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Original Article
Relationships of Total Lymphocyte Count and Subpopulation Lymphocyte Counts with the Nutritional Status in Patients Undergoing Hemodialysis/Peritoneal Dialysis
Ye Na Kim, Ho Sik Shin
Kosin Medical Journal 2017;32(1):58-71.
DOI: https://doi.org/10.7180/kmj.2017.32.1.58
Published online: January 19, 2017

Department of Internal Medicine, College of Medicine, Kosin University, Busan, Korea

Corresponding Author: Ho Sik Shin, Department of Internal Medicine, Kosin University College of Medicine, Kosin University, 262, Gamcheon-ro, Seo-gu, Busan 49267, Korea Tel: +82-51-990-6250 Fax: +82-51-248-5686 E-mail: danieljoseph@hanmail.net
• Received: September 24, 2015   • Accepted: January 11, 2016

Copyright © 2017 Kosin University School of Medicine Proceedings

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  • Objectives
    Dialysis patients’ nutritional indicators are quite subjective and complex and cannot be easily measured in clinical settings. Based on previous reports that total lymphocyte count (TLC) and subpopulation lymphocyte counts (SLCs) are associated with nutritional status in patients with dialysis, we designed this study to examine the relationships of the TLC and SLCs with clinical outcome and nutritional status in patients undergoing maintenance hemodialysis (HD) and peritoneal dialysis (PD).
  • Methods
    In this prospective, observational study, we enrolled 66 patients (50 HD patients and 16 PD patients) receiving stable maintenance dialysis. We evaluated the baseline parameters of height; weight; TLC; SLCs expressing CD3, CD4, CD8 and CD19; CBC; iron profile (iron, TIBC, ferritin); BUN; Cr; Na; K; total CO2; Ca; P; iPTH; protein; albumin; total cholesterol; HDL; LDL; uric acid and CRP and calculated Onodera’s prognostic nutritional index (OPNI) and the Geriatric Nutritional Risk Index (GNRI) at baseline and three months. To analyze differences in the TLC and SLCs between the HD group and the PD group, we performed an independent samples t-test. Logistic regression analysis was performed to predict malnutrition in dialysis patients. In addition, to analyze changes in TLC, SLCs expressing each marker (CD3, CD4, CD8 and CD19) and other nutritional markers, we performed general linear model (GLM)-repeated measures ANOVA.
  • Results
    Mean age was 55.8 ± 12.7 years in HD paitents and 49.8 ± 14.5 years in PD patients. The duration of dialysis was 59.7 ± 52.9 months in HD patients and 66.1 ± 33.6 years in PD patients. Logistic regression analysis revealed that patients aged 60 years or older, women, and those whose CD19 SLCs were lower than 100 had a higher risk of developing malnutrition. In GLM-repeated measures ANOVA, CD19 SLCs were significantly higher in women and in patients with a shorter period of dialysis.
  • Conclusions
    Our results indicate that GNRI, OPNI, TLC and SLCs (especially CD19 count) may be significant nutritional markers in HD and PD patients.
  • Keywords: Dialysis; Lymphocyte Count; Total Lymphocyte Counts
Table 1.
Clinical characteristics of 66 dialysis patients according to methods of dialysis at start of the study
Variables HD (n=50) PD (n=16) Pvalue
Age 55.8 ± 12.7 49.8 ± 14.5 0.127
Sex (Male/Female) 28/22 10/6 0.774
DM 18 (36%) 7 (43.8%) 0.768
Duration of dialysis (months) 59.7 ± 52.9 66.1 ± 33.6 0.653
Body Mass Index 21.3 ± 2.5 23.8 ± 4.1 0.005
GNRI 100.1 ± 8.4 99.2 ± 8.1 0.708
OPNI 47.0 ± 4.6 39.5 ± 4.3 0.003
Kt/V 1.68 ± 0.22 1.85 ± 0.36 0.034
Urea Reduction Rate (%) 75.0 ± 4.5 NA NA
TLCs (/㎣) 1597 ± 512 1105 ± 658 0.019
CD3 count (/㎣) 1015 ± 400 964 ± 366 0.655
CD4 count (/㎣) 632 ± 260 585 ± 231 0.523
CD8 count (/㎣) 384 ± 171 366 ± 171 0.731
CD19 count (/㎣) 132 ± 85 127 ± 84 0.831
CD4/CD8 ratio 1.8 ± 0.7 1.7 ± 0.7 0.835
Hemoglobin (g/dL) 10.9 ± 0.6 11.3 ± 1.1 0.141
Iron (ug/dL) 88.6 ± 34.8 103.6 ± 43.9 0.195
TIBC (ug/dL) 244.9 ± 35.5 261.1 ± 49.1 0.182
TSAT (%) 37.0 ± 16.5 41.1 ± 19.6 0.457
Ferritin (ng/mL) 367.5 ± 275.6 306.4 ± 204.4 0.458
BUN (mg/dL) 64.8 ± 19.5 64.0 ± 16.2 0.944
Cr (mg/dL) 9.5 ± 2.2 11.9 ± 2.3 0.001
Sodium (mEq/L) 137.9 ± 2.8 136.7 ± 3.2 0.192
Potassium (mEq/L) 5.3 ± 0.7 4.4 ± 0.7 0.001
Calcium (mg/dL) 8.8 ± 0.5 9.0 ± 0.5 0.233
Phosphorus (mg/dL) 5.1 ± 1.4 5.6 ± 1.2 0.161
Parathyroid hormone (pg/mL) 191.2 ± 199.7 389.1 ± 311.6 0.005
Albumin (g/dL) 3.9 ± 0.3 3.4 ± 0.3 0.001

