POOR NUTRITIONAL STATUS AND INFLAMMATION: Anthropometric and Body Composition Assessment in Dialysis Patients

Nutritional and Inflammatory Aspects of Low Parathyroid Hormone in Maintenance Hemodialysis Patients-A Longitudinal Study

BACKGROUND

Low serum parathyroid hormone (PTH) is an accepted marker for adynamic bone disease which is characterized by increased morbidity and mortality in maintenance hemodialysis (MHD) patients. In light of the known cross-sectional associations between PTH and malnutrition-inflammation syndrome, we aimed to examine the longitudinal associations between PTH with changes in nutritional and inflammatory parameters and clinical outcomes in MHD patients with low PTH.

METHODS

This historical prospective and longitudinal study analyzed a clinical database at a single hemodialysis center, containing the medical records of 459 MHD patients (mean age of 71.4 ± 12.9 years old, 171 women), treated between the years 2007-2020. Bone turnover, nutritional and inflammatory marker levels were recorded at 0, 6, 12, 18, 24, 30, and 36 months followed by a median of 24 additional months of clinical observations. According to previous use of vitamin D analogs and/or calcium-sensing receptor agonists, the study participants were divided into treatment-related and disease-related groups. A linear mixed effects model was adjusted for baseline demographics and clinical parameters.

RESULTS

Of 459 MHD patients, 81 (17.6%) had PTH lower than 150pg/mL. Among them, 30 patients had treatment-related and 51 had disease-related low PTH. At baseline, MHD patients with treatment-related low PTH had a higher rate of diabetes compared to the disease-related group. In a linear mixed effects model, increased PTH over time was associated with decreased levels of alkaline phosphatase and C-reactive protein and with increased hemoglobin and albumin, but not the geriatric nutritional risk index at 3-year follow-up. The survival rate did not differ between the groups, with the risk of hospitalizations due to fractures being higher (HR: 4.04 with 95% CI: 1.51-10.8) in the disease-related group. Statistical significance of this association was abolished after adding C-reactive protein or alkaline phosphatase to the multivariate models.

CONCLUSIONS

Low serum PTH in MHD patients behaves differently depending on its cause, with a higher risk of fractures in the disease-related group. This association is dependent on inflammation. Our results should be verified in larger epidemiological studies.

Assessment of Nutritional Intake in Patients With Kidney Failure Treated by Haemodialysis on Dialysis and Non-dialysis Days

INTRODUCTION/AIMS/OBJECTIVE

Inadequate nutritional intake in haemodialysis (HD) patients increases the risk of muscle wasting, nutrient deficiencies, leading to an increased risk of additional morbidity and mortality. We aimed to assess nutritional intake on the dialysis day and nondialysis day (NDD) of patients established on HD.

METHODS

We employed a 2-day dietary record, one on the day of dialysis and one on the NDD, and then determined nutritional intake using the Nutritics software. Muscle strength was assessed by hand grip strength, and the body composition was determined using multifrequency bioelectrical impedance recorded postdialysis.

RESULTS

We recruited 51 established HD patients dialysing between May 2022 and July 2022, of mean age 60 ± 15 years, 52.9% male, and 51% diabetic. Only 25% achieved the calorie and protein intake recommended by Kidney Disease Outcomes Quality Initiative. Most patients had inadequate consumption of fiber (96%), calcium (86%), iron (80%), zinc (82%), selenium (92%), folate (82%), vitamin A (88%), and (100%) vitamin D. On the other hand, the great majority followed the restriction guidelines for potassium (96%), phosphorus (86%), and sodium (84%), respectively. However, consumption was greater for potassium (P = .007), phosphorus (P = .015), and zinc (P = .032) on NDDs versus dialysis days, but there was no difference in protein or calorie intake between days.

CONCLUSION

Our results suggest that many of our HD patients do not achieve the recommended nutritional targets. Patient compliance with restricting sodium, potassium, and phosphate limits protein and calorie intake. HD patients are at increased risk of sarcopenia, so failure to achieve dietary protein intake will further increase this risk.

Assessment of fluid removal using ultrasound, bioimpedance and anthropometry in pediatric dialysis: a pilot study

BACKGROUND

Fluid overload is associated with morbidity and mortality in children receiving dialysis. Accurate clinical assessment is difficult, and using deuterium oxide (D₂O) to measure total body water (TBW) is impractical. We investigated the use of ultrasound (US), bioimpedance spectroscopy (BIS), and anthropometry to assess fluid removal in children receiving maintenance hemodialysis (HD).

