Association of morbidity with markers of nutrition and inflammation in chronic hemodialysis patients: a prospective study

Inflammation and Adverse Outcomes in Patients With Acute Ischemic Stroke With and Without Chronic Kidney Disease

BACKGROUND

Elevated white blood cell count, fibrinogen levels, and lower levels of albumin signify higher systemic inflammatory response, hypercoagulable state, and poorer nutritional status, respectively. However, a consistent conclusion could not be drawn on whether the association between inflammatory markers and cardiovascular disease was affected by the presence of chronic kidney disease (CKD). We aimed to explore the association between inflammation and adverse outcomes in patients with acute ischemic stroke (AIS), as well as whether this association differs due to the presence of CKD.

METHODS AND RESULTS

This research was based on the Third China National Stroke Registry. The main adverse outcomes were poor functional outcome, stroke recurrence, and combined vascular event after 1 year. Inflammation was defined as the worst quartile of at least 2 of the aforementioned 3 markers. Finally, 8493 patients with AIS were enrolled in this study. The adjusted odds ratios/hazard ratios and 95% CIs of inflammation were 1.58 (1.34-1.86) for poor functional outcomes, 1.25 (1.06-1.47) for stroke recurrence, and 1.25 (1.06-1.46) for combined vascular event. The association between inflammation and adverse outcomes existed only in patients with AIS without CKD, although the interaction between CKD and inflammation was not statistically significant. (P for interaction >0.05).

CONCLUSIONS

Inflammation, which was defined as a combination of fibrinogen, white blood cell count, and albumin, was associated with all 1-year adverse outcomes among patients with AIS. Routine assessment of these biomarkers could become a potential part of the clinical evaluation for patients with AIS, especially those without CKD, aiding clinicians in risk stratification and treatment decision-making.

Could cooling dialysate improve inflammatory and nutritional status of hemodialysis patients?

BACKGROUND

It has been shown that dialysate cooling (lowering the dialysate temperature to 0.5 °C below central body temperature) reduces the incidence of intradialytic hypotension. Other influences on hemodialysis patients, however, have not been adequately investigated. The purpose of this study was to determine the impact of individualized dialysate cooling on nutritional and inflammatory parameters in chronic hemodialysis (HD) patients.

METHODS

Seventy HD patients were separated into two groups: group A: (control group) standard dialysate temperature was 37 °C, and group B: (intervention group) dialysate temperature was 0.5 °C below core body temperature. In addition to routine laboratory tests, blood pressure, anthropometric measurements, inflammatory markers, and the malnutrition inflammation score (MIS) were calculated.

RESULTS

After six months of dialysate cooling, intradialytic hypotension episodes were much less prevalent in the intervention group (p = 0.001). Serum ferritin, transferrin saturation (TSAT), high sensitive C-reactive protein (HS-CRP), and Interleukin-6 (IL-6) reduced following dialysate cooling, whereas serum albumin rose. In the control group, IL-6 dropped but serum ferritin, TSAT, albumin, and HS-CRP rose. In both groups, hemoglobin levels dropped, and erythrocyte sedimentation rate (ESR) rose, both groups' midarm muscle circumference and MIS worsened.

CONCLUSION

Cold dialysate decreased intradialytic hypotension with no significant improvement of the nutritional and inflammatory surrogates. However, more studies including larger number of patients with longer duration of follow up are required to adequately assess its effect on inflammation and nutrition in chronic hemodialysis patients.

Associations of Air Pollution and Serum Biomarker Abnormalities in Individuals with Hemodialysis-Dependent Kidney Failure

BACKGROUND

Ambient particles with a median aerodynamic diameter of <2.5 µm (PM2.5) is a ubiquitous air pollutant with established adverse health consequences. While postulated to promote a systemic inflammatory response, limited studies have demonstrated changes in serum biomarkers related to PM2.5 exposure. We aim to examine associations between short-term PM2.5 exposure and commonly measured biomarkers known to be affected by inflammation among patients receiving maintenance in-center hemodialysis.

METHODS

We conducted a retrospective open cohort study from January 1, 2008, to December 31, 2014. Adult hemodialysis patients were identified from the United States Renal Data System and linked at the patient level to laboratory data from a large dialysis organization. Daily ambient PM2.5 was estimated on a 1-km grid and assigned to cohort patients based on the ZIP codes of dialysis clinics. Serum albumin, serum ferritin, transferrin saturation (TSAT), and serum hemoglobin were ascertained from the dialysis provider organization database. Mixed-effect models were used to assess the changes in biomarker levels associated with PM2.5 exposure.

RESULTS

The final cohort included 173,697 hemodialysis patients. Overall, the daily ZIP-level ambient PM2.5 averages were 8.4-8.5 µg/m3. A 10-µg/m3 increase in same-day ambient PM2.5 exposure was associated with higher relative risks of lower albumin (relative risk [RR], 1.01; 95% confidence interval [95% CI], 1.01 to 1.02) and lower hemoglobin (RR, 1.02; 95% CI, 1.01 to 1.03). Associations of same-day ambient PM2.5 exposure and higher ferritin and lower TSAT did not reach statistical significance.

CONCLUSIONS

Short-term PM2.5 exposure was associated with lower serum hemoglobin and albumin among patients receiving in-center hemodialysis. These findings lend support to the role of inflammation in PM2.5 exposure-outcome associations.

Handgrip Strength Index: A Novel Parameter Which Quantifies Clinical Weakness in People on Haemodialysis

OBJECTIVE

The muscle strength in people on haemodialysis is associated with nutritional status, quality of life, functional independence, and survival. Handgrip Strength (HGS) is simple to measure, but clinical interpretation is limited by the lack of reference ranges for a haemodialysis population. This study aims to define a novel parameter, HGS index, which quantifies degree of clinical weakness specific to a haemodialysis population and to test if this predicts survival.

METHODS

In a cross-sectional single center study HGS was measured in stable participants on haemodialysis. HGS in the well-nourished subgroup, was used to develop a predictive equation for "expected" HGS according to demographic variables. This then was compared to observed HGS resulting in HGS index (%), an individualized parameter indicating weakness due to clinical variables while accounting for demographic contributors to strength. The association between HGS index and survival was explored in all participants.

RESULTS

Among 427 well-nourished individuals on haemodialysis, HGS was strongly associated with demographic variables and predicted in males by the equation: HGS (kg) = 0.38∗height (cm) - 0.31∗age (years) - 18, and in females by the equation: HGS (kg) = 0.25∗height (cm) - 0.11∗age (years) - 16. Among 547 participants (22% with protein energy wasting), lower HGS index was associated with diabetes (P = .004), lower body mass index (BMI) (P = .005), lower albumin (P = .033), and longer dialysis vintage (P = .007). Over a mean observation period of 2.8 years, quintile of HGS index was strongly associated with survival (P = .023), and in a Cox proportional hazards model, the independent predictors of mortality were age, albumin, BMI and HGS index.

CONCLUSION

HGS index, defined as observed relative to expected HGS, is an individualized measure of clinical weakness. It is a novel parameter which independently predicts survival. HGS index improves the detection of clinically relevant muscle weakness in people on haemodialysis, opening up the possibility of earlier, individualized interventions, and improving outcomes in this vulnerable group.

Impact of phase angle and sarcopenia estimated by bioimpedance analysis on clinical prognosis in patients undergoing hemodialysis: A retrospective study

Bioimpedance analysis (BIA) has been widely used in the evaluation of body composition in patients undergoing maintenance hemodialysis. We conducted this study to evaluate impact of phase angle (PA) and sarcopenia measured by BIA on clinical prognosis in these patients.This longitudinal retrospective study enrolled patients who underwent hemodialysis between January 2016 and March 2019. The patients were stratified into higher (> 4°) and lower (≤ 4.0°) PA groups. Sarcopenia was defined when the appendicular skeletal muscle mass was < 20 kg in men and < 15 kg in women.Of the 191 patients, 63.4% were men. The mean age was 64.2 ± 12.4 years. The lower PA group was older, had a higher proportion of women, a lower body mass index, lower albumin, cholesterol, uric acid, and phosphorus levels, and a higher incidence of history of coronary artery disease than the higher PA group. Linear regression analysis revealed that PA was significantly associated with body mass index (B = 0.18, P = .005), serum albumin (B = 0.23, P = .001), and creatinine levels (B = 0.32, P < .001). During a median follow-up of 16.7 months, 14.1% (n = 27) of patients experienced major adverse cardiovascular events and 11.0% (n = 21) died. Kaplan-Meier survival analysis showed that the higher PA group had significantly better survival, regardless of sarcopenia. Multivariate Cox analyses revealed that lower PA (0.51 [0.31-0.85], P = .010), higher IDWG (1.06 [1.01-1.12], P = .028) and C-reactive protein level (1.01 [1.01-1.02], P < .001), and a history of coronary artery disease (3.02 [1.04-8.77], P = .042) were significantly related to all-cause mortality after adjusting for other covariates.PA measured by BIA was an independent factor in the prediction of mortality in maintenance hemodialysis patients, regardless of sarcopenia. Intervention studies are needed to confirm if the improvement in PA is associated with better clinical outcome.

Predialysis Urea Nitrogen Is a Nutritional Marker of Hemodialysis Patients

End-stage renal disease (ESRD) patients on hemodialysis have poor nutritional status and associated problems such as inflammation and sarcopenia. Blood urea nitrogen (BUN) is an important measure of uremic toxins, and urea reduction is a marker of hemodialysis efficacy. However, a low protein diet for lower BUN could aggravate malnutrition in patients, and optimal pre-dialysis BUN is not defined. We investigated the association of pre-dialysis BUN with patients' comorbidities and the relationship between pre-dialysis BUN and serum albumin as a nutrient marker. Among the 67 patients, the average pre- and post-dialysis BUN were 59.2 and 15.0 mg/dL, respectively, serum creatinine was 10.1 mg/dL, and the average serum albumin was 4.0 g/dL. Patients' age was negatively correlated with serum creatinine (r=-0.277, p<0.05) and albumin (r=-0.453, p<0.001). Predialysis BUN showed a significant positive correlation with serum albumin (r=0.287, p<0.05) and creatinine (r=0.454, p<0.001). However, the predialysis BUN was not significantly related to diabetes, coronary artery disease, congestive heart failure, or cerebrovascular disease. Hemodialysis patients with high pre-dialysis BUN and high serum creatinine could be regarded as having good nutritional status. The significance of this study lies in the potential utility of pre-dialysis blood urea nitrogen as an indicator of the nutritional status of patients. Liberal protein intake might be recommended to adequately dialyzed patients.

