Association of Malnutrition-Inflammation Score with quality of life and mortality in hemodialysis patients: a 5-year prospective cohort study

Machine learning approaches for the mortality risk assessment of patients undergoing hemodialysis

Introduction:

Mortality is a major primary endpoint for long-term hemodialysis (HD) patients. The clinical status of HD patients generally relies on longitudinal clinical observations such as monthly laboratory examinations and physical examinations.

Methods:

A total of 829 HD patients who met the inclusion criteria were analyzed. All patients were tracked from January 2009 to December 2013. Taken together, this study performed full-adjusted-Cox proportional hazards (CoxPH), stepwise-CoxPH, random survival forest (RSF)-CoxPH, and whale optimization algorithm (WOA)-CoxPH model for the all-cause mortality risk assessment in HD patients. The model performance between proposed selections of CoxPH models were evaluated using concordance index.

Results:

The WOA-CoxPH model obtained the highest concordance index compared with RSF-CoxPH and typical selection CoxPH model. The eight significant parameters obtained from the WOA-CoxPH model, including age, diabetes mellitus (DM), hemoglobin (Hb), albumin, creatinine (Cr), potassium (K), Kt/V, and cardiothoracic ratio, have also showed significant survival difference between low- and high-risk characteristics in single-factor analysis. By integrating the risk characteristics of each single factor, patients who obtained seven or more risk characteristics of eight selected parameters were dichotomized as high-risk subgroup, and remaining is considered as low-risk subgroup. The integrated low- and high-risk subgroup showed greater discrepancy compared with each single risk factor selected by WOA-CoxPH model.

Conclusion:

The study findings revealed WOA-CoxPH model could provide better risk assessment performance compared with RSF-CoxPH and typical selection CoxPH model in the HD patients. In summary, patients who had seven or more risk characteristics of eight selected parameters were at potentially increased risk of all-cause mortality in HD population.

Low serum prealbumin concentration predicts long-term mortality in maintenance hemodialysis patients with hepatitis B and/or C virus infections

Background and Aim

A low serum prealbumin concentration is common in maintenance hemodialysis patients with hepatitis B and C and may be associated with mortality. In this study, we assessed Department of Nephrology and Hemodialysis predictive value of a low serum prealbumin concentration on mortality in HD patients using reused low-flux dialyzers who were infected with hepatitis B and/or C virus.

Methods

We used serum prealbumin levels to predict the long-term mortality of 326 hemodialysis patients. The patients were divided into two groups: group 1 (n = 140, with hepatitis B and/or C virus infections), and group 2 (n = 186, without hepatitis virus infections).

Results

During a 5-year follow-up, there were 75 deaths due to all-cause mortality (23.0%). Mortality was significantly higher (P < 0.001) in patients with hepatitis B and/or C infection (44%) than in those without hepatitis infection (8%). Serum prealbumin was lower in the hepatitis infected group and mortality group than in non-infected group and survival group. Multivariate Cox regression analysis showed that long duration of HD and lower serum prealbumin and albumin were related to mortality in patients undergoing maintenance HD. Receiver operating characteristic curves showed that serum prealbumin had a good prognostic value in predicting mortality in both groups with hepatitis B and/or C virus infection and without hepatitis infection (AUC = 0.792 [95% confidence interval: 0.714-0.87], P < 0.001; cut-off value = 24.5 mg/dl, sensitivity = 62.3%, and specificity = 88.6%).

Conclusion

In HD patients, serum prealbumin was a good prognostic biomarker of mortality in both groups of patients with hepatitis B and/or C virus infections and without hepatitis infections.

Nutritional Status, Nutritional Phenotypes, and Oral Nutritional Supplement Prescription Patterns Among Patients With Non-Dialysis Chronic Kidney Disease in British Columbia

OBJECTIVES

Management of protein-energy wasting and undernutrition with oral nutritional supplements (ONS) has not been systematically studied in the non-dialysis chronic kidney disease (CKD-ND) population. We aimed to describe nutritional status, identify phenotypes of patients prescribed ONS, and evaluate ONS prescription patterns among CKD-ND patients in British Columbia.

DESIGN AND METHODS

This observational study assessed adult CKD-ND patients who entered multidisciplinary CKD clinics during 2013-2018 in British Columbia. Descriptive statistics were used to describe baseline nutrition and inflammation parameters among patients prescribed ONS versus patients not prescribed ONS within 1 year of clinic entry. Hierarchical clustering method with consensus clustering was applied to identify phenotypes of patients prescribed ONS. Multivariable logistic regression was used to assess the associations between ONS prescription and health region/dietitian full-time equivalents per 1,000 CKD patients.

RESULTS

Of 15,859 CKD-ND patients, 9% of patients entering CKD clinics were prescribed ONS within 1 year of clinic entry, and these patients demonstrated lower baseline estimated glomerular filtration rate, body mass index (BMI), serum albumin, bicarbonate, as well as greater age, serum phosphate, and neutrophil-to-lymphocyte ratio compared with those not receiving ONS. Cluster analysis revealed 5 phenotypes of ONS users: cluster 1 had the highest mean neutrophil-to-lymphocyte ratio; cluster 2 had the lowest mean albumin; cluster 3 had the lowest mean BMI; cluster 4 had the highest mean BMI; and cluster 5 had the lowest mean bicarbonate. There was regional variability in ONS prescription, and an odds ratio for ONS prescription of 1.32 (95% confidence interval 1.16-1.50) for every 1-unit increase in dietitian full-time equivalents per 1,000 patients. Over 3 years of follow-up, overall ONS use among CKD-ND patients remained stable.

CONCLUSIONS

This study demonstrates appropriate prescribing of ONS to patients with suboptimal nutritional status, although regional variation exists. Patients receiving ONS represent a heterogenous group with phenotypes reflecting several clinical and biochemical features of the protein-energy wasting syndrome. These findings will assist with updating ONS policy, planning quality improvement initiatives, and informing dietitian resource allocation.

Prognostic Value of the Malnutrition-inflammation Score in Hospitalization and Mortality on Long-term Hemodialysis

OBJECTIVE

Since its development, cumulative evidence has accumulated regarding the prognostic value of the Malnutrition-Inflammation Score (MIS/Kalantar score) prognostic value; however, there is a shortage of recent and large studies with comprehensive statistical methodologies that contribute to support a higher level of evidence and a consensual cutoff. The aim of this study was to assess the strength of MIS association with hospitalization and mortality in a nationwide cohort.

METHODS

This was a historical cohort study of hemodialysis patients from 25 outpatient centers followed up for 48 months. Univariable and multivariable Cox additive regression models were used to analyze the data. The C-index was estimated to assess the performance of the final model.

RESULTS

Two thousand four hundred forty-four patients were analyzed, 59.0% males, 32.0% diabetic, and median age of 71 years (P₂₅ = 60, P₇₅ = 79). During a median period of 45-month follow-up, with a maximum of 48 months (P₂₅ = 31; P₇₅ = 48), 875 patients presented an MIS <5 (35.8%) and 860 patients (35.2%) died. The proportion of deaths was 23.1% for patients with the MIS <5 and 41.9% if the MIS ≥5 (P < .001). A total of 1,528 patients (62.5%) were hospitalized with a median time to the first hospitalization of 26 months (P₂₅ = 9; P₇₅ = 45). A new cutoff point regarding the risk of death, MIS ≥6, was identified for this study data set. In multivariable analysis for hospitalization risk, a higher MIS, higher comorbidity index, and arteriovenous graft or catheter increased the risk, whereas higher Kt/V and higher albumin had a protective effect. In multivariable analysis for mortality risk, adjusting for age, albumin, normalized protein catabolic rate, Charlson comorbidity index, interdialytic weight gain, Kt/V, diabetes, hematocrit, and vascular access, patients with the MIS ≥6 showed a hazard ratio of 1.469 (95% confidence interval: 1.262-1.711; P < .001). Higher age, higher interdialytic weight gain, higher comorbidity index, and catheter increased significantly the risk, whereas higher Kt/V, higher albumin, and higher normalized protein catabolic rate (≥1.05 g/kg/d) reduced the risk.

CONCLUSION

The MIS maintains its relevant and significant association with hospitalization and mortality.

U-Shaped Association between Waist-to-Hip Ratio and All-Cause Mortality in Stage 3-5 Chronic Kidney Disease Patients with Body Mass Index Paradox

The obesity paradox, referring to the association of high body mass index (BMI) with low all-cause mortality risk, is found in patients with chronic kidney disease (CKD). Central obesity is associated with metabolic syndrome and may have better prognostic value than BMI for all-cause mortality. Whether central obesity is associated with all-cause mortality in cases of obesity paradox in CKD patients remains unknown. We included 3262 patients with stage 3–5 CKD, grouped into five quintiles (Q1–5) by waist-to-hip ratio (WHR). Low WHR and BMI were associated with malnutrition and inflammation. In Cox regression, high BMI was not associated with all-cause mortality, but BMI < 22.5 kg/m² increased the mortality risk. A U-shaped association between central obesity and all-cause mortality was found: WHR Q1, Q4, and Q5 had higher risk for all-cause mortality. The hazard ratio (95% confidence interval) of WHR Q5 and Q1 for all-cause mortality was 1.39 (1.03–1.87) and 1.53 (1.13–2.05) in male and 1.42 (1.02–1.99) and 1.28 (0.88–1.85) in female, respectively. Waist-to-height ratio and conicity index showed similar results. Low WHR or low BMI and high WHR, but not high BMI, are associated with all-cause mortality in advanced CKD.

