Hand grip strength measurement in haemodialysis patients: before or after the session?

Pea hull fiber supplementation does not modulate uremic metabolites in adults receiving hemodialysis: a randomized, double-blind, controlled trial

Background

Fiber is a potential therapeutic to suppress microbiota-generated uremic molecules. This study aimed to determine if fiber supplementation decreased serum levels of uremic molecules through the modulation of gut microbiota in adults undergoing hemodialysis.

Methods

A randomized, double-blinded, controlled crossover study was conducted. Following a 1-week baseline, participants consumed muffins with added pea hull fiber (PHF) (15 g/d) and control muffins daily, each for 4 weeks, separated by a 4-week washout. Blood and stool samples were collected per period. Serum p-cresyl sulfate (PCS), indoxyl sulfate (IS), phenylacetylglutamine (PAG), and trimethylamine N-oxide (TMAO) were quantified by LC-MS/MS, and fecal microbiota profiled by 16S rRNA gene amplicon sequencing and specific taxa of interest by qPCR. QIIME 2 sample-classifier was used to discover unique microbiota profiles due to the consumption of PHF.

Results

Intake of PHF contributed an additional 9 g/d of dietary fiber to the subjects' diet due to compliance. No significant changes from baseline were observed in serum PCS, IS, PAG, or TMAO, or for the relative quantification of Akkermansia muciniphila, Faecalibacterium prausnitzii, Bifidobacterium, or Roseburia, taxa considered health-enhancing. Dietary protein intake and IS (r = -0.5, p = 0.05) and slow transit stool form and PCS (r = 0.7, p < 0.01) were significantly correlated at baseline. PHF and control periods were not differentiated; however, using machine learning, taxa most distinguishing the microbiota composition during the PHF periods compared to usual diet alone were enriched Gemmiger, Collinsella, and depleted Lactobacillus, Ruminococcus, Coprococcus, and Mogibacteriaceae.

Conclusion

PHF supplementation did not mitigate serum levels of targeted microbial-generated uremic molecules. Given the high cellulose content, which may be resistant to fermentation, PHF may not exert sufficient effects on microbiota composition to modulate its activity at the dose consumed.

Anxiety, depression and post-traumatic stress disorder in patients on hemodialysis in the setting of the pandemic, inflation, and the Beirut blast: a cross-sectional study

BACKGROUND

In 2020, Lebanon has witnessed its worst economic crisis, exacerbated by the COVID-19 pandemic and a massive explosion of its capital. Amidst these stressors, this study aims at assessing the prevalence of depression, anxiety, suicidality, post-traumatic stress disorder (PTSD) and cognitive impairment in patients undergoing hemodialysis in an academic hospital destroyed by the explosion.

METHODS

This cross-sectional study conducted 6 months after the blast included adults on hemodialysis, with no previous diagnoses of dementia or intellectual disability. It explores prevalence rates of psychiatric disorders, in addition to other medical and psychosocial variables such as frailty, malnutrition, sarcopenia, quality of life and religiosity.

RESULTS

Forty two patients (mean age 66.1; SD: 11.2 years) undergoing hemodialysis for 6.12 years (SD:7.22 years) were included. Anxiety and depression rates reached 54.8% and 57.1% using cut-offs of 6 and 7 respectively on the Hospital Anxiety and Depression rating Scale. 9.5% of the patients reported being in the hospital at the time of the blast and 7.1% reported being injured. 33.3% screened positively for PTSD using a cut-off of 23 on the PCL-5. 26.2% had passive death wishes and 7.1% had suicide plans, however no one had attempted it. 23.8% were found cognitively impaired as shown by the Mini-Cog (<3). Around two-third of participants were moderately to severely malnourished per the GLIM criteria. One third suffered from frailty, according to the FRAIL screening tool. Around 60% suffered from sarcopenia, based on handgrip strength measures. These findings contrast with "acceptable to good" quality of life subjectively reported by participants on the Short Form 36 (SF-36) Health Survey. While one-third of participants participated in organizational religious activities, 88% reported significant subjective meaning of religion in their heart.