Systemic Immune-Inflammation Index Is Associated With Increased Urinary Albumin Excretion: A Population-Based Study

Background

Systemic immune-inflammation index (SII) is a novel inflammatory marker, and inflammation has been reported to be related with renal damage. We aimed to investigate the possible relationship between SII and albuminuria.

Methods

The present cross-sectional study was conducted among adults with complete data about SII and urinary albumin-to-creatinine ratio (ACR) in 2005–2018 National Health and Nutrition Examination Survey (NHANES). SII was calculated as the platelet count × neutrophil count/lymphocyte count. Albuminuria was defined as ACR >30mg/g. Weighted multivariable regression analysis and subgroup analysis were conducted to explore the independent relationship between SII and albuminuria.

Results

A total of 36,463 individuals were included in our analysis; 9.56% participants were categorized as having albuminuria overall and increased with the higher SII tertiles (tertile 1, 7.83%; tertile 2, 8.49%; tertile 3, 12.13%; p for trend <0.0001). Multivariable logistic regression showed that a higher SII level was associated with increased likelihood of albuminuria independently (OR = 1.31; 95% CI, 1.17–1.48, p<0.0001) after full adjustment. Subgroup analysis and interaction test showed that there was no significant dependence of gender, age, body mass index, hypertension, diabetes, non‐alcoholic fatty liver disease, and estimated glomerular filtration rate (eGFR) on this positive association (all p for interaction >0.05).

Conclusions

SII was positively associated with increased urinary albumin excretion in US adults. Further large-scale prospective studies are still needed to analyze the role of SII in albuminuria.

Probiotic Intake and Inflammation in Patients With Chronic Kidney Disease: An Analysis of the CKD-REIN Cohort

Background and Aims

Little is known about the effects of probiotics on inflammation in the context of chronic kidney disease (CKD). We investigated the association between probiotic intake and inflammation in patients with moderate-to-advanced CKD.

Methods

We performed a cross-sectional study of 888 patients with stage 3–5 CKD and data on serum C-reactive protein (CRP) levels and a concomitant food frequency questionnaire. We estimated the odds ratios (ORs) [95% confidence interval (CI)] for various CRP thresholds (>3, >4, >5, >6, and >7 mg/L) associated with three intake categories (no yoghurt, ordinary yoghurt, and probiotics from yoghurts or dietary supplements) and two frequency categories (daily or less than daily).

Results

The 888 study participants (median age: 70; men: 65%) had a median estimated glomerular filtration rate of 28.6 mL/min/1.73 m² and a median [interquartile range] CRP level of 3.0 [1.6, 7.0] mg/L. Fifty-seven percent consumed ordinary yoghurt and 30% consumed probiotic yoghurt. The median intake frequency for yoghurt and probiotics was 7 per week. Relative to participants not consuming yoghurt, the ORs [95% CI] for CRP > 6 or >7 mg/L were significantly lower for participants consuming ordinary yoghurt (0.58 [0.37, 0.93] and 0.57 [0.35, 0.91], respectively) and for participants consuming probiotics (0.54 [0.33, 0.9] and 0.48 [0.28, 0.81], respectively), independently of age, sex, body mass index, CKD stage, cardiovascular disease, and fibre, protein and total energy intakes. The ORs were not significantly lower for CRP thresholds >3, >4, and >5 mg/L and were not significantly greater in daily consumers than in occasional consumers.

Conclusion

We observed independent associations between the consumption of yoghurt or probiotics and lower levels of inflammation in patients with CKD. There was no evidence of a dose-effect relationship.

Clinical Trial Registration

[https://www.clinicaltrials.gov/ct2/show/NCT03381950], identifier [NCT03381950].

Emerging Roles for G Protein-Coupled Estrogen Receptor 1 in Cardio-Renal Health: Implications for Aging

Cardiovascular (CV) and renal diseases are increasingly prevalent in the United States and globally. CV-related mortality is the leading cause of death in the United States, while renal-related mortality is the 8th. Despite advanced therapeutics, both diseases persist, warranting continued exploration of disease mechanisms to develop novel therapeutics and advance clinical outcomes for cardio-renal health. CV and renal diseases increase with age, and there are sex differences evident in both the prevalence and progression of CV and renal disease. These age and sex differences seen in cardio-renal health implicate sex hormones as potentially important regulators to be studied. One such regulator is G protein-coupled estrogen receptor 1 (GPER1). GPER1 has been implicated in estrogen signaling and is expressed in a variety of tissues including the heart, vasculature, and kidney. GPER1 has been shown to be protective against CV and renal diseases in different experimental animal models. GPER1 actions involve multiple signaling pathways: interaction with aldosterone and endothelin-1 signaling, stimulation of the release of nitric oxide, and reduction in oxidative stress, inflammation, and immune infiltration. This review will discuss the current literature regarding GPER1 and cardio-renal health, particularly in the context of aging. Improving our understanding of GPER1-evoked mechanisms may reveal novel therapeutics aimed at improving cardio-renal health and clinical outcomes in the elderly.

Pentraxin 3 Predicts Arteriovenous Fistula Functional Patency Loss and Mortality in Chronic Hemodialysis Patients

INTRODUCTION

Viable vascular access is the lifeline for hemodialysis patients. In the nondialysis population, emerging evidence suggests that circulating pentraxin 3 (PTX3), neutrophil gelatinase-associated lipocalin (NGAL), and chitinase-3-like protein 1 (CHI3L1) are associated with cardiovascular inflammation and endothelial injury. However, predictive values of these three biomarkers on arteriovenous fistula (AVF) outcomes are unknown.

METHODS

This prospective observational cohort study enrolled 135 hemodialysis patients using AVF and then followed them for 3 years. Plasma levels of PTX3, NGAL, and CHI3L1 were measured. Patients were followed up prospectively for two clinical outcomes, including AVF functional patency loss and death. Cox proportional hazards regression models were used to analyze hazard ratios for the commencement of AVF functional patency loss and mortality.

RESULTS

Among 135 patients, the mean age was 66.0 ± 15.7 years old and 48.1% were male. The plasma level of PTX3, NGAL, and CHI3L1 was 2.8 ± 2.3 ng/mL, 349.2 ± 111.4 ng/mL, and 185.5 ± 66.8 ng/mL, respectively. During a 3-year follow-up period, the plasma level of PTX3 was an independent predictor for AVF functional patency loss (per 1 ng/mL increase, HR 1.112 [95% CI: 1.001-1.235], p = 0.048). Besides, patients with higher plasma levels of PTX3 were more likely to suffer from cardiovascular mortality (per 1 ng/mL increase, HR 1.320 [95% CI: 1.023-1.703], p = 0.033), infectious mortality (per 1 ng/mL increase, HR 1.394 [95% CI: 1.099-1.769], p = 0.006), and all-cause mortality (per 1 ng/mL increase, HR 1.233 [95% CI: 1.031-1.476], p = 0.022).

CONCLUSIONS

The plasma level of PTX3, not NGAL or CHI3L1, was associated with higher risks of AVF functional patency loss in chronic hemodialysis patients, showing its value in reflecting AVF endothelial dysfunction. Furthermore, PTX3 also predicts mortality in chronic hemodialysis patients.

Serum Albumin Trends in Relation With Prognosis of Individuals Receiving Hemodialysis Therapy

Introduction

Hypoalbuminemia is recognized as an indication of protein-energy depletion in several disease states. According to many studies, hemodialysis (HD) patients who have decreased baseline serum albumin levels exhibit a poor prognosis. However, serum albumin does not stay at a constant level with the progress of the disease, considering that only a baseline value may not precisely reflect prognostic value. The study objective was to ascertain whether there is a link between serum albumin trajectories and all-cause mortality in incident HD patients. 

Methods

Retrospective cohort analysis was conducted in the HD unit at the University of Health Sciences, Kayseri Training and Research Hospital, Nephrology Clinic between June 19, 2010, and December 29, 2017. A total of 408 individuals aged 18 years or older, who had at least one measurement of serum albumin at baseline, were enrolled. The outcome was all-cause death. Time-dependent Cox regression and joint model were used to investigate the associations between serum albumin trend in time and the risk of all-cause mortality.

Results

Mean (SD) age was 62.17 (12.33) years, and 50.7% were male. At baseline, the mean (SD) albumin level was 3.59 (0.27). A faster decrease (per 1-SD increase in negative slope) in serum albumin levels was associated with increased risk of all-cause mortality (HR, 1.63; 95% CI, 1.08-2.84; p=0.023) in a fully adjusted joint model with slope parameterization. Also, an annual 1-SD increase in albumin level declined the hazard of all-cause mortality by 22% (HR, 0.78; 95% CI, 0.66-0.92; p=0.008) in a fully adjusted joint model with value parameterization. Similar results were obtained from time-dependent Cox models.

Conclusion

These findings suggest that longitudinal albumin evaluation, including the rate of change as a slope parameter, may be valuable for risk stratification of patients receiving HD.

Bioelectrical impedance vector analysis in patients on the waiting list for liver transplant: Associated factors and prognostic effects

OBJECTIVES

The aim of this study was to assess patients on the waiting list for liver transplant (LTx) according to bioelectrical impedance vector analysis (BIVA), as well as to verify the association between the placement of the vectors on the graph with clinical outcomes and identify the predictors to vector placement in quadrant 4 (Q4; indicating more hydration and less cellularity).

METHODS

This was a retrospective observational study including 129 patients ≥20 y of age awaiting LTx. Patients' nutritional status was assessed by using different tools, including single-frequency bioelectrical impedance analysis and the Subjective Global Assessment (SGA). Clinical data were registered. The BIVA was evaluated by comparing the individual vectors plotted for all patients to the tolerance ellipses of 50%, 75%, and 95% of the reference healthy population. The quadrant of the vector for each patient was registered.