Intradialytic nutrition and quality of life in Chilean older patients in hemodialysis with protein-energy wasting

PURPOSE

The study assessed the impact of intradialytic oral nutritional supplementation on the quality of life in patients receiving hemodialysis and diagnosed with protein energy wasting.

METHODS

A pre-test post-test quasi-experimental study was conducted before and after 3 months of intradialytic oral nutritional supplementation on 109 older hemodialysis patients. We measured before and after 3 months of intradialytic oral nutritional supplementation, the quality of life score, the burden of kidney disease, three quality of life scales and the mental and physical health status using KDQoL-SF™ 1.3, body composition and biochemical parameters of nutritional condition.

RESULTS

The mean age of the patients was 69.4 ± 3.4 years, 59% were male, and the time on dialysis was 63.5 ± 52.6 months. Comparing the baseline with month 3 of intradialytic oral nutritional supplementation, we observed to better quality of life. In contrast to malnutrition, score, specifically increased significantly score of symptoms/problems list related to hemodialysis, sexual function, social and cognitive function, sleep, pain, energy/fatigue and general state of health. Significant changes were also found in nutritional status, energy intake and body composition indicators. After 3 months of intradialytic oral nutritional supplementation, we observed a nutritional status recovery in one or more indicators in 92% of the patients.

CONCLUSION

Our findings indicate that 3 months of intradialysis oral nutritional supplementation improves the components of physical and mental quality of life and nutritional status in older patients receiving hemodialysis diagnosed with loss of protein energy. These results are relevant to improve the experience of patients with protein energy loss receiving hemodialysis.

Is malnutrition a determining factor of health-related quality of life in hemodialysis patients? A cross-sectional design examining relationships with a comprehensive assessment of nutritional status

PURPOSE

To identify relationships between health-related quality of life (HRQOL) and nutritional status in hemodialysis (HD) patients.

METHOD

Secondary data from a cross-sectional survey was utilized. HRQOL was assessed for 379 HD patients using the generic Short Form 36 (SF-36) and disease-specific Kidney-Disease Quality of Life-36 (KDQOL-36). Malnutrition was indicated by malnutrition inflammation score (MIS) ≥ 5, and presence of protein-energy wasting (PEW). The individual nutritional parameters included the domains of physical status, serum biomarkers, and dietary intake. Multivariate associations were assessed using the general linear model.

RESULTS

MIS ≥ 5 was negatively associated with SF-36 scores of physical functioning (MIS < 5 = 73.4 ± 8.0 SE vs MIS ≥ 5 = 64.6 ± 7.7 SE, P < 0.001), role-limitation-physical (MIS < 5 = 65.3 ± 14.3 SE vs MIS ≥ 5 = 52.9 ± 14.0 SE, P = 0.006), general health (MIS < 5 = 53.7 ± 7.5 SE vs MIS ≥ 5 = 47.0 ± 7.1 SE, P = 0.003), and PCS-36 (MIS < 5 = 40.5 ± 3.3 SE vs MIS ≥ 5 = 35.9 ± 3.1 SE, P < 0.001); and KDQOL-36 score of symptoms/problems (MIS < 5 = 78.9 ± 5.6 SE vs MIS ≥ 5 = 74.8 ± 5.4 SE, P = 0.022), but not with PEW by any tool. Of individual nutritional parameters, underweight (68.1 ± 5.4 SE, P = 0.031), normal weight (63.8 ± 2.8 SE, P = 0.023), and overweight (64.3 ± 2.9 SE, P = 0.003) patients had significantly higher physical functioning scores compared to obese patients (44.8 ± 5.5 SE). Serum albumin levels were positively associated with physical functioning (P = 0.041) score. HGS was also positively associated with physical functioning (P = 0.036), and vitality (P = 0.041) scores. Greater dietary phosphorus intakes were significantly associated with lower scores for role limitation-physical (P = 0.008), bodily pain (P = 0.043), and PCS-36 (P = 0.024).

CONCLUSION

Malnutrition diagnosis by MIS, but not PEW, indicated associations with HRQOL in HD patients. Individual nutritional parameters that related to higher HRQOL were BMI < 30 kg/m², better dietary phosphorus control, greater muscle strength and higher visceral protein pool.

Utility of Geriatric Nutritional Risk Index in Patients with Chronic Kidney Disease: A Mini-Review

Chronic kidney disease (CKD) is one of the most significant risk factors for cardiovasculardisese. Malnutrition has been recognized as a significant risk factor for cardiovascular disease in patients with CKD, including those on chronic dialysis. Current studies showed higher all-cause and cardiovascular mortality rates in patients with CKD and malnutrition. Geriatric nutritional risk index (GNRI), a simple and validated nutritional screening measure for both elderly people and patients on dialysis, is based only on three objective parameters: body weight, height, and serum albumin level. Recently, we demonstrated that the cutoff GNRI for predicting all-cause and cardiovascular mortality was 96 in patients on hemodialysis. Moreover, together with left ventricular hypertrophy and low estimated glomerular filtration rate, the utility of GNRI as a significant determinant of cardiovascular events was demonstrated in non-dialysis-dependent patients with CKD. In the present review, we summarize available evidence regarding the relationship of GNRI with all-cause and cardiovascular mortality in patients with CKD including those on dialysis.

Malnutrition and Sarcopenia Combined Increases the Risk for Mortality in Older Adults on Hemodialysis

Aim: Sarcopenia and malnutrition are highly prevalent in older adults undergoing hemodialysis (HD) and are associated with negative outcomes. This study aimed to evaluate the role of sarcopenia and malnutrition combined on the nutritional markers, quality of life, and survival in a cohort of older adults on chronic HD. Methods: This was an observational, longitudinal, and multicenter study including 170 patients on HD aged >60 years. Nutritional status was assessed by 7-point-subjective global assessment (7p-SGA), body composition (anthropometry and bioelectrical impedance), and appendicular skeletal muscle mass (Baumgartner's prediction equation). Quality of life was assessed by KDQoL-SF. The cutoffs for low muscle mass and low muscle strength established by the 2019 European Working group on sarcopenia for Older People (EWGSOP) were used for the diagnosis of sarcopenia. Individuals with a 7p-SGA score ≤5 were considered malnourished, individuals with low strength or low muscle mass were pre-sarcopenic, and those with low muscle mass and low muscle strength combined as sarcopenic. The sample was divided into four groups: sarcopenia and malnutrition; sarcopenia and no-malnutrition; no-sarcopenia with malnutrition; and no-sarcopenia and no-malnutrition. Follow-up for survival lasted 23.5 (12.2; 34.4) months. Results: Pre-sarcopenia, sarcopenia, and malnutrition were present in 35.3, 14.1, and 58.8% of the patients, respectively. The frequency of malnutrition in the group of patients with sarcopenia was not significantly higher than in the patients without sarcopenia (66.7 vs. 51.2%; p = 0.12). When comparing groups according to the occurrence of sarcopenia and malnutrition, the sarcopenia and malnutrition group were older and presented significantly lower BMI, calf circumference, body fat, phase angle, body cell mass, and mid-arm muscle circumference. In the survival analysis, the group with sarcopenia and malnutrition showed a higher hazard ratio 2.99 (95% CI: 1.23: 7.25) for mortality when compared to a group with no-sarcopenia and no-malnutrition. Conclusion: Older adults on HD with sarcopenia and malnutrition combined showed worse nutritional parameters, quality of life, and higher mortality risk. In addition, malnutrition can be present even in patients without sarcopenia. These findings highlight the importance of complete nutritional assessment in patients on dialysis.

Stroke in Hemodialysis Patients Randomized to Different Intravenous Iron Strategies: A Prespecified Analysis from the PIVOTAL Trial

Background

People with kidney failure treated with hemodialysis (HD) are at increased risk of stroke compared with similarly aged people with normal kidney function. One concern is that treatment of renal anemia might increase stroke risk. We studied risk factors for stroke in a prespecified secondary analysis of a randomized, controlled trial of intravenous iron treatment strategies in HD.

Methods

We analyzed data from the Proactive IV Iron Therapy in Haemodialysis Patients (PIVOTAL) trial, focusing on variables associated with risk of stroke. The trial randomized 2141 adults who had started HD <12 months earlier and who were receiving an erythropoiesis-stimulating agent (ESA) to high-dose IV iron administered proactively or low-dose IV iron administered reactively in a 1:1 ratio. Possible stroke events were independently adjudicated. We performed analyses to identify variables associated with stroke during follow-up and assessed survival following stroke.

Results

During a median 2.1 years of follow-up, 69 (3.2%) patients experienced a first postrandomization stroke. Fifty-seven (82.6%) were ischemic strokes, and 12 (17.4%) were hemorrhagic strokes. There were 34 postrandomization strokes in the proactive arm and 35 postrandomization strokes in the reactive arm (hazard ratio, 0.90; 95% confidence interval, 0.56 to 1.44; P=0.66). In multivariable models, women, diabetes, history of prior stroke at baseline, higher baseline systolic BP, lower serum albumin, and higher C-reactive protein were independently associated with stroke events during follow-up. Hemoglobin, total iron, and ESA dose were not associated with risk of stroke. Fifty-eight percent of patients with a stroke event died during follow-up compared with 23% without a stroke.

