Sarcopenia, obesity, and mortality in US adults with and without chronic kidney disease

Interaction of general obesity and abdominal obesity with frailty in patients with chronic kidney disease: a nationally representative analysis

Background

General and abdominal obesity are prevalent, with established associations to frailty in the elderly. However, few studies have investigated these associations in patients with chronic kidney disease (CKD), yielding inconsistent results.

Methods

This cross-sectional study analysed data from the National Health and Nutrition Examination Survey (NHANES 2003-2018). Frailty was evaluated by the 36-item frailty index. General obesity was defined as a body mass index (BMI) >30 kg/m2; abdominal obesity was identified if waist circumference (WC) reached 102 cm in men and 88 cm in women. The associations of general and abdominal obesity with frailty were analysed using weighted multivariate logistic regression and restricted cubic splines. The interaction of general and abdominal obesity with frailty was examined.

Results

A total of 5604 adult patients (median age 71 years, 42% men) with CKD were included in this analysis, with a median estimated glomerular filtration rate of 57.3 ml/min/1.73 m2. A total of 21% were frail with general obesity and 32% were frail with abdominal obesity. Neither general nor abdominal obesity alone was associated with frailty. There was an interaction between general and abdominal obesity with frailty. Compared with individuals with normal BMI and WC, those with both general and abdominal obesity, rather than either alone, exhibited significantly increased odds of frailty {odds ratio [OR] 1.53 [95% confidence interval (CI) 1.20-1.95]}. General obesity was associated with being frail only when CKD patients had abdominal obesity [OR 1.59 (95% CI 1.08-2.36)].

Conclusions

There may be an interaction between general and abdominal obesity with frailty in patients with CKD. Interventions aimed at preventing frailty should consider both aspects.

Sarcopenia and mild kidney dysfunction and risk of all-cause and cause-specific mortality in older adults

BACKGROUND

Sarcopenia has been identified as a risk factor for increased mortality in individuals with CKD. However, when considering individuals with mild kidney dysfunction prior to CKD, the impact of sarcopenia on adverse outcomes, particularly mortality, remains uncertain.

METHODS

This study included 323 801 participants from the UK Biobank. Mild kidney dysfunction was defined as estimated glomerular filtration rate between 60 and 89.9 mL/min/1.73 m2, and sarcopenia was defined according to the criteria of the 2019 European Working Group of Sarcopenia in Older People. Cox proportional hazard models with inverse probability weighting and competing risk models were used for analysis.

RESULTS

During a median follow-up of 11.8 years, 20 146 participants died from all causes. Compared with participants with normal kidney function and without sarcopenia, those with mild kidney dysfunction or sarcopenia had significantly increased risks of all-cause mortality [hazard ratio (HR) 1.16, 95% confidence interval (CI) 1.12-1.19; HR 1.29, 95% CI 1.20-1.37]; those with both mild kidney dysfunction and sarcopenia had an even higher risk of all-cause mortality (HR 1.61, 95% CI 1.52-1.71), with a significant overall additive interaction (relative risk due to interaction 0.17, 95% CI 0.05-0.29). Further subgroup analyses revealed that the associations of probable sarcopenia with all-cause and cause-specific mortality (non-accidental cause, non-communicable diseases and cancer) were stronger among participants with mild kidney dysfunction than those with normal kidney function.

CONCLUSIONS

The study indicates that sarcopenia and mild kidney dysfunction synergistically increase the risk of all-cause and cause-specific mortality. Early recognition and improvement of mild kidney function or sarcopenia in older people may reduce mortality risk but would require more prospective confirmation.

Association of sarcopenia with rapid kidney function decline and chronic kidney disease in adults with normal kidney function

The association between sarcopenia and kidney function remains poorly investigated. We aimed to evaluate the associations between sarcopenia status and kidney function (rapid kidney function decline and chronic kidney disease (CKD)) in middle-aged and older Chinese population. A total of 9375 participants from the China Health and Retirement Longitudinal Study 2011 were included in the cross-sectional analyses. A total of 5864 participants with eGFRcr-cys ≥ 60 ml/min per 1·73 m2 at baseline were included in the longitudinal analyses and were followed up in 2015. Sarcopenia status was defined according to the Asian Working Group for Sarcopenia 2019 criteria. In the cross-sectional analyses, possible sarcopenia and sarcopenia were significantly associated with an increased risk of CKD. During the 4 years of follow-up, 359 (6·12 %) participants experienced rapid decline in kidney function and 126 (2·15 %) participants developed CKD. After multivariable adjustment of baseline eGFRcr-cys level and other risk factors, possible sarcopenia (OR, 1·33; 95 % CI 1·01, 2·12) and sarcopenia (OR, 1·49; 95 % CI 1·05, 2·12) were associated with an increased risk of primary outcome (composite of rapid decline in kidney function (annualised decline in eGFRcr-cys ≥ 5 ml/min per 1·73 m2) and progression to CKD (eGFRcr-cys < 60 ml/min per 1·73 m2). Individuals with low muscle mass or low muscle strength alone also had an increased risk of rapid decline in kidney function and progression to CKD.

Korean Nationwide Exploration of Sarcopenia Prevalence and Risk Factors in Late Middle-Aged Women

This study examined specific clinical risk factors for age-related loss of skeletal muscle mass in late middle-aged women with sarcopenia. This Korean nationwide cross-sectional study analyzed data from 2814 community-dwelling women aged from 50 to 64 years old and screened them for sarcopenia. This study examined various risk factors such as age; height; weight; body mass index; waist circumference; skeletal muscle mass index; systolic and diastolic blood pressure; smoking and drinking habits; fasting glucose levels; triglyceride; and cholesterol levels. Complex sampling analysis was used for the data set. Prevalence of sarcopenia with a weighted prevalence of 13.43% (95% confidence interval: 2.15-15.78). The risk factors for sarcopenia were height, body mass index, waist circumference, skeletal muscle mass index, systolic blood pressure, diastolic blood pressure, triglyceride level, and total cholesterol level (p < 0.05). Weight, fasting glucose level, drinking status, and smoking status were not significant (p > 0.05). These results are expected to contribute to the existing literature on sarcopenia and identify potential risk factors associated with the development of sarcopenia in late middle-aged females. By acknowledging prevalence and recognized risk factors, healthcare professionals may augment their proficiency in recognizing and discerning potential instances of sarcopenia in female patients.

Obesity paradox in older sarcopenic adults - a delay in aging: A systematic review and meta-analysis

The prognostic significance of obesity in sarcopenic adults is controversial. This systematic review and meta-analysis aimed to investigate the effect of additional obesity on health outcomes in sarcopenia. MEDLINE, EMBASE, Scopus and CENTRAL were systematically searched for studies to compare health outcomes of adults with sarcopenic obesity (SO) to those of sarcopenic non-obese (SNO) adults. We also considered the methods of assessing obesity. Of 15060 records screened, 65 papers were included (100612 participants). Older community-dwelling SO adults had 15% lower mortality risk than the SNO group (hazard ratio, HR: 0.85, 95% confidence interval 0.76, 0.94) even when obesity was assessed by measurement of body composition. Additionally, meta-regression analysis revealed a significant negative linear correlation between the age and the HR of all-cause mortality in SO vs. SNO community-dwelling adults, but not in severely ill patients. Compared with SNO, SO patients presented lower physical performance, higher risk for metabolic syndrome, but similar cognitive function, risk of falls and cardiovascular diseases. Age-related obesity, SO and later fat loss leading to SNO represent consecutive phases of biological aging. Additional obesity could worsen the health state in sarcopenia, but above 65 years SO represents a biologically earlier phase with longer life expectancy than SNO.

Early onset age increases the risk of musculoskeletal damage in patients with type 2 diabetes

Introduction

It's not clear whether there are differences in musculoskeletal damage and body composition among different age groups of type 2 diabetes. Therefore, the purpose of this study is to analyze the difference between early-onset type 2 diabetes (EOT2D) and non-early-onset type 2 diabetes (NOT2D) in musculoskeletal damage.

Methods

A total of 964 patients with type 2 diabetes mellitus were selected by 1:1 propensity score matching, including 534 males and 430 females, with an average age of 52 ± 7 years and an average course of 10 ± 8.5 years. Bone mineral density and body composition were measured, and combined with biochemical tests, linear regression and binary logic regression were used to analyze the relationship between EOT2D, NOT2D and musculoskeletal damage. In addition, 414 patients with T2DM were selected according to whether they were hospitalized twice or not, and the median follow-up period was 44 months. COX survival analysis further elucidates the relationship between EOT2D, NOT2D and musculoskeletal damage.

Results

Compared with patients with non-early-onset type 2 diabetes, A/G was negatively correlated with the age of onset, and had statistical significance. EOT2D has a higher risk of sarcopenia, osteoporosis and even musculoskeletal damage. With the prolongation of the course of the disease, the risk of muscle mass and/or bone mineral density decrease in EOT2D increases.

Conclusion

EOT2D brings a greater risk of sarcopenia and/or osteoporosis, as well as a higher risk of reduced ASM and BMD. In addition, fat distribution may be more central.

