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Altunok M, Çankaya E, Gözübüyük Kaplan H, Çınar E, Uyanık A, Sevinç C. The effect of body mass index on mortality, peritonitis, technique proficiency and residual renal function in peritoneal dialysis patients. Int Urol Nephrol 2024; 56:2379-2389. [PMID: 38431535 DOI: 10.1007/s11255-024-03988-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 02/12/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND The prevalence of obesity is increasing worldwide. Obesity is also increasing in the chronic kidney disease (CKD) population. There are conflicting data on complications such as mortality, peritonitis, and technique proficiency of peritoneal dialysis (PD) in underweight and obese patients according to body mass index (BMI). We aimed to present the data in our region to the literature by comparing the residual renal function (RRF), peritonitis, technique proficiency, and mortality rates of the patients we grouped according to BMI. METHODS The data of 404 patients who were started and followed up in our clinic between March 2005 and November 2021 were evaluated retrospectively. They were grouped as underweight, normal weight, overweight, and obese according to BMI. RRF, mortality, technique proficiency and peritonitis data of the groups were compared. RESULTS Of the 404 patients, 44 were underweight, 199 were normal weight, 110 were overweight, and 55 were obese. No difference was found between the groups in the technique survey and in the time to first peritonitis with Kaplan-Meier analysis (respectively; p = 0.610, p = 0.445). Multivariate Cox regression analysis showed that BMI did not affect mortality (HR 1.196 [95% CI 0.722-1.981] (p = 0.488)). CONCLUSION In conclusion, we report that BMI has no effect on RRF, peritonitis, technique proficiency, and mortality in patients undergoing PD, and that mortality may depend on additional factors such as mean albumin, time to first peritonitis, and loss of RRF.
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Affiliation(s)
- Murat Altunok
- Department of Nephrology, Faculty of Medicine, Atatürk University, 25240, Erzurum, Turkey.
| | - Erdem Çankaya
- Department of Nephrology, Faculty of Medicine, Atatürk University, 25240, Erzurum, Turkey
| | | | - Enes Çınar
- Department of Nephrology, Faculty of Medicine, Atatürk University, 25240, Erzurum, Turkey
| | - Abdullah Uyanık
- Department of Nephrology, Faculty of Medicine, Atatürk University, 25240, Erzurum, Turkey
| | - Can Sevinç
- Department of Nephrology, Faculty of Medicine, Atatürk University, 25240, Erzurum, Turkey
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2
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Betancourt L, Pico S, Rojas E, Gordo MJ, Oliva JC, Almirall J, Ponz E. Relationship between intraperitoneal pressure and the development of hernias in peritoneal dialysis: confirmation for the first time of a widely accepted concept. Int Urol Nephrol 2024; 56:759-765. [PMID: 37566322 DOI: 10.1007/s11255-023-03663-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 06/06/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Intraperitoneal pressure (IPP) in peritoneal dialysis (PD) is an individual characteristic that can be modified by posture and intraperitoneal volume (IPV). It is considered one of the predisposing factors for complications in the abdominal wall, such as the appearance of hernias. No studies to date have confirmed this. The main aim of this study was to assess the relationship between the development of hernia in incident PD patients and IPP measured at PD onset. METHODS A prospective observational study of incident patients in a PD programme between 2010 and 2020. IPP was measured using the Durand's method. RESULTS One hundred and twenty-four incident patients on PD, 68% male, mean age 62.1 ± 15.23 years, body mass index (BMI) 27.7 ± 4.82 kg/m2, 44% were diabetic. IPP in supine was 16.6 ± 4.60 cm H2O for a mean IPV of 2047.1 ± 359.19 mL. Hernias were reported in 18.5% of patients during PD follow-up: 57% were inguinal hernias, 33% umbilical, and a further 10% presented in a combined form. PD hernias correlated positively with IPP in supine position (p = 0.037), patient age (p = 0.008), BMI (p = 0.043), a history of prior hernia (0.016), laparoscopic catheter placement (p = 0.026), and technique failure (p = 0.012). In the multivariate analysis, a higher IPP was independently related to the development of hernias (p = 0.028). CONCLUSIONS The development of hernias in PD was related to a higher IPP at PD onset, older age, higher BMI, history of prior hernia, catheter placement by laparoscopy, and technique failure.
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Affiliation(s)
- Loreley Betancourt
- Department of Nephrology, Parc Tauli Sabadell, University Hospital, Parc Tauli 1, 08208, Sabadell, Barcelona, Spain.
- Department of Medicine UAB, Barcelona, Spain.
| | - Sandy Pico
- Department of Nephrology, Parc Tauli Sabadell, University Hospital, Parc Tauli 1, 08208, Sabadell, Barcelona, Spain
- Department of Medicine UAB, Barcelona, Spain
| | - Estefania Rojas
- Department of Nephrology, Parc Tauli Sabadell, University Hospital, Parc Tauli 1, 08208, Sabadell, Barcelona, Spain
- Department of Medicine UAB, Barcelona, Spain
| | - Maria Jose Gordo
- Department of Nephrology, Parc Tauli Sabadell, University Hospital, Parc Tauli 1, 08208, Sabadell, Barcelona, Spain
- Department of Medicine UAB, Barcelona, Spain
| | - Juan Carlos Oliva
- Department of Medicine UAB, Statistics Unit, Parc Tauli Sabadell, University Hospital, Barcelona, Spain
| | - Jaume Almirall
- Department of Nephrology, Parc Tauli Sabadell, University Hospital, Parc Tauli 1, 08208, Sabadell, Barcelona, Spain
- Department of Medicine UAB, Barcelona, Spain
| | - Esther Ponz
- Department of Nephrology, Parc Tauli Sabadell, University Hospital, Parc Tauli 1, 08208, Sabadell, Barcelona, Spain
- Department of Medicine UAB, Barcelona, Spain
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3
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Echefu G, Stowe I, Burka S, Basu-Ray I, Kumbala D. Pathophysiological concepts and screening of cardiovascular disease in dialysis patients. FRONTIERS IN NEPHROLOGY 2023; 3:1198560. [PMID: 37840653 PMCID: PMC10570458 DOI: 10.3389/fneph.2023.1198560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 08/10/2023] [Indexed: 10/17/2023]
Abstract
Dialysis patients experience 10-20 times higher cardiovascular mortality than the general population. The high burden of both conventional and nontraditional risk factors attributable to loss of renal function can explain higher rates of cardiovascular disease (CVD) morbidity and death among dialysis patients. As renal function declines, uremic toxins accumulate in the blood and disrupt cell function, causing cardiovascular damage. Hemodialysis patients have many cardiovascular complications, including sudden cardiac death. Peritoneal dialysis puts dialysis patients with end-stage renal disease at increased risk of CVD complications and emergency hospitalization. The current standard of care in this population is based on observational data, which has a high potential for bias due to the paucity of dedicated randomized clinical trials. Furthermore, guidelines lack specific guidelines for these patients, often inferring them from non-dialysis patient trials. A crucial step in the prevention and treatment of CVD would be to gain better knowledge of the influence of these predisposing risk factors. This review highlights the current evidence regarding the influence of advanced chronic disease on the cardiovascular system in patients undergoing renal dialysis.
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Affiliation(s)
- Gift Echefu
- Division of Cardiovascular Medicine, The University of Tennessee Health Science Center, Memphis, TN, United States
| | - Ifeoluwa Stowe
- Department of Internal Medicine, Baton Rouge General Medical Center, Baton Rouge, LA, United States
| | - Semenawit Burka
- Department of Internal Medicine, University of Texas Rio Grande Valley, McAllen, TX, United States
| | - Indranill Basu-Ray
- Department of Cardiology, Memphis Veterans Affairs (VA) Medical Center, Memphis, TN, United States
| | - Damodar Kumbala
- Nephrology Division, Renal Associates of Baton Rouge, Baton Rouge, LA, United States
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4
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Lee HS, Noh HM, An JN, Song YR, Kim SG, Kim JK. Elevated Ferritin Levels Associated with High Body Fat Mass Affect Mortality in Peritoneal Dialysis Patients. Nutrients 2023; 15:2149. [PMID: 37432308 DOI: 10.3390/nu15092149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 04/28/2023] [Accepted: 04/29/2023] [Indexed: 07/12/2023] Open
Abstract
Obesity is a common health problem in peritoneal dialysis (PD) patients and causes high serum ferritin levels. However, mixed results have been reported on whether serum ferritin levels affect the prognosis of PD patients. We investigated the effect of increased adiposity on ferritin levels and its association with mortality in 350 well-nourished PD patients. Body composition was measured using a portable whole-body bioimpedance spectroscope, and clinical determinants of high ferritin levels were evaluated. High ferritin levels (≥600 ng/mL) were observed in 63 (18.0%) patients. Patients with high ferritin levels had a significantly higher body fat percentage and a lower lean tissue index than patients with low or normal ferritin levels. During a median follow-up of 30 months, there were 65 deaths. Ferritin ≥ 600 ng/mL was associated with significantly higher all-cause mortality compared with 200-600 ng/mL of ferritin. Multivariate analysis showed that high ferritin levels were significantly associated with a higher percentage of body fat after adjustment for lean tissue index and volume status. High ferritin increased all-cause mortality in PD patients, and increased fat mass was an important determinant of the high ferritin. Our results support that adiposity may lead to an adverse clinical outcome in PD patients.
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Affiliation(s)
- Hyung Seok Lee
- Department of Internal Medicine & Kidney Research Institute, Hallym University Sacred Heart Hospital, Anyang 14068, Republic of Korea
| | - Hye-Mi Noh
- Department of Family Medicine, Hallym University Sacred Heart Hospital, Anyang 14068, Republic of Korea
| | - Jung Nam An
- Department of Internal Medicine & Kidney Research Institute, Hallym University Sacred Heart Hospital, Anyang 14068, Republic of Korea
| | - Young Rim Song
- Department of Internal Medicine & Kidney Research Institute, Hallym University Sacred Heart Hospital, Anyang 14068, Republic of Korea
| | - Sung Gyun Kim
- Department of Internal Medicine & Kidney Research Institute, Hallym University Sacred Heart Hospital, Anyang 14068, Republic of Korea
| | - Jwa-Kyung Kim
- Department of Internal Medicine & Kidney Research Institute, Hallym University Sacred Heart Hospital, Anyang 14068, Republic of Korea
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Zhang L, Fang L, Lihua H, Li C. Association between obesity and 1-year mortality in septic patients: a retrospective cohort study. BMJ Open 2023; 13:e066526. [PMID: 36764727 PMCID: PMC9923324 DOI: 10.1136/bmjopen-2022-066526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
OBJECTIVE Sepsis is a major contributor of intensive care units (ICUs) patient mortality. Prior investigations claimed that obesity enhances overall survival (OS) of septic patients. However, the reported results were inconsistent. This study examined the association between obesity and the 1-year mortality of septic patients. DESIGN A retrospective cohort study. SETTING The Medical Information Mart for Intensive Care III database. PARTICIPANTS 3145 septic patients were separated into three distinct cohorts, based on their WHO body mass index (BMI) status. OUTCOMES Our primary endpoint was the 1-year mortality from the date of ICU hospitalization. RESULT 1334 (42.4%) died within 1 year. The 1-year mortality rate was low in obese patients (38.8%), compared with normal (46.9%) and overweight (42.1%) patients. Crude assessment revealed that obese patients experienced reduced 1-year mortality, relative to normal weight patients (HR 0.79, 95% CI 0.69 to 0.9, p<0.001). However, once adjusted for baseline variables and comorbidities, no correlation was found between obesity and the 1-year mortality (HR 0.93, 95% CI 0.81 to 1.06, p=0.28) of septic patients. There was an association among diabetic (HR 0.72, 95% CI 0.56 to 0.93, p=0.012) and hypertensive (HR 0.73, 95% CI 0.58 to 0.92, p=0.008) patients, and among males (HR 0.71, 95% CI 0.59 to 0.86, p<0.001), with obese individuals experiencing the lowest mortality rate. Given these evidences, the interactions between BMI and mortality in diabetic (p=0.031) and hypertensive (p=0.035) patients were significant. CONCLUSION In our study, obese diabetic and hypertensive patients associated to less sepsis-related mortality risk, compared with normal weight patients. Further researches were need to validated.
