C-reactive protein as predictor of death in end-stage diabetic nephropathy: role of peripheral arterial disease.
BACKGROUND
Patients with diabetes type 2 receiving dialysis therapy have a poor survival prognosis, mainly due to cardiovascular events. Increased C-reactive protein (CRP) levels, important in atherosclerosis, are associated with an increased risk for cardiovascular events. However, to date no study has shown the predictive value of CRP in relation to peripheral arterial disease stage.


METHODS
We enrolled all 445 prevalent patients with diabetic nephropathy receiving maintenance hemodialysis in 30 centers in Southern Germany from August 1999 to January 2000 for prospective study until December 2003. At inclusion, CRP and a complete clinical phenotype, including peripheral arterial disease Fontaine Stage were determined. The primary end point was all-cause mortality.


RESULTS
A total of 305 (68.5%) patients died. An increased log CRP at study inclusion was significantly associated with an increase in hazard ratio (HR) by multivariate Cox regression for all-cause (HR = 1.5, P= 0.002) and cardiac death (HR = 1.76, P= 0.02) in the entire collective. This result was applicable only to patients with peripheral arterial disease Fontaine stage IV (N= 190, multivariate HR = 1.75 for all-cause mortality, P= 0.006). Possibly due to inadequate power, we observed only an insignificant trend for CRP as predictor of all-cause death in patients without peripheral arterial disease or with less severe forms of peripheral arterial disease (HR = 1.36, P= 0.08).


CONCLUSIONS
In contrast to patients with peripheral arterial disease stage IV, patients with less severe atherosclerosis and elevated CRP are, if any, at less risk for cardiovascular mortality, possibly due to the difference in extent of affected vasculature and thus activated platelets and coagulation. Before judging the predictive value of CRP for mortality, peripheral vessel status should be determined.
Böger
Carsten A
CA
Klinik und Poliklinik für Innere Medizin II, University of Regensburg, Regensburg, Germany. carsten.boeger@klinik.uni-regensburg.de
Götz
Angela
A
Stubanus
Mike
M
Banas
Bernhard
B
Deinzer
Martina
M
Krüger
Bernd
B
Holmer
Stephan R
SR
Schmitz
Gerd
G
Riegger
Günter A J
GA
Krämer
Bernhard K
BK
D000368:Aged; D002097:C-Reactive Protein / Q000378:metabolism*; D015331:Cohort Studies; D003324:Coronary Artery Disease / Q000378:metabolism / Q000401:mortality; D003924:Diabetes Mellitus, Type 2 / Q000378:metabolism / Q000401:mortality; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000378:metabolism* / Q000401:mortality* / Q000628:therapy; D008297:Male; D008875:Middle Aged; D009017:Morbidity; D016491:Peripheral Vascular Diseases / Q000378:metabolism* / Q000401:mortality*; D011237:Predictive Value of Tests; D011446:Prospective Studies; D006435:Renal Dialysis / Q000379:methods; D012307:Risk Factors; D017678:Sex Distribution; D016019:Survival Analysis
D002097:C-Reactive Protein