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Ng JKC, Lau SLF, Chan GCK, Tian N, Li PKT. Nutritional Assessments by Bioimpedance Technique in Dialysis Patients. Nutrients 2023; 16:15. [PMID: 38201845 PMCID: PMC10780416 DOI: 10.3390/nu16010015] [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: 10/23/2023] [Revised: 12/11/2023] [Accepted: 12/12/2023] [Indexed: 01/12/2024] Open
Abstract
Bioelectrical impedance analysis (BIA) has been extensively applied in nutritional assessments on the general population, and it is recommended in establishing the diagnosis of malnutrition and sarcopenia. The bioimpedance technique has become a promising modality through which to measure the whole-body composition in dialysis patients, where the presence of subclinical volume overload and sarcopenic obesity may be overlooked by assessing body weight alone. In the past two decades, bioimpedance devices have evolved from applying a single frequency to a range of frequencies (bioimpedance spectroscopy, BIS), in which the latter is incorporated with a three-compartment model that allows for the simultaneous measurement of the volume of overhydration, adipose tissue mass (ATM), and lean tissue mass (LTM). However, clinicians should be aware of common potential limitations, such as the adoption of population-specific prediction equations in some BIA devices. Inherent prediction error does exist in the bioimpedance technique, but the extent to which this error becomes clinically significant remains to be determined. Importantly, reduction in LTM has been associated with increased risk of frailty, hospitalization, and mortality in dialysis patients, whereas the prognostic value of ATM remains debatable. Further studies are needed to determine whether modifications of bioimpedance-derived body composition parameters through nutrition intervention can result in clinical benefits.
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Affiliation(s)
- Jack Kit-Chung Ng
- Carol and Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong 999077, China; (J.K.-C.N.); (S.L.-F.L.); (G.C.-K.C.)
| | - Sam Lik-Fung Lau
- Carol and Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong 999077, China; (J.K.-C.N.); (S.L.-F.L.); (G.C.-K.C.)
| | - Gordon Chun-Kau Chan
- Carol and Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong 999077, China; (J.K.-C.N.); (S.L.-F.L.); (G.C.-K.C.)
| | - Na Tian
- Department of Nephrology, General Hospital of Ningxia Medical University, Yinchuan 750004, China;
| | - Philip Kam-Tao Li
- Carol and Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong 999077, China; (J.K.-C.N.); (S.L.-F.L.); (G.C.-K.C.)
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Verger C, Ronco C, Van Biesen W, Heaf J, Vrtovsnik F, Vera Rivera M, Puide I, Azar R, Gauly A, Atiye S, De Los Ríos T. Association of Prescription With Body Composition and Patient Outcomes in Incident Peritoneal Dialysis Patients. Front Med (Lausanne) 2022; 8:737165. [PMID: 35004718 PMCID: PMC8738083 DOI: 10.3389/fmed.2021.737165] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 11/22/2021] [Indexed: 02/03/2023] Open
Abstract
Objective: The nutritional status of patients on peritoneal dialysis (PD) is influenced by patient- and disease-related factors and lifestyle. This analysis evaluated the association of PD prescription with body composition and patient outcomes in the prospective incident Initiative for Patient Outcomes in Dialysis–Peritoneal Dialysis (IPOD-PD) patient cohort. Design and Methods: In this observational, international cohort study with longitudinal follow-up of 1,054 incident PD patients, the association of PD prescription with body composition was analyzed by using the linear mixed models, and the association of body composition with death and change to hemodialysis (HD) by means of a competing risk analysis combined with a spline analysis. Body composition was regularly assessed with the body composition monitor, a device applying bioimpedance spectroscopy. Results: Age, time on PD, and the use of hypertonic and polyglucose solutions were significantly associated with a decrease in lean tissue index (LTI) and an increase in fat tissue index (FTI) over time. Competing risk analysis revealed a U-shaped association of body mass index (BMI) with the subdistributional hazard ratio (HR) for risk of death. High LTI was associated with a lower subdistributional HR, whereas low LTI was associated with an increased subdistributional HR when compared with the median LTI as a reference. High FTI was associated with a higher subdistributional HR when compared with the median as a reference. Subdistributional HR for risk of change to HD was not associated with any of the body composition parameters. The use of polyglucose or hypertonic PD solutions was predictive of an increased probability of change to HD, and the use of biocompatible solutions was predictive of a decreased probability of change to HD. Conclusion: Body composition is associated with non-modifiable patient-specific and modifiable treatment-related factors. The association between lean tissue and fat tissue mass and death and change to HD in patients on PD suggests developing interventions and patient counseling to improve nutritional markers and, ultimately, patient outcomes. Study Registration: The study has been registered at Clinicaltrials.gov (NCT01285726).