RESULTS

The majority of the vectors were placed in Q1 (n = 54; 41.9%) and Q4 (n = 39; 30.2%). The presence of ascites or edema (hazard ratio [HR], 2.43; 95% confidence interval [CI], 1.15-5.12; P = 0.019) and the BIVA vector placed in Q4 in any ellipse (HR, 2.10; 95% CI, 1.07-4.09; P = 0.029) were independent predictors for mortality on the waiting list or ≤1 y after LTx. BIVA was not associated with longer hospital length of stay. The predictors of vector placement in Q4 were higher age, malnutrition according to SGA, and presence of ascites or edema.

CONCLUSION

Patients on the waiting list for LTx with BIVA vectors placed in Q4, in the 50%, 75%, or 95% tolerance ellipses, presented a worse prognosis.

Serum leptin concentration can predict cardiovascular outcomes and all-cause death in maintenance hemodialysis patients

BACKGROUND

We explored the associations between serum leptin concentration and cardiovascular prognosis in maintenance hemodialysis patients.

METHODS

In our prospective study with no intervention, demographics data at baseline were collected from electronic medical records. Serum leptin concentration was determined by ELISA. Patients underwent body composition assessment and echocardiographic measurements after hemodialysis. The primary endpoints were defined as cardiovascular events (CVEs), cardiovascular death (CVD) and all-cause death.

RESULTS

A total of 165 eligible patients aged 51(43-65) y were enrolled and the mean serum leptin concentration was 35.49 (29.98) ng/ml. During a median follow-up of 18 (12-22) months, CVEs occurred in 37 (22.42%) patients and the cardiovascular and all-cause mortality was 10.91% and 21.82%. Serum leptin concentration was associated with CVEs (HR = 0.982, p = 0.003), CVD (HR = 0.934, p = 0.002) and all-cause death (HR = 0.943, p < 0.001). Decreased serum leptin concentration was an independent risk factor for the development of left ventricular hypertrophy (LVH, OR = 0.98, p = 0.007) and peripheral vascular disease (PVD, OR = 0.974, p = 0.007).

CONCLUSION

Serum leptin concentration can independently predict cardiovascular outcomes and all-cause death in MHD patients. The effects that serum leptin concentration on development of LVH and PVD maybe the potential mechanism.

Clinical and predictive value of simplified creatinine index used as muscle mass surrogate in end-stage kidney disease haemodialysis patients-results from the international MONitoring Dialysis Outcome initiative

Background

Protein-energy wasting, muscle mass (MM) loss and sarcopenia are highly prevalent and associated with poor outcome in haemodialysis (HD) patients. Monitoring of MM and/or muscle metabolism in HD patients is of paramount importance for timely detection of muscle loss and to intervene adequately. In this study we assessed the reliability and reproducibility of a simplified creatinine index (SCI) as a surrogate marker of MM and explored its predictive value on outcome.

Method

We included all in-centre HD patients from 16 European countries with at least one SCI. The baseline period was defined as 30 days before and after the first multifrequency bioimpedance spectroscopy measurement; the subsequent 7 years constituted the follow-up. SCI was calculated by the Canaud equation. Multivariate Cox proportional hazards models were applied to assess the association of SCI with all-cause mortality. Using backward analysis, we explored the trends of SCI before death. Bland–Altman analysis was performed to analyse the agreement between estimated and measured MM.

Results

We included 23 495 HD patients; 3662 were incident. Females and older patients have lower baseline SCI. Higher SCI was associated with a lower risk of mortality [hazard ratio 0.81 (95% confidence interval 0.79–0.82)]. SCI decline accelerated ∼5–7 months before death. Lean tissue index (LTI) estimated by SCI was correlated with measured LTI in both sexes (males: R² = 0.94; females: R² = 0.92; both P < 0.001). Bland–Altman analysis showed that measured LTI was 4.71 kg/m² (±2 SD: −12.54–3.12) lower than estimated LTI.

Conclusion

SCI is a simple, easily obtainable and clinically relevant surrogate marker of MM in HD patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Efficacy of Lactobacillus-Containing Probiotic Supplementation in Hemodialysis Patients: A Randomized, Double-Blind, Placebo-Controlled Trial

OBJECTIVES

This study was performed to determine the effects of probiotic supplementation on cholesterol-triglyceride ratio, an indirect marker of insulin resistance, protein-bound uremic toxins, biomarkers of inflammation, and microbial translocation in end-stage renal disease patients on hemodialysis.

METHODS

Fifty-six patients aged 39-75 years were assigned into two groups to receive either probiotic sachets (n = 28) or a placebo (n = 28) in a randomized double-blinded placebo-controlled clinical trial. The patients in the probiotic group received twice daily sachets that contained a mixture of three viable and freeze-dried strains: Lactococcus lactis subsp. Lactis LL358, Lactobaccillus salivarius LS159, and Lactobaccillus pentosus LPE588 at high dose (100 billion; 1 × 10¹¹ cfu/day) for 6 months.

RESULTS

A total of 50 patients were available for final analysis. Probiotic supplementation did not have a significant influence on cholesterol-triglyceride ratio. Probiotic supplementation for 6 months caused a significant decrease in serum levels of indoxyl sulfate. Compared with the placebo, probiotic supplementation did not result in significant changes in hemoglobin levels, blood urea nitrogen, blood glucose, serum p-cresyl sulfate, inflammatory, and microbial translocation markers. No clinically significant changes in body composition were observed between the two groups during the study period. The probiotic supplementation was well tolerated by all subjects with minimal adverse effects during the 6-month-long study.

CONCLUSION

Our results suggest that high-dose multistrain lactobaccillus probiotic supplementation over 6 months as a monotherapy did not significantly decrease markers of insulin resistance, cholesterol-triglyceride ratio, and most of the studied markers, with the exception of levels of indoxyl sulfate in patients on HD.

The Time Course of Serum C-Reactive Protein is More Predictive of Mortality than its Baseline Level in Peritoneal Dialysis Patients

Background

Several recent studies reported that a high baseline serum C-reactive protein (CRP) is a powerful predictor of mortality in dialysis patients. However, the acute-phase response is intermittent and not a continuous feature in an individual patient. The aim of this prospective study was to determine whether serial analysis of serum CRP during follow-up allows better prediction of mortality and echocardiographic cardiac disease than a single baseline measurement in peritoneal dialysis (PD) patients.

Methods

97 PD patients were monitored for 3 years from the beginning of the treatment. We evaluated the effect of demographic features, comorbidity, blood pressure, blood biochemistry, including CRP, residual renal function, and indices of dialysis adequacy, on mortality and left ventricular hypertrophy (LVH). Cox regression analysis using both the baseline and the averaged values of the study parameters was carried out to determine factors predicting mortality. Logistic regression analysis was performed to determine which factors were independently predictive for LVH and the type of time course of serum CRP.

Results

Baseline serum CRP was elevated in 29 patients (29.9%). While serum CRP exhibited a stable course (normal or high) in 55 patients (56.7%), it varied considerably over time in 42 patients (43.2%). In the Cox models, both the averaged serum CRP and the type of variability of CRP were predictors of mortality. On the contrary, baseline CRP did not affect adjusted survival. The averaged CRP was also an independent factor affecting LVH, but baseline CRP was not. Age, comorbidity index, instilled dialysate glucose concentration, and Kt/V urea were independently associated with the type of time course of serum CRP.

Conclusion

The averaged value of serum CRP is more predictive of prognosis compared to the baseline value in PD patients. Determining serum CRP on a regular basis may be helpful to detect early signs of tissue damage or asymptomatic inflammation.

Effects of keto acid supplements on Chinese patients receiving maintenance hemodialysis: a prospective, randomized, controlled, single-center clinical study

BACKGROUND

The effects of keto acid (KA) supplements on Chinese patients receiving maintenance hemodialysis (MHD) are unclear. This study aimed to evaluate the effects of KA supplementation on nutritional status, inflammatory markers, and bioelectric impedance analysis (BIA) parameters in a cohort of Chinese patients with MHD without malnutrition.

METHODS

This was a prospective, randomized, controlled, single-center clinical study conducted in 2011 till 2014. Twenty-nine patients with MHD were randomly assigned to a control (n = 14) or a KA (n = 15) group. The control group maintained a dietary protein intake of 0.9 g/kg/day. The KA group received additional KA supplement (0.1 g/kg/day). BIA was used to determine the lean tissue mass, adipose tissue mass, and body cell mass. The patients' nutritional status, dialysis adequacy, and biochemical parameters were assessed at the ends of the third and sixth months with t test or Wilcoxon rank-sum test.

RESULTS

The daily total energy intake for both groups was about 28 kcal/kg/day. After 6 months, the Kt/V (where K is the dialyzer clearance of urea, t is the dialysis time, and V is the volume of the distribution of urea) was 1.33 ± 0.25 in KA group, and 1.34 ± 0.25 in the control group. The median triceps skin-fold thickness in KA group was 12.00 and 9.00 mm in the control group. In addition, the median hand-grip strength in KA group was 21.10 and 25.65 kg in the control group. There were no significant differences between the groups with respect to the anthropometry parameters, dialysis adequacy, serum calcium and phosphorus levels, inflammatory markers, and amino-acid profiles, or in relation to the parameters determined by BIA. Both groups achieved dialysis adequacy and maintained nutritional status during the study.

CONCLUSIONS

In this cohort of Chinese patients with MHD, the patients in the control group whose dietary protein intake was 0.9 g/kg/day and total energy intake was 28 kcal/kg/day, maintained well nutritional status during study period. The KA supplement (0.1 g/kg/day) did not improve the essential amino acid/non-essential amino acid ratio, nor did it change the patients' mineral metabolism, inflammatory parameters, or body compositions.

Characterising recovery from renal transplantation and live-related donation using cardiopulmonary exercise testing

BACKGROUND

An association between end-stage renal failure and exercise intolerance exists. Whether live kidney donation impacts on exercise tolerance is unknown. Here recovery post renal transplant and donation using cardiopulmonary exercise testing is investigated.

