Abstract
-
Objectives
- Dialysis patients’ nutritional indicators are quite subjective and complex and cannot be easily measured in clinical settings. Based on previous reports that total lymphocyte count (TLC) and subpopulation lymphocyte counts (SLCs) are associated with nutritional status in patients with dialysis, we designed this study to examine the relationships of the TLC and SLCs with clinical outcome and nutritional status in patients undergoing maintenance hemodialysis (HD) and peritoneal dialysis (PD).
-
Methods
- In this prospective, observational study, we enrolled 66 patients (50 HD patients and 16 PD patients) receiving stable maintenance dialysis. We evaluated the baseline parameters of height; weight; TLC; SLCs expressing CD3, CD4, CD8 and CD19; CBC; iron profile (iron, TIBC, ferritin); BUN; Cr; Na; K; total CO2; Ca; P; iPTH; protein; albumin; total cholesterol; HDL; LDL; uric acid and CRP and calculated Onodera’s prognostic nutritional index (OPNI) and the Geriatric Nutritional Risk Index (GNRI) at baseline and three months. To analyze differences in the TLC and SLCs between the HD group and the PD group, we performed an independent samples t-test. Logistic regression analysis was performed to predict malnutrition in dialysis patients. In addition, to analyze changes in TLC, SLCs expressing each marker (CD3, CD4, CD8 and CD19) and other nutritional markers, we performed general linear model (GLM)-repeated measures ANOVA.
-
Results
- Mean age was 55.8 ± 12.7 years in HD paitents and 49.8 ± 14.5 years in PD patients. The duration of dialysis was 59.7 ± 52.9 months in HD patients and 66.1 ± 33.6 years in PD patients. Logistic regression analysis revealed that patients aged 60 years or older, women, and those whose CD19 SLCs were lower than 100 had a higher risk of developing malnutrition. In GLM-repeated measures ANOVA, CD19 SLCs were significantly higher in women and in patients with a shorter period of dialysis.
-
Conclusions
- Our results indicate that GNRI, OPNI, TLC and SLCs (especially CD19 count) may be significant nutritional markers in HD and PD patients.
-
Keywords: Dialysis; Lymphocyte Count; Total Lymphocyte Counts
Table 1.Clinical characteristics of 66 dialysis patients according to methods of dialysis at start of the study
Variables |
HD (n=50) |
PD (n=16) |
Pvalue |
Age |
55.8 ± 12.7 |
49.8 ± 14.5 |
0.127 |
Sex (Male/Female) |
28/22 |
10/6 |
0.774 |
DM |
18 (36%) |
7 (43.8%) |
0.768 |
Duration of dialysis (months) |
59.7 ± 52.9 |
66.1 ± 33.6 |
0.653 |
Body Mass Index |
21.3 ± 2.5 |
23.8 ± 4.1 |
0.005 |
GNRI |
100.1 ± 8.4 |
99.2 ± 8.1 |
0.708 |
OPNI |
47.0 ± 4.6 |
39.5 ± 4.3 |
0.003 |
Kt/V |
1.68 ± 0.22 |
1.85 ± 0.36 |
0.034 |
Urea Reduction Rate (%) |
75.0 ± 4.5 |
NA |
NA |
TLCs (/㎣) |
1597 ± 512 |
1105 ± 658 |
0.019 |