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Affiliation(s)
- Li Zhang
- Department of Anesthesiology, The First People's Hospital of Kunshan Affiliated with Jiangsu University, Kunshan, Jiangsu, People's Republic of China
| | - Lingna Fang
- Department of Endocrinology, The First People's Hospital of Kunshan Affiliated with Jiangsu University, Kunshan, China
| | - Hang Lihua
- Department of Anesthesiology, The First People's Hospital of Kunshan Affiliated with Jiangsu University, Kunshan, Jiangsu, People's Republic of China
| | - Chong Li
- Department of Osteoporosis, The First People's Hospital of Kunshan Affiliated with Jiangsu University, Kunshan, Jiangsu, People's Republic of China
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Ng JKC, Than WH, Szeto CC. Obesity, Weight Gain, and Fluid Overload in Peritoneal Dialysis. FRONTIERS IN NEPHROLOGY 2022; 2:880097. [PMID: 37675033 PMCID: PMC10479638 DOI: 10.3389/fneph.2022.880097] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 06/02/2022] [Indexed: 09/08/2023]
Abstract
Obesity is a global epidemic that has a complicated pathogenesis as well as impact on the outcome of peritoneal dialysis (PD) patients. In this review, the prevalence of obesity in incident PD patients as well as the phenomenon of new-onset glucose intolerance after PD will be reviewed. Published literature on the effect of obesity on the survival and incidence of cardiovascular disease in PD patients will be discussed. Particular emphasis would be put on literature that compared the impact of obesity on the outcome of hemodialysis and PD, and the confounding effect of dialysis adequacy. Next, the complex concept of obesity and its relevance for PD will be explored. The focus would be put on the methods of assessment and clinical relevance of central versus general obesity, as well as visceral versus subcutaneous adipose tissue. The relation between obesity and systemic inflammation, as well as the biological role of several selected adipokines will be reviewed. The confounding effects of metabolic syndrome and insulin resistance will be discussed, followed by the prevalence and prognostic impact of weight gain during the first few years of PD. The differences between weight gain due to fluid overload and accumulation of adipose tissue will be discussed, followed by the current literature on the change in body composition after patients are put on chronic PD. The methods of body composition will be reviewed, and the clinical relevance of individual body component (fluid, fat, muscle, and bone) will be discussed. The review will conclude by highlighting current gaps of knowledge and further research directions in this area.
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Affiliation(s)
- Jack Kit-Chung Ng
- Carol & Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Win Hlaing Than
- Carol & Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
- Li Ka Shing Institute of Health Sciences (LiHS), Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Cheuk Chun Szeto
- Carol & Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
- Li Ka Shing Institute of Health Sciences (LiHS), Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
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7
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Choudhury D, Yalamanchili HB, Hasan A. Dialysis of the Obese Patient: Meeting Needs for a Growing Epidemic. Semin Nephrol 2021; 41:371-379. [PMID: 34715966 DOI: 10.1016/j.semnephrol.2021.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Increasing population obesity and associated metabolic consequences has led to increased number of obese patients with chronic kidney disease and end-stage renal disease. While obesity is associated with increased cardiovascular morbidity and mortality, obese dialysis patients present a seeming paradox for survival benefit, given other acute intervening illnesses for those on dialysis with loss of lean body mass overtime. Challenges remain in providing adequate renal replacement options and therapy for this growing segment of obese patients on dialysis which are discussed in this article.
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Affiliation(s)
- Devasmita Choudhury
- Department of Medicine, Division of Nephrology, Salem Veterans Affairs Health System, Salem, VA; Department of Medicine, Division of Nephrology, Virginia Tech Carilion School of Medicine, Roanoke, VA; Department of Medicine, Division of Nephrology, University of Virginia School of Medicine, Charlottesville, VA.
| | - Hima Bindu Yalamanchili
- Department of Medicine, Division of Nephrology, Salem Veterans Affairs Health System, Salem, VA; Department of Medicine, Division of Nephrology, Virginia Tech Carilion School of Medicine, Roanoke, VA
| | - Alia Hasan
- Department of Medicine, Division of Nephrology, Salem Veterans Affairs Health System, Salem, VA
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8
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Abstract
The prevalence of obesity in peritoneal dialysis (PD) populations has risen dramatically since the mid-1980s. This epidemic has been driven by the increased prevalence of obesity in the general population, the increased risk of progression of chronic kidney disease to end-stage renal failure (ESRF) in obese subjects, the reduced probability of listing obese dialysis patients for renal transplantation, a paradoxical enhanced survival in at least some obese populations on dialysis as compared with non-obese ESRF patients, and a possible adipogenic effect of excessive peritoneal glucose absorption in PD. Although obesity has consistently been associated with improved outcomes in hemodialysis, conflicting results have been seen in PD. In general, an elevated body mass index (BMI) has been associated with a neutral or deleterious impact on PD outcomes, and the relationship appears to be explained predominantly by fat mass. Risk is also elevated in patients with a low BMI, such that the “optimal BMI” appears to lie between 20 kg/m2 and 25 kg/m2. The mechanisms underpinning the harmful effect of obesity appear to include increased peritonitis rate, proinflammatory effects, and a more rapid decline of residual renal function in obese patients. No proof exists that weight reduction engenders an improvement in outcome in PD patients, but the available studies suggest that cautious weight reduction is advisable. A few studies have demonstrated that clinically important and sustained weight reduction can be successfully achieved through a combination of individual meal plans, regular exercise, and substitution of icodextrin for dextrose in the once-daily long dwell.
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Affiliation(s)
- David W. Johnson
- Department of Renal Medicine, University of Queensland at Princess Alexandra Hospital, Brisbane, Queensland, Australia
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9
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Fortes PC, Versari PH, Stinghen AE, Pecoits–Filho R. Controlling Inflammation in Peritoneal Dialysis: The Role of PD-Related Factors as Potential Intervention Targets. Perit Dial Int 2020. [DOI: 10.1177/089686080702702s14] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Cardiovascular (CV) disease is the main cause of death in peritoneal dialysis (PD) patients, but the mechanisms mediating the increased CV risk observed in this group of patients are still largely unknown, which limits the perspective on effective therapeutic strategies. Patients on PD are already exposed to a number of traditional risk factors from the start of their chronic kidney disease (CKD), because many of those risk factors are common to CV disease and CKD alike. As renal dysfunction progresses, CKD-related risk factors are introduced, changing the profile of both the CV disease and the markers of risk. In this phase, which usually starts when glomerular filtration rate falls below 60 mL/min, the list of risk factors is expanded to include disturbances of mineral metabolism, anemia, fluid overload, uremic toxicity, and increased signs of oxidative stress and inflammation. Although many of the risk factors linked to CV burden are not related to the dialytic procedure, additional harm is introduced after the initiation of PD—with, for example, the presence of chronic infections and factors related to PD fluids, particularly reabsorption of glucose. In the present article, we review the impact of the novel risk factors introduced with the initiation of PD therapy, and we propose potential therapeutic strategies (which remain to be tested) for reducing CV mortality in this group of patients.
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Affiliation(s)
- Paulo C. Fortes
- Center for Health and Biological Sciences, Pontifícia Universidade Católica do Paraná, Curitiba, Brazil
| | - Priscilla H. Versari
- Center for Health and Biological Sciences, Pontifícia Universidade Católica do Paraná, Curitiba, Brazil
| | - Andréa E.M. Stinghen
- Center for Health and Biological Sciences, Pontifícia Universidade Católica do Paraná, Curitiba, Brazil
| | - Roberto Pecoits–Filho
- Center for Health and Biological Sciences, Pontifícia Universidade Católica do Paraná, Curitiba, Brazil
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10
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Van Laecke S, Veys N, Verbeke F, Vanholder R, Van Biesen W. The Fate of Older Diabetic Patients on Peritoneal Dialysis: Myths and Mysteries and Suggestions for Further Research. Perit Dial Int 2020. [DOI: 10.1177/089686080702700602] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The outcome of older and especially of female diabetic patients appears to be worse on peritoneal dialysis (PD) than on hemodialysis (HD). This opinion is based mostly on data coming from the USA, whereas data from other regions seem to give a more balanced picture. The questions arise whether indeed outcome is worse in this patient group, and what might be the underlying reasons for this; further research to unravel this phenomenon is warranted. This review proposes several suggestions for further exploration. The observed differences in outcome might be attributable to differences in treatment practices and experience with PD versus HD. As cardiovascular mortality is a major killer in end-stage renal disease patients, differences in fluid homeostasis and how it is achieved are potential explanations. Fluid balance is potentially more difficult to obtain in PD patients, especially as in the past it was spuriously suggested that fluid restriction was less important in PD patients. PD and HD might also have different impacts on factors related to inflammation, insulin resistance, and hormone balance. The adipocytokine network is of special interest in this respect. It is also possible that bias introduced by the way we measure body composition might have a more negative impact on PD than on HD patients. Finally, it still is not fully established that if diabetic patients are treated appropriately, their outcome on PD is worse than that on HD; further observational trials in this respect are needed. All these topics require further clarification and investigation.
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Affiliation(s)
- Steven Van Laecke
- Renal Division, Department of Internal Medicine, University Hospital Ghent, Belgium
| | - Nic Veys
- Renal Division, Department of Internal Medicine, University Hospital Ghent, Belgium
| | - Francis Verbeke
- Renal Division, Department of Internal Medicine, University Hospital Ghent, Belgium
| | - Raymond Vanholder
- Renal Division, Department of Internal Medicine, University Hospital Ghent, Belgium
| | - Wim Van Biesen
- Renal Division, Department of Internal Medicine, University Hospital Ghent, Belgium
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11
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Caron-Lienert RS, Poli-de-Figueiredo CE, Figueiredo AEPL, da Costa BEP, Crepaldi C, Pizzato AC, Ferrari F, Giuliani A, Ronco C. The Influence of Glucose Exposure Load and Peritoneal Membrane Transport on Body Composition and Nutritional Status Changes after 1 Year on Peritoneal Dialysis. Perit Dial Int 2020; 37:458-463. [DOI: 10.3747/pdi.2016.00265] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 02/14/2017] [Indexed: 12/20/2022] Open
Abstract
BackgroundThe characteristics of peritoneal membrane transport differ among patients, affecting the prescription of peritoneal dialysis (PD) modality and glucose exposure in order to achieve an effective dialysis. This study aims to verify the influence of glucose exposure load and peritoneal membrane transport on body composition and nutritional status changes after the first year of PD.MethodsWe examined a cohort of 85 incident PD patients during the first year of treatment. We established a cut-off of 5% to define changes in dry weight (DW), lean tissue mass (LTM), and fat mass (FM).ResultsIn total, 50.6% of the patients presented DW gain, 41.2% showed LTM loss, and 65.9% presented FM gain. Over the time (T0 – T12), we found significant differences in DW, body mass index (BMI), adipose tissue mass (ATM), FM and fat tissue index (FTI). Patients with lower dialysate-to-plasma creatinine ratio showed DW and FM gain. We observed a higher percentage of nonfast transporters in DW gain when comparing with DW no gain. As for glucose exposure load, no body composition changes were seen.ConclusionsMost patients presented DW gain, FM gain, and LTM loss. The characteristics of peritoneal membrane transport affected DW during the first year, changes being greater in nonfast than in fast transporters.
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Affiliation(s)
- Rafaela Siviero Caron-Lienert
- Pontifical Catholic University of Rio Grande do Sul, Rio Grande do Sul, Brazil
- International Renal Research Institute of Vicenza, Italy
| | | | | | | | - Carlo Crepaldi
- International Renal Research Institute of Vicenza, Italy
| | | | | | - Anna Giuliani
- International Renal Research Institute of Vicenza, Italy
| | - Claudio Ronco
- International Renal Research Institute of Vicenza, Italy
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12
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Imam TH, Coleman KJ. Obesity and Mortality in End-Stage Renal Disease. Is It Time to Reverse the “Reverse Epidemiology”—at Least in Peritoneal Dialysis? J Ren Nutr 2019; 29:269-275. [DOI: 10.1053/j.jrn.2018.09.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 08/21/2018] [Accepted: 09/20/2018] [Indexed: 11/11/2022] Open
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13
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Abstract
Cardiovascular disease (CVD) is highly prevalent in the peritoneal dialysis (PD) population, affecting up to 60% of cohorts. CVD is the primary cause of death in up to 40% of PD patients in Australia, New Zealand, and the United States. Cardiovascular mortality rates are reported to be approximately 14 per 100 patient-years, which are 10- to 20-fold greater than those of age- and sex-matched controls. The excess risk of CVD is related to a combination of traditional risk factors (such as hypertension, dyslipidemia, obesity, smoking, sedentary lifestyle, and insulin resistance), nontraditional (kidney disease-related) risk factors (such as anemia, chronic volume overload, inflammation, malnutrition, hyperuricemia, and mineral and bone disorder), and PD-specific risk factors (such as dialysis solutions, glycation end products, hypokalemia, residual kidney function, and ultrafiltration failure). Interventions targeting these factors may mitigate cardiovascular risk, although high-level clinical evidence is lacking. This review summarizes the evidence relating to cardiovascular interventions targeting modifiable CVD risk factors in PD patients, as well as highlighting the key recommendations of the International Society for Peritoneal Dialysis Cardiovascular and Metabolic Guidelines.