Conclusions

In patients on HD, stroke risk is broadly associated with risk factors previously described to increase cardiovascular risk in this population. Proactive intravenous iron does not increase stroke risk.Clinical Trial registry name and registration number: Proactive IV Iron Therapy in Haemodialysis Patients (PIVOTAL), 2013-002267-25.

According to Revised EWGSOP Sarcopenia Consensus Cut-Off Points, Low Physical Function Is Associated With Nutritional Status and Quality of Life in Maintenance Hemodialysis Patients

OBJECTIVE

The aim of this study is to assess the association of nutritional status and quality of life with low physical function, according to the revised European Working Group on Sarcopenia in Older People (EWGSOP) - sarcopenia consensus cut-offs in maintenance hemodialysis patients.

DESIGN AND METHODS

This is a cross-sectional study including patients on maintenance hemodialysis. Participants were submitted to a single evaluation of physical function, nutritional status, and quality of life. Handgrip strength, Short Physical Performance Battery (SPPB), sit-to-stand test, and gait speed were performed to evaluate physical function. Cut-offs proposed by the revised EWGSOP consensus were considered. Malnutrition Inflammation Score was used to assess nutritional status. Quality of life was assessed by the 36-Item Short Form Health Survey.

RESULTS

Seventy-seven patients were enrolled, 64.9% male, mean age 55 ± 14 years. According to the cut-offs proposed by the most recent EWGSOP consensus, 55.8% of patients presented SPPB <8, 48.1% gait speed test ≤0.8 m/seconds, sit-to-stand test >15 seconds, and 39.0% handgrip strength <27 kg and <16 kg for men and women, respectively. Malnutrition Inflammation Score was significantly associated with all physical function parameters, except gait speed, in receiver operating characteristic curve and logistic regression. The 36-Item Short Form Health Survey domains or component summary were associated with SSPB, gait speed, and handgrip strength in logistic regression.

CONCLUSION

Poor nutritional status and quality of life are associated with low physical function (according to the cut-offs proposed by EWGSOP) in hemodialysis patients.

Association of the nutritional risk index for Japanese hemodialysis patients with long-term mortality: The Q-Cohort Study

BACKGROUND

Protein-energy wasting (PEW) is a risk factor for mortality in patients undergoing hemodialysis. Recently, a nutritional risk index for Japanese hemodialysis patients (NRI-JH) has been proposed as a surrogate index of PEW. However, no study has determined the association of the NRI-JH with long-term mortality in patients undergoing hemodialysis. Furthermore, the validity of the NRI-JH has not been confirmed.

METHODS

In total, 3046 patients undergoing hemodialysis and registered in the Q-Cohort Study were followed up for 10 years. The NRI-JH was calculated on the basis of body mass index and serum levels of albumin, total cholesterol, and creatinine. The patients were divided into four groups according to the NRI-JH scores: 0-3 (G1, n = 1343), 4-7 (G2, n = 1136), 8-10 (G3, n = 321), and 11-13 (G4, n = 246). We examined the association between the NRI-JH and the 4-year and 10-year risks of all-cause, cardiovascular, and infection-related deaths using the Cox proportional hazards model.

RESULTS

During the follow-up period, 647 patients died during the first 4 years, and 1503 patients died within 10 years. The 4-year prognosis was analyzed and compared with the lowest NRI-JH score group. Multivariable-adjusted hazard ratios (95% confidence intervals) for all-cause death were 1.93 (1.57-2.38), 2.68 (2.05-3.50), and 3.16 (2.40-4.16) in the G2, G3, and G4 groups, respectively. Similarly, a higher NRI-JH score was associated with an increased risk of cardiovascular and infection-related deaths.

CONCLUSION

A higher NRI-JH score was associated with an increased risk of long-term mortality in patients undergoing maintenance hemodialysis.

TRIAL REGISTRATION

The study protocol was registered in the University Hospital Medical Information Network (UMIN) clinical trial registry (UMIN ID: 000000556).

Chronic Dialysis Patients Are Depleted of Creatine: Review and Rationale for Intradialytic Creatine Supplementation

There is great need for the identification of new, potentially modifiable risk factors for the poor health-related quality of life (HRQoL) and of the excess risk of mortality in dialysis-dependent chronic kidney disease patients. Creatine is an essential contributor to cellular energy homeostasis, yet, on a daily basis, 1.6-1.7% of the total creatine pool is non-enzymatically degraded to creatinine and subsequently lost via urinary excretion, thereby necessitating a continuous supply of new creatine in order to remain in steady-state. Because of an insufficient ability to synthesize creatine, unopposed losses to the dialysis fluid, and insufficient intake due to dietary recommendations that are increasingly steered towards more plant-based diets, hemodialysis patients are prone to creatine deficiency, and may benefit from creatine supplementation. To avoid problems with compliance and fluid balance, and, furthermore, to prevent intradialytic losses of creatine to the dialysate, we aim to investigate the potential of intradialytic creatine supplementation in improving outcomes. Given the known physiological effects of creatine, intradialytic creatine supplementation may help to maintain creatine homeostasis among dialysis-dependent chronic kidney disease patients, and consequently improve muscle status, nutritional status, neurocognitive status, HRQoL. Additionally, we describe the rationale and design for a block-randomized, double-blind, placebo-controlled pilot study. The aim of the pilot study is to explore the creatine uptake in the circulation and tissues following different creatine supplementation dosages.

Usual nutritional scores have acceptable sensitivity and specificity for diagnosing malnutrition compared to GLIM criteria in hemodialysis patients

Diagnosing malnutrition by the recently published Global Leadership Initiative on Malnutrition (GLIM) criteria requires using modern techniques for body composition measurements. We hypothesized that the prevalence of malnutrition identified by usual nutritional scores and according to GLIM criteria may be close to each other due to the number of components shared between them. Our aim was to compare the concurrent validity of four nutritional scores, malnutrition-inflammation score (MIS), objective score of nutrition on dialysis, geriatric nutritional index (GNRI), and nutritional risk index against the GLIM criteria for malnutrition in maintenance hemodialysis patients. This prospective observational study was performed on 318 maintenance hemodialysis outpatients (37% women) with a mean age of 68.7 ± 13.1 years and a median dialysis vintage of 21 months. According to the GLIM criteria, 45.9% of these patients were diagnosed with malnutrition. Nutritional scores, dietary intake and body composition parameters were measured. All nutritional scores showed a strong association with malnutrition in multivariable logistic regression models. In discriminating the nutritional risk, the ROC AUC was largest for GNRI (0.70, 95% CI: 0.65-0.75; P< .001). Nutritional risk index and MIS showed high specificity but lower sensitivity compared to GNRI and objective score of nutrition on dialysis. Compared to MIS, GNRI had better concurrent validity (higher sensitivity and acceptable specificity) but was inferior to MIS in terms of relation to certain etiologic and phenotypic components of the GLIM criteria (specifically, to dietary intake and decrease in dry weight). In summary, of the nutritional scores tested, GNRI is the most sensitive score in identifying malnutrition diagnosed by GLIM criteria, but MIS is more specific and better in predicting the individual components of the GLIM criteria.

Malnutrition inflammation score (MIS) is stronger predictor of mortality in hemodialysis patients than waist-to-hip ratio (WHR)-4-year follow-up

PURPOSE

The main purpose of this study is to correlate the significance of the malnutrition inflammation score (MIS) and the waist-to-hip ratio (WHR) in the prediction of mortality in hemodialysis patients.

METHODS

The study was conducted from March 2016 to April 2020, covering 100 hemodialysis patients. Anthropometric measures (Waist circumference (WC), Hip circumference (HC), Waist-to-hip ratio (WHR), Caliper and BMI) and biomarkers of inflammation (IL6, hsCRP) and nutrition (Transfferin, Albumin) were determined and for the above-mentioned biomarkers, we monitored all-cause mortality for 4 years. The hemodialysis patients were divided in three groups based on their MIS score.

RESULTS

In this prospective, longitudinal study, we enrolled 100 patients (54 males and 46 females) with a median age of 58 (51-65) years. All patients were divided into three groups according to MIS score values. We performed univariate Cox regression survival analysis for a period of 4 years, and then included for multivariate survival Cox regression analysis well-defined nutritional markers: BMI, mid-arm circumference, WHR and MIS score. The MIS score was demonstrated to be the best independent predictor of 4-year mortality in our study (p < 0.001).

CONCLUSION

The results of our study have shown that there is no significance of WHR in the prediction of mortality in hemodialysis patients, but that the MIS score is a strong, independent predictor of all-cause 4-year mortality.

Nutritional status, hyperkalaemia and attainment of energy/protein intake targets in haemodialysis patients following plant-based diets: a longitudinal cohort study

Background

Patients undergoing haemodialysis (HD) are often discouraged from eating fruits and vegetables because of fears of hyperkalaemia and undernutrition, yet evidence to support these claims is scarce. We here explore the association between adherence to a healthy plant-based diet with serum potassium, surrogates of nutritional status and attainment of energy/protein intake targets in HD patients.