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Affiliation(s)
- Christian Verger
- Registre de Dialyse Péritonéale de Langue Française, Pontoise, France
| | - Claudio Ronco
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute (IRRIV), San Bortolo Hospital, Vicenza, Italy
| | - Wim Van Biesen
- Renal Division, Ghent University Hospital, Ghent, Belgium
| | - James Heaf
- Zealand University Hospital, Roskilde, Denmark
| | | | | | - Ilze Puide
- Pauls Stradins Clinical University Hospital, Riga, Latvia
| | | | - Adelheid Gauly
- Global Medical Office, Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Saynab Atiye
- Global Medical Office, Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Tatiana De Los Ríos
- Global Medical Office, Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
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Wu B, Zhang S, Wang J, Yan W, Gao M, Ge Y, Liu K, Xu X, Yu X, Zhu Y, Xu X, Xing C, Mao H. Ratio of Overhydration and Extracellular Water Versus Ratio of Extracellular Water and Body Cell Mass in the Assessment of Fluid Status in Patients With Acute Kidney Injury Requiring Kidney Replacement Therapy: A Cohort Study. J Ren Nutr 2021; 32:152-160. [PMID: 33727001 DOI: 10.1053/j.jrn.2021.01.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 01/13/2021] [Accepted: 01/16/2021] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES The aim of this study is to analyze the association between the ratio of overhydration and extracellular water (OH/ECW) and the ratio of extracellular water and body cell mass (ECW/BCM) measured by bioelectrical impedance and outcomes of patients with acute kidney injury (AKI) requiring kidney replacement therapy (KRT). METHODS Patients with severe AKI treated with KRT in our hospital between September 2016 and August 2018 were enrolled. These patients were assessed using a body composition monitor before KRT, and on the 3rd day and the 7th day after initiation of KRT. The predictors mainly included OH/ECW and ECW/BCM. The association between all-cause mortality and predictors were analyzed using Cox regression. RESULTS A total of 152 patients were included in this study with a median follow-up of 39 (interquartile range 8-742) days. The 28-day mortality, 90-day mortality, and 1-year mortality were 46.7%, 54.6%, and 60.5%, respectively. A high ratio of OH/ECW (adjusted hazard ratio per standard deviation, 1.45; 95% confidence interval = 1.15-1.82, P = .002) and a high ratio of ECW/BCM (adjusted hazard ratio per standard deviation, 1.33, 95% confidence interval = 1.07-1.64, P = .009) before KRT were associated with all-cause mortality during follow-up. Higher ECW/BCM rather than OH/ECW at 7th day was associated with poorer outcomes. Furthermore, a reduction of OH/ECW with an increase of ECW/BCM had higher 1-year mortality as compared to others (85.7% vs. 51.2%, P = .004) in patients who survived 7 days after KRT initiation. CONCLUSIONS ECW/BCM performed better than OH/ECW in assessment of fluid status in AKI patients requiring KRT. This study suggested that a simple reduction of OH/ECW without decreasing ECW/BCM may not improve outcomes.
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Affiliation(s)
- Buyun Wu
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, People's Republic of China
| | - Sufeng Zhang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, People's Republic of China; Department of Nephrology, Tongling People's Hospital, Tongling, People's Republic of China
| | - Junfeng Wang
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Wenyan Yan
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, People's Republic of China
| | - Min Gao
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, People's Republic of China
| | - Yifei Ge
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, People's Republic of China
| | - Kang Liu
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, People's Republic of China
| | - Xueqiang Xu
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, People's Republic of China
| | - Xiangbao Yu
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, People's Republic of China
| | - Yamei Zhu
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, People's Republic of China
| | - Xianrong Xu
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, People's Republic of China
| | - Changying Xing
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, People's Republic of China
| | - Huijuan Mao
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, People's Republic of China.
