Comparison of hydration and nutritional status between young and elderly hemodialysis patients through bioimpedance analysis

The phase angle before transplantation can predict the status of low muscle mass after kidney transplantation

BACKGROUND

This study aimed to evaluate the association between phase angle, muscle strength, and muscle mass in patients undergoing kidney transplantation.

METHODS

Patients whose pre- and follow-up phase angles were measured after kidney transplantation were enrolled. Phase angle and body composition were measured using a multi-frequency bioimpedance analysis device before and at 7 and 14 days and 3, 6, and 12 months after transplantation. Muscle strength was evaluated using handgrip strength (HGS). Low HGS was defined as < 28 kg in males and < 18 kg in females. Low muscle mass was defined as an appendicular lean mass index of < 7.0 kg/m2 in males and < 5.7 kg/m2 in females.

RESULTS

Eighty-eight patients (mean age 52.3 ± 10.1 years) were analyzed. The mean phase angle of pre-transplantation was 5.0 ± 1.0°. Body fat percentage was significantly higher at 6 and 12 months after transplantation than pre-transplantation (P < 0.0001). Twelve months after kidney transplantation, the prevalence of low HGS decreased (pre-transplantation vs. 12 months post-transplantation: 28.4% vs. 17.0%), and the prevalence of low muscle mass (pre-transplantation vs. 12 months post-transplantation: 21.6% vs. 28.4%) increased. The pre-transplantation phase angle was significantly associated with low muscle mass at 12 months after kidney transplantation (odds ratio [OR]: 0.34; 95% confidence interval [CI]: 0.16-0.72; P = 0.005). The pre-transplantation phase angle was not significantly associated with low HGS (OR: 0.37; 95% CI 0.12-1.17; P = 0.090) 12 months after kidney transplantation.

CONCLUSIONS

Pre-transplantation phase angle can predict muscle mass status 12 months after kidney transplantation.

Factors associated with skeletal muscle mass in middle-aged men living with HIV

BACKGROUND

Despite extensive research on muscle loss in people living with HIV (PLWH), the prevalence and contributing factors specifically among middle-aged men remain unclear. This study aimed to determine the prevalence of low muscle mass within this demographic and to identify associated factors.

METHODS

A total of 378 men living with HIV were enrolled in the study. They were classified into low muscle mass group if they displayed a skeletal muscle index (SMI) <7.00 kg/m2 or fell within the lowest quintile of SMI based on the criteria established by the Asian Working Group for Sarcopenia 2019.

RESULTS

Out of the 378 men living with HIV enrolled, 351 had normal muscle mass, while 27 (7.1%) had low muscle mass. Antiretroviral drugs Zidovudine (AZT) (OR = 0.246, P = 0.022) and higher serum albumin levels (OR = 0.899, P = 0.026) were found to be protective factors against low muscle mass according to quintile grouping. Strong positive associations between SMI and body mass index (BMI), nutritional risk index (NRI), oedema index and fat-free mass index (FFMI) (R > 0.5, P < 0.001) were observed. In addition, both BMI (sensitivity = 0.741, specificity = 0.906) and NRI (sensitivity = 0.963, specificity = 0.601) had high sensitivity and specificity in diagnosing low muscle mass, with critical values of 19.85 and 114.177 for BMI and NRI, respectively. The oedema index was the most effective measure of body composition in detecting abnormal fluid retention with high sensitivity (92.6%) and moderate specificity (71.8%) in identifying individuals with low muscle mass. Notably, PLWH with low muscle mass participants had a significantly higher prevalence (92.6%) of a high oedema index compared with those with normal muscle mass (28.2%). This observation indicates that individuals with HIV who experience reduced muscle mass is commonly accompanied with abnormal fluid retention within the body.

CONCLUSIONS

Antiretroviral medication types, specifically Zidovudine, BMI and NRI can be independent risk factors for low muscle mass in men with HIV. These factors, along with BMI, could be used conveniently to predict low muscle mass. Furthermore, the association between the oedema index and muscle mass suggests that observing signs of oedema may indicate a risk of low muscle mass in PLWH.

Predictors of excess fluid volume in hemodialysis patients: an observational study

OBJECTIVES

to assess risk factors for excess fluid volume in hemodialysis patients.

METHODS

a retrospective case-control study was conducted. A total of 392 patients (196 cases and 196 controls) from two hemodialysis centers were included. Sociodemographic data and 23 risk factors for excess fluid volume were assessed using a data collection form. Data were analyzed using a multivariate logistic regression model.