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14
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Association of body mass index and uncontrolled blood pressure with cardiovascular mortality in peritoneal dialysis patients. J Hum Hypertens 2018; 33:106-114. [DOI: 10.1038/s41371-018-0107-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 08/09/2018] [Accepted: 08/10/2018] [Indexed: 12/14/2022]
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15
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Naderi N, Kleine CE, Park C, Hsiung JT, Soohoo M, Tantisattamo E, Streja E, Kalantar-Zadeh K, Moradi H. Obesity Paradox in Advanced Kidney Disease: From Bedside to the Bench. Prog Cardiovasc Dis 2018; 61:168-181. [PMID: 29981348 DOI: 10.1016/j.pcad.2018.07.001] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 07/02/2018] [Indexed: 02/06/2023]
Abstract
While obesity is associated with a variety of complications including diabetes, hypertension, cardiovascular disease and premature death, observational studies have also found that obesity and increasing body mass index (BMI) can be linked with improved survival in certain patient populations, including those with conditions marked by protein-energy wasting and dysmetabolism that ultimately lead to cachexia. The latter observations have been reported in various clinical settings including end-stage renal disease (ESRD) and have been described as the "obesity paradox" or "reverse epidemiology", engendering controversy. While some have attributed the obesity paradox to residual confounding in an effort to "debunk" these observations, recent experimental discoveries provide biologically plausible mechanisms in which higher BMI can be linked to longevity in certain groups of patients. In addition, sophisticated epidemiologic methods that extensively adjusted for confounding have found that the obesity paradox remains robust in ESRD. Furthermore, novel hypotheses suggest that weight loss and cachexia can be linked to adverse outcomes including cardiomyopathy, arrhythmias, sudden death and poor outcomes. Therefore, the survival benefit observed in obese ESRD patients can at least partly be derived from mechanisms that protect against inefficient energy utilization, cachexia and protein-energy wasting. Given that in ESRD patients, treatment of traditional risk factors has failed to alter outcomes, detailed translational studies of the obesity paradox may help identify innovative pathways that can be targeted to improve survival. We have reviewed recent clinical evidence detailing the association of BMI with outcomes in patients with chronic kidney disease, including ESRD, and discuss potential mechanisms underlying the obesity paradox with potential for clinical applicability.
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Affiliation(s)
- Neda Naderi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA; Department of Internal Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Carola-Ellen Kleine
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA; Nephrology Section, Tibor Rubin VA Medical Center, Long Beach, CA
| | - Christina Park
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA; Nephrology Section, Tibor Rubin VA Medical Center, Long Beach, CA
| | - Jui-Ting Hsiung
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA; Nephrology Section, Tibor Rubin VA Medical Center, Long Beach, CA
| | - Melissa Soohoo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA; Nephrology Section, Tibor Rubin VA Medical Center, Long Beach, CA; Dept. of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA
| | - Ekamol Tantisattamo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA; Nephrology Section, Tibor Rubin VA Medical Center, Long Beach, CA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA; Nephrology Section, Tibor Rubin VA Medical Center, Long Beach, CA; Dept. of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA.
| | - Hamid Moradi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA; Nephrology Section, Tibor Rubin VA Medical Center, Long Beach, CA.
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16
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Kanazawa Y, Nakao T, Murai S, Okada T, Matsumoto H. Diagnosis and prevalence of protein-energy wasting and its association with mortality in Japanese haemodialysis patients. Nephrology (Carlton) 2018; 22:541-547. [PMID: 27165723 DOI: 10.1111/nep.12814] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 05/06/2016] [Accepted: 05/08/2016] [Indexed: 12/14/2022]
Abstract
AIM The International Society of Renal Nutrition and Metabolism (ISRNM) has proposed the diagnostic criteria for protein-energy wasting (PEW). We studied Japanese haemodialysis (HD) patients to verify the diagnostic method, especially with respect to the body mass index (BMI) criterion, as well as the prevalence of PEW and its association with mortality. METHODS Japanese patients receiving maintenance HD at three outpatient clinics in Tokyo (n = 210) were enrolled, and prospectively followed-up for 3 years. PEW was diagnosed at baseline, according to the four categories (serum chemistry, body mass, muscle mass and dietary intake) recommended by the ISRNM. For the category of body mass, we select a body mass index (BMI) and set up three thresholds, <18.5, <20.0 and <23.0 kg/m2 , as the diagnostic criterion. The patients who satisfied at least three out of the four categories were diagnosed as PEW. RESULTS Protein-energy wasting, when the threshold of a BMI among the diagnostic criteria was defined as <18.5 kg/m2 , was recognized as an independent risk factor for mortality. However, PEW was not recognized as a risk factor when the BMI diagnostic criterion was set at <20.0 or <23.0 kg/m2 . Overall, 14.8% of the patients had PEW. The survival rate of PEW patients was significantly lower than that of non-PEW patients (log rank, P < 0.001). CONCLUSIONS The diagnosis algorithm of PEW proposed by an expert panel of the ISRNM strongly associates with mortality. However, given differences in body size in Japan, we suggest to revise the BMI criterion from <23.0 kg/m2 to <18.5 kg/m2 .
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Affiliation(s)
- Yoshie Kanazawa
- Tokyo Kaseigakuin University, Tokyo, Japan.,Organization for Kidney Metabolic Disease Treatment, Tokyo, Japan
| | - Toshiyuki Nakao
- Organization for Kidney Metabolic Disease Treatment, Tokyo, Japan.,Bousei Shinjuku Minamiguchi Clinic, Tokyo, Japan
| | | | - Tomonari Okada
- Department of Nephrology, Tokyo Medical University, Tokyo, Japan
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17
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Park JY, Cho JH, Jang HM, Kim YS, Kang SW, Yang CW, Kim NH, Choi JY, Park SH, Kim CD, Kim YL. Survival predictors in anuric patients on peritoneal dialysis: A prospective, multicenter, propensity score-matched cohort study. PLoS One 2018; 13:e0196294. [PMID: 29694445 PMCID: PMC5919016 DOI: 10.1371/journal.pone.0196294] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 04/10/2018] [Indexed: 11/19/2022] Open
Abstract
Prevalent anuric peritoneal dialysis (PD) patients usually have higher mortality than PD patients with residual urine volume. We aimed to evaluate the predictors of survival in anuric PD patients. Anuric PD patients (n = 505, <100 mL of daily urine) enrolled in Korean nationwide prospective cohort were analyzed. Survived and non-survived anuric PD patients were compared by propensity score matching analysis with a ratio of two to one. The propensity method was used to adjust for patient age, dialysis duration, and presence of diabetes. Among the total anuric PD patients, non-survived patients showed a significantly older age, higher incidence of diabetes, coronary artery disease, and arrhythmia, and lower serum creatinine and albumin. After propensity score matching, multivariate Cox regression analysis for patient survival showed a decreasing risk as serum albumin increased (HR = 0.347, p = 0.0094). Analysis using the receiver-operating-characteristic (ROC) curve showed that survival could be predicted with a sensitivity of 59.4% and a specificity of 63.2% using a cutoff value of 3.6 g/dL of serum albumin in unmatched total PD patients. The beneficial impact of high albumin level on death was significantly greater for patients with older age (≥50 years), no diabetes, low ultrafiltration (UF) volume (<1000 mL/day), and low levels of serum creatinine (<10 mg/dL), total cholesterol (<177.5 mg/dL), ferritin (<100 ng/mL), and high-sensitivity C-reactive protein (hs-CRP) (<0.1 mg/dL). Survival in anuric PD patients was associated with age, comorbidities, and nutritional factors such as creatinine and albumin. After adjustment by propensity score matching, serum albumin level was an independent predictor for survival in anuric PD patients.
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Affiliation(s)
- Ja-Yong Park
- Clinical Research Center for End-Stage Renal Disease (CRC for ESRD) in Korea
- School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jang-Hee Cho
- Clinical Research Center for End-Stage Renal Disease (CRC for ESRD) in Korea
- School of Medicine, Kyungpook National University, Daegu, Korea
| | - Hye Min Jang
- Clinical Research Center for End-Stage Renal Disease (CRC for ESRD) in Korea
- School of Medicine, Kyungpook National University, Daegu, Korea
| | - Yon Su Kim
- Clinical Research Center for End-Stage Renal Disease (CRC for ESRD) in Korea
- Seoul National University College of Medicine, Seoul, Korea
| | - Shin-Wook Kang
- Clinical Research Center for End-Stage Renal Disease (CRC for ESRD) in Korea
- Yonsei University College of Medicine, Seoul, Korea
| | - Chul Woo Yang
- Clinical Research Center for End-Stage Renal Disease (CRC for ESRD) in Korea
- Catholic University of Korea College of Medicine, Seoul, Korea
| | - Nam-Ho Kim
- Clinical Research Center for End-Stage Renal Disease (CRC for ESRD) in Korea
- Chonnam National University Medical School, Gwangju, Korea
| | - Ji-Young Choi
- Clinical Research Center for End-Stage Renal Disease (CRC for ESRD) in Korea
- School of Medicine, Kyungpook National University, Daegu, Korea
| | - Sun-Hee Park
- Clinical Research Center for End-Stage Renal Disease (CRC for ESRD) in Korea
- School of Medicine, Kyungpook National University, Daegu, Korea
| | - Chan-Duck Kim
- Clinical Research Center for End-Stage Renal Disease (CRC for ESRD) in Korea
- School of Medicine, Kyungpook National University, Daegu, Korea
- * E-mail: (CDK); (YLK)
| | - Yong-Lim Kim
- Clinical Research Center for End-Stage Renal Disease (CRC for ESRD) in Korea
- School of Medicine, Kyungpook National University, Daegu, Korea
- * E-mail: (CDK); (YLK)
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Liu J, Zeng X, Hong HG, Li Y, Fu P. The association between body mass index and mortality among Asian peritoneal dialysis patients: A meta-analysis. PLoS One 2017; 12:e0172369. [PMID: 28207885 PMCID: PMC5313204 DOI: 10.1371/journal.pone.0172369] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 02/03/2017] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Previous studies have revealed that increased body mass index (BMI) is associated with decreased mortality among hemodialysis patients. However, few studies have dealt with the association between BMI and mortality among patients undergoing peritoneal dialysis (PD) and even fewer studies have focused on the Asian PD patients. The reported studies were often non-conclusive and some even yielded contradictory results. This paper, to our best knowledge, registers the first attempt to systematically review the current literature and summarize new results on the association between BMI and mortality among the Asian PD population. METHOD A systematic literature review was performed in Medline and EMBASE to identify relevant cohort studies on all-cause and cardiovascular disease (CVD) mortality stratified by BMI categories tailored to Asians among the Asian PD population. We meta-analyzed individual results based on a random effect model, strictly complying with Preferred Reporting Items for Systematic Reviews and Meta-analysis. RESULTS The paper reviews seven cohort studies with a total of 3,610 Asian PD patients. Obese group (BMI = 25-29.9 kg/m2) was associated with higher risk of all-cause mortality (HR = 1.46, 95%CI [1.07-1.98]; p = 0.02) and CVD mortality (HR = 2.01, 95%CI [1.14-3.54]; p = 0.02), compared to the normal group (BMI = 18.5-22.9 kg/m2). The underweight group (BMI<18.5kg/m2) was also associated with an elevated risk of all-cause mortality (HR = 2.11, 95%CI [1.46-3.07]; p<0.001). No significant associations between BMI with all-cause mortality were found among the overweight group (23-24.9 kg/m2) (HR = 1.00, 95%CI [0.76-1.32]; p = 0.9). The association between BMI and CVD mortality risk among the underweight and overweight groups was found nonsignificant (p = 0.5 and 0.6 respectively). CONCLUSION Obesity is associated with increased mortality in Asian PD patients. The study indicates a "V-shaped" trend in the association between BMI and mortality in these patients.