Assessment of the components of sarcopenia and quality of life perceived of individuals on hemodialysis

OBJECTIVES

to evaluate the prevalence of sarcopenia in individuals aged 50 years or older on hemodialysis; to verify the association between sarcopenia and sociodemographic, clinical, anthropometric factors, components of sarcopenia and quality of life (QoL); and to correlate the components of sarcopenia with QoL.

METHODS

Participated 83 individuals on hemodialysis. Sarcopenia was established according to the current European consensus. Dynamometry to determine strength, calf circumference (CC) and appendicular skeletal muscle mass index (ASMMI) to obtain muscle mass and gait speed (GS) for physical performance. For QoL used the WHOQOL-bref.

RESULTS

the prevalence of sarcopenia was 32.6% (CC) and 18.1% (ASMMI). There was no association between sarcopenia and QoL. Both handgrip strength (r=0.25) and GS (r=0.36) showed a correlation with physical domain.

CONCLUSIONS

sarcopenia was expressive, and the aspects of functionality determine the physical impairment in this population.

A Korean Nationwide Cross-Sectional Study Investigating Risk Factors, Prevalence, and Characteristics of Sarcopenia in Men in Early Old Age

The present study investigated the risk factors, prevalence, and characteristics of sarcopenia among men aged 50-64 years. A total of 2868 participants were enrolled in this study. Of these, 328 individuals were classified into a sarcopenia group; the remaining 2540 were assigned to a control group. This study examined several variables, including skeletal muscle mass index, age, height, weight, body mass index, waist circumference, systolic and diastolic blood pressure, fasting glucose, triglyceride and total cholesterol levels, alcohol consumption, and tobacco use. It employed a stratified, clustered, and multistage probability sampling design. Complex sampling was used for the data analysis. The prevalence of sarcopenia was 10.25% (95% CI: 8.98-11.69). All anthropometric measures, including height, weight, BMI, and waist circumference, were significantly different between the two groups (p < 0.05). In terms of blood pressure, only systolic blood pressure (SBP) was significant (p < 0.05), and fasting glucose and triglyceride levels were risk factors for sarcopenia (p < 0.05). Tobacco use differed significantly between the two groups (p < 0.05). This study reported the specific prevalence of sarcopenia and identified its risk factors among men in early old age.

Decreased intracellular water is associated with sarcopenic obesity in chronic haemodialysis patients

OBJECTIVE

To explore the association between intracellular water (ICW) and sarcopenic obesity in patients undergoing chronic haemodialysis (HD).

METHODS

A multicentre, cross-sectional study of 3354 adult chronic HD patients was conducted in 20 haemodialysis centres from June 1, 2021, to August 30, 2021. The diagnosis of sarcopenic obesity was made according to the revised Asian Working Group's definition of sarcopenia combined with obesity per the body fat percentage definition. Body composition was evaluated by a body composition monitor using bioimpedance spectroscopy. Multiple logistic regression models, stratified analyses, interactive analyses, and receiver-operating characteristic analyses were conducted.

RESULTS

A total of 752 patients were diagnosed with sarcopenic obesity among 3354 participants. The patients were grouped by sex-specific ICW median levels, and the prevalence of sarcopenic obesity was significantly higher in the low ICW group than in the high ICW group (41.3%vs 3.0%). Decreased ICW was significantly associated with sarcopenic obesity. The association remained statistically significant even after adjusting for dialysis vintage, age, body mass index, biochemical indicators, and various medical histories. The odds ratios of the low ICW group were much higher than those of the high ICW group in both males and females (P for trend < 0.001). The association was stable across subgroups, and the interaction analysis showed that age, body mass index and history of diabetes had interactive roles in the association between ICW and sarcopenic obesity (P for interaction < 0.05). Furthermore, the ICW cut-off values for identifying sarcopenic obesity were 19.1 kg and 14.5 kg for males and females, respectively.

CONCLUSION

Decreased ICW was an independent risk factor for sarcopenic obesity in chronic HD patients. The measurement of ICW by bioimpedance spectroscopy might be a non-invasive and valid means for identifying the risk of future sarcopenic obesity in HD patients.

Sarcopenia Diagnosis and Management in Hematological Malignancies and Differences with Cachexia and Frailty

Sarcopenia is a geriatric syndrome characterized by a progressive loss of systemic muscle mass and decreased muscle strength or physical function. Several conditions have a role in its pathogenesis, significantly impacting adverse outcomes such as falls, functional decline, frailty, disability, multiple hospitalizations, and mortality. In the oncological setting, sarcopenia is associated with an increased risk of treatment toxicity, postoperative complications, and a higher mortality rate related to other causes (e.g., pneumonia). In the hematological field, even more so, sarcopenia predicts toxicity and response to treatments. In patients with hematologic malignancy, low muscle mass is associated with adverse outcomes and is a predictor of overall survival and non-relapse mortality. Therefore, it is essential to correctly recognize sarcopenia, evaluate the risk factors and their impact on the patient's trajectory, and effectively treat sarcopenia. Sarcopenia is a reversible condition. The most effective intervention for reversing it is physical exercise combined with nutrition. The objective of clinical assessment focused on sarcopenia is to be able to carry out a "tailor-made treatment".

Sarcopenic obesity and its relation with muscle quality and mortality in patients on chronic hemodialysis

BACKGROUND & AIMS

Sarcopenia is prevalent in patients with end-stage kidney disease (ESKD) on hemodialysis (HD), and is associated with poor outcomes, while obesity may be protective. Sarcopenic obesity is associated with increased frailty, morbidity and mortality in the general population. Myosteatosis, i.e., muscle fat infiltration, has major effects on muscle strength and physical performance, but is poorly investigated in the nephrology setting. In the present study we aimed to assess the association between sarcopenic obesity, as diagnosed by abdominal CT, and mortality. Moreover, the relationship between myosteatosis, sarcopenic obesity and mortality was also investigated.

METHODS

This is a retrospective study in which ESKD patients on HD submitted to unenhanced abdominal CT for clinical reasons at least 6 months after dialysis initiation were evaluated for sarcopenic obesity and myosteatosis, defined as intermuscular fat area and low attenuation muscle area. Sarcopenic obesity was diagnosed in cases of low abdominal skeletal muscle area and high total fat area. Receiver-operating characteristics (ROC) analysis with Youden index was used to determine the cut-off for high total fat area. Intermuscular fat area and low attenuation muscle area were evaluated by applying the Hounsfield unit of interest (-190; -30, and -29; +29 respectively). Cox regression analysis was used to evaluate the association between predictors and mortality risk.

RESULTS

We enrolled 212 patients, aged 68.8 (±14.7) years, 65.5% (139/212) male. Median follow-up was 19.7 (interquartile range [IQR] 2.7-35) months. Sarcopenic obesity was diagnosed in 19.8% of patients and was associated with increased mortality (HR: 3.29 (1.72; 6.27), P < 0.001), and with the presence of myosteatosis. Both intermuscular fat area and low attenuation muscle area were associated with increased mortality in adjusted analyses.

CONCLUSIONS

Patients with sarcopenic obesity have increased myosteatosis. Sarcopenic obesity and myosteatosis are associated with increased mortality in patients on HD.

Dynapenic abdominal obesity is related to cardiovascular risk in older adults with Parkinson's disease: A cross sectional study

BACKGROUND AND AIMS

Currently, the impact of nutritional status in Parkinson's disease over the cardiovascular risk is poorly understood. Thus, this study aimed to evaluate dynapenic abdominal obesity and its influence in anthropometric parameters of cardiovascular risk in older patients with Parkinson's disease.

METHODS

This is a cross-sectional study involving outpatients diagnosed with Parkinson's disease in two treatment centers in northeast of Brazil. We included patients who aged 60 years and older. The data was collected from January to July of 2019. For abdominal obesity, waist circumference was used. For dynapenia, Handgrip Strength was measured. Dynapenic abdominal obesity was established as the coexistence of dynapenia and abdominal obesity.

RESULTS

The dynapenic abdominal obesity occurred in 25% of the patients and was higher in women (p = 0.073). The dynapenic abdominal obesity group had a decreased muscle strength, higher values of Body Mass Index, a worse Waist Height Ratio; increased values of Fat Mass and percentual of Fat Mass and an increased value of Conicity Index (p < 0,05).

CONCLUSION

The occurrence of dynapenic abdominal obesity in our population was related to the worsening of anthropometric values of cardiovascular risk. From our results we can suggest that the early identification of the coexistence of nutritional disorders, such as dynapenia and abdominal obesity can help in the appropriate intervention to mitigate the risks related to adverse events.

