Malnutrition, chronic inflammation and atherosclerosis in dialysis patients

Mysore K. Phanish1, Samuele M. Marcora2 and Andrew B. Lemmey2

1 Department of Nephrology Gwynedd District General Hospital 2 School of Sports, Health and Exercise Sciences University of Wales Bangor Gwynedd UK Email: aphanish{at}doctors.org.uk

Sir,

The supplement volume of Nephrology Dialysis Transplantation on chronic inflammation, atherosclerosis and immunointervention in dialysis [1,2] has provided readers with an excellent review of this extremely important topic. We would like to contribute two further comments.

Firstly, Wanner and Metzger [1] have given a list of potential causes of high C-reactive protein (CRP) in dialysis patients. We would like to add that metastatic extra-vascular calcification in dialysis patients can also be associated with a systemic inflammatory state [3]. In fact, we reported a case of tumoral calcinosis associated with pyrexia and high CRP in a haemodialysis patient [4]. It is worth remembering this infrequent cause of ‘pro-inflammatory state’ in dialysis patients. Various therapeutic options for this condition would be: intensification of dialysis therapy with low calcium dialysate, aggressive management of hyperphosphataemia with dietary phosphate restriction and phosphate binders, parathyroidectomy, if appropriate, and renal transplantation. Bisphosphonate therapy could be considered in selected cases.

Secondly, we wish to comment on the treatment strategies that could be considered in dialysis patients with MIA (malnutrition, inflammation and atherosclerosis) syndrome [2]. Numerous studies have shown exercise training to be of benefit for dialysis patients [5]. In addition to its well-known beneficial effects on cardiovascular fitness and mortality [6], exercise also has an anabolic effect and has been shown to reduce muscular atrophy in dialysis patients [7]. This latter effect of exercise is, at least in part, probably due to its immunomodulatory effects, as aerobic exercise training has been shown to reduce elevated circulating tumour necrosis factor-{alpha} (TNF-{alpha}) levels concomitant with improvement in exercise capacity in patients with heart failure [8]. In addition, resistance exercise training has been shown to reduce skeletal muscle TNF-{alpha} protein and mRNA levels in frail elderly humans [9].

Studies such as these suggest that exercise training may have an anti-inflammatory effect and could play an important role in attenuating ‘pro-inflammatory cytokine’-induced muscle wasting and cardiovascular mortality in dialysis patients. Consequently, we feel that well-conducted studies on the effect of exercise training on pro-inflammatory cytokines, malnutrition and cardiovascular mortality in dialysis patients would be of immense value. Also, we feel that exercise rehabilitation should be considered an important intervention in the management of inflammation, malnutrition and cardiovascular disease in dialysis patients.

References

  1. Wanner C, Metzger T. C-reactive protein a marker for all-cause and cardiovascular mortality in haemodialysis patients. Nephrol Dial Transplant2002; 17 [Suppl 8]: 29–32[Abstract/Free Full Text]
  2. Stenvinkel P. Inflammation in end-stage renal failure: could it be treated? Nephrol Dial Transplant2002; 17 [Suppl 8]:33–38[Abstract/Free Full Text]
  3. Borras M, Marco MP, Belart M, Pena JM, Amoedo ML, Fernandez E. Presentation of tumoral calcinosis with systemic signs pointing to inflammatory disease. Nephrol Dial Transplant1998; 13:3277–3279[Free Full Text]
  4. Phanish MK, Kallarackal G, Ravanan R, Lawson T, Baboolal K. Tumoral calcinosis associated with pyrexia and systemic inflammatory response in a haemodialysis patient: successful treatment using intravenous pamidronate. Nephrol Dial Transplant2000; 15:1691–1693[Free Full Text]
  5. Cappy CS, Jablonka J, Schroeder ET. The effects of exercise during haemodialysis on physical performance and nutrition assessment. J Ren Nutr1999; 9:63–70[Medline]
  6. U.S. Department of Health and Human Services. Surgeon General's Report on Physical Activity and Health. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 1996
  7. Kouidi A, Albani M, Natsis K et al. The effects of exercise training on muscle atrophy in haemodialysis patients. Nephrol Dial Transplant1998; 13:685–699[Abstract]
  8. Larsen AI, Aukrust P, Aarsland T, Dickstein K. Effect of aerobic exercise training on plasma levels of tumor necrosis factor alpha in patients with heart failure. Am J Cardiol2001; 88:805–808[CrossRef][ISI][Medline]
  9. Creiwe JS, Cheng BO, Rubin DC, Yarasheski KE, Semenkovich CF. Resistance training decreases skeletal muscle tumor necrosis factor alpha in frail elderly humans. FASEB J2001; 15:475–482[Abstract/Free Full Text]




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