Mechanisms of hypoalbuminemia in hemodialysis patients

Pre-Transplant Hypoalbuminemia Is Not Associated With Early Key Outcomes Among Simultaneous Pancreas and Kidney Transplant Recipients

The role of pre-transplant hypoalbuminemia and its impact on post-transplant outcomes in patients undergoing simultaneous pancreas-kidney (SPK) transplantation remains unclear. We analyzed all SPK recipients at our center, who had at least 2 weeks of pancreas and kidney graft survival and had serum albumin measured within 45 days pre-transplant. Recipients were categorized based on pretransplant albumin level as normal (≥4.0 g/dL, N = 222, 42%), mild hypoalbuminemia (≥3.5-<4.0 g/dL, N = 190, 36%), and moderate hypoalbuminemia (<3.5 g/dL, N = 120, 23%). Kidney delayed graft function (DGF), length of stay (LOS) after transplant, re-hospitalization within 30 days after discharge, and need for a return to the operating room (OR) related to transplant surgical complications, acute rejection, and uncensored and death-censored graft failure, within the first years post-transplant were outcomes of interest. A total of 532 SPK recipients were included. Mild or moderate hypoalbuminemia was not associated with DGF, LOS, re-hospitalization, or return to the OR in unadjusted or adjusted analyses. Similarly, mild or moderate hypoalbuminemia was not associated with a risk of graft rejection or graft failure. Among SPK recipients, pre-transplant hypoalbuminemia was not associated with worse outcomes and should not be the determining factor in selecting patients for SPK transplant.

Effects of Replacing Intradialytic Parenteral Nutrition by Oral Nutritional Supplements and Polyester-Polyarylate Membrane on Nutritional Status in Maintenance Hemodialysis Patients with End-Stage Kidney Disease

Introduction

In patients receiving hemodialysis, protein-energy wasting may be frequent and is associated with nutritional and metabolic alterations. This study aimed to describe the effects of a new therapeutic strategy, i.e., oral nutritional supplements (ONS) associated with a polyester-polyarylate (PEPA) membrane, on nutritional markers in high-risk patients with intradialytic parenteral nutrition (IDPN) history.

Methods

Patients, who received individually IDPN (M-6 to M0) then ONS (M0 to M6), were followed over a 12-month period.

Results

There was no change in serum albumin over time. The BMI increased between M-6 and M6. Food intake showed increase between M0 and M3. Quality-of-life score was stable between M0 and M6. None of the adverse events was judged related to ONS, PEPA, or research procedure.

Conclusion

This study focusing on a new therapeutic strategy composed of ONS and PEPA membrane replacing IDPN to maintain nutritional markers in high-risk patients receiving hemodialysis might warrant further research with robust methodology.

Application of deep learning to predict the low serum albumin in new hemodialysis patients

BACKGROUND

Serum albumin level is a crucial nutritional indicator for patients on dialysis. Approximately one-third of patients on hemodialysis (HD) have protein malnutrition. Therefore, the serum albumin level of patients on HD is strongly correlated with mortality.

METHODS

In study, the data sets were obtained from the longitudinal electronic health records of the largest HD center in Taiwan from July 2011 to December 2015, included 1,567 new patients on HD who met the inclusion criteria. Multivariate logistic regression was performed to evaluate the association of clinical factors with low serum albumin, and the grasshopper optimization algorithm (GOA) was used for feature selection. The quantile g-computation method was used to calculate the weight ratio of each factor. Machine learning and deep learning (DL) methods were used to predict the low serum albumin. The area under the curve (AUC) and accuracy were calculated to determine the model performance.

RESULTS

Age, gender, hypertension, hemoglobin, iron, ferritin, sodium, potassium, calcium, creatinine, alkaline phosphatase, and triglyceride levels were significantly associated with low serum albumin. The AUC and accuracy of the GOA quantile g-computation weight model combined with the Bi-LSTM method were 98% and 95%, respectively.

CONCLUSION

The GOA method was able to rapidly identify the optimal combination of factors associated with serum albumin in patients on HD, and the quantile g-computation with DL methods could determine the most effective GOA quantile g-computation weight prediction model. The serum albumin status of patients on HD can be predicted by the proposed model and accordingly provide patients with better a prognostic care and treatment.

Oxygen Extraction and Mortality in Patients Undergoing Chronic Haemodialysis Treatment: A Multicentre Study

Patients on haemodialysis (HD) suffer a high mortality rate linked to developing subclinical hypoxic parenchymal stress during HD sessions. The oxygen extraction ratio (OER), an estimate of the oxygen claimed by peripheral tissues, might represent a new prognostic factor in HD patients. This study evaluated whether the intradialytic change in OER (ΔOER) identified patients with higher mortality risks. We enrolled chronic HD patients with permanent central venous catheters with available central venous oxygen saturation (ScvO2) measurements; the arterial oxygen saturation was measured with peripheral oximeters (SpO2). We measured OER before and after HD at enrolment; deaths were recorded during two-years of follow-up. In 101 patients (age: 72.9 ± 13.6 years, HD vintage: 9.6 ± 16.6 years), 44 deaths were recorded during 11.6 ± 7.5 months of follow-up. Patients were divided into two groups according to a 40% ΔOER threshold (ΔOER < 40%, n = 56; ΔOER ≥ 40%, n = 45). The ΔOER ≥ 40% group showed a higher incidence of death (60% vs. 30%; p = 0.005). The survival curve (log-rank-test: p = 0.0001) and multivariate analysis (p = 0.0002) confirmed a ΔOER ≥ 40% as a mortality risk factor. This study showed the intradialytic ΔOER ≥ 40% was a mortality risk factor able to highlight critical hypoxic damage. Using a ΔOER ≥ 40% could be clinically applicable to characterise the most fragile patients.

Clinical significance of hemodialysis quality of care indicators in very elderly patients with end stage kidney disease

INTRODUCTION

Improvement in life expectancy has increased the number of very elderly patients undergoing hemodialysis. However, it is not clear which quality measures for hemodialysis should be employed in this population. Therefore, in this paper we investigated the association between major adverse cardiovascular and cerebrovascular events (MACCE) indicators of hemodialysis quality in very elderly patients. PATIENTS AND METHODS: Data regarding a total of 29,692 patients undergoing maintenance hemodialysis (median age 61 years, 41.5% females) who participated in a national hemodialysis quality assessment program were analyzed. They were divided into < 80 years and ≥ 80 years age groups. The primary and secondary outcomes were MACCE and all-cause mortality, respectively. The association between the outcomes and some of the most widely used standard hemodialysis quality-of-care indicators, including spKt/V, hemoglobin, serum calcium, serum phosphate, and albumin levels, was evaluated. To explore the association between Cox proportional hazard models were constructed. Model 1 was adjusted for age and sex. Model 2 included additional demographic characteristics, such as Charlson Comorbidity Index (excluding diabetes), diabetes, cause of ESKD, dialysis vintage, BMI, and pre-dialysis systolic blood pressure. Model 3 was further adjusted for the main medications. To evaluate the relationship between MACCE risk and quality assessment indicators as a continuous variable, cubic spline analyses were conducted.

RESULTS

During a median follow-up of 3.7 years, MACCE occurred at a higher rate in the ≥ 80-years group than in the < 80-years group (282.0 vs. 110.1 events/1000 person-years). Multivariate Cox regression analysis revealed that spKt/V, serum calcium and phosphate, and hemoglobin levels were associated with MACCE and all-cause mortality risk in patients aged < 80 years. However, these indicators showed no significant relationship with MACCE and all-cause mortality in patients aged ≥ 80 years. Low serum albumin levels were significantly associated with increased MACCE and all-cause mortality risks, regardless of age.

CONCLUSION

In conclusion, hemodialysis quality-of-care indicators including spKt/V, serum calcium and phosphate levels, and hemoglobin were not related to MACCE or all-cause mortality in very elderly hemodialysis patients. However, lower serum albumin levels were associated with poor outcomes, regardless of patient age. Assuring nutritional status rather than improving hemodialysis management adequacy may be more beneficial for improving outcomes in very elderly hemodialysis patients. Further prospective evaluations are needed to confirm these findings.