RESULTS

the insufficient knowledge (OR=2.06), excessive fluid intake (OR=2.33), inadequate fluid removal during hemodialysis (OR=2.62) and excessive sodium intake (OR=1.91) risk factors may increase the chance of occurrence of excess fluid volume in hemodialysis patients by approximately two times. Education level (OR=0.95) and age (OR=0.97) are protective factors for excessive fluid volume.

CONCLUSIONS

knowing these risk factors may help nurses with accurate and rapid diagnostic inference of the risk of excessive fluid volume.

Association of extracellular water/total body water ratio with protein-energy wasting and mortality in patients on hemodialysis

Bioimpedance analysis-assessed extracellular water/total body water (ECW/TBW) ratio may be a marker for mortality and poor nutritional status in hemodialysis patients. In 193 maintenance hemodialysis patients, we retrospectively investigated the relationships among ECW/TBW ratio, mortality, and protein-energy wasting (PEW). Four components-body mass index, normalized protein catabolic rate, normalized serum creatinine level, and serum albumin level-constitute the simple PEW score; this score was calculated based on the positive number of items concerning malnutrition among these four components. A score ≥ 3 indicated PEW. Patients were stratified by an ECW/TBW ratio cut-off value (0.40) and by PEW versus non-PEW status. The simple PEW score, cardiothoracic ratio, and log-transformed C-reactive protein level were independently correlated with the ECW/TBW ratio. Eighty-four patients died during follow-up (median 4.3 years). After adjustments for sex, age, hemodialysis vintage, histories of cardiovascular events and diabetes, and C-reactive protein level, a higher ECW/TBW ratio and PEW were independently related to elevated risks of all-cause death. Adding the ECW/TBW ratio to a baseline risk model including PEW significantly increased C-statistics from 0.788 to 0.835. In conclusion, the ECW/TBW ratio may be an indicator of PEW and may be a predictor of death even accounting for PEW, in hemodialysis patients.

Phase angle as a marker of outcome in hospitalized pediatric patients. A systematic review of the evidence (GRADE) with meta-analysis

Phase angle (PhA) is a valuable tool for evaluating the nutritional and inflammatory status, which can accompany acute and severe disorders. PhA is a cellular health biomarker, whose value is particularly substantial due to the negative consequences of these situations in the pediatric population. Relevant literature was collected with the aim of comprehensively analysing the evidence on the association between an altered PhA can serve as a predictive-marker for mortality and poor-outcomes in at-risk-pediatric patients. Understanding this relationship could have significant implications for identifying high-risk individuals and implementing timely interventions. A systematic review with meta-analysis was conducted in the primary electronic databases from inception until January 2023. Overall, four studies with a total of 740 patients were eligible for our analysis. Evidence demonstrates that PhA is associated with nutritional status, reflecting undernutrition and changes in body composition related to illness. This review suggests that PhA can indeed be used as an indicator of nutritional status and a tool for predicting prognosis, including mortality and poor-outcomes, in hospitalized pediatric patients. A low PhA was associated with a significant mortality risk [RR:1.51;95%CI (1.22-1.88),p = 0.0002;I2 = 0%,(p = 0.99)] and an increased complications risk [OR:8.17;95%CI (2.44-27.4),p = 0.0007;I2 = 44%,(p = 0.18)]. These findings highlight the importance of taking a comprehensive approach to clinical nutrition, integrating multiple evaluation aspects to establish an accurate diagnosis and personalized therapeutic plans. While PhA emerges as a valuable tool for assessing the risk of malnutrition and as a prognostic-indicator for poor-outcomes in pediatric patients. Further future studies are needed to focus on investigating this relationship in larger and diverse population to strengthen the evidence base.

Bioimpedanciometry in nutritional and hydration assessments in a single dialysis center

BACKGROUND

Bioimpedance analysis (BIA) has been demonstrated to add accuracy to nutritional and volume status assessments in dialysis (HD) patients.

AIM

to describe a sample of dialysis patients from a single center on their demographics and BIA of volume distribution and nutritional status, and mortality during 12-month follow-up.

METHODS

prospective observational cohort study to evaluate vintage HD patients with single-frequency BIA.

RESULTS

we evaluated 82 patients, 29% over 65 years old. Elderly patients had higher ECW/TBW (0.51 vs. 0.44, p < 0.0001), and narrower phase angle (PhA) (4.9 vs. 6.4º, p < 0.0001). Fifteen patients (18.2%) died during follow-up, eight (53%) were elderly. Death was associated with age (62.6 vs. 50.2 years, p = 0.012), post-HD PhA (4.8 vs. 6.2º, p = 0.0001), and post-HD ECW/TBW (0.50 vs. 0.45, p = 0.015). The ROC curve analysis to predict mortality found ECW/TBW ≥ 0.47 and PhA ≤ 5.5º to have the best sensitivity and specificity. One-year patient survival was lower with post-HD ECW/TBW ≥ 0.47 (69.5% vs. 90.6%, p = 0.019), age ≥ 65 years (64.2%, vs. 86.2%, p = 0.029), and PhA ≤ 5.5º (68.2 vs. 91.0%, p = 0.002). Cox regression analysis demonstrated that PhA [HR 5.04 (95%CI 1.60-15.86), p = 0.006] remained associated with death after adjusting for age and ECW/TBW.