Methods

We performed an observational single-centre study of stable patients undergoing HD with repeated dietary assessment every 3 months. Patients were provided with personalized nutritional counselling according to current guidelines. The diet was evaluated by 3-day food records and characterized by a healthy plant-based diet score (HPDS), which scores positively the intake of plant foods and negatively animal foods and sugar. The malnutrition inflammation score (MIS) and serum potassium were also assessed at each visit. We used mixed-effects models to evaluate the association of the HPDS with markers of nutritional status, serum potassium levels and attainment of energy/protein intake targets.

Results

After applying inclusion and exclusion criteria, a total of 150 patients contributing to 470 trimestral observations were included. Their mean age was 42 years [standard deviation (SD) 18] and 59% were women. In multivariable models, a higher HPDS was not associated with serum potassium levels or odds of hyperkalaemia {potassium >5.5 mEq/L; odds ratio [OR] 1.00 [95% confidence interval (CI) 0.94–1.07] per HPDS unit higher}. Patients with a higher HPDS did not differ in terms of energy intake [OR for consuming <30 kcal/kg day 1.05 (95% CI 0.97–1.13)] but were at risk of low protein intake [OR for consuming <1.1 g of protein/kg/day 1.11 (95% CI 1.04–1.19)]. A higher HPDS was associated with a lower MIS, indicating better nutritional status.

Conclusions

In patients undergoing HD, adherence to a healthy plant-based diet was not associated with serum potassium, hyperkalaemia or differences in energy intake. Although these patients were less likely to reach daily protein intake targets, they appeared to associate with better nutritional status over time.

Significance of Adipose Tissue Maintenance in Patients Undergoing Hemodialysis

In the general population, obesity is known to be associated with adverse outcomes, including mortality. In contrast, high body mass index (BMI) may provide a survival advantage for hemodialysis patients, which is known as the obesity paradox. Although BMI is the most commonly used measure for the assessment of obesity, it does not distinguish between fat and lean mass. Fat mass is considered to serve as an energy reserve against a catabolic condition, while the capacity to survive starvation is also thought to be dependent on its amount. Thus, fat mass is used as a nutritional marker. For example, improvement of nutritional status by nutritional intervention or initiation of hemodialysis is associated with an increase in fat mass. Several studies have shown that higher levels of fat mass were associated with better survival in hemodialysis patients. Based on body distribution, fat mass is classified into subcutaneous and visceral fat. Visceral fat is metabolically more active and associated with metabolic abnormalities and inflammation, and it is thus considered to be a risk factor for cardiovascular disease and mortality. On the other hand, subcutaneous fat has not been consistently linked to adverse phenomena and may reflect nutritional status as a type of energy storage. Visceral and subcutaneous adipose tissues have different metabolic and inflammatory characteristics and may have opposing influences on various outcomes, including mortality. Results showing an association between increased subcutaneous fat and better survival, along with other conditions, such as cancer or cirrhosis, in hemodialysis patients have been reported. This evidence suggests that fat mass distribution (i.e., visceral fat and subcutaneous fat) plays a more important role for these beneficial effects in hemodialysis patients.

Nutritional Status of Patients on Maintenance Hemodialysis at Muhimbili National Hospital in Dar es Salaam, Tanzania: A Cross-Sectional Study

Background

Patients on hemodialysis therapy are at high risk of malnutrition which is attributed to multiple factors. Protein-energy malnutrition in these patients confers poor clinical outcomes. This study investigated the nutritional status of patients on maintenance hemodialysis at Muhimbili National Hospital in Dar es Salaam, Tanzania.

Methods

A cross-sectional descriptive study was done among 160 adult patients on maintenance hemodialysis therapy. Data concerning patients' personal, medical, dietary, and hemodialysis-related information were collected. Patients' anthropometric and laboratory tests (complete blood count, albumin, total cholesterol, creatinine, and urea) were measured. The quantitative Subjective Global Assessment (SGA) dialysis malnutrition score (DMS) was used to assess their nutritional status. Data analysis was done using the SPSS software version 20.

Results

Among the 160 hemodialysis patients, 49 (30.6%) were female. Patients' mean age was 52.2 ± 13.3 years. The median duration on hemodialysis was 18 (8.25–29.75) months. Malnutrition was present in 98 (61.2%) of the patients. Severe malnutrition was found in only 3 (1.9%) patients and 16.9% were underweight. The longer duration on hemodialysis, having diabetes mellitus, and being single were associated with increased risk for malnutrition in multivariate logistic regression. Malnourished patients had significantly lower dry weight, body mass index, mid-upper arm circumference, waist circumference, albumin, total cholesterol, and creatinine levels.

Conclusion

Malnutrition is very common among hemodialysis patients at Muhimbili National Hospital, especially those on longer duration of hemodialysis, and diabetic patients. We recommend that hemodialysis patients should be regularly assessed for malnutrition and appropriately treated which if left unattended heralds worse outcomes.

Comorbidity burden may explain adiponectin's paradox as a marker of increased mortality risk in hemodialysis patients

Despite experimental evidence of beneficial metabolic, antiatherosclerotic and antiinflammatory effects of the 30 kDa adipokine, adiponectin, maintenance hemodialysis (MHD) patients with high adiponectin blood levels have paradoxically high mortality rates. We aimed to examine the direction of the associations between adiponectin and all-cause and cardiovascular mortality as well as with markers of oxidative stress, inflammation and nutrition in MHD patients with varying degrees of comorbidities. A cohort of 261 MHD patients (mean age 68.6 ± 13.6 years, 38.7% women), grouped according to baseline comorbidity index (CI) and serum adiponectin levels, were followed prospectively for six years. High and low concentrations were established according to median CI and adiponectin levels and cross-classified. Across the four CI-adiponectin categories, the group with low comorbidities and high adiponectin exhibited the best outcomes. Conversely, the high comorbidity group with high adiponectin levels had the lowest survival rate in both all-cause mortality (log rankχ² = 23.74, p < 0.001) and cardiovascular mortality (log rankχ² = 34.16, p < 0.001). Further data adjustment for case-mix covariates including fat mass index did not substantially affect these results. In conclusion, the direction of adiponectin’s prognostic associations in MHD patients is inverse in those with few comorbidities and direct in those with many comorbidities.

The modulating effect of dietary protein intake on mortality in long-term hemodialysis patients: A nationwide population-based study

AIMS OF THE STUDY

A high prevalence of protein-energy wasting and malnutrition among uremic patients is associated with an increase in morbidity and mortality. We aimed to investigate the modulating effect of daily dietary protein intake (DPI) evaluated by normalised protein catabolic rate (nPCR) on mortality in long-term haemodialysis (HD) patient from a nationwide population-based study.

METHODS USED TO CONDUCT THE STUDY

By Taiwan Renal Registry Data System between 2005 and 2012, we divided the long-term HD patients into average nPCR < 1.2 and nPCR ≥ 1.2 groups according to the current guideline. The relation of nPCR with three-year all-cause and cardiovascular (CV) mortality were evaluated. The cox regression method for predicted mortality by nPCR was used.

RESULTS OF THE STUDY

Among 88 330 HD patients, 58 122 (65.8%) patients were in average nPCR < 1.2 group and 30 208 (34.2%) in average nPCR ≥ 1.2 group. Both all-cause and cardiovascular (CV) mortality risks were increased in nPCR < 1.2 group after adjusting for demographics and laboratories cofactors in our multivariate cox regression model. Patients with nPCR < 1.2 and albumin ≥ 3.7 had a higher adjusted hazard ratio (aHR) for all-cause and CV mortality (1.16 [95% confidence interval (CI): 1.07-1.25, P < .001]; 1.15 [95% CI: 1.02-1.31, P = .03], respectively), compared with the reference group with nPCR ≥ 1.2 and albumin ≥ 3.7. Interestingly, there was no difference in mortality risk between low DPI subgroup (nPCR < 1.2 and Alb < 3.7) and the reference group (nPCR ≥ 1.2 and Alb < 3.7). Further stratification analysis revealed that low DPI subgroup (nPCR < 1.2, Alb ≥ 3.7 and TC ≥ 150) had an increased risk of both all-cause and CV mortality (aHR 1.14 [95% CI: 1.04-1.25, P = .005]; aHR 1.17 [95% CI: 1.02-1.35, P = .026], respectively).

CONCLUSIONS DRAWN FROM THE STUDY

Low DPI (as presented by nPCR) independently correlated with all-cause and CV mortality among HD patients. Mortality risks were higher in low DPI patients even with normoalbuminaemia and non-hypocholesterolaemia. Further investigations on the importance of increasing DPI in HD patients is warranted.

The association between self-management ability and malnutrition-inflammation-atherosclerosis syndrome in peritoneal dialysis patients: a cross-sectional study

BACKGROUND

The relationship between malnutrition-inflammation-atherosclerosis syndrome (MIAS) and self-management ability has not been previously revealed even though both play an important role in the management of peritoneal dialysis (PD) patients.

METHODS

In total, 93 patients were enrolled in this study. A self-management questionnaire was used for the evaluation of self-management ability. The identification of MIAS was based on one or more of the following three conditions: C-reactive protein (CRP)≥10 mg/L, malnutrition-inflammation score (MIS)> 7, and the presence of atherosclerosis-related medical records. The possible association between different self-management abilities and MIAS was analyzed with a Spearman correlation analysis.