The Correlation of Interleukin-6, Malnutrition Inflammation Score and Asymmetric Dimethylarginine in Chronic Kidney Disease Patients Undergoing Routine Hemodialysis

Introduction: Chronic kidney disease (CKD) patients undergoing routine hemodialysis (HD) have a high prevalence of protein-energy malnutrition (PEM) and inflammation. The combination of inflammation and PEM is associated with cardiovascular disease and poor outcomes. Interleukin-6 (IL-6) is an inflammatory factor that runs parallel to endothelial damage and is closely related to the nutritional status of CKD HD patients. The tool to assess nutrition status is Malnutrition Inflammation Score (MIS) and to assess endothelial damage is Asymmetric Dimethylarginine (ADMA). It is currently unclear whether there is a correlation between inflammation, malnutrition, and endothelial dysfunction. Therefore the aim of this study is to determine the correlation between IL-6, MIS and ADMA in CKD HD patients.  Methods: A cross-sectional design with analytic observational study was conducted on end stage renal disease patient who undergo routine hemodialysis for at least 2 years with the duration of hemodialysis is 4-5 hours and at least twice per week. IL-6 was examined by kit (ELISA) and ADMA using LC-MS/MS at a certified laboratory in Manado city. History taking and physical examination were used to calculate MIS. Data analysis was done using SPSS version 22. Results: There were 30 participants consisting of 22 men (72%) and 8 women (28%). The median age of the subjects was 56.50 years. There was a statistically significant positive correlation between IL-6 and ADMA (r = 0.440, p = 0.015), MIS and ADMA (r = 0.378, p = 0.039), and IL-6 and MIS (r = 0.682, p = 0.0001). Conclusion: There was a significant correlation between IL-6, MIS and ADMA.

Prevalence of sarcopenia and associated factors in patients in hemodialysis

Objective: To assess the prevalence of sarcopenia and associated factors in patients with chronic kidney disease (CKD) undergoing hemodialysis (HD). Methods: This cross-sectional study evaluated patients with CKD undergoing HD from January to October 2016 in two dialysis centers located in Recife, Pernambuco. For the diagnosis of sarcopenia, the criteria proposed by the 2019 European Consensus on Sarcopenia, which advocates low muscle strength as the main criterion, were considered. Demographic, clinical, anthropometric, and behavioral covariates were evaluated. Results: 108 patients were included, with a mean age of 51.4 ± 17.0 years and homogeneous distribution between the sexes.Sarcopenia was present in 38.9% of the population, of which 69% had severe sarcopenia. A higher prevalence of sarcopenia was observed among men (60% vs. 17%; p < 0.001), in those without a partner (48.1% vs. 30.4%; p < 0.045), in smokers (50% vs. 30%; p < 0.034), with low weight (underweight 73.3%, eutrophic 33.9%, overweight 32.4%; p = 0.001) and those with normal albumin levels (47.5% vs. 28.6%; p = 0.045). Conclusion: Approximately one in three nephropathic patients on hemodialysis presented sarcopenia and, among these, most had the severe form of this condition.Uremic sarcopenia was more prevalent in males, in individuals without partners, underweight, in smokers, and among those with normal albumin levels.

Clinical relevance of abstruse transport phenomena in haemodialysis

Haemodialysis (HD) utilizes the bidirectional properties of semipermeable membranes to remove uraemic toxins from blood while simultaneously replenishing electrolytes and buffers to correct metabolic acidosis. However, the nonspecific size-dependent transport across membranes also means that certain useful plasma constituents may be removed from the patient (together with uraemic toxins), or toxic compounds, e.g. endotoxin fragments, may accompany electrolytes and buffers of the dialysis fluids into blood and elicit severe biological reactions. We describe the mechanisms and implications of these undesirable transport processes that are inherent to all HD therapies and propose approaches to mitigate the effects of such transport. We focus particularly on two undesirable events that are considered to adversely affect HD therapy and possibly impact patient outcomes. Firstly, we describe how loss of albumin (and other essential substances) can occur while striving to eliminate larger uraemic toxins during HD and why hypoalbuminemia is a clinical condition to contend with. Secondly, we describe the origins and mode of transport of biologically active substances (from dialysis fluids with bacterial contamination) into the blood compartment and biological reactions they elicit. Endotoxin fragments activate various proinflammatory pathways to increase the underlying inflammation associated with chronic kidney disease. Both phenomena involve the physical as well as chemical properties of membranes that must be selected judiciously to balance the benefits with potential risks patients may encounter, in both the short and long term.

Slipping Through the Pores: Hypoalbuminemia and Albumin Loss During Hemodialysis

Hypoalbuminemia results when compensatory mechanisms are unable to keep pace with derangements in catabolism/loss and/or decreased synthesis of albumin. Across many disease states, including chronic kidney disease (CKD), hypoalbuminemia is a well-established, independent risk factor for adverse outcomes, including mortality. In the setting of CKD, reduced serum albumin concentrations are often a manifestation of protein-energy wasting, a state of metabolic and nutritional alterations resulting in reduced protein and energy stores. The progression of CKD to kidney failure and the initiation of maintenance hemodialysis (HD) further predisposes an already at-risk population toward hypoalbuminemia such that approximately 60% of HD patients have albumin concentrations <4.0 g/dl. Albumin loss into the dialysate through the dialyzer appears to be a potentially modifiable cause of hypoalbuminemia in some patients. A group of newer dialyzers for maintenance HD-sometimes termed protein-leaking or medium cut-off membranes-aim to improve clearance of middle molecules (vs high flux dialyzers) but are associated with increased albumin losses. In this article, we will examine the impact of dialyzer selection on albumin losses during conventional HD, including the clinical relevance of such losses on serum albumin levels. Data on the clinical relevance of albumin losses during dialysis and current gaps in the evidence base are also discussed.

Intravascular albumin loss is strongly associated with plasma volume withdrawal in dialysis patients

INTRODUCTION

Low circulating albumin closely predicts mortality in end-stage renal disease (ESRD) patients. The cause(s) of hypoalbuminemia (hALB) in ESRD patients remains to be elucidated. The aim of the present study was to determine the role of plasma volume (PV) withdrawal in the reduction of total circulating albumin and essential blood solutes induced by hemodialysis (HD).

METHODS

PV determined with high-precision automated carbon monoxide-rebreathing, total circulating as well as concentration of plasma albumin and electrolytes were assessed prior to and after 4-hour HD in 10 ESRD patients.

FINDINGS

Baseline PV ranged from 3.5 to 6.2 l. After HD, PV was decreased by 689 ± 566 mL (-16%) (P = 0.004). Total circulating albumin was largely reduced after HD (170.8 ± 35.1 vs. 146.1 ± 48.9 g, P = 0.008), while albumin concentration was unaltered. According to a strong linear relationship (r = 0.91, P < 0.001), one-third of total circulating albumin is lost from the intravascular compartment for every liter of PV removed. Similar results were found regarding Na⁺ and Ca²⁺ electrolytes.

DISCUSSION

Total circulating albumin, but not albumin concentration, is substantially reduced by HD in proportion to the amount of PV removed from the circulation. This study highlights the potential contributing role of PV withdrawal to hALB in ESRD patients.

Short- and Long-Term Outcome of Chronic Dialyzed Patients Admitted to the ICU and Assessment of Prognosis Factors: Results of a 6-Year Cohort Study

OBJECTIVES

Data about end-stage kidney disease patients admitted to the ICU are scarce, dated, and mostly limited to short-term survival. The aim of this study was to assess the short- and long-term outcome and to determine the prognostic factors for end-stage kidney disease patients admitted to the ICU.

DESIGN

Prospective observational study.

SETTING

Medical ICUs in two university hospitals.