CONCLUSION

BIA is useful in assessing volume distribution and nutrition in HD patients, and combined with clinical judgement, may help determine dry weight, especially in elderly patients. Narrower PhA and higher ECW/TBW after HD were associated with poorer one-year survival.

Bioimpedanciometria em avaliações nutricionais e de hidratação em um único centro de diálise

RESUMO Antecedentes: Análise de bioimpedância (BIA) demonstrou adicionar acurácia às avaliações de estado nutricional e de volume em pacientes em diálise (HD). Objetivo: descrever amostra de pacientes em diálise de um único centro quanto aos aspectos demográficos e BIA na distribuição de volume e no estado nutricional, e a mortalidade em 12 meses de acompanhamento. Métodos: estudo de coorte observacional prospectivo para avaliar pacientes prevalentes em HD com BIA de frequência única. Resultados: avaliamos 82 pacientes, 29% acima de 65 anos. Pacientes idosos apresentaram maior AEC/ACT (0,51 vs. 0,44; p < 0,0001), e ângulo de fase mais estreito (PhA) (4,9 vs. 6,4º; p < 0,0001). Quinze pacientes (18,2%) foram a óbito durante acompanhamento, oito (53%) eram idosos. Óbito foi associado à idade (62,6 vs. 50,2 anos, p = 0,012), PhA pós-HD (4,8 vs. 6,2º; p = 0,0001), e AEC/ACT pós-HD (0,50 vs. 0,45, p = 0,015). A análise da curva ROC para prever mortalidade constatou que AEC/ACT ≥ 0,47 e PhA ≤ 5,5º apresentam melhor sensibilidade e especificidade. Sobrevida do paciente em um ano foi menor com AEC/ACT pós-HD ≥ 0,47 (69,5% vs. 90,6%; p = 0,019), idade ≥ 65 anos (64,2% vs. 86,2%; p = 0,029), e PhA ≤ 5,5º (68,2 vs. 91,0%; p = 0,002). A análise de regressão de Cox demonstrou que PhA [HR 5,04 (IC 95% 1,60–15,86); p = 0,006] permaneceu associado ao óbito após ajuste para idade e AEC/ACT. Conclusão: BIA é útil ao avaliar distribuição de volume e nutrição em pacientes em HD, e juntamente com julgamento clínico, pode ajudar a determinar o peso seco, principalmente em pacientes idosos. PhA mais estreito e maior AEC/ACT pós-HD foram associados a pior sobrevida em um ano.

Association between Disability and Edema Index Values in Rural Older Adult Osteosarcopenia Patients

PURPOSE

This study analyzed the relationship between degree of disability and edema index [extracellular water/total body water (ECW/TBW) ratio] values in a rural population of older adult patients with osteopenia, sarcopenia, or osteosarcopenia (OS).

MATERIALS AND METHODS

This study used data from the Namgaram-2 cohort. The degree of disability was measured using the World Health Organization Disability Assessment Schedule (WHODAS) 12, and ECW/TBW ratio was calculated using bioelectrical impedance analysis. Based on ECW/TBW ratio, the participants were stratified into normal (<0.391) and abnormal (≥0.391) groups, and the mean WHODAS 12 scores were compared between the two groups. Multiple regression analysis corrected for demographic factors, smoking history, hypertension, diabetes, and serological test results was also conducted.

RESULTS

Significant differences in mean WHODAS 12 scores were observed in the healthy group (5.8±7.4 vs. 9.2±9.7, p=0.008), the osteopenia only group (7.4±8.7 vs. 12.9±12.0, p<0.001), and the OS group (16.0±13.2 vs. 23.1±17.1, p=0.004). However, no significant difference in mean WHODAS 12 score was observed in the sarcopenia only group (14.9±13.4 vs. 20.7±14.8, p= 0.051). There were significant differences in ECW/TBW ratio values between the abnormal and normal groups in the osteopenia only group (B=4.646 and p=0.001), the sarcopenia only group (B=5.097 and p=0.016), and the OS group (B=5.653 and p=0.043).

CONCLUSION

This study found that the degree of disability is related to the edema index in older patients with osteopenia, sarcopenia, or OS. Since the edema index indicates the nutritional status of an individual, proper nutrition and fluid intake are important to reduce disability.