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Affiliation(s)
- Jing Liu
- Division of Nephrology, Kidney Research Institution, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Xiaoxi Zeng
- Division of Nephrology, Kidney Research Institution, West China Hospital of Sichuan University, Chengdu, Sichuan, China
- West China Biomedical Big Data Center, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Hyokyoung G. Hong
- Department of Statistics and Probability, Michigan State University, East Lansing, Michigan, United States of America
| | - Yi Li
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Ping Fu
- Division of Nephrology, Kidney Research Institution, West China Hospital of Sichuan University, Chengdu, Sichuan, China
- West China Biomedical Big Data Center, West China Hospital of Sichuan University, Chengdu, Sichuan, China
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Choi SJ, Park MY, Kim JK, Hwang SD. The 24-Month Changes in Body Fat Mass and Adipokines in Patients Starting Peritoneal Dialysis. Perit Dial Int 2017; 37:290-297. [PMID: 28096439 DOI: 10.3747/pdi.2016.00053] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Accepted: 11/13/2016] [Indexed: 12/31/2022] Open
Abstract
♦ BACKGROUND: Peritoneal dialysis (PD) is characterized by a gain in fat mass. The fat tissue is a complex endocrine organ that releases various adipokines. In this study, we prospectively examined serial changes of fat composition and adipokines in patients undergoing PD. ♦ METHODS: Body composition was assessed by computed tomography (CT). Nutrition status and adipokines (leptin, adiponectin, interleukin [IL]-6, and tumor necrosis factor [TNF]-α) were assessed on the 7th day and 6 months, 12 months, and 24 months after the start of PD. ♦ RESULTS: Fifty-four patients (28 men), with a mean age of 53.2 ± 13.2 years, were enrolled. Baseline fat mass, especially subcutaneous fat mass, was correlated with baseline leptin (ρ = 0.612), adiponetin (ρ = -0.477), and interleukin-6 (IL-6) (ρ = 0.391). Visceral fat mass was correlated with leptin (ρ = 0.545) and adiponectin (ρ = -0.514). Baseline adiponectin was negatively correlated with baseline leptin (ρ = -0.363). While body weight and leptin increased during the 24 months, serum adiponectin decreased in that period. The changes in visceral and subcutaneous fat mass were greater in the first 12 months and 6 months, respectively. There was no difference in IL-6 and TNF-α. Eight patients died during the follow-up period (mean 47.4 months). Twenty-seven patients continued PD. Increased baseline and serial change of IL-6 level were risk factors for mortality. After adjusting for age, sex, diabetes mellitus (DM), and coronary vascular disease (CVD), the significance of the IL-6 level disappeared. ♦ CONCLUSIONS: Baseline subcutaneous fat in patients starting PD is correlated with baseline adipokine levels rather than visceral fat. The increase in subcutaneous fat was greatest in the first 6 months. While leptin and adiponectin increased and decreased respectively, IL-6 did not change in the first 24 months.
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Affiliation(s)
- Soo Jeong Choi
- Department of Internal Medicine, College of Medicine, Soonchunhyang University Bucheon Hospital, Republic of Korea
| | - Moo Yong Park
- Department of Internal Medicine, College of Medicine, Soonchunhyang University Bucheon Hospital, Republic of Korea
| | - Jin Kuk Kim
- Department of Internal Medicine, College of Medicine, Soonchunhyang University Bucheon Hospital, Republic of Korea
| | - Seung Duk Hwang
- Department of Internal Medicine, College of Medicine, Soonchunhyang University Bucheon Hospital, Republic of Korea
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20
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Ekart R, Hojs R. Obese and diabetic patients with end-stage renal disease: Peritoneal dialysis or hemodialysis? Eur J Intern Med 2016; 32:1-6. [PMID: 27067614 DOI: 10.1016/j.ejim.2016.03.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Revised: 02/20/2016] [Accepted: 03/18/2016] [Indexed: 12/13/2022]
Abstract
Obesity is a chronic disease that is increasingly prevalent around the world and is a well-recognized risk factor for type 2 diabetes and hypertension, leading causes of end-stage renal disease (ESRD). The obese diabetic patient with ESRD is a challenge for the nephrologist with regard to the type of renal replacement therapy that should be suggested and offered to the patient. There is no evidence that either peritoneal dialysis or hemodialysis is contraindicated in obese ESRD patients. In the literature, we can find a discrepancy in the impact of obesity on mortality among hemodialysis vs. peritoneal dialysis patients. Several studies in hemodialysis patients suggest that a higher BMI confers a survival advantage - the so-called "reverse epidemiology". In contrast, the literature among obese peritoneal dialysis patients is inconsistent, with various studies reporting an increased risk of death, no difference, or a decreased risk of death. Many of these studies only spanned across a few years, and this is probably too short of a time frame for a realistic assessment of obesity's impact on mortality in ESRD patients. The decision for dialysis modality in an obese diabetic patient with ESRD should be individualized. According to the results of published studies, we cannot suggest PD or HD as a better solution for all obese diabetic patients. The obese patient should be educated about all their dialysis options, including home dialysis therapies. In this review, the available literature related to the dialysis modality in obese patients with diabetes and ESRD was reviewed.
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Affiliation(s)
- Robert Ekart
- University Medical Centre Maribor, Clinic for Internal Medicine, Department of Dialysis, Maribor, Slovenia; University of Maribor, Faculty of Medicine, Maribor, Slovenia.
| | - Radovan Hojs
- University of Maribor, Faculty of Medicine, Maribor, Slovenia; University Medical Centre Maribor, Clinic for Internal Medicine, Department of Nephrology, Maribor, Slovenia
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21
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Jin S, Lu Q, Su C, Pang D, Wang T. Shortage of Appendicular Skeletal Muscle Is an Independent Risk Factor for Mortality in Peritoneal Dialysis Patients. Perit Dial Int 2016; 37:78-84. [PMID: 27282855 DOI: 10.3747/pdi.2016.00019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 04/05/2016] [Indexed: 01/05/2023] Open
Abstract
♦ BACKGROUND: Limited data are available on clinical outcomes among peritoneal dialysis patients with shortage of appendicular skeletal muscle (ASM). In this study, we tested the hypothesis that the shortage of ASM is an independent risk factor for mortality in continuous ambulatory peritoneal dialysis (CAPD) patients. ♦ METHODS: Adult patients undergoing CAPD between March and August 2007 in a single center in China were recruited in this prospective cohort study. Body composition, protein/energy intake, clinical, and biochemical data were collected at baseline, 6 months, and 12 months. End points were all-cause mortality by 12 September 2014. The mean follow-up time was 60.21 (± 24.45) months (11.00 - 89.00). ♦ RESULTS: Compared with the baseline, the mean value of ASM in CAPD patients decreased at 12 months (19.40 ± 5.60 vs 21.85 ± 6.14, p < 0.001). According to the estimation of patient survival by Kaplan-Meier, patients with a shortage of ASM had a worse survival rate than those with normal ASM (χ2 = 16.588, p < 0.001). In the Cox's proportional hazards model, patients' survival was independently associated with a shortage of ASM (hazard ratio [HR] = 2.318, p = 0.024, 95% confidence interval [CI] = 1.116 - 4.812). Standard daily protein intake (stDPI) and standard daily energy intake (stDEI) in patients with a shortage of ASM were significantly lower than those in patients with normal ASM in the first follow-up year (t = 2.067, p = 0.041; t = 3.673, p = 0.001). ♦ CONCLUSIONS: A shortage of ASM is an independent risk factor for mortality in CAPD patients. Further studies are needed to demonstrate that nutritional intervention helps with improving muscle mass and, consequently, the survival of CAPD patients.
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Affiliation(s)
- Sanli Jin
- School of Nursing, Peking University, Beijing, China
| | - Qian Lu
- School of Nursing, Peking University, Beijing, China
| | - Chunyan Su
- Division of Nephrology, Peking University Third Hospital, Beijing, China
| | - Dong Pang
- School of Nursing, Peking University, Beijing, China
| | - Tao Wang
- Division of Nephrology, Peking University Third Hospital, Beijing, China
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22
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Lo WK. Metabolic syndrome and obesity in peritoneal dialysis. Kidney Res Clin Pract 2016; 35:10-4. [PMID: 27069852 PMCID: PMC4811989 DOI: 10.1016/j.krcp.2015.12.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 12/30/2015] [Accepted: 12/31/2015] [Indexed: 02/06/2023] Open
Abstract
Metabolic syndrome (MS) refers to clustering of features related to increased risk of cardiovascular disease, which include obesity or central obesity, dyslipidemia, diabetes mellitus or insulin resistance, together with hypertension. The prevalence of MS in end-stage renal failure patients on peritoneal dialysis is quite common, ranging from 40% to 60%, depending on the population studied and the definition used. However, there are controversies about the clinical outcome of patients with MS, particularly in the area of obesity. Whether peritoneal dialysis predisposes patients to MS is another unsolved issue. Despite these controversies, preventing patients from developing MS is important, at least from a theoretical point of view.
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Affiliation(s)
- Wai Kei Lo
- Department of Medicine, Tung Wah Hospital, Hong Kong SAR, China
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23
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Ahmadi SF, Zahmatkesh G, Streja E, Mehrotra R, Rhee CM, Kovesdy CP, Gillen DL, Ahmadi E, Fonarow GC, Kalantar-Zadeh K. Association of Body Mass Index With Mortality in Peritoneal Dialysis Patients: A Systematic Review and Meta-Analysis. Perit Dial Int 2015; 36:315-25. [PMID: 26475847 DOI: 10.3747/pdi.2015.00052] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 05/07/2015] [Indexed: 01/13/2023] Open
Abstract
UNLABELLED ♦ BACKGROUND Although higher body mass index (BMI) is associated with better outcomes in hemodialysis patients, the relationship in peritoneal dialysis (PD) patients is less clear. We aimed to synthesize the results from all large and high-quality studies to examine whether underweight, overweight, or obesity is associated with any significantly different risk of death in peritoneal dialysis patients. ♦ METHODS We searched MEDLINE, EMBASE, Web of Science, CINAHL, and Cochrane CENTRAL, and screened 7,123 retrieved studies for inclusion. Two investigators independently selected the studies using predefined criteria and assessed each study's quality using the Newcastle-Ottawa Quality Assessment Scale. We meta-analyzed the results of the largest studies with no overlap in their data sources. ♦ RESULTS We included 9 studies (n = 156,562) in the systematic review and 4 studies in the meta-analyses. When examined without stratifying studies by follow-up duration, the results of the studies were inconsistent. Hence, we pooled the study results stratified based upon their follow-up durations, as suggested by a large study, and observed that being underweight was associated with higher 1-year mortality but had no significant association with 2- and 3- to 5-year mortalities. In contrast, being overweight or obese was associated with lower 1-year mortality but it had no significant association with 2-, and 3- to 5-year mortalities. ♦ CONCLUSION Over the short-term, being underweight was associated with higher mortality and being overweight or obese was associated with lower mortality. The associations of body mass with mortality were not significant over the long-term.
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Affiliation(s)
- Seyed-Foad Ahmadi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California, USA Department of Population Health and Disease Prevention, Program in Public Health, University of California Irvine, Irvine, California, USA
| | - Golara Zahmatkesh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California, USA Veterans Affairs Long Beach Healthcare System, Long Beach, California, USA
| | - Rajnish Mehrotra
- Kidney Research Institute and Division of Nephrology, University of Washington, Seattle, Washington, USA
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California, USA
| | - Csaba P Kovesdy
- Memphis Veterans Affairs Medical Center, Memphis, Tennessee, USA Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Daniel L Gillen
- Department of Population Health and Disease Prevention, Program in Public Health, University of California Irvine, Irvine, California, USA Department of Statistics, Donald Bren School of Information and Computer Sciences, University of California Irvine, Irvine, California, USA Department of Epidemiology, UCLA School of Public Health, Los Angeles, California, USA
| | - Emad Ahmadi
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gregg C Fonarow
- Division of Cardiology, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California, USA Department of Population Health and Disease Prevention, Program in Public Health, University of California Irvine, Irvine, California, USA Veterans Affairs Long Beach Healthcare System, Long Beach, California, USA Department of Epidemiology, UCLA School of Public Health, Los Angeles, California, USA
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Kim JK, Kim YS, Song YR, Kim HJ, Kim SG, Moon SJ. Excessive Weight Gain during the First Year of Peritoneal Dialysis Is Associated with Inflammation, Diabetes Mellitus, and a Rapid Decrease in Residual Renal Function. PLoS One 2015; 10:e0139033. [PMID: 26406589 PMCID: PMC4583287 DOI: 10.1371/journal.pone.0139033] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 09/07/2015] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Significant weight gain is a potential problem in most patients starting peritoneal dialysis (PD); however, few studies have explored the clinical effects of increased body weight (BW) in these patients. We evaluated the effect of excess weight gain during the first year after PD on residual renal function (RRF). METHODS A total of 148 incident PD patients were analyzed in a longitudinal observational study. The mean duration of follow-up was 23.8 months. RRF was measured at baseline (within 1 month of starting PD) and thereafter at 6-month intervals for 2-3 years or until loss of RRF. BW was measured at the time of RRF measurement, and excess weight gain was defined as a BW increase over the median value (3.0%). RESULTS The median 1-year increase in BW was 2.3kg (IQR, 1.01-4.58) or 3.0% (IQR, 1.13-5.31). The mean slope of RRF decline was -0.068 ± 0.053 mL/min/month/1.73m2, and RRF loss developed in 48 patients at a mean follow-up time of 19.4 ± 6.8 months. Patients with BW increases > 3.0% showed significantly increased RRF decline rate compared to those without excess weight gain (p<0.001), and the BW increase (%/year) correlated significantly with higher hs-CRP levels and RRF decline rate. High systolic blood pressure, diabetes, large amount of proteinuria and excess BW gain significantly influenced the RRF decline rate. Also, it increased the risk of RRF loss by 4.17-fold (95% confidence intervals, 1.87-9.28; p<0.001). CONCLUSIONS Excess weight gain during the first year of PD was closely linked to systemic inflammation, diabetes and rapid decline in RRF.
