Subjective Global Assessment in chronic kidney disease: A review

Nutritional Status and Other Clinical Variables Are Associated to the Resting Energy Expenditure in Patients With Chronic Kidney Disease: A Validity Study

Background

Estimating energy requirements (ER) is crucial for nutritional attention to chronic kidney disease (CKD) patients. Current guidelines recommend measuring ER with indirect calorimetry (IC) when possible. Due to clinical settings, the use of simple formulas is preferred. Few studies have modeled equations for estimating ER for CKD. Nevertheless, variables of interest such as nutritional status and strength have not been explored in these models. This study aimed to develop and validate a model for estimating REE in patients with CKD stages 3–5, who were not receiving renal replacement therapy (RTT), using clinical variables and comparing it with indirect calorimetry as the gold standard.

Methods

In this study 80 patients with CKD participated. Indirect calorimetry (IC) was performed in all patients. The calorimeter analyzed metabolic measurements every minute for 15 min after autocalibration with barometric pressure, temperature, and humidity. Bioelectrical Impedance Analysis (BIA) was performed. Fat-free mass (FFM) was registered among other bioelectrical components. Handgrip strength (HGS) was evaluated and an average of 3 repetitions was recorded. Nutritional status was assessed with the subjective global assessment (SGA). Patients categorized as B or C were then considered as having malnutrition.

Results

We analyzed 71 patients and 3 models were generated. Model 1a included FFM; Model 2a included weight; Model 3c included handgrip strength (HGS). All other variables were stepwise, computer-selected with a p < 0.01 significance level; Malnutrition was consistently associated with ER among other clinical variables in all models (p < 0.05). The model that included BIA-FFM had R²_adjusted = 0.46, while the model that included weight (Kg) had an adjusted R²_adjusted = 0.44. The models had moderate concordance, LC = 0.60–0.65 with the gold standard, whereas other energy expenditure estimation equations had LC = 0.36 and 0.55 with indirect calorimetry. Using these previously validated equations as a reference, our models had concordance values ranging from 0.66 to 0.80 with them.

Conclusion

Models incorporating nutritional status and other clinical variables such as weight, FFM, comorbidities, gender, and age have a moderate agreement with REE. The agreement between our models and others previously validated for the CKD patient is good; however, the agreement between the latter and IC measurements is moderate. The KDOQI lowest recommendation (25 Kcals/kg body weight) considering the 22% difference with respect to the IC for total energy expenditure rather than for REE.

Association Between the Normal-Density Psoas Muscle Index and Handgrip Strength or Gait Speed in Maintenance Hemodialysis Patients

Introduction: This study aimed to evaluate the association between the psoas muscle (PM) index with or without fatty infiltration and various indices associated with muscle mass in hemodialysis (HD) patients.

Methods: We included stable HD patients (n = 83). The collected data included subjective global assessment (SGA) score, ASM/Ht² (appendicular skeletal muscle mass divided by the squared height in meters), gait speed (GS; m/s), and handgrip strength (HGS; kg). The abdominal computed tomography (CT) image was obtained using a CT scanner. The PM and normal-density PM (NPM) indices (mm²/m²) were calculated using the whole PM area or the area with an attenuation range of 35–100 HU divided by the squared height in meters.

Results: Correlation coefficients for the SGA score, ASM/Ht², HGS, and GS were greater for the NPM index than for the PM index. The linear regression analysis showed that, on multivariate analysis, the NPM index was significantly associated with the SGA score, ASM/Ht², and GS. However, the PM index was significantly associated with the SGA score and ASM/Ht² but not with HGS or GS. For calculating the low GS, the area under the receiver operating characteristic curve area was significantly greater for the NPM index than for the PM index (P = 0.012).

Conclusion: The present study suggested that the NPM index excluding fatty infiltration may be an early and useful indicator for detecting muscle strength and physical performance among HD patients.