METHODS

Renal donors (n = 28) and recipients (n = 24) undertook a cardiopulmonary exercise test, Duke activity score index and patient reported health score questionnaires pre-operatively and in the 7th and 14th week post-operatively. Anaerobic threshold, peak oxygen uptake and ventilatory equivalents were measured in relation to activity and reported health scores. Haemoglobin and renal function was recorded.

RESULTS

Recipients showed impaired cardiopulmonary function compared to donors with lower anaerobic threshold (10.5 vs. 14.4 ml/kg/min) and peak oxygen uptake (18.5 vs 23.0 ml/kg/min). Post-operatively the anaerobic threshold of recipients improved and normalised by the 14th week, whereas that in donors fell by ∼20% by the 7th (mean 11.4 ml/kg/min), recovering by the 14th (mean 15.6 ml/kg/min). Reported health but not activity scores showed similar changes.

CONCLUSIONS

Recovery following renal transplantation and donation differ. Transplantation improves renal function resulting in an increase in anaerobic threshold and peak oxygen uptake which essentially normalise by the 14th week post-operatively. Donors suffer a 20% reduction in cardiopulmonary reserve post-operatively, which recovers by the 14th week, suggesting no associated chronic exercise intolerance.IMPLICATIONS FOR REHABILITATIONCardiopulmonary exercise testing is a real-time predictor of functional capacity and thus is used as a pre-operative tool to measure physiological fitness and predict outcomes.Renal failure is associated with exercise intolerance and transplantation is transformational in terms of quality of life, longevity and healthcare cost.Live - related renal donation is increasingly available but whether donation itself carries a long-term health burden has not been previously well established.This study suggests that renal donation is not associated with long-term cardiopulmonary compromise and patients who donate their kidneys recover their previous fitness within 14 weeks.

Trajectory of Lean Body Mass Assessed Using the Modified Creatinine Index and Mortality in Hemodialysis Patients

RATIONALE & OBJECTIVE

Although a declining body mass index (BMI) is associated with higher mortality in patients on hemodialysis, BMI cannot distinguish lean body mass from fat mass. It remains unclear whether changes over time in lean body mass are associated with mortality. We examined the prognostic significance of changes in the modified creatinine index, a proxy for lean body mass.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

Outpatients (n=349; mean age, 67.4 years; 60% men) undergoing maintenance hemodialysis 3 times a week at a treatment center.

PREDICTOR

Modified creatinine index and BMI trajectories over a 1-year period.

OUTCOMES

All-cause mortality.

ANALYTICAL APPROACH

We calculated the percentage of change in modified creatinine index and BMI over a 1-year period. Patients were categorized according to change in modified creatinine index/BMI: no decline (≥0%) or decline (<0%). Kaplan-Meier and Cox proportional hazard analyses were performed to examine whether modified creatinine index and BMI trajectories were associated with mortality.

RESULTS

During follow-up (median, 1,157 days), 79 patients died. Decreasing modified creatinine index (HR, 1.31; 95% CI, 1.11-1.54) and BMI (HR, 1.25; 95% CI, 1.01-1.54) over time, measured as continuous variables and expressed per 1-standard deviation decrease, were independently associated with higher risk for all-cause mortality. The decline in modified creatinine index/no decline in BMI group (HR, 2.14; 95% CI, 1.04-4.45) and the decline in modified creatinine index/decline in BMI group (HR, 3.05; 95% CI, 1.58-5.90) had higher rates of mortality compared to the no decline in modified creatinine index/decline in BMI group.

LIMITATIONS

The absence of a direct measure of lean body and fat mass and limited generalizability to non-Japanese hemodialysis populations.

CONCLUSIONS

The modified creatinine index trajectory is independently associated with mortality and provides additional prognostic information to the BMI trajectory in patients on hemodialysis.

Risk factors for catheter-related infections in patients receiving permanent dialysis catheter

Background

Due to rising vascular comorbidities of patients undergoing dialysis, the prevalence of permanent hemodialysis catheters as hemodialysis access is increasing. However, infection is a major complication of these catheters. Therefore, identification of potential predicting risk factors leading to early infection related complications is valuable, in particular the significance the CRP (C-reactive protein)-value is of interest.

Methods

In this retrospective study 151 permanent hemodialysis catheters implanted in 130 patients were examined. The following data were collected at the time of catheter implantation: CRP-value, history of catheter-related infection, microbiological status, immunosuppression and diabetes mellitus. The primary outcomes were recorded over the 3 months following the implantation: catheter-related infection, days of hospital stay and death. Catheter removal or revision, rehospitalization and use of antibiotics were identified as secondary outcomes.

Results

We identified a total of 27 (17.9%) infections (systemic infection: 2.26 episodes/ 1000 catheter days, local infection: 0.6 episodes/ 1000 catheter days). The development of an infection was independent of the CRP-value (p = 0.66) as well as the presence of diabetes mellitus (p = 0.64) or immunosuppression (p = 0.71). Univariate analysis revealed that infection was more frequent in patients with MRSA-carriage (p < 0.001), in case of previous catheter-related infection (p < 0.05) and of bacteremia or bacteriuria in the period of 3 months before catheter implantation (p < 0.001). Catheter removal or revision (p = 0.002), rehospitalization (p = 0.001) and use of antibiotics (p = 0.02) were also more often observed in patients with MRSA-carriage.

Conclusions

The CRP-value at the time of implantation of a permanent hemodialysis catheter is not associated with the development of early catheter related infections, but an individual history of catheter-related infection, MRSA-carriage and bacteremia or bacteriuria in the period of 3 months prior to catheter implantation are significant risk factors.

Malnutrition predicts long-term survival in hospitalized patients with gastroenterological and hepatological diseases

BACKGROUND & AIMS

Malnutrition is a common problem in hospitalized patients, influencing treatment outcomes, length of hospital stay, quality of life and overall survival. However, the association of nutritional status parameters with long-term mortality has not yet been studied systematically in gastroenterological-hepatological patients. The present study aimed to assess the association between nutritional status parameters as characterized by Nutritional Risk Screening (NRS), anthropometry, serum transferrin, bioelectrical impedance analysis (BIA) and long-term overall survival in hospitalized gastroenterological-hepatological patients.

METHODS

Nutritional status was assessed in 644 gastroenterological-hepatological patients by NRS score. In addition, body mass index (BMI) and serum transferrin were determined and BIA was performed. Mid-upper arm circumference (MUAC) and triceps skinfold thickness (TST) were measured. Patients were followed for a mean period of 67 months (mean 54.8, range 0-107 months).

RESULTS

During malnutrition screening, 475 (73.8%) patients were diagnosed as sufficiently nourished by NRS (NRS 0-2), while an increased risk of malnutrition was found in 169 (26.2%) patients (NRS≤3). Malnutrition was significantly associated with less favourable results for BMI (p < 0.001), serum transferrin (p < 0.001), BIA (p < 0.001), MUAC (p < 0.001) and TST (p < 0.05). Overall 5-year survival rates (YSR) were much shorter in malnourished patients whether with (5-YSR: 43.9%) or without (73.6%) malignancy. Overall 5-year survival rates (YSR) were much shorter in malnourished patients whether with (5-YSR: 43.9%) or without (73.6%) malignancy. By the multivariable analysis the NRS ≥3 and, phase angle (PhA) over the 5th percentile or over the mean of the cohort were found to be associated with long-term survival.

CONCLUSIONS

Malnutrition is highly prevalent in hospitalized gastroenterological-hepatological patients and is associated with distinct clinical diagnoses. In the present study we demonstrated that malnutrition characterized by the NRS, anthropometry, serum transferrin and BIA, not only predicts short-term but also significantly poor long-term outcome in these patients.

Assessment of Severity of Illness and Monitoring Response to Treatment of Odontogenic Space Infection Using Serum Prealbumin

PURPOSE

To assess Serum Prealbumin in the severity of illness and monitor response to treatment in odontogenic space infection.

PATIENTS AND METHODS

This was a prospective cohort study comprising patients being managed for odontogenic space infection at the Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria. The calculated sample size was 69. Clinical parameters (Swelling Size, Visual Analogue Scale for pain intensity, and Maximal Interincisal Distance) were measured on day 0, day 4, and day 8. Other clinical parameters were Number of Anatomic Spaces Involved, setting of treatment, and Length of Hospital Stay. Serum Prealbumin levels were also serially measured. The relationship between Serum Prealbumin level and the clinical parameters was established using Spearman's correlation test, independent t test, Friedman's test, and linear regression. Significance level was set at .05.

RESULTS

The mean Serum Prealbumin level at presentation (day 0) was 19.19 ± 4.61 mg/dl, which was significantly lower among inpatients (p = 0.001). On days 0, 4, and 8, Serum Prealbumin negatively correlated with Number of Anatomic Spaces Involved (p < 0.001). Serum Prealbumin levels on days 0, 4, and 8 and response in Serum Prealbumin negatively correlated with Length of Hospital Stay. On each day, Serum Prealbumin negatively correlated with pain intensity and Swelling Size and positively correlated with mouth opening. The response in Serum Prealbumin also positively correlated with response in each of the three clinical parameters.

CONCLUSION

This study suggests that Serum Prealbumin is a reliable tool for grading severity of illness and monitoring response to treatment in odontogenic space infection.

