Liu Yongmei, Coresh Josef, Eustace Joseph A, Longenecker J Craig, Jaar Bernard, Fink Nancy E, Tracy Russell P, Powe Neil R, Klag Michael J
Johns Hopkins University, Baltimore, Md 21205, USA.
JAMA. 2004 Jan 28;291(4):451-9. doi: 10.1001/jama.291.4.451.
Total cholesterol level is inversely associated with mortality in dialysis patients, a group at high risk of cardiovascular disease (CVD). This paradox may be explained by systemic inflammation and/or malnutrition, which are associated with lower cholesterol levels and higher mortality.
To determine the relationship between cholesterol level and outcome in patients undergoing dialysis, accounting for inflammation and malnutrition.
DESIGN, SETTING, AND PARTICIPANTS: Prospective study of 823 patients enrolled from October 1995 to June 1998 who recently initiated dialysis, from 79 clinics, classified by absence or presence of inflammation and/or malnutrition (defined as serum albumin levels <3.6 mg/dL, C-reactive protein > or =10 mg/L, or interleukin 6 > or =3.09 pg/mL).
All-cause and cardiovascular disease mortality.
During a median follow-up of 2.4 years, 324 deaths (159 CVD deaths), 153 renal transplantations, and 10 losses to follow-up occurred. Average serum cholesterol level was lower in the presence of inflammation/malnutrition than in its absence. In a Cox model adjusted for age, race, and sex, a 40-mg/dL (1.0-mmol/L) increment in baseline total serum cholesterol level was associated with a decreased risk of all-cause mortality overall (relative hazard [RH], 0.92; 95% confidence interval [CI], 0.87-0.98) and in the presence of inflammation/malnutrition (RH, 0.89; CI, 0.84-0.95). In contrast, serum cholesterol level was associated with an increased risk in the absence of inflammation/malnutrition (RH, 1.32; 95% CI, 1.07-1.63). For CVD mortality, an inverse trend was not statistically significant in the presence of inflammation/malnutrition, and a positive association was evident in the absence of inflammation/malnutrition (RH, 1.41; 95% CI, 1.04-1.89). Further adjustment for traditional CVD risk factors, dialysis modality, comorbidity, and inflammatory markers attenuated the inverse association but strengthened the positive association.
The inverse association of total cholesterol level with mortality in dialysis patients is likely due to the cholesterol-lowering effect of systemic inflammation and malnutrition, not to a protective effect of high cholesterol concentrations. These findings support treatment of hypercholesterolemia in this population.
总胆固醇水平与透析患者的死亡率呈负相关，而透析患者是心血管疾病（CVD）的高危人群。这种矛盾现象可能由全身炎症和/或营养不良来解释，它们与较低的胆固醇水平及较高的死亡率相关。
在考虑炎症和营养不良因素的情况下，确定透析患者胆固醇水平与预后之间的关系。
设计、地点和参与者：对1995年10月至1998年6月期间从79家诊所招募的823例近期开始透析的患者进行前瞻性研究，根据是否存在炎症和/或营养不良进行分类（定义为血清白蛋白水平<3.6mg/dL、C反应蛋白>或=10mg/L或白细胞介素6>或=3.09pg/mL）。
全因死亡率和心血管疾病死亡率。
在中位随访2.4年期间，发生了324例死亡（159例心血管疾病死亡）、153例肾移植以及10例失访。存在炎症/营养不良时的平均血清胆固醇水平低于不存在时。在根据年龄、种族和性别进行校正的Cox模型中，基线总血清胆固醇水平每增加40mg/dL（1.0mmol/L），总体全因死亡率风险降低（相对风险[RH]，0.92；95%置信区间[CI]，0.87 - 0.98），在存在炎症/营养不良时也是如此（RH，0.89；CI，0.84 - 0.95）。相比之下，在不存在炎症/营养不良时，血清胆固醇水平与风险增加相关（RH，1.32；95%CI，1.07 - 1.63）。对于心血管疾病死亡率，在存在炎症/营养不良时，负相关趋势无统计学意义，而在不存在炎症/营养不良时，正相关明显（RH，1.41；95%CI，1.04 - 1.89）。进一步对传统心血管疾病危险因素、透析方式、合并症和炎症标志物进行校正后，减弱了负相关，但加强了正相关。
透析患者总胆固醇水平与死亡率之间的负相关可能是由于全身炎症和营养不良的降胆固醇作用，而非高胆固醇浓度的保护作用。这些发现支持对该人群的高胆固醇血症进行治疗。
