NDT Advance Access originally published online on June 16, 2007
Nephrology Dialysis Transplantation 2007 22(7):2093; doi:10.1093/ndt/gfm235
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Reply
Email: mohamed.suliman{at}klinvet.ki.seSir,
We thank Dr Movilli for his comments and for the interest shown in our study [1]. We agree that there was no statistically significant difference in hazard ratio after adjustment for inflammation and wasting. In our paper, this was clearly acknowledged, and several study limitations were discussed. We should note that the small size of our study population limits the statistical power leading to widening confidence intervals. Not withstanding this and other limitations of our study, the reversal of the direction of the associations after multivariate adjustment for surrogates of inflammation and wasting indicates a trend with possible biological plausibility. Indeed, patients with higher total serum homocysteine (tHcy) levels tended to have lower mortality before adjustment for inflammation-wasting, whereas after adjustment they had a 27% higher all-cause and 22% higher cardiovascular mortality. Consistent with our foregoing findings, a recent study by Ducloux et al. [2] found that tHcy in haemodialysis (HD) patients with inflammation-wasting syndrome was inversely related to all-cause mortality, but this association was in the opposite direction in HD patients without the inflammation-wasting. Although these studies may not provide sufficient explanation for the reverse epidemiology phenomenon, they show that the inflammation-wasting confounds the background association between tHcy and mortality in CKD and that this effect may be so overwhelming that it may even reverse the direction of the associations. Prospective studies including larger numbers of patients are required to better examine the true aetiology of the enigmatic phenomenon of reverse epidemiology of tHcy in CKD.
Conflict of interest statement. None declared.
1Renal Medicine and
Baxter Novum
Karolinska Hospital Huddinge
Karolinska Institute
Karolinska Hospital Huddinge
K56 Stockholm 141 86
Sweden
References
- Suliman M, Stenvinkel P, Qureshi AR, et al. The reverse epidemiology of plasma total homocysteine as a mortality risk factor is related to the impact of wasting and inflammation. Nephrol Dial Transplant (2007) 22:209–217.
[Abstract/Free Full Text] - Ducloux D, Klein A, Kazory A, et al. Impact of malnutrition-inflammation on the association between homocysteine and mortality. Kidney Int (2006) 69:331–335.[CrossRef][Web of Science][Medline]
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