CD3 count (/㎣) |
1015 ± 400 |
964 ± 366 |
0.655 |
CD4 count (/㎣) |
632 ± 260 |
585 ± 231 |
0.523 |
CD8 count (/㎣) |
384 ± 171 |
366 ± 171 |
0.731 |
CD19 count (/㎣) |
132 ± 85 |
127 ± 84 |
0.831 |
CD4/CD8 ratio |
1.8 ± 0.7 |
1.7 ± 0.7 |
0.835 |
Hemoglobin (g/dL) |
10.9 ± 0.6 |
11.3 ± 1.1 |
0.141 |
Iron (ug/dL) |
88.6 ± 34.8 |
103.6 ± 43.9 |
0.195 |
TIBC (ug/dL) |
244.9 ± 35.5 |
261.1 ± 49.1 |
0.182 |
TSAT (%) |
37.0 ± 16.5 |
41.1 ± 19.6 |
0.457 |
Ferritin (ng/mL) |
367.5 ± 275.6 |
306.4 ± 204.4 |
0.458 |
BUN (mg/dL) |
64.8 ± 19.5 |
64.0 ± 16.2 |
0.944 |
Cr (mg/dL) |
9.5 ± 2.2 |
11.9 ± 2.3 |
0.001 |
Sodium (mEq/L) |
137.9 ± 2.8 |
136.7 ± 3.2 |
0.192 |
Potassium (mEq/L) |
5.3 ± 0.7 |
4.4 ± 0.7 |
0.001 |
Calcium (mg/dL) |
8.8 ± 0.5 |
9.0 ± 0.5 |
0.233 |
Phosphorus (mg/dL) |
5.1 ± 1.4 |
5.6 ± 1.2 |
0.161 |
Parathyroid hormone (pg/mL) |
191.2 ± 199.7 |
389.1 ± 311.6 |
0.005 |
Albumin (g/dL) |
3.9 ± 0.3 |
3.4 ± 0.3 |
0.001 |
Table 2.Clinical characteristics of 66 dialysis patients according to methods of dialysis after 3 month
Variables |
HD (n=50) |
PD (n=16) |
Pvalue |
Age |
55.8 ± 12.7 |
49.8 ± 14.5 |
0.127 |
Sex (Male/Female) |
28/22 |
10/6 |
0.774 |
DM |
18 (36%) |
7 (43.8%) |
0.768 |
Duration of dialysis (months) |
61.4 ± 50.9 |
69.1 ± 30.2 |
0.653 |
Body Mass Index |
21.1 ± 2.5 |
23.8 ± 4.1 |
0.032 |
GNRI |
99.5 ± 7.7 |
96.2 ± 9.2 |
0.184 |
OPNI |
46.1 ± 4.5 |
38.4 ± 5.6 |
0.035 |
Systolic blood pressure (mmHg) |
138.0 ± 31.4 |
133.7 ± 24.1 |
0.568 |
Diastolic blood pressure (mmHg) |
80.6 ± 16.6 |
80.8 ± 11.8 |
0.972 |
Kt/V |
1.76 ± 0.25 |
1.86 ± 0.37 |
0.263 |
Urea Reduction Rate (%) |
76.0 ± 4.9 |
NA |
NA |
Neutrophil Lymphocyte Ratio |
0.43 ± 0.15 |
0.60 ± 0.22 |
0.139 |
TLCs (/㎣) |
1520 ± 526 |
1386 ± 697 |
0.570 |
CD3 count (/㎣) |
1023 ± 428 |
905 ± 464 |
0.365 |
CD4 count (/㎣) |
644 ± 296 |
627 ± 281 |
0.845 |
CD8 count (/㎣) |
372 ± 169 |
380 ± 181 |
0.881 |
CD19 count (/㎣) |
125 ± 81 |
112 ± 63 |
0.541 |
CD4/CD8 ratio |
1.8 ± 0.7 |
0.7 ± 0.6 |
0.638 |
Table 3.Clinical characteristics of 66 dialysis patients according to GNRI at start of the study
Variables |
GNRI ≥ 100(n=33) |
GNRI < 100 (n=33) |
Pvalue |
Age |
54.0 ± 14.5 |
54.6 ± 12.4 |
0.860 |
Sex (Male/Female) |
22/11 |
15/17 |
0.136 |
DM |
11 (33.3%) |
13 (40.6%) |
0.612 |
HD/PD |
27/6 |
24/9 |
0.389 |
Duration of dialysis (months) |
47.1 ± 35.6 |
77.4 ± 55.9 |
0.011 |
Body Mass Index |
23.8 ± 2.8 |
20.0 ± 2.1 |
0.001 |
GNRI |
106.7 ± 3.4 |
92.9 ± 5.5 |
0.001 |
Systolic blood pressure (mmHg) |
137.0 ± 20.9 |
137.2 ± 37.3 |
0.977 |
Diastolic blood pressure (mmHg) |
81.2 ± 12.4 |
80.1 ± 18.5 |
0.788 |
Kt/V |
1.7 ± 0.3 |
1.7 ± 0.2 |
0.576 |
Neutrophil Lymphocyte Ratio |
0.43 ± 0.15 |
0.38 ± 0.11 |
0.226 |
TLCs (/㎣) |
1530 ± 556 |
1555 ± 557 |
0.866 |
CD3 count (/㎣) |
1093 ± 379 |
922 ± 387 |
0.076 |
