Malnutrition, a new inducer for arterial calcification in hemodialysis patients?

Chronic kidney disease mineral bone disorder in childhood and young adulthood: a 'growing' understanding

Chronic kidney disease (CKD) mineral and bone disorder (MBD) comprises a triad of biochemical abnormalities (of calcium, phosphate, parathyroid hormone and vitamin D), bone abnormalities (turnover, mineralization and growth) and extra-skeletal calcification. Mineral dysregulation leads to bone demineralization causing bone pain and an increased fracture risk compared to healthy peers. Vascular calcification, with hydroxyapatite deposition in the vessel wall, is a part of the CKD-MBD spectrum and, in turn, leads to vascular stiffness, left ventricular hypertrophy and a very high cardiovascular mortality risk. While the growing bone requires calcium, excess calcium can deposit in the vessels, such that the intake of calcium, calcium- containing medications and high calcium dialysate need to be carefully regulated. Normal physiological bone mineralization continues into the third decade of life, many years beyond the rapid growth in childhood and adolescence, implying that skeletal calcium requirements are much higher in younger people compared to the elderly. Much of the research into the link between bone (de)mineralization and vascular calcification in CKD has been performed in older adults and these data must not be extrapolated to children or younger adults. In this article, we explore the physiological changes in bone turnover and mineralization in children and young adults, the pathophysiology of mineral bone disease in CKD and a potential link between bone demineralization and vascular calcification.

Impact of serum albumin level and variability on short-term cardiovascular-related and all-cause mortality in patients on maintenance hemodialysis

Studies have shown that low serum albumin (Salb) levels are associated with a high risk of mortality among patients on maintenance hemodialysis (MHD); however, the impact of Salb variability on short-term cardiovascular mortality remains unclear. Herein, we investigated the association between Salb levels and Salb variability on short-term all-cause and cardiovascular-related mortality in patients on MHD.Eligible patients on MHD at Chongqing General Hospital between June 2017 and June 2020 were recruited in this study. Patients were grouped by Salb levels (normal Salb, ≥3.8 g/dL; low Salb, 3.4-3.8 g/dL; and lower Salb, 2-3.4 g/dL) and Salb variability (decreased, >5% loss; increased, >5% gain; and steady, 5% loss to 5% gain). Associations between Salb levels, Salb variability, and all-cause and cardiovascular-related mortality were analyzed using Cox regression models. A survival analysis was performed using the Kaplan-Meier analysis.We enrolled a total of 181 patients on MHD with an average age of 65 years (interquartile range [IQR], 53-75 years). The mean Salb level was 3.8 ± 0.6 g/dL (IQR 2.9-4.4 g/dL), and the median Salb variability was 2.6% per year (IQR, -4.1 to 6.5). Fifty-two (29%) patients died, including 31 (17%) patients who died due to cardiovascular-related causes. Compared with the other groups, the lower Salb group had higher all-cause mortality (P < .01). Cox regression analyses revealed that lower Salb levels and decreased Salb variability were independently associated with all-cause mortality (hazard ratio [HR] = 1.95, 95% confidence interval [CI] 1.103-3.452; HR = 2.245, 95% CI 1.084-4.650), whereas increased Salb variability was independently associated with cardiovascular-related mortality (HR = 2.919, 95% CI 1.178-7.234; P < .05).Lower Salb levels were an independent predictor of all-cause mortality in patients on MHD. Increased Salb variability was strongly associated with cardiovascular-related mortality in the same population, especially in the short-term and in patients with normal Salb levels. Significantly elevated Salb variability should be evaluated to reduce cardiovascular-related mortality.

Malnutrition as a risk factor for cardiac valve calcification in patients under maintenance dialysis: a cross-sectional study

PURPOSE

Cardiac valve calcification (CVC) is a significant risk factor for cardiovascular morbidity and mortality in patients with chronic kidney disease on maintenance hemodialysis. The aim of this study was to investigate the association of several risk factors and particularly of malnutrition on CVC.

METHODS

In this cross-sectional cohort study, we included stable adult patients on maintenance hemodialysis. Calcification of cardiac valves was evaluated using two-dimensional echocardiography. Nutritional assessment and body composition measurements were performed using the MQSGA clinical tool and bioelectrical impedance analysis, respectively. Biochemical parameters such as serum calcium, phosphorus, iPTH, 1.25 hydroxy-vitamin-D, triglycerides, total cholesterol, HDL-C, LDL-C, total proteins, albumin, creatinine and CRP were assessed as potentially risk factors. The receiver operating characteristic (ROC) curve analysis was used to evaluate the prognostic ability of the aforementioned variables on severe degree CVC. Binary logistic regression analysis was also performed to identify independent variables of severe CVC.

