Periodontal Status, Inflammation, and Malnutrition in Hemodialysis Patients – Is There a Link?

Background

Periodontal disease (PDD) was associated with inflammation, malnutrition, and higher mortality in hemodialysis (HD) patients.

Study Design and Objective

Cross-sectional observational study, aiming to assess the prevalence of PDD and the possible relationship among PDD, inflammation, and malnutrition in HD patients.

Settings and Participants

Single HD center, 263 patients (age: 57.4 ± 12.3 years; 60% males; HD vintage 6.6 ± 4.9 years; the primary renal diseases were mainly primary glomerular nephropathies in 34% cases, with 11% diabetic nephropathy).

Measurements

Oral health status was assessed by the Silness and Loe plaque index, loss of clinical attachment level, periodontal pocket depth according to World Health Organization recommendations, by a single examiner. Patients were stratified by periodontal pocket depth (PPD): normal oral status/mild PDD (PPD < 4 mm), moderate PDD (PPD 4-5 mm), and severe PDD (PPD ≥ 6 mm). Demographic, smoking status, hematologic, dialysis-related data and parameters of the nutritional (Subjective Global Assessment score, anthropemetrical, and biochemical) and inflammatory status were collected.

Results

Poor periodontal status was shown by 75% of patients, 23% of them with severe PDD. Patients with PDD were older; higher percentages of them were smokers, diabetics, had malnutrition, and inflammation. Subjects with severe PDD had higher HD vintage, lower hemoglobin, and required higher darbepoetin doses than those with healthy periodontium. Darbepoetin resistance index was higher in patients with severe PDD than in those with normal periodontium. Models of multivariable linear logistic regression for the potential promoters and for the consequences of PDD revealed smoking and HD duration as significant contributors; increased C-reactive protein was associated with severe PDD.

Limitation

Cross-sectional observational design.

Conclusions

Impaired periodontal health is highly prevalent in HD patients. PDD is more frequent in elderly diabetic smokers and in those with longer HD vintage; smoking and HD duration seems to be the most important determinants. The prevalence is higher in malnourished and in inflamed patients; inflammation seems to accompany PDD and to influence anemia response to treatment.

Introduction

Recent studies have shown that malnutrition, inflammation, and atherosclerosis are highly prevalent in hemodialysis (HD) patients and are associated with increased morbidity and mortality.1, 2, 3, 4, 5, 6

During the past decade, studies revealed oral infections, particularly periodontal disease (PDD), to be associated with malnutrition, inflammation, atherosclerotic cardiovascular disease7, 8, 9 and therefore with higher mortality rate in HD patients.

Oral health is defined by the World Health Organization (WHO) as “a state of being free from mouth and facial pain, oral infection and sores and PDD”¹⁰ and “is essential to the quality of life”.10, 11

Patients with chronic kidney disease (CKD) are predisposed to PDD of various causes: high prevalence of diabetes, protein waste products retention, metabolic, endocrinologic and immunologic disturbances, drugs, dialysis treatment itself,12, 13 changes in daily life, with dental hygiene neglection.11, 14, 15

PDD is highly prevalent in HD patients (about 80%).¹⁶ However, oral health status is not regularly investigated; periodontitis is underdiagnosed and undertreated, although a treatable risk factor.¹⁷

The aim of the study was to assess the prevalence of PDD and the possible relationship among PDD, inflammation and malnutrition in HD patients.