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Effect of an Increase in C-Reactive Protein Level during a Hemodialysis Session on Mortality

Johanna C. Korevaar^*, Jeannette G. van Manen, Friedo W. Dekker, Dirk R. de Waart, Elisabeth W. Boeschoten and Raymond T. Krediet^|| for the NECOSAD Study Group

*Department of Clinical Epidemiology and Biostatistics, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands; Department of Clinical Epidemiology, Leiden University Medical Centre, University of Leiden, Leiden, The Netherlands; Department of Experimental Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands; Hans Mak Institute, Naarden, The Netherlands; and ^||Department of Nephrology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands

Correspondence to Dr. J.C. Korevaar, Department of Clinical Epidemiology & Biostatistics, Academic Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands. Phone: +31-20-5664489; Fax: +31-20-6912683; E-mail: j.korevaar{at}amc.uva.nl

The prevalence of chronic inflammation is high in dialysis patients. Moreover, it is associated with an increased mortality risk, yet the origin of chronic inflammation in dialysis patients remains unclear. The aim of this study was to determine the effect of a hemodialysis session (HD) on C-reactive protein (CRP) levels and to study the relation with survival. As part of a large, prospective, multicenter study in the Netherlands (Netherlands Cooperative Study on the Adequacy of Dialysis), patients who were started on dialysis treatment between September 1997 and May 1999 were included. Demographic data, clinical data, and serum samples were collected at regularly timed intervals. From this cohort, a random sample of patients was taken. CRP levels were determined before and after an HD session and before the next session. Date of death or censoring was recorded until September 2002. A total of 186 HD patients were included. Mean age was 65 yr (SD, 13); 56% were male. A total of 71 patients had a CRP level below the detection limit (3 mg/L), 68 patients showed no increase in CRP during an HD session (no-increase group), and 47 (25%) patients showed an increase in CRP level during an HD session (increase-group). No statistically difference in mean CRP levels before the dialysis session was found between the increase group (22.3 mg/L) and the no-increase group (19.4 mg/L). In the subsequent interdialytic period, CRP levels returned to the levels of the initial CRP value. Two-year survival was 44% in the increase group and 66% in the no-increase group (P = 0.09). Independent of CRP level before the session and adjusted for age, comorbidity, nutritional status, and primary kidney disease, a raise of 1 mg/L CRP during a session was associated with a 9% increased mortality risk (adjusted hazard ratio, 1.09; 95% CI, 1.02 to 1.16). The present study showed an increase in CRP level during a single dialysis session in 25% of the patients; during the succeeding interdialytic period, CRP level returned to its original value. More important, however, an increase in CRP level during an HD session was independently associated with a higher mortality risk.

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