MO936: Oral Nutritional Supplementation Support in HEmodialysis Patients: Impact on Nutritional Rehabilitation

BACKGROUND AND AIMS

Nutritional status management and rehabilitation are significant concern treating maintenance haemodialysis (HD) patients. Oral nutritional supplements are essential to complement insufficient dietary intake, namely of energy and protein, and to rehabilitate a patient's nutritional status. Therefore, the objective of this preliminary study was to assess the impact of oral nutritional supplementation (ONS) prescription patterns on patients’ nutritional status.

METHOD

We did a cross-sectional analysis of HD patients’ first oral nutritional supplementation with commercial formulas between October 2018 and March 2020 in 25 outpatient HD clinics. The registered nutritionist dietitian decided to initiate, choosing the type of supplement and dose as part of a routine protocol of a comprehensive nutritional intervention and assessment. We assessed albumin, normalized protein catabolic rate, potassium and phosphate at the beginning (t = 0) and end (t = 1) of the supplementation period to understand the nutritional impact. We also estimated the daily proportion of energy, and protein contribution of each oral nutritional supplementation implemented, categorizing in cut-offs of 100 kcal and 5 g of protein.

RESULTS

We analyzed 398 patients, 217 (54.5%) males, 165 (41.5%) diabetic, with a median age of 79 years. Concerning feeding support status, 24.6% were autonomous, 54.8% had family care and 20.6% were institutionalized.

  Globally, the ONS impact was significant in the increment of albumin (P < 0.001) and nPCR (P = 0.002), although nPCR was not significant in the categorized group providing <5 g of protein/day (Table 2). The increment of K was also significant (P < 0.001) but not clinically relevant in increasing the risk of hyperkalaemia. There was no significant difference in P (P = 0.086).

CONCLUSION

ONS significantly impacted nutritional rehabilitation, with an albumin and nPCR increase (except for the categorized group of < 5 g protein/day). Although the increment of potassium was statistically significant, it was not clinically relevant in increasing the risk of hyperkalaemia. Further analyses are needed to understand the best targets for the energy and protein contribution of ONS.

Prognostic Value of the Malnutrition-inflammation Score in Hospitalization and Mortality on Long-term Hemodialysis

OBJECTIVE

Since its development, cumulative evidence has accumulated regarding the prognostic value of the Malnutrition-Inflammation Score (MIS/Kalantar score) prognostic value; however, there is a shortage of recent and large studies with comprehensive statistical methodologies that contribute to support a higher level of evidence and a consensual cutoff. The aim of this study was to assess the strength of MIS association with hospitalization and mortality in a nationwide cohort.

METHODS

This was a historical cohort study of hemodialysis patients from 25 outpatient centers followed up for 48 months. Univariable and multivariable Cox additive regression models were used to analyze the data. The C-index was estimated to assess the performance of the final model.

RESULTS

Two thousand four hundred forty-four patients were analyzed, 59.0% males, 32.0% diabetic, and median age of 71 years (P₂₅ = 60, P₇₅ = 79). During a median period of 45-month follow-up, with a maximum of 48 months (P₂₅ = 31; P₇₅ = 48), 875 patients presented an MIS <5 (35.8%) and 860 patients (35.2%) died. The proportion of deaths was 23.1% for patients with the MIS <5 and 41.9% if the MIS ≥5 (P < .001). A total of 1,528 patients (62.5%) were hospitalized with a median time to the first hospitalization of 26 months (P₂₅ = 9; P₇₅ = 45). A new cutoff point regarding the risk of death, MIS ≥6, was identified for this study data set. In multivariable analysis for hospitalization risk, a higher MIS, higher comorbidity index, and arteriovenous graft or catheter increased the risk, whereas higher Kt/V and higher albumin had a protective effect. In multivariable analysis for mortality risk, adjusting for age, albumin, normalized protein catabolic rate, Charlson comorbidity index, interdialytic weight gain, Kt/V, diabetes, hematocrit, and vascular access, patients with the MIS ≥6 showed a hazard ratio of 1.469 (95% confidence interval: 1.262-1.711; P < .001). Higher age, higher interdialytic weight gain, higher comorbidity index, and catheter increased significantly the risk, whereas higher Kt/V, higher albumin, and higher normalized protein catabolic rate (≥1.05 g/kg/d) reduced the risk.

CONCLUSION

The MIS maintains its relevant and significant association with hospitalization and mortality.