RESULTS

There were 40 (43.0%) patients in the atherosclerosis group, and 38 (40.9%), 38 (40.9%), 10 (10.8%), and 7 (7.5%) patients in the MIAS0, MIAS1, MIAS2, and MIAS3 groups, respectively. The group with a score above the mean score of the Dialysis Effect Evaluation and Monitoring dimension had a fewer number of hospitalizations, higher albumin levels, lower MIS scores, a lower level of IL-6, and a lower number of MIAS factors. The Pearson and Spearman correlation analyses also revealed that this dimension was negatively correlated with the MIAS, MIS, IL-6, BNP, number of hospitalizations, and age and positively associated with albumin and prealbumin.

CONCLUSION

The Dialysis Effect Evaluation and Monitoring dimension of the self-management scale for PD patients is closely linked to the MIAS, and a better dialysis effect evaluation and monitoring capacity results in a decreased likelihood of exposure to malnutrition and inflammation.

TRIAL REGISTRATION

Chinese Clinical Trial Registry: ChiCTR2000035525 ( http://www.chictr.org.cn/showproj.aspx?proj=58110 ), registered August 13, 2020.

Impact of health-related quality of life on survival after dialysis initiation: a prospective cohort study in Korea

Background

The effect of each health-related quality of life (HRQOL) component on hemodialysis prognosis has not been well studied. We aimed to investigate the clinical factors associated with HRQOL and the effect of HRQOL after dialysis initiation on long-term survival in an Asian population.

Methods

A total of 568 hemodialysis patients were included from a nationwide prospective cohort study. HRQOL was evaluated using the Kidney Disease Quality of Life (KDQOL) Short FormTM 1.3 at 3 months after dialysis initiation. The effect of each KDQOL item score on mortality was analyzed. Multivariable Cox analysis was performed after adjusting for age, sex, modified Charlson comorbidity index, and causes of primary kidney disease.

Results

Old age, diabetes mellitus, high comorbidities, and low serum albumin levels were associated with poor physical health status. Decreased urine output was associated with both poor physical and mental health status. The scores of 3 indices in the kidney disease domain (effect of kidney disease, social support, and dialysis staff encouragement) showed significant associations with mortality, as did the 3 indices (physical function, physical role limitation, and body pain) in the physical health domain. Neither the 4 indices in the mental health domain nor the mental composite score showed a significant association with mortality. However, a high physical composite score was associated with decreased overall patient mortality (P = 0.003). The effect of physical composite score on survival was prominent among young or middle-aged groups.

Conclusion

Poor physical health status 3 months after hemodialysis start correlates significantly with overall mortality.

Prevalence of malnutrition inflammation complex syndrome among patients on maintenance haemodialysis at Muhimbili National Hospital in Tanzania: a cross-sectional study

Background

Malnutrition, inflammation, and the combination thereof are predictors of poor outcomes in haemodialysis patients. Malnutrition Inflammation Complex Syndrome (MICS) is an accelerator of atherosclerosis and portends high mortality. Early recognition and treatment of MICS may help to improve the clinical outlook of such patients. This study investigated the prevalence of MICS and its associated factors among patients on maintenance haemodialysis at Muhimbili National Hospital (MNH) in Dar es Salaam, Tanzania.

Methods

This was a prospective cross-sectional observational study done among 160 adult patients on maintenance haemodialysis at MNH in 2019. All participants provided written informed consent. Questionnaires were used to collect data and patients’ blood was tested for complete blood count (CBC), C-reactive protein (CRP), ferritin, transferrin, creatinine, urea, total cholesterol, and albumin. The Malnutrition Inflammation Score was used to assess MICS and its severity. Data analysis was done using the SPSS 20 software.

Results

Of the 160 patients included in the study, 111 (69.4%) were male. The mean age (±SD) of patients and mean duration (±SD) on haemodialysis were 52.2(13.3) years and 22(18) months respectively. MICS was prevalent in 46.3% (mild in 24.4% and moderate to severe in 21.9%).

Long-term haemodialysis (> 4 years) was an independent predictor of MICS [Adjusted Odds Ratio, AOR 5.04 (95% CI: 1.33–19.2), p < 0.05]. Hypercholesterolaemia was a negative predictor of MICS [AOR 0.11 (95% CI: 0.01–0.97), p < 0.05]. Patients with MICS had significantly lower mean body mass index, serum albumin, total cholesterol, transferrin, haemoglobin, and creatinine levels. The presence of MICS was higher in underweight patients and those who had inflammation. Haemodialysis adequacy did not correlate with MICS.

Conclusion

Malnutrition Inflammation Complex Syndrome is relatively common among patients on haemodialysis in Dar es Salaam, Tanzania. Our study has shown a longer duration on haemodialysis to be associated with the occurrence of MICS; on the contrary, having hypercholesterolaemia seems to be protective against MICS consistent with the concept of reverse epidemiology. Patients on haemodialysis should be assessed regularly for malnutrition and inflammation and should receive appropriate and timely treatment to reduce the burden of associated morbidity, and mortality to these patients.

Impact of Medium Cut-Off Dialyzers on Patient-Reported Outcomes: COREXH Registry

INTRODUCTION

A new generation of hemodialysis (HD) membranes called medium cut-off (MCO) membranes possesses enhanced capacities for middle molecule clearance, which have been associated with adverse outcomes in this population. These improvements could potentially positively impact patient-reported outcomes (PROs).

OBJECTIVE

The objective of this study was to evaluate the impact of MCO membranes on PROs in a cohort of HD patients in Colombia.

METHODS

This was a prospective, multicenter, observational cohort study of 992 patients from 12 renal clinics in Colombia who were switched from high-flux HD to MCO therapy and observed for 12 months. Changes in Kidney Disease Quality of Life 36-Item Short Form Survey (KDQoL-SF36) domains, Dialysis Symptom Index (DSI), and restless legs syndrome (RLS) 12 months after switching to MCO membranes were compared with time on high-flux membranes. Repeated measures of ANOVA were used to evaluate changes in KDQoL-SF36 scores; severity scoring was used to assess DSI changes over time; Cochran's Q test was used to evaluate changes in frequency of diagnostic criteria of RLS.

RESULTS

During 12 months of follow-up, 3 of 5 KDQoL-SF36 domains improved compared with baseline: symptoms (p < 0.0001), effects of kidney disease (p < 0.0001), and burden of kidney disease (p < 0.001). The proportion of patients diagnosed with RLS significantly decreased from 22.1% at baseline to 10% at 12 months (p < 0.0001). No significant differences in the number of symptoms (DSI, p = 0.1) were observed, although their severity decreased (p = 0.009).

CONCLUSIONS

In conventional HD patients, the expanded clearance of large middle molecules with MCO-HD membranes was associated with higher health-related quality of life scores and a decrease in the prevalence of RLS.

Impact of Annual Change in Geriatric Nutritional Risk Index on Mortality in Patients Undergoing Hemodialysis

Regular nutritional assessment may decrease the mortality rate in patients undergoing hemodialysis. This study aimed to evaluate whether annual change in geriatric nutritional risk index (ΔGNRI) can precisely predict mortality. We retrospectively examined 229 patients undergoing hemodialysis who measured geriatric nutritional risk index (GNRI). Patients were divided into four groups according to the baseline GNRI of 91.2, previously reported cutoff value, and declined or maintained GNRI during the first year (ΔGNRI < 0% vs. ΔGNRI ≥ 0%): Group 1 (G1), GNRI ≥ 91.2 and ΔGNRI ≥ 0%; G2, GNRI ≥ 91.2 and ΔGNRI < 0%; G3, GNRI < 91.2 and ΔGNRI ≥ 0%; and G4, GNRI < 91.2 and ΔGNRI < 0%. They were followed for mortality. During a median follow-up of 3.7 (1.9–6.9) years, 74 patients died, of which 35 had cardiovascular-specific causes. The GNRI significantly decreased from 94.8 ± 6.3 to 94.1 ± 6.7 in the first year (p = 0.035). ΔGNRI was negatively associated with baseline GNRI (ρ = −0.199, p = 0.0051). The baseline GNRI < 91.2 and ΔGNRI < 0% were independently associated with all-cause mortality (adjusted hazard ratio (aHR) 2.59, 95%, confidence interval (CI) 1.54–4.33, and aHR 2.33, 95% CI 1.32–4.32, respectively). The 10-year survival rates were 69.8%, 43.2%, 39.9%, and 19.2% in G1, G2, G3, and G4, respectively (p < 0.0001). The aHR value for G4 vs. G1 was 3.88 (95% CI 1.62–9.48). With regards to model discrimination, adding ΔGNRI to the baseline risk model including the baseline GNRI significantly improved the net reclassification improvement by 0.525 (p = 0.0005). With similar results obtained for cardiovascular mortality. We concluded that the ΔGNRI could not only predict all-cause and cardiovascular mortality but also improve predictability for mortality; therefore, GNRI might be proposed to be serially evaluated.

