in recent years , it has been established that in patients maintained on chronic hemodialysis ( hd ) there is a strong association between markers of inflammation , nutritional status , cardiovascular disease and overall morbidity and mortality . it was found that 3060% of hd patients have evidence of activation of inflammation [ 24 ] . the stimuli for such a response have not been clearly defined , however , several have been proposed , such as reduced renal clearance of cytokines , accumulation of age s , occult inflammatory processes or infections , bioincompatibility of dialysis membranes and exposure to endotoxins , bacterial dna fragments , and unspecified pro - inflammatory substances present in dialysis fluid . nonetheless , activation of inflammation , even if low grade , is linked to malnutrition . an important role in the innate immune system is played by a cd14 pattern - recognition receptor . cd14 is a receptor for endotoxin , and binds components of gram - positive and gram - negative bacteria . cd14 protein is present both in soluble ( scd14 ) and membrane - bound forms . increased scd14 levels have been described in hd patients [ 68 ] and linked to increased mortality risk , inflammation and protein - energy wasting . in the promoter region of the cd14 gene polymorphism ( dbsnp : rs2569190 ) was identified at position -159 designated according to the transcription start site that corresponds to -260 from the aug start codon , which is associated with the intensity of cd14 gene product expression . the aim of the present study was to investigate the distribution of cd14 promoter gene c-159 t polymorphism in hd patients , and to determine whether this polymorphism in the cd14 gene is associated with indices of nutritional status . the study population consisted of 185 caucasian patients ( 81 females and 104 males ) undergoing hd in 3 centers in warsaw , 1 in bydgoszcz and 1 in bialystok , poland . patients had been maintained on chronic hemodialysis for at least 3 months before entering the study . causes of crf were as follows : uncertain ( n=36 ) , chronic glomerulonephritis histologically not examined ( n=54 ) , primary glomerulonephritis ( 9 ) , chronic pyelonephritis / interstitial nephritis ( n=31 ) , various cystic kidney diseases ( n=25 ) , renal vascular diseases and ischemic renal diseases ( n=16 ) , amyloidosis ( n=6 ) and other ( n=8 ) . dietary recommendations during the study were as follows : protein 0.81.0 g / kg of ideal body mass ( with at least half of the protein being of high biologic value ) , 30% of calories derived from fat , and 62% of calories from carbohydrates . the control group consisted of 94 apparently healthy volunteers ( 34 males , 60 females ; aged 45.717.2 y ) . patients were eligible if they were between the ages of 18 and 90 years , had been receiving hd treatment for at least 3 months before entering the study , and agreed to participate in the study . exclusion criteria included : recent acute inflammatory disease , history of allergy , diabetes mellitus , lupus erythematosus , wegener s granulomatosis , colitis ulcerosa , crohn s disease , history of juvenile rheumatoid arthritis , history of neoplastic disease , and treatment with steroids and immunosuppressive drugs . subjects were weighed in light clothing to the nearest 0.5 kg and their height recorded to the nearest 0.5 cm . skinfold thickness ( sft ) was measured using harpenden skinfold calipers at the triceps , biceps , and subscapular sites , using defined anatomical landmarks . the waist and hip circumference were measured to the nearest 0.5 cm at the umbilicus and greater trochanter . nutritional status was assessed using the modified sga scale ( mis ) proposed by kalantar - zadeh and colleagues . each mis component has 4 levels of severity from 0 ( normal ) to 3 ( very severe ) . the sum of all 10 mis components ranged from 0 to 30 , denoting increasing degree of severity . nutritional status was also evaluated by anthropometric methods , including triceps skinfold thickness , mid - arm circumference ( mac ) and mid - arm muscle circumference ( mamc ) . mamc was calculated as follows : skinfold measurement was performed by trained investigators ( as , tp , ap ) . blood samples for analysis of crp , albumin , creatinine , urea , cholesterol and triglycerides were taken before