Association of Fluid Status and Body Composition with Physical Function in Patients with Chronic Kidney Disease

Acute Water Supplementation Improved the Body Composition of Young Female Adults After Water Restriction of 12 h in Baoding, China: A Randomized Controlled Trial (RCT)

Insufficient intake of water may influence the balance of water in the human body. In this study, we explore the impacts of water supplementation on body composition indices among young adults after 12 h of water restriction, with the aim to determine the optimum volume of water for improving body water composition. A randomized controlled trial study was conducted among 64 young men and women in Baoding, China. After fasting overnight for 12 h, anthropometric measurements and urine and blood samples were collected as a baseline test at 8:00 a.m. of Day 2. Body composition was determined by measuring the ECW (extracellular water), ICW (intracellular water), and TBW (total body water) through bioelectrical impedance analysis (BIA). The participants were randomly divided into four groups, including water supplementation (WS) groups 1, 2, and 3, with 500, 200, and 100 mL of water, respectively, and a no water supplementation (NW) group. After 90 min, they were reassessed in a rehydration test (at 10:00 a.m. of Day 2). Repeated measurement ANOVA was used to assess the impact of water supplementation on body composition. Comparing the baseline and rehydration tests, interactions between time and volume were not significant among the men (all p > 0.05). Among women, a significant interaction was only found in ECW (p = 0.043), with TBW tending toward being significant (p = 0.055). Comparing the baseline and rehydration tests, the ECW in WS group 1, WS group 3, and the NW group all decreased (p = 0.028, p = 0.001, and p = 0.029), with reductions of 0.1, 0.3, and 0.2 kg, respectively; however, no significant decrease was observed in WS group 2 (p = 0.329). Furthermore, comparing the WS groups with the NW group in the rehydration test, the differences were not significant (p = 1.000, p = 1.000, and p = 0.288, respectively). Between men and women within groups, all of the body composition indices differed significantly, both at baseline and rehydration tests (all p < 0.05). Water supplementation led to changes in the distribution of the water content in young female adults in this study-but not men-after 12 h of water restriction, with no decrease in ECW. Finally, we found that 200 mL was the minimum volume capable of improving the water content distribution in participants in this study.

Trial Registration

[www.chictr.org.cn], identifier [ChiCTR-IOR-17011568].

Relationship between quadriceps thickness and 60-second sit-to-stand test in patients with chronic kidney disease

BACKGROUND

This study aimed to evaluate the relationship between quadriceps muscle thickness and functional performance on the 60s sit-to-stand test (60s-STS), the six-minute walk test (6MWT), and handgrip strength in non-dialytic stage 4 and 5 chronic kidney disease (CKD) patients.

METHODS

This was a cross-sectional study that evaluated 40 CKD patients aged between 30-70 years. Participants were submitted to an assessment that included quadriceps muscle thickness evaluated by a portable ultrasound. Functional performance tests included the 60s-STS, distance walked in the 6MWT, and handgrip strength. Also, body composition evaluated using electrical bioimpedance analysis and physical activity level through the short version of International Physical Activity were measured. Multiple linear regression was used to investigate the relationship between the quadriceps thickness and functional performance.

RESULTS

Quadriceps muscle thickness was correlated to 60s-STS (R2 = 43.6%; 95% CI = 0.022 - 0.665; β = 0.34; p = 0.037). Also, a moderate correlation between this muscle thickness and appendicular skeletal muscle (ALM) was found in CKD patients (r = 0.603, p <0.001). No relationship was found between quadriceps muscle thickness with the 6MWT and handgrip strength.

CONCLUSION

Quadriceps muscle thickness is associated to 60s-STS, thus our results demonstrate the repercussions of the disease on the musculoskeletal system.

The Impact of Home-Based Exercise Program on Physical Function of Chronic Kidney Disease Patients: A Meta-Analysis of Randomized Controlled Trials

Background Home-based exercise program showed the potential in improving physical function of chronic kidney disease patients, and it might need low associated costs. We conducted a systematic review and meta-analysis to explore the impact of home-based exercise program on physical function of chronic kidney disease patients.