Nutritional status and the risk of malnutrition in older adults with chronic kidney disease - implications for low protein intake and nutritional care: A critical review endorsed by ERN-ERA and ESPEN

Increased life expectancy is posing unprecedented challenges to healthcare systems worldwide. These include a sharp increase in the prevalence of chronic kidney disease (CKD) and of impaired nutritional status with malnutrition-protein-energy wasting (PEW) that portends worse clinical outcomes, including reduced survival. In older adults with CKD, a nutritional dilemma occurs when indications from geriatric nutritional guidelines to maintain the protein intake above 1.0 g/kg/day to prevent malnutrition need to be adapted to the indications from nephrology guidelines, to reduce protein intake in order to prevent or slow CKD progression and improve metabolic abnormalities. To address these issues, the European Society for Clinical Nutrition and Metabolism (ESPEN) and the European Renal Nutrition group of the European Renal Association (ERN-ERA) have prepared this conjoint critical review paper, whose objective is to summarize key concepts related to prevention and treatment of both CKD progression and impaired nutritional status using dietary approaches, and to provide guidance on how to define optimal protein and energy intake in older adults with differing severity of CKD. Overall, the authors support careful assessment to identify the most urgent clinical challenge and the consequent treatment priority. The presence of malnutrition-protein-energy wasting (PEW) suggests the need to avoid or postpone protein restriction, particularly in the presence of stable kidney function and considering the patient's preferences and quality of life. CKD progression and advanced CKD stage support prioritization of protein restriction in the presence of a good nutritional status. Individual risk-benefit assessment and appropriate nutritional monitoring should guide the decision-making process. Higher awareness of the challenges of nutritional care in older adult patients with CKD is needed to improve care and outcomes. Research is advocated to support evidence-based recommendations, which we still lack for this increasingly large patient subgroup.

The Role of Mitochondrial and Redox Alterations in the Skeletal Myopathy Associated with Chronic Kidney Disease

Significance: An estimated 700 million people globally suffer from chronic kidney disease (CKD). In addition to increasing cardiovascular disease risk, CKD is a catabolic disease that results in a loss of muscle mass and function, which are strongly associated with mortality and a reduced quality of life. Despite the importance of muscle health and function, there are no treatments available to prevent or attenuate the myopathy associated with CKD. Recent Advances: Recent studies have begun to unravel the changes in mitochondrial and redox homeostasis within skeletal muscle during CKD. Impairments in mitochondrial metabolism, characterized by reduced oxidative phosphorylation, are found in both rodents and patients with CKD. Associated with aberrant mitochondrial function, clinical and preclinical findings have documented signs of oxidative stress, although the molecular source and species are ill-defined. Critical Issues: First, we review the pathobiology of CKD and its associated myopathy, and we review muscle cell bioenergetics and redox biology. Second, we discuss evidence from clinical and preclinical studies that have implicated the involvement of mitochondrial and redox alterations in CKD-associated myopathy and review the underlying mechanisms reported. Third, we discuss gaps in knowledge related to mitochondrial and redox alterations on muscle health and function in CKD. Future Directions: Despite what has been learned, effective treatments to improve muscle health in CKD remain elusive. Further studies are needed to uncover the complex mitochondrial and redox alterations, including post-transcriptional protein alterations, in patients with CKD and how these changes interact with known or unknown catabolic pathways contributing to poor muscle health and function. Antioxid. Redox Signal. 38, 318-337.

Diagnosis, Prevalence and Significance of Obesity in a Cohort of CKD Patients

BACKGROUND

data regarding the association between obesity and morbidity/mortality in patients with chronic kidney disease (CKD) are uncertain and sometimes contradictory. The aims of our study were to determine the associations among different measures of obesity and adiposity, and the risk of all-cause mortality or dialysis entry in stage 3-5 CKD patients.

MATERIALS

this observational cohort study included 178 CKD patients followed for a median of 71 months. Biochemistry, anthropometric measures such as body mass index (BMI), waist-to-hip ratio, mid-arm muscle circumference (MAMC) and body composition by bioimpedance analysis were evaluated.

RESULTS

we found a weak agreement between BMI and other measures of adiposity. In multivariable regression analysis, all measures of obesity such as BMI, waist circumference and waist-to-height ratio were not associated with dialysis entry and/or mortality. Instead, MAMC was associated with dialysis entry HR 0.82 [95% CI: 0.75-0.89] and high FM% with mortality HR 2.08 [95% CI: 1.04-4.18].

CONCLUSIONS

in our CKD population, lower MAMC was predictive of dialysis commencing, while a higher percentage of fatty mass was a predictor of mortality. Instead, obesity, as defined by BMI, is not associated with dialysis commencing or all-cause mortality.

Gender-Specific Prevalence and Risk Factors of Sarcopenic Obesity in the Korean Elderly Population: A Nationwide Cross-Sectional Study

Sarcopenic obesity (SO) is characterized by the combination of sarcopenia and obesity. This study evaluates the gender-specific prevalence of SO and examines the identified gender-specific risk factors in a community-dwelling elderly population aged 75-84 years. A total of 813 subjects participated in the study via the Korea National Health and Nutrition Examination Survey. The SO prevalence in males and females was 15.46% (95%CI: 11.36-20.70) and 13.59% (95%CI: 10.59-17.28), respectively. The clinical sex-specific risk factors for males were low height, high weight, body mass index, waist circumference, skeletal muscle index, fasting glucose, and triglycerides. The clinical risk factors for females were low height, high weight, body mass index, waist circumference, skeletal muscle index, smoking status, fasting glucose, total cholesterol, and systolic blood pressure. These results are essential to assist healthcare professionals and primary care clinicians with early detection, diagnosis, and intervention for potential SO patients by acknowledging the sex-based prevalence and risk factors.

Could sarcopenia-related mortality in end-stage renal disease be underpinned by the number of hospitalizations and cardiovascular diseases?

PURPOSE

To investigate the association between sarcopenia with the number of all-cause mortality, hospitalizations, and cardiovascular diseases in patients with end-stage renal disease (ESRD).

METHODS

247 patients with ESRD (women, n = 97) (66.6 ± 3.53 years) participated in this study. At baseline, all participants were measured with dual-energy X-ray absorptiometry and handgrip dynamometer and were prospectively followed up for 5 years. The European Working Group on Sarcopenia in Older People guidelines were utilized for Sarcopenia determination. Cox proportional hazard analysis adjusted for established risk factors was used to quantify the risk between Sarcopenia and all-cause mortality.

RESULTS

Sixty-five participants (26%) were determined to have Sarcopenia at baseline and 38 (15%) have died during the follow-up. At baseline, Participants with Sarcopenia had lower body mass index and fat-free mass index. Moreover, through the 5-year follow-up, sarcopenic patients had higher number of cardiovascular disease (56.9% vs. 12.6%) and hospitalizations (93.8% vs. 49.5%) (all P < 0.0001). Sarcopenia was associated with significantly higher risk of mortality, [Hazard ratio = 3.3, (95% CI: 1.6-6.9), P = 0.001].

CONCLUSION

Sarcopenia may be a risk factor for hospitalizations, cardiovascular diseases, and all-cause mortality in patients with ESRD. These results provide support of the relevance in assessing sarcopenia in the clinical practice of chronic kidney disease and how muscle mass and strength may negatively impact the daily life of ESRD patients undergoing hemodialysis. Greater efforts at preventing muscle wasting and malfunctioning are needed through the worldwide healthcare system.

The Association of Sarcopenia and Central Obesity with Mortality Risk in Patients with Chronic Kidney Disease - a 2-Year Observational Study

Background

Patients with chronic kidney disease (CKD) face numerous challenges regarding their nutritional status, including undernutrition, wasting, overweight, and obesity. However, there is a gap in the knowledge on the importance of nutritional status on the survival of CKD in patients along the spectrum of progression of CKD.

Objectives

This study aimed to investigate the association of several nutritional measures with all-cause mortality. The hypothesis was that indicators of nutritional status exceeding BMI are associated with increased mortality risk.

Methods

One-hundred seventy adult patients with predialysis CKD (n = 82), receiving hemodialysis (n = 42) or kidney transplantation (n = 46) were recruited from 2014 to 2019. At baseline, nutritional status was assessed by anthropometry, body composition, and muscle function by handgrip strength. Patient survival was assessed after a 2-y follow-up by Cox regression models adjusted for age, sex, and renal function and generalized additive models.

Results

Thirty-one patients (18%) died during the 2-y follow-up. Sarcopenia (n = 30) was associated with an increased risk of death (HR: 2.92; 95% CI: 1.24, 6.89), whereas central obesity (n = 82) was not associated with mortality (1.05; 0.51, 2.15) in the Cox regression analyses. An association between BMI and mortality risk per unit increase (0.97; 0.90, 1.05) was not observed. Other markers of nutritional status were inversely associated with mortality risk, including handgrip strength (0.89; 0.83, 0.95), mid-upper arm circumference (0.86; 0.78, 0.95), and phase angle (per 0.1 degree increase 0.86; 0.81, 0.92). In the generalized additive models, U-shaped relationships were observed between mortality risk and waist circumference and mid-upper arm muscle circumference, while BMI < 22 kg/m2 was associated with increased mortality risk.

Conclusions

Sarcopenia, but not central obesity was associated with total mortality in patients with CKD. The inclusion of muscle strength and mass measures in clinical practice should be considered.

Sarcopenic Obesity Versus Nonobese Sarcopenia in Hemodialysis Patients: Differences in Nutritional Status, Quality of Life, and Clinical Outcomes

OBJECTIVE

Sarcopenia and sarcopenic obesity (SO) are linked to unfavorable prognosis in maintenance hemodialysis (MHD) populations. We tested whether nonobese sarcopenia and SO, as different stages of extreme protein-energy wasting, have different prognoses.