Identification of fluid overload in elderly CKD Patients using bioimpedance techniques

Diagnosis of fluid overload (FO) in early stage is essential to manage chronic kidney disease (CKD) patients' fluid balance and to prevent cardiovascular disease (CVD). However, identification of fluid status in CKD patient is largely dependent on physician's clinical acumen. The ratio of fluid overload to extracellular volume (FO/ECV) has been used as a reference to assess fluid status. The primary aim of this study was to compare FO/ECV with other bioimpedance methods and clinical assessment in CKD patients. Whole body ECV, intracellular volume (ICV), total body water (TBW) and calf normalized resistivity (CNR) were measured (Hydra 4200). Thresholds of FO utilizing CNR and ECV/TBW were derived by receiver operator characteristic (ROC) analysis based on data from pooled CKD patients and healthy subjects (HS). Clinical assessments of FO in CKD patients were performed by nephrologists . CKD (stage 3 and stage 4) patients (n=50) and HS (n=189) were studied. The thresholds of FO were ≤ 14.3 (10^-2 Ωm³/kg) for females and ≤ 13.1 (10^-2 Ωm³/kg) for males using CNR and ≥ 0.445 in females and ≥ 0.434 in males using ECV/TBW. FO was diagnosed in 78%, 62% and 52% of CKD patients by CNR, FO/ECV and ECV/TBW, respectively while only 24% of CKD patients were diagnosed to be FO by clinical assessment . The proportion of FO in non-dialysis CKD patients was largely underestimated by clinical assessment compared to FO/ECV, CNR and ECV/TBW. CNR, and FO/ECV methods were more sensitive than ECV/TBW in identifying fluid overload in these CKD patients.

Excessive fluid volume risk middle-range theory

ABSTRACT Objective to construct a middle range theory for developing the excessive fluid volume risk diagnostic proposition in patients undergoing hemodialysis. Method this is a methodological study, developed for the theoretical-causal validity of a nursing diagnosis. The study was carried out in four stages: study selection, identification of the main concepts of the theory, pictogram construction and proposition elaboration. These steps were operationalized through an integrative literature review, with a sample of 82 articles selected from the Web of Science, PubMed, CINAHL, Scopus and Science Direct databases. Results the data extracted from the sample articles enabled identifying five essential terms to define excessive fluid volume risk. Furthermore, 31 etiological factors of excessive fluid volume risk were identified, in addition to a pictogram and 12 propositions. Conclusion and implications for practice the construction of a middle-range theory focused on excessive fluid volume risk in patients undergoing hemodialysis refines terminology and expands the understanding of nursing phenomena. Thus, the data from this research will provide clear and robust knowledge for the conduct of nurses’ actions in clinical practice.

Fatigue Is Not Associated with Phase Angle in Hemodialysis Patients

PURPOSE

The aim of this study was to investigate the association between fatigue and phase angle (PA) in patients with chronic kidney disease (CKD) on hemodialysis (HD).

METHODS

A cross-sectional study with older patients than 18 years diagnosed with CKD undergoing HD. From 160 (58.36±15.05 years) patients, (n=96; 60%) are men. Body mass and height were assessed using a portable scale and stadiometer, followed by body mass index (BMI) calculus. The bioimpedance electrical analysis was performed using the Bodystat QuadScan 4000. The sample size was dichotomized in two groups, using the median of our sample, either normal when PA ≥5.4º, or low when the PA <5.4º. The Chalder fatigue questionnaire was used the assess the fatigue. The multiple regression was applied to assess the association between fatigue questionnaire and PA.

RESULTS

Were considered normal PA≥5.4º (n=78, 48.8%) and low PA<5.4º (n=82, 51.2%). The patients of the PA<5.4º group are older compared to the PA≥5.4º group (63.1±15.1 vs. 53.3±13.4 years, p<0.001). There was no association between PA and fatigue score in the crude model (OR: 1.02, 95%CI: 0.96-1.08, p=0.47) and after confounding variables (OR: 1.03, CI: 0.95-1.12, p=0.43).

CONCLUSIONS

In HD patients, we found that patients with lower PA values are older. In addition, we did not find association between fatigue and PA.

