Effect of malnutrition-inflammation complex syndrome on EPO hyporesponsiveness in maintenance hemodialysis patients

Kalantar-Zadeh, Kamyar; McAllister, Charles J.; Lehn, Robert S.; Lee, Grace H.; Nissenson, Allen R.; Kopple, Joel D.

doi:10.1016/s0272-6386(03)00915-6

Cited by 247 publications

(199 citation statements)

References 49 publications

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“…Participants in the NIED Study originated from a pool of approximately 1200 MHD outpatients in eight DaVita, Inc., dialysis facilities in the South Bay Los Angeles area (see NIED Study web site at www.NIEDStudy.org for more details, as well as previous publications (20,21)). Inclusion criteria were outpatients who had been undergoing MHD for at least 8 wk, were 18 yr or older, and signed a written consent form.…”

Section: Patientsmentioning

confidence: 99%

“…We studied the hypotheses that a low level of tHcy in dialysis patients indicates protein-energy malnutrition, with or without inflammation, and is associated with poor clinical outcome in maintenance dialysis patients. To verify the above hypotheses, we first examined baseline associations between tHcy and some markers of protein-energy malnutrition and inflammation at the start of the cohort of the Nutritional and Inflammatory Evaluation in Dialysis (NIED) Study (20,21). We then explored longitudinal associations between the baseline tHcy and the prospective mortality and hospitalization measures in the same group of patients.…”

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confidence: 99%

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A Low, Rather than a High, Total Plasma Homocysteine Is an Indicator of Poor Outcome in Hemodialysis Patients

Kalantar-Zadeh

Block

Humphreys

et al. 2004

Journal of the American Society of Nephrology

153

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Abstract. An increased level of total plasma homocysteine (tHcy) is a risk factor for poor cardiovascular outcome in the general population. However, a decreased, rather than an increased, tHcy concentration may predict poor outcome in maintenance hemodialysis (MHD) patients, a phenomenon referred to as reverse epidemiology. Associations were examined between tHcy level and markers of malnutrition-inflammation complex syndrome and 12-mo prospective hospitalization and mortality in 367 MHD patients, aged 54.5 Ϯ 14.7 (mean Ϯ SD) years, who included 199 men and 55% individuals with diabetes. tHcy was 24.4 Ϯ 11.8 mol/L, and 94% of the patients had hyperhomocysteinemia (tHcy Ͼ13.5 mol/L). tHcy had weak to moderate but statistically significant bivariate and multivariate correlations with some laboratory markers of nutrition (serum albumin, prealbumin, creatinine, and urea nitrogen) but no significant correlation with serum C-reactive protein or two proinflammatory cytokines (IL-6 and TNF-␣).During 12 mo of follow-up, 191 MHD patients were hospitalized, 37 died, nine underwent renal transplantation, and 38 transferred out. Hospitalization rates were significantly higher in patients with lower tHcy levels. Mortality rate in the lowest tHcy quartile (17.4%) was significantly higher compared with other three quartiles (6.5 to 9.8%; Kaplan-Meier P ϭ 0.04). Relative risk of death for the lowest tHcy quartile, even after adjustment for case-mix and serum albumin, was 2.27 (95% confidence interval, 1.14 to 4.53; P ϭ 0.02). Hence, tHcy may be a more exclusive nutritional marker in MHD patients with no association with inflammatory measures. Despite a very high prevalence of hyperhomocysteinemia in MHD patients, lower values of tHcy are paradoxically associated with increased hospitalization and mortality. The lowest tHcy quartile confers a twofold increase in risk of death independent of hypoalbuminemia. The nutritional feature of tHcy in MHD patients may explain its reverse association with outcome.In the general population, an increased level of total plasma homocysteine (tHcy) is a risk factor for increased cardiovascular events and mortality (1-4). In maintenance hemodialysis (MHD) outpatients, however, the association between tHcy and clinical outcome is inconsistent and even paradoxical. Some studies have shown a poor outcome in MHD patients with hyperhomocysteinemia (5-9). However, a few recent studies have suggested that a decreased, not an increased, tHcy concentration is related to a higher prevalence of cardiovascular disease and poor outcome in these individuals (10 -12). This seems to be due to the empirical association between a low tHcy and protein-energy malnutrition, which is per se a known risk factor for poor clinical outcome in dialysis patients (11,13,14). This recently described paradoxical association between tHcy and clinical outcome in dialysis patients has now been referred to as a possible component of the reversal of the cardiovascular risks (15-17). It is believed that both inflammation and protei...