GNRI: Geriatric Nutritional Risk Index; OPNI: Onodera’s prognostic nutritional index; Kt/V: Dialysis adequacy; TLCs: Total lymphocyte counts; NA: Not Applicable; TIBC: Total iron binding capacity; TAST: transferrin saturation.

Table 2.
Clinical characteristics of 66 dialysis patients according to methods of dialysis after 3 month
Variables HD (n=50) PD (n=16) Pvalue
Age 55.8 ± 12.7 49.8 ± 14.5 0.127
Sex (Male/Female) 28/22 10/6 0.774
DM 18 (36%) 7 (43.8%) 0.768
Duration of dialysis (months) 61.4 ± 50.9 69.1 ± 30.2 0.653
Body Mass Index 21.1 ± 2.5 23.8 ± 4.1 0.032
GNRI 99.5 ± 7.7 96.2 ± 9.2 0.184
OPNI 46.1 ± 4.5 38.4 ± 5.6 0.035
Systolic blood pressure (mmHg) 138.0 ± 31.4 133.7 ± 24.1 0.568
Diastolic blood pressure (mmHg) 80.6 ± 16.6 80.8 ± 11.8 0.972
Kt/V 1.76 ± 0.25 1.86 ± 0.37 0.263
Urea Reduction Rate (%) 76.0 ± 4.9 NA NA
Neutrophil Lymphocyte Ratio 0.43 ± 0.15 0.60 ± 0.22 0.139
TLCs (/㎣) 1520 ± 526 1386 ± 697 0.570
CD3 count (/㎣) 1023 ± 428 905 ± 464 0.365
CD4 count (/㎣) 644 ± 296 627 ± 281 0.845
CD8 count (/㎣) 372 ± 169 380 ± 181 0.881
CD19 count (/㎣) 125 ± 81 112 ± 63 0.541
CD4/CD8 ratio 1.8 ± 0.7 0.7 ± 0.6 0.638

GNRI: Geriatric Nutritional Risk Index; OPNI: Onodera’s prognostic nutritional index; Kt/V: Dialysis adequacy; TLCs: Total lymphocyte counts; NA: Not Applicable

Table 3.
Clinical characteristics of 66 dialysis patients according to GNRI at start of the study
Variables GNRI ≥ 100(n=33) GNRI < 100 (n=33) Pvalue
Age 54.0 ± 14.5 54.6 ± 12.4 0.860
Sex (Male/Female) 22/11 15/17 0.136
DM 11 (33.3%) 13 (40.6%) 0.612
HD/PD 27/6 24/9 0.389
Duration of dialysis (months) 47.1 ± 35.6 77.4 ± 55.9 0.011
Body Mass Index 23.8 ± 2.8 20.0 ± 2.1 0.001
GNRI 106.7 ± 3.4 92.9 ± 5.5 0.001
Systolic blood pressure (mmHg) 137.0 ± 20.9 137.2 ± 37.3 0.977
Diastolic blood pressure (mmHg) 81.2 ± 12.4 80.1 ± 18.5 0.788
Kt/V 1.7 ± 0.3 1.7 ± 0.2 0.576
Neutrophil Lymphocyte Ratio 0.43 ± 0.15 0.38 ± 0.11 0.226
TLCs (/㎣) 1530 ± 556 1555 ± 557 0.866
CD3 count (/㎣) 1093 ± 379 922 ± 387 0.076
CD4 count (/㎣) 672 ± 255 574 ± 245 0.118
CD8 count (/㎣) 420 ± 172 342 ± 162 0.065
CD19 count (/㎣) 146 ± 82 114 ± 85 0.123
CD4/CD8 ratio 1.7 ± 0.7 1.8 ± 0.7 0.612

GNRI: Geriatric Nutritional Risk Index; OPNI : Onodera’s prognostic nutritional index; Kt/V : Dialysis adequacy; TLCs : Total lymphocyte counts.