CONCLUSIONS

Rates of depression, anxiety, PTSD, suicidality, and cognitive impairment were found to be alarming in the setting of an urban dialysis unit following a major explosion. Psychiatric disorders were found to be compounded with increased prevalence of malnutrition, frailty, and sarcopenia. These findings urge healthcare providers to implement early diagnostic and intervention strategies to improve both mental and physical wellbeing of this vulnerable population, in similar settings.

Effects of a Combined Intradialytic Exercise Training Program on Functional Capacity and Body Composition in Kidney Transplant Candidates

Chronic kidney disease (CKD) leads to gradual muscle mass loss, which is strongly associated with lower functional capacity, which limits a patient’s daily activities. The aim of the present study is to examine the effects of a 4-month intradialytic exercise program on the functional capacity and body composition of kidney transplant (KT) candidates. Twenty-nine male patients on hemodialysis (HD) waiting for a kidney transplant, with a mean age of 53.86 ± 9.56 years old and BMI 27.11 ± 5.55 kg/m2, were randomly assigned into the following two groups: A (nA = 15 HD patients), who followed a 4-month intradialytic exercise program combining aerobic and resistance training, with a supervised, progressively increasing workload, and B (nB = 14 HD patients), who continued to receive usual care. At baseline and the end of the study, the KT candidates underwent a 6-min walking distance (6-MWD), and a 10-repetition sit-to-stand test (10-STS) to access physical function, a handgrip strength (HGS) test to evaluate the muscle strength of the non-fistula hand. Moreover, the bioelectrical impedance analysis (BIA) was performed to assess body composition indices, such as body fat (BF), body fat mass index (BFMI), fat-free mass index (FFMI), body cell mass (BCM), basal metabolic rate (BMR), extracellular water (ECW), intracellular water (ICW), total body water (TBW) and phase angle (PhA). Following the exercise program, group A showed favorable improvements in HGS (from 26.59 ± 9.23 to 28.61 ± 9.58 kg, p < 0.05) and 6-MWD (from 427.07 ± 7.66 to 468.16 ± 11.39 m, p < 0.05). Intergroup results from 6-MWD showed a statistically significant difference (Δp = 0.04), at the end of the study. Moreover, group A results from BIA revealed a significant increase of BMR by 2.4% (p < 0.05), ECW by 3.6% (p = 0.01), ICW by 3.8% (p = 0.01), TBW by 4.1% (p = 0.01), lean mass by 2.7% (p = 0.01), and PhA by 13.3% (p = 0.04), while a reduction in BF by 5.0% (p = 0.01) and BFMI by 6.6% (p = 0.03) was also noticed. At the end of the study, group A showed statistical differences in BMR (Δp = 0.01), BMR/BW (Δp = 0.01), dry lean (Δp = 0.01), and PhA (Δp = 0.03), compared to the group B. Linear regression analysis in group A after training showed positive correlations between HGS and both PhA (r = 0.52, p = 0.04) and FFMI (r = 0.64, p = 0.01), and a strong negative correlation between 6-MWT and BF (r = −0.61, p = 0.01). In conclusion, a 4-month intradialytic exercise program can enhance body composition and some physical parameters in HD patients awaiting kidney transplantation.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Protein Energy Wasting in a Cohort of Maintenance Hemodialysis Patients in Dhaka, Bangladesh

