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Wang W, Meng X, Liu J, Lou X, Zhang P, He P, Chen J, Yuan J. Study on the correlation between bioelectrical impedance analysis index and protein energy consumption in maintenance dialysis patients. Nutr J 2023; 22:56. [PMID: 37940938 PMCID: PMC10633946 DOI: 10.1186/s12937-023-00890-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 11/01/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Protein-energy wasting (PEW) has been reported to be pretty common in maintenance dialysis patients. However, the existing PEW diagnostic standard is limited in clinical use due to the complexity of it. Bioelectrical impedance analysis (BIA), as a non-invasive nutritional assessment method, can objectively and quantitatively analyze the changes of body tissue components under different nutritional states. We aim to explore the association between PEW and BIA and establish a reliable diagnostic model of PEW. METHODS We collected cross-sectional data of 609 maintenance dialysis patients at the First Affiliated Hospital, College of Medicine, Zhejiang University. PEW was diagnosed according to International Society of Renal Nutrition and Metabolism (ISRNM) criteria. Among them, 448 consecutive patients were included in the training set for the establishment of a diagnostic nomogram. 161 consecutive patients were included for internal validation. 52 patients from Zhejiang Hospital were included for external validation of the diagnostic model. Correlation analysis of BIA indexes with other nutritional indicators was performed. Logistic regression was used to examine the association of BIA indexes with PEW. 12 diagnostic models of PEW in maintenance dialysis patients were developed and the performance of them in terms of discrimination and calibration was evaluated using C statistics and Hosmer-Lemeshow-type χ2 statistics. After comparing to existing diagnostic models, and performing both internal and external validation, we finally established a simple but reliable PEW diagnostic model which may have great value of clinical application. RESULTS A total of 609 individuals from First Affiliated Hospital, College of Medicine, Zhejiang University and 52 individuals from Zhejiang Hospital were included. After full adjustment, age, peritoneal dialysis (compared to hemodialysis), subjective global assessment (SGA, compared to non-SGA) and water ratio were independent risk factors, while triglyceride, urea nitrogen, calcium, ferritin, BCM, VFA and phase angle were independent protective factors of PEW. The model incorporated water ratio, VFA, BCM, phase angle and cholesterol revealed best performance. A nomogram was developed according to the results of model performance. The model achieved high C-indexes of 0.843 in the training set, 0.841 and 0.829 in the internal and external validation sets, respectively, and had a well-fitted calibration curve. The net reclassification improvement (NRI) showed 8%, 13%, 2%, 38%, 36% improvement of diagnostic accuracy of our model compared with "PEW score model", "modified PEW score model", "3-index model", "SGA model" and "BIA decision tree model", respectively. CONCLUSIONS BIA can be used as an auxiliary tool to evaluate PEW risk and may have certain clinical application value.
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Affiliation(s)
- Weina Wang
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310000, China
| | - Xinxuan Meng
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310000, China
- College of Medicine, Zhejiang University, Hangzhou, 310000, China
| | - Jiaojiao Liu
- Hebei ophthalmology hospital, Xingtai, 054000, China
| | - Xiaowei Lou
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310000, China
- College of Medicine, Zhejiang University, Hangzhou, 310000, China
| | - Ping Zhang
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310000, China
| | - Peipei He
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310000, China
| | - Jianghua Chen
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310000, China.
| | - Jing Yuan
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310000, China.
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Orozco-González CN, Márquez-Herrera RM, Cortés-Sanabria L, Cueto-Manzano AM, Gutiérrez-Medina M, Gómez-García EF, Rojas-Campos E, Paniagua-Sierra JR, Martín Del Campo F. Severity of protein-energy wasting and obesity are independently related with poor quality of life in peritoneal dialysis patients. Nefrologia 2022; 42:186-195. [PMID: 36153915 DOI: 10.1016/j.nefroe.2022.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 04/05/2021] [Indexed: 06/16/2023] Open
Abstract
Protein-energy wasting (PEW) and poor health-related quality of life (HRQoL) are independently associated with morbi-mortality in continuous ambulatory peritoneal dialysis (CAPD). PEW may reduce HRQoL; however, we hypothesized HRQoL is affected differentially by PEW degrees or by individual criteria of nutritional status. AIM: To evaluate HRQoL according to PEW severity and nutritional status indicators in CAPD. This is a cross-sectional study in 151 patients. Subjective global assessment (SGA) was employed, and nutritional status classified as normal, mild-moderate PEW, and severe PEW. HRQoL was evaluated using Kidney Disease Quality of Life Short Form™, including physical (PCS), mental (MCS) and kidney disease (KDCS) components, and their subscales. Dietary intake, anthropometric and biochemical variables were measured. Forty-six percent of patients were well-nourished, 44% had mild-moderate PEW, and 10% severe PEW. Compared with well-nourished patients, those with mild-moderate (p=0.06) and severe (p=0.005) PEW had lower HRQoL score [68 (52-75), 55 (45-72), 46 (43-58), respectively]. PCS, MCS, and KDCS and their subscales had lower values as PEW was more severe. Patients with obesity and hypoalbuminemia had significantly lower HRQoL overall and component scores than their counterparts. Dietary intake was not associated with quality of life. In multivariate analysis obesity, PEW (by SGA), hypoalbuminemia, and low educational level predicted poor HRQoL (χ2 58.2, p<0.0001). As conclusion, PEW severity was related with worse HRQoL, either as overall score or in every component or subscale in CAPD patients. Poor HRQoL was predicted independently by PEW severity and obesity; additional predictors were hypoalbuminemia and low education.
