MAY 2002 VOL. 22, NO.

SHORT REPORTS

Hyperlipidemia in Children on Peritoneal

Dialysis: Effect of Energy Intake on
Serum Triglyceride

PATIENTS AND METHODS

The subjects of this study were 51 patients (22 girls,

29 boys) who had been on PD for 6 months and were
followed up at Tokyo Metropolitan Kiyose Childrens
Hospital between 1981 and 1997. We considered a
6-month period of PD long enough to eliminate the
influence of the original disease and the severe uremia in end-stage renal failure (6). Thirteen of the
patients were on automated PD and 38 were on CAPD.
The mean age of the patients was 7.6 5.2 years
(range 1.0 16.4 years). The original diseases included hypoplastic or dysplastic kidney, congenital
nephrotic syndrome, focal segmental glomerulosclerosis, rapid progressive glomerulonephritis, hemolytic
uremic syndrome, and several other forms of nephritis.
To exclude the influence of adiposity on dyslipidemia, the body mass index (BMI) and obesity
index were calculated from patients actual weight,
height, and ideal weight for heightage.
Fasting blood samples were obtained from the patients, and the serum total cholesterol, high density
lipoprotein (HDL), triglyceride, and albumin levels
were measured using a Toshiba 2000 FR automatic
analyzer (Toshiba, Tokyo, Japan). The albumin, triglyceride, and total cholesterol levels were measured
by EIA, and the HDL levels were measured directly.
Total protein loss via the dialysate was also determined
from protein concentration in the drained dialysate.
A dietitian estimated dietary intake based on dietary records kept for 3 consecutive days by the patients parents. Glucose concentration in the drained
dialysate was measured and the energy absorbed from
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the dialysate in the form of glucose was added to the

total energy intake. To avoid the influence of obesity
or leanness, energy intake is expressed as kilocalories/ideal weight for heightage, since recommended
daily allowances are also expressed in those units.
Relationships between serum lipid profile (total
cholesterol and triglyceride) and factors such as daily
energy intake, protein loss, and serum albumin levels were examined.
RESULTS

Mean BMI was 14.9 1.5 and obesity index was

5.1 1.5, showing that the patients on PD were lean;
the degree of the leanness was greater in the smaller
patients (data not shown). Mean serum total cholesterol was 246 53 mg/dL, and mean serum triglyceride was 262 170 mg/dL.
Table 1 shows the relationship between factors
examined and actual body weight. Total cholesterol
and triglyceride levels were significantly higher in
the low-body-weight patients. Serum albumin levels
showed a positive correlation with body weight; energy intake per body weight and protein loss via dialysate showed negative correlations.
The relationships between serum lipid levels (total
cholesterol and triglyceride) and each of the factors
were examined. A strong positive correlation was detected between energy intake and serum triglyceride
levels (r = 0.53, p < 0.0001), but there was no correlation between energy intake and serum total cholesterol levels (r = 0.20, p = 0.18) (Figure 1). The strong
positive correlation between energy intake and triglyceride level was attributable to energy intake in the
diet rather than from dialysate in the form of glucose. Weak negative correlations were observed between serum albumin levels and serum total
cholesterol levels (r = 0.30, p = 0.04) and triglyceride levels (r = 0.33, p = 0.002). No significant correlation was found between protein loss and lipid profile
(vs total cholesterol r = 0.18, p = 0.22; vs triglyceride
r = 0.14, p = 0.34).
Multiple regression analysis did not show any significant correlations between any of the factors examined and serum total cholesterol levels; triglyceride
levels, however, were correlated with daily energy intake [regression coefficients (t value): energy intake
t = 3.44, p = 0.0012; serum albumin t = 0.88, p = 0.39;
protein loss t = 0.75, p = 0.45; r = 0.54, r2 = 0.29, p =
0.001].
DISCUSSION

The serum lipid levels of the smaller children on

PD, especially their triglyceride levels, were extremely
high. As the BMI and obesity index show, any effect

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Hyperlipidemia is one of the major complications

of peritoneal dialysis (PD). As reported by us previously, an interesting phenomenon is observed in children on PD: the younger the patient, the higher the
serum lipid levels (1). Several hypotheses have been
proposed regarding the etiology of the hyperlipidemia
in continuous ambulatory peritoneal dialysis (CAPD)
patients, including reduced catabolic function (2), protein loss via the dialysate (3), hypoalbuminemia (4),
and glucose absorption from dialysate (5).
To determine the cause of hyperlipidemia in young
children on PD, the relationships between serum lipids and several factors that vary with age, namely
daily energy intake (including energy from absorbed
glucose), protein loss via the dialysate, and serum
albumin levels, were examined.