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Wu B, Peng Y, Zhang S, Yan W, Gao M, Ge Y, Liu K, Xu X, Yu X, Zhu Y, Xu X, Xing C, Mao H. Body Composition Analysis as a Predictor of Prognosis for Patients With Acute Kidney Injury Requiring Kidney Replacement Therapy. J Ren Nutr 2021; 31:560-568.e2. [PMID: 33678546 DOI: 10.1053/j.jrn.2020.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 11/12/2020] [Accepted: 12/27/2020] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVES The aim of this study is to investigate the association between body composition, measured by bioelectrical impedance analysis, and outcomes in patients with acute kidney injury (AKI) receiving kidney replacement therapy (KRT). METHODS Patients with severe AKI treated with KRT in our hospital between September 2016 and August 2018 were enrolled. These patients were assessed by body composition analysis before KRT, and on the 3rd day and the 7th day after initiation of KRT. The predictors included lean tissue index (LTI), fat tissue index, and body cell mass index (BCMI). The association between all-cause mortality and predictors was analyzed using Cox regression. RESULTS A total of 152 patients were included in this study, with a 28-day mortality of 46.7% and 1-year mortality of 60.5%. LTI (adjusted hazard ratio per standard deviation: 0.37; 95% confidence interval = 0.21-0.66, P < .001) and BCMI (adjusted hazard ratio per standard deviation: 0.37; 95% confidence interval = 0.21-0.67, P < .001) on day 7 after initiation of KRT, rather than before KRT, were associated with mortality during follow-up. LTI and BCMI before KRT were associated with 28-day mortality rather than 1-year mortality. CONCLUSIONS LTI and BCMI before KRT were associated with short-term prognosis, and those on day 7 after KRT initiation were associated with intermediate mortality in patients with AKI requiring KRT.
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Affiliation(s)
- Buyun Wu
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University (Jiangsu Province Hospital), Nanjing, People's Republic of China
| | - Yudie Peng
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University (Jiangsu Province Hospital), Nanjing, People's Republic of China
| | - Sufeng Zhang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University (Jiangsu Province Hospital), Nanjing, People's Republic of China; Department of Nephrology, Tongling People's Hospital, Tongling, People's Republic of China
| | - Wenyan Yan
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University (Jiangsu Province Hospital), Nanjing, People's Republic of China
| | - Min Gao
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University (Jiangsu Province Hospital), Nanjing, People's Republic of China
| | - Yifei Ge
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University (Jiangsu Province Hospital), Nanjing, People's Republic of China
| | - Kang Liu
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University (Jiangsu Province Hospital), Nanjing, People's Republic of China
| | - Xueqiang Xu
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University (Jiangsu Province Hospital), Nanjing, People's Republic of China
| | - Xiangbao Yu
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University (Jiangsu Province Hospital), Nanjing, People's Republic of China
| | - Yamei Zhu
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University (Jiangsu Province Hospital), Nanjing, People's Republic of China
| | - Xianrong Xu
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University (Jiangsu Province Hospital), Nanjing, People's Republic of China
| | - Changying Xing
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University (Jiangsu Province Hospital), Nanjing, People's Republic of China
| | - Huijuan Mao
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University (Jiangsu Province Hospital), Nanjing, People's Republic of China.