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Affiliation(s)
- Claudia N Orozco-González
- Unidad de Investigación Biomédica 02, Hospital de Especialidades, CMNO, IMSS, Guadalajara, Mexico; Universidad Internacional Iberoamericana, Campeche, Mexico
| | - Roxana M Márquez-Herrera
- Unidad de Investigación Biomédica 02, Hospital de Especialidades, CMNO, IMSS, Guadalajara, Mexico
| | - Laura Cortés-Sanabria
- Unidad de Investigación Biomédica 02, Hospital de Especialidades, CMNO, IMSS, Guadalajara, Mexico.
| | - Alfonso M Cueto-Manzano
- Unidad de Investigación Biomédica 02, Hospital de Especialidades, CMNO, IMSS, Guadalajara, Mexico
| | | | - Erika F Gómez-García
- Unidad de Investigación Biomédica 02, Hospital de Especialidades, CMNO, IMSS, Guadalajara, Mexico
| | - Enrique Rojas-Campos
- Unidad de Investigación Biomédica 02, Hospital de Especialidades, CMNO, IMSS, Guadalajara, Mexico
| | - José R Paniagua-Sierra
- Unidad de Investigación en Enfermedades Nefrológicas, Hospital de Especialidades, CMN Siglo XXI, IMSS, Ciudad de México, Mexico
| | - Fabiola Martín Del Campo
- Unidad de Investigación Biomédica 02, Hospital de Especialidades, CMNO, IMSS, Guadalajara, Mexico
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Protein energy wasting-based nutritional assessment predicts outcomes of acute ischemic stroke and solves the epidemiologic paradox. Nutrition 2021; 93:111431. [PMID: 34479047 DOI: 10.1016/j.nut.2021.111431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 07/10/2021] [Accepted: 07/18/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Overweight and hyperlipidemia, the two established risk factors for acute ischemic stroke, are paradoxically associated with favorable outcomes. The paradox may be resolved by the concept of protein energy wasting (PEW), in which total cholesterol level and body mass index are used as nutritional indexes for predicting outcomes of chronic kidney disease. METHODS Among 12 271 people with acute ischemic stroke and chronic kidney disease, 2086 were defined as being at risk of PEW-with a body mass index <22 kg/m2 plus either a serum albumin level <38 g/L or a total cholesterol level <4.14 mmol/L (160 mg/dL) without the use of lipid-lowering drugs-and all the others were a control group. The hazards of PEW for mortality and functional outcomes were evaluated using propensity score matching and multivariate Cox regression analysis. RESULTS Based on the propensity score, 2081 PEW participants were matched to the same number of non-PEW control participants. PEW was associated with a higher mortality risk at 3 mo (adjusted hazard ratio, 1.19; 95% confidence interval [CI], 1.02-1.42) and 1 y (adjusted hazard ratio, 1.33; 95% CI1.13-1.52). PEW was also associated with poor functional outcomes (modified Rankin Scale score >2) at 1 mo (adjusted odds ratio, 1.32; 95% CI, 1.08-1.61) and 3 mo (adjusted odds ratio, 1.27; 95% CI, 1.03-1.56). CONCLUSIONS According to the PEW-based assessment system, a modest decrease in body mass index and total cholesterol levels suggests malnutrition and is associated with adverse outcomes of acute ischemic stroke.
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Zhou H, Yao W, Pan D, Sun G. Predicational ability of phase angle on protein energy wasting in kidney disease patients with renal replacement therapy: A cross-sectional study. Food Sci Nutr 2021; 9:3573-3579. [PMID: 34262718 PMCID: PMC8269568 DOI: 10.1002/fsn3.2310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 04/05/2021] [Accepted: 04/12/2021] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To investigate the ability of phase angle (PA) and body composition for predicting protein energy wasting (PEW) in renal replacement therapy (RRT) patients. METHODS Renal replacement therapy (RRT) patients were enrolled in this study. Body composition was measured by direct segmental multi-frequency biolectrical impedance analysis method (DSM-BIA); phase angle (PA), fat-free mass (FFM), fat mass (FM), mid-arm circumference (MAC), WC (waist circumference), and ECW/TBW (extracellular water/total body water) were obtained. Biochemicals (serum albumin, triglyceride, and cholesterol) were tested. PEW patients were classified according to ISRNM (The International Society of Renal Nutrition and Metabolism) criteria. Cutoff value of PA and related variables was calculated by ROC analysis. The ability of body composition variables as indicators to predict PEW was evaluated. RESULTS Sixty-four patients were enrolled in this study. Thirty-three patients (52.6%) were males, and forty (62.5%) patients were diagnosed with PEW. The ROC curve showed that the optimal cutoff values of PA, FFMI (fat-free mass index), MAC, WC, and BMI for PEW risk were 4.45°, 16.71, 29.7 cm, 86.4 cm, and 21.1 kg/m2, respectively. These indicators showed significant association with PEW; meanwhile, the PA and MAC can be used as the predictors for PEW with OR 6.333 (95% CI, 1.956-20.505) and 3.267 (95% CI, 1.136-9.394), respectively. Both groups have a lower BUN/Cr ratio (<20). CONCLUSION In the RRT patients, over than 60% patients were diagnosed with PEW. PA, MAC, and other body composition can be used as the independent indicators for predicting PEW in renal replacement therapy kidney disease patients.
