with serum very low-density lipoprotein levels. While increased serum 2-AG levels were associated with reduced risk of all-cause mortality (hazard ratio [HR] 0.52, 95% CI 0.28-0.98), there was no clear association between serum AEA levels and mortality (HR 0.91, 95% CI 0.48-1.72).

CONCLUSIONS

In MHD patients, the circulating levels of ECB ligand, 2-AG, may play an important role in determining body mass and risk of mortality. These observations were unique to 2-AG as similar findings were not obtained with serum AEA. Future studies need to investigate the mechanisms responsible for these associations and examine the modulation of the ECB system as a potential target for therapy in ESRD.

Cardiovascular risk factors in children on dialysis: an update

Cardiovascular disease (CVD) is a life-limiting comorbidity in patients with chronic kidney disease (CKD). In childhood, imaging studies have demonstrated early phenotypic characteristics including increases in left ventricular mass, carotid artery intima-media thickness, and pulse wave velocity, which occur even in young children with early stages of CKD. Vascular calcifications are the signature of an advanced phenotype and are mainly found in adolescents and young adults treated with dialysis. Association studies have provided valuable information regarding the significance of a multitude of risk factors in promoting CVD in children with CKD by using intermediate endpoints of measurements of surrogate parameters of CVD. Dialysis aggravates pre-existing risk factors and accelerates the progression of CVD with additional dialysis-related risk factors. Coronary artery calcifications in children and young adults with CKD accumulate in a time-dependent manner on dialysis. Identification of risk factors has led to improved understanding of principal mechanisms of CKD-induced damage to the cardiovascular system. Treatment strategies include assessment and monitoring of individual risk factor load, optimization of treatment of modifiable risk factors, and intensified hemodialysis if early transplantation is not possible.

Lipid-modifying therapy in chronic kidney disease: Pathophysiological and clinical considerations

Chronic kidney disease (CKD), which affects >10% of the population worldwide, is associated with a dramatically increased rate of cardiovascular disease (CVD). More people with CKD will die from CVD than develop end-stage renal disease with dialysis-dependency. However, the contribution of classical atherosclerotic cardiovascular risk factors is less evident than in the general population. Particularly, the relationship between dyslipidemia and CVD morbidity and mortality in CKD patients is not as evident as in the general population. While LDL cholesterol-lowering drugs such as statins significantly reduce the rate of cardiovascular events in the general population, their role in patients with end-stage renal disease has been questioned. This could be caused by a shift from atherosclerotic to non-atherosclerotic CVD in patients with advanced CKD, which cannot be effectively prevented by lipid-lowering drugs. In addition, many lines of evidence suggest that impaired renal function directly affects the metabolism, composition and functionality of lipoproteins, which may affect their responsiveness to pharmacological interventions. In this review, we highlight the challenges for the therapeutic application of lipid-lowering treatment strategies in CKD and discuss why treatment strategies used in the general population cannot be applied uncritically to CKD patients.

Dyslipidemia and Intraperitoneal Inflammation Axis in Peritoneal Dialysis Patients: A Cross-Sectional Pilot Study

Background

We have hypothesized that the problem of dyslipidemia in peritoneal dialysis (PD) patients lies beyond certain levels of plasma lipoprotein and involves cardiovascular risk, but can also influence the development of chronic intraperitoneal inflammation.

Objectives

The aim of our work was to define whether the association of dyslipidemia with intraperitoneal inflammation really exists and if it could it be used in a prospective cohort of PD patients.

Patients and Methods

We performed a cross-sectional, single-center, pilot study involving 40 nondiabetic PD patients (27 men and 13 women with an average age of 49.3 ± 12.2 years). The median time on PD was 29 (18.5-37) months. The parameters dialysis adequacy, blood lipid profile, and the concentrations of tumor necrosis factor (TNF)-α, monocyte chemoattractant protein (MCP)-1, and interleukin (IL)-10 in peritoneal dialysate effluent (PDE) were determined. Cohen's d effect size was computed post hoc to determine the differences between groups in the concentrations of pro- and anti-inflammatory mediators.

Results

PD patients with atherogenic dyslipidemia had significantly high levels of MCP-1 compared with dyslipidemia-free patients (Cohen's d = 1.32). A reduced high-density lipoprotein cholesterol level was associated with a high intraperitoneal production of the proinflammatory mediator TNF-α (p < 0.0001) and anti-inflammatory IL-10 (p < 0.0001). Atherogenic index of plasma was directly correlated with MCP-1 (p < 0.0001) and TNF-α (p < 0.0001). In multiple regression analysis, MCP-1 appeared to predict PD inadequacy (R ² = 0.58; F ratio = 9.4; p = 0.006) independently of age and blood C-reactive protein level. Effect size was 1.38 with α = 0.05, n = 40, and 3 predictors.

Conclusions

Our cross-sectional pilot study first demonstrated a close interaction between the atherogenic lipid profile and a high concentration of MCP-1 in PDE; this might be a prognostic marker for PD inadequacy. The potential significance of our finding is that it provides useful preliminary information necessary for further research into this area.

The interplay between mineral metabolism, vascular calcification and inflammation in Chronic Kidney Disease (CKD): challenging old concepts with new facts

Chronic kidney disease (CKD) is one of the most powerful predictors of premature cardiovascular disease (CVD), with heightened susceptibility to vascular intimal and medial calcification associated with a high cardiovascular mortality. Abnormal mineral metabolism of calcium (Ca) and phosphate (P) and underlying (dys)regulated hormonal control in CKD-mineral and bone disorder (MBD) is often accompanied by bone loss and increased vascular calcification (VC). While VC is known to be a multifactorial process and a major risk factor for CVD, the view of primary triggers and molecular mechanisms complexity has been shifting with novel scientific knowledge over the last years. In this review we highlight the importance of calcium-phosphate (CaP) mineral crystals in VC with an integrated view over the complexity of CKD, while discuss past and recent literature aiming to highlight novel horizons on this major health burden. Exacerbated VC in CKD patients might result from several interconnected mechanisms involving abnormal mineral metabolism, dysregulation of endogenous calcification inhibitors and inflammatory pathways, which function in a feedback loop driving disease progression and cardiovascular outcomes. We propose that novel approaches targeting simultaneously VC and inflammation might represent valuable new prognostic tools and targets for therapeutics and management of cardiovascular risk in the CKD population.