METHODS

In this prospective observational study, 261 MHD patients were recruited from October 2010 to April 2012 and followed until October 2020. Two definitions were used to diagnose sarcopenia: the European Working Group on Sarcopenia in Older People consensus and the Foundation for the National Institutes of Health (FNIH) Biomarkers Consortium criteria. Obesity was determined as the percentage of total body fat, ≥27% for men and ≥38% for women. Data for all-cause and cardiovascular morbidity and mortality, baseline nutrition markers, inflammation and oxidative stress, adipokines, body composition parameters, handgrip strength, and quality of life (QoL) scores were measured.

RESULTS

According to European Working Group on Sarcopenia in Older People, 115 (44.1%) patients were sarcopenic and 120 (46.0%) according to FNIH definitions. Of them, 28.4% and 34.5% were SO, respectively. Higher levels of albumin, creatinine, uric acid, leptin, phase angle, better nutritional scores, and lower adiponectin levels characterized SO patients compared with nonobese sarcopenic patients regardless of indexing method. Better QoL scores were noted in SO compared with nonobese sarcopenic patients using the FNIH sarcopenia criteria. The hazard of all-cause death, cardiovascular death, and first cardiovascular event for patients with SO was lower compared with the nonobese patients after multivariate adjustments. Statistical significance of these associations disappeared after including fat mass in multivariate models.

CONCLUSIONS

MHD patients with SO have better nutritional status and prognosis for cardiovascular events, all-cause and cardiovascular disease mortality, and possibly better QoL compared with nonobese sarcopenic MHD patients. The better prognosis appears to be entirely due to the excess fat, which is protective in sarcopenic MHD patients similar to that described in the entire MHD population.

The Relationship between Sarcopenia and Injury Events: A Systematic Review and Meta-Analysis of 98,754 Older Adults

The main purpose of this study was to investigate the relationship between sarcopenia and injury events (falls, fractures, hospitalization, disability, and death). This study systemically searched the literature from Embase, PubMed, MEDLINE, CINAHL, and Cochrane Library and analyzed the collected literature using the random effects model to demonstrate the relationship between sarcopenia and injury events. This study followed the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and collected a total of 38 prospective studies, and the results showed that, when compared to robust individuals, the risk of injury events for older individuals with sarcopenia was significantly higher for fractures (HR = 9.66, CI: 5.07-18.38), hospital admissions (HR = 11.80, CI: 4.86-28.65), and death (HR = 9.57, CI: 3.17-28.94). In consideration of the negative impact of sarcopenia on the subsequent health of older adults, professional nursing personnel should assess older adults for sarcopenia as early as possible and propose relevant care policies to further reduce negative health impacts.

Therapeutic effects of exercise interventions for patients with chronic kidney disease: an umbrella review of systematic reviews and meta-analyses

OBJECTIVE

To conduct an overview of meta-analyses evaluating the impact of exercise interventions on improving health outcomes in patients with chronic kidney disease (CKD).

DESIGN

An umbrella review of systematic review and meta-analyses of intervention trials was performed.

DATA SOURCES

PubMed, Web of Science, Embase and the Cochrane Database of Systematic Reviews were searched from inception to 9 March 2021 for relevant articles.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Eligible meta-analyses compared the effects of usual care with and without exercise in patients with CKD. Health outcomes included those related to cardiovascular risk factors, physical fitness, dialysis-related symptoms, dialysis adequacy and health-related quality of life. Systematic reviews and meta-analyses that included fewer than 3 RCTs or fewer than 100 participants were excluded from the analysis.

RESULTS

A total of 31 eligible systematic reviews and meta-analyses were included that assessed 120 outcomes. For physical fitness, there was a moderate effect size for cardiorespiratory fitness, muscle strength and body composition and small effect size for muscle endurance. The effect sizes for cardiovascular risk factors, dialysis-related symptoms and health-related quality of life outcomes were small. According to the Grading of Recommendations Assessment, Development and Evaluation framework, most outcomes were low or very low quality.

CONCLUSION

Exercise appears to be a safe way to affect concomitant cardiovascular risk factors, such as blood pressure, improve physical fitness and health-related quality of life and reduce dialysis-related symptoms in patients with CKD.

PROSPERO REGISTRATION NUMBER

CRD42020223591.

The application of body mass index-based eligibility criteria may represent an unjustified barrier to renal transplantation in people with obesity

The prevalence of both obesity and end-stage kidney disease is increasing. In many centres, obesity is considered a relative contraindication to kidney transplantation due to an association with short- and longer-term adverse outcomes. This leads to delayed transplant waitlisting and longer organ waiting times for people with obesity. This review evaluates whether intentional pre-transplant weight loss in people with obesity improves kidney transplant outcomes. There are currently no data showing that non-surgical weight loss of 10% or more improves graft or patient survival over 4-5 years. Outcomes from bariatric surgery cohorts have been generally neutral or favourable after pre-transplant weight loss of ~25%. Given the survival benefit of kidney transplantation compared to maintenance dialysis, and the difficulty of achieving and maintaining weight loss, the common practice of recommending weight loss to achieve arbitrary targets prior to waiting list activation needs to be carefully considered.

Trajectories of Nutritional Parameters Before and After Prescribed Oral Nutritional Supplements: A Longitudinal Cohort Study of Patients With Chronic Kidney Disease Not Requiring Dialysis

Background:

The association between oral nutritional supplement use and nutritional parameters among patients with nondialysis chronic kidney disease (CKD-ND) with or at high risk of undernutrition/protein-energy wasting has not been previously studied. The definition of patient subgroups most likely to benefit from oral nutritional supplementation (ONS) is also an area where more research is needed.

Objective:

To assess nutritional parameter trajectories among patients with CKD-ND prescribed oral nutritional supplements in British Columbia, and to compare trajectories by nutritional phenotype.

Design:

Longitudinal cohort study, pre-post design.

Setting:

Multidisciplinary CKD clinics across British Columbia.

Patients:

A total of 3957 adult patients with CKD-ND, who entered multidisciplinary CKD clinics during 2010 to 2019, met criteria for oral nutritional supplement prescription based on dietitian assessment, and received ≥1 oral nutritional supplement prescription.

Measurements:

Longitudinal nutritional parameters, including body mass index (BMI), serum albumin, serum bicarbonate, serum phosphate, and neutrophil-to-lymphocyte ratio (NLR).

Methods:

Using linear mixed models, slopes for nutritional and inflammation parameters were assessed in the 2-year periods before and after the first oral nutritional supplement prescription. Hierarchical cluster analysis was applied to identify nutritional phenotypes using baseline data, and slope analysis was repeated by cluster.

Results:

In the pre-oral-nutritional-supplement period, declines in BMI (−0.87 kg/m2/year, 95% confidence interval [CI]: −0.99 to −0.75), albumin (−1.11 g/L/year, 95% CI: −1.27 to −0.95), and bicarbonate (−0.49 mmol/L/year; 95% CI: −0.59 to −0.39), and increases in NLR (+0.79/year; 95% CI: 0.60 to 0.98) and phosphate (+0.05 mmol/L/year; 95% CI: 0.04 to 0.06) were observed. Following oral nutritional supplement prescription, there were statistically significant increases in BMI slope (+0.91 kg/m2/year, P < .0001), albumin slope (+0.82 g/L/year, P < .0001), and phosphate slope (+0.02 mmol/L/year, P = .005), as well as a decline in NLR slope of −0.55/year ( P < .0001). There was no significant change in bicarbonate slope. Cluster analysis identified 5 distinct phenotypes. The cluster with the highest mean baseline NLR and lowest mean BMI demonstrated the greatest number of improvements in nutritional parameter slopes in the post-oral-nutritional-supplement period.

Limitations:

Possibility of residual confounding. Data on dietary intake, muscle mass, and nutritional scoring systems were not available in the registry.

Conclusions:

Among patients with CKD-ND prescribed oral nutritional supplements, there were improvements in nutrition/inflammation parameters over time following the first ONS prescription. The heterogeneity in response to ONS by cluster subgroup suggests an individualized approach to nutritional management may be beneficial.

Sarcopenia in Chronic Kidney Disease: A Scoping Review of Prevalence, Risk Factors, Association with Outcomes, and Treatment

Sarcopenia, a condition characterized by loss of skeletal muscle mass and function, has important clinical ramifications. We aimed to map the existing literature about prevalence, risk factors, associated adverse outcomes, and treatment of sarcopenia in individuals with chronic kidney disease (CKD). A scoping review of the literature was conducted to identify relevant articles published from databases' inception to September 2019. Individuals with CKD, regardless of their disease stage and their comorbidities, were included. Only studies with sarcopenia diagnosed using both muscle mass and function, based on published consensus definitions, were included. For studies on treatment, only randomized controlled trials with at least one sarcopenia parameter as an outcome were included. Our search yielded 1318 articles, of which 60 from were eligible for this review. The prevalence of sarcopenia ranged from 4 to 42% according to the definition used, population studied, and the disease stage. Several risk factors for sarcopenia were identified including age, male gender, low BMI, malnutrition, and high inflammatory status. Sarcopenia was found to be associated with several adverse outcomes, including disabilities, hospitalizations, and mortality. In CKD subjects, several therapeutic interventions have been assessed in randomized controlled trial with a muscle mass, strength, or function endpoint, however, studies focusing on sarcopenic CKD individuals are lacking. The key interventions in the prevention and treatment of sarcopenia in CKD seem to be aerobic and resistance exercises along with nutritional interventions. Whether these interventions are effective to treat sarcopenia and prevent clinical consequences in this population remains to be fully determined.