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Affiliation(s)
- Haiteng Zhou
- Key Laboratory of Environmental Medicine and Engineering Ministry of EducationDepartment of Nutrition and Food HygieneSchool of Public HealthSoutheast UniversityNanjingChina
| | | | - Da Pan
- Key Laboratory of Environmental Medicine and Engineering Ministry of EducationDepartment of Nutrition and Food HygieneSchool of Public HealthSoutheast UniversityNanjingChina
| | - Guiju Sun
- Key Laboratory of Environmental Medicine and Engineering Ministry of EducationDepartment of Nutrition and Food HygieneSchool of Public HealthSoutheast UniversityNanjingChina
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Orozco-González CN, Márquez-Herrera RM, Cortés-Sanabria L, Cueto-Manzano AM, Gutiérrez-Medina M, Gómez-García EF, Rojas-Campos E, Paniagua-Sierra JR, Martín Del Campo F. Severity of protein-energy wasting and obesity are independently related with poor quality of life in peritoneal dialysis patients. Nefrologia 2021; 42:S0211-6995(21)00103-X. [PMID: 34154849 DOI: 10.1016/j.nefro.2021.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 03/10/2021] [Accepted: 04/05/2021] [Indexed: 12/18/2022] Open
Abstract
Protein-energy wasting (PEW) and poor health-related quality of life (HRQoL) are independently associated with morbi-mortality in continuous ambulatory peritoneal dialysis (CAPD). PEW may reduce HRQoL; however, we hypothesized HRQoL is affected differentially by PEW degrees or by individual criteria of nutritional status. AIM: To evaluate HRQoL according to PEW severity and nutritional status indicators in CAPD. This is a cross-sectional study in 151 patients. Subjective global assessment (SGA) was employed, and nutritional status classified as normal, mild-moderate PEW, and severe PEW. HRQoL was evaluated using Kidney Disease Quality of Life Short Form™, including physical (PCS), mental (MCS) and kidney disease (KDCS) components, and their subscales. Dietary intake, anthropometric and biochemical variables were measured. Forty-six percent of patients were well-nourished, 44% had mild-moderate PEW, and 10% severe PEW. Compared with well-nourished patients, those with mild-moderate (p=0.06) and severe (p=0.005) PEW had lower HRQoL score [68 (52-75), 55 (45-72), 46 (43-58), respectively]. PCS, MCS, and KDCS and their subscales had lower values as PEW was more severe. Patients with obesity and hypoalbuminemia had significantly lower HRQoL overall and component scores than their counterparts. Dietary intake was not associated with quality of life. In multivariate analysis obesity, PEW (by SGA), hypoalbuminemia, and low educational level predicted poor HRQoL (χ2 58.2, p<0.0001). As conclusion, PEW severity was related with worse HRQoL, either as overall score or in every component or subscale in CAPD patients. Poor HRQoL was predicted independently by PEW severity and obesity; additional predictors were hypoalbuminemia and low education.
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Affiliation(s)
- Claudia N Orozco-González
- Unidad de Investigación Biomédica 02, Hospital de Especialidades, CMNO, IMSS, Guadalajara, Mexico; Universidad Internacional Iberoamericana, Campeche, Mexico
| | - Roxana M Márquez-Herrera
- Unidad de Investigación Biomédica 02, Hospital de Especialidades, CMNO, IMSS, Guadalajara, Mexico
| | - Laura Cortés-Sanabria
- Unidad de Investigación Biomédica 02, Hospital de Especialidades, CMNO, IMSS, Guadalajara, Mexico.
| | - Alfonso M Cueto-Manzano
- Unidad de Investigación Biomédica 02, Hospital de Especialidades, CMNO, IMSS, Guadalajara, Mexico
| | | | - Erika F Gómez-García
- Unidad de Investigación Biomédica 02, Hospital de Especialidades, CMNO, IMSS, Guadalajara, Mexico
| | - Enrique Rojas-Campos
- Unidad de Investigación Biomédica 02, Hospital de Especialidades, CMNO, IMSS, Guadalajara, Mexico
| | - José R Paniagua-Sierra
- Unidad de Investigación en Enfermedades Nefrológicas, Hospital de Especialidades, CMN Siglo XXI, IMSS, Ciudad de México, Mexico
| | - Fabiola Martín Del Campo
- Unidad de Investigación Biomédica 02, Hospital de Especialidades, CMNO, IMSS, Guadalajara, Mexico
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Leal DV, Ferreira A, Watson EL, Wilund KR, Viana JL. Muscle-Bone Crosstalk in Chronic Kidney Disease: The Potential Modulatory Effects of Exercise. Calcif Tissue Int 2021; 108:461-475. [PMID: 33388899 DOI: 10.1007/s00223-020-00782-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 11/25/2020] [Indexed: 02/06/2023]
Abstract
Chronic kidney disease (CKD) is a prevalent worldwide public burden that increasingly compromises overall health as the disease progresses. Two of the most negatively affected tissues are bone and skeletal muscle, with CKD negatively impacting their structure, function and activity, impairing the quality of life of these patients and contributing to morbidity and mortality. Whereas skeletal health in this population has conventionally been associated with bone and mineral disorders, sarcopenia has been observed to impact skeletal muscle health in CKD. Indeed, bone and muscle tissues are linked anatomically and physiologically, and together regulate functional and metabolic mechanisms. With the initial crosstalk between the skeleton and muscle proposed to explain bone formation through muscle contraction, it is now understood that this communication occurs through the interaction of myokines and osteokines, with the skeletal muscle secretome playing a pivotal role in the regulation of bone activity. Regular exercise has been reported to be beneficial to overall health. Also, the positive regulatory effect that exercise has been proposed to have on bone and muscle anatomical, functional, and metabolic activity has led to the proposal of regular physical exercise as a therapeutic strategy for muscle and bone-related disorders. The detection of bone- and muscle-derived cytokine secretion following physical exercise has strengthened the idea of a cross communication between these organs. Hence, this review presents an overview of the impact of CKD in bone and skeletal muscle, and narrates how these tissues intrinsically communicate with each other, with focus on the potential effect of exercise in the modulation of this intercommunication.
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Affiliation(s)
- Diogo V Leal
- Research Center in Sports Sciences, Health Sciences and Human Development, CIDESD, University Institute of Maia, ISMAI, Maia, Portugal
| | - Aníbal Ferreira
- Department of Nephrology, Curry Cabral Hospital, Hospital Centre of Central Lisbon, Lisbon, Portugal
- Nova Medical School, Lisbon, Portugal
| | - Emma L Watson
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Kenneth R Wilund
- Department of Kinesiology and Community Health, University of Illinois At Urbana-Champaign, Champaign, IL, USA
| | - João L Viana
- Research Center in Sports Sciences, Health Sciences and Human Development, CIDESD, University Institute of Maia, ISMAI, Maia, Portugal.