scheduled hemodialysis , as a part of routine protocol . genomic dna was isolated from blood , using a commercially available kit ( nucleospin blood , macherey - nagel , germany ) . genotyping was performed after amplification of the target sequence using specific primers ( f 5-gtgccaacagatgaggttca -3 ; r 5-cgcagcggaaatcttcatc-3 ) . the ethics committee of central clinical hospital of the ministry of home affairs approved the study protocol , and informed consent was obtained from all the patients and control subjects . results are expressed as means  standard deviations for normally distributed variables , or as median ( interquartile range ) . univariate statistical analysis was performed using chi - square test , fisher s exact test or student s t - test as appropriate . associations between variables were analyzed using pearson s correlation coefficient or spearman rank correlation , as appropriate . genotype distributions between the study groups were compared by 22 and 23 contingency table and chi - square analysis . stata software , version 9.2 ( stata corporation , college station , tx , usa ) was used for statistical computations . the study population consisted of 185 caucasian patients ( 81 females and 104 males ) undergoing hd in 3 centers in warsaw , 1 in bydgoszcz and 1 in bialystok , poland . patients had been maintained on chronic hemodialysis for at least 3 months before entering the study . causes of crf were as follows : uncertain ( n=36 ) , chronic glomerulonephritis histologically not examined ( n=54 ) , primary glomerulonephritis ( 9 ) , chronic pyelonephritis / interstitial nephritis ( n=31 ) , various cystic kidney diseases ( n=25 ) , renal vascular diseases and ischemic renal diseases ( n=16 ) , amyloidosis ( n=6 ) and other ( n=8 ) . dietary recommendations during the study were as follows : protein 0.81.0 g / kg of ideal body mass ( with at least half of the protein being of high biologic value ) , 30% of calories derived from fat , and 62% of calories from carbohydrates . the control group consisted of 94 apparently healthy volunteers ( 34 males , 60 females ; aged 45.717.2 y ) . patients were eligible if they were between the ages of 18 and 90 years , had been receiving hd treatment for at least 3 months before entering the study , and agreed to participate in the study . exclusion criteria included : recent acute inflammatory disease , history of allergy , diabetes mellitus , lupus erythematosus , wegener s granulomatosis , colitis ulcerosa , crohn s disease , history of juvenile rheumatoid arthritis , history of neoplastic disease , and treatment with steroids and immunosuppressive drugs . subjects were weighed in light clothing to the nearest 0.5 kg and their height recorded to the nearest 0.5 cm . skinfold thickness ( sft ) was measured using harpenden skinfold calipers at the triceps , biceps , and subscapular sites , using defined anatomical landmarks . the waist and hip circumference were measured to the nearest 0.5 cm at the umbilicus and greater trochanter . nutritional status was assessed using the modified sga scale ( mis ) proposed by kalantar - zadeh and colleagues . each mis component has 4 levels of severity from 0 ( normal ) to 3 ( very severe ) . the sum of all 10 mis components ranged from 0 to 30 , denoting increasing degree of severity . nutritional status was also evaluated by anthropometric methods , including triceps skinfold thickness , mid - arm circumference ( mac ) and mid - arm muscle circumference ( mamc ) . mamc was calculated as follows : skinfold measurement was performed by trained investigators ( as , tp , ap ) . blood samples for analysis of crp , albumin , creatinine , urea , cholesterol and triglycerides were taken before scheduled hemodialysis , as a part of routine protocol . genomic dna was isolated from blood , using a commercially available kit ( nucleospin blood , macherey - nagel , germany ) . genotyping was performed after amplification of the target sequence using specific primers ( f 5-gtgccaacagatgaggttca -3 ; r 5-cgcagcggaaatcttcatc-3 ) . the ethics committee of central clinical hospital of the ministry of home affairs approved the study protocol , and informed consent was obtained from all the patients and control subjects . results are expressed as means  standard deviations for normally distributed variables , or as