Relationship between serum protein and mortality in adults on long-term hemodialysis: exhaustive review and meta-analysis

Nutrition. 2010 Jan;26(1):10-32. doi: 10.1016/j.nut.2009.07.009.


The aim of this exhaustive review and meta-analysis was to explore the relation among serum protein, inflammatory markers, and all-cause and cardiovascular mortalities in adult patients on maintenance hemodialysis. We searched the Medline, Science Citation Index, Academic Search Premier, Cochrane Library, and Embase electronic data bases. Data extraction and quality assessment were done independently by two reviewers and results were pooled using the random effects model. Cochran's Q was used to identify heterogeneity and a funnel plot was used for assessment of publication bias. A meta-analysis was performed on 38 studies (265 330 patients) reporting on serum proteins, inflammatory markers, and mortality. A significant inverse relation was found between serum albumin and all-cause (hazard ratio [HR] 0.7038, 95% confidence interval [CI] 0.6367-0.7781) and cardiovascular (HR 0.8726, 95% CI 0.7909-0.9628) mortalities, with a significantly stronger relation with all-cause mortality (P=0.0014). Pooled results for C-reactive protein showed a weak but significant direct relation with all-cause mortality (HR 1.0322, 95% CI 1.0151-1.0496), but there was not a significant relation between C-reactive protein and cardiovascular mortality (HR 1.0172, 95% CI 0.9726-1.0639). A high degree of heterogeneity was identified among studies especially in the case of all-cause mortality. An asymmetrical funnel plot for serum albumin is suggestive of publication bias. From the meta-analysis it is concluded that serum albumin showed a significant inverse relation with all-cause and cardiovascular mortalities but the relation between prealbumin and all-cause mortality was not significant. C-reactive protein showed a significant direct relation with all-cause mortality but not with cardiovascular mortality. The potential adverse effects of malnutrition and infections in relation to mortality highlight the need for continued treatment of infections and correction of malnutrition in patients on dialysis.

Publication types

  • Meta-Analysis
  • Review

MeSH terms

  • Adult
  • Biomarkers / blood
  • C-Reactive Protein / metabolism*
  • Cardiovascular Diseases / complications
  • Cardiovascular Diseases / mortality*
  • Cause of Death
  • Humans
  • Infections / complications
  • Infections / mortality
  • Kidney Failure, Chronic / complications
  • Kidney Failure, Chronic / mortality*
  • Kidney Failure, Chronic / therapy
  • Protein-Energy Malnutrition / complications
  • Protein-Energy Malnutrition / mortality
  • Renal Dialysis*
  • Serum Albumin*


  • Biomarkers
  • Serum Albumin
  • C-Reactive Protein