title: Association of morbidity with markers of nutrition and inflammation in chronic hemodialysis patients: a prospective study.
abstract: BACKGROUND
  Numerous studies suggest a strong association between nutrition and clinical outcome in chronic hemodialysis (CHD) patients. Nevertheless, the pathophysiological link between malnutrition and morbidity remains to be clarified. In addition, recent evidence suggests that nutritional indices may reflect an inflammatory response, as well as protein-calorie malnutrition. In this study, we prospectively assessed the relative importance of markers of nutritional status and inflammatory response as determinants of hospitalization in CHD patients.
  
  
  METHODS
  The study consisted of serial measurements of concentrations of serum albumin, creatinine, transferrin, prealbumin, C-reactive protein (CRP), and reactance values by bio-electrical impedance analysis (BIA) as an indirect measure of lean body mass every 3 months over a period of 15 months in 73 CHD patients. Outcome was determined by hospitalizations over the subsequent three months following each collection of data.
  
  
  RESULTS
  Patients who required hospitalization in the three months following each of the measurement sets had significantly different values for all parameters than patients who were not hospitalized. Thus, serum albumin (3.93 +/- 0.39 vs. 3.74 +/- 0.39 g/dl), serum creatinine (11.0 +/- 3.7 vs. 9.1 +/- 3.5 mg/dl), serum transferrin (181 +/- 35 vs. 170 +/- 34 mg/dl), serum prealbumin (33.6 +/- 9.2 vs. 30.0 +/- 10.1 mg/dl), and reactance (50.4 +/- 15.6 vs. 43.0 +/- 13.0 ohms) were higher for patients not hospitalized, whereas CRP (0.78 +/- 0.89 vs. 2.25 +/- 2.72 mg/dl) was lower in patients who were not hospitalized. All differences were statistically significant (P < 0.05 for all parameters). When multivariate analysis was performed, serum CRP and reactance values were the only statistically significant predictors of hospitalization (P < 0.05 for both). When a serum CRP concentration of 0.12 mg/dl was considered as a reference range (relative risk 1.0), the relative risk for hospitalization was 7% higher (relative risk = 1.07) for a CRP concentration of 0.92 mg/dl and was 30% (relative risk = 1.30) higher for a CRP concentration of 3.4 mg/dl. When a reactance value of 70 ohms was considered as a reference range with a relative risk of 1.0, the relative risk of hospitalization increased to 1.09 for a reactance value of 43 ohms and further increased to 1.14 for a reactance value of 31 ohms.
  
  
  CONCLUSIONS
  The results of this study strongly indicate that both nutritional status and inflammatory response are independent predictors of hospitalization in CHD patients. CRP and reactance values by BIA are reliable indicators of hospitalization. Visceral proteins such as serum albumin, prealbumin, and transferrin are influenced by inflammation when predicting hospitalization. When short-term clinical outcomes such as hospitalizations are considered, markers of both inflammation and nutrition should be evaluated.
authors.affiliation: Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA. alp.ikizler@mcmail.vanderbilt.edu
authors.forename: T A
authors.initials: TA
authors.lastname: Ikizler
authors.forename: R L
authors.initials: RL
authors.lastname: Wingard
authors.forename: J
authors.initials: J
authors.lastname: Harvell
authors.forename: Y
authors.initials: Y
authors.lastname: Shyr
authors.forename: R M
authors.initials: RM
authors.lastname: Hakim
mesh_terms: D000368:Aged; D015415:Biomarkers; D002097:C-Reactive Protein / Q000032:analysis; D017097:Electric Impedance; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D007249:Inflammation / Q000453:epidemiology* / Q000276:immunology / Q000628:therapy; D007676:Kidney Failure, Chronic / Q000453:epidemiology* / Q000276:immunology / Q000628:therapy; D008297:Male; D008875:Middle Aged; D009017:Morbidity; D009747:Nutritional Physiological Phenomena; D011237:Predictive Value of Tests; D011446:Prospective Studies; D011502:Protein-Energy Malnutrition / Q000453:epidemiology / Q000276:immunology / Q000628:therapy; D012044:Regression Analysis; D006435:Renal Dialysis; D012307:Risk Factors; D012709:Serum Albumin; D014511:Uremia / Q000453:epidemiology / Q000276:immunology / Q000628:therapy
chemical_list: D015415:Biomarkers; D012709:Serum Albumin; D002097:C-Reactive Protein