PATIENTS

Consecutive end-stage kidney disease patients admitted in two ICUs between 2012 and 2017.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

Renal replacement therapy variables, demographic, clinical, and biological data were collected. The requirement of mechanical ventilation and vasopressive drugs were also collected. In-ICU and one-year mortality were estimated and all data were analyzed in order to identify predictive factors of short and long-term mortality. A total of 140 patients were included, representing 1.7% of total admissions over the study period. Septic shock was the main reason for admission mostly of pulmonary origin. Median Simplified Acute Physiology Score II and Sequential Organ Failure Assessment score were at 63 and 6.7, respectively. In-ICU, hospital, and 1-year mortality were 41.4%, 46.4%, and 63%, respectively. ICU mortality was significantly higher as compared with ICU control group non-end-stage kidney disease (25% vs 41.4%; p = 0.005). By multivariate analysis, the short-term outcome was significantly associated with nonrenal Sequential Organ Failure Assessment score, and with the requirement of mechanical ventilation or/and vasoconstrictive agents during ICU stay. One-year mortality was associated with increased dialysis duration (> 3 yr) and phosphatemia (> 2.5 mmol/L), with lower albuminemia (< 30 g/L) and nonrenal Sequential Organ Failure Assessment greater than 8.

CONCLUSIONS

End-stage kidney disease patients presented frequently severe complications requiring critical care that induced significant short- and long-term mortality. ICU and hospital mortality depended mainly on the severity of the critical event reflected by Sequential Organ Failure Assessment score and the need of mechanical ventilation and/or catecholamines. One-year mortality was associated with both albuminemia and phosphatemia and with prior duration of chronic dialysis treatment, and with organ failure at ICU admission.

Hypoalbuminemia: a price worth paying for improved dialytic removal of middle-molecular-weight uremic toxins?

Hemodiafiltration (HDF) increases the removal of middle-molecular-weight uremic toxins and may improve outcomes in patients with end-stage kidney disease (ESKD), but it requires complex equipment and comes with risks associated with infusion of large volumes of substitution solution. New high-flux hemodialysis membranes with improved diffusive permeability profiles do not have these limitations and offer an attractive alternative to HDF. However, both strategies are associated with increased albumin loss into the dialysate, raising concerns about the potential for decreased serum albumin concentrations that have been associated with poor outcomes in ESKD. Many factors can contribute to hypoalbuminemia in ESKD, including protein energy wasting, inflammation, volume expansion, renal loss and loss into the dialysate; of these factors, loss into the dialysate is not necessarily the most important. Furthermore, recent studies suggest that mild hypoalbuminemia per se is not an independent predictor of increased mortality in dialysis patients, but in combination with inflammation it is a poor prognostic sign. Thus, whether hypoalbuminemia predisposes to increased morbidity and mortality may depend on the presence or absence of inflammation. In this review we summarize recent findings on the role of dialysate losses in hypoalbuminemia and the importance of concomitant inflammation on outcomes in patients with ESKD. Based on these findings, we discuss whether hypoalbuminemia may be a price worth paying for increased dialytic removal of middle-molecular-weight uremic toxins.

Nutritional Markers during Peritoneal Dialysis: Data from the 1998 Peritoneal Dialysis Core Indicators Study

Objective

This analysis explores the nutritional status of adult U.S. peritoneal dialysis (PD) patients.

Design

The Peritoneal Dialysis Core Indicators Study is a prospective cross-sectional prevalence survey describing the care provided to a random sample of adult U.S. PD patients.

Methods and Population

Prevalence data were collected from a national random sample of 1381 adult PD patients participating in the United States End Stage Renal Disease (ESRD) program.

Results

The median age of these patients was 55 years, 61% were Caucasian; the leading cause of ESRD was diabetes mellitus. Age, sex, size, peritoneal permeability, dialysis adequacy, and nutritional indices did not differ between patients on continuous ambulatory PD and patients on automated PD. The dialysis prescriptions employed achieved mean weekly Kt/V urea (wKt/V) and creatinine clearance (wCCr) values of 2.22 ± 0.57 and 67.8 ± 22.5 L/1.73 m2/week, respectively. The PD patients were large, with a mean body weight of 77 ± 21 kg and body mass index (BMI) of 27 ± 8.6 kg/m2. The mean serum albumin of these patients was 3.5 ± 0.51 g/dL, and 43% of values fell below the National Kidney Foundation Dialysis Outcomes Quality Initiative's desired range. The PD patients had a normalized protein equivalent of nitrogen appearance (nPNA) of 1.0 ± 0.57 g/kg/day, a normalized creatinine appearance rate (nCAR) of 17 ± 7.3 mg/kg/day, and an estimated lean body mass (%LBM) of 62% ± 18% of body weight. Serum albumin correlated positively with patient size, nCAR, and nPNA, but negatively with age, the presence of diabetes mellitus, female gender, erythropoietin dose, the creatinine dialysate-to-plasma ratio results of peritoneal equilibration testing, and the dialysis portion of the wCCr. The duration of ESRD experience correlated negatively with both serum albumin and patient size, although these relationships were complex.

Conclusion

Peritoneal dialysis patients generally have marginal serum albumin levels, a finding incongruent with alternative measures of nutritional status, such as weight, BMI, and creatinine generation. Serum albumin is reduced in patients with high peritoneal permeability ( i.e., rapid transporters) and, because these patients generally have higher than average wCCr values, serum albumin is inversely correlated with the dialysis component of the wCCr. The presumptive nutritional indicators (BMI, %LBM, nPNA, and serum albumin) provide disparate estimates, varying from 10% to 50% for the prevalence of nutritionally stressed PD patients.

Answers to All Your Questions about Peritoneal Urea Clearance and Nutrit Ion in Capd Patients

In summary, SA and a number of other indices related to nutritional status have been identified as being strongly predictive of outcome in CAPD patients. Evidence connecting these indices to KTN urea, or even to protein intake, remains limited, however. Increased dialytic dose may well increase protein intake, but neither of these parameters have been shown prospectively to raise SA, total body nitrogen, or SGA status on a consistent basis. Studies addressing this issue, however, have been few and small, and more data are required. For now, we will likely continue to deal with malnutrition by attempting to raise small solute clearance and protein intake, but we should be aware that such measures will frequently be unsuccessful, and we must pay attention to other factors, particularly comorbidity.

It is clear from this review that there are many unanswered questions relating to this topic and that, in particular, the effect of prospective increases in the dialytic dose needs to be further elucidated.

Total Lymphocyte Count: A Promising Prognostic Index of Mortality in Patients on CAPD

Objective

In view of the limitations of albumin in peritoneal dialysis (PD), we set out to evaluate whether total lymphocyte counts (TLC) could serve as a better prognostic indicator. We were also interested in how these parameters might differ between PD and hemodialysis (HD) patients.

Design

In a retrospective study, we reviewed 113 charts from our dialysis unit. All laboratory analyses were performed by the Department of Clinical Pathology of the Nassau County Medical Center, using standard procedures. Intact parathyroid hormone (PTH) was sent out to Nichols Laboratories.

Setting

All patients originated from the renal clinic at Nassau County Medical Center, a 612 bed public hospital.

Patients

The 38 PD and 75 HD patients selected had been receiving dialysis for at least 12 months and up to 3 years. The PD patients received either continuous ambulatory and/or cycler PD. For the survivors, the averages of their routine chemical analyses were considered their representative values. For the nonsurvivors, the most recent laboratory values prior to their end point were considered.

Main Outcome Measures

Mortality or apparent malnutrition leading to transfer to HD represented the end points for PD patients. Mortality alone was used as the end point for HD patients.

Results

Within the PD population, serum albumin was not significantly lower in nonsurvivors compared to survivors, while the TLC was significantly lower in nonsurvivors (1277 ± 146/mm3 vs 2249 ± 236/mm3, p = 0.0036). The HD population demonstrated a significant difference in both TLC and serum albumin levels between its two prognostic groups; albumin was the better discriminator. Nonsurvivors had a 20% lower serum albumin than did the survivors (27.0 ± 1.6 g/L vs 34.0 ± 0.5 g/L, p = 0.0001). Patients on PD had a higher TLC than those on HD ( p = 0.0001).

Conclusions

In the HD population, but not in the PD population, both serum albumin and TLC were significantly higher in the group that survived. Serum albumin is a more powerful discriminator of mortality in the HD population, while TLC is a better discriminator of mortality in the PD population. For uncertain reasons, PD patients have a higher TLC than those on HD.