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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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Mizuiri S, Nishizawa Y, Doi T, Yamashita K, Shigemoto K, Usui K, Arita M, Naito T, Doi S, Masaki T. Association and predictive value of geriatric nutritional risk index, body composition, or bone mineral density in haemodialysis patients. Nephrology (Carlton) 2020; 26:341-349. [PMID: 33169473 DOI: 10.1111/nep.13826] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 10/20/2020] [Accepted: 10/28/2020] [Indexed: 12/15/2022]
Abstract
AIM Assess the association and predictive value of geriatric nutritional risk index (GNRI), body composition, and bone mineral density (BMD) in haemodialysis (HD) patients. METHODS Laboratory data, body composition parameters measured via body composition monitor, and radius, lumbar spine, femoral neck BMD measured using dual energy X-ray absorptiometry were assessed in all subjects on HD or online haemodiafiltration (HDF) at baseline. Regression analysis for GNRI, Cox proportional hazard analyses and comparison of multiple receiver operating characteristic (ROC) curves were performed. RESULTS Among all 264 patients, age was 65 ± 12 years and dialysis vintage was 79 (39-144) months. GNRI tertile (T)1, T2, and T3 were 88 (85-91), 94 (93-95), and 98 (97-101), respectively. Patients in GNRI T1 had lower fat tissue index (FTI), lean tissue index, and femoral neck, lumbar spine, and distal mid-third radius BMD, but higher overhydration/extracellular fluid than patients in GNRI T2 or T3 (P < .05). GNRI was significantly associated with FTI, lean tissue index, and femoral neck, lumbar spine, and distal mid-third radius BMD (P < .01). GNRI was a significant predictor of 2-year all-cause mortality (HR 0.92, P < .05). Area under the ROC curve for all-cause mortality using traditional risk factors (age, sex, diabetes mellitus, cardiovascular disease, use of vasopressors for dialysis-related hypotension, and C-reactive protein) was 0.67 and changed by adding GNRI (0.78, P < .05), FTI (0.75), or femoral neck BMD (0.66), respectively. CONCLUSION Associations between GNRI, body composition, and BMD were confirmed in HD patients. Combining GNRI with traditional risk factors improved mortality prediction in HD patients.
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Affiliation(s)
- Sonoo Mizuiri
- Division of Nephrology, Ichiyokai Harada Hospital, Hiroshima, Japan
| | | | - Toshiki Doi
- Division of Nephrology, Ichiyokai Harada Hospital, Hiroshima, Japan.,Department of Nephrology, Hiroshima University, Hiroshima, Japan
| | | | | | - Koji Usui
- Ichiyokai Ichiyokai Clinic, Hiroshima, Japan
| | | | | | - Shigehiro Doi
- Department of Nephrology, Hiroshima University, Hiroshima, Japan
| | - Takao Masaki
- Department of Nephrology, Hiroshima University, Hiroshima, Japan
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Comparative Performance of Body Composition Parameters in Prediction of Death in Hospitalized Patients on Maintenance Hemodialysis: A Cohort Study. Sci Rep 2020; 10:10199. [PMID: 32576950 PMCID: PMC7311464 DOI: 10.1038/s41598-020-67019-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 05/29/2020] [Indexed: 01/01/2023] Open
Abstract
We compared the prognostic value of nutritional or volumetric parameters measured by body composition in hospitalized patients on maintenance hemodialysis. We conducted a cohort study to assess the association of different parameters of body composition with all-cause mortality in inpatients admitted to our nephrology department from January 2014 to December 2016. Of the 704 study patients, 160 (22.7%) died during a median follow-up of 33 months. In multivariate adjusted Cox models, higher ratio of extracellular water to body cell mass (ECW/BCM) (adjusted HR per 1-SD, 1.49; 95% CI, 1.19 to 1.85), lower lean tissue index (LTI) (adjusted HR per 1-SD, 0.70; 95% CI, 0.57 to 0.86) and lower body cell mass index (BCMI) (adjusted HR per 1-SD, 0.70; 95% CI, 0.58 to 0.85) were associated with a significantly greater risk of death. When these parameters were added to the fully adjusted model, BCMI performed best in improving the predictability for all-cause mortality (integrated discrimination improvement = 0.02, P = 0.04; net reclassification index = 0.11, P = 0.04). Among body composition indexes, ECW/BCM was the most relevant fluid volume indices to mortality and BCMI and LTI were the most relevant nutritional status indices to mortality in maintenance hemodialysis patients.
