Inflammation, Cholesterol Levels, and Risk of Mortality Among Patients Receiving Dialysis To the Editor: Dr Liu and colleagues1 reported that among patients receiving dialysis, cholesterol levels and mortality were inversely associated among patients with chronic inflammation but were positively associated in those without inflammation. The authors concluded that inverse relationships between cholesterol and mortality in previous studies of this population are due to the cholesterol-lowering effect of malnutrition and systemic inflammation, rather than to a protective effect of high cholesterol levels. However, there is considerable epidemiologic, clinical, and laboratory evidence that high cholesterol levels protect against infections, while low cholesterol levels predispose to infections.2 For instance, in a 15-year follow-up study of more than 100 000 healthy individuals, cholesterol levels were inversely associated with the risk of being admitted to the hospital with a diagnosis of infectious disease.3 Evidently, low cholesterol levels analyzed at baseline could not have been caused by a disease these individuals had not yet acquired. Children with Smith-Lemli-Opitz syndrome have extremely low cholesterol levels and experience frequent and severe infections, which can be prevented with supplementary dietary cholesterol.4 Numerous experimental studies have demonstrated an important role of low-density lipoprotein cholesterol (LDL-C) as an effective inhibitor of bacterial toxins. For instance, the survival of rats with experimental hypolipidemia challenged with lipopolysaccharide or gram-negative bacteria is much lower, and the survival of mice with familial hypercholesterolemia challenged similarly is much higher than normal.5 Finally, in at least 7 studies of people aged 60 and older, total mortality was inversely associated with cholesterol levels, or high cholesterol levels were associated with longevity.2 Therefore, if statin treatment should be used in dialysis patients, it may be wise to use the lowest possible dose, if any at all. References 1. Liu Y, Coresh J, Eustace JA. et al. Association between cholesterol level and mortality in dialysis patients: role of inflammation and malnutrition. JAMA.2004;291:451-459.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14747502&dopt=AbstractGoogle Scholar 2. Ravnskov U. High cholesterol may protect against infections and atherosclerosis. QJM.2003;96:927-934.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14631060&dopt=AbstractGoogle Scholar 3. Iribarren C, Jacobs Jr DR, Sidney S, Claxton AJ, Feingold KR. Cohort study of serum total cholesterol and in-hospital incidence of infectious diseases. Epidemiol Infect.1998;121:335-347.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9825784&dopt=AbstractGoogle Scholar 4. Elias ER, Irons MB, Hurley AD, Tint GS, Salen G. Clinical effects of cholesterol supplementation in six patients with the Smith-Lemli-Opitz syndrome (SLOS). Am J Med Genet.1997;68:305-310.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9024564&dopt=AbstractGoogle Scholar 5. Feingold KR, Funk JL, Moser AH, Shigenaga JK, Rapp JH, Grunfeld C. Role for circulating lipoproteins in protection from endotoxin toxicity. Infect Immun.1995;63:2041-2046.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=7729918&dopt=AbstractGoogle Scholar
JAMA – American Medical Association
Published: Apr 21, 2004
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