Teoria de médio alcance do risco de volume de líquidos excessivo

RESUMO Objetivo construir uma teoria de médio alcance para o desenvolvimento da proposição diagnóstica risco de volume de líquidos excessivo em pacientes em hemodiálise. Método trata-se de um estudo metodológico, desenvolvido para a validade teórico-causal de um diagnóstico de enfermagem. O estudo foi realizado em quatro etapas: seleção dos estudos, identificação dos conceitos principais da teoria, construção do pictograma e elaboração das proposições. Essas etapas foram operacionalizadas por meio de uma revisão integrativa da literatura, com uma amostra de 82 artigos selecionados nas bases de dados Web of Science, PubMed, CINAHL, Scopus e Science Direct. Resultados os dados extraídos dos artigos da amostra possibilitaram a identificação de cinco termos essenciais para a definição do risco de volume de líquidos excessivo. Além disso, foram identificados 31 fatores etiológicos do risco de volume de líquidos excessivo, além de construídos um pictograma e 12 proposições. Conclusão e implicações para a prática a construção de uma teoria de médio alcance voltada para o risco de volume de líquidos excessivo em pacientes em hemodiálise refina as terminologias e amplia a compreensão dos fenômenos da enfermagem. Assim, os dados desta pesquisa fornecerão conhecimentos claros e robustos para a condução das ações do enfermeiro na prática clínica.

Serum PTH Associated with Malnutrition Determined by Bioelectrical Impedance Technology in Chronic Kidney Disease Patients

PURPOSE

Chronic malnutrition and cachexia are common in chronic kidney disease (CKD), and importance should be given to these complications because they affect the patient's quality of life and prognosis. This study analyzed the correlation between the serum PTH level, nutritional status, and body composition of patients with CKD.

METHODS

CKD patients were enrolled in Center for Kidney Disease, Second Affiliated Hospital of Nanjing Medical University, from December 1, 2016, to November 30, 2020. Bioelectrical impedance technology was applied to estimate the body composition. The characteristics of the body composition were compared among different stages of CKD patients, and then the correlation between PTH and body composition was analyzed.

RESULTS

205 CKD patients were enrolled. Twenty-five patients were in stage 1 or 2 of CKD, 78 patients were in stage 3 or 4, 31 patients were in stage 5 without dialysis (referred to as CKD stage 5A), and 71 patients were in stage 5 with dialysis (referred to as CKD stage 5B). Body composition analysis showed that the patients had a phase angle (PA) of 5.02 ± 1.07°, a percentage of body fat (PBF) of 27.74 ± 8.8%, and a skeletal muscle mass index (SMI) of 7.4 ± 1.34 kg/m². PBF peaked in the CKD stage 3/4 group and gradually decreased with the progression of CKD. The PA and SMI differed significantly between the CKD stage 1/2 and stage 5B groups. The proportion of low SMI did not differ significantly between the CKD stage 1/2 and stage 3/4 groups, but it was obviously higher in the CKD stage 5A and 5B groups. PTH was significantly correlated with BMI, hemoglobin, albumin, total cholesterol, triglycerides, and SMI. Binary logistic regression of low SMI showed that the odds ratio for PTH levels was greater than the upper limit of the normal range, which was 11.769 (p=0.043, 95% confidence interval: 1.078-128.536), and the model predictive power was 0.986 after correction for age, sex, height, weight, hemoglobin, serum calcium, serum phosphorus, serum total cholesterol, serum triglyceride, and basal metabolic rate.

CONCLUSIONS

Bioelectrical impedance analysis might be useful in estimating the nutritional status of CKD patients in terms of fat and muscle parameters. High levels of PTH are an independent risk factor for developing low SMI in CKD patients.

Short-term intradialytic NMES targeting muscles of the legs improves the phase angle: A pilot randomized clinical trial

PURPOSE

Neuromuscular electrical stimulation (NMES) elicits muscle contraction and has been shown to attenuate muscle atrophy when physical activity is not possible. Thus, we hypothesized that intradialytic NMES would attenuate the loss leg lean mass and improve the phase angle in patients undergoing hemodialysis (HD).

METHODS

A randomized controlled trial was performed with twenty-one adult HD patients (n = 8 F, n = 13 M; 45.8 ± 10.6 y) randomly assigned to usual care (control group, n = 11; 4F/7M) or to the NMES group (n = 10; 4F/6M). NMES was applied bilaterally at the origin and insertion points of the quadriceps or gastrocnemius muscles for 40 min during each HD session (3x/wk for one month). Pre-and post-intervention, we measured leg lean mass using dual-energy x-ray absorptiometry and phase angle using bioelectrical impedance analysis.

RESULTS

NMES did not change leg lean mass compared to the control group. Phase angle increased in the NMES compared to the control group (Δ: +0.71 ± 0.27° vs. -0.46 ± 0.23°, p = 0.004) with interaction time x treatment (ANOVA p = 0.004).

CONCLUSION

Short-term intradialytic NMES targeting muscles of the legs improved the phase angle but did not change leg lean mass.