Malnutrition is associated with high rates of mortality among patients with end stage kidney disease (ESKD). There is a paucity of data from Bangladesh, where around 35,000−40,000 people reach ESKD annually. We assessed protein-energy wasting (PEW) amongst 133 patients at a single hemodialysis setting in Dhaka. Patients were 49% male, age 50 ± 13 years, 62% were on twice-weekly hemodialysis. Anthropometric, biochemical, and laboratory evaluations revealed: BMI 24.1 ± 5.2 kg/m2, mid-arm muscle circumference (MAMC) 21.6 ± 3.6 cm, and serum albumin 3.7 ± 0.6 g/dL. Based on published criteria, 18% patients had PEW and for these patients, BMI (19.8 ± 2.4 vs. 25.2 ± 5.2 kg/m2), MAMC (19.4 ± 2.4 vs. 22.2 ± 3.8 cm), serum albumin (3.5 ± 0.7 vs. 3.8 ± 0.5 g/dL), and total cholesterol (135 ± 34 vs. 159 ± 40 mg/dL), were significantly lower as compared to non-PEW patients, while hand grip strength was similar (19.5 ± 7.6 vs. 19.7 ± 7.3 kg). Inflammatory C-reactive protein levels tended to be higher in the PEW group (20.0 ± 34.8 vs. 10.0 ± 13.9 p = 0.065). Lipoprotein analyses revealed PEW patients had significantly lower low density lipoprotein cholesterol (71 ± 29 vs. 88 ± 31 mg/dL, p < 0.05) and plasma triglyceride (132 ± 51 vs. 189 ± 103 mg/dL, p < 0.05), while high density lipoprotein cholesterol was similar. Nutritional assessments using a single 24 h recall were possible from 115 of the patients, but only 66 of these were acceptable reporters. Amongst these, while no major differences were noted between PEW and non-PEW patients, the majority of patients did not meet dietary recommendations for energy, protein, fiber, and several micronutrients (in some cases intakes were 60−90% below recommendations). Malnutrition Inflammation Scores were significantly higher in PEW patients (7.6 ± 3.1 vs. 5.3 ± 2.7 p < 0.004). No discernible differences were apparent in measured parameters between patients on twice- vs. thrice-weekly dialysis. Data from a larger cohort are needed prior to establishing patient-management guidelines for PEW in this population.

Assessment of uremic sarcopenia in dialysis patients: An update

Uremic sarcopenia, which is highly prevalent in dialysis patients, leads to an increased risk of adverse outcomes, such as poor quality of life, falls, fracture, hospitalization, and even mortality. Therefore, early detection of uremic sarcopenia is crucial for administering quick and adequate multidisciplinary therapy to improve clinical outcomes. This review updates the current information about uremic sarcopenia assessment in chronic dialysis patients. We discuss the methods of assessing skeletal muscle mass, strength, and physical performance. We also discuss surrogate markers derived from serum and dialysate creatinine, in addition to emerging screening tools. The prevalence, clinical relevance, and impact of uremic sarcopenia on survival are reviewed and we discuss the limitations and challenges in applying the current working definition of sarcopenia based on the senior population to dialysis patients. The review shows that dialysis patients with skeletal muscle weakness or poor physical performance, either with or without low skeletal muscle mass, should undergo multidisciplinary therapy, included nutritional counseling, lifestyle modification, and exercise intervention, to mitigate the detrimental effects of uremic sarcopenia.

Geriatric nutritional risk index in prediction of muscular strength of elderly patients undergoing hemodialysis

PURPOSE

Geriatric nutritional risk index (GNRI) is one of the new tools to determine nutritional status in the elderly. This study assessed the association between GNRI and muscular strength through handgrip strength (HGS) in patients undergoing hemodialysis.

METHODS

This cross-sectional analytical study assessed 110 hemodialysis patients at Guilan, North of Iran, (mean age of 70.3 ± 6.93), 57 men and 53 women through simple random sampling. Demographic characteristics, GNRI, and HGS of patients were determined. Data were analyzed using descriptive and inferential statistics, including independent t test, AVOVA, Pearson correlation, and linear multiple regression tests.

RESULTS

The mean values of the GNRI and HGS were 93.90 ± 11.06 and 14.82 ± 3.72, respectively. Finally, it was identified that there is a direct and significant association between GNRI and HGS (p = 0.001, r = 0.734). Linear multiple regression showed that GNRI is an independent predictor of HGS (Adj.R² = 0.67, β_GNRI = 8.13).

CONCLUSION

GNRI can be used as a predictor of muscular strength in hemodialysis patients.

