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Delgado C, Powe NR, Chertow GM, Grimes B, Johansen KL. Muscle Mass and Serum Creatinine Concentration by Race and Ethnicity among Hemodialysis Patients. J Am Soc Nephrol 2024; 35:66-73. [PMID: 37822022 PMCID: PMC10786608 DOI: 10.1681/asn.0000000000000240] [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: 01/12/2023] [Accepted: 09/14/2023] [Indexed: 10/13/2023] Open
Abstract
SIGNIFICANCE STATEMENT Serum creatinine is a product of skeletal muscle metabolism. Differences in serum creatinine concentration between Black and non-Black individuals have been attributed to differences in muscle mass but have not been thoroughly examined. Furthermore, other race and ethnic groups have not been considered. If differences in body composition explain differences in serum concentration by race or ethnicity, then estimates of body composition could be used in eGFR equations rather than race. Adjustment for intracellular water (ICW) as a proxy of muscle mass among patients with kidney failure in whom creatinine clearance should minimally influence serum concentration does not explain race- and ethnicity-dependent differences. BACKGROUND Differences in serum creatinine concentration among groups defined by race and ethnicity have been ascribed to differences in muscle mass. We examined differences in serum creatinine by race and ethnicity in a cohort of patients receiving hemodialysis in whom creatinine elimination by the kidney should have little or no effect on serum creatinine concentration and considered whether these differences persisted after adjustment for proxies of muscle mass. METHODS We analyzed data from 501 participants in the A Cohort Study to Investigate the Value of Exercise in ESKD/Analyses Designed to Investigate the Paradox of Obesity and Survival in ESKD study who had been receiving hemodialysis for >1 year. We examined the independent associations among race and ethnicity (Black, Asian, non-Hispanic White, and Hispanic), serum creatinine, and ICW (L/m 2 ), a proxy for muscle mass, derived by whole-body multifrequency bioimpedance spectroscopy, using multivariable linear regression with adjustment for several demographic, clinical, and laboratory characteristics. We examined the association of race and ethnicity with serum creatinine concentration with and without adjustment for ICW. RESULTS Black, Asian, and Hispanic patients had higher serum creatinine concentrations (+1.68 mg/dl [95% confidence interval (CI), 1.09 to 2.27], +1.61 mg/dl [95% CI, 0.90 to 2.32], and +0.83 [95% CI, 0.08 to 1.57], respectively) than non-Hispanic White patients. Overall, ICW was associated with serum creatinine concentration (0.26 mg/dl per L/m 2 ICW; 95% CI, 0.006 to 0.51) but was not statistically significantly different by race and ethnicity. Black, Asian, and Hispanic race and ethnicity remained significantly associated with serum creatinine concentration after adjustment for ICW. CONCLUSION Among patients receiving dialysis, serum creatinine was higher in Black, Asian, and Hispanic patients than in non-Hispanic White patients. Differences in ICW did not explain the differences in serum creatinine concentration across race groups.
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Affiliation(s)
- Cynthia Delgado
- Division of Nephrology, University of California, San Francisco and Nephrology Section, San Francisco VA Medical Center, San Francisco, California
| | - Neil R. Powe
- Department of Medicine, University of California, San Francisco and Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Glenn M. Chertow
- Departments of Medicine and Epidemiology and Population Health, Stanford University, Palo Alto, California
| | - Barbara Grimes
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - Kirsten L. Johansen
- Department of Medicine, Division of Nephrology, Hennepin Healthcare, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
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Duran S, Çakar H, Çağlar N, Dağaşan S. The Effects of Nutrition Education on the Handgrip Strength and Nutrition Status of Elderly Patients on Hemodialysis. TOP CLIN NUTR 2023. [DOI: 10.1097/tin.0000000000000312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
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3
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Delgado C, Chiang JM, Kittiskulnam P, Sheshadri A, Grimes B, Segal M, Kaysen GA, Johansen KL. Longitudinal Assessment of Body Composition and Its Association With Survival Among Participants of the ACTIVE/ADIPOSE Study. J Ren Nutr 2021; 32:396-404. [PMID: 34930665 DOI: 10.1053/j.jrn.2021.09.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 08/16/2021] [Accepted: 09/05/2021] [Indexed: 11/11/2022] Open
Abstract
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.
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Affiliation(s)
- Cynthia Delgado
- Division of Nephrology, University of California, San Francisco and Nephrology Section, San Francisco VA Medical Center, San Francisco, California, USA.
| | - Janet M Chiang
- Division of Endocrinology, University of California, San Francisco and San Francisco VA Medical Center, San Francisco, California, USA
| | | | - Anoop Sheshadri
- Division of Nephrology, University of California, San Francisco and Nephrology Section, San Francisco VA Medical Center, San Francisco, California, USA
| | - Barbara Grimes
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco California, USA
| | - Mark Segal
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco California, USA
| | - George A Kaysen
- Department of Medicine, Division of Nephrology, University of California, Davis, Davis, California, USA; Department of Biochemistry and Molecular Medicine University of California, Davis, Davis, California, USA
| | - Kirsten L Johansen
- Department of Medicine, Division of Nephrology, Hennepin Healthcare, Minneapolis, Minnesota, USA; Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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Sabatino A, Broers NJH, van der Sande FM, Hemmelder MH, Fiaccadori E, Kooman JP. Estimation of Muscle Mass in the Integrated Assessment of Patients on Hemodialysis. Front Nutr 2021; 8:697523. [PMID: 34485360 PMCID: PMC8415223 DOI: 10.3389/fnut.2021.697523] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 07/16/2021] [Indexed: 01/26/2023] Open
Abstract
Assessment of muscle mass (MM) or its proxies, lean tissue mass (LTM) or fat-free mass (FFM), is an integral part of the diagnosis of protein-energy wasting (PEW) and sarcopenia in patients on hemodialysis (HD). Both sarcopenia and PEW are related to a loss of functionality and also increased morbidity and mortality in this patient population. However, loss of MM is a part of a wider spectrum, including inflammation and fluid overload. As both sarcopenia and PEW are amendable to treatment, estimation of MM regularly is therefore of major clinical relevance. Whereas, computer-assisted tomography (CT) or dual-energy X-ray absorptiometry (DXA) is considered a reference method, it is unsuitable as a method for routine clinical monitoring. In this review, different bedside methods to estimate MM or its proxies in patients on HD will be discussed, with emphasis on biochemical methods, simplified creatinine index (SCI), bioimpedance spectroscopy (BIS), and muscle ultrasound (US). Body composition parameters of all methods are related to the outcome and appear relevant in clinical practice. The US is the only parameter by which muscle dimensions are measured. BIS and SCI are also dependent on either theoretical assumptions or the use of population-specific regression equations. Potential caveats of the methods are that SCI can be influenced by residual renal function, BIS can be influenced by fluid overload, although the latter may be circumvented by the use of a three-compartment model, and that muscle US reflects regional and not whole body MM. In conclusion, both SCI and BIS as well as muscle US are all valuable methods that can be applied for bedside nutritional assessment in patients on HD and appear suitable for routine follow-up. The choice for either method depends on local preferences. However, estimation of MM or its proxies should always be part of a multidimensional assessment of the patient followed by a personalized treatment strategy.