RESULTS

Overall, 42 patients were included in the study with half of them exhibiting mitral calcification, 38% aortic valve calcification, and 16.7% calcification in both valves. ROC analysis indicated that aging (p = 0.011), increased CRP (p = 0.038) and decreased value of serum albumin to total proteins ratio (p = 0.012) were positive prognostic factors for moderate to severe degree cardiac valve calcification. Low phase angle was also associated with CVC, although with moderate specificity.

CONCLUSION

Aging, inflammation, low serum albumin to total proteins ratio and low phase angle values as indicators of malnutrition are predictors of severe CVC in end-stage renal disease patients on hemodialysis.

Malnutrition and cardiovascular risk in haemodialysis patients with chronic kidney disease

ABSTRACT Objective To verify the association between nutritional status and traditional and non-traditional cardiovascular risk factors in haemodialysis patients. Methods A cross-sectional study with 132 patients over 18 years of age on haemodialysis to evaluate nutritional status through Subjective Global Assessment. Information on traditional and non-traditional cardiovascular disease risk factors were obtained using a structured questionnaire; the Framingham score was also used to assess cardiovascular risk. Data analysis was performed using the Chi-square Test or Fischer Exact Test and a Log-binomial Regression Model. Results Malnutrition affected 31.1% of patients. Among them, a higher percentage of smokers (p=0.016), former smokers (p=0.034) and diabetes Mellitus patients (p=0.001) were detected. Malnutrition was found to be 4.53 times more prevalent in diabetic individuals (95%CI: 1.99-10.27) and 2.26 times more prevalent among former smokers (95%CI: 1.04-4.95). Malnourished individuals exhibited a 4.03 times prevalence of moderate to severe cardiovascular risk. Conclusion A high prevalence of malnutrition and of other risk factors for cardiovascular disease were observed. Such factors included diabetes Mellitus, smoking and former smoker conditions and were associated with malnutrition. Inaddition, it was found that malnourished individuals were more likely to develop cardiovascular disease within 10 years.

The relationship between poor nutritional status and progression of aortic calcification in patients on maintenance hemodialysis

Background

Although aortic calcification has a significant negative impact on prognosis in patients on hemodialysis (HD), risk factors for aortic calcification progression remain unclear. The aim of this study was to investigate the relationship between malnutrition and aortic calcification progression in patients on HD.

Methods

Between April 2015 and October 2016, we treated 232 patients on HD. Of those, we retrospectively evaluated data from 184 patients who had had regular blood tests and computed tomography (CT) scans. The abdominal aortic calcification index (ACI) was quantitatively measured by abdominal CT. Nutritional status was evaluated using the Geriatric Nutritional Risk Index (GNRI). A normalized treatment ratio of functional urea clearance was evaluated by Kt/V. The difference in ACI values between 2015 and 2016 was evaluated as a ΔACI, and patients were stratified into two groups according to ΔACI value: high (≥75th percentile, ΔACI-high group) and low (<75th percentile, ΔACI-low group). Variables such as age, sex, comorbidities, dialysis vintage, serum data, and GNRI were compared between ΔACI-high and ΔACI-low patients. Factors independently associated with a higher ΔACI progression (ΔACI ≥75th percentile) were determined using multivariate logistic analysis.

Results

Median values of ACIs in 2015 and 2016 were 40.8 and 44.6%, respectively. Of 184 patients, 125 (68%) patients experienced ACI progression for 1 year. The median ΔACI and 75th percentile of ΔACI were 2.5% and 5.8%, respectively. The number of patients in the ΔACI-low and ΔACI-high groups were 128 (70%) and 56 (30%), respectively. There were significant differences in sex, presence of diabetic nephropathy, HD vintage, serum albumin, serum phosphate, C-reactive protein, intact parathyroid hormone, Kt/V, and GNRI. Multivariate logistic regression analysis revealed that independent factors associated with a higher ΔACI progression were male sex, serum phosphate levels, HD vintage, and GNRI of < 90.

