Observations with regard to the National Kidney Foundation K/DOQI clinical practice guidelines concerning serum transthyretin in chronic renal failure

Range of serum transthyretin levels in hemodialysis patients at a high risk of 1-year mortality: A retrospective cohort study

INTRODUCTION

Transthyretin (TTR) is a sensitive marker of nutritional status and independent risk factor for mortality in hemodialysis patients. However, its range associated with prognosis in Japanese hemodialysis patients is unknown.

METHODS

Maintenance hemodialysis Patients (n = 664) were enrolled, and their TTR levels were measured to assess 1-year mortality. Patients were assigned to four groups based on TTR levels: <20, 20 to <30 (control), 30 to <40, and ≥40 mg/dl. One-year mortality at each TTR range was analyzed using a Cox proportional hazards model after adjustment for prognostic factors.

RESULTS

Seventy-seven (11.6%) deaths were recorded during follow-up. The hazard ratio (HR) of TTR <20 mg/dl was significantly higher compared with the control group in terms of all-causes (HR: 3.14) and non-cardiovascular mortality (HR: 6.986).

CONCLUSION

TTR levels were independent and sensitive predictors of mortality in hemodialysis patients. TTR <20 mg/dl is a risk factor for 1-year mortality in Japanese hemodialysis patients.

Squamous cell carcinoma antigen, platelet distribution width, and prealbumin collectively as a marker of squamous cell cervical carcinoma

BACKGROUND

Squamous cell cervical carcinoma is the most common gynecological malignant disorder worldwide. Early detection of squamous cell cervical carcinoma is needed for proper clinical management. Squamous cell carcinoma antigen (SCCA) is commonly used as a tumor marker for squamous cell cervical carcinoma. Platelet distribution width (PDW) is an indicator of platelet activation. Prealbumin is a negative acute-phase protein.

OBJECTIVE

The aim of this study was to investigate the ability of SCCA, PDW, and prealbumin individually or in combination, to distinguish between cervical carcinoma and control subjects.

MEHTODS

Two hundred and twenty patients with squamous cell cervical carcinoma and 211 control subjects were included in the study. Patients' characteristics and hematologic tests data at initial diagnosis were collected.

RESULTS

Our results showed that SCCA and PDW were higher, and prealbumin was lower in cervical carcinoma patients than in control subjects. Single biomarker had AUC value ranging from 0.753 for SCCA to 0.845 for PDW. The combination of SCCA and PDW increased the AUC to 0.900 (p< 0.0001). In addition, the combination of SCCA, PDW and prealbumin exhibited a significantly larger AUC of 0.917 (0.887-0.942), significantly higher than those of any single marker.

CONCLUSIONS

The combined use of SCCA, PDW and prealbumin can accurately distinguish squamous cell cervical carcinoma from control subjects. This promising approach could be helpful in early detection of squamous cell cervical carcinoma.

Association Between Comprehensive Nutritional Scoring System (CNSS) and Outcomes of Continuous Ambulatory Peritoneal Dialysis Patients

BACKGROUND/AIMS

The presence of protein-energy wasting (PEW) among dialysis patients is a crucial risk factor for outcomes. The complicated pathogenesis of PEW makes it difficult to assess and treat. This single-center retrospective study focuses on the association between nutritional markers and the outcomes of continuous ambulatory peritoneal dialysis(CAPD) patients, aiming to establish a practical comprehensive nutritional scoring system for CAPD patients.

METHODS

924 patients who initiated peritoneal dialysis in our center from January 1st,2005 to December 31st,2015 were enrolled. Comprehensive nutritional scoring system(CNSS) was based on items including SGA, BMI, ALB, TC, MAC and TSF. We divide patients into 3 groups according to their CNSS score. Outcomes including mortality, hospitalization days and hospitalization frequency were compared between 3 grades.

RESULTS

The CNSS grade correlated significantly with hospitalization days (P<0.05). Both categorized CNSS grade (HR:0.56; 95% CI:0.41-0.78; P = 0.001) and continuous CNSS score (HR:0.87; 95% CI: 0.80-0.94; P = 0.001) independently protect PD patients from all-cause mortality.

CONCLUSION

CNSS provides an integrated scoring system with significant associations with hospitalization and mortality in PD patients. The CNSS grade differentiates patients with malnutritional risk and independently predicts high risk of morbidity and mortality.