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Affiliation(s)
- Alice Sabatino
- Nephrology Unit, Department of Medicine and Surgery, Parma University Hospital, University of Parma, Parma, Italy
| | - Natascha J H Broers
- Division on Nephrology, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, Netherlands.,NUTRIM School of Nutrition and Translational Research in Metabolism, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, Netherlands
| | - Frank M van der Sande
- Division on Nephrology, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, Netherlands.,NUTRIM School of Nutrition and Translational Research in Metabolism, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, Netherlands
| | - Marc H Hemmelder
- Division on Nephrology, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, Netherlands.,NUTRIM School of Nutrition and Translational Research in Metabolism, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, Netherlands
| | - Enrico Fiaccadori
- Nephrology Unit, Department of Medicine and Surgery, Parma University Hospital, University of Parma, Parma, Italy
| | - Jeroen P Kooman
- Division on Nephrology, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, Netherlands.,NUTRIM School of Nutrition and Translational Research in Metabolism, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, Netherlands
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Bioelectrical impedance analysis-guided fluid management promotes primary fascial closure after open abdomen: a randomized controlled trial. Mil Med Res 2021; 8:36. [PMID: 34099065 PMCID: PMC8180439 DOI: 10.1186/s40779-021-00329-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 05/27/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Fluid overload (FO) after resuscitation is frequent and contributes to adverse outcomes among postinjury open abdomen (OA) patients. Bioelectrical impedance analysis (BIA) is a promising tool for monitoring fluid status and FO. Therefore, we sought to investigate the efficacy of BIA-directed fluid resuscitation among OA patients. METHODS A pragmatic, prospective, randomized, observer-blind, single-center trial was performed for all trauma patients requiring OA between January 2013 and December 2017 to a national referral center. A total of 140 postinjury OA patients were randomly assigned in a 1:1 ratio to receive either a BIA-directed fluid resuscitation (BIA) protocol that included fluid administration with monitoring of hemodynamic parameters and different degrees of interventions to achieve a negative fluid balance targeting the hydration level (HL) measured by BIA or a traditional fluid resuscitation (TRD) in which clinicians determined the fluid resuscitation regimen according to traditional parameters during 30 days of ICU management. The primary outcome was the 30-day primary fascial closure (PFC) rate. The secondary outcomes included the time to PFC, postoperative 7-day cumulative fluid balance (CFB) and adverse events within 30 days after OA. The Kaplan-Meier method and the log-rank test were utilized for PFC after OA. A generalized linear regression model for the time to PFC and CFB was built. RESULTS A total of 134 patients completed the trial (BIA, n = 66; TRD, n = 68). The BIA patients were significantly more likely to achieve PFC than the TRD patients (83.33% vs. 55.88%, P < 0.001). In the BIA group, the time to PFC occurred earlier than that of the TRD group by an average of 3.66 days (P < 0.001). Additionally, the BIA group showed a lower postoperative 7-day CFB by an average of 6632.80 ml (P < 0.001) and fewer complications. CONCLUSION Among postinjury OA patients in the ICU, the use of BIA-guided fluid resuscitation resulted in a higher PFC rate and fewer severe complications than the traditional fluid resuscitation strategy.
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Delgado C, Johansen KL. Revisiting serum creatinine as an indicator of muscle mass and a predictor of mortality among patients on hemodialysis. Nephrol Dial Transplant 2020; 35:2033-2035. [PMID: 33275759 DOI: 10.1093/ndt/gfaa251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 09/06/2020] [Indexed: 01/15/2023] Open
Affiliation(s)
- Cynthia Delgado
- Nephrology Section, San Francisco VA Medical Center and Division of Nephrology, University of California, San Francisco, CA, USA
| | - Kirsten L Johansen
- Division of Nephrology, Department of Medicine, Hennepin Healthcare, Minneapolis, MN, USA.,Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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Ruperto M, Barril G. Extracellular mass to body cell mass ratio in patients on peritoneal dialysis. Clin Nutr 2020; 39:1628-1629. [PMID: 32249113 DOI: 10.1016/j.clnu.2020.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 02/17/2020] [Indexed: 10/24/2022]
Affiliation(s)
- M Ruperto
- Department of Pharmaceutical & Health Sciences, Faculty of Pharmacy, University CEU San Pablo, 28668, Boadilla Del Monte, Madrid, Spain.
| | - G Barril
- Nephrology Department. Hospital Universitario La Princesa, Madrid, Spain
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Davies SJ, Finkelstein FO. Accuracy of the estimation of V and the implications this has when applying Kt/Vurea for measuring dialysis dose in peritoneal dialysis. Perit Dial Int 2020; 40:261-269. [DOI: 10.1177/0896860819893817] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Background: Current guidelines for the prescription of peritoneal dialysis dose rely on a single cut-off ‘minimal’ value of K t/ V. To apply this in the clinic, this requires an accurate estimation of V, the volume of urea distribution that equates to the total body water (TBW). This analysis sought to determine the accuracy to which V can be estimated. Methods: A literature search was undertaken of studies comparing TBW estimation using two or three of the following methods: isotopic dilution (gold standard), anthropometric equations (e.g. Watson formula) and bioimpedance analysis. Studies of healthy and dialysis populations of all ages were included. Mean differences and 95% limits of agreement (LOA) were extracted and pooled. Results: In 44 studies (31 including dialysis subjects), the between-method population means were typically within 1–1.5 L of each other, although larger bias was seen when applying anthropometric equations to different racial groups. However, the 95% LOA for all comparisons were consistently wide, typically ranging ±12–18% of the TBW. For a typical individual whose TBW is 35 L with a measured K t/ V of 1.7, this translates into a range of K t/ V 1.4–2.05. Conclusions: There are limitations to the accuracy of estimation of V which call into question the validity of applying a single threshold K t/ V value as indicative of adequate dialysis. This should be taken into account in guideline development such that if a target K t/ V was deemed appropriate that this should be expressed as a range; alternatively single targets should be avoided and dialysis dose should be determined according to patient need.
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Affiliation(s)
- Simon J Davies
- Faculty of Medicine and Health Sciences, Keele University, UK
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Ruperto M, Barril G. Extracellular mass to body cell mass ratio as a potential index of wasting and fluid overload in hemodialysis patients. Clin Nutr 2019; 39:316-317. [PMID: 31812469 DOI: 10.1016/j.clnu.2019.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 11/06/2019] [Indexed: 10/25/2022]
Affiliation(s)
- M Ruperto
- Department of Pharmaceutical & Health Sciences, Faculty of Pharmacy, Universidad San Pablo-CEU, CEU Universities, Urbanización Montepríncipe, 28660 Boadilla del Monte, Spain.
