Serum albumin concentration in dialysis patients: Why does it remain resistant to therapy?

Intradialytic neuromuscular electrical stimulation with optional virtual reality distraction improves not only muscle strength and functional capacity but also serum albumin level in haemodialysis patients: a pilot randomized clinical trial

BACKGROUND

Sarcopenia is highly prevalent in haemodialysis (HD) patients and linked to a poor prognosis regarding comorbidities and premature mortality. Previous studies assessed the effects of neuromuscular electrical stimulation in haemodialysis patients. This study adds to the relevance of neuromuscular electrical stimulation (NMES) applications combined with a virtual reality (VR) distraction to increase intensity, dosage, and efficiency of NMES and slow sarcopenia progression in HD patients.

METHODS

We conducted a 12-week multicenter prospective randomised controlled trial. The patients were randomly assigned to one of the three groups: neuromuscular electrical stimulation with or without combined virtual reality distraction or control group.

RESULTS

The final analysis included 32 haemodialysis patients (mean age of 68 ± 10 years, 26 men). Interaction effects between groups and time (12 weeks) were significant regarding serum albumin levels (p = 0.008) and left quadriceps femoris muscle (QFM) force (p = 0.026). Both endpoints were increased in the NMES compared to the CO group at the end of the intervention. The NMES group increased serum albumin levels significantly after 12 weeks. The main effect of time was an increase in mean right QFM force between beginning and end of the intervention (p = 0.021). Functional capacity improved after 12 weeks in the NMES and NMES + VR but not in the control group, with a significant difference between the three groups (p = 0.022). Weight and body mass index increased in the NMES and NMES + VR groups, albeit not significantly. The effects of VR distraction on NMES efficiency were inconclusive.

CONCLUSION

Intradialytic NMES increases serum albumin level, functional capacity, muscle strength in lower limb and in tendency weight and body mass index of HD patients. Effects on VR distraction are inconclusive. Large-scaled follow-up studies on integrated sports programs with NMES and active training in combination with VR as distraction and motivation accelerator are needed.

TRIAL REGISTRATION

German Clinical Trial Register: DRKS00029276 (Retrospectively registered: 30/06/2022).

Utility of a modified Controlling Nutritional Status score in mortality risk assessment of patients on hemodialysis

PURPOSE

Malnutrition is common among hemodialysis patients. A nutritional index may be important for their prognosis prediction. We examined the use of a modified version of the Controlling Nutritional Status (CONUT) score as a predictor of mortality in hemodialysis patients and investigated whether statin use modified the association.

METHODS

We conducted a retrospective cohort study in 1130 adults (mean age 67.7 years, 35.0% women) on maintenance hemodialysis at four outpatient dialysis clinics in Japan. The exposure of interest was modified CONUT scores calculated by one-time data of serum albumin and total cholesterol at baseline, or mean data of these measures using multiple blood test results. The primary outcome was all-cause mortality. We examined the association between modified CONUT groups (low-risk, middle-risk, and high-risk) and mortality using multivariate Cox proportional hazard regression and logistic regression models in overall patients and by statin use.

RESULTS

During a median follow-up of 6.6 years, 525 (46.5%) patients died. Analysis using both one-time and mean data showed increased mortality risk in the high-risk modified CONUT score group as compared to the low-risk group (mean data: HR 2.52, 95% CI 1.96, 3.24); when stratified by statin use, the effect appeared stronger among users (mean data: HR 5.84, 95% CI 2.98, 11.44). Strong predictive ability was observed, particularly for mortality risk at 5 year follow-up using mean data (AUC = 0.842).

CONCLUSION

Our results suggest that the modified CONUT score may be useful in helping clinicians quickly identify hemodialysis patients with poorer prognosis who may benefit from close monitoring and interventions.

Prognostic value of fibrinogen to albumin ratios among critically ill patients with acute kidney injury

Fibrinogen to albumin ratios (FAR) have shown to be a promising prognostic factor for improving the predictive accuracy in various diseases. This study explores FAR's prognostic significance in critically ill patients with acute kidney injury (AKI). All clinical data were extracted from the Multiparameter Intelligent Monitoring in Intensive Care Database III version 1.4. All patients were divided into four groups based on FAR quartiles. The primary endpoint was in-hospital mortality. A generalized additive model was applied to explore a nonlinear association between FAR and in-hospital mortality. The Cox proportional hazards models were used to determine the association between FAR and in-hospital mortality. A total of 5001 eligible subjects were enrolled. Multivariate analysis demonstrated that higher FAR was an independent predictor of in-hospital mortality after adjusting for potential confounders (HR, 95% CI 1.23, 1.03-1.48, P = 0.025). A nonlinear relationship between FAR and in-hospital mortality was observed. FAR may serve as a potential prognostic biomarker in critically patients with AKI and higher FAR was associated with increased risk of in-hospital mortality among these patients.

Prognostic Significance of the Albumin to Fibrinogen Ratio in Peritoneal Dialysis Patients

Background

Albumin to fibrinogen ratio (AFR) is a demonstrated predictor of mortality in various diseases. The aim of this study was to evaluate the prognostic value of AFR to predict mortality in peritoneal dialysis (PD) patients.

Methods

We retrospectively analyzed 212 incident PD patients from January 2010 to December 2017 and followed them until December 2019. We used receiver operating curve (ROC) analysis to determine the optimal cut-off point for AFR at baseline to predict overall and cardiovascular mortality during the follow-up period. Kaplan-Meier curve and Cox regression analysis were applied to evaluate the association between AFR and all-cause and cardiovascular mortality.

Results

The optimal threshold for AFR to predict mortality was 8.48. A low AFR was strongly correlated with worse all-cause and cardiovascular mortality in PD patients. Multivariate analysis revealed that elevated AFR was an independent marker predicting reduced all-cause and cardiovascular mortality (HR 2.41, 95% CI 1.11–5.22, P = 0.026; and HR 2.18, 95% CI 1.21–3.95, P = 0.010, respectively).

Conclusions

Patients with a high AFR had reduced all-cause and cardiovascular mortality. AFR is a potential prognostic biomarker in PD patients.

Correlation between Noncompliance Behavior and Biochemical Parameters of Chronic Kidney Disease Patients Undergoing Hemodialysis

Background and Objectives Compliance with dietary, fluid, and medication instructions is a critically significant factor for the health and well-being of patients undergoing hemodialysis for an extended period. The current study assessed the correlation between noncompliance behavior and biochemical parameters of chronic kidney disease (CKD) patients undergoing hemodialysis. The study's objectives were 1) to assess patients' noncompliance behavior using a questionnaire, 2) to determine the biochemical parameters of CKD patients having noncompliance behavior, and 3) to find the correlation between biological parameters and noncompliance behavior.

Methods A cross-sectional study was conducted from July 12, 2018, to February 10, 2019. A purposive sampling technique was used to recruit the participants, and 100 participants were included in the study. The End-Stage Renal Disease–Adherence Questionnaire was used to assess the non-compliance behavior.

Results Most dialysis patients (70%) were compliant with the therapeutic regime, while 30% failed to comply. The study revealed a significant positive correlation between noncompliance behavior and biochemical parameters of CKD patients undergoing hemodialysis (r = 0.578, p < 0.05).

Conclusion Noncompliance behavior is significantly correlated with the biochemical parameters among patients with CKD on dialysis. Optimal health is possible through fluid and dietary compliance in these patients. Hence, adherence behavior plays a significant role in the health and recovery of dialysis patients with CKD.

Nutritional Status, Nutritional Phenotypes, and Oral Nutritional Supplement Prescription Patterns Among Patients With Non-Dialysis Chronic Kidney Disease in British Columbia

OBJECTIVES

Management of protein-energy wasting and undernutrition with oral nutritional supplements (ONS) has not been systematically studied in the non-dialysis chronic kidney disease (CKD-ND) population. We aimed to describe nutritional status, identify phenotypes of patients prescribed ONS, and evaluate ONS prescription patterns among CKD-ND patients in British Columbia.

DESIGN AND METHODS

This observational study assessed adult CKD-ND patients who entered multidisciplinary CKD clinics during 2013-2018 in British Columbia. Descriptive statistics were used to describe baseline nutrition and inflammation parameters among patients prescribed ONS versus patients not prescribed ONS within 1 year of clinic entry. Hierarchical clustering method with consensus clustering was applied to identify phenotypes of patients prescribed ONS. Multivariable logistic regression was used to assess the associations between ONS prescription and health region/dietitian full-time equivalents per 1,000 CKD patients.

RESULTS

Of 15,859 CKD-ND patients, 9% of patients entering CKD clinics were prescribed ONS within 1 year of clinic entry, and these patients demonstrated lower baseline estimated glomerular filtration rate, body mass index (BMI), serum albumin, bicarbonate, as well as greater age, serum phosphate, and neutrophil-to-lymphocyte ratio compared with those not receiving ONS. Cluster analysis revealed 5 phenotypes of ONS users: cluster 1 had the highest mean neutrophil-to-lymphocyte ratio; cluster 2 had the lowest mean albumin; cluster 3 had the lowest mean BMI; cluster 4 had the highest mean BMI; and cluster 5 had the lowest mean bicarbonate. There was regional variability in ONS prescription, and an odds ratio for ONS prescription of 1.32 (95% confidence interval 1.16-1.50) for every 1-unit increase in dietitian full-time equivalents per 1,000 patients. Over 3 years of follow-up, overall ONS use among CKD-ND patients remained stable.