METHODS

Participants completed US, BIS, and anthropometry immediately before and 1-2 h after HD for up to five sessions. US measured inferior vena cava (IVC) diameter, lung B-lines, muscle elastography, and dermal thickness. BIS measured the volume of extracellular (ECF) and intracellular (ICF) fluid. Anthropometry included mid-upper arm, calf and ankle circumferences, and triceps skinfold thickness. D₂O was performed once pre-HD. We assessed the change in study measures pre- versus post-HD, and the correlation of change in study measures with percent change in body weight (%∆BW). We also assessed the agreement between TBW measured by BIS and D₂O.

RESULTS

Eight participants aged 3.4-18.5 years were enrolled. Comparison of pre- and post-HD measures showed significant decrease in IVC diameters, lung B-lines, dermal thickness, BIS %ECF, mid-upper arm circumference, ankle, and calf circumference. Repeated measures correlation showed significant relationships between %∆BW and changes in BIS ECF (r_rm =0.51, 95% CI 0.04, 0.80) and calf circumference (r_rm=0.80, 95% CI 0.51, 0.92). BIS TBW correlated with D₂O TBW but overestimated TBW by 2.2 L (95% LOA, -4.75 to 0.42).

CONCLUSION

BIS and calf circumference may be helpful to assess changes in fluid status in children receiving maintenance HD. IVC diameter, lung B-lines and dermal thickness are potential candidates for future studies.

Nutritional status and quality of life in diabetic patients on hemodialysis: a cross-sectional study from Palestine

BACKGROUND

End-stage renal disease (ESRD) is a leading cause of death and morbidity worldwide. Malnutrition is a common problem among hemodialysis (HD) patients that negatively impacts their prognosis and is linked to an increase in morbidity and mortality in these patients, as well as a decrease in their quality of life (QOL). In this study, we aimed to evaluate the QOL and to investigate factors that can influence it, including nutritional status, as well as socio-demographic factors, among Palestinian diabetic patients on HD therapy.

METHODS

This was a cross-sectional study that occurred at a large hemodialysis center in Palestine. Malnutrition was assessed by the malnutrition-inflammation scale (MIS), and the quality of life was evaluated by using the EuroQoL five-dimensional instrument (EQ-5D). Multivariable linear regression analysis was carried out to look at the effect of multiple variables on QOL.

RESULTS

A total of 118 diabetic patients on HD were included. Of these, 66.9% were male, and 60.2% were aged 60 years or higher. Having multiple comorbid diseases (p=0.004) and having been on HD for >4 years (p=0.003) were significantly associated with a higher MIS score, whereas living alone (p=0.037) and having been on HD for >4 years (p=0.002) was significantly associated with lower EQ-5D score. We also observed a significant association between the MIS score and the EQ-5D score(r=-0.616, p<0.001). Multiple linear regression analysis demonstrated that diabetic hemodialysis patients who lived within a family household were positively correlated with the QOL score (standardized coefficient, 0.178; 95% confidence interval (CI), 0.042 to 0.372; p = 0.015), and MIS score was significantly and negatively correlated with QOL scores (standardized coefficient, -0.587; 95% CI, -0.047 to -0.028; p < 0.001).

CONCLUSIONS

We found that malnutrition was associated with a lower QOL score among diabetic patients on HD. We recommend general practitioners, dietitians, nephrologists, and nurses to make plans that pay more attention to this group of patients who show evidence of malnutrition. Patients on dialysis for ≥ 4 years, patients who live alone, and those suffering from multiple co-morbid diseases should receive special care due to their higher risk of being impacted by this problem.

Approaches to Obesity Management in Dialysis Settings: Renal Dietitian Perspectives

OBJECTIVES

Over 40% of individuals in the United States with end-stage kidney disease have obesity. Little is known about renal dietitian perspectives on obesity management in the setting of dialysis dependence.

DESIGN AND METHODS

An online 21-item survey was distributed to 118 renal dietitians via individual outreach and a professional organization e-mail listserv. Four themes were explored: the burden of obesity among dialysis patients, concepts of healthy weight loss, weight loss approaches, and challenges of obesity management in dialysis settings. Respondents were asked to rank approaches and biomarkers for obesity management from 0 (least important or not used) to 100 (most important). Free text fields were provided in each category for additional comments.

