Urinary Creatinine Excretion Reflecting Muscle Mass is a Predictor of Mortality and Graft Loss in Renal Transplant Recipients

Creatine homeostasis and the kidney: comparison between kidney transplant recipients and healthy controls

Creatine is a natural nitrogenous organic acid that is integral to energy metabolism and crucial for proper cell functioning. The kidneys are involved in the first step of creatine production. With kidney transplantation being the gold-standard treatment for end-stage kidney disease, kidney transplant recipients (KTR) may be at risk of impaired creatine synthesis. We aimed to compare creatine homeostasis between KTR and controls. Plasma and urine concentrations of arginine, glycine, guanidinoacetate, creatine and creatinine were measured in 553 KTR and 168 healthy controls. Creatine intake was assessed using food frequency questionnaires. Iothalamate-measured GFR data were available in subsets of 157 KTR and 167 controls. KTR and controls had comparable body weight, height and creatine intake (all P > 0.05). However, the total creatine pool was 14% lower in KTR as compared to controls (651 ± 178 vs. 753 ± 239 mmol, P < 0.001). The endogenous creatine synthesis rate was 22% lower in KTR as compared to controls (7.8 ± 3.0 vs. 10.0 ± 4.1 mmol per day, P < 0.001). Despite lower GFR, the plasma guanidinoacetate and creatine concentrations were 21% and 41% lower in KTR as compared to controls (both P < 0.001). Urinary excretion of guanidinoacetate and creatine were 66% and 59% lower in KTR as compared to controls (both P < 0.001). In KTR, but not in controls, a higher measured GFR was associated with a higher endogenous creatine synthesis rate (std. beta: 0.21, 95% CI: 0.08; 0.33; P = 0.002), as well as a higher total creatine pool (std. beta: 0.22, 95% CI: 0.11; 0.33; P < 0.001). These associations were fully mediated (93% and 95%; P < 0.001) by urinary guanidinoacetate excretion which is consistent with production of the creatine precursor guanidinoacetate as rate-limiting factor. Our findings highlight that KTR have a disturbed creatine homeostasis as compared to controls. Given the direct relationship of measured GFR with endogenous creatine synthesis rate and the total creatine pool, creatine supplementation might be beneficial in KTR with low kidney function.Trial registration ID: NCT02811835.Trial registration URL: https://clinicaltrials.gov/ct2/show/NCT02811835 .

Sarcopenia augments the risk of excess weight on COVID-19 hospitalization: A prospective study using the Lifelines COVID-19 cohort

OBJECTIVE

We investigated the associations of sarcopenia alone, overweight or obesity, and sarcopenic overweight or obesity with COVID-19 hospitalization.

METHODS

Participants from the Lifelines COVID-19 cohort who were infected with COVID-19 were included in this study. Sarcopenia was defined as a relative deviation of muscle mass of ≤ -1.0 SD from the sex-specific mean 24-h urinary creatinine excretion. Overweight or obesity was defined as a body mass index ≥ 25 kg/m2. Sarcopenic overweight or obesity was defined as the presence of overweight or obesity and low muscle mass. COVID-19 hospitalization was self-reported. Logistic regression models were used to analyze the associations of sarcopenia alone, overweight or obesity, and sarcopenic overweight or obesity with COVID-19 hospitalization.

RESULTS

Of the 3594 participants infected with COVID-19 and recruited in this study, 173 had been admitted to the hospital. Compared with the reference group, individuals with overweight or obesity and sarcopenic overweight or obesity were 1.78-times and 2.09-times more likely to have been hospitalized for COVID-19, respectively, whereas sarcopenia alone did not increase the risk of COVID-19 hospitalization.

CONCLUSIONS

In this middle-aged population, sarcopenic overweight or obesity elevated the risk of hospitalization for COVID-19 in those infected with COVID-19 more than overweight or obesity alone. These data support the relevance of sarcopenic overweight or obesity as a risk factor beyond the geriatric setting and should be considered in risk stratification in future public health and vaccination campaigns.

Myosteatosis is associated with poor survival after kidney transplantation: a large retrospective cohort validation

PURPOSE

We aim to establish diagnostic thresholds of sarcopenia and myosteatosis based on CT measurements, and to validate their prognostic value in a large cohort of kidney transplant recipients.

METHODS

Local healthy population with abdominal CT between 2010 and 2022, and patients underwent kidney transplantation between 2015 and 2019 at our center were retrospectively included. The skeletal muscle index and muscle attenuation of abdominal muscles were calculated based on CT image at the middle of the third lumbar vertebra. Primary endpoints included all-cause mortality and death censored allograft survival.

RESULTS

Age- and sex-specific thresholds for sarcopenia and myosteatosis were established based on 1598 healthy local population. The final patient cohort consisted of 992 kidney transplant recipients (median age 34 years, interquartile range 28-44 years; 694 males), including 33 (3.3%) with sarcopenia and 95 (9.5%) with myosteatosis. Multivariate analysis revealed myosteatosis (adjusted hazard ratio = 3.08, p = 0.022) was an independent baseline risk factor of mortality after adjusting for age, the history of cancer, and the history of cardiovascular event. Multivariate analysis found preemptive transplantation (adjusted hazard ratio = 0.36, p = 0.037) was an independent protective factor of allograft loss. No difference was found in the prognosis between kidney transplant recipients with and without sarcopenia.

CONCLUSION

Myosteatosis was an independent risk factor of mortality after kidney transplantation, but sarcopenia was not. Neither sarcopenia nor myosteatosis was associated with graft loss.

Decreased abdominal wall muscle mass defined by muscle ultrasound is associated with malnutrition according to Global Leadership Initiative on Malnutrition criteria in renal transplant recipients: A cross-sectional study

BACKGROUND

Changed body composition with increased fat content and decreased muscle mass is seen in renal transplantation recipients (RTRs). Increased fat mass might mask underlying muscle mass loss; measuring low body mass index and weight reduction alone may not be sensitive enough to diagnose malnutrition in RTRs. We aimed to determine the prevalence of malnutrition in stable RTRs using the Global Leadership Initiative on Malnutrition (GLIM) criteria and to assess the use of muscle ultrasonography (US) to compare the performance of various muscle US measurements in the diagnosis of reduced muscle mass.

METHODS

Ninety-one patients who had renal transplantation >6 months ago were enrolled in the study. GLIM criteria were performed for all patients, but not those at risk of malnutrition. Bioelectrical impedance analysis and muscle US were performed to identify reduced muscle mass.

RESULTS

The prevalence of malnutrition according to GLIM criteria was 25.3% (n = 23). All muscle US measurements were lower in the malnourished group than the well-nourished group; however, the malnourished group had substantially lower muscle thicknesses in abdominal muscles, specifically the external oblique (EO) and internal oblique (IO) muscles, than the well-nourished group (P = 0.001 and P = 0.007, respectively). There was a significant association between malnutrition and EO (odds ratio [OR] = 0.338, 95% CI = 0.163-0.699; P = 0.003) and IO (OR = 0.620, 95% CI = 0.427-0.900; P = 0.012) regardless of age and sex.

CONCLUSION

One in four RTRs experience malnutrition. Muscle US could be used effectively for the diagnosis of reduced muscle mass and malnutrition in RTRs according to GLIM criteria.

Measuring Albuminuria in Individuals With Obesity: Pitfalls of the Urinary Albumin-Creatinine Ratio

An increased urinary albumin excretion rate is an important early risk factor for chronic kidney disease and other major outcomes and is usually measured using the urinary albumin-creatinine ratio (ACR). Obesity is highly prevalent in the general and chronic kidney disease populations and is an independent risk factor for moderately increased albuminuria (henceforth, moderate albuminuria). In this review, we describe how the ACR was developed and used to define moderate albuminuria. We then investigate how biases related to urinary creatinine excretion are introduced into the ACR measurement and how the use of the 30-mg/g threshold decreases the performance of the test in populations with higher muscle mass, with a primary focus on why and how this occurs in the obese population. The discussion then raises several strategies that can be used to mitigate such bias. This review provides a comprehensive overview of the medical literature on the uses and limitations of ACR in individuals with obesity and critically assesses related issues. It also raises into question the widely accepted 30-mg/g threshold as universally adequate for the diagnosis of moderate albuminuria. The implications of our review are relevant for clinicians, epidemiologists, and clinical trialists.

