The predictive study of the relation between elevated low-density lipoprotein cholesterol to high-density lipoprotein cholesterol ratio and mortality in peritoneal dialysis

The predictive role of the hs-CRP/HDL-C ratio for long-term mortality in the general population: evidence from a cohort study

BACKGROUND

The high-sensitivity C-reactive protein (hs-CRP) to high-density lipoprotein cholesterol (HDL-C) ratio, a composite marker of low-grade inflammation and lipid metabolism, is reportedly associated with the occurrence of new cardiovascular diseases (CVDs) in certain people. However, the predictive value of the hs-CRP/HDL-C ratio for long-term mortality in the general population remains unclear.

METHODS

This retrospective cohort study included data from 9,492 adults obtained from the National Health and Nutrition Examination Survey (NHANES) (2015-2018) in the United States. Multivariate Cox regression, two-piecewise linear regression, restricted cubic spline (RCS) models and subgroup analysis by age, sex, smoking status and drinking status were applied to evaluate the associations of the hs-CRP/HDL-C ratio with long-term all-cause and cardiovascular mortality.

RESULTS

The overall median age of the cohort was 47.0 years (interquartile range (IQR) 32.0-62.0), and 4,585 (48.30%) patients were male. During a median follow-up period of 37.0 months, 239 (2.52%) all-cause deaths occurred, 59 (0.62%) of which were attributed to cardiovascular events. Participants with all-cause and cardiovascular mortality presented a higher hs-CRP/HDL-C ratio than did those without events [0.56 (0.24-1.38) vs. 0.37 (0.14-0.94) and 0.60 (0.23-1.60) vs. 0.37 (0.14-0.95), P < 0.001 and P = 0.002]. According to multivariate Cox regression models, the hs-CRP/HDL-C ratio was found to be an independent risk factor for both long-term all-cause mortality [hazard ratio (HR) = 1.09, 95% confidence interval (CI): 1.05-1.13] and cardiovascular mortality (HR = 1.11, 95% CI: 1.05-1.19). A two-piecewise linear regression model indicated that the risk of all-cause mortality increased more prominently when the hs-CRP/HDL-C ratio was less than 1.21. In addition, a significant interaction effect with smoking status was discovered (P = 0.006), indicating that the association of the hs-CRP/HDL-C ratio with all-cause mortality was stronger in nonsmokers. The RCS curve revealed a positive linear association of the hs-CRP/HDL-C ratio with long-term mortality after adjustment for potential confounders.

CONCLUSIONS

The hs-CRP/HDL-C ratio is a crucial predictor of long-term mortality in the general population, independent of potential confounding factors.

Higher LDL-C/HDL-C Ratio Is Associated with Elevated HbA1c and Decreased eGFR Levels and Cardiac Remodeling in Elderly with Hypercholesterolemia

Background: This study aims to explore the relationship of the low-density lipoprotein cholesterol (LDL-C)/high-density lipoprotein (HDL-C) ratio with glycated hemoglobin (HbA1c), renal dysfunction, coronary heart disease (CHD) and cardiac structure and function in elderly patients with hypercholesterolemia. Methods: A total of 1129 hospitalized Chinese elderly (aged ≥ 65 years) with hypercholesterolemia were collected retrospectively. The patients were divided into low (<2.63), moderate (≥2.63 to <3.33) and high (≥3.33) LDL-C/HDL-C ratio groups according to the tertiles of LDL-C/HDL-C. Results: Regression analysis of the LDL-C/HDL-C ratio with metabolic and echocardiographic parameters revealed that a high LDL-C/HDL-C ratio (≥3.33) was associated independently with male gender, elevated HbA1c, decreased estimated glomerular filtration rate (eGFR), prevalent CHD and left ventricular dilatation (all p < 0.05). Conclusions: A high LDL-C/HDL-C ratio was associated with male gender, increased HbA1c, decreased eGFR, CHD and enlarged left ventricle in elderly with hypercholesterolemia.

The association between new inflammation markers and frequent peritoneal dialysis-associated peritonitis

OBJECTIVE

To validate an association between new inflammation and frequent peritoneal dialysis-associated peritonitis (PDAP).