The associations of fat tissue and muscle mass indices with all-cause mortality in patients undergoing hemodialysis

Protein-energy wasting, which involves loss of fat and muscle mass, is prevalent and is associated with mortality in hemodialysis (HD) patients. We investigated the associations of fat tissue and muscle mass indices with all-cause mortality in HD patients. The study included 162 patients undergoing HD. The fat tissue index (FTI) and skeletal muscle mass index (SMI), which represent respective tissue masses normalized to height squared, were measured by bioimpedance analysis after dialysis. Patients were divided into the following four groups according to the medians of FTI and SMI values: group 1 (G1), lower FTI and lower SMI; G2, higher FTI and lower SMI; G3, lower FTI and higher SMI; and G4, higher FTI and higher SMI. The associations of the FTI, SMI, and body mass index (BMI) with all-cause mortality were evaluated. During a median follow-up of 2.5 years, 29 patients died. The 5-year survival rates were 48.6%, 76.1%, 95.7%, and 87.4% in the G1, G2, G3, and G4 groups, respectively (P = 0.0002). The adjusted hazard ratio values were 0.34 (95% confidence interval [CI] 0.10–0.95, P = 0.040) for G2 vs. G1, 0.13 (95%CI 0.01–0.69, P = 0.013) for G3 vs. G1, and 0.25 (95%CI 0.07–0.72, P = 0.0092) for G4 vs. G1, respectively. With regard to model discrimination, on adding both FTI and SMI to a model with established risk factors, the C-index increased significantly when compared with the value for a model with BMI (0.763 vs. 0.740, P = 0.016). Higher FTI and/or higher SMI values were independently associated with reduced risks of all-cause mortality in HD patients. Moreover, the combination of the FTI and SMI may more accurately predict all-cause mortality when compared with BMI. Therefore, these body composition indicators should be evaluated simultaneously in this population.

Association of Pre-End-Stage Renal Disease Serum Albumin With Post-End-Stage Renal Disease Outcomes Among Patients Transitioning to Dialysis

OBJECTIVE

Serum albumin is a marker of malnutrition and inflammation and has been demonstrated as a strong predictor of mortality in chronic kidney disease (CKD) and end-stage renal disease (ESRD) patients. Yet, whether serum albumin levels in late-stage CKD are associated with adverse outcomes after the transition to ESRD is unknown. We hypothesize that lower levels and a decline in serum albumin in late-stage CKD are associated with higher risk of mortality and hospitalization rates 1 year after transition to ESRD.

DESIGN AND METHODS

This retrospective cohort study included 29,124 US veterans with advanced CKD transitioning to ESRD between 2007 and 2015. We evaluated the association of pre-ESRD (91 days before transition) serum albumin with 12-month post-ESRD all-cause, cardiovascular, and infection-related mortalities and hospitalization rates as well as the association of 1-year pre-ESRD albumin slope and 12-month post-ESRD mortality using hierarchical multivariable adjustments.

RESULTS

There was a negative linear association between serum albumin and all-cause mortality, such that risk doubled (hazard ratio [HR]: 2.07, 95% confidence interval [CI]: 1.87, 2.28) for patients with the lowest serum albumin <2.8 g/dL (ref: ≥4.0 g/dL) after full adjustment. A consistent relationship was observed between serum albumin and cardiovascular and infection-related mortality, and hospitalization outcomes. An increase in serum albumin of >0.25 g/dL/year was associated with reduced mortality risk (HR: 0.76, 95% CI: 0.63, 0.91) compared with a slight decline in albumin (ref: >-0.25 to 0 g/dL/year), whereas a decline more than 0.5 g/dL/year was associated with a 55% higher risk in mortality (HR: 1.55, 95% CI: 1.43, 1.68) in fully adjusted models.

CONCLUSIONS

Lower pre-ESRD serum albumin was associated with higher post-ESRD all-cause, cardiovascular, and infection-related mortalities and hospitalization rates. Declining serum albumin levels in the pre-ESRD period were also associated with worse 12-month post-ESRD mortality.

Proteomic Analysis of Human Dermal Fibroblast Conditioned Medium (DFCM)

Growth factors and extracellular matrix (ECM) proteins are involved in wound healing. Human dermal fibroblasts secrete wound-healing mediators in culture medium known as dermal fibroblast conditioned medium (DFCM). However, the composition and concentration of the secreted proteins differ with culture conditions and environmental factors. We cultured human skin fibroblasts in vitro using serum-free keratinocyte-specific media (EpiLife™ Medium [KM1] and defined keratinocyte serum-free medium [KM2]) and serum-free fibroblast-specific medium (FM) to obtain DFCM-KM1, DFCM-KM2 and DFCM-FM, respectively. We identified and compared their proteomic profiles using bicinchoninic acid assay (BCA), 1-dimensional sodium dodecyl sulphate-polyacrylamide gel electrophoresis (1D SDS-PAGE), enzyme-linked immunosorbent assay (ELISA), matrix-assisted laser desorption ionisation-time-of-flight mass spectrometry (MALDI-TOF/TOF MS/MS) and liquid chromatography MS (LC-MS/MS). DFCM-KM1 and DFCM-KM2 had higher protein concentrations than DFCM-FM but not statistically significant. MALDI-TOF/TOF MS identified the presence of fibronectin, serotransferrin, serpin and serum albumin. LC-MS/MS and bioinformatics analysis identified 59, 46 and 58 secreted proteins in DFCM-KM1, DFCM-KM2 and DFCM-FM, respectively. The most significant biological processes identified in gene ontology were cellular process, metabolic process, growth and biological regulation. STRING® analysis showed that most secretory proteins in the DFCMs were associated with biological processes (e.g. wound healing and ECM organisation), molecular function (e.g. ECM binding) and cellular component (e.g. extracellular space). ELISA confirmed the presence of fibronectin and collagen in the DFCMs. In conclusion, DFCM secretory proteins are involved in cell adhesion, attachment, proliferation and migration, which were demonstrated to have potential wound-healing effects by in vitro and in vivo studies.

Nutritional Management for Chronic Kidney Disease Patients who Undergo Bariatric Surgery: A Narrative Review

Bariatric surgery (BS) may be effective for chronic kidney disease (CKD) patients by reducing microalbuminuria and proteinuria, and by facilitating their meeting inclusion criteria for kidney transplantation. However, nutritional management for this population is complex and specific guidelines are scarce. A literature search was performed to create dietetic practice for these patients based on the most recent evidence. For the purposes of nutritional recommendations, we divided the patients into 2 subgroups: 1) patients with CKD and dialysis, and 2) patients after kidney transplantation. Before surgery, nutritional care includes nutritional status evaluation and adjusting doses of supplements to treat deficiencies and daily nutrient intake according to the dietary restrictions derived from kidney disease, including quantities of fluids, protein, phosphorus, potassium, and vitamins. After BS, these patients are at major risk for lean body mass loss, malnutrition and dehydration because of fluid restriction and diuretics. Postoperative nutritional recommendations should be carefully tailored according to CKD nutritional limitations and include specific considerations regarding protein, fluids, and supplementation, in particular calcium, vitamin A, and vitamin D. Nutritional management of CKD and kidney transplant patients undergoing BS is challenging and future studies are required to establish uniform high-level evidence-based guidelines.

A new renal inpatient nutrition screening tool (Renal iNUT): a multicenter validation study

BACKGROUND

Screening of patients with renal disease for malnutrition risk on hospital admission provides an opportunity to improve prognosis. This study aimed to assess the validity and reliability of the Renal iNUT, a novel renal-specific inpatient nutrition screening tool.

METHODS

Adult inpatient admissions to three renal units were screened using the Renal Inpatient Nutrition Screening Tool (iNUT) and the generic Malnutrition Universal Screening Tool (MUST) and compared against nutritional status using Subjective Global Assessment (SGA) as the standard. Construct validity was assessed by Handgrip Strength (HGS), reliability by repeated iNUT administration and nurse opinion by questionnaire.

RESULTS

Of 141 admissions, 45% were malnourished (SGA score B or C). Using iNUT, 49% patients had increased malnutrition risk (score ≥1), 35.5% requiring dietetic referral (score ≥2). MUST indicated 20% at increased malnutrition risk and dietetic referral in 7%. iNUT was more sensitive than MUST in identifying increased malnutrition risk (92.1% vs 44.4%) and dietetic referral (69.8% vs 15.9%). Specificity of iNUT for increased risk was 82.1% and 92.3% for dietetic referral. 47% patients had sarcopenic-range HGS, with significant difference between iNUT score ≥2 and 0 (p < 0.001). iNUT reliability assessed by kappa was 0.74 (95% CI, 0.58 to 0.9), indicating substantial agreement. Nurse evaluation (n = 71) was highly favorable.

CONCLUSIONS

The Renal iNUT is a valid and reliable nutrition screening tool when used by nurses admitting patients to specialist renal wards. In comparison with MUST, use of iNUT is likely to improve the identification of malnourished patients for nutritional intervention and dietetic referral.

Lower body mass index and mortality in older adults starting dialysis

Lower body mass index (BMI) has consistently been associated with mortality in elderly in the general and chronic disease populations. Remarkably, in older incident dialysis patients no association of BMI with mortality was found. We performed an in-depth analysis and explored possible time-stratified effects of BMI. 908 incident dialysis patients aged ≥65 years of the NECOSAD study were included, and divided into tertiles by baseline BMI (<23.1 (lower), 23.1–26.0 (reference), ≥26.0 (higher) kg/m²). Because the hazards changed significantly during follow-up, the effect of BMI was modeled for the short-term (<1 year) and longer-term (≥1 year after dialysis initiation). During follow-up (median 3.8 years) 567 deaths occurred. Lower BMI was associated with higher short-term mortality risk (adjusted-HR 1.63 [1.14–2.32] P = 0.007), and lower longer-term mortality risk (adjusted-HR 0.81 [0.63–1.04] P = 0.1). Patients with lower BMI who died during the first year had significantly more comorbidity, and worse self-reported physical functioning compared with those who survived the first year. Thus, lower BMI is associated with increased 1-year mortality, but conditional on surviving the first year, lower BMI yielded a similar or lower mortality risk compared with the reference. Those patients with lower BMI, who had limited comorbidity and better physical functioning, had better survival.

