Background: In chronic hemodialysis patients, malnutrition, inflammation, depression and arteriosclerosis are pathogenetically associated suggesting the presence of malnutrition-inflammation-depression-arteriosclerosis (MIDA) complex acting as a risk factor for cardiovascular disease (CVD). Methods: Nutritional status was assessed by serum albumin, subjective global assessment and normalized protein catabolic rate (nPCR). Inflammation was assessed by serum high-sensitivity C-reactive protein (hsCRP). Depression was assessed with the Beck Depression Inventory and DSM-IV criteria. The severity of arteriosclerosis was measured by pulse wave velocity (PWV). Results: Among 81 hemodialysis patients, 44 (54.3%) had malnutrition (albumin <4.0 mg/dl with subjective global assessment score <6 and/or nPCR <1.0) and 39 (48.1%) had inflammation (hsCRP >1 mg/l). The prevalence of depression was 50.6% (n = 41). Fifty-nine (73.8%) had arteriosclerosis (measured PWV > expected PWV based on age/blood pressure/gender adjustment). The severity of the all four individual MIDA components correlated well with each other. The average number of the MIDA complication (MIDA score) was 2.27 ± 1.33. -During the 5-year follow-up, 40 cases of CVD and 26 cases of all-cause death occurred. In Cox analysis adjusted for -previous CVD, age, diabetes, blood pressure, pulse pressure, intradialytic hypotension, B-type natriuretic peptide, -hemoglobin and hemodialysis incompliance, the MIDA score was an independent predictor of CVD and all-cause death: hazard ratio (95% confidence interval); 1.89 (1.13-3.17) and 3.48 (1.32-9.21) for an increase of 1 MIDA score. Conclusions: This study suggests the presence of MIDA complex, which is composed of malnutrition, inflammation, depression and arteriosclerosis. The MIDA complex syndrome was an independent risk factor for CVD and all-cause death in chronic hemodialysis patients.

Keywords:
Arteriosclerosis, Cardiovascular disease, Depression, Hemodialysis, Inflammation, Malnutrition, Mortality
1.
Sarnak MJ: Cardiovascular complications in chronic kidney disease. Am J Kidney Dis 2003;1:11-17.
2.
Goldsmith DJ, Covic A: Coronary artery disease in uremia: etiology, diagnosis, and therapy. Kidney Int 2001;60:2059-2078.
3.
Collins AJ, Li S, Ma JZ, Herzog C: Cardiovascular disease in end-stage renal disease patients. Am J Kidney Dis 2001;38:26-29.
4.
Lowrie EG, Lew NL: Death risk in hemodialysis patients: the predictive value of commonly measured variables and an evaluation of death rate differences between facilities. Am J Kidney Dis 1990;15:458-482.
5.
Kimmel PL, Phillips TM, Simmens SJ, Peterson RA, Weihs KL, Alleyne S, Cruz I, Yanovski JA, Veis JH: Immunologic function and survival in hemodialysis patients. Kidney Int. 1998;54:236-244.
6.
Akdag I, Yilmaz Y, Kahvecioglu S, Bolca N, Ercan I, Ersoy A, Gullulu M: Clinical value of the malnutrition-inflammation-atherosclerosis syndrome for long-term prediction of cardiovascular mortality in patients with end-stage renal disease: a 5-year prospective study. Nephron Clin Pract 2008;108:99-105.
7.
Blacher J, Safar ME, Guerin AP, Pannier B, Marchais SJ, London GM: Aortic pulse wave velocity index and mortality in end-stage renal disease. Kidney Int 2003;63:1852-1860.
8.
DeLoach SS, Berns JS: Arterial stiffness and vascular calcification in dialysis patients: new measures of cardiovascular risk. Semin Dial 2007;20:477-479.
9.
Stenvinkel P, Heimburger O, Lindholm B, Kaysen GA, Bergström J: Are there two types of malnutrition in chronic renal failure? Evidence for relationships between malnutrition, inflammation and atherosclerosis (MIA syndrome). Nephrol Dial Transplant 2000;15:953-960.
10.
Stenvinkel P, Heimbürger O, Paultre F, Diczfalusy U, Wang T, Berglund L, Jogestrand T: Strong association between malnutrition, inflammation and atherosclerosis in chronic renal failure. Kidney Int 1999;55:1899-1911.
11.
Finkelstein FO, Finkelstein SH: Depression in chronic dialysis patients: assessment and treatment. Nephrol Dial Transplant 2000;15:1911-1913.
12.
Kimmel PL, Peterson RA, Weihs KL, Simmens SJ, Alleyne S, Cruz I, Veis JH: Multiple measurements of depression predict mortality in a longitudinal study of chronic hemodialysis patients. Kidney Int 2000;57:2093-2098.
13.
Lopes AA, Bragg J, Young E, Goodkin D, Mapes D, Combe C, Piera L, Held P, Gillespie B, Port FK: Dialysis Outcomes and Practice Patterns Study (DOPPS). Depression as a predictor of mortality and hospitalization among hemodialysis patients in the United States and Europe. Kidney Int 2002;62:199-207.
14.
Raison CL, Capuron L, Miller AH: Cytokines sing the blues: inflammation and the pathogenesis of depression. Trends Immunol 2006;27:24-31.
15.
Howren MB, Lamkin DM, Suls J: Associations of depression with C-reactive protein, IL-1, and IL-6:a meta-analysis. Psychosom Med 2009;71:171-186.
16.
Stenvinkel P, Barany P, Heimburger O, Pecoits-Filho R, Lindholm B: Mortality, malnutrition, and atherosclerosis in ESRD: what is the role of interleukin-6? Kidney Int 2002;80(suppl):S103-S108.
17.
Koo JR, Yoon JW, Kim SG, Lee YK, Oh KH, Kim GH, Kim HJ, Chae DW, Noh JW, Lee SK, Son BK: Association of depression with malnutrition in chronic hemodialysis patients. Am J Kidney Dis 2003;41:1037-1042.
18.
Lee SK, Lee HS, Lee TB, Kim DH, Koo JR, Kim YK, Son BK: The effects of antidepressant treatment on serum cytokines and nutritional status in hemodialysis patients. J Korean Med Sci 2004;19:384-389.
19.
Ko GJ, Kim MG, Yu YM, Jo SK, Cho WY, HK Kim: Association between depression symptoms with inflammation and cardiovascular risk factors in patients undergoing peritoneal dialysis. Nephron Clin Pract 2010;116:29-35.
20.
Shroff RC, Shanahan CM: The vascular biology of calcification. Semin Dial 2007;20:103-109.
21.
London GM, Marchais SJ, Guérin AP, Métivier F: Arteriosclerosis, vascular calcifications and cardiovascular disease in uremia. Curr Opin Nephrol Hypertens 2005;14:525-531.
22.
Ketteler M, Westenfeld R, Schlieper G, Brandenburg V: Pathogenesis of vascular calcification in dialysis patients Clin Exp Nephrol 2005;9:265-270.
23.
Amann K: Media calcification and intima calcification are distinct entities in chronic kidney disease. Clin J Am Soc Nephrol 2008;3:1599-1605.
24.
Yamashina A, Tomiyama H, Takeda K, Tsuda H, Hirose K, Koji Y, Hori S, Yamamoto Y: Validity, reproducibility, and clinical significance of noninvasive brachial-ankle pulse wave velocity measurement. Hypertens Res 2002;25:359-364.
25.
Yamashina A, Tomiyama H, Arai T, Koji Y, Yambe M, Glunizia Z, Hori S: Nomogram of the relation of brachial-ankle pulse wave velocity with blood pressure. Hypertens Res 2003;26:801-806.
26.
Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J: An inventory for measuring depression. Arch Gen Psychiatry 1961;4:561-571.
27.
Canada-USA (CANUSA) Peritoneal Dialysis Study Group: Adequacy of dialysis and nutrition in continuous peritoneal dialysis: association with clinical outcomes. J Am Soc Nephrol 1996;7:198-207.
28.
Schiller NB, Shah PM, Crawford M, DeMaria A, Devereux R, Feigenbaum H, Gutgesell H, Reichek N, Sahn D, Schnittger I: Recommendations for quantitation of the left ventricle by two-dimensional echocardiography. American Society of Echocardiography Committee on Standards, Subcommittee on Quantitation of Two-Dimensional Echocardiograms. J Am Soc Echocardiogr 1989;2:358-367.
29.
Hecking E, Bragg-Gresham JL, Rayner HC, Pisoni RL, Andreucci VE, Combe C, Greenwood R, McCullough K, Feldman HI, Young EW, Held PJ, Port FK: Haemodialysis prescription, adherence and nutritional indicators in five European countries: results from the Dialysis Outcomes and Practice Patterns Study (DOPPS). Nephrol Dial Transplant 2004;19:100-107.
30.
Kimmel PL, Peterson RA, Weihs KL, Simmens SJ, Boyle DH, Verme D, Umana WO, Veis JH, Alleyne S, Cruz I: Behavioral compliance with dialysis prescription in hemodialysis patients. J Am Soc Nephrol 1995;5:1826-1834.
31.
Knoll GA, Grabowski JA, Dervin GF, O'Rourke K: A randomized, controlled trial of albumin versus saline for the treatment of intradialytic hypotension. J Am Soc Nephrol 2004;15:487-492.
32.
Stenvinkel P, Alvestrand A: Inflammation in end-stage renal disease: sources, consequences, and therapy. Semin Dial 2002;15:329-337.
33.
Matsumae T, Matsumae M, Hasegawa Y, Tanaka T, Yoshitake K, Noda R, Ogahara S, Murata T, Kaneoka H: Relationship between fluctuation pattern of blood pressure during hemodialysis treatment and cardiovascular morphology: an autopsy study of 53 cases. Nephron 2001;88:113-119.
34.
London GM, Guérin AP, Marchais SJ, Métivier F, Pannier B, Adda H: Arterial media calcification in end-stage renal disease: impact on all-cause and cardiovascular mortality. Nephrol Dial Transplant 2003;18:1731-1740.
35.
Martola L, Barany P, Stenvinkel P: Why do dialysis patients develop a heart of stone and bone of china? Blood Purif 2005;23:203-210.
36.
Kalantar-Zadeh K, McAllister CJ, Lehn RS, Lee GH, Nissenson AR, Kopple JD: Effect of malnutrition-inflammation complex syndrome on EPO hyporesponsiveness in maintenance hemodialysis patients. Am J Kidney Dis 2003;42:761-773.
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2013
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