Understanding Development of Malnutrition in Hemodialysis Patients: A Narrative Review

Influence of infection control for COVID-19 on nutrition in relatively healthy Japanese HD patients: a retrospective observational study

BACKGROUND

Infection control for the novel coronavirus disease 2019 (COVID-19) has been linked to decreased physical activity and nutritional deterioration in the general population; however, the influence on hemodialysis (HD) patients is not well discussed.

METHODS

This multicenter retrospective study utilized the Geriatric Nutritional Risk Index (GNRI), Survival Index, and Nutritional Risk Index for Japanese HD patients (NRI-JH) to assess nutritional status and body composition over five observation periods. The primary endpoint was the body fluid removal rate (%) pre- and post-HD, whereas secondary endpoints included changes in GNRI, SI, body composition, and differences in NRI-JH.

RESULTS

We enrolled 139 HD patients in three facilities. The results showed a decrease in GNRI score, which indicates nutritional deterioration, between February 2020 and August 2020 (96.8 (93.2-98.9) vs. 93.8 (90.8-97.6)) (P = 0.0005). Multivariable analysis revealed that nutritional deterioration was associated with higher C-reactive protein and lower hemoglobin levels (P = 0.0004 and P = 0.0010, respectively), which were more noticeable in the urban facility. Furthermore, nutritional deterioration was linked to a decrease in soft lean and somatic cell mass and an increase in body fat mass, suggesting reduced physical activity.

CONCLUSIONS

Nutritional deterioration was observed shortly after the first COVID-19 outbreak, suggesting an association with decreased physical activity.

The impact of predialytic oral protein-based supplements on nutritional status and quality of life in hemodialysis patients: a randomized clinical trial

BACKGROUND

Administration of oral nutritional supplements (ONS) inside hemodialysis (HD) units before sessions is an increasingly adopted option. Our aim was to assess the effects of predialytic ONS on nutritional status and quality of life (QOL) in HD patients.

METHODS

One hundred HD patients were enrolled in this prospective, multicentric randomized clinical trial. Patients were assigned to receive ONS (25 gm protein powder) 1 h prior to the start of the HD session (predialytic) or maintained on their routine nutrition regimen for 3 months.

RESULTS

At study end, supplemented patients showed a significant increase in serum albumin (p < 0.001), and a non-significant decrease in the median subjective global assessment (SGA) score. While in the control group, serum albumin remained stable, and the median SGA score increased significantly (p < 0.001). Body mass index and anthropometric measures did not differ between both groups. The supplemented patients showed significant improvement in three subscales of the Kidney Disease Quality of Life-36, without a significant change in QOL in control patients. Supplemented patients had significantly higher blood pressure (BP) (p = 0.037), lower urea reduction ratio (p = 0.020) and Kt/V (p = 0.021), higher serum calcium, lower total cholesterol and lower CRP (p = 0.047) levels compared to controls. There was no significant difference between groups regarding serum sodium, potassium, or phosphorus or adverse events.

CONCLUSIONS

Predialytic ONS administration may contribute to improvements in serum albumin, and QOL. The effects on BP, CRP, and the reduction in dialysis adequacy, should be carefully considered while adopting such strategy.

CLINICAL TRIALS REGISTRATION

ClinicalTrials.gov NCT05952570.

FIRST REGISTRATION DATE

2/07/2023.

Comparative effectiveness of nonpharmacological interventions for the nutritional status of maintenance hemodialysis patients: a systematic review and network meta-analysis

Objective

We aim to analyze the effects of different nonpharmacological interventions on the nutritional status of patients on maintenance hemodialysis (MHD).

Methods

Randomized controlled trials (RCTs) conducted up to October 12, 2023 were searched in the Cochrane Library, Chinese National Knowledge Infrastructure, Wan Fang Database, VIP databases, and China Biomedical Literature Database. R and Review Manager software were used for data analysis, the quality of the literature was assessed using the Cochrane Risk Bias Tool RoB2.0, the reliability of evidence was evaluated using Grading of Recommendations, Assessment, Development, and Evaluation guidelines, and sources of heterogeneity were explored through sensitivity analyses. This study was registered in PROSPERO with registration number CRD42023458187.

Results

A total of 54 studies met the criteria, 3,861 patients were enrolled in this study, and 11 interventions were explored. The results of the network meta-analysis (NMA) showed that dietary intervention is the best intervention in terms of improving patients' body mass index and serum albumin levels and health education is the best intervention in terms of improving patients' hemoglobin levels.

Conclusion

This NMA confirmed that different nonpharmacological interventions benefit the nutritional status of patients on MHD, providing novel insights for healthcare practitioners. However, high-quality RCTs should be designed to validate the stability of the level of evidence for different nonpharmacological interventions.

Yunpiqiangshen gel improves quality of life in dialysis patients

OBJECTIVE

To evaluate the efficacy and safety of Yunpiqiangshen gel which composed of eleven herbs on quality of life (QOL) improvement.

METHODS

We enrolled 180 patients lasted from January 2020 to December 2021. Seventy-eight patients received standards of care (control group) and 76 patients received Yunpiqiangshen gel [Traditional Chinese Medicine, (TCM) group] for 6 months in statistical analysis. The primary outcome assessed using Kidney Disease Quality of Life Short Form Questionnaire version 1.3 (KDQOL-SFTM 1.3), including Short Form Health Survey (SF-36) and Kidney Disease Targeted Areas (KDTA) scores. The second outcomes included the TCM syndrome score, Fatigue Assessment Instrument (FAI) score, Modified Quantitative Subjective Global Assessment (MQSGA) score, anthropometric indicators, and blood chemical testing. Adverse events, including decompensated gastrointestinal symptoms, were evaluated.

RESULTS

The results showed that the mean change of SF-36 (75 ± 13 vs 64 ± 16, F = 6.070, P = 0.015) and KDTA (76 ± 7 vs 70 ± 9, F = 4.118, P = 0.044) scores in the TCM group had an improvement (increase) from baseline, as compared with the control group. Yunpiqiangshen gel also resulted in a significant improvement in almost dimensions of QOL. At the end of follow-up, the imputed percentage of patients in the response rate of TCM syndrome was greater in the TCM group than in the control group (76.32% vs 20.51%, χ 2 = 48.02, P = 0.000). The fatigue, soreness of waist, anorexia, abdominal distension, loose stool, and constipation were alleviated after Yunpiqiangshen gel therapy. The FAI (98.58 ± 25.08 vs 131.21 ± 31.85, F = 8.745, P = 0.004) and MQSGA (10.13 ± 2.84 vs 12.83 ± 3.85, F = 11.396, P = 0.001) scores in the TCM group had an improvement (reduce) from baseline compared with the control group. A higher level of albumin of patients in the TCM group compared with the control group. Diarrhea, vomit, and loose stool were more common in the TCM group, but generally mild in severity.

CONCLUSION

Compared with the standards of care, added Yunpiqiangshen gel was a safe and effective therapy for improving QOL in dialysis patients.

Turkish version of the renal inpatient nutrition screening tool: validity and reliability for haemodialysis patients

The aim of this study was to analyse the validity and reliability of the Turkish version of the renal inpatient nutrition screening tool (Renal iNUT) for haemodialysis patients. The Renal iNUT and the malnutrition universal screening tool (MUST) were used in adult haemodialysis patients at two different centres to identify malnutrition. The subjective global assessment (SGA), regarded as the gold standard for nutritional status assessment, was utilised for comparison. Structural validity was assessed using biochemical values and anthropometric measurements, while reliability was assessed using repeated the Renal iNUT assessment. Of the 260 patients admitted, 42·3 % were malnourished (SGA score was B or C). According to the Renal iNUT, 59·6 % of the patients were at increased risk for malnutrition (score ≥ 1) and 3·8 % required referral to a dietitian (score ≥ 2). According to the MUST, 13·1 % of the patients were at increased risk for malnutrition and 8·5 % required referral to a dietitian. The Renal iNUT was found to be more sensitive in detecting increased risk of malnutrition in haemodialysis patients compared with the MUST (59·6 % v. 13·1 %). According to the SGA, the sensitivity of the Renal iNUT is higher compared to the MUST (89 % and 45 %, respectively). Kappa-assessed reliability of the Renal iNUT was 0·48 (95 % CI, 0·58, 0·9) and a moderate concordance was observed. The Renal iNUT is a valid and reliable nutritional screening tool for evaluating haemodialysis patients to determine their nutritional status. The use of the Renal iNUT by dietitians will contribute to the identification of malnutrition and its treatment.

Factors associated with malnutrition inflammation score among hemodialysis patients: A cross-sectional investigation in tertiary care hospital, Palestine

Malnutrition is a prevalent complication in hemodialysis patients and is associated with increased mortality and morbidity. This study aimed to identify the risk factors associated with malnutrition among hemodialysis patients including patient's general characteristics, functional status, and dietary intake. This study involved hemodialysis patients in An-Najah National University Hospital at Nablus/Palestine. An interview-based questionnaire was used to collect data related to sociodemographic, lifestyle, hemodialysis, medical history, anthropometrics, biochemical indices, dietary data using 3-days diet recall, and functional status. Malnutrition-inflammation score tool (MIS) was used for malnutrition screening of the studied patients. The study involved 188 patients, with a mean age of 57.8±14 years. A total of 28.2% participants are reported malnourished. Malnutrition was significantly associated with being female (p = 0.001), unemployed (p = 0.009), nonsmoker or ex-smoker (p = 0.018). Patients with CVDs (p = 0.006), higher months on dialysis (p = 0.002), lower BMI (p = 0.018), and using catheter for dialysis access are more likely to develop malnutrition (p = 0.018). Furthermore, patients with poor functional status (poor handgrip strength (p<0.001), inability to walk (p<0.001), needing help in daily activity or in transfer (p<0.001)) were significantly associated with malnutrition. Additionally, malnutrition was significantly higher among patients who does not meet their recommended calorie intake (p = 0.008), whose sodium intake within recommendation (p = 0.049), patients with low levels of hemoglobin (p = 0.022), albumin (p<0.001), TIBC (p = 0.002), phosphate (p<0.001), and patients with higher levels of ferritin (p<0.001). Higher months on dialysis (Exp(B) = 1.02), unmet calorie intake (Exp(B) = 4.3), needing help in daily activities (Exp(B) = 0.238), and low albumin level (Exp(B) = 0.048) were the independent predictors of malnutrition. This study highlights the significant association between malnutrition and various demographic, clinical, functional, and dietary factors in hemodialysis patients, revealing the burden of malnutrition during HD. It also necessitates targeted intervention to address these risk factors and improve nutritional status and the overall health outcomes of HD patients.