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Affiliation(s)
- Jwa-Kyung Kim
- Department of Internal Medicine, Kidney Research Institute, Hallym University Sacred Heart Hospital, Hallym University, Anyang, Korea
| | - Young-Su Kim
- Department of Internal Medicine, Kidney Research Institute, Hallym University Sacred Heart Hospital, Hallym University, Anyang, Korea
| | - Young Rim Song
- Department of Internal Medicine, Kidney Research Institute, Hallym University Sacred Heart Hospital, Hallym University, Anyang, Korea
| | - Hyung Jik Kim
- Department of Internal Medicine, Kidney Research Institute, Hallym University Sacred Heart Hospital, Hallym University, Anyang, Korea
| | - Sung Gyun Kim
- Department of Internal Medicine, Kidney Research Institute, Hallym University Sacred Heart Hospital, Hallym University, Anyang, Korea
| | - Sung Jin Moon
- Department of Internal Medicine, International St. Mary’s Hospital, Catholic Kwandong University College of Medicine, Incheon, Korea
- * E-mail:
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Nessim SJ. Extremes of body mass index and mortality among Asian peritoneal dialysis patients. Perit Dial Int 2015; 34:338-41. [PMID: 24991049 DOI: 10.3747/pdi.2014.00031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Sharon J Nessim
- Division of Nephrology Jewish General Hospital McGill University Montreal, Quebec, Canada
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Van Huffel L, Tomson CRV, Ruige J, Nistor I, Van Biesen W, Bolignano D. Dietary restriction and exercise for diabetic patients with chronic kidney disease: a systematic review. PLoS One 2014; 9:e113667. [PMID: 25423489 PMCID: PMC4244158 DOI: 10.1371/journal.pone.0113667] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Accepted: 10/29/2014] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Obesity and sedentary lifestyle are major health problems and key features to develop cardiovascular disease. Data on the effects of lifestyle interventions in diabetics with chronic kidney disease (CKD) have been conflicting. STUDY DESIGN Systematic review. POPULATION Diabetes patients with CKD stage 3 to 5. SEARCH STRATEGY AND SOURCES: Medline, Embase and Central were searched to identify papers. INTERVENTION Effect of a negative energy balance on hard outcomes in diabetics with CKD. OUTCOMES Death, cardiovascular events, glycaemic control, kidney function, metabolic parameters and body composition. RESULTS We retained 11 studies. There are insufficient data to evaluate the effect on mortality to promote negative energy balance. None of the studies reported a difference in incidence of Major Adverse Cardiovascular Events. Reduction of energy intake does not alter creatinine clearance but significantly reduces proteinuria (mean difference from -0.66 to -1.77 g/24 h). Interventions with combined exercise and diet resulted in a slower decline of eGFR (-9.2 vs. -20.7 mL/min over two year observation; p<0.001). Aerobic and resistance exercise reduced HbA1c (-0.51 (-0.87 to -0.14); p = 0.007 and -0.38 (-0.72 to -0.22); p = 0.038, respectively). Exercise interventions improve the overall functional status and quality of life in this subgroup. Aerobic exercise reduces BMI (-0.74% (-1.29 to -0.18); p = 0.009) and body weight (-2.2 kg (-3.9 to -0.6); p = 0.008). Resistance exercise reduces trunk fat mass (-0,7±0,1 vs. +0,8 kg ±0,1 kg; p = 0,001-0,005). In none of the studies did the intervention cause an increase in adverse events. LIMITATIONS All studies used a different intervention type and mixed patient groups. CONCLUSIONS There is insufficient evidence to evaluate the effect of negative energy balance interventions on mortality in diabetic patients with advanced CKD. Overall, these interventions have beneficial effects on glycaemic control, BMI and body composition, functional status and quality of life, and no harmful effects were observed.
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Affiliation(s)
- Liesbeth Van Huffel
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
- European Renal Best Practice (ERBP), Ghent University Hospital, Ghent, Belgium
| | | | - Johannes Ruige
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
| | - Ionut Nistor
- European Renal Best Practice (ERBP), Ghent University Hospital, Ghent, Belgium
- Nephrology Department, "Dr. C.I. Parhon" University Hospital, University of Medicine and Pharmacy "Gr. T. Popa," Iasi, Romania
| | - Wim Van Biesen
- European Renal Best Practice (ERBP), Ghent University Hospital, Ghent, Belgium
- Renal Division, Ghent University Hospital, Ghent, Belgium
- * E-mail:
| | - Davide Bolignano
- European Renal Best Practice (ERBP), Ghent University Hospital, Ghent, Belgium
- CNR-Institute of Clinical Physiology, Reggio Calabria, Italy
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Sawant A, House AA, Overend TJ. Anabolic Effect of Exercise Training in People with End-Stage Renal Disease on Hemodialysis: A Systematic Review with Meta-analysis. Physiother Can 2014; 66:44-53. [PMID: 24719508 DOI: 10.3138/ptc.2012-59] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE The primary purpose of this systematic review was to evaluate the anabolic effect of exercise intervention in adults with end-stage renal disease on hemodialysis (HD). The secondary objectives were to evaluate the influences of participant characteristics and exercise parameters on changes in muscle size. METHODS Electronic databases (Cochrane, CINAHL, EMBASE, PEDro, PubMed and SCOPUS) were searched from inception to November 2012. Randomized clinical trials published in English that included adults on HD undergoing an exercise intervention where muscle mass was measured as an outcome were included in this review. Two reviewers independently selected the studies, extracted data, and assessed risk of bias within the included studies. RESULTS were then combined by meta-analysis. The effect of exercises was determined using a standardized mean difference (SMD), expressed as Hedges' g, computed using a random effects model. RESULTS Seven SMDs extracted from five studies were included for final analysis. Strength training was used in all studies; one study used aerobic and mixed strength and aerobic training with two subgroups of participants. The overall effect of exercise on muscle mass was statistically significant (SMD: 0.272; 95% CI, 0.020-0.525). CONCLUSIONS Our results confirm a small but significant effect of strengthening exercise as an anabolic intervention to increase muscle mass. Exercise training should be included in routine management of people on maintenance HD. Although current results indicate that one in nine people on HD is likely to benefit from exercise intervention, parameters influencing these results require further research.
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Affiliation(s)
- Anuradha Sawant
- Graduate Program in Health and Rehabilitation Sciences, Physical Therapy Field, Western University ; University Hospital Campus
| | - Andrew A House
- Western University Division of Nephrology, London Health Sciences Centre
| | - Tom J Overend
- School of Physical Therapy, Western University, London, Ont
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Kim YK, Kim SH, Kim HW, Kim YO, Jin DC, Song HC, Choi EJ, Kim YL, Kim YS, Kang SW, Kim NH, Yang CW. The association between body mass index and mortality on peritoneal dialysis: a prospective cohort study. Perit Dial Int 2014; 34:383-9. [PMID: 24584607 DOI: 10.3747/pdi.2013.00008] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Previous studies have demonstrated that increased body mass index (BMI) is associated with decreased mortality in hemodialysis (HD) patients. However, the association between BMI and survival has not been well established in patients undergoing peritoneal dialysis (PD). The aim of the study was to determine the association between BMI and mortality in the PD population using the Clinical Research Center (CRC) registry for end-stage renal disease (ESRD) cohort in Korea. METHODS Prevalent patients with PD were selected from the CRC registry for ESRD, a prospective cohort study on dialysis patients in Korea. Patients were categorized into four groups by quartiles of BMI. Cox regression analysis was used to calculate the adjusted hazard ratio (HR) of mortality with a BMI of quartile 2 (21.4 - 23.5 kg/m(2)) as the reference. RESULTS A total of 900 prevalent patients undergoing PD were included. The median follow-up period was 24 months. The multivariate Cox proportional hazard model showed that the lowest quartile of BMI was associated with higher mortality (HR 3.00, 95% confidence interval (CI), 1.26 - 7.15). However, the higher quartiles of BMI were not associated with mortality compared with the reference category of BMI quartile 2 (Quartile 3: HR 1.11, 95% CI, 0.43 - 2.85, Quartile 4: HR 1.64, 95% CI, 0.66 - 4.06) after adjustment for clinical variables. CONCLUSIONS Lower BMI was a significant risk factor for death, but increased BMI was not associated with mortality in Korean PD patients.
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Affiliation(s)
- Yong Kyun Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea; Department of Internal Medicine, College of Medicine, Chung-Ang University, Seoul, Korea; Department of Internal Medicine, School of Medicine, Kyungpook National University, Korea; Department of Internal Medicine, College of Medicine, Seoul National University, Seoul, Korea; Department of Internal Medicine, College of Medicine, Yonsei University, Seoul, Korea; Department of Internal Medicine, Chonnam National University Medical School, Korea
| | - Su-Hyun Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea; Department of Internal Medicine, College of Medicine, Chung-Ang University, Seoul, Korea; Department of Internal Medicine, School of Medicine, Kyungpook National University, Korea; Department of Internal Medicine, College of Medicine, Seoul National University, Seoul, Korea; Department of Internal Medicine, College of Medicine, Yonsei University, Seoul, Korea; Department of Internal Medicine, Chonnam National University Medical School, Korea
| | - Hyung Wook Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea; Department of Internal Medicine, College of Medicine, Chung-Ang University, Seoul, Korea; Department of Internal Medicine, School of Medicine, Kyungpook National University, Korea; Department of Internal Medicine, College of Medicine, Seoul National University, Seoul, Korea; Department of Internal Medicine, College of Medicine, Yonsei University, Seoul, Korea; Department of Internal Medicine, Chonnam National University Medical School, Korea
| | - Young Ok Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea; Department of Internal Medicine, College of Medicine, Chung-Ang University, Seoul, Korea; Department of Internal Medicine, School of Medicine, Kyungpook National University, Korea; Department of Internal Medicine, College of Medicine, Seoul National University, Seoul, Korea; Department of Internal Medicine, College of Medicine, Yonsei University, Seoul, Korea; Department of Internal Medicine, Chonnam National University Medical School, Korea
| | - Dong Chan Jin
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea; Department of Internal Medicine, College of Medicine, Chung-Ang University, Seoul, Korea; Department of Internal Medicine, School of Medicine, Kyungpook National University, Korea; Department of Internal Medicine, College of Medicine, Seoul National University, Seoul, Korea; Department of Internal Medicine, College of Medicine, Yonsei University, Seoul, Korea; Department of Internal Medicine, Chonnam National University Medical School, Korea
| | - Ho Chul Song
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea; Department of Internal Medicine, College of Medicine, Chung-Ang University, Seoul, Korea; Department of Internal Medicine, School of Medicine, Kyungpook National University, Korea; Department of Internal Medicine, College of Medicine, Seoul National University, Seoul, Korea; Department of Internal Medicine, College of Medicine, Yonsei University, Seoul, Korea; Department of Internal Medicine, Chonnam National University Medical School, Korea
| | - Euy Jin Choi
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea; Department of Internal Medicine, College of Medicine, Chung-Ang University, Seoul, Korea; Department of Internal Medicine, School of Medicine, Kyungpook National University, Korea; Department of Internal Medicine, College of Medicine, Seoul National University, Seoul, Korea; Department of Internal Medicine, College of Medicine, Yonsei University, Seoul, Korea; Department of Internal Medicine, Chonnam National University Medical School, Korea
| | - Yong-Lim Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea; Department of Internal Medicine, College of Medicine, Chung-Ang University, Seoul, Korea; Department of Internal Medicine, School of Medicine, Kyungpook National University, Korea; Department of Internal Medicine, College of Medicine, Seoul National University, Seoul, Korea; Department of Internal Medicine, College of Medicine, Yonsei University, Seoul, Korea; Department of Internal Medicine, Chonnam National University Medical School, Korea
| | - Yon-Su Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea; Department of Internal Medicine, College of Medicine, Chung-Ang University, Seoul, Korea; Department of Internal Medicine, School of Medicine, Kyungpook National University, Korea; Department of Internal Medicine, College of Medicine, Seoul National University, Seoul, Korea; Department of Internal Medicine, College of Medicine, Yonsei University, Seoul, Korea; Department of Internal Medicine, Chonnam National University Medical School, Korea
| | - Shin-Wook Kang
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea; Department of Internal Medicine, College of Medicine, Chung-Ang University, Seoul, Korea; Department of Internal Medicine, School of Medicine, Kyungpook National University, Korea; Department of Internal Medicine, College of Medicine, Seoul National University, Seoul, Korea; Department of Internal Medicine, College of Medicine, Yonsei University, Seoul, Korea; Department of Internal Medicine, Chonnam National University Medical School, Korea
| | - Nam-Ho Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea; Department of Internal Medicine, College of Medicine, Chung-Ang University, Seoul, Korea; Department of Internal Medicine, School of Medicine, Kyungpook National University, Korea; Department of Internal Medicine, College of Medicine, Seoul National University, Seoul, Korea; Department of Internal Medicine, College of Medicine, Yonsei University, Seoul, Korea; Department of Internal Medicine, Chonnam National University Medical School, Korea
| | - Chul Woo Yang
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea; Department of Internal Medicine, College of Medicine, Chung-Ang University, Seoul, Korea; Department of Internal Medicine, School of Medicine, Kyungpook National University, Korea; Department of Internal Medicine, College of Medicine, Seoul National University, Seoul, Korea; Department of Internal Medicine, College of Medicine, Yonsei University, Seoul, Korea; Department of Internal Medicine, Chonnam National University Medical School, Korea
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Prasad N, Sinha A, Gupta A, Sharma RK, Bhadauria D, Chandra A, Prasad KN, Kaul A. Effect of body mass index on outcomes of peritoneal dialysis patients in India. Perit Dial Int 2014; 34:399-408. [PMID: 24584600 DOI: 10.3747/pdi.2013.00056] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES We studied the effect of body mass index (BMI) at peritoneal dialysis (PD) initiation on patient and technique survival and on peritonitis during follow-up. METHODS We followed 328 incident patients on PD (176 with diabetes; 242 men; mean age: 52.6 ± 12.6 years; mean BMI: 21.9 ± 3.8 kg/m(2)) for 20.0 ± 14.3 months. Patients were categorized into four BMI groups: obese, ≥ 25 kg/m(2); overweight, 23 - 24.9 kg/m(2); normal, 18.5 - 22.9 kg/m(2) (reference category); and underweight, <18.5 kg/m(2). The outcomes of interest were compared between the groups. RESULTS Of the 328 patients, 47 (14.3%) were underweight, 171 (52.1%) were normal weight, 53 (16.2%) were overweight, and 57 (17.4%) were obese at commencement of PD therapy. The crude hazard ratio (HR) for mortality (p = 0.004) and the HR adjusted for age, subjective global assessment, comorbidities, albumin, diabetes, and residual glomerular filtration rate (p = 0.02) were both significantly greater in the underweight group than in the normal-weight group. In comparison with the reference category, the HR for mortality was significantly greater for underweight PD patients with diabetes [2.7; 95% confidence interval (CI): 1.5 to 5.0; p = 0.002], but similar for all BMI categories of nondiabetic PD patients. Median patient survival was statistically inferior in underweight patients than in patients having a normal BMI. Median patient survival in underweight, normal, overweight, and obese patients was, respectively, 26 patient-months (95% CI: 20.9 to 31.0 patient-months), 50 patient-months (95% CI: 33.6 to 66.4 patient-months), 57.7 patient-months (95% CI: 33.2 to 82.2 patient-months), and 49 patient-months (95% CI: 18.4 to 79.6 patient-months; p = 0.015). Death-censored technique survival was statistically similar in all BMI categories. In comparison with the reference category, the odds ratio for peritonitis occurrence was 1.8 (95% CI: 0.9 to 3.4; p = 0.086) for underweight patients; 1.7 (95% CI: 0.9 to 3.2; p = 0.091) for overweight patients; and 3.4 (95% CI: 1.8 to 6.4; p < 0.001) for obese patients. CONCLUSIONS In our PD patients, mean BMI was within the normal range. The HR for mortality was significantly greater for underweight diabetic PD patients than for patients in the reference category. Death-censored technique survival was similar in all BMI categories. Obese patients had a greater risk of peritonitis.