Characterization and Correction of Olfactory Deficits in Kidney Disease

Patients with CKD suffer from food aversion, anorexia, and malnutrition. Although olfaction has a significant role in determining food flavor, our understanding of olfactory impairment and of the olfaction-nutrition axis in patients with kidney disease is limited. We quantified odor identification, odor threshold, and subjective odor perception in a cohort (n=161) comprising 36 participants with CKD, 100 participants with ESRD, and 25 controls. We investigated olfaction-nutrition associations in these participants and examined a novel intervention to improve olfaction in ESRD. The mean odor identification score was lower in patients with CKD (75.6%±13.1%; P=0.02) and ESRD (66.8%±15.1%; P<0.001) than in controls (83.6%±11.4%). Patients with ESRD exhibited higher odor threshold than the remaining participants exhibited. All groups had similar scores for subjective smell assessment. In multivariable adjusted analyses, kidney disease associated with increased odds of odor identification deficits (odds ratio, 4.80; 95% confidence interval, 1.94 to 11.89). A reduction in odor identification score was associated with higher subjective global assessment score and lower serum total cholesterol, LDL cholesterol, and albumin concentrations. We found no associations between odor threshold and nutritional parameters. In a proof of concept, 6-week, open-label clinical trial, intranasal theophylline (an epithelial membrane transport and proton secretion activator) increased odor identification score in five out of seven (71%) patients with ESRD. In conclusion, patients with kidney disease have olfactory deficits that may influence their nutritional status. Our preliminary results regarding olfactory improvement using intranasal theophylline warrant confirmation in a randomized controlled trial.

Assessment of Nutritional Status of Nepalese Hemodialysis Patients by Anthropometric Examinations and Modified Quantitative Subjective Global Assessment

OBJECTIVE

To assess the nutritional status of patients on maintenance hemodialysis by using modified quantitative subjective global assessment (MQSGA) and anthropometric measurements.

METHOD

We Conducted a cross sectional descriptive analytical study to assess the nutritional status of fifty four patients with chronic kidney disease undergoing maintenance hemodialysis by using MQSGA and different anthropometric and laboratory measurements like body mass index (BMI), mid-arm circumference (MAC), mid-arm muscle circumference (MAMC), triceps skin fold (TSF) and biceps skin fold (BSF), serum albumin, C-reactive protein (CRP) and lipid profile in a government tertiary hospital at Kathmandu, Nepal.

RESULTS

Based on MQSGA criteria, 66.7% of the patients suffered from mild to moderate malnutrition and 33.3% were well nourished. None of the patients were severely malnourished. CRP was positive in 56.3% patients. Serum albumin, MAC and BMI were (mean + SD) 4.0 + 0.3 mg/dl, 22 + 2.6 cm and 19.6 ± 3.2 kg/m² respectively. MQSGA showed negative correlation with MAC (r = −0.563; P = <0.001), BMI (r = −0.448; P = <0.001), MAMC (r = −0.506; P = <.0001), TSF (r = −0.483; P = <.0002), and BSF (r = −0.508; P = <0.0001). Negative correlation of MQSGA was also found with total cholesterol, triglyceride, LDL cholesterol and HDL cholesterol without any statistical significance.

CONCLUSION

Mild to moderate malnutrition was found to be present in two thirds of the patients undergoing hemodialysis. Anthropometric measurements like BMI, MAC, MAMC, BSF and TSF were negatively correlated with MQSGA. Anthropometric and laboratory assessment tools could be used for nutritional assessment as they are relatively easier, cheaper and practical markers of nutritional status.

Association of plasma des-acyl ghrelin levels with CKD

BACKGROUND AND OBJECTIVES

There are no effective therapies for malnutrition in CKD/ESRD patients. This study hypothesized that ghrelin, an endogenous orexigenic hormone, would correlate with renal function and might suggest therapeutic interventions for CKD/ESRD malnutrition.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Fifty-one CKD and 15 hemodialysis patients were enrolled. Acyl ghrelin (AG) and des-acyl ghrelin (DG) were determined using separate two-site-specific assays. Leptin, insulin, growth hormone, insulin-link growth factor-1, C-reactive protein, TNF-α, and IL-6 were also measured.