MATERIALS AND METHODS

In China, retrospective clinical data were collected on 208 patients who received continuous ambulatory peritoneal dialysis (CAPD) between 2010 and 2021. The patients were divided into two groups: non-frequent PDAP (the interval between two peritonitis episodes of more than one year) and frequent PDAP (the interval between two peritonitis episodes of less than one year). Patients with their first episode of peritonitis had their age, gender, history of hypertension, diabetic disease, underlying renal disease, bacterial infection, and laboratory data collected. The outcomes of bacterial dispersion, systemic immune-inflammation index (SII), high-density lipoprotein cholesterol (HDL-C), C-reactive protein (CRP), and risk variables associated with frequent PDAP were analyzed.

RESULTS

There are differences between the two groups in dialysis time (p = 0.006), hypertensive nephropathy (p = 0.038), staphylococcus (p = 0.035), white blood cells (p = 0.001), neutrophil (p < 0.01), lymphocyte (p < 0.01), platelet(p = 0.01), SII(p < 0.01), CRP/HDL-C (p = 0.002), CRP (p < 0.001), serum creatinine (p = 0.007), blood urea nitrogen (p = 0.05), serum magnesium (0.03), serum potassium (p = 0.007), and dialysate polymorphonuclear cells (p = 0.004). Multifactorial logistic regression analysis found that SII (p < 0.001), CRP/HDL-C (p = 0.041), and Diabetes mellitus (p = 0.027) were independent risk factors for frequent PDAP. The ROC curve analysis revealed that combining SII with CRP/HDL-C resulted in the largest AUC area (AUC = 0.814).

CONCLUSIONS

Our findings offer clinical proof of the combination of SII and CRP/HDL-C in patients with frequent PDAP.

Neutrophil Percentage-to-Albumin Ratio and Risk of Mortality in Patients on Peritoneal Dialysis

Background

Neutrophil percentage-to-albumin ratio (NPAR), a new inflammatory marker, has been shown to be associated with poor prognosis in patients with cardiovascular disease. However, limited evidence is available for its role in peritoneal dialysis (PD) patients. Our study aimed at investigating the prognostic value of NPAR for mortality in PD patients.

Patients and Methods

This was a single center retrospective cohort study. A total of 1966 PD patients were enrolled in our study from January 2006 to December 2016 and were followed up until December 2021. Patients were stratified into tertiles according to baseline NPAR levels. The associations between NPAR levels with all-cause and cardiovascular mortality were estimated using Cox proportional hazards models. Receiver operating characteristic (ROC) analysis was performed to compare the mortality predictive values of NPAR and other known biomarkers, such as NLR (neutrophil-to-lymphocyte ratio), PLR (platelet-to-lymphocyte ratio), LHR (low-density lipoprotein cholesterol-to-high-density lipoprotein cholesterol ratio) and MLR (monocyte-to-lymphocyte ratio).

Results

During a median follow-up of 48.1 months, 503 (25.6%) patients died, in which cardiovascular disease (CVD) death dominated 50.3%. Multivariate Cox regression analysis revealed that the highest NPAR tertile was significantly associated with a higher risk of all-cause and cardiovascular mortality (HR 1.51, 95% CI 1.14-1.98; HR 1.57, 95% CI 1.07-2.31; respectively) compared with tertile 1. The AUC values of NPAR were 0.62 (95% CI 0.60-0.65, P < 0.001) for all-cause mortality and 0.61 (95% CI 0.57-0.65, P < 0.001) for cardiovascular mortality.

Conclusion

Our study showed that higher NPAR levels were independently associated with increased risk of all-cause and cardiovascular mortality in PD patients. Notably, our results demonstrated that NPAR exhibited superior predictive value for mortality compared to NLR, PLR, MLR, and LHR.

Remnant cholesterol predicts cardiovascular mortality beyond low-density lipoprotein cholesterol in patients with peritoneal dialysis

BACKGROUND

Patients undergoing peritoneal dialysis (PD) are prone to dyslipidemia. However, studies concerning remnant cholesterol (RC) in such patients are limited.

OBJECTIVE

We aimed to investigate the association between RC and cardiovascular (CV) mortality in patients on PD.

METHODS

Patients who initiated PD at our center (2006-2018) were retrospectively enrolled. Adjusted Cox models were used to evaluate the independent association between baseline RC levels and CV mortality. We classified patients into 4 concordant/discordant categories according to their baseline lipid profiles. Cox models were then used to determine the association between different low-density lipoprotein cholesterol (LDL-C) and RC levels and CV mortality risk.