Assessment of Nutritional Intake in Patients With Kidney Failure Treated by Haemodialysis on Dialysis and Non-dialysis Days

INTRODUCTION/AIMS/OBJECTIVE

Inadequate nutritional intake in haemodialysis (HD) patients increases the risk of muscle wasting, nutrient deficiencies, leading to an increased risk of additional morbidity and mortality. We aimed to assess nutritional intake on the dialysis day and nondialysis day (NDD) of patients established on HD.

METHODS

We employed a 2-day dietary record, one on the day of dialysis and one on the NDD, and then determined nutritional intake using the Nutritics software. Muscle strength was assessed by hand grip strength, and the body composition was determined using multifrequency bioelectrical impedance recorded postdialysis.

RESULTS

We recruited 51 established HD patients dialysing between May 2022 and July 2022, of mean age 60 ± 15 years, 52.9% male, and 51% diabetic. Only 25% achieved the calorie and protein intake recommended by Kidney Disease Outcomes Quality Initiative. Most patients had inadequate consumption of fiber (96%), calcium (86%), iron (80%), zinc (82%), selenium (92%), folate (82%), vitamin A (88%), and (100%) vitamin D. On the other hand, the great majority followed the restriction guidelines for potassium (96%), phosphorus (86%), and sodium (84%), respectively. However, consumption was greater for potassium (P = .007), phosphorus (P = .015), and zinc (P = .032) on NDDs versus dialysis days, but there was no difference in protein or calorie intake between days.

CONCLUSION

Our results suggest that many of our HD patients do not achieve the recommended nutritional targets. Patient compliance with restricting sodium, potassium, and phosphate limits protein and calorie intake. HD patients are at increased risk of sarcopenia, so failure to achieve dietary protein intake will further increase this risk.

Risk Factors for Long-Term Nutritional Disorders One Year After COVID-19: A Post Hoc Analysis of COVID-19 Recovery Study II

Background/Objectives: COVID-19 patients develop various clinical symptoms, including malnutrition. However, the risk factors for long-term nutritional disorders remain unclear. Identifying these factors is crucial for preventing nutritional disorders by initiating early nutritional interventions. Methods: This was a post hoc analysis of COVID-19 Recovery Study II (CORESII). The study included adult patients hospitalized for COVID-19 and discharged from the hospital. Information, including post-COVID-19 symptoms one month after onset and changes in daily life during the first year, was collected using a self-administered questionnaire sent one year after hospital discharge. We examined the association between baseline characteristics, disease severity, and symptoms that persisted one month after onset with malnutrition disorders one year after onset, defined as a Malnutrition Universal Screening Tool score ≥1, using a logistic regression analysis. Results: A total of 1081 patients (mean age of 56.0 years; 34% females; 38% admitted to the intensive care unit) were analyzed. Of these patients, 266 patients (24.6%) had malnutrition one year after onset. In a multivariable logistic regression analysis using variables that were significant in a univariate logistic regression analysis, the following factors were independently associated with malnutrition: BMI < 18.5 kg/m2 (odds ratio [95% confidence interval (CI)], 48.9 [14.3-168]), 18.5 ≤ BMI ≤ 20 (10.5 [5.89-18.8]), 30 < BMI (2.64 [1.84-3.75]), length of hospital stay (1.01 [1.00-1.02]), maintenance dialysis (3.19 [1.19-8.61]), and difficulty concentrating one month after onset (1.73 [1.07-2.79]). Conclusions: Being underweight or obese, prolonged hospitalization, maintenance dialysis, and difficulty concentrating one month after onset were associated with a risk of malnutrition one year post-illness. Patients with these factors may be at a high risk of long-term nutritional disorders.

Transferrin levels are associated with malnutrition markers in hemodialysis patients in KwaZulu-Natal, South Africa

INTRODUCTION

Malnutrition is a global phenomenon and may be contributing to the increasing size of the hemodialysis (HD) population in South Africa and is affecting morbidity and clinical outcomes. Our study assessed whether transferrin could be a possible marker for malnutrition in the HD population.

METHODS

Clinical parameters (including skinfold thickness and mid-upper arm circumference [MUAC]) and laboratory markers (including transferrin and hemoglobin) were measured during a six-month period in a sample of 59 HD patients.

RESULTS

Linear regression analysis showed that MUAC (p = 0.027) as well as skinfold thickness (p = 0.021) had a significant association with transferrin levels within the HD participants. There was no significant association between transferrin levels or MUAC with hemoglobin levels (p = 0.075). Furthermore, the study found that decreased transferrin levels (< 2.15 g/dL to 3.80 g/dL) were closely related to malnutrition in the malnutrition distribution groups within the study, with 97.7% of HD participants being classified in one of the malnutrition groups.

CONCLUSION

Thus, transferrin levels are a valuable marker for malnutrition within the HD patient population and can be included along with clinical assessment parameters such as MUAC and skinfold thickness as primary indicators for malnutrition.

Risk factors associated with mortality among patients on maintenance hemodialysis: The Thailand Renal Replacement Therapy registry

INTRODUCTION

End-stage kidney disease (ESKD) has been increasing in prevalence across the world, including Thailand, and patients with ESKD on hemodialysis have a high mortality risk.

METHODS

A retrospective cohort study was performed across 855 hemodialysis centers in the Thailand Renal Replacement Therapy registry. The database and mortality data were analyzed.

RESULTS

A total of 58 952 patients were included. The survival rates at 1, 3, and 5 years were 93.5%, 69.7%, and 41.2%, respectively. On multivariate analysis, factors such as aging, permanent catheter or arteriovenous graft, twice-weekly hemodialysis, low levels of urea reduction ratio, normalized protein catabolic rate, hemoglobin, transferrin saturation, serum albumin, LDL-cholesterol, intact-parathyroid hormone, uric acid, sodium, phosphate, and bicarbonate were significantly related to death.

CONCLUSION

Mortality is high in ESKD patients on hemodialysis. Age, type of vascular access, twice-weekly hemodialysis, inadequate dialysis, low protein intake, anemia, abnormal electrolytes, and bone mineral disorders are associated with all-cause mortality.

Short-Term Safety of Nutri-Jelly in Adults Undergoing Hemodialysis

Excessive water consumption from liquid or reconstituted oral nutrition supplements may increase risk of fluid overload in renal patients. Nutri-jelly, a ready-to-eat texture-modified diet with 52.8% water, some protein, low potassium, phosphorus, and sodium, could be an alternative. However, its safety is unknown for adults undergoing hemodialysis (HD). This study investigated the short-term physiological safety of Nutri-Jelly intake and its preliminary impact on renal outcomes. A randomized open-label, single-arm, two-sequence, two-period cross-over trial was conducted in 20 adults undergoing HD with inadequate protein intake (0.50 - 0.70 g/ kg body weight/day). Participants were randomly allocated into 2 groups (n =10 each) and assigned in random sequence into both Without-Jelly (HD 3 times during 7 days) and With-Jelly periods (100 g Nutri-Jelly twice daily along with HD 3 times during 7 days). A two-week washout was between the periods. Outcome measures included adverse symptoms, changes in body weight, heart rate, blood pressure, and blood biochemical parameters relevant to renal outcomes. The results showed no intervention-related adverse symptoms or significant changes in body weight, heart rate, systolic blood pressure, creatinine, albumin, and sodium. Potassium level and pre-HD diastolic blood pressure were better controlled during the With Jelly than the Without Jelly Periods (p < 0.01 and p < 0.05, respectively). The eGFR was improved with no significant difference between the periods. The findings suggest that continuous intake of 100 g Nutri-Jelly twice daily for 7 days is safe in adults undergoing hemodialysis. Its efficacy on renal-related parameters warrants further investigations in long-term studies.

Development and validation of a nomogram to estimate fatigue probability in hemodialysis patients

OBJECTIVE

This study aims to investigate the factors that influence fatigue in hemodialysis (HD) patients and to develop and validate a nomogram to estimate the probability of fatigue in this population.

METHODS

This cross-sectional study collected 453 patients who underwent HD at the tertiary hospital in Hubei, China, from April to December 2023. They were randomly divided into a 70% training group (n = 316) and a 30% validation group (n = 137). In the training set, factors influencing fatigue were screened using multivariate logistic regression analysis, and a nomogram was developed to estimate fatigue probability in HD patients. The discrimination and calibration of the nomogram were validated in both the training and validation sets through the area under the receiver operating characteristic (ROC) curve (AUC) and the Hosmer-Lemeshow (H-L) test.

RESULTS

In the training group, logistic regression showed that age, dialysis vintage, inter-dialysis weight gain, hemoglobin, depression, insomnia, and social support were variables associated with fatigue in HD patients. Based on these factors, a nomogram for assessing fatigue probability in HD patients was developed. The AUC was 0.955 (95% CI: 0.932-0.977) and 0.979 (95% CI: 0.961-0.997) in the training and validation sets. The results from the H-L test indicated a good fit.

CONCLUSION

The nomogram can evaluate fatigue probability in HD patients and may serve as a convenient clinical tool.

Independent Association Between Malnutrition Inflammation Score and C Reactive Protein/Albumin Ratio in Hemodialysis Patients

Introduction

This study aimed to investigate the relationship between the Malnutrition Inflammation Score (MIS) and the C-reactive protein/albumin ratio (CAR) in patients undergoing hemodialysis (HD).

Materials and Methods

Sixty-six End-Stage Renal Disease (ESRD) patients on maintenance hemodialysis were recruited for the study. Malnutrition Inflammation Score, biochemical parameters, and C-reactive protein/albumin ratio were analyzed.

Results

The mean age of the participants was 56.47 ± 17.3 years. A statistically significant positive correlation was found between the CRP/albumin ratio and MIS ≥7 (r = 0.413, p = 0.026), CRP and MIS ≥7 (r = 0.388, p = 0.038) and a negative correlation between albumin and MIS (r = -0.511, p = 0.005). Additionally, MIS was negatively correlated with hemoglobin (r = -0.412, p = 0.026) and creatinine (r = -0.568, p = 0.001), while a positive correlation was found between MIS and ferritin (r = 0.584, p = 0.001) for MIS ≥7. A multiple regression ANOVA model confirmed a significant association between CAR, CRP, albumin, and MIS (F = 6.432, p = 0.002), with significant contributions from CAR (p = 0.003), albumin (p = 0.008), and CRP (p = 0.003).