Comparison between DOQI and Canadian Guidelines for Peritoneal Dialysis

The recently published Canadian Society of Nephrology (CSN) Guidelines for Peritoneal Dialysis Adequacy differ in a number of ways from the United States National Kidney Foundation Dialysis Outcomes Quality Initiative (DOQI) guidelines on the same topic. The three main differences are ( 1 ) the CSN targets are the same for continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD), whereas the DOQI targets are higher for APD; ( 2 ) the CSN guidelines have a lower creatinine clearance (CCr) target of 50 L/wk for low and low-average transporters compared to 60 L/wk for high and high-average transporters, but no such distinction is made by DOQI; and ( 3 ) the CSN has set lower limit targets as well as preferred targets for Kt/V and CCr.

Other differences are that the CSN recommendations do not give Kt/V the same primacy over CCr that DOQI does. Also, the CSN recommendations give greater emphasis to the risks associated with high transport status.

This review looks at the reasons for these differences and demonstrates that some are due to information that has become available since the publication of the DOQI guidelines. However, it is emphasized that, when recommendations are predominantly opinion- rather than evidence-based, geographic and economic factors may also account for differences.

Serum C-Reactive Protein: A Predictor of Mortality in Continuous Ambulatory Peritoneal Dialysis Patients

Objective

To evaluate the predictive value of a single baseline serum C-reactive protein (sCRP) as a marker of mortality in continuous ambulatory peritoneal dialysis (CAPD) patients.

Design

A review of prospectively collected data in a 2-year follow-up study.

Setting

Tertiary medical center.

Patients

The study included 106 patients who were stable and had been on CAPD for a minimum of 3 months.

Main Outcome Measures

Patient survival rate was the main outcome measure of this study. Other outcome measures were technique survival rate, peritonitis rate, and hospitalized days. Covariables used in the survival analysis were age, sex, the presence of cardiovascular disease or diabetes mellitus, sCRP, serum albumin, hematocrit, cholesterol, HDL-cholesterol, malnutrition by subjective global assessment (SGA), weekly Kt/V urea, and weekly standardized creatinine clearance (SCCr).

Results

The 2-year patient survival rate was significantly lower in the increased sCRP group than in the normal sCRP group (66.7% vs 94.1%, p = 0.001), although there was no significant difference in technique failure, peritonitis rate, and hospitalized days between the two groups. By Cox proportional hazards analysis, independent predictors of mortality were: cardiovascular disease (relative risk, RR = 8.96, p < 0.005); increased sCRP level (RR = 1.19, p < 0.05); and high hematocrit (RR = 1.18, p < 0.05).

← Conclusion

Serum CRP at enrollment is an independent predictor of 2-year patient survival in CAPD patients.

Randomised trial on clinical performances and biocompatibility of four high-flux hemodialyzers in two mode treatments: hemodialysis vs post dilution hemodiafiltration

This prospective multicenter randomized comparative cross-over trial aimed at evaluating the influence of hemodialysis vs post-dilution hemodiafiltration with high-flux dialyzers in solute clearance and biocompatibility profile. 32 patients were sequentially dialyzed with Leoceed-21HX, Polypure-22S+, Rexsys-27H and VIE-21A. Primary outcome was β2-microglobulin removal. Secondary outcomes were (i) extraction of other uremic solutes (ii) parameters of inflammation and nutrition and (iii) comparative quantification of perdialytic albumin losses (using total ‘TDC’ vs partial ‘PDC’ collection of dialysate). Significant increases in removal rates of β2-microglobulin (84.7 ± 0.8 vs 71.6 ± 0.8 mg/L), myoglobin (65.9 ± 1.3 vs 38.6 ± 1.3 µg/L), free immunoglobulin light chains Kappa (74.9 ± 0.8 vs 55.6 ± 0.8 mg/L), β-trace protein (54.8 ± 1.3 vs 26.8 ± 1.4 mg/L) and orosomucoid (11.0 ± 1.1 vs 6.0 ± 1.1 g/L) but not myostatin (14.8 ± 1.5 vs 13.0 ± 1.5 ng/mL) were observed in HDF compared to HD when pooling all dialyzers. Rexsys and VIE-A use in both HD and HDF subgroups was associated to a better removal of middle/large-size molecules compared to Leoceed and Polypure, except β2-microglobulin for Rexsys. Inflammatory parameters were unchanged between dialyzers without any interaction with dialysis modality. Mean dialysate albumin loss was comparable between TDC and PDC (1.855 vs 1.826 g/session for TDC and PDC respectively). In addition, a significant difference in albumin loss was observed between dialyzers with the highest value (4.5 g/session) observed using Rexsys. Use of all dialyzers was associated with good removals of the large spectrum of uremic toxins tested and good biocompatibility profiles, with an additional gain in removal performances with HDF. Larger surface area, thinner wall and resultant very high ultrafiltration coefficient of Rexsys should be taken into account in its clear performance advantages.

Membrane innovation: closer to native kidneys

Modern methods in analytical biochemistry have established that uraemia is associated with the retention of proteins, both in their native state and post-translationally modified, over a wide range of molecular weights up to 60 kDa. Evidence is accumulating that these higher molecular weight retention solutes are important uraemic toxins, and therapies such as online haemodiafiltration (HDF), which enhance their removal, are associated with improved outcomes. However, HDF has limitations regarding cost, clinical implementation and the need for an external source of sterile substitution solution to maintain fluid balance. New membranes that have a solute removal profile more closely approaching that of the glomerular filtration barrier when used for conventional haemodialysis, while at the same time not allowing the passage of clinically significant amounts of beneficial proteins, are needed to address these limitations. Tighter control of the molecular characteristics of the polymers used for membrane fabrication, along with the introduction of additives and improvements in the manufacturing process, has led to membranes with a tighter pore size distribution that allows the use of an increased absolute pore size without leaking substantial amounts of albumin. At the same time, the wall thickness and internal diameter of membrane fibres have been decreased, enhancing convective transport within the dialyser without the need for an external source of substitution solution. These new expanded range membranes provide a solute removal profile more like that of the native kidney than currently available membranes when used in conventional haemodialysis.

Albumin handling in different hemodialysis modalities

Hypoalbuminemia is a major risk factor for morbidity and mortality in dialysis patients. With increasing interest in highly permeable membranes and convective therapies to improve removal of middle molecules, transmembrane albumin loss increases accordingly. Currently, the acceptable upper limit of albumin loss for extracorporeal renal replacement therapies is unknown. In theory, any additional albumin loss should be minimized because it may contribute to hypoalbuminemia and adversely affect the patient's prognosis. However, hypoalbuminemia-associated mortality may be a consequence of inflammation and malnutrition, rather than low albumin levels per se. The purpose of this review is to give an overview of albumin handling with different extracorporeal renal replacement strategies. We conclude that the acceptable upper limit of dialysis-related albumin loss remains unknown. Whether enhanced middle molecule removal outweighs the potential adverse effects of increased albumin loss with novel highly permeable membranes and convective therapies is yet to be determined.

Theoretical overview of clinical and pharmacological aspects of the use of etelcalcetide in diabetic patients undergoing hemodialysis

Etelcalcetide is the first intravenous calcimimetic agent authorized for the treatment of secondary hyperparathyroidism (sHPT) in patients undergoing hemodialysis in Europe, the US, and Japan. The relationship between sHPT and diabetes resides on complex, bidirectional effects and largely unknown homeostatic mechanisms. Although 30% or more patients with end-stage renal disease are diabetics and about the same percentage of those patients suffer from sHPT associated with hemodialysis, no data on the specificities of the use of etelcalcetide in such patients are available yet. Regarding pharmacokinetic interactions, etelcalcetide may compete with oral hypoglycemics recommended for use in patients undergoing hemodialysis and insulins detemir and degludec, causing unexpected hypocalcemia or hypoglycemia. More importantly, hypocalcemia, a common side effect of etelcalcetide, may cause decompensation of preexisting cardiac insufficiency in diabetic patients or worsen dialysis-related hypotension and lead to hypotension-related cardiac events, such as myocardial ischemia. In diabetic patients, hypocalcemia may lead to dangerous ventricular arrhythmias, as both insulin-related hypoglycemia and hemodialysis prolong QT interval. Patients with diabetes, therefore, should be strictly monitored for hypocalcemia and associated effects. Due to an altered parathormone activity in this patient group, plasma calcium should be the preferred indicator of etelcalcetide effects. Until more clinical experience with etelcalcetide is available, the clinicians should be cautious when using this calcimimetic in patients with diabetes.