| | - G Barril
- Nephrology Department, Hospital Universitario La Princesa, Madrid, Spain
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Tanaka S, Ando K, Kobayashi K, Seki T, Hamada T, Machino M, Ota K, Morozumi M, Kanbara S, Ito S, Ishiguro N, Hasegawa Y, Imagama S. Reduction in body cell mass as a predictor of osteoporosis: A cross-sectional study. Mod Rheumatol 2019; 30:391-396. [DOI: 10.1080/14397595.2019.1589911] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Satoshi Tanaka
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kei Ando
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuyoshi Kobayashi
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Taisuke Seki
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takashi Hamada
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masaaki Machino
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kyotaro Ota
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masayoshi Morozumi
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shunsuke Kanbara
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Sadayuki Ito
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Naoki Ishiguro
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yukiharu Hasegawa
- Department of Rehabilitation, Kansai University of Welfare Science, Osaka, Japan
| | - Shiro Imagama
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Is 3-Carboxy-4-methyl-5-propyl-2-furanpropionate (CMPF) a Clinically Relevant Uremic Toxin in Haemodialysis Patients? Toxins (Basel) 2018; 10:toxins10050205. [PMID: 29783628 PMCID: PMC5983261 DOI: 10.3390/toxins10050205] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 05/10/2018] [Accepted: 05/15/2018] [Indexed: 02/04/2023] Open
Abstract
3-Carboxy-4-methyl-5-propyl-2-furanpropionate (CMPF) is a metabolite of furan fatty acid and a marker of fish oil intake. CMPF is described as a protein-bound uremic toxin and interacts with free oxygen radicals, which can induce cell damages. However, the clinical consequences of CMPF accumulation in haemodialysis patients remain poorly documented. The aims of this study are to investigate potential association between CMPF levels and (i) biochemical and nutritional parameters; (ii) cardiovascular events and (iii) mortality. Two hundred and fifty-two patients undergoing maintenance haemodialysis were included. Routine clinical biochemistry tests and assay for CMPF by HPLC technique were performed at the inclusion. Body composition parameters were measured using a bioimpedance spectroscopy method. The enrolled patients were prospectively monitored for cardiovascular events and mortality. CMPF level was positively correlated with nutritional parameters and lean mass and is significantly higher in patients without protein-energy wasting. However, the multivariate linear regression analysis indicated that CMPF level was not independently associated with albumin, prealbumin, creatinemia and body mass index. Elevated serum CMPF was not associated with mortality and cardiovascular morbidity. Our results indicate that CMPF is not a relevant uremic toxin in haemodialysis and in contrast could be a marker of healthy diet and omega 3 intakes.
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Beberashvili I, Yermolayeva T, Katkov A, Garra N, Feldman L, Gorelik O, Stav K, Efrati S. Estimating of Residual Kidney Function by Multi-Frequency Bioelectrical Impedance Analysis in Hemodialysis Patients Without Urine Collection. Kidney Blood Press Res 2018; 43:98-109. [PMID: 29414836 DOI: 10.1159/000487106] [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: 10/23/2017] [Accepted: 01/25/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Residual kidney function (RKF) is a pivotal predictor of better clinical outcomes in maintenance hemodialysis (MHD) patients. So far there has been no attempt to use bioimpedance analysis (BIA) measurements to calculate residual glomerular filtration rate (GFR) in dialysis population. We hypothesized that performing of multi-frequency BIA at the beginning and end of hemodialysis session can enable us to predict the measured residual GFR in MHD patients. Thus our aim was to develop and validate a new RKF prediction equation using multi-frequency BIA in MHD patients. METHODS It was diagnostic test evaluation study in a prospective cohort. Participants (n=88; mean age, 66.3±13.2 years, 59.1% males) were recruited from a single hemodialysis center. A new equation (eGFRBIA) to predict RKF, utilizing BIA measurements performed pre- and post-dialysis, was generated and cross-validated by the leave-one-out procedure. GFR estimated as the mean of urea and creatinine clearance (mGFR) using urine collections during entire interdialytic period. RESULTS A prediction equation for mGFR that includes both pre- and post-dialysis BIA measurements provided a better estimate than either pre- or post-dialysis measurements alone. Mean bias between predicted and measured GFR was -0.12 ml/min. Passing and Bablok regression showed no bias and no significant deviation in linearity. Concordance correlation coefficient indicated good agreement between the eGFRBIA and mGFR (0.75, P<0.001). Using cut-off predicted mGFR levels >2 ml/min/1.73 m2 yielded an area under curve of 0.96, sensitivity 85%, and specificity 89% in predicting mGFR. The κ scores for intraobserver reproducibility were consistent with substantial agreement between first and second estimation of RKF according to eGFRBIA (weighted κ was 0.60 [0.37-0.83]). CONCLUSION We present a valid and clinically obtainable method to predict RKF in MHD patients. This method, which uses BIA, may prove as accurate, convenient and easily reproducible while it is operator independent.
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Affiliation(s)
- Ilia Beberashvili
- Nephrology Division, Assaf Harofeh Medical Center, Zerifin, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tatyana Yermolayeva
- Internal Department E, Barzilai University Medical Center Campus, Ashkelon, Israel
| | - Anna Katkov
- Nephrology Division, Assaf Harofeh Medical Center, Zerifin, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nedal Garra
- Nephrology Division, Assaf Harofeh Medical Center, Zerifin, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Leonid Feldman
- Nephrology Division, Assaf Harofeh Medical Center, Zerifin, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Oleg Gorelik
- Internal Department F, Assaf Harofeh Medical Center, Zerifin, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Kobi Stav
- Urology Department, Assaf Harofeh Medical Center, Zerifin, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shai Efrati
- Nephrology Division, Assaf Harofeh Medical Center, Zerifin, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Jo IY, Kim WJ, Park HC, Choi HY, Lee JE, Lee SM. Effect of Personalized Nutritional Counseling on the Nutritional Status of Hemodialysis Patients. Clin Nutr Res 2017; 6:285-295. [PMID: 29124049 PMCID: PMC5665750 DOI: 10.7762/cnr.2017.6.4.285] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 10/18/2017] [Accepted: 10/23/2017] [Indexed: 01/01/2023] Open
Abstract
This study set out to evaluate the impact of personalized nutritional counseling (PNC) on the nutritional status of hemodialysis (HD) patients. This was an intervention study for 10 months at 2 hospitals. Anthropometric, biochemical, dietary, and body composition parameters were measured at baseline and after 3 and 6 months of PNC. A total of 42 patients (23 men and 19 women) were included. Intake of dietary protein, serum albumin, and cholesterol levels had increased significantly from baseline to month 6 (p < 0.05). Among the bioelectrical impedance analysis (BIA) parameters, both the body cell mass (BCM) and the fat free mass (FFM) had significantly reduced at month 3 compared to baseline (p < 0.05). However, there was no difference between baseline and month 6. We assessed the nutritional status of the subjects using the malnutrition inflammation score (MIS), and divided them into an adequately nourished (AN) and a malnourished (MN) group at baseline. In the subgroup analysis, serum levels of albumin and cholesterol had increased significantly, particularly from baseline to month 6 in the MN group (p < 0.05). This study suggests that consecutive PNC contributed to the improvement of the protein intake, serum levels of albumin, cholesterol and to the delay of muscle wasting, which could also have a positive impact on the nutritional status, particularly in malnourished patients receiving HD treatment.