PDI

MAY 2002 VOL. 22, NO. 3

SHORT REPORTS

Yuriko Tanaka1
Hiroshi Hataya2
Yoshinori Araki2
Masahiro Ikeda2
Takeshi Matsuyama3
Masataka Honda2
Pediatric Department1
Otawara Red Cross Hospital
Renal Failure Unit2
Tokyo Metropolitan Kiyose Childrens Hospital
Pediatric Department3
Hussa Hospital, Japan

r= 0 .2 0
p = 0 .0 7

(m g/d l)

Total cholesterol

400

300

200

100
20

40
60
E nergy Intake

r= 0 .53
p < 0.0 00 1

(m g/d l)
800
600
400
200
0
20

40

E nergy Intake

REFERENCES
1. Matsuyama T, Honda M, Ito H. Lipoprotein and
apoprotein abnormalities in children undergoing
CAPD. In: Ota K, Maher J, Winchester J, Herszel P,
eds. Current Concepts in Peritoneal Dialysis. Tokyo:

TABLE 1
Data on Factors Examined and Lipid Levels
According to Actual Body Weight

Actual body weight versus

Serum total cholesterol
Serum triglyceride
Serum high density lipoprotein
Serum albumin
Protein loss
Energy intake
Energy intake from dialysate

p Value

0.47
0.62
0.41
0.50
0.41
0.70
0.26

0.0005
<0.0001
0.003
0.0002
0.0003
<0.0001
0.07

80
100
(kcal/kg /d ay)

60

80

100

(kcal/kg /d ay)

Figure 1 Relationships between energy intake and serum

lipid levels.
Excerpta Medica; 1992:5559.
2. Bergesio F, Montani G, Ciuti R, Serruto A, Berucci A,
Frizzi V, et al. Lipid and apoproteins change during the
progression of chronic renal failure. Clin Nephrol 1992;
38:24670.
3. Broyer M, Champion G, Jean G, Chopin N, Niaudet P,
Czernichow P. Nutritional and metabolic studies in
children on continuous ambulatory peritoneal dialysis. Kidney Int Suppl 1983; 15:S10610.
4. Scolnik D, Balfe W. Initial hypoalbuminemia and hyperlipidemia persist during chronic peritoneal dialysis in
children. Perit Dial Int 1993; 13:1369.
5. Kaysen GA. Hyperlipidemia of chronic renal failure.
Blood Purif 1994; 12:607.
6. Kawaguchi Y, Kubo H, Yamamoto H, Nakayama M,
Yokohama M, Shigenatsu T, et al. Is atherosclerosis
427

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of adiposity on dyslipidemia can be ruled out. Our

results show that the cause of hypertriglyceridemia
in smaller children is related to energy intake, not to
protein loss in the dialysate or serum albumin levels,
and that the energy came mainly from their diet. This
result is different from those reported in previous
papers (35,7). It is well known that lipoprotein lipase (LPL) activities and hepatic triglyceride lipase
activity are reduced in end-stage renal disease patients (8), and our previous data showed that the
apolipoprotein C2/C3 ratio, which reflects LPL activity, was low in children on PD, but it was not statistically correlated with age. We suppose that, if the
catabolic rate were the same, the increased energy
intake would raise the triglyceride levels.
We were unable to detect any factors significantly
related to the increase in cholesterol. Further studies
are required, for example, evaluation of cholesteryl
ester transfer protein, which changes the composition of lipoprotein, and also lathosterol, which is a
marker of cholesterol synthesis (9).

Triglyceride

PDI

SHORT REPORTS

MAY 2002 VOL. 22, NO. 3

PDI

accelerated by CAPD? Perit Dial Int 1996; 16(Suppl 1):

S22330.
7. Querfeld U, Salusky IB, Nelson P, Foley J, Fine RN.
Hyperlipidemia in pediatric patients undergoing peritoneal dialysis. Pediatr Nephrol 1988; 2:44752.
8. Asayama K, Nakahara C, Hasegawa A, Ito H, Kato K.
Lipid profiles and lipase activities in children and adolescents with CRF treated conservatively or with HD
or transplantation. Pediatr Res 1984; 18:7838.
9. Kempen H, Glatz J, Leuven J, van der Voort H, Katan
M. Serum lathosterol concentration is an indicator of
whole-body cholesterol synthesis in humans. J Lipid
Res 1988; 29:114955.

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