Obesity Paradox in Advanced Kidney Disease: From Bedside to the Bench

While obesity is associated with a variety of complications including diabetes, hypertension, cardiovascular disease and premature death, observational studies have also found that obesity and increasing body mass index (BMI) can be linked with improved survival in certain patient populations, including those with conditions marked by protein-energy wasting and dysmetabolism that ultimately lead to cachexia. The latter observations have been reported in various clinical settings including end-stage renal disease (ESRD) and have been described as the "obesity paradox" or "reverse epidemiology", engendering controversy. While some have attributed the obesity paradox to residual confounding in an effort to "debunk" these observations, recent experimental discoveries provide biologically plausible mechanisms in which higher BMI can be linked to longevity in certain groups of patients. In addition, sophisticated epidemiologic methods that extensively adjusted for confounding have found that the obesity paradox remains robust in ESRD. Furthermore, novel hypotheses suggest that weight loss and cachexia can be linked to adverse outcomes including cardiomyopathy, arrhythmias, sudden death and poor outcomes. Therefore, the survival benefit observed in obese ESRD patients can at least partly be derived from mechanisms that protect against inefficient energy utilization, cachexia and protein-energy wasting. Given that in ESRD patients, treatment of traditional risk factors has failed to alter outcomes, detailed translational studies of the obesity paradox may help identify innovative pathways that can be targeted to improve survival. We have reviewed recent clinical evidence detailing the association of BMI with outcomes in patients with chronic kidney disease, including ESRD, and discuss potential mechanisms underlying the obesity paradox with potential for clinical applicability.

Subjective Global Assessment-Dialysis Malnutrition Score and cardiovascular risk in hemodialysis patients: an observational cohort study

BACKGROUND

Malnutrition is an important risk factor for cardiovascular mortality in hemodialysis (HD) patients. However, current malnutrition biomarkers seem unable to accurately estimate the role of malnutrition in predicting cardiovascular risk. Our aim was to investigate the role of the Subjective Global Assessment-Dialysis Malnutrition Score (SGA-DMS) compared to two well-recognized comorbidity scores-Charlson Comorbidity Index (CCI) and modified CCI (excluding age-factor) (mCCI)-in predicting cardiovascular events in HD patients.

METHODS

In 86 maintenance HD patients followed from June 2015 to June 2017, we analyzed biohumoral data and clinical scores as risk factors for cardiovascular events (acute heart failure, acute coronary syndrome and stroke). Their impact on outcome was investigated by linear regression, Cox regression models and ROC analysis.

RESULTS

Cardiovascular events occurred in 26/86 (30%) patients during the 2-year follow-up. Linear regression showed only age and dialysis vintage to be positively related to SGA-DMS: B 0.21 (95% CI 0.01; 0.30) p 0.05, and B 0.24 (0.09; 0.34) p 0.02, respectively, while serum albumin, normalized protein catabolic rate (nPCR) and dialysis dose (Kt/V) were negatively related to SGA-DMS: B - 1.29 (- 3.29; - 0.81) p 0.02; B - 0.08 (- 1.52; - 0.35) p 0.04 and B - 2.63 (- 5.25; - 0.22) p 0.03, respectively. At Cox regression analysis, SGA-DMS was not a risk predictor for cardiovascular events: HR 1.09 (0.9; 1.22), while both CCI and mCCI were significant predictors: HR 1.43 (1.13; 1.87) and HR 1.57 (1.20; 2.06) also in Cox adjusted models. ROC analysis reported similar AUCs for CCI and mCCI: 0.72 (0.60; 0.89) p 0.00 and 0.70 (0.58; 0.82) p 0.00, respectively, compared to SGA-DMS 0.56 (0.49; 0.72) p 0.14.

CONCLUSIONS

SGA-DMS is not a superior and significant prognostic tool compared to CCI and mCCI in assessing cardiovascular risk in HD patients, even it allows to appraise both malnutrition and comorbidity status.

Longitudinal Weight Change During CKD Progression and Its Association With Subsequent Mortality

BACKGROUND

Few studies have investigated the changes in weight that may occur over time among adults with the progression of chronic kidney disease (CKD). Whether such weight changes are independently associated with death after the onset of end-stage renal disease has also not been rigorously examined.

STUDY DESIGN

Prospective cohort study.

SETTING & PARTICIPANTS

We studied 3,933 participants of the Chronic Renal Insufficiency Cohort (CRIC) Study, a longitudinal cohort of patients with CKD. We also performed similar analyses among 1,067 participants of the African American Study of Kidney Disease and Hypertension (AASK).

PREDICTORS

Estimated glomerular filtration rate (eGFR) and weight change during CKD.

OUTCOME

Weight and all-cause mortality after dialysis therapy initiation.

RESULTS

During a median follow-up of 5.7 years in CRIC, weight change was not linear. Weight was stable until cystatin C-based eGFR (eGFRcys) decreased to <35mL/min/1.73m2; thereafter, weight declined at a mean rate of 1.45 kg (95% CI, 1.19-1.70) for every 10 mL/min/1.73m2 decline in eGFRcys. Among the 770 CRIC participants who began hemodialysis or peritoneal dialysis therapy during follow-up, a >5% annualized weight loss after eGFR decreased to <35mL/min/1.73m2 was associated with a 54% higher risk for death after dialysis therapy initiation (95% CI, 1.17-2.03) compared with those with more stable weight (annualized weight changes within 5% of baseline) in adjusted analysis. Similar findings were observed in the AASK.

LIMITATIONS

Inclusion of research participants only; inability to distinguish intentional versus unintentional weight loss.

CONCLUSIONS

Significant weight loss began relatively early during the course of CKD and was associated with a substantially higher risk for death after dialysis therapy initiation. Further studies are needed to determine whether interventions to optimize weight and nutritional status before the initiation of dialysis therapy will improve outcomes after end-stage renal disease.

Body Mass Index and All-cause Mortality in Chronic Kidney Disease: A Dose-response Meta-analysis of Observational Studies

This article provides a dose-response meta-analysis to evaluate the relationship between body mass index (BMI) and all-cause and disease-specific mortality in chronic kidney disease (CKD) by pooling together early stage, hemodialysis, and peritoneal dialysis patients. We evaluated eligible studies that published between 1966 and December 2014 by searching in PubMed, Object View and Interaction Design (OVID), and the Scopus databases. We used random-effects generalized least squares spline models for trend estimation to derive pooled dose-response estimates. Nonlinear associations of BMI with all-cause mortality were observed (P-nonlinearity < .0001), with an increased rate of mortality with BMIs > 30 kg/m² in all stages of CKD together. However, reanalysis of data separately by stage of CKD (hemodialysis and peritoneal dialysis) showed that the risk of all-cause mortality decreased with a steep slope in individuals with BMIs > 30 kg/m². This meta-analysis indicates that higher BMI has protective effects with respect to all-cause mortality in patients with both type of dialysis.

Charlson Comorbidity Index is a Predictor of Outcomes in Incident Hemodialysis Patients and Correlates with Phase Angle and Hospitalization

Background

The adjustment of comorbidity is important in international hemodialysis comparisons. The aim of this study is to verify if it is possible to use the Charlson Comorbidity Index (CCI), in an Italian population of incident hemodialysis patients from the Campania region as outcome predictors. A similar proposal has already been made for an American population of incident patients in peritoneal dialysis. Methods: The data for this study come from the Uremic Registry of Campania taken in the year 2001. This is an observational study in which demographic, comorbid, laboratory, treatment and insurance data were collected in 111 dialysis units (70%) in Campania. We evaluated 515 hemodialysis incident patients who were hemodialyzed in Campania between January 1 and December 31, 2001. The study was restricted to patients who had already undergone 90 days of hemodialysis. The duration of this study was 15 months. Charlson Comorbidity Index was performed. In 128 patients (24.8%) BIA measurements were performed after dialysis. Statistics: We used Student's t test for unpaired data and Cox proportional model to analyze predictors of mortality. The variables analyzed were age at start of hemodialysis, sex, CCI, hemoglobin, diabetes, hypertension, albumin, days of hospitalization. The statistically significant variables, analyzed initially by univariate analysis, were chosen for multivariate analysis. We considered p< 0.05 statistically significant.

Results

A total of 515 patients (M=316, F=199) (age: 63.62±15.35 years) presented with the following diseases: NO diagnosed in 93 patients (19%), GN in 64 (13%) IN in 42 (9%), Hereditary in 55 (11%), Vascular in 66 (14%), Diabetes in 135 (28%), others in 30 (6%). Hemoglobin levels were 10.71±1.51 g/dL and albumin was 3.79±0.54 g/dL. The days of hospitalization for the population studied were 3364/year. After the study, 75 patients died and the overall mortality rate was 11.65/100 patient/years. Univariate analysis shows that there are significant differences calculated for age (median value 73 and 65 years, respectively for non-survivers and survivers), BMI (median value and 22 and 24 kg/m2, respectively), Hb (median value 9.5 and 11g/dL, respectively), Albumin (median value 3.5 and 3.8 g/dL, respectively), days of hospitalization (median value 8 and zero days, respectively), CCI (median value 6 and 4 score, respectively, phase angle (median value 3.3 and 4 degree, respectively). The mortality rates (100 dialysis years) by the CCI score: the mortality rate was zero for patients with a CCI of 3; and it increased to approximately 60% of patient years with a CCI score of 6 or greater. The linear correlation between CCI and phase angle in living (y=18.90 × - 3.83; R2 = 0.56) and in the dead (y = 13.01 × - 1.87; R2 = 0.29).

Discussion

We found that CCI is a strong predictor of mortality in incident HD patients as has also been indicated in PD patients; CCI correlates with phase angle calculated from Bioelectrical Impedance Analysis and this last factor can be used in the following examinations; several days of hospitalization are a very important determinant in the survival in hemodialysis patients.

Inadequacy of Dialysis, Chronic Inflammation and Malnutrition in Nigerian Patients on Chronic Hemodialysis

Purpose

To identify the extent of underdialysis, chronic inflammation and malnutrition and their interrelationships in Nigerian hemodialysis patients.

Methods

In a prospective study including 10 adult patients, (6 men, 4 women) on hemodialysis in North Central Nigeria, malnutrition was assessed by body mass index (BMI), serum albumin and prealbumin, and bioimpedance (BIA) pre-and post dialysis, inflammation was evaluated by C-reactive protein (CRP) and adequacy of dialysis was judged by frequency of the hemodialysis sessions and Kt/V urea.