CONCLUSIONS

This study demonstrates appropriate prescribing of ONS to patients with suboptimal nutritional status, although regional variation exists. Patients receiving ONS represent a heterogenous group with phenotypes reflecting several clinical and biochemical features of the protein-energy wasting syndrome. These findings will assist with updating ONS policy, planning quality improvement initiatives, and informing dietitian resource allocation.

Effect of nonsurgical periodontal therapy on C-reactive protein and iron indices in hemodialysis patients

Background and Aim:

The aim of the study was to evaluate the effect of nonsurgical periodontal therapy on clinical, renal, and hematological parameters at baseline and 3 months postoperatively on chronic kidney disease (CKD) patients undergoing hemodialysis. This comparative interventional study was conducted among CKD patients undergoing hemodialysis.

Materials and Methods:

This study included chronic periodontitis (CP) patients divided into three groups Group I: CKD patients undergoing hemodialysis for less than a year; Group II: CKD patients undergoing hemodialysis for more than a year; and Group III: systemically healthy CP patients. Clinical parameters (bleeding on probing [BOP], probing pocket depth (PPD), and clinical attachment level [CAL]) were recorded at baseline (T0), 1 month (T1), and 3 months after scaling and root planing (SRP) (T2). C-reactive protein (CRP) and transferrin saturation (TSAT) were observed at T0 and at T2. Paired t-test and Chi-square test were applied to find the statistical significance (P < 0.05 was considered statistically significant at 95% confidence interval) between the T0 and T2 time within the groups.

Results:

Clinical parameters such as PPD and CAL decreased with statistical significance in Group III alone, whereas BOP decreased with statistical significance in all the three groups. The study showed statistically significant reduction of CRP (in Group I and Group III) and TSAT increased with statistical significance in all the three groups after SRP.

Conclusion:

This suggests that SRP can bring an improvement in the systemic markers in CP patients under hemodialysis. However, we need a longitudinal study with a larger sample size to confirm the results.

Increase Serum Tumor Necrosis Factor Alpha decreased Serum Cholesterol Level, but not Albumin, in Hemodialysis Patients with Non-Fibrotic Hepatitis C Infection

BACKGROUND: Hepatitis C infection could increase the morbidity and mortality of chronic kidney disease patients on hemodialysis by enhancing the inflammatory process. Tumor Necrosis Factor-alpha (TNF-a) is the main regulator of the inflammatory cascade, which could induce malnutrition and suppress cholesterol and albumin production in the liver. AIM: Therefore, this study aimed to determine the correlation between serum TNF-a level with serum albumin and cholesterol levels in chronic kidney disease patients on hemodialysis with and without hepatitis C infection. METHODS: This research was an analytical cross-sectional study. The sample of this study consisted of patients undergoing routine hemodialysis at Dr. Hasan Sadikin Hospital, Bandung, in February 2020. The sample selection was using a random sampling method and analyzed with the Spearman rank correlation test. RESULTS: One hundred nineteen patients were divided into two groups, with hepatitis C infection (n=53) and without hepatitis C infection (n=66). The median value of serum TNF-α _was higher in the hepatitis C infection group compared to the group without hepatitis c infection (31.86 pg/ml vs 11.71 pg/ml, p <0.001). There was a correlation between serum TNF-α _and cholesterol in the hepatitis C infection (r = -0.246; p = 0.039) and without hepatitis c infection group (r = -0.256; p = 0.022). After adjusting with the duration of hemodialysis, this association was found to be significant in patients without Hepatitis C infection (p = 0.02) and borderline significant in patients with Hepatitis C infection (p = 0.09). There was no correlation between TNF-α _with albumin in both hepatitis C infection group (r = 0.082; p = 0.281) and without hepatitis C infection (r = -0.168; p = 0.094). CONCLUSION: Serum TNF-α _negatively correlates with cholesterol levels in chronic kidney disease patients on hemodialysis with and without hepatitis C infection. However, there was no correlation between TNF-α _and albumin level in both groups.

Low serum albumin a predictor sign of the incidence of peritoneal dialysis-associated peritonitis? A quasi-systematic review

Peritonitis is associated with an increasing morbidity and mortality rate in peritoneal dialysis patients. A number of peritonitis cases result in hypoalbuminemia, and in other cases, peritonitis follows a decline in the serum albumin level. However, it is not clear whether the level of serum albumin can be utilized to predict and prevent the incidence of peritonitis. A quasi-systematic search of the literature was conducted in the following databases: Cochrane, EBSCO, ProQuest, AHMED, CINHAL, MEDLINE, and EMBASE, from January 2008 to January 2018. The data was reviewed and extracted from each study. The quality of the studies was assessed using the Critical Appraisal Skills Programme and the Newcastle-Ottawa Scale. Six articles met the stated inclusion criteria of the quasi-systematic review. The study found a significant correlation between a low serum albumin level at the start of continuous ambulatory peritoneal dialysis (CAPD) and the development of peritonitis. Thus, hypoalbuminemia can be utilized as a warning sign of the occurrence of peritonitis in CAPD. Consequently, immediate intervention is required when the level of serum albumin declines in order to prevent peritonitis.

ALBI grade in dialysis patients with hepatocellular carcinoma: prognostic impact and staging strategy

BACKGROUND

Patients with hepatocellular carcinoma (HCC) may develop end-stage renal disease and receive dialysis, but the impact of dialysis on the prognosis is unclear. This study aimed to evaluate the outcome of dialysis HCC patients and the prognostic role of albumin-bilirubin (ALBI) grade in these patients.

METHODS

Among the consecutive 3,794 HCC patients between 2002-2017, 43 patients undergoing dialysis, and 129 age, sex-matched controls were analyzed. Multivariate Cox hazards model was used to identify independent prognostic predictors.

RESULTS

Dialysis patients had decreased overall survival when compared with non-dialysis patients (n=3,751) and matched controls (n=129; each P=0.004). Patients with ALBI grade 1 had the best survival in the pooled cohort of dialysis and matched controls (n=172). In the Cox model, total tumor volume >33 cm3 [hazard ratio (HR): 6.763, P<0.001], presence of ascites (HR: 6.168, P<0.001), dialysis duration less than 24 months (HR: 3.144, P=0.006), diabetes-related dialysis (HR: 9.366, P=0.001) and non-curative treatments (HR: 9.220, P<0.001) were poor prognosis factors associated with increase mortality among dialysis patients. Of the 9 currently-used HCC staging systems, the CLIP score was the optimal cancer staging for dialysis patients.

CONCLUSIONS

Patients receiving dialysis had decreased overall survival compared with non-dialysis patients. Longer duration of dialysis, non-diabetes related dialysis, absence of ascites, and curative treatments were associated with improved survival in these patients. The ALBI grade is a feasible prognostic model to evaluate liver functional reserve, and the CLIP model is the best staging system for dialysis patients with HCC.

Renal Replacement Modality Affects Uremic Toxins and Oxidative Stress

Nowadays, the high prevalence of kidney diseases and their related complications, including endothelial dysfunction and cardiovascular disease, represents one of the leading causes of death in patients with chronic kidney diseases. Renal failure leads to accumulation of uremic toxins, which are the main cause of oxidative stress development. The renal replacement therapy appears to be the best way to lower uremic toxin levels in patients with end-stage renal disease and reduce oxidative stress. At this moment, despite the increasing number of recognized toxins and their mechanisms of action, it is impossible to determine which of them are the most important and which cause the greatest complications. There are many different types of renal replacement therapy, but the best treatment has not been identified yet. Patients treated with diffusion methods have satisfactory clearance of small molecules, but the clearance of medium molecules appears to be insufficient, but treatment with convection methods cleans medium molecules better than small molecules. Hence, there is an urgent need of new more validated, appropriate, and reliable information not only on toxins and their role in metabolic disorders, including oxidative stress, but also on the best artificial renal replacement therapy to reduce complications and prolong the life of patients with chronic kidney disease.

Protein-bound uremic toxins (PBUTs) in chronic kidney disease (CKD) patients: Production pathway, challenges and recent advances in renal PBUTs clearance

Uremic toxins, a group of uremic retention solutes with high concentration which their accumulation on the body makes several biological problems, have recently gained a large interest. The importance of this issue more targets patients with compromised kidney function since the presence of these toxins in their bodies contributes to serious illness and death. It is reported that around 14% of people are subjected of CKD's problems. Among different classifications of uremic toxins, protein bound uremic toxins are poorly removed from the body as they tightly bind to proteins like serum albumin. A deeper and closer understanding of methods for removing protein bound uremic toxins and their efficiency is of paramount importance. This article discussed the most critical protein bound uremic toxins from different points of view including their chemistry, binding sites, interactions, and their biological impacts. Concerning the toxicity and high concentration, p-cresyl sulfate (PCS), Indoxyl sulfate (IS), 3-Carboxy-4-methyl-5-propyl-2-furanpropionic acid (CMPF), and Indole- 3-acetic acid (IAA) was chosen to study in this article. Results offered that the functional groups of mentioned PBUTs and the way that they interact with the adsorbent play an important role in finding substances for removal of them. Furthermore, the development of nanoparticle (NPs) for promising biomedical purposes has been explored. However, there is still a need for further investigation to find biocompatible substances focusing on the removal of PBUTs. PBUTs are a unique class of uremic toxins whose renal clearance mechanisms and role in uremic pathophysiology are still unclear. This review outlines the biochemical aspects of PBUT/protein binding in a view to explaining their renal formation to elimination mechanisms; some examples are drawn from routes involving albumin-binding with indoxyl sulphate, p-cresyl sulfate, p-cresyl glucuronide and hippuric acid. We have also highlighted the kinetic behaviors during dialytic removal of PBUTs to address future concerns regarding dialytic therapy.

