Elevated neutrophil to lymphocyte ratio predicts overall and cardiovascular mortality in maintenance peritoneal dialysis patients

Background

Neutrophil to lymphocyte ratio (NLR) is widely used as a marker of inflammation and an indicator of cardiovascular outcomes in patients with coronary artery disease. However, its prognostic value in peritoneal dialysis (PD) patients is still unknown.

Methods

We studied 138 newly started PD patients and 60 healthy controls at the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China. Baseline NLR as well as demographic, clinical, and biochemical parameters were recorded. All patients were followed up until March 2011 to evaluate mortality as the primary outcome. Overall and cardiovascular disease-free survival rates were compared according to NLR level. Multivariate analysis was performed to assess the prognostic value of NLR.

Results

Baseline NLR levels (mean 3.5 ± 1.6) were significantly increased in PD patients compared to healthy controls (mean 1.5 ± 0.5; P < 0.001). Patients with higher NLR had a higher mortality rate compared with patients with lower NLR (51.5% vs 22.9%; P?=?0.006). The 1-year and 3-year overall survival rates were 86.6% and 65.9% for patients with higher NLR compared with 97% and 85.1% for patients with lower NLR (P = 0.006). Patients with higher NLR also showed a higher cardiovascular mortality rate, compared with patients with lower NLR (38% vs 7.6%; P?=?0.003). The 1-year and 3-year cardiovascular event-free survival rates were 90.7% and 81.9% for patients with higher NLR, compared with 98.6% and 95.1% for patients with lower NLR. Multivariate analysis showed high NLR value was an independent risk factor for all-cause and cardiovascular mortality.

Conclusion

Neutrophil to lymphocyte ratio is a strong predictor for overall and cardiovascular mortality in PD patients.     

Peripheral arterial disease predicts overall and cardiovascular mortality in peritoneal dialysis patients

Background: Peripheral arterial disease (PAD) is an important manifestation of systemic atherosclerosis and is common among dialysis patients. Cardiovascular disease (CVD) accounts for the leading cause of mortality in dialysis patients, and PAD has been found as a predictor for cardiovascular as well as overall mortality in general population. However, the study on the role of PAD in the prognosis of peritoneal dialysis patients is rather limited. Methods: Prevalent continuous ambulatory peritoneal dialysis patients over 60 years old were recruited in this study and were followed-up regularly to death or the end of the study. The diagnosis of PAD was based on ankle-brachial pressure index (ABI) < 0.9 or intermittent claudication. Univariate and multivariate Cox proportional hazard models were used to identify the risk factors for cardiovascular and overall mortality. Survival curves were estimated by the Kaplan-Meier method followed by log-rank test to compare the mortality rate between PAD and non-PAD patients. Results: One hundred and seventy-one patients were included and 62 (36%) had PAD complication. In the follow-up of 24.4 (median 34.6) months, 36 deaths were recorded: 19 from PAD group and 17 from non-PAD group. Twenty-one patients died due to CVD: 13 from PAD group and 8 from non-PAD group. The presence of PAD and serum albumin was found independently associated with cardiovascular and overall mortality using Cox proportional hazards model. Conclusion: PAD is very common in aged peritoneal dialysis patients and independently associated with both cardiovascular and overall mortality.     

Elevated cardiac troponin T in peritoneal dialysis patients is associated with CRP and predicts all-cause mortality and cardiac death.