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Affiliation(s)
- In-Young Jo
- Department of Nutrition Care, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Woo Jeong Kim
- Department of Nutrition Services, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea
| | - Hyeong Cheon Park
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea
| | - Hoon Young Choi
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea
| | - Jung Eun Lee
- Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin 17046, Korea
| | - Song Mi Lee
- Department of Nutrition Care, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Korea
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Donadio C, Moriconi D, Berta R, Anselmino M. Estimation of Urinary Creatinine Excretion and Prediction of Renal Function in Morbidly Obese Patients: New Tools from Body Composition Analysis. Kidney Blood Press Res 2017; 42:629-640. [DOI: 10.1159/000481630] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 06/06/2017] [Indexed: 11/19/2022] Open
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Mandic A, Cavar I, Skoro I, Tomic I, Ljubic K, Coric S, Mikulic I, Azinovic I, Pravdic D. Body Composition and Inflammation in Hemodialysis Patients. Ther Apher Dial 2017; 21:556-564. [DOI: 10.1111/1744-9987.12575] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Revised: 05/02/2017] [Accepted: 05/09/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Ante Mandic
- Department of Internal Medicine; Mostar University Hospital; Mostar Bosnia and Herzegovina
| | - Ivan Cavar
- Department of Physiology; Mostar University Faculty of Medicine; Mostar Bosnia and Herzegovina
| | - Ivana Skoro
- Department of Internal Medicine; Mostar University Hospital; Mostar Bosnia and Herzegovina
| | - Ivan Tomic
- Department of Internal Medicine; Mostar University Hospital; Mostar Bosnia and Herzegovina
| | - Kristina Ljubic
- Department of Laboratory Diagnostics; Mostar University Hospital; Mostar Bosnia and Herzegovina
| | - Slavica Coric
- Department of Internal Medicine; Mostar University Hospital; Mostar Bosnia and Herzegovina
| | - Ivanka Mikulic
- Department of Laboratory Diagnostics; Mostar University Hospital; Mostar Bosnia and Herzegovina
| | - Igor Azinovic
- Laboratory Diagnostics; Mostar University Faculty of Medicine; Mostar Bosnia and Herzegovina
| | - Danijel Pravdic
- Department of Internal Medicine; Mostar University Hospital; Mostar Bosnia and Herzegovina
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Body Composition Analysis Allows the Prediction of Urinary Creatinine Excretion and of Renal Function in Chronic Kidney Disease Patients. Nutrients 2017; 9:nu9060553. [PMID: 28555040 PMCID: PMC5490532 DOI: 10.3390/nu9060553] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 05/09/2017] [Accepted: 05/23/2017] [Indexed: 11/16/2022] Open
Abstract
The aim of this study was to predict urinary creatinine excretion (UCr), creatinine clearance (CCr) and the glomerular filtration rate (GFR) from body composition analysis. Body cell mass (BCM) is the compartment which contains muscle mass, which is where creatinine is generated. BCM was measured with body impedance analysis in 165 chronic kidney disease (CKD) adult patients (72 women) with serum creatinine (SCr) 0.6-14.4 mg/dL. The GFR was measured (99mTc-DTPA) and was predicted using the Modification of Diet in Renal Disease (MDRD) formula. The other examined parameters were SCr, 24-h UCr and measured 24-h CCr (mCCr). A strict linear correlation was found between 24-h UCr and BCM (r = 0.772). Multiple linear regression (MR) indicated that UCr was positively correlated with BCM, body weight and male gender, and negatively correlated with age and SCr. UCr predicted using the MR equation (MR-UCr) was quite similar to 24-h UCr. CCr predicted from MR-UCr and SCr (MR-BCM-CCr) was very similar to mCCr with a high correlation (r = 0.950), concordance and a low prediction error (8.9 mL/min/1.73 m²). From the relationship between the GFR and the BCM/SCr ratio, we predicted the GFR (BCM GFR). The BCM GFR was very similar to the GFR with a high correlation (r = 0.906), concordance and a low prediction error (12.4 mL/min/1.73 m²). In CKD patients, UCr, CCr and the GFR can be predicted from body composition analysis.
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Association between B-lines detected during lung ultrasound and various factors in hemodialysis patients. RENAL REPLACEMENT THERAPY 2017. [DOI: 10.1186/s41100-017-0101-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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18
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Balbino KP, Epifânio APS, Ribeiro SMR, da Silva LDM, Gouvea MG, Hermsdorff HHM. Comparison between direct and indirect methods to diagnose malnutrition and cardiometabolic risk in haemodialisys patients. J Hum Nutr Diet 2017; 30:646-654. [DOI: 10.1111/jhn.12468] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- K. P. Balbino
- Department of Nutrition and Health; Universidade Federal de Viçosa; Viçosa Minas Gerais Brazil
| | - A. P. S. Epifânio
- Department of Nutrition and Health; Universidade Federal de Viçosa; Viçosa Minas Gerais Brazil
| | - S. M. R. Ribeiro
- Department of Nutrition and Health; Universidade Federal de Viçosa; Viçosa Minas Gerais Brazil
| | | | - M. G. Gouvea
- Division of Nephrology; São João Batista Hospital; Viçosa Brazil
| | - H. H. M. Hermsdorff
- Department of Nutrition and Health; Universidade Federal de Viçosa; Viçosa Minas Gerais Brazil
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Kuchnia A, Earthman C, Teigen L, Cole A, Mourtzakis M, Paris M, Looijaard W, Weijs P, Oudemans-van Straaten H, Beilman G, Day A, Leung R, Compher C, Dhaliwal R, Peterson S, Roosevelt H, Heyland DK. Evaluation of Bioelectrical Impedance Analysis in Critically Ill Patients: Results of a Multicenter Prospective Study. JPEN J Parenter Enteral Nutr 2016; 41:1131-1138. [PMID: 27221673 DOI: 10.1177/0148607116651063] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND In critically ill patients, muscle loss is associated with adverse outcomes. Raw bioelectrical impedance analysis (BIA) parameters (eg, phase angle [PA] and impedance ratio [IR]) have received attention as potential markers of muscularity, nutrition status, and clinical outcomes. Our objective was to test whether PA and IR could be used to assess low muscularity and predict clinical outcomes. METHODS Patients (≥18 years) having an abdominal computed tomography (CT) scan and admitted to intensive care underwent multifrequency BIA within 72 hours of scan. CT scans were landmarked at the third lumbar vertebra and analyzed for skeletal muscle cross-sectional area (CSA). CSA ≤170 cm2 for males and ≤110 cm2 for females defined low muscularity. The relationship between PA (and IR) and CT muscle CSA was evaluated using multivariate regression and included adjustments for age, sex, body mass index, Charlson Comorbidity Index, and admission type. PA and IR were also evaluated for predicting discharge status using dual-energy x-ray absorptiometry-derived cut-points for low fat-free mass index. RESULTS Of 171 potentially eligible patients, 71 had BIA and CT scans within 72 hours. Area under the receiver operating characteristic (c-index) curve to predict CT-defined low muscularity was 0.67 ( P ≤ .05) for both PA and IR. With covariates added to logistic regression models, PA and IR c-indexes were 0.78 and 0.76 ( P < .05), respectively. Low PA and high IR predicted time to live ICU discharge. CONCLUSION Our study highlights the potential utility of PA and IR as markers to identify patients with low muscularity who may benefit from early and rigorous intervention.