Trace element imbalances in patients undergoing chronic hemodialysis therapy - Report of an observational study in a cohort of Portuguese patients

INTRODUCTION

Patients with end-stage renal disease undergoing hemodialysis therapy are at risk of developing deficiencies of essential trace elements and/or overload of toxic trace elements, both of which may significantly affect their clinical status of. Those imbalances may result from the disease itself but also from the quality of the therapeutic process, namely the hemodialysis process, which has greatly evolved in the last decades. Thus, old observations that have been assumed as very well-proven have been recently questioned. In this case-control study we evaluate the current trace elements status in a group of Portuguese patients under hemodialysis therapy.

MATERIAL AND METHODS

Serum samples from patients (n = 93), collected for the routine periodic control of Al levels, were analyzed for a wide panel of trace elements (Li, Al, Mn, Co, Ni, Cu, Zn, Se, Rb, Sr, Mo, Cd, Ba, Pb) using inductively coupled plasma mass spectrometry technique (hemodialysis patients' group). For comparison purposes, samples of individuals with no evidence of renal disease according to standard laboratory analytical criteria (n = 50) were also analyzed (control group).

RESULTS

The results showed significant differences between the two groups, with higher values in hemodialysis patients group for Al (14.6 vs. 9.5 μg/L), Co, Ni, Sr, Mo (4.5 vs. 1.4 μg/L), Cd (0.058 vs. 0.025 μg/L) and Pb (0.55 vs. 0.30 μg/L); and lower values in hemodialysis patients group for Li (4.0 vs. 75.8 μg/L), Mn, Cu (943.5 vs. 1038.5 μg/L), Zn (943.5 vs. 1038.5 μg/L), Se (71.5 vs. 103.8 μg/L), Rb (202.4 vs. 300.3 μg/L) and Ba (0.65 vs. 8.7 μg/L).

CONCLUSION

This study confirms that hemodialysis patients tend to present significant trace elements imbalances, which may be related to the higher morbidity and mortality observed in this specific patients' group.

Intravascular albumin loss is strongly associated with plasma volume withdrawal in dialysis patients

INTRODUCTION

Low circulating albumin closely predicts mortality in end-stage renal disease (ESRD) patients. The cause(s) of hypoalbuminemia (hALB) in ESRD patients remains to be elucidated. The aim of the present study was to determine the role of plasma volume (PV) withdrawal in the reduction of total circulating albumin and essential blood solutes induced by hemodialysis (HD).

METHODS

PV determined with high-precision automated carbon monoxide-rebreathing, total circulating as well as concentration of plasma albumin and electrolytes were assessed prior to and after 4-hour HD in 10 ESRD patients.

FINDINGS

Baseline PV ranged from 3.5 to 6.2 l. After HD, PV was decreased by 689 ± 566 mL (-16%) (P = 0.004). Total circulating albumin was largely reduced after HD (170.8 ± 35.1 vs. 146.1 ± 48.9 g, P = 0.008), while albumin concentration was unaltered. According to a strong linear relationship (r = 0.91, P < 0.001), one-third of total circulating albumin is lost from the intravascular compartment for every liter of PV removed. Similar results were found regarding Na⁺ and Ca²⁺ electrolytes.

DISCUSSION

Total circulating albumin, but not albumin concentration, is substantially reduced by HD in proportion to the amount of PV removed from the circulation. This study highlights the potential contributing role of PV withdrawal to hALB in ESRD patients.

Association between Albumin-Globulin Ratio and Mortality in Patients with Chronic Kidney Disease

Background: Malnutrition and inflammation are highly prevalent and tightly regulated with each other in chronic kidney disease (CKD) patients. Inflammation can lead to malnutrition in patients with sufficient nourishment, while malnutrition may also induce an inflammatory response. This study investigated whether the albumin-globulin ratio (AGR) can predict the mortality risk in CKD patients. Methods: We enrolled 956 stage 3–5 CKD patients retrospectively at a medical center. Patients’ baseline characteristics including demographics, laboratory data, pharmacotherapy, and comorbidities were collected for statistical adjustments. The study patients were stratified into three AGR groups according to similar magnitudes of hazards for mortality as follows: low AGR group, AGR ≤ 1.0; moderate AGR group, 1.1 ≤ AGR < 1.3; high AGR group, AGR ≥1.3. Multivariate Cox proportional hazard analysis was performed to evaluate the association of the AGR with the study outcomes, including overall and cardiovascular disease (CVD) mortality. Results: During a median follow-up duration of 2.44 years, 108 (11.3%) deaths were recorded and 50 patients died from CVD. In adjusted model 1, the moderate AGR group was associated with hazard ratios (HR) of 0.57 (95% CI = 0.36–0.90, p = 0.016) and 0.52 (95% CI = 0.28–0.98, p = 0.043) for all-cause and CVD mortality compared with the low AGR group, respectively. The high AGR group was associated with HRs of 0.49 (95% CI = 0.27–0.90, p = 0.021) and 0.27 (95% CI = 0.1–0.74, p = 0.01) for all-cause and CVD mortality compared with the low AGR group, respectively. Similar results were obtained in the adjusted model 2 (inverse probability of the group weighted Cox model). In addition, the association between the AGR and mortality risk remained significant when the AGR was treated as a continuous variable. Conclusion: AGR is a significant biomarker predicting overall and cardiovascular mortality risk independent of various important factors amongst stage 3–5 CKD patients. We suggest that the AGR may be a simple and inexpensive measurement for detecting CKD patients at risk of mortality.

Changes in serum albumin and other nutritional markers when using sucroferric oxyhydroxide as phosphate binder among hemodialysis patients: a historical cohort study

Background

Elevated serum phosphorus concentrations are common among maintenance hemodialysis patients. Protein is a major source of dietary phosphate, but restriction of protein intake can result in hypoalbuminemia and protein-energy wasting. We hypothesized that sucroferric oxyhydroxide (SO), a potent phosphate binder with a low pill burden, may reduce serum phosphorus levels in hemodialysis patients with hypoalbuminemia without adversely impacting albumin levels or dietary intake of protein.

Methods

We retrospectively examined de-identified data from 79 adult, in-center hemodialysis patients with baseline hypoalbuminemia (≤ 3.5 g/dL) switched to SO as part of routine clinical care for at least 1 year. Temporal changes (3-month intervals from baseline through Q4) in phosphate binder pill burden, serum phosphorous levels, nutritional markers, and equilibrated Kt/V were analyzed. Data from a matched reference group of non-hypoalbuminemic patients (N = 79) switched to SO were also examined.

Results

SO therapy was associated with a mean reduction of 45.7 and 45.1% in daily phosphate binder pill burden, and a mean reduction of 0.4 mg/dL and 0.51 mg/dL in serum phosphorus levels for the hypoalbuminemic and non-hypoalbuminemic patients, respectively. Hypoalbuminemic patients demonstrated significant increases in mean serum albumin levels from 3.50 mg/dL at baseline to 3.69, 3.74, 3.70, and 3.69 mg/dL during Q1 through Q4, respectively (P < 0.0001), whereas serum albumin levels remained unchanged in the non-hypoalbuminemic group.

Conclusions

Both hypoalbuminemic and non-hypoalbuminemic patients switching to SO exhibited significant reductions in serum phosphorus concentrations and daily phosphate binder pill burden. Among hypoalbuminemic patients, the initiation of SO therapy was also associated with increases in serum albumin, suggesting therapy may have allowed patients to increase their dietary intake of protein.

Potential life-years gained over a 5-year period by correcting DOPPS-identified modifiable practices in haemodialysis: results from the European MONITOR-CKD5 study

BACKGROUND

DOPPS reported that thousands of life-years could be gained in the US and Europe over 5 years by correcting six modifiable haemodialysis practices. We estimated potential life-years gained across 10 European countries using MONITOR-CKD5 study data.

METHODS

The DOPPS-based target ranges were used, except for haemoglobin due to label changes, as well as DOPPS-derived relative mortality risks. Percentages of MONITOR-CKD5 patients outside targets were calculated. Consistent with the DOPPS-based analyses, we extrapolated life-years gained for the MONITOR-CKD5 population over 5 years if all patients were within targets.

RESULTS

Bringing the 10 MONITOR-CKD5 countries' dialysis populations into compliance on the six practices results in a 5-year gain of 97,428 patient-years. In descending order, survival impact was the highest for albumin levels, followed by phosphate levels, vascular access, haemoglobin, dialysis adequacy, and interdialytic weight gain.