RESULTS

Thirty-one renal dietitians responded to the survey (26% response rate). The majority of respondents (90%) indicated that access to kidney transplantation was the main reason that dialysis patients with obesity desired weight loss. Calorie restriction was rated as the most common weight loss approach, and dry weight as the most important weight loss biomarker. Nearly 40% of respondents do not alter their nutritional approach when dialysis patients with obesity are losing weight, and 42% of respondents do not monitor changes in waist circumference. Exercise, diet counseling, and stress management were variably prioritized as weight loss management strategies. Barriers to obesity management in dialysis settings included lack of time, lack of training in weight loss counseling, and gaps in current renal nutritional guidelines.

CONCLUSION

Despite the high prevalence of obesity among individuals with end-stage kidney disease, the results of this survey suggest that current approaches to obesity management in dialysis settings are highly variable. Many renal dietitians lack time to counsel patients on healthy weight loss strategies. Nutritional guidelines are also needed to support people with dialysis dependence and obesity who desire or require weight loss.

Assessment of nutritional status in the maintenance of haemodialysis patients: a cross-sectional study from Palestine

BACKGROUND

Protein-energy wasting (PEW) is a relatively prevalent problem among adult haemodialysis patients (HDP). PEW is an important determinant of morbidity and mortality in HDP, therefore it is essential for dietitians to accurately assess malnutrition (MN) in these patients. HDP appear to be more susceptible to developing MN; however, this is not well documented. Therefore this study aimed to assess the nutritional status among HDP and to establish the factors associated with MN in these patients.

METHODS

A cross-sectional survey was carried out in Nablus, northern West Bank, in the main haemodialysis (HD) centre at the An-Najah National University Hospital. MN was detected using the malnutrition-inflammation scale (MIS), which involved four major elements: the patient's related medical history, their body mass index, a physical examination and laboratory parameters.

RESULTS

A total of 174 patients (91 male) were included in the study. Patients were aged 57.7 ± 12.8 years, and the median dialysis vintage was 3 years (interquartile range 1-5 years). HDP, especially the elderly (unstandardized coefficient β, 1.728; 95% CI, 0.700 to 2.756; P = 0.001), those with multiple comorbid diseases (unstandardized coefficient β, 1.673; 95% CI, 0.556 to 2.789; P = 0.004); those taking multiple chronic medications (unstandardized coefficient β, 1.259; 95% CI, 0.197 to 2.321; P = 0.020), or those with a long dialysis vintage (unstandardized coefficient β, 1.449; 95% CI, 0.410 to 2.487; P = 0.007), were positively associated with the MIS score in a multivariable linear regression model. Furthermore, HDP living with their family were negatively associated with the MIS score (unstandardized coefficient β, - 2.545; 95% CI, - 4.738 to - 0.352; P = 0.023).

CONCLUSIONS

The MIS score results indicate that MN is prevalent among HDP. These results demonstrate some correlations between nutritional status and patient characteristics (i.e. clinical and sociodemographic factors). Therefore these findings should help to increase the awareness of healthcare providers for interventions to enhance the nutritional status of HDP, especially those who are elderly, have multiple comorbid diseases, have multiple chronic medications, have experienced a long dialysis vintage or who live alone.

Nutritional Status Predicts 10-Year Mortality in Patients with End-Stage Renal Disease on Hemodialysis

Protein-energy wasting (PEW) is associated with mortality in patients with end-stage renal disease (ESRD) on maintenance hemodialysis. The correct diagnosis of PEW is extremely important in order to predict clinical outcomes. However, it is unclear which parameters should be used to diagnose PEW. Therefore, this retrospective observational study investigated the relationship between mortality and nutritional parameters in ESRD patients on maintenance hemodialysis. A total of 144 patients were enrolled. Nutritional parameters, including body mass index, serum albumin, dietary intake, normalized protein catabolic rate (nPCR), and malnutrition inflammation score (MIS), were measured at baseline. Fifty-three patients died during the study. Survivors had significantly higher nPCR (1.10 ± 0.24 g/kg/day vs. 1.01 ± 0.21 g/kg/day; p = 0.048), energy intake (26.7 ± 5.8 kcal/kg vs. 24.3 ± 4.2 kcal/kg; p = 0.009) and protein intake (0.91 ± 0.21 g/kg vs. 0.82 ± 0.24 g/kg; p = 0.020), and lower MIS (5.2 ± 2.3 vs. 6.1 ± 2.1, p = 0.039). In multivariable analysis, energy intake <25 kcal/kg (HR 1.860, 95% CI 1.018–3.399; p = 0.044) and MIS > 5 (HR 2.146, 95% CI 1.173–3.928; p = 0.013) were independent variables associated with all-cause mortality. These results suggest that higher MIS and lower energy intake are harmful to ESRD patients on maintenance hemodialysis. Optimal energy intake could reduce mortality in these patients.