BACKGROUND: Cardiac troponin T (cTnT) is a highly sensitive and specific marker of myocardial damage. In sera from patients with end-stage renal disease, cTnT may be elevated without other signs of acute myocardial injury. It has been shown that elevated cTnT in haemodialysis patients is associated with poor prognostic outcome. The aim of the present study was to test the hypothesis that elevated cTnT in a single serum sample from peritoneal dialysis (PD) patients is of prognostic importance. METHODS: Blood samples were taken from 26 randomly selected PD patients without signs of acute myocardial ischaemia. Sera were analysed for: cTnT with the second generation TnT ELISA on ES 300; cardiac troponin I (cTnI) with Opus Plus; and for creatine kinase-MB (CKMB) mass and C-reactive protein (CRP). After 4 years, clinical outcomes were evaluated by chart review. The influence on survival was tested with Kaplan-Meier analysis and Cox's proportional regression analysis. RESULTS: Concentrations of cTnT >/=0.04 micro g/l and CRP >/=10 mg/l were strong predictors of all-cause mortality in univariate analysis. Twelve out of 14 patients with cTnT >/=0.04 micro g/l died compared with three out of 12 with cTnT <0.04 micro g/l. Other factors that influenced survival were age and the presence of ischaemic heart disease (IHD). There was a significant positive correlation between cTnT and CRP, and between cTnT and age. Cardiac troponin T was an independent predictor compared with age but not compared with CRP and IHD. Neither cTnI nor CKMB mass concentrations were related to survival. CONCLUSION: Elevated serum concentrations of cTnT significantly predicted poor outcome and there was a correlation between cTnT and CRP concentrations in samples from PD patients. Cardiac troponin I and CKMB mass had no prognostic value.     

Postoperative white blood cell count predicts atrial fibrillation after cardiac surgery

BACKGROUND: Postoperative atrial fibrillation (AF) occurs in as many as 50% of cardiac surgery patients and represents the most common postoperative rhythm complication. The cause of AF after cardiac surgery is incompletely understood, and its prevention remains suboptimal. Currently the role of inflammation and oxidative stress on electrical remodeling is under investigation, and recent studies have demonstrated that C-reactive protein levels are elevated in AF. The purpose of the present study was to investigate the correlation between the postoperative white blood cell (WBC) count as a marker of inflammation and the development of postoperative AF after cardiac surgery. METHODS AND RESULTS: Patients undergoing elective cardiac surgery in the absence of significant left ventricular dysfunction (n = 253; average age, 65 +/- 11 years) were recruited to the present prospective study. Atrial fibrillation developed during the postoperative period in 99 patients (39.1%) of the total study population. The WBC count was prospectively assessed in all patients to determine the predictive value of baseline and postoperative WBC count on development of postoperative AF. Baseline WBC count was 6.8 +/- 1.9 x 10(9)/L and 6.8 +/- 2.2 x 10(9)/L (p = 0.95), respectively, in patients with and without postoperative AF; and postoperative peak WBC count was 16.3 +/- 6.5 x 10(9)/L and 15 +/- 4.2 x 10(9)/L (p = 0.048), respectively, in patients without postoperative AF. However, neither baseline nor peak monocyte count differed significantly among patients with and without postoperative AF: 0.43 +/- 0.15 x 10(9)/L and 0.46 +/- 0.46 x 10(9)/L (p = 0.5), and 0.91 +/- 0.3 x 10(9)/L and 0.93 +/- 0.4 x 10(9)/L (p = 0.8), respectively. In addition to a more pronounced increase in peak WBC count (above v below median; odds ratio [OR], 1.8; 95% confidence interval [CI], 1.1-2.7; p < 0.05), increasing age (above v below median; OR, 2.6; CI, 1.2-3.9; p < 0.01), surgery for valvular heart disease versus coronary artery bypass grafting (OR, 2.8; CI, 1.1-3.5; p < 0.01), development of postoperative complications, such as stroke, infections, or unstable hemodynamics (OR, 1.9; CI, 1.0-7.5; p < 0.05), and perioperative nonuse of beta-adrenergic blockers (OR, 1.7; CI, 1.1-4.9; p < 0.05) were identified as independent predictors of postoperative AF by multivariate logistic regression analysis. CONCLUSIONS: Cardiac surgery is associated with an elevated postoperative WBC count that represents a common marker of inflammation. A more pronounced increase in postoperative WBC count independently predicts development of postoperative AF. These data provide additional evidence to support the association between the inflammatory response and postoperative AF.     

Elevated cardiac troponin T is associated with increased left ventricular mass index and predicts mortality in continuous ambulatory peritoneal dialysis patients

Nephrol Dial Transplant     

Elevated cardiac troponin T is associated with increased left ventricular mass index and predicts mortality in continuous ambulatory peritoneal dialysis patients.