Conclusion

Our study is the first to show an independent association between CAR and MIS in hemodialysis patients. The CRP/albumin ratio can serve as a valuable indicator of malnutrition in this population, providing a reliable tool for assessing nutritional status.

Prevalence and severity of sarcopenia in patients on maintenance hemodialysis: a cross-sectional study

BACKGROUND

Sarcopenia, the progressive loss of muscle mass and strength, is common among patients with chronic kidney disease, especially those on maintenance hemodialysis. This condition often arises from factors like reduced physical activity and metabolic changes associated with chronic kidney disease. This study aims to assess the prevalence and severity of sarcopenia in patients on maintenance hemodialysis (MHD), focusing on probable sarcopenia and its correlations with physical activity, body mass index, and inorganic phosphorus levels.

METHODS

This cross-sectional study involved 220 patients on MHD who visited to West China Hospital of Sichuan University between February and April 2023. The demographic data, body measurements, and laboratory results were retrospectively collected. Sarcopenia was assessed using the 2019 criteria from the Asian Working Group and the European Working Group on Sarcopenia in Older People, and physical activity was measured via the International Physical Activity Questionnaire.

RESULTS

Of the study participants, 141 (64.1%) were diagnosed with probable [110 (50.0%) or confirmed sarcopenia [31 (14.1%)], including 22 (10%) with severe sarcopenia. Multivariable logistic regression analysis revealed that physical activity (International Physical Activity Questionnaire score, OR = 0.998, 95% CI: 0.998-0.999, P < 0.001), body mass index (OR = 0.868, 95% CI: 0.788-0.957, P = 0.004), and inorganic phosphorus levels (OR = 0.513, 95% CI: 0.270-0.975, P = 0.042) independently influenced the likelihood of sarcopenia. Within the sarcopenic group, physical activity and BMI significantly correlated with the condition's severity.

CONCLUSION

The prevalence of probable or confirmed sarcopenia in patients on MHD is significant. Factors such as physical activity, body mass index, and inorganic phosphorus levels are independently associated the presence and severity of sarcopenia in this population.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR2100051111), registered on 2021-09-13.

Association between dietary fatty acids and depressive symptoms in Chinese haemodialysis patients: a cross-sectional study

Depression is highly prevalent in haemodialysis patients, and diet might play an important role. Therefore, we conducted this cross-sectional study to determine the association between dietary fatty acids (FA) consumption and the prevalence of depression in maintenance haemodialysis (MHD) patients. Dietary intake was assessed using a validated FFQ between December 2021 and January 2022. The daily intake of dietary FA was categorised into three groups, and the lowest tertile was used as the reference category. Depression was assessed using the Patient Health Questionnaire-9. Logistic regression and restricted cubic spline (RCS) models were applied to assess the relationship between dietary FA intake and the prevalence of depression. As a result, after adjustment for potential confounders, a higher intake of total FA [odds ratio (OR)T3 vs. T1 = 1·59, 95 % confidence interval (CI) = 1·04, 2·46] and saturated fatty acids (SFA) (ORT3 vs. T1 = 1·83, 95 % CI = 1·19, 2·84) was associated with a higher prevalence of depressive symptoms. Significant positive linear trends were also observed (P < 0·05) except for SFA intake. Similarly, the prevalence of depression in MHD patients increased by 20% (OR = 1.20, 95% CI = 1.01-1.43) for each standard deviation increment in SFA intake. RCS analysis indicated an inverse U-shaped correlation between SFA and depression (P nonlinear > 0·05). Additionally, the sensitivity analysis produced similar results. Furthermore, no statistically significant association was observed in the subgroup analysis with significant interaction. In conclusion, higher total dietary FA and SFA were positively associated with depressive symptoms among MHD patients. These findings inform future research exploring potential mechanism underlying the association between dietary FA and depressive symptoms in MHD patients.

Effects of Diet and Supplements on Parameters of Oxidative Stress, Inflammation, and Antioxidant Mechanisms in Patients with Chronic Renal Failure Undergoing Hemodialysis

The prevalence of chronic kidney disease (CKD) worldwide increases as the population ages. The progression of the disease increases the risk of complications and death and leads to end-stage renal failure, requiring renal replacement therapy. Despite the positive effect of hemodialysis (HD), patients are at risk of developing malnutrition, inflammation, oxidative stress, or cardiovascular disease, which worsens quality of life and can lead to organ dysfunction. The occurrence of the mentioned disorders depends largely on the diet, so changes in diet composition are an important part of the treatment of kidney disease. This study aimed to evaluate the effects of a balanced diet on some parameters of oxidative stress, immune response, and nutritional status in patients. This study included 57 HD patients (19 women and 38 men). In all of them, nutritional status and diet were initially determined, and then, they were divided into six groups, which received different diets and supplements. Serum levels of albumin, total protein, MDA, and the cytokines Il-1, IL-6, IL-8, TNF-α, and IL-10 were determined, and the activity of the enzymes such as CAT, SOD, and GSH-Px were determined in erythrocytes by spectrophotometry. Based on the results of BMI, albumin, and total protein, it can be concluded that a well-balanced diet can reduce weight loss. This study shows that a well-balanced diet can reduce the secretion of pro-inflammatory cytokines, and ensure the normal activity of antioxidative enzymes in the blood of HD patients.

Construction of frailty and risk prediction models in maintenance hemodialysis patients: a cross-sectional study

Objective

As the prevalence of diabetic nephropathy and hypertensive nephropathy increases with age in mainland China, the number of patients with end-stage renal disease is increasing, leading to an increase in the number of patients receiving maintenance hemodialysis. Considering the harmful effects of frailty on the health of maintenance hemodialysis patients, this study aims to identify hemodialysis patients at risk for frailty at an early stage, in order to prevent or delay the progression of frailty in the early stage, so as to prevent the adverse consequences of frailty.

Methods

A total of 479 patients admitted to the blood purification centers of two grade tertiary hospitals in Anhui Province, China, using convenient sampling. The Frailty Scale, the SARC-F questionnaire, the Simplified Food Appetite Questionnaire (SNAQ) and the mini nutritional assessment short-form (MNA-SF) were used in the study. Pearson correlation analysis was used to explore the correlation among the frailty influencing factors.

Results

The incidence of frailty was 24.0% among 479 Chinese hemodialysis patients. Gender (p < 0.05), Malnutrition (p < 0.001), sarcopenia (p < 0.001), and feel tired after dialysis (p < 0.001) were highly correlated with frailty in Chinese hemodialysis patients. Serum albumin concentration (p < 0.05) was a protective factor of frailty.

Conclusion

This survey shows that frailty was highly prevalent among Chinese hemodialysis patients. Medical staff and their families should make early judgments and carry out interventions on the risk of frailty.

Association between objectively measured protein intake and muscle status, health-related quality of life, and mortality in hemodialysis patients

BACKGROUND

Protein intake is known to be associated with muscle mass, health-related quality of life (HRQoL), and mortality in patients with stage 5 chronic kidney disease undergoing dialysis. However, most studies evaluated protein intake based on 24 h dietary recall or food frequency questionnaire, and these methods are prone to bias. Therefore, this study aimed to evaluate the association of objectively measured protein intake with muscle mass and strength, HRQoL, and mortality.

METHODS

Dietary protein intake was calculated based on the combined (urinary and dialysate) urea excretion rate according to the Maroni formula and indexed to body weight. Muscle mass was calculated based on the combined dialysate and urinary creatinine excretion rate, and muscle strength was assessed by handgrip strength. HRQoL was based on the Short Form 36. Linear and Cox regression were used for the analyses.

RESULTS

We included 59 hemodialysis patients (mean age 65 ± 15 years, 37% female, median hemodialysis vintage 15 [6-39] months). Mean protein intake was 0.82 ± 0.23 g/kg/day, and 76% had a low protein intake (<1.0 g/kg/day). Higher protein intake was independently associated with higher muscle mass (Standardized beta (St. β) [95% confidence interval (95%CI) = 0.56 [0.34 to 0.78]) and higher scores on the physical functioning domain of HRQoL (St. β [95%CI] = 0.49 [0.25 to 0.73]), but not with muscle strength (St. β [95%CI] = 0.17 [-0.10 to 0.43]). During a median follow-up of 21.6 [8.6-36.6] months, 16 (27.1%) patients died. Higher protein intake was associated with lower mortality risk (hazard ratio [95%CI] = 0.34 [0.16-0.73]). This association remained significant after adjustment for potential confounders.

CONCLUSIONS

Protein intake is independently associated with muscle mass, physical functioning domain of HRQOL, and mortality. Clinicians and dietitians should closely monitor the protein intake of hemodialysis patients.

Replacement of the massive amino acid losses induced by hemodialysis: A new treatment option proposal for a largely underestimated issue

BACKGROUND

A series of interesting literature reports acknowledges the notable loss of essential and non-essential amino acids (EAAs and NEAAs) during hemodialysis sessions. These losses may exceed 800 g/year, thus contributing towards accelerating the onset of malnutrition in hemodialysis patients (HD).

OBJECTIVE

A novel tailored amino acid formula for oral administration was developed to replace total amounts of each individual amino acid lost during dialysis diffusive/convective HD strategies, monitoring the effects produced on nutritional and hematological status.

METHODS

A three-month randomized double-blind study was conducted on 30 subjects over the age of 70 years extrapolated from a total population of 86 hemodialysis patients. The 30 patients were randomly assigned to two groups: a treatment group of 15 HD patients (TG) to whom a novel mixture containing 5.4 g of AAs was administered solely on interdialytic days, and a control group of 15 HD patients (CG) who received no amino acid supplementation. The AAs mixture was administered post-dialysis at an extended interval from the end of solute and compartmental rebound to replace AA losses and optimize their role in protein anabolism.

RESULTS

The results obtained highlighted a significant improvement in protein intake g/kg/day (Protein Catabolic Rate, p = 0.014), and increased IgG (p = 0.008) and C3 serum levels (p = 0.003) in the TG group alone. Fat mass losses were initially confirmed by means of bioelectrical impedance analysis (BIA) (p = 0.011) and plicometry (p < 0.001) in the CG group alone, although the main objective was to preserve nutritional status and, particularly, muscle mass. The study was extended to investigate the effects produced on anemia, yielding evidence of continued positive effects three months after the end of the study in the TG group alone based on an increase in Hb levels from 11.2 ± 0.6 to 12.1 ± 0.6 (p = 0.004) associated with a reduced demand for erythropoietin i.v. from 12928 ± 9033 to 9286 ± 5398 U.I/week (p = 0.012) and iron i.v. from 75.9 ± 55 to 71.4 ± 33.4 mg/week (p = 0.045).