Relationship between the target dose for hemodialysis adequacy and nutritional assessment

BACKGROUND

Some studies have shown an increased relative risk of death for patients with higher levels of Kt/V, which may be associated with marked malnutrition.

OBJECTIVE

The aim of this study was to investigate the relationship between the target dose for hemodialysis adequacy, as measured by Kt/V, and various nutritional parameters in hemodialysis patients.

DESIGN

Cross-sectional.

SETTINGS

Sakarya University Faculty of Medicine, Turkey between February 2014 and March 2014.

PATIENTS AND METHODS

For consecutive patients who met criteria, the following were recorded: nutritional status, dialysis malnutrition score (DMS), the geriatric nutritional risk index (GNRI), serum albumin level, anthropometric measurements, and bioelectrical impedance analysis. Patients were classified into two groups according to the target hemodialysis dose for single-pool Kt/V: patients with spKt/V >=1.4 and patients with spKt/V < 1.4.

MAIN OUTCOME MEASURE(S)

Association of hemodialysis adequacy by nutritional assessment.

RESULTS

The prevalence of malnutrition in 286 patients with target dose hemodialysis (spKt/V >=1.4) was significantly higher according to body mass index (BMI), DMS, and GDRI (P=.001, P=.006, and P=.004, respectively) compared with patients with a lower target dose (spKt/V < 1.4). BMI, biceps skinfolds, mid-arm circumference, calf circumference, fat free mass, and total body water were statistically significantly lower in patients at a higher target dose (spKt/V >= 1.4) (P < .001, P=.034, P=.010, P < .001, P < .001, and P < .001 respectively).

CONCLUSIONS

Malnutrition was more frequent in chronic hemodialysis patients who received the target hemodialysis. Evaluation of nutritional status in patients at the target hemodialysis dose should be considered.

LIMITATIONS

Data collected from a single region; small sample size; cross-sectional design is disadvantageous.

Nutrition assessment and risk prediction in dialysis patients-a new integrative score

OBJECTIVE

We developed a quantitative nutritional score, based on biochemical measures, taken as part of monthly routine care. The score can be accomplished within a short time after routine laboratory results completion and identify a monthly change in nutritional status.

DESIGN

A longitudinal observational cohort study

SETTING

The Institute of Nephrology, Wolfson Medical Center, Holon, Israel.

SUBJECTS

A total of 179 hemodialysis patients were followed up for up to 2.5 years after study baseline.

INTERVENTION

The Integrative Clinical Nutrition Dialysis Score (ICNDS) is based on the biochemical measures of albumin, creatinine, urea, cholesterol, C-reactive protein, dialysis adequacy, and weight change. Each parameter is ranked between 1 and 5, with the higher rank derived from recommended National Kidney Foundation Kidney Disease/Dialysis Outcomes and Quality Initiative values and the lower rank indicating deviation from those values. The final ICNDS is the sum of ranks over 7 parameters.

MAIN OUTCOME MEASURE

The Pearson correlation coefficient was calculated for association between subjective global assessment and ICNDS in 63 randomly selected patients. In 179 dialysis patients, the baseline ICNDS, the slope of 3 subsequent monthly ICNDS values, were tested for their correlation with odds of all-cause mortality, hospitalization frequency, length of stay, after 31 months. Spline Cox regression was used to select the best cutoff point, associated with severe mortality risk.

RESULTS

Score results were significantly correlated with nutrition evaluation by subjective global assessment (r = 0.842, P < .01). For a unit increase in baseline score, death odds were significantly decreased (hazard ratio [HR] = 0.929, 95% confidence interval [CI] 0.88-0.974, P < .002). Each unit increase in slope significantly reduced mortality risk (HR = 0.485, 95% CI 0.278-0.847, P < .011). Hospitalization frequency was significantly increased across worsening baseline score (HR = 0.935, 95% CI 0.906-0.964, P < .0001). A 1-unit increase in slope significantly decreased hospitalization (HR = 0.799, 95% CI 0.726-0.881, P < .0001).

