Can Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP) be elevated in patients undergoing dialysis?

Elevated ESR and CRP in Dialysis Patients

Yes, both Erythrocyte Sedimentation Rate (ESR) and C-reactive Protein (CRP) can be elevated in patients undergoing dialysis due to chronic inflammation associated with kidney failure and the dialysis process itself. 1

Prevalence and Causes of Inflammation in Dialysis Patients

• Chronic, low-grade inflammation is a common comorbid condition in chronic kidney disease (CKD), particularly in chronic dialysis patients 2
• Inflammatory markers increase as renal function decreases, even in pre-dialysis phases of renal failure 3
• Multiple factors contribute to elevated inflammatory markers in dialysis patients:
  • The uremic milieu itself 1
  • Dialysis-related factors such as bioincompatible dialysis membranes, impure dialysate, and back-filtration 1
  • Clotted access grafts and persistent infections 1
  • Failed kidney grafts in transplant patients returning to dialysis 1
  • Vascular calcification and oxidative stress 1

Clinical Significance of Elevated Inflammatory Markers

• Elevated CRP predicts all-cause and cardiovascular mortality in both hemodialysis and peritoneal dialysis patients 1
• CRP levels >10 mg/L are associated with increased cardiovascular risk in dialysis patients 4
• Inflammatory markers are associated with:
  • Increased risk of cardiovascular events 1
  • Protein-energy wasting and diminished motor function 2
  • Cognitive impairment 2
  • CKD-mineral and bone disorder, anemia, and insulin resistance 2

Differences Between ESR and CRP in Dialysis Patients

• CRP is a direct measure of inflammation with a shorter half-life, making it more responsive to acute changes 5
• ESR is an indirect measure of fibrinogen and has a longer half-life, making it more suitable for monitoring chronic inflammatory conditions 5
• ESR and CRP are significantly increased in hemodialysis patients compared to peritoneal dialysis and transplanted patients 6
• Transplantation is associated with lower inflammatory markers compared to dialysis modalities 6

Clinical Applications and Monitoring

• Regular assessment of CRP levels in dialysis patients is recommended to identify sources of inflammation 1
• A highly sensitive method for measuring CRP is recommended for dialysis patients 1
• When elevated inflammatory markers are detected, clinicians should:
  • Look for occult infectious processes (such as clotted arteriovenous grafts) 1
  • Consider periodontitis as a potential source of inflammation in dialysis patients 4
  • Evaluate for graft intolerance syndrome in patients with failed kidney transplants 1
  • Monitor for symptoms of cardiovascular disease 1

Pitfalls and Caveats

• There is no consensus on the optimal "cut-off" point of CRP to define inflammation in CKD patients 1
• Single determinations of inflammatory markers may be problematic since they vary with time in dialysis patients 1
• ESR and CRP may be elevated in dialysis patients even in the absence of active infection 3
• In failed kidney transplant patients, elevated inflammatory markers may indicate graft intolerance syndrome rather than infection 1
• Inflammatory markers should be interpreted in conjunction with clinical findings, as elevated levels can result from multiple causes in dialysis patients 1