Modulation of miR-29a and miR-29b Expression and Their Target Genes Related to Inflammation and Renal Fibrosis by an Oral Nutritional Supplement with Probiotics in Malnourished Hemodialysis Patients

Malnutrition is prevalent in patients with chronic kidney disease (CKD), especially those on hemodialysis. Recently, our group described that a new oral nutritional supplement (ONS), specifically designed for malnourished (or at risk) hemodialysis patients with a "similar to the Mediterranean diet" pattern, improved caloric-protein intake, nutritional status and biomarkers of inflammation and oxidation. Our aim in this study was to evaluate whether the new ONS, associated with probiotics or not, may produce changes in miRNA's expression and its target genes in malnourished hemodialysis patients, compared to individualized diet recommendations. We performed a randomized, multicenter, parallel-group trial in malnourished hemodialysis patients with three groups (1: control (C) individualized diet (n = 11); 2: oral nutritional supplement (ONS) + placebo (ONS-PL) (n = 10); and 3: ONS + probiotics (ONS-PR) (n = 10)); the trial was open regarding the intake of ONS or individualized diet recommendations but double-blinded for the intake of probiotics. MiRNAs and gene expression levels were analyzed by RT-qPCR at baseline and after 3 and 6 months. We observed that the expression of miR-29a and miR-29b increased significantly in patients with ONS-PR at 3 months in comparison with baseline, stabilizing at the sixth month. Moreover, we observed differences between studied groups, where miR-29b expression levels were elevated in patients receiving ONS-PR compared to the control group in the third month. Regarding the gene expression levels, we observed a decrease in the ONS-PR group compared to the control group in the third month for RUNX2 and TNFα. TGFB1 expression was decreased in the ONS-PR group compared to baseline in the third month. PTEN gene expression was significantly elevated in the ONS-PR group at 3 months in comparison with baseline. LEPTIN expression was significantly increased in the ONS-PL group at the 3-month intervention compared to baseline. The new oral nutritional supplement associated with probiotics increases the expression levels of miR-29a and miR-29b after 3 months of intervention, modifying the expression of target genes with anti-inflammatory and anti-fibrotic actions. This study highlights the potential benefit of this oral nutritional supplement, especially associated with probiotics, in malnourished patients with chronic renal disease on hemodialysis.

Clinical Significance of Nutritional Status, Inflammation, and Body Composition in Elderly Hemodialysis Patients-A Case-Control Study

Nutritional and inflammatory disorders are factors that increase the risk of adverse clinical outcomes and mortality in elderly hemodialysis (HD) patients. This study aimed to examine nutritional and inflammation status as well as body composition in older adults on HD compared to matched controls. A case-control study was conducted on 168 older participants (84 HD patients (cases) and 84 controls) age- and sex-matched. Demographic, clinical, anthropometric, and laboratory parameters were collected from medical records. The primary outcome was nutritional status assessment using a combination of nutritional and inflammatory markers along with the geriatric nutritional risk index (GNRI). Sarcopenic obesity (SO) was studied by the combined application of anthropometric measures. Body composition and hydration status were assessed by bioelectrical impedance analysis (BIA). Univariate and multivariate regression analyses were performed to identify nutritional and inflammatory independent risk indicators in elderly HD patients and controls. A significantly high prevalence of nutritional risk measured by the GNRI was found in HD patients (32.1%) compared to controls (6.0%) (p < 0.001). Elderly HD patients were overweight and had lower percent arm muscle circumference, phase angle (PA), serum albumin (s-albumin), as well as higher percent extracellular body water (ECW%) and serum C-reactive protein (s-CRP) than controls (all at least, p < 0.01). SO was higher in HD patients (15.50%) than in controls (14.30%). By multi-regression analyses, age < 75 years (OR: 0.119; 95%CI: 0.036 to 0.388), ECW% (OR: 1.162; 95%CI: 1.061 to 1.273), PA (OR: 0.099; 95%CI: 0.036 to 0.271), as well as BMI, s-albumin ≥ 3.8 g/dL, and lower s-CRP were independently related between cases and controls (all at least, p < 0.05). Elderly HD patients had increased nutritional risk, SO, inflammation, overhydration, and metabolic derangements compared to controls. This study highlights the importance of identifying nutritional risk along with inflammation profile and associated body composition disorders in the nutritional care of elderly HD patients. Further studies are needed to prevent nutritional disorders in elderly HD patients.

Effect on nutritional status and biomarkers of inflammation and oxidation of an oral nutritional supplement (with or without probiotics) in malnourished hemodialysis patients. A multicenter randomized clinical trial "Renacare Trial"

Background

Malnutrition in patients undergoing hemodialysis is frequent and associated with a reduction in muscular mass and strength, with an increment in biomarkers of inflammation and oxidation.

Materials and methods

Randomized, multicenter, parallel-group trial in malnourished hemodialysis patients with three groups [(1) control (C) individualized diet, (2) oral nutritional supplement-ONS- + placebo-SU- PL-, and (3) ONS + probiotics-SU-PR]; the trial was open regarding the intake of ONS or individualized diet recommendations, but double-blind for the intake of probiotics. We obtained, at baseline and after 3 and 6 months, anthropometric measurements, handgrip strength, bioelectrical impedance analysis (BIA), dietary records, and routine biochemical parameters. Inflammation and oxidation were determined using ELISA techniques (Versamax and ProcartaPlex multiplex Immunoassay). Results were analyzed by intention to treat.

Results

A total of 31 patients (11 corresponding to group C, 10 to SU-PL, and 10 to SU-PR) completed the 6-months trial. The two groups that took supplements significantly increased their protein calorie, fat (total and n-3), and fiber intake. Weight and fat-free mass (FFM) also increased significantly in the groups on supplements, both at 3 and 6 months, and dynamometry did so in the SU-PL group. At month 3, prealbumin and vitamin D were significantly increased in the SU-TOT (SU-PL + SU-PR) group. No changes were observed regarding levels of phosphorus and potassium in any of the groups. Urea increased significantly at 6 months in the SU-PL group. There were significant changes in some inflammation biomarkers in the groups on supplements during the intervention (brain-derived neurotrophic factor, bone morphogenetic protein-2, MCP-1, IL-1-beta, IL-10, IL-4, and IL-8). The total antioxidant capacity (TAC) increased significantly in the supplemented patients, with no significant changes observed in isoprostanes.

Conclusion

The specific ONS improved protein-calorie intake, nutritional status (mainly FFM), and some biomarkers of inflammation/oxidation. The addition of probiotics could have a synergistic effect with ONS in such biomarkers.

Clinical trail registration

https://clinicaltrials.gov/ct2/show/, identifier NCT03924089.

Comorbidity and nutritional status in adult with advanced chronic kidney disease influence the decision-making choice of renal replacement therapy modality: A retrospective 5-year study

Background

Nutritional and inflammation status are significant predictors of morbidity and mortality risk in advanced chronic kidney disease (ACKD). To date, there are a limited number of clinical studies on the influence of nutritional status in ACKD stages 4-5 on the choice of renal replacement therapy (RRT) modality.