Conclusions

Our results suggest that poor nutritional status is an independent risk factor for the progression of aortic calcification. Nutrition management may have the potential to improve progression of aortic calcification in patients on HD.

Trial registration

UMIN Clinical Trials Registry UMIN000028050.

Apocynin attenuates angiotensin II-induced vascular smooth muscle cells osteogenic switching via suppressing extracellular signal-regulated kinase 1/2

Vascular calcification (VC) is a significant risk factor for cardiovascular morbidity and mortality. We recently reported that apocynin had benefits for preventing cardiovascular diseases. However, whether apocynin could attenuate VC is unknown. Here, we investigated the role of apocynin in VC and its underlying mechanisms. 163 participants with high or normal ankle–brachial index (ABI) were enrolled in this study for analyzing the demographic and biochemical data. In vitro, vascular smooth muscle cells (VSMCs) were exposed to calcification medium containing b-glycerophosphate and angiotensin II (Ang II) for 24 hours. The results showed that serum level of Ang II was significantly increased in patients with high ABI (P<0.05). In cultured VSMCs, Ang II significantly exacerbated osteogenic switching. The expression of osteogenic phenotype markers, including bone morphogenetic protein 2 (BMP2), runt-related transcription factor 2 (Runx2) and osteopontin (OPN), were significantly upregulated, whereas contractile markers expression, including alpha smooth muscle actin (a-SMA) and smooth muscle 22 alpha (SM22a) were simultaneously downregulated. However, these effects were greatly attenuated by apocynin. Apocynin enhanced expression of a-SMA by 5.3%, and reduced expression of BMP2, Runx2, OPN by 3.37%, 0.61% and 3.07%, respectively. Furthermore, extracellular signal-regulated kinase 1/2 (ERK1/2) phosphorylation was upregulated by Ang II, and this effect was also reversed by apocynin. Intriguingly, pretreatment with U0126, an inhibitor of ERK1/2, had similar effects with apocynin. Apocynin may act as a novel molecular candidate to protect against VSMCs osteogenic switching through suppressing ERK1/2 pathway.

Worsening calcification propensity precedes all-cause and cardiovascular mortality in haemodialyzed patients

A novel in-vitro test (T₅₀-test) assesses ex-vivo serum calcification propensity which predicts mortality in HD patients. The association of longitudinal changes of T₅₀ with all-cause and cardiovascular mortality has not been investigated. We assessed T₅₀ in paired sera collected at baseline and at 24 months in 188 prevalent European HD patients from the ISAR cohort, most of whom were Caucasians. Patients were followed for another 19 [interquartile range: 11–37] months. Serum T₅₀ exhibited a significant decline between baseline and 24 months (246 ± 64 to 190 ± 68 minutes; p < 0.001). With serum Δ-phosphate showing the strongest independent association with declining T₅₀ (r = −0.39; p < 0.001) in multivariable linear regression. The rate of decline of T₅₀ over 24 months was a significant predictor of all-cause (HR = 1.51 per 1SD decline, 95% CI: 1.04 to 2.2; p = 0.03) and cardiovascular mortality (HR = 2.15; 95% CI: 1.15 to 3.97; p = 0.02) in Kaplan Meier and multivariable Cox-regression analysis, while cross-sectional T₅₀ at inclusion and 24 months were not. Worsening serum calcification propensity was an independent predictor of mortality in this small cohort of prevalent HD patients. Prospective larger scaled studies are needed to assess the value of calcification propensity as a longitudinal parameter for risk stratification and monitoring of therapeutic interventions.

Evaluation of nutritional status using anthropometric measurements and MQSGA in geriatric hemodialysis patients

OBJECTIVE

Malnutrition is common among hemodialysis patients and is associated with higher rates of morbidity and mortality. The aim of this study was to evaluate nutritional status of geriatric hemodialysis patients.

METHODS

Total of 163 hemodialysis patients were initially screened, and 55 patients (28 males, 27 females; mean age: 72.9±8.4 years) met the criteria for inclusion. Patients were divided into 3 groups according to modified quantitative subjective global assessment (MQSGA) scores: Group I (n=22) normal nutrition, Group II (n=20) mild-to-moderate malnutrition, and Group III (n=13) severe malnutrition.

RESULTS

When we assessed the correlation between MQSGA nutrition score and data of malnourished patients (n=33), positive significant correlation was found between age, C-reactive protein level, and malnutrition-inflammation score. Negative significant correlation was found between body mass index, bicep skinfold, tricep skinfold, mid-arm circumference, mid-arm muscle circumference, and phosphate and albumin levels.