BRAZILIAN REGISTRY OF CLINICAL TRIALS UNDER THE CODE

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Fluid overload is associated with use of a higher number of antihypertensive drugs in hemodialysis patients

INTRODUCTION

Hypertension is multifactorial, highly prevalent in the hemodialysis (HD) population and its adequate control requires, in addition to adequate volume management, often the use of multiple antihypertensive drugs. We aimed to describe the use of antihypertensive agents in a group of HD patients and to evaluate the factors associated with the use of multiple classes (≥3) of antihypertensives.

METHODS

We analyzed the baseline data from the HDFit study. Clinically stable patients with HD vintage between 3 and 24 months without any severe mobility limitation were recruited from sites throughout southern Brazil. Fluid status was measured pre-dialysis with the Body Composition Monitor (BCM; Fresenius, Germany). Fluid overload (FO) was considered when the overhydration index (OH) was greater than 7% of extracellular water (OH/ECW > 7%) and overweight was defined as a body mass index (BMI) greater than 25 kg/m² . Prescriptions of antihypertensive drugs were obtained from participants' reports and medical records. Logistic regression was employed to determine factors associated with excessive use of antihypertensive medication (≥3 classes).

FINDINGS

Of 195 studied patients, 171 with complete data were included (70% male, 53 ± 15 years old, 57% of them with FO). Pre-dialysis systolic blood pressure (SBP) was 150 ± 24 mmHg and patients used a median of 2 (1-3) antihypertensive drugs. Vasodilators (20%) were of lowest prevalence, use of other classes varied from 40% to 53%. Sixty-two (36%) subjects used ≥3 classes and presented a higher prevalence of diabetes and FO, lower prevalence of overweight, and higher SBP. In a logistic regression model age, BMI <25 kg/m² , and OH/ECW > 7% were associated with excessive drug use.

DISCUSSION

More than one-third of participants used ≥3 classes of antihypertensive drugs, and it was associated with older age, BMI <25 kg/m² and FO. Strategies that better manage FO may aid better blood pressure control and avoid the use of multiple antihypertensive medications.

Association of Sarcopenia With Nutritional Parameters, Quality of Life, Hospitalization, and Mortality Rates of Elderly Patients on Hemodialysis

OBJECTIVE

This study aimed to assess whether diminished muscle mass, diminished muscle strength, or both conditions (sarcopenia) are associated with worse nutritional status, poor quality of life (QoL), and hard outcomes, such as hospitalization and mortality, in elderly patients on maintenance hemodialysis (MHD).

DESIGN AND SUBJECTS

This is a multicenter observational longitudinal study that included 170 patients on MHD (age 70 ± 7 years, 65% male) from 6 dialysis centers.

MAIN OUTCOME MEASURE

The European Working Group on Sarcopenia in Older People defines sarcopenia as the presence of both low muscle mass by appendicular skeletal + low muscle function by handgrip strength. This study evaluated the clinical and nutritional status (laboratory, anthropometry, dual-energy X-ray absorptiometry, 7-point subjective global assessment) and QoL (Kidney Disease Quality of Life) at baseline. Hospitalization and mortality were recorded during 36 months.

RESULTS

Reduced muscle mass was observed in 64% of the patients, reduced muscle strength in 52%, and sarcopenia in 37%. The group with sarcopenia was older, had a higher proportion of men and showed worse clinical and nutritional conditions when compared with patients without sarcopenia. Although reduced muscle mass was strongly associated with poor nutritional status, low muscle strength was associated with worse QoL domains. In the multivariate Cox analyses adjusted by age, gender, dialysis vintage, and diabetes mellitus, low muscle strength alone and sarcopenia were associated with higher hospitalization, and sarcopenia was a predictor of mortality.

CONCLUSION

In conclusion, in this sample, comprised of elderly patients on MHD, sarcopenia was associated with worse nutritional and clinical conditions and was a predictor of hospitalization and mortality.

Bioelectrical impedance analysis as a nutritional assessment tool in Autosomal Dominant Polycystic Kidney Disease

OBJECTIVE

Autosomal dominant polycystic kidney disease (ADPKD) patients with massive organomegaly suffer from pressure-related complications including malnutrition. In this study, we analyzed the efficacy of segmental bioelectrical impedance analysis (BIA) for objective and quantitative nutritional assessment in ADPKD patients.

DESIGN AND METHODS

We conducted a cross-sectional study, to evaluate the clinical utility of segmental BIA for assessing the nutritional status of ADPKD patients. BIA measurements was assessed according to modified subjective global assessment (SGA) scores and were compared with data from a healthy population. The association between BIA measurements and the height adjusted kidney and liver volumes (htTKLV), were analyzed.

SUBJECTS

A total of 288 ADPKD patients, aged ≥ 18 years old, were analyzed.