CONCLUSIONS

Optimal management of the six modifiable haemodialysis practices may achieve 6.2% increase in 5-year survival.

TRIAL REGISTRATION

NCT01121237 . Clinicaltrials.gov registration May 12, 2010 (retrospectively registered).

Effects of Oral Nutritional Supplements on Mortality, Missed Dialysis Treatments, and Nutritional Markers in Hemodialysis Patients

OBJECTIVE

Protein-energy wasting is common in end-stage renal disease patients undergoing dialysis and is strongly associated with mortality and adverse outcomes. Intradialytic oral nutritional supplements (ONS) reduce risk of mortality in these patients. Large studies characterizing the impact of ONS on other outcomes are lacking. We assessed the associations between administration of ONS and clinical and nutritional outcomes.

DESIGN

Retrospective evaluation of a pilot program providing ONS to patients at a large dialysis organization in the United States. The pilot program provided ONS to in-center hemodialysis patients with serum albumin ≤3.5 g/dL at 408 facilities.

SUBJECTS

ONS patients were compared to matched controls with serum albumin ≤3.5 g/dL, identified from facilities not participating in the ONS program (n = 3,374 per group).

INTERVENTION

Receipt of ONS.

MAIN OUTCOME MEASURES

Death, missed dialysis treatments, hospitalizations, serum albumin, normalized protein catabolic rate, and postdialysis body weight were abstracted from large dialysis organization electronic medical records.

RESULTS

There was a 69% reduction in deaths (hazard ratio = 0.31; 95% confidence interval = 0.25-0.39), and 33% fewer missed dialysis treatments (incidence rate ratio = 0.77; 95% confidence interval = 0.73-0.82) among ONS patients compared to controls (P < .001 for both). The effects of ONS on nutritional indices were mixed: serum albumin was lower, whereas normalized protein catabolic rate values, a surrogate for dietary protein intake, and postdialysis body weights were higher for ONS patients compared to controls during follow-up.

CONCLUSIONS

Our evaluation confirmed the beneficial effects of ONS in reducing mortality and improving some indices of nutritional status for hypoalbuminemic hemodialysis patients. We also report the novel finding that ONS can reduce the number of missed dialysis treatments. These results support the use of intradialytic ONS as an effective intervention to improve the outcomes in hemodialysis patients with low serum albumin.

Associations of adiponectin and leptin levels with protein-energy wasting, in end stage renal disease patients

OBJECTIVE

The aim of the study was to examine the prevalence of protein-energy wasting (PEW) in hemodialysis (HD) and peritoneal dialysis (PD) patients in our center and determine whether adiponectin and leptin are involved in the development of PEW.

DESIGN

Prospective (18 months).

SETTING

University Hospital of Heraklion, Crete, Greece.

SUBJECTS

Seventy-four end-stage-renal-disease patients, 47 on HD and 27 on PD.

MAIN OUTCOME MEASURES

At three sequential time points (baseline, 6 and 18 months) anthropometric, nutritional and inflammatory status data were collected. Serum adiponectin and leptin were also assessed at each time point. Patients were allocated to 3 strata according to PEW severity (0, 1-2 and ≥3 criteria for PEW).

RESULTS

Adiponectin and leptin levels were greater among PD compared to HD patients (p≤0.035). Adiponectin levels were incrementally greater across increasing strata of PEW (p≤0.002). Leptin showed the opposite trend, with lower levels in malnourished patients and higher levels in patients with zero PEW criteria (p≤0.042). Alterations of adiponectin levels during the observation period were dependent on PEW stratum (p≤0.021) and mode of dialysis (p≤0.002), after adjustment for age, dialysis vintage, gender and fat mass index. Particularly, adiponectin levels increased over time in HD patients with ≥3 criteria for PEW, whereas adiponectin levels decreased in PD patients with ≥3 criteria for PEW throughout the study. Leptin alterations over time were not affected by dialysis mode or PEW stratification.

CONCLUSIONS

Our study provides evidence that increased adiponectin and decreased leptin levels are independently associated with PEW and thus, poor prognosis.

A retrospective analysis of biochemical and haematological parameters in patients with eating disorders

BACKGROUND

The objective of the study was to determine whether levels of biochemical and haematological parameters in patients with eating disorders (EDs) varied from the general population. Whilst dietary restrictions can lead to nutritional deficiencies, specific abnormalities may be relevant to the diagnosis, pathogenesis and treatment of EDs.

METHODS

With ethics approval and informed consent, a retrospective chart audit was conducted of 113 patients with EDs at a general practice in Brisbane, Australia. This was analysed first as a total group (TG) and then in 4 ED subgroups: Anorexia nervosa (AN), Bulimia nervosa (BN), ED Not Otherwise Specified (EDNOS), and AN/BN. Eighteen parameters were assessed at or near first presentation: cholesterol, folate, vitamin B12, magnesium, manganese, zinc, calcium, potassium, urate, sodium, albumin, phosphate, ferritin, vitamin D, white cell count, neutrophils, red cell count and platelets. Results were analysed using IBM SPSS 21 and Microsoft Excel 2013 by two-tailed, one-sample t-tests (TG and 4 subgroups) and chi-square tests (TG only) and compared to the population mean standards. Results for the TG and each subgroup individually were then compared with the known reference interval (RI).

RESULTS

For the total sample, t-tests showed significant differences for all parameters (p < 0.05) except cholesterol. Most parameters gave results below population levels, but folate, phosphate, albumin, calcium and vitamin B12 were above. More patients than expected were below the RI for most parameters in the TG and subgroups.

CONCLUSIONS

At diagnosis, in patients with EDs, there are often significant differences in multiple haematological and biochemical parameters. Early identification of these abnormalities may provide additional avenues of ED treatment through supplementation and dietary guidance, and may be used to reinforce negative impacts on health caused by the ED to the patient, their family and their treatment team (general practitioner, dietitian and mental health professionals). Study data would support routine measurement of a full blood count and electrolytes, phosphate, magnesium, liver function tests, ferritin, vitamin B12, red cell folate, vitamin D, manganese and zinc for all patients at first presentation with an ED.

Dynamics of Nutritional Competence in the Last Year Before Death in a Large Cohort of US Hemodialysis Patients

OBJECTIVES

Recently, a new Nutritional Competence Score (NCS) has been shown to associate with hospitalization and outcome in hemodialysis patients. The aim of this study was to investigate the dynamics, the individual components, and the impact of hospitalizations of this score's trajectory in the year before death. In addition, we investigated whether dynamics in the NCS add additional independent prognostic value over a single cross-sectional assessment.

DESIGN

We included all Fresenius Medical Care North America patients who initiated hemodialysis between January 1, 2006, and December 31, 2011 with data on all 5 NCS components (serum albumin, creatinine, phosphate, equilibrated normalized protein catabolic rate, and interdialytic weight gain) in at least 1 month. NCS was quantified monthly, and trajectories were compared between nonsurvivors and survivors across different dialysis vintage strata. Survivors and nonsurvivors were matched by dialysis vintage. The association of baseline NCS and NCS dynamics with mortality risk were assessed with Cox proportional hazards models.

RESULTS

In this cohort of 110,794 patients, we found that across all vintage groups, NCS was lower in patients who died than in survivors. NCS was found to significantly decline before death, whereas survivors showed no decline in NCS. The rate of NCS decline before death was not materially influenced by hospitalization in the months before death. Cox models showed that NCS dynamics over time carry significant predictive power above a cross-sectional NCS assessment.

CONCLUSIONS

There are distinct differences in NCS values and their trajectories between patients who die and vintage-matched controls. These differences may be able to be exploited for implementation of a routine, prospective monitoring tool for early detection of patients at increased risk of death. Prospective studies are required to validate such an approach.

A Practical Standardized Composite Nutrition Score Based on Lean Tissue Index: Application in Nutrition Screening and Prediction of Outcome in Hemodialysis Population

OBJECTIVE

Rapid screening and monitoring of nutritional status is mandatory in hemodialysis population because of the increasingly encountered nutritional problems. Considering the limitations of previous composite nutrition scores applied in this population, we tried to develop a standardized composite nutrition score (SCNS) using low lean tissue index as a marker of protein wasting to facilitate clinical screening and monitoring and to predict outcome.

DESIGN AND METHODS

This retrospective cohort used 2 databases of dialysis populations from Taiwan between 2011 and 2014. First database consisting of data from 629 maintenance hemodialysis patients was used to develop the SCNS and the second database containing data from 297 maintenance hemodialysis patients was used to validate this developed score.

RESULTS

SCNS containing albumin, creatinine, potassium, and body mass index was developed from the first database using low lean tissue index as a marker of protein wasting. When applying this score in the original database, significantly higher risk of developing protein wasting was found for patients with lower SCNS (odds ratio 1.38 [middle tertile vs highest tertile, P < .0001] and 2.40 [lowest tertile vs middle tertile, P < .0001]). The risk of death was also shown to be higher for patients with lower SCNS (hazard ratio 4.45 [below median level vs above median level, P < .0001]). These results were validated in the second database.