Aim

This study aimed to examine relationships between comorbidity and nutritional and inflammatory status and the decision-making on the choice of RRT modalities in adults with ACKD.

Methods

A retrospective cross-sectional study was conducted on 211 patients with ACKD with stages 4-5 from 2016 to 2021. Comorbidity was assessed using the Charlson comorbidity index (CCI) according to severity (CCI: ≤ 3 and >3 points). Clinical and nutritional assessment was carried out by prognosis nutritional index (PNI), laboratory parameters [serum s-albumin, s-prealbumin, and C-reactive protein (s-CRP)], and anthropometric measurements. The initial decision-making of the different RRT modalities [(in-center, home-based hemodialysis (HD), and peritoneal dialysis (PD)] as well as the informed therapeutic options (conservative treatment of CKD or pre-dialysis living donor transplantation) were recorded. The sample was classified according to gender, time on follow-up in the ACKD unit (≤ 6 and >6 months), and the initial decision-making of RRT (in-center and home-RRT). Univariate and multivariate regression analyses were carried out for evaluating the independent predictors of home-based RRT.

Results

Of the 211 patients with ACKD, 47.4% (n = 100) were in stage 5 CKD, mainly elderly men (65.4%). DM was the main etiology of CKD (22.7%) together with hypertension (96.6%) as a CV risk factor. Higher CCI scores were significantly found in men, and severe comorbidity with a CCI score > 3 points was 99.1%. The mean time of follow-up time in the ACKD unit was 9.6 ± 12.8 months. A significantly higher CCI was found in those patients with a follow-up time > 6 months, as well as higher mean values of eGFR, s-albumin, s-prealbumin, s-transferrin, and hemoglobin, and lower s-CRP than those with a follow-up <6 months (all, at least p < 0.05). The mean PNI score was 38.9 ± 5.5 points, and a PNI score ≤ 39 points was found in 36.5%. S-albumin level > 3.8 g/dl was found in 71.1% (n = 150), and values of s-CRP ≤ 1 mg/dl were 82.9% (n = 175). PEW prevalence was 15.2%. The initial choice of RRT modality was higher in in-center HD (n = 119 patients; 56.4%) than in home-based RRT (n = 81; 40.5%). Patients who chose home-based RRT had significantly lower CCI scores and higher mean values of s-albumin, s-prealbumin, s-transferrin, hemoglobin, and eGFR and lower s-CRP than those who chose in-center RRT (p < 0.001). Logistic regression demonstrated that s-albumin (OR: 0.147) and a follow-up time in the ACKD unit >6 months (OR: 0.440) were significantly associated with the likelihood of decision-making to choose a home-based RRT modality (all, at least p < 0.05).

Conclusion

Regular monitoring and follow-up of sociodemographic factors, comorbidity, and nutritional and inflammatory status in a multidisciplinary ACKD unit significantly influenced decision-making on the choice of RRT modality and outcome in patients with non-dialysis ACKD.

Differences in Malnutrition Inflammation Score of Hemodialysis Patients Associated With Hemodialysis Factors. A Spanish Multicenter Epidemiologic Study

OBJECTIVES

The aims of this study are to analyze the prevalence of malnutrition in hemodialysis (HD) patients in Spain, and to assess the association of malnutrition in these patients with sociodemographic characteristics, comorbidity, and parameters related to HD.

DESIGN AND METHODS

A multicenter, retrospective, cross-sectional study in HD patients from centers all over Spain was conducted. Nutritional status of patients was assessed using Malnutrition Inflammation Score (MIS), and was stratified according to MIS values into 5 categories: ≤2, normal nutrition; >2 to ≤5, mild malnutrition or risk of malnutrition; >5 to ≤7, moderate malnutrition; >7 to ≤10, severe malnutrition, and >10, extreme malnutrition.

RESULTS

A total of 52 Spanish HD Units participated in the study enrolling 2,748 patients. Mean age of patients was 68.20 ± 14.24 years, 1,811 (65.9%) were men. Mean time on HD was 55.63 ± 63.25 months. Using an MIS cut-off point of 2 for malnutrition, 89% of patients were malnourished (MIS > 2). However, with a cut-off point of 5, more commonly described in the literature, the percentage of patients with malnutrition was reduced to 51.7%. Using this cut-off, we observed significant differences between patients with malnutrition and normo-nourished patients in biochemical parameters, age, Charlson Index, HD residual renal function, scheme, and vascular access (permanent catheter vs arteriovenous fistula). A multivariate regression analysis showed that age, sex, HD scheme, vascular access, residual renal function, and comorbidity index were predictive factors for malnutrition. We found that a high percentage of HD patients with malnutrition did not receive oral supplementation.

CONCLUSIONS

The prevalence of malnutrition in HD patients in Spain, assessed using the MIS scale, was high. Higher malnutrition was associated with the use of catheter versus fistula, and standard HD versus online hemodiafiltration, and with the absence of residual renal function, older age, greater comorbidity, and male sex. Malnourished patients had a low rate of oral supplementation.

Impact of the Nutrition-Inflammation Status on the Functionality of Patients with Chronic Kidney Disease

Functional capacity of chronic kidney disease (CKD) patients is compromised by their nutrition-inflammation status. We evaluated the functional capacity of advanced chronic kidney disease (ACKD) patients and the influence of the nutrition-inflammation status. In a cross-sectional study, which included ACKD patients from the nephrology department of the Hospital Universitario de la Princesa in Madrid, Spain, we assessed: functional capacity with the Short Physical Performance Battery (SPPB) test, interpreting a result <7 in the test as low functionality; body composition with monofrequency bioimpedance; muscular strength with hand grip strength; nutritional and inflammatory status using biochemical parameters and the Malnutrition Inflammation Scale (MIS). A total of 255 patients with ACKD were evaluated, 65.8% were men, their mean age was 70.65 ± 11.97 years and 70.2% of the patients had an age >65 years. The mean score of SPPB was 8.50 ± 2.81 and 76.4% of the patients presented a score ≥7, with a higher percentage in the group of men. The percentage of patients with limitations increased with age. The patients with SPPB values higher than 7 showed high values of albumin and low soluble C-reactive protein (s-CRP) and MIS. We found better functionality in well-nourished patients. A multivariate logistic regression model established an association of high albumin values with a better functional capacity (OR: 0.245 CI: 0.084−0.714 p < 0.010), while another model showed an association between CRP values and decreased functionality (OR: 1.267 CI: 1.007−1.594 p = 0.044). Conclusion: nutritional status and body composition influence on the functional capacity of patients with ACKD.

