Ratio of C-Reactive Protein to Albumin Predicts Muscle Mass in Adult Patients Undergoing Hemodialysis

Prognostic Usefulness of Basic Analytical Data in Chronic Obstructive Pulmonary Disease Exacerbation

Introduction

COPD causes high morbidity and mortality and high health costs. Thus, identifying and analyzing the distinctive and treatable traits seems useful to optimize the management of AEPOC patients. While various biomarkers have been researched, no solid data for systematic use have been made available.

Aim

Assessing the short-term prognostic usefulness of clinical and analytical parameters available in routine clinical practice in COPD exacerbations.

Material and methods

Multicenter prospective observational study conducted between 2016 and 2018. Patients admitted for COPD exacerbation who agreed to participate and signed an informed consent form were included. Prolonged stay, in-hospital mortality or early readmission was considered an unfavorable progression. 30-Day mortality was also analyzed.

Results

615 patients were included. Mean age was 73.9 years (SD 10.6); 86.2% were male. Progression of 357 patients (58%) was considered unfavorable. Mortality at 1 month from discharge was 6.7%. The multivariate analysis shows a relationship between the CRP/Albumin ratio and unfavorable progression (OR 1.008, 95% CI 1.00; 1.01), as well as increased risk of death at 1 month from discharge with elevated urea (OR 1.01, 95% CI 1.005; 1.02) and troponin T (OR 2.21, 95% CI 1.06; 4.62).

Conclusion

Elevated CRP/Albumin, urea and TnT are prognostic indicators of poor short-term outcome in patients admitted for COPD exacerbation. Cardiovascular comorbidity and systemic inflammation could explain these findings.

Interleukin-6-to-Albumin Ratio as a Superior Predictor of Mortality in End-Stage Kidney Disease Patients

INTRODUCTION

In patients with chronic kidney disease (CKD), high interleukin-6 (IL-6) and low albumin circulating concentrations are associated with worse outcomes. We examined the IL-6-to-albumin ratio (IAR) as a predictor of risk of death in incident dialysis patients.

METHODS

In 428 incident dialysis patients (median age 56 years, 62% men, 31% diabetes mellitus, 38% cardiovascular disease [CVD]), plasma IL-6 and albumin were measured at baseline to calculate IAR. We compared the discrimination of IAR with other risk factors for predicting 60-month mortality using receiver operating characteristic curve (ROC) and analyzed the association of IAR with mortality using Cox regression analysis. We divided patients into IAR tertiles and analyzed: (1) cumulative incidence of mortality and the association of IAR with mortality risk in Fine-Gray analysis, taking kidney transplantation as competing risk and (2) the restricted mean survival time (RMST) to 60-month mortality and differences of RMST (∆RMST) between IAR tertiles to describe quantitative differences of survival time.

RESULTS

For all-cause mortality, the area under the ROC curve (AUC) for IAR was 0.700, which was greater than for IL-6 and albumin separately, while for CV mortality, the AUC for IAR (0.658) showed negligible improvement over IL-6 and albumin separately. In Cox regression analysis, IAR was significantly associated with all-cause mortality but not with CV mortality. Both high versus low and middle versus low tertiles of IAR associated with higher risk of all-cause mortality, subdistribution hazard ratio of 2.22 (95% CI 1.40-3.52) and 1.85 (95% CI 1.16-2.95), respectively, after adjusting for age, sex, diabetes mellitus, CVD, smoking, and estimated glomerular filtration rate. ∆RMST at 60 months showed significantly shorter survival time in middle and high IAR tertiles compared with low IAR tertile for all-cause mortality.

CONCLUSIONS

Higher IAR was independently associated with significantly higher all-cause mortality risk in incident dialysis patients. These results suggest that IAR may provide useful prognostic information in patients with CKD.