Skeletal muscle atrophy in clinical and preclinical models of chronic kidney disease: A systematic review and meta-analysis

Patients with chronic kidney disease (CKD) are often regarded as experiencing wasting of muscle mass and declining muscle strength and function, collectively termed sarcopenia. The extent of skeletal muscle wasting in clinical and preclinical CKD populations is unclear. We evaluated skeletal muscle atrophy in preclinical and clinical models of CKD, with multiple sub-analyses for muscle mass assessment methods, CKD severity, sex and across the different preclinical models of CKD. We performed a systematic literature review of clinical and preclinical studies that measured muscle mass/size using the following databases: Ovid Medline, Embase and Scopus. A random effects meta-analysis was utilized to determine standard mean difference (SMD; Hedges' g) between healthy and CKD. Heterogeneity was evaluated using the I2 statistic. Preclinical study quality was assessed via the Systematic Review Centre for Laboratory Animal Experimentation and clinical studies quality was assessed via the Newcastle-Ottawa Scale. This study was registered in PROSPERO (CRD42020180737) prior to initiation of the search. A total of 111 studies were included in this analysis using the following subgroups: 106 studies in the primary CKD analysis, 18 studies that accounted for diabetes and 7 kidney transplant studies. Significant atrophy was demonstrated in 78% of the preclinical studies and 49% of the clinical studies. The random effects model demonstrated a medium overall SMD (SMD = 0.58, 95% CI = 0.52-0.64) when combining clinical and preclinical studies, a medium SMD for the clinical population (SMD = 0.48, 95% CI = 0.42-0.55; all stages) and a large SMD for preclinical CKD (SMD = 0.95, 95% CI = 0.76-1.14). Further sub-analyses were performed based upon assessment methods, disease status and animal model. Muscle atrophy was reported in 49% of the clinical studies, paired with small mean differences. Preclinical studies reported significant atrophy in 78% of studies, with large mean differences. Across multiple clinical sub-analyses such as severity of CKD, dialysis modality and diabetes, a medium mean difference was found. Sub-analyses in both clinical and preclinical studies found a large mean difference for males and medium for females suggesting sex-specific implications. Muscle atrophy differences varied based upon assessment method for clinical and preclinical studies. Limitations in study design prevented conclusions to be made about the extent of muscle loss with disease progression, or the impact of dialysis. Future work would benefit from the use of standardized measurement methods and consistent clinical staging to improve our understanding of atrophy changes in CKD progression, and analysis of biological sex differences.

Sarcopenic obesity and its relation with muscle quality and mortality in patients on chronic hemodialysis

BACKGROUND & AIMS

Sarcopenia is prevalent in patients with end-stage kidney disease (ESKD) on hemodialysis (HD), and is associated with poor outcomes, while obesity may be protective. Sarcopenic obesity is associated with increased frailty, morbidity and mortality in the general population. Myosteatosis, i.e., muscle fat infiltration, has major effects on muscle strength and physical performance, but is poorly investigated in the nephrology setting. In the present study we aimed to assess the association between sarcopenic obesity, as diagnosed by abdominal CT, and mortality. Moreover, the relationship between myosteatosis, sarcopenic obesity and mortality was also investigated.

METHODS

This is a retrospective study in which ESKD patients on HD submitted to unenhanced abdominal CT for clinical reasons at least 6 months after dialysis initiation were evaluated for sarcopenic obesity and myosteatosis, defined as intermuscular fat area and low attenuation muscle area. Sarcopenic obesity was diagnosed in cases of low abdominal skeletal muscle area and high total fat area. Receiver-operating characteristics (ROC) analysis with Youden index was used to determine the cut-off for high total fat area. Intermuscular fat area and low attenuation muscle area were evaluated by applying the Hounsfield unit of interest (-190; -30, and -29; +29 respectively). Cox regression analysis was used to evaluate the association between predictors and mortality risk.

RESULTS

We enrolled 212 patients, aged 68.8 (±14.7) years, 65.5% (139/212) male. Median follow-up was 19.7 (interquartile range [IQR] 2.7-35) months. Sarcopenic obesity was diagnosed in 19.8% of patients and was associated with increased mortality (HR: 3.29 (1.72; 6.27), P < 0.001), and with the presence of myosteatosis. Both intermuscular fat area and low attenuation muscle area were associated with increased mortality in adjusted analyses.

CONCLUSIONS

Patients with sarcopenic obesity have increased myosteatosis. Sarcopenic obesity and myosteatosis are associated with increased mortality in patients on HD.

Association of Alpha-Actinin-3 Polymorphism With Sarcopenia in Kidney Transplant Recipients

BACKGROUND

Sarcopenia is defined as the loss of skeletal muscle mass and function and is associated with increased mortality. Certain genetic polymorphisms represent risk factors used to assess the incidence of sarcopenia; however, few studies have evaluated the association between genetic polymorphisms and sarcopenia after kidney transplantation (KTx). We examined single-nucleotide polymorphisms (SNPs) in the genes involved in sarcopenia after KTx.

METHODS

Sixty-five patients who underwent KTx were enrolled in this study. We used the psoas mass index (PMI; the cross-sectional area of the bilateral psoas muscle/height) as a surrogate marker for assessing the extent of sarcopenia. We determined the PMI before KTx and 1 year after KTx, and we identified 5 SNPs in 5 genes associated with sarcopenia in the general population. Finally, the link between the changes in PMI 1 year after KTx and each SNP was examined.

RESULTS

The median PMI before KTx and 1 year after KTx was 7.4 (4.6-13.2) and 7.0 (3.6-13.6), respectively. The PMI decreased in 43 patients (66.2%). The alpha-actinin-3 rs1815739 genotype was associated with changes in PMI; the distribution of CT+TT genotypes in the PMI decrease group was significantly higher than that of the CC genotype (odds ratio, 4.23; 95% CI 0.05-0.97; P = 0.025). Moreover, the T allele frequency was significantly higher in the PMI decrease group than in the PMI increase group (odds ratio, 2.34; 95% CI 0.18-0.950; P = 0.025).

CONCLUSION

The alpha-actinin-3 rs1815739 genotype may represent a genetic risk factor for sarcopenia after KTx.

Sarcopenia of kidney transplant recipients as a predictive marker for reduced graft function and graft survival after kidney transplantation

PURPOSE

The association between sarcopenia of kidney transplant recipients and outcome after kidney transplantation (KT) has not yet been fully understood and is still considered controversial. The aim of our study was to analyze the impact of pre-transplant sarcopenia on graft function, postoperative complication rates, and survival of the patients after renal transplantation.

METHODS

In this retrospective single-center study, all patients who underwent KT (01/2013-12/2017) were included. Demographic data, rejection rates, delayed graft function, and graft and patient survival rates were analyzed. Sarcopenia was measured in computed tomography images by the sex-adjusted Hounsfield unit average calculation (HUAC).

RESULTS

During the study period, 111 single KTs (38 women and 73 men) were performed. Living donor kidney transplants were performed in 48.6%. In total, 32.4% patients had sarcopenia. Sarcopenic patients were significantly older (59.6 years vs. 49.8 years; p < 0.001), had a higher body mass index (BMI = 27.6 kg/m2 vs. 25.0 kg/m2; p = 0.002), and were more likely to receive deceased donor kidneys (72.2% vs. 41.3%; p = 0.002). Interestingly, 3 years after KT, the creatinine serum levels were significantly higher (2.0 mg/dl vs. 1.5 mg/dl; p = 0.001), whereas eGFR (39.9 ml/min vs. 53.4 ml/min; p = 0.001) and graft survival were significantly lower (p = 0.004) in sarcopenic transplant recipients. Sarcopenic patients stayed in hospital significantly longer postoperatively than those who were non-sarcopenic.

CONCLUSIONS

At the time of kidney transplantation, sarcopenia was found to predict reduced long-term graft function and diminished graft survival after KT. The early identification of sarcopenic patients can not only enable an optimized selection of recipients, but also the initiation of pre-habilitation programs during the waiting period.

Diagnosis, prevalence, and outcomes of sarcopenia in kidney transplantation recipients: A systematic review and meta-analysis

The prevalence of sarcopenia and its clinical predictors and clinical impact vary among kidney transplant recipients (KTRs), in part because of different diagnostic criteria. This study aimed to assess the reported diagnosis criteria of sarcopenia and compare them in terms of prevalence, clinical predictors, and impact of sarcopenia. The Medline, Embase, and Cochrane Library were searched for the full-length reports published until 28 January 2022. The subgroup analysis, meta-regression, and sensitivity analysis were performed and heterogeneity was assessed using the I² . A total of 681 studies were retrieved, among which only 23 studies (including 2535 subjects, 59.7% men, mean age 49.8 years) were eventually included in the final analysis. The pooled prevalence in these included studies was 26% [95% confidence interval (95% CI): 20-34%, I²  = 93.45%], including 22% (95% CI: 14-32%, I²  = 88.76%) in men and 27% (95% CI: 14-41%, I²  = 90.56%) in women (P = 0.554 between subgroups). The prevalence of sarcopenia diagnosed using low muscle mass was 34% (95% CI: 21-48%, I²  = 95.28%), and the prevalence of using low muscle mass in combination with low muscle strength and/or low physical performance was 21% (95% CI: 15-28%, I²  = 90.37%) (P = 0.08 between subgroups). In meta-regression analyses, the mean age (regression coefficient: 1.001, 95% CI: 0.991-1.011) and percentage male (regression coefficient: 0.846, 95% CI: 0.367-1.950) could not predict the effect size. Lower body mass index (odds ratio (OR): 0.57, 95% CI: 0.39-0.84, I²  = 61.5%), female sex (OR: 0.31, 95% CI: 0.16-0.61, I²  = 0.0%), and higher age (OR: 1.08, 95% CI: 1.05-1.10, I²  = 10.1%) were significantly associated with a higher risk for sarcopenia in KTRs, but phase angle (OR: 0.81, 95% CI: 0.16-4.26, I²  = 84.5%) was not associated with sarcopenia in KTRs. Sarcopenia was not associated with rejections (risk ratio (RR): 0.67, 95% CI: 0.23-1.92, I²  = 12.1%), infections (RR: 1.03, 95% CI: 0.34-3.12, I²  = 87.4%), delayed graft functions (RR: 0.81, 95% CI: 0.46-1.43, I²  = 0.0%), and death (RR: 0.95, 95% CI: 0.32-2.82, I²  = 0.0%) in KRTs. Sarcopenia was found to be very common in KRTs. However, we have not found that sarcopenia had a negative impact on clinical health after kidney transplantation. Large study cohorts and multicentre longitudinal studies in the future are urgently needed to explore the prevalence and prognosis of sarcopenia in kidney transplant patients.