BACKGROUND: Patients with end-stage renal disease have a high risk of premature death, which is due mainly to cardiovascular (CV) events. Elevated cardiac troponin T (cTnT) is related to increased left ventricular mass index (LVMI) and predicts poor outcome in chronic haemodialysis patients. We investigated the prognostic value of cTnT and its relationship with left ventricular mass in continuous ambulatory peritoneal dialysis (CAPD) patients. METHODS: Sixty-five CAPD patients (mean age: 56+/-12 years; 36% males) with no evidence of acute coronary syndrome in 28 days prior to the study were examined prospectively. After 48 months of follow-up, we evaluated total and CV mortality. RESULTS: During follow-up, 23 patients (35%) died (70% CV causes, 22% infection, 4% tumour, 4% unknown). In univariate analysis, concentrations of cTnT >/=0.035 ng/ml, increased LVMI, diabetes, serum albumin and age were all strong predictors of total mortality. In multivariate logistic regression analysis, cTnT >/=0.035 ng/ml and age independently predicted total mortality [odds ratio (OR): 4.31; 95% confidence interval (95% CI): 1.16-16.04; P = 0.008 and OR: 1.08; 95% CI: 1.02-1.15; P = 0.002, respectively]. cTnT level >/=0.035 ng/ml was the only independent predictor of CV mortality in multivariate logistic regression analysis (OR: 8.94; 95% CI: 2.23-35.88; P<0.005). There was a significant positive correlation between serum cTnT level and LVMI (rho = 0.41; P<0.002). Neither cTnI, CK nor CK-MB were related to total or CV mortality. CONCLUSIONS: Elevated serum cTnT but not cTnI predicted total and CV mortality in CAPD patients. Elevated cTnT levels were also associated with increased LVMI.     

Heart rate variability predicts mortality in peritoneal dialysis patients

Abstract

Background: The predictive value of heart rate variability (HRV) in peritoneal dialysis (PD) has never been tested. Methods: In this study, the associations between HRV measures and the mortality in 81 PD patients were analyzed. HRV was measured by using 5-min recordings of a stationary system by a standardized method. Both time domain and frequency domain parameters were analyzed. Results: During a follow-up period of 43.78?±?14.77 months, 25 patients died, four patients were transferred to hemodialysis. Of the 81 patients, the time domain parameters, such as the standard deviation of differences between adjacent normal sinus to normal sinus (NN) intervals (SDSD) and the square root of the mean of the squared differences between adjacent normal NN intervals (RMSSD), were higher; the frequency domain parameters, such as the ratio of low-frequency power to high-frequency power (LF/HF) and the normalized LF, were lower, and the normalized HF was higher in the non-survived group as compared with the survived group. A Cox proportional hazards model analysis revealed that, of the HRV measures, decrease of the normalized LF, LF/HF and increase of rMSSD, SDSD, normalized HF had significant predictive value for mortality. After adjustment for other univariate predictors including age, urine volume, renal Kt/V, high-sensitivity C-reactive protein (hs-CRP), the predictive value of decreased LF/HF remained significant. Kaplan–Meier survival analysis showed mortality rate was much higher in patients with a low LF/HF (median value of 1.56). Conclusion: The decreases of LF/HF which reflects impaired sympathetic nerve regulation is an independent predictor of mortality in PD patients.     

Predictors of mortality at initiation of peritoneal dialysis in children after cardiac surgery

BACKGROUND: The development of renal dysfunction in the postoperative course of cardiac surgery is still associated with high mortality in pediatric patients. In particular for small infants peritoneal dialysis offers a secure and useful treatment option. The aim of the present study was to investigate if routinely used laboratory and clinical variables could help predict mortality at initiation of peritoneal dialysis. METHODS: We performed a retrospective chart analysis of pediatric intensive care unit patients with renal dysfunction who were treated with peritoneal dialysis after cardiac surgery between 1993 and 2001 and analyzed variables obtained 3 hours or less before starting peritoneal dialysis. RESULTS: Results are documented as means and standard errors. A total of 1141 children underwent a cardiac operation on cardiopulmonary bypass. Sixty-two children (5.4%) were treated with peritoneal dialysis. Mortality was 40.3% (37 survivors, 25 nonsurvivors). The pH in survivors was 7.35 (0.01); in nonsurvivors it was 7.23 (0.03; p = 0.0037). Base excess in survivors was -1.37 mmol/L (0.61); in nonsurvivors it was -7.17 mmol/L (1.49; p = 0.0026). Lactate in survivors was 4.5 mmol/L (0.60); in nonsurvivors it was 10.5 mmol/L (1.78; p = 0.0089). Positive inspiratory pressure in survivors was 24.6 cm H(2)O (0.78); in nonsurvivors it was 28.9 cm H(2)O (1.08; p = 0.0274). Tidal volume per kilogram bodyweight in survivors was 11.0 mL/kg (0.48); in nonsurvivors it was 8.7 mL/kg (0.50; p = 0.0493). CONCLUSIONS: We conclude from our data that the consideration of pH, base excess, lactate, positive inspiratory pressure, and tidal volume per kilogram bodyweight help predict mortality at initiation of peritoneal dialysis. We were able to observe significant differences between survivors and nonsurvivors using these variables.     

