Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA; Department of Internal Medicine, National Health Insurance Service Medical Center, Ilsan Hospital, Goyangshi, Gyeonggi-do, Republic of Korea.
Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA.
J Clin Lipidol. 2018 Mar-Apr;12(2):488-497. doi: 10.1016/j.jacl.2018.01.010. Epub 2018 Jan 31.
Elevated serum high-density lipoprotein cholesterol (HDL-C) has not been associated with better cardiovascular (CV) and all-cause mortality in hemodialysis patients. However, the association between change in HDL over time and mortality has not been fully examined.
In a nationally representative cohort of incident hemodialysis patients who had available HDL data at baseline and 6 months after dialysis initiation, we studied the association of change in HDL-C during the first 6 months of dialysis with all-cause and CV mortality.
Associations between HDL-C change and mortality were determined in Cox proportional hazard regression models with adjustment for multiple variables.
In case-mix models, there was a J-shaped association between change in HDL-C and mortality, such that quartiles 1 (<-5 mg/dL) and 4 (≥7 mg/dL) were each associated with higher all-cause (hazard ratio, 1.32 [95% confidence interval, 1.21-1.45] and 1.09 [1.01-1.18]) and CV (1.28 [1.06-1.55] and 1.23 [1.04-1.45]) death risk, respectively. In fully adjusted models that included indices of malnutrition and inflammation, the higher death risk observed in the lowest quartile was attenuated, whereas the highest quartile continued to demonstrate significantly higher all-cause (1.11 [1.02-1.20]) and CV mortality (1.15 [1.00-1.32]). These associations persisted across various subgroups.
Although malnutrition and inflammation may explain the increased risk for mortality in patients with decreasing serum HDL-C concentrations over time, these indices do not mitigate the elevated risk in patients with rising serum HDL-C. We found that increasing serum HDL-C over time is paradoxically associated with worse outcomes in incident hemodialysis patients.
在血液透析患者中，血清高密度脂蛋白胆固醇（HDL-C）升高与心血管（CV）和全因死亡率的改善无关。然而，HDL 随时间变化与死亡率之间的关系尚未得到充分研究。
在一个具有全国代表性的新进入血液透析患者队列中，这些患者在透析开始时和 6 个月后均有 HDL 数据，我们研究了透析开始后前 6 个月内 HDL-C 变化与全因和 CV 死亡率之间的关系。
使用 Cox 比例风险回归模型，在调整了多个变量后，确定 HDL-C 变化与死亡率之间的关系。
在混杂因素模型中，HDL-C 变化与死亡率之间存在 J 形关系，即第 1 四分位（<-5mg/dL）和第 4 四分位（≥7mg/dL）与全因（风险比，1.32 [95%置信区间，1.21-1.45] 和 1.09 [1.01-1.18]）和 CV（1.28 [1.06-1.55] 和 1.23 [1.04-1.45]）死亡风险均升高。在包含营养不良和炎症指标的完全调整模型中，观察到最低四分位的死亡风险增加程度减弱，而最高四分位继续显示出显著更高的全因（1.11 [1.02-1.20]）和 CV 死亡率（1.15 [1.00-1.32]）。这些关联在各种亚组中仍然存在。
尽管营养不良和炎症可能解释了随时间推移血清 HDL-C 浓度降低的患者死亡风险增加，但这些指标并不能减轻血清 HDL-C 浓度升高的患者的风险增加。我们发现，随时间推移血清 HDL-C 升高与新进入血液透析患者的预后恶化呈悖论关系。