Risk Factors for Muscle Loss in Hemodialysis Patients with High Comorbidity

With expanding kidney transplantation programs, remaining hemodialysis patients are more likely to have a high comorbidity burden and may therefore be more prone to lose muscle mass. Our aim was to analyze risk factors for muscle loss in hemodialysis patients with high comorbidity. Fifty-four chronic hemodialysis patients (Charlson Comorbidity Index 9.0 ± 3.4) were followed for 20 weeks using 4-weekly measurements of lean tissue mass, intracellular water, and body cell mass (proxies for muscle mass), handgrip strength (HGS), and biochemical parameters. Mixed models were used to analyze covariate effects on LTM. LTM (-6.4 kg, interquartile range [IQR] -8.1 to -4.8), HGS (-1.9 kg, IQR -3.1 to -0.7), intracellular water (-2.11 L, IQR -2.9 to -1.4) and body cell mass (-4.30 kg, IQR -5.9 to -2.9) decreased in all patients. Conversely, adipose tissue mass increased (4.5 kg, IQR 2.7 to 6.2), resulting in no significant change in body weight (-0.5 kg, IQR -1.0 to 0.1). Independent risk factors for LTM loss over time were male sex (-0.26 kg/week, 95% CI -0.33 to -0.19), C-reactive protein above median (-0.1 kg/week, 95% CI -0.2 to -0.001), and baseline lean tissue index ³10th percentile (-1.6 kg/week, 95% CI -2.1 to -1.0). Age, dialysis vintage, serum albumin, comorbidity index, and diabetes did not significantly affect LTM loss over time. In this cohort with high comorbidity, we found universal and prominent muscle loss, which was further accelerated by male sex and inflammation. Stable body weight may mask muscle loss because of concurrent fat gain. Our data emphasize the need to assess body composition in all hemodialysis patients and call for studies to analyze whether intervention with nutrition or exercise may curtail muscle loss in the most vulnerable hemodialysis patients.

Subjective global assessment of nutrition, dialysis quality, and the theory of the scientific method in Nephrology practice

In an era of evidence-based medicine and dialysis performance measures, there is strong motivation to find specific, objective, quantifiable, and reproducible parameters to characterize the clinical condition of chronic kidney disease patients and to present population-wide statistics that may describe quality of care in dialysis centers. Yet, in the last three decades, several studies demonstrated that while parameters including Kt/V urea, serum phosphorus, parathyroid hormone, serum cholesterol fulfill all these criteria, efforts to optimize these lab parameters failed to improve survival on dialysis. However, subjective assessments of nutrition including subjective global assessment and malnutrition-inflammation score, while not ideally suited for statistical analysis and not optimal from the point of view of scientific methodology due to their general, semi-quantifiable, subjective nature have, nevertheless, proved themselves as some of the strongest predictors of clinical outcomes in the dialysis population. Where does this paradox leave us? We propose that a deeper understanding of relevance of these variables in the dialysis population may improve appreciation of the clinical situation of individual patients and may result in a paradigm shift from dialysis adequacy to quality dialysis.

Impact of Dietary Potassium Restrictions in CKD on Clinical Outcomes: Benefits of a Plant-Based Diet

In patients with advanced-stage chronic kidney disease (CKD), progressive kidney function decline leads to increased risk for hyperkalemia (serum potassium > 5.0 or >5.5 mEq/L). Medications such as renin-angiotensin-aldosterone system inhibitors pose an additional hyperkalemia risk, especially in patients with CKD. When hyperkalemia develops, clinicians often recommend a diet that is lower in potassium content. This review discusses the barriers to adherence to a low-potassium diet and the impact of dietary restrictions on adverse clinical outcomes. Accumulating evidence indicates that a diet that incorporates potassium-rich foods has multiple health benefits, which may also be attributable to the other vitamin, mineral, and fiber content of potassium-rich foods. These benefits include blood pressure reductions and reduced risks for cardiovascular disease and stroke. High-potassium foods may also prevent CKD progression and reduce mortality risk in patients with CKD. Adjunctive treatment with the newer potassium-binding agents, patiromer and sodium zirconium cyclosilicate, may allow for optimal renin-angiotensin-aldosterone system inhibitor therapy in patients with CKD and hyperkalemia, potentially making it possible for patients with CKD and hyperkalemia to liberalize their diet. This may allow them the health benefits of a high-potassium diet without the increased risk for hyperkalemia, although further studies are needed.

Plant-Dominant Low-Protein Diet for Conservative Management of Chronic Kidney Disease

Chronic kidney disease (CKD) affects >10% of the adult population. Each year, approximately 120,000 Americans develop end-stage kidney disease and initiate dialysis, which is costly and associated with functional impairments, worse health-related quality of life, and high early-mortality rates, exceeding 20% in the first year. Recent declarations by the World Kidney Day and the U.S. Government Executive Order seek to implement strategies that reduce the burden of kidney failure by slowing CKD progression and controlling uremia without dialysis. Pragmatic dietary interventions may have a role in improving CKD outcomes and preventing or delaying dialysis initiation. Evidence suggests that a patient-centered plant-dominant low-protein diet (PLADO) of 0.6–0.8 g/kg/day composed of >50% plant-based sources, administered by dietitians trained in non-dialysis CKD care, is promising and consistent with the precision nutrition. The scientific premise of the PLADO stems from the observations that high protein diets with high meat intake not only result in higher cardiovascular disease risk but also higher CKD incidence and faster CKD progression due to increased intraglomerular pressure and glomerular hyperfiltration. Meat intake increases production of nitrogenous end-products, worsens uremia, and may increase the risk of constipation with resulting hyperkalemia from the typical low fiber intake. A plant-dominant, fiber-rich, low-protein diet may lead to favorable alterations in the gut microbiome, which can modulate uremic toxin generation and slow CKD progression, along with reducing cardiovascular risk. PLADO is a heart-healthy, safe, flexible, and feasible diet that could be the centerpiece of a conservative and preservative CKD-management strategy that challenges the prevailing dialysis-centered paradigm.

Description of a multidisciplinary model of care in a French cohort of adult patients with tuberous sclerosis complex

BACKGROUND

Tuberous sclerosis complex (TSC) is a rare autosomal dominant genetic disorder. Due to the various manifestations of TSC and their potential complications, a multidisciplinary care approach is recommended by consensus guidelines.

OBJECTIVES

Our study aimed to give a complete description of our TSC adult cohort and to evaluate the multidisciplinary and interdisciplinary management model.

METHODS

Data on each adult patient diagnosed with TSC, including disease manifestations, interventions and outcomes, were collected at baseline and updated annually. A multidisciplinary TSC approach with all the recommended explorations was carried out annually.

RESULTS

90 patients were enrolled in Centre Hospitalier Universitaire de Bordeaux, between January 2000 and September 2018. Median age of patients at inclusion was 37 years (range, 27-47) and 20 years old at diagnosis of TSC. Regarding the occurrence of TSC manifestations, 97% of the patients had cutaneous lesions, 89% had neurological manifestations, 83% had renal manifestations and 100% had dental lesions with pits. More than half the patients had sclerotic bone lesions (68%), TSC-associated neuropsychiatric disorders (64%) and lymphangioleiomyomatosis (59%). A TSC multidisciplinary approach was developed including a global follow-up and an evaluation of TSC targeting organs, according to the recommendations. A satisfaction survey revealed global and entire satisfaction of patients with TSC.

CONCLUSION

We obtained an accurate description of a cohort of adult patients with TSC. Our multidisciplinary approach model allowed us to provide optimal management of patients with TSC with a high level of patient satisfaction.

Racial differences in utilization and outcomes of hemodialysis access in the Unites States

OBJECTIVE

To evaluate patterns of use and outcomes of arteriovenous fistulas and prosthetic grafts within racial categories in a large population based cohort of hemodialysis (HD) patients in the United States.

METHODS

A retrospective analysis of white, black, and Hispanic patients in the prospectively maintained United States Renal Database System who had an autogenous fistula or prosthetic graft placed for HD access between January 2007 and December 2014 was performed. Analysis of variance, χ2, t-tests, Kaplan-Meier, log-rank tests, multivariable logistic, and Cox regression analyses were used to evaluate maturation, patency, infection, and mortality.

RESULTS

This study of 359,942 patients, composed of 285,781 autogenous fistulas (79.4%) and 74,161 prosthetic grafts (20.6%) placed in 213,877 white (59.4%), 115,727 black (32.2%), and 30,338 Hispanic (8.4%) patients. There was a 11% increase in the risk-adjusted odds of HD catheter use as bridge to autogenous fistula placement in blacks (adjusted odds ratio, 1.11; 95% confidence interval [CI], 1.08-1.14; P < .001) and a 9% increase in Hispanics (adjusted odds ratio, 1.09; 95% CI, 1.05-1.14; P < .001) compared with whites. Fistula maturation for HD access for whites vs blacks vs Hispanics was 77.0% vs 76.3% vs 77.8% (P = .35). After adjusting for covariates, fistula maturation was higher for blacks (adjusted hazard ratio, 1.09; 95% CI, 1.06-1.13; P < .001) and Hispanics (adjusted hazard ratio, 1.13; 95% CI, 1.06-1.20; P < .001) compared with whites. There was no significant difference in prosthetic graft maturation for blacks and Hispanics compared with whites. Primary, primary-assisted, and secondary patency were highest for Hispanic and least for black autogenous fistula recipients. Primary, primary-assisted, and secondary patency was also highest for Hispanic patients who received prosthetic grafts. Prosthetic grafts were associated with a decrease in patency and patient survival compared with fistulas in all racial categories. Mortality was lower for blacks and Hispanics relative to white patients. Initiation of HD with a catheter and conversion to autogenous fistula was associated with decrease in patency and patient survival compared with initiation with a fistula in all racial groups.