Table 4.
Clinical characteristics of 66 dialysis patients according to OPNI 45 at start of the study
Variables OPNI ≥ 45 (n=46) OPNI < 45 (n=20) Pvalue
Age 53.2 ± 14.0 59.3 ± 10.5 0.080
Sex (Male/Female) 25/21 13/7 0.768
DM 18 (39.1%) 7 (35.3%) 0.988
HD/PD 39/7 11/9 0.002
Duration of dialysis (months) 50.8 ± 38.6 89.0 ± 66.8 0.009
Body Mass Index 21.7 ± 2.6 21.9 ± 3.3 0.797
OPNI 49.0 ± 2.6 39.7 ± 3.6 0.001
Systolic blood pressure (mmHg) 139.9 ± 25.5 133.5 ± 44.1 0.492
Diastolic blood pressure (mmHg) 80.2 ± 12.2 80.1 ± 24.3 0.986
Kt/V 1.7 ± 0.2 1.6 ± 0.2 0.476
Neutrophil Lymphocyte Ratio 0.38 ± 0.10 0.48 ± 0.18 0.011
TLCs (/㎣) 1710 ± 475 1164 ± 552 0.001
CD3 count (/㎣) 1085 ± 419 863 ± 353 0.049
CD4 count (/㎣) 677 ± 268 524 ± 222 0.034
CD8 count (/㎣) 411 ± 181 326 ± 160 0.089
CD19 count (/㎣) 141 ± 77 96 ± 89 0.061
CD4/CD8 ratio 1.8 ± 0.7 1.7 ± 0.7 0.851

GNRI : Geriatric Nutritional Risk Index; OPNI : Onodera’s prognostic nutritional index; Kt/V : Dialysis adequacy; TLCs : Total lymphocyte counts.

Table 5.
Logistic regression for predicting malnutrition according to GNRI 100 at start of the study
Variables OR (95% CI) Pvalue
Age > 60 years 10.783(1.936−60.059) 0.007
Female 2.115(0.752−9.194) 0.255
PD 3.159(0.338−29.533) 0.313
Duration of dialysis (months) > 60 0.705(0.136−3.657) 0.677
DM 1.507(0.342−6.633) 0.588
Total Lymphocyte Counts (/㎣) < 1500 0.473(0.113−1.972) 0.304
CD3 count (/㎣) < 1000 0.598(0.040−8.996) 0.711
CD4 count (/㎣) < 600 0.969(0.176−5.329) 0.971
CD8 count (/㎣) < 350 3.509(0.331−37.193) 0.297
CD19 count (/㎣) < 100 9.202(1.481−57.191) 0.017
Table 6.
Logistic regression for predicting malnutrition according to OPNI 45 at start of study
Variables OR (95% CI) Pvalue
Age > 60 years 6.724(1.450−19.884) 0.024
Female 1.115(0.152−8.194) 0.915
PD 5.307(1.872−14.457) 0.021
Duration of dialysis (months) > 60 2.467(0.326−18.672) 0.382
DM 0.541(0.053−5.473) 0.603
Total Lymphocyte Counts (/㎣) < 1500 4.351(0.698−27.121) 0.115
CD3 count (/㎣) < 1000 8.041(0.158−40.833) 0.298
CD4 count (/㎣) < 600 0.771(0.076−7.833) 0.826
CD8 count (/㎣) < 350 0.317(0.010−10.081) 0.515
CD19 count (/㎣) < 100 3.444(0.367−32.347) 0.279
Table 7.
Clinical characteristics of 66 dialysis patients according to CD19 count at start of the study
Variables CD19 ≥ 100 (n = 41) CD19 < 100 (n = 25) Pvalue
Age 55.1 ± 13.7 53.1 ± 12.7 0.565
Sex (Male/Female) 21/20 17/8 0.208
DM 15 (36.6%) 10 (40%) 0.799
HD/PD 32/9 18/7 0.768
Duration of dialysis (months) 50.6 ± 37.7 78.8 ± 59.6 0.022
Body Mass Index 21.4 ± 2.9 22.3 ± 3.5 0.511
GNRI 101.2 ± 8.0 97.9 ± 8.4 0.121
OPNI 47.2 ± 5.1 44.4 ± 4.8 0.045
Systolic blood pressure (mmHg) 131.8 ± 30.6 145.4 ± 26.5 0.062
Diastolic blood pressure (mmHg) 78.2 ± 17.6 84.7 ± 10.2 0.065
Kt/V 1.74 ± 0.29 1.70 ± 0.22 0.504
Neutrophil Lymphocyte Ratio 0.42 ± 0.15 0.41 ± 0.15 0.931
TLCs (/㎣) 1525 ± 586 1537 ± 513 0.933
CD3 count (/㎣) 1129 ± 406 796 ± 256 0.001
CD4 count (/㎣) 701 ± 262 488 ± 169 0.001
CD8 count (/㎣) 426 ± 177 302 ± 127 0.002
CD19 count (/㎣) 176 ± 74 57 ± 26 0.001
CD4/CD8 ratio 1.7 ± 0.7 1.7 ± 0.7 0.905