Low skeletal muscle mass is associated with mortality in kidney transplant recipients

Muscle wasting in chronic kidney disease is associated with increased cardiovascular events, morbidity, and mortality. However, whether pretransplantation skeletal muscle mass affects kidney transplantation (KT) outcomes has not been established. We analyzed 623 patients who underwent KT between 2004 and 2019. We measured the cross-sectional area of total skeletal muscle at the third lumbar vertebra level on pretransplantation computed tomography scan. The patients were grouped into low and normal skeletal muscle mass groups based on the sex-specific skeletal muscle mass index lowest quartile. During the entire follow-up period, 45 patients (7.2%) died and 56 patients (9.0%) experienced death-censored graft loss. Pretransplantation low skeletal muscle mass was independently associated with all-cause mortality (adjusted hazard ratio, 2.269; 95% confidence interval, 1.232-4.182). Low muscle mass was also associated with an increased risk of hospital readmission within 1 year after transplantation. Death-censored graft survival rates were comparable between the 2 groups. The low muscle group showed higher creatinine-based estimated glomerular filtration rates (eGFRs) than the normal muscle group. Although cystatin C-based eGFRs were measured in only one-third of patients, cystatin C-based eGFRs were comparable between the 2 groups. Pretransplantation low skeletal muscle mass index is associated with an increased risk of mortality and hospital readmission after KT.

Serum Creatinine-to-Cystatin-C Ratio as a Potential Muscle Mass Surrogate and Racial Differences in Mortality

OBJECTIVES

Serum creatinine-based estimated glomerular filtration rate equations and muscle mass are powerful markers of health and mortality risk. However, the serum creatinine-to-cystatin-C ratio may be a better indicator of health status. The objective of this study was to describe the relationship between creatinine-to-cystatin-C ratio and all-cause mortality when stratifying patients as per race and as per chronic kidney disease status.

METHODS

This was a retrospective cohort study examining black and nonblack US veterans between October 2004 and September 2019, with baseline cystatin C and creatinine data from those not on dialysis during the study period. Veterans were divided into four creatinine-to-cystatin-C ratio groups: <0.75, 0.75-<1.00, 1.0-<1.25, and ≥1.25. The primary outcome of interest was all-cause mortality subsequent to the cystatin C laboratory measure.

RESULTS

Among 22,316 US veterans, the mean (± standard deviation) age of the cohort was 67 ± 14 years, 5% were female, 82% were nonblack, and 18% were black. The proportion of black veterans increased across creatinine-to-cystatin-C ratio groups. In the fully adjusted model, compared with the reference (creatinine-to-cystatin-C ratio: 1.00-<1.25), a creatinine-to-cystatin-C ratio <0.75 had the highest mortality risk among both black and nonblack veterans (nonblack: hazard ratio [HR] [95% confidence interval {CI}]: 3.01 [2.78-3.26] and black: 4.17 [3.31-5.24]). A creatinine-to-cystatin-ratio ≥1.25 was associated with lower death risk than the referent in both groups (nonblack: HR [95% CI]: 0.89 [0.80-0.99] and black: HR [95% CI]: 0.55 [0.45-0.69]). However, there was a significant difference in the effect by race (Wald's P-value: <0.01).

CONCLUSIONS

Higher creatinine-to-cystatin-C ratios indicate better health status and are strongly associated with lower mortality risk regardless of the kidney function level, and the relation was similar for both black and nonblack veterans, but with different strengths of effect across racial groups. Thereby, use of a fixed race coefficient in estimating kidney function may be biased.

Muscle mass, muscle strength and mortality in kidney transplant recipients: results of the TransplantLines Biobank and Cohort Study

BACKGROUND

Survival of kidney transplant recipients (KTR) is low compared with the general population. Low muscle mass and muscle strength may contribute to lower survival, but practical measures of muscle status suitable for routine care have not been evaluated for their association with long-term survival and their relation with each other in a large cohort of KTR.

METHODS

Data of outpatient KTR ≥ 1 year post-transplantation, included in the TransplantLines Biobank and Cohort Study (ClinicalTrials.gov Identifier: NCT03272841), were used. Muscle mass was determined as appendicular skeletal muscle mass indexed for height² (ASMI) through bio-electrical impedance analysis (BIA), and by 24-h urinary creatinine excretion rate indexed for height² (CERI). Muscle strength was determined by hand grip strength indexed for height² (HGSI). Secondary analyses were performed using parameters not indexed for height². Cox proportional hazards models were used to investigate the associations between muscle mass and muscle strength and all-cause mortality, both in univariable and multivariable models with adjustment for potential confounders, including age, sex, body mass index (BMI), estimated glomerular filtration rate (eGFR) and proteinuria.

RESULTS

We included 741 KTR (62% male, age 55 ± 13 years, BMI 27.3 ± 4.6 kg/m²), of which 62 (8%) died during a median [interquartile range] follow-up of 3.0 [2.3-5.7] years. Compared with patients who survived, patients who died had similar ASMI (7.0 ± 1.0 vs. 7.0 ± 1.0 kg/m²; P = 0.57), lower CERI (4.2 ± 1.1 vs. 3.5 ± 0.9 mmol/24 h/m²; P < 0.001) and lower HGSI (12.6 ± 3.3 vs. 10.4 ± 2.8 kg/m²; P < 0.001). We observed no association between ASMI and all-cause mortality (HR 0.93 per SD increase; 95% confidence interval [CI] [0.72, 1.19]; P = 0.54), whereas CERI and HGSI were significantly associated with mortality, independent of potential confounders (HR 0.57 per SD increase; 95% CI [0.44, 0.81]; P = 0.002 and HR 0.47 per SD increase; 95% CI [0.33, 0.68]; P < 0.001, respectively), and associations of CERI and HGSI with mortality remained independent of each other (HR 0.68 per SD increase; 95% CI [0.47, 0.98]; P = 0.04 and HR 0.53 per SD increase; 95% CI [0.36, 0.76]; P = 0.001, respectively). Similar associations were found for unindexed parameters.

CONCLUSIONS

Higher muscle mass assessed by creatinine excretion rate and higher muscle strength assessed by hand grip strength are complementary in their association with lower risk of all-cause mortality in KTR. Muscle mass assessed by BIA is not associated with mortality. Routine assessment using both 24-h urine samples and hand grip strength is recommended, to potentially target interdisciplinary interventions for KTR at risk for poor survival to improve muscle status.

Allograft function and muscle mass evolution after kidney transplantation

BACKGROUND

Advanced chronic kidney disease is associated with muscle wasting, but how glomerular filtration rate (GFR) recovery after kidney transplantation is associated with muscle mass is unknown.

METHODS

We took advantage of the simultaneous measurement of GFR (using iohexol plasma clearance; ioGFR) and creatinine excretion rate (a surrogate marker of muscle mass; CER) performed 3 months after transplantation and at a later time point at our institution to investigate the interplay between allograft function, muscle mass, and outcome in kidney transplant recipients.

RESULTS

Between June 2005 and October 2019, 1319 successive kidney transplant recipients (mean age 50.4 ± 14.6; 38.7% female) underwent GFR measurement at our institution 3 months after kidney transplantation. CER (CER₃ ) and ioGFR (ioGFR₃ ) were 7.7 ± 2.6 μmol/min and 53 ± 17.1 mL/min/1.73 m² , respectively. Multivariable analysis identified female gender, older donor and recipient age, reduced body mass index, coronary disease, dialysis history, proteinuria, and reduced ioGFR₃ as independent predictors of low CER₃ (ioGFR₃ : β coefficient 0.19 [95% confidence interval 0.14 to 0.24]). A total of 1165 patients had a subsequent CER measurement after a median follow-up of 9.5 months. Of them, 373 (32%) experienced an increase in CER > 10%, while 222 (19%) showed a CER decrease of more than 10%. Multivariable analysis adjusted for CER₃ and other confounders identified ioGFR₃ as an independent predictor of CER at follow-up (β coefficient 0.11 [95% confidence interval 0.07 to 0.16]). In multivariable Cox analysis, reduced CER at 3 months or at follow-up were consistently associated with mortality (hazard ratio [95% confidence interval] at 3 months: 0.82 [0.74 to 0.91]; at follow-up: 0.79 [0.69 to 0.99]) but not with graft loss.

CONCLUSIONS

Glomerular filtration rate recovery is a determinant of muscle mass variation after kidney transplantation. Early interventions targeting muscle mass gain may be beneficial for kidney transplant recipients.

Weight-adjusted urinary creatinine excretion predicts transplant outcomes in adult patients with acute myeloid leukemia in complete remission

Sarcopenia is a prognostic factor for cancer. Because creatinine is formed from creatine phosphate in muscle tissue, urinary creatinine excretion (UCE) serves as an index of muscle volume. However, as of yet, there are no studies assessing the clinical impact of UCE or weight- adjusted urinary creatinine excretion (WA-UCE) on allogeneic hematopoietic stem cell transplantation (allo-HSCT) recipients. We analyzed the association between pre-transplant WA-UCE and transplant outcomes among 164 adult patients with acute myeloid leukemia in complete remission who underwent their first allo-HSCT at our center. The patients were classified into a high (n = 106) and a low WA-UCE group (n = 58) for predicting overall survival (OS) based on the receiver operating characteristics curve. On multivariate analysis, low WA-UCE was associated with poor OS, progression-free survival and a high incidence of non-relapse mortality. WA-UCE has the potential to be an objective biomarker for predicting transplant outcomes, especially the incidence of infection-related death.

