Nutrition in patients on peritoneal dialysis

Dietary energy intake predicts mortality in Chinese patients with peritoneal dialysis: a single-center 18 years' follow-up study

BACKGROUND

Lower dietary energy intake (DEI) may be associated with increased mortality risk. This study aims to analyze the influence of baseline DEI, time average DEI, and other factors on survival in peritoneal dialysis (PD) patients.

METHOD

It was a single-center retrospective cohort study. Patients who started PD from January 2006 to June 2021 were included in this study and followed up until June 2023. Their baseline (six months after the beginning of PD) demographic, dietary intake, laboratory data, and time varying dietary intake data were collected and analyzed. The relationships between these data and survