Nephrol Dial Transplant Vol. 19 No. 11 © ERA-EDTA 2004; all rights reserved
Original Article
The prognostic impact of fluctuating levels of C-reactive protein in Brazilian haemodialysis patients: a prospective study
1 Karolinska Institutet, Karolinska University Hospital Huddinge, Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science Stockholm, Sweden, 2 Faculdade Evangélica de Medicina do Paraná, 3 Post-Graduation Nephrology Program, Universidade Federal do Rio Grande do Sul and 4 Division of Nephrology Pontificia Universidade Catolica do Paraná, Brazil
Correspondence and offprint requests to: Bengt Lindholm, MD, PhD, Divisions of Renal Medicine and Baxter Novum, K-56 Karolinka University Hospital Huddinge, S-141 86 Stockholm, Sweden. Email: bengt.lindholm{at}klinvet.ki.se
Background. A single elevated C-reactive protein (CRP) value predicts mortality in haemodialysis (HD) patients, but the relative importance of repeated vs occasional positive systemic inflammatory response findings is not known.
Methods. To assess the influence on survival of occasional inflammation, CRP, serum albumin (S-Alb) and fibrinogen were analysed bimonthly in 180 HD patients (54% male, 49±14 years). Clinically significant inflammation was defined as CRP >5.1 mg/l, based on the receiver operating characteristics curve for CRP as predictor of death. Based on four consecutive measurements of CRP, patients were assigned into three groups: group 1 (n = 74; 41%), no inflammation (CRP 
5.1 mg/l in all measurements); group 2 (n = 65; 36%), occasional inflammation (1–3 measurements of CRP > 5.1 mg/l); and group 3 (n = 41; 23%), persistent inflammation (all measurements of CRP >5.1 mg/l). The nutritional status was evaluated by subjective global assessment (SGA) and body mass index (BMI), and the survival (21 months of follow-up) by Kaplan–Meier curve and Cox model.
Results. The median and range of CRP values (mg/l) for group 1, 2 and 3 were: 3.2 (3.2–5.1), 3.6 (3.2–54.9) and 13.8 (5.2–82), respectively (P<0.001), whereas the prevalence of malnutrition, assessed by SGA and BMI, did not differ significantly between the groups. The survival rate by Kaplan–Meier analysis was significantly different among the groups (
2 = 12.34; P = 0.0004). Patients in group 3 showed the highest mortality (34%; P = 0.001), compared with group 1 (8%) and group 2 (14%; P = 0.01), respectively, whereas there was no significant difference in mortality between groups 1 and 2. Age, CRP, S-Alb level and SGA were independent predictors of mortality.
Conclusion. The patients with a persistent elevation of CRP had a higher mortality rate than the patients with occasional CRP elevation. Thus, persistent, rather than occasional, inflammation is an important predictor of death in HD patients.
Keywords: C-reactive protein; ESRD; haemodialysis; inflammation; malnutrition
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