Assessment of the Nutritional Status of the Hemodialysis Patients by Anthropometric Measurements

Objective This study assessed the nutritional status of end-stage renal disease (ESRD) patients on maintenance hemodialysis (MHD) by utilizing bedside anthropometric measurements. Methods This prospective cross-sectional study was done from November 2020 till April 2021 on ESRD patients three times a week MHD at our centre. Anthropometric measurements including body mass index (BMI), triceps skinfold thickness (TSFT), mid-arm circumference (MAC), calf circumference (CC) and handgrip strength (HGS) were measured mid-arm muscle circumference (MAMC) was calculated, and nutritional status was determined. Results Out of 195 patients recruited in our study, 127 (65.1%) were male. The mean age was 51.2 ± 14.8 years with a minimum of 20 and a maximum of 90 years, while the mean duration of HD was 4.6 ± 4.1 years. The majority of our patients had TSFT of 60 % to 90% 93 (47.7%), indicating mild to moderate depletion of fat stores and MAMC of >90 % 128 (65.6%), indicating good protein stores. Among all anthropometric measures, BMI was strongly associated with age (<0.001), while gender and duration of MHD were associated with TSFT (p <0.001). Conclusion Anthropometric measurements are easy and inexpensive bedside methods for assessing the nutritional status of ESRD patients on MHD. Our study concluded that our MHD patients have overall good nutritional status, though our young patients have low BMI and old have obesity. Male patients have weaker HGS. With the increased number of years on MHD, malnutrition increases. Our study will help to treat physicians and nutritionists for proper nutritional planning and implementation to prevent malnutrition.

A Protocol of Intradialytic Exercise for Improvements in Inflammatory Status, Body Composition, and Functional Capacity

Skeletal muscle wasting has been well-documented among hemodialysis patients. This catabolic condition can be induced by numerous factors, including low-grade inflammation, and is associated with impairments in functional capacity and quality of life, as well as an increased mortality risk. We previously showed that 12 weeks of intradialytic resistance training increases lean mass, functional capacity, and the quality of life of hemodialysis patients. This chapter provides the details of a protocol of intradialytic exercise that leads to improvements in inflammatory status, body composition, and functional capacity.

A Systematic Review of Handgrip Strength Measurement in Clinical and Epidemiological Studies of Kidney Disease: Toward a Standardized Approach

In chronic kidney disease (CKD), handgrip strength (HGS) is recommended as a surrogate measure of protein-energy status and functional status. However, it is not routinely used because of inconsistencies such as the optimal timing of the HGS measurement and unclear guidance regarding technique. We aimed to determine the extent of variation in the protocols and methods of HGS assessment. We aimed to identify clinical and epidemiological studies conducted on CKD that reported on the use of HGS as an outcome. A systematic literature search identified n = 129 studies with a total participant population of n = 35,192. We identified large variations in all aspects of the methodology including body and arm position, repetitions, rest time, timing, familiarization, and how scores were calculated. The heterogeneous methodologies used reinforce the need to standardize HGS measurement. After reviewing previously employed methodology in the literature, we propose a comprehensive HGS assessment protocol for use in CKD.

Identification of the most clinically useful skeletal muscle mass indices pertinent to sarcopenia and physical performance in chronic kidney disease

AIM

Patients with chronic kidney disease (CKD) are characterised by low skeletal muscle mass that negatively impacts physical performance. Operational definitions of 'low muscle mass' are inconsistent, and it is unknown how different skeletal muscle mass indices affect the relationship between muscle mass and physical function.

METHODS

Appendicular skeletal muscle mass (ASM) was measured by dual-energy X-ray absorptiometry in 72 CKD patients. Along with crude ASM, alternative muscle indices were calculated adjusting for height, height-squared, body mass, and BMI. Physical performance was assessed by handgrip strength, sit-to-stand tests, gait speed, the incremental shuttle walk test and 'Short Physical Performance Battery'.

RESULTS

Prevalence of 'low muscle mass' ranged from 26% to 35% of patients depending on the criteria used. The relationship between muscle mass indices and physical function differed for each criteria. Using average coefficients, the association with overall physical function and muscle indices were as follows: crude ASM (r = .258), ASM/height (r = .249), ASM/height-squared (r = .332), ASM/body mass (r = .249) and ASM/BMI (r = .206). Muscle adjusted for markers of adiposity (ASM/body fat %, r = .266; ASM/fat mass, r = .338) provided the best overall associations with physical function.