C-Reactive Protein-to-Albumin Ratio and Clinical Outcomes in COVID-19 Patients: A Systematic Review and Meta-Analysis

C-reactive protein-to-albumin ratio (CAR) is an independent risk factor in cardiovascular, cerebrovascular, and infectious diseases. Through this study, we investigated the CAR values with respect to the severity and mortality of COVID-19 patients. We performed a systematic review and meta-analysis to retrieve studies that evaluated CAR values upon hospital admission in relation to the severity or mortality of COVID-19 patients. We adopted a random-effect model to calculate the pooled mean difference (MD) and their 95% confidence intervals (CI). Quality assessment was appraised using a Newcastle−Ottawa scale and publication bias was assessed using the Begg-test and funnel plot. We equally performed a subgroup analysis using study location and a sensitivity analysis only with studies with low risk of bias. We analyzed 32 studies (n = 12445). Severe COVID-19 patients had higher on-admission CAR values than non-severe COVID-19 patients (MD: 1.69; 95% CI: 1.35−2.03; p < 0.001; I2 = 89%). Non-survivor patients with COVID-19 had higher CAR values than survivor patients (MD: 2.59; 95% CI: 1.95−3.23; p < 0.001; I2 = 92%). In sensitivity analysis, the relationship remained with a decreasing of heterogeneity for severity (MD: 1.22; 95% CI: 1.03−1.40; p < 0.001; I2 = 13%) and for mortality (MD: 2.99; 95% CI: 2.47−3.51; p < 0.001; I2 = 0%). High CAR values were found in COVID-19 patients who developed severe disease or died.

Correlations among lean tissue index, physical activity, clinical parameters, diet quality, and nutritional status in patients receiving haemodialyses

INTRODUCTION

Poor diet quality and malnutrition accelerate protein and energy depletion. This can result in a diminished lean tissue index (LTI) and an inability to perform daily activities, both of which increase the risk of falls and affect the quality of life.

OBJECTIVE

This study investigated the correlations among LTI, physical activity (PA), clinical parameters, diet quality, and nutritional status.

METHODS

A cross-sectional study design was employed. Participants in stable conditions receiving haemodialyses were enroled. LTI was measured using a body composition monitor. Three-day dietary records and demographic and clinical parameters were collected.

RESULTS

In total, 104 patients receiving haemodialyses were recruited (53.8% men, aged 57.7 ± 11.78 years; dialysis duration, 7.3 ± 6.04 years). LTI was not associated with diet quality; LTI was positively correlated with sex and negatively correlated with age, dialysis duration, and fat tissue index (FTI); and lean tissue index was positively correlated with PA. Among patients with a normal LTI, the odds ratio for low-FTI was 31.04 times higher than that for high-FTI. In total, 80.8% of the participants had poor diet quality, which was mainly attributed to their excessive intake of saturated fatty acids and insufficient fruit intake.

CONCLUSIONS

Although diet quality was unrelated to the LTI, the results indicated that most patients receiving haemodialyses had poor diet quality. Therefore, this topic merits further investigation.

Advanced oxidation protein products contribute to chronic kidney disease-induced muscle atrophy by inducing oxidative stress via CD36/NADPH oxidase pathway

BACKGROUND

Sarcopenia with chronic kidney disease (CKD) progression is associated with life prognosis. Oxidative stress has attracted interest as a trigger for causing CKD-related muscular atrophy. Advanced oxidation protein products (AOPPs), a uraemic toxin, are known to increase oxidative stress. However, the role of AOPPs on CKD-induced muscle atrophy remains unclear.

METHODS

In a retrospective case-control clinical study, we evaluated the relationship between serum AOPPs levels and muscle strength in haemodialysis patients with sarcopenia (n = 26, mean age ± SEM: 78.5 ± 1.4 years for male patients; n = 22, mean age ± SEM: 79.1 ± 1.5 for female patients), pre-sarcopenia (n = 12, mean age ± SEM: 73.8 ± 2.0 years for male patients; n = 4, mean age ± SEM: 74.3 ± 4.1 for female patients) or without sarcopenia (n = 12, mean age ± SEM: 71.3 ± 1.6 years for male patients; n = 7, mean age ± SEM: 77.7 ± 1.6 for female ). The molecular mechanism responsible for the AOPPs-induced muscle atrophy was investigated by using 5/6-nephrectomized CKD mice, AOPPs-overloaded mice, and C2C12 mouse myoblast cells.

