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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2010  |  Volume : 21  |  Issue : 3  |  Page : 565-570
Pattern of lipid profile in patients on maintenance hemodialysis


1 Department of Medicine, Liaquat University of Medical and Health Sciences (LUMHS), Jamshoro, Sindh, Pakistan
2 Department of Nephro-Urology, Liaquat University of Medical and Health Sciences (LUMHS), Jamshoro, Sindh, Pakistan

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Date of Web Publication26-Apr-2010
 

   Abstract 

This hospital-based cross-sectional comparative observational study was performed to determine the pattern of lipid profile in patients on maintenance hemodialysis. The study was performed at the Department of Nephro-Urology, Liaquat University Hospital, Hyderabad, Pakistan from April 2008 to June 2008. Fifty patients with end-stage renal disease on maintenance hemo­dialysis (MHD) were studied. They comprised of 31 males and 19 females, the mean duration on HD was 7.58 ± 2.05 yrs, with frequency of two to three sessions per week and each session las­ting for four hours. Additionally, 25 healthy volunteers (16 male, 9 female) were also studied. Af­ter obtaining informed, written consent, general information of each patient was recorded on the proforma. After 12-hours fasting, blood samples were drawn from the arterio-venous fistula before starting dialysis. The total cholesterol, triglyceride (TG) or low density lipoprotein (LDL) levels more than 95 th percentile for age and gender or high density lipoprotein (HDL) less then 35 mg/dL was defined as dyslipidemia. Descriptive and inferential statistical analysis were performed using SPSS version 16.0. The age among MHD and control groups was 47.88 ± 13.92 and 54.56 ± 11.16 years respectively. Serum TG and lipoprotein-a (LPa) were significantly increased (P= < 0.001 for each) while HDL-c was significantly lower (P= < 0.001) in MHD patients than in the control group. The serum cholesterol, LDL-c, VLDL-c and chylomicron levels were not signi­ficantly different in the two groups. Our study suggests that patients on MHD show abnor­malities of lipid metabolism like hypertriglyceridemia, elevated lipoprotein-a and low HDL-c, which could contribute to atherosclerosis and cardiovascular disease that may increase the mor­bidity and mortality in these patients.

How to cite this article:
Maheshwari N, Ansari MR, Laghari MS, Darshana, Lal K, Ahmed K. Pattern of lipid profile in patients on maintenance hemodialysis. Saudi J Kidney Dis Transpl 2010;21:565-70

How to cite this URL:
Maheshwari N, Ansari MR, Laghari MS, Darshana, Lal K, Ahmed K. Pattern of lipid profile in patients on maintenance hemodialysis. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2019 Jul 23];21:565-70. Available from: http://www.sjkdt.org/text.asp?2010/21/3/565/62730

   Introduction Top


The incidence and prevalence of chronic kid­ney disease (CKD) are increasing worldwide. According to the 1998-2004 National Health and Nutritional Survey (NHANES), the preva­lence of CKD in the US population is 15.3%. [1] Patients with CKD are in the highest risk cate­gory for coronary heart disease (CHD). [2] The incidence of cardiovascular disease (CVD) is high in patients on hemodialysis (HD). [3]

Approximately 50% of patients with end-stage renal disease (ESRD) die from cardiovascular events, [4] which indicates that cardiovascular mortality is 30-times higher in dialysis patients. The Kidney Dialysis Outcome Quality Initia­tive (K/DOQI) guidelines state that patients on MHD with fasting triglycerides (TG) > 5.65 mmol/L, low density lipoprotein (LDL) > 2.59 mmol/L and non-HDL cholesterol >3 .36 mmol/ L, should be considered for treatment to re­duce the cardiovascular complications in these patients. [5] Dyslipidemia has been established as a well known traditional risk factor for CVD in the general population as well as in CKD pa­tients on maintenance HD. CKD is known to cause an increase in triglycerides and a dec­rease in high-density lipoprotein that mimic the lipid abnormalities of the metabolic syn­drome, which accelerate the progresssion of CKD and increase the risk for cardiovascular mortality.

Hemodialysis patients usually display eleva­ted TG, reduced serum high density lipopro­tein (HDL) cholesterol and elevated concentra­tion of lipoprotein-a (LP-a). Total and LDL cho­lesterol levels usually remain within normal limits. [6] Cholesterol levels may be lower in MDH patients. There is an inverse relationship between mortality and the cholesterol concentration. [7] This pattern of reverse epidemiology, i.e., hyper­cholesterolemia associated with decreased mor­tality and low cholesterol concentration asso­ciated with increased CVD mortality seen in MHD patients has been related to the malnu­trition-inflammation-atherosclerosis complex. [8],[9] Keeping in view the mortality associated with CVD in patients on HD, we investigated the serum lipid status in CKD patients undergoing long-term maintenance HD treatment and com­pared the values with healthy subjects. Addi­tionally, LP-a levels were also investigated as an independent risk factor of CVD in these patients.