Serum prealbumin and its changes over time are associated with mortality in acute kidney injury

Serum prealbumin is a clinically relevant indicator of nutritional status and inflammation in patients with acute kidney injury (AKI). This study aimed to determine whether serum prealbumin and its longitudinal changes over a week could improve the prediction of 90-day mortality in AKI patients. This prospective cohort study included 340 adults with AKI between 2014 and 2015. There were 94 (27.6%) patient deaths within 90 days. Serum prealbumin level <10 mg/dL at the time of AKI diagnosis was associated with a 155% increased death risk ratio (adjusted hazard ratio [HR], 2.55; 95% confidence interval [CI], 1.18 to 5.49; P = 0.02). Serum prealbumin fall >4 mg/dL was also associated with 90-day mortality in adjusted Cox regression models (HR, 1.79; 95% CI, 1.06 to 3.03; P = 0.03). Compared to serum albumin, mortality-predictability of serum prealbumin (P = 0.01) and its changes (P = 0.01) were both increased. Adding prealbumin and its changes on the conventional covariates improved the prediction of progression to 90-day mortality (NRI 0.29, P = 0.04; aIDI 0.08; P = 0.03). In conclusion, serum prealbumin, and its changes were independent predictors of worse prognosis in AKI, and could be potential surrogates to better predict 90-day mortality.

Serum prealbumin as an effective prognostic indicator for determining clinical status and prognosis in patients with hemorrhagic stroke

Serum prealbumin is a recognized marker of malnutrition, but its prognostic role in patients with hemorrhagic stroke remains unclear. In this study, we retrospectively reviewed the records of 105 patients with hemorrhagic stroke admitted to Renmin Hospital of Wuhan University, China, from January to December 2015. We collected demographic and radiological data, and recorded serum prealbumin levels at admission and on days 1, 3, 6, 9, and 14–21. The existence of infections and gastrointestinal hemorrhage, and clinical condition at discharge were also recorded. Serum prealbumin levels during hospitalization were significantly lower in patients with infections compared with those without infections, and also significantly lower in patients with gastrointestinal hemorrhage compared with those without. Serum prealbumin levels at discharge were significantly higher in patients with good recovery than in those with poor recovery. We conclude that regular serum prealbumin measurements in patients with hemorrhagic stroke may be a useful indicator for determining clinical status and prognosis, which may therefore help to guide clinical decision-making.

Protein-energy malnutrition: a risk factor for various ailments

The wheel of industrialization that spun throughout the last century resulted in urbanization coupled with modifications in lifestyles and dietary habits. However, the communities living in developing economies are facing many problems related to their diet and health. Amongst, the prevalence of nutritional problems especially protein-energy malnutrition (PEM) and micronutrients deficiencies are the rising issues. Moreover, the immunity or susceptibility to infect-parasitic diseases is also directly linked with the nutritional status of the host. Likewise, disease-related malnutrition that includes an inflammatory component is commonly observed in clinical practice thus affecting the quality of life. The PEM is treatable but early detection is a key for its appropriate management. However, controlling the menace of PEM requires an aggressive partnership between the physician and the dietitian. This review mainly attempts to describe the pathophysiology, prevalence and consequences of PEM and aims to highlight the importance of this clinical syndrome and the recent growth in our understanding of the processes behind its development. Some management strategies/remedies to overcome PEM are also the limelight of the article. In the nutshell, early recognition, prompt management, and robust follow up are critical for best outcomes in preventing and treating PEM.

The role of dietary proteins among persons with diabetes

Examining the role of dietary protein and establishing intake guidelines among individuals with diabetes is complex. The 2013 American Diabetes Association (ADA) standards of care recommend an individualized approach to decision making with regard to protein intake and dietary macronutrient composition. Needs may vary based on cardiometabolic risk factors and renal function. Among individuals with impaired renal function, the ADA recommends reducing protein intake to 0.8-1.0 g/kg per day in earlier stages of chronic kidney disease (CKD), and to 0.8 g/kg per day in the later stages of CKD. Epidemiological studies suggest animal protein may increase risk of diabetes; however, few data are available to suggest how protein sources influence diabetes complications.