Methods PubMed, EMBASE, Web of science, EBSCO, and Cochrane library databases were systematically searched. This meta-analysis included randomized controlled trials (RCTs) assessing the effect of home-based exercise program on physical function of chronic kidney disease patients. Two investigators independently searched articles, extracted data, and assessed the quality of included studies. The primary outcomes were 6-min walk test and grip strength change.

Results Seven RCTs were included in the meta-analysis. Overall, compared with control intervention in chronic kidney disease patients, home-based exercise program could significantly improve 6-min walk test (MD=79.01; 95% CI=22.39–135.62; P=0.006) and grip strength (SMD=0.52; 95% CI=0.14–0.89; P=0.007), but showed no impact on pain scores (SMD=−1.43; 95% CI=−3.75 to 0.88; P=0.22), Kidney Disease Quality of life including symptom/problem list (SMD=1.92; 95% CI=−1.06 to 4.90; P=0.21), effects of kidney disease (SMD=−3.69; 95% CI=−8.56 to 1.19; P=0.14), or burden of kidney disease (SMD=1.04; 95% CI=−0.75 to 2.82; P=0.26).

Conclusions Home-based exercise program might improve physical function for chronic kidney disease, and more RCTs should be conducted to confirm this issue.

Association of Body Composition, Physical Functioning, and Protein Intake in Adult Patients With Mitochondrial Diseases

BACKGROUND

Whether decreased physical functioning of patients with mitochondrial disease (MD) is related to altered body composition or low protein intake needs clarification at the background of the nutrition state.

METHODS

In this 2-site cross-sectional study, MD patients were age-, body mass index (BMI)-, and gender-matched to controls. Body composition was assessed by dual-energy x-ray absorptiometry. Physical functioning was measured by handgrip strength, 6-minute walking test, 30-second sit-to-stand test (30SCT), and 6-minute mastication test. Total daily protein intake was calculated by 3-day food records. Malnutrition was assessed by Patient-Generated Subjective Global Assessment and the Global Leadership Initiative on Malnutrition (GLIM) criteria and sarcopenia by the 2018 consensus. Data were analyzed using independent samples t-tests, Fisher exact test, and Spearman and Pearson correlation coefficients.

RESULTS

Thirty-seven MD patients (42 ± 12 years, BMI: 23 ± 4 kg/m² , 59% females) and 37 matched controls were included. Handgrip strength was moderate, inversely related to fat mass index in both MD patients and controls, whereas it correlated with fat-free mass index in controls solely. Protein intake was associated with muscle strength (handgrip strength and 30SCT) in MD patients but not in controls. Twenty-seven MD patients (73%) were malnourished, and 5 (14%) were classified as sarcopenic.

CONCLUSIONS

Muscle strength is related to body composition and protein intake in MD patients. This, in combination with the high incidence of both malnutrition and sarcopenia, warrants individual nutrition assessment in MD patients.

Effects of a Structured Physical Activity Program on Serum Adipokines and Markers of Inflammation and Volume Overload in Kidney Transplant Recipients