Serum albumin at 1 year after peritoneal dialysis predicts long-term outcomes on continuous ambulatory peritoneal dialysis

BackgroundHypoalbuminemia at baseline is a powerful predictor of long-term outcomes in peritoneal dialysis patients. However, the levels of serum albumin are dynamically changed during PD. The present study investigated whether the improvement of hypoalbuminemia during PD can affect the patients’ outcomes.Methods436 consecutive incidents continuous ambulatory peritoneal dialysis patients were involved in this study. Demographic, hematologic, biochemical, and dialysis-related data at baseline as well as 1 year after PD were collected. All patients were followed for at least 1 year for mortality.ResultsAmong the 436 patients, the mean age was 48.44 ± 14.98 years, with 58.26% males and 18.12% prevalence of diabetes. The mean follow-up time was 48.25 ± 24.05 months. During the follow-up period, a total of 68 patients died. Serum albumin was 34.35 ± 5.65 g/L at baseline, which increased to 37.39 ± 5.05 g/L at 1 year after PD. Multivariate linear regression analysis showed that sex, age, BMI, diabetic nephropathy, as well as albumin at baseline were independently associated with albumin at 1 year. Every 1 year of age rise would result in a 3.9% increase in the risk of mortality (HR = 1.039, 95%CI 1.016–1.061, p = 0.001). Every 1 g/L increase in albumin at 1 year after PD confers an 8.7% decrease in the risk of mortality (HR = 0.913, 95%CI 0.856–0.973, p = 0.005).ConclusionThe level of serum albumin was increased in the first year of PD. Serum albumin after 1 year of PD predicted mortality in peritoneal dialysis.     

SAPS 3 at dialysis commencement is predictive of hospital mortality in patients supported by extracorporeal membrane oxygenation and acute dialysis

Objective: This study examined the association between hospital mortality and five illness–severity scoring systems evaluated at different time points in the intensive care unit (ICU) as well as clinical variables as predictors in critically ill patients supported by extracorporeal membrane oxygenation (ECMO) and acute dialysis. Methods: This multicenter prospective observational study included 104 patients who received ECMO support and acute dialysis from January 2002 to December 2006. Patients’ demographic, clinical and laboratory variables were analyzed as predictors of survival. The SAPS 2, APACHE II, SOFA, MODS, and SAPS 3 scores upon ICU admission and at acute dialysis commencement were evaluated to predict the patient's hospital mortality. Results: Hospital mortality for the study group was 76% (79/104). Among the five scoring systems, only SAPS 3 score showed a significant difference between survivors and non-survivors either upon ICU admission (p = 0.038) or at dialysis commencement (p = 0.001). SAPS 3 score at dialysis commencement showed the best discrimination ability by using the area under the receiver operating characteristic curve (SOFA, 0.55; SAPS 2, 0.56; MODS, 0.58; APACHE II, 0.59; and SAPS 3, 0.73). Multiple logistic regression analysis indicated that SAPS 3 score at dialysis commencement (OR: 1.070, 95% CI: 1.016–1.216) and IABP usage before ECMO (OR: 4.181, 95% CI: 1.448–12.075) were two independent risk factors for hospital mortality. Conclusions: Among five common ICU scoring systems evaluated at different time points, SAPS 3 at dialysis commencement is the best risk adjustment systems to predict hospital mortality in critically ill patients supported by ECMO and acute dialysis. Furthermore, the SAPS 3 score at dialysis commencement and IABP usage before ECMO are two major independent predictors for hospital mortality in patients supported by ECMO and acute dialysis.     