Low-protein diet for diabetic nephropathy

Diabetic nephropathy is the leading cause of progressive kidney disease, leading to end-stage renal disease and renal replacement therapy. Angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers have been considered effective at slowing the progression of kidney function deterioration. However, these drugs cannot sufficiently halt the progression of nephropathy to the extent that is required. A low-protein diet (LPD) is believed to be a nutritional intervention that may slow kidney disease progression. In fact, preclinical animal experiments have demonstrated excellent renoprotective effects of an LPD. However, in human clinical trials, analyses of the effects of protein restriction on diabetic nephropathy have not yet revealed consistently positive outcomes of this nutritional intervention. In this review, we analyze the potential renoprotective effects of an LPD on diabetic nephropathy and summarize the outcomes of clinical trials that have systematically investigated the efficacy of an LPD in diabetic nephropathy. In addition, we discuss some potential approaches associated with nutritional interventions to combat progressive kidney disease.

Transthyretin predicts cardiovascular outcome in hemodialysis patients with type 2 diabetes

OBJECTIVE

BMI and albumin are commonly accepted parameters to recognize wasting in dialysis patients and are powerful predictors of morbidity and mortality. However, both parameters reveal limitations and may not cover the entire range of patients with wasting. The visceral protein transthyretin (TTR) may be helpful in overcoming the diagnostic and prognostic gap. Therefore, the aim of this study was to assess the association of TTR with morbidity and mortality in hemodialysis patients.

RESEARCH DESIGN AND METHODS

The TTR concentration was determined in plasma samples of 1,177 hemodialysis patients with type 2 diabetes. Cox regression analyses were used to determine hazard ratios (HRs) for the risk of cardiovascular end points (CVEs) and mortality according to quartiles of TTR concentration for the total study cohort and the subgroups BMI ≥23 kg/m(2), albumin concentration ≥3.8 g/dL, and a combination of both.

RESULTS

A low TTR concentration was associated with an increased risk for CVE for the total study cohort (HR 1.65 [95% CI 1.27-2.14]), patients with BMI ≥23 kg/m(2) (1.70 [1.22-2.37]), albumin ≥3.8 g/dL (1.68 [1.17-2.42]), and the combination of both (1.69 [1.13-2.53]). Additionally, a low TTR concentration predicted mortality for the total study cohort (1.79 [1.43-2.24]) and patients with BMI ≥23 kg/m(2) (1.46 [1.09-1.95]).

CONCLUSIONS

The current study demonstrated that TTR is a useful predictor for cardiovascular outcome and mortality in diabetic hemodialysis patients. TTR was particularly useful in patients who were not identified to be at risk by BMI or albumin status.

Accuracy and limitations of the diagnosis of malnutrition in dialysis patients

Uremic malnutrition, also known as protein-energy wasting (PEW), is a common phenomenon in maintenance dialysis patients and a risk factor for poor clinical outcomes including worse quality of life and increased hospitalization and mortality. The paradoxical association between traditional cardiovascular risk factors and better outcomes in dialysis patients also referred to as "reverse epidemiology," is a good example of the powerful effect-modifying impact of the nutritional status in this population. Measures of food intake, body composition tools, nutritional scoring systems, and laboratory values such as serum albumin are used to diagnose PEW and to assess the degree of severity of PEW without clearly validated diagnostic criteria. Some observational studies suggest that inflammation is a missing link between the PEW and poor clinical outcomes in dialysis patients, although PEW per se may also predispose to illness and inflammation. Ongoing debate as to whether such surrogates as serum albumin or prealbumin concentrations are markers of nutritional status, inflammation, comorbidity, or other conditions has led to confusion and diagnostic and therapeutic nihilism. Irrespective of the cause of hypoalbuminemia in dialysis patients, evidence suggests that nutritional interventions can increase serum albumin in dialysis patients. Hence, we should continue assessing serum albumin and other surrogates of nutritional status to risk-stratify patients and to allocate nutritional therapy, while well-designed, large-scale, randomized, controlled trials of the effects of nutritional intake on clinical outcomes are awaited.