RESULTS

The haemodialysis patients with sarcopenia showed higher serum AOPPs levels as compared with the patients without sarcopenia. The serum AOPPs levels showed a negative correlation with grip strength (P < 0.01 for male patients, P < 0.01 for female patients) and skeletal muscle index (P < 0.01 for male patients). Serum AOPPs levels showed a positive correlation with cysteinylated albumin (Cys-albumin), a marker of oxidative stress (r2  = 0.398, P < 0.01). In the gastrocnemius of CKD mice, muscle AOPPs levels were also increased, and it showed a positive correlation with atrogin-1 (r2  = 0.538, P < 0.01) and myostatin expression (r2  = 0.421, P < 0.05), but a negative correlation with PGC-1α expression (r2  = 0.405, P < 0.05). Using C2C12 cells, AOPPs increased atrogin-1 and myostatin expression through the production of reactive oxygen species via CD36/NADPH oxidase pathway, and decreased myotube formation. AOPPs also induced mitochondrial dysfunction. In the AOPPs-overloaded mice showed that decreasing running time and hanging time accompanied by increasing AOPPs levels and decreasing cross-sectional area in gastrocnemius.

CONCLUSIONS

Advanced oxidation protein products contribute to CKD-induced sarcopenia, suggesting that AOPPs or its downstream signalling pathway could be a therapeutic target for the treatment of CKD-induced sarcopenia. Serum AOPPs or Cys-albumin levels could be a new diagnostic marker for sarcopenia in CKD.

Adaptation and Validation of Alternative Healthy Eating Index in Hemodialysis Patients (AHEI-HD) and Its Association with all-Cause Mortality: A Multi-Center Follow-Up Study

A valid diet quality assessment scale has not been investigated in hemodialysis patients. We aimed to adapt and validate the alternative healthy eating index in hemodialysis patients (AHEI-HD), and investigate its associations with all-cause mortality. A prospective study was conducted on 370 hemodialysis patients from seven hospital-based dialysis centers. Dietary data (using three independent 24-hour dietary records), clinical and laboratory parameters were collected. The construct and criterion validity of original AHEI-2010 with 11 items and the AHEI-HD with 16 items were examined. Both scales showed reasonable item-scale correlations and satisfactory discriminant validity. The AHEI-HD demonstrated a weaker correlation with energy intake compared with AHEI-2010. Principle component analysis yielded the plateau scree plot line in AHEI-HD but not in AHEI-2010. In comparison with patients in lowest diet quality (tertile 1), those in highest diet quality (tertile 3) had significantly lower risk for death, with a hazard ratio (HR) and 95% confidence intervals (95%CI) of HR: 0.40; 95%CI: 0.18 – 0.90; p = 0.028, as measured by AHEI-2010, and HR: 0.37; 95%CI: 0.17–0.82; p = 0.014 as measured by AHEI-HD, respectively. In conclusion, AHEI-HD was shown to have greater advantages than AHEI-2010. AHEI-HD was suggested for assessments of diet quality in hemodialysis patients.

Insulin Resistance and Cardiovascular Risks in Different Groups of Hemodialysis Patients: A Multicenter Study

BACKGROUND

To investigate the association between insulin resistance (IR) and cardiovascular disease (CVD) risks among hemodialysis patients.

METHODS

We conducted a cross-sectional study between 2013 and 2017, on 384 hemodialysis patients from seven hospital-based-dialysis centers. HOMA-IR is classified according to median value. The CVD risks were defined by the K/DOQI Guidelines. Logistic regression analysis was used.