Nutritional Status, Body Composition, and Inflammation Profile in Older Patients with Advanced Chronic Kidney Disease Stage 4-5: A Case-Control Study

Nutritional status is a predictor of adverse outcomes and mortality in patients with advanced chronic kidney disease (ACKD). This study aimed to explore and evaluate risk factors related to nutritional status, body composition, and inflammatory profile in patients with ACKD compared with age- and sex-matched controls in a Mediterranean cohort of the Spanish population. Out of 200 volunteers recruited, 150 participants (64%) were included, and a case-control study was conducted on 75 ACKD patients (stages 4−5), matched individually with controls at a ratio of 1:1 for both age and sex. At enrolment, demographic, clinical, anthropometric, and laboratory parameters were measured. Bioimpedance analysis (BIA) was used to assess both body composition and hydration status. ACKD patients had lower body cell mass (BCM%), muscle mass (MM%) phase angle (PA), s-albumin, and higher C-reactive protein (s-CRP) than controls (at least, p < 0.05). PA correlated positively with BCM% (cases: r = 0.84; controls: r = 0.53, p < 0.001), MM% (cases: r = 0.65; controls: r = 0.31, p < 0.001), and inversely with s-CRP (cases: r = −0.30, p < 0.001; controls: r = −0.31, p = 0.40). By univariate and multivariate conditional regression analysis, total body water (OR: 1.186), extracellular mass (OR: 1.346), s-CRP (OR: 2.050), MM% (OR: 0.847), PA (OR: 0.058), and s-albumin (OR: 0.475) were significantly associated among cases to controls. Nutritional parameters and BIA-derived measures appear as prognostic entities in patients with stage 4−5 ACKD compared to matched controls in this Mediterranean cohort.

The Extracellular Mass to Body Cell Mass Ratio as a Predictor of Mortality Risk in Hemodialysis Patients

The extracellular mass/body cell mass ratio (ECM/BCM ratio) is a novel indicator of nutritional and hydration status in hemodialysis (HD) patients. This study aimed to explore the ECM/BCM ratio as a predictor of mortality risk with nutritional-inflammatory markers in HD patients. A prospective observational study was conducted in 90 HD patients (male: 52.2%; DM: 25.60%). Clinical and biochemical parameters [serum albumin, serum C-reactive protein (s-CRP), interleukine-6 (IL-6)] were analysed and bioelectrical impedance analysis (BIA) was performed. Protein-energy wasting syndrome (PEW) was diagnosed using malnutrition-inflammation score (MIS). Based on BIA-derived measurements, the ECM/BCM ratio with a cut-off point of 1.20 was used as a PEW-fluid overload indicator. Comorbidity by Charlson index and hospital admissions were measured. Out of 90 HD patients followed up for 36 months, 20 patients (22.22%) died. PEW was observed in 24 survivors (34.28%) and all non-survivors. The ECM/BCM ratio was directly correlated with MIS, s-CRP, Charlson index and hospital admissions but was negatively correlated with phase angle and s-albumin (all, p < 0.001). Values of the ECM/BCM ratio ≥ 1.20 were associated with higher probability of all-cause mortality (p = 0.002). The ECM/BCM ratio ≥ 1.20, IL-6 ≥ 3.1 pg/mL, s-CRP and s-albumin ≥ 3.8 g/dL and Charlson index were significantly associated with all-cause mortality risk in multivariate adjusted analysis. This study demonstrates that the ECM/BCM ratio ≥ 1.20 as a nutritional marker and/or fluid overload indicator had a significant prognostic value of death risk in HD patients.

MO664DYNAMIC ASSESSMENT OF INTERLEUKIN-6 DURING HEMODIALYSIS AND MORTALITY IN COVID 19

Background and Aims

The impact of the newly discovered severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causing coronavirus disease-19 (COVID-19) in hemodialysis patients remains poorly characterized. Some hemodialysis techniques reduce systemic inflammation but their impact on COVID-19 has not been addressed. The aim of this prospective study was to evaluate factors associated to mortality in COVID-19 hemodialysis patients, including the impact of reducing interleukin-6 using a cytokine adsorbent filter.

Method

This is a prospective single-center study including 16 hemodialysis patients with COVID-19. All were dialyzed using a polymethyl methacrylate (PMMA) filter. Interleukin-6 levels were obtained before and after the first admission hemodialysis session and at one week. Also we collected serum samples from 8 patients of our unit as controls: 4 in online hemodiafiltration (OLHDF) and 4 in high-flux hemodialysis Baseline comorbidities, laboratory values, chest X-ray and treatments were recorded and compared between survivors and non-survivors.

Results

Sixteen patients were included (13 males, mean age 72±15 years). Four patients (25%) died. Factors associated to mortality were dialysis vintage (p=0.01), the presence of infiltrates in chest X-ray (p=0.032), serum C-reactive protein (p=0.05) and lactate dehydrogenase (p=0.02) at one week, the requirement of oxygen therapy (p=0.02) and the use of anticoagulation (p<0.01). At admission, post-dialysis interleukin-6 levels were higher (p<0.01) in non-survivors and these patients differed from survivors in the reduction of interleukin-6 levels during the dialysis session despite using a PMMA filter (survivors vs non survivors (25 [17-53]% vs -3 [-109-12] %, p=0.04).

Conclusion

In hemodialysis COVID-19 patients, a positive balance of interleukin-6 during the session was associated to higher mortality.

MO909MULTICENTER EPIDEMIOLOGICAL STUDY OF MALNUTRITION INFLAMATION IN DIALYSIS “EMID” IN SPANISH DIALYSIS CENTERS

Background and Aims

There is a high prevalence of malnutrition (PEW) in patients on dialysis (HD-PD). There is no single tool to diagnose it, varying the percentage according to the one used.

Aim

To assess prevalence of malnutrition-inflammation by MIS scale (malnutrition-inflammation-score) in HD or PD patients of Spanish dialysis units.

Method

We evaluated  2937 patients on dialysis (HD+PD) in Spain were evaluated on the MIS scale strata (Kalantar-Zadeh 1999) also analyzing:

Common data

Age, sex, dialysis time, Charlson-I., RRF, albumin,prealbumin,Kt/V transferrin, CRP, DM

, Specific-HD

HD type, AVF or Catheter

, Specific-PD

PD-type, transport type.

Statistical analysis with SPSS.23 software, using parametric and non-parametric test.

Results

We evaluate 2748 HD patients, median age 71 (RIC20), 65.90% male, median MIS 6 (RIC4), DM 36.91%, T in HD 36m (RIC54), FRR 35.44% , Charlson Index 7 (RIC4) and 186 in PD (62.96% men), median

-age 62 (RIC 24), median-MIS 4 (RIC 2), T in PD of 18.5 m (RIC 23.5),DM 30.77%, FRR 79.89%, I Charlson 5 (RIC 4), In PDA 99pac-52.38%.

Prevalence of global malnutrition (MIS&gt;2) was 89% considering HD+DP and 50% when MIS&gt;5 (table 1)

In PD the higher normonutrides greater Kt/V in manual vs automatic not the malnourished ones. FRR significantly in greater % in normonutrides. No differences in malnutrition depending on carrier type. CRP sig major in MIS&gt;2 and &gt;5

In HD, Normo versus malnourished and with MIS&gt;5 significant difference: HD type, CRP, HD Type, AVF vs catheter, age,sex.

The prescription for Oral supplement was low and higher in HD 12.4% vs DP 6.3%.

