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Tao X, Niu R, Lu W, Zeng X, Sun X, Liu C. Obstructive sleep apnea (OSA) is associated with increased risk of early-onset sarcopenia and sarcopenic obesity: Results from NHANES 2015-2018. Int J Obes (Lond) 2024; 48:891-899. [PMID: 38383717 DOI: 10.1038/s41366-024-01493-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 02/01/2024] [Accepted: 02/02/2024] [Indexed: 02/23/2024]
Abstract
OBJECTIVE This study aims to estimate the prevalence of early-onset sarcopenia and sarcopenic obesity in the United States and its relative risk due to obstructive sleep apnea (OSA). METHODS Data in this cross-sectional study were extracted from the National Health and Nutritional Examination Survey (NHANES) 2015-2018. Weighted multistage stratified probability sampling design was considered to estimate the prevalence of early-onset sarcopenia and sarcopenic obesity. Weighted multivariable logistic regression analyses and weighted multivariable mediation models were performed to evaluate the association between OSA and early-onset sarcopenia. RESULTS The prevalence of early-onset sarcopenia and early-onset sarcopenic obesity was estimated to be 5.5% and 4.6%, respectively. A higher prevalence of sarcopenia (12% V.S. 5.5%, P < 0.01) and sarcopenic obesity (10.3% V.S. 4.0%, P < 0.01) was observed among participants with OSA than those without OSA. Multivariable logistic regression models suggested that participants with OSA had higher odds ratios of suffering from early-onset sarcopenia [Odds Ratio (OR): 1.5, 95% confidence interval (CI):1.1-2.7] and early-onset sarcopenic obesity [OR: 1.8, 95% CI: 1.1-3.1] after adjusting for potential confounding variables. Mediation analyses suggested serum chronic reaction protein (CRP) mediated 23.7% (P < 0.01) & 26.2% (P < 0.01), homeostasis model assessment insulin resistance index (HOMA-IR) mediated 24.8% (P < 0.01) & 20.7% (P < 0.05), body mass index (BMI) mediated 46.4% (P < 0.05) & 49.9% (P < 0.01), HEI-2015 mediated 23.3% (P < 0.01) & 25.6% (P < 0.01), and Vitamin D mediated 7.5% (P < 0.01) & 8.5% (P < 0.01) of the potential effects of OSA on early-onset sarcopenia and sarcopenic obesity, respectively. CONCLUSION Early-onset sarcopenia and sarcopenic obesity were prevalent among young adults in the US. OSA is a significant independent risk factor and may induce muscle loss by unhealthy diet habits, higher BMI, chronic inflammation, insulin resistance, and Vitamin D. It was essential for clinicians to arrange appropriate screening and interventions for patients with OSA to prevent muscle loss as early as possible.
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Affiliation(s)
- Xinge Tao
- Department of Endocrinology and Diabetes, the First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
- National Institute for Data Science in Health and Medicine, Xiamen University, Xiamen, China
| | - Rui Niu
- Department of Endocrinology and Diabetes, the First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Wenjing Lu
- Department of Endocrinology and Diabetes, the First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Xiying Zeng
- Department of Endocrinology and Diabetes, the First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Xin Sun
- Department of Outpatient, The First Affiliated Hospital of Jinan University, Guangzhou, China.
| | - Changqin Liu
- Department of Endocrinology and Diabetes, the First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China.
- Xiamen Key Laboratory for Clinical Efficacy and Evidence-Based Research of Traditional Chinese Medicine, the First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China.
- Fujian Province Key Laboratory of Diabetes Translational Medicine, the First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China.