CONCLUSIONS

The results obtained following oral administration of this novel tailored AA replacement mixture aimed at reinstating the high AA losses produced during hemodialysis suggest the mixture should be prescribed as a standard procedure to all HD patients.

Intradialytic eating practices and health outcomes among hemodialysis patients, cross-sectional study

BACKGROUND AND AIMS

Intradialytic eating practices is a subject of debate among hemodialysis patients and is associated with a variety of clinical implications. This study aimed to investigate eating practices during hemodialysis and their influence on health outcome, including various symptoms experienced during dialysis, intradialytic hypotension, dialysis adequacy, and malnutrition.

METHODS

A cross-sectional study was conducted on hemodialysis patients. A structured questionnaire was used to collect information related to sociodemographic, medical history, lifestyle, dialysis, and eating practices. The occurrence of intradialytic hypotension was determined according to the patients' blood pressure measured at the beginning and end of the session, and dialysis adequacy was determined based on the ultrafiltration rate of the patients. Malnutrition was evaluated using renal inpatient screening tool (renal iNUT), and biochemical data was recruited from the patient's hospital records.

RESULTS

A total of 260 hemodialysis patients participated in this study. The mean age was 51.29 ± 15.92, and half of the participants were females. The findings showed no significant association between intradialytic eating practices and symptoms developed during dialysis session, intradialytic hypotension, or malnutrition (p > 0.05). According to Chi-square test, a statistically significant association was found between eating practices and dialysis adequacy (p = 0.037), hemoglobin level (p < 0.001), and phosphorous level (p = 0.003).

CONCLUSION

Eating practices were not associated with symptoms that developed during dialysis sessions, intradialytic hypotension, or malnutrition, according to our findings. However, findings reveal that it is possible that eating practices may affect the adequacy of dialysis.

Effect of periodic nursing interventions on improving compliance behavior and health status in long-term Hemodialysis patients

Objective

To investigate the effect of periodic nursing interventions on improving compliance behavior and health status in long-term hemodialysis patients.

Method

This was retrospective study. A total of 88 patients on long-term hemodialysis admitted to Qinhuangdao Haigang Hospital from January 2022 to April 2023 were randomly divided into the control group and the intervention group, who received routine hemodialysis nursing and periodic nursing interventions, respectively. Afterward, compliance behavior and health status were compared between the two groups, along with a comprehensive assessment of the health status using renal function indexes, complication rates, and anxiety and depression scores.

Result

Before nursing, no significant difference was observed in each index between the two groups (p > 0.05). After 16 months of nursing, the score of compliance behavior in the intervention group (88.68 ± 6.27) was significantly higher than that in the control group (70.91 ± 7.48) (p< 0.05), with the renal function indexes of BUN and SCr lower than those in the control group (p< 0.05). Meanwhile, the intervention group saw higher SAS and SDS scores than the control group (p< 0.05).

Conclusion

Periodic nursing interventions may effectively improve the compliance behavior and health status of patients, enhance the efficacy of hemodialysis treatment, and improve the quality of life of patients.

Knowledge, attitude, and practice toward nutrition support and management among hemodialysis patients

Nutrition support is an important care component for patients on hemodialysis. Also, patient self-management is important to maintaining proper nutritional intake during hemodialysis. This cross-sectional study investigated the knowledge, attitude, and practice (KAP) towards nutrition support and management among hemodialysis patients treated at the West China Hospital of Sichuan University between January and March 2023. Among 445 (95.91%) valid questionnaires, 58.43% were filled out by male patients. The knowledge, attitude, and practice scores were 11.44 ± 1.80 (possible range: 0-13), 30.29 ± 3.22 (possible range: 8-40), and 31.27 ± 5.67 (possible range: 8-40), respectively. Age > 60 years (OR = 0.487, 95%CI: 0.260-0.913, P = 0.025) and junior college or undergraduate or above (OR = 2.606, 95%CI: 1.621-4.189, P < 0.001) were independently associated with adequate knowledge. The knowledge (OR = 1.151, 95%CI: 1.024-1.294, P = 0.018) and female gender (OR = 0.632, 95%CI: 0.419-0.953, P = 0.029) were independently associated with positive attitude. The knowledge (OR = 1.404, 95%CI: 1.221-1.614, P < 0.001), attitude (OR = 1.146, 95%CI: 1.069-1.227, P < 0.001), age 51-60 years (OR = 1.879, 95%CI: 1.093-3.229, P = 0.022), and BMI of 24.0-27.9 kg/m2 (OR = 0.434, 95%CI: 0.269-0.700, P = 0.001) were independently associated with proactive practice. Hemodialysis patients showed adequate knowledge, positive attitudes, and proactive practice; however, there were also several gaps in knowledge and misconceptions regarding proper nutritional self-management. Accordingly, addressing these gaps and misconceptions through carefully designed and effectively implemented education is crucial for providing comprehensive guidance on optimal nutrition and self-management strategies.

Copper Serum Levels in the Hemodialysis Patient Population

Copper is an essential element in the diet of mammals, including humans. It plays an important role in the physiological regulation of various enzymes and is consequently involved in several biological processes such as angiogenesis, oxidative stress regulation, neuromodulation, and erythropoiesis. Copper is essential for facilitating the transfer of iron from cells to the bloodstream, which is necessary for proper absorption of dietary iron and the distribution of iron throughout the body. In particular, patients with end-stage renal failure who require renal replacement therapy are at increased risk for disorders of copper metabolism. Many studies on hemodialysis, peritoneal dialysis, and kidney transplant patients have focused on serum copper levels. Some reported mild deficiency, while others reported elevated levels or even toxicity. In some cases, it has been reported that alterations in copper metabolism lead to an increased risk of cardiovascular disease, malnutrition, anemia, or mielopathy. The aim of this review is to evaluate the role of copper in patients undergoing hemodialysis and its potential clinical implications.

Dietary Needs, Barriers, and Facilitators Among Patients on Hemodialysis and Their Caregivers: The GoodRENal Project in Spain

OBJECTIVE

Dietary restrictions are common in patients undergoing hemodialysis (HD). These restrictions result in a complex diet that becomes difficult for patients to understand and to follow. Therefore, we aimed to identify dietary needs, barriers, and facilitators that influence the adherence to dietary recommendations as perceived by patients on HD and their caregivers.

METHODS

Seventy-two Spanish patients on HD and 57 caregivers participated in this explorative study by replying a questionnaire consisting of 20 and 10 questions respectively. The responses were assessed using a Likert scale varying from 1 to 5 (strongly agree, agree, neither disagree or disagree, disagree, strongly disagree, respectively) to evaluate the perception of patients and caregivers regarding dietary needs, barriers, and facilitators to adhere to the recommended diet. For analysis purposes, the responses were grouped in 3 categories (agree, neither agree or disagree, disagree).

RESULTS

Seventy percent of the patients agreed that knowing the food sources of potassium, protein and phosphate was a need for them to know to be able to adhere to the dietary recommendations. Moreover, patients stated that not being able to eat what they liked, and feeling thirsty, were important barriers. For caregivers, the support of a renal dietitian was mentioned as an important facilitator to assist those they cared for to adhere to the diet.

CONCLUSIONS

Knowing food sources of potassium, phosphate, and protein, exploring foods patients like to eat and adjusting fluid intake to avoid feeling thirsty were identified as important by the patients. These findings can be used to develop strategies and educational material to improve the dietary adherence in patients undergoing HD. Moreover, the presence of a renal dietitian was identified as an important resource by the caregivers.

Nutrition Profile and Quality of Life of Adult Chronic Kidney Disease Patients on Maintenance Hemodialysis in India: An Exploratory Study

Background

Malnutrition and suboptimal food intake are common concerns among chronic kidney disease (CKD) patients. Medical nutrition therapy plays a significant role in ensuring the well-being of CKD patients undergoing maintenance hemodialysis (MHD). The present study explored the dietary intake and quality of life (QOL) of CKD patients on MHD.

Materials and Methods

Adult CKD patients (n = 107, >20 years, 72% male) on MHD were conveniently selected from dialysis centers across India. This cross-sectional exploratory study elicited information on general profile, height, dry body weight, biochemical parameters, food intake, and QOL of the patients. Nutrient intake was compared with Kidney Disease Outcomes Quality Initiative (KDOQI) Guidelines.

Results

The average energy and protein intake per kg body weight was below the recommendations (energy ∼21 kcal/kg vs. 30-35 kcal/kg body weight and protein ∼0.7g/kg vs. 1-1.2 g/kg body weight). Majority of them (>75%) had inadequate energy and protein intake. The sodium intake of the participants (3109.42 ± 1012.31 mg) was higher than the suggested limit. The energy and protein intake/kg ideal body weight of female patients was significantly higher than male patients (p < 0.05). Overall, their QOL was satisfactory. However, nearly half of them (47%) reported moderate-level problem in the pain and discomfort dimension.

Conclusion

Patients were not meeting the recommendations especially for energy and protein. Patient-specific customized nutrition counseling along with routine nutrition assessment, follow-up of patients and continued nutrition education, and motivation and support from the medical care team, especially the dietitian is needed for better dietary compliance and overall improvement of QOL.

Association between TMSE/MoCA and MIS/NAF in ESKD patients undergoing hemodialysis: a cross-sectional study

BACKGROUND

Both cognitive impairment and malnutrition are common in hemodialysis (HD) patients and are associated with increased hospitalization rates, infection, poor clinical outcomes, and mortality. The study investigated the association between cognitive and nutrition status among end-stage kidney disease (ESKD) patients undergoing hemodialysis.

METHODS

In this cross-sectional study, we enrolled 115 patients with ESKD who underwent regular hemodialysis (HD). Data collection included the use of screening tools for mild cognitive impairment (MCI), specifically Thai Mental State Examination (TMSE) and Montreal Cognitive Assessment (MoCA). In addition, we collected data using nutritional screening tools including Malnutrition Inflammation Score (MIS) and Nutrition Alert Form (NAF). Our primary outcome was to demonstrate whether there was a relationship between TMSE/MoCA and MIS/NAF scores in this population. Secondary outcomes were a prevalence of MCI and malnutrition status in ESKD patients, an association between TMSE and MoCA with other surrogate nutritional markers, and factors affecting MCI in such patients.