Quadriceps muscle thickness assessed by ultrasound is independently associated with mortality in hemodialysis patients

BACKGROUND/OBJECTIVES

Estimation of muscle mass is an integral part of nutritional assessment in End-Stage Kidney Disease (ESKD) patients on chronic hemodialysis (HD). In this respect, muscle ultrasound (US) is a valid and reliable tool but has not been previously related to outcomes in this population. Aims of this study were to assess the relationship between quadriceps muscle thickness as assessed by US and outcomes in ESKD patients on HD; we also compared US with anthropometry and malnutrition inflammation score (MIS).

SUBJECTS/METHODS

In this prospective study, 181 prevalent patients on HD were included. Thickness of the quadriceps rectus femoris and vastus intermedius (VIT) were assessed separately using ultrasonography, and were indexed for height squared. Mid-arm muscle circumference (MAMC) and area (MAMA) were assessed by anthropometry. MIS was evaluated. In the absence of predetermined cut-offs, values below the median of the distribution of VIT index were considered low. Instead, cut-off for anthropometric values such as MAMC and MAMA were set at ≥90% of agreement with the 50th percentile of the sex- and age-specific normal distribution. Cox-regression analysis was used to assess the association of US, MIS, and anthropometric parameters with mortality.

RESULTS

Patients were followed for a median of 35 months. During this period 36% of patients died. Multivariable Cox-regression analysis (adjusted for demographic, biochemical and clinical variables), demonstrated that higher VIT distal index values were independently associated with lower mortality risk (HR: 0.76 (0.59-0.99); P = 0.040), whilst higher MIS values were independently associated with higher (HR 1.22 (1.10-1.35); P < 0.001) mortality risk. When assessing muscle parameters as categorical variables, both low VIT distal index (HR: 1.71 (1.01-2.89); 0.045) and MAMC (HR: 1.74 (1.02-2.96); 0.042) were independently associated with increased risk of death.

CONCLUSION

Indexed distal VIT was independently associated with mortality both as continuous and as a categorical variable. Muscle US is a simple practical tool that adds prognostic information to the bedside nutritional assessment in ESKD patients on maintenance HD.

Decreased haemoglobin levels are associated with lower muscle mass and strength in kidney transplant recipients

BACKGROUND

Post-transplant anaemia and reduced muscle mass and strength are highly prevalent in kidney transplant recipients (KTRs). Decreased haemoglobin levels, a marker of anaemia, could adversely affect muscle mass and strength through multiple mechanisms, among others, through diminished tissue oxygenation. We aimed to investigate the association between haemoglobin levels with muscle mass and strength in KTRs.

METHODS

We included stable KTRs from the TransplantLines Biobank and Cohort study with a functional graft ≥1 year post-transplantation. Muscle mass was assessed using 24 h urinary creatinine excretion rate (CER) and bioelectrical impedance analysis (BIA). Muscle strength was assessed with a handgrip strength test using a dynamometer and, in a subgroup (n = 290), with the five-times sit-to-stand (FTSTS) test. We used multivariable linear and logistic regression analyses to investigate the associations of haemoglobin levels with muscle mass and strength.

RESULTS

In 871 included KTRs [median age 58 (interquartile range (IQR), 48-66)] years; 60% men; eGFR 51 ± 18 mL/min/1.73 m² ) who were 3.5 (1.0-10.2) years post-transplantation, the mean serum haemoglobin level was 13.9 ± 1.8 g/dL in men and 12.8 ± 1.5 g/dL in women. Lower haemoglobin levels were independently associated with a lower CER (std. β = 0.07, P = 0.01), BIA-derived skeletal muscle mass (std. β = 0.22, P < 0.001), handgrip strength (std. β = 0.15, P < 0.001), and worse FTSTS test scores (std. β = -0.17, P = 0.02). KTRs in the lowest age-specific and sex-specific quartile of haemoglobin levels had an increased risk of being in the worst age-specific and sex-specific quartile of CER (fully adjusted OR, 2.09; 95% CI 1.15-3.77; P = 0.02), handgrip strength (fully adjusted OR, 3.30; 95% CI 1.95-5.59; P < 0.001), and FTSTS test score (fully adjusted OR, 7.21; 95% CI 2.59-20.05; P < 0.001).

CONCLUSIONS

Low haemoglobin levels are strongly associated with decreased muscle mass and strength in KTRs. Future investigation will need to investigate whether maintaining higher haemoglobin levels may improve muscle mass and strength in KTRs.

The Change in Muscle Mass Among Kidney Transplant Recipients: A Prospective Cohort Study

BACKGROUND

Recovery of renal function after transplantation leads to improved uremic conditions, increased physical activity, and liberation from severe dietary restrictions. Consequently, the muscle mass of kidney transplant recipients increases for several years after their transplant. However, the change in muscle mass and its associated factors among these patients remain largely unknown. Herein, we carried out a prospective cohort study with 1-year follow-up to investigate how muscle mass changes and to identify its risk factors among kidney transplant recipients.

PATIENTS AND METHODS

We performed a single-center, 1-year, prospective, observational cohort study from August 2017 to February 2019 at Osaka City University Hospital in Japan. The skeletal muscle mass index (SMI) was measured by bioelectrical impedance analysis. The risk factors related to the change in muscle mass were analyzed using multivariate linear regression models of age, sex, body mass index (BMI), dialysis vintage, transplant vintage, diabetes mellitus, hemoglobin, C-reactive protein, estimated glomerular filtration rate, and SMI at baseline.

RESULTS

A total of 180 kidney transplant recipients were enrolled in the present study. The median age was 55 years, and the median transplant vintage was 78 months. The median rate of change in SMI was +2.07%, and SMI increased in 118 (66%) patients during the 1-year follow-up. By multivariate analysis, the change in SMI at 1-year follow-up was independently associated with age (P = 0.017) and BMI (P = .023).

CONCLUSIONS

SMI increased in most of the kidney transplant recipients, and age and BMI might be the risk factors for this change in muscle mass among these patients.

Clinical and Dietary Determinants of Muscle Mass in Patients with Type 2 Diabetes: Data from the Diabetes and Lifestyle Cohort Twente

Low muscle mass in patients with type 2 diabetes is associated with a progressively higher risk of morbidity and mortality. The aim of this study was to identify modifiable targets for intervention of muscle mass in type 2 diabetes. Cross-sectional analyses were performed in 375 patients of the Diabetes and Lifestyle Cohort Twente-1 study. Muscle mass was estimated by 24 h urinary creatinine excretion rate (CER, mmol/24 h). Patients were divided in sex-stratified tertiles of CER. To study determinants of CER, multivariable linear regression analyses were performed. Protein intake was determined by Maroni formula and by a semi-quantitative Food Frequency Questionnaire. The mean CER was 16.1 ± 4.8 mmol/24 h and 10.9 ± 2.9 mmol/24 h in men and women, respectively. Lower CER was significantly associated with older age (p < 0.001) as a non-modifiable risk factor, whereas higher BMI (p = 0.015) and lower dietary protein intake (both methods p < 0.001) were identified as modifiable risk factors for lower CER. Overall body mass index (BMI) was high, even in the lowest CER tertile the mean BMI was 30.9 kg/m², mainly driven by someone’s body weight (p = 0.004) instead of someone’s height (p = 0.58). In the total population, 28% did not achieve adequate protein intake of >0.8 g/kg/day, with the highest percentage in the lowest CER tertile (52%, p < 0.001). Among patients with type 2 diabetes treated in secondary care, higher BMI and low dietary protein intake are modifiable risk factors for lower muscle mass. Considering the risk associated with low muscle mass, intervention may be useful. To that purpose, dietary protein intake and BMI are potential targets for intervention.

Low skeletal muscle mass by computerized tomography is associated with increased mortality risk in end-stage kidney disease patients on hemodialysis

BACKGROUND AND AIMS

Skeletal muscle (SM) area, as measured by abdominal CT at the level of the third lumbar vertebra (L3), has been proposed as a proxy of whole body muscle mass. However, population-specific reference values are lacking. In the present study we aimed at: (1) detecting low SM area on abdominal CT images in patients on hemodialysis by applying cut-offs derived from a group of healthy subjects, and (2) estimating the independent risk of all-cause mortality associated with low SM area.

METHODS

We retrospectively enrolled 212 adult patients on hemodialysis, undergoing abdominal CT scan (study group), and 87 healthy kidney donors (reference group). We obtained the gender-specific 5th percentile values of the abdominal SM area distribution from both the whole control group and the subgroup of younger (29-60 years) subjects, which we used as reference cut-offs. Then we applied those cut-offs in the study group to identify patients with low SM area. We used survival and Cox regression analysis to evaluate the risk of all-cause mortality associated with low abdominal SM area.

RESULTS

In the fully adjusted Cox regression analysis, the patients with low abdominal SM area had a higher risk of death than the patients with values above the reference cut-off derived in the subgroup of younger controls (adjHR = 1.79 (1.21; 2.67), P = 0.004).

CONCLUSIONS

Abdominal CT imaging can be used to detect low abdominal SM area in patients on hemodialysis by applying cut-offs derived from healthy subjects sharing a similar ethnic background. Low SM area as assessed by CT is independently associated with all-cause mortality in ESKD patients on hemodialysis.