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Pisano A, Zoccali C, Bolignano D, D'Arrigo G, Mallamaci F. Sleep apnoea syndrome prevalence in chronic kidney disease and end-stage kidney disease patients: a systematic review and meta-analysis. Clin Kidney J 2024; 17:sfad179. [PMID: 38186876 PMCID: PMC10768783 DOI: 10.1093/ckj/sfad179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Indexed: 01/09/2024] Open
Abstract
Background Several studies have examined the frequency of sleep apnoea (SA) in patients with chronic kidney disease (CKD), reporting different prevalence rates. Our systematic review and meta-analysis aimed to define the clinical penetrance of SA in CKD and end-stage kidney disease (ESKD) patients. Methods Ovid-MEDLINE and PubMed databases were explored up to 5 June 2023 to identify studies providing SA prevalence in CKD and ESKD patients assessed by different diagnostic methods, either sleep questionnaires or respiration monitoring equipment [such as polysomnography (PSG), type III portable monitors or other diagnostic tools]. Single-study data were pooled using the random-effects model. The Chi2 and Cochrane-I2 tests were used to assess the presence of heterogeneity, which was explored performing sensitivity and/or subgroup analyses. Results A cumulative analysis from 32 single-study data revealed a prevalence of SA of 57% [95% confidence interval (CI) 42%-71%] in the CKD population, whereas a prevalence of 49% (95% CI 47%-52%) was found pooling data from 91 studies in ESKD individuals. The prevalence of SA using instrumental sleep monitoring devices, including classical PSG and type III portable sleep monitors, was 62% (95% CI 52%-72%) and 56% (95% CI 42%-69%) in CKD and ESKD populations, respectively. Sleep questionnaires revealed a prevalence of 33% (95% CI 16%-49%) and 39% (95% CI 30%-49%). Conclusions SA is commonly seen in both non-dialysis CKD and ESKD patients. Sleep-related questionnaires underestimated the presence of SA in this population. This emphasizes the need to use objective diagnostic tools to identify such a syndrome in kidney disease.
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Affiliation(s)
- Anna Pisano
- CNR-Institute of Clinical Physiology; Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - Carmine Zoccali
- Renal Research Institute, NY, USA
- Institute of Molecular Biology and Genetics (BIOGEM), Ariano Irpino, Italy
- Associazione Ipertensione Nefrologia e Trapianto Renale (IPNET), Reggio Calabria, Italy
| | - Davide Bolignano
- Department of Surgical and Medical Sciences-Magna Graecia, University of Catanzaro, Catanzaro, Italy
| | - Graziella D'Arrigo
- CNR-Institute of Clinical Physiology; Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - Francesca Mallamaci
- CNR-Institute of Clinical Physiology; Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy
- Nephology and Transplantation Unit, Grande Ospedale Metropolitano, Reggio Calabria, Italy
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3
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Barreto Silva MI, Picard K, Klein MRST. Sarcopenia and sarcopenic obesity in chronic kidney disease: update on prevalence, outcomes, risk factors and nutrition treatment. Curr Opin Clin Nutr Metab Care 2022; 25:371-377. [PMID: 36039925 DOI: 10.1097/mco.0000000000000871] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW This review summarizes literature from the last 18 months reporting on sarcopenia (or its components) in chronic kidney disease (CKD). RECENT FINDINGS The prevalence of sarcopenia in CKD is reported to be 5-62.5%, with higher rates observed later in the disease. Sarcopenic obesity rates are reported to be 2-23%. Sarcopenia in CKD is associated with increased risk of mortality, cardiovascular disease and vascular calcification. Risk factors include kidney disease itself and the impacts of CKD on lifestyle (reduced physical activity, diet changes). In earlier stages of CKD, if the risks from sarcopenia outweigh the risk of reaching end-stage renal disease, ensuring adequate energy intake combined with modest protein liberalization and physical activity may be indicated. Protein intakes above 1.3 g/kg of body weight per day should be avoided. For dialysis patients, interventions that provide a combination of carbohydrate, protein and fat appear more effective than those that provide protein alone, though it may take as long as 48 weeks for detectable changes in muscle mass. SUMMARY Sarcopenia is prevalent in CKD as kidney disease significantly impacts muscle mass and function. Nutrition interventions can improve components of sarcopenia, with an emphasis on adequate energy and protein.