Association of Fat Mass with SARC-F in Older Patients Undergoing Haemodialysis

BACKGROUND/OBJECTIVES

An increase in fat mass is accompanied by a loss of muscle mass and function in chronic kidney disease. However, no studies in haemodialysis (HD) patients have investigated the relationship between fat mass and sarcopenia. The primary aim of this study is to assess the prevalence of sarcopenia, while the secondary aim is to verify the association between the fat mass percentage and SARC-F and SARC-F combined with calf circumference (SARC-F+CC) in elderly HD patients.

SUBJECTS/METHODS

A cross-sectional study enrolled 96 HD older patients (male, n = 66). SARC-F ≥4 is used to define the muscle function loss, whereas SARC-F ≥6 or SARC-F ≥11 (with the calf circumference added) are the thresholds to diagnose sarcopenia. The fat mass percentage is obtained using bioelectrical impedance analysis.

RESULTS

We found that 37.5% had a risk of muscle function loss due to SARC-F ≥4, 21.8% risk of sarcopenia using the SARC-F ≥6, and when using CC, the prevalence of risk of sarcopenia increased to 41.6% according to SARC-F+CC ≥11. In addition, there was an association between adiposity and sarcopenia for SARC-F ≥6 (OR: 1.25, p= 0.028) and SARC-F+CC ≥11 (OR: 1.25, p= 0.0003), but not with muscle function loss (SARC-F ≥4).

CONCLUSION

In conclusion, we found that 37.5% of HD patients had a risk of muscle function loss and 21-41% presented sarcopenia, depending on the cut-off point used. In addition, higher adiposity was associated with an increased likelihood of having sarcopenia by 25%.

Longitudinal Assessment of Body Composition and Its Association With Survival Among Participants of the ACTIVE/ADIPOSE Study

OBJECTIVES

The importance of muscle wasting as a predictor of mortality in the hemodialysis population is not clear. Lack of association of muscle mass with survival in some studies could be related to reliance on single measures or to incorporation of excess extracellular water (ECW) into estimates of muscle mass. We examined changes in body composition over a 2-year period and the association of body composition with survival.

DESIGN AND METHODS

We analyzed data from 325 adults receiving hemodialysis in the Bay Area. We estimated ECW, intracellular water (ICW), and fat mass by whole-body bioimpedance spectroscopy (BIS) at 0, 12, and 24 months from enrollment. We used linear mixed modeling to examine changes in body mass index and BIS-derived estimates of body composition and Cox modeling with BIS-derived estimates as time-varying independent variables to examine associations between body composition and survival in multivariable analyses.

RESULTS

Body mass index declined over time. Considering individual components of body composition, ICW declined (-0.09 kg/m² per year, 95% confidence interval -0.14 to -0.04), but fat mass and ECW did not change significantly. There were 120 deaths over a median of 5.2 years. The relationship between ICW and mortality was not linear such that the association was steeper at low values of ICW, whereas higher ICW was associated with better survival that was relatively stable above 9 kg/m2. Higher ECW was associated with higher mortality, and fat mass was not associated with survival. These associations were independent of markers of inflammation and nutritional status.

CONCLUSIONS

ICW declined over 2 years in this cohort, whereas fat mass and ECW remained relatively stable. Higher ICW was associated with better survival, but higher fat mass was not. Higher ECW was associated with worse survival. These results suggest that muscle mass may predict survival among patients on hemodialysis.

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.

Effects of hormonal changes on sarcopenia in chronic kidney disease: where are we now and what can we do?

Sarcopenia or muscle wasting is a progressive and generalized skeletal muscle disorder involving the accelerated loss of muscle mass and function, often associated with muscle weakness (dynapenia) and frailty. Whereas primary sarcopenia is related to ageing, secondary sarcopenia happens independent of age in the context of chronic disease states such as chronic kidney disease (CKD). Sarcopenia has become a major focus of research and public policy debate due to its impact on patient's health-related quality of life, health-care expenditure, morbidity, and mortality. The development of sarcopenia in patients with CKD is multifactorial and it may occur independently of weight loss or cachexia including under obese sarcopenia. Hormonal imbalances can facilitate the development of sarcopenia in the general population and is a common finding in CKD. Hormones that may influence the development of sarcopenia are testosterone, growth hormone, insulin, thyroid hormones, and vitamin D. Although the relationship between free testosterone level that is low in uraemic patients and sarcopenia in CKD is not well-defined, functional improvement may be seen. Unlike testosterone, it is known that vitamin D is associated with muscle strength, muscle size, and physical performance in patients with CKD. Outcomes after vitamin D replacement therapy are still controversial. The half-life of growth hormone (GH) is prolonged in patients with CKD. Besides, IGF-1 levels are normal in patients with Stage 4 CKD-a minimal reduction is seen in the end-stage renal disease. Unresponsiveness or resistance of IGF-1 and changes in the GH/IGF-1 axis are the main causes of sarcopenia in CKD. Low serum T3 level is frequent in CKD, but the net effect on sarcopenia is not well-studied. CKD patients develop insulin resistance (IR) from the earliest period even before GFR decline begins. IR reduces glucose utilization as an energy source by hepatic gluconeogenesis, decreasing muscle glucose uptake, impairing intracellular glucose metabolism. This cascade results in muscle protein breakdown. IR and sarcopenia might also be a new pathway for targeting. Ghrelin, oestrogen, cortisol, and dehydroepiandrosterone may be other players in the setting of sarcopenia. In this review, we mainly examine the effects of hormonal changes on the occurrence of sarcopenia in patients with CKD via the available data.

Medication Prescription, Common Side-effects, and Nutritional Status are Associated in Patients With Chronic Kidney Disease

OBJECTIVE

Chronic kidney disease (CKD) is associated with metabolic, nutritional, and extra-renal changes, as well as a high rate of comorbidities, which necessitates the prescription of numerous medications. Patients with CKD often experience poor nutritional status related to disease severity and prescribed medication; however, this association has not been investigated in depth. Therefore, this study aimed at investigating the association between prescribed medication and nutritional status in patients with CKD.

METHODS

Assessment of nutritional status was performed using anthropometric and functional measurements and by biochemical measures. Patient history and the number and type of currently prescribed medications were collected from patients' records. We evaluated the total number and the number of specific medicines with common or very common side-effects of nausea or xerostomia.

RESULTS

Two hundred seventeen patients with CKD were included in this cross-sectional study (n = 112 with pre-dialysis CKD stages 3-5, n = 33 with hemodialysis, and n = 72 with kidney transplant). On average, patients were prescribed nine medications concurrently. The number of prescribed medications was inversely associated with mid-upper arm circumference, skinfold thickness triceps, handgrip strength, serum albumin, and hemoglobin after adjustment for age, sex, and kidney function. Prescription of medications with nausea as a side-effect showed similar associations, whereas prescription of medications with xerostomia as a side-effect was associated with lower handgrip strength.

CONCLUSION

Medication prescription was associated with poor nutritional status in patients with CKD, and monitoring of nutritional status in patients with CKD with long medication lists is warranted to identify and treat patients with poor nutritional status.

Significant Association of Diabetes With Mortality of Chronic Hemodialysis Patients, Independent of the Presence of Obesity, Sarcopenia, and Sarcopenic Obesity

OBJECTIVES

This retrospective cohort study investigated the association of diabetes with mortality in hemodialysis patients with regard to obesity, sarcopenia, and sarcopenic obesity, along with examining the prevalence of each group and diabetes.

METHODS

Muscle strength, muscle mass, and fat mass were evaluated using a hand dynamometer and dual-energy X-ray absorptiometry, respectively, in 308 chronic hemodialysis patients (age 58.0 ± 11.9 years, hemodialysis duration 6.5 ± 6.0 years, males 60.1%, diabetes 32.8%). Sarcopenia was defined according to the new criteria established by the Asian Working Group on Sarcopenia 2019. Obesity was defined by percent body fat mass (males ≥25%, females ≥35%).

RESULTS

The enrolled patients were divided into the normal (38.7%), obesity (18.8%), sarcopenia (26.9%), and sarcopenic obesity (15.6%) groups. The prevalence of diabetes was significantly skewed among the 4 groups (χ² test, P = .0057), being higher in the sarcopenic obesity group (54.2%) compared to the others (25.9-33.7%). Multivariate regression analysis revealed that diabetes was significantly and independently associated with sarcopenic obesity (odds ratio 3.495, 95% confidence interval 1.683-7.255, P = .0008) after adjustments for several cofounders, but not significantly associated with sarcopenia. During the follow-up period of 76 ± 35 months, 100 patients died. Those in the sarcopenia and sarcopenic obesity groups had significantly higher rates of all-cause mortality compared to patients in the normal and obesity groups (P = .0004, log-rank test). Furthermore, multivariate Cox proportional hazards analysis revealed that presence of diabetes was significantly associated with higher all-cause mortality in all 308 patients, after adjustments for several factors, including the presence of each group in 4 models.