MO901ASSOCIATION OF MALNUTRITION AND INFLAMMATION WITH ERYTHROPOIETIN RESISTANCE INDEX

Background and Aims

Erythropoietin Resistance Index (EPORI) has been previously associated with higher risk of mortality and morbidity in hemodialysis (HD) patients (pts). The objectives of this study were to identify which factors, such as the risk of malnutrition, are associated with EPORI and to assess its association with mortality and hospitalization risk.

Method

Historical cohort study in a group of high-flux HD pts from 25 outpatient HD clinics, starting from a baseline group of 2975 pts. We evaluated EPORI, interdialytic weigh gain (IDWG), Malnutrition Inflammation Score (MIS) and the other parameters at the study baseline. For a better understanding of weight gain patterns, we calculated the average of the IDWG at the day of monthly blood sample collection of the previous 3 months, values &gt;4% were considered high. A MIS&gt;5 indicated nutritional risk.

Results

We analyzed 2044 pts, 1148 (56%) males, 642 (31%) diabetic, with a mean age 68.4±14.12 years, a mean HD vintage 105±74 months and mean EPORI 7.23±7.51 (U/week/kg)/(g/dL). During a follow-up of 48 months, 719 pts (35%) died and 1291 pts (63%) were hospitalized at least once after baseline assessment, 531 pts and 400 pts were excluded because follow up was not possible and EPORI data was not available, respectively.

ROC curve analysis identified different cut-off values for EPORI in relation with all-cause mortality and hospitalizations.

Univariable analysis

An EPORI&gt;5 was associated with higher MIS (7.06±3.9, vs 6.02±3.48, p&lt;0.001), higher IDWG (3.15±1.23 vs 1.26±1.09, p&lt;0.001), lower Hematocrit (Htc) (33.26±3.17 vs 33.69±2.61, p&lt;0.001), higher C-Reactive Protein (CRP) 14.94±24.45 vs 10.4±18.9, p&lt;0.001), female gender (57% vs 48%, p&lt;0.001), death (58% vs 49%, p&lt;0.001) and hospitalization (55% vs 47%, p&lt;0.001).

When analyzing with Kaplan-Meier estimator using log-rank test to compare survival curves, mortality and hospitalizations were increased in all sub-groups with higher values for EPORI (cut-offs of 5 to 8) when compared, respectively, with lower EPORI values.

Multivariable analysis

The predictors of EPORI were MIS&gt;5 (OR 1.564, p&lt;0.001), IDWG (OR 1.234, p&lt; 0.001), CRP (OR 1.010, p&lt;0.001) and Htc (OR 0.948, p&lt;0.001).

In similar models, adjusting for MIS&gt;5 (p&lt;0.001), gender (p&lt;0.001), age (p&lt;0.001), CRP (p&lt;0.001) and dialysis vintage (p&lt;0.001), different EPORI cut-off values were associated with higher risk of mortality and hospitalizations.

Conclusion

In the modern hemodialysis era, higher EPORI cut-off values were associated with a progressive higher risk of mortality and of hospitalization. The modification of the EPORI predictors that are susceptible to improvement, such as the nutritional and inflammation status, may contribute for a better prognosis in this population.

Can an intradialytic snack model compensate the catabolic impact of hemodialysis?

BACKGROUND AND AIMS

Hemodialysis (HD) has a catabolic effect caused by alterations in protein metabolism, increase in resting energy expenditure (REE) and protein needs due to inflammation, HD circuit blood and heat losses, protein losses to dialysate and HD filter membrane biocompatibility. We aim to determine, as a proof of concept, whether a standardized intradialytic snack model is adequate to compensate the catabolic impact of HD.

METHODS

Cross sectional analysis of patients' chosen intradialytic intake according to a snack model, at the day of blood sample collection of three different months. As targets for the compensation of the catabolic impact of HD, we considered 316.8kCal (1.32 (±0.18) kcal/min - 240' of HD) for the estimated increase in REE and at least 7 g of protein losses/HD treatment.

RESULTS

A total of 448 meals were analyzed, with 383 given during daytime shifts. No intolerances were registered. The mean nutritional profile of the daytime shifts intakes was 378.8 (±151.4) kcal, 13.5 (±7.2) g of protein, 676 (±334) mg of sodium (Na), 361.0 (±240.3) mg of potassium (K) and 249.3 (±143.0) mg of phosphates (P). We found that 68% of the meals provided an intake ≥316.8kCal and 82% a protein intake ≥ 7 g, with a significant association found between treatment shift and energy (p < 0.028), protein (p < 0.028), lipids (p < 0.004), Na (p < 0.004), K (p < 0.009) and P (p < 0.039) intakes.