RESULTS

Univariate correlation analyses showed that CKD stage was highly, positively correlated with the levels of preprandial and postprandial DG and positively correlated with TNF-α, IL-6, leptin, and age. Multivariate partial-correlation analyses showed that CKD was independently associated with the proportion of preprandial and postprandial DG, whereas TNF-α, IL-6, leptin, insulin, and age were not independently associated with either. Geometric mean (GM) preprandial and postprandial AG were comparable between CKD stages ≤2 and >2, whereas GM preprandial DG and postprandial DG were 1.95-fold and 2.17-fold greater, respectively, for CKD stage >2 versus stage ≤2. DG was the dominant form of ghrelin preprandially and postprandially for both CKD stages ≤2 and >2. Dialysis had no effect on AG, but reduced DG by 73% to levels even lower (GM 48.7 pg/ml) than those seen postprandially in CKD stage ≤2 patients (GM 77.0 pg/ml).

CONCLUSIONS

This study shows a strong and independent correlation of DG with CKD stage. Postprandial suppression of ghrelin is impaired with reduced renal function. Hemodialysis selectively removes DG but not AG.

Assessment of myeloperoxidase and oxidative alpha1-antitrypsin in patients on hemodialysis

BACKGROUND AND OBJECTIVES

The present study assesses the effects of the oxidative stress marker, myeloperoxidase (MPO), and the possible MPO-related oxidative stress marker, oxidative alpha(1)-antitrypsin (oxAT), on carotid intima-media thickness (CIMT) and protein-energy wasting (PEW) in patients on hemodialysis (HD).

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Blood samples were obtained from 383 patients before HD to measure WBC count, serum albumin, lipids, high-sensitivity C-reactive protein (CRP), alpha(1)-antitrypsin (AT), interleukin-6, oxidative LDL-C, MPO, and oxAT. We assessed both CIMT and the geriatric nutritional risk index (GNRI) in this cross-sectional competitive study.

RESULTS

Levels of MPO and oxAT correlated. Myeloperoxidase was associated with max-CIMT, and oxAT correlated with max-CIMT and GNRI. Multivariate linear regression models showed that MPO and oxAT were independent predictors of increasing max-CIMT, whereas oxAT, but not MPO, independently correlated with GNRI. In four combined MPO and oxAT groups classified according to median values, a multinomial logistic regression model showed that high MPO together with high oxAT was independently associated with increased max-CIMT. Moreover, the OR for max-CIMT with positive PEW and high MPO was significantly increased in the four groups with combined MPO and PEW.

CONCLUSIONS

High MPO with high oxAT and high MPO with PEW seem to contribute to plaque formation in patients on HD, whereas elevated MPO or oxAT alone might not predict increasing CIMT. In contrast, a high oxAT value seems to be an independent predictor of PEW in patients on HD.

Comprehensive malnutrition inflammation score as a marker of nutritional status in Chinese peritoneal dialysis patients

BACKGROUND

Malnutrition is common among peritoneal dialysis (PD) patients. However, the ideal marker of nutritional status in PD patients remained controversial.

METHODS

We studied 165 unselected adult PD patients. We compared the comprehensive Malnutrition-Inflammation Score (MIS) and the 7-point Subjective Global Assessment (SGA) score.

RESULTS

The mean age was 59.2 +/- 11.5 years. Seventy patients were male. MIS significantly correlated with the SGA score (r =-0.667, P < 0.001). Of the 165 patients, 132 (80.0%) had similar classification of nutritional status by SGA and MIS (Group I); 17 (10.3%) were classified as normal by SGA but moderately malnourished by MIS (Group II), while 16 (9.7%) were classified as normal by MIS but moderately malnourished by SGA (Group III). Group II had been dialysed longer than Group I (71.7 +/- 50.3 vs 40.7 +/- 37.5 months, P = 0.011). As compared with Group I, Group III was more likely to require helper for PD exchange (37.5%vs 9.7%, P = 0.004), marginally more likely to be diabetic (62.5%vs 35.6%, P = 0.085) and had a slightly higher Charlson's comorbidity score (6.13 +/- 1.78 vs 4.98 +/- 2.1, P = 0.085), although the latter two were not statistically significant.

CONCLUSION

MIS has a reasonable correlation with the conventional SGA score in PD patients. Patients with limited self-care capability, diabetes and multiple comorbidities probably had worse score (i.e. worse nutrition) revealed by SGA than by MIS, while patients who had been dialysed longer had worse score revealed by MIS than by SGA.