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Affiliation(s)
- Narayan Prasad
- Departments of Nephrology and Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Archana Sinha
- Departments of Nephrology and Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Amit Gupta
- Departments of Nephrology and Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Raj Kumar Sharma
- Departments of Nephrology and Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Dharmendra Bhadauria
- Departments of Nephrology and Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Abhilash Chandra
- Departments of Nephrology and Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Kashi Nath Prasad
- Departments of Nephrology and Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Anupama Kaul
- Departments of Nephrology and Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Kiran VR, Zhu TY, Yip T, Lui SL, Lo WK. Body mass index and mortality risk in Asian peritoneal dialysis patients in Hong Kong-impact of diabetes and cardiovascular disease status. Perit Dial Int 2014; 34:390-8. [PMID: 24497598 DOI: 10.3747/pdi.2013.00055] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Obesity increases mortality in the general population, but improves survival in hemodialysis patients. In peritoneal dialysis (PD) patients, the reported effect is controversial. We investigated the effect of body mass index (BMI) on patient survival in Asian PD patients. METHODS The survival of incident Asian PD patients from 2001 to 2008 in a single center in Hong Kong was analyzed retrospectively. Baseline demographic and clinical data were collected from patient records. Patients who had a total Kt/V below 1.7 or who died within 6 months were excluded. The BMI was categorized using the World Health Organization recommendation for Asian populations. RESULTS In the 274 study patients [154 men (56%); 138 with diabetes (50.4%); mean age: 63.4 ± 14.6 years; mean BMI: 21.97 ± 3.23 kg/m(2); 37 underweight (13.5%); 35 obese (12.8%)], the relative risk (RR) for mortality [adjusted for age, diabetes status, and cardiovascular disease (CVD)] was similar for the normal and overweight groups, but higher for the underweight (RR: 1.909; p = 0.028) and obese groups (RR: 1.799; p = 0.048). The increased mortality in obese patients was more prominent in patients with diabetes (RR: 1.9 vs 1.19 in patients without diabetes; p = 0.074 and 0.76 respectively), and in patients with CVD (RR: 8.895 vs 1.642 in patients without CVD; p = 0.012 and 0.122 respectively). CONCLUSIONS In Asian PD patients, the relationship between BMI and mortality was U-shaped, with higher mortality in the underweight and obese patients. The negative impact of obesity was more prominent in patients with diabetes and CVD.
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Affiliation(s)
- Verukonda Ravi Kiran
- Care Hospitals, Hyderabad, Andhra Pradesh, India; Huashan Hospital, Fudan University, Shanghai, PR China; and Dr. Lee Iu Cheung Memorial Renal Centre, Department of Medicine, Tung Wah Hospital, Hong Kong SAR, PR China
| | - Tong Ying Zhu
- Care Hospitals, Hyderabad, Andhra Pradesh, India; Huashan Hospital, Fudan University, Shanghai, PR China; and Dr. Lee Iu Cheung Memorial Renal Centre, Department of Medicine, Tung Wah Hospital, Hong Kong SAR, PR China
| | - Terence Yip
- Care Hospitals, Hyderabad, Andhra Pradesh, India; Huashan Hospital, Fudan University, Shanghai, PR China; and Dr. Lee Iu Cheung Memorial Renal Centre, Department of Medicine, Tung Wah Hospital, Hong Kong SAR, PR China
| | - Sing Leung Lui
- Care Hospitals, Hyderabad, Andhra Pradesh, India; Huashan Hospital, Fudan University, Shanghai, PR China; and Dr. Lee Iu Cheung Memorial Renal Centre, Department of Medicine, Tung Wah Hospital, Hong Kong SAR, PR China
| | - Wai Kei Lo
- Care Hospitals, Hyderabad, Andhra Pradesh, India; Huashan Hospital, Fudan University, Shanghai, PR China; and Dr. Lee Iu Cheung Memorial Renal Centre, Department of Medicine, Tung Wah Hospital, Hong Kong SAR, PR China
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31
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Di Micco L, Quinn RR, Ronksley PE, Bellizzi V, Lewin AM, Cianciaruso B, Ravani P. Urine creatinine excretion and clinical outcomes in CKD. Clin J Am Soc Nephrol 2013; 8:1877-83. [PMID: 24158796 DOI: 10.2215/cjn.01350213] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Twenty-four-hour urine creatinine excretion is a reliable approximation of muscle mass. Whether changes in urine creatinine predict clinical outcomes in persons with CKD is unknown. This work studied the relationship between urine creatinine and patient and renal survival in people with CKD not requiring renal replacement therapy. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This longitudinal cohort study included incident stages 3-5 CKD patients referred to the renal clinic at the University Federico II in Naples between January of 1995 and December of 2005. Clinical data and urine creatinine were updated at each visit. Main outcomes were all-cause mortality and kidney failure requiring dialysis. RESULTS This study enrolled 525 individuals and followed them for a median of 6 years (range of 4 months to 15 years). Urine creatinine excretion declined by 16 mg/d per year (95% confidence interval, 14 to 19) in participants with CKD stages 3a, 3b, and 4, and it remained stable in participants with stage 5 CKD. Per each 20 mg/d decline in urine creatinine, mortality increased by 3% (adjusted hazard ratio, 1.03; 95% confidence interval, 1.01 to 1.05), and the risk of initiating dialysis increased by 2% (adjusted hazard ratio, 1.02; 95% confidence interval, 1.01 to 1.03). These associations were independent of body mass index and GFR. CONCLUSIONS In persons with CKD stages 3 and 4, urine creatinine declines at a rate of 16 mg/d per year. Lower urine creatinine excretion predicts greater risk of kidney failure and patient mortality.
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Affiliation(s)
- Lucia Di Micco
- Department of Medicine, Division of Nephrology, Hospital A. Landolfi, Solofra (AV), Italy;, †Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada;, ‡Division of Nephrology, Dialysis and Transplantation, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy, §Department of Nephrology, University of Naples "Federico II," Naples, Italy
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Park J, Ahmadi SF, Streja E, Molnar MZ, Flegal KM, Gillen D, Kovesdy CP, Kalantar-Zadeh K. Obesity paradox in end-stage kidney disease patients. Prog Cardiovasc Dis 2013; 56:415-25. [PMID: 24438733 DOI: 10.1016/j.pcad.2013.10.005] [Citation(s) in RCA: 242] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In the general population, obesity is associated with increased cardiovascular risk and decreased survival. In patients with end-stage renal disease (ESRD), however, an "obesity paradox" or "reverse epidemiology" (to include lipid and hypertension paradoxes) has been consistently reported, i.e. a higher body mass index (BMI) is paradoxically associated with better survival. This survival advantage of large body size is relatively consistent for hemodialysis patients across racial and regional differences, although published results are mixed for peritoneal dialysis patients. Recent data indicate that both higher skeletal muscle mass and increased total body fat are protective, although there are mixed data on visceral (intra-abdominal) fat. The obesity paradox in ESRD is unlikely to be due to residual confounding alone and has biologic plausibility. Possible causes of the obesity paradox include protein-energy wasting and inflammation, time discrepancy among competitive risk factors (undernutrition versus overnutrition), hemodynamic stability, alteration of circulatory cytokines, sequestration of uremic toxin in adipose tissue, and endotoxin-lipoprotein interaction. The obesity paradox may have significant clinical implications in the management of ESRD patients especially if obese dialysis patients are forced to lose weight upon transplant wait-listing. Well-designed studies exploring the causes and consequences of the reverse epidemiology of cardiovascular risk factors, including the obesity paradox, among ESRD patients could provide more information on mechanisms. These could include controlled trials of nutritional and pharmacologic interventions to examine whether gain in lean body mass or even body fat can improve survival and quality of life in these patients.
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Affiliation(s)
- Jongha Park
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA; Division of Nephrology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea.
| | - Seyed-Foad Ahmadi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA
| | - Miklos Z Molnar
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA
| | | | - Daniel Gillen
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA; Department of Statistics, University of California Irvine, Irvine, CA
| | - Csaba P Kovesdy
- Division of Nephrology, Memphis Veterans Affairs Medical Center, Memphis, TN, USA; Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA; Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA.
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Peritoneal dialysis outcomes in a modern cohort of overweight patients. Int Urol Nephrol 2013; 46:183-9. [PMID: 23793809 DOI: 10.1007/s11255-013-0472-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Accepted: 05/13/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND The incidence of obesity is increasing both in the general population and in incident dialysis patients. While there is evidence that being overweight is associated with good outcomes in hemodialysis, the evidence in peritoneal dialysis (PD) patients is not very clear. We studied a modern cohort of PD patients to examine outcomes in large patients. METHODS Forty-three patients who started PD, who weighed more than 90 kg at dialysis initiation, between January/2000 and June/2010 were matched with 43 control patients who weighed less than 90 kg. Detailed review of the charts was undertaken. RESULTS The mean weight and body mass index of the wt < 90 kg group were 69.3 ± 11.3 kg and 25.0 ± 3.9 kg/m(2). The number of peritonitis episodes per year was 0.33 ± 0.6 (wt < 90 kg) and 0.82 ± 1.7 (wt ≥ 90 kg) (p = 0.26). The median time to first peritonitis showed a trend toward earlier peritonitis in larger patients [9.5 (4.3, 27) months in wt ≥ 90 kg, 19.1(7.9, 30.8) months in wt < 90 kg] but did not reach statistical significance (p = 0.12). Surprisingly, hernias and leaks were more common in the weight <90 kg group (44 vs. 18.6 % p = 0.02). There was no difference in total number of hospitalizations or the number of days hospitalized. Kaplan-Meier analysis of survival on PD showed no differences between the two groups (logrank p = 0.99). Cox regression analysis using age, race, cause of ESRD due to diabetes and Charlson comorbidity index as the covariates did not show weight to be associated with survival on PD. CONCLUSIONS Large patients tend to do just as well on PD, with survival on PD being no different compared to individuals with lower weight and body mass index.