Conclusions

1.- There is a high prevalence of malnutrition on dialysis being higher in HD. 2.- In PD, FRR major and CRP minor in well-nourished versus malnourished. 3.- In HD: Normo versus malnourished and with MIS&gt;5 significant difference: HD type, CRP,Charlson I. AVF vs catheter, age,sex. 4.- There is a percentage of malnourished patients with very low percentage of oral supplement.

MO600DIFFERENCES IN BODY COMPOSITION, MUSCLE STRENGHT AND BIOCHEMICAL PARAMETERS IN CKD PATIENTS WITH AND WITHOUT PROTEIN ENERGY WASTING (PEW)

Background and Aims

PEW sometimes produces irreversible alterations in nutritional status, and early diagnosis could mark the sindrome reversibility.

Aim.-To establish the prevalence of PEW in an advanced CKD unit in a sample of 325 patients with CKD and to establish the differences in nutritional parameters, body composition and muscle strength.

Method

The patients treated in Advanced CKD Unit (ACKD) nutritional status monitoring is performed every 3 months, will be assessed through a cross-sectional , with the frequency being able to increase if malnutrition is detected in the screening.

The ISRNM criteria are applied to diagnose PEW, and the patients are classified according to whether or not they have PEW and the differences in nutritional parameters are analyzed: albumin, transferrin, CRP, linphocytes, Hb, body composition with Akhern HD-01 monofrequency BIA and anthropometric measurements and muscular strength with dynamometer (baseline).

Results

We have evaluated 325 patients with CKD xage 70.88 ± 12.55 years, 66.8% 217pac are men with xCKD-EPI of 19.19 ± 9.28ml / min / 1.73m2 PEW prevalence 8.9% (29 patients) aged 74.06 ± 12.79 years, with no significant difference between sexes with and without PEW (18/215 men and 11/108 women). We found significant differences between the groups with PEW vs without PEW in protein intake (nPNA) 0.73 ± 0.21 vs 0.93 ± 0.26, p0.003, albumin 3.74 ± 0.66 vs 4.21 ± 0.41, CRP 1.20 ± 2.09 vs 0.68 ± 1.20, p0.05, Hb 11.33 ± 1.52 vs 11.90 ± 1.50, p0.023, transferrin 199.71 ± 48.38 vs224.95 ± 48.85, p0.013.

Data on anthropometric and body composition measures as showing in the table. The values of biochemical parameters and body composition in patients with PEW are striking, as some are close to the low limit of normality, which suggests the possible reversibility if action is taken on time.

Conclusion

The monitoring of nutritional status in a protocolized way provides low prevalences of PEW and allows its early detection, which favors its reversibility with the appropriate intervention.

MO606FUNCTIONAL CAPACITY AND NUTRITION-INFLAMMATION BINOMIUM IN PATIENTS WITH ADVANCED CHRONIC KIDNEY DISEASE (ACKD)

Background and Aims

There are differents factors that will influence the functional capacity of ACKD patients, among them the nutritional condition.

Aim

to assess the functional capacity of ACKD patients with the Short Physical Performance test Battery (SPPB), and its relationship with the malnutrition-inflammation binomium.

Method

We have evaluated 216 ACKD patients, 66.2% (143) male. xage 70.85 ?12.01 years, being female older than male (72.58 ?13.19 vs 69.96 ?11.32, p = 0.129). We have determine plasma proteins indicators of nutritional status such as albumin, prealbumin and CRP as a marker of the status of inflammation. And we have applied malnutrition inflamation score (MIS).

Results

In the univariate analysis, we found an association between the functionality determined with the test and the age (RR95% 0.866 p = 0.000), sex (RR95% 0.387 p = 0.005). albumin (RR95% 2,222 p = 0.035), prealbumin (RR95% 1.065 p = 0.018), CRP (RR95% 0.733 p = 0.022) and the state nutritional value determined with the MIS scale (RR95% 0.791 p = 0.000). We donot any found any association with DM, transferrin and total lymphocytes. Albumin values were established as 3.8g / dl, and CRP at 1g / dl, obtaining 4 groups: (G1: alb> 3,7-PCR <1, G2: alb> 3,7-PCR> 1, G3: alb <3,7-PCR <1 and G4: alb <3,7-PCR> 1 ).

The table shows the results of the relationship between groups and the limitations determined with SPBB. Group 1 was the most numerous, also being the one with the best nutrition-inflammation profile, observing that in this group 68 patients (78.2%) presented minimal / no limitations.

Conclusions

1. The nutritional-inflammation status will influence the functional capacity of the patient with ERCA.

2. The SPPB test, in addition to being a good choice to evaluate the functional capacity of patients with ACKD, can provide guidance on the nutritional status of patients.

3. Maintaining a good nutritional status will also have a positive influence on the functional capacity of ACKD patients.

Dynamic assessment of interleukin-6 during hemodialysis and mortality in coronavirus disease-19

The impact of the newly discovered severe acute respiratory syndrome coronavirus 2 causing coronavirus disease‐19 (COVID‐19) in hemodialysis patients remains poorly characterized. Some hemodialysis techniques reduce systemic inflammation but their impact on COVID‐19 has not been addressed. The aim of this prospective study was to evaluate factors associated with mortality in COVID‐19 hemodialysis patients, including the impact of reducing interleukin‐6 using a cytokine adsorbent filter. This is a prospective single‐center study including 16 hemodialysis patients with COVID‐19. All were dialyzed using a polymethyl methacrylate (PMMA) filter. Interleukin‐6 levels were obtained before and after the first admission hemodialysis session and at 1 week. Baseline comorbidities, laboratory values, chest X‐ray, and treatments were recorded and compared between survivors and non‐survivors. Out of 16 patients (13 males, mean age 72 ± 15 years), 4 (25%) died. Factors associated with mortality were dialysis vintage (P = 0.01), chest X‐ray infiltrates (P = 0.032), serum C‐reactive protein (P = 0.05), and lactate dehydrogenase (P = 0.02) at 1 week, oxygen therapy requirement (P = 0.02) and anticoagulation (P < 0.01). At admission, non‐survivors had higher predialysis and postdialysis interleukin‐6 levels (P = 0.02 for both) and did not present the reduction of interleukin‐6 levels during the dialysis session with PMMA filter that was observed in survivors (survivors vs. non‐survivors: 25.0 [17.5–53.2]% vs. −2.8 [−109.4–12.8]% reduction, P = 0.04). A positive balance of interleukin‐6 during the admission dialysis was associated with mortality (P = 0.008). In conclusion, in hemodialysis COVID‐19 patients, a positive interleukin‐6 balance during the admission hemodialysis session was associated with higher mortality.

P0943FAT MASS/FAT FREE MASS RATIO AS A CARDIOVASCULAR RISK FACTOR. SURVIVAL STUDY

Background and Aims

Excess fat mass correlates with cardiovascular risk and if the increase in BMI is at the expense of fat mass it can increase mortality.