   Patients and Methods Top


This cross sectional comparative observatio­nal study was conducted at the Department of Nephro-Urology, Liaquat University Hospital, Hyderabad, Pakistan. Fifty patients with CKD, who were on maintenance HD treatment were studied. There were 31 males and 19 females; their mean duration on HD treatment was 7.58 ± 2.05 yrs, with frequency of two to three times per week and each session of HD treat­ment lasting for four hours. Additionally, 25 healthy volunteers (16 male and 9 female) who had no history of hematological or renal disease, were included in the study. After they were in­formed about the study, written consent was obtained. General information of each patient (age, sex, BMI, duration and frequency of HD, underlying renal disease, and family history of hypertension, hyperlipedemia and myocardial infarction) were recorded. Patients were dialy­zed with volumetric dialyzer machines, bicar­bonate buffer-based dialysate with blood flow of 250 mL/min and dialysate flow of 500 mL/ min. All patients were dialyzed using 1.6 m 2 surface area hollow fiber polysulfone mem­brane dialyzers. Patients taking diuretics, lipid lowering agents as well as those with acute or chronic infection were excluded from the study. After 12-hours of fasting, blood samples of pa­tients were drawn from the AV fistula before starting dialysis for lipid profile analysis which included total cholesterol, serum triglycerides (TG), high density lipoprotein (HDL) choles­terol, low density lipoprotein (LDL) choleste­rol, very low density lipoprotein (VLDL) cho­lesterol, and LP-a. Total cholesterol, TG, HDL were measured by electrophoresis method and if TG was less than 400 mg/dL, LDL and VLDL were derived from Friedwald's formula. [10] (LDL­C=TC-(HDL-C+TG/2.2). Lipoprotein electro­phoresis was performed for LP-a by enzyme linked immune assay (ELISA) with immuno­biological laboratories (IBL) kit of Germany. Serum magnesium, creatinine, blood urea, se­rum calcium, and serum phosphorus were mea­sured using standard methods. In the control group, blood samples were collected from the cubital vein after 12-hours fasting. For each patient, total cholesterol, TG or LDL levels more then 95 th percentile for age and gender or HDL less then 35 mg/dL was defined as dyslipedemia.


   Statistical Analysis Top


The data were analyzed in statistical program SPSS version 16.0. Frequencies and percen­tages of categorical parameters were computed on 95% confidence interval and Pearson chi square test was used for BMI parameter which was recoded and categorized into four groups. Student's t test was applied for numerical va­riables of investigations. P value ≤ 0.05 was considered as significant level.


   Results Top


Seventy five subjects, 50 in the maintenance hemodialysis (MHD) group and 25 in the con­trol group were studied. There were 31 males (62%) and 19 females (38%) in the MHD group, and 16 males (64%) and nine females (36%) in the control group [Table 1]. Age among MHD and control groups were 47.88 ± 13.92 and 54.56 ± 11.16 years respectively. The mean duration on HD among the MHD patients was 7.58 + 2.05 years, with frequency of twice weekly in 42 (88%) and thrice weekly in eight patients (16%).

The MHD patients had lower BMI compared with the control group; mean (SD) 19.83 ± 4.05 vs. 22.21 ± 3.8 [Table 2]. The mean he­moglobin among MHD patients and control groups was 10.45 + 1.47 and 13.43 + 2.06 gm/ dL. Among MHD patients, the mean urea was 118.64 + 45.1 mg/dL and creatinine was 7.67 + 3.53 mg/dL [Table 1]. The serum triglyce­ride and LP-a levels were significantly higher in MHD patients than in the control group (P=< 0.001 for each), while HDL-c was signifi­cantly lower in MHD patients compared to control group (P= <0.001). The serum cho­lesterol, LDL-c, VLDL-c and chylomicron le­vels were not significantly different in the two groups. The most common abnormality observed among MHD patients was low HDL choles­terol followed by increased serum triglycerides and LP-a levels [Table 3].

