the causes of malnutrition in hd and pd patients include low energy intake induced by anorexia , loss of nutrients due to dialysis , dietary restriction before dialysis , increased protein catabolism and acidosis .
the need for protein increases in pd patients due to severe peritoneal protein loss which is aggravated due to peritoneal infections .
in addition to the foregoing , inflammation and inflammatory factors also play an important role in the development of malnutrition in these patients
. some complications of prolonged inflammatory process include protein loss , adipose and muscle atrophy , increased catabolism , oxidative stress , and atherosclerosis .
following the deterioration of the nutritional status , esrd results in inflammatory responses with various mechanisms such as decreased clearance of proinflammatory cytokines , release of oxidative substances such as free oxygen radicals and reduced intake of antioxidants such as vitamin e. recent studies have shown that patients suffering from malnutrition have a higher rate of mortality compared to well - nutritioned patients .
the risk of cardiovascular diseases among hd patients with protein - energy malnutrition ( pem ) is higher compared to well - nourished hd patients .
traditional risk factors for cardiovascular diseases such as a high body mass index ( bmi ) and serum total cholesterol can not explain the high prevalence of cardiovascular diseases in hd patients with pem .
nevertheless , heart failure is an important cause of mortality and morbidity in esrd patients .
the prevalence of hypertension , left ventricular hypertrophy , ischemic heart disease , and heart failure is higher in patients with chronic renal failure on dialysis .
their cardiovascular mortality is about 1030 times more than normal populations . in one study ,
the prevalence of some cardiovascular disease in esrd patients includes 14% coronary artery disease , 19% angina pectoris , 31% cardiac failure , 7% dysrhythmia , and 8% peripheral vascular disease .
on echocardiography 15% had systolic dysfunction , 32% left ventricular dilatation , and 74% left ventricular hypertrophy . according to above studies ,
however , no study has evaluated the relationship of echocardiographic findings and malnutrition in dialysis patients .
therefore , we compared the frequency distribution of malnutrition between hemodialysis and peritoneal dialysis patients and its relationship with echocardiographic findings .
this case  control study was done in a dialysis center , both hd and continuous ambulatory pd , in 20112012 in isfahan university of medical sciences , iran .
the exclusion criteria included : patients with severe infection during 1 month before our study , change of dialysis method , history of rheumatic heart disease , cardiomyopathy , and primary pulmonary hypertension were not included .
malnutrition - inflammation score ( mis ) index was used for the evaluation of malnutrition .
mis consists of ten components , each with four levels of intensity , from 0 ( normal ) to 3 ( severe ) .
the ten components include dry weight change , dietary intake , gastrointestinal symptoms , work capacity , associated diseases , reduced fat stores or loss of subcutaneous fat , reduced muscle mass symptoms , bmi , serum albumin , and total iron - binding capacity levels .
the sum of scores ranged from 0 ( normal ) to 30 ( severe malnutrition ) . according to studies ,
the grading of severity of malnutrition according to mis score is as follows : 
 lack of malnutrition to mild malnutrition : mis < 9moderate malnutrition : mis = 918severe malnutrition : mis > 18 . 
 