CONCLUSION

We developed an SCNS consisting of 4 easily available biochemical parameters. This kind of scoring system can be easily applied in different dialysis facilities for screening and monitoring of protein wasting. The wide application of body composition monitor in dialysis population will also facilitate the development of specific nutrition scoring model for individual facility.

Preoperative Albumin to Globulin Ratio (AGR) as Prognostic Factor in Renal Cell Carcinoma

Background: Malnutrition and systemic inflammatory response are frequently associated with prognosis in patients with several types of cancer, including renal cell carcinoma (RCC). The study is aimed to investigate the ability of preoperative serum albumin to globulin ratio (AGR) to predict the long-term mortality of RCC patients. Methods: The study is a retrospective study of an unselected cohort of 895 RCC patients who underwent a curative radical or partial nephrectomy at the Department of Urology in the Sun Yat-Sen University Cancer Center between January 2000 and December 2012 and had documented preoperative serum total protein and albumin (ALB) levels. The preoperative AGR was calculated as the ratio of ALB to (total protein-ALB) and its association with other clinical indices was assessed using survival analysis. Results: Low preoperative AGR was associated with older population, lower hemoglobin, higher total protein, lower ALB, lower body mass index and advanced stage. The univariate and multivariate Cox analyses demonstrated that preoperative AGR was an independent prognostic indicator of overall survival (OS) (hazard ratio (HR): 0.63, 95% confidence interval (CI): 0.43 to 0.93, P=0.022). In addition, patients with low preoperative AGR at pT1-2, pT3-4, pN0, pN1, pM0 and pM1 stages had significantly shorter OS than patients with high preoperative AGR. Conclusion: Preoperative AGR is a proven objective, reproducible, inexpensive survival predictor of RCC patients following surgical resection and should be considered for routine clinical use.

Association of a high normalized protein catabolic rate and low serum albumin level with carpal tunnel syndrome in hemodialysis patients

Carpal tunnel syndrome (CTS) is the most common mononeuropathy in patients with end-stage renal disease (ESRD). The association between chronic inflammation and CTS in hemodialysis (HD) patients has rarely been investigated. HD patients with a high normalized protein catabolic rate (nPCR) and low serum albumin level likely have adequate nutrition and inflammation. In this study, we assume that a low serum albumin level and high nPCR is associated with CTS in HD patients. We recruited 866 maintenance hemodialysis (MHD) patients and divided them into 4 groups according to their nPCR and serum albumin levels: (1) nPCR <1.2 g/kg/d and serum albumin level <4 g/dL; (2) nPCR ≥1.2 g/kg/d and serum albumin level <4 g/dL; (3) nPCR <1.2 g/kg/d and serum albumin level ≥4 g/dL; and (4) nPCR ≥1.2 g/kg/d and serum albumin level ≥4 g/dL. After adjustment for related variables, HD duration and nPCR ≥1.2 g/kg/d and serum albumin level <4 g/dL were positively correlated with CTS. By calculating the area under the receiver-operating characteristic curve, we calculated that the nPCR and HD duration cut-off points for obtaining the most favorable Youden index were 1.29 g/kg/d and 7.5 years, respectively. Advance multivariate logistic regression analysis revealed that in MHD patients, nPCR ≥1.29 g/kg/d and serum albumin <4 g/dL, and also HD duration >7.5 years were associated with CTS. A high nPCR and low serum albumin level, which likely reflect adequate nutrition and inflammation, were associated with CTS in MHD patients.

In Quality We Trust; but Quality of Life or Quality of Care?

The ESRD program provides medical care to a diverse and medically complex patient population. The care for the ESRD patient population has become increasingly benchmarked with process of care measures. These measures include dialysis adequacy, anemia, nutrition, and vascular access outcomes. These process-related dialysis measures may not improve the care of the individual patient as care relates to the individual's goals and values. There is also evidence that these process measures may not be causally related to quality of life, hospitalization, and survival. The adoption of patient-reported outcomes may shift the balance toward more patient-centered care. However, the extent to which mandated measures of health-related quality of life and patient satisfaction result in improved outcomes remains unclear.

Prognostic Significance of Preoperative Albumin-Globulin Ratio in Patients with Upper Tract Urothelial Carcinoma

Background

Preoperative albumin-globulin ratio (AGR) reflects both malnutrition and systemic inflammation in cancer patients. In particular, systemic inflammation has been reported to contribute to tumor progression and poor oncological outcome in various malignancies. However, the prognostic value of preoperative AGR in upper tract urothelial carcinoma (UTUC) has not been examined.

Methods

We retrospectively reviewed medical data of 187 operable UTUC patients in a Chinese cohort with a high incidence of chronic kidney disease (CKD). AGR was calculated as [AGR = albumin/(serum total protein—albumin)]. The associations of preoperative AGR with clinicopathologic characteristics and prognosis were assessed. Multivariate analyses using Cox regression models were performed to determine the independent prognostic factors.

Results

The median (IQR) preoperative AGR was 1.50 (1.30–1.70), and the optimal cutoff value was determined to be 1.45 according to the receiver operating curve analysis. Low AGR was significantly associated with female gender, high CKD stage and tumor grade (P < 0.05). Eighty-three patients died before the follow-up endpoint. Kaplan-Meier analysis showed that an AGR < 1.45 predicted significantly poorer overall and cancer-specific survivals compared to an AGR ≥ 1.45 (P < 0.001 and P = 0.008, respectively). Multivariate analyses showed that an AGR < 1.45 was an independent risk factor for poorer overall and cancer-specific survivals (P = 0.002 and P = 0.015, respectively).

Conclusions

Preoperative AGR can act as an effective biomarker with easy accessibility for evaluating the prognosis of patients with UTUC. AGR should be applied in UTUC patients for risk stratification and determination of optimal therapeutic regimens.

Nutritional Competence and Resilience among Hemodialysis Patients in the Setting of Dialysis Initiation and Hospitalization

BACKGROUND AND OBJECTIVES

Dialysis patients have a high risk for inadequate nutrition. Their nutritional status is particularly susceptible to deterioration when faced with intercurrent events such as hospitalization. This study was conducted to improve the understanding of the temporal evolution of nutritional parameters as a foundation for rational and proactive nutritional intervention.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A retrospective cohort study was performed to investigate the temporal evolution of nutritional parameters (serum albumin, serum phosphate, serum creatinine, equilibrated normalized protein catabolic rate, and interdialytic weight gain) and a composite nutritional score derived from these parameters, in two populations: (1) incident hemodialysis (HD) patients who started HD between January 2006 and December 2011 and were followed for up to 54 months (median 16.3), and (2) prevalent patients with HD vintage ≥2.5 years who were hospitalized between January 2006 and December 2011 and followed from 6 months before to 6 months after hospitalization.

RESULTS

In incident patients (n=126,964), each of the nutritional parameters improved after HD initiation, with a mean composite nutritional score at the 24th percentile at the start of HD and reaching a plateau at the 57th percentile toward the end of the second year on dialysis. Nutritional parameters increased more rapidly and reached higher values among patients who survived longer. In hospitalized patients (n=14,193), the nutritional parameters and the composite score began to decline 1-2 months before hospitalization, reached their lowest level in the month after hospitalization, and then partially recovered in the subsequent 5 months. The degree of recovery of the nutritional score was inversely related to the number of rehospitalizations.

CONCLUSIONS

This study increases the understanding of nutritional resilience and its determinants in HD patients. Application of the nutritional score, pending further validation, may facilitate targeted and timely interventions to avert the negative consequences of inadequate nutrition in chronic HD patients.

Clinical and demographic characteristics predictive of treatment outcomes for certolizumab pegol in moderate to severe Crohn's disease: analyses from the 7-year PRECiSE 3 study

BACKGROUND

Clinical factors were previously identified as predictors of short-term treatment efficacy in Crohn's disease (CD). The PRECiSE 3 (P3) 7-year trial provides an opportunity to study predictors of short- and long-term clinical remission among CD patients treated with certolizumab pegol (CZP).

AIM

To identify factors that influence long-term remission of CD with CZP treatment.

METHODS

Patients who had completed placebo-controlled studies (PRECiSE 1/PRECiSE 2, P1/P2) enrolled in P3 and received open-label CZP 400 mg every 4 weeks up to 7 years. Baseline predictors included, but were not limited to, smoking status, disease duration, prior inflammatory bowel disease (IBD) surgery, Harvey-Bradshaw Index (HBI), albumin, haematocrit and CZP exposure; association with time to initial remission (HBI ≤4) was tested for patients who received CZP in P1/P2; time to loss of remission/frequency of maintenance of remission was also tested. Univariate analyses and multivariate Cox or logistic regression models were used.

RESULTS

Predictors for initial remission (N = 377) included age, haematocrit, prior IBD surgery and entry HBI (P < 0.05 for all). Predictors for loss of remission (N = 437) included HBI, serum albumin concentration, haematocrit, smoking status and exposure. Predictors of maintenance of remission (N = 437) included haematocrit, IBD surgery, HBI, disease duration, serum albumin concentration and exposure. Significant predictors were confirmed with stepwise multivariate regression models.

CONCLUSIONS

These analyses identified several influential parameters for short-and long-term remission of Crohn's disease with certolizumab pegol treatment. The data yield valuable hypotheses regarding factors that influence certolizumab pegol treatment. More investigation is needed. (ClinicalTrials.gov identifier NCT00552058).