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Section: Patientsmentioning

confidence: 99%

mentioning

confidence: 99%

A Low, Rather than a High, Total Plasma Homocysteine Is an Indicator of Poor Outcome in Hemodialysis Patients

Kalantar-Zadeh

Block

Humphreys

et al. 2004

Journal of the American Society of Nephrology

153

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“…Another method, the malnutrition-inflammation score (MIS), was proposed by Kalantar-Zadeh et al as a nutritional screening tool for hemodialysis patients (7,8). MIS has been validated as a better nutritional indicator than SGA (7) and was reported to correlate with morbidity, mortality, various nutritional variables, inflammation (7,8), quality of life (9), anemia, and erythropoietin hyporesponsiveness in hemodialysis patient maintenance (10). Still, MIS is based on the SGA and therefore requires a subjective assessment.…”

Section: Introductionmentioning

confidence: 99%

Comparison Analysis of Nutritional Scores for Serial Monitoring of Nutritional Status in Hemodialysis Patients

Beberashvili

Azar

Sinuani

et al. 2013

Clinical Journal of the American Society of Nephrology

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SummaryBackground and objectives This study aimed to compare the longitudinal performance of the malnutritioninflammation score (MIS) and the geriatric nutritional risk index (GNRI), two nutritional scores for patients on maintenance hemodialysis.Design, setting, participants, & measurements Nutritional scores, dietary intake, biochemical markers, and body composition analysis were performed at baseline and at 6, 12, and 18 months after enrollment (which took place from January through December 2006) on 75 prevalent hemodialysis patients (43% women, mean age 64.8611.9 years). The patients underwent simultaneous MIS and GNRI assessments calculated by two independent examiners from baseline. The study period was 46.8616.4 months.Results GNRI had higher interobserver agreement (weighted k-score 0.98) than MIS (weighted k-score 0.62). Longitudinally, a 1-unit increase in MIS was associated with a 0.41 kcal/kg per day reduction in daily energy intake (P,0.001) and with a 0.014 g/kg per day reduction in nPNA (P=0.02). GNRI did not correlate with the change over time of dietary intake. Longitudinal changes of both scores were associated with appropriate changes over time in levels of nutritional biomarkers, inflammation (IL-6), and body composition parameters. Both scores expressed significant associations with prospective hospitalization, whereas only MIS was associated with mortality in this cohort. The multivariate Cox proportional hazard ratio was 1.15 for death for each 1-unit increase in the MIS (95% confidence interval, 1.03-1.3; P=0.02).Conclusions Both MIS and GNRI are valid tools for longitudinal assessment of hemodialysis patients' nutritional status. MIS has lower interobserver reproducibility than GNRI; however, MIS is more comprehensive than GNRI.

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“…Inflammation is an important factor associated with renal anemia because it leads to hyporesponsiveness of erythropoiesis-stimulating agent (ESA), as indicated by significantly increased ESA dose requirements in patients with elevated C-reactive protein (CRP) levels (14,15). One trigger of inflammation is the contact between the blood and dialysis membranes during hemodialysis, which may lead to the release of cytokines, such as TNF-a, IL-6, and IL-1 (16).…”

Section: Introductionmentioning

confidence: 99%

The Effect of High-Flux Hemodialysis on Hemoglobin Concentrations in Patients with CKD

Schneider

Drechsler

Krane

et al. 2012

Clinical Journal of the American Society of Nephrology

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SummaryBackground and objectives Hemodialysis treatment induces markers of inflammation and oxidative stress, which could affect hemoglobin levels and the response to erythropoietin use. This study sought to determine whether high-flux dialysis would help improve markers of renal anemia, inflammation, and oxidative stress compared with low-flux dialysis.Design, settings, participants, & measurements In a prospective, controlled study, 221 patients undergoing maintenance hemodialysis and receiving darbepoetin-alfa treatment (mean age, 66 years; 55% male) from 19 centers were screened in a 20-week run-in period of low-flux hemodialysis with a synthetic dialysis membrane. Thereafter, 166 patients were enrolled and randomly assigned to receive a synthetic high-flux membrane or to continue on low-flux dialysis for 52 weeks. Data on myeloperoxidase, oxidized LDL, high-sensitivity C-reactive protein, and the Malnutrition Inflammation Score were collected at baseline and after 52 weeks; routine laboratory data, such as hemoglobin, ferritin, and albumin, and the use of darbepoetin-alfa, were also measured in the run-in period.Results After 52 weeks, the low-flux and the high-flux groups did not differ with respect to hemoglobin (mean 6 SD, 11.760.9 g/dl versus 11.761.1 g/dl; P=0.62) or use of darbepoetin-alfa (mean dosage 6 SD, 29.8624.8 mg/wk versus 26.0631.1 mg/wk; P=0.85). Markers of inflammation, oxidative stress, or nutritional status also did not differ between groups.Conclusion Over 1 year, high-flux dialysis had no superior effects on hemoglobin levels or markers of inflammation, oxidative stress, and nutritional status. These data do not support the hypothesis that enhanced convective toxin removal would improve patient outcome.

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Effect of malnutrition-inflammation complex syndrome on EPO hyporesponsiveness in maintenance hemodialysis patients

Cited by 247 publications

References 49 publications

A Low, Rather than a High, Total Plasma Homocysteine Is an Indicator of Poor Outcome in Hemodialysis Patients

A Low, Rather than a High, Total Plasma Homocysteine Is an Indicator of Poor Outcome in Hemodialysis Patients

Comparison Analysis of Nutritional Scores for Serial Monitoring of Nutritional Status in Hemodialysis Patients

The Effect of High-Flux Hemodialysis on Hemoglobin Concentrations in Patients with CKD

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