Relationship between age-related decreases in serum 25-hydroxyvitamin D levels and skeletal muscle mass in Japanese women

A clearer understanding of skeletal muscle mass (SMM) in middle-aged and elderly individuals is important for maintaining functionality. In the present study, age-related changes in SMM, the threshold of SMM with walking difficulty, intestinal nutrient absorption rate, and various serum factors were examined in Japanese populations of different ages. We used 24-h creatinine excretion as a measure of total body SMM. Age-related decreases in SMM, intestinal nutrient absorption rates, and serum 25-hydroxyvitamin D [25(OH)D] concentrations were significantly higher in women than in men. The cut-off values for SMM (kg), its percentage of total body weight (BW), the SMM index [SMMI] (Kg / m2), and creatinine height index (CHI) (%) in elderly individuals with walking difficulty were approximately 8-10 kg, 17-20% of BW, 3.9-4.6 kg / m2, and 44%, respectively. Serum 25(OH)D concentrations were closely associated with SMM (kg, % of BW, kg / m2) and CHI (%) as well as the intestinal absorption rates of nitrogen (%) and phosphorus (%) in women, but not in men. The present results demonstrate that vitamin D is an important metabolic factor in skeletal muscle, and contributes to the optimal management of skeletal muscle and the prevention of sarcopenia. J. Med. Invest. 67 : 151-157, February, 2020.

Novel approaches to sarcopenic obesity and weight management before and after kidney transplantation

PURPOSE OF REVIEW

Although a widely recognized and complex pathophysiological condition, sarcopenic obesity remains less appreciated and may elude diagnosis and workup in both kidney transplant waitlisted candidates and kidney transplant recipients. The lack of consensus definition, and practical diagnostic tools for evaluating waitlisted candidates and transplant recipients are barriers to early detect and initiate therapeutic management for sarcopenic obesity. Although sarcopenia leads to poor clinical outcomes, posttransplant obesity yields conflicting results. Exercise and nutritional managements are common therapies for sarcopenic obese patients; however, surgery weight loss or bariatric surgery in both transplant candidates and potential living kidney donors shows promising benefits for kidney transplant access in waitlist obese candidates but may require to be selected for appropriate patients.

RECENT FINDINGS

Pathogenesis and management for sarcopenia and obesity are interconnected. The benefits of exercise to improve muscle mass and function is clear in waitlist kidney transplant candidates and transplant recipients. However, there are several barriers for those to increase exercise and improve physical activity including patient, provider, and healthcare or environmental factors. The advantages of fat mass reduction to lose weight can promote muscle mass and strength. However, epidemiological data regarding the obesity paradox in dialysis-dependent patients when overnutrition provides survival benefits for this population should be taken into account when performing weight loss especially bariatric surgery.

SUMMARY

Barriers in providing optimal care to kidney transplant waitlisted candidates and transplant recipients may partly result from underdiagnosis of sarcopenic obesity; notwithstanding that this entity has increasingly been more recognized. Mechanistic studies to better understand pathogenesis of sarcopenic obesity will help determine pathogenesis and clinical tools for diagnosis of this entity, which can facilitate further studies related to the outcomes and weight management to ultimately improve kidney transplant outcomes.

Malnutrition according to GLIM criteria in stable renal transplant recipients: Reduced muscle mass as predominant phenotypic criterion

BACKGROUND & AIMS

Malnutrition has a negative impact on quality of life and survival in renal transplant recipients (RTR). Therefore, malnutrition detection is important in RTR, but this may be hampered by concomitant presence of weight gain and overweight. Recently, the Global Leadership Initiative on Malnutrition (GLIM) developed a set of diagnostic criteria for malnutrition. We aimed to assess the prevalence of malnutrition according to the GLIM criteria and the distribution of phenotypic criteria in RTR. Additionally, we examined the potential value of 24-h urinary creatinine excretion rate (CER) as alternative measure for the criterion reduced muscle mass.

METHODS

We used data from stable outpatient RTR included in the TransplantLines Cohort and Biobank Study (NCT02811835). Presence of weight loss and reduced intake or assimilation were derived from Patient-Generated Subjective Global Assessment (PG-SGA) item scores. Reduced muscle mass was assessed by multi-frequency bio-electrical impedance analysis (MF-BIA) and defined as an appendicular skeletal muscle mass index (ASMI) < 7 kg/m² for men and <5.5 kg/m² for women, and in additional analysis defined as creatinine-height index (CHI, based on 24 h urine CER) < 80%. Inflammation was present if C-reactive protein (CRP) was >5 mg/L. Malnutrition was defined as presence of at least one phenotypic (weight loss and/or low BMI and/or reduced muscle mass) and one etiologic criterion (reduced intake/assimilation and/or disease burden/inflammation).

RESULTS

We included 599 RTR (55 ± 13 years old, 62% male, BMI 27.2 ± 4.7 kg/m²) at a median of 3.1 years after transplantation. According to GLIM criteria, 14% was malnourished, of which 91% met the phenotypic criterion for reduced muscle mass. Similar results were found by using CHI as measure for muscle mass (13% malnutrition of which 79% with reduced muscle mass).

CONCLUSIONS

Malnutrition is present in one in 7 stable RTR, with reduced muscle mass as the predominant phenotypic criterion. Assessment of nutritional status, most importantly muscle status, is warranted in routine care, to prevent malnutrition in RTR from remaining undetected and untreated. The diagnostic value of 24-h urinary CER in this regard requires further investigation.

Association of obesity and muscle mass with risk of albuminuria in renal transplant recipients

BACKGROUND

Increased albuminuria is a predictor of graft loss in kidney graft recipients. It is unknown whether obesity is an independent risk factor for the development of increased albuminuria in this population. The aim of this study was to elucidate the association between obesity and albuminuria in renal transplant recipients.

METHODS

We enrolled 330 renal transplant recipients and prospectively collected demographic, anthropomorphic, clinical and laboratory variables susceptible to influence albumin excretion. The outcome was albuminuria, measured using accurately timed urine collections. Data from 201 patients were analyzed after exclusion of participants with missing data and patients enrolled less than 6 months since renal transplantation. Analysis was carried out for an early and a late period, defined according to the 2.4-year median follow-up time.

RESULTS

Body mass index (BMI), waist circumference and urinary creatinine excretion rate were independent predictors of albuminuria in the late post-transplant period, indicating that the predictive value of body mass index for albuminuria is related to both increased abdominal fat mass and increased muscle mass. BMI was an independent predictor of microalbuminuria. Waist circumference and urinary creatinine were independent predictors of microalbuminuria for values above certain cutoffs: 110% of the accepted thresholds defining abdominal obesity and 1500 mg/day, respectively.

CONCLUSIONS

These associations, which have not previously been reported, suggest, but do not prove, that an imbalance between metabolic demand and nephron mass may be responsible for increased albuminuria in the renal transplant population.

Effects of a resistance training program in kidney transplant recipients: A randomized controlled trial

Kidney transplant recipients are at risk of developing important adverse effects after transplantation. The objective of this study was to investigate the effects of a 10-week supervised resistance exercise-based intervention in kidney transplant recipients. Sixteen participants were randomized to a training (n = 8, 49.7 ± 9.6 years) or control group (n = 8, 48.6 ± 10.6 years). The primary endpoint was health-related quality of life evaluated through the Kidney Disease Quality of Life-Short Form (KDQOL-SF), which includes the 36-Item Short Form Survey (SF-36), and secondary endpoints included physical performance (6-minute walk distance [6-MWD], 60-second sit to stand test [60-STS], 8-foot up and go test, and handgrip and lower limb muscle strength), muscle mass, and biochemical parameters. Endpoints were assessed at baseline and after 10 weeks. Resistance exercise significantly increased (P < .05) some SF-36 domains and tended to induce improvements in one specific KDQOL-SF domain (P = .050). Further, exercise benefits were observed for 6-MWD (9% and 1% for the training and control groups, respectively; P < .001), handgrip strength (7% and -1%; P = .005), 60-STS repetitions (18% and -7%; P < .001), and 8-foot up and go test performance time (-5% and 6%; P = .010). No between-group differences (P > .05) were found for the remaining endpoints. There were no adverse events, musculoskeletal injuries, hypoglycemic episodes, cardiovascular events, or hospitalizations related to the intervention. In conclusion, 10 weeks of supervised resistance training is enough to improve quality of life and physical performance without side effects such as musculoskeletal injuries, hypoglycemic episodes, cardiovascular events, or hospitalizations related to the intervention in kidney transplant recipients.

Urinary 3-hydroxyisovaleryl carnitine excretion, protein energy malnutrition and risk of all-cause mortality in kidney transplant recipients: Results from the TransplantLines cohort studies

BACKGROUND

Leucine is an essential amino acid and a potent stimulator of muscle protein synthesis. Since muscle wasting is a major risk factor for mortality in kidney transplant recipients (KTR), dietary leucine intake might be linked to long-term mortality. Urinary 3-hydroxyisovaleryl carnitine (3-HIC) excretion, a functional marker of marginal biotin deficiency, may also serve as a marker for dietary leucine intake.

OBJECTIVE

In this study we aimed to investigate the cross-sectional determinants of urinary 3-HIC excretion and to prospectively investigate the association of urinary 3-HIC excretion with all-cause mortality in KTR.

DESIGN

Urinary 3-HIC excretion and plasma biotin were measured in a longitudinal cohort of 694 stable KTR. Cross-sectional and prospective analyses were performed using ordinary least squares linear regression analyses and Cox regression analyses, respectively.