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Affiliation(s)
- Maria Inês Barreto Silva
- Human Nutrition Research Unit, Division of Human Nutrition, Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, Alberta, Canada
- Department of Applied Nutrition, Nutrition Institute, Rio de Janeiro State University
- Department of Applied Nutrition, Nutrition School, Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Kelly Picard
- Human Nutrition Research Unit, Division of Human Nutrition, Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, Alberta, Canada
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Szlejf C, Suemoto CK, Drager LF, Griep RH, Fonseca MJM, Diniz MFHS, Lotufo PA, Benseãor IM. Association of sleep disturbances with sarcopenia and its defining components: the ELSA-Brasil study. Braz J Med Biol Res 2021; 54:e11539. [PMID: 34878063 PMCID: PMC8647897 DOI: 10.1590/1414-431x2021e11539] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 09/21/2021] [Indexed: 11/22/2022] Open
Abstract
Sarcopenia and sleep problems share common physiopathology. We aimed to investigate the association of sleep disturbances with sarcopenia and its defining components in Brazilian middle-aged and older adults. In this cross-sectional analysis of the second wave of the ELSA-Brasil study, we included data from 7948 participants aged 50 years and older. Muscle mass was evaluated by bioelectrical impedance analysis and muscle strength by hand-grip strength. Sarcopenia was defined according to the Foundation for the National Institutes of Health criteria. Sleep duration and insomnia complaint were self-reported. Short sleep duration was considered as ≤6 h/night and long sleep duration as >8 h/night. High risk of obstructive sleep apnea (OSA) was assessed using the STOP-Bang questionnaire. Possible confounders included socio-demographic characteristics, lifestyle, clinical comorbidities, and use of sedatives and hypnotics. The frequencies of sarcopenia, low muscle mass, and low muscle strength were 1.6, 21.1, and 4.1%, respectively. After adjustment for possible confounders, high risk of OSA was associated with low muscle mass (OR=2.17, 95%CI: 1.92-2.45). Among obese participants, high risk of OSA was associated with low muscle strength (OR=1.68, 95%CI: 1.07-2.64). However, neither short nor long sleep duration or frequent insomnia complaint were associated with sarcopenia or its defining components. In conclusion, high risk of OSA was associated with low muscle mass in the whole sample and with low muscle strength among obese participants. Future studies are needed to clarify the temporal relationship between both conditions.
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Affiliation(s)
- C Szlejf
- Centro de Pesquisa Clínica e Epidemiológica, Hospital Universitário, Universidade de São Paulo, São Paulo, SP, Brasil
| | - C K Suemoto
- Centro de Pesquisa Clínica e Epidemiológica, Hospital Universitário, Universidade de São Paulo, São Paulo, SP, Brasil.,Divisão de Geriatria, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - L F Drager
- Centro de Pesquisa Clínica e Epidemiológica, Hospital Universitário, Universidade de São Paulo, São Paulo, SP, Brasil.,Unidade de Hipertensão, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - R H Griep
- Laboratório de Educação em Ambiente e Saúde, Instituto Oswaldo Cruz, Fundação Oswaldo Cruz, Rio de Janeiro, RJ, Brasil
| | - M J M Fonseca
- Departamento de Epidemiologia e Métodos Quantitativos em Saúde, Fundação Oswaldo Cruz, Rio de Janeiro, RJ, Brasil
| | - M F H S Diniz
- Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil
| | - P A Lotufo
- Centro de Pesquisa Clínica e Epidemiológica, Hospital Universitário, Universidade de São Paulo, São Paulo, SP, Brasil.,Departamento de Medicina Interna, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - I M Benseãor
- Centro de Pesquisa Clínica e Epidemiológica, Hospital Universitário, Universidade de São Paulo, São Paulo, SP, Brasil.,Departamento de Medicina Interna, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
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Voulgaris A, Bonsignore MR, Schiza S, Marrone O, Steiropoulos P. Is kidney a new organ target in patients with obstructive sleep apnea? Research priorities in a rapidly evolving field. Sleep Med 2021; 86:56-67. [PMID: 34474225 DOI: 10.1016/j.sleep.2021.08.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 07/15/2021] [Accepted: 08/05/2021] [Indexed: 11/28/2022]
Abstract
The bidirectional relationship between sleep disordered breathing and chronic kidney disease (CKD) has recently gained a lot of interest. Several lines of evidence suggest the high prevalence of coexistent obstructive sleep apnea (OSA) in patients with CKD and end-stage renal disease (ESRD). In addition, OSA seems to result in loss of kidney function in some patients, especially in those with cardio-metabolic comorbidities. Treatment of CKD/ESRD and OSA can alter the natural history of each other; still better phenotyping with selection of appropriate treatment approaches is urgently needed. The aim of this narrative review is to provide an update of recent studies on epidemiological associations, pathophysiological interactions, and management of patients with OSA and CKD or ESRD.
