The Relationship Between Plasma Adiponectin And Nutrition State, Microinflammation In Patients Undergoing Different Ways Of Hemodialysis

The incidence of Chronic kidney disease (CKD) is high in worldwide.In recent our country has about 100 million people suffering from varying degrees of chronic kidney disease, and the number of chronic kidney disease is almost the same with hypertensive disease. CKD has brought a heavy financial burden to the state, society and the patients’ families, and also brought great pain to the patients. At present, the main treatment for end-stage renal disease is transplantation and dialysis. The dialysis include hemodialysis (HD) and peritoneal dialysis (PD). With the popularization and development of blood purification technology, the survival was significantly prolonged and the quality of life improved obviously in uremic patients. But with prolonged hemodialysis, patients appear a variety of complications such as micro-inflammation, dialysis related amyloidosis, malnutrition, cardiovascular events and residual renal function impairment. Medical workers pay more and more attention to these complications. Doctors believe that the middle molecular toxin result in toxin poisoning in patient with chronic kidney disease.many complications are mainly related to the middle molecular toxin removal insufficiently. Low-flux hemodialysis mainly remove small molecule toxins through the diffusion way. Small molecules substance can effectively remove by low-flux hemodialysis, but β2-microglobulin (β2-MG) and the macromolecular toxins can not effectively remove. The high-flux hemodialysis, hemofiltration which rely on diffusion way and convection way combination can effectively remove the molecular weight ranging from 1-15kDa large molecular substances. Because different ways of hemodialysis to remove toxin effect is different, the endotoxin levels of patients undergoing different ways of hemodialysis, especially inflammatory cytokines and the macromolecular toxin levels are different. To seek the biochemical indicators which could predict dialysis-related complication,inflamematin,malnutrition and other complications is necessary in clinical diagnosis. And hemodialysis program adjustment is based on these biochemical parameters and the patient’s condition.ADPN belongs to a collagen-like superfamily sharing homologies with collagens, complement factors and also tumor-necrosis factor (TNF) a. ADPN circulates as low-molecular weight(LMW), medium-molecular weight(MMW) and high--molecular weight(HMW) complexes. These high-order complexes are the predominant forms in human serum. In 2003, Yamauchi et al for the first time cloned adiponectin receptors gene from skeletal muscle cells of human:the adiponectin receptorl(adipoRl) genes is mainly expressed in skeletal muscle, although in humans they are obviously expressed ubiquitously in the body, and adiponectin receptor 2(adipoR2) gene is mainly expressed in the liver. The expression of AdipoR 1/R2 appears to be inversely regulated by insulin in physiological and pathophysiological states such as fasting/refeeding, insulin deficiency, and hyperinsulinemia models via the insulin/phosphoinositide3-kinase/Foxol pathway and is correlated with adiponectin sensitivity. Hug et al.showed that T-cadherin is the third receptor,and T-cadherin is an receptor for the hexameric and HMW species of ADPN, but not for the trimeric species. Calreticulin was demonstrated to be another ADPN receptor facilitating the uptake of early apoptotic cells by macrophages, which is an essential feature of immune function. Adiponectin binds to membrane receptors and then activates the AMP-activated protein kinase (AMPK), the phosphatidylinositol 3-kinase (PI3K)/Akt, p38 mitogen-activated protein(MAP)-kinase, peroxisome proliferators-activated receptor (PPAR a) signaling pathways; after this activation, adiponectin exerts its functions, modulating glucose homeostasis and lipid metabolism, antiatherogenesis,anti-inflammation, and insulin sensitization. Adiponectin is reported to be abundant in the human bloodstream, accounted for by about 0.01% of total plasma protein. Plasma adiponectin level is stable and is cleared rapidly from the circulation primarily from the liver, involving at least in part the biliary route, and secondarily from the kidney. Adiponectin monomers(28kDa) and dimers have a molecular weight small enough to cross the normal functioning glomerular filtration barrier and thereby adiponectin can be traced in the urine of healthy subjects. Although urinary adiponectin of normal humans has been reported to be below the limit of detection with ELISA kits, low-intensity signals of urinary adiponectin have been detected with western blotting. Although monomers and dimmers are the only isoforms of adiponectin detected in urine of healthy subjects, in patients with albuminuria trimers of adiponectin (low-molecular-weight adiponectin) are also excreted to a considerable extent.Highmolecular-weight (HMW) adiponectin has been reported to be minimally detected in urine of patients with proteinuria, possibly due to the leakage of HMW adiponectin through a dysfunctional glomerular filtration barrier. Adiponectin concentration is also reduced in type 2 diabetes, coronary artery disease, and dyslipidemia.Plasma adiponectin values have been reported to be increased in various stages of chronic renal failure, and in the nephritic syndrome. In chronic kidney disease (CKD),adiponectin concentration is increased when renal function declines, and that this is related to metabolic markers such as insulin and leptin. Because the gradual increase of plasma adiponectin concentration parallels the progression of CKD, the highest levels are usually found in end-stage renal disease(ESRD), hemodialysis(HD) and peritoneal dialysis(PD) patients. In ESRD,HD and PD patients, adiponectin concentrations are about three times higher than in healthy subjects. The reasons for the high adiponectin levels in uremic milieu are not fully unclear, and reduced renal excretion has been proposed as the