CONCLUSION

Malnutrition is very common and increasing with aging in geriatric hemodialysis patients. MQSGA score and anthropometric measurements can be used to assess nutritional status in geriatric hemodialysis patients.

Apocynin improving cardiac remodeling in chronic renal failure disease is associated with up-regulation of epoxyeicosatrienoic acids

Cardiac remodeling is one of the most common cardiac abnormalities and associated with a high mortality in chronic renal failure (CRF) patients. Apocynin, a nicotinamide-adenine dinucleotide phosphate (NADPH) oxidase inhibitor, has been showed cardio-protective effects. However, whether apocynin can improve cardiac remodeling in CRF and what is the underlying mechanism are unclear. In the present study, we enrolled 94 participants. In addition, we used 5/6 nephrectomized rats to mimic cardiac remodeling in CRF. Serum levels of epoxyeicosatrienoic acids (EETs) and its mainly metabolic enzyme-soluble epoxide hydrolase (sEH) were measured. The results showed that the serum levels of EETs were significantly decreased in renocardiac syndrome participants (P < 0.05). In 5/6 nephrectomized CRF model, the ratio of left ventricular weight / body weight, left ventricular posterior wall thickness, and cardiac interstitial fibrosis were significantly increased while ejection fraction significantly decreased (P < 0.05). All these effects could partly be reversed by apocynin. Meanwhile, we found during the process of cardiac remodeling in CRF, apocynin significantly increased the reduced serum levels of EETs and decreased the mRNA and protein expressions of sEH in the heart (P < 0.05). Our findings indicated that the protective effect of apocynin on cardiac remodeling in CRF was associated with the up-regulation of EETs. EETs may be a new mediator for the injury of kidney-heart interactions.

MICS, an easily ignored contributor to arterial calcification in CKD patients

In chronic kidney disease (CKD), simultaneous mineral and skeleton changes are prevalent, known as CKD-mineral bone disorder (CKD-MBD). Arterial calcification (AC) is a clinically important complication of CKD-MBD. It can increase arterial stiffness, which leads to severe cardiovascular events. However, current treatments have little effect on regression of AC, as its mechanisms are still unclear. There are multiple risk factors of AC, among which Malnutrition-Inflammation Complex Syndrome (MICS) is a new and crucial one. MICS, a combined syndrome of malnutrition and inflammation, generally begins at the early stage of CKD and becomes obvious in end-stage renal disease (ESRD). It was linked to reverse epidemiology and associated with increased cardiovascular mortality in ESRD patients. Recent data suggest that MICS can trigger CKD-MBD and accelerate the course of AC. In this present review, we summarize the recent understanding about the aggravating effects of MICS on AC and discuss the possible underlying mechanisms. A series of findings indicate that targeting MICS will provide a potential strategy for treating AC in CKD.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Factors associated with depression and anxiety in patients with end-stage renal disease receiving maintenance hemodialysis

OBJECTIVES

To investigate anxiety, depression, and related factors in patients with end-stage renal disease (ESRD) receiving maintenance hemodialysis and provide a reference for the establishment of a healthier life for such patients.

METHODS

A total of 81 patients were enrolled in the study. Qualified participants filled out self-rating anxiety scale (SAS) and depression self-assessment scale (SDS) questionnaires as well as assessments of health knowledge and health self-efficacy. Linear regression analysis was performed to relate demographic factors, lifestyle habits, and nutrition parameters to SDS and SAS score indices.

RESULTS

The mean SAS and SDS score indices for the 81 patients were 52.96 and 46.71, respectively; 56 patients (69.1 %) had a depressive disorder (SDS score ≥ 50), and 31 patients (36.9 %) had anxiety symptoms (SAS score ≥ 50). SAS score index correlated with gender (p < .05) and history of alcohol use (p < .01), whereas SDS score index correlated with administration of erythropoietin (EPO) (p < .05) as well as gender and history of alcohol use.

CONCLUSION

History of alcohol consumption may predict less depressive symptoms and more anxiety among Chinese patients living in a northeastern Chinese city with ESRD. EPO administration may reduce anxiety in patients with ESRD. Female patients were more prone to anxiety, whereas males were more likely to show symptoms of depression. These factors should be evaluated by nephrologists treating patients with ESRD.