Moradi Hamid, Streja Elani, Kashyap Moti L, Vaziri Nosratola D, Fonarow Gregg C, Kalantar-Zadeh Kamyar
Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA, USA.
Department of Medicine, University of California Irvine, School of Medicine, Orange, CA, USA Atherosclerosis Research Center, Veterans Affairs Healthcare System, Long Beach, CA, USA.
Nephrol Dial Transplant. 2014 Aug;29(8):1554-62. doi: 10.1093/ndt/gfu022. Epub 2014 Feb 25.
High-density lipoprotein (HDL) confers protection against atherosclerosis by several different mechanisms. Although in the general population, increasing levels of HDL are associated with reduced cardiovascular (CV) mortality, this association is not well known in patients with chronic disease states such as end-stage renal disease. We hypothesize that the association of serum HDL concentration and its ratio to total cholesterol with all-cause and CV mortality in hemodialysis patients is different from the general population.
A 3-year (July 2004 to June 2007) cohort of 33 109 chronic hemodialysis patients was studied in the USA in the dialysis clinics where lipid profile was measured in at least 50% of all outpatients of the clinic during a given calendar quarter. Cox proportional hazard models were adjusted for demographics and case-mix variables and cubic splines were plotted.
Higher HDL concentrations up to 50 mg/dL were associated with better overall survival, while HDL at 60 mg/dL and above was associated with a rise in all-cause and CV mortality. All-cause and CV mortality hazard ratio was 1.28 (1.20-1.38) and 1.08 (1.01-1.16) for HDL <30 mg/dL and 1.05 (1.00-1.10) and 1.08 (1.00-1.16) for HDL ≥ 60 mg/dL, respectively (reference: HDL: 30-<60 mg/dL).
In contrast to the general population, low total cholesterol to HDL ratio was associated with higher mortality in hemodialysis patients. A U-shaped association between HDL cholesterol level and all-cause and CV mortality exists in hemodialysis patients with HDL between 50 and <60 mg/dL exhibiting the best survival. The underlying mechanisms responsible for these seemingly paradoxical associations await further investigation.
高密度脂蛋白（HDL）通过多种不同机制对动脉粥样硬化起到保护作用。在一般人群中，HDL水平升高与心血管（CV）死亡率降低相关，但在诸如终末期肾病等慢性疾病患者中，这种关联并不为人熟知。我们推测，血液透析患者血清HDL浓度及其与总胆固醇的比值与全因死亡率和CV死亡率之间的关联与一般人群不同。
在美国，对33109例慢性血液透析患者进行了为期3年（2004年7月至2007年6月）的队列研究，研究在透析诊所开展，在给定日历季度内，该诊所至少50%的门诊患者进行了血脂谱测量。Cox比例风险模型针对人口统计学和病例组合变量进行了调整，并绘制了三次样条曲线。
HDL浓度高达50mg/dL时，较高浓度与更好的总体生存率相关，而HDL浓度在60mg/dL及以上时，则与全因死亡率和CV死亡率上升相关。HDL<30mg/dL时，全因死亡率和CV死亡率风险比分别为1.28（1.20 - 1.38）和1.08（1.01 - 1.16）；HDL≥60mg/dL时，风险比分别为1.05（1.00 - 1.10）和1.08（1.00 - 1.16）（参考：HDL：30 - <60mg/dL）。
与一般人群不同，血液透析患者中总胆固醇与HDL比值低与较高死亡率相关。HDL胆固醇水平与全因死亡率和CV死亡率之间呈U形关联，在HDL为50至<60mg/dL的血液透析患者中生存率最佳。造成这些看似矛盾关联的潜在机制有待进一步研究。