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Choi SJ, Kim EJ, Park MY, Kim JK, Hwang SD. Does body fat mass define survival in patients starting peritoneal dialysis? Perit Dial Int 2013; 34:376-82. [PMID: 23378474 DOI: 10.3747/pdi.2011.00152] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND AIMS Peritoneal dialysis (PD) is characterized by a gain in fat mass. Unlike subcutaneous fat, visceral fat is associated with metabolic syndrome and survival. We prospectively examined whether visceral or subcutaneous fat could predict outcome in patients undergoing PD. METHODS We studied 117 new patients (57 men) undergoing PD between February 2006 and November 2011. Baseline body composition was measured on computed tomograms. Visceral obesity was defined as a visceral fat area exceeding 100 cm(2), and subcutaneous obesity, as a subcutaneous fat area exceeding 130 cm(2). RESULTS Among the 117 patients, 37 and 29 were diagnosed with visceral and subcutaneous obesity respectively. Visceral and subcutaneous obesity were both present in 21 patients. In the study population, the 1-year and 5-year survival rates were 94% and 59%. The rates of peritonitis and exit-infection were 0.31 and 0.14 episodes per patient-year. Mortality was greater in patients with visceral obesity than in those without visceral obesity (p = 0.005). Visceral obesity had no influence on peritonitis and exit-infection rates. Subcutaneous obesity was associated neither with survival nor with peritonitis or exit-site infection. In a multivariate Cox regression analysis, visceral obesity was not a risk factor for poor outcome. CONCLUSIONS Increased visceral fat at PD initiation is not an independent predictor of poor survival. Any impact of visceral or subcutaneous fat mass on outcomes in patients undergoing PD would be better defined by larger, long-term studies.
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Affiliation(s)
- Soo Jeong Choi
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon Hospital, Korea
| | - Eun Jung Kim
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon Hospital, Korea
| | - Moo Yong Park
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon Hospital, Korea
| | - Jin Kuk Kim
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon Hospital, Korea
| | - Seung Duk Hwang
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon Hospital, Korea
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Fernandes NMDS, Bastos MG, Franco MRG, Chaoubah A, Lima MDG, Divino-Filho JC, Qureshi AR. Body size and longitudinal body weight changes do not increase mortality in incident peritoneal dialysis patients of the Brazilian peritoneal dialysis multicenter study. Clinics (Sao Paulo) 2013; 68:51-8. [PMID: 23420157 PMCID: PMC3552459 DOI: 10.6061/clinics/2013(01)oa08] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Accepted: 09/23/2012] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To determine the roles of body size and longitudinal body weight changes in the survival of incident peritoneal dialysis patients. PATIENTS AND METHODS Patients (n = 1911) older than 18 years of age recruited from 114 dialysis centers (Dec/ 2004-Oct/2007) and participating in the Brazilian Peritoneal Dialysis Multicenter Cohort Study were included. Clinical and laboratory data were collected monthly (except if the patient received a transplant, recovered renal function, was transferred to hemodialysis, or died). RESULTS Survival analyses were performed using Kaplan-Meier survival curves and Cox proportional hazards. Total follow-up was 34 months. The mean age was 59 years (54% female). The weight category percentages were as follows: underweight: 8%; normal: 51%; overweight: 29%; and obese 12%. The multivariate model showed a higher risk of death for a body mass index <18.5 kg/m², a neutral risk between 25 and 29.9 kg/m² and a protective effect for an index >30 kg/m². Patients were divided into five categories according to quintiles of body weight changes during the first year of dialysis: <-3.1%, -3.1 to+0.12%, +0.12 to <+3.1% (reference category), +3.1 to +7.1% and >+7.1%. Patients in the lowest quintile had significantly higher mortality, whereas no negative impact was observed in the other quintiles. CONCLUSION These findings suggest that overweight/obesity and a positive body weight variation during the first year of peritoneal dialysis therapy do not increase mortality in incident dialysis patients in Brazil.
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Affiliation(s)
- Natália Maria da Silva Fernandes
- Federal University of Juiz de Fora, Interdisciplinary Program of Studies, Research, and Treatment in Nephrology, Juiz de Fora/MG, Brazil.
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Kim JC, Kalantar-Zadeh K, Kopple JD. Frailty and protein-energy wasting in elderly patients with end stage kidney disease. J Am Soc Nephrol 2012; 24:337-51. [PMID: 23264684 DOI: 10.1681/asn.2012010047] [Citation(s) in RCA: 195] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Older people constitute an increasingly greater proportion of patients with advanced CKD, including those patients undergoing maintenance dialysis treatment. Frailty is a biologic syndrome of decreased reserve and resistance to stressors that results from cumulative declines across multiple physiologic systems and causes vulnerability to adverse outcomes. Frailty is common in elderly CKD patients, and it may be associated with protein-energy wasting (PEW), sarcopenia, dynapenia, and other complications of CKD. Causes of frailty with or without PEW in the elderly with CKD can be classified into three categories: causes primarily caused by aging per se, advanced CKD per se, or a combination of both conditions. Frailty and PEW in elderly CKD patients are associated with impaired physical performance, disability, poorer quality of life, and reduced survival. Prevention and treatment of these conditions in the elderly CKD patients often require a multifaceted approach. Here, we examine the causes and consequences of these conditions and examine the interplay between frailty and PEW in elderly CKD patients.
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Affiliation(s)
- Jun Chul Kim
- Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California 90502, USA
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Lee MJ, Shin DH, Kim SJ, Oh HJ, Yoo DE, Kim JK, Park JT, Han SH, Kang SW, Choi KH, Yoo TH. Visceral fat thickness is associated with carotid atherosclerosis in peritoneal dialysis patients. Obesity (Silver Spring) 2012; 20:1301-7. [PMID: 21818151 DOI: 10.1038/oby.2011.245] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Visceral fat has been known to associate with atherosclerosis, inflammation, and insulin resistance. However, the influence of visceral fat on cardiovascular disease (CVD) in peritoneal dialysis (PD) patients has never been elucidated. We investigated whether visceral fat thickness (VFT) has a predictive role in carotid atherosclerosis determined by carotid intima-media thickness (cIMT) in PD patients. A cross-sectional study was undertaken in 88 prevalent PD patients. BMI and waist circumference (WC) were measured as anthropometric indexes of obesity. VFT and subcutaneous fat thickness (SFT) were determined by sonographic measurement of abdominal fat. Carotid atherosclerosis was defined as increased cIMT (>1.0 mm) or presence of plaque. Thirty-two (36.3%) patients had carotid atherosclerosis. Patients with carotid atherosclerosis showed significantly higher VFT, BMI, and WC. In univariate logistic analysis, BMI, WC, and VFT except SFT were significant risk factors of carotid atherosclerosis. However, multivariate analysis revealed VFT was an independent factor associated with carotid atherosclerosis after adjusting for demographic, biochemical parameters, and anthropometric indexes (per 1 mm increase, odds ratio (OR) = 2.294, 95% confidence interval: 1.048-5.021, P = 0.038). When the patients were divided into three groups according to VFT, log high sensitivity C-reactive protein (hs-CRP), and homeostasis model assessment-insulin resistance (HOMA(IR)) were both higher in the third tertile compared to other tertiles. In conclusion, VFT, not SFT, is independently associated with carotid atherosclerosis in PD patients. Therefore sonographic measurement of VFT could be useful to stratify the risk of cardiovascular disease in PD patients.
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Affiliation(s)
- Mi Jung Lee
- Department of Internal Medicine, College of Medicine, Yonsei University, Seoul, Korea
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Abstract
Protein-energy wasting (PEW) is prevalent among patients on dialysis and has emerged as an important risk factor for morbidity and mortality in these patients. Numerous factors, including inflammation, inadequate dialysis, insufficient nutrient intake, loss of protein during dialysis, chronic acidosis, hypercatabolic illness and comorbid conditions, are involved in the development of PEW. The causes and clinical features of PEW in patients on peritoneal dialysis and hemodialysis are comparable; assessment of the factors that lead to PEW in patients receiving peritoneal dialysis is important to ensure that PEW is managed correctly in these patients. For the past 20 years, much progress has been made in the prevention and treatment of PEW. However, the results of most nutritional intervention studies are inconclusive. In addition, the multifactorial and complicated pathogenesis of PEW makes it difficult to assess and treat. This Review summarizes the nutritional issues regarding the causes, assessment and treatment of PEW, with a focus on patients receiving peritoneal dialysis. In addition, an in-depth overview of the results of nutritional intervention studies is provided.
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Gołębiewska JE, Lichodziejewska-Niemierko M, Aleksandrowicz-Wrona E, Majkowicz M, Lysiak-Szydłowska W, Rutkowski B. Influence of megestrol acetate on nutrition, inflammation and quality of life in dialysis patients. Int Urol Nephrol 2011; 44:1211-22. [PMID: 21805328 PMCID: PMC3401504 DOI: 10.1007/s11255-011-0025-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2011] [Accepted: 06/17/2011] [Indexed: 12/21/2022]
Abstract
AIM Malnutrition is a common clinical problem in dialysis patients. The objective of this study was to evaluate the efficacy and safety of megestrol acetate in malnourished dialysis patients. Thirty-two hypoalbuminemic dialysis patients took 160 mg of megestrol acetate daily for up to 6 months. METHODS We measured height, dry weight, BMI, modified Subjective Global Assessment (SGA) score, and serum albumin, triglycerides, total cholesterol, hsCRP, IL-1β and IL-6 concentrations. We used validated questionnaires to evaluate selected dimensions of the quality of life. RESULTS Only 12 patients completed the study. All patients reported improved appetite, and there were concurrent statistically significant increases in weight, BMI, SGA and albumin concentration (P < 0.05). For the 12 patients who completed 6 months of treatment the increase in these parameters was from 63.26 ± 13.04 to 65.58 ± 12.53 kg, from 23.5 ± 3.8 to 24.66 ± 4.23 kg/m(2), from 5.16 ± 0.94 to 6.16 ± 0.72 points, and from 36.45 ± 1.82 to 40.33 ± 2.71 g/l, respectively. However, there were no significant changes in the levels of inflammatory markers and in quality of life. Side effects included overhydration, excessive weight gain and hyperglycaemia. CONCLUSION Megestrol acetate may be effective in reversing poor appetite in carefully selected maintenance dialysis patients, but it might not reduce inflammation or improve the quality of life. Because of the potential side effects, close monitoring is essential.
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Affiliation(s)
- Justyna E Gołębiewska
- Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdańsk, ul. Dębinki 7, 80-952 Gdańsk, Poland.
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Liberek T, Warzocha A, Galgowska J, Taszner K, Clark WF, Rutkowski B. When to initiate dialysis--is early start always better? Nephrol Dial Transplant 2011; 26:2087-91. [PMID: 21543652 DOI: 10.1093/ndt/gfr181] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
The question when to initiate dialysis is attracting increasing attention. In recent years, there has been a tendency to initiate dialysis earlier in terms of estimated glomerular filtration rate (eGFR) in an attempt to achieve better patient outcomes. However, several observational studies and one randomized controlled trial have found no benefit for early dialysis initiation. On the contrary, they have found that starting dialysis with a higher eGFR is associated with increased mortality. These studies need to be carefully interpreted in light of their reliance on eGFR to estimate kidney function at dialysis initiation. The decision to start dialysis should not be based solely on a predefined eGFR value, but more importantly on a careful clinical assessment of the individual patient.
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Bonanni A, Mannucci I, Verzola D, Sofia A, Saffioti S, Gianetta E, Garibotto G. Protein-energy wasting and mortality in chronic kidney disease. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2011; 8:1631-54. [PMID: 21655142 PMCID: PMC3108132 DOI: 10.3390/ijerph8051631] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2011] [Revised: 04/29/2011] [Accepted: 05/03/2011] [Indexed: 02/06/2023]
Abstract
Protein-energy wasting (PEW) is common in patients with chronic kidney disease (CKD) and is associated with an increased death risk from cardiovascular diseases. However, while even minor renal dysfunction is an independent predictor of adverse cardiovascular prognosis, PEW becomes clinically manifest at an advanced stage, early before or during the dialytic stage. Mechanisms causing loss of muscle protein and fat are complex and not always associated with anorexia, but are linked to several abnormalities that stimulate protein degradation and/or decrease protein synthesis. In addition, data from experimental CKD indicate that uremia specifically blunts the regenerative potential in skeletal muscle, by acting on muscle stem cells. In this discussion recent findings regarding the mechanisms responsible for malnutrition and the increase in cardiovascular risk in CKD patients are discussed. During the course of CKD, the loss of kidney excretory and metabolic functions proceed together with the activation of pathways of endothelial damage, inflammation, acidosis, alterations in insulin signaling and anorexia which are likely to orchestrate net protein catabolism and the PEW syndrome.
