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
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DOI：
10.1097/01.asn.0000107564.60018.51
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发表时间：
2004-02-01
影响因子：
13.6
通讯作者：
McAllister, CJ
中科院分区：
文献类型：
--
作者：
Kalantar-Zadeh, K;Block, G;McAllister, CJ
血浆总同型半胱氨酸（tHcy）水平升高是一般人群心血管不良结局的危险因素。然而，降低，而不是增加，tHcy浓度可能预测维持性血液透析（MHD）患者的不良结局，这种现象被称为反向流行病学。在367例年龄为54.5 ± 14.7（平均值±标准差）岁的MHD患者中，研究了tHcy水平和营养不良-炎症复合综合征标志物与12个月前瞻性住院和死亡率之间的关系，其中包括199例男性和55%的糖尿病患者。tHcy为24.4 +/- 11.8 mumol/L，94%的患者有高同型半胱氨酸血症（tHcy >13.5 mumol/L）。tHcy与一些实验室营养标志物（血清白蛋白、前白蛋白、肌酐和尿素氮）有弱至中度但统计学显著的双变量和多变量相关性，但与血清C反应蛋白或两种促炎细胞因子（IL-6和TNF-α）无显著相关性。在12个月的随访中，191例MHD患者住院，37例死亡，9例接受肾移植，38例转出。tHcy水平较低的患者的住院率显著较高。最低tHcy四分位数的死亡率（17.4%）显著高于其他三个四分位数（6.5 - 9.8%; Kaplan-Meier P = 0.04）。即使在调整病例组合和血清白蛋白后，最低tHcy四分位数的相对死亡风险为2.27（95%置信区间，1.14至4.53; P = 0.02）。因此，在MHD患者中，tHcy可能是一个更排他性的营养标志物，与炎症指标无关。尽管MHD患者中高同型半胱氨酸血症的患病率非常高，但tHcy值较低与住院率和死亡率增加矛盾相关。最低的tHcy四分位数使死亡风险增加两倍，与低白蛋白血症无关。MHD患者tHcy的营养特点可能解释其与预后的负相关性。
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 +/- 14.7 (mean +/- SD) years, who included 199 men and 55% individuals with diabetes. tHcy was 24.4 +/- 11.8 mumol/L, and 94% of the patients had hyperhomocysteinemia (tHcy >13.5 mumol/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-alpha). 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 = 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 = 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.