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Broers NJH, Canaud B, Dekker MJE, van der Sande FM, Stuard S, Wabel P, Kooman JP. Three compartment bioimpedance spectroscopy in the nutritional assessment and the outcome of patients with advanced or end stage kidney disease: What have we learned so far? Hemodial Int 2020; 24:148-161. [PMID: 31970883 PMCID: PMC7216830 DOI: 10.1111/hdi.12812] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 12/05/2019] [Accepted: 12/06/2019] [Indexed: 12/15/2022]
Abstract
Bioimpedance spectroscopy (BIS) is an easily applicable tool to assess body composition. The three compartment model BIS (3C BIS) conventionally expresses body composition as lean tissue index (LTI) (lean tissue mass [LTM]/height in meters squared) and fat tissue index (FTI) (adipose tissue mass/height in meters squared), and a virtual compartment reflecting fluid overload (FO). It has been studied extensively in relation to diagnosis and treatment guidance of fluid status disorders in patients with advanced‐stage or end‐stage renal disease. It is the aim of this article to provide a narrative review on the relevance of 3C BIS in the nutritional assessment in this population. At a population level, LTI decreases after the start of hemodialysis, whereas FTI increases. LTI below the 10th percentile is a consistent predictor of outcome whereas a low FTI is predominantly associated with outcome when combined with a low LTI. Recent research also showed the connection between low LTI, inflammation, and FO, which are cumulatively associated with an increased mortality risk. However, studies toward nutritional interventions based on BIS data are still lacking in this population. In conclusion, 3C BIS, by disentangling the components of body mass index, has contributed to our understanding of the relevance of abnormalities in different body compartments in chronic kidney disease patients, and appears to be a valuable prognostic tool, at least at a population level. Studies assessing the effect of BIS guided nutritional intervention could further support its use in the daily clinical care for renal patients.
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Affiliation(s)
- Natascha J H Broers
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Center+, Maastricht, The Netherlands.,NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Bernard Canaud
- Research and Development, Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Marijke J E Dekker
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Frank M van der Sande
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Stefano Stuard
- Research and Development, Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Peter Wabel
- Research and Development, Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Jeroen P Kooman
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Center+, Maastricht, The Netherlands.,NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
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9
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Lin YL, Liou HH, Wang CH, Lai YH, Kuo CH, Chen SY, Hsu BG. Impact of sarcopenia and its diagnostic criteria on hospitalization and mortality in chronic hemodialysis patients: A 3-year longitudinal study. J Formos Med Assoc 2019; 119:1219-1229. [PMID: 31744647 DOI: 10.1016/j.jfma.2019.10.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 10/23/2019] [Accepted: 10/29/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND/PURPOSE Sarcopenia is prevalent in chronic hemodialysis patients. This prospective cohort study evaluated the impact of sarcopenia and its diagnostic criteria on hospitalization and mortality in 126 chronic hemodialysis patients. METHODS Skeletal muscle mass, handgrip strength (HGS), gait speed, and blood parameters were assessed. Sarcopenia was evaluated using the criteria of the European Working Group on Sarcopenia in Older People and the Taiwanese criteria for Sarcopenia. Muscle quality was defined as HGS divided by mid-arm muscle circumference. RESULTS Prevalences of uremic sarcopenia were 8.7% and 13.5% according to Taiwanese and European criteria, respectively. Low HGS and gait speed were much more prevalent than low muscle mass. Within 3 years, 79 (62.7%) patients were hospitalized and 26 (20.6%) died. Low HGS and slow gait speed were associated with hospitalization and mortality, while sarcopenia was associated with mortality but not with hospitalization. Notably, in our patients without sarcopenia, close associations between increased hospitalization and mortality risk with low HGS and slow gait speed remained unchanged. In Cox proportional hazard analysis, muscle quality [hazard ratio (HR) = 0.42, 95% confidence interval (CI) = 0.19-0.93, p = 0.032] and serum creatinine (HR = 0.82, 95% CI = 0.71-0.95, p = 0.009) were independently associated with composite outcome of hospitalization or death. CONCLUSION Muscle functionality and quality can predict hospitalization and overall survival in chronic hemodialysis patients, better than muscle mass.
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Affiliation(s)
- Yu-Li Lin
- Division of Nephrology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 97004, Taiwan.
| | - Hung-Hsiang Liou
- Division of Nephrology, Department of Internal Medicine, Hsin-Jen Hospital, New Taipei City 24243, Taiwan.
| | - Chih-Hsien Wang
- Division of Nephrology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 97004, Taiwan.
| | - Yu-Hsien Lai
- Division of Nephrology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 97004, Taiwan.
| | - Chiu-Huang Kuo
- Division of Nephrology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 97004, Taiwan.
| | - Shu-Yuan Chen
- Department of Public Health, Tzu Chi University, Hualien 97004, Taiwan.
| | - Bang-Gee Hsu
- Division of Nephrology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 97004, Taiwan; School of Medicine, Tzu Chi University, Hualien 97004, Taiwan.