Differential white cell count relationships with human cardiac allograft rejection

The focus of research in allograft rejection has targeted the lymphocyte, with little attention given to the neutrophil. Recent data indicate that a perioperative neutrophil influx into the cardiac allograft influences early rejection. Factors that influence neutrophil transendothelial migration might offer predictive markers of rejection. We explored the relationship between the number of circulating neutrophils in heart transplant recipients and the development of rejection. Differential white cell counts were obtained prior to transplantation and concurrently with subsequent endomyocardial rejection surveillance biopsies for 53 heart transplant recipients undergoing 410 biopsies. Preoperative differential white cell counts had no relationship with rejection. In the first 3 months after transplantation, no relationship was found between contemporary differential white cell counts and rejection. However, more than 3 months following surgery, rejection grade positively correlated on univariate analysis with neutrophil counts and the usage of cyclosporine, prednisolone, and mycophenolate. There was no relationship with eosinophils or lymphocytes. Multivariate analysis demonstrated a persistent relationship among rejection severity, neutrophil count, and prednisolone usage. A significant positive association of higher steroid usage with higher rejection grades must reflect efforts to treat patients with rejection. The significant association of higher neutrophil counts with higher rejection severity might suggest a pathological contribution to rejection. However, given the neutrophilia response to acute steroid administration, we must conclude that the neutrophil association was related to steroid administration. The absence of a relationship between white cell counts and rejection suggests that functional rather than antiproliferative strategies may offer the greatest therapeutic potential.     

Hyperleptinaemia and chronic inflammation after peritonitis predicts poor nutritional status and mortality in patients on peritoneal dialysis.

BACKGROUND: The serum leptin level is elevated in patients undergoing peritoneal dialysis (PD) and associated with a loss of lean body mass. The nutritional status of PD patients may further be worsened following peritonitis. We investigated the association between hyperleptinaemia, inflammation and malnourishment in PD-related peritonitis. METHODS: We conducted a prospective study on PD patients who developed peritonitis. Blood samples were obtained as baseline (D0) before the onset of peritonitis, and once peritonitis developed, leptin, adiponectin (ADPN) and other inflammatory markers were collected, on day 1 (D1), day 7 (D7) and day 42 (D42) of peritonitis. Patients were followed-up for any censor event or 1 year after peritonitis. RESULTS: Forty-two patients with a mean age of 62.9+/-13.2 years were recruited. Fourteen (33.3%) were diabetic. The serum leptin levels increased significantly from baseline to day 1 and 7, but fell back to the premorbid state at day 42. In contrast, the ADPN level decreased from a baseline value of 15.60+/-10.4 microg/ml to 13.01+/-8.1 microg/ml on day 1 (P=0.01) but rose to 14.39+/-8.9 microg/ml on day 7 (P=0.28) and 13.87+/-7.9 microg/ml on day 42 (P=0.21). High-sensitivity C-reactive protein (hs-CRP) increased significantly from baseline to day 1, 7 and even at day 42. The lean body mass (LBM) and nutritional markers decreased significantly after peritonitis. For patients with high hs-CRP (>3.0 mg/l) at day 42, there was a higher mortality rate than for those with lower hs-CRP (<3.0 mg/l, P=0.02), even if they were in clinical remission of peritonitis. CONCLUSIONS: Our study confirmed an increase in serum leptin during acute peritonitis and a prolonged course of systemic inflammation after apparent clinical remission of peritonitis. These factors related to the persistent chronic inflammation may contribute to the development of malnourishment and poor survival rate.     