RESULTS

A total of 109 patients undergoing HD completed our protocol. Their mean age was 63.42 (± 15.82) years, and 51.38% were male. Mean TMSE and MoCA were 23.98 (± 5.06) points and 18.3 (± 6.40) points, respectively. The prevalence of TMSE ≤ 23 and MoCA ≤ 24 were 39.45% and 83.49%, respectively. TMSE had a statistically significant negative correlation with MIS (R2 = 0.16, p < 0.001) and NAF. MoCA also negatively correlated with MIS and NAF. The age, total educational year, the status of whether having a caregiver, serum albumin, serum phosphorus level, handgrip strength, and lean mass tissue were correlated with TMSE.

CONCLUSION

Nutritional parameters, including MIS score, NAF score, serum albumin, lean tissue mass, and lean tissue index, significantly correlate with TMSE and MoCA.

Simplified Creatinine Index as Predictor of Malnutrition in Stage 5 Chronic Kidney Disease Patients on Maintenance Haemodialysis

Background

Malnutrition inflammation score (MIS) is an instrument for assessing the nutritional status of stage 5 CKD patients, while simplified creatinine index (SCI) is used to assess muscle mass indirectly.

Purpose

This study aims to analyse the correlation between SCI and MIS, as well as determine the SCI cut-off value as a predictor of malnutrition in stage 5 CKD patients on maintenance HD.

Methods

This research was an analytical observational study with a cross-sectional study approach. The 132 research subjects were stage 5 CKD patients at the HD Unit of RSUP Dr. Hasan Sadikin Bandung. The research used the Rank-Spearman test with SPSS for correlative bivariate analysis. The area under the curve (AUC) on the receiver operating characteristic (ROC) curve was analysed to find the SCI cut-off value as a predictor of malnutrition in stage 5 CKD patients.

Results

Sixty-three subjects (47.7%) were classified as good nutrition and 69 subjects (52.3%) as poor nutrition. The average SCI value in this study was 24.5 mg/kg/day ± SD 3.2 mg/kg/day, with a median MIS value was 6. This study showed a significant negative correlation between SCI and MIS (r = -0.586, p < 0.001). The optimal SCI cut-off from the ROC curve analysis value was ≤ 24.53 mg/kg/day (sensitivity = 76.8%; specificity = 79.4%).

Conclusion

A negative correlation existed between SCI and MIS, with an SCI value ≤ 24.53 indicating poor nutritional status in stage 5 CKD patients on maintenance HD. SCI can be used as a predictor of malnutrition at a lower cost and easier.

Effects and safety of Ophiocordyceps sinensis preparation in the adjuvant treatment for dialysis patients: a systematic review and meta-analysis

Ethnopharmacological relevance

Ophiocordyceps sinensis (O. sinensis), a genus of ascomycete fungi, has been widedly used in China as a dietary supplement or natural remedy and intensively studied in various disease models with its immunomodulatory potentials. It is a rich source of various bioactive compounds and used for treating end-stage renal disease. This systematic review with clinical evidence aimed to highlight the efficacy and safety of O. Sinensis as an adjuvant treatment for patients undergoing dialysis.

Materials and methods

A systematic search through nine electronic databases up to 31 April 2024, was conducted for related studies. The Cochrane risk-of-bias tool was used to evaluate the quality of studies. The Grading of Recommendations Assessment, Development, and Evaluation system was used to assess the certainty of evidence. Two researchers independently searched the literature and evaluated the risk of bias.

Results

After the screening, 35 randomized controlled trials (RCTs) involving 2,914 patients were eventually included. The meta-analysis showed that using O. sinensis effectively reduced the following outcomes in patients undergoing dialysis: C-reactive protein (15RCTs, MD = -2.22, 95% CI -3.24 to -1.20; very low certainty evidence); creatinine (22RCTs, MD =1.33, 95% CI -1.79 to -0.87; very low certainty evidence); blood urea nitrogen (21RCTs, MD = -1.57, 95% CI -2.07 to -1.07; low certainty evidence);. It could also effectively improve the following outcomes in patients undergoing dialysis: albumin (20RCTs, MD = -0.81, 95% CI -1.21 to -0.41; low certainty evidence); hemoglobin (19RCTs, MD = -1.00, 95% CI -1.43 to -0.57; low certainty evidence). The rate of adverse drug reactions was higher in the control group than in the experimental group (4RCTs, MD = 1.81, 95% CI 0.88-3.74).

Conclusion

The current evidence indicates that patients with dialysis receiving O. sinensis in the adjuvant treatment may improve nutritional and micro-inflammatory status and renal function for both hemodialysis and peritoneal dialysis patients. However, some limitation affected the generalizability of our findings. High-quality studies evaluating mortality outcomes of patients with different dialytic modalities in CKD are warranted in future.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022324508, registration number CRD42022324508.

Frailty in patients on dialysis

Frailty is a condition that is frequently observed among patients undergoing dialysis. Frailty is characterized by a decline in both physiological state and cognitive state, leading to a combination of symptoms, such as weight loss, exhaustion, low physical activity level, weakness, and slow walking speed. Frail patients not only experience a poor quality of life, but also are at higher risk of hospitalization, infection, cardiovascular events, dialysis-associated complications, and death. Frailty occurs as a result of a combination and interaction of various medical issues in patients who are on dialysis. Unfortunately, frailty has no cure. To address frailty, a multifaceted approach is necessary, involving coordinated efforts from nephrologists, geriatricians, nurses, allied health practitioners, and family members. Strategies such as optimizing nutrition and chronic kidney disease-related complications, reducing polypharmacy by deprescription, personalizing dialysis prescription, and considering home-based or assisted dialysis may help slow the decline of physical function over time in subjects with frailty. This review discusses the underlying causes of frailty in patients on dialysis and examines the methods and difficulties involved in managing frailty among this group.

Relationship between altered taste and smell with malnutrition among hemodialysis patients

INTRODUCTION

Alterations in taste and smell are among the most distressing symptoms experienced by haemodialysis patients. There is limited research on the relationship between these two symptoms and malnutrition in haemodialysis patients. This study aimed to investigate alterations in taste and smell in hemodialysis patients and their relationship with malnutrition.

METHODS

This cross-sectional study was carried out with 149 hemodialysis patients at the dialysis centers of three state hospitals. The Taste and Smell Dysfunction Questionnaire was used to assess the changes in patients' taste and smell, and the Prognostic Nutritional Index (PNI), as well as the Controlling Nutritional Status (CONUT) tool, were utilized to evaluate their nutritional status.

FINDINGS

A substantial percentage (45.6%) of patients reported an altered sense of smell, and 40.2% reported an altered sense of taste. The aspect of taste that was most abnormal was bitterness (46.7%); 53.0% of the patients were at moderate risk of malnutrition by PNI score, and 14.8% were categorized as malnourished by CONUT score. Malnutrition was related to dialysis vintage: a 1-year increase in vintage was associated with an increased risk of malnutrition (OR: 1.17, 95% CI 1.02-1.32, p < 0.001). Altered taste was associated with malnutrition: one-unit increase in the standard deviation of the taste subdimension score was associated with a relative risk of malnutrition (OR: 6.89, 95% CI 1.67-28.39, p < 0.001). A one-unit increase in the standard deviation of the smell subdimension was associated with relative risk of malnutrition (OR: 1.35, 95% CI 1.10-1.64, p < 0.001).

DISCUSSION

Malnutrition was found in a significantpercentage of hemodialysis patients. Altered taste and smell and the durationof dialysis treatment were significantly associated with malnutrition scores It isrecommended that healthcare professionals regularly assess alterations in tasteand smell in hemodialysis patients, as these alterations may be associated withmalnutrition, and manage these alterations accordingly.

Malnutrition as a potential predictor of mortality in chronic kidney disease patients on dialysis: A systematic review and meta-analysis

BACKGROUND & AIMS

Malnutrition, a significant problem in patients with chronic kidney disease (CKD), is linked to lower health-related quality of life, longer and more frequent hospital admissions, worse functional capacity, and higher levels of morbidity. However, the extent of its impact on mortality is poorly elucidated. This systematic review and meta-analysis aimed to investigate the impact of malnutrition on mortality among CKD patients on dialysis.

METHODS

This meta-analysis was designed and performed in accordance with the PRISMA guidelines (CRD42023394584). A systematic electronic literature search was conducted in PubMed, ScienceDirect, and Embase to identify relevant cohort studies. The studies that reported nutritional status and its impact on mortality in patients were considered for analysis. The generic inverse variance method was used to pool the hazard ratio effect estimates by employing a random effects model. The Newcastle-Ottawa scale was used for the quality assessment. The statistical analysis was performed by utilizing RevMan and CMA 2.0.

RESULTS

A total of 29 studies that comprised 11,063 patients on dialysis whose nutritional status was evaluated were eligible for quantitative analysis. Based on a comparison between the "malnutrition" category and the reference "normal nutrition status" category, the results showed that the overall pooled hazard risk (HR) for mortality was (HR 1.49, 95% CI: 1.36-1.64, p < 0.0001). According to the subgroup analysis, the hemodialysis subgroup had greater mortality hazards (HR 1.53; 95% CI 1.38-1.70, p < 0.0001), compared to the peritoneal dialysis subgroup (HR 1.26; 95% CI 1.15-1.37, p < 0.00001). Additionally, the overall incidence of mortality was explored but the authors were unable to combine the results due to limitations with the data.

CONCLUSION

The findings conclude that malnutrition is a strong predictor of mortality among patients on dialysis, with the hemodialysis subgroup having a higher mortality hazard compared to the peritoneal dialysis subgroup. The results of this study will advocate for early nutritional evaluation and timely dietary interventions to halt the progression of CKD and death.