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10
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Kittiskulnam P, Johansen KL. The obesity paradox: A further consideration in dialysis patients. Semin Dial 2019; 32:485-489. [PMID: 31338891 DOI: 10.1111/sdi.12834] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Several epidemiological cohorts have demonstrated that higher body mass index (BMI) is associated with lower mortality risk among patients receiving hemodialysis. However, BMI may be an inaccurate indicator of nutritional status among dialysis patients because it does not differentiate between muscle and fat mass or provide information about body fat distribution. More sophisticated methods of body composition analysis are therefore required to address the question of which component is associated with greater survival. Recent evidence has also shown that changes in body weight and body composition are more strongly associated with mortality in dialysis patients than measurement of BMI at a single time point. Given that obesity is common among the dialysis population, weight loss interventions are encouraged for obese dialysis patients who are on a transplant waiting list in order to increase the access for transplantation.
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Affiliation(s)
- Piyawan Kittiskulnam
- Division of Internal Medicine-Nephrology, Department of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,Special Task force for Activating Research in Renal Nutrition (Renal Nutrition Research Group), Office of Research Affairs, Chulalongkorn University, Bangkok, Thailand
| | - Kirsten L Johansen
- Division of Nephrology, Hennepin County Medical Center, Minneapolis, Minnesota, USA.,Division of Nephrology, University of Minnesota, Minneapolis, Minnesota, USA
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11
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Lee SW, Ngoh CLY, Chua HR, Haroon S, Wong WK, Lee EJ, Lau TW, Sethi S, Teo BW. Evaluation of different bioimpedance methods for assessing body composition in Asian non-dialysis chronic kidney disease patients. Kidney Res Clin Pract 2019; 38:71-80. [PMID: 30897894 PMCID: PMC6481966 DOI: 10.23876/j.krcp.18.0069] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 11/14/2018] [Accepted: 12/01/2018] [Indexed: 02/03/2023] Open
Abstract
Background Chronic kidney disease (CKD) is associated with fluid retention, which increases total body water (TBW) and leads to changes in intracellular water (ICW) and extracellular water (ECW). This complicates accurate assessments of body composition. Analysis of bioelectrical impedance may improve the accuracy of evaluation in CKD patients and multiple machines and technologies are available. We compared body composition by bioimpedance spectroscopy (BIS) against multi-frequency bioimpedance analysis (BIA) in a multi-ethnic Asian population of stable, non-dialysis CKD patients. Methods We recruited 98 stable CKD patients comprising 54.1% men and 70.4% Chinese, 9.2% Malay, 13.3% Indian, and 8.2% other ethnicities. Stability was defined as no variation in serum creatinine > 20% over three months. Patients underwent BIS analyses using a Fresenius body composition monitor, while BIA analyses employed a Bodystat Quadscan 4000. Results Mean TBW values by BIS and BIA were 33.6 ± 7.2 L and 38.3 ± 7.4 L; mean ECW values were 15.8 ± 3.2 L and 16.9 ± 2.7 L; and mean ICW values were 17.9 ± 4.3 L and 21.0 ± 4.9 L, respectively. Mean differences for TBW were 4.6 ± 1.9 L (P < 0.001), for ECW they were 1.2 ± 0.5 L (P < 0.001), and for ICW they were 3.2 ±1.8 L (P < 0.001). BIA and BIS measurements were highly correlated: TBW r = 0.970, ECW r = 0.994, and ICW r = 0.926. Compared with BIA, BIS assessments of fluid overload appeared to be more associated with biochemical and clinical indicators. Conclusion Although both BIA and BIS can be used for body water assessment, clinicians should be aware of biases that exist between bioimpedance techniques. The values of body water assessments in our study were higher in BIA than in BIS. Ethnicity, sex, body mass index, and estimated glomerular filtration rate were associated with these biases.