Aims- To evaluate the Fat Mass/Fat Free Mass ratio (FM/FFM)in 195 CKD patients and establish a correlation with nutrition-inflammation parameters, body composition and hand grip strenght

Method

We have studied 195 patients aged 67.01 ± 14.52 years, 126 (64.6%) men and 69 (35.4%) women. 41% in HD and 59% with advanced CKD. We have determined FM/FFM ratio using BIA monofrequency Bodigram Plus (Akhern) and hand grip stengh ( baseline).We determine biochemical nutrition-inflammation parameters also.

Results

xRatio FM/FFM = 0.499 ± 0.2304, in men = 0.41 ± 0.16 and in women = 0.64 ± 0.26 (both less than published 0.57 men and 0.867 in women). Median 0.4558 and percentils (p) with cut-off points 0.3868 and 0.5574. In HD 31 in P1, 23 in P2 and 26 in P3. In advanced CKD 32 in P1, 41 in P2 and 42 in P3. Anova significant according to percentiles: SMI, age, TBW% BCMI, albumin, waist circunference, and Hand grip strenght.

Correlations

Men

FM / FFM ratio direct sig correlation with weight, AEC% and Trasferrin%, inverse with MIS, SMI, Na / K, BCM%, TBW%, IBW%, BCMI and right dynamometry. Do not continue with BMI, Phase Angle, Hb, lymphocytes, prealbumin, PCR.

Women

FM/FFM ratio direct sig correlation wih: weight, Na / k, BMI, prealbumin, CRP, MIS, inverse with: TBW. No sig: SMI, BCM%, EBW%, IBW%, MAMC, BCMI, Hb, hand grip strenght, lymphocytes or transferrin.

In the 24-month mortality study we found no significant differences in Kaplan Meier overall mortality using the 3 percentiles. They died 7/63 in P1, 1/64 in P2 and 8/68 in P3. If we make the union of 1 and 2 vs percentil3 we find significant differences in mortality between strata, especially in HD with Long Rank 0.05.

Conclusions

1.-The FM /FFM ratio is a useful tool for diagnosis of sarcopenic obesity

2.-It correlates significantly with parameters of CRP (direct) inflammation, muscle strength (inverse) and CV risk (direct waist circumference and tricipital fold)

3.- In a survival study joining P1 + P2 vs P3 we found greater survival in P1 + P2, mainly in HD.

P1552CAN WE GET ADEQUATE DIALYSIS WITH LIQUID AT 300 ML/MIN ?

Background and Aims

The portable HD monitors achieve a good adaptation with HD dialysate at 200ml / min using the concept of saturation of the HD dialysate. We decrease from 800ml / min to 500ml / min with good adaptation some years ago.

To assess the effectiveness of HD in both HD-standard and HDF-online with dialysate flow at 300ml / min by establishing approximate mathematical model of clearance.

Methods

We conducted an HD session with dialysate flow at a speed of 300ml / min, half week session to 52 patients in our unit. We value vascular access, session time, liters of blood-purified and total infusion in HDF online. We review HD monitor and dialyzer.

We perform pre and postHD blood determinations: Urea, B2microglobulin, P and uric acid, assessing urea reduction rate (PRU), b2microglobulin reduction rate (PR2microg) with both dialysate flows at 300ml / min and 500ml / min. We also have evaluated the differences between the two methods.

In the HD dialysate flow we determine at 300ml / min at 5, 10, 30, 45 and 60min (total dialysate collection in the first hour with sample of the mixture) urea, B2microg, Uric acid and P and at 2, 3 and 4 hours establishing a mathematical model with an approximation curve in both HD and online HDF.

Results

Five patients in standard HD (4h), 35 HDF online (4h) (x Liters infused 24.87 ± 2.79 l) and 12 short-daily HD (2h30min). 18 catheter and 34 FAV. Xliters purified blood = HD daily 54.41 ± 5.63l, HD standard 87.38 ± 6.01 and HDFonline 82.02 ± 16.13l.

The xPRU = 76.17 ± 10.49%, PRB2microg = 73.82 ± 13.49, Kt / V = 1.52 ± 0.28. By scheme at 300ml / min of HD fluid flow: HDFonline xPRU = 81.54 ± 5.25, Standard HD = 78.01 ± 3.03, Daily HD = 60.19 ± 6.71; xPRb2microg HDFonline = 76.70 ± 14.76%, Standard HD 65.44 ± 11.81, Daily HD = 69.16 ± 6.49.

Comparing the xPRU at 300ml / min of liquid vs 500ml / min we didn´t found significant differences, nor in the x preHD of urea and B2microglobulin.

With the dialysate samples we obtain a polynomial model of order 7 allowing cuantitative adjustment of the curve.R2 0.9, observing in the first 2 hours the greater removing.

Conclusions

1. The results are sufficient to consider the result of the removing in each scheme adequate. 2. The decrease in costs would be important (40% of water + energy saving and longer duration elements water treatment. 3. Further study are necessary.

Prevalence of TT Virus in Serum and Peripheral Mononuclear Cells from a CAPD Population

Background

A novel virus named TT virus (TTV) has been isolated recently from patients with posttransfusional hepatitis of unknown etiology. The prevalence of TTV in several groups at risk has been reported, however, there is no information about the prevalence of TTV in patients on continuous ambulatory peritoneal dialysis (CAPD) without blood transfusions or hemodialysis antecedents.

Objective

To study the incidence of TTV in serum and peripheral blood mononuclear cells (PBMC) of CAPD patients.

Design

TTV DNA was detected by polymerase chain reaction, using primers from the open reading frames (ORF) 1 and 2, in serum and PBMC from 22 CAPD patients who had not received blood transfusions or hemodialysis therapy prior to CAPD. As controls, sera from 20 patients with chronic viral hepatitis (10 with HBV and 10 with HCV) and 20 healthy donors were included in the study.

Results

TTV DNA was detected in the serum of 5 of 22 (22.7%) CAPD patients with both sets of primers. Four of the 5 (80%) patients with TTV DNA in their serum were TTV positive in their PBMC with primers from ORF1 and ORF2. Five of 20 (25%) patients with chronic viral hepatitis (2 patients with HBV and 3 with HCV) and 4 of 20 (20%) healthy donors were TTV DNA positive in serum. No relation was found between TTV infection and the underlying kidney disease, previous surgery, and abnormal alanine aminotranferase levels.

Conclusion

We have found a relatively high prevalence of TTV that is similar to that found in healthy donors and in patients with chronic viral hepatitis.

Analysis of Patient Flow into Dialysis: Role of Education in Choice of Dialysis Modality

♦ Background

Despite advances in predialysis care, morbidity and mortality remain high.

♦ Objectives

To analyze end-stage renal disease (ESRD) patient demographics and clinical data on education on dialysis treatment options, type of chronic renal replacement therapy (RRT), and effects of planned versus non-planned dialysis start.

♦ Methods

621 patients, from 24 Spanish hospitals, who started RRT in 2002. Peritoneal or vascular access at dialysis initiation was considered “planned.”