Different independent susceptibility markers for first-ever cerebral infarction and myocardial infarction in young patients

Cerebral infarction (CI) and myocardial infarction (MI) share some common features, but there are other differences in risk factors. The aim of our study is to determine whether there are some significantly independent susceptibility markers for them. All consecutive patients between the ages of 18 and 45 years with first-ever CI and MI during 2001-2010 were recruited to participate in the study. Using multivariate logistic regression modeling, we explore many different data, such as age at onset, sex ratio, numbers of patients with history of hypertension, smoking, drinking, and serum lipid, uric acid, prealbumin (PA), and white blood cell (WBC) count levels. Logistic regression analysis adjusted for confounders confirmed the following independent susceptibility markers for young CI patients: hypertension, admission serum PA levels, daily alcohol [odds ratio (OR), 0.251; 95% confidence interval (CI), 0.097-0.648, p = 0.004; OR, 0.994; 95% CI, 0.988-0.999, p = 0.031; OR, 0.150; 95% CI, 0.047-0.473, p = 0.001], and for MI patients: age at onset, current smoking, serum WBC, and glucose levels (OR, 1.293; 95% CI, 1.146-1.457, p = 0.000; OR, 8.914; 95% CI, 3.575-22.231, p = 0.000; OR, 1.344; 95% CI, 1.169-1.544, p = 0.000; OR, 1.149; 95% CI, 1.022-1.291, p = 0.020). We conclude that there are some significantly different independent susceptibility markers for young CI and MI patients.

Comparison of nutritional parameters among adult and elderly hemodialysis patients

AIM

The aim of this study was to compare the nutritional biochemical parameters, prealbumin levels, and bioimpedance analysis parameters of adult and elderly hemodialysis (HD) patients.

METHODS

This prospective cross-sectional study included 50 adult HD patients (42.0 % female). Nutritional status was assessed by post-dialysis multifrequency bioimpedance analysis (BIA), serum prealbumin and other nutritional biochemical parameters.

RESULTS

Mean age of patients was 57.4±15.1 years (range: 30-83 years) and mean dialysis duration was 68.3 ± 54.5 months (range: 3-240 months). When the patients were divided into two groups according to age of patients (<65 and ≥65), prealbumin (p=0.003), blood urea nitrogen (BUN) (p=0.000), serum creatinine (p=0.013), albumin (p=0.016), protein catabolic rate per normalized body weight (nPCR) (p=0.001), intracellular water (ICW)/total body weight (0.003) , body fat mass (p00.000), lean body mass (p=0.031), lean dry mass (p=0.001), illness marker (p=0.005), basal metabolism (p=0.007), body mass index (BMI) (p=0.028), body fat mass index (BFMI) (p=0.000), fat free mass index (FFMI) (p=0.040) values were significantly different between the groups. In the elderly patients (age ≥65), body fat mass, illness marker, BMI, BFMI were higher compared to adult patients (age <65). Additionally, in the elderly patients, prealbumin, BUN, creatinine, albumin, nPCR, ICW/ total body weight, lean body weight, lean dry weight, basal metabolism and FFMI were lower than adult patients.

CONCLUSIONS

Our results indicate that BFMI were higher, albumin, prealbumin, nPCR and lean body mass and FFMI were lower in elderly patients compared to adults. These results imply that elderly HD patients may be prone sarcopenic obesity and may require special nutritional support.

Serum prealbumin (transthyretin) predict good outcome in young patients with cerebral infarction

Low serum protein and albumin are considered to significantly associate with malnutrition, impaired functional status, poor outcome, and mortality. We hypothesized that serum prealbumin (transthyretin, PA) was a reliable and robust survival marker in young cerebral infarction patients and attempted to test the foregoing hypothesis. We analyzed the relationship between serum PA and stroke severity as determined by the modified Rankin Scale at discharge in 585 young cerebral infarction patients. By multivariate logistic regression modeling, we determined the influence of prealbumin on stroke severity, and the analyses were adjusted for the effects of potential confounders. Patients with a severe stroke had significantly more often prealbumin on admission in the lowest quintile (P = 0.031). Those cardiogenic cerebral infarction patients had significantly lower serum prealbumin concentrations and higher mRS scores. A logistic regression adjusted for confounders confirmed the following independent (odds ratio, 95% CI) good outcome predictors: uric acid (-0.002, 0.996-1.000) and prealbumin (-0.003, 0.995-1.000). Prealbumin is an independent predictor of the good clinical outcome of young cerebral infarction patients. The serum prealbumin may be a useful prognostic indicator for judging the prognosis of cerebral infarction.

Association of serum prealbumin and its changes over time with clinical outcomes and survival in patients receiving hemodialysis

BACKGROUND

In patients receiving maintenance hemodialysis (MHD), a low serum prealbumin is an indicator of protein-energy wasting.

OBJECTIVE

We hypothesized that baseline serum prealbumin correlates independently with health-related quality of life (QoL) and death and that its change over time is a robust mortality predictor.