lack of malnutrition to mild malnutrition : mis < 9 moderate malnutrition : mis = 918 severe malnutrition : mis > 18 .
the patient 's demographic information including age and sex along with their echocardiographic information such as ejection fraction , regurgitation of aortic , mitral , tricuspid , pulmonary valves , and mis were recorded .
all the data were analyzed by spss version 18.0 , inc , chicago , ill .
, usa using descriptive statistics ( mean and standard deviation of variables ) and chi - square tests to compare mis based on the type of dialysis and echocardiographic findings and mann  whitney u - test .
thirty - nine patients ( 72.2% ) were men and 15 ( 27.8% ) were women with a mean age of 59.77  1.33 .
thirty - five patients ( 63.60% ) were men and 20 ( 36.4% ) were women with the mean age of 54.21  1.30 .
table 1 shows the frequency distribution of mis in pd and hd groups and compares them .
the frequency distribution of the malnutrition - inflammation score index there was no significant difference between the two groups in terms of the frequency distribution of malnutrition indicators ( mis ) ( p > 0.05 ) .
the relationship between the type of dialysis and echocardiographic findings were analyzed using chi - squared test . in the hd group
, there was no significant relationship between mis and echocardiographic findings ( p > 0.05 ) , except for aortic and mitral valve insufficiencies ( p < 0.05 ) . table 2 indicates that there was no significant relationship between mis and echocardiographic findings in pd patients ( p > 0.05 ) .
the relationship between malnutrition - inflammation score and echocardiographic findings in hemodialysis and peritoneal dialysis groups
many factors that appear to lead to these two conditions overlap , as do assessment tools and such criteria for detecting them as hypoalbuminemia . both these conditions are related to poor dialysis outcome . low appetite and a hypercatabolic state are among common features .
pem in dialysis patients has been suggested to be secondary to inflammation ; however , the evidence is not conclusive , and an equicausal status or even opposite causal direction is possible .
possible causes of mis include comorbid illnesses , oxidative and carbonyl stress , nutrient loss through dialysis , anorexia and low nutrient intake , uremic toxins , decreased clearance of inflammatory cytokines , volume overload , and dialysis - related factors .
mis is believed to be the main cause of erythropoietin hyporesponsiveness , high rate of cardiovascular atherosclerotic disease , decreased the quality of life and increased mortality and hospitalization in dialysis patients . because mis leads to a low bmi , hypocholesterolemia , hypocreatininemia , and hypohomocysteinemia , a 
therefore , obesity , hypercholesterolemia , and increased blood levels of creatinine and homocysteine appear to be protective and paradoxically associated with a better outcome .
there is no consensus about how to determine the degree of severity of mis or how to manage it .
successful management of mis may ameliorate the cardiovascular epidemic and poor outcome in dialysis patients . in the comparison between the frequency distribution of mis in the participants of pd and hd groups , despite the 1.8% participants with severe malnutrition in the hd group , no statistically significant differences was observed .
although it was calculated in this study that there is no significant relationship between mis and echocardiographic findings ( ejection fraction , aortic , mitral , pulmonary , and tricuspid valve insufficiencies ) in pd participants , there was a significant relationship between mis and echocardiographic findings and aortic and mitral valve insufficiencies , and other echocardiographic findings had no significant relationship .
the study by liu et al . who evaluated peripheral vascular disease in hd patients , found that the rate of cardiac death , death due to infection , peripheral vascular disease , and cardiovascular hospitalization was higher in them compared to healthy participants . in another study , by pecoits - filho
, it was found that the risk of diastolic heart failure was higher in patients with chronic renal failure compared to the general population .
it can be concluded that if severe malnutrition aggravates in hd patients , the chance of a significant relationship between mis and echocardiographic findings increases .
finally , this project is recommended to be conducted with a lager sample size to repeat these results so that they are proven with greater certainty .

 aen contributed in the conception of the work , conducting the study , revising the draft , approval of the final version of the manuscript , and agreed for all aspects of the work.ak contributed in the conception of the work , collecting data , conducting the study , revising the draft , approval of the final version of the manuscript , and agreed for all aspects of the work.ma contributed in the conception of the work , conducting the study , revising the draft , approval of the final version of the manuscript , and agreed for all aspects of the workga contributed in the conception of the work , revising the draft , approval of the final version of the manuscript , and agreed for all aspects of the work.fm contributed in the conception of the work , analyzing data , revising the draft , approval of the final version of the manuscript , and agreed for all aspects of the work . 
 
aen contributed in the conception of the work , conducting the study , revising the draft , approval of the final version of the manuscript , and agreed for all aspects of the work .
ak contributed in the conception of the work , collecting data , conducting the study , revising the draft , approval of the final version of the manuscript , and agreed for all aspects of the work .
ma contributed in the conception of the work , conducting the study , revising the draft , approval of the final version of the manuscript , and agreed for all aspects of the work ga contributed in the conception of the work , revising the draft , approval of the final version of the manuscript , and agreed for all aspects of the work .
fm contributed in the conception of the work , analyzing data , revising the draft , approval of the final version of the manuscript , and agreed for all aspects of the work .
 background : malnutrition is common in patients with end - stage renal disease ( esrd ) who on peritoneal dialysis ( pd ) or hemodialysis ( hd ) . 
 this study aimed to compare the frequency distribution of malnutrition in hd and pd patients and its relationship with echocardiographic findings.materials and methods : this is a case  control study . using the simple random sampling , 
 109 patients were selected among hd and pd patients based on the inclusion criteria . 
 hd and pd groups included 55 and 54 patients , respectively . 
 the malnutrition - inflammation score ( mis ) index was used to assess malnutrition . 
 echocardiography was performed by a cardiologist . 
 all the data were analyzed by spss version 18.results:in this study , 79.6% ( 43 patients ) were in the pd group with mis < 9 ( no malnutrition to mild malnutrition ) and 20.4% ( 11 patients ) with 9  mis  18 suffered from moderate malnutrition . in the hd group , 72.7% ( forty patients ) had mis < 9 , 25.5% ( 14 ) had 9  mis  18 , and 1.8% ( one patient ) with mis > 18 suffered from severe malnutrition ( p = 0.74 ) . 
 there was no significant relationship between mis and echocardiographic findings in pd patients ( p > 0.05 ) . in the hd group 
 , there was no significant relationship between mis and echocardiographic findings ( p > 0.05 ) , except for aortic and mitral valve insufficiencies ( p < 0.05).conclusion : the findings of this study show 27.3% of hd patients had moderate to severe malnutrition . 
 there was a statistically significant relationship between mis index and aortic and mitral valve insufficiencies in hd patients . 