♦ Results

304 (49%) patients were non-planned and half of them had prior nephrology follow-up. Of the patients with ≥3 months nephrology follow-up (76% of all), only half were educated on dialysis modalities. Dialysis education was associated with planned start in 73.4% versus 26% in non-educated patients ( p < 0.05), shorter follow-up (55 vs 65 months, p = 0.033), more medical visits in the prior year (6.5 vs 4.4, * p < 0.001), more patients starting peritoneal dialysis (31% vs 8.3%*), and more specific follow-up by ESRD unit versus general nephrology care (63% vs 26%*). Non-planned start was associated with older age (63 vs 60.6 years, p = 0.06), fewer medical visits (4.6 vs 6.4*), less education about modality options, and greater use of hemodialysis (92% vs 75%*). Planned patients had better biochemical parameters at start of dialysis.

♦ Conclusion

Despite nephrology follow-up, half the patients did not have a planned dialysis start. Planned start was associated with better clinical status. More patients chose peritoneal dialysis when educated about dialysis modality options. ESRD-specific units were more likely to provide patient education.

Effectiveness, safety/tolerability of OBV/PTV/r ± DSV in patients with HCV genotype 1 or 4 with/without HIV-1 co-infection, chronic kidney disease (CKD) stage IIIb-V and dialysis in Spanish clinical practice - Vie-KinD study

BACKGROUND AND AIMS

Limited data are available on the effectiveness and tolerability of direct-acting antivirals (DAAs) therapies in the real world for HCV-infected patients with comorbidities. This study aimed to describe the effectiveness of OBV/PTV/r ± DSV (3D/2D regimen) with or without ribavirin (RBV) in HCV or HCV/HIV co-infected patients with GT1/GT4 and CKD (IIIb-V stages), including those under hemodialysis and peritoneal dialysis in routine clinical practice in Spain in 2015.

MATERIAL AND METHODS

Non-interventional, retrospective, multicenter data collection study in 31 Spanish sites. Socio-demographic, clinical variables, study treatment characteristics, effectiveness and tolerability data were collected from medical records.

RESULTS

Data from 135 patients with a mean age (SD) of 58.3 (11.4) years were analyzed: 92.6% GT1 (81.6% GT1b and 17.6% GT1a) and 7.4% GT4, 14 (10.4%) HIV/HCV co-infected, 19.0% with fibrosis F3 and 28.1% F4 by FibroScan®, 52.6% were previously treated with pegIFN and RBV. 11.1%, 14.8% and 74.1% of patients had CKD stage IIIb, IV and V respectively. 68.9% of patients were on hemodialysis; 8.9% on peritoneal dialysis and 38.5% had history of renal transplant. A total of 125 (96.2%) of 135 patients were treated with 3D, 10 (7.4%) with 2D and 30.4% received RBV. The overall intention-to-treat (ITT) sustained virologic response at week 12 (SVR12) was 92.6% (125/135) and the overall modified-ITT (mITT) SVR12 was 99.2% (125/126). The SVR12 rates (ITT) per sub-groups were: HCV mono-infected (91.7%), HCV/HIV co-infected (100%), GT1 (92.0%), GT4 (100%), CKD stage IIIb (86.7%), stage IV (95%) and stage V (93%). Among the 10 non-SVR there was only 1 virologic failure (0.7%); 4 patients had missing data due lost to follow up (3.0%) and 5 patients discontinued 3D/2D regimen (3.7%): 4 due to severe adverse events (including 3 deaths) and 1 patient´s decision.

CONCLUSIONS

These results have shown that 3D/2D regimens are effective and tolerable in patients with advanced CKD including those in dialysis with GT 1 or 4 chronic HCV mono-infection and HIV/HCV coinfection in a real-life cohort. The overall SVR12 rates were 92.6% (ITT) and 99.2% (mITT) without clinically relevant changes in eGFR until 12 weeks post-treatment. These results are consistent with those reported in clinical trials.

Extracellular mass to body cell mass ratio as a potential index of wasting and fluid overload in hemodialysis patients. A case-control study

BACKGROUND & AIMS

Extracellular mass-to-body cell mass ratio (ECM/BCM ratio) which differentiates the proportion between intraextracellular compartments, could be a nutrition index of being wasted overloaded in hemodialysis (HD) patients. This study aimed to describe a cut-off point of the ECM/BCM ratio and, to find out the relationship between the nutritional-hydration status and this ratio in HD patients.

METHODS

A case-control study was carried out in 64 HD patients individually age-gender-matched to controls. Demographic, clinical and laboratory parameters were recorded. Bioelectrical impedance analysis was used to estimate ECM/BCM ratio as an indicator of the nutritional hydration status. Receiver operator characteristic (ROC) curve analysis was applied to determine the optimal cut-off point for identification of ECM/BCM ratio. An univariate and multivariate conditional logistic regression for the ECM/BCM ratio ≥1.20 was performed.

RESULTS

Median of ECM/BCM ratio was 1.50 (IQR:0.66) in HD patients, whereas 0.87 (IQR: 0.35) was found in controls (p < 0.001). HD-patients had lower body weight, serum albumin (s-albumin) and higher serum C-reactive protein (s-CRP) than controls. By ROC curve analysis, a cut-off point of 1.20 for the ECM/BCM ratio best discriminates to be wasted-overhydrated (sensitivity: 81.2%; specificity: 87.5%). Conditional logistic regression showed that for each 10%, ECM/BCM ratio increase the probability of developing fluid overload was increased 63% (OR: 1.63; 95% CI, 1.15-2.29), whereas an inverse association with s-albumin (OR: 0.15; 95% CI, 0.03-0.61) and other nutritional indicators were found.

CONCLUSIONS

The ECM/BCM ratio appears as a sensitive index that discriminates nutritional and/or hydration status in HD patients compared with age-gender-matched-controls. ECM/BCM ratios ≥1.20 are indicators of wasting and fluid overload in HD patients.

Is SPPB useful as a screening method of functional capacity in patients with advanced chronic kidney disease?

INTRODUCTION AND OBJECTIVE

One of the consequences of the CKD, is the deterioration of the functional capacity, being able to manifest from different stages of the disease, until renal replacement therapy. The objective of this study was to determine the functionality of patients with CKD through functional capacity test, valuing the usefulness of the SPPB as a screening test in parallel.

MATERIALS AND METHODS

It assessed the functional capacity of patients with CKD, using the test SPPB, 6MM, TUTG and STS. Also found the muscle strength with manual dynamometry.

RESULTS

Of 121 patients who came to the CKD query, 118 presented a minimum functionality to perform tests of functional capacity, a 71.2% of the patients were able to perform 4 tests, a 28.8% only could make the SPPB test. To a 71.43% of patients who presented a low score in SPPB, not could follow assessed them with the rest of the test, while the 92.31% of which had a high score, continued with the rest of the evidence. To differentiate by age ranges, the majority of young patients have minimal limitations, finding higher rates of disability in older age ranges. A good score in SPPB meant to present good functional capacity and allowed to continue evaluating the patient, obtaining better results with the rest of test and more muscle strength. A good nutritional better status and body composition was a better functionality.

CONCLUSION

In the absence of a consensus of what is the best method of determining the functional capacity of the kidney patient, and to assess all patients, propose to use the test SPPB as screening method, and depending on the result used as the rest of the test to more complete if it is necessary to study.