RESULTS

In KTR (57% male, 53 ± 13 years, estimated glomerular filtration rate 45 ± 19 mL/min/1.73 m²), urinary 3-HIC excretion (0.80 [0.57-1.16] μmol/24 h) was significantly associated with plasma biotin (std. β = -0.17; P < 0.001). Subsequent adjustment for potential covariates revealed urinary creatinine excretion (std. β = 0.24; P < 0.001) and urinary urea excretion (std. β = 0.53; P < 0.001) as the primary determinant of urinary 3-HIC excretion. Whereas plasma biotin explained only 1% of the variance in urinary 3-HIC excretion, urinary urea excretion explained >45%. During median follow-up for 5.4 [4.8-6.1] years, 150 (22%) patients died. Log₂-transformed urinary 3-HIC excretion was inversely associated with all-cause mortality (HR: 0.52 [0.43-0.63]; P < 0.001). This association was independent of potential confounders.

CONCLUSIONS

Urinary 3-HIC excretion more strongly serves as a marker of leucine intake than of biotin status. A higher urinary 3-HIC excretion is associated with a lower risk of all-cause mortality. Future studies are warranted to explore the underlying mechanism.

TRIAL REGISTRATION ID

NCT02811835. TRIAL REGISTRATION URL: https://clinicaltrials.gov/ct2/show/NCT02811835.

Sarcopenia in chronic kidney disease: what have we learned so far?

The term sarcopenia was first introduced in 1988 by Irwin Rosenberg to define a condition of muscle loss that occurs in the elderly. Since then, a broader definition comprising not only loss of muscle mass, but also loss of muscle strength and low physical performance due to ageing or other conditions, was developed and published in consensus papers from geriatric societies. Sarcopenia was proposed to be diagnosed based on operational criteria using two components of muscle abnormalities, low muscle mass and low muscle function. This brought awareness of an important nutritional derangement with adverse outcomes for the overall health. In parallel, many studies in patients with chronic kidney disease (CKD) have shown that sarcopenia is a prevalent condition, mainly among patients with end stage kidney disease (ESKD) on hemodialysis (HD). In CKD, sarcopenia is not necessarily age-related as it occurs as a result of the accelerated protein catabolism from the disease and from the dialysis procedure per se combined with low energy and protein intakes. Observational studies showed that sarcopenia and especially low muscle strength is associated with worse clinical outcomes, including worse quality of life (QoL) and higher hospitalization and mortality rates. This review aims to discuss the differences in conceptual definition of sarcopenia in the elderly and in CKD, as well as to describe etiology of sarcopenia, prevalence, outcome, and interventions that attempted to reverse the loss of muscle mass, strength and mobility in CKD and ESKD patients.

Muscle mass assessment in renal disease: the role of imaging techniques

Muscle wasting is a frequent finding in patients with chronic kidney disease (CKD), especially in those with end-stage kidney disease (ESKD) on chronic dialysis. Muscle wasting in CKD is a main feature of malnutrition, and results principally from a vast array of metabolic derangements typical of the syndrome, that converge in determining reduced protein synthesis and accelerated protein catabolism. In this clinical setting, muscle wasting is also frequently associated with disability, frailty, infections, depression, worsened quality of life and increased mortality. On these grounds, the evaluation of nutritional status is crucial for an adequate management of renal patients, and consists of a comprehensive assessment allowing for the identification of malnourished patients and patients at nutritional risk. It is based essentially on the assessment of the extent and trend of body weight loss, as well as of spontaneous dietary intake. Another key component of this evaluation is the determination of body composition, which, depending on the selected method among several ones available, can identify accurately patients with decreased muscle mass. The choice will depend on the availability and ease of application of a specific technique in clinical practice based on local experience, staff resources and good repeatability over time. Surrogate methods, such as anthropometry and bioimpedance analysis (BIA), represent the most readily available techniques. Other methods based on imaging modalities [dual-energy X-ray absorptiometry (DXA), magnetic resonance imaging (MRI), and whole body computed tomography (CT)] are considered to be the "gold standard" reference methods for muscle mass evaluation, but their use is mainly confined to research purposes. New imaging modalities, such as segmental CT scan and muscle ultrasound have been proposed in recent years. Particularly, ultrasound is a promising technique in this field, as it is commonly available for bedside evaluation of renal patients in nephrology wards. However, more data are needed before a routine use of ultrasound for muscle mass evaluation can be recommended in clinical practice.

Should we pay more attention to low creatinine levels?

A review is made of the basic aspects of creatine/creatinine metabolism and the close relationship between creatinine and muscle mass, which makes the former a biochemical marker of the latter. Emphasis is placed on the current prognostic value of both the low urinary excretion of creatinine and low serum creatinine levels in different clinical settings in which sarcopenia probably plays a significant role in morbidity and mortality.

Sodium-Glucose Cotransporter 2 Inhibitors and Kidney Outcomes: True Renoprotection, Loss of Muscle Mass or Both?

Inhibitors of sodium-glucose cotransporter 2 (SGLT2) have emerged as practice-changing treatments for patients with type 2 diabetes, reducing both the risk of cardiovascular events and kidney events. However, regarding the latter, caution is warranted, as these kidney endpoints are defined using glomerular filtration rate estimations based on creatinine, the non-enzymatic product of creatine residing in muscles. Creatinine-based estimations of the glomerular filtration rate are only valid if the treatment has no effect on changes in muscle mass over time. Yet, circumstantial evidence suggests that treatment with SGLT2 inhibitors does result in a loss of muscle mass, rendering serum creatinine-based kidney endpoints invalid. Currently, it cannot be excluded that the described renoprotective effect of SGLT2 inhibitors is in part or in whole the consequence of a loss of muscle mass. Post-hoc analyses of existing trials or new trials based on kidney function markers independent of muscle mass can provide more definitive answers on the proposed renoprotective effects of SGLT2 inhibitors.

Physical activity in elderly kidney transplant patients with multiple renal arteries

INTRODUCTION

Kidney transplantation (KT) is the gold standard for treatment of patients with end- stage-renal disease. To expand the donor reserve, it is necessary to use marginal/suboptimal kidneys.

METHODS

We retrospectively evaluated the short/long-term outcome of 34 KT elderly patients who received allografts with vascular abnormalities (MRA group), in comparison with 34 KT patients who received a kidney with a single renal artery (SRA group) pair-matched by age, length of time on dialysis, comorbidity and donor age.

RESULTS

All participants completed the International Physical Activity Questionnaire at KT, and then 4, 8, and 12 weeks after transplantation. Our data indicate that kidney with vascular anatomical variants may be successfully transplanted, since the overall rate of surgical complications was 20.6% in the SRA group and 17.6% in the MRA group and that the 5-year survival rate after KT was 100% in both groups.

CONCLUSIONS

The data also underline that individualized physical activity programs induced similar excellent results in both groups, improving physical capacities, arterial pressure, lipid metabolism, insulin sensitivity, quality of life and physical and mental status.

Female Specific Association of Low Insulin-Like Growth Factor 1 (IGF1) Levels with Increased Risk of Premature Mortality in Renal Transplant Recipients

Associations between insulin-like growth factor 1 (IGF1) and mortality have been reported to be female specific in mice and in human nonagenarians. Intervention in the growth hormone (GH)-IGF1 axis may particularly benefit patients with high risk of losing muscle mass, including renal transplant recipients (RTR). We investigated whether a potential association of circulating IGF1 with all-cause mortality in stable RTR could be female specific and mediated by variation in muscle mass. To this end, plasma IGF1 levels were measured in 277 female and 343 male RTR by mass spectrometry, and their association with mortality was assessed by Cox regression. During a median follow-up time of 5.4 years, 56 female and 77 male RTR died. In females, IGF1 was inversely associated with risk (hazard ratio (HR) per 1-unit increment in log2-transformed (doubling of) IGF1 levels, 95% confidence interval (CI)) of mortality (0.40, 0.24-0.65; p < 0.001), independent of age and the estimated Glomerular filtration rate (eGFR). In equivalent analyses, no significant association was observed for males (0.85, 0.56-1.29; p = 0.44), for which it should be noted that in males, age was negatively and strongly associated with IGF1 levels. The association for females remained materially unchanged upon adjustment for potential confounders and was furthermore found to be mediated for 39% by 24 h urinary creatinine excretion. In conclusion, low IGF1 levels associate with an increased risk of all-cause mortality in female RTR, which may link to conditions of low muscle mass that are known to be associated with poor outcomes in transplantation patients. For males, the strongly negative association of age with IGF1 levels may explain why low IGF1 levels were not found to be associated with an increased risk of all-cause mortality.

Plasma Vitamin C and Cancer Mortality in Kidney Transplant Recipients

There is a changing trend in mortality causes in kidney transplant recipients (KTR), with a decline in deaths due to cardiovascular causes along with a relative increase in cancer mortality rates. Vitamin C, a well-known antioxidant with anti-inflammatory and immune system enhancement properties, could offer protection against cancer. We aimed to investigate the association of plasma vitamin C with long-term cancer mortality in a cohort of stable outpatient KTR without history of malignancies other than cured skin cancer. Primary and secondary endpoints were cancer and cardiovascular mortality, respectively. We included 598 KTR (mean age 51 ± 12 years old, 55% male). Mean (SD) plasma vitamin C was 44 ± 20 μmol/L. At a median follow-up of 7.0 (IQR, 6.2-7.5) years, 131 patients died, of which 24% deaths were due to cancer. In Cox proportional hazards regression analyses, vitamin C was inversely associated with cancer mortality (HR 0.50; 95%CI 0.34-0.74; P < 0.001), independent of potential confounders, including age, smoking status and immunosuppressive therapy. In secondary analyses, vitamin C was not associated with cardiovascular mortality (HR 1.16; 95%CI 0.83-1.62; P = 0.40). In conclusion, plasma vitamin C is inversely associated with cancer mortality risk in KTR. These findings underscore that relatively low circulating plasma vitamin C may be a meaningful as yet overlooked modifiable risk factor of cancer mortality in KTR.