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Kittiskulnam P, Chuengsaman P, Kanjanabuch T, Katesomboon S, Tungsanga S, Tiskajornsiri K, Praditpornsilpa K, Eiam-Ong S. Protein-Energy Wasting and Mortality Risk Prediction Among Peritoneal Dialysis Patients. J Ren Nutr 2021; 31:679-686. [PMID: 33642190 DOI: 10.1053/j.jrn.2020.11.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 11/12/2020] [Accepted: 11/22/2020] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES Protein-energy wasting (PEW) is defined as the loss of body protein and energy reserves associated with kidney disease. However, the extent to which PEW contributes to increased mortality among peritoneal dialysis (PD) patients remains unclear. METHODS This is a retrospective cohort study from 2012 to 2020. The PEW was diagnosed by applying at least 3 of the 4 following criteria: (1) altered serum biochemistry indicated by a serum albumin level of <3.5 g/L; (2) decreased body mass status identified by a body mass index (BMI) of <23 kg/m2 or <10% total body fat; (3) muscle wasting defined by the lean tissue index, calculated as a lean tissue mass normalized to the height-squared in the <10th percentile of the reference population; and (4) low dietary protein intake determined by the normalized protein equivalent of a total nitrogen appearance of <0.8 g/kg/day. The Malnutrition Inflammation Score (MIS) was also examined as an alternative tool for assessment of PEW. RESULTS The average age of the 555 participants was 57.5 ± 12.6 years. The prevalence of PEW was 27.3%, with 196 deaths observed during the mean follow-up of 25.5 months. Patients with PEW who fulfilled at least 3 of the 4 listed criteria had a higher risk of death in the unadjusted model (hazard ratio 1.61, 95% confidence interval 1.19-2.18, P = .002). However, these associations were attenuated after adjusting for potential confounders. Regarding the individual PEW criterion, decreased serum albumin and low muscle mass were significantly associated with mortality in the multivariable models. In contrast, decreased body mass and low protein intake were not associated with a higher risk of death. High MIS (≥5 points) and each one-point increase in the MIS were also significantly associated with higher risk of death in both unadjusted and adjusted models. CONCLUSIONS Among PD patients, the presence of PEW was not a better predictor of all-cause mortality than either the altered serum biochemistry (albumin) or low muscle mass criteria. The MIS performed well as an independent predictor of death and might be an option for assessment of PEW status in the PD population.
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Affiliation(s)
- Piyawan Kittiskulnam
- Department of Internal Medicine-Nephrology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand; Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Special Task Force for Activating Research in Renal Nutrition (Renal Nutrition Research Group), Office of Research Affairs, Chulalongkorn University, Bangkok, Thailand
| | - Piyatida Chuengsaman
- Banphaeo-Charoenkrung Peritoneal Dialysis Center, Banphaeo Dialysis Group, Banphaeo Hospital, Banphaeo, Thailand
| | - Talerngsak Kanjanabuch
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Center of Excellence in Kidney Metabolic Disorders, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Sirarat Katesomboon
- Banphaeo-Charoenkrung Peritoneal Dialysis Center, Banphaeo Dialysis Group, Banphaeo Hospital, Banphaeo, Thailand
| | - Somkanya Tungsanga
- Department of Internal Medicine-Nephrology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand; Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Krittaya Tiskajornsiri
- Banphaeo-Charoenkrung Peritoneal Dialysis Center, Banphaeo Dialysis Group, Banphaeo Hospital, Banphaeo, Thailand
| | - Kearkiat Praditpornsilpa
- Department of Internal Medicine-Nephrology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand; Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Special Task Force for Activating Research in Renal Nutrition (Renal Nutrition Research Group), Office of Research Affairs, Chulalongkorn University, Bangkok, Thailand
| | - Somchai Eiam-Ong
- Department of Internal Medicine-Nephrology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand; Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Special Task Force for Activating Research in Renal Nutrition (Renal Nutrition Research Group), Office of Research Affairs, Chulalongkorn University, Bangkok, Thailand.
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Yashiro M, Kotera H. Association of bioimpedance-derived 50-kHz phase angle as marker of body composition with electrical parameters regarding the Cole-Cole model. Ther Apher Dial 2020; 25:166-178. [PMID: 32603005 DOI: 10.1111/1744-9987.13554] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 06/24/2020] [Accepted: 06/25/2020] [Indexed: 11/26/2022]
Abstract
Our aim is to clarify the association of the bioelectrical impedance-derived 50-kHz phase angle (φ50 ) with electrical parameters regarding the Cole-Cole model and clinical parameters. A total of 440 sets of bioelectrical impedance data from pre- and post-hemodialysis from 157 patients were used. Resistance at infinite frequency (Rinf ), resistance at 0 frequency (R0 ), capacitance of the cell membrane (Cm), and a parameter for the distribution of the time constant (α) were examined as electrical parameters. Normally hydrated lean tissue mass as a percentage of the dry weight (PNHLT ), excess fluid mass as a percentage of the dry weight (PExF ), body mass index (BMI), age, and sex (Nsex , 0 for male, 1 for female) were examined as clinical parameters. φ50 increased with the decrease in Rinf /R0 and α and also with the increase in Cm (multiple regression coefficients [β]: pre/post, -0.886/-0.936, -0.175/-0.212, and 0.167/0.141), which determined the ratio of intra- to extracellular fluid volume (ICV/ECV), tissue homogeneity, and total cell mass. φ50 increased with an increase in PNHLT and BMI and decrease in PExF , Nsex , and age (β: pre/post, 0.654/0.581, 0.466/0.412, -0.483/-0.473, -0.216/-0.154, and -0.145/-0.127). The concordance correlation coefficient between φ50 for pre- and post-hemodialysis (ρ = 0.772) may be improved (ρ = 0.950) by adding a multiplication of 0.2 and PExF to φ50 for correction. φ50 may be used to estimate body composition through the association with ICV/ECV, tissue homogeneity, and total cell mass. The correction for excess fluid is essential in order to use φ50 as a marker of body composition related to nutrition.