Influence of dietary protein intake on body composition in chronic kidney disease patients in stages 3-5: A cross-sectional study

INTRODUCTION

A controlled protein intake has shown beneficial effects to preserve renal function and nutritional status in chronic kidney disease (CKD) patients. This study aimed to analyze usual dietary protein intake and its potential contribution to body composition in CKD patients in stages 3-5.

METHOD

Cross-sectional study in 134 CKD patients in stages 3-5 (mean e-GFR: 19.4±8.7ml/min/1.73m²; males 68.7% and primary CKD etiology was diabetes mellitus, 35.8%). Demographic, clinical and nutritional parameters were evaluated. Normalized protein nitrogen appearance (nPNA), was used as a surrogate marker of dietary protein intake. The sample was classified into three nPNA groups (G_n): G₁: <0.8g/kg/day; G₂: 0.8-1g/kg/day and, G₃: ≥1g/kg/day. Assessment of nutritional status using the malnutrition-inflammation score (MIS), anthropometric measures and laboratory parameters. Analysis of body composition and hydration status by bioelectrical impedance analysis (BIVA-101-RJL system). Statistical analysis by SPSS v.20.

RESULTS

Overall mean nPNA values were 0.91±0.23g of protein/kg BW/day and only 32.1% had a dietary protein intake <0.8g of protein/kg BW/day. Most of the CKD patients (65.5%) were in stages 4 or 5. Prevalence of protein-energy-wasting (PEW) syndrome measured by MIS was 15%. By analyzing differences between nPNA groups, body weight (BW), BMI and triceps-skinfold (TSF) thickness were significantly higher in the group with nPNA ≥1g/kg BW/day (G₃), whereas a significant inverse relationship was found with the percentages of body cell mass (BCM%), fat-free mass (FFM%), muscle mass (MM%) and phase angle (PA) in the group with the lowest nPNA (G₁). Analysis of gender among subjects showed significant differences with BW, FFM%, TSF and mid-arm muscle circumference (MAMC%). Linear regression analysis showed that resistance, BCM%, MM%, and serum albumin were significant predictors of nPNA as a surrogate marker of daily protein intake (R=0.51; R²=0.29; R² adjusted=0.23; p<0.001).

CONCLUSION

Controlled protein intake is one of the cornerstones of treatment in CKD patients. A low protein intake in patients with CKD stages 3 and 4-5 was associated with loss of muscle mass in the advanced-CKD unit. The loss of muscle mass appears as an early indicator of nutritional comprised. Factors such, elderly age and loss of eGFR, showed lower protein intake and were associated with muscle loss, especially in women. Further longitudinal studies are required to evaluate the contribution of different protein intakes to uremic symptoms, nutritional status, body composition and CKD progression.

Asymmetric cellulose triacetate is a safe and effective alternative for online haemodiafiltration

BACKGROUND

In post-dilution haemodiafiltration only synthetic membranes have been used to date. Asymmetric cellulose triacetate (ATA™) is now available, whose characteristics are suitable for this technique.

OBJECTIVES

To describe the in vivo performance and behaviour of this membrane, to identify its depurative effectiveness, use in clinical practice and its biocompatibility, both acute and after one month of treatment.

METHODS

Observational prospective study of 23 patients who were dialysed for 4 weeks using an ATA™ membrane and who maintained their prior regimen.

RESULTS

A total of 287 sessions were performed and 264 complete sessions were collected. With an effective time of 243.7 (17.6) min and a mean blood flow of 371.7 (23) ml/min, an average Kt of 56.3 (5.3) l was observed, as well as a convection volume of 27.1 (4.2) l, a filtration fraction of 29.9 (3.7) %, a urea reduction ratio (RR) of 81 (5.2) %, a creatinine RR of 74.7 (4.6) %, a β₂-microglobulin RR of 76.5 (4.8) % and a retinol binding protein RR of 18.6 (7.6) %. There were no technical problems or alarms. Changing the heparin dosage was not necessary. No increases in C3a or C5a concentrations or leukopenia were observed in the first 30min of the session. Neither the monocyte subpopulations nor IL-β1 or IL-6 were significantly altered after one month of treatment.

CONCLUSIONS

The new ATA™ membrane achieves adequate Kt and convection volume, without technical problems and with good biocompatibility and inflammatory profiles. It is therefore a valid option for post-dilution haemodiafiltration, particularly in patients allergic to synthetic membranes.

Vascular calcification in patients with nondialysis CKD over 3 years

BACKGROUND AND OBJECTIVES

Vascular calcification (VC) is common in CKD, but little is known about its prognostic effect on patients with nondialysis CKD. The prevalence of VC and its ability to predict death, time to hospitalization, and renal progression were assessed.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The Study of Mineral and Bone Disorders in CKD in Spain is a prospective, observational, 3-year follow-up study of 742 patients with nondialysis CKD stages 3-5 from 39 centers in Spain from April to May 2009. VC was assessed using Adragao (AS; x-ray pelvis and hands) and Kauppila (KS; x-ray lateral lumbar spine) scores from 572 and 568 patients, respectively. The primary end point was death. Secondary outcomes were hospital admissions and appearance of a combined renal end point (beginning of dialysis or drop >30% in eGFR). Factors related to VC were assessed by logistic regression analysis. Survival analysis was assessed by Cox proportional models.

RESULTS

VC was present in 79% of patients and prominent in 47% (AS≥3 or KS>6). Age (odds ratio [OR], 1.05; 95% confidence interval [95% CI], 1.02 to 1.07; P<0.001), phosphorous (OR, 1.68; 95% CI, 1.28 to 2.20; P<0.001), and diabetes (OR, 2.11; 95% CI, 1.32 to 3.35; P=0.002) were independently related to AS≥3. After a median follow-up of 35 months (interquartile range=17-36), there were 70 deaths (10%). After multivariate adjustment for age, smoking, diabetes, comorbidity, renal function, and level of phosphorous, AS≥3 but not KS>6 was independently associated with all-cause (hazard ratio [HR], 2.07; 95% CI, 1.07 to 4.01; P=0.03) and cardiovascular (HR, 3.46; 95% CI, 1.27 to 9.45; P=0.02) mortality as well as a shorter hospitalization event-free period (HR, 1.14; 95% CI, 1.06 to 1.22; P<0.001). VC did not predict renal progression.

CONCLUSIONS

VC is highly prevalent in patients with CKD. VC assessment using AS independently predicts death and time to hospitalization. Therefore, it could be a useful index to identify patients with CKD at high risk of death and morbidity as previously reported in patients on dialysis.

[Executive summary of the recommendations on the evaluation and management of renal disease in human immunodeficiency virus-infected patients]

The aim of this article is to update the 2010 recommendations on the evaluation and management of renal disease in human immunodeficiency virus (HIV)-infected patients. Renal function should be monitored in all HIV-infected patients. The basic renal work-up should include measurements of serum creatinine, estimated glomerular filtration rate by CKD-EPI, urine protein-to-creatinine ratio, and urinary sediment. Tubular function tests should include determination of serum phosphate levels and urine dipstick for glycosuria. In the absence of abnormal values, renal screening should be performed annually. In patients treated with tenofovir, or with risk factors for chronic kidney disease (CKD), more frequent renal screening is recommended. In order to prevent disease progression, potentially nephrotoxic antiretroviral drugs are not recommended in patients with CKD or risk factors for CKD. The document provides indications for renal biopsy and advises on the optimal time for referral of a patient to the nephrologist. The indications for and evaluation and management of dialysis and renal transplantation are also addressed.