CONCLUSIONS

Results confirm that ICNDS is a useful prognostic tool that serves to detect nutrition deterioration at its very beginning.

Prevalence of malnutrition and associated factors in hemodialysis patients

OBJECTIVE: To assess the prevalence of malnutrition and associated factors in hemodialysis patients. METHODS: This is a cross-sectional study of 344 hemodialysis patients from Goiânia, Goiás aged 18 years or more. The dependent variable, malnutrition, was investigated by the Subjective Global Assessment. The independent variables included socioeconomic, demographic, and lifestyle data, clinical history, and energy and protein intakes. The patients underwent anthropometric measurements and laboratory tests. Multiple Poisson regression determined the associated factors (p<0.05). RESULTS: Mild or moderate malnutrition was found in 22.4% of the patients. Malnourished patients had lower body mass index, mid-arm muscle circumference, percentage of body fat, serum creatinine (p<0.001), and normalized protein nitrogen appearance (p=0.001). Multivariate analysis identified the following factors associated with malnutrition: age between 19 and 29 years (PR=1.23, 95%CI=1.06-1.43), family income less than 2 minimum salaries (PR=1.13, 95%CI=1.01-1.27), hemodialysis vintage >60 months (PR=1.08, 95%CI=1.01-1.16), Kt/V>1.2 (RP=1.12, 95%CI=1.03-1.22), calorie intake <35 kcal/kg/day (PR=1.22, 95%CI=1.10-1.34), and normalized protein nitrogen appearance <1.0 g/kg/day (PR=1.13, 95%CI=1.05-1.21). CONCLUSION: The prevalence of malnutrition in this population was high, corroborating the literature. The prevalence was higher in patients aged less than 29 years and those with low family income, longer hemodialysis vintage, higher Kt/V, and inadequate protein and calorie intakes. Strategies to reverse this situation should include more nutritional care.

Changes in waist circumference following haemodialysis: a brief report

BACKGROUND

Waist circumference (WC) is a known indicator of cardiovascular disease in the haemodialysis (HD) population. However it is not known if HD results in clinically significant changes in WC.

OBJECTIVE

The study purpose was to quantify the degree of change in WC induced by HD.

METHODS

This was a prospective cohort study with 27 patients on HD. Height, body weight, WC, hip circumference (HC), body mass index (BMI) and waist to hip ratio (WHR) were measured immediately prior to and following HD over three consecutive treatments. Differences between three-day average pre- and post-HD weight, BMI, WC, HC and WHR were assessed.

RESULTS

Post-HD WC was significantly lower than that measured pre-HD. Differences in pre-post HD body weight, BMI, HC and WHR were also observed.

CONCLUSIONS

All of the traditional clinical indicators of body composition (WC, HC, WHR, body weight and BMI) were lower following HD.

Precision of GE Lunar iDXA for the measurement of total and regional body composition in nonobese adults

Dual-energy X-ray absorptiometry (DXA) is a well-accepted technique for measuring body composition. Knowledge of measurement precision is critical for monitoring of changes in bone mineral content (BMC), and fat and lean masses. The purpose of this study was to characterize in vivo precision of total body and regional body composition parameters using the GE Lunar iDXA (GE Healthcare Lunar, Madison, WI) system in a sample of nonobese subjects. We also evaluated the difference between expert and automatic region-of-interest (ROI) analysis on body composition precision. To this end, 2 total body scans were performed on each subject with repositioning between scans. Total body precision for BMC, fat and lean mass were 0.5%, 1.0%, and 0.5% coefficient of variation (CV), respectively. Regional body composition precision error was less than 2.5% CV for all regions except arms. Precision error was higher for the arms (CV: BMC 1.5%; fat mass 2.8%; lean mass 1.6%), likely owing to the placement of arms relative to torso leading to differences in ROI. There was a significant correlation between auto ROI and expert ROI (r>0.99). Small, but statistically significant differences were found between auto and manual ROI. Differences were small in total body, leg, trunk, and android and gynoid regions (0.004-2.8%), but larger in arm region (3.0-6.3%). Total body and regional precision for iDXA are small and it is suggested that iDXA may be useful for monitoring changes in body composition during longitudinal trials.

Comparison of nutritional parameters among adult and elderly hemodialysis patients

AIM

The aim of this study was to compare the nutritional biochemical parameters, prealbumin levels, and bioimpedance analysis parameters of adult and elderly hemodialysis (HD) patients.