Prevalence and factors associated with the correlation between malnutrition and pain in hemodialysis patients

Malnutrition and pain are common in patients with chronic kidney disease who undergo hemodialysis. Although both pain and malnutrition are associated with increased morbidity and mortality, few studies have explored the correlation between pain and nutritional status. This study aimed to investigate the factors associated with pain intensity in patients undergoing hemodialysis, focusing on the risk of malnutrition. This was a cross-sectional study conducted at a regional dialysis center in a large tertiary hospital. Convenience sampling was used to recruit adult patients who had undergone hemodialysis for more than three months. An interviewer-administered questionnaire was used to gather sociodemographic and clinical data related to dialysis status, comorbidities, and body mass index (BMI). Pain severity and pain interference with functioning domains of the Brief Pain Index (BPI) were used to assess pain, and the malnutrition inflammation score (MIS) was used to assess nutritional status. Descriptive and inferential statistics were used to report the findings. The data were analyzed using the 25th version of the Statistical Package for the Social Sciences (IBM-SPSS) software. Of the final sample of 230 patients, 63.0% were males and 37.0% were females, with an average age of 58.3 years. Almost one-third of the participants had a BMI within the normal range (33.9%), and nearly one-third had a BMI within the underweight range (33.9%). Slightly more than half had a normal nutritional status or mild malnutrition (54.8%), while just under half had moderate or severe malnutrition (45.2%). The prevalence of pain was 47.0%. At the multivariate level, the severity of pain was associated with malnutrition (p < 0.001). Pain interference with function was associated with marital status (p = 0.045), number of comorbidities (p = 0.012), and malnutrition (p < 0.001). The MIS was positively correlated with both the severity of pain and the interference score. Pain and malnutrition were found to be prevalent in patients undergoing hemodialysis. Pain severity was associated with malnutrition, and pain interference was associated with malnutrition, marital status, and the number of comorbidities. Hemodialysis treatment should follow a patient-tailored approach that addresses pain, nutritional status, and associated chronic conditions. In addition, pain assessment and management should be included in the curriculum of nephrology training programs.

Early Detection of Inflammation and Malnutrition and Prediction of Acute Events in Hemodialysis Patients through PINI (Prognostic Inflammatory and Nutritional Index)

Protein-energy wasting and inflammation are major risk factors for complications in hemodialysis patients. As these risk factors are triggered by a pro-inflammatory state, oxidative stress and hemodynamic dysfunction, which overlap in hemodialyzed subjects, we aimed to assess the efficacy of a cost-effective and straightforward screening tool, the Prognostic Inflammatory and Nutritional Index (PINI), in regularly screening maintenance hemodialysis (MHD) patients, to detect early signs of inflammation and malnutrition. A 12-month follow-up was carried out on a cohort of 102 adult patients undergoing maintenance dialysis, during which the Prognostic Inflammatory and Nutritional Index (PINI) was calculated using the formula alpha1-Acid Glycoprotein (AGP) × C-reactive protein (CRP)/albumin (ALB) × transthyretin (TTR). A PINI score < 1 was considered normal. The patients were stratified based on their PINI score: 66 patients (64.70%) had a normal score, below 1, while 36 patients (35.30%) had a PINI score ≥ 1. Despite the absence of clinical evidence of inflammation at enrollment, the latter group exhibited higher levels of CRP. During the follow-up period, all patients with a PINI score ≥ 1 experienced at least one acute event, compared to only 6% of patients with a normal PINI score, which presented COVID-19 infection as an acute event. The evaluation of the PINI can effectively identify the silent malnutrition-inflammation syndrome and predict the risk of acute events. This straightforward test appears to be a rapid tool that is independent of the examiner's experience and subjectivity, thereby potentially reducing hospitalization costs.

Pre-Infection Nutritional Status, Oxidative Stress, and One-Year-Long COVID Persistence in Patients Undergoing Hemodialysis: A Prospective Cohort Study

BACKGROUND

Nutritional status's role in long COVID is evident in the general population, yet unexplored in patients undergoing hemodialysis (HD), posing a research gap. We hypothesized that pre-infection undernutrition in HD patients might impact long COVID persistence by accelerating oxidative stress. The present study aimed to investigate the association between pre-infection nutritional status, oxidative stress, and one-year-long COVID persistence in HD patients.

METHODS

This prospective observational cohort study enrolled 115 HD patients with confirmed COVID-19. Nutritional status was assessed using the Controlling Nutritional Status (CONUT) score twice: before infection and three months post-infection. Oxidative markers included malondialdehyde (MDAs), ceruloplasmin, transferrin, and sulfhydryl groups. The endpoint was one-year-long COVID persistence.

RESULTS

Moderate pre-infection CONUT scores were associated with heightened severe undernutrition risk (p < 0.0001), elevated MDAs (p < 0.0001), and reduced ceruloplasmin levels (p = 0.0009) at three months post-COVID-19 compared to light CONUT scores. Pre-infection CONUT score independently predicted post-COVID oxidative damage [OR 2.3 (95% CI 1.2; 4.6), p < 0.0001] and one-year-long COVID persistence [HR 4.6 (95% CI 1.4; 9.9), p < 0.0001], even after adjusting for potential confounders.

CONCLUSION

Moderate pre-infection undernutrition heightens post-COVID oxidative stress and increases the risk of one-year-long COVID persistence in HD patients.

Pretransplant Malnutrition, Particularly With Muscle Depletion Is Associated With Adverse Outcomes After Kidney Transplantation

Background

Kidney transplant centers lack consistent diagnostic malnutrition tools. The Academy of Nutrition and Dietetics and American Society of Parenteral Nutrition Adult Malnutrition Criteria (AMC) is the widely accepted and utilized tool by Registered Dietitian Nutritionists (RDNs) to diagnose malnutrition.

Methods

In this single-center, retrospective observational study, we evaluated the outcomes of prekidney transplant malnutrition based on Academy of Nutrition and Dietetics and American Society of Parenteral Nutrition AMC, as well as the individual components of the AMC, on posttransplant outcomes including length of stay, delayed graft function (DGF), early readmission, cardiovascular events, acute rejection, death-censored graft failure, and death. Bivariable and multivariable logistic regression models were used to assess the association of malnutrition or its components with outcomes of interest.

Results

A total of 367 recipients were included, of whom 36 (10%) were malnourished (23 moderately and 13 severely) at pretransplant evaluation. In adjusted models, pretransplant malnutrition was significantly associated with increased risk for early readmission (adjusted odds ratio 2.86; 95% confidence interval: 1.14-7.21; P = 0.03) and with DGF (adjusted odds ratio 8.33; 95% confidence interval: 1.07-64.6; P = 0.04). Muscle depletion was also associated with an increased risk for readmission and with DGF. Fat depletion and reduced functionality in the adjusted model were only associated with increased risk for readmission.

Conclusions

Malnutrition could be an important consideration for selecting kidney transplant recipients because it was associated with poor clinical outcomes. A multidisciplinary approach with the involvement of RDNs to outline a nutrition intervention plan may help mitigate some of the poor outcomes.

Prevalence and factors associated with malnutrition among hemodialysis patients in a single hemodialysis center in Vietnam: A cross-sectional study

Malnutrition is a common problem among hemodialysis patients that increases morbidity and mortality and decreases the quality of life. This study aimed to assess the prevalence of malnutrition and associated factors and survey the consumption of energy and several nutrients among hemodialysis patients. A prospective observational study with a cross-sectional design was conducted on 76 patients on hemodialysis therapy at Nguyen Tri Phuong Hospital, Ho Chi Minh City, Vietnam, for 2 months (from May to July 2022). Dialysis malnutrition score was used to determine patients' nutritional status. Data about their biochemical parameters were retrieved from records with the newest results. Among the 76 patients, 38 (50.0%) were female. The mean age of the patients was 55.0 ± 13.5 years. Based on the dialysis malnutrition score, 56 (73.7%) patients had mild to moderate malnutrition, while 2 (2.6%) had severe malnutrition. The average energy intake was 21.5 kcal/kg/day, with only 3.9% meeting the recommended intake. The average protein intake was 1.0 g/kg/day, and about 10.5% of participants complied with the recommended protein level. In addition, the majority of patients did not reach the recommendations for sodium (56.6%), potassium (88.2%), phosphate (75.0%), and calcium (82.9%). We found a significant association between patients' occupation (P < .05), dialysis vintage (P < .001), and malnutrition status. Malnutrition is widespread among Vietnamese hemodialysis patients, which necessitates regular assessment and monitoring. We recommend paying more attention to the nutritional status of patients who are unemployed, retired, or stopped working and those with ≥ 5 years of hemodialysis.

The Association of Frailty and Malnutrition With Dietary Intake and Gastrointestinal Symptoms in People With Kidney Failure: 2-Year Prospective Study

BACKGROUND

Frailty and malnutrition are both associated with worsening morbidity and mortality and become more prevalent in the elderly and as kidney function declines. Anorexia and reduced oral intake are common features of both frailty and malnutrition. However, there are sparse data evaluating the impact of other gastrointestinal (GI) symptoms, such as taste changes, on rates of frailty and malnutrition in people with kidney failure. The aim of this study is to describe the prevalence of frailty and malnutrition and their association with dietary intake and nutrition-related symptoms in people with kidney failure.

METHODS

This observational study recruited people with kidney failure who were commencing Conservative Kidney Management or elderly people (aged > 75 years) newly commenced on dialysis from 3 renal units. Participants underwent assessments of frailty, nutritional status, dietary intake, and GI symptom burden when they attended clinic appointments, approximately every 6 months.

RESULTS

Of the 85 participants, 57% were assessed as being frail and 33% were assessed as being malnourished. Participants assessed as frail reported more GI symptoms (3 vs. 2, P < .001) that were more severe (1.75 vs. 1.0, P < .001) compared to nonfrail participants. Being malnourished was associated with a 5 times higher chance of being frail (odds ratio 5.8; 95% confidence interval 1.5, 21.8; P = .015) and having more severe symptoms was associated with a 2 times higher chance (odds ratio 2.8; 95% CI 1.1, 7.0; P = .026) of being frail. In addition to experiencing more GI symptoms, that were more severe, participants who were malnourished consumed significantly less energy (1234 kcal vs. 1400 kcal, P = .01) and protein (51 g vs. 74 g, P < .001).

CONCLUSIONS

Frailty and malnutrition are common and are associated with a higher GI symptom burden and poorer dietary intake. Future research is needed to determine effective interventions targeting frailty and malnutrition, including nutrition-related symptoms and optimal protein intake.

Hyperparathyroidism, Serum Phosphorus and Dietary Intake in Hemodialysis Patients: Is There a Novel Relationship?