Effect of Adequacy of Dialysis and Nutrition on Morbidity and Working Rehabilitation of Patients Treated by Maintenance Hemodialysis

Numerous studies have demonstrated a correlation between adequacy of hemodialysis (HD) and patient mortality. In this study we evaluated the effect of adequacy of dialysis and nutrition on morbidity and working rehabilitation. Single center experience carried out in 1998 in an outpatient university-affiliated dialysis facility was presented. A total of 181 patients, on HD over 3 months, was included in the study; mean age 54.5 years, mean duration of HD 5.4 years. Thirthy-two patients were hospitalized in 1998. Patients with an eKt/V < 0.8 had significantly more frequent and extended hospitalizations than patients with eKt/V > 1.2. In the regression model eKt/V had a significant effect on hospital days. Serum albumin, as an index of nutrition, was also found to significantly influence hospitalizations. Patients with a BMI < 20.0 kg/m2 were found to have significantly more frequent hospitalizations, more hospital days/patient, and hospital days/hospitalized patient/year than those with a BMI > 25.0 kg/m2. BMI < 20.0 kg/m2 was associated with a significantly lower dialysis adequacy (eKt/V and URR) and more severe anemia. However, regression model failed to confirm a statistically significant association of BMI with hospital days. The best working rehabilitation (stage 1), according to the EDTA criteria, was obtained in patients with significantly (p<0.05) higher eKt/V, URR, albumin, nPNA, and body fat than in patients at stage 6 (not able to work, and not able to take care of themselves).

This study has established that dialysis adequacy and nutrition have an effect on morbidity (estimated through hospitalizations) and patient rehabilitation. (Int J Artif Organs 2000; 23: 83–9)

Precise Quantitative Assessment of the Clinical Performances of Two High-Flux Polysulfone Hemodialyzers in Hemodialysis: Validation of a Blood-Based Simple Kinetic Model Versus Direct Dialysis Quantification

Highly permeable dialysis membranes with better design filters have contributed to improved solute removal and dialysis efficacy. However, solute membrane permeability needs to be well controlled to avoid increased loss of albumin that is considered to be detrimental for dialysis patients. A novel high-flux dialyzer type (FX CorDiax; Fresenius Medical Care) incorporating an advanced polysulfone membrane modified with nano-controlled spinning technology to enhance the elimination of a broader spectrum of uremic toxins has been released. The aim of this study was to compare in the clinical setting two dialyzer types having the same surface area, the current (FX dialyzer) and the new dialyzer generation (FX CorDiax), with respect to solute removal capacity over a broad spectrum of markers, including assessment of albumin loss based on a direct dialysis quantification method. We performed a crossover study following an A1-B-A2 design involving 10 patients. Phase A1 was 1 week of thrice-weekly bicarbonate hemodialysis with the FX dialyzer, 4 h per treatment; phase B was performed with a similar treatment regimen but with a new FX CorDiax dialyzer and finally the phase A2 was repeated with FX dialyzer as the former phase. Solute removal markers of interest were assessed from blood samples taken before and after treatment and from total spent dialysate collection (direct dialysis quantification) permitting a mass transfer calculation (mg/session into total spent dialysate/ultrafiltrate). On the blood side, there were no significant differences in the solute percent reduction between FX CorDiax 80 and FX 80. On the dialysate side, no difference was observed regarding eliminated mass of different solutes including β₂ -microglobulin (143.1 ± 33.6 vs. 138.3 ± 41.9 mg, P = 0.8), while the solute mass removal of total protein (1.65 ± 0.51 vs. 2.14 ± 0.75 g, P = 0.04), and albumin (0.41 ± 0.21 vs. 1.22 ± 0.51 g, P < 0.001) were significantly less for FX CorDiax 80 compared to the FX 80 dialyzer. The results of this cross-over study indicate that the new FX CorDiax dialyzer has highly effective removal of middle molecules, without any concomitant increase in total protein and albumin loss. The clinical relevance and potential benefit of this finding needs to be determined.

A novel mathematical model of protein-bound uremic toxin kinetics during hemodialysis

Protein-bound uremic toxins (PBUTs) are difficult to remove by conventional hemodialysis; a high degree of protein binding reduces the free fraction of toxins and decreases their diffusion across dialyzer membranes. Mechanistic understanding of PBUT kinetics can open new avenues to improve their dialytic removal. We developed a comprehensive model of PBUT kinetics that comprises: (1) a three-compartment patient model, (2) a dialyzer model. The model accounts for dynamic equilibrium between protein, toxin, and the protein-toxin complex. Calibrated and validated using clinical and experimental data from the literature, the model predicts key aspects of PBUT kinetics, including the free and bound concentration profiles for PBUTs and the effects of dialysate flow rate and dialyzer size on PBUT removal. Model simulations suggest that an increase in dialysate flow rate improves the reduction ratio (and removal) of strongly protein-bound toxins, namely, indoxyl sulfate and p-cresyl sulfate, while for weakly bound toxins, namely, indole-3-acetic acid and p-cresyl glucuronide, an increase in blood flow rate is advantageous. With improved dialyzer performance, removal of strongly bound PBUTs improves gradually, but marginally. The proposed model can be used for optimizing the dialysis regimen and for in silico testing of novel approaches to enhance removal of PBUTs.

Impact of nutritional index on the association between phosphorus concentrations and mortality in haemodialysis patients: a cohort study from dialysis outcomes and practice pattern study in Japan

OBJECTIVES

While maintenance of both phosphorus concentration and nutritional status is a major concern in managing haemodialysis patients, the interaction between these parameters is not well understood. The aim of this study was to assess whether or not nutritional index influences the association between phosphorus concentration and all-cause mortality.

DESIGN

A cohort study.

SETTING

The Dialysis Outcomes and Practice Pattern Study, which included 99 representative dialysis facilities in Japan between 1997 and 2010.

PARTICIPANTS

A total of 6230 adult haemodialysis patients who had spent at least 6 months on haemodialysis.

MAIN PREDICTORS

Six categories based on time-averaged factors of the geriatric nutritional risk index (GNRI; the lowest two and highest tertiles) and phosphorus concentration (<3.5, 3.5 to <6 and ≥6 mg/dL).

PRIMARY OUTCOME MEASURE

All-cause mortality rate.

ANALYSIS

Time-dependent Cox regression adjusting for potential confounders.

RESULTS

During the follow-up period (12 294 person-years), we noted 561 deaths (4.6 per 100 person-years), and both high phosphorus concentrations and low-middle GNRI were separately associated with all-cause mortality. The harmful effect of high phosphorus concentrations on all-cause mortality was stronger in patients with high GNRI than in those with low-middle GNRI. On the other hand, the harmful effect of low phosphorus concentrations was stronger in those with low-middle GNRI than in those with high GNRI. Relative excess risk due to interaction (RERI) between high phosphorus concentrations and low-middle GNRI was -0.57, indicating an antagonistic interaction. We also observed a significant statistical multiplicative interaction between phosphorus concentrations and GNRI (p=0.05 by likelihood ratio test).

CONCLUSIONS

The association between time-averaged serum phosphorus concentration and all-cause mortality differs across the nutritional index. Accordingly, nutritional index should be considered when the impact of phosphorus concentration on mortality in haemodialysis patients is evaluated.