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Affiliation(s)
- Masatomo Yashiro
- Division of Medical Engineering, Faculty of Medical Care Sciences, Himeji Dokkyo University, Himeji, Japan
| | - Hirohisa Kotera
- Division of Medical Engineering, Faculty of Medical Care Sciences, Himeji Dokkyo University, Himeji, Japan
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9
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Moradi H, Park C, Streja E, Argueta DA, DiPatrizio NV, You AS, Rhee CM, Vaziri ND, Kalantar-Zadeh K, Piomelli D. Circulating Endocannabinoids and Mortality in Hemodialysis Patients. Am J Nephrol 2020; 51:86-95. [PMID: 31935741 DOI: 10.1159/000505444] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 12/16/2019] [Indexed: 01/30/2023]
Abstract
BACKGROUND Mortality in patients with end-stage renal disease (ESRD) on maintenance hemodialysis (MHD) remains exceptionally high. While traditional risk factors such as obesity are paradoxically associated with better survival, nontraditional risk factors including cachexia increase the likelihood of poor outcomes. There is accumulating evidence that the endocannabinoid (ECB) system plays a major role in energy preservation and storage, factors which can prevent the deleterious effects of cachexia. Hence, in this study, we evaluated the association of circulating ECB levels with mortality in MHD patients. METHODS Serum concentrations of anandamide (AEA) and 2-arachidonoyl-sn-glycerol (2-AG), major ECB ligands, were measured in MHD patients. Their correlation with various clinical/laboratory indices and association with 12-month all-cause mortality were examined. RESULTS Serum 2-AG levels positively correlated with body mass index, serum triglycerides and body anthropometric measures. Meanwhile, serum AEA levels correlated positively with serum interleukin-6, and negatively with serum very low-density lipoprotein levels. While increased serum 2-AG levels were associated with reduced risk of all-cause mortality (hazard ratio [HR] 0.52, 95% CI 0.28-0.98), there was no clear association between serum AEA levels and mortality (HR 0.91, 95% CI 0.48-1.72). CONCLUSIONS In MHD patients, the circulating levels of ECB ligand, 2-AG, may play an important role in determining body mass and risk of mortality. These observations were unique to 2-AG as similar findings were not obtained with serum AEA. Future studies need to investigate the mechanisms responsible for these associations and examine the modulation of the ECB system as a potential target for therapy in ESRD.
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Affiliation(s)
- Hamid Moradi
- Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine School of Medicine, Irvine, California, USA,
- Tibor Rubin VA Medical Center, Nephrology Section, Long Beach, California, USA,
| | - Christina Park
- Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine School of Medicine, Irvine, California, USA
| | - Elani Streja
- Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine School of Medicine, Irvine, California, USA
- Tibor Rubin VA Medical Center, Nephrology Section, Long Beach, California, USA
| | - Donovan A Argueta
- Division of Biomedical Sciences, University of California Riverside School of Medicine, Riverside, California, USA
| | - Nicholas V DiPatrizio
- Division of Biomedical Sciences, University of California Riverside School of Medicine, Riverside, California, USA
| | - Amy S You
- Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine School of Medicine, Irvine, California, USA
| | - Connie M Rhee
- Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine School of Medicine, Irvine, California, USA
| | - Nosratola D Vaziri
- Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine School of Medicine, Irvine, California, USA
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine School of Medicine, Irvine, California, USA
- Tibor Rubin VA Medical Center, Nephrology Section, Long Beach, California, USA
| | - Daniele Piomelli
- Anatomy and Neurobiology, University of California Irvine School of Medicine, Irvine, California, USA
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10
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Martin-Alemañy G, Espinosa-Cuevas MDLÁ, Pérez-Navarro M, Wilund KR, Miranda-Alatriste P, Cortés-Pérez M, García-Villalobos G, Gómez-Guerrero I, Cantú-Quintanilla G, Ramírez-Mendoza M, Valdez-Ortiz R. Effect of Oral Nutritional Supplementation With and Without Exercise on Nutritional Status and Physical Function of Adult Hemodialysis Patients: A Parallel Controlled Clinical Trial (AVANTE-HEMO Study). J Ren Nutr 2019; 30:126-136. [PMID: 31607547 DOI: 10.1053/j.jrn.2019.06.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 06/27/2019] [Accepted: 06/30/2019] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE Protein energy wasting affects the nutritional status (NS) and physical function (PF) of dialysis patients. Among the different anabolic strategies to improve NS and PF, oral nutritional supplementation (ONS) and resistance exercise (RE) or aerobic exercise (AE) have been shown to be effective. Nevertheless, the combination of both anabolic strategies has not been completely evaluated. The aim of this study is to assess the effect of exercise combined with ONS versus ONS without exercise during hemodialysis sessions on PF and NS indicators. METHODS Young hemodialysis patients (29 ± 9.3 years) with predominantly unknown causes of renal disease (80%) were divided into the following 3 groups during a period of 12 weeks: (1) ONS (n = 15), (2) ONS + RE (n = 15), and (3) ONS + AE (n = 15). Anthropometric, biochemical, PF, and quality of life measurements were recorded at baseline and after 3 months. Repeated measures analysis of variance and effect sizes (Cohen's d) were used to assess the effect of exercise and nutrition (ISRCTN registry 10251828). RESULTS At the completion of the study, the ONS and ONS + RE groups exhibited statistically significant increases in body weight, body mass index, and in the percentage of fat mass (P < .05); the greatest effect sizes were observed in the ONS + RE group (d = 0.30 for body weight, d = 0.63 for body mass index, and d = 0.90 for the percentage of fat mass). Groups with RE and AE had statistically significant increases and large effect sizes in the six-minute walk test (RE: d = 0.94, P = .02; AE: d = 1.11, P = .03), sit-to-stand test (RE: d = 0.81, P = .041; AE: d = 1.20, P = .002), timed up and go test (RE: d = 1.04, P = .036; AE: d = 1.6, P = .000), and muscle strength (RE: d = 1.01, P = .000; AE: d = 0.60, P = .003). Regarding quality of life, the ONS + RE group had more areas of improvement at the end of the study, followed by the ONS + AE group. No statistically significant differences were found in the repeated measures ANOVA. CONCLUSIONS The combination of exercise with ONS had larger effects on PF than on ONS alone. Further studies to examine the impact of exercise on the effect of oral nutritional supplementation in dialysis patients are indicated.