RESULTS

Patients' age was 60.9 ± 11.8, 58.1% men, and 40.3% overweight/obese. The median of HOMA-IR was 5.4, 82.8% high systolic blood pressure, and 85.7% hyperhomocysteinemia. In multivariate analysis, IR was significantly associated with higher odds of low high-density lipoprotein cholesterol, high triglyceride, and impaired fasting glucose in groups of normal weight, overweight/obese, nondiabetes, diabetes, and overall sample. IR linked with elevated high-sensitive C-reactive protein in normal weight patients (odd ratio, OR=2.21, 95% confidence interval, 1.16-4.22, p < .05), with hypoalbuminemia in normal weight patients (OR=8.31, 95% CI, 2.35-29.37, p < .01), in nondiabetes patients (OR=6.59, 95% CI, 1.81-23.95, p < .01), and overall sample (OR=3.07, 1.51-6.23, p < .01).

CONCLUSIONS

The level of IR and prevalence of CVD risks were high in hemodialysis patients. IR was independently associated with CVD risks.

The prognostic value of C-reactive protein to albumin ratio in patients with lung cancer

BACKGROUND

To perform a meta-analysis of retrospective studies exploring the association of C-reactive protein to albumin (CAR) with overall survival (OS) in patients with lung cancer.

METHODS

Relevant studies were enrolled by searching databases of PubMed, Cochrane Library, Web of Science, and Embase were searched until July 16, 2017. We combined the hazard ratios (HRs) and 95% confidence intervals (CIs) to assess the correlation between CAR and OS in patients with lung cancer RESULTS:: Four studies involving 1257 participants from several countries were involved in the meta-analysis. In a pooled analysis of all studies, elevated CAR predicted poor OS (HR: 2.13; 95% CI: 1.52-2.97; P < .05). Subgroup analysis showed that high level of CAR predicted poor OS in patients with lung cancer though multivariate analyses on 1092 participants (HR: 1.63; 95% CI: 1.24-2.51; P < .001) and the heterogeneity decreased to 45.4%. Moreover, a similar trend was observed in patients receiving surgery (HR: 2.64; 95% CI: 2.08-3.35; P < .001) and chemotherapy (HR: 1.75; 95% CI: 1.93-2.57; P = .004). And the HRs for patients receiving surgery was moderately higher than that for patients receiving chemotherapy.

CONCLUSION

Our findings indicate that CAR may have a prognostic value in lung cancer as we detected a significant association between elevated CAR and poorer OS. However, further studies are warranted to draw firm conclusions.

Inadequate dietary energy intake associates with higher prevalence of metabolic syndrome in different groups of hemodialysis patients: a clinical observational study in multiple dialysis centers

BACKGROUND

Metabolic syndrome (MetS) has been established as a risk for cardiovascular diseases and mortality in hemodialysis patients. Energy intake (EI) is an important nutritional therapy for preventing MetS. We examined the association of self-reported dietary EI with metabolic abnormalities and MetS among hemodialysis patients.

METHODS

A cross-sectional study design was carried out from September 2013 to April 2017 in seven hemodialysis centers. Data were collected from 228 hemodialysis patients with acceptable EI report, 20 years old and above, underwent three hemodialysis sessions a week for at least past 3 months. Dietary EI was evaluated by a three-day dietary record, and confirmed by 24-h dietary recall. Body compositions were measured by bioelectrical impedance analysis. Biochemical data were analyzed using standard laboratory tests. The cut-off values of daily EI were 30 kcal/kg, and 35 kcal/kg for age ≥ 60 years and < 60 years, respectively. MetS was defined by the American Association of Clinical Endocrinologists (AACE-MetS), and Harmonizing Metabolic Syndrome (HMetS). Logistic regression models were utilized for examining the association between EI and MetS. Age, gender, physical activity, hemodialysis vintage, Charlson comorbidity index, high sensitive C-reactive protein, and interdialytic weight gains were adjusted in the multivariate analysis.