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Affiliation(s)
- Adam Kuchnia
- 1 Food Science and Nutrition, University of Minnesota-Twin Cities, Minnesota, USA
| | - Carrie Earthman
- 1 Food Science and Nutrition, University of Minnesota-Twin Cities, Minnesota, USA
| | - Levi Teigen
- 1 Food Science and Nutrition, University of Minnesota-Twin Cities, Minnesota, USA
| | - Abigail Cole
- 1 Food Science and Nutrition, University of Minnesota-Twin Cities, Minnesota, USA
| | | | - Michael Paris
- 2 Kinesiology, University of Waterloo, Waterloo, Ontario, Canada
| | - Willem Looijaard
- 3 Department of Intensive Care Medicine, VU University Medical Center Amsterdam, Amsterdam, the Netherlands
| | - Peter Weijs
- 3 Department of Intensive Care Medicine, VU University Medical Center Amsterdam, Amsterdam, the Netherlands
| | | | - Gregory Beilman
- 4 Division of Critical Care/Acute Care Surgery, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Andrew Day
- 5 Clinical Evaluation Research Unit, Kingston General Hospital and Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | - Roger Leung
- 5 Clinical Evaluation Research Unit, Kingston General Hospital and Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | - Charlene Compher
- 6 School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rupinder Dhaliwal
- 5 Clinical Evaluation Research Unit, Kingston General Hospital and Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | - Sarah Peterson
- 7 Food and Nutrition, Rush University Medical Center, Chicago, Illinois, USA
| | - Hannah Roosevelt
- 7 Food and Nutrition, Rush University Medical Center, Chicago, Illinois, USA
| | - Daren K Heyland
- 5 Clinical Evaluation Research Unit, Kingston General Hospital and Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
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Yashiro M, Ochiai M, Yanai Y, Kotera H, Iehara N. Patient-Specific Relationship Between Hydraulic Permeability of Microvasculature and the Extent of Burden of Excess Fluid in Hemodialysis Patients. Ther Apher Dial 2016; 20:492-500. [DOI: 10.1111/1744-9987.12414] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 01/08/2016] [Accepted: 01/13/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Masatomo Yashiro
- Division of Medical Engineering, Faculty of Medical Care Sciences; Himeji Dokkyo University; Hyogo Japan
| | - Miyuki Ochiai
- Division of Nephrology; Kyoto City Hospital; Kyoto Japan
| | - Yuko Yanai
- Division of Nephrology; Kyoto City Hospital; Kyoto Japan
| | - Hirohisa Kotera
- Division of Medical Engineering, Faculty of Medical Care Sciences; Himeji Dokkyo University; Hyogo Japan
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21
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Samoni S, Vigo V, Reséndiz LIB, Villa G, De Rosa S, Nalesso F, Ferrari F, Meola M, Brendolan A, Malacarne P, Forfori F, Bonato R, Donadio C, Ronco C. Impact of hyperhydration on the mortality risk in critically ill patients admitted in intensive care units: comparison between bioelectrical impedance vector analysis and cumulative fluid balance recording. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:95. [PMID: 27060079 PMCID: PMC4826521 DOI: 10.1186/s13054-016-1269-6] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 03/22/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Studies have demonstrated a positive correlation between fluid overload (FO) and adverse outcomes in critically ill patients. The present study aims at defining the impact of hyperhydration on the Intensive Care Unit (ICU) mortality risk, comparing Bioelectrical Impedance Vector Analysis (BIVA) assessment with cumulative fluid balance (CFB) recording. METHODS We performed a prospective, dual-centre, clinician-blinded, observational study of consecutive patients admitted to ICU with an expected length of ICU stay of at least 72 hours. During observational period (72-120 hours), CFB was recorded and cumulative FO was calculated. At the admission and daily during the observational period, BIVA was performed. We considered FO between 5% and 9.99% as moderate and a FO ≥ 10% as severe. According to BIVA hydration scale of lean body mass, patients were classified as normohydrated (>72.7%-74.3%), mild (>71%-72.7%), moderate (>69%-71%) and severe (≤ 69%) dehydrated and mild (>74.3%-81%), moderate (>81%-87%) and severe (>87%) hyperhydrated. Two multivariate logistic regression models were performed: the ICU mortality was the response variable, while the predictor variables were hyperhydration, measured by BIVA (BIVA model), and FO (FO model). A p-value <0.05 was considered to indicate statistical significance. RESULTS One hundred and twenty-five patients were enrolled (mean age 64.8 ± 16.0 years, 65.6% male). Five hundred and fifteen BIVA measurements were performed. The mean CFB recorded at the end of the observational period was 2.7 ± 4.1 L, while the maximum hydration of lean body mass estimated by BIVA was 83.67 ± 6.39%. Severe hyperhydration measured by BIVA was the only variable found to be significantly associated with ICU mortality (OR 22.91; 95% CI 2.38-220.07; p < 0.01). CONCLUSIONS The hydration status measured by BIVA seems to predict mortality risk in ICU patients better than the conventional method of fluid balance recording. Moreover, it appears to be safe, easy to use and adequate for bedside evaluation. Randomized clinical trials with an adequate sample size are needed to validate the diagnostic properties of BIVA in the goal-directed fluid management of critically ill patients in ICU.
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Affiliation(s)
- Sara Samoni
- Institute of Life Sciences, Sant'Anna School of Advanced Studies, Pisa, Italy. .,Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, International Renal Research Institute Vicenza (IRRIV), Viale Rodolfi, 37, 36100, Vicenza, Italy.
| | - Valentina Vigo
- Department of Clinical & Experimental Medicine, University of Pisa, Pisa, Italy
| | - Luis Ignacio Bonilla Reséndiz
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, International Renal Research Institute Vicenza (IRRIV), Viale Rodolfi, 37, 36100, Vicenza, Italy
| | - Gianluca Villa
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, International Renal Research Institute Vicenza (IRRIV), Viale Rodolfi, 37, 36100, Vicenza, Italy
| | - Silvia De Rosa
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, International Renal Research Institute Vicenza (IRRIV), Viale Rodolfi, 37, 36100, Vicenza, Italy
| | - Federico Nalesso
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, International Renal Research Institute Vicenza (IRRIV), Viale Rodolfi, 37, 36100, Vicenza, Italy
| | - Fiorenza Ferrari
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, International Renal Research Institute Vicenza (IRRIV), Viale Rodolfi, 37, 36100, Vicenza, Italy.,Department of Anaesthesiology and Intensive Care, San Bortolo Hospital, Vicenza, Italy
| | - Mario Meola
- Institute of Life Sciences, Sant'Anna School of Advanced Studies, Pisa, Italy.,Department of Clinical & Experimental Medicine, University of Pisa, Pisa, Italy
| | - Alessandra Brendolan
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, International Renal Research Institute Vicenza (IRRIV), Viale Rodolfi, 37, 36100, Vicenza, Italy
| | - Paolo Malacarne
- Department of Anaesthesia and Intensive Care Unit 6, Cisanello Hospital, Pisa, Italy
| | - Francesco Forfori
- Department of Anaesthesia and Intensive Care Unit 4, Cisanello Hospital, Pisa, Italy
| | - Raffaele Bonato
- Department of Anaesthesiology and Intensive Care, San Bortolo Hospital, Vicenza, Italy
| | - Carlo Donadio
- Department of Clinical & Experimental Medicine, University of Pisa, Pisa, Italy
| | - Claudio Ronco
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, International Renal Research Institute Vicenza (IRRIV), Viale Rodolfi, 37, 36100, Vicenza, Italy
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Flury S, Trachsler J, Schwarz A, Ambühl PM. Quantification of excretory renal function and urinary protein excretion by determination of body cell mass using bioimpedance analysis. BMC Nephrol 2015; 16:174. [PMID: 26508208 PMCID: PMC4624191 DOI: 10.1186/s12882-015-0171-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Accepted: 10/19/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Creatinine clearance (CrCl) based on 24 h urine collection is an established method to determine glomerular filtration rate (GFR). However, its measurement is cumbersome and the results are frequently inaccurate. The aim of this study was to develop an alternative method to predict CrCl and urinary protein excretion based on plasma creatinine and the quantification of muscle mass through bioimpedance analysis (BIA). METHODS In 91 individuals with normal and impaired renal function CrCl was measured from 24 h urine excretion and plasma creatinine concentration. A model to predict 24 h-creatininuria was developed from various measurements assessing muscle mass such as body cell mass (BCM) and fat free mass (FFM) obtained by BIA, skinfold caliper and other techniques (training group, N = 60). Multivariate regression analysis was performed to predict 24 h-creatininuria and to calculate CrCl. A validation group (N = 31) served to compare predicted and measured CrCl. RESULTS Overall (accuracy, bias, precision, correlation) the new BIA based prediction model performed substantially better compared with measured CrCl (P15 = 87 %, bias = 0, IQR of differences = 7.9 mL/min/1.73 m(2), R = 0.972) versus established estimation formulas such as the 4vMDRD (P15 = 6 %, bias = -8.3 mL/min/1.73 m(2), IQR = 13.7 mL/min/1.73 m(2), R = 0.935), CKD-EPI (P15 = 29 %, bias = -7.0 mL/min/1.73 m(2), IQR = 12.1 mL/min/1.73 m(2), R = 0.932, Cockcroft-Gault equations (P15 = 55 %, bias = -4.4 mL/min/1.73 m(2), IQR = 9.0 mL/min/1.73 m(2), R = 0.920). The superiority of the new method over established prediction formulas was most obvious in a subgroup of individuals with BMI > 30 kg/m(2) and in a subgroup with CrCl > 60 mL/min/1.73 m(2). Moreover, 24 h urinary protein excretion could be estimated accurately by normalization with 24 h-creatininuria derived from BIA based BCM. CONCLUSION Prediction of CrCl based on estimated urinary creatinine excretion determined from measurement of BCM by BIA technique is both accurate and convenient to quantify renal function in normal and diseased states. This new method may become particularly helpful for the evaluation of patients with borderline renal insufficiency and/or with abnormal body composition.