CD4 count (/㎣) |
672 ± 255 |
574 ± 245 |
0.118 |
CD8 count (/㎣) |
420 ± 172 |
342 ± 162 |
0.065 |
CD19 count (/㎣) |
146 ± 82 |
114 ± 85 |
0.123 |
CD4/CD8 ratio |
1.7 ± 0.7 |
1.8 ± 0.7 |
0.612 |
Table 4.Clinical characteristics of 66 dialysis patients according to OPNI 45 at start of the study
Variables |
OPNI ≥ 45 (n=46) |
OPNI < 45 (n=20) |
Pvalue |
Age |
53.2 ± 14.0 |
59.3 ± 10.5 |
0.080 |
Sex (Male/Female) |
25/21 |
13/7 |
0.768 |
DM |
18 (39.1%) |
7 (35.3%) |
0.988 |
HD/PD |
39/7 |
11/9 |
0.002 |
Duration of dialysis (months) |
50.8 ± 38.6 |
89.0 ± 66.8 |
0.009 |
Body Mass Index |
21.7 ± 2.6 |
21.9 ± 3.3 |
0.797 |
OPNI |
49.0 ± 2.6 |
39.7 ± 3.6 |
0.001 |
Systolic blood pressure (mmHg) |
139.9 ± 25.5 |
133.5 ± 44.1 |
0.492 |
Diastolic blood pressure (mmHg) |
80.2 ± 12.2 |
80.1 ± 24.3 |
0.986 |
Kt/V |
1.7 ± 0.2 |
1.6 ± 0.2 |
0.476 |
Neutrophil Lymphocyte Ratio |
0.38 ± 0.10 |
0.48 ± 0.18 |
0.011 |
TLCs (/㎣) |
1710 ± 475 |
1164 ± 552 |
0.001 |
CD3 count (/㎣) |
1085 ± 419 |
863 ± 353 |
0.049 |
CD4 count (/㎣) |
677 ± 268 |
524 ± 222 |
0.034 |
CD8 count (/㎣) |
411 ± 181 |
326 ± 160 |
0.089 |
CD19 count (/㎣) |
141 ± 77 |
96 ± 89 |
0.061 |
CD4/CD8 ratio |
1.8 ± 0.7 |
1.7 ± 0.7 |
0.851 |
Table 5.Logistic regression for predicting malnutrition according to GNRI 100 at start of the study
Variables |
OR (95% CI) |
Pvalue |
Age > 60 years |
10.783(1.936−60.059) |
0.007 |
Female |
2.115(0.752−9.194) |
0.255 |
PD |
3.159(0.338−29.533) |
0.313 |
Duration of dialysis (months) > 60 |
0.705(0.136−3.657) |
0.677 |
DM |
1.507(0.342−6.633) |
0.588 |
Total Lymphocyte Counts (/㎣) < 1500 |
0.473(0.113−1.972) |
0.304 |
CD3 count (/㎣) < 1000 |
0.598(0.040−8.996) |
0.711 |
CD4 count (/㎣) < 600 |
0.969(0.176−5.329) |
0.971 |
CD8 count (/㎣) < 350 |
3.509(0.331−37.193) |
0.297 |
CD19 count (/㎣) < 100 |
9.202(1.481−57.191) |
0.017 |
Table 6.Logistic regression for predicting malnutrition according to OPNI 45 at start of study
Variables |
OR (95% CI) |
Pvalue |
Age > 60 years |
6.724(1.450−19.884) |
0.024 |
Female |
1.115(0.152−8.194) |
0.915 |
PD |
5.307(1.872−14.457) |
0.021 |
Duration of dialysis (months) > 60 |
2.467(0.326−18.672) |
0.382 |
DM |
0.541(0.053−5.473) |
0.603 |
Total Lymphocyte Counts (/㎣) < 1500 |
4.351(0.698−27.121) |
0.115 |
CD3 count (/㎣) < 1000 |
8.041(0.158−40.833) |
0.298 |
CD4 count (/㎣) < 600 |
0.771(0.076−7.833) |
0.826 |
CD8 count (/㎣) < 350 |
0.317(0.010−10.081) |
0.515 |
CD19 count (/㎣) < 100 |
3.444(0.367−32.347) |
0.279 |
Table 7.Clinical characteristics of 66 dialysis patients according to CD19 count at start of the study
Variables |
CD19 ≥ 100 (n = 41) |
CD19 < 100 (n = 25) |
Pvalue |
Age |
55.1 ± 13.7 |
53.1 ± 12.7 |
0.565 |
Sex (Male/Female) |
21/20 |
17/8 |
0.208 |
DM |
15 (36.6%) |
10 (40%) |
0.799 |
HD/PD |
32/9 |
18/7 |
0.768 |