median ( interquartile range ) . univariate statistical analysis was performed using chi - square test , fisher s exact test or student s t - test as appropriate . associations between variables were analyzed using pearson s correlation coefficient or spearman rank correlation , as appropriate . genotype distributions between the study groups were compared by 22 and 23 contingency table and chi - square analysis . stata software , version 9.2 ( stata corporation , college station , tx , usa ) was used for statistical computations . the frequencies of the c and the t allele in hd subjects were 61.3% and 38.7% , respectively . sixty - seven ( 36.0% ) were homozygous for the c allele ( cc ) , 89 were heterozygous ( ct , 48.1% ) , 26 patients ( 14.1% ) had the genotype tt , and in 3 cases ( 1.6% ) it was not possible to determine genotype due to technical reasons . in the control group , frequencies of the c and the t allele were 55.9% and 44.2% , respectively . twenty - eight patients ( 29.8% ) had cc , 49 ( 52.1% ) had ct , and 17 ( 18.1% ) had tt genotype . neither allele ( p=0.225 ) nor genotype ( p=0.460 ) frequencies differed between hd patients and controls . allele and genotype frequencies did not show a significant departure from the hardy  weinberg equilibrium in hd patients ( p=0.630 ) or controls ( p=0.580 ) . there were no differences in investigated biochemical ( with the exception of triglycerides ) , clinical and anthropometrical parameters , between groups defined by the presence of non - c allele status ( tt ) or c allele presence ( ct , cc ) in the cd14 promoter gene 159 site ( table 2 ) . interestingly , carriers of the c allele had lower triglyceride levels in comparison to tt genotype ( p=0.007 ) . due to technical reasons , il-6 level determinations were possible only in 115 patients , and therefore are not given in table i. its concentration was 8.5 pg / ml ( 5.414.3 ; n=98 ) 8.2 pg / ml ( 5.211.2 ; n=17 ) in c allele ( ct / cc ) and non - c allele ( tt ) allele carriers , respectively ( ns ) . the frequencies of the c and the t allele in hd subjects were 61.3% and 38.7% , respectively . sixty - seven ( 36.0% ) were homozygous for the c allele ( cc ) , 89 were heterozygous ( ct , 48.1% ) , 26 patients ( 14.1% ) had the genotype tt , and in 3 cases ( 1.6% ) it was not possible to determine genotype due to technical reasons . in the control group , frequencies of the c and the t allele were 55.9% and 44.2% , respectively . twenty - eight patients ( 29.8% ) had cc , 49 ( 52.1% ) had ct , and 17 ( 18.1% ) had tt genotype . neither allele ( p=0.225 ) nor genotype ( p=0.460 ) frequencies differed between hd patients and controls . allele and genotype frequencies did not show a significant departure from the hardy  weinberg equilibrium in hd patients ( p=0.630 ) or controls ( p=0.580 ) . there were no differences in investigated biochemical ( with the exception of triglycerides ) , clinical and anthropometrical parameters , between groups defined by the presence of non - c allele status ( tt ) or c allele presence ( ct , cc ) in the cd14 promoter gene 159 site ( table 2 ) . interestingly , carriers of the c allele had lower triglyceride levels in comparison to tt genotype ( p=0.007 ) . due to technical reasons , il-6 level determinations were possible only in 115 patients , and therefore are not given in table i. its concentration was 8.5 pg / ml ( 5.414.3 ; n=98 ) 8.2 pg / ml ( 5.211.2 ; n=17 ) in c allele ( ct / cc ) and non - c allele ( tt ) allele carriers , respectively ( ns ) . we found no association between cd14 c-159 t polymorphism and indices of nutrition in patients on maintenance hemodialysis therapy . genotype and allele frequencies in our study were not different from the control group , and were similar to previously described results from central europe . additionally , allele and genotype frequencies did not show a significant departure from the hardy  weinberg equilibrium . in recent papers , groups from the usa and sweden have show in 2 separate cohorts that scd14 levels correlate positively with levels of several inflammatory markers , and independently predict mortality in hd patients . there is a growing body of evidence that inflammatory response in chronic hd patients is at least in part induced by cytokines . the simultaneous combination of malnutrition