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Affiliation(s)
- Geovana Martin-Alemañy
- Departamento de Nefrología, Hospital General de México "Dr. Eduardo Liceaga", Mexico City, Mexico
| | | | - Monserrat Pérez-Navarro
- Departamento de Nefrología, Hospital General de México "Dr. Eduardo Liceaga", Mexico City, Mexico
| | - Kenneth R Wilund
- Department of Kinesiology and Community Health, University of Illinois, Urbana, Illinois; Division of Nutritional Sciences, University of Illinois, Urbana, Illinois
| | - Paola Miranda-Alatriste
- Departamento de Nefrología y Metabolismo Mineral, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Mario Cortés-Pérez
- Departamento de Nefrología, Hospital General de México "Dr. Eduardo Liceaga", Mexico City, Mexico
| | - Gloria García-Villalobos
- Departamento de Nefrología, Hospital General de México "Dr. Eduardo Liceaga", Mexico City, Mexico
| | - Irma Gómez-Guerrero
- Departamento de Nefrología, Hospital General de México "Dr. Eduardo Liceaga", Mexico City, Mexico
| | | | - Marcelo Ramírez-Mendoza
- Departamento de Cardiología, Hospital General de México "Dr. Eduardo Liceaga", Mexico City, Mexico
| | - Rafael Valdez-Ortiz
- Departamento de Nefrología, Hospital General de México "Dr. Eduardo Liceaga", Mexico City, Mexico.
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11
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Dong ZJ, Zhang HL, Yin LX. Effects of intradialytic resistance exercise on systemic inflammation in maintenance hemodialysis patients with sarcopenia: a randomized controlled trial. Int Urol Nephrol 2019; 51:1415-1424. [PMID: 31270740 PMCID: PMC6660503 DOI: 10.1007/s11255-019-02200-7] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 06/10/2019] [Indexed: 12/24/2022]
Abstract
PURPOSE To investigate the effect of intradialytic resistance exercise on inflammation markers and sarcopenia indices in maintenance hemodialysis (MHD) patients with sarcopenia. METHODS Forty-one MHD patients with sarcopenia were divided into an intervention group (group E, n = 21) and a control group (group C, n = 20). Group C patients only received routine hemodialysis care, whereas group E patients received progressive intradialytic resistance exercise with high or moderate intensity for 12 weeks at three times per week (using the weight of the lower limbs and elastic ball movement of the upper limb) on the basis of routine hemodialysis care. RESULTS After 12 weeks, a significant difference in physical activity status (maximum grip strength, daily pace, and physical activity level), Kt/V, and C-reactive protein was found between groups E and C. Inflammatory factors (interleukin (IL)-6, IL-10, and tumor necrosis factor(TNF)-α) increased or decreased more significantly in group E than in group C. CONCLUSIONS This study showed that intradialytic resistance exercise can improve physical activity effectively and reduce microinflammatory reactions even if this simple exercise does not affect the muscle mass in MHD patients with sarcopenia.
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Affiliation(s)
- Zhi-Juan Dong
- Department of Nursing, The First People's Hospital of Lianyungang, No. 182, Tongguan North Road, Haizhou District, Lianyungang, Jiangsu, China
| | - Hai-Lin Zhang
- Department of Nursing, The First People's Hospital of Lianyungang, No. 182, Tongguan North Road, Haizhou District, Lianyungang, Jiangsu, China.
| | - Li-Xia Yin
- Department of Hemopurification Center, The First People's Hospital of Lianyungang, Lianyungang, Jiangsu, China
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12
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Koppe L, Fouque D, Kalantar‐Zadeh K. Kidney cachexia or protein-energy wasting in chronic kidney disease: facts and numbers. J Cachexia Sarcopenia Muscle 2019; 10:479-484. [PMID: 30977979 PMCID: PMC6596400 DOI: 10.1002/jcsm.12421] [Citation(s) in RCA: 116] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Weight loss and homeostatic disturbances of both energy and protein balances are characteristics of several illnesses including cancer, heart failure, and chronic kidney disease (CKD). Different definitions have been used to describe this deleterious process. The term protein-energy wasting (PEW) has been proposed for CKD patients by the International Society of Renal Nutrition and Metabolism. METHODS We searched the publication in Medline from February 2008 to September 2018 using PEW or cachexia in their title. RESULTS Since its inception, the term PEW has been exceptionally successful, highlighted by 327 original publications referenced in PubMed over 10 years. Using this classification, several studies have confirmed that PEW is among the strongest predictors of mortality in CKD patients [hazard ratio of 3.03; confidence interval of 1.69-5.26 in 1068 haemodialysis patients and 1.40 (1.04-1.89) in 1487 non-dialysed patients across PEW stages 0 to 4]. Based on this classification, prevalence of PEW is 28% to 54% among 16 434 adults undergoing maintenance dialysis. PEW prevalence increases when renal function declines, that is, from <2% in CKD stages 1-2 to 11-54% in CKD stages 3-5. A more general definition of cachexia for all chronic diseases proposed by the Society on Sarcopenia, Cachexia and Wasting Disorders was also published concurrently. In the CKD area, we found 180 publications using 'cachexia' underlining that some confusion or overlap may exist. The definitions of PEW and cachexia are somewhat similar, and the main difference is that a loss of body weight >5% is a mandatory criterion for cachexia but supportive for PEW. CONCLUSIONS The recent understanding of cachexia physiopathology during CKD progression suggests that PEW and cachexia are closely related and that PEW corresponds the initial state of a continuous process that leads to cachexia, implicating the same metabolic pathways as in other chronic diseases. Despite the success of the definition of PEW, using a more uniform term such as 'kidney disease cachexia' could be more helpful to design future research through collaborative groups of researchers with focus on cachexia.
