Yeun J Y, Levine R A, Mantadilok V, Kaysen G A
Department of Medicine, Division of Nephrology, and the Department of Statistics, University of California Davis, Sacramento 95817, USA.
Am J Kidney Dis. 2000 Mar;35(3):469-76. doi: 10.1016/s0272-6386(00)70200-9.
Hypoalbuminemia predicts death in dialysis patients. Although hypoalbuminemia has been attributed to malnutrition, evidence of inflammation (C-reactive protein [CRP] and cytokine levels) has recently been recognized to predict albumin concentration in dialysis patients. We measured CRP and albumin levels in October 1995 in 91 hemodialysis (HD) patients. During a 34-month follow-up period, we determined the incidence and cause of death. Patients were divided into four groups based on serum albumin levels (<3.5 [lowest quartile], 3.5 to 3.8, 3.9 to 4.0, and >4.0 g/dL [highest quartile]). Survival differed among the four groups (P = 0.0063). Patients with albumin levels greater than 4.0 g/dL had the greatest survival. Kaplan-Meier survival estimates of patients from varying CRP quartiles (<2.6, 2.6 to 5.2, 5.3 to 11.5, and >11.5 microg/mL) differed among the four groups (P < 0.0001). The group with the greatest CRP level (>11.5 microg/mL) had the lowest survival. Multivariate analysis using the Cox proportional hazards model showed that only CRP level (chi-square = 21.11; P < 0.0001) and age (chi-square = 5.44; P = 0.020) predicted death. Albumin level (chi-square = 0.16; P = 0.69) was not predictive. Only when CRP was excluded from the model did low serum albumin level (chi-square = 12. 04; P = 0.0004) predict death. CRP level (chi-square = 16.79; P < 0. 0001) and age (chi-square = 6.38; P = 0.012) also superceded albumin level (chi-square = 0.45; P = 0.51) in predicting cardiovascular mortality. Although values for blood urea nitrogen, creatinine, and normalized protein catabolic rate were significantly less among patients who died, these parameters, as well as cholesterol level and diabetes, were not important predictors of death in multivariate analysis. The acute-phase response or the cause of the acute-phase response is largely responsible for the effect of hypoalbuminemia on mortality in HD patients.
低白蛋白血症可预测透析患者的死亡。尽管低白蛋白血症一直被归因于营养不良，但炎症证据（C反应蛋白[CRP]和细胞因子水平）最近已被认为可预测透析患者的白蛋白浓度。我们于1995年10月测量了91例血液透析（HD）患者的CRP和白蛋白水平。在34个月的随访期内，我们确定了死亡的发生率和原因。根据血清白蛋白水平（<3.5[最低四分位数]、3.5至3.8、3.9至4.0以及>4.0 g/dL[最高四分位数]）将患者分为四组。四组患者的生存率存在差异（P = 0.0063）。白蛋白水平大于4.0 g/dL的患者生存率最高。不同CRP四分位数（<2.6、2.6至5.2、5.3至11.5以及>11.5 μg/mL）患者的Kaplan-Meier生存估计在四组间存在差异（P < 0.0001）。CRP水平最高（>11.5 μg/mL）的组生存率最低。使用Cox比例风险模型进行的多变量分析显示，只有CRP水平（卡方 = 21.11；P < 0.0001）和年龄（卡方 = 5.44；P = 0.020）可预测死亡。白蛋白水平（卡方 = 0.16；P = 0.69）无预测作用。只有当CRP被排除在模型之外时，低血清白蛋白水平（卡方 = 12.04；P = 0.0004）才可预测死亡。在预测心血管死亡率方面，CRP水平（卡方 = 16.79；P < 0.0001）和年龄（卡方 = 6.38；P = 0.012）也超过了白蛋白水平（卡方 = 0.45；P = 0.51）。尽管死亡患者的血尿素氮、肌酐和标准化蛋白分解率值显著较低，但在多变量分析中，这些参数以及胆固醇水平和糖尿病并非死亡的重要预测因素。急性期反应或急性期反应的原因在很大程度上导致了低白蛋白血症对HD患者死亡率的影响。