The management of hyperparathyroidism (intact parathyroid hormone (iPTH) serum levels > 585 pg/mL), frequently focuses on the appropriate control of mineral and bone markers, with the decrease in serum and dietary phosphorus as two of the targets. We aimed to investigate the association between iPTH, serum phosphorus levels and dietary intake. This was a cross-sectional, multicenter, observational study with 561 patients on hemodialysis treatment. Clinical parameters, body composition and dietary intake were assessed. For the analysis, patients were divided into three groups: (a) iPTH < 130, (b) iPTH between 130 and 585 and (c) iPTH > 585 pg/mL. The association between PTH, serum phosphorus and dietary intake was analyzed using linear regression models. In the whole sample, 23.2% of patients presented an iPTH > 585 pg/mL. Patients with higher iPTH levels were those with longer HD vintage and lower ages, higher serum phosphorus, serum calcium, Ca/P product, albumin and caffeine intake, and a lower dietary intake of phosphorus, fiber, riboflavin and folate. Higher serum phosphorus predicted higher iPTH levels, even in the adjusted model. However, lower dietary phosphorus and fiber intake were predictors of higher iPTH levels, including in the adjusted model. Our results bring new data to the relationship between dietary intake and iPTH values. Despite higher serum phosphorus being observed in patients with HPTH, an opposite association was noted regarding dietary phosphate and fiber.

An Investigation of the Effectiveness of Distance Learning on Nutrition Quality of Hemodialysis Patients during the COVID-19 Pandemic: A Single-Blind Randomized Clinical Trial

Introduction

The COVID-19 pandemic has limited hemodialysis patient's attendance in healthcare centers and receiving diet education. This study was conducted to investigate the effectiveness of distance learning on the nutrition quality of hemodialysis patients during the COVID-19 pandemic.

Methods

In the single-blind randomized clinical trial, 60 patients undergoing hemodialysis were randomly divided into control (n=30) and experimental (n=30) groups. Before and after the intervention, Dialysis Malnutrition Score (DMS), Malnutrition-Inflammation Score (MIS) (primary outcome), albumin, the total iron-binding capacity of the blood (TIBC), and body mass index (BMI) (Secondary outcome) were investigated. The experimental group received educational content through social networks for three months, whereas the control group received routine care and training.

Results

There was no significant difference between the two groups in terms of the mean of DMS, MIS, albumin, and TIBC before the intervention. Pre-test BMI had a confounding effect; therefore, an analysis of covariance was performed to eliminate that effect. This analysis showed significant differences in the post-test mean DMS, MIS, TIBC, and BMI between the two groups. In the control group, significant differences were observed in MIS and BMI toward deterioration. The results also indicated a significant relationship between education level and age with TIBC and between marital status and albumin index.

Conclusion

Distance learning can be considered by healthcare managers and police makers as a suitable alternative to the classic face-to-face learning method to enhance hemodialysis patients' nutrition quality during the COVID-19 pandemic.

Relation between myostatin levels and malnutrition and muscle wasting in hemodialysis patients

BACKGROUND AND AIM

Malnutrition is one of the most troublesome comorbidities among hemodialysis patients (HD). Myostatin (MSTN) belongs to the transforming growth factor-β superfamily. In HD patients, MSTN effects are not limited to skeletal muscle growth. The present study aimed to assess MSTN levels in HD patients and its relation to various clinical and biochemical parameters.

PATIENTS AND METHODS

The present case control study included 60 patients on HD for at least three years. In addition, there were age and sex-matched healthy subjects who constitutes the control group. Nutritional status was evaluated using the malnutrition inflammation score (MIS). Muscle wasting in the present study was evaluated using the lean tissue index (LTI) as assessed by the body composition monitor (BCM). Rectus Femoris Muscle (RFM) thickness was also measured as indicator for nutritional status of patient.

RESULTS

The present study included 60 HD patients, and ageand sex-matched healthy controls. Patients expressed significantly higher myostatin levels when compared to controls [median (IQR): 221.3 (153.5-688.2) versus 144.8 (97.0-281.7), p < 0.001]. According to MIS, patients were classified into those with no/mild malnutrition (n = 22) and others with moderate/severe malnutrition (n = 38). Comparison between the two subgroups revealed that the former group had significantly lower myostatin levels [167.7 (150.3-236.3) versus 341.7 (160.9-955.9), p = 0.004]. According to LTI, patients were classified into those with muscle wasting (n = 23) and others without muscle wasting (n = 37). Comparative analysis showed that patients in the former group had significantly higher myostatin levels [775.1 (325.1-2133.7) versus 161.8 (142.6-302.3), p < 0.001].

CONCLUSIONS

Myostatin seems to be a promising marker for identification of malnutrition and muscle wasting in HD patients.

Progress in the study of nutritional status and selenium in dialysis patients

Malnutrition is very common in patients with chronic kidney disease, especially in those on maintenance dialysis. Malnutrition is one of the major factors affecting survival and death of dialysis patients, and reducing their activity tolerance and immunity. There are numerous and interacting risk factors for malnutrition, such as reduced nutritional intake, increased energy expenditure, hormonal disorders, and inflammation. Selenium, in the form of selenoproteins, is involved in many physiological processes in the body and plays an important role in maintaining redox homeostasis. Oxidative stress and infection are very common in dialysis patients, and selenium levels in dialysis patients are significantly lower than those in the healthy population. It has been shown that there is a correlation between selenium levels in hemodialysis patients and their nutrition-related indicators, and that selenium supplementation may improve malnutrition in patients. However, further studies are needed to support this conclusion and there is a lack of basic research to further characterize the potential mechanisms by which selenium may improve malnutrition in dialysis patients. The purpose of this review is to provide a comprehensive overview of factors associated with malnutrition in dialysis patients and to describe the progress of research on nutritional status and selenium levels in dialysis patients.

Is intradialytic oral nutritional supplementation safe and effective on clinical outcomes? A systematic review with conventional meta-analysis and network meta-analysis

AIM

determine the effect of intradialytic oral nutrition (ION) on clinical and safety outcomes.

DESIGN

Systematic Review with conventional Meta-analysis, and a Network Meta-analysis (NMA) as sensitivity analysis. We searched on MEDLINE, LILACS, CENTRAL, and EMBASE in June 2020, and the last update was until August 2022. We selected observational and randomized controlled trials with ION for at least four weeks. Primary outcomes were all-cause mortality and quality of life (QoL); adverse events, physical performance, and appetite were secondary outcomes.

RESULTS

Seven clinical trials and three observational studies were selected. Even when we did not obtain significant differences in physical performance and gastrointestinal symptoms, we identified a clinical improvement in the QoL's physical role, bodily pain, and physical performance domains. After pooling the data on mortality, a protection rate trend was observed in the ION group without statistical significance. The home-prepared ION was the best nutritional supplementation when assessing the appetite outcome through NMA.

CONCLUSIONS

ION seems to have a protective trend in mortality risk; the current evidence is insufficient to establish a relationship with adverse events or other clinical outcomes. The lack of homogeneity in the trials makes it difficult to generalize these results.

PROSPERO REGISTRATION

CRD42020186311.

Effects of nutritional supplementation stabilizing muscle mass loss in older patients on hemodiafiltration

BACKGROUND & AIMS

Malnutrition is common in older individuals with end-stage renal disease on maintenance dialysis. Whether nutritional supplementation may improve skeletal muscle mass (SMM) and survival rate in this population is uncertain. We aimed to analyze the effect of a year of nutritional supplementation on muscle mass and survival rate in older patients on hemodiafiltration.

METHODS

In this observational study, older patients (≥65 years old) on maintenance hemodiafiltration were selected to receive nutritional counselling + nutritional supplementation (N = 85, Supp+) or nutritional counselling alone (N = 47, Supp-) and followed for 1 year. The outcomes were a change in SMM and sarcopenia diagnosis. The secondary outcome was 1-year mortality rate. Nutritional parameters included calf circumference, body mass index, anthropometric measurements, subjective global assessment, and handgrip strength (HGS). Data were evaluated using GLM for repeated measures with adjustment for covariates (age and diabetes).

RESULTS

Malnutrition was found in 50.8% of patients. At baseline, patients from the Supp+ group were older and had worse nutritional parameters including hand grip strength, calf circumference, anthropometric findings and sarcopenia (all p values < 0.05). During the follow-up, there was no significant change in sarcopenia (from 50.8% to 58.3%, p = 0.108), and there was a more pronounced decrease in the SMM index in the Supp-group (p = 0.049), with a significant intervention interaction (p = 0.030). Twenty deaths occurred, 7 (35%) in the Supp- and 13 (65%) in the Supp+ group (p = 0.540). SMM index (relative risk 0.90, p = 0.030) and age (relative risk 1.07, p = 0.046) were independently associated with higher mortality rates.

CONCLUSION

Nutritional supplementation in older and malnourished individuals undergoing hemodiafiltration mitigates the loss of the SMM index and benefits survival rate.

Malnutrition in solid organ transplant patients: A review of the literature

Screening for malnutrition is of vital importance for solid organ transplant candidates to optimize nutrition status before transplant, to improve clinical outcomes and to inform selection committees of nutritional contraindications and risks. There are multiple criteria and screening tools available for determining malnutrition diagnosis and risk. Registered Dietitian Nutritionists use these tools for nutrition assessments to quantify the severity of malnutrition, provide patient-centered interventions, and monitor progression. Many transplant centers in the United States utilize the American Society of Parenteral and Enteral Nutrition and the Academy of Nutrition and Dietetics' Adult Malnutrition Criteria, though there is limited research using these criteria specifically in the transplant population. Malnutrition, utilizing other diagnostic and screening tools, has been associated with important complications, including longer length of hospital stay, increased mortality, decreased quality of life, worsened end-stage organ progression, and decreased functional status. Malnutrition typically results from sarcopenia and cachexia, and can ultimately lead to frailty, causing further negative impacts on transplant outcomes. This literature review summarizes the current research on malnutrition in solid organ transplant candidates and provides recommendations for future research and current practice implications.

Deleterious effects of intradialytic meals' suppression during the COVID pandemic

BACKGROUND&AIMS

Patients with end-stage renal failure on chronic hemodialysis present an important risk of malnutrition, which is associated with a significant risk of morbidity and mortality. Meals during the dialysis session are important for maintaining the nutritional status of dialysis patients but represent a risk for intradialytic hypotension. During the COVID-19 pandemic, several dialysis centers stopped providing meals during the dialysis session as a protective measure. The aim of this retrospective, multicentric cross-over study was to study the evolution of the nutritional parameters of a cohort of hemodialysis patients for 12 months before, during and after the suspension of meals during dialysis due to the COVID-19 pandemics.

METHODS

We registered the evolution of dry weight, C Reactive Protein (CRP), serum Potassium and Phosphate before the dialysis session, serum albumin and prealbumin levels as well as normalized Protein Catabolic Ratio (nPCR).