The etiology of CKD among MHD patients was diabetes mellitus in 15 (30%), hypertension in 11 (22%), both hypertension and diabetes mellitus in six (12%), ADPKD in four (8%), analgesic nephropathy, obstructive nephropathy and idiopathic in three patients each (6%), pri­mary glomerular disease and chronic pyelo­nephritis in two patients each (4%) and renal artery stenosis in one patient (2%) [Figure 1], [Table 4].


   Discussion Top


In our study, the pattern of dyslipedemia in ESRD patients on MHD showed hypertrigly­ceridemia, elevated LP-a and reduced HDL-c. Also, patients on MHD treatment had signifi­cantly low BMI as compared to control group, a finding that has been observed in several other studies [11],[12] About 48% of the patients on MHD, in our study, had BMI < 18.5 kg/m 2 ; this indicates increased prevalence of malnu­trition in our patients according to WHO gui­delines for adults. [13] In our study, 42% were of normal weight, 8% were over weight and 2% were obese in the MHD group. In contrast, Tourn et al reported that 59% had normal weight, 24% were over weight and 17% were obese in their MHD patients. [14] This indicates that our patients are more malnourished as com­pared to their western counterparts.

In our study, the serum triglyceride levels were found to be significantly higher in MHD patients as compared to control group. Similar hyper­triglyceridemia was also observed in several other studies including the CHOICE study. [15],[16],[17],[18]

The second most common lipid abnormality in our study was low HDL-c level as compared to healthy volunteers. HDL-C was similarly found to be low in MHD patients by Pennell P et al [17] and in the CHOICE study. [18] Piperi C et al [19] also reported significantly low HDL-c level in their study. Total cholesterol, LDL-c, VLDL-c and chylomicrons were not significantly diffe­rent between the patient and control groups.

We also observed elevated levels of LP-a in MHD patients as compared to the control group. Lipoprotein-(a) is an independent risk factor for cardiovascular disease. [20],[21] Liu J et al [22] have suggested that increased levels of LP-a is highly atherogenic. Kaysen GA [23] also repor­ted elevated LP-a levels in patients with kid­ney disease, which was associated with cardio­vascular events among their dialysis patients.

Routine counseling and encouraging physical activity in MHD patients has potential to im­prove physical functioning, optimizing the qua­lity of life [24] and possibly improving the plas­ma lipids and lipoprotein pattern. Our study in­dicates that if we apply regular exercise pro­gram in our dialysis patients, we can achieve improvement in lipid and lipoprotein levels.


   Conclusion Top


Our results indicate that patients undergoing MHD show important abnormalities of lipid metabolism such as hypertriglyceridemia, ele­vated LP-a and low HDL-c, which could con­tribute to atherosclerosis and cardiovascular di­sease and may increase the morbidity and mor­tality in this group. As a first step of control­ling hyperlipidemia, body weight normaliza­tion, dietary modification, regular exercise and education about diet should be applied. It may also be useful to supplement the diet with poly­unsaturated fatty acids from fish oil in order to reduce triglycerides. Fibrates are not recom­mended in patients with renal failure, because of their renal excretion. Statins can be used sa­fely in patients with CKD with careful moni­toring. They reduce plasma LDL cholesterol by approximately 25-40%.