CONCLUSIONS

We found that this intradialytic snack model meets the target for the treatment-related increases in protein and energy needs. Although sodium intake was found to be high, potassium and phosphate intake was considered adequate.

SO045DOES MALNUTRITION INFLAMMATION SCORE MAINTAINS ITS PREDICTIVE RISK ASSESSMENT IN THE MODERN HEMODIALYSIS ERA?

Background and Aims

Malnutrition Inflammation score (MIS) is a risk score published in 2001 (Kalantar-Zadeh, 2001) and validated in 2008 (Rambod, 2009). It is associated with a high mortality and morbidity risk in hemodialysis (HD) patients (pts).

Currently, HD pts population is composed of much older individuals, submitted to a high efficient treatment with access to pharmacological and nutritional therapy, assured by a bundled payment, when comparing with the validation study population.

The objective of this study is to evaluate if MIS maintain its predictive risk assessment.

Method

Cross sectional analysis of HD pts from 25 outpatient clinics. MIS was evaluated at the study baseline. Univariable and multivariable Cox additive regression models were used to analyze the data. C-index was estimated to assess the performance of the final model. A level of significance of α= 0.05 was considered.

Results

A total of 2444 pts were analyzed (59.0% males; 32.0% diabetic) during a median period of 48 months (P25=31; P75=48), 875 patients registered MIS&lt;5, corresponding to 35.8%. All-cause mortality was observed in 860 pts (35.2%). There were 202 (35.8%) events in the group of patients with MIS&lt;5, while in the group with MIS≥5, the number of deaths was higher (658 pts, 41.9%).

In univariable analysis using Cox additive model, the main results were:

In multivariable analysis, adjusting for age, nPNA, IDWG, Kt/V and diabetes, a MIS ≥ 5 and ≥ 7 showed, respectively, a HR of 1.761 (IC 95%, p&lt;0.001) and 1.822 (IC 95%, p&lt;0.001).

Conclusion

The findings of this analysis confirms that MIS maintains a discriminative power to identify higher risk of mortality. In this model, age and diabetes also correlate with mortality risk increase, while nPNA, IDWG and Kt/V have the opposite effect.

205 Preliminary characterization of ovarian stem cells from bovine ovaries

Ovarian stem cells (OSCs) have been reportedly isolated from ovaries of rodents, pigs, humans, and cattle by targeting the germ cell marker protein DDX4. Although the role of OSCs in female reproduction is unknown, the ability to culture OSCs and differentiate oocytes invitro could benefit the cattle industry and the study of oogenesis. The aim of this study was to describe isolation and preliminary characterisation of putative bovine OSCs. Slaughterhouse-derived ovaries from adult cows were processed by mechanical and enzymatic dissociation into a single cell suspension followed by immunostaining. Cells were incubated in blocking solution followed by 10µgmL−1 rabbit anti-human polyclonal DDX4 antibody (#13840; Abcam) for 15min and 2µgmL−1 goat anti-rabbit IgG labelled with Alexa Fluor 647 for 15min in the dark. Next, cells were resuspended in Hanks’ balanced salt solution with 1% bovine serum albumin/25mM HEPES, filtered through a 30-µm strainer and subjected to fluorescence-activated cell sorting. Controls used to establish gates were unstained cells and cells incubated with secondary antibody only. 4’,6-Diamidino-2-phenylindole (DAPI) exclusion was used as a viability test. Putative OSCs were placed in culture in OSC medium (MEMα Glutamax containing 10% fetal bovine serum, 1mM sodium pyruvate, 1× nonessential amino acids, 103 units of leukemia inhibitory factor, 10µgmL−1 glial cell-derived neurotrophic factor, 10µgmL−1 basic fibroblast growth factor, 1µgmL−1 epidermal growth factor, 1× N2-max, penicillin/streptomycin) for expansion and characterisation by gene expression using reverse transcription-PCR and protein expression using immunolocalization and confocal microscopy. To ensure specificity against bovine DDX4, the same antibody used for cell sorting was used to label oocytes within ovarian follicles in histological sections. Two cell lines were obtained and expanded invitro. Gene expression was performed in putative OSCs at passages 1 to 3; cumulus-oocyte complexes (COCs) were used as positive controls and adult skin fibroblasts as negative controls, and ACTB was used as an endogenous control. Both putative OSC lines and COCs expressed the germ cell markers DAZL and C-KIT, and COCs also expressed BMP15. Only ACTB was detected in fibroblasts. Immunolocalization was performed in putative OSCs at passage 4, with oocytes and fibroblasts used as positive and negative controls. Additional controls were cells exposed to secondary antibody only. Both putative OSC lines and oocytes expressed DAZL and DDX4 and no marker was detected in fibroblasts. Next, OSC line #2 was transfected with a retroviral vector using the EF1α promoter for green fluorescent protein (GFP) expression. This is a critical step to ensure the success of experiments requiring cell tracking. Transfected cells were expanded and sorted to establish a pure population of GFP+ OSCs. To verify replication deficiency of the viral particles, supernatant from GFP+ OSCs was collected 1 passage after transfection and applied to GFP- OSCs. No GFP+ cells were observed after 24, 48, or 72h. These preliminary results confirm the presence of putative OSCs in the ovaries of cows of reproductive age. If these cells are capable of invitro differentiation, they could provide a powerful tool to study oogenesis and further develop assisted reproductive technologies.