CONCLUSIONS

Autogenous fistulas are associated with better patency and patient survival compared with prosthetic grafts for all races studied. The use of HD catheter before fistula placement is more prevalent in Hispanic and black patients and is associated with worse patency and patient survival irrespective of race. Fistula and graft patency is highest for Hispanic patients. Patient survival is higher for Hispanic and black patients relative to whites. These associations suggest potential benefit with initiation of HD via autogenous fistula and minimizing temporizing catheter use, irrespective of race.

Evaluation of the prognostic significance of the malnutrition inflammation score in hemodialysis patients

BACKGROUND & AIMS

To verify the performance of Malnutrition Inflammation Score (MIS) in the evaluation of nutritional status and its relation with clinical outcomes.

METHODS

Nutritional status was evaluated by MIS. The Mann Whitney and chi-square tests were used to compare the dependent variables MIS, death, and hospitalization. We used the forward stepwise multivariate regression model to evaluate the relationship between age, dialysis time, albumin, total iron binding capacity, C-reactive protein (CRP), and ferritin and the outcome variables. The Kaplan-Meier curve was constructed to evaluate the influence of MIS on survival in the two groups of patients, and log rank tests were used to ascertain the equality of survival distributions in these groups. ROC curves were fitted to measure the area under the curve and the significance of MIS in predicting mortality.

RESULTS

A total of 47 patients on hemodialysis with a median age of 62 (48.5-72) took part in this study. The median total MIS was 9 (5.5-10). The MIS of 51% of the patients indicated they were malnourished. After 29 months' follow-up, 27.7% of the patients had died and survival was significantly lower in the high MIS group. The score from Part B of the MIS form and ferritin were higher for the patients who deceased during the follow-up period. Patients with an MIS >9 presented a significantly shorter survival time than those with an MIS ≤9.

CONCLUSION

MIS is effective in evaluating the nutritional status of patients on hemodialysis and has a predictive capacity for negative clinical outcomes.

Malnutrition-Inflammation Score VS Phase Angle in the Era of GLIM Criteria: A Cross-Sectional Study among Hemodialysis Patients in UAE

(1) Background: Malnutrition is prevalent in hemodialysis (HD) patients and is associated with an increased risk of morbidity and mortality. The aim of this study was to explore the prevalence of malnutrition using the malnutrition-inflammation score (MIS) and phase angle (PhA) and compare their concordance with the new Global Leadership Initiative on Malnutrition (GLIM) criteria for the diagnosis of malnutrition. (2) Methods: Seventy HD patients were assessed. Malnutrition was diagnosed based on the GLIM criteria and MIS questionnaire. The agreement between the diagnostic tools (MIS, PhA derived from the bioelectrical impedance analysis (BIA), and GLIM criteria) was assessed. The optimal gender-specific cutoff points were identified for the PhA according to the GLIM criteria. (3) Results: Almost half of the sample was diagnosed as malnourished according to the MIS (48.57%) and GLIM criteria (54.29%). A fair agreement was observed between the GLIM criteria, MIS (k = 0.202), and PhA (k = 0.279) among the malnourished patients. The PhA had better sensitivity but worse specificity compared to the MIS. The optimum cutoff points of PhA to detect malnutrition according to the GLIM criteria were a PhA value of ≤5.7° for males and ≤3.8° for females. (4) Conclusion: The MIS performed slightly better than PhA in the diagnosis of malnutrition among HD patients within the spectrum of the GLIM criteria.

Non-adherence to Haemodialysis, Interdialytic weight gain and cardiovascular mortality: a cohort study

Background

Patients with chronic kidney diseases (CKD) on haemodialysis (HD) have high morbidity and mortality rates, which are also due to the inherent risks associated with nephropathy. Non-adherence (NA) to the different demands of the treatment can have consequences for the outcome of patients undergoing HD; nevertheless, there are still doubts about such repercussions. This study was conducted to evaluate the association between NA to conventional HD and all-cause mortality and cardiovascular mortality.

Methods

We prospectively evaluated mortality in a 6-year period in a cohort of 255 patients on HD in northeast Brazil. The evaluated parameters of NA to HD were interdialytic weight gain (IDWG) ≥ 4% of dry weight (DW), hyperphosphatemia and regular attendance at treatment, assessed as the correlation between the periods on HD completed and those prescribed. We used the Cox multivariate regression model to analyse survival and the predictors of all-cause mortality and cardiovascular mortality.

Results

With a median follow-up period of 1493 days and a mortality rate of 9.1 per 100 people-years, there were 87 deaths, of which 54% were cardiovascular deaths. IDWG ≥4% of DW was associated with a risk of all-cause mortality however presenting a borderline outcome for cardiovascular mortality, with hazard ratios of 2.02 (CI 95% 1.17–3.49, p = 0.012) and 2.09 (CI 95% 1.01–4.35, p = 0.047), respectively. No significant association was found between other parameters of NA and mortality. Subgroup analysis showed that for patients with IDWG ≥4% of DW, malnutrition, age and diagnosis of cardiovascular and cerebrovascular diseases were associated with higher all-cause mortality.

Conclusions

IDWG ≥4% of DW was identified as an independent predictor of all-cause mortality and demonstrated a borderline outcome for cardiovascular mortality in patients on conventional HD. The occurrence of excessive IDWG in the presence of malnutrition represented a significant increase in the risk of death, indicating a subgroup of patients with a worse prognosis.

Combined Predictive Value of Extracellular Fluid/Intracellular Fluid Ratio and the Geriatric Nutritional Risk Index for Mortality in Patients Undergoing Hemodialysis

The ratio of extracellular fluid (ECF) to intracellular fluid (ICF) may be associated with mortality in patients undergoing hemodialysis, possibly associated with protein-energy wasting. We therefore investigated the relationship of the ECF/ICF ratio and the geriatric nutritional risk index (GNRI) with the all-cause and cardiovascular-specific mortality in 234 patients undergoing hemodialysis. Bioimpedance analysis of the ECF and ICF was performed and the ECF/ICF ratio was independently associated with GNRI (β = −0.247, p < 0.0001). During a median follow-up of 2.8 years, 72 patients died, of which 29 were cardiovascular. All-cause mortality was independently associated with a lower GNRI (adjusted hazard ratio [aHR] 3.48, 95% confidence interval [CI] 2.01–6.25) and a higher ECF/ICF ratio (aHR 11.38, 95%CI 5.29–27.89). Next, we divided patients into four groups: group 1 (G1), higher GNRI and lower ECF/ICF ratio; G2, lower GNRI and lower ECF/ICF ratio; G3, higher GNRI and higher ECF/ICF ratio; and G4, lower GNRI and higher ECF/ICF ratio. Analysis of these groups revealed 10-year survival rates of 91.2%, 67.2%, 0%, and 0% in G1, G2, G3, and G4, respectively. The aHR for G4 versus G1 was 43.4 (95%CI 12.2–279.8). Adding the GNRI alone, the ECF/ICF ratio alone, or both to the established risk model improved the net reclassification improvement by 0.444, 0.793 and 0.920, respectively. Similar results were obtained for cardiovascular mortality. In conclusion, the ECF/ICF ratio was independently associated with GNRI and could predict mortality in patients undergoing hemodialysis. Combining the GNRI and ECF/ICF ratio could improve mortality predictions.

Short-Term Creatine Supplementation May Alleviate the Malnutrition-Inflammation Score and Lean Body Mass Loss in Hemodialysis Patients: A Pilot Randomized Placebo-Controlled Trial

BACKGROUND

Creatine supplementation has been proposed to alleviate muscle loss in various populations, but has not been investigated in hemodialysis (HD) patients. Thus, our objective was to evaluate whether creatine supplementation could attenuate the loss of lean body mass (LBM) and malnutrition-inflammation score (MIS) in HD patients.

METHODS

A randomized, placebo-controlled, double blind, parallel-design study included HD patients, of both sexes, aged 18-59 years. The patients were allocated to a Placebo Group (PG; n = 15; received maltodextrin, 1st week: 40 g/day and 2nd-4th weeks: 10 g/day) and a Creatine Group (CG; n = 15; received creatine plus maltodextrin, 1st week: 20 g/day of creatine plus 20 g/day of maltodextrin and 2nd-4th weeks: 5 g/day of creatine plus 5 g/day of maltodextrin). Pre and post the intervention, patients were evaluated for food intake, MIS, body composition and biochemical parameters.

RESULTS

CG group attenuated the MIS (Pre: 5.57 ± 0.72 vs. Post: 3.85 ± 0.47 score, P = 0.003) compared with PG (Pre: 5.71 ± 0.97 vs. Post: 5.36 ± 0.95 score, P = 0.317) (supplement × time P = 0.017, effect size: 0.964). The change of LBM was greater in CG than in PG (CG: Δ0.95 vs PG: Δ0.13 kg). At post-intervention, 28.6% of PG patients presented LBM loss and 71.4% remain stable. In contrast, 14.4% of CG patients had LBM loss, 42.8% remain stable and 42.8% gained. Food intake and quality of life did not change. CG increased the BMI and gait speed in post-compared to pre-moment, but no difference among the groups.