RESULTS

The study enrolled 2333 individuals, with a mean RC of 33.4 mg/dL. RC levels were positively associated with CV mortality risk independent of LDL-C in patients on PD (hazard ratio [HR]: 1.05; 95% confidence interval [CI]: 1. 00-1.10). In the concordant/discordant categories, patients with high LDL-C and RC levels had a higher CV mortality risk (HR: 1.52; 95% CI: 1.01-2.28) than those with low LDL-C and RC levels in the entire cohort. Moreover, in older patients, a higher RC level increased CV mortality risk regardless of the LDL-C level (HR: 2.41, 95% CI: 1.22-4.74; HR: 2.15, 95% CI: 1.12-4.14).

CONCLUSIONS

RC levels are elevated in patients on PD and can predict CV mortality beyond LDL-C levels. RC levels should be considered alongside LDL-C levels when assessing prognostic lipid levels in these patients. More attention should be given to RC than to LDL-C in older patients undergoing PD.

Global, regional, and national incidence, mortality, and disability-adjusted life years of non-rheumatic valvular heart disease and trend analysis from 1990 to 2019: Results from the Global Burden of Disease study 2019

BACKGROUND

In the context of the population growing and aging worldwide, the incidence of non-rheumatic valvular heart disease increased rapidly. This study aimed to describe the burden of non-rheumatic valvular heart disease, providing an up-to-date and comprehensive analysis on the global and regional levels and time trends from 1900 to 2019.

METHODS

The Global Burden of Disease 2019 was used to obtain data for this analysis. Non-rheumatic valvular heart disease in the Global Burden of Disease study includes both non-rheumatic calcific aortic valve disease and non-rheumatic degenerative mitral valve disease. The incidence, mortality, and disability-adjusted life year in 204 countries from 1990 to 2019 were analyzed by location, year, sex, age, and socio-demographic index. Estimated annual percentage change was calculated to represent the temporal trends from 1990 to 2019. Spearman's rank order correlation was used to determine the correlation between socio-demographic index and the incidence and burden of non-rheumatic valvular heart disease.

RESULTS

Globally, there were 1.65 million (95% uncertainty interval, 1.56-1.76 million) incident cases, 0.16 million (95% uncertainty interval, 0.14-0.18 million) death cases, and 2.79 million (95% uncertainty interval, 2.52-3.31 million) disability-adjusted life years of non-rheumatic valvular heart disease. Compared with 1990, the number of incident cases, death cases, and disability-adjusted life years in 2019 increased by 104.58%, 210.60%, and 167.62%, respectively, the age-standardized incidence rate (estimated annual percentage change, 0.39; 95% confidence interval, 0.29 to 0.49) increased due to population growth, and the age-standardized death rates (estimated annual percentage change, -0.32; 95% confidence interval, -0.39 to -0.25) and age-standardized disability-adjusted life year rate (estimated annual percentage change, -0.81; 95% confidence interval, -0.87 to -0.74) decreased during this period. Regarding the socio-demographic index, the highest age-standardized incidence, death, and disability-adjusted life year rates of non-rheumatic valvular heart disease were found in high-socio-demographic index countries in 2019. Meantime, the age-standardized incidence rate remained increased from 1990 to 2019, while significant decreases were found in the age-standardized death rate and age-standardized disability-adjusted life year rate. Females have higher age-standardized incidence rate, while higher age-standardized death rate and age-standardized disability-adjusted life year rate belong to males globally during the period of 1990-2019. Increasing trends were observed for both incidence, death, and disability-adjusted life year rates with age. High systolic blood pressure was the leading cause for non-rheumatic valvular heart disease across all ages.

CONCLUSIONS

From 1990 to 2019, the age-standardized incidence rate of non-rheumatic valvular heart disease remained increased, while age-standardized death rate and age-standardized disability-adjusted life year rate decreased, resulting from the growing population worldwide and improving medical resources. The aged, who has high systolic blood pressure and diet high in sodium, should pay more attention to, especially in high-socio-demographic index regions. With the population aging, the number of patients who require heart valve replacement is estimated to increase significantly in the future. Effective measures are warranted to control and treat the incidence and burden of non-rheumatic valvular heart disease.

