PREVALENCE OF UNEXPLAINED INFLAMMATION IN …



PREVALENCE OF UNEXPLAINED INFLAMMATION IN HAEMODIALYSIS PATIENTSWong J1, Sridharan S1, Vilar E1, 2 & Farrington K1, 21Lister Hospital, 2University of HertfordshireINTRODUCTION: Morbidity and mortality is unacceptably high in patients on maintenance haemodialysis (HD). It has become increasingly clear that systemic inflammation is a powerful predictor of cardiovascular mortality. Signs of sustained low-grade inflammation, such as increased levels of C-reactive protein (CRP) are present in patients on HD. Implicating factors include low grade sepsis, infected vascular catheters and exposure to impure dialysate water. However despite modification of risk factors for inflammation, a significant proportion of patients have persistent inflammation. The aim of this study is to establish the prevalence of unexplained inflammation in the HD population.METHODS: A database of all patients undergoing HD at our unit was generated. Patients with two measured levels of CRP > 5 mg/l carried out at least one month apart within the last 3 months were defined as having persistent inflammation. The health records of patients with inflammation but without an obvious cause were reviewed to look for potential implicating or risk factors driving chronic inflammation such as failed kidney transplant in-situ, presence of vascular catheters, chronic ulcers and active cancer or inflammatory conditions. Charleson comorbidity index (CCI) was calculated from these health records. Patients were divided into 4 groups – those with: 1. Elevated CRP with obvious causes (e.g. active infection)2. Normal CRP3. Elevated CRP with potential underlying risk factors4. Elevated CRP without obvious underlying risk factors Demographic, comorbidity and dialysis adequacy data were compared for Groups 2 to 4.RESULTS: There were 444 prevalent HD patients, 287 (64.6%) of whom had persistently elevated CRPs. In this group, 183 patients had an obvious cause for elevated CRP (41.2% of all HD patients). 104 patients (23.4% of all HD patients) had a persistently elevated CRP with no clear cause. 65 (62.5%) of these had a potential underlying risk factor to explain an elevated CRP. The remaining 39 (37.5%) had no underlying risk factors – representing 8.8% of whole HD population. Those with elevated CRP (groups 3&4) were older than those with normal CRP – group 2 (mean age 66.6 vs. 62.6 years, p = 0.045), heavier (80kg vs. 70.8kg, p < 0.001), and had a lower Kt/V (1.3 vs. 1.4 p = 0.02), but were similar with respect to male:female ratio, residual renal function, CCI, beta-2 microglobulin, PTH, presence of vascular catheters or grafts, mean dialysis time, access blood flow or mean inter-dialytic weight gain. There were no significant differences between those with persistently elevated CRP with and without risk factors in terms of age, weight, gender, residual renal function, CCI, beta-2 microglobulin, PTH, Kt/V, mean CRP, dialysis time, access blood flow and mean inter-dialytic weight gain. CONCLUSION: Around one quarter of prevalent HD patients have persistent unexplained elevation of CRP. Many of these (37.5%) had no potential underlying risk factors which might possibly explain the elevated CRP. Those with unexplained high CRP levels were older, heavier and had lower Kt/V than those with normal CRP, though there were no obvious differences between the groups with and without potential underlying risk factors. Further studies are needed to investigate the cause of unexplained inflammation and define appropriate interventions which may help mitigate the poor prognostic outcomes in HD patients. ................
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