mechanism for the elevated circulating levels of ADPN in chronic kidney disease.Although varied factors affected the survival of maintenance hemodialysis patients, cardiovascular disease, malnutrition, inflammation and macromolecules toxin-related complications is still the most important risk factor. Adiponectin binds to membrane receptors and then plays a important role in cardiovascular diseases, malnutrition, bone metabolic disorders and inflammation. Maintenance hemodialysis patients plasma adiponectin level is significantly higher than healthy people. Plasma adiponectin level of patients undergoing different ways of hemodialysis whether is a difference? Plasma adiponectin level of patients whether there is a difference in different stages of hemodialysis treatment? what role does adiponectin play in the development of dialysis-related complications is unclear. To explore the difference of plasma adiponectin levels in patients undergoing different ways of hemodialysis and to investigate the relationship between adiponectin and micro-inflammation, nutritional status and macromolecules toxin-related complications is necessary. After patients of end-stage renal disease adopt different ways of hemodialysis treatment, adiponectin levels change is discussed in the research. Plasma adiponectin levels in patients with different ways of hemodialysis is compared in our research. Our research conclude that adiponectin plays an important role in the development of the disease, such as inflammation, malnutrition, bone metabolism and macromolecule toxin dialysis-related complications. The research analysis relationship between plasma adiponectin concentrations and other biochemical indicators.Objective:To explore the change of plasma adiponectin levels after patients of end-stage renal disease adoptted different ways of hemodialysis treatment, and to analysis relationship between plasma adiponectin concentration and nutritional status, micro-inflammation and macromolecules toxin-related complications.Method:84 cases of patients treated maintenance hemodialysis in Beijiao Hospitalp’s hemodialysis center in a stable condition,dialysis age≥six months. Those patients were randomly assigned to three groups for low-flux hemodialysis group(LFHD) high-flux hemodialysis group(HFHD), high-flux hemodialysis in combination with hemodiafiltration group(HFHD+HDF). The baseline and post treatment levels of subjective global assessment of nutrition(SGA), total protein(TP), albumin(Alb), prealbumin(PA), hemoglobin(Hb), ferritin(FER), C reactive protein(CRP), total cholesterol(TC), triglyceride(TG), high density lipoprotein(HDL), low density lipoprotein(HDL), potassium(K), sodium(Na), calcium(Ca), phosphate(P), blood urea nitrogen(BUN), creatinine(Cr), urea acid(UA), intact parathyroid homone(iPTH), β2-microglobulin(β2-MG), cystatin C(CysC) and adiponectin(ADPN) were compared among three groups.Result:(1) Before the first hemodialysis treatment, the levels of those biochemical indicators were of no significant difference among the three groups.(2)①Nutrition indicators:In LFHD group SGA, PA increased afer six months, and increases were statistically significantly(P<0.05). After the treatment for 6 months, serum TP, Alb and Hb change were statistically insignificant(P>0.05). In HFHD group, after the treatment for 6 months, however, serum TP and PA levels increased significant(P<0.05) without change of SGA, Alb, Hb levels(P>0.05). In HFHD+HDF group, after the treatment for 6 months, however, serum SGA,Hb and PA levels changed significant(P<0.05) without change of serum Alb levels(P>0.05). After treatment, SGA of the HFHD group and the HFHD+HDF group were remarkably lower than the LFHD group(P<0.05), and significant difference was noted between the HFHD group and HFHD+HDF group(P<0.05).Hb of the HFHD group and the HFHD+HDF group were higher than the LFHD group(P<0.05), while no significant difference was noted between the HFHD group and HFHD+HDF group. The level of TP in HFHD group was higer than levels of TP in the other two groups. ②Inflammation indicators:In LFHD group,serum CRP, Fer increased after hemodialysis treatment, but the increases were statistically insignificant(P>0.05). In HFHD group and HFHD+HDF group, serum CRP, Fer decreased after hemodialysis treatment, and the decreases were statistically significant (P<0.05). after treatment, CRP, Fer notably decreased in the HFHD group and the HFHD+HDF group in comparison with the LFHD group (P<0.05), while no significant difference was noted between the HFHD group and the HFHD+HDF group(P>0.05).③ADPN and lipid metabolism indicators:In LFHD group, serum ADPN, TC, TG, HDL, LDL were not statistically significant after treatment (P>0.05). After six months, plasma ADPN level of the HFHD group and the HFHD+HDF group increase (P<0.05), and were markedly higher than LFHD group (P<0.05). while diferences in TC, TG, HDL, LDL among the three groups were not statistically significant (P>0.05).④Electrolytes and toxins index:In LFHD group,serum β2-MG increased after hemodialysis treatment, and the increases were statistically significant (P<0.05). In HFHD group,serum CysC decreased after hemodialysis treatment, and the deincreases were statistically significant(P<0.05). In HFHD+HDF group, serumβ2-MG, CysC decreased after hemodialysis treatment, and thedecreases were statistically significant(P<0.05). after treatment, CysC, β2-MG notably decreased in the HFHD group and the HFHD+HDF group in comparison with the LFHD group (P<0.05), while no significant difference was noted between the HFHD group and the HFHD+HDF group(P>0.05).(3) Serum ADPN level related factors analysis:Correlation analysis showed that plasma ADPN level was inversely associated with Fer, CRP, CysC, β2-MG, iPTH, whereas was associated with SGA, PA, Alb, Hb.Conclusion:The different ways of hemodialysis could have an effect on the final levels of adiponectin in MHD patients. ADPN can be used as a meaningful indicator of microinflammation, macromolecule toxin dialysis-related complications, nutrition status in hemodialysis patients.