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Affiliation(s)
- Laetitia Koppe
- Centre Hospitalier Lyon‐SudUniv Lyon, CarMeN, Dept NephrologyPierre‐BéniteFrance
| | - Denis Fouque
- Centre Hospitalier Lyon‐SudUniv Lyon, CarMeN, Dept NephrologyPierre‐BéniteFrance
| | - Kamyar Kalantar‐Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and HypertensionUniversity of California, Irvine, School of Medicine, OrangeIrvineCAUSA
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13
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Wilkinson TJ, Richler-Potts D, Nixon DG, Neale J, Smith AC. Anthropometry-based Equations to Estimate Body Composition: A Suitable Alternative in Renal Transplant Recipients and Patients With Nondialysis Dependent Kidney Disease? J Ren Nutr 2019; 29:16-23. [DOI: 10.1053/j.jrn.2018.04.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 03/09/2018] [Accepted: 04/05/2018] [Indexed: 01/10/2023] Open
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14
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Barril G, Nogueira A, Ruperto López M, Castro Y, Sánchez-Tomero JA. Influence of dietary protein intake on body composition in chronic kidney disease patients in stages 3-5: A cross-sectional study. Nefrologia 2018; 38:647-654. [PMID: 30293714 DOI: 10.1016/j.nefro.2018.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 06/01/2018] [Accepted: 06/07/2018] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION A controlled protein intake has shown beneficial effects to preserve renal function and nutritional status in chronic kidney disease (CKD) patients. This study aimed to analyze usual dietary protein intake and its potential contribution to body composition in CKD patients in stages 3-5. METHOD Cross-sectional study in 134 CKD patients in stages 3-5 (mean e-GFR: 19.4±8.7ml/min/1.73m2; males 68.7% and primary CKD etiology was diabetes mellitus, 35.8%). Demographic, clinical and nutritional parameters were evaluated. Normalized protein nitrogen appearance (nPNA), was used as a surrogate marker of dietary protein intake. The sample was classified into three nPNA groups (Gn): G1: <0.8g/kg/day; G2: 0.8-1g/kg/day and, G3: ≥1g/kg/day. Assessment of nutritional status using the malnutrition-inflammation score (MIS), anthropometric measures and laboratory parameters. Analysis of body composition and hydration status by bioelectrical impedance analysis (BIVA-101-RJL system). Statistical analysis by SPSS v.20. RESULTS Overall mean nPNA values were 0.91±0.23g of protein/kg BW/day and only 32.1% had a dietary protein intake <0.8g of protein/kg BW/day. Most of the CKD patients (65.5%) were in stages 4 or 5. Prevalence of protein-energy-wasting (PEW) syndrome measured by MIS was 15%. By analyzing differences between nPNA groups, body weight (BW), BMI and triceps-skinfold (TSF) thickness were significantly higher in the group with nPNA ≥1g/kg BW/day (G3), whereas a significant inverse relationship was found with the percentages of body cell mass (BCM%), fat-free mass (FFM%), muscle mass (MM%) and phase angle (PA) in the group with the lowest nPNA (G1). Analysis of gender among subjects showed significant differences with BW, FFM%, TSF and mid-arm muscle circumference (MAMC%). Linear regression analysis showed that resistance, BCM%, MM%, and serum albumin were significant predictors of nPNA as a surrogate marker of daily protein intake (R=0.51; R2=0.29; R2 adjusted=0.23; p<0.001). CONCLUSION Controlled protein intake is one of the cornerstones of treatment in CKD patients. A low protein intake in patients with CKD stages 3 and 4-5 was associated with loss of muscle mass in the advanced-CKD unit. The loss of muscle mass appears as an early indicator of nutritional comprised. Factors such, elderly age and loss of eGFR, showed lower protein intake and were associated with muscle loss, especially in women. Further longitudinal studies are required to evaluate the contribution of different protein intakes to uremic symptoms, nutritional status, body composition and CKD progression.