Functional linear models for zero-inflated count data with application to modeling hospitalizations in patients on dialysis

We propose functional linear models for zero-inflated count data with a focus on the functional hurdle and functional zero-inflated Poisson (ZIP) models. Although the hurdle model assumes the counts come from a mixture of a degenerate distribution at zero and a zero-truncated Poisson distribution, the ZIP model considers a mixture of a degenerate distribution at zero and a standard Poisson distribution. We extend the generalized functional linear model framework with a functional predictor and multiple cross-sectional predictors to model counts generated by a mixture distribution. We propose an estimation procedure for functional hurdle and ZIP models, called penalized reconstruction, geared towards error-prone and sparsely observed longitudinal functional predictors. The approach relies on dimension reduction and pooling of information across subjects involving basis expansions and penalized maximum likelihood techniques. The developed functional hurdle model is applied to modeling hospitalizations within the first 2 years from initiation of dialysis, with a high percentage of zeros, in the Comprehensive Dialysis Study participants. Hospitalization counts are modeled as a function of sparse longitudinal measurements of serum albumin concentrations, patient demographics, and comorbidities. Simulation studies are used to study finite sample properties of the proposed method and include comparisons with an adaptation of standard principal components regression.

The value of the pretreatment albumin/globulin ratio in predicting the long-term survival in colorectal cancer

BACKGROUND

Low serum albumin was found as a predictor of long-term mortality in colorectal cancer (CRC) patients. Our aim was to evaluate the value of the pretreatment albumin/globulin ratio (AGR) to predict the long-term mortality in CRC patients.

METHODS

Patients were included if they had comprehensive metabolic panel (CMP) before treatment (surgery or chemotherapy). The albumin/globulin ratio, routinely reported in CMP, is calculated [AGR = Albumin/(Total protein - Albumin)]. Patients were divided into three equal tertiles according to their pretreatment AGR. The primary outcome was cancer-related mortality, which was obtained from our cancer registry database.

RESULTS

A total of 534 consecutive CRC patients had pretreatment CMP. The 1st AGR tertile had a significant higher 4-year mortality compared to the second and third AGR tertiles (42 vs. 19 and 7 %, p < 0.0001 according to Fisher's exact two-tailed test). In the multivariate model, AGR remained an independent predictor of survival with 75 % decrease in mortality among the highest AGR tertile in comparison to the lowest AGR tertile, p < 0.0001. In the subset of 234 patients with normal serum albumin (albumin of >3.5 g/dl), serum AGR continues to be an independent predictor of cancer-related mortality with an adjusted hazard ratio of the third tertile compared to the first tertile equal to 0.05 (95 % confidence interval 0.01-0.33, p = 0.002).

CONCLUSION

Low AGR was a strong independent predictor of long-term cancer-specific survival among colorectal cancer patients. Additionally, among the patients with normal albumin (>3.5 g/dl), patients with lower globulins but higher albumin and AGR levels had better survival.

A Study of Inflammatory Status in Nephropathy Patients with History of Type-II Diabetes Mellitus Undergoing Haemodialysis

INTRODUCTION AND OBJECTIVE

Diabetic nephropathy is one of the leading cause of chronic kidney failure. Local vascular inflammation is increased in diabetes mellitus (DM), which results in higher burden of microvascular and macrovascular complications. The present study was carried out to assess the importance of inflammatory status in nephropathy patients with Type-II DM.

METHODOLOGY

Eighty diagnosed cases of type II DM who had end stage renal disease (Nephropathy Stage-5) were selected for the study, they were further divided equally into 2 sub-categories; Group I (patients who were undergoing haemodialysis) and Group II (patients who were not undergoing haemodialysis). The control group comprised of 40 individuals who were age and sex matched healthy individuals. Inflammatory status was assessed by estimating serum C-reactive protein (CRP) and serum albumin.

RESULTS

A significant increase in serum CRP and a significant decrease in serum albumin were seen in test group- I and test group-2 as compared to controls. There was a positive correlation between serum albumin and GFR with r=0.904 in the Test Group-I and r=0.946 in Test Group-II. A negative correlation was observed between serum CRP and GFR r= -0.597 in Test Group-I and with r= -0.6231 in Test Group-II. Also, the correlation between CRP and albumin showed a negative trend with r= -0.848 in Test Group-I and with r= -0.78 in Test Group-II.

CONCLUSION

Microinflammation is a common finding in haemodialysis patients who have a history of nephropathy with Type-II diabetes mellitus. With a proper knowledge on factors which lead to this microinflammation, we can employ preventive strategies for a better management of Type-II diabetic nephropathy patients and thereby, for improving their survival.

Let them eat during dialysis: an overlooked opportunity to improve outcomes in maintenance hemodialysis patients

In individuals with chronic kidney disease, surrogates of protein-energy wasting, including a relatively low serum albumin and fat or muscle wasting, are by far the strongest death risk factor compared with any other condition. There are data to indicate that hypoalbuminemia responds to nutritional interventions, which may save lives in the long run. Monitored, in-center provision of high-protein meals and/or oral nutritional supplements during hemodialysis is a feasible, inexpensive, and patient-friendly strategy despite concerns such as postprandial hypotension, aspiration risk, infection control and hygiene, dialysis staff burden, diabetes and phosphorus control, and financial constraints. Adjunct pharmacologic therapies can be added, including appetite stimulators (megesterol, ghrelin, and mirtazapine), anabolic hormones (testosterone and growth factors), antimyostatin agents, and antioxidative and anti-inflammatory agents (pentoxiphylline and cytokine modulators), to increase efficiency of intradialytic food and oral supplementation, although adequate evidence is still lacking. If more severe hypoalbuminemia (<3.0 g/dL) not amenable to oral interventions prevails, or if a patient is not capable of enteral interventions (e.g., because of swallowing problems), then parenteral interventions such as intradialytic parenteral nutrition can be considered. Given the fact that meals and supplements during hemodialysis would require only a small fraction of the funds currently used for dialysis patients this is also an economically feasible strategy.

Serum phosphorus reduction in dialysis patients treated with cinacalcet for secondary hyperparathyroidism results mainly from parathyroid hormone reduction

Background

The calcimimetic cinacalcet lowers parathyroid hormone (PTH), calcium (Ca) and phosphorus (P) in dialysis patients with secondary hyperparathyroidism (SHPT). We explored serum P changes in dialysis patients treated with cinacalcet, while controlling for vitamin D sterol and phosphate binder (PB) changes, based on data from the pan-European observational study ECHO.

Methods

Patients were categorized by serum P change (decreased/unchanged/increased) at 12 months after starting cinacalcet and subcategorized by vitamin D sterol and PB dose changes (decreased/unchanged/increased). The impact of PTH, Ca and P, and vitamin D sterol, PB and cinacalcet doses (absolute values and/or change) was evaluated. Predictors of P change were explored using univariate and multivariate general linear models (GLM) and logistic regression analysis.

Results

At Month 12, 661 (41%) of 1607 patients had decreased, 61 (4%) unchanged and 400 (25%) increased serum P, while 485 patients had missing data. In 45% of the patients with serum P reduction, vitamin D was either increased or unchanged and P binders decreased or unchanged. PTH was a key predictor of serum P reduction, with an estimated 3% decrease in P per 10% reduction in PTH. Changes in vitamin D sterol and PB doses were not generally significant factors in GLM and regression analyses.

Conclusions

The serum P reduction observed in a significant proportion of dialysis patients after adding cinacalcet to an existing therapeutic regimen for SHPT appears to result mainly from PTH reduction, rather than from changes in vitamin D sterol or PB doses. Financial support for the ECHO study was provided by Amgen.

The progression of bone mineral density loss in dialysis patients compared with the general population

BACKGROUND/AIMS

The aim of this study was to compare the progression of bone mass loss in chronic hemodialysis patients (CHPs) with that in general population patients (GPPs) over an 18-month period.

METHODS

The control group consisted of 60 patients (aged 57.5 ± 10.9 years) with a glomerular filtration rate > 60 mL/min/1.73 m(2). The study group included 80 patients undergoing hemodialysis (aged 59.3 ± 11.8 years; duration of dialysis 5.47 ± 5.16 years). Bone mineral density (BMD) testing was conducted in both groups using dual energy X-ray absorptiometry at hip and lumbar spine regions at baseline and after 18 months. Biochemical parameters (albumin, C-reactive protein, calcium, ionized calcium, alkaline phosphatase, and parathyroid hormone) were determined in all participants using standard laboratory procedures.

RESULTS

The mean values of BMD (average hip + lumbar spine) were 0.900 ± 0.14 g/cm(2) and 0.866 ± 0.14 g/cm(2) in the GPP and 0.823 ± 0.16 g/cm(2) and 0.769 ± 0.13 g/cm(2) in the CHP groups at baseline and 18 months, respectively. The statistical significance (p value) of hip bone loss progression over 18 months was 0.0577 for GPP and 0.0002 for CHP, whereas that of lumbar spine bone loss progression was 0.6820 for GPP and 0.5389 for CHP.