DESIGN

Associations and survival predictability of serum prealbumin at baseline and its changes over 6 mo were examined in a 5-y (2001-2006) cohort of 798 patients receiving MHD.

RESULTS

Patients with serum prealbumin >or= 40 mg/dL had greater mid-arm muscle circumference but lower percentage of total body fat. Both serum interleukin-6 and dietary protein intake correlated independently with serum prealbumin. Measures of QoL indicated better physical health, physical function, and functionality with higher prealbumin concentrations. Although baseline prealbumin was not superior to albumin in predicting survival, in both all and normoalbuminemic (albumin >or= 3.5 g/dL; n = 655) patients, prealbumin < 20 mg/dL was associated with higher death risk in adjusted models, but further adjustments for inflammatory cytokines mitigated the associations. In 412 patients with baseline prealbumin between 20 and 40 mg/dL whose serum prealbumin was remeasured after 6 mo, a >or=10-mg/dL fall resulted in a death hazard ratio of 1.37 (95% CI: 1.02, 1.85; P = 0.03) after adjustment for baseline measures, including inflammatory markers.

CONCLUSIONS

Even though baseline serum prealbumin may not be superior to albumin in predicting mortality in MHD patients, prealbumin concentrations <20 mg/dL are associated with death risk even in normoalbuminemic patients, and a fall in serum prealbumin over 6 mo is independently associated with increased death risk.

A proposed nomenclature and diagnostic criteria for protein-energy wasting in acute and chronic kidney disease

The recent research findings concerning syndromes of muscle wasting, malnutrition, and inflammation in individuals with chronic kidney disease (CKD) or acute kidney injury (AKI) have led to a need for new terminology. To address this need, the International Society of Renal Nutrition and Metabolism (ISRNM) convened an expert panel to review and develop standard terminologies and definitions related to wasting, cachexia, malnutrition, and inflammation in CKD and AKI. The ISRNM expert panel recommends the term 'protein-energy wasting' for loss of body protein mass and fuel reserves. 'Kidney disease wasting' refers to the occurrence of protein-energy wasting in CKD or AKI regardless of the cause. Cachexia is a severe form of protein-energy wasting that occurs infrequently in kidney disease. Protein-energy wasting is diagnosed if three characteristics are present (low serum levels of albumin, transthyretin, or cholesterol), reduced body mass (low or reduced body or fat mass or weight loss with reduced intake of protein and energy), and reduced muscle mass (muscle wasting or sarcopenia, reduced mid-arm muscle circumference). The kidney disease wasting is divided into two main categories of CKD- and AKI-associated protein-energy wasting. Measures of chronic inflammation or other developing tests can be useful clues for the existence of protein-energy wasting but do not define protein-energy wasting. Clinical staging and potential treatment strategies for protein-energy wasting are to be developed in the future.

Intradialytic parenteral nutrition does not improve survival in malnourished hemodialysis patients: a 2-year multicenter, prospective, randomized study

Although intradialytic parenteral nutrition (IDPN) is a method used widely to combat protein-calorie malnutrition in hemodialysis patients, its effect on survival has not been thoroughly studied. We conducted a prospective, randomized trial in which 186 malnourished hemodialysis patients received oral nutritional supplements with or without 1 year of IDPN. IDPN did not improve 2-year mortality (primary end point), hospitalization rate, Karnofsky score, body mass index, or laboratory markers of nutritional status. Instead, both groups demonstrated improvement in body mass index and the nutritional parameters serum albumin and prealbumin (P < 0.05). Multivariate analysis showed that an increase in prealbumin of >30 mg/L within 3 months, a marker of nutritional improvement, independently predicted a 54% decrease in 2-year mortality, as well as reduced hospitalizations and improved general well-being as measured by the Karnofsky score. Therefore, although we found no definite advantage of adding IDPN to oral nutritional supplementation, this is the first prospective study demonstrating that an improvement in prealbumin during nutritional therapy is associated with a decrease in morbidity and mortality in malnourished hemodialysis patients.