Results

Post-dialysis BMI was 21.3 (19.9, 24.3) kg/m2 (< 20 kg/m2 in 4 patients), serum albumin 31.5 (24.0, 32.0) g/L (< 30.0 g/L in 5), serum pre-albumin 25.2 (15.3, 31.1) mg/dL (< 18.0 mg/dL in 4), serum CRP 4.8 (1.2, 11.5) mg/dL (> 1.0 mg/dL in 8), phase angle 4.2 (3.7, 5.1)° (< 3° in 3) and body fat deficit was diagnosed by BIA in 4 patients. Weekly frequency of dialysis was 3 times in 2 patients, twice in 1 and ≤1 time in 7. Single-pool Kt/V urea was 0.81 (0.68, 0.95, <1.2 in 9 patients and > 1.2 in one patient receiving dialysis only twice weekly). By combined frequency of dialysis and Kt/V urea values, no patient received an adequate dose of dialysis and, indeed, all patients had overt symptoms of uremia. Low body weight, low serological and BIA nutrition indices, and high CRP levels occurred in the same patients. Patients on dialysis for > 1 year had worse nutrition indices than those on dialysis for < 1 year.

Conclusions

Underdialysis was universal, while poor nutrition and chronic malnutrition were found in the majority of the small number of patients studied. These three adverse conditions, which were interlinked, may be common in Nigerian hemodialysis patients, because their underlying socioeconomic causes are widespread. (Int J Artif Organs 2006; 29: 1067–73)

Association Between Comprehensive Nutritional Scoring System (CNSS) and Outcomes of Continuous Ambulatory Peritoneal Dialysis Patients

BACKGROUND/AIMS

The presence of protein-energy wasting (PEW) among dialysis patients is a crucial risk factor for outcomes. The complicated pathogenesis of PEW makes it difficult to assess and treat. This single-center retrospective study focuses on the association between nutritional markers and the outcomes of continuous ambulatory peritoneal dialysis(CAPD) patients, aiming to establish a practical comprehensive nutritional scoring system for CAPD patients.

METHODS

924 patients who initiated peritoneal dialysis in our center from January 1st,2005 to December 31st,2015 were enrolled. Comprehensive nutritional scoring system(CNSS) was based on items including SGA, BMI, ALB, TC, MAC and TSF. We divide patients into 3 groups according to their CNSS score. Outcomes including mortality, hospitalization days and hospitalization frequency were compared between 3 grades.

RESULTS

The CNSS grade correlated significantly with hospitalization days (P<0.05). Both categorized CNSS grade (HR:0.56; 95% CI:0.41-0.78; P = 0.001) and continuous CNSS score (HR:0.87; 95% CI: 0.80-0.94; P = 0.001) independently protect PD patients from all-cause mortality.

CONCLUSION

CNSS provides an integrated scoring system with significant associations with hospitalization and mortality in PD patients. The CNSS grade differentiates patients with malnutritional risk and independently predicts high risk of morbidity and mortality.

Associations Between Weight Loss, Kidney Function Decline, and Risk of ESRD in the Chronic Kidney Disease in Children (CKiD) Cohort Study

BACKGROUND

Anorexia and malnutrition are associated with poor outcomes in children with chronic kidney disease (CKD).

STUDY DESIGN

Observational cohort study.

SETTING & PARTICIPANTS

We assessed changes in body mass index (BMI) as kidney function declines and its association with risk for end-stage renal disease (ESRD) among 854 participants followed between 2005 to 2013 in the CKD in Children (CKiD) Study.

PREDICTORS

Repeated measurements of estimated glomerular filtration rate (eGFR) by serum creatinine concentration in our trajectory analysis using mixed models; change in BMI z score (per year) after eGFR decreased to <35mL/min/1.73m² in logistic regression models.

OUTCOMES

Repeated measurements of BMI z score (as a reflection of weight status) in our trajectory analysis; ESRD in logistic regression models.

RESULTS

During a mean longitudinal follow-up of 3.4 years, BMI z scores remained stable until eGFR decreased to <35mL/min/1.73m². When eGFR decreased to <35mL/min/1.73m², a mean decline in BMI z score of 0.13 (95% CI, 0.09-0.17) was noted with each 10-mL/min/1.73m² further decline in eGFR. This was statistically significantly different from the weight trajectory when eGFR was ≥35mL/min/1.73 m² (P<0.001). Among children and adolescents with significant weight loss (defined as decline in BMI z score > 0.2 per year) after eGFR decreased to <35mL/min/1.73m², the odds of ESRD was 3.28 (95% CI, 1.53-7.05) times greater compared with participants with stable BMI z scores (BMI z score change per year of 0-0.1).

LIMITATIONS

Observational nature of our study, lack of longitudinal assessments of inflammatory markers.

CONCLUSIONS

In children and adolescents with CKD, weight loss mostly occurs when eGFR decreases to <35mL/min/1.73m², and this weight loss was associated with higher risk for ESRD. Further studies are needed to define the reasons for the association between weight loss and more rapid progression to ESRD in children and adolescents.

Estimation of clinical parameters of chronic kidney disease by exhaled breath full-scan mass spectrometry data and iterative PCA with intensity screening algorithm

Breath mass spectrometry is a useful tool for identifying important compounds associated with health. However, there have been few studies that have explored human exhaled breath by full-scan mass spectrometry as a non-invasive method for medical diagnosis, which may be attributed to the difficulties resulting from multicollinearity and small sample sizes relative to a large number of product ions. In this study, breath samples from 54 chronic kidney disease patients were analyzed by selected ion flow tube mass spectrometry in the full-scan mode. With the signal intensities of product ions, we developed a novel and robust algorithm, iterative PCA with intensity screening (IPS), to build linear models for estimating important clinical parameters of chronic kidney disease. It has been shown that IPS provided good estimations in cross-validated samples, and furthermore the identified product ions could have direct medical relevance to the disease. The study demonstrated the potential of quantitative breath analysis using mass spectrometry for medical diagnosis, and the importance of applying appropriate statistical tools to unveil the rich information in this type of data.

Applicability of the direct parameters of bioelectrical impedance in assessing nutritional status and surgical complications of women with gynecological cancer

BACKGROUND/OBJECTIVES

Bioelectrical impedance vector analysis (BIVA) has been considered a promising technique in monitoring the nutritional and hydration status of patients with different types of diseases. The aim of this study was to assess the nutritional status provided by direct parameters of bioelectrical impedance analysis (BIA), BIVA and phase angle (PA), in patients with cervical and endometrial cancer undergoing surgical treatment, associating to other parameters of nutritional status and surgical outcomes.

SUBJECTS/METHODS

In a prospective cohort, 208 women eligible to surgical treatment, admitted from January to December 2015, were enrolled. Patients were assessed according to the body mass index (BMI), Patient Generated Subjective Global Assessment (PG-SGA) and BIA. The PA was categorized as below and above percentiles 25 and 50 of studied population.

RESULTS

According to BMI and PG-SGA, most of them were classified as obese (69%) and well nourished (84%), respectively. PA was significantly lower in patients with endometrial cancer, PG-SGA B or C, and in those who remained longer in hospital. PA below 25th percentile was also associated with surgical complications. Comparison of BIVA detachment of our population with a reference population showed significant impedance vector displacement, characterized by decreased reactance value and increased resistance value in our group of patients.

CONCLUSIONS

PA was associated with other parameters of nutritional status and surgical outcomes. BIVA was associated with nutritional status and length of hospital, but did not present significant result for surgical complications.

Sarcopenia in patients with chronic kidney disease not yet on dialysis: Analysis of the prevalence and associated factors

INTRODUCTION

Sarcopenia is a chronic condition that is associated with aging and characterized by a reduction of muscle mass, strength, and function. Sarcopenia is prevalent in patients with chronic kidney disease (CKD) and associated with increased morbidity and mortality, as well as cardiovascular complications.

OBJECTIVES

To investigate the prevalence of sarcopenia in patients with CKD not yet on dialysis and its correlation with clinical and laboratory variables and inflammatory markers.

METHODS

A total of 100 patients of both sexes aged over 18 were evaluated. Sarcopenia was defined using the criteria of the European Working Group on Sarcopenia in Older People (EWGSOP) and of the Foundation for the National Institutes of Health (FNIH) Sarcopenia Project. Sociodemographic and clinical data, activities of daily living, functional capacity, and physical activity were also evaluated. Inflammation was assessed by the serum levels of high-sensitivity C-reactive protein (hsCRP) and interleukin (IL) 4 and 6.

RESULTS

The prevalence of sarcopenia was 11.9% and 28.7% using the EWGSOP and FNIH criteria, respectively. Sarcopenia was more prevalent in the more advanced stages of CKD (34.5% in stages 2 and 3A; and 65.5% in stages 3B, 4, and 5) and associated with worse performance in activities of daily living (p = 0.049), lower walking speeds (p < 0.001), and higher body mass indexes (BMIs) (p = 0.001) in the non-adjusted model. In addition, patients with sarcopenia had lower functional capacity (p = 0.012) and higher prevalence of physical inactivity (p = 0.041) compared with patients without sarcopenia. After adjustment for confounding variables, sarcopenia was still significantly correlated with walking speed (p = 0.004) and BMI (p = 0.002). HsCRP levels were inversely correlated with appendicular lean mass adjusted for BMI (p = 0.007) and were also positively associated with BMI (p = 0.001). IL4 levels were positively correlated with walking speed (p = 0.007) and lean mass in the lower limbs (p = 0.022).

CONCLUSIONS

Sarcopenia is common in patients with CKD, particularly in the most advanced stages of the disease. We observed an association between the levels of inflammatory markers and peripheral lean body mass, physical performance, and BMI. This association between sarcopenia and modifiable factors highlights the importance of early diagnosis and the implementation of therapeutic measures to minimize adverse outcomes in patients with CKD not yet on dialysis.

Level of inflammatory factors in chronic hemodialysis patients with and without cardiovascular disease

Background:

Considering the existence of controversies about the predictive value of inflammatory markers for cardiovascular disease (CVD), we aimed to compare the level of high-sensitivity C-reactive protein (hs-CRP) and interlukin-6 (IL-6) level in chronic hemodialysis (HD) patients with and without CVD.