Duration of dialysis (months) |
50.6 ± 37.7 |
78.8 ± 59.6 |
0.022 |
Body Mass Index |
21.4 ± 2.9 |
22.3 ± 3.5 |
0.511 |
GNRI |
101.2 ± 8.0 |
97.9 ± 8.4 |
0.121 |
OPNI |
47.2 ± 5.1 |
44.4 ± 4.8 |
0.045 |
Systolic blood pressure (mmHg) |
131.8 ± 30.6 |
145.4 ± 26.5 |
0.062 |
Diastolic blood pressure (mmHg) |
78.2 ± 17.6 |
84.7 ± 10.2 |
0.065 |
Kt/V |
1.74 ± 0.29 |
1.70 ± 0.22 |
0.504 |
Neutrophil Lymphocyte Ratio |
0.42 ± 0.15 |
0.41 ± 0.15 |
0.931 |
TLCs (/㎣) |
1525 ± 586 |
1537 ± 513 |
0.933 |
CD3 count (/㎣) |
1129 ± 406 |
796 ± 256 |
0.001 |
CD4 count (/㎣) |
701 ± 262 |
488 ± 169 |
0.001 |
CD8 count (/㎣) |
426 ± 177 |
302 ± 127 |
0.002 |
CD19 count (/㎣) |
176 ± 74 |
57 ± 26 |
0.001 |
CD4/CD8 ratio |
1.7 ± 0.7 |
1.7 ± 0.7 |
0.905 |
Table 8.Total lymphocyte count by several variables
Variables |
Baseline |
3 months |
Pvalue*
|
Age |
Age ≥ 60 years (n = 28) |
1615 ± 535 |
1606 ± 550 |
0.193 |
Age < 60 years (n = 38) |
1470 ± 550 |
1421 ± 474 |
0.193 |
Pvalue+
|
0.472 |
0.621 |
|
Sex |
Male (n = 38) |
1588 ± 563 |
1558 ± 593 |
0.547 |
Female (n = 28) |
1506 ± 518 |
1486 ± 401 |
0.547 |
Pvalue+
|
0.533 |
0.891 |
|
Dialysis |
Hemodialysis (n = 50) |
1597 ± 512 |
1514 ± 522 |
0.433 |
Peritoneal Dialysis (n = 16) |
1417 ± 625 |
1569 ± 520 |
0.433 |
Pvalue+
|
0.009 |
0.009 |
|
Duration of dialysis |
Duration ≥ 60 months (n = 30) |
1464 ± 551 |
1450 ± 508 |
0.223 |
Duration < 60 months (n = 36) |
1628 ± 530 |
1592 ± 525 |
0.223 |
Pvalue+
|
0.043 |
0.043 |
|
DM |
Yes (n = 25) |
1587 ± 495 |
1508 ± 501 |
0.372 |
No (n = 41) |
1533 ± 574 |
1539 ± 534 |
0.372 |
Pvalue+
|
0.292 |
0.292 |
|
Table 9.CD19 count by several variables
Variables |
Baseline |
3 months |
Pvalue*
|
Age |
Age ≥ 60 years (n = 28) |
135 ± 93 |
126 ± 80 |
0.206 |
Age < 60 years (n = 38) |
128 ± 77 |
118 ± 73 |
0.206 |
Pvalue+
|
0.709 |
0.709 |
|
Sex |
Male (n = 38) |
114 ± 63 |
111 ± 66 |
0.146 |
Female (n = 28) |
154 ± 103 |
135 ± 87 |
0.146 |
Pvalue+
|
0.043 |
0.043 |
|
Dialysis |
|
|
|
Hemodialysis (n = 50) |
132 ± 85 |
124 ± 80 |
0.179 |
Peritoneal Dialysis (n = 16) |
127 ± 84 |
111 ± 61 |
0.179 |
Pvalue+
|
0.666 |
0.666 |
|
Duration of dialysis |
Duration ≥ 60 months (n = 30) |
106 ± 78 |
94 ± 55 |
0.190 |
Duration < 60 months (n = 36) |
152 ± 78 |
144 ± 84 |
0.190 |
Pvalue+
|
0.009 |
0.009 |
|
DM |
Yes (n = 25) |
118 ± 68 |
116 ± 61 |
0.294 |
No (n = 41) |
139 ± 92 |
124 ± 84 |
0.294 |
Pvalue+
|
0.449 |
0.449 |
|
References
- 1.Yamada K, Furuya R, Takita T, Maruyama Y, Yamaguchi Y, Ohkawa S, et al. Simplified nutritional screening tools for patients on maintenance hemodialysis. Am J Clin Nutr 2008;87:106–13.ArticlePubMed
- 2.Panichi V, Cupisti A, Rosati A, Di Giorgio A, Scatena A, Menconi O, et al. Geriatric nutritional risk index is a strong predictor of mortality in hemodialysis patients: data from the Riscavid cohort. J Nephrol 2014;27:193–201.ArticlePubMed