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Affiliation(s)
- Stefan Flury
- Division of Nephrology, Stadtspital Waid, Tièchestrasse 99, 8037, Zürich, Switzerland. .,Current address: Imperial College Renal and Transplant Centre, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK.
| | - Johannes Trachsler
- Division of Nephrology, Stadtspital Waid, Tièchestrasse 99, 8037, Zürich, Switzerland.
| | - Albin Schwarz
- Division of Nephrology, Stadtspital Waid, Tièchestrasse 99, 8037, Zürich, Switzerland.
| | - Patrice M Ambühl
- Division of Nephrology, Stadtspital Waid, Tièchestrasse 99, 8037, Zürich, Switzerland.
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Donadio C, Bozzoli L, Colombini E, Pisanu G, Ricchiuti G, Picano E, Gargani L. Effective and timely evaluation of pulmonary congestion: qualitative comparison between lung ultrasound and thoracic bioelectrical impedance in maintenance hemodialysis patients. Medicine (Baltimore) 2015; 94:e473. [PMID: 25674735 PMCID: PMC4602752 DOI: 10.1097/md.0000000000000473] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The assessment of pulmonary congestion in maintenance hemodialysis (MHD) patients is challenging. Bioelectrical impedance analysis (BIA) can estimate body water compartments. Natriuretic peptides are markers of hemodynamic stress, neurohormonal activation and extracellular volume overload. Lung ultrasound (LUS) has been proposed for the non-invasive estimation of extravascular lung water through B-lines assessment. Up to now, no study evaluated the correlation between B-lines, segmental thoracic BIA, and natriuretic peptides in MHD patients. The aims of this study were: (1) To validate LUS as a tool for an effective and timely evaluation of pulmonary congestion in MHD patients, in comparison with segmental thoracic BIA, and with natriuretic peptides; (2) To compare a comprehensive whole chest ultrasound scanning with a simplified and timely scanning scheme limited to the lateral chest regions.Thirty-one MHD adult patients were examined. LUS, total body and thoracic BIA, and natriuretic peptides were performed immediately before and after a mid-week dialysis session. The number of B-lines assessed by LUS was compared with total body and thoracic impedance data and with natriuretic peptides.Pre-HD B-lines ranged 0-147 (mean 31) and decreased significantly post-HD (mean 16, P < 0.001). A significant correlation was found between the number of B-lines and extra-cellular water index (ECWI, r = 0.45, P < 0.001), with thoracic impedance (r = 0.30, P < 0.05), and with BNP (r = 0.57, P < 0.01). The dynamic changes in B-lines correlated better with thoracic impedance than with total body impedance, and correlated with extra-cellular but not with intra-cellular water index. The correlation between B-lines and ECWI was similar when LUS was limited to the lateral chest regions or performed on the whole chest. Multivariate analysis showed that only segmental thoracic impedance was an independent predictor of residual pulmonary congestion.The dynamic changes in B-lines after hemodialysis are correlated to the changes in total body and extra-cellular water, and particularly to lung fluids removal. B-line assessment in MHD patients is highly feasible with a simplified and timely scanning scheme limited to the lateral chest regions. These premises make B-lines a promising biomarker for a bedside assessment of pulmonary congestion in MHD patients.
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Affiliation(s)
- Carlo Donadio
- From the Department of Clinical and Experimental Medicine, Division of Nephrology, School of Nephrology, University of Pisa, Pisa, Italy (CD, LB, EC, GP, GR); Institute of Clinical Physiology, National Research Council, Pisa, Italy (EP, LG)
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Boos CJ, Holdsworth DA, Hall DP, Mellor A, O'Hara J, Woods DR. Comparison of two methods of assessing total body water at sea level and increasing high altitude. Clin Physiol Funct Imaging 2014; 34:478-84. [DOI: 10.1111/cpf.12121] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Accepted: 12/02/2013] [Indexed: 11/30/2022]
Affiliation(s)
- C. J. Boos
- Defence Medical Services; Department of Postgraduate Medicine; Lichfield UK
- Department of Cardiology; Poole Hospital NHS Foundation Trust; Dorset UK
- Centre of Postgraduate Medical Research & Education; Bournemouth University; Bournemouth UK
- Department of Cardiology; Royal Berkshire Hospital; Reading UK
| | - D. A. Holdsworth
- Defence Medical Services; Department of Postgraduate Medicine; Lichfield UK
- Department of Cardiology; Poole Hospital NHS Foundation Trust; Dorset UK
| | - D. P. Hall
- Defence Medical Services; Department of Postgraduate Medicine; Lichfield UK
- Department of Anaesthesia; Western General Hospital; Edinburgh UK
| | - A. Mellor
- Defence Medical Services; Department of Postgraduate Medicine; Lichfield UK
- James Cook University Hospital; Middlesborough UK
- Leeds Metropolitan University; 104 Carnegie Research Institute (CRI); Leeds UK
| | - J. O'Hara
- Leeds Metropolitan University; 104 Carnegie Research Institute (CRI); Leeds UK
| | - D. R. Woods
- Defence Medical Services; Department of Postgraduate Medicine; Lichfield UK
- Department of Medicine; Royal Victoria Infirmary and Northumbria NHS Foundation Trust; Newcastle upon Tyne UK
- University of Newcastle; Newcastle upon Tyne UK
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Morishita Y, Kubo K, Haga Y, Miki A, Ishibashi K, Kusano E, Nagata D. Skeletal muscle loss is negatively associated with single-pool Kt/V and dialysis duration in hemodialysis patients. Ther Apher Dial 2014; 18:612-7. [PMID: 24674153 DOI: 10.1111/1744-9987.12174] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
We evaluated the skeletal muscle loss in hemodialysis (HD) patients by bioelectrical impedance analysis (BIA) and handgrip strength test. Thirty-four HD patients and 16 healthy subjects (control group) were measured for skeletal muscle mass normalized as the skeletal muscle mass index (SMI), calculated as skeletal muscle mass (kg)/height (m)(2) using a tetrapolar bioelectrical impedance plethysmograph. Handgrip strength test was also performed using a hand dynamometer in both groups. In HD patients, the associations of SMI and handgrip strength with age, sex, HD conditions, and HD parameters such as body mass index (BMI), single-pool Kt/V (spKt/V), normalized protein catabolic rate (nPCR), creatinine generation rate (CGR) and serum albumin level (Alb) were investigated. SMI of HD patients (4.58 ± 0.95 kg/m(2) ) was significantly lower than that of the control group (5.55 ± 0.80 kg/m(2) , P<0.01). The handgrip strength of HD patients (19.9 ± 7.74 kg) was also significantly lower than that of the control group (33.0 ± 8.94 kg, P<0.01). In HD patients, HD duration was associated with both SMI and handgrip strength. Among HD parameters, spKt/V was negatively associated with both SMI and handgrip strength, BMI and Alb were positively associated with SMI, while nPCR and CGR were associated with neither SMI nor handgrip strength. HD duration independently contributed to skeletal muscle loss and the value of spKt/V may be affected by skeletal muscle loss in HD patients.