Novel oxidized LDL-based clinical markers in peritoneal dialysis patients for atherosclerosis risk assessment

Maintenance peritoneal dialysis (PD) is commonly associated with cardiovascular diseases (CVDs), whose risk is assessed via LDL-C. Nonetheless, oxidized LDL (oxLDL), as being a key component of atherosclerotic lesions, could be also associated with atherosclerosis and related CVDs. However, its predictive value for CVDs risk assessment is subject of research studies due to the lack of specific methods to measure oxLDL status from its individual lipid/protein components. In the present study, six novel oxLDL markers, representative of certain oxidative modifications on the LDL protein and lipid components, are measured in atherosclerosis-prone PD patients (39) versus those in chronic kidney disease patients (61) under hemodialysis (HD) and healthy controls (40). LDL from serum of PD, HD and control subjects were isolated and fractionated into cholesteryl esters, triglycerides, free cholesterol, phospholipids and apolipoprotein B100 (apoB100). Subsequently the oxLDL markers cholesteryl ester hydroperoxides (-OOH), triglyceride-OOH, free cholesterol-OOH, phospholipid-OOH, apoB100 malondialdehyde and apoB100 dityrosines were measured. LDL carotenoid levels and LDL particle serum concentration were also measured. The levels of all oxLDL lipid-OOH markers were significantly elevated in PD patients versus control, while the levels of cholesteryl ester-/triglyceride-/free cholesterol-OOH were significantly elevated in PD versus HD patients, regardless of patients' underlying medical conditions, sex, age, PD type, clinical biochemical markers and medication. It should be noted that all fractionated lipid-OOH levels were inversely correlated with LDL-P concentration, while LDL-P concentration was not correlated with LDL-C in PD patients. Moreover, LDL carotenoids were significantly lower in PD patients versus control. The increased levels of oxLDL status specific markers in both PD and HD patients (compared to control), support a potential prognostic value of oxLDL regarding CVD risk assessment in both patient groups. Lastly, the study introduces the oxLDL peroxidation markers free cholesterol-OOH and cholesteryl ester-OOH as complementary to LDL-P number, and as possible alternatives to LDL-C.

The prognostic value of monocyte-to-lymphocyte ratio in peritoneal dialysis patients

BACKGROUND

The monocyte-to-lymphocyte ratio (MLR) is considered as a new inflammation marker. This study was aimed to investigate the prognostic value of MLR for all-cause mortality and new-onset cardiovascular disease (CVD) events in peritoneal dialysis (PD) patients.

METHODS

This study enrolled patients receiving PD treatment for  ≥ 3 months. Baseline characteristics were obtained within 1 week before PD catheterization. The receiver operating characteristic curve analysis was conducted to determine the optimal cut-off value of MLR. The Kaplan-Meier curve estimated the cumulative survival rate and new CVD free survival rate. Univariate and multivariate Cox regression models were preformed to investigate the association between MLR and clinical outcomes.

RESULTS

A total of 369 PD patients participated in this study. During a median follow-up period of 32.83 months, 65 patients (24.2%) died, and 141 patients (52.4%) occurred new-onset CVD events. The Kaplan-Meier curve revealed that survival rate in high MLR group (MLR  > 0.2168) was significantly lower than in low MLR group (P = 0.008). Patients in high MLR group were more likely to experience CVD events (P = 0.002). Even after adjustment of traditional risk factors, including age, diabetes mellitus, CVD history, smoking, hyperlipidemia, high MLR remained an independent predictor of all-cause mortality [hazard ration (HR) = 2.518, 95% confidence intervals (CI) = 1.020-6.214, P = 0.045] and new-onset CVD events (HR = 1.815, 95% CI = 1.157-2.849, P = 0.010).

CONCLUSIONS

This study suggested that high MLR was significantly and independently associated with all-cause mortality and CVD events in PD patients. The MLR is an inexpensive and straightforward indicator to reflect systemic inflammation status and help clinicians improve PD management.

The association between diabetes coexisting with low levels of high-density lipoprotein cholesterol and peritoneal dialysis-related peritonitis

BACKGROUND

Low levels of high-density lipoprotein cholesterol (HDL-C) and diabetes are common in patients undergoing peritoneal dialysis (PD). The aim of this study was to investigate the association between the coexistence of diabetes with a low level of HDL-C and the first episode of peritoneal dialysis-related peritonitis (PDRP) in patients with PD.