- 3.Kang SH, Cho KH, Park JW, Yoon KW, Do JY. Geriatric Nutritional Risk Index as a prognostic factor in peritoneal dialysis patients. Perit Dial Int 2013;33:405–10.ArticlePubMedPMC
- 4.Onodera T, Goseki N, Kosaki G. [Prognostic nutritional index in gastrointestinal surgery of malnourished cancer patients]. Nihon Geka Gakkai Zasshi 1984;85:1001–5.PubMed
- 5.Kang SH, Cho KH, Park JW, Yoon KW, Do JY. Onodera's prognostic nutritional index as a risk factor for mortality in peritoneal dialysis patients. J Korean Med Sci 2012;27:1354–8.ArticlePubMedPMC
- 6.Kato S, Chmielewski M, Honda H, Pecoits-Filho R, Matsuo S, Yuzawa Y, et al. Aspects of immune dysfunction in end-stage renal disease. Clin J Am Soc Nephrol 2008;3:1526–33.ArticlePubMedPMC
- 7.Grzegorzewska AE, Leander M. Total lymphocyte count and subpopulation lymphocyte counts in relation to dietary intake and nutritional status of peritoneal dialysis patients. Adv Perit Dial 2005;21:35–40.PubMed
- 8.Ates K, Ates A, Kutlay S, Nergizoglu G, Karatan O. Total lymphocyte count in peripheral blood of peritoneal dialysis patients: relationship to clinical parameters and outcome. J Nephrol 2004;17:246–52.PubMed
- 9.Examination Committee of Criteria for 'Obesity Disease' in Japan; Japan Society for the Study of Obesity. New criteria for 'obesity disease' in Japan. Circ J 2002;66:987–92.ArticlePubMed
- 10.Risch L, Saely CH, Neyer U, Hoefle G, Gouya G, Zerlauth M, et al. Prevalence of decreased glomerular filtration rate in patients seeking non-nephrological medical care--an evaluation using IDMS-traceable creatinine based MDRD as well as Mayo Clinic quadratic equation estimates. Clin Chim Acta 2007;378:71–7.ArticlePubMed
- 11.Beberashvili I, Azar A, Sinuani I, Kadoshi H, Shapiro G, Feldman L, et al. Comparison analysis of nutritional scores for serial monitoring of nutritional status in hemodialysis patients. Clin J Am Soc Nephrol 2013;8:443–51.ArticlePubMedPMC
- 12.Park JH, Kim SB, Shin HS, Jung YS, Rim H. Geriatric nutritional risk index may be a significant predictor of mortality in Korean hemodialysis patients: a single center study. Ther Apher Dial 2012;16:121–6.ArticlePubMed
- 13.Saad K, Elsayh KI, Zahran AM, Sobhy KM. Lymphocyte populations and apoptosis of peripheral blood B and T lymphocytes in children with end stage renal disease. Ren Fail 2014;36:502–7.ArticlePubMed
- 14.Schaible UE, Kaufmann SH. Malnutrition and in-fection: complex mechanisms and global impacts. PLoS Med 2007;4:e115.ArticlePubMedPMC
- 15.Jung YS, You G, Shin HS, Rim H. Relationship between Geriatric Nutritional Risk Index and total lymphocyte count and mortality of hemodialysis patients. Hemodial Int 2014;18:104–12.ArticlePubMed
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