Frailty and Sarcopenia in Older Patients Receiving Kidney Transplantation

Kidney transplantation is the treatment of choice for most of the patients with end-stage renal disease (ESRD). It improves quality of life, life expectancy, and has a lower financial burden to the healthcare system in comparison to dialysis. Every year more and more older patients are included in the kidney transplant waitlist. Within this patient population, transplanted subjects have better survival and quality of life as compared to those on dialysis. It is therefore crucial to select older patients who may benefit from renal transplantation, as well as those particularly at risk for post-transplant complications. Sarcopenia and frailty are frequently neglected in the evaluation of kidney transplant candidates. Both conditions are interrelated complex geriatric syndromes that are linked to disability, aging, comorbidities, increased mortality, and graft failure post-transplantation. Chronic kidney disease (CKD) and more importantly ESRD are characterized by multiple metabolic complications that contribute for the development of sarcopenia and frailty. In particular, anorexia, metabolic acidosis and chronic low-grade inflammation are the main contributors to the development of sarcopenia, a key component in frail transplant candidates and recipients. Both frailty and sarcopenia are considered to be reversible. Frail patients respond well to multiprofessional interventions that focus on the patients' positive frailty criteria, while physical rehabilitation and oral supplementation may improve sarcopenia. Prospective studies are still needed to evaluate the utility of formally measuring frailty and sarcopenia in the older candidates to renal transplantation as part of the transplant evaluation process.

Effects of Combined Resistance Plus Aerobic Training on Body Composition, Muscle Strength, Aerobic Capacity, and Renal Function in Kidney Transplantation Subjects

Lima, PS, de Campos, AS, de Faria Neto, O, Ferreira, TCA, Amorim, CEN, Stone, WJ, Prestes, J, Garcia, AMC, and Urtado, CB. Effects of combined resistance plus aerobic training on body composition, muscle strength, aerobic capacity, and renal function in kidney transplantation subjects. J Strength Cond Res XX(X): 000-000, 2019-Immunosuppression and a sedentary lifestyle may exacerbate complications such as early graft dysfunction and muscle loss, and reduce patient survival after kidney transplantation (KT). Therefore, the purpose of this study was to evaluate changes in body composition (BC), muscular strength, aerobic, and renal function in KT subjects submitted to combined resistance plus aerobic training. Twelve KT subjects were randomly assigned into groups: (G1) 12 weeks of combined training (3 males and 4 females, 54 ± 3 years); or (G2) nonexercise control (5 females, 43 ± 18 years). The subjects were evaluated for BC (dual-energy X-ray absorptiometry), estimated V[Combining Dot Above]O2peak, right-hand maximal grip strength (RHMGS) and left-hand maximal grip strength (LHMGS), and renal function. Post-training revealed that G1 reduced body fat percentage (p = 0.046), uric acid (Δ = -0.87; p = 0.023), urea (Δ = -9.43; p = 0.032), and creatinine (Δ = -0.15; p = 0.045), increased fat-free mass, estimated V[Combining Dot Above]O2peak, RHMGS, LHMGS (p < 0.05), and estimated glomerular filtration rate (eGFR) (Δ = 11.64; p = 0.017). G2 increased urea (Δ = 8.20; p = 0.017), creatinine (Δ = 0.37; p = 0.028), and decreased eGFR (Δ = -16.10; p = 0.038). After 12 weeks, urea (Δ = 24.94; p = 0.013), uric acid (Δ = 1.64; p = 0.044), and creatinine (Δ = 0.9; p = 0.011) were lower, whereas eGFR (Δ = 36.51; p = 0.009) was higher in G1. These data indicate that combined training instigates positive changes in BC, muscular strength, aerobic capacity, and renal function after KT.

Circulating Advanced Glycation Endproducts and Long-Term Risk of Cardiovascular Mortality in Kidney Transplant Recipients

BACKGROUND AND OBJECTIVES

In kidney transplant recipients, elevated circulating advanced glycation endproducts (AGEs) are the result of increased formation and decreased kidney clearance. AGEs trigger several intracellular mechanisms that ultimately yield excess cardiovascular disease. We hypothesized that, in stable kidney transplant recipients, circulating AGEs are associated with long-term risk of cardiovascular mortality, and that such a relationship is mediated by inflammatory, oxidative stress, and endothelial dysfunction biomarkers.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Prospective cohort study of stable kidney transplant recipients recruited between 2001 and 2003 in a university setting. We performed multivariable-adjusted Cox regression analyses to assess the association of AGEs (i.e., N^ε -[Carboxymethyl]lysine (CML) and N^ε -[Carboxyethyl]lysine (CEL), measured by tandem mass spectrometry) with cardiovascular mortality. Mediation analyses were performed according to Preacher and Hayes's procedure.

RESULTS

We included 555 kidney transplant recipients (age 51±12 years, 56% men). During a median follow-up of 6.9 years, 122 kidney transplant recipients died (52% deaths were due to cardiovascular causes). CML and CEL concentrations were directly associated with cardiovascular mortality (respectively, hazard ratio, 1.55; 95% confidence interval, 1.24 to 1.95; P<0.001; and hazard ratio, 1.53; 95% confidence interval 1.18 to 1.98; P=0.002), independent of age, diabetes, smoking status, body mass index, eGFR and proteinuria. Further adjustments, including cardiovascular history, did not materially change these findings. In mediation analyses, free thiol groups and soluble vascular cell adhesion molecule-1 consistently explained approximately 35% of the association of CML and CEL with cardiovascular mortality.

CONCLUSIONS

In stable kidney transplant recipients, circulating levels of AGEs are independently associated with long-term risk of cardiovascular mortality.

PODCAST

This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2019_09_17_CJN00540119.mp3.

Muscle mass determined from urinary creatinine excretion rate, and muscle performance in renal transplant recipients

BACKGROUND

Muscle mass, as determined from 24-h urinary creatinine excretion rate (CER), is an independent predictor for mortality and graft failure in renal transplant recipients (RTR). It is currently unknown whether CER is comparable with healthy controls after transplantation and whether it reflects muscle performance besides muscle mass. We aimed to compare urinary CER and muscle performance between RTR and healthy controls and to investigate whether urinary CER is associated with muscle performance in RTR.

METHODS

We included RTR, transplanted between 1975 and 2016 in the University Medical Center Groningen. Healthy controls were subjects screened for kidney donation. CER was calculated from a 24-h urine collection. Muscle performance was assessed by handgrip strength, sit-to-stand test, and 2-min walk test. Statistical analyses were performed using linear regression analyses.

RESULTS

We included 184 RTR (mean age 56.9 ± 11.9 years, 54% male recipient) and 78 healthy controls (age 57.9 ± 9.9, 47% male recipient). RTR were at a median time of 4.0 (1.1-8.8) years after transplantation. Mean CER was lower in RTR compared to healthy controls (11.7 ± 4.0 vs. 13.1 ± 5.2 mmol/24 h; P = 0.04). Significantly poorer results in muscle performance were found in RTR compared to controls for the handgrip strength (30.5 [23.7-41.1] N vs. 38.3 [29.3-46.0] N, P < 0.001) and the 2-min walk test (151.5 ± 49.2 m vs. 172.3 ± 12.2 m, P < 0.001) but not for the sit-to-stand (12.2 ± 3.3 m vs. 11.9 ± 2.8 m, P = 0.46). In RTR, CER was significantly associated with handgrip strength (std. β 0.33; P < 0.001), independent of adjustment for potential confounders. In RTR, CER was neither associated with the time used for the sit-to-stand test (std. β -0.09; P = 0.27) nor with the distance covered during the 2-min walk test (std. β 0.07; P = 0.40).

CONCLUSIONS

Muscle mass as measured by CER in RTR is lower compared to controls. CER is positively associated with muscle performance in RTR. The results demonstrate that CER does not only reflect muscle mass but also muscle performance in this patient setting. Determination of CER could be an interesting addition to the imaging technique armamentarium available and applied for evaluation of muscle mass in clinical intervention studies and observational studies.

Creatine is a Conditionally Essential Nutrient in Chronic Kidney Disease: A Hypothesis and Narrative Literature Review

To accommodate the loss of the plethora of functions of the kidneys, patients with chronic kidney disease require many dietary adjustments, including restrictions on the intake of protein, phosphorus, sodium and potassium. Plant-based foods are increasingly recommended as these foods contain smaller amounts of saturated fatty acids, protein and absorbable phosphorus than meat, generate less acid and are rich in fibers, polyunsaturated fatty acids, magnesium and potassium. Unfortunately, these dietary recommendations cannot prevent the occurrence of many symptoms, which typically include fatigue, impaired cognition, myalgia, muscle weakness, and muscle wasting. One threat coming with the recommendation of low-protein diets in patients with non-dialysis-dependent chronic kidney disease (CKD) and with high-protein diets in patients with dialysis-dependent CKD, particularly with current recommendations towards proteins coming from plant-based sources, is that of creatine deficiency. Creatine is an essential contributor in cellular energy homeostasis, yet on a daily basis 1.6–1.7% of the total creatine pool is degraded. As the average omnivorous diet cannot fully compensate for these losses, the endogenous synthesis of creatine is required for continuous replenishment. Endogenous creatine synthesis involves two enzymatic steps, of which the first step is a metabolic function of the kidney facilitated by the enzyme arginine:glycine amidinotransferase (AGAT). Recent findings strongly suggest that the capacity of renal AGAT, and thus endogenous creatine production, progressively decreases with the increasing degree of CKD, to become absent or virtually absent in dialysis patients. We hypothesize that with increasing degree of CKD, creatine coming from meat and dairy in food increasingly becomes an essential nutrient. This phenomenon will likely be present in patients with CKD stages 3, 4 and 5, but will likely be most pronouncedly present in patients with dialysis-dependent CKD, because of the combination of lowest endogenous production of creatine and unopposed losses of creatine into the dialysate. It is likely that these increased demands for dietary creatine are not sufficiently met. The result of which, may be a creatine deficiency with important contributions to the sarcopenia, fatigue, impaired quality of life, impaired cognition, and premature mortality seen in CKD.