Predictors of nutritional and inflammation risk in hemodialysis patients

BACKGROUND

Malnutrition and chronic inflammation are prevalent complications in hemodialysis (HD) patients. Different nutritional assessment tools are used to identify patients at risk. A composite and comprehensive malnutrition inflammation score (MIS) has been correlated with morbidity and mortality, and appears to be a robust and quantitative tool.

OBJECTIVES

Determine malnutrition risk profile in a sample of portuguese HD patients; determine the association of clinical and laboratory factors with MIS, and the impact of each parameter on MIS.

METHODS AND RESULTS

We performed, between September 15th of 2015 and January 31st of 2016, a cross sectional analysis of 2975 patients, representing 25% of portuguese HD patients. 59% were men (66.7 ± 14.8 years); 31% diabetic; 79% and 21% performed, respectively, high-flux HD and HDF. A MIS >5 was considered to indicate higher risk and was present in 1489 patients (50%). Amongst all parameters, comorbilities/dialysis vintage, transferrin, functional capacity, changes in body weight and decreased fat stores showed the higher impact, while albumin had one of the lowest impact on the nutritional risk.

MULTIVARIABLE ANALYSIS

Higher age (>75 years, OR 1.71, p < 0.001), diabetes (OR 1.25, p = 0.026), lower P levels (OR 1.57,p = 0.001), higher Ca levels (OR 1.51, p < 0.001), higher ERI (OR 1.05, p < 0.001), higher Kt/V (OR 2.14, p < 0.001) and higher CRP (OR 1.01, p < 0.001) were independently associated with a higher risk of MIS>5; higher nPNA (OR 0.29, p < 0.001) and higher Pcreat (OR 0.88, p < 0.001) were associated with a risk reduction of MIS>5 (95% CI).

CONCLUSIONS

Routine clinical and analytic parameters were found to be associated with MIS range that might indicate higher risk, and may represent a simple alert sign for the need of further assessments.

Efficacy of venlafaxine extended-release capsules in nondepressed outpatients with generalized anxiety disorder: A 6-month randomized controlled trial

CONTEXT

Generalized anxiety disorder (GAD) is a chronic disorder that is associated with debilitating psychic and somatic symptoms. Venlafaxine extended-release (XR) capsules have been shown to be effective in short-term treatment of patients with GAD without major depressive disorder (MDD), but long-term data are needed to establish whether this agent confers persistent benefits.

OBJECTIVE

To compare the 6-month efficacy and safety of a flexible dosage of venlafaxine XR in outpatients with GAD without associated MDD.

DESIGN

Six-month, randomized, double-blind, placebo-controlled, parallel-group trial conducted May 1996 to October 1997.

SETTING

Fourteen outpatient clinics and private psychiatric practices in the United States.

PARTICIPANTS

A total of 251 outpatients aged 18 years or older who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for GAD, had sufficient symptoms to require treatment, and did not have coexisting MDD.

INTERVENTIONS

Participants were randomly assigned to receive either placebo (n=127) or venlafaxine XR (75, 150, or 225 mg/d, as required to control symptoms; n=124) for 28 weeks.