 
   References Top

1.Whaley-Connell AT, Sowers JR, Stevens LA, et al. CKD in the United States: Kidney Early Evaluation Program (KEEP) and National Health and Nutrition Examination Survey (NHANES) 1999-2004. Am J Kidney Dis 2008;51(suppl 2):S13-20.  Back to cited text no. 1      
2.National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: Evaluation, classification, and stratification. Am J Kidney Dis 2002;39:S1-266.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]  
3.Gowdak LH, Arantes RL, de Paula FJ, Krieger EM, De Lima JJ. Under use of American College of Cardiology/American Heart Asso­ciation Guidelines in hemodialysis patients. Ren Fail 2007;29(5):559-65.  Back to cited text no. 3      
4.Foley RN, Parfrey PS, Sarnak MJ. Clinical epidemiology of cardiovascular disease in chronic renal disease. Am J Kidney Dis 1998; 32:S112-9.  Back to cited text no. 4  [PUBMED]    
5.National Kidney Foundation. K/DOQI clinical practice guidelines for managing dyslipidemias in chronic kidney disease. Am J Kidney Dis 2003;41(suppl 3):S1-92.  Back to cited text no. 5      
6.Deighan CJ, Caslake MJ, McConnell M, Boulton­Jones JM, Packard CJ. Atherogenic lipoprotein phenotype in end-stage renal failure: origin and extent of small dense low density lipoprotein formation. Am J Kidney Dis 2000;35:852-62.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]  
7.Iseki K, Yamazato M, Tozawa M, Takishita S. Hypocholesterolemia is a significant predictor of death in a cohort of chronic hemodialysis patients. Kidney Int 2002;61:1887-93.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]  
8.Liu Y, Coresh J, Eustace JA, et al. Association between cholesterol level and mortality in dia­lysis patients: Role of inflammation and mal­nutrition. JAMA 2004;291:451-9.  Back to cited text no. 8  [PUBMED]    
9.Kalantar-Zadeh K, Block G, Humphreys MH, Kopple JD. Reverse epidemiology of cardio­vascular risk factors in maintenance dialysis patients. Kidney 2003;63(3):793-808.  Back to cited text no. 9      
10.Friedwald WT, Levy RI, Fredrickson DS. Esti­mation of the concentration of low-density lipoprotein cholesterol in plasma without use of preparative ultracentrifuge. Clin Chem 1972;18:499-502.  Back to cited text no. 10      
11.Bednarek-Skublewska A, Baranowicz-Gaszczyk I, Jozwiak L, Dzik M, Majdan M, Ksiazek A. Comparison of some nutritional parameters in hemodialysis patients over and below 65 years of age. Pol Arch Med Wewn 2005;113(5):417­-23.  Back to cited text no. 11      
12.Basaleem HO, Alwan SM, Ahmed AA, Al-Sakkaf KA. Assessment of the nutritional status of end­stage renal disease patients on maintenance he­modialysis. Saudi J Kidney Dis Transpl 2004; 15(4):455-6.  Back to cited text no. 12      
13.Physical status: the use and interpretation of anthropometry. Report of a WHO Expert Committee. Geneva, World Health Organization, 1995 (WHO Technical Report Series, No.854).  Back to cited text no. 13      
14.Torun D, Micozkadioglu H, Torun N, et al. Increased body mass index is not a reliable marker of good nutrition in hemodialysis pa­tients. Ren Fail 2007;29(4):487-93.  Back to cited text no. 14      
15.Shah B, Nair S, Sirsat RA, Ashavaid TF, Nair KG. Dyslipedemia in patients with chronic renal failure and in renal transplant patients. J Postgrad Med 1994;40(2):57-60.  Back to cited text no. 15      
16.de Gomez Dumm NT, Giammona AM, Touceda LA, Raimondi C. Lipid abnormalities in chro­nic renal failure patients undergoing hemo­dialysis. Medicina (Buenos Aires) 2001;61:142-­6.  Back to cited text no. 16      
17.Pennell P, Leclercq B, Delahunty MI, Walters BA. The utility of non-HDL in managing dys­lipidemia of stage 5 chronic kidney diseases. Clin Nephrol 2006;66(5):336-47.  Back to cited text no. 17      
18.Longenecker JC, Coresh J, Powe NR, et al. Traditional cardiovascular disease risk factors in dialysis patients compared with the general population: The CHOICE Study. J Am Soc Nephrol 2002;13(7):1918-27.  Back to cited text no. 18      
19.Piperi C, Kalofoutis C, Tzivras M, Troupis T, Skenderis A, Kalofoutis A. Effects of hemo­dialysis on serum lipids and phospholipids of end-stage renal failure patients. Mol Cell Biochem 2004;265(1-2):57-61.  Back to cited text no. 19      
20.Kronenberg F, Kathrein H, Ko͸nig P, et al. Apolipoprotein (a) phenotypes predicts the risk for carotid atherosclerosis in patients with end­stage renal disease. Arterioscler Thromb 1994; 14:1405-11.  Back to cited text no. 20      
21.Cressman MD, Heyka RJ, Paganini EP, et al. Lipoprotein (a) is an independent risk factor for cardiovascular disease in hemodialysis patients. Circulation 1992;86:475-82.  Back to cited text no. 21  [PUBMED]  [FULLTEXT]  
22.Liu J, Rosner MH. Lipid abnormalities asso­ciated with end-stage renal disease. Semin Dial 2006;19(1):32-40.  Back to cited text no. 22      
23.Kaysen GA. Hyperlipidemia in chronic kidney disease. Int J Artif Organs 2007;30(11):987­-92.  Back to cited text no. 23      
24.Painter P. Physical functioning in end-stage renal disease patients: Update 2005. Hemodial Int 2005;9(3):218-35.  Back to cited text no. 24      

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Correspondence Address:
Muhammad Rafique Ansari
Department of Nephro-Urology, Liaquat University of Medical and Health Sciences (LUMHS), Jamshoro, Sindh
Pakistan
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