CONCLUSION

Sarcopenic obesity is highly prevalent in chronic hemodialysis patients. Diabetes was found to be a significant and independent contributor to the presence of sarcopenic obesity. Diabetes was shown to be a significant predictor of all-cause mortality, independent of the present normal, obesity, sarcopenia, and sarcopenic obesity groups.

Dynapenic abdominal obesity in hospitalized elderly patients with acute myocardial infarction

Obesity and dynapenia are cardiovascular risk factors. When present together, it is called dynapenic abdominal obesity and can potentiate adverse outcomes. This study aims to estimate the prevalence of dynapenic abdominal obesity and its relationship with prognostic markers in patients with acute myocardial infarction (AMI). This is a hybrid study with a longitudinal component plus a cross-sectional component at baseline involving elderly patients admitted to a reference hospital in cardiology due to AMI in the Brazilian Northeast from May to October 2015. We analyzed patients' admission data and evaluated some prognostic markers up to two years after admission. We established abdominal obesity by measuring waist circumference (>102 cm for men and >88 cm for women) and dynapenia by handgrip strength (<27 kg/F for men and <16 kg/F for women). We considered the prognostic markers troponin and creatinine kinase - MB (CKMB), AMI classification according to ST segment elevation, TIMI score, need for coronary angioplasty or coronary artery bypass surgery, complications during hospitalization and within two years after admission, and re-admission to the same service. We evaluated 92 patients with a mean age of 71.4 ± 7.5 years. The prevalence of abdominal obesity and dynapenia was 56.5% and 44.6%, respectively. The coexistence of the two conditions occurred in 25.0% of the patients, being higher among women (p < 0.001). When comparing the dynapenic abdominal obese groups with the group of patients who had one of the two isolated conditions we observed that, for a same mean age and clinical characteristics, patients with only one of the conditions had a higher CKMB (p = 0.046) and troponin median (p = 0.032). The presence of dynapenia in the groups of abdominal obese and non-abdominal obese individuals is not associated with risk marker parameters (p > 0.05). High prevalence of abdominal obesity and dynapenia occurred among patients with AMI and in a quarter of these both conditions coexisted. Dynapenic abdominal obesitydoes not increase the risk of adverse outcomes and isolated dynapenia is not a marker of a poor prognosis.

Association of sarcopenia with mortality and end-stage renal disease in those with chronic kidney disease: a UK Biobank study

BACKGROUND

Sarcopenia, a degenerative and generalized skeletal muscle disorder involving the loss of muscle function and mass, is an under-recognized problem in clinical practice, particularly in chronic kidney disease (CKD). We aimed to investigate the prevalence of sarcopenia in individuals with CKD, its risk factors, and its association with all-cause mortality and progression to end-stage renal disease (ESRD).

METHODS

UK Biobank participants were grouped according to the presence of CKD (defined as an estimated glomerular filtration rate <60 mL/min/1.73 m² ) and as having probable (low handgrip strength), confirmed (plus low muscle mass), and severe sarcopenia (plus poor physical performance) based on the 2019 European Working Group of Sarcopenia in Older People and Foundation for the National Institutes of Health criteria. Risk factors were explored using logistic regression analysis. Survival models were applied to estimate risk of mortality and ESRD.

RESULTS

A total of 428 320 participants, of which 8767 individuals with CKD (46% male, aged 62.8 (standard deviation 6.8) years, median estimated glomerular filtration rate 54.5 (interquartile range 49.0-57.7) mL/min/1.72 m² ) were included. Probable sarcopenia was present in 9.7% of individuals with CKD compared with 5.0% in those without (P < 0.001). Sarcopenia was associated with being older; inflammation; poorer renal function; and lower serum albumin, total testosterone, and haemoglobin. The largest risk factors for sarcopenia were having three or more comorbidities (odds ratio: 2.30; 95% confidence interval: 1.62 to 3.29; P < 0.001) and physical inactivity: participants in the highest quartile of weekly activity were 43% less likely to have sarcopenia compared to the lowest quartile (odds ratio: 0.57; 0.42 to 0.76; P < 0.001). Participants with CKD and sarcopenia had a 33% (7% to 66%; P = 0.011) higher hazard of mortality compared with individuals without. Sarcopenic CKD individuals had a 10 year survival probability of 0.85 (0.82 to 0.88) compared with 0.89 (0.88 to 0.30) in those without sarcopenia, an absolute difference of 4%. Those with sarcopenia were twice as likely to develop ESRD (hazard ratio: 1.98; 1.45 to 2.70; P < 0.001).

CONCLUSIONS

Participants with reduced kidney function are at an increased risk of premature mortality. The presence of sarcopenia increases the risk of mortality and ESRD. Appropriate measurement of sarcopenia should be used to identify at-risk individuals. Interventions such as physical activity should be encouraged to mitigate sarcopenia.

Body Weight, BMI, Percent Fat and Associations with Mortality and Incident Mobility Limitation in Older Men

How different measures of adiposity are similarly or differentially related to mobility limitation and mortality is not clear. In total, 5849 community-dwelling men aged ≥65 years (mean age: 72 years) were followed mortality over 10 years and self-reported mobility limitations (any difficulty walking 2–3 blocks or with climbing 10 steps) at six contacts over 14 years. Baseline measures of adiposity included weight, BMI and percent fat by DXA. Appendicular lean mass (ALM, by DXA) was analyzed as ALM/ht2. Proportional hazards models estimated the risk of mortality, and repeated measures generalized estimating equations estimated the likelihood of mobility limitation. Over 10 years, 27.9% of men died; over 14 years, 48.0% of men reported at least one mobility limitation. We observed U-shaped relationships between weight, BMI, percent fat and ALM/ht2 with mortality. There was a clear log-linear relationship between weight, BMI and percent fat with incident mobility limitation, with higher values associated with a greater likelihood of mobility limitation. In contrast, there was a U-shaped relationship between ALM/ht2 and incident mobility limitation. These observational data suggest that no single measure of adiposity or body composition reflects both the lowest risk of mortality and the lowest likelihood for developing mobility limitation in older men.

Serum creatinine to cystatin C ratio is associated with major adverse cardiovascular events in patients with obstructive coronary artery disease

BACKGROUND & AIMS

Sarcopenia is a clinical syndrome that features muscle atrophy and weakness, and has been associated with cardiovascular events and poor clinical outcomes. Recently, the sarcopenia index (SI) was developed as a simple screening tool based upon the serum creatinine to cystatin C (CysC) ratio. We investigated the association between SI and the prevalence of major adverse cardiovascular events (MACE) in patients with obstructive CAD.

METHODS & RESULTS

Between January 2010 and December 2018, patients with angina pectoris and obstructive CAD requiring coronary artery intervention were enrolled. Serum levels of CysC and other biomarkers were assessed. Patients were divided into two groups according to the SI ([Cr/CysC] x 100). Demographic characteristics and clinical outcomes of the two groups were evaluated. A total of 427 patients (79.6% men, mean age 69.55 ± 12.04 years) were enrolled. Patients with SI < 120 (n = 214, 28%) were older, more likely to be of the female gender, and to have more hypertension and congestive heart failure (all p < 0.05). The prevalence of major adverse cardiovascular events (MACE) composed of myocardial infarction, stroke, and all-cause mortality was higher in patients with lower SI (p = 0.026). After adjusting for potential confounding factors, multivariate Cox regression (hazard ratio 2.08, p = 0.045) and Kaplan-Meier analyses (log-rank p = 0.0371) revealed that lower SI was significantly associated with a higher prevalence of MACE.

CONCLUSIONS

Serum creatinine to cystatin C ratio (SI) may be a useful surrogate marker to predict the future prevalence of MACE in patients with obstructive CAD.

Pre-Kidney Transplant Unintentional Weight Loss Leads to Worse Post-Kidney Transplant Outcomes

BACKGROUND

Weight loss before kidney transplant (KT) is a known risk factor for weight gain and mortality; however, whereas unintentional weight loss is a marker of vulnerability, intentional weight loss might improve health. We tested whether pre-KT unintentional and intentional weight loss have differing associations with post-KT weight gain, graft loss, and mortality.

METHODS

Among 919 KT recipients from a prospective cohort study, we used adjusted mixed effects models to estimate post-KT BMI trajectories, and Cox models to estimate death-uncensored graft loss, death-censored graft loss, and all-cause mortality by one-year pre-KT weight change category [stable weight (change≤5%), intentional weight loss (loss>5%), unintentional weight loss (loss>5%), and weight gain (gain>5%)].