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Affiliation(s)
- Alice Bonanni
- Division of Nephrology, Dialysis and Transplantation, Department of Internal Medicine, Azienda Ospedale Università San Martino, Genoa University, Viale Benedetto XV 6, Genoa, Italy; E-Mails: (A.B.); (I.M.); (D.V.); (A.S.); (S.S.)
| | - Irene Mannucci
- Division of Nephrology, Dialysis and Transplantation, Department of Internal Medicine, Azienda Ospedale Università San Martino, Genoa University, Viale Benedetto XV 6, Genoa, Italy; E-Mails: (A.B.); (I.M.); (D.V.); (A.S.); (S.S.)
| | - Daniela Verzola
- Division of Nephrology, Dialysis and Transplantation, Department of Internal Medicine, Azienda Ospedale Università San Martino, Genoa University, Viale Benedetto XV 6, Genoa, Italy; E-Mails: (A.B.); (I.M.); (D.V.); (A.S.); (S.S.)
| | - Antonella Sofia
- Division of Nephrology, Dialysis and Transplantation, Department of Internal Medicine, Azienda Ospedale Università San Martino, Genoa University, Viale Benedetto XV 6, Genoa, Italy; E-Mails: (A.B.); (I.M.); (D.V.); (A.S.); (S.S.)
| | - Stefano Saffioti
- Division of Nephrology, Dialysis and Transplantation, Department of Internal Medicine, Azienda Ospedale Università San Martino, Genoa University, Viale Benedetto XV 6, Genoa, Italy; E-Mails: (A.B.); (I.M.); (D.V.); (A.S.); (S.S.)
| | - Ezio Gianetta
- Department of Surgery, Azienda Ospedale Università San Martino, Genoa University, Largo R. Benzi, Genoa, Italy; E-Mail:
| | - Giacomo Garibotto
- Division of Nephrology, Dialysis and Transplantation, Department of Internal Medicine, Azienda Ospedale Università San Martino, Genoa University, Viale Benedetto XV 6, Genoa, Italy; E-Mails: (A.B.); (I.M.); (D.V.); (A.S.); (S.S.)
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Leinig CE, Moraes T, Ribeiro S, Riella MC, Olandoski M, Martins C, Pecoits-Filho R. Predictive value of malnutrition markers for mortality in peritoneal dialysis patients. J Ren Nutr 2010; 21:176-83. [PMID: 21193323 DOI: 10.1053/j.jrn.2010.06.026] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2009] [Revised: 05/23/2010] [Accepted: 06/13/2010] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Alterations in nutritional status have been described as important predictors of mortality in patients with chronic kidney disease (CKD). However, the association between multiple markers for nutritional status and the mortality rates of patients with CKD on peritoneal dialysis (PD) has not yet been illustrated in previously published data, particularly by using the new definition of protein energy wasting (PEW). OBJECTIVE To evaluate the predictive value of malnutrition markers for mortality rates, on the basis of the PEW definition, of PD patients. MATERIALS AND METHODS At the start of PD treatment, the nutritional status of 199 patients (mean age, 56 ± 13.3 years; 53% females) was evaluated. Body mass index (BMI), arm circumference, mid-arm muscle circumference, protein and caloric intake (by using a 3-day food record), and serum albumin were all recorded, as well as a subjective global assessment (SGA) and presence of PEW. Cut-off points were defined on the basis of the consensus of the International Society for Renal Nutrition and Metabolism (albumin, <3.8 g/dL; BMI, <23 kg/m(2); mid-arm muscle circumference, >10% in comparison with the 50th percentile for the reference population; protein intake, <0.8 g/kg/daily; caloric intake, <25 kcal/kg/daily). The data were obtained retrospectively between the years 2001 and 2008 on the basis of routine nutritional evaluation. Patients were monitored for fatal events from all possible causes. RESULT The mean BMI for the population was 26.6 ± 5.0 kg/m(2). A median protein intake of 0.94 (0.18 to 4.57) g/kg/daily was reported and 60.3% of the patients reported a protein intake of <0.8 g/kg/daily. With respect to caloric intake, 38.7% of the patients consumed <25 kcal/kg/daily. A median of 3.5 (1.4 to 5.3) g/dL for serum albumin was observed and 29.3% of the patients presented values of <3.8 g/dL. PEW was diagnosed in 17.5% of patients. In the univariate model, being of age >65 years (P = .002), cardiovascular disease (P < .001), diabetes mellitus (P = .02), SGA (P = .02), and albumin (P = .002), were all significant markers for mortality. The presence of patients aged >65 years (P = .02), with diabetes mellitus (P = .057), cardiovascular disease (P = .005), and albumin were considered as independent factors for mortality in this study. CONCLUSION SGA, albumin, and PEW were the only nutritional markers found to be associated with mortality in this cohort of PD patients. In the multivariate analysis, after adjusting for classic mortality risk factors, only patients with hypoalbuminemia were found to be at a high risk for mortality at follow-up. These results may be limited by the number of observations and a necessity for confirmation in larger prospective studies.
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Affiliation(s)
- Cyntia Erthal Leinig
- Division of Nephrology, Center for Health and Biological Sciences, Pontifícia Universidade Católica do Paraná, Curitiba, Brazil
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Sloand JA, Leypoldt JK, Culleton BF, Gellens ME, Paniagua R, Amato D, Vonesh EF. Assessing creatinine clearance from modification of diet in renal disease study equations in the ADEMEX cohort: limitations and potential applications. Clin J Am Soc Nephrol 2010; 6:598-604. [PMID: 21164018 DOI: 10.2215/cjn.04970610] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVES Twenty-four-hour urine and dialysate collections provide accepted means to assess adequacy in peritoneal dialysis (PD). Recent publications suggest that creatinine clearance (CrCl) estimated from the Modification of Diet in Renal Disease (MDRD) equations (eCrCl) accurately approximates measured CrCl (mCrCl) derived from 24-hour collections of urine and dialysate and might serve as an alternative means to assess small-solute clearance and adequacy in PD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Post hoc analysis of data from patients enrolled in ADEMEX was used to assess agreement between mCrCl and eCrCl derived by four- and six-variable MDRD equations (4V-MDRDE and 6V-MDRDE, respectively). Additionally, associations among mCrCl, eCrCl, and survival were determined. RESULTS Acceptable precision was observed between mCrCl and 4V-MDRDE-eCrCl and 6V-MDRDE-eCrCl for the entire cohort. Precision was markedly diminished when analysis was limited to functionally anuric patients with mCrCl < 12 ml/min per 1.73 m². Although there was no association between survival and mCrCl, for every 1-ml/min per 1.73 m² increase in 4V- and 6V-MDRDE-eCrCl, there was a 6% and 4% increase in risk of death, respectively. There was a negative association between MDRDE-eCrCl and creatinine appearance rates, suggesting MDRDE-eCrCl is significantly confounded by individual differences in muscle mass. CONCLUSIONS MDRDE-eCrCl provides demographically comparable values to 24-hour urine and dialysate collections across the ADEMEX cohort. However, MDRDEs should not be used to assess small-solute removal or adequacy in individual PD patients or to predict outcome in any cohort of patients over narrow ranges of limited clearance.
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Affiliation(s)
- James A Sloand
- Baxter Healthcare Corporation, Renal Division, McGaw Park, IL 60085, USA.
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Noori N, Kovesdy CP, Dukkipati R, Kim Y, Duong U, Bross R, Oreopoulos A, Luna A, Benner D, Kopple JD, Kalantar-Zadeh K. Survival predictability of lean and fat mass in men and women undergoing maintenance hemodialysis. Am J Clin Nutr 2010; 92:1060-70. [PMID: 20844076 PMCID: PMC2954443 DOI: 10.3945/ajcn.2010.29188] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Nazanin Noori
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA 90502, USA
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Choi SJ, Kim NR, Hong SA, Lee WB, Park MY, Kim JK, Hwang SD, Lee HK. Changes in body fat mass in patients after starting peritoneal dialysis. Perit Dial Int 2010; 31:67-73. [PMID: 20448238 DOI: 10.3747/pdi.2009.00131] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Peritoneal dialysis (PD) is characterized by gain in fat mass. Visceral fat mass is associated with metabolic syndrome and atherosclerosis rather than subcutaneous fat mass. In addition, the change in visceral fat mass is a more reliable predictor of survival in PD patients. In this study, we prospectively examined serial changes in fat composition and nutritional status and analyzed factors associated with gain in fat mass in patients undergoing PD. METHODS Body composition was assessed by bioelectric impedance analysis (BIA) and computed tomogram (CT). Nutrition status was assessed by Subjective Global Assessment (SGA), protein equivalent of nitrogen appearance (nPNA), serum albumin, C-reactive protein (CRP), and lipid profile. All measurements except BIA were performed on the seventh day and at 6 and 12 months after the start of PD. RESULTS 60 patients (30 men; mean age 55.0 ± 12.5 years) were enrolled. Increase in body weight continued during the 12 months but visceral and subcutaneous fat mass increased during the first 6 months and decreased during the second 6 months. While hematocrit and serum albumin decreased during the first 6 months, they did not change during the second 6 months. Serum creatinine, total cholesterol, and triglyceride increased similarly to the weight pattern. While nPNA decreased during the 12 months, Kt/V, SGA, and CRP did not change. Patients that had more visceral fat mass at the start of PD had less gain of visceral fat mass during the first 6 months (r = -0.821, p = 0.002). Patients that had more subcutaneous fat mass at the start of PD had less gain of subcutaneous fat mass (r = -0.709, p = 0.015). The change in weight was not associated with the change in visceral or subcutaneous fat during the first 6 months. CONCLUSION Patients starting PD experience weight gain, including visceral and subcutaneous fat, during the first 6 months of PD. Patients with high baseline fat mass had less increase in fat mass than those with low baseline fat mass, regardless of visceral or subcutaneous fat mass.
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Affiliation(s)
- Soo Jeong Choi
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon Hospital, Korea
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Wu HY, Hung KY, Hu FC, Chen YM, Chu TS, Huang JW, Wu KD, Tsai TJ. Risk factors for high dialysate glucose use in PD patients--a retrospective 5-year cohort study. Perit Dial Int 2010; 30:448-55. [PMID: 20228176 DOI: 10.3747/pdi.2009.00063] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Use of high concentrations of glucose for peritoneal dialysis (PD) may produce unfavorable results. Our previous study showed that high initial glucose load is associated with poor PD technique survival. OBJECTIVE This retrospective cohort study at a medical center in Taiwan aimed to understand the factors associated with high glucose load in long-term PD patients. PATIENTS AND METHODS We reviewed 90 newly started PD patients over 5 years. We determined glucose load by calculating annual glucose weight and dialysate volume administered. Multiple linear regression analyses with time-dependent covariates were used to determine factors that influence the annual average dialysate glucose concentration. RESULTS The study group included 47 men and 43 women with a mean age of 53.4 +/- 13.9 years. Technique survival rates were 91.0%, 84.1%, and 77.6% at the beginning of the second, third, and fourth year of PD therapy respectively. The presence of diabetes mellitus (DM), high body mass index (BMI), and low weekly renal Kt/V were significantly correlated with high average dialysate glucose concentration during the first, second, and third years. For patients undergoing PD for more than 3 years, residual renal function (RRF) deteriorated, and only DM significantly affected higher dialysate glucose concentration in the fourth year. CONCLUSIONS Patients with DM, high BMI, and low RRF were more likely to require a high glucose load for PD therapy, especially during the first 3 years. After those 3 years of PD, DM was the only significant factor in the need for higher glucose load. To reduce the glucose load in chronic PD patients, alternative osmotic agents such as icodextrin or amino acids should be considered in the daily PD regimen.
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Affiliation(s)
- Hon-Yen Wu
- Department of Internal Medicine, Far Eastern Memorial Hospital, Pan-Chiao, Taipei, Taiwan
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Liberek T, Warzocha A, Chmielewski M, Rutkowski B. Initiation of dialysis--the right timing and the right tools. Nephrol Dial Transplant 2009; 24:3895-6; author reply 3896. [DOI: 10.1093/ndt/gfp438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Phelan PJ, O'Kelly P, Walshe JJ, Conlon PJ. The Importance of Serum Albumin and Phosphorous as Predictors of Mortality in ESRD Patients. Ren Fail 2009; 30:423-9. [DOI: 10.1080/08860220801964236] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Oreopoulos DG, Thodis E, Passadakis P, Vargemezis V. Home dialysis as a first option: a new paradigm. Int Urol Nephrol 2009; 41:595-605. [DOI: 10.1007/s11255-009-9575-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2009] [Accepted: 04/15/2009] [Indexed: 11/24/2022]
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