MAIN OUTCOME MEASURES

Nutritional status was evaluated with SGA and segmental BIA. The htTKLV were measured in each patients using computed tomonography images.

RESULTS

Higher ratios of extracellular water to total body water (ECW/TBW) in the whole-body (ECW/TBWWB), trunk (ECW/TBWTR), and lower extremities (ECW/TBWLE) and lower phase angle of lower extremities (PhALE) correlated with lower SGA scores in the ADPKD population and in both gender. The four parameters, ECW/TBWWB, ECW/TBWTR, and ECW/TBWLE of >0.38 and PhALE of <5.8 θ were associated with malnutrition in ADPKD patients. These correlations were preserved in the subgroup analysis for chronic kidney disease stages 1-3A. Compared to healthy populations' data, body fluid parameters and segmental ECW/TBW values, except for the upper extremities (ECW/TBWUE), were greater in ADPKD patients. Increased htTKLV was an independent risk factor for malnutrition in ADPKD. The highest correlation with htTKLV was observed for the ECW/TBWTR (r = 0.466), followed by ECW/TBWWB (r = 0.407), ECW/TBWLE (r = 0.385), PhALE (r = -0.279), and PhATR (r = 0.215).

CONCLUSIONS

These results demonstrated that segmental BIA parameters of ECW/TBWWB, ECW/TBWTR, ECW/TBWLE and PhALE provide useful information on nutritional status including the impact of organomegaly in ADPKD.

No Survival Benefit in Octogenarians and Nonagenarians with Extended Hemodialysis Treatment Time

BACKGROUND

The population of elderly end-stage renal disease patients initiating dialysis is rapidly growing. Although longer treatment is supposed to benefit for hemodialysis (HD) patients through more solute clearance and slower fluid removal, it is not yet clear how treatment session length affects mortality risk in octogenarians and nonagenarians.

METHODS

In a cohort of 112,026 incident HD patients between 2007 and 2011, we examined the association of treatment session length with all-cause mortality, adjusting for demographics and comorbid conditions. We also used restricted spline functions for age to evaluate continuous changes in the association of short (< 210 min) and extended (≥240 min) HD treatment (vs. 210 to < 240 min) with all-cause mortality over continuous age.

RESULTS

During the first 91 days of dialysis, patients aged ≥80 years tended to have the lowest treatment session length (median [interquartile range] 211 [193-230] min, r > 0.5). Longer treatment was associated with better survival in patients < 65 and 65 to < 80 years but not in octogenarians/nonagenarians. The association of extended treatment (≥240 min) with better survival was attenuated across age and not significant among patients aged ≥80 years with a hazard ratio of 1.10 (95% CI 0.99-1.20). Shorter treatment sessions (< 210 min) was associated with higher mortality across all age groups.

CONCLUSION

Extended HD was not associated with lower mortality among octogenarians and nonagenarians, while it was associated with better survival among younger patients. Further studies are needed to determine the optimal treatment session length in elderly incident HD patients.

Evaluating haemodialysis patient's nutritional status: Body mass index or body cell mass index?

OBJECTIVE

Evaluate which of two combinations of parameters based on International Society of Renal Nutrition and Metabolism recommendations could better identify patients with protein-energy wasting (PEW) and to compare the relationship of these two combinations with other clinical and body composition parameters.

METHODS

This was a multicentre longitudinal study with 24 months of follow-up. The PEW patients were characterized by: Group A (G_A ) - normalized protein catabolic rate (nPCR) < 1.0 g/kg per day, albumin <3.8 g/dL and body cell mass index (BCMI) < 6.4 kg/m² (n = 203); Group B (G_B ) - nPCR <1.0 g/kg per day, albumin <3.8 g/dL and body mass index (BMI) <23 kg/m² (n = 109). All the patients who did not meet these requirements were considered "well-nourished" (G_A : n = 1818; G_B : n = 3292).

RESULTS

When compared to the well-nourished patients, PEW patients in the G_A presented higher age, Kt/V, C-reactive protein, relative overhydration, fat tissue index (FTI); lower creatinine, albumin, nPCR, PTH, haemoglobin, phosphorus, calcium X phosphorus product, potassium, dry weight, BMI, BCMI, lean tissue index, %IDWG . In the G_B , well-nourished patients FTI was significantly higher. In Cox analysis, the combination with BCMI was a strong independent predictor of mortality in these patients (hazard ratio: 1.48; confidence interval: 1.00-2.19; P = 0.048), even after adjustment. Although G_B combination seemed to be also a predictor of death (hazard ratio: 2.67; confidence interval: 1.92-3.71; P < 0.001), when adjusted, the association remained no longer significant.

CONCLUSION

A new combination of parameters including protein intake, albumin and BCMI demonstrated significant associations with other nutrition and inflammation parameters as well as with mortality.