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Affiliation(s)
- Guillermina Barril
- Department of Nephrology, Advanced-chronic Kidney Disease Unit, Hospital Universitario de la Princesa, C/ Diego de León n° 62, 28006 Madrid, Spain.
| | - Angel Nogueira
- Advanced-chronic Kidney Disease Unit, Hospital Universitario de la Princesa, C/ Diego de León n° 62, 28006 Madrid, Spain
| | - Mar Ruperto López
- Human Nutrition and Dietetics Department, Faculty of Health Sciences, Universidad Alfonso X el Sabio, Avda. Universidad s/n, 28691 Villanueva de la Cañada, Madrid, Spain
| | - Yone Castro
- Orientation Department, Area of Investigation, Prodis Foundation, C/ Bulevar Indalecio Prieto 2, 28032 Madrid, Spain
| | - José Antonio Sánchez-Tomero
- Department of Nephrology, Advanced-chronic Kidney Disease Unit, Hospital Universitario de la Princesa, 28006 Madrid, Spain
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15
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Antón-Pérez G, Santana-Del-Pino Á, Henríquez-Palop F, Monzón T, Sánchez AY, Valga F, Morales-Umpierrez A, García-Cantón C, Rodríguez-Pérez JC, Carrero JJ. Diagnostic Usefulness of the Protein Energy Wasting Score in Prevalent Hemodialysis Patients. J Ren Nutr 2018; 28:428-434. [PMID: 29983232 DOI: 10.1053/j.jrn.2018.05.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 04/19/2018] [Accepted: 05/29/2018] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE To study whether the score proposed by the International Society of Renal Nutrition and Metabolism to define the protein energy wasting (PEW) syndrome has diagnostic validity in patients undergoing dialysis. DESIGN AND METHODS Cross-sectional study including 468 prevalent hemodialysis patients from Canary Islands, Spain. Individual PEW syndrome criteria and the number of PEW syndrome categories were related to other objective markers of PEW using linear and logistic regression analyses: subjective global assessment, handgrip strength, bioimpedance-assessed body composition, and levels of high-sensitivity C-reactive protein. RESULTS Study participants (34% women) had a median age of 66 years, 37 months of maintenance dialysis, and 50% were diabetics. About 23% of patients had PEW (≥3 PEW categories), and 68% were at risk of PEW (1-2 PEW categories). Low prealbumin was the most frequently found derangement (52% of cases), followed by low albumin (46%), and low protein intake (35%). Across higher number of PEW syndrome categories, patients showed a longer dialysis vintage and had lower creatinine, triglycerides, and transferrin (P for trend <.001 for all). All nutritional assessments not included in the PEW definition worsened across higher number of PEW categories. In multivariable regression analyses, there was a linear inverse relationship between muscle and fat mass as well as handgrip strength with the number of PEW syndrome categories. Likewise, the proportion of subjective global assessment-defined malnutrition and serum concentration of C-reactive protein gradually increased despite adjustment for confounders (P for trend <.05 for all). CONCLUSION The PEW score reflects systemic inflammation, malnutrition and wasting among dialysis patients and may thus be used for diagnostic purposes.
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Affiliation(s)
| | | | | | - Tania Monzón
- Avericum Hemodialysis Centers, Islas Canarias, Spain
| | - Ana Y Sánchez
- Avericum Hemodialysis Centers, Islas Canarias, Spain
| | | | | | - Cesar García-Cantón
- Nephrology Department, Complejo Hospitalario Universitario Insular Materno Infantil, Las Palmas de Gran Canaria, Spain
| | | | - Juan J Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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Cirillo M, Cavallo P, Bilancio G, Lombardi C, Terradura Vagnarelli O, Laurenzi M. Low Protein Intake in the Population: Low Risk of Kidney Function Decline but High Risk of Mortality. J Ren Nutr 2018; 28:235-244. [PMID: 29439930 DOI: 10.1053/j.jrn.2017.11.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 11/01/2017] [Accepted: 11/19/2017] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE This population-based study investigated low protein intake, mortality, and kidney function decline. DESIGN Observational longitudinal cohort study. SUBJECTS Target cohort consisted of 4,679 adults participating in 1988-1992 and 2001-2007 examinations of the Gubbio Study (baseline and follow-up). Data collection included overnight urine urea nitrogen (UUN) and other variables at baseline, serum creatinine at baseline and follow-up, and mortality from baseline to follow-up. Three hundred seventy-two persons were excluded for missing data. UUN in the lowest 20% of the distribution was defined as low and used as index of low protein intake. Estimated glomerular filtration rate (eGFR, mL/minute × 1.73 m2) was used as kidney function index. INTERVENTION None (observational study). MAIN OUTCOME MEASURE Mortality and eGFR decline are the main outcome measures, and eGFR decline was defined as eGFR change from baseline to follow-up ≤ mean-1 standard deviation (Z-score ≤ -1). RESULTS Eight hundred seventy-one deaths occurred over 15.9 ± 4.0 years of observation (417 from cardiovascular disease and 276 from neoplastic disease). Low UUN associated with mortality (hazard ratio, HR = 1.31, 95% confidence interval, CI = 1.12/1.53) due to association with mortality from neoplastic disease (HR = 1.33, 95% CI = 1.02/1.76). Mortality-corrected follow-up response rate was 79.9% (n = 2845). Baseline to follow-up eGFR change was -9.9 ± 10.1, and eGFR decline was found in 454 examinees. Low UUN associated with eGFR decline only in subgroup with baseline eGFR <90 (n = 1441, odds ratio = 0.44, 95% CI = 0.22/0.85). Low baseline eGFR interacted with the association between low UUN and eGFR decline (P = .024). CONCLUSION Low protein intake predicted higher mortality in the whole population and lower incidence of eGFR decline only in subgroup with reduced kidney function.
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Affiliation(s)
- Massimo Cirillo
- Unit of Nephrology, Department "Scuola Medica Salernitana", University of Salerno, Salerno, Italy; Unit of Nephrology, Department of Medical Sciences, University Hospital, Salerno, Italy.
| | - Pierpaolo Cavallo
- Lab of Complex Systems in Physics of Public Health, Department of Physics, University of Salerno, Salerno, Italy
| | - Giancarlo Bilancio
- Unit of Nephrology, Department "Scuola Medica Salernitana", University of Salerno, Salerno, Italy; Unit of Nephrology, Department of Medical Sciences, University Hospital, Salerno, Italy
| | - Cinzia Lombardi
- Unit of Medical Genetics, Department of Maternal and Child Health, Rummo Hospital, Benevento, Italy
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