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Hyperhomocysteinemia, nutritional status, and cardiovascular disease in hemodialysis patients
M E Suliman1, A R Qureshi, P Bárány
1Divisions of Baxter Novum and Renal Medicine, Department of Clinical Science, Karolinska Institutet, Huddinge University Hospital, Stockholm, Sweden.
Insights
Elevated total homocysteine (tHcy) is common in dialysis patients, linked to malnutrition and cardiovascular disease (CVD). Lower tHcy levels correlated with worse survival, suggesting malnutrition
Area of Science:
- Nephrology
- Cardiovascular Medicine
- Nutritional Science
Background:
- Hyperhomocysteinemia, cardiovascular disease (CVD), and malnutrition are prevalent in end-stage renal disease (ESRD) patients.
- This study investigated the interplay between total plasma homocysteine (tHcy), nutritional status, and ischemic CVD in ESRD.
- High prevalence of malnutrition (56%) and CVD (60%) was noted in maintenance hemodialysis (HD) patients.
Purpose of the Study:
- To assess relationships between total plasma homocysteine (tHcy), nutritional status, and ischemic CVD in patients undergoing maintenance hemodialysis.
- To explore the impact of nutritional status on tHcy levels and CVD prevalence.
- To evaluate the association between tHcy levels and long-term mortality in ESRD patients.
Main Methods:
- Cross-sectional study of 117 maintenance hemodialysis (HD) patients.
- Nutritional status assessed using subjective global nutritional assessment (SGNA).
- Prospective four-year follow-up for overall mortality.
Main Results:
- 95% of HD patients exhibited elevated tHcy; total plasma cysteine (tCys) was also elevated, while methionine (Met), serine (Ser), and taurine (Tau) were lower than controls.
- Malnourished patients (SGNA) had lower serum albumin (SAlb), plasma IGF-1 (p-IGF-1), tHcy, tCys, and Met.
- Malnutrition prevalence was higher in patients with CVD (70%) than without (30%), with CVD patients showing lower tHcy, SAlb, p-IGF-1, serum creatinine (SCr), and hemoglobin.
- tHcy positively correlated with SAlb, Met, tCys, and SCr; tCys, SAlb, and normalized protein equivalent of nitrogen appearance (nPNA) were independent predictors of tHcy.
- Patients with lower tHcy (<24 micromol/L) had significantly worse four-year survival.
Conclusions:
- Most HD patients have significantly elevated tHcy, influenced by nutritional status, protein intake, and SAlb.
- Lower tHcy in CVD patients may stem from higher malnutrition and hypoalbuminemia rates.
- Lower tHcy levels are associated with worse survival, underscoring malnutrition as a mortality risk factor in ESRD, where CVD is the leading cause of death.
Background:
Hyperhomocysteinemia, cardiovascular disease (CVD), and malnutrition are common in patients with end-stage renal disease (ESRD). This study was designed to assess possible relationships between total plasma homocysteine (tHcy), nutritional status, and ischemic CVD.
Methods:
We performed a cross-sectional study in 117 unselected patients on maintenance hemodialysis (HD) treatment, among whom there was a high prevalence of malnutrition (56%), as assessed by the subjective global nutritional assessment (SGNA), and a high prevalence of CVD (60%), and prospectively, we followed-up the overall mortality for four years.
Results:
The level of tHcy was elevated in 95% of the HD patients, and that of total plasma cysteine (tCys) was also significantly elevated, while the plasma concentrations of methionine (Met), serine (Ser), and taurine (Tau) were significantly lower than those in healthy controls. The 65 patients who were malnourished according to the SGNA score had significantly lower levels of serum albumin (SAlb), plasma IFG-1 (p-IGF-1), tHcy, tCys, and Met than the 52 patients with normal nutritional status, whereas the levels of Ser, Tau, plasma folate, and vitamin B12 were similar in the two groups. The prevalence of malnutrition was 30% in the 47 patients without CVD and was significantly higher (70%, P < 0.001) in the 70 patients with CVD, who also had lower tHcy, SAlb, plasma IGF-1, serum creatinine (SCr), and blood hemoglobin. The tHcy levels were positively correlated with SAlb, Met, tCys, and SCr. Stepwise, multiple-regression analysis showed that tCys, SAlb, and normalized protein equivalent of nitrogen appearance (nPNA), an indicator of protein intake, were independent predictors of tHcy. The patients with tHcy <24 micromol/L (median value) had a significantly worse four-year survival than those with a higher tHcy (> or =24 micromol/L).
Conclusions:
Our results demonstrate that most of HD patients have grossly elevated tHcy levels, but that the absolute level appears to be dependent on nutritional status, protein intake, and SAlb. The results also suggest that the lower tHcy levels in patients with CVD than in those without CVD may be related to the higher prevalence of malnutrition and hypoalbuminemia in the CVD patients. This is also in accordance with our observation that the patients with lower tHcy had a worse survival rate than those with higher tHcy, considering that malnutrition is a strong risk factor for mortality and that CVD is the most common cause of death in ESRD patients.