Paradox of risk factors for cardiovascular mortality in uremia: Is a higher cholesterol level better for atherosclerosis in uremia?
Section snippets
Dyslipidemia and atherosclerotic arterial wall changes in ESRD
Previous studies by us and others clearly showed that dyslipidemia is an independent factor associated with atherosclerotic arterial wall changes in patients with ESRD as well as in the general population. Carotid artery intima-media thickness (CA-IMT) was greater in nondiabetic hemodialysis patients than in healthy control subjects comparable in terms of age and gender.5 Increase of cholesterol in the non-high density lipoprotein (HDL) fraction was an independent factor associated with an
Mortality rate, event rate, and fatality rate
Because the cardiovascular mortality rate is theoretically the product of event rate and fatality rate after an event, risk factors for cardiovascular mortality could fall into two categories: those raising the event rate and those affecting the fatality rate. Therefore, some populations have an elevated risk of cardiovascular mortality due to an increased event rate, and other populations have an elevated risk of cardiovascular mortality due to an increased fatality rate. If both event rate
Cardiovascular event rate in ESRD
A few studies have shown that the cardiovascular event rate is increased in patients with ESRD. According to Iseki and Fukiyama,10 the incidence (equal to the event rate) of acute myocardial infarction (AMI) was 2 to 5 times higher in hemodialysis patients than in the general population. They also reported that the incidence of stroke was higher in hemodialysis patients than in the general population11 and that the relative risk was higher in younger generations.
Risk factors for cardiovascular event rate
Previous studies indicated that lipid abnormalities, diabetes, and hyperhomocysteinemia are risk factors for cardiovascular events. Koch et al12 compared 607 hemodialysis patients with and without coronary artery disease and found that those with coronary artery disease had higher levels of total cholesterol, triglycerides, low-density lipoprotein (LDL) cholesterol, and apolipoprotein B (apo B) and lower levels of HDL cholesterol and apo A-I. The cross-sectional association of apo B and HDL
Fatality rate in ESRD
There are a few studies demonstrating that the fatality rate after a cardiovascular event is increased in ESRD patients. Herzog et al16 retrospectively identified 34,189 dialysis patients who experienced AMI after starting dialysis and found that dialysis patients had a poorer survival rate than did transplant recipients. Iseki and Fukiyama10 followed-up a cohort of 3,741 dialysis patients and identified 61 patients who experienced AMI during the follow-up. The survival rate during the first
Risk factors for fatality rate
There is only small amount of data showing factors affecting fatality rate after an event. Foley et al14 reported that ESRD patients with diabetes showed a higher death rate after cardiac events. The relative risk of death as compared with nondiabetic ESRD patients was 1.7 for death after ischemic heart disease and 2.2 for death after cardiac failure. Foley et al17 showed that a lower hemoglobin concentration was not significantly associated with de novo ischemic heart disease, but it was
Paradox between homocysteine and cardiovascular mortality in ESRD
In addition to the paradoxical association between cholesterol and mortality, there is another example of a paradox in risk factors-hyperhomocysteinemia. As mentioned above,15 an elevated plasma homocysteine level is an independent risk factor for atherosclerosis in ESRD patients as well as in the general population. In contrast, a recent study by Suliman et al18 showed that a lower homocysteine level was an independent predictor of higher mortality in a cohort of 117 hemodialysis patients.
Conclusions
Patients with ESRD have a substantially increased cardiovascular mortality rate. This difference is due to an increase in both the event rate and the fatality rate. Although a lower plasma cholesterol level was associated with a higher risk of cardiovascular mortality in dialysis patients, dyslipidemia itself has adverse effects on the arterial wall and the cardiovascular event rate in ESRD patients. Some risk factors for mortality appear to be associated with an increased fatality rate rather
References (19)
- et al.
High-resolution B-mode ultrasonography in evaluation of atherosclerosis in uremia
Kidney Int
(1995) - et al.
Additive impacts of diabetes and renal failure on carotid atherosclerosis
Atherosclerosis
(2000) - et al.
Long-term prognosis and incidence of acute myocardial infarction in patients on chronic hemodialysis. The Okinawa Dialysis Study Group
Am J Kidney Dis
(2000) - et al.
The impact of anemia on cardiomyopathy, morbidity, and and mortality in end-stage renal disease
Am J Kidney Dis
(1996) - et al.
Hyperhomocysteinemia, nutritional status, and cardiovascular disease in hemodialysis patients
Kidney Int
(2000) - et al.
Accelerated atherosclerosis in prolonged maintenance hemodialysis
N Engl J Med
(1974) - et al.
Should hyperlipemia of renal failure be treated?
Kidney Int Suppl
(1985) - et al.
Mortality risk factors in patients treated by chronic hemodialysis. Report of the Diaphane collaborative study
Nephron
(1982) - et al.
Association between baseline risk factors, cigarette smoking, and CHD mortality after 10.5 years. MRFIT Research Group
Prev Med
(1991)
Cited by (94)
Obesity and Mortality in End-Stage Renal Disease. Is It Time to Reverse the “Reverse Epidemiology”—at Least in Peritoneal Dialysis?
2019, Journal of Renal NutritionCitation Excerpt :However, survival in the ESRD population has not improved significantly. In the early 2000s, many epidemiologic studies indicated a paradoxically inverse relationship with traditional CVD risk factors and mortality in dialysis patients.8-11 Specifically, the paradoxical relationship between high BMI and lack of mortality increase in chronic HD patients was first reported in 1982 from France by the Diaphane collaborative study.12,13
The heart and vascular system in dialysis
2016, The LancetCitation Excerpt :Other predictors of all-cause mortality related to mineral bone disorders in chronic kidney disease included high serum calcium, high intact parathyroid hormone concentrations, and the absence of exogenous vitamin D receptor activators63 and phosphate binders.64 An increased susceptibility to death after a cardiovascular event contributes to the increased cardiovascular mortality in patients with chronic kidney disease.65 In patients undergoing haemodialysis, survival was low after myocardial infarction66 and stroke67 compared with the general population who had also had a myocardial infarction or stroke.
Can be galectin-3 a novel marker in determining mortality in hemodialysis patients?
2015, Clinical BiochemistryEndocrine and metabolic changes affecting cardiovascular disease in dialysis patients
2015, Journal of Renal Nutrition