BACKGROUND Kidney transplantation (KTx) reverses most abnormalities related to chronic kidney disease (CKD), but sedentary lifestyle persists in most kidney graft recipients. Physical inactivity has been associated with altered adipokine profile and inflammation in CKD. We postulated that increased physical activity achieved through an individually-tailored program can reverse these changes. MATERIAL AND METHODS We included 25 clinically stable KTx recipients at least 12 months after transplantation and with eGFR >30 mL/min and 15 age-matched non-dialysis patients with CKD stage 3. Body composition, pattern of daily physical activity, and serum concentrations of leptin, adiponectin, NT-proBNP, and hsCRP were assessed at baseline. All patients in both groups participated in a 12-week supervised exercise program with short cell phone text reminders. All measurements were repeated after 3 months. RESULTS Active energy expenditure increased significantly during the 3 months in both the KTx and CKD patients, compared with baseline by 47% (p<0.001) and 20% (p=0.01), respectively. Time spent daily on physical activity was also increased (129±83 vs. 194±142 and 81±56 vs. 124±57 min, respectively, p<0.001). Adipose tissue mass decreased significantly in the KTx group (from 40.8±11 to 38.5±10.3 kg, p=0.01). Serum leptin decreased significantly in both KTx and CKD patients (from 11.5±7.0 to 10.0±5.6, p=0.03 and from 14.1±8.3 to 12.2±6.1 ng/mL, p=0.01, respectively). Serum adiponectin increased only in the KTx group (from 1900±953 to 2015±1133 ng/L, p=0.004). Serum CRP decreased in both groups (from 15.1±5.2 to 14.0±5.6 mg/L, p=0.01 in the KTx group and from 16.5±3.9 to 15.4±4.3 mg/L in the CKD group p=0.05). NTpro-BNP was unchanged during the study. CONCLUSIONS Increased physical activity induces beneficial effects on adipokine profile and inflammation but does not seem to affect volume overload in kidney transplant recipients and CKD patients.

Body composition is associated with clinical outcomes in patients with non-dialysis-dependent chronic kidney disease

An inverse relationship between body mass index (BMI) and mortality (the obesity paradox) has been found in patients with non-dialysis-dependent chronic kidney disease (CKD). However, it is unclear whether increased muscle mass or body fat confers the survival advantage. To resolve this we investigated the impact of body makeup on a composite outcome of death or cardiovascular events in a prospective cohort of 326 patients with stage 3-5 CKD not yet on dialysis. Lean mass and body fat were determined using the Body Composition Monitor, a multifrequency bioimpedance spectroscopy device, and were expressed as the lean tissue or fat tissue index, respectively. Patients were stratified as High (above median) or Low (below median) BMI, High or Low lean tissue index, or as High or Low fat tissue index. During a median follow-up of 4.6 years, there were 40 deaths and 68 cardiovascular events. In Cox proportional hazards models, a High lean tissue index, but not High BMI or High fat tissue index, predicted a lower risk of both the composite or its component outcomes (reference: below median). When patients were further stratified into four distinct body composition groups based on both the lean and fat tissue index, only the High lean/fat tissue index group had a significantly lower risk of the composite outcome (hazard ratio 0.36, 95% confidence interval 0.14-0.87; reference: Low lean/fat tissue index group). Thus, the lean tissue index can provide better risk prediction than the BMI alone in non-dialysis-dependent patients with CKD. The High lean/fat tissue index appears to be associated with best outcomes. An optimal body composition for improving the prognosis of CKD needs to be determined.

Implications of low muscle mass across the continuum of care: a narrative review

Abnormalities in body composition can occur at any body weight. Low muscle mass is a predictor of poor morbidity and mortality and occurs in several populations. This narrative review provides an overview of the importance of low muscle mass on health outcomes for patients in inpatient, outpatient and long-term care clinical settings. A one-year glimpse at publications that showcases the rapidly growing research of body composition in clinical settings is included. Low muscle mass is associated with outcomes such as higher surgical and post-operative complications, longer length of hospital stay, lower physical function, poorer quality of life and shorter survival. As such, the potential clinical benefits of preventing and reversing this condition are likely to impact patient outcomes and resource utilization/health care costs. Clinically viable tools to measure body composition are needed for routine screening and intervention. Future research studies should elucidate the effectiveness of multimodal interventions to counteract low muscle mass for optimal patient outcomes across the healthcare continuum. Key messages Low muscle mass is associated with several negative outcomes across the healthcare continuum. Techniques to identify and counteract low muscle mass in clinical settings are needed.

