Reverse epidemiology of cardiovascular risk factors in maintenance dialysis patients.

By Kamyar Kalantar-Zadeh, G. Block, M. Humphreys, J. Kopple. Kidney International, 2003

1,256 citations recorded by the source corpus.

Conventional risk factors of cardiovascular disease and mortality in the general population such as body mass, serum cholesterol, and blood pressure are also found to relate to outcome in maintenance dialysis patients, but often in an opposite direction. Obesity, hypercholesterolemia, and hypertension appear to be protective features that are associated with a greater survival among dialysis patients. A similar protective role has been described for high serum creatinine and possibly homocysteine levels in end-stage renal disease (ESRD) patients. These findings are in contrast to the well-known association between over-nutrition and poor outcome in the general population. The association between under-nutrition and adverse cardiovascular outcome in dialysis patients, which stands in contrast to that seen in non-ESRD individuals, has been referred to as "reverse epidemiology." Publication bias may have handicapped or delayed additional reports with such paradoxical findings in ESRD patients. The etiology of this inverse association between conventional risk factors and clinical outcome in dialysis patients is not clear. Several possible causes are hypothesized. First, survival bias may play a role since only a small number of patients with chronic kidney disease (CKD) survive long enough to reach ESRD. Hence, the dialysis patients are probably a distinctively selected population out of CKD patients and may not represent the risk factor constellations of their CKD predecessors. Second, the time discrepancy between competitive risk factors may play a role. For example, the survival disadvantages of under-nutrition, which is frequently present in dialysis patients, may have a major impact on mortality in a shorter period of time, and this overwhelms the long-term negative effects of over-nutrition on survival. Third, the presence of the "malnutrition-inflammation complex syndrome" (MICS) in dialysis patients may also explain the existence of reverse epidemiology in dialysis patients. Both protein-energy malnutrition and inflammation or the combination of the two are much more common in dialysis patients than in the general population and many elements of MICS, such as low weight-for-height, hypocholesterolemia, or hypocreatininemia, are known risk factors of poor outcome in dialysis patients. The existence of reverse epidemiology may have a bearing on the management of dialysis patients. It is possible that new standards or goals for such traditional risk factors as body mass, serum cholesterol, and blood pressure should be considered for these individuals.

Subfields: Nephrology, Physiology, Rheumatology

View Paper: https://www.semanticscholar.org/paper/1dd6ea7b9c9a591efa1fb8d11088310494af9b0b

How researchers see this paper

The researchers whose trusted networks rank it highest, strongest advocate first. Every researcher gets a different order.

In Nephrology

1. Kamyar Kalantar-Zadeh
2. G. Block
3. Nur Samsu

In Rheumatology

1. Kai-Uwe Eckardt
2. B. Kasiske

Citations in the corpus

• Survival advantages of obesity in dialysis patients. (2005, background): “ology, and components of the reverse epidemiology and the role of MICS in its development in MHD patients remain of paramount importance, because the annual mortality and hospitalization rate among MHD patients remain high (5).”
• Cardiovascular disease in chronic kidney disease. A clinical update from Kidney Disease: Improving Global Outcomes (KDIGO). (2011, background): “Standard cardiovascular risk factors are common in CKD, but do not fully explain the high incidence of cardiovascular events or increased mortality rates; their association with cardiovascular outcomes is attenuated or even reversed at the most advanced CKD stages.(20) Inflammation and oxidative str”
• Hemodialysis-induced cardiac injury: determinants and associated outcomes. (2009, background): “D ialysis patients display hugely elevated rates of cardiac mortality (1), and this rate of cardiovascular attrition is not driven by the same risk factors, or pathophysiological processes, that are important in the general population (2).”
• Reverse epidemiology of conventional cardiovascular risk factors in patients with chronic heart failure. (2004, background): “These paradoxical observations, hich have also been reported in patients with end-stage enal disease (ESRD) undergoing dialysis treatment, have een referred to as “reverse epidemiology” (7).”
• Emerging biomarkers for evaluating cardiovascular risk in the chronic kidney disease patient: how do new pieces fit into the uremic puzzle? (2008, neutral): “reversed, in patients with advanced CKD (27).”
• Diabetic Kidney Disease: A Report From an ADA Consensus Conference (2014, neutral): “verse association in which obesity, hypercholesterolemia, and hypertension appear to confer survival advantages has been described (141,142).”
• Appetite and inflammation, nutrition, anemia, and clinical outcome in hemodialysis patients. (2004, background): “It may be the missing link between inflammation and PEM and contributes to the development of the reverse epidemiology phenomenon (5, 17).”
• Mineral metabolism, mortality, and morbidity in maintenance hemodialysis. (2004, background): “The direct association between total cholesterol and the risk of cardiovascular hospitalization was noteworthy, given the paradoxical association between total cholesterol and all-cause mortality described in several studies of dialysis patients (31,32).”