and inflammation has been referred to as  malnutrition - inflammation complex syndrome ( mics )   or  malnutrition - inflammation - atherosclerosis  syndrome . mics appears to play a central role in poor clinical outcome , including the high rate of mortality and hospitalization and diminished quality of life seen in dialysis patients . reverse epidemiology  of cardiovascular risks in these patients , where a low , and not a high , bmi or serum cholesterol is associated with poor dialysis outcome several putative factors were proposed as triggers of this reaction . from previous studies it appears , however , that endotoxin is one of the most active . lipopolysaccharide ( lps ) , after interacting with lps - binding protein , binds to cd14 , tlr4 and md4 - 2 , making lipopolysaccharide - recognition complex . this complex activates nuclear factor-b , which moves into the nucleus and induces the transcriptional activation of inflammatory and immune - response genes , including tumor necrosis factor- ( tnf- ) . in addition , caspase-1 is activated , resulting in the activation of the pro - inflammatory cytokine il-1 . cd14 is upregulated by bacterial stimuli , ifn- and tnf- , and is downregulated by th2-type cytokines such as il-4 . low concentrations of lps induce inflammatory genes , including il-10 , il-12 p35 , tnf- , and irf-1 through cd14 and tlr4-dependent pathways in macrophages . pretreatment of healthy subjects with a cd14-specific monoclonal antibody prior to lps attenuates lps - induced fever , clinical symptoms , and leukocyte activation and degranulation , and inhibits release of tnf - alpha , il-6 and il-10 , and delays the release of stnfr(i ) and il-1ra . wang et al . reported that anti - cd14 antibody can alleviate the progression of acute necrotizing pancreatitis in mice . sharif et al . found that , in mice lacking either tlr4 or cd14 receptors , the severity of acute experimental pancreatitis was ameliorated . cd14-deficient mice are resistant to shock induced by either gram - negative bacteria or lps . tt homozygotes appear to have significantly higher scd14 serum levels , and higher cd14 density on the surface of monocytes than do carriers of both the cc and ct genotypes , although some authors dispute this . the cd14 - 260 polymorphism is also associated with il-1 beta levels , and higher values were found in c homozygotes . no association was found between the cd14 - 260 genotypes or the tnf-308  cd14 - 260 genotypes and the leukocyte tnf- and il-1 synthesis capacity upon endotoxin stimulation . in clinical reports , cd14 promoter gene c-159 t polymorphism was reported to be associated with decreased kidney function , progression of iga nephropathy , carotid artery disease in hd patients , coronary heart disease , septic shock susceptibility and mortality , and may affect susceptibility to allergic asthma . although rahman et al . found that soluble cd14 receptor expression was associated with severity of acute pancreatitis , c-260 t cd14 genotype was not . we have found significant association of cd14 c-159 t polymorphism with serum triglyceride levels , but this must be interpreted with caution . this finding was not confirmed , however , by a group from europe in a population closely related to ours ethnically . it should be mentioned , however , that age of our subjects was more similar ( mean 61.2 ) to the report by shin et al . ( mean 64.8 years ) than to hubacek s   paper ( mean 48.9 years ) . firstly , and most important , is the small sample size of the study , which therefore may be regarded rather as hypothesis - generating . secondly , our patients were relatively well nourished , and this might have obscured a weak relationship with genotype cd14 c-159 t polymorphism . while our study focused on the impact of only 1 polymorphism , a combination of different polymorphisms , as well as environmental factors , very likely might have influenced the investigated parameters . in conclusion , the results of this study indicate that cd14 promoter gene c-159 t polymorphism does not seem to be associated with nutritional status parameters in hd patients . it may , however , influence triglyceride blood levels . the possible influence of other genetic polymorphisms on nutritional status and inflammatory response in chronic kidney disease patients should be investigated .