CONCLUSIONS

The of progression bone mass loss was significantly greater in CHP than in GPP. Bone mass loss was evident even over 1 month, albeit in only the CHP with accelerated osteoporosis.

Transthyretin predicts cardiovascular outcome in hemodialysis patients with type 2 diabetes

OBJECTIVE

BMI and albumin are commonly accepted parameters to recognize wasting in dialysis patients and are powerful predictors of morbidity and mortality. However, both parameters reveal limitations and may not cover the entire range of patients with wasting. The visceral protein transthyretin (TTR) may be helpful in overcoming the diagnostic and prognostic gap. Therefore, the aim of this study was to assess the association of TTR with morbidity and mortality in hemodialysis patients.

RESEARCH DESIGN AND METHODS

The TTR concentration was determined in plasma samples of 1,177 hemodialysis patients with type 2 diabetes. Cox regression analyses were used to determine hazard ratios (HRs) for the risk of cardiovascular end points (CVEs) and mortality according to quartiles of TTR concentration for the total study cohort and the subgroups BMI ≥23 kg/m(2), albumin concentration ≥3.8 g/dL, and a combination of both.

RESULTS

A low TTR concentration was associated with an increased risk for CVE for the total study cohort (HR 1.65 [95% CI 1.27-2.14]), patients with BMI ≥23 kg/m(2) (1.70 [1.22-2.37]), albumin ≥3.8 g/dL (1.68 [1.17-2.42]), and the combination of both (1.69 [1.13-2.53]). Additionally, a low TTR concentration predicted mortality for the total study cohort (1.79 [1.43-2.24]) and patients with BMI ≥23 kg/m(2) (1.46 [1.09-1.95]).

CONCLUSIONS

The current study demonstrated that TTR is a useful predictor for cardiovascular outcome and mortality in diabetic hemodialysis patients. TTR was particularly useful in patients who were not identified to be at risk by BMI or albumin status.

Diets and enteral supplements for improving outcomes in chronic kidney disease

Protein-energy wasting (PEW), which is manifested by low serum levels of albumin or prealbumin, sarcopenia and weight loss, is one of the strongest predictors of mortality in patients with chronic kidney disease (CKD). Although PEW might be engendered by non-nutritional conditions, such as inflammation or other comorbidities, the question of causality does not refute the effectiveness of dietary interventions and nutritional support in improving outcomes in patients with CKD. The literature indicates that PEW can be mitigated or corrected with an appropriate diet and enteral nutritional support that targets dietary protein intake. In-center meals or oral supplements provided during dialysis therapy are feasible and inexpensive interventions that might improve survival and quality of life in patients with CKD. Dietary requirements and enteral nutritional support must also be considered in patients with CKD and diabetes mellitus, in patients undergoing peritoneal dialysis, renal transplant recipients, and in children with CKD. Adjunctive pharmacological therapies, such as appetite stimulants, anabolic hormones, and antioxidative or anti-inflammatory agents, might augment dietary interventions. Intraperitoneal or intradialytic parenteral nutrition should be considered for patients with PEW whenever enteral interventions are not possible or are ineffective. Controlled trials are needed to better assess the effectiveness of in-center meals and oral supplements.

Is serum albumin a marker of malnutrition in chronic disease? The scleroderma paradigm

BACKGROUND

Malnutrition is common in many chronic diseases, but physicians may rely on a low albumin value before deciding that malnutrition is present.

OBJECTIVE

To determine the relationship between serum albumin and malnutrition in systemic sclerosis (SSc) as a paradigm for other chronic diseases.

DESIGN

Cross-sectional, multicenter study of patients from the Canadian Scleroderma Research Group Registry. We used the Malnutrition Universal Screening Tool (MUST) to evaluate patients for malnutrition. Disease extent was measured in several ways, including physician global assessment. Multiple linear regression was performed to identify independent predictors of serum albumin.

RESULTS

Two hundred fifty-eight patients were studied. The mean (SD) serum albumin level was 44.4 (4.2) g/L. Only 2% of the values were below normal and all these patients were in MUST category > or =2, or high risk for malnutrition, which included 21.3% of the cohort. MUST, shorter disease duration, greater disease severity (physician global assessment of disease severity and modified Rodnan skin score), and greater disease activity (physician global assessment of disease activity, C-reactive protein, and Scleroderma Disease Activity Index) all correlated significantly but weakly with albumin. Multivariate analysis demonstrated that a higher MUST score and worse disease severity were independently associated with lower serum albumin, but only 7% of the variance of albumin was explained in the adjusted model.

CONCLUSIONS

Serum albumin is not useful as a marker for malnutrition in SSc and should not be assumed to be useful as a marker in other chronic diseases. More attention should be paid to clinical features of malnutrition, including assessment of body mass index and unplanned weight loss, and overall disease severity.

Determinants of resting energy expenditure in hemodialysis patients, and comparison with healthy subjects

OBJECTIVE

This study evaluated the factors that affect the resting energy expenditure (REE) and nutritional status of hemodialysis patients, and to assess any differences with healthy subjects.

DESIGN

This was an observational case-control study.

SETTING

This study took place at the Hemodialysis Units of the Laikon General Hospital and 401 General Military Hospital (Athens, Greece).

PATIENTS

Twenty-five patients undergoing hemodialysis and 23 controls were recruited. Controls were healthy volunteers with no history of diseases or medication use. Patients with active infectious or inflammatory disease were excluded.

INTERVENTION

We measured REE using indirect calorimetry. Body composition as measured by Bioelectrical Impedance Analysis (BIA), anthropometry, and biochemical parameters were assessed in both groups.

MAIN OUTCOME MEASURE

Adjusted or unadjusted for muscle mass, REE was compared between the two groups. Multiple linear regression analysis was used to study independent determinants of REE.

RESULTS

Patients had no clinical signs of malnutrition. Resting energy expenditure was not different between the two groups, but REE adjusted for muscle mass was significanlty higher in hemodialysis patients. There were no differences in body composition, with the exception of muscle mass. Patients had lower muscle mass than controls, as determined by duration of disease. The only significant determinant of REE was muscle mass.

CONCLUSION

Patients had a higher REE adjusted for muscle mass than did controls, implying that they might be at a catabolic stage, and at risk of malnutrition. These findings indicate the need for determining body composition and for nutritional assessment and support in hemodialysis patients, even without indications of malnutrition.

A review of albumin binding in CKD

Hypoalbuminemia is associated with excess mortality in patients with kidney disease. Albumin is an important oxidant scavenger and an abundant carrier protein for numerous endogenous and exogenous compounds. Several specific binding sites for anionic, neutral, and cationic ligands were described. Overall, the extent of binding depends on the ligand and albumin concentration, albumin-binding affinity, and presence of competing ligands. Chronic kidney disease affects all these determinants. This may result in altered pharmacokinetics and increased risk of toxicity. Renal clearance of albumin-bound solutes mainly depends on tubular clearance. Dialytic clearance by means of conventional hemodialysis/hemofiltration and peritoneal dialysis is limited. Other epuration techniques combining hemodialysis with adsorption have been developed. However, the benefit of these techniques remains to be proved.

Influence of vascular access type on outcome measures in patients on maintenance hemodialysis

BACKGROUND

Previous studies postulate that end-stage renal disease (ESRD) patients dialyzed with central venous catheters (CVC) have poorer outcomes compared to patients using arteriovenous fistulae (AVF) or arteriovenous grafts (AVG). Clinical practice guidelines should obviate these differences if access was not important. This study compared clinical measures of adequacy, anemia, and nutrition/inflammation in prevalent hemodialysis patients in 2003 by access type.

METHODS

Data from The Renal Network Data System were analyzed by univariate analysis of variance to compare Kt/V, URR, albumin, hemoglobin (Hb) and recombinant human erythropoietin (EPO) dose by access type, while adjusting for pertinent factors.

RESULTS

12,501 patients were included. The access type distribution was AVF 36%, AVG 41%, and CVC 23%. CVC patients had lower mean URR, Kt/V, albumin concentration (p < 0.001) than other accesses. Serum Hbs were similar (p = 0.416), however EPO dose (U/kg/week) was higher in those dialyzed with CVC compared to AVF/AVG (p < 0.001).

CONCLUSIONS

Despite practice guidelines, patients dialyzed via CVC have poorer outcome measures compared to other accesses. This suggests that AVF should be used and/or appropriate adjustments need to be made for those dialyzed with CVC to achieve equal outcomes. Further studies defining barriers need to be conducted.