METHODS

This prospective cross-sectional study included 50 adult HD patients (42.0 % female). Nutritional status was assessed by post-dialysis multifrequency bioimpedance analysis (BIA), serum prealbumin and other nutritional biochemical parameters.

RESULTS

Mean age of patients was 57.4±15.1 years (range: 30-83 years) and mean dialysis duration was 68.3 ± 54.5 months (range: 3-240 months). When the patients were divided into two groups according to age of patients (<65 and ≥65), prealbumin (p=0.003), blood urea nitrogen (BUN) (p=0.000), serum creatinine (p=0.013), albumin (p=0.016), protein catabolic rate per normalized body weight (nPCR) (p=0.001), intracellular water (ICW)/total body weight (0.003) , body fat mass (p00.000), lean body mass (p=0.031), lean dry mass (p=0.001), illness marker (p=0.005), basal metabolism (p=0.007), body mass index (BMI) (p=0.028), body fat mass index (BFMI) (p=0.000), fat free mass index (FFMI) (p=0.040) values were significantly different between the groups. In the elderly patients (age ≥65), body fat mass, illness marker, BMI, BFMI were higher compared to adult patients (age <65). Additionally, in the elderly patients, prealbumin, BUN, creatinine, albumin, nPCR, ICW/ total body weight, lean body weight, lean dry weight, basal metabolism and FFMI were lower than adult patients.

CONCLUSIONS

Our results indicate that BFMI were higher, albumin, prealbumin, nPCR and lean body mass and FFMI were lower in elderly patients compared to adults. These results imply that elderly HD patients may be prone sarcopenic obesity and may require special nutritional support.

Survival predictability of lean and fat mass in men and women undergoing maintenance hemodialysis

BACKGROUND

Larger body size is associated with greater survival in maintenance hemodialysis (MHD) patients. It is not clear how lean body mass (LBM) and fat mass (FM) compare in their associations with survival across sex in these patients.

OBJECTIVE

We examined the hypothesis that higher FM and LBM are associated with greater survival in MHD patents irrespective of sex.

DESIGN

In 742 MHD patients, including 31% African Americans with a mean (± SD) age of 54 ± 15 y, we categorized men (n = 391) and women (n = 351) separately into 4 quartiles of near-infrared interactance-measured LBM and FM. Cox proportional hazards models estimated death hazard ratios (HRs) (and 95% CIs), and cubic spline models were used to examine associations with mortality over 5 y (2001-2006).

RESULTS

After adjustment for case-mix and inflammatory markers, the highest quartiles of FM and LBM were associated with greater survival in women: HRs of 0.38 (95% CI: 0.20, 0.71) and 0.34 (95% CI: 0.17, 0.67), respectively (reference: first quartile). In men, the highest quartiles of FM and percentage FM (FM%) but not of LBM were associated with greater survival: HRs of 0.51 (95% CI: 0.27, 0.96), 0.45 (95% CI: 0.23, 0.88), and 1.17 (95% CI: 0.60, 2.27), respectively. Cubic spline analyses showed greater survival with higher FM% and higher "FM minus LBM percentiles" in both sexes, whereas a higher LBM was protective in women.

CONCLUSIONS

In MHD patients, higher FM in both sexes and higher LBM in women appear to be protective. The survival advantage of FM appears to be superior to that of LBM. Clinical trials to examine the outcomes of interventions that modify body composition in MHD patients are indicated.

Assessment of prealbumin in hemodialysis and renal-transplant patients

OBJECTIVE

This study assessed prealbumin in hemodialysis (HD) and renal-transplant (RT) patients, and compared it with other biochemical and anthropometric markers, clinical conditions, and treatment variables.

DESIGN

We used a research design.

PATIENTS

Serum prealbumin was measured in 84 HD patients with a mean age of 60.47 +/- 17.81 years and a mean body mass index (BMI) of 24.38 +/- 4.87 kg/m(2), and in 154 RT patients with a mean age of 44.08 +/- 13.59 years and a mean BMI of 24.97 +/- 3.87 kg/m(2). Renal-transplant patients were divided into three groups, based on year of renal transplantation (first year, first to second year, and third to tenth year). Serum albumin, creatinine, cholesterol, glucose, triglycerides, white blood cells, BMI, midarm circumference, and triceps and biceps skinfolds were measured.

