MALNUTRITION, CARDIAC DISEASE, AND MORTALITY - AN INTEGRATED POINT-OF-VIEW

Malnutrition and hypoalbuminemia, which are prevalent in patients with end-stage renal disease (ESRD), are strong predictors of increased mo rtality. However, cardiovascular disease predominates among direct cau ses of death, whereas malnutrition appears to be of minor importance i n this respect. Reports in the literature demonstrate that cardiac fai lure may cause malnutrition and that infection/inflammation may predis pose to atherosclerosis as well as to catabolism and hypoalbuminemia. Proinflammatory cytokines, generated in response to cardiac failure, i nfection, and other inflammatory stimuli, appear to play a pivotal rol e by causing muscle wasting, hypoalbuminemia, and anorexia as well as reduced cardiac contractility and atherosclerotic vascular disease. We hypothesize that this scenario also applies to ESRD patients, in whom congestion, hypertension, cardiac failure, and ischemic cardiovascula r disease are common. Malnutrition rarely may be the direct cause of d eath, except in elderly dialysis patients, but may contribute to a poo r prognosis by aggravating pre-existing heart failure and increasing t he susceptibility to infections. (C) 1998 by the National Kidney Found ation, Inc.