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Affiliation(s)
- Athanasios Voulgaris
- MSc Programme in Sleep Medicine, Medical School, Democritus University of Thrace, Alexandroupolis, Greece; Department of Respiratory Medicine, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Maria R Bonsignore
- Institute of Biomedicine and Molecular Immunology, CNR, Palermo, Italy; Sleep Disordered Breathing and Chronic Respiratory Failure Clinic, PROMISE Department, University of Palermo, and IRIB, National Research Council (CNR), Palermo, Italy
| | - Sophia Schiza
- Sleep Disorders Center, Department of Respiratory Medicine, Medical School, University of Crete, Heraklion, Greece
| | - Oreste Marrone
- Institute of Biomedicine and Molecular Immunology, CNR, Palermo, Italy
| | - Paschalis Steiropoulos
- MSc Programme in Sleep Medicine, Medical School, Democritus University of Thrace, Alexandroupolis, Greece; Department of Respiratory Medicine, Medical School, Democritus University of Thrace, Alexandroupolis, Greece.
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6
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Gregg LP, Bossola M, Ostrosky-Frid M, Hedayati SS. Fatigue in CKD: Epidemiology, Pathophysiology, and Treatment. Clin J Am Soc Nephrol 2021; 16:1445-1455. [PMID: 33858827 PMCID: PMC8729574 DOI: 10.2215/cjn.19891220] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Fatigue is a commonly reported and debilitating symptom among patients with CKD, yet little is known about its epidemiology, pathogenesis, and treatment. Various measurement tools have been used in published studies to identify and quantify fatigue. These include several single-item measures embedded in longer questionnaires for assessing depression, quality of life, or symptom burden in patients with kidney disease. Approximately 70% of patients with CKD report fatigue, with up to 25% reporting severe symptoms. Patient-reported fatigue is associated with death, dialysis initiation, and hospitalization among individuals with CKD. The pathophysiology is multifactorial and likely includes decreased oxygen delivery and increased reliance on anaerobic metabolism, thus generating lactic acidosis in response to exertion; the effects of chronic metabolic acidosis and hyperphosphatemia on skeletal muscle myocytes; protein-energy wasting and sarcopenia; and depression. Physical activity has been shown to improve fatigue in some small but promising trials, and so should be recommended, given the additional benefits of exercise. Targeting higher hemoglobin levels with erythropoiesis-stimulating agents may improve fatigue, but potential adverse cardiovascular effects preclude their use to solely treat fatigue without the presence of another indication. Current guidelines recommend cautious individualization of hemoglobin targets for those at low cardiovascular risk who still experience fatigue or functional limitation despite a hemoglobin level of 10 g/dl. Sodium bicarbonate supplementation for the treatment of metabolic acidosis may also improve functional status. Selective serotonin reuptake inhibitors have not been consistently shown to improve fatigue in patients with kidney disease, but an ongoing trial will evaluate the effect of alternative antidepressant drug and behavioral activation therapy on fatigue in patients with CKD. Overall, more research is needed to further clarify underlying mechanisms of fatigue and identify effective, targeted treatments for patients with CKD.
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Affiliation(s)
- L. Parker Gregg
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Division of Nephrology, Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
- Veterans Affairs Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety, Houston, Texas
| | - Maurizio Bossola
- Haemodialysis Unit, Fondazione Policlinico Universitario “Agostino Gemelli,” Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - S. Susan Hedayati
- Division of Nephrology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
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Hansrivijit P, Puthenpura MM, Ghahramani N, Thongprayoon C, Cheungpasitporn W. Bidirectional association between chronic kidney disease and sleep apnea: a systematic review and meta-analysis. Int Urol Nephrol 2020; 53:1209-1222. [PMID: 33155087 DOI: 10.1007/s11255-020-02699-1] [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: 08/09/2020] [Accepted: 10/27/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Previous data have suggested a link between chronic kidney disease (CKD) and sleep apnea (SA). However, the prevalence and risk association of both disease entities are not uniformly described. METHODS Ovid MEDLINE, EMBASE, and the Cochrane Library were searched for eligible publications that included patients aged ≥ 18 years diagnosed with CKD or SA. Included studies were divided into two cohorts: (1) a cohort of CKD or end-stage kidney disease (ESKD) patients reporting the prevalence of SA or odds ratio (OR) for SA (CKD cohort) and (2) a cohort of SA patients reporting the prevalence of CKD/ESKD or OR for CKD/ESKD (SA cohort). RESULTS CKD cohort: Of 16 studies (n = 340,587), the pooled estimated prevalence of SA among CKD/ESKD patients was 47.5% (95% CI 28.8-66.9). The pooled adjusted OR for SA among CKD/ESKD patients was 1.961 (95% CI 1.702-2.260). Male sex, history of diabetes, and lower BMI were associated with increased prevalence of SA. SA cohort: Of 12 studies (n = 3,103,074), the pooled prevalence of CKD/ESKD among patients with SA was 8.2% (95% CI 4.7-13.7), whereas the pooled adjusted OR for CKD/ESKD among patients with SA was 2.088 (95% CI 1.777-2.452). Increasing age, higher BMI, male sex, white race, and history of diabetes were associated with higher prevalence of CKD/ESKD. CONCLUSION There was a bidirectional association between CKD/ESKD and SA. Interventions aiming to prevent the progression of either CKD or SA are important.