RESULTS

Prealbumin levels were significantly higher in HD patients compared with RT patients. Both groups had prealbumin levels <30 mg/dL, but almost all RT patients in our study had prealbumin levels <20 mg/dL. Gender, age, and presence of anemia, hypertension, and diabetes did not significantly affect prealbumin levels in the two groups. Prealbumin levels were significantly positively correlated with duration of dialysis in the HD group and with albumin in the RT group.

CONCLUSIONS

Hemodialysis patients have higher levels of prealbumin compared with RT patients. Prealbumin levels are below normal range in both groups of patients. Prealbumin reflects nutritional status in RT patients, but is also affected by other factors.

Dialysis adequacy and nutritional status of hemodialysis patients

To characterize the nutritional status of renal failure patients and its relationship with hemodialysis adequacy measured by Kt/V, a study was carried out with a population of 44 adult patients with renal failure and mean age 51+/-15 years. Anthropometric data, such as dry weight, height, arm circumference, triceps skinfold thickness, mid-arm muscle circumference, and body mass index were assessed, and biochemical tests were conducted for urea, potassium, creatinine, serum albumin, and phosphorus levels, in addition to hemogram and quarterly urea reduction rate average (Kt/V). In order to evaluate calorie intake, a dietary questionnaire on habitual daily food ingestion was administered, taking into consideration the hemodialysis date. The patients were divided into 2 separate groups for the statistical analysis, with 50% of the patients in each group: A (Kt/V<1.2) and B (Kt/V>1.2). The data were tabulated as mean and standard deviation, with differences tested by Student's t test. The correlations between variables were established by the coefficient p of Pearson. Most of the patients (43%) were considered eutrophic, based on the BMI, and presented inadequate calorie intake, corresponding to 88.5+/-24% (30.8 kcal/kg actual weight) of the total energy required and adequate protein intake, reaching 109.9+/-40% of the recommended daily allowance (1.24 g/kg of actual weight). There was a correlation of Kt/V with anthropometric parameters such as body mass index, arm circumference, and mid-arm muscle circumference. The biochemical parameters related to dialysis adequacy were albumin, ferritin, and urea (predialysis). Well-dialyzed patients presented better levels of serum albumin. There was an influence of gender and age on correlations of the analyzed variables. Female and younger patients presented better dialysis adequacy. The dialysis adequacy was related to the nutritional status and influenced by the protein intake and body composition. Gender and age had an important influence in the dialysis adequacy, as men presented lower dialysis adequacy and younger adults presented better dialysis adequacy. Further research is necessary to understand better how to facilitate effective and efficient techniques for the nutritional status assessment of hemodialysis patients.

Assessing the prevalence of malnutrition in chronic kidney disease patients in jordan

OBJECTIVE

The study objective was to validate the use of subjective global assessment (SGA) in assessing the prevalence of malnutrition among patients on hemodialysis in Jordan by comparing SGA grades with anthropometric and biochemical measurements.

DESIGN

This was a cross-sectional survey.

SETTING

The study was performed at hospital hemodialysis units.

PATIENTS

End-stage renal-failure outpatients (n = 178; 94 women and 84 men; mean age +/- SD, 43.9 +/- 14.6 years) who underwent hemodialysis were recruited from five large Jordanian hospitals. The obtained data were compared with tabulated measurements of the reference population in term of age and sex.

MAIN OUTCOME MEASURES

Subjective global assessment, anthropometric (dry weight, body mass index, fat percentage, fat mass, triceps skinfold thickness, mid-arm circumference, mid-arm muscle circumference, and arm muscle area), and biochemical (albumin, total protein, hemoglobin, creatinine, urea, cholesterol, phosphorus, calcium, and potassium) measurements were assessed in all patients.

RESULTS

In this study, 56.2% of patients on hemodialysis were moderately malnourished, and 5.6% were severely malnourished. Age was inversely associated with patients' nutritional status as well as SGA grades. The findings also suggest a significant (P < .001) decrease in some anthropometric parameters (dry weight, body mass index, fat percentage, fat mass, triceps skinfold thickness, mid-arm circumference, mid-arm muscle circumference, and arm muscle area) with advanced malnutrition.

CONCLUSION

A comparison of SGA grades with biochemical and anthropometric variables indicated that SGA could be used to assess nutritional status in patients on hemodialysis. Overall, about 38.2% of patients were well-nourished. Age and duration of hemodialysis appeared to be associated with nutritional status.