Nutritional Status Predicts 10-Year Mortality in Patients with End-Stage Renal Disease on Hemodialysis

Protein-energy wasting (PEW) is associated with mortality in patients with end-stage renal disease (ESRD) on maintenance hemodialysis. The correct diagnosis of PEW is extremely important in order to predict clinical outcomes. However, it is unclear which parameters should be used to diagnose PEW. Therefore, this retrospective observational study investigated the relationship between mortality and nutritional parameters in ESRD patients on maintenance hemodialysis. A total of 144 patients were enrolled. Nutritional parameters, including body mass index, serum albumin, dietary intake, normalized protein catabolic rate (nPCR), and malnutrition inflammation score (MIS), were measured at baseline. Fifty-three patients died during the study. Survivors had significantly higher nPCR (1.10 ± 0.24 g/kg/day vs. 1.01 ± 0.21 g/kg/day; p = 0.048), energy intake (26.7 ± 5.8 kcal/kg vs. 24.3 ± 4.2 kcal/kg; p = 0.009) and protein intake (0.91 ± 0.21 g/kg vs. 0.82 ± 0.24 g/kg; p = 0.020), and lower MIS (5.2 ± 2.3 vs. 6.1 ± 2.1, p = 0.039). In multivariable analysis, energy intake <25 kcal/kg (HR 1.860, 95% CI 1.018–3.399; p = 0.044) and MIS > 5 (HR 2.146, 95% CI 1.173–3.928; p = 0.013) were independent variables associated with all-cause mortality. These results suggest that higher MIS and lower energy intake are harmful to ESRD patients on maintenance hemodialysis. Optimal energy intake could reduce mortality in these patients.

Clinical features, long-term clinical outcomes, and prognostic factors of tuberculous meningitis in West China: a multivariate analysis of 154 adults

BACKGROUND

Tuberculosis is prevalent in China, which is the second greatest contributor to the global tuberculosis burden. Tuberculosis meningitis (TBM) is the most severe disease form but few reports describe long-term clinical outcomes and prognostic factors. Thus, we studied these features in Chinese TBM patients.

METHODS

A retrospective follow-up study was used to collect clinical features and outcomes of adult TB meningitis at the First Affiliated Hospital of Chongqing Medical University from June 2012 to August 2015. Univariate analysis and multivariate analysis were used to identify predictive factors associated with outcomes at discharge and follow-up.

RESULTS

TBM patients (N = 154) were a median age of 41 years (range: 16-82 years). Median time to follow-up was 26.4 months (range: 9.3-46.5 months) and 31% had poor outcomes at follow-up and limb weakness (p = 0.016), lower GCS scores (p < 0.001), cranial-nerve palsy (p = 0.024), and hydrocephalus (p = 0.009) were closely associated with these poor outcomes. Furthermore, a high neutrophil to lymphocytes ratio, high D-dimer, a low albumin to globulin ratio and slow background of EEG associated with poor outcomes as well.

CONCLUSIONS

Mortality and disability associated with TBM are high in China. Limb weakness, GCS scores, cranial-nerve palsy and hydrocephalus were independent predictors of poor outcomes, and AGR, NLR, D-dimer, and EEG abnormalities may be prognostic factors of TBM.

Protein and Energy Depletion in Chronic Hemodialysis Patients: Clinical Applicability of Diagnostic Tools

Protein and energy depletion states are common and associated with increased morbidity and mortality in chronic hemodialysis (CHD) patients. Therefore, proper use of diagnostic tools to assess depleted states in CHD patients is critical. Assessment of protein and energy status can be done by an array of methodologies that include simple estimates of the visceral and somatic pools of protein to more refined techniques to measure protein and energy balance. The nutritional and metabolic derangements in the CHD population are highly complex and can be confounded by multiple comorbidities and fluid shifts between body compartments. Therefore, assessment of protein and energy status in CHD patients requires a wide range of methodologies that not only identify depleted states but also monitor nutrition therapy and predict clinical outcome. Most important, these methods require cautious and individualized interpretation in order to minimize the interference of comorbid conditions frequently observed in the CHD population. Currently, there is not a single method that can be considered the gold standard for assessment of protein and energy status in CHD patients. Therefore, a combination of methods is recommended. In this review, we describe available methods to assess protein and energy status, with special considerations pertaining to CHD patients.

Association of a high normalized protein catabolic rate and low serum albumin level with carpal tunnel syndrome in hemodialysis patients

Carpal tunnel syndrome (CTS) is the most common mononeuropathy in patients with end-stage renal disease (ESRD). The association between chronic inflammation and CTS in hemodialysis (HD) patients has rarely been investigated. HD patients with a high normalized protein catabolic rate (nPCR) and low serum albumin level likely have adequate nutrition and inflammation. In this study, we assume that a low serum albumin level and high nPCR is associated with CTS in HD patients. We recruited 866 maintenance hemodialysis (MHD) patients and divided them into 4 groups according to their nPCR and serum albumin levels: (1) nPCR <1.2 g/kg/d and serum albumin level <4 g/dL; (2) nPCR ≥1.2 g/kg/d and serum albumin level <4 g/dL; (3) nPCR <1.2 g/kg/d and serum albumin level ≥4 g/dL; and (4) nPCR ≥1.2 g/kg/d and serum albumin level ≥4 g/dL. After adjustment for related variables, HD duration and nPCR ≥1.2 g/kg/d and serum albumin level <4 g/dL were positively correlated with CTS. By calculating the area under the receiver-operating characteristic curve, we calculated that the nPCR and HD duration cut-off points for obtaining the most favorable Youden index were 1.29 g/kg/d and 7.5 years, respectively. Advance multivariate logistic regression analysis revealed that in MHD patients, nPCR ≥1.29 g/kg/d and serum albumin <4 g/dL, and also HD duration >7.5 years were associated with CTS. A high nPCR and low serum albumin level, which likely reflect adequate nutrition and inflammation, were associated with CTS in MHD patients.

Exploring Problems in Following the Hemodialysis Diet and Their Relation to Energy and Nutrient Intakes: The BalanceWise Study

OBJECTIVE

To identify the problems experienced by hemodialysis (HD) patients in attempting to follow the HD diet and their relation to energy and nutrient intakes.

DESIGN

Cross-sectional analysis of baseline data from the BalanceWise Study.

SUBJECTS

Participants included community-dwelling adults recruited from outpatient HD centers. After excluding participants with incomplete dietary analyses (n = 50), 140 African American and white (40/60%) men and women (52/48%) on chronic intermittent HD for at least 3 months (median 3 years) were included.

INTERVENTION

Participant responses, on a 5-point Likert scale ranging from "not at all a problem" to "a very important problem for me," to 34 questions pertaining to potential barriers to following the HD diet in the previous 2 months were classified as either a problem (1) or not a problem (2-5).

MAIN OUTCOME MEASURE

Energy and nutrient intakes determined using the Nutrition Data System for Research® based on 3, non-consecutive, unscheduled, 2-pass 24-hour dietary recalls collected on 1 dialysis and 1 non-dialysis weekday, and 1 non-dialysis weekend day.

RESULTS

More than half of participants reported having problems related to specific behavioral factors (e.g., feeling deprived), technical difficulties (e.g., tracking nutrients), and physical condition (e.g., appetite), but issues of time and food preparation and behavioral factors tended to be most deterministic of reported dietary intakes. Longer duration of HD was associated with lower intakes of protein, potassium, and phosphorus (P < .05).

CONCLUSION

Registered dietitian nutritionists should consider issues of time and food preparation, and behavioral factors in their nutrition assessment of HD patients and should continually monitor HD patients for changes in protein intake that may occur over time.

Characterization of a Cardiorenal-like Syndrome in Aged Chimpanzees (Pan troglodytes)

Cardiorenal syndrome involves disease and dysfunction of the heart that leads to progressive renal dysfunction. This study investigated the relationship between cardiac and renal disease in 91 aged chimpanzees at the Alamogordo Primate Facility by evaluation of the medical histories, metabolic parameters, functional measurements of the cardiovascular system, clinical pathology, and histopathology focused on the heart and kidney. Cardiac fibrosis was the most frequent microscopic finding in 82 of 91 animals (90%), followed by glomerulosclerosis with tubulointerstitial fibrosis in 63 of 91 (69%). Cardiac fibrosis with attendant glomerulosclerosis and tubulointerstitial fibrosis was observed in 58 of 91 animals (63%); there was a statistically significant association between the 2 conditions. As the severity of cardiac fibrosis increased, there was corresponding increase in severity of glomerulosclerosis with tubulointerstitial fibrosis. Altered metabolic, cardiovascular, and clinical pathology parameters indicative of heart and kidney failure were commonly associated with the moderate to severe microscopic changes, and concurrent heart and kidney failure were considered the cause of death. The constellation of findings in the chimpanzees were similar to cardiorenal syndrome in humans.