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Affiliation(s)
- Sean Wy Lee
- Division of Nephrology, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Clara Lee Ying Ngoh
- Division of Nephrology, Department of Medicine, National University Health System, Singapore
| | - Horng Ruey Chua
- Division of Nephrology, Department of Medicine, National University Health System, Singapore
| | - Sabrina Haroon
- Division of Nephrology, Department of Medicine, National University Health System, Singapore
| | - Weng Kin Wong
- Division of Nephrology, Department of Medicine, National University Health System, Singapore
| | - Evan Jc Lee
- Division of Nephrology, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Division of Nephrology, Department of Medicine, National University Health System, Singapore
| | - Titus Wl Lau
- Division of Nephrology, Department of Medicine, National University Health System, Singapore
| | - Sunil Sethi
- Department of Pathology, National University Health System, Singapore
| | - Boon Wee Teo
- Division of Nephrology, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Division of Nephrology, Department of Medicine, National University Health System, Singapore
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12
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Arias-Guillén M, Perez E, Herrera P, Romano B, Ojeda R, Vera M, Ríos J, Fontseré N, Maduell F. Bioimpedance Spectroscopy as a Practical Tool for the Early Detection and Prevention of Protein-Energy Wasting in Hemodialysis Patients. J Ren Nutr 2018; 28:324-332. [PMID: 29691162 DOI: 10.1053/j.jrn.2018.02.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 01/19/2018] [Accepted: 02/14/2018] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES To evaluate whether body composition monitor (BCM) could be a practical instrument for nephrologists to assess nutritional status in patients on hemodialysis (HD) and whether it is more effective in identifying patients at highest risk of developing protein-energy wasting (PEW) alone or in combination with other tools currently used for that purpose. DESIGN Observational cross-sectional study in 91 HD patients (60 ± 14 years, 70.3% male, 24 ± 4.1 kg/m2 body mass index) from 2 different locations. METHODS Nutritional status was evaluated by anthropometric methods (biceps and triceps skinfold thickness, waist circumference, and arm muscular circumference), biochemical nutritional markers, malnutrition-inflammation score (MIS), and BCM. The patients were grouped into those with and without PEW by using classical criteria and then classified as being adequately or inadequately nourished according to a BCM flow chart to detect those requiring preferential nutritional intervention. A multivariate approach was used to calculate the risk of developing PEW. RESULTS Anthropometric measurements revealed significantly lower body mass index (<23 kg/m2; odds ratios [OR] = 13.3 and P = 0.001) and arm muscular circumference < p10 (OR = 34, P < 0.001) in the PEW group. MIS was above 5 in all the patients classified as having PEW. BCM showed that fat tissue index < p10 was significantly lower in this group (OR = 1.52), and a decision tree using the lean tissue index < p10, fat tissue index < p10, and extracellular water > 15% revealed that 42.9% of the patients would need nutritional monitoring. On multivariate analysis, insufficient nutritional status detected by BCM decision tree was an independent prognostic factor for developing PEW. About 9.89% of the patients were classified as PEW, with MIS > 5, and insufficient nutritional status detected by BCM required preferential nutritional intervention. CONCLUSION BCM is a practical instrument for nephrologists to assess nutritional status in patients on HD and is useful for the early prevention and detection of PEW, as is able to identify differences in body composition, predict clinically important outcomes, and classify patients requiring preferential nutritional intervention.
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Affiliation(s)
- Marta Arias-Guillén
- Nephrology and Renal Transplantation, Hospital Clinic Barcelona, Barcelona, Spain.
| | - Eduardo Perez
- Nephrology and Renal Transplantation, Hospital Clinic Barcelona, Barcelona, Spain
| | - Patricia Herrera
- Nephrology and Renal Transplantation, Hospital Clinic Barcelona, Barcelona, Spain
| | - Bárbara Romano
- Nutrition and Dietetic Unit, Hospital Clinic Barcelona, Barcelona, Spain
| | - Raquel Ojeda
- Nephrology and Renal Transplantation, Hospital Clinic Barcelona, Barcelona, Spain
| | - Manel Vera
- Nephrology and Renal Transplantation, Hospital Clinic Barcelona, Barcelona, Spain
| | - José Ríos
- Medical Statistics Core Facility, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) and Hospital Clinic, Barcelona, Spain; Biostatistics Unit, Faculty of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Néstor Fontseré
- Nephrology and Renal Transplantation, Hospital Clinic Barcelona, Barcelona, Spain
| | - Francisco Maduell
- Nephrology and Renal Transplantation, Hospital Clinic Barcelona, Barcelona, Spain
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