Hypoalbuminemia is Also a Marker of Fluid Excess Determined by Bioelectrical Impedance Parameters in Dialysis Patients

Hypoalbuminemia may be secondary to volume expansion conditions and an independent risk factor for cardiovascular disease. Bioelectrical impedance analysis (BIA) is an accurate, non-invasive method to measure body composition, especially the water compartments in humans. The aim of this cross-sectional study is to evaluate the relationship between serum albumin concentration (SA) and hydration state measured by whole BIA. The study investigated 108 non-selected patients (73 on hemodialysis, 35 on peritoneal dialysis) with a mean age of 61.4 +/- 15.6 years, 42.7% of whom were female. The patients were allotted to groups according to their SA: Group 1, < or = 3.5 g/dL; Group 2, 3.6-4.0 g/dL; and Group 3, >4.0 g/dL. The BIA parameters used included: total body water, intracellular water (ICW), extracellular water (ECW), phase angle (PA), body cell mass (BCM), ICW/ECW ratio and ICW/ECW ratio patients/controls (fluid index). Seventy-five healthy volunteers formed the control group. A strong positive correlation was found between the PA and fluid index (r (2) = 0.993, P < 0.001), as well as between the PA and SA (r = 0.386, P < 0.001), and the ICW/ECW ratio and SA (r = 0.227, P < 0.001). The ECW was negatively correlated with SA (r = -0.330, P < 0.001). Every 0.1 g/dL decrease in SA was associated with a 0.33 L increase in ECW. Group 1 patients had lower reactance (P = 0.006), PA (P < 0.001), BCM (P = 0.012), fluid index (P < 0.001) and ICW/ECW ratio (P = 0.015), and an increased ECW (NS) than groups 2 and 3. We conclude that hypoalbuminemia is also a marker of fluid excess. The SA is associated to the fluid index and the PA allows assessment of the dry weight and its variations in an individualized manner in dialysis patients.

Ultrapure dialysate and inflammatory response in haemodialysis evaluated by darbepoetin requirements—a randomized study

BACKGROUND

Dialysate quality has been suggested to influence inflammation status in patients subject to haemodialysis (HD). The aim of this study was to compare ultrapure dialysate (UPD) vs conventional dialysate (CD) with respect to darbepoetin requirements and other inflammation markers.

METHODS

A controlled prospective randomized study was carried out on 78 patients from two HD units who were treated with low-flux polyamide dialysers. Patients were assigned to two groups by using different sized blocks per unit and dialysis session. One group received CD treatment while the other was treated with UPD over 12 months. From the groups, 37 patients started treatment with CD and 41 with UPD while 31 patients ended with CD and 30 with UPD. The main variables analysed were haemoglobin (Hb) and darbepoetin dose; other variables studied were C-reactive protein (CRP), albumin, interleukin-6 (IL-6) and interleukin-1 receptor antagonist (IL-1Ra).

RESULTS

No significant differences were observed between the two groups for the variables analysed. At the beginning of the study the following values of CD and UPD were assessed: Hb 11.3 and 11.3 (g/dl); darbepoetin dose: 0.49 and 0.44 (microg/kg/week); CRP: 13 and 24 (mg/l); albumin: 3.8 and 3.7 (g/dl); IL-6: 5.94 and 4.18; and IL-1Ra: 345 and 420 (ng/l), respectively. At the end of the study the values of CD and UPD were: Hb 12 and 11.9 (g/dl); darbepoetin dose: 0.47 and 0.48 (microg/kg/week); CRP: 14 and 14 (mg/l); albumin: 3.8 and 3.7 (g/dl); IL-6: 14.03 and 12.93 and IL-1Ra: 322 and 340 (ng/l).

CONCLUSIONS

UPD does not improve the inflammatory status evaluated by darbepoetin requirements in conventional HD patients treated with low-flux polyamide dialyser. Further controlled studies are required to evaluate the clinical influence of UPD in HD with other low- and high-flux membranes.

Multiple Factors Affect Renal Dietitians’ Use of the NKF-K/DOQI Adult Nutrition Guidelines

OBJECTIVE

We investigated the components of the National Kidney Foundation-Kidney Disease Outcomes Quality Initiative Nutrition Guidelines that are implemented by renal dietitians and the types of resources and support available to assist in implementing these guidelines.

DESIGN AND PARTICIPANTS

A 49-item survey was mailed to 1694 dietitians in the United States. who were members of the National Kidney Foundation Council on Renal Nutrition in June 2003. The survey included sections on clinical practice, tools available to perform nutrition assessments, daily activities of the dietitian, and demographic and professional questions.

RESULTS

Of the 1694 surveys mailed, 951 were returned (56% response rate); 848 were useable (89%). The primary employer was for-profit dialysis units (67%) and the mean (+/- SD) number of patients per dietitian was 104.9 +/- 48.3. Virtually all of the dietitians were aware of the nutrition guidelines (97%); 58% read all of the guidelines, whereas only 41% read some of the guidelines. Ninety-two percent of respondents implemented at least one guideline in their clinical practice; 72% and 55% had implemented 5 and 10 guidelines, respectively; but only 5% implemented all of the guidelines. Several barriers to implementation included lack of tools such as computers, calipers, and food models (57%); inadequate time including high dietitian-to-patient ratios (40%); and lack of administrative support from the dialysis unit (29%).

CONCLUSIONS

There are multiple barriers that prevent the adequate assessment of the nutritional status of dialysis patients. Only after these resources are provided will it be possible to determine the impact of the nutrition guidelines on patient outcomes.

Correlation of nutritional status and food intake in hemodialysis patients

BACKGROUND

Patients in end-stage renal disease often suffer from poor appetite, various comorbidities, and dietary restrictions. Despite regular hemodialysis, nutritional imbalances are frequently reported. Aiming to correlate nutritional status with food ingestion, a prospective study was done in an outpatient group.

METHODS

Stable patients undergoing chronic hemodialysis for at least 3 months (n=44) were investigated by dietary recall and standard anthropometric, biochemical, and bioimpedance determinations, including subjective and objective global assessment. The mean age of the group was 47.0+/-16.9 years, and 63.6% were men. Body mass index was 22.2+/-3.9 kg/m2 (mean+/-SD), calorie intake was 1471+/-601 kcal/day (20.7+/-6.7 kcal/kg/day), and protein ingestion was 74.3+/-16.6 g protein/day (1.2 g/kg/day). Dietary and clinical findings were correlated with nutritional indices by linear regression analysis.

RESULTS

Malnutrition estimated by subjective global assessment was very common (>90%), despite the fact that body mass index and serum albumin were within an acceptable range in the majority of the population. Objective global assessment yielded roughly comparable numerical findings, with 6.8% being well nourished, 61.4% at nutritional risk or lightly undernourished, 29.6% moderately malnourished, and 2.3% severely malnourished. Total calorie intake was devoid of associations, but protein, carbohydrate, and lipid input positively correlated with triceps skinfold (P=.02). Lipid ingestion was the only marker directly associated with arm circumference, and it correlated with body mass index, as well as with total body fat (bioimpedance analysis) (P<.001).

CONCLUSIONS

1) Bioimpedance analysis was useful and was correlated with clinical findings; 2) Lipid intake was the best dietary index in this experience, surpassing protein or total energy; 3) Despite its shortcomings, dietary recall was useful in the assessment of hemodialysis patients.

POOR NUTRITIONAL STATUS AND INFLAMMATION: Serum Albumin: Relationship to Inflammation and Nutrition

Hypoalbuminemia is the result of the combined effects of inflammation and inadequate protein and caloric intake in patients with chronic disease such as chronic renal failure. Inflammation and malnutrition both reduce albumin concentration by decreasing its rate of synthesis, while inflammation alone is associated with a greater fractional catabolic rate (FCR) and, when extreme, increased transfer of albumin out of the vascular compartment. A vicious cascade of events ensues in which inflammation induces anorexia and reduces the effective use of dietary protein and energy intake and augments catabolism of the key somatic protein, albumin. Hypoalbuminemia is a powerful predictor of mortality in patients with chronic renal failure, and the major cause of death in this population is due to cardiovascular events. Inflammation is associated with vascular disease and likely causes injury to the vascular endothelium, and hypoalbuminemia as two separate expressions of the inflammatory process. Albumin has a myriad of important physiologic effects that are essential for normal health. However, simply administering albumin to critically ill patients with hypoalbuminemia has not been shown to improve survival or reduce morbidity. Thus the inference from these clinical studies suggests that the cause of hypoalbuminemia, rather than low albumin levels specifically, is responsible for morbidity and mortality.

Association of body size with outcomes among patients beginning dialysis

BACKGROUND

Although obesity confers an increased risk of mortality in the general population, observational reports on the dialysis population have suggested that obesity is associated with improved survival. These reports have generally not examined extremely high values of body mass index (BMI; in kg/m(2)), survival >1 y, or alternative measures of adiposity.

OBJECTIVE

We sought to clarify the relation between body size and outcomes among a large cohort of patients beginning dialysis.

DESIGN

Data on 418 055 patients beginning dialysis between 1 April 1995 and 1 November 2000 were analyzed by using US Renal Data System data. BMI was divided into 8 categories in increments of 3 units, ranging from < 19 to > or =37, and the relation between survival and BMI was examined by using proportional hazards regression with adjustment for demographic, laboratory, and comorbidity data.

RESULTS

High BMI was associated with increased survival in this cohort, even at extremely high BMI, after adjustment, and over a 2-y average follow-up time. This was true for whites, African Americans, and Hispanics but not for Asians. High BMI was also associated with a reduced risk of hospitalization and a lower rate of mortality in all mortality categories. Alternative estimates of adiposity, including the Benn index and estimated fat mass, yielded similar results, and adjustments for lean body mass did not substantially alter the findings.

CONCLUSIONS

High BMI is not associated with increased mortality among patients beginning dialysis. This finding does not appear to be a function of lean body mass and, although modified by certain patient characteristics, it is a robust finding.