Pro-inflammatory cytokines: a possible relationship with dialytic adequacy and serum albumin in peritoneal dialysis patients

Background

Inflammation and serum albumin concentration are both important predictors of survival in patients treated with peritoneal dialysis (PD). Furthermore, systemic and local inflammatory mediators may induce structural and functional alterations in the peritoneal membrane, thus interfering with dialysis adequacy. PD adequacy is monitored primarily by indices of small solute clearance, such as Kt/V urea and weekly creatinine clearance (wCc). The aim of this study was to investigate the possible relationship between pro-inflammatory cytokines, such as interleukin-6 (IL-6) and interleukin-1β (IL-1β), and serum albumin and C-reactive protein (CRP). Moreover, the relationship between IL-6 and IL-1β and PD adequacy has been analysed.

Methods

We enrolled 46 stable PD patients undergoing maintenance PD for a minimum of 3 months. Plasma levels of serum albumin, high-sensitivity (hs)-CRP, IL-6 and IL-1β were measured in all patients. We used weekly Kt/V urea and wCc to monitor PD adequacy. Daily urine volume was measured in all patients.

Results

The median values of serum albumin, hs-CRP, IL-6 and IL-1β showed no significant differences between continuous ambulatory PD and automated PD patients. IL-6 levels showed a positive correlation with hs-CRP levels (P < 0.001) and a negative correlation with serum albumin concentration (P = 0.01). There was no statistically significant relationship between IL-1β and hs-CRP or serum albumin concentrations. Subsequently, PD patients were divided into two groups based on Kt/V urea value. PD patients with Kt/V ≤1.7 had significantly higher IL-6 levels compared with PD patients with Kt/V >1.7 (P = 0.015). No statistically significant relationship between IL-6 and wCc was observed. There was no significant difference in IL-1β levels between PD patients with Kt/V ≤1.7 and with Kt/V >1.7 [median (interquartile range) 0.82 (0.88–5.2) versus 1.82 (0.95–2.7)]. There was no significant difference in IL-6 and IL-1β levels in PD patients with and without residual diuresis (P = 0.32 and P = 0.77, respectively).

Conclusion

Our data suggest a possible relationship between serum IL-6 levels and serum albumin and hs-CRP in PD patients. Furthermore, IL-6 seems to be higher in patients with lower Kt/V, thus suggesting a possible use of this inflammatory biomarker in PD adequacy monitoring.

A cohort study of insulin-like growth factor 1 and mortality in haemodialysis patients

Background

Protein-energy wasting (PEW) is highly prevalent in haemodialysis (HD) patients and associated with increased mortality and cardiovascular disease (CVD). Insulin-like growth factor 1 (IGF-1) correlates to markers of PEW and CVD. Disturbances in the growth hormone axis in end-stage renal disease (ESRD) could have an impact on survival through increased PEW and CVD.

Methods

A cohort of 265 incident HD patients (median age 68 years, 59% males) was followed for 3 years. Subjects were categorized according to IGF-1 levels at dialysis initiation. Outcome and comorbidity data were retrieved from national registers. The Kaplan–Meier diagram and Cox proportional hazards model were used for the analysis of survival.

Results

Patients with IGF-1 levels in the lowest tertile were characterized by female sex, low creatinine, hypoalbuminemia and high C-reactive protein (CRP) levels. IGF-1 levels within the lowest tertile were associated with increased mortality [hazard ratio (HR) 2.4, 95% confidence interval (CI) 1.7–3.4]. This association persisted when corrected for demographic factors (age, sex) and comorbidities (diabetes mellitus, CVD, heart failure) in multivariable analysis. Including high-sensitivity C-reactive protein (hs-CRP) and serum creatinine in the model had a small effect on the magnitude of the hazard. When serum albumin was added to the model, the HR declined from 2.2 to 1.6, but remained significant (P = 0.02).

Conclusion

Low IGF-1 levels associate with increased mortality in HD, independent of biomarkers of inflammation (hs-CRP) and PEW (creatinine, albumin). Serum albumin modulates the relationship between IGF-1 levels and mortality, indicating shared pathophysiological pathways with IGF-1.

Comparison of Nutrition Profile and Diet Record Between Veteran and Nonveteran End-Stage Renal Disease Patients Receiving Hemodialysis in Veterans Affairs and Community Clinics in Metropolitan South-Central Texas

BACKGROUND

U.S. military veterans have high rates of chronic disease and social disadvantage, which are risk factors for protein-energy wasting (PEW). It is not known whether this translates into high prevalence of PEW in veterans with end-stage renal disease.

METHODS

We compared the clinical, socioeconomic, and nutrition status and the diet of 33 veteran and 38 nonveteran clinically stable patients receiving maintenance hemodialysis (MHD) in south-central Texas.

RESULTS

The whole cohort included 82% Mexican Americans (MAs), 72% type 2 diabetics, and 73% males. The body mass index was 28.9 ± 6.2, while energy intake was 21.5 ± 8.2 kcal/kg/d and protein intake was 1.0 ± 0.4 g/kg/d. Serum albumin (bromocresol purple) was 3.5 ± 0.4 g/dL, transferrin was 171.9 ± 27.8 mg/d, C-reactive protein was 2.9 (1.4-6.5) mg/L, interleukin-6 (IL-6) was 8.3 (4.2-17.9) pg/mL, neutrophil gelatinase-associated lipocalin was 729 (552-1256) ng/mL, and the malnutrition-inflammation score was 8.8 ± 3.0. In group comparison that adjusted for sex and ethnicity, the veterans had better household income, less MAs (60% vs 100%), more males (94% vs 55%), more use of a renin-angiotensin-aldosterone system blockade (66% vs 33%), and lower IL-6 levels (4.4 [3.1-5.8] vs 15.4 [8.3-20.5] pg/mL; P = .01) than nonveterans. In regression analysis, the lower serum IL-6 level in veterans was independently explained by dialysis clinic, sex, and, possibly, household income (intermediate significance).

CONCLUSION

In a relatively small cohort of clinically stable MHD patients, the veterans showed equivalent nutrition status and dietary intake and less inflammation than the nonveterans, thus not supporting the possibility that veteran MHD patients may have worse nutrition than the nonveteran counterpart.

Relation between the serum albumin level and nutrition supply in patients with pressure ulcers: retrospective study in an acute care setting

This retrospective study examined the validity of the commonly used serum albumin level as an indicator of nutrition status of patients with pressure ulcer(s), particularly because the serum albumin level is affected by various factors and may not be specific to malnutrition. Specifically, we investigated whether nutrition supply or inflammation affects the serum albumin level in 82 patients with pressure ulcers(s) (29 in whom pressure ulcer was present upon admission and 53 in whom pressure ulcer developed after hospital admission). Serum albumin levels, blood test including C-reactive protein (CRP) levels and blood count, caloric intake, and depth and healing of pressure ulcers were compared between various subgroups of patients. Serum albumin levels correlated with red blood cell counts and hemoglobin and CRP levels but not with caloric intake. The correlation with CRP before and after several weeks of pressure ulcer treatment was negative. The serum albumin level upon admission was higher in patients in whom the ulcer healed than in those in whom it did not heal as well as in patients who were discharged than in those who died in the hospital. The serum albumin level appears to reflect inflammation, wound healing, and disease severity rather than nutrition supply in patients with pressure ulcer. J. Med. Invest. 61: 15-21, February, 2014.

Nutritional status of patients on maintenance hemodialysis in urban sub-Saharan Africa: evidence from Cameroon

BACKGROUND

Malnutrition is an important predictive factor for morbidity and mortality in patients on maintenance dialysis. The evidence on the magnitude of the problem in sub-Saharan Africa is scanty. We assessed the nutritional status of patients on maintenance hemodialysis in the renal unit of the Douala General Hospital (Cameroon).

METHODS

Patients on maintenance hemodialysis for ≥3 months were enrolled between March and June 2012. Nutritional status was assessed via dietary recalls, anthropometric, and biochemical measurements including body mass index (BMI), triceps skinfold thickness, mid-arm circumference, mid-arm muscle circumference (MAMC), serum albumin, C-reactive protein (CRP) and hemoglobin, calcium, phosphorus, and vitamin D.