Posttransplant muscle mass measured by urinary creatinine excretion rate predicts long-term outcomes after liver transplantation

Long-term survival in orthotopic liver transplant (OLT) recipients remains impaired because of many contributing factors, including a low pretransplant muscle mass (or sarcopenia). However, influence of posttransplant muscle mass on survival is currently unknown. We hypothesized that posttransplant urinary creatinine excretion rate (CER), an established noninvasive marker of total body muscle mass, is associated with long-term survival after OLT. In a single-center cohort study of 382 adult OLT recipients, mean ± standard deviation CER at 1 year posttransplantation was 13.3 ± 3.7 mmol/24 h in men and 9.4 ± 2.6 mmol/24 h in women. During median follow-up for 9.8 y (interquartile range 6.4-15.0 y), 104 (27.2%) OLT recipients died and 44 (11.5%) developed graft failure. In Cox regression analyses, as continuous variable, low CER was associated with increased risk for mortality (HR = 0.43, 95% CI: 0.26-0.71, P = .001) and graft failure (HR = 0.42, 95% CI: 0.20-0.90, P = .03), independent of age, sex, and body surface area. Similarly, OLT recipients in the lowest tertile had an increased risk for mortality (HR = 2.69; 95% CI: 1.47-4.91, P = .001) and graft failure (HR = 2.77, 95% CI: 1.04-7.39, P = .04), compared to OLT recipients in the highest tertile. We conclude that 1 year posttransplant low total body muscle mass is associated with long-term risk of mortality and graft failure in OLT recipients.

Satellite cell function, intramuscular inflammation and exercise in chronic kidney disease

Skeletal muscle wasting is a common feature of chronic kidney disease (CKD) and is clinically relevant due to associations with quality of life, physical functioning, mortality and a number of comorbidities. Satellite cells (SCs) are a population of skeletal muscle progenitor cells responsible for accrual and maintenance of muscle mass by providing new nuclei to myofibres. Recent evidence from animal models and human studies indicates CKD may negatively affect SC abundance and function in response to stimuli such as exercise and damage. The aim of this review is to collate recent literature on the effect of CKD on SCs, with a particular focus on the myogenic response to exercise in this population. Exercise is widely recognized as important for the maintenance of healthy skeletal muscle mass and is increasingly advocated in the care of a number of chronic conditions. Therefore a greater understanding of the impact of uraemia upon SCs and the possible altered myogenic response in CKD is required to inform strategies to prevent uraemic cachexia.

Complementary Biomarker Assessment of Components Absorbed from Diet and Creatinine Excretion Rate Reflecting Muscle Mass in Dialysis Patients

To prevent protein energy malnutrition (PEM) and accumulation of waste products, dialysis patients require diet adjustments. Dietary intake assessed by self-reported intakes often provides biased information and standard 24-h urinary excretion is inapplicable in dialysis patients. We aimed to assess dietary intake via a complementary, less biased biomarker method, and to compare this to dietary diaries. Additionally, we investigated the prospective association of creatinine excretion rate (CER) reflecting muscle mass with mortality. Complete intradialytic dialysate and interdialytic urinary collections were used to calculate 24-h excretion of protein, sodium, potassium, phosphate and creatinine in 42 chronic dialysis patients and compared with protein, sodium, potassium, and phosphate intake assessed by 5-day dietary diaries. Cox regression analyses were employed to investigate associations of CER with mortality. Mean age was 64 ± 13 years and 52% were male. Complementary biomarker assessed (CBA) and dietary assessed (DA) protein intake were significantly correlated (r = 0.610; p < 0.001), but there was a constant bias, as dietary diaries overestimated protein intake in most patients. Correlations were found between CBA and DA sodium intake (r = 0.297; p = 0.056), potassium intake (r = 0.312; p = 0.047) and phosphate uptake/intake (r = 0.409; p = 0.008). However, Bland-Altman analysis showed significant proportional bias. During a median follow-up of 26.6 (25.3–31.5) months, nine dialysis patients (23%) died. CER was independently and inversely associated with survival (HR: 0.59 (0.42–0.84); p = 0.003). Excretion measurements may be a more reliable assessment of dietary intake in dialysis patients, as this method is relatively free from biases known to exist for self-reported intakes. CER seems to be a promising tool for monitoring PEM.

Urinary creatinine excretion is related to short-term and long-term mortality in critically ill patients

Purpose

Patients with reduced muscle mass have a worse outcome, but muscle mass is difficult to quantify in the ICU. Urinary creatinine excretion (UCE) reflects muscle mass, but has not been studied in critically ill patients. We evaluated the relation of baseline UCE with short-term and long-term mortality in patients admitted to our ICU.

Methods

Patients who stayed ≥ 24 h in the ICU with UCE measured within 3 days of admission were included. We excluded patients who developed acute kidney injury stage 3 during the first week of ICU stay. As muscle mass is considerably higher in men than women, we used sex-stratified UCE quintiles. We assessed the relation of UCE with both in-hospital mortality and long-term mortality.

Results

From 37,283 patients, 6151 patients with 11,198 UCE measurements were included. Mean UCE was 54% higher in males compared to females. In-hospital mortality was 17%, while at 5-year follow-up, 1299 (25%) patients had died. After adjustment for age, sex, estimated glomerular filtration rate, body mass index, reason for admission and disease severity, patients in the lowest UCE quintile had an increased in-hospital mortality compared to the patients in the highest UCE quintile (OR 2.56, 95% CI 1.96–3.34). For long-term mortality, the highest risk was also observed for patients in the lowest UCE quintile (HR 2.32, 95% CI 1.89–2.85), independent of confounders.

Conclusions

In ICU patients without severe renal dysfunction, low urinary creatinine excretion is associated with short-term and long-term mortality, independent of age, sex, renal function and disease characteristics, underscoring the role of muscle mass as risk factor for mortality and UCE as relevant biomarker.

Electronic supplementary material

The online version of this article (10.1007/s00134-018-5359-6) contains supplementary material, which is available to authorized users.

Skeletal muscle mass of old Japanese women suffering from walking difficulty in nursing home

By using 24 hour urinary creatinine levels, skeletal muscle mass (kg), its rate (%) of body weight and creatinine height index (%) were determined in old Japanese women suffering from walking difficulty in nursing home and compare with those of young university students. Those of old subjects showed approximately 30-50%, 36-44% and 44-46% of young subjects, respectively. It is suggested that these values are important and useful biomarkers for the planning and the achievement of rehabilitation program for the maintaining and restoring skeletal muscle mass and for the careful support by registered care workers to aged persons. J. Med. Invest. 65:122-125, February, 2018.

Lifestyle intervention to improve quality of life and prevent weight gain after renal transplantation: Design of the Active Care after Transplantation (ACT) randomized controlled trial

BACKGROUND

Low physical activity and reduced physical functioning are common after renal transplantation, resulting in a reduced quality of life. Another common post-transplantation complication is poor cardio-metabolic health, which plays a main role in long-term outcomes in renal transplant recipients (RTR). It is increasingly recognized that weight gain in the first year after transplantation, especially an increase in fat mass, is a highly common contributor to cardio-metabolic risk. The aim of this study is to compare the outcomes of usual care to the effects of exercise alone, and exercise combined with dietary counseling, on physical functioning, quality of life and post-transplantation weight gain in RTR.

METHODS

The Active Care after Transplantation study is a multicenter randomized controlled trial with three arms in which RTR from 3 Dutch hospitals are randomized within the first year after transplantation to usual care, to exercise intervention (3 months supervised exercise 2 times per week followed by 12 months active follow-up), or to an exercise + diet intervention, consisting of the exercise training with additional dietary counseling (12 sessions over 15 months by a renal dietician). In total, 219 participants (73 per group) will be recruited. The primary outcome is the subdomain physical functioning of quality of life, (SF-36 PF). Secondary outcomes include other evaluations of quality of life (SF-36, KDQOL-SF, EQ-5D), objective measures of physical functioning (aerobic capacity and muscle strength), level of physical activity, gain in adiposity (body fat percentage by bio-electrical impedance assessment, BMI, waist circumference), and cardiometabolic risk factors (blood pressure, lipids, glucose metabolism). Furthermore, data on renal function, medical history, medication, psychological factors (motivation, kinesiophobia, coping style), nutrition knowledge, nutrition intake, nutrition status, fatigue, work participation, process evaluation and cost-effectiveness are collected.

DISCUSSION

Evidence on the effectiveness of an exercise intervention, or an exercise + diet intervention on physical functioning, weight gain and cardiometabolic health in RTR is currently lacking. The outcomes of the present study may help to guide future evidence-based lifestyle care after renal transplantation.

TRIAL REGISTRATION

Number: NCT01047410 .