Renal tubular transporter-mediated interactions of HIV drugs: implications for patient management

Interactions of drugs with renal transporters can reduce the tubular secretion of endogenous products and affect drug pharmacokinetics, efficacy, and toxicity. This review aims to understand the clinical implications of renal transporter-mediated interactions of HIV drugs. These interactions have been fully investigated for nucleoside/nucleotide reverse transcriptase inhibitors, particularly tenofovir disoproxil fumarate, and for some of the newer agents, such as rilpivirine, dolutegravir, and cobicistat. Interactions may include competition, inhibition, or induction of transporters, and interference with renal active secretion of creatinine, the most commonly used marker of renal function. Drug-drug interactions may result in an increased risk of drug toxicity. This interaction is more likely to occur with the protease inhibitors, particularly ritonavir, due to the inhibitory effects of these drugs on specific transporters involved in renal excretion of other drugs. Interactions with the transport of creatinine have been identified with rilpivirine, dolutegravir, and cobicistat. While rilpivirine and dolutegravir inhibit mainly the renal transporter OCT2 in the basolateral membrane of the proximal tubular cell, cobicistat predominantly inhibits the renal transporter MATE1 in the luminal membrane. These interactions can cause mild-to-moderate increases in serum creatinine concentrations and moderate reductions in estimated glomerular filtration rate that do not translate into real decreases in glomerular filtration. To use these drugs safely, clinicians must correctly interpret changes upon initiation of therapy to differentiate these spurious elevations in serum creatinine from clinically significant toxicity. In this article we propose a set of recommendations for clinical use of antiretroviral drugs that interfere with creatinine renal transporters.

Conicity index as a contributor marker of inflammation in haemodialysis patients

INTRODUCTION

Abdominal fat mass is an important risk factor of inflammation in the general population as it is in haemodialysis (HD) patients. The aim of this study was to investigate the association of adiposity using the conicity index (Ci) with nutritional-inflammatory markers and to analyse whether these factors were related with the clinical outcome in HD patients.

METHODS

A cross-sectional study in 80 HD patients (men, 65%; aged 68.2 ± 14.2) was carried out. Abdominal fat deposition was evaluated by Ci median with regard to baseline inflammatory, anthropomorphic, and nutritional markers. Linear regression analysis was applied to identify whether serum C-reactive protein (CRP), as an inflammatory biomarker, was an independent predictor of Ci in HD patients.

RESULTS

Mean Ci was significantly greater in men (p = 0.001). Significant positive correlations were observed between Ci and serum triglycerides (r = 0.23; p < 0.05) and Ln of serum CRP (r = 0.27; p < 0.01). A significantly higher median Ci (men ≥ 1.39 and women ≥ 1.33) was observed in inflammated overweight patients by multivariate analysis (p < 0.05). Serum CRP, as an inflammatory biomarker, was a significant predictor (p = 0.021) of Ci, but its predictive value disappeared after median Ci adjustment of linear regression analysis.

CONCLUSION

Abdominal fat mass, measured by Ci, appears directly linked to inflammation in dialysis. Results support the hypothesis that inflammation in HD patients has pleiotropic effects depending on abdominal body adiposity.

A clinical approach to the nutritional care process in protein-energy wasting hemodialysis patients

INTRODUCTION

Malnutrition/wasting/cachexia are complex-disease conditions that frequently remain undiagnosed and/or untreated in up to 75% of prevalent hemodialysis (HD) patients. The nutrition care process (NCP) based on assessment, diagnosis, intervention and monitoring of nutritional status is a systematic method that nutrition professionals use to make decisions in clinical practice.

OBJECTIVE

This review examines from a clinical-nutritional practice point of view: a) nutritional status as a mortality causative factor; b) phenotypic characteristics of malnutrition/wasting/cachexia, and c) current trends of NCP with special emphasis on nutritional support and novel nutrient and pharmacologic adjunctive therapies in HD patients.

METHOD

A literature review was conducted using the Pubmed, Science Direct, Scielo, Scopus, and Medline electronic scientific basis. Studies which assessing nutritional status and nutritional support published from 1990 to 2013 in HD patients were included and discussed.

RESULTS

From all the epidemiological data analyzed, NCP was the suggested method for identifying malnutrition/ wasting or cachexia in clinical practice. Nutrition support as an unimodal therapy was not completely able to reverse wasting in HD patients. Novel experimental therapeutic strategies including the use of appetite stimulants, ghrelin agonist, MC4-R antagonists, anabolic steroids, anti-inflammatory drugs, cholecalciferol, and other components are still under clinical evaluation.

CONCLUSION

Nutritional status is a strong predictor of morbidity and mortality in HD patients. The terms called malnutrition, wasting and cachexia have different nutritional therapeutics implications. The NCP is a necessary tool for assessing and monitoring nutritional status in the current clinical practice. Novel pharmacological therapies or specific nutrient supplementation interventions studies are required.

Endogenous testosterone, muscle strength, and fat-free mass in men with chronic kidney disease

OBJECTIVE

Testosterone deficiency is a common finding in men with chronic kidney disease (CKD). Testosterone is thought to play an important anabolic role in muscle synthesis, and muscle wasting is an important and deleterious characteristic of protein-energy wasting (PEW) in CKD. It is presently unknown if reduced endogenous testosterone associates with features of muscle wasting in men with CKD.

METHODS

This was a cross-sectional observational study of 267 men with CKD stages 2-4 (mean ± standard deviation age 67 ± 13 years, estimated glomerular filtration rate 42.9 [interquartile range 30.2-56.7] mL/min/1.73 m²) with measurements of endogenous testosterone and surrogates of PEW such as albumin, prealbumin, high-sensitivity C-reactive protein (CRP) and normalized protein nitrogen appearance (nPNA). Fat-free mass was estimated by bioelectrical impedance vector analysis (BIVA) and muscle strength by handgrip dynamometry.

RESULTS

Across decreasing thirds of testosterone distribution, patients were incrementally older and CRP levels rose significantly. Prealbumin, hemoglobin, nPNA, handgrip strength, and BIVA estimated surrogates of muscle mass and nutritional status (fat-free mass, body cell mass, and phase angle) were progressively reduced (P < .05 for all). In multivariate regression analyses including age, renal function, and other important confounders, testosterone significantly and independently contributed to explain the variances of handgrip strength and fat-free mass (P < .05 for all).

CONCLUSIONS

Endogenous testosterone independently associates with muscle strength and fat-free mass in men with moderate CKD. It is plausible that the reduction in testosterone levels that accompanies CKD may further contribute to the procatabolic environment leading to muscle wasting.