CONCLUSION

In HD patients, four weeks of creatine supplementation may alleviate the MIS as well as attenuate the LBM loss compared to placebo.

Lipids, Lipoprotein Distribution and Nutritional Parameters over the Ramadan Period in Hemodialysis Patients

The period of Ramadan (R) is associated with dramatic changes in eating habits involving extended periods of fasting on a daily basis. The current study assessed whether lipids and lipoproteins were impacted during R in chronic hemodialysis (HD) patients. Forty-five subjects in an outpatient dialysis clinic in Saudi Arabia were evaluated for anthropometric and lipid changes on a monthly basis before, during as well as one and two months after R. In addition to routine biochemical measures, anthropometric assessments including hand-grip strength (HGS), mid-arm muscle circumference (MAMC), plasma lipids and lipoproteins were evaluated. Dietary assessment was carried out using 24 h recalls. Over the course of the study, changes in renal-related parameters (creatinine, albumin, Kt/V) were minor, as were changes in plasma lipids. Large high-density lipoproteins (HDLs) and low-density lipoproteins (LDLs) accounted for the majority of their respective lipoproteins and their proportions did not change over the study period. Mean LDL particle diameters were higher during the R period, but the changes over the study period were small. Calorie intake during R (2139 ± 709 kcal/d) was significantly higher than the value noted two month post-R (1755 ± 424 kcal/d) and this was associated with significant increases in protein (69 ± 24 vs. 60 ± 24 g/d) and fat (97 ± 38, vs. 73 ± 35 g/d), respectively. No changes were noted with respect to HGS and MAMC. These data show that for HD patients, the period of R results in temporal or non-significant effects on plasma lipids, despite changes in nutrient intake.

Association Between Weight Loss Before Deceased Donor Kidney Transplantation and Posttransplantation Outcomes

RATIONALE & OBJECTIVE

There is debate on whether weight loss, a hallmark of frailty, signals higher risk for adverse outcomes among recipients of deceased donor kidney transplantation (DDKT).

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

Using national Organ Procurement and Transplantation Network data, we included all DDKT recipients in the United States between December 4, 2004, and December 3, 2014, who were adults (aged ≥ 18 years) when listed for DDKT.

EXPOSURES

Relative pre-DDKT weight change as a continuous predictor and categorized as <5% weight change from listing to DDKT, ≥5% to <10% weight loss, ≥10% weight loss, ≥5% to <10% weight gain, and ≥10% weight gain.

OUTCOMES

We examined 3 post-DDKT outcomes: (1) transplant hospitalization length of stay (LOS) in days, (2) all-cause graft failure, and (3) mortality.

ANALYTIC APPROACH

Unadjusted fractional polynomial methods, multivariable log-gamma models, and multivariable Cox proportional hazards models.

RESULTS

Among 94,465 recipients of DDKT, median pre-DDKT weight change was 0 (interquartile range, -3.5 to +3.9) kg. There were nonlinear unadjusted associations between relative pre-DDKT weight loss and longer transplant hospitalization LOS, higher all-cause graft loss, and higher mortality. Compared with recipients with <5% pre-DDKT weight change (n = 49,366; 52%), recipients who lost ≥10% of their listing weight (n = 10,614; 11%) had 0.66 (95% CI, 0.23-1.09) days longer average transplant hospitalization LOS (P = 0.003), 1.11-fold higher graft loss (adjusted HR [aHR], 1.11; 95% CI, 1.06-1.17; P < 0.001), and 1.18-fold higher mortality (aHR, 1.18; 95% CI, 1.11-1.25; P < 0.001) independent of recipient, donor, and transplant factors. Pre-DDKT dialysis exposure, listing body mass index category, and waiting time modified the association of pre-DDKT weight change with hospital LOS (interaction P < 0.10), but not with all-cause graft loss and mortality.

LIMITATIONS

Unmeasured confounders and inability to identify volitional weight change. Also, the higher significance level set to increase the power of detecting interactions with the fixed sample size may have resulted in increased risk for type 1 error.

CONCLUSIONS

DDKT recipients with ≥10% pre-DDKT weight loss are at increased risk for adverse outcomes and may benefit from augmented support post-DDKT.

Predictors of nutritional and inflammation risk in hemodialysis patients

BACKGROUND

Malnutrition and chronic inflammation are prevalent complications in hemodialysis (HD) patients. Different nutritional assessment tools are used to identify patients at risk. A composite and comprehensive malnutrition inflammation score (MIS) has been correlated with morbidity and mortality, and appears to be a robust and quantitative tool.

OBJECTIVES

Determine malnutrition risk profile in a sample of portuguese HD patients; determine the association of clinical and laboratory factors with MIS, and the impact of each parameter on MIS.

METHODS AND RESULTS

We performed, between September 15th of 2015 and January 31st of 2016, a cross sectional analysis of 2975 patients, representing 25% of portuguese HD patients. 59% were men (66.7 ± 14.8 years); 31% diabetic; 79% and 21% performed, respectively, high-flux HD and HDF. A MIS >5 was considered to indicate higher risk and was present in 1489 patients (50%). Amongst all parameters, comorbilities/dialysis vintage, transferrin, functional capacity, changes in body weight and decreased fat stores showed the higher impact, while albumin had one of the lowest impact on the nutritional risk.

MULTIVARIABLE ANALYSIS

Higher age (>75 years, OR 1.71, p < 0.001), diabetes (OR 1.25, p = 0.026), lower P levels (OR 1.57,p = 0.001), higher Ca levels (OR 1.51, p < 0.001), higher ERI (OR 1.05, p < 0.001), higher Kt/V (OR 2.14, p < 0.001) and higher CRP (OR 1.01, p < 0.001) were independently associated with a higher risk of MIS>5; higher nPNA (OR 0.29, p < 0.001) and higher Pcreat (OR 0.88, p < 0.001) were associated with a risk reduction of MIS>5 (95% CI).

CONCLUSIONS

Routine clinical and analytic parameters were found to be associated with MIS range that might indicate higher risk, and may represent a simple alert sign for the need of further assessments.

Clinical outcomes of stroke in hemodialysis patients: a retrospective single-center study

PURPOSE

The incidence of stroke in patients undergoing hemodialysis (HD) is eight-to-ten times greater than that of the general population. However, data on the outcome of stroke in these patients are limited.

METHODS

In this retrospective observational cohort study, electronic medical records of all patients undergoing HD from 1.1.2014 to 31.12.2017 at Meir Medical Center, Israel, were reviewed. Stroke was defined as a focal neurological deficit of cerebrovascular origin, and confirmed as ischemic or hemorrhagic by computed tomography. Age- and sex-matched HD patients who did not experience a stroke (HD-NS) and hospitalized stroke patients with normal kidney function (NRF-S) served as the two control groups. Baseline demographic, clinical, and laboratory data were collected. Thrombolytic therapy, duration of hospital stay, and mortality were recorded. Functional status at discharge was assessed by the Modified Rankin Scale.

RESULTS

In the cohort study group (HD-S), 52 strokes occurred during 248.3 patient years, an incidence rate of 8.13%, and a stroke rate of 0.19% patients/month. Most strokes in HD patients were ischemic, and only four patients were administered tissue plasminogen activator. HD-S had longer hospitalization than did NRF-S (10.6 ± 9.9 vs. 5.96 ± 5.3 days, p = 0.004) and lower functional status at discharge (Rankin score 3.75 ± 1.57 vs. 2.29 ± 1.89, p < 0.001). HD-S patients had a higher mortality than both HD-NS and NRF-S patients.

CONCLUSIONS

Stroke outcome in these patients is dismal with prolonged hospital stay, poor functional status at discharge, very limited response to rehabilitation, and increased mortality.

Comparison of three nutritional screening tools for predicting mortality in maintenance hemodialysis patients

OBJECTIVES

The aim of this study was to compare the effect of different nutritional screening tools on predicting the risk for mortality in patients on maintenance hemodialysis (MHD).

METHODS

A cohort of 1025 patients on MHD were enrolled from eight hospitals. The malnutrition-inflammation score (MIS), objective score of nutrition on dialysis (OSND), and geriatric nutritional risk index (GNRI) were measured at baseline. All-cause mortality and cardiovascular (CV) mortality were the major study outcomes.

RESULTS

The median follow-up duration was 28.1 mo. The MIS (per SD increase, hazard ratio [HR], 1.35; 95% confidence interval [CI], 1.18-1.55), the OSND (per SD decrease, HR, 1.24; 95% CI, 1.09-1.42), and the GNRI (per SD decrease, HR, 1.26; 95% CI, 1.10-1.43) were significantly associated with the risk for all-cause mortality. More importantly, the mortality predictability of the MIS appears similar to the GNRI (P = 0.182) and greater than the OSND (MIS versus OSND: P = 0.001; GNRI versus OSND: P = 0.045). Similar results were found for CV mortality.

CONCLUSIONS

Each of the three nutritional screening tools was significantly associated with an increased risk for all-cause and CV mortality. The mortality predictability of the MIS was similar to the GNRI and greater than the OSND.