Assessment of adult malnutrition and prognosis with bioelectrical impedance analysis: phase angle and impedance ratio

PURPOSE OF REVIEW

Malnutrition affects prognosis in many groups of patients. Although screening tools are available to identify adults at risk for poor nutritional status, a need exists to improve the assessment of malnutrition by identifying the loss of functional tissues that can lead to frailty, compromised physical function, and increased risk of morbidity and mortality, particularly among hospitalized and ill patients and older adults. Bioimpedance analysis (BIA) offers a practical approach to identify malnutrition and prognosis by assessing whole-body cell membrane quality and depicting fluid distribution for an individual.

RECENT FINDINGS

Two novel applications of BIA afford opportunities to safely, rapidly, and noninvasively assess nutritional status and prognosis. One method utilizes single-frequency phase-sensitive measurements to determine phase angle, evaluate nutritional status, and relate it to prognosis, mortality, and functional outcomes. Another approach uses the ratio of multifrequency impedance values to indicate altered fluid distribution and predict prognosis.

SUMMARY

Use of basic BIA measurements, independent of use of regression prediction models and assumptions of constant chemical composition of the fat-free body, enables new options for practical assessment and clinical evaluation of impaired nutritional status and prognosis among hospitalized patients and elders that potentially can contribute to improved patient care and clinical outcomes. However, these novel applications have some technical and physiological limitations that should be considered.

Elderly patients on hemodialysis have worse dietary quality and higher consumption of ultraprocessed food than elderly without chronic kidney disease

OBJECTIVES

The multiple dietary restrictions recommended to patients on hemodialysis (HD), coupled with conditions imposed by aging, may lead to poor dietary quality in these patients. The aim of this study was to investigate the dietary quality and consumption of ultraprocessed food by elderly patients on HD and those without chronic kidney disease (CKD). Additionally, diets on the day of dialysis and on nondialysis days were evaluated.

METHODS

This was a cross-sectional study conducted with 153 noninstitutionalized elderly patients on HD (Elder-HD) and 47 non-CKD elderly (Elder-Healthy) aged ≥60 y. From a 3-d food record, the dietary quality was assessed using the Brazilian Healthy Eating Index Revised (BHEI-R) and the energy contribution of food-processing groups.

RESULTS

Compared with the Elder-Healthy group, the Elder-HD group showed a lower total BHEI-R score (P < 0.05). On the weekdays, the Elder-HD group showed lower scores (P < 0.05) of whole fruit, dark green vegetables and legumes, meat, eggs, and legumes, whereas total cereals showed a higher score (P < 0.05). When furthering the analysis on the Elder-HD group, although the total BHEI-R score did not differ among the days assessed, the components whole fruit, dark green vegetables, and legumes had lower scores (P < 0.05) on the day of dialysis, and the opposite was observed for milk and dairy products. Moreover, the Elder-HD showed a higher (P < 0.05) contribution of processed and ultraprocessed foods and lower (P < 0.05) contribution of natural or minimally processed foods.

CONCLUSION

The Elder-HD group showed poorer dietary quality and higher consumption of processed and ultraprocessed foods than the Elder-Healthy group. Moreover, when compared with the nondialysis day, these patients exhibited worse dietary quality, on the day of dialysis.

[Challenges of aging skin: Care and therapy using the example of venous ulcers]

BACKGROUND

One of the most significant, and growing, challenges in modern medicine, i.e. the treatment of chronic wounds, is marked by nonuniform data. This concerns both prevalence and incidence of chronic dermatosis, in particular venous ulcers (ulcus cruris), as well as the impact on the health-related quality of life, and practical and economic parameters of the success of different therapies.

PURPOSE

The aim of this work is to examine the epidemiology of chronic wounds, in particular age-associated venous ulcers, their impact on health-related quality of life, the treatment regimen, and practical and economic parameters of the success of different therapies.

MATERIALS AND METHODS

Performed were analysis of data on the care of venous ulcers in Germany, based on secondary data of Barmer GEK from 2009 and 2012, comparison with data of a NHS Kent Community Health Trust study, and analysis of studies concerning structures, processes and critical success factors for the treatment of chronic wounds, including economic effects.

CONCLUSION

Early causal therapy with treatment based on the stage of the wound, consequent goal-oriented interdisciplinary care, and relapse prophylaxis is critical for successful healing of venous ulcers. The costs of treatment significantly correlate with the duration of treatment which can be reduced by up to 60% using guideline-based concepts for the treatment of chronic wounds. Treatment success, in particular with regard to cost-benefit considerations, can be optimized by telemedicine networks of key players who treat chronic wounds.