RESULTS

Mean age was 53 years, 38% were Black, and 40% were female. In the pre-KT year, 62% of recipients had stable weight, 15% had weight gain, 14% had unintentional weight loss, and 10% had intentional weight loss. In the first three years post-KT, BMI increases were similar among those with pre-KT weight gain and intentional weight loss, and lower compared to those with unintentional weight loss (difference +0.79 kg/m2/year, 95% CI: 0.50-1.08 kg/m2/year, p < 0.001). Only unintentional weight loss was independently associated with higher death-uncensored graft loss (adjusted Hazard Ratio [aHR]=1.80, 95% CI:1.23-2.62), death-censored graft loss (aHR=1.91, 95% CI:1.12-3.26) and mortality (aHR=1.72, 95% CI:1.06-2.79) relative to stable pre-KT weight.

CONCLUSIONS

This study suggests that unintentional, but not intentional, pre-KT weight loss is an independent risk factor for adverse post-KT outcomes.

Sarcopenia and Mortality in Patients With Chronic Non-dialytic Renal Disease: Systematic Review and Meta-Analysis

OBJECTIVE

To analyze the results of prospective studies on the presence of sarcopenia and its association with cardiovascular events and mortality in patients with non-dialysis-dependent chronic renal disease.

METHODS

This study used the PRISMA protocol for systematic review. The systematic review and meta-analysis protocol was recorded in the prospective record of systematic reviews by PROSPERO International: CRD42019120391.

DATA SOURCES

MEDLINE via PubMed, Embase, Cochrane Library, CINAHL, Scopus, Web of Science and LILACS from December 2018 to April 20, 2019, with the survey results updated in January 2021.

DATA ANALYSIS

Random effect models were calculated to compare the results due to high heterogeneity identified.

RESULTS

The survey identified 951 studies. Of these, 392 were removed by duplicates and 559 references were selected for analysis. In the stage of evaluating titles and abstracts, 555 articles were excluded because they did not include inclusion criteria related to the population and study design, leaving 4 articles that were included in the systematic review and meta-analysis. A meta-analysis identified that the presence of sarcopenia increased the risk of mortality by 143%.

CONCLUSION(S)

The meta-analysis identified the influence of sarcopenia on mortality in non-dialysis-dependent chronic renal disease.

Effects of pre-dialysis resistance training on sarcopenia, inflammatory profile, and anemia biomarkers in older community-dwelling patients with chronic kidney disease: a randomized controlled trial

BACKGROUND

Sarcopenia and chronic kidney disease (CKD) have been associated with negative outcomes in older people, including inflammatory profile and anemia biomarkers.

AIMS

To investigate the effects of pre-dialysis resistance training (RT) on sarcopenia, inflammatory profile, and anemia biomarkers in older patients with CKD.

METHODS

A total of 107 patients with CKD (65.4 ± 3.7 years) were randomly allocated into four groups: sarcopenic RT (n = 37), non-sarcopenic RT (n = 20), sarcopenic control (n = 28), and non-sarcopenic control (n = 22). DXA and handgrip strength were used to classify sarcopenia according to EWGSOP-2. Treatment groups underwent a 24-week intervention with RT before each dialysis session, three times per week. Blood sample analysis for ferritin, hepcidin, iron availability, and inflammatory profile (TNFα, IL-6, and IL-10) was conducted. All-cause mortality was recorded over 5 years.

RESULTS

Sarcopenic RT group increased iron availability after the intervention, while their counterparts decreased. Ferritin and hepcidin significantly decreased in sarcopenic RT group. RT elicited a reduction in both TNFα and IL-6, while increasing IL-10 in both intervention groups. The rate of sarcopenic subjects substantially decreased after the intervention period (from 37 to 17 in the RT group; p = 0.01). The proportion of deaths was higher (P = 0.033) for sarcopenic subjects (Controls 35.7% vs RT 29.7%) when compared to non-sarcopenic subjects (Controls 18% vs RT 10%). The proportion of deaths decreased according to the randomization group (X2 = 8.704; P < 0.1).

CONCLUSIONS

The 24-week RT intervention elicited a better sarcopenia status, better inflammatory profile, and improved anemia biomarkers. Sarcopenia was associated with higher mortality rate in older patients with CKD.

Systematic review and meta-analysis of lean mass and mortality: Rationale and study description

Objectives

Muscle mass is one of the key components in defining sarcopenia and is known to be important for locomotion and body homeostasis. Lean mass is commonly used as a surrogate of muscle mass and has been shown to be associated with increased mortality. However, the relationship of lean mass with mortality may be affected by different clinical conditions, modalities used, cut-off point to define low or normal lean mass, and even types of cancer among cancer patients. Thus, we aim to perform a comprehensive meta-analysis of lean mass with mortality by considering all these factors.

Methods

Systematic search was done in PubMed, Cochrane Library and Embase for articles related to lean mass and mortality. Lean mass measured by dual X-ray absorptiometry, bioelectrical impedance analysis, and computerized tomography were included.

Results

The number of relevant studies has increased continuously since 2002. A total of 188 studies with 98 468 people were included in the meta-analysis. The association of lean mass with mortality was most studied in cancer patients, followed by people with renal diseases, liver diseases, elderly, people with cardiovascular disease, lung diseases, and other diseases. The meta-analysis can be further conducted in subgroups based on measurement modalities, site of measurements, definition of low lean mass adopted, and types of cancer for studies conducted in cancer patients.

Conclusions

This series of meta-analysis provided insight and evidence on the relationship between lean mass and mortality in all directions, which may be useful for further study and guideline development.

Association between the uremic toxins indoxyl-sulfate and p-cresyl-sulfate with sarcopenia and malnutrition in elderly patients with advanced chronic kidney disease

BACKGROUND

in patients with chronic kidney disease (CKD) indoxyl sulfate (IS) and p-cresyl sulfate (PCs) may induce sarcopenia either directly or via systemic inflammation. We evaluated whether IS and PCs were associated with: sarcopenia, systemic inflammation and nutritional status.

METHODS

we examined cross sectionally 93 patients with advanced CKD. Sarcopenia was identified according to EWGSOP2 definition. Malnutrition was assessed by Malnutrition Inflammation Score (MIS) and Protein Energy Wasting syndrome (PEW). Inflammatory status was assessed by dosing: CRP, IL6, TNFα, MCP1, IL10, IL17, IL12p70.

RESULTS

we did not find any association of sarcopenia with IS and PCs. IS was associated with LogTNFα and LogMCP-1 in the overall cohort (r = 0.30, p = 0.0043; r = 0.22 p = 0.047) and in not sarcopenic patients (r = 0.32, p = 0.0077; r = 0.25, p = 0.041). PCs was associated with LogIL10 and LogIL12p70 in sarcopenic patients (r = 0.58, p = 0.0042; r = 0.52, p = 0.013). IS was higher in patients without PEW (p = 0.029), while PCs was higher in patients with PEW (p = 0.0040). IS and PCs were not different in patients with normal or increased MIS.

CONCLUSIONS

IS and PCs were not associated with sarcopenia, although they were both associated with some inflammatory pathways. Notably, we found a positive association of PCs with PEW syndrome.

Physical Function in Kidney Transplantation: Current Knowledge and Future Directions

Purpose of review

Low physical function (PF) is common among individuals with end-stage kidney disease. In this review, we explore data on the impacts of PF on access to kidney transplantation (KT) and KT outcomes. We also discuss the latest interventions to improve PF in pre- and post-KT settings.

Recent Findings

Many US KT programs measure PF or related constructs when assessing KT candidacy. Although carefully selected KT candidates with low PF can benefit from KT with respect to survival and quality of life, low PF decreases the likelihood of being listed for KT and increases the risk of adverse post-KT outcomes. Recent trials suggest that exercise is a promising strategy to improve PF among KT candidates and recipients.

Summary

PF is a potentially modifiable risk factor for adverse pre- and post-KT outcomes. Research is needed to determine the ideal PF metric for use in KT evaluations and interventions to improve PF.

Bed-side measures for diagnosis of low muscle mass, sarcopenia, obesity, and sarcopenic obesity in patients with chronic kidney disease under non-dialysis-dependent, dialysis dependent and kidney transplant therapy

Muscle depletion and sarcopenic obesity are related to a higher morbimortality risk in chronic kidney disease (CKD). We evaluated bed-side measures/indexes associated with low muscle mass, sarcopenia, obesity, and sarcopenic obesity in CKD and proposed cutoffs for each parameter. Sarcopenia was diagnosed according to the European Working Group on Sarcopenia in Older People revised consensus applying dual energy X-ray absorptiometry (DXA) and hand grip strength (HGS), and obesity according to the International Society for Clinical Densitometry. Anthropometric parameters including calf (CC) and waist (WC) circumferences and WC/height (WC/H); bioelectrical impedance data including appendicular fat free mass (AFFM) and fat mass index (FMI) were assessed. ROC analysis and area under the curve (AUC) were applied for performance analyses. AFFM and CC presented the best performances for low muscle mass diagnosis-AFFM AUC for women was 0.96 and for men, 0.94, and CC AUC for women was 0.89 and for men, 0.85. FMI and WC/H were the best parameters for obesity diagnosis-FMI AUC for women was 0.99 and for men, 0.96, and WC/H AUC for women was 0.94 and for men, 0.95. The cutoffs (sensibility and specificity, respectively) for women were AFFM≤15.87 (90%; 96%), CC≤35.5 (76%; 94%), FMI>12.58 (100%; 93%), and WC/H>0.66 (91%; 84%); and for men, AFFM≤21.43 (98%; 84%), CC≤37 (88%; 69%), FMI>8.82 (93%; 88%), and WC/H>0.60 (95%; 80%). Sensibility and specificity for sarcopenia diagnosis were for AFFM+HGS in women 85% and 99% and in men, 100% and 99%; for CC+HGS in women 85% and 99% and in men, 100% and 100%; and for sarcopenic obesity were for FMI+AFFM in women 75% and 97% and in men, 75% and 95%. The tested bed-side measures/indexes presented excellent performance.