RESULTS

A total of 113 patients (75 men) were included. They were aged 49.4 years, and had been on dialysis for a median of 25 months. The mean BMI, MAMC and serum albumin was 22.4 kg/m(2), 23.7 cm and 42.4 g/l respectively. We observed that 28.3 % of patients were underweight (BMI ≤20 kg/m(2)), 23.9 % had muscle wasting (MAMC < adequacy to 50th percentile), and 31.6 % had low serum albumin (≤40 g/dl), while 21 % of patients had a combination of the three abnormalities. Prevalence rates for other indicators of under-nutrition were 26.3 % (low plasma cholesterol), 28 % (positive CRP) and 82.7 % (anemia). Female gender, younger age, less meals/day and frequent vegetable intake were associated with malnutrition risk.

CONCLUSIONS

Patients on maintenance hemodialysis in this setting have rates of malnutrition similar to those reported elsewhere. However, the high prevalence of malnutrition among women and young patients deserves further consideration.

A prospective study: inflammation, infection and comorbidity in patients on long-term dialysis

BACKGROUND

The goal of this study was to identify inflammatory and infectious markers and their roles in mortality.

METHODS

We enrolled 111 patients on haemodialysis (HD) and collected data at three time points (baseline, 33 and 76 months).

RESULTS

Rates of Chlamydophila pneumoniae IgG, CRP ≥3 mg/l, ESR >50 mm/hour and fibrinogen >4 g/l were, respectively, 63.1%, 60.4%, 48.6% and 42.3%. Mortality was 21.6% and 43.2% at 33 and 76 months where 58.3% of all deaths were cardiocerebrovascular (CCV) related. Non-survivors were older than survivors. Univariate analysis showed diabetes mellitus (DM) and cerebrovascular accident (CVA) as important for the 33-month all-cause mortality, and CRPlog , fibrinogen, ESR >50 mm/hour, cardiovascular disease (CVD) and DM for the 76-month all-cause mortality. CVA was meaningful for the 33-month CCV mortality, and CVD, DM and ESR >50 mm/hour for the 76-month CCV mortality. Kaplan-Meier revealed poorer survival for patients with ESR >50 mm/hour at 76 months. Cox regression showed CVD, CVA and age as mortality predictors.

CONCLUSION

Age, CVD and CVA are predictors for mortality in patients on HD patients, but the presence of C. pneumoniae IgG and inflammation are not.

Validation of Mini Nutritional Assessment Scale in peritoneal dialysis patients

INTRODUCTION

Malnutrition is a negative predictive factor for survival in end stage renal disease (ESRD) patients. Coincidence of malnutrition, inflammation and atherosclerosis (MIA syndrome) in the dialysis population is an exceptionally poor outcome event. Due to flexibility, ease of performance and reproducibility, clinical scales are of particular value in assessment of nutritional status in ESRD patients. The aim of the present study was to evaluate the clinical value of Mini Nutritional Assessment (MNA) in peritoneal dialysis (PD) patients.

MATERIAL AND METHODS

Nutritional status was assessed in 41 peritoneal dialysis patients by means of the MNA scale and malnutrition inflammation score (MIS). Some other clinical and laboratory parameters associated with nutritional status were analyzed. Patients were followed up for 30 months.

RESULTS

In the analyzed group of patients a good nutritional state was diagnosed in 22 patients (54%), risk of malnutrition in 17 (41%) and malnutrition in 2 patients (5%) based on the MNA scale. A strong correlation between MNA based nutritional status and MIS was found (r = -0.85, p < 0.01, ANOVA, p < 0.01). Differences in time on dialysis, body mass index, concentration of albumin, cholesterol and triglycerides were noted between at risk/malnourished and well-nourished (according to MNA) patients. Statistically significant factors determining survival of patients by Cox proportional hazard analysis were age (HR 1.07), being at risk/malnourished according to MNA (HR 5.7), MIS (HR 1.2), and albumin (HR 0.13).

CONCLUSIONS

The MNA scale is a valuable, clinically suitable tool for assessment of nutritional status in peritoneal dialysis patients. Risk of malnutrition and malnutrition diagnosed by MNA identifies patients at high mortality risk.

Value of the pretreatment albumin to globulin ratio in predicting long-term mortality in breast cancer patients

BACKGROUND

Prior studies have demonstrated the prognostic value of pretreatment serum albumin in different types of cancer. The aim of this study was to assess the predictive value of the albumin to globulin ratio (AGR) on survival in breast cancer patients.

METHODS

This retrospective study used an unselected cohort of 354 breast cancer patients who had documented total protein and albumin levels prior to chemotherapy. Survival status was obtained from our cancer registry. Survival analysis, stratified by AGR tertiles, was used to evaluate the prognostic value of AGR.

RESULTS

Patients in the highest AGR tertiles (AGR > 1.45) had a lower 5-year mortality rate compared with those in the middle (AGR 1.21 to 1.45) and the lowest (AGR < 1.21) tertiles (6% vs. 18% and 32%, P < .001). After adjusting for confounding variables, AGR remained a significant predictor of mortality (P < .002). Moreover, after excluding the patients with albumin levels less than 3.6, the AGR remained a significant predictor of survival (P .0018).

CONCLUSIONS

Pretreatment AGR is an independent, significant predictor of long-term mortality in breast cancer patients, even in patients with normal albumin levels.

Treatment of cachexia: melanocortin and ghrelin interventions

Cachexia is a condition typified by wasting of fat and LBM caused by anorexia and further endocrinological modulation of energy stores. Diseases known to cause cachectic symptoms include cancer, chronic kidney disease, and chronic heart failure; these conditions are associated with increased levels of proinflammatory cytokines and increased resting energy expenditure. Early studies have suggested the central melanocortin system as one of the main mediators of the symptoms of cachexia. Pharmacological and genetic antagonism of these pathways attenuates cachectic symptoms in laboratory models; effects have yet to be studied in humans. In addition, ghrelin, an endogenous orexigenic hormone with receptors on melanocortinergic neurons, has been shown to ameliorate symptoms of cachexia, at least in part, by an increase in appetite via melanocortin modulation, in addition to its anticatabolic and anti-inflammatory effects. These effects of ghrelin have been confirmed in multiple types of cachexia in both laboratory and human studies, suggesting a positive future for cachexia treatments.

Relative contributions of inflammation and inadequate protein intake to hypoalbuminemia in patients on maintenance hemodialysis

PURPOSE

Serum albumin is one of the strongest mortality predictors in maintenance hemodialysis (MHD) patients. Yet, the degree to which serum albumin represents dietary protein intake or an inflammatory state, among others, is not clear. We hypothesize that these inadequate protein intake and inflammation contribute somewhat equally to hypoalbuminemia.

METHODS

In a cross-sectional analysis, we examined correlates of low serum albumin, <3.8 g/dL, in 812 MHD patients in whom interleukin-6 (IL-6) and normalized protein nitrogen appearance (nPNA), also known as normalized protein catabolic rate (nPCR), were also measured. Logistic regression estimated odds ratios were employed, and spline models were plotted to examine the likelihood of relatively low serum albumin <3.8 g/dL.

RESULTS

Mean age (±SD) of patients was 54 ± 15 years; 53 % of patients were men, 50 % Hispanic, 31 % African-American, and 55 % diabetic. The mean dialysis vintage was 31 ± 34 months (median: 19, inter-quartile range: 7-44 months). The baseline serum albumin, averaged over a 3-month period (mean ± SD), was 3.88 ± 0.38 g/mL. The unadjusted correlation coefficients of l IL-6 and nPNA with serum albumin were -0.36 and +0.20, respectively (p < 0.001 for each comparison). The likelihood for an albumin <3.8 gr/dL increased linearly with decreasing nPNA and rising serum IL-6. This trend was steeper with increasing serum IL-6 up to a concentration of 30 ng/mL.

CONCLUSIONS

Both low protein intakes and a high state of inflammation are associated with low serum albumin in MHD patients.