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Affiliation(s)
- Yoshiyuki Morishita
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan; Department of Dialysis Center, Haga Red Cross Hospital, Mooka, Tochigi, Japan
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Ismael S, Savalle M, Trivin C, Gillaizeau F, D'Auzac C, Faisy C. The consequences of sudden fluid shifts on body composition in critically ill patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:R49. [PMID: 24666889 PMCID: PMC4057272 DOI: 10.1186/cc13794] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Accepted: 03/13/2014] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Estimation of body composition as fat-free mass (FFM) is subjected to many variations caused by injury and stress conditions in the intensive care unit (ICU). Body cell mass (BCM), the metabolically active part of FFM, is reported to be more specifically correlated to changes in nutritional status. Bedside estimation of BCM could help to provide more valuable markers of nutritional status and may promote understanding of metabolic consequences of energy deficit in the ICU patients. We aimed to quantify BCM, water compartments and FFM by methods usable at the bedside for evaluating the impact of sudden and massive fluid shifts on body composition in ICU patients. METHODS We conducted a prospective experimental study over an 6 month-period in a 18-bed ICU. Body composition of 31 consecutive hemodynamically stable patients requiring acute renal replacement therapy for fluid overload (ultrafiltration ≥5% body weight) was investigated before and after the hemodialysis session. Intra-(ICW) and extracellular (ECW) water volumes were calculated from the raw values of the low- and high-frequency resistances measured by multi-frequency bioelectrical impedance. BCM was assessed by a calculated method recently developed for ICU patients. FFM was derived from BCM and ECW. RESULTS Intradialytic weight loss was 3.8 ± 0.8 kg. Percentage changes of ECW (-7.99 ± 4.60%) and of ICW (-7.63 ± 5.11%) were similar, resulting ECW/ICW ratio constant (1.26 ± 0.20). The fall of FFM (-2.24 ± 1.56 kg, -4.43 ± 2.65%) was less pronounced than the decrease of ECW (P < 0.001) or ICW (P < 0.001). Intradialytic variation of BCM was clinically negligible (-0.38 ± 0.93 kg, -1.56 ± 3.94%) and was significantly less than FFM (P < 0.001). CONCLUSIONS BCM estimation is less driven by sudden massive fluid shifts than FMM. Assessment of BCM should be preferred to FFM when severe hydration disturbances are present in ICU patients.
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Morishita Y, Kubo K, Miki A, Ishibashi K, Kusano E, Nagata D. Positive association of vigorous and moderate physical activity volumes with skeletal muscle mass but not bone density or metabolism markers in hemodialysis patients. Int Urol Nephrol 2014; 46:633-9. [DOI: 10.1007/s11255-014-0662-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2013] [Accepted: 01/30/2014] [Indexed: 12/31/2022]
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Sanders JE, Cagle JC, Harrison DS, Myers TR, Allyn KJ. How does adding and removing liquid from socket bladders affect residual-limb fluid volume? JOURNAL OF REHABILITATION RESEARCH AND DEVELOPMENT 2013; 50:845-60. [PMID: 24203546 DOI: 10.1682/jrrd.2012.06.0121] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Adding and removing liquid from socket bladders is a means for people with limb loss to accommodate residual-limb volume change. We fit 19 people with transtibial amputation using their regular prosthetic socket with fluid bladders on the inside socket surface to undergo cycles of bladder liquid addition and removal. In each cycle, subjects sat, stood, and walked for 90 s with bladder liquid added, and then sat, stood, and walked for 90 s again with the bladder liquid removed. The amount of bladder liquid added was increased in each cycle. We used bioimpedance analysis to measure residual-limb fluid volume. Results showed that the preferred bladder liquid volume was 16.8 +/- 8.4 mL (mean +/- standard deviation), corresponding with 1.7% +/- 0.8% of the average socket volume between the bioimpedance voltage-sensing electrodes. Residual-limb fluid volume driven out of the residual limb when bladder liquid was added was typically not recovered upon subsequent bladder liquid removal. Of the 19 subjects, 15 experienced a gradual residual-limb fluid volume loss over the test session. Care should be taken when implementing adjustable socket technologies in people with limb loss. Reducing socket volume may accentuate residual-limb fluid volume loss.
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Affiliation(s)
- Joan E Sanders
- University of Washington, 3720 15th Ave NE, Seattle, WA 98195.
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Çelik G, Yöntem M, Cilo M, Bilge M, Mehmetoğlu İ, Ünaldi M. The relationship between glutathione peroxidase and bioimpedance parameters in nondiabetic hemodialysis patients. Hemodial Int 2013; 16:274-81. [PMID: 22099743 DOI: 10.1111/j.1542-4758.2011.00628.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
There is growing evidence from experimental and clinical studies that oxidative stress is involved in the pathogenesis of malnutrition. This cross-sectional study aimed to investigate the relationship between glutathione peroxidase (GPx) levels as a marker of antioxidant status and the nutritional status assessed by bioimpedance analysis (BIA). Ninety-seven nondiabetic stable outpatient uremic adults undergoing chronic hemodialysis (HD) were recruited for this study. Impedance measurements were performed using a multifrequency bioelectrical impedance analyzer after dialysis. GPx levels correlated with intracellular water (ICW) (r = 0.341, P = 0.011), ICW/total body weight (r = 0.320, P = 0.017), lean body mass (r = 0.300, P = 0.026) and total body cell mass (r = 0.339, P = 0.011). When patients were divided into two groups according to mean GPx levels (83.9 U/gr hemoglobin), the patients with higher GPx (GPx > 83.9 U/gr hemoglobin) had higher albumin (P = 0.038), lean body mass (P = 0.026), ICW (P = 0.011), and total body cell mass (P = 0.011) compared with those with lower GPx (GPx ≤ 83.9 U/gr hemoglobin). Furthermore, in the patients with higher GPx, body fat; extracellular water/total body water; illness marker and body fat mass index were lower than other group. In conclusion, our results reveal correlation indicating a relationship between antioxidant status (as measured by GPx) and nutritional status as assessed by BIA in nondiabetic HD patients.
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Affiliation(s)
- Gülperi Çelik
- Division of Nephrology, Department of Internal Medicine, Selçuklu School of Medicine, Selçuk University, Konya, Turkey.