CONCLUSION

The use of alternative muscle mass indices provide different estimates of 'low muscle mass' prevalence, and the strongest (and most useful definition in regard to functional status) involves adjustment for either total or relative body fat. ASM adjusted for adiposity may be physiologically and clinically more relevant in patients with renal disease.

Lipids, Lipoprotein Distribution and Nutritional Parameters over the Ramadan Period in Hemodialysis Patients

The period of Ramadan (R) is associated with dramatic changes in eating habits involving extended periods of fasting on a daily basis. The current study assessed whether lipids and lipoproteins were impacted during R in chronic hemodialysis (HD) patients. Forty-five subjects in an outpatient dialysis clinic in Saudi Arabia were evaluated for anthropometric and lipid changes on a monthly basis before, during as well as one and two months after R. In addition to routine biochemical measures, anthropometric assessments including hand-grip strength (HGS), mid-arm muscle circumference (MAMC), plasma lipids and lipoproteins were evaluated. Dietary assessment was carried out using 24 h recalls. Over the course of the study, changes in renal-related parameters (creatinine, albumin, Kt/V) were minor, as were changes in plasma lipids. Large high-density lipoproteins (HDLs) and low-density lipoproteins (LDLs) accounted for the majority of their respective lipoproteins and their proportions did not change over the study period. Mean LDL particle diameters were higher during the R period, but the changes over the study period were small. Calorie intake during R (2139 ± 709 kcal/d) was significantly higher than the value noted two month post-R (1755 ± 424 kcal/d) and this was associated with significant increases in protein (69 ± 24 vs. 60 ± 24 g/d) and fat (97 ± 38, vs. 73 ± 35 g/d), respectively. No changes were noted with respect to HGS and MAMC. These data show that for HD patients, the period of R results in temporal or non-significant effects on plasma lipids, despite changes in nutrient intake.

Investigating Physical and Nutritional Changes During Prolonged Intermittent Fasting in Hemodialysis Patients: A Prospective Cohort Study

OBJECTIVE

Studies investigating the health effects of prolonged intermittent fasting during Ramadan among Muslim patients on hemodialysis (HD) are limited and reported heterogeneous findings. This study aimed to evaluate the effects of intermittent fasting during Ramadan on nutritional and functional status of patients on maintenance HD.

DESIGN AND METHODS

This was a 12-week, multicenter, prospective observational study. The study setting included three HD centers. Adult Muslim patients, who were undergoing HD session thrice weekly and planned to fast during Ramadan, were screened for eligibility and recruited. Nutritional and functional status assessments were carried out 2 weeks before (V₀), at the fourth week of Ramadan (V₁), and 4 weeks after Ramadan (V₂). Nutritional status parameters included anthropometry (body mass index, interdialytic weight gain, waist circumference), body composition (mid-arm circumference, triceps skinfold, body fat percentage), blood biochemistry (albumin, renal profile, lipid profile, and inflammatory markers), blood pressure, dietary intake, and handgrip strength. Changes in nutritional and functional status parameters across study timepoints were analyzed using repeated-measures analysis of variance.

RESULTS

A total of 87 patients completed the study, with 68 patients (78.2%) reporting fasting ≥20 days. Ramadan fasting led to significant reductions (all P < .05) in body mass index, interdialytic weight gain, waist circumference, mid-arm circumference, fat tissue mass, and body fat percentage, but these were not accompanied by any significant change in lean tissue mass (P > .05). Significant improvement was observed in serum phosphate levels, but serum albumin, urea, and creatinine were also reduced significantly during Ramadan (P < .05). There were no significant changes in lipid profile and inflammatory markers. Interestingly, energy and protein intakes remain unchanged during Ramadan. Handgrip strength improved significantly during Ramadan and further improved after Ramadan.

CONCLUSION

Intermittent Ramadan fasting leads to temporary changes in nutritional status parameters and poses nondetrimental nutritional risk for patients on maintenance HD.