MAIN OUTCOME MEASURES

Changes from baseline in the Hamilton Rating Scale for Anxiety (HAM-A) total score, the HAM-A psychic anxiety factor score, and the Clinical Global Impressions (CGI) scale Severity of Illness and Global Improvement scores, compared by intervention group.

RESULTS

During weeks 6 through 28, response rates in the venlafaxine XR group were 69% or higher compared with rates of 42% to 46% in the placebo group (P<.001). By an evaluable-patient analysis, venlafaxine XR compared with placebo significantly improved anxiety scores from week 1 or 2 through week 28 on all primary efficacy measures, including the HAM-A total (P<.001), the HAM-A psychic anxiety factor (P<.001), and the CGI scale scores (P<.001). Adjusted mean changes from baseline to week 28 using last-observation-carried-forward methods were for HAM-A, venlafaxine XR -13.4, placebo -8.7 (P<.001); for HAM-A psychic anxiety score, venlafaxine XR -7.4, placebo -4.2 (P<.001); and for CGI-Improvement, venlafaxine XR 2.2, placebo 3.0 (P<.001). The most common treatment-emergent adverse event was nausea, followed by somnolence and dry mouth.

CONCLUSIONS

This study is the first placebo-controlled demonstration of the long-term efficacy of any drug class in treating outpatients with DSM-IV-diagnosed GAD. Venlafaxine XR is an effective, rapidly acting, safe, once-daily agent for both the short- and long-term treatment of anxiety and may provide an important alternative to currently available anxiolytics. JAMA. 2000.

Color vision discrimination in the capuchin monkey Cebus apella: evidence for trichromaticity

Primates display significant differences in color vision. The purpose of this study was to assess the ability of capuchin monkeys in discriminating chromatic and achromatic Munsell color chips through behavioral tests. The subjects were trained in a simple and reverse discrimination learning procedure. All subjects were capable of discriminations along five color categories investigated. The results are discussed in terms of the hypothesis of male dichromatism in New World monkeys, the role of color vision in adaptation to feeding ecology, as well as to aspects regarding primate evolution.

[Anomalous venous drainage of the left lung. Clinical and surgical findings and diagnostic difficulties]

PURPOSE

To analyze clinical and surgical aspects of patients with anomalous left pulmonary venous drainage (ALPVD).

METHODS

Seven patients, 3 males, with ages ranging from 18 months to 29 years were retrospectively studied, by analyzing the symptoms, electrocardiograms, chest X-ray, echocardiograms, angiography and surgical technique.

RESULTS

All patients, but one, were symptomatic being the effort dyspnea the most prevalent symptom. Electrocardiogram showed incomplete right bundle branch block in all but one case. Chest X-ray showed prominent pulmonic vessels (6 patients), different degrees of cardiomegaly (6) and a left superior vena cava like image (3). Echocardiography correctly depicted the anomaly in 4 cases. The ALPVD was lobar in 4 cases and total in 3. In 3 patients there was pulmonary hypertension and in one venous drainage obstruction (8mmHg gradient). Six patients were operated on, 3 through a sternotomy approach with cardiopulmonary bypass and other 3 through a left thoracotomy without cardiopulmonary bypass.

CONCLUSION

ALPVD has varying clinical repercussion and its clinical picture resembles atrial septal defect. Some cases may present diagnostic difficulties and echocardiograms may result in false negative findings. Cardiac catheterization is important to obtain detailed anatomic diagnosis, to evaluate the degree of pulmonary hypertension and to rule out venous obstruction. Left thoracotomy without extracorporeal circulation is indicated in ALPVD without associated defects.

Comparison of processed bovine internal mammary arteries and autologous veins as arterial femoral substitutes in dogs: blood compatibility and pathological characteristics

This study was undertaken to compare the chemically processed internal mammary artery (BIMA) and the autologous femoral vein as arterial grafts. The BIMA prosthesis was implanted as a left femoral artery bypass and the femoral vein as a right femoral artery bypass graft in 27 dogs. In groups of three dogs the grafts were implanted for predetermined durations: 4, 24 and 48 hours (short term), 1, 2 and 4 weeks (medium term) and 3, 6 and 9 months (long term). All autologous veins were patent when the dogs were killed. The patency rates of the BIMA grafts were 100% in the short-term group, 67% in the medium-term group and 29% in the long-term group. The deposition of labelled fibrinogen and platelets on flow surfaces, the structural preservation of the wall of the BIMA prosthesis and accumulation of thrombi during the period of implantation were studied.