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Demirci C, Ozkahya M, Demirci MS, Asci G, Kose T, Colak T, Duman S, Toz H, Ergin P, Adam SM, Ok E. Effects of three times weekly eight-hour nocturnal hemodialysis on volume and nutritional status. Am J Nephrol 2013; 37:559-67. [PMID: 23735837 DOI: 10.1159/000351182] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 04/01/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND This prospective cohort study compared the changes in body water composition and nutritional parameters measured with multifrequency bioimpedance analysis between 8-hour three times weekly nocturnal hemodialysis (NHD) and 4-hour conventional hemodialysis (CHD) patients. PATIENTS AND METHODS 55 patients on CHD and 57 patients on NHD were included in the study. Multifrequency bioimpedance analysis was performed at baseline and at the 12th month. The primary outcomes of the study were changes in extracellular water (ECW), fat mass, dry lean mass and phase angle. Secondary outcomes of the study included changes in blood pressure and biochemical parameters related to nutrition and inflammation. RESULTS ECW/height values decreased in the NHD group, while they increased in the CHD group. Fat mass, dry lean mass, and serum albumin increased and high sensitive CRP decreased in the NHD group but did not change in the CHD group. When changes in parameters from baseline to the 12th month between the groups were compared, NHD was associated with improvement in volume parameter including ECW/height (difference -0.44 l/m, p < 0.001). Change in blood pressure was not different between the groups, however requirement for antihypertensive medication decreased from 26.5 to 8.5% in the NHD group (p = 0.002). NHD was also associated with increases in fat mass (difference 1.8 kg, p < 0.001), dry lean mass (difference 0.6 kg, p = 0.006), serum albumin (difference 0.19 g/dl, p < 0.001) and cholesterol (difference 18.8 mg, p < 0.001). Phase angle values decreased in the CHD group but did not change in the NHD group (difference between the groups 0.37°, p = 0.04). CONCLUSION This study revealed that longer HD facilitates volume control and improves nutritional status.
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Affiliation(s)
- Cenk Demirci
- Division of Nephrology, Fresenius Medical Care Turkey Clinics, Izmir, Turkey.
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CHUA HORNGRUEY, XIANG LING, CHOW PEKYEE, XU HUI, SHEN LIANG, LEE EVAN, TEO BOONWEE. Quantifying acute changes in volume and nutritional status during haemodialysis using bioimpedance analysis. Nephrology (Carlton) 2012; 17:695-702. [DOI: 10.1111/j.1440-1797.2012.01653.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Sanders JE, Harrison DS, Myers TR, Allyn KJ. Effects of elevated vacuum on in-socket residual limb fluid volume: case study results using bioimpedance analysis. ACTA ACUST UNITED AC 2012; 48:1231-48. [PMID: 22234667 DOI: 10.1682/jrrd.2010.11.0219] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Bioimpedance analysis was used to measure the residual limb fluid volume of seven transtibial amputee subjects using elevated vacuum sockets and nonelevated vacuum sockets. Fluid volume changes were assessed during sessions with the subjects sitting, standing, and walking. In general, fluid volume losses during 3 or 5 min walks and losses over the course of the 30 min test session were less for elevated vacuum than for suction. Numerous variables, including the time of day that data were collected, soft tissue consistency, socket-to-limb size and shape differences, and subject health, may have affected the results and had an equivalent or greater effect on limb fluid volume compared with elevated vacuum. Researchers should well consider these variables in the study design of future investigations on the effects of elevated vacuum on residual limb volume.
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Affiliation(s)
- Joan E Sanders
- University of Washington-Bioengineering, 3720 15th Ave NE, University of Washington, Seattle, WA 98195, USA.
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Donadio C, Kanaki A, Caprio F, Donadio E, Tognotti D, Olivieri L. Prediction of glomerular filtration rate from serum concentration of cystatin C: comparison of two analytical methods. Nephrol Dial Transplant 2012; 27:2826-38. [DOI: 10.1093/ndt/gfs010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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Çelik G, Oc B, Kara I, Yılmaz M, Yuceaktas A, Apiliogullari S. Comparison of nutritional parameters among adult and elderly hemodialysis patients. Int J Med Sci 2011; 8:628-34. [PMID: 22022216 PMCID: PMC3198259 DOI: 10.7150/ijms.8.628] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2011] [Accepted: 08/02/2011] [Indexed: 11/13/2022] Open
Abstract
AIM The aim of this study was to compare the nutritional biochemical parameters, prealbumin levels, and bioimpedance analysis parameters of adult and elderly hemodialysis (HD) patients. METHODS This prospective cross-sectional study included 50 adult HD patients (42.0 % female). Nutritional status was assessed by post-dialysis multifrequency bioimpedance analysis (BIA), serum prealbumin and other nutritional biochemical parameters. RESULTS Mean age of patients was 57.4±15.1 years (range: 30-83 years) and mean dialysis duration was 68.3 ± 54.5 months (range: 3-240 months). When the patients were divided into two groups according to age of patients (<65 and ≥65), prealbumin (p=0.003), blood urea nitrogen (BUN) (p=0.000), serum creatinine (p=0.013), albumin (p=0.016), protein catabolic rate per normalized body weight (nPCR) (p=0.001), intracellular water (ICW)/total body weight (0.003) , body fat mass (p00.000), lean body mass (p=0.031), lean dry mass (p=0.001), illness marker (p=0.005), basal metabolism (p=0.007), body mass index (BMI) (p=0.028), body fat mass index (BFMI) (p=0.000), fat free mass index (FFMI) (p=0.040) values were significantly different between the groups. In the elderly patients (age ≥65), body fat mass, illness marker, BMI, BFMI were higher compared to adult patients (age <65). Additionally, in the elderly patients, prealbumin, BUN, creatinine, albumin, nPCR, ICW/ total body weight, lean body weight, lean dry weight, basal metabolism and FFMI were lower than adult patients. CONCLUSIONS Our results indicate that BFMI were higher, albumin, prealbumin, nPCR and lean body mass and FFMI were lower in elderly patients compared to adults. These results imply that elderly HD patients may be prone sarcopenic obesity and may require special nutritional support.
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Affiliation(s)
- Gülperi Çelik
- Department Internal Medicine, Division of Nephrology, Faculty of Medicine, Selcuk University, Konya, Turkey.
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Avram MM, Fein PA, Borawski C, Chattopadhyay J, Matza B. Extracellular mass/body cell mass ratio is an independent predictor of survival in peritoneal dialysis patients. Kidney Int 2010:S37-40. [DOI: 10.1038/ki.2010.192] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Sanders JE, Harrison DS, Allyn KJ, Myers TR. Clinical utility of in-socket residual limb volume change measurement: case study results. Prosthet Orthot Int 2009; 33:378-90. [PMID: 19961297 PMCID: PMC4435543 DOI: 10.3109/03093640903214067] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Bioimpedance analysis was used to measure conductive tissue extracellular fluid (ECF) volume changes in the residual limbs of four unilateral transtibial amputee subjects during standing and walking conditions. Results showed that all residual limbs experienced ECF volume decreases during 5 min standing intervals. During 5 min of walking immediately after a standing interval, the residual limbs of healthy subjects increased in ECF volume while those of diseased subjects, one with peripheral vascular disease and another with cardiovascular insufficiency and a high-salt intake, decreased. One subject demonstrated less absolute value ECF volume change during standing and walking at 12 months post-surgical revision compared with at six months. Presentation of bioimpedance data to patients improved compliance to practitioner recommendations and patient understanding. Results were useful towards clinical assessment, patient education, and decision-making about treatment.
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Affiliation(s)
- Joan E Sanders
- Department of Bioengineering, University of Washington, Seattle, WA 98195-5061, USA.
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Donadio C, Halim AB, Caprio F, Grassi G, Khedr B, Mazzantini M. Single- and multi-frequency bioelectrical impedance analyses to analyse body composition in maintenance haemodialysis patients: comparison with dual-energy x-ray absorptiometry. Physiol Meas 2008; 29:S517-24. [DOI: 10.1088/0967-3334/29/6/s43] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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