Nutritional status and length of stay in patients admitted to an Acute Assessment Unit

BACKGROUND

The Redesigning Care initiative at Flinders Medical Centre aimed to improve access to timely, consistent, quality care. This led to the creation of an Acute Assessment Unit (AAU) where all patients are assessed by the Allied Health team on admission. This study aimed to: (i) determine the nutritional status of patients admitted to the AAU using the scored Patient Generated-Subjective Global Assessment (PG-SGA); and (ii) determine the association between nutritional status and length of stay (LOS).

METHODS

A prospective, observational study was conducted in 64 patients (mean age 79.9 +/- 11 years, 76% female). Nutritional status was assessed within 48 h of admission and LOS data were collected prospectively.

RESULTS

According to PG-SGA global rating, 53% (n = 34) of patients were malnourished. There was a weak association between PG-SGA score and LOS (r = 0.250, P = 0.046). The malnourished patients had a longer LOS by 1 day compared to well-nourished patients, and while this did not reach statistical significance (Z = -0.988, P = 0.323), it has implications for health care costs. LOS overall was short at a median of 4.5 days (range 1-24).

CONCLUSIONS

A significant proportion of patients admitted to the AAU is malnourished. There was a trend for these patients to have a longer LOS, indicating a critical need for nutritional management; however LOS as a whole was short. While nutrition support in hospital is useful in reinforcing dietary education, the short LOS emphasized the importance of discharge education and follow-up.

GFR Estimation Using Cystatin C Is Not Independent of Body Composition

BACKGROUND

Cystatin C (CysC) is an endogenous marker of glomerular filtration rate (GFR) that is claimed to be unaffected by body composition. In this study, we tested this speculation.

METHODS

In 77 patients with chronic kidney disease (mean age, 65.1 +/- 11.9 [SD] years; mean indexed GFR, 45.7 +/- 28.6 mL/min/1.73 m(2) [0.76 +/- 0.48 mL/s]), we evaluated kidney function (GFR) by means of inulin clearance. CysC level was determined by using a particle-enhanced turbidimetric immunoassay. Total lean (LM) and fat masses were measured by means of dual-energy x-ray absorptiometry. Multiple regression was used to analyze relationships between absolute GFR, LM, fat mass, demographic and anthropometric variables (age, sex, height, and weight), and CysC levels. Then prediction equations were built that included only CysC level or CysC level and LM. Their performance to predict absolute GFR was evaluated in a subset of patients with extreme body composition (LM or fat mass > +/-1 SD of the entire sample).

RESULTS

Only absolute GFR and LM significantly explained variance in CysC levels, and an equation including LM explained more variance in absolute GFR than an equation including CysC level alone. Consequently, the equation including LM performed better than the equation with only CysC level, especially in patients with extreme body composition, showing reduced bias and improved limits of agreement and accuracy (71.4% versus 51.4% of patients' predicted GFR did not deviate by >30% of GFR).

CONCLUSION

LM is a previously unrecognized, but important, factor affecting CysC level, and GFR estimation improves when including LM. CysC level is not independent of body composition, as previously assumed, and hence accounting for body composition improves CysC-based GFR estimation.

Body composition analysis with bioelectric impedance in adult Indians with ESRD: Comparison with healthy population

Evaluation of body composition provides clinically useful information in several diseases including chronic kidney disease. Bioimpedance analysis (BIA) is a simple, cheap, and noninvasive tool for monitoring body composition. We performed BIA in 451 healthy adults and 162 end-stage renal disease (ESRD) patients. Resistance (R) and reactance (Xc) values were obtained at 50-kHz frequency using a tetrapolar impedance meter. Body compartments were derived using population-specific regression equations. Phase angles (arctan Xc/R) were calculated and impedance vector distribution was determined using the RXc graph method. Compared to healthy population, ESRD patients had similar post-dialysis resistance with lower reactance and phase angle, indicating decreased soft tissue mass and inadequate ultrafiltration. BIA equations estimated decreased fat mass index and intracellular water, whereas the total body and extracellular water percentages were increased. Sex-specific reference RXc plots with 95, 75, and 50% tolerance ellipses were drawn for the healthy population. A significant difference was noted in the vector positions and 95% confidence ellipses of the two sexes and body mass indices of </=25 and >25. In conclusion, we present the reference BIA parameters for Indian population. ESRD patients show significant body compartment alterations. The RXc score graph can differentiate ESRD patient from normal controls and can be used to monitor nutrition and hydration status.