Association of physical activity with cardiovascular and renal outcomes and quality of life in chronic kidney disease

Patients with chronic kidney disease (CKD) are more readily prone to have impaired physical activity than the general population. The aim of this study is to examine the relationship between physical activity and adverse clinical outcomes and quality of life (QOL) in CKD. One hundred and sixty-one patients with CKD stages 1–5 was enrolled from February 2013 to September 2013 and followed up until June 2016. Physical activity was measured using high handgrip strength, 30-second chair stand, and 2-minute step. The QOL was assessed using the Taiwan version of the World Health Organization Quality of Life-BREF. Clinical outcomes included commencing dialysis, major adverse cardiovascular events (MACEs), and first hospitalization. Of all participants, 1 kgf increase in handgrip strength was significantly associated with 0.13 score increase in total scores of QOL and 0.05 score increase in physical domain of QOL in adjusted analysis. One time increase in 30-second chair stand was significantly correlated with 0.14 score increase in psychological domain of QOL. Over a mean follow-up period of 29.1±11.2 months, 37 (23.0%) reached commencing dialysis, 11(6.8%) had MACEs, and 50(31.1%) had first hospitalization. High handgrip strength (hazard ratio (HR): 0.89, 95% CI: 0.84–0.96) and high 2-minute step (HR: 0.04, 95% CI: 0.01–0.95) were significantly associated with decreased risk for commencing dialysis in multivariate analysis. Thirty-second chair-stand was negatively associated with MACEs (HR: 0.65, 95%CI: 0.47–0.89) and first hospitalization (HR: 0.84, 95%CI: 0.74–0.95). In conclusion, physical activity is a potential predictor of QOL and adverse clinical outcomes in patients with CKD.

Clinical relevance of sarcopenia in chronic kidney disease

PURPOSE OF REVIEW

In this article, we review sarcopenia in chronic kidney disease (CKD). We aim to present how definitions of sarcopenia from the general population may pertain to those with CKD, its assessment by clinicians and emerging therapies for sarcopenia in CKD. For this review, we limit our description and recommendations to patients with CKD who are not on dialysis.

RECENT FINDINGS

Poorer parameters of lean mass, strength and physical function are associated with worsening patient-centered outcomes such as limiting mobility, falls and mortality in CKD; however, the magnitude of these associations are different in those with and without CKD. Sarcopenia in CKD is a balance between skeletal muscle regeneration and catabolism, which are both altered in the uremic environment. Multiple pathways are involved in these derangements, which are briefly reviewed. Differences between commonly used terms cachexia, frailty, protein-energy wasting, dynapenia and sarcopenia are described. Therapeutic options in predialysis CKD are not well studied; therefore, we review exercise options and emerging pharmacological therapies.

SUMMARY

Sarcopenia, now with its own International Classification of Diseases, 10th Revision (ICD-10) code, is of importance clinically and should be accounted for in research studies in patients with CKD. Multiple therapies for sarcopenia are in development and will hopefully be available for our patients in the future.

Exercise and CKD: Skeletal Muscle Dysfunction and Practical Application of Exercise to Prevent and Treat Physical Impairments in CKD

Patients with chronic kidney disease experience substantial loss of muscle mass, weakness, and poor physical performance. As kidney disease progresses, skeletal muscle dysfunction forms a common pathway for mobility limitation, loss of functional independence, and vulnerability to disease complications. Screening for those at high risk for mobility disability by self-reported and objective measures of function is an essential first step in developing an interdisciplinary approach to treatment that includes rehabilitative therapies and counseling on physical activity. Exercise has beneficial effects on systemic inflammation, muscle, and physical performance in chronic kidney disease. Kidney health providers need to identify patient and care delivery barriers to exercise in order to effectively counsel patients on physical activity. A thorough medical evaluation and assessment of baseline function using self-reported and objective function assessment is essential to guide an effective individualized exercise prescription to prevent function decline in persons with kidney disease. This review focuses on the impact of kidney disease on skeletal muscle dysfunction in the context of the disablement process and reviews screening and treatment strategies that kidney health professionals can use in clinical practice to prevent functional decline and disability.