Homocysteine Is a Risk Factor in Predialysis Patients When Associated with Malnutrition and Inflammation

Abstract

The increased level of plasma total homocysteine (tHcy) in chronic kidney disease patients has been reported as a new and independent risk factor for cardiovascular disease. However, after the description of reverse epidemiology in the renal population, the association of tHcy and nutrition became less clear. We evaluated the association between homocysteine, nutritional status, and inflammation, and their impact on mortality in 95 predialysis patients. High sensitivity C-Reactive Protein (hs-CRP), interleukin 6 (IL-6), Tumor Necrosis Factor α (TNF-α)], and tHcy were evaluated, as was the nutritional status by the modified Subjective Global Nutritional Assessment (mSGA). We divided our population in four groups according to their tHcy and mSGA values being above or below the mean level and found the lowest survival in the group with tHcy and mSGA above the mean level, as well as higher levels of IL-6 (P = .03) and TNF-α (P = .045). Higher levels of homocysteine can be associated with higher mortality in predialysis patients, as long as they are associated with malnutrition and inflammation.

Homocysteine and methylmalonate: when should I measure them and what do they mean?

“…There are also parallel changes in plasma creatinine, suggesting a renal component. This is consistent with the mild increases (up to about 30 μmol/L) found with renal dysfunction 14. Mild increases in plasma total homocysteine may also occur with lifestyle factors including heavy coffee and tea consumption, smoking and lack of exercise.…”

Maintained Folic Acid Supplementation Reduces the Risk of Mortality in Continuous Ambulatory Peritoneal Dialysis Patients

“…Although the mechanisms by which homocysteine induce vascular injury are not yet completely unraveled, homocysteine has been reported to induce oxidative stress, inhibit antioxidant enzymes, accelerate endothelial dysfunction, and so on [3,4]. Consistently, previous observations have shown that hyper-homocysteinemia is an independent risk factor for atherosclerotic vascular disease in patients with end-stage renal disease (ESRD) [5,6,7]. Folic acid (FA) supplements reduce serum homocysteine levels and improve endothelial dysfunction [8,9], thereby initiating a hypothesis that FA supplements may have a positive impact on clinical outcomes in patients with chronic kidney disease (CKD).…”

The Nutritional Status of Patients Starting Specialized Predialysis Care

“…[8][9][10][11][12] Furthermore, an advantage of this study compared with others is that it is a multicenter study consisting entirely of incident patients. [8][9][10][11][12] Therefore, the results of this analysis can be generalized to CKD patients starting with a regular program of predialysis care.…”

“…Studies performed in this specific population show a prevalence of moderate malnutrition of 19.6% to 28.9%, whereas in these studies, severely malnourishment was very rare. [8][9][10][11][12] It has to be noted that only a few small studies, the biggest consisting of 95 patients, have been performed including a mixture of incident and prevalent predialysis patients. [8][9][10][11][12] Different tools for assessing nutritional status have been used in these studies.…”

“…Among these studies, 4 used a validated subjective global assessment (SGA) to assess nutritional status. 8,[10][11][12] One study used mid-arm muscle circumference and body mass index (BMI) as indicators for nutritional status. 9 Thus, there is uncertainty about the prevalence of malnutrition measured with a validated method such as SGA in patients at the start of specialized predialysis care, and results from a reasonably powered study are lacking.…”