Clinical indications for plasma protein assays: transthyretin (prealbumin) in inflammation and malnutrition

A large number of circumstances are associated with reduced serum concentrations of transthyretin (TTR), or prealbumin. The most common of these is the acute phase response, which may be due to inflammation, malignancy, trauma, or many other disorders. Some studies have shown a decrease in hospital stay with nutritional therapy based on TTR concentrations, but many recent studies have shown that concentrations of albumin, transferrin, and transthyretin correlate with severity of the underlying disease rather than with anthropometric indicators of hypo- or malnutrition. There are few if any conditions in which the concentration of this protein by itself is more helpful in diagnosis, prognosis, or follow up than are other clinical findings. In the majority of cases, the serum concentration of C-reactive protein is adequate for detection and monitoring of acute phase responses and for prognosis. Although over diagnosis and treatment of presumed protein energy malnutrition is probably not detrimental to most patients, the failure to detect other causes of decreased concentrations (such as serious bacterial infections or malignancy) of the so-called visceral or hepatic proteins could possibly result in increased morbidity or even mortality. In addition to these caveats, assays for TTR have a relatively high level of uncertainty ("imprecision"). Clinical evaluation--history and physical examination--should remain the mainstay of nutritional assessment.

Analysis of proteomic components of sera from patients with uremia by two dimensional electrophoresis and matrix assisted laser desorption/ionization time of flight mass spectrometry

The different sera proteomic components between uremia patients and normal subjects were studied through two-dimensional gel electrophoresis technique. Immobilized pH gradient two-dimensional polyacrylamide gel electrophoresis (2DE), silver staining, ImageMaster 2D 5.0 analysis software, matrix assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF-TOF-MS) and IPI human database searching were used to separate and identify the proteome of the sera from the patients with uremia. The results showed that satisfactory 2DE patterns of the serum proteins were obtained. Twenty-six protein spots showed significant difference in quantity in uremia patients, and 20 protein spots were identified by MALDI-TOF-TOF-MS. It was concluded that good reproducibility could be obtained by applying immobilized pH gradient 2DE to separate and identify the proteome in serum, which provided the foundation for the further study on uremia toxins pertaining to protein.

Albumin turnover: experimental approach and its application in health and renal diseases

Plasma albumin is an important protein in the human body and is responsible for transport and binding of many molecules. Furthermore, it is involved in mediating blood volume and colloid osmotic pressure (COP). As hypoalbuminemia occurs, as is the case in a number of clinical disorders, adaptation mechanisms may be involved. Serum albumin concentration is the net result of physiological processes like synthesis and catabolism. Measurement of one of these processes can provide therefore a more dynamic insight into the adaptation mechanism of albumin metabolism in relation to an underlying disease than would be obtained by changes in albumin concentration alone. This review highlights several studies over the past years that have contributed to knowledge of albumin metabolism. A short introduction is given for synthesis, formation and catabolism of albumin, after which an overview is given on how to measure albumin turnover including a general approach. Finally, albumin metabolism focused on patients with renal diseases will be discussed.

Malnutrition-inflammation complex syndrome in dialysis patients: causes and consequences

Protein-energy malnutrition (PEM) and inflammation are common and usually concurrent in maintenance dialysis patients. Many factors that appear to lead to these 2 conditions overlap, as do assessment tools and such criteria for detecting them as hypoalbuminemia. Both these conditions are related to poor dialysis outcome. Low appetite and a hypercatabolic state are among common features. PEM in dialysis patients has been suggested to be secondary to inflammation; however, the evidence is not conclusive, and an equicausal status or even opposite causal direction is possible. Hence, malnutrition-inflammation complex syndrome (MICS) is an appropriate term. Possible causes of MICS include comorbid illnesses, oxidative and carbonyl stress, nutrient loss through dialysis, anorexia and low nutrient intake, uremic toxins, decreased clearance of inflammatory cytokines, volume overload, and dialysis-related factors. MICS is believed to be the main cause of erythropoietin hyporesponsiveness, high rate of cardiovascular atherosclerotic disease, decreased quality of life, and increased mortality and hospitalization in dialysis patients. Because MICS leads to a low body mass index, hypocholesterolemia, hypocreatininemia, and hypohomocysteinemia, a "reverse epidemiology" of cardiovascular risks can occur in dialysis patients. Therefore, obesity, hypercholesterolemia, and increased blood levels of creatinine and homocysteine appear to be protective and paradoxically associated with a better outcome. There is no consensus about how to determine the degree of severity of MICS or how to manage it. Several diagnostic tools and treatment modalities are discussed. Successful management of MICS may ameliorate the cardiovascular epidemic and poor outcome in dialysis patients. Clinical trials focusing on MICS and its possible causes and consequences are urgently required to improve poor clinical outcome in dialysis patients.