GNRI : Geriatric Nutritional Risk Index; OPNI : Onodera’s prognostic nutritional index; Kt/V : Dialysis adequacy; TLCs : Total lymphocyte counts

Table 8.
Total lymphocyte count by several variables
Variables Baseline 3 months Pvalue*
Age
Age ≥ 60 years (n = 28) 1615 ± 535 1606 ± 550 0.193
Age < 60 years (n = 38) 1470 ± 550 1421 ± 474 0.193
Pvalue+ 0.472 0.621
Sex
Male (n = 38) 1588 ± 563 1558 ± 593 0.547
Female (n = 28) 1506 ± 518 1486 ± 401 0.547
Pvalue+ 0.533 0.891
Dialysis
Hemodialysis (n = 50) 1597 ± 512 1514 ± 522 0.433
Peritoneal Dialysis (n = 16) 1417 ± 625 1569 ± 520 0.433
Pvalue+ 0.009 0.009
Duration of dialysis
Duration ≥ 60 months (n = 30) 1464 ± 551 1450 ± 508 0.223
Duration < 60 months (n = 36) 1628 ± 530 1592 ± 525 0.223
Pvalue+ 0.043 0.043
DM
Yes (n = 25) 1587 ± 495 1508 ± 501 0.372
No (n = 41) 1533 ± 574 1539 ± 534 0.372
Pvalue+ 0.292 0.292

* P-values by treatment period obtained from linear model using repeated measured ANOVA

+ P-values by content obtained from linear model using repeated measured ANOVA

Table 9.
CD19 count by several variables
Variables Baseline 3 months Pvalue*
Age
Age ≥ 60 years (n = 28) 135 ± 93 126 ± 80 0.206
Age < 60 years (n = 38) 128 ± 77 118 ± 73 0.206
Pvalue+ 0.709 0.709
Sex
Male (n = 38) 114 ± 63 111 ± 66 0.146
Female (n = 28) 154 ± 103 135 ± 87 0.146
Pvalue+ 0.043 0.043
Dialysis
Hemodialysis (n = 50) 132 ± 85 124 ± 80 0.179
Peritoneal Dialysis (n = 16) 127 ± 84 111 ± 61 0.179
Pvalue+ 0.666 0.666
Duration of dialysis
Duration ≥ 60 months (n = 30) 106 ± 78 94 ± 55 0.190
Duration < 60 months (n = 36) 152 ± 78 144 ± 84 0.190
Pvalue+ 0.009 0.009
DM
Yes (n = 25) 118 ± 68 116 ± 61 0.294
No (n = 41) 139 ± 92 124 ± 84 0.294
Pvalue+ 0.449 0.449

* P-values by treatment period obtained from linear model using repeated measured ANOVA

+ P-values by content obtained from linear model using repeated measured ANOVA

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      Relationships of Total Lymphocyte Count and Subpopulation Lymphocyte Counts with the Nutritional Status in Patients Undergoing Hemodialysis/Peritoneal Dialysis
      Kosin Med J. 2017;32(1):58-71.   Published online January 19, 2017
      DOI: https://doi.org/10.7180/kmj.2017.32.1.58
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