Preoperative white blood cell count and mortality and morbidity after coronary artery bypass grafting

BACKGROUND: Arteriosclerosis is increasingly viewed as an inflammatory disease. The purpose of these analyses was to examine the preoperative white blood cell (WBC) count, a generalized marker of inflammation, and to assess its association with in-hospital mortality and other adverse outcomes after coronary artery bypass grafting. METHODS: Information was collected prospectively on 11,270 consecutive patients who had isolated coronary artery bypass grafting in northern New England from 1996 through 2000. Patients were divided into five categories based on their preoperative WBC count. Crude and adjusted in-hospital mortality rates and adverse event rates were calculated using logistic regression. RESULTS: Increasing WBC count across its entire range was associated with a linear increase in the mortality rate. This finding was highly significant (p [trend] < 0.001) and persisted after adjustment for patient and disease characteristics. Patients with preoperative WBC of at least 12.0 x 10(9)/L had an adjusted mortality rate 2.8 times higher than those with a WBC less than 6.0 x 10(9)/L (4.8% versus 1.7%). An increasing preoperative WBC count was also significantly associated with increasing rates of perioperative strokes and the need for an intraaortic balloon pump but was not associated with mediastinitis. CONCLUSIONS: The preoperative WBC count across its entire observed range is a statistically significant independent predictor of in-hospital death and other adverse outcomes after coronary artery bypass grafting. Although the cause of the association between increased WBC count and increased morbidity and mortality is unknown, the preoperative WBC count, which is objectively measured, inexpensive, and always available, can serve as a useful marker to help predict risk before coronary artery bypass grafting.     

Comparative mortality of hemodialysis and peritoneal dialysis in Canada

BACKGROUND: Comparisons of mortality rates in patients on hemodialysis versus those on peritoneal dialysis have been inconsistent. We hypothesized that comorbidity has an important effect on differential survival in these two groups of patients. METHODS: Eight hundred twenty-two consecutive patients at 11 Canadian institutions with irreversible renal failure had an extensive assessment of comorbid illness collected prospectively, immediately prior to starting dialysis therapy. The cohort was assembled between March 1993 and November 1994; vital status was ascertained as of January 1, 1998. RESULTS: The mean follow-up was 24 months. Thirty-four percent of patients at baseline, 50% at three months, and 51% at six months used peritoneal dialysis. Values for a previously validated comorbidity score were higher for patients on hemodialysis at baseline (4.0 vs. 3.1, P < 0.001), three months (3.7 vs. 3.2, P = 0.001), and six months (3.6 vs. 3.2, P = 0.005). The overall mortality was 41%. The unadjusted peritoneal dialysis/hemodialysis mortality hazard ratios were 0.65 (95% CI, 0. 51 to 0.83, P = 0.0005), 0.84 (95% CI, 0.66 to 1.06, P = NS), and 0. 83 (95% CI, 0.64 to 1.08, P = NS) based on the modality of dialysis in use at baseline, three months, and six months, respectively. When adjusted for age, sex, diabetes, cardiac failure, myocardial infarction, peripheral vascular disease, malignancy, and acuity of renal failure, the corresponding hazard ratios were 0.79 (95% CI, 0. 62 to 1.01, P = NS), 1.00 (95% CI, 0.78 to 1.28, P = NS), and 0.95 (95% CI, 0.73 to 1.24, P = NS). Adjustment for a previously validated comorbidity score resulted in hazard ratios of 0.74 (95% CI, 0.58 to 0.94, P = 0.01), 0.94 (95% CI, 0.74 to 1.19, P = NS), and 0.88 (95% CI, 0.68 to 1.13, P = NS) at baseline, three months, and six months. There was no survival advantage for either modality in any of the major subgroups defined by age, sex, or diabetic status. CONCLUSIONS: The apparent survival advantage of peritoneal dialysis in Canada is due to lower comorbidity and a lower burden of acute onset end-stage renal disease at the inception of dialysis therapy. Hemodialysis and peritoneal dialysis, as practiced in Canada in the 1990s, are associated with similar overall survival rates.     

Patient mortality in chronic dialysis: comparisons between hemodialysis and peritoneal dialysis

Patients with approaching end-stage renal disease often must choose between hemodialysis or peritoneal dialysis as the initial form of renal replacement therapy. Should nephrologists recommend one form of dialysis as superior to the other? This review focuses on studies that compared patient mortality for these two dialysis techniques. Explanations for the disparate findings of these studies will be put forth. Finally, suggestions regarding what we can recommend to patients are made.