RESULTS

The prevalence of inadequate EI, AACE-MetS, and HMetS were 60.5%, 63.2%, and 53.9%, respectively. Inadequate EI was related to higher proportion of metabolic abnormalities and MetS (p <  0.05). Results of the multivariate analysis shows that inadequate EI was significantly linked with higher prevalence of impaired fasting glucose (OR = 2.42, p <  0.01), overweight/obese (OR = 6.70, p <  0.001), elevated waist circumference (OR = 8.17, p <  0.001), AACE-MetS (OR = 2.26, p <  0.01), and HMetS (OR = 3.52, p <  0.01). In subgroup anslysis, inadequate EI strongly associated with AACE-MetS in groups of non-hypertension (OR = 4.09, p = 0.004), and non-cardiovascular diseases (OR = 2.59, p = 0.012), and with HMetS in all sub-groups of hypertension (OR = 2.59~ 5.33, p <  0.05), diabetic group (OR = 8.33, p = 0.003), and non-cardiovascular diseases (OR = 3.79, p <  0.001).

CONCLUSIONS

Inadequate EI and MetS prevalence was high. Energy intake strongly determined MetS in different groups of hemodialysis patients.

Associations of dietary macronutrients and micronutrients with the traditional and nontraditional risk factors for cardiovascular disease among hemodialysis patients: A clinical cross-sectional study

The current study was to examine the association of adequate intake of macronutrients and micronutrients with traditional and nontraditional cardiovascular risk factors in hemodialysis patients.A clinical cross-sectional study was conducted between September 2013 and April 2017 on 492 hemodialysis patients aged 20 years and above, received thrice-weekly hemodialysis treatment for at least 3 months, adequate dialysis quality (equilibrated Kt/V ≥ 1.2 g/kg/d) from 7 hospital-based hemodialysis centers in Taiwan. The dietary intake was evaluated by the 3-day dietary record, and a 24-hour dietary recall. Biochemical parameters were archived from laboratory tests. The cardiovascular disease (CVD) risk factors were defined by the Kidney Disease Outcomes Quality Initiative (K/DOQI) Clinical Practice Guidelines. The adequate dietary intake of macronutrients and micronutrients was recommended by the European Best Practice Guidelines, K/DOQI, and Institute of Medicine guidelines. Logistic regression analysis was used.All hemodialysis patients had CVD risks, the lowest proportion of patients with adequate intake of macronutrients and micronutrients were 8.7% and 1.8%, respectively. The adequate dietary intake associated with lower likelihood of having CVD risks in hemodialysis patient by 47% to 84%, including 39% to 58% lower hypertension, 37% to 50% lower dyslipidemia, 42% to 63% diabetes mellitus, 44% to 84% lower obesity, 58% lower low calcium, 38% lower hyperparathyroidism, 47% to 64% lower hyperhomocysteinemia, and 41% to 67% lower inflammation, 63% to 74% lower hypoalbumin, 73% lower inadequate normalized protein nitrogen appearance.Adequate dietary nutrients intake may reduce the cardiovascular risks factors, in turn, to prevent the cardiovascular morbidity and mortality.

The cut-off values of dietary energy intake for determining metabolic syndrome in hemodialysis patients: A clinical cross-sectional study

Dietary energy intake strongly linked to dialysis outcomes. We aimed to explore the optimal cut-off point of energy intake (EI) for identification of metabolic syndrome (MetS) in hemodialysis patients. The cross-sectional data of 243 hemodialysis patients from multi-dialysis centers in Taiwan was used. The dietary intake was assessed by using the three-day dietary questionnaire, and a 24-hour dietary recall, clinical and biochemical data were also evaluated. The MetS was diagnosed by the Harmonized Metabolic Syndrome criteria. The receiver operating characteristic (ROC) curve was to depict the optimal cut-off value of EI for the diagnosis of MetS. The logistic regression was also used to explore the association between inadequate EI and MetS. The optimal cut-off points of EI for identifying the MetS were 26.7 kcal/kg/day for patients aged less than 60 years, or with non-diabetes, and 26.2 kcal/kg/day for patients aged 60 years and above, or with diabetes, respectively. The likelihood of the MetS increased with lower percentiles of energy intake in hemodialysis patients. In the multivariate analysis, the inadequate dietary energy intake strongly determined 3.24 folds of the MetS. The assessment of dietary EI can help healthcare providers detecting patients who are at risk of metabolic syndrome.