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Affiliation(s)
- Panupong Hansrivijit
- Department of Internal Medicine, University of Pittsburgh Medical Center Pinnacle, 504 S. Front St, Suite 3C, Harrisburg, PA, 17104, USA.
| | - Max M Puthenpura
- Drexel University College of Medicine, Philadelphia, PA, 19129, USA
| | - Nasrollah Ghahramani
- Division of Nephrology, Department of Medicine, Penn State University College of Medicine, Hershey, PA, 17033, USA
| | - Charat Thongprayoon
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, 55905, USA
| | - Wisit Cheungpasitporn
- Division of Nephrology, University of Mississippi Medical Center, Jackson, MS, 39216, USA
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Umbro I, Fabiani V, Fabiani M, Angelico F, Del Ben M. A systematic review on the association between obstructive sleep apnea and chronic kidney disease. Sleep Med Rev 2020; 53:101337. [PMID: 32629235 DOI: 10.1016/j.smrv.2020.101337] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 03/25/2020] [Accepted: 04/02/2020] [Indexed: 12/22/2022]
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Sabatino A, Cuppari L, Stenvinkel P, Lindholm B, Avesani CM. Sarcopenia in chronic kidney disease: what have we learned so far? J Nephrol 2020; 34:1347-1372. [PMID: 32876940 PMCID: PMC8357704 DOI: 10.1007/s40620-020-00840-y] [Citation(s) in RCA: 195] [Impact Index Per Article: 48.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 08/12/2020] [Indexed: 02/07/2023]
Abstract
The term sarcopenia was first introduced in 1988 by Irwin Rosenberg to define a condition of muscle loss that occurs in the elderly. Since then, a broader definition comprising not only loss of muscle mass, but also loss of muscle strength and low physical performance due to ageing or other conditions, was developed and published in consensus papers from geriatric societies. Sarcopenia was proposed to be diagnosed based on operational criteria using two components of muscle abnormalities, low muscle mass and low muscle function. This brought awareness of an important nutritional derangement with adverse outcomes for the overall health. In parallel, many studies in patients with chronic kidney disease (CKD) have shown that sarcopenia is a prevalent condition, mainly among patients with end stage kidney disease (ESKD) on hemodialysis (HD). In CKD, sarcopenia is not necessarily age-related as it occurs as a result of the accelerated protein catabolism from the disease and from the dialysis procedure per se combined with low energy and protein intakes. Observational studies showed that sarcopenia and especially low muscle strength is associated with worse clinical outcomes, including worse quality of life (QoL) and higher hospitalization and mortality rates. This review aims to discuss the differences in conceptual definition of sarcopenia in the elderly and in CKD, as well as to describe etiology of sarcopenia, prevalence, outcome, and interventions that attempted to reverse the loss of muscle mass, strength and mobility in CKD and ESKD patients.
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Affiliation(s)
- Alice Sabatino
- Division of Nephrology, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Lilian Cuppari
- Division of Nephrology, Federal University of São Paulo and Oswaldo Ramos Foundation, São Paulo, Brazil
| | - Peter Stenvinkel
- Division of Renal Medicine and Baxter Novum, Department of Clinical Science, Technology and Intervention, Karolinska Institute, Stockholm, Sweden
| | - Bengt Lindholm
- Division of Renal Medicine and Baxter Novum, Department of Clinical Science, Technology and Intervention, Karolinska Institute, Stockholm, Sweden
| | - Carla Maria Avesani
- Division of Renal Medicine and Baxter Novum, Department of Clinical Science, Technology and Intervention, Karolinska Institute, Stockholm, Sweden.
- Nutrition Institute, Rio de Janeiro State University, Rio de Janeiro, Brazil.
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