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Temporal discrepancies in the association between the apoB/apoA-I ratio and mortality in incident dialysis patients
M Chmielewski1, J J Carrero, A R Qureshi
1Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden. chmiel@amg.gda.pl
Insights
In chronic kidney disease (CKD) patients, a high apolipoprotein B/apolipoprotein A-I (apoB/apoA-I) ratio unexpectedly predicts short-term survival. This finding highlights the reverse epidemiology phenomenon in CKD, requiring cautious interpretation of the apoB/apoA-I ratio.
Area of Science:
- Cardiovascular research
- Nephrology
- Biomarker analysis
Background:
- The apolipoprotein B/apolipoprotein A-I (apoB/apoA-I) ratio is a known cardiovascular disease risk factor in the general population.
- Its prognostic value in chronic kidney disease (CKD) patients remains undetermined.
Purpose of the Study:
- To investigate the association between the apoB/apoA-I ratio and mortality in patients with advanced CKD.
- To explore the relationship between apoB/apoA-I ratio dynamics during dialysis initiation and patient survival.
Main Methods:
- Evaluated apoB/apoA-I ratio in 391 incident CKD stage 5 patients near dialysis initiation.
- Re-assessed the ratio in 182 patients after 1 year of dialysis, with follow-up for up to 3 years.
- Analyzed correlations with body mass index (BMI) and fat mass, adjusting for confounders.
Main Results:
- Baseline apoB/apoA-I ratio did not predict 4-year mortality but predicted short-term survival (first year) and subsequent long-term mortality after confounder adjustment.
- An increasing apoB/apoA-I ratio during the first year of dialysis was associated with a survival advantage, though this lost significance after adjusting for protein-energy wasting.
- Ratio changes correlated with BMI and fat mass.
Conclusions:
- A high apoB/apoA-I ratio and its increase during early dialysis are linked to short-term survival benefits in CKD patients.
- This paradoxical association exemplifies reverse epidemiology in CKD, necessitating careful interpretation of the apoB/apoA-I ratio in this population.
Background:
In the general population, a high apoB/apoA-I ratio is a strong risk factor for cardiovascular disease and mortality. However, whether this is the case in chronic kidney disease (CKD) patients is currently unknown.
Study Design:
The apoB/apoA-I ratio was evaluated in 391 incident CKD stage 5 patients examined close to dialysis initiation, and again after 1 year of dialysis in a subgroup of 182 patients, subsequently followed for up to 3 years.
Results:
Baseline values of the apoB/apoA-I ratio as well as changes in the ratio during the first year of dialysis correlated with body mass index (BMI) and fat mass. The baseline apoB/apoA-I ratio showed no association with 4-year mortality. However, after adjustment for confounders, a high apoB/apoA-I ratio (>0.9) predicted short-term (first year) survival [hazard ratio (HR): 0.35; 95% confidence interval (CI): 0.13-0.85)] and long-term (next 3 years) mortality (HR: 1.72; 95% CI: 1.01-2.96). An increase in the apoB/apoA-I ratio during the first year of dialysis was linked to a survival advantage thereafter (HR: 0.48; 95% CI: 0.22-0.98). However, this association lost its significance (HR: 0.62; 95% CI: 0.26-1.36) after adjustment for indices of protein-energy wasting.
Conclusions:
A high apoB/apoA-I ratio and an increase in this ratio during the first year on dialysis were associated with short-term survival advantage in CKD patients. This paradoxical relationship represents an example of the so-called reverse epidemiology phenomenon in CKD patients and suggests that the apoB/apoA-I ratio should always be interpreted with caution in this patient population.