Association of skeletal muscle mass, kidney disease and mortality in older men and women: the cardiovascular health study

Low muscle mass (sarcopenia) is a prevalent and major concern in the aging population as well as in patients with chronic kidney disease (CKD). We hypothesized that sarcopenia is an independent predictor of incident and progressive CKD and increased mortality in older men and women (≥65 years) from the Cardiovascular Health Study. Sarcopenia was defined by bioimpedance-estimated skeletal muscle mass index (SMI) as a continuous variable and categorically (normal, class I, and class II). Cox regression hazard ratios (HRs) estimated the risk of incident and prevalent CKD and mortality in individuals with and without CKD. Low SMI was associated with increased prevalence of CKD in men (p<0.001), but lower prevalence of CKD in women (p=0.03). Low muscle mass was not associated with incident CKD or rapid CKD progression (>3 ml/minute/1.73m²/year decline in eGFR) in men, but was associated with lower risk of incident CKD in women ([adjusted RR=0.69, 95% (0.51,0.94)]. Low muscle mass (class II) was independently associated with higher mortality only in men [(adjusted HR=1.26, 95% (1.05,1.50)]. Neither definition of sarcopenia was associated with mortality in men or women with CKD. Further studies are needed to understand the mechanisms by which sarcopenia contributes to higher mortality in aging men.

The Effect of Exercise on Nutritional Status and Body Composition in Hemodialysis: A Systematic Review

Chronic kidney disease (CKD) is associated with aggravating factors which can affect both body composition and nutritional status. The purpose of the present systematic review was to investigate the potential effects of any physical activity on body composition or nutritional status among patients with stage 5 CKD undergoing hemodialysis (HD). A literature search on PubMed, Scopus, Web of Science, Google Scholar, and Cochrane was conducted and 14 randomized clinical trials were included. Skeletal muscle index and mid-arm muscular circumference increased after resistance exercise, and the results on body mass index, % body fat, and lean body mass varied. Serum albumin and C-reactive protein, in most cases, showed a slight increase and decrease, respectively. An improvement was also observed in body strength and overall performance status. The results suggest that physical activity can be beneficial for both the body composition and nutritional status of patients undergoing HD and can help in the prevention of sarcopenia. However, further research is needed mainly in the field of nutritional status.

Physical performance and chronic kidney disease development in elderly adults: results from a nationwide cohort study

Sarcopenia, which is characterized by muscle mass and physical performance, is closely associated with morbidities and mortality, especially among the elderly. However, the effect of physical performance on chronic kidney disease (CKD) development is not yet fully elucidated. A total of 30,871 adults aged 66 years with preserved renal function who underwent health screening examinations were evaluated. Physical performance was assessed using a 3-m timed up and go (TUG) test and the one-leg stand (OLS) test. The primary outcome was the development of CKD, defined as at least two consecutive measurements of estimated glomerular filtration rate < 60 mL/min/1.73 m². The rates of mortality and incident CKD development were significantly elevated with increases in TUG test scores but not in OLS scores. In the Cox hazards model, the highest TUG test score tertile was associated with an increased risk for CKD development (hazard ratio, 1.23; 95% confidence interval, 1.10-1.38) compared with the lowest tertile. No significant relationship was observed between OLS score and incident CKD risk. Poor physical performance, assessed using the TUG test, was related to an increased risk of CKD development.

Sarcopenia in chronic kidney disease: what have we learned so far?

The term sarcopenia was first introduced in 1988 by Irwin Rosenberg to define a condition of muscle loss that occurs in the elderly. Since then, a broader definition comprising not only loss of muscle mass, but also loss of muscle strength and low physical performance due to ageing or other conditions, was developed and published in consensus papers from geriatric societies. Sarcopenia was proposed to be diagnosed based on operational criteria using two components of muscle abnormalities, low muscle mass and low muscle function. This brought awareness of an important nutritional derangement with adverse outcomes for the overall health. In parallel, many studies in patients with chronic kidney disease (CKD) have shown that sarcopenia is a prevalent condition, mainly among patients with end stage kidney disease (ESKD) on hemodialysis (HD). In CKD, sarcopenia is not necessarily age-related as it occurs as a result of the accelerated protein catabolism from the disease and from the dialysis procedure per se combined with low energy and protein intakes. Observational studies showed that sarcopenia and especially low muscle strength is associated with worse clinical outcomes, including worse quality of life (QoL) and higher hospitalization and mortality rates. This review aims to discuss the differences in conceptual definition of sarcopenia in the elderly and in CKD, as well as to describe etiology of sarcopenia, prevalence, outcome, and interventions that attempted to reverse the loss of muscle mass, strength and mobility in CKD and ESKD patients.

Sarcopenic Obesity in Facioscapulohumeral Muscular Dystrophy

Background

Sarcopenic obesity has been observed in people with neuromuscular impairment, and is linked to adverse health outcomes. It is unclear, however, if sarcopenic obesity develops in adults with facioscapulohumeral muscular dystrophy (FSHD).

Methods

The purpose of this study was to determine if adults with FSHD meet criteria for sarcopenic obesity (appendicular lean mass index (ALMI) scores of < 7.26 or 5.45 kg/m²; % fat mass (FM) ≥ 28 or 40% in men/women). Ten people with FSHD (50 ± 11 years, 2 females) and ten age/sex-matched controls (47 ± 13 years, 2 females) completed one visit, which included a full-body dual-energy x-ray absorptiometry (DXA) scan. Regional and whole body total mass, fat mass (FM), and lean mass (LM) were collected and body mass index (BMI) and sarcopenia measures were computed.

Results

People with FSHD and controls had a similar whole body total mass (84.5 ± 12.9 vs. 81.8 ± 13.5 kg, respectively, p = 0.65). Though BMI was 2% lower in the FSHD group (p = 0.77), the % FM was 46% higher in FSHD, compared with controls (p < 0.01). In addition, ALM volume was 23% lower (p = 0.02) and ALMI was 27% lower in FSHD compared with controls (p < 0.01). Whole body LM trended to be lower in FSHD vs. controls (p = 0.05), and arm and leg LM were both lower in FSHD compared with controls (p < 0.05). Furthermore, the % LM was 18% lower in FSHD vs. controls (p < 0.01). FSHD participants exhibited greater total body FM (p < 0.01) and total leg FM (p < 0.01), but were similar in volume of total arm FM compared with controls (p = 0.09).

Conclusion

Findings from this study suggest that people with FSHD, although similar in BMI and total body mass compared with controls, commonly meet the definition of sarcopenic obesity. Adults with co-existing FSHD and sarcopenic obesity may be at risk for significant impairments in quality of life, and encounter additional challenges in the management of FSHD manifestations.

Alterations of body composition patterns in pre-dialysis chronic kidney disease patients

PURPOSE

Body mass index (BMI) might be an inaccurate estimate of detailed body composition because it does not differentiate muscle from fat mass. We sought to understand the effect of kidney function decline on alterations of body composition patterns among pre-dialysis CKD patients.

METHODS

Body composition was measured by multi-frequency bioelectrical impedance analysis (BIA). Low muscle mass was defined as appendicular muscle mass (kg) adjusted to the square of height in meters < 7.0 and 5.7 kg/m² in men and women, respectively. The designation of obesity by percent body fat was ≥ 25% in men and ≥ 30% in women. Alternative definition of obesity by BMI was ≥ 25 kg/m². Visceral fat area cut point was > 100 cm² as indication of abdominal obesity.

RESULTS

Mean age of participants was 61.3 ± 13.8 years (n = 103). The average glomerular filtration rate (GFR) was 34.0 ± 24.2 mL/min/1.73 m². By BIA, the prevalence of low muscle mass was 16.5% and was comparable between both sexes. Obesity by percent body fat was identified in 71.8% of patients and 38.2% had abdominal obesity. Using BMI criteria, the prevalence of obesity was less common (55.3%) and associated with under-identification of obesity by 27.0%. Low muscle mass and obesity by percent body fat were more prevalent in the more advanced stages of CKD. By multivariable regression analysis, a 10 mL/min/1.73 m² decline in GFR was associated with a 0.59 kg reduction of total body muscle mass (p = 0.01), but not fat mass or BMI, after adjusting for confounders.

CONCLUSION

Low muscle mass was prevalent among pre-dialysis CKD patients. BMI commonly classified obese CKD individuals by percent body fat criteria as non-obese. The reduction of muscle mass was associated with GFR decline.