Materials and Methods:

In this historical cohort study, HD patients with and without CVD disease were enrolled. The presence of CVD risk factors, level of inflammatory factors including IL-6 and hs-CRP as well as lipid levels, fasting blood sugar, and other biochemical factors were compared in two studied groups.

Results:

During the study, eighty HD patients with (n = 40) and without (n = 40) CVD were enrolled. Diabetes was more prevalent among HD patients with CVD than those without CVD (P < 0.05). The level of IL-6 and hs-CRP were not different in two studied groups (P > 0.05). Univariate analysis of variance test indicated that there was not any significant relationship between hs-CRP and CVD (P > 0.05).

Conclusion:

The findings indicated that the level of inflammatory factors including hs-CRP and IL-6 are not significantly different in HD patients with and without CVD. However, for obtaining more definite conclusion in this field and evaluation their predicting role in this field, it is recommended to study other novel inflammatory markers as well as the additive effect of the inflammatory factors with traditional ones in larger sample size and longer follow-up.

Serum albumin levels and their correlates among individuals with motor disorders at five institutions in Japan

BACKGROUND/OBJECTIVES

The level of serum albumin is an index of nourishment care and management. However, the distribution and correlates of serum albumin levels among individuals with motor disorders have not been reported until now. Therefore, we examined the distribution and correlates of serum albumin levels among individuals with motor disorders.

SUBJECTS/METHODS

A cross-sectional study on 249 individuals with motor disabilities (144 men, mean age: 51.4 years; 105 women, mean age: 51.4 years) was conducted at five institutions in Ibaraki Prefecture, Japan in 2008. The results were compared with data from the National Health and Nutrition Survey.

RESULTS

The mean serum albumin levels were 4.0 ± 0.4 g/dL for men and 3.8 ± 0.5 g/dL for women. Overall, 17 (11.8%) men and 25 (23.8%) women had hypoalbuminemia (serum albumin level ≤ 3.5 g/dL); these proportions were greater than those among healthy Japanese adults (≤ 1%). Low serum albumin level was related with female sex, older age, low calf circumference, low relative daily energy intake, low hemoglobin (Hb), low blood platelet count, low high-density lipoprotein cholesterol (HDL-C), low HbA_1c, and high C-reactive protein (CRP) levels. The strongest correlates, based on standardized betas, were Hb (0.321), CRP (-0.279), and HDL-C (0.279) levels.

CONCLUSIONS

These results indicate that the prevalence of hypoalbuminemia is higher in individuals with motor disabilities than in healthy individuals and that inflammation is a strong negative correlate of serum albumin levels. Therefore, inflammation should be examined for the assessment of hypoalbuminemia among institutionalized individuals with motor disabilities.

Variables de la desnutrición en pacientes en diálisis

Introducción: El paciente en diálisis va a sufrir una desnutrición proteico-calórica, con diferentes factores implicados en su aparición, lo cual se asocia con una elevadísima morbilidad cardiovascular y mortalidad. Se ha estimado una prevalencia de desnutrición en la población en hemodiálisis del 18-75%, siendo por tanto, un problema de especial relevancia en este tipo de pacientes. Objetivo: Realizar una revisión bibliográfica de los artículos científicos existentes sobre las variables que intervienen en la desnutrición del paciente en diálisis. Metodología: Se ha realizado una revisión bibliográfica mediante las bases de datos PubMed, Scielo, Pro- Quest. La búsqueda se ha realizado con términos Mesh, con una antigüedad no mayor de 5 años y con distintas palabras clave. Resultados: Se han revisado 19 artículos. La mayoría de los artículos fueron estudios observacionales y de revisión. Los factores que se asocian con desnutrición son la edad, pérdida de masa muscular, baja actividad física y dieta pobre en micronutrientes. Otro factor muy importante, es la inflamación. En cuanto a los métodos diagnósticos, son variados y diferentes, debido a la gran cantidad de variables que influyen en la desnutrición. Conclusiones: La desnutrición en pacientes en diálisis depende de distintas variables y no solamente de la dieta. Los factores que se asocian con desnutrición son mayor edad, pérdida de masa muscular, baja actividad física y dieta pobre en micronutrientes. Además, habría que añadir el doble papel que juega la inflamación en este proceso, pues puede ser tanto consecuencia como factor predisponente a la desnutrición.

Nutritional Status in Nocturnal Hemodialysis Patients - A Systematic Review with Meta-Analysis

Background

Hemodialysis patients experience an elevated risk of malnutrition associated with increased morbidity and mortality. Nocturnal hemodialysis (NHD) results in more effective removal of waste products and fluids. Therefore, diet and fluid restrictions are less restricted in NHD patients. However, it is ambiguous whether transition from conventional hemodialysis (CHD) to NHD leads to improved intake and nutritional status. We studied the effect of NHD on protein intake, laboratory indices of nutritional status, and body composition.

Study design

Systematic review with meta-analysis.

Population

NHD patients.

Search strategy

Systematic literature search from databases, Medline, Cinahl, EMBASE and The Cochrane Library, to identify studies reporting on nutritional status post-transition from CHD to NHD.

Intervention

Transition from CHD to NHD.

Outcomes

Albumin, normalized protein catabolic rate (nPCR), dry body weight (DBW), body mass index (BMI), phase angle, protein intake, and energy intake.

Results

Systematic literature search revealed 13 studies comprising 282 patients that made the transition from CHD to NHD. Meta-analysis included nine studies in 229 patients. In control group controlled studies (n = 4), serum albumin increased significantly from baseline to 4–6 months in NHD patients compared with patients that remained on CHD (mean difference 1.3 g/l, 95% CI 0.02; 2.58, p = 0.05). In baseline controlled studies, from baseline to 4–6 months of NHD treatment, significant increases were ascertained in serum albumin (mean difference (MD) 1.63 g/l, 95% CI 0.73–2.53, p<0.001); nPCR (MD 0.16 g/kg/day; 95% CI 0.04–0.29, p = 0.01); protein intake (MD 18.9 g, 95% CI 9.7–28.2, p<0.001); and energy intake (MD 183.2 kcal, 95% CI 16.8–349.7, p = 0.03). Homogeneity was rejected only for nPCR (baseline versus 4–6 months). DBW, BMI, and phase angle did not significantly change. Similar results were obtained for comparison between baseline and 8–12 months of NHD treatment.

Limitations

Most studies had moderate sample sizes; some had incomplete dietary records and relatively brief follow-up period. Studies markedly differed with regard to study design.

Conclusions

NHD is associated with significantly higher protein and energy intake as well as increases in serum albumin and nPCR. However, the data on body composition are inconclusive.

The Association between Nutritional Markers and Biochemical Parameters and Residual Renal Function in Peritoneal Dialysis Patients

Residual renal function (RRF) is an important prognostic factor for peritoneal dialysis patients as it influences the quality of life and mortality. This study was conducted to explore the potential factors correlated with RRF. A cross-sectional study was conducted by recruiting 155 patients with residual GFR more than 1mL/min per 1.73m2 at the initiation of peritoneal dialysis. We collected the demographic characteristics, nutritional markers and biochemical parameters of all participants, and analyzed the correlation between these variables and residual GFR as well. The odds ratio of RRF loss associated with each of the nutritional markers and biochemical parameters were estimated by logistic regression model. The residual GFR was negatively correlated with serum phosphate (ORQ3 = 2.67, 95%CI: 1.03-6.92; ORQ4 = 3.45, 95%CI: 1.35-9.04), magnesium (ORQ4 = 3.77, 95%CI: 1.48-3.63), and creatinine (ORQ3 = 2.93, 95%CI: 1.09-7.88; ORQ4 = 8.64 95%CI: 2.79-26.78), while positively associated with normalized protein catabolic rate (ORQ3 = 0.24, 95%CI: 0.09-0.65; ORQ4 = 0.11, 95%CI: 0.03-0.35), 24 hours urine volume(ORQ1 = 22.87, 95%CI: 2.76-189.24; ORQ3 = 0.08, 95%CI: 0.02-0.28) and serum chlorine concentrations (ORQ1 = 5.34, 95%CI: 1.94-14.68; ORQ4 = 0.28, 95%CI: 0.09-0.85), respectively. Our study suggested that the nutritional markers and biochemical parameters, though not all, but at least in part were closely correlated with RRF in peritoneal dialysis patients.

Leucine disposal rate for assessment of amino acid metabolism in maintenance hemodialysis patients

BACKGROUND

Protein energy wasting (PEW) is common in patients undergoing maintenance hemodialysis (MHD) and closely associated with poor outcomes. Insulin resistance and associated alterations in amino acid metabolism are potential pathways leading to PEW. We hypothesized that the measurement of leucine disposal during a hyperinsulinemic- euglycemic-euaminoacidemic clamp (HEAC) procedure would accurately measure the sensitivity to insulin for its actions on concomitant carbohydrate and protein metabolism in MHD patients.

METHODS

We examined 35 MHD patients and 17 control subjects with normal kidney function by hyperinsulinemic-euglycemic clamp (HEGC) followed by HEAC clamp procedure to obtain leucine disposal rate (LDR) along with isotope tracer methodology to assess whole body protein turnover.

RESULTS

The glucose disposal rate (GDR) by HEGC was 5.1 ± 2.1 mg/kg/min for the MHD patients compared to 6.3 ± 3.9 mg/kg/min for the controls (p = 0.38). The LDR during HEAC was 0.09 ± 0.03 mg/kg/min for the MHD patients compared to 0.11 ± 0.05 mg/kg/min for the controls (p = 0.009). The LDR level was correlated with whole body protein synthesis (r = 0.25; p = 0.08), with whole body protein breakdown (r = -0.38 p = 0.01) and net protein balance (r = 0.85; p < 0.001) in the overall study population. Correlations remained significant in subgroup analysis. The GDR derived by HEGC and LDR correlated well in the controls (r = 0.79, p < 0.001), but less so in the MHD patients (r = 0.58, p < 0.001).

CONCLUSIONS

Leucine disposal rate reliably measures amino acid utilization in MHD patients and controls in response to high dose insulin.