RESULTS

We studied 168 hemodialysis patients (113M, 55F, mean age at inclusion:68.45 ± 0.45 years). The results ares shown as mean values (±SEM). The supression of the intradialytic meals led to significant reduction of the patients' dry weight (in Kg) from 78.66 ± 0.72 to 76.50 ± 0.49, p = 0.013, serum albumin (in g/l) (from 40.72 ± 0.16 to 39.25 ± 0.12, p < 0.001) and prealbumin levels (in g/l) (from 33.82 ± 0.31 to 32.73 ± 0.22, p = 0.004) as well as the nPCR values (from 1.08 ± 0.08 to 1.05 ± 0.11, p = 0.021). Serum CRP as well as predialytic Potassium and Phosphate levels did not change significantly. The reinstitution of the intradialytic meals led to a complete correction of the studied nutritional parameters with Body weight values evolving from 76.50 ± 0.49 to 78.28 ± 1.01, p = 0.025, serum albumin from 39.25 ± 0.12 to 40.53 ± 1.04, p < 0.001, serum prealbumin levels from 32.73 ± 0.22 to 33.95 ± 0.64, p = 0.001 an nPCR from 1.05 ± 0.11 to 1.08 ± 0.08, p = 0.021.

CONCLUSION

In conclusion, the suppression of intradialytic meals during the COVID-19 pandemic had deleterious effects on the nutritional parameters of patients on chronic hemodialysis.

One-year change in sarcopenia was associated with cognitive impairment among haemodialysis patients

BACKGROUND

Our study aimed to evaluate change in sarcopenia, its defining components over 1 year follow-up and investigate associations with subsequent cognitive decline, incident mild cognitive impairment (MCI) and dementia among patients undergoing haemodialysis (HD).

METHODS

In the multicentre, longitudinal study, 1117 HD patients aged 56.8 ± 14.3 years (654 men; and 463 women) from 17 dialysis centres in Guizhou Province, China, were recruited in 2019 and followed up for 1 year in 2020. Sarcopenia was diagnosed with Asian Working Group for Sarcopenia criteria using appendicular skeletal muscle mass index (ASMI) and handgrip strength (HGS). Body composition was measured using body composition monitor; body water, weight, and height were corrected to calculate ASMI. HGS was measured by mechanical handgrip dynamometer. Cognitive function was measured with Mini Mental State Examination. Multivariate linear, logistic regression models and subgroup analyses were employed to examine the associations of changes in sarcopenia, ASMI, and HGS with Mini Mental State Examination score change, and incident MCI, dementia.

RESULTS

Four hundred fourteen (37.1%) patients had sarcopenia at baseline; during 1 year follow-up, 257 (23.0%) developed MCI and 143 (12.8%) developed dementia. According to changes in sarcopenia, patients were stratified into four groups: non-sarcopenia; non-sarcopenia to sarcopenia; sarcopenia; and sarcopenia to non-sarcopenia. HD patients in sarcopenia and non-sarcopenia to sarcopenia groups had higher risk of MCI (34.8%, 32.0%, vs. 17.4%) and dementia (20.6%, 19.8%, vs. 8.7%), compared non-sarcopenia group (P < 0.001). Multivariate linear regression analyses showed that sarcopenia [regression coefficients (β) -1.098, 95% confidence interval (CI) -1.872, -0.324, P = 0.005] and non-sarcopenia to sarcopenia (β -1.826, -2.441, -1.212, P < 0.001) were associated with faster cognitive decline compared to non-sarcopenia. HGS decline (β 0.046, 0.027-0.064, P < 0.001) and ASMI decline (β 0.236, 0.109-0.362, P < 0.001) were both positively associated with cognitive decline. Multivariate logistic regression analyses demonstrated that patients with sarcopenia and non-sarcopenia to sarcopenia were both at increased risk of developing MCI [odds ratio (OR) 1.788, 95% CI 1.115-2.870, P = 0.016 and OR 1.589, 95% CI 1.087-2.324, P = 0.017, respectively], but only non-sarcopenia to sarcopenia was at increased risk of dementia (OR 1.792, 95% CI 1.108-2.879, P = 0.017). Both greater change of ASMI and HGS had lower risk of MCI with adjusted ORs of 0.857 (0.778-0.945, P = 0.002) and 0.976 (0.963-0.989, P < 0.001). Robust associations were found among female individuals, aged >60 years, and with low educational level.

CONCLUSIONS

Longitudinal associations were observed between new-onset, persistent sarcopenia, and cognitive impairment. Early detection and intervention should be implemented to delay the onset of sarcopenia and improve cognitive health among HD patients.

Mapping the global research landscape on malnutrition for patients with chronic kidney disease: a visualization analysis

BACKGROUND

Chronic kidney disease (CKD) is seen as a diverse disease and a primary contributor to global mortality. Malnutrition arises within chronic illness, which involves protein energy depletion and inadequate levels of essential nutrients. These factors increase the likelihood of death and the overall impact of the disease on affected individuals. Consequently, this study aims to utilize bibliometric and visual analysis to assess the current state of research, the latest advances and emerging patterns in the fields of CKD and malnutrition.

METHODS

Extensive research was conducted using the Scopus database, which is the most authoritative database of research publications and citations, to focus on CKD research between 2003 and 2022, as indicated by title and author keywords. Then, within this vast collection of academic publications, a notable subset of articles was exclusively dedicated to investigating the relationship between CKD and malnutrition. Finally, we performed bibliometric analysis and visualization using VOSviewer 1.6.19 and Microsoft Excel 2013.

RESULTS

Large global research between 2003 and 2022 resulted in 50,588 documents focused on CKD, as indicated by title and author keywords. In this extensive collection of scientific publications, a staggering portion of 823 articles is devoted exclusively to investigating the link between CKD and malnutrition. Further analysis reveals that this body of work consists of 565 articles (68.65%), 221 reviews (26.85%), and 37 miscellaneous entries (4.50%), which encompass letters and editorials. The USA was found to be the most productive country (n = 173; 21.02%), followed by Italy (n = 83; 10.09%), Sweden (n = 56; 6.80%), Brazil (n = 54; 6.56%) and China (n = 51; 6.20%). The most common terms on the map include those related to the topic of (a) malnutrition in hemodialysis patients and predicting factors; terms associated with the (b) impact of malnutrition on cardiovascular risk and complications in CKD patients; and terms related to the (c) dietary protein intake and malnutrition in CKD.

CONCLUSIONS

This study is the first of its kind to analyze CKD and malnutrition research using data from Scopus for visualization and network mapping. Recent trends indicate an increasing focus on protein-energy wasting/malnutrition in hemodialysis patients and predicting factors, dietary protein intake, and malnutrition in CKD. These topics have gained significant attention and reflect the latest scientific advances. Intervention studies are crucial to examining diet therapy's impact on patients with stages 1 to 5 CKD. We hope this study will offer researchers, dietitians and nephrologists valuable information.

Association between the dietary inflammatory index and markers of endothelial and systemic inflammation in hemodialysis patients

Objectives

The current survey aimed to investigate the link between energy-adjusted dietary inflammatory index (E-DII) and risk factors for CVD including markers of endothelial and systemic inflammation in Iranian hemodialysis patients.

Methods

Patients on hemodialysis for at least 6 months prior to enrollment were considered eligible in this cross-sectional study. The usual dietary intakes of the hemodialysis individuals were examined through 4 non-consecutive days including 2 dialysis days and 2 non-dialysis days using a 24-h recall approach to calculate E-DII. Multiple linear regression analysis was utilized to investigate the link between E-DII and selected biomarkers of inflammation and oxidative stress including high-sensitive C reactive protein (hs-CRP), serum intercellular adhesion molecule (sICAM), serum vascular cell adhesion molecule (sVCAM), malondialdehyde, and nitric oxide (NO), sE-selectin, and endothelin-1, and beta (β) and 95% confidence interval (CI) was reported. Value of p < 0.05 was considered statistically significant.

Results

Overall, 291 hemodialysis patients make up our study population. In the crude model, the E-DII score was positively associated with a higher sVCAM-1 (β = 177.39; 95% CI: 60.51, 294.26; ptrend = 0.003). Further adjustment for potential confounders attenuated the findings in a way that an increase of 128.72 in the sVCAM-1 was observed when the E-DII score increased from -2.68 to -1.14 (95% CI: 13.50, 243.94). After controlling for potential confounders, E-DII was associated with sE-selectin in hemodialysis patients in the highest category of E-DII as compared to the lowest category (β = 4.11; 95% CI: 0.22, 8.00; ptrend = 0.039).

Conclusion

The present findings suggest that adherence to a pro-inflammatory diet among hemodialysis patients is associated with a higher inflammatory status as evidenced by sVCAM-1 and sE-selectin; however, bidirectionality may exist and the role of residual confounders should be taken into account. Therefore, more longitudinal investigations are needed to elucidate the role of diet on the inflammatory status of hemodialysis patients.

Neutrophil reactive oxygen formation, bacterial infections and mortality in malnourished hemodialysis patients: Evaluation of clinical outcomes

INTRODUCTION

Patients with end stage kidney disease undergoing maintenance hemodialysis (MHD) are prone to malnutrition and infections.

OBJECTIVE

The objective of this study was to evaluate the effect of polymorphonuclear (PMN) cell dysfunction on clinical outcomes of MHD patients, in association with nutritional status.

METHODS

This prospective study investigated 39 MHD patients by evaluating the oxidative activity of their PMN cells using Phorbol 12-Myristate-13-Acetate (PMA) stimulation. Blood samples were taken from each participant at dialysis initiation. Demographics, laboratory data, and clinical outcomes during a 24-month follow-up period were obtained from electronic medical records.

RESULTS

Phagocytic activity was described in percentiles of mean fluorescence intensity (MFI) of PMA levels. There were no differences in comorbidities between patients with low or high MFI-PMA percentiles. Patients in the lowest (25th) MFI-PMA percentile (N = 10) had poorer nutritional status and more frequent severe infections compared to the other 29 patients (4.3 ± 3.4 events versus 2 ± 2.2 events, p = 0.017). Furthermore, they had more frequent hospitalizations (>3) due to infections (70% versus 41%, p = 0.073) and their mortality rate was higher (80% versus 31%, p = 0.007). The odds ratio for all-cause mortality was 8.85. In multivariate analysis, the MFI-PMA percentile and ischemic heart disease were the strongest predictors of all-cause mortality (p = 0.02 and p = 0.005, respectively).

CONCLUSIONS

Low MFI-PMA levels were associated with poor nutritional status and adverse clinical outcomes and might serve as a prognostic biomarker, predicting severe infections and mortality among malnourished MHD patients.