METHODS

We retrospectively investigated patients with PD from January 1, 2003, to May 31, 2020, in four PD centers. Patients with PD were divided into four groups: no comorbidities, low HDL-C only, diabetes only, and diabetes plus low HDL-C. The clinical and laboratory baseline data of the four groups were collected and compared. The association between diabetes coexisting with low HDL-C levels and the first episode of PDRP was analyzed by multivariate Cox regression analysis.

RESULTS

A total of 1013 patients with PD were included in our study. The mean age was 49.94 ± 14.32 years, and 597 (58.99%) patients were males. A total of 301 (29.7%) patients had their first episodes of PDRP, and low HDL-C levels coexisted with diabetes in 72 patients with PD. After adjusting for confounding factors, a low level of HDL-C coexisting with diabetes was significantly associated with the first episode of PDRP in our study (hazard ratio: 2.81, 95% CI 1.32 ~ 4.73, p = 0.005). The associations among HDL-C, diabetes and PDRP were consistent in the following subgroups: sex, age, and pre-existing CVD (all P interaction > 0.05).

CONCLUSIONS

Patients with both diabetes and low HDL-C levels were at higher risk for PDRP in patients with PD.

Prognostic Role of Neutrophil to High-Density Lipoprotein Cholesterol Ratio for All-Cause and Cardiovascular Mortality in the General Population

Background

Neutrophil counts to high-density lipoprotein cholesterol ratio (NHR), a composite marker of inflammation and lipid metabolism, has been considered as a predictor of clinical outcomes in patients with acute ischemic stroke and acute myocardial infarction. However, the predictive value of NHR for all-cause and cardiovascular mortality in the general population remains unclear.

Methods

Our study population comprised 34,335 adults in the United States obtained from the National Health and Nutrition Examination Survey (NHANES) (1999–2014) and were grouped in accordance with tertiles of NHR. Kaplan–Meier curves and log-rank test were used to investigate the differences of survival among groups. Multivariate Cox regression, restricted cubic spline analysis, and subgroup analysis were applied to explore the relationship of NHR with all-cause and cardiovascular mortality.

Results

The mean age of the study cohort was 49.6 ± 18.2 years and 48.4% were men. During a median follow-up of 82 months, 4,310 (12.6%) all-cause deaths and 754 (2.2%) cardiovascular deaths occurred. In a fully-adjusted Cox regression model, participants in the highest tertile had 29% higher hazard of all-cause mortality than those in the lowest tertile [hazard ratio (HR) = 1.29, 95% CI: 1.19–1.41]. For cardiovascular mortality, the continuously increased HR with 95% CIs among participants in the middle and highest tertile were 1.30 (1.06–1.59) and 1.44 (1.17–1.78), respectively. The restricted cubic spline curve indicated that NHR had a non-linear association with all-cause mortality (p for non-linearity < 0.001) and a linear association with cardiovascular mortality (p for non-linearity = 0.553).

Conclusion

Increased NHR was a strong and independent predictor of all-cause and cardiovascular mortality in the general population.

Utility of TG/HDL-c ratio as a predictor of mortality and cardiovascular disease in patients with chronic kidney disease undergoing hemodialysis: A systematic review

The triglyceride/high-density cholesterol-lipoprotein (TG/HDL-c) is a biomarker of cardiovascular events and mortality. In hemodialysis patients, the evidence is controversial. A systematic review was carried out in the Medline, Scopus, Embase, Web of Science, and Pubmed databases to identify the relevant cohort studies on cardiovascular events and mortality in hemodialysis patients the role of TG/HDL-c as a risk factor. Four cohort-type studies were evaluated, with a total of 52,579 hemodialysis patients. Three studies conducted in Asian populations and one study in the United States had the highest percentage of the sample (50,673 patients). The elevated TG/HDL-c ratio is associated with better survival, and there is a consistent gradual inverse association between TG/HDL-c and mortality in all analysis subgroups. In the decile categorization of the exposure variable, a 21% decrease in the risk of cardiovascular mortality and a 15% decrease in all-cause mortality in the highest decile compared to the reference group (D10 aHR = 0.79; 95% CI: 0.69-0.91 and D10 aHR = 0.85; 95%CI: 0.78-0.92). Our results show that the TG/HDL-c ratio is a protective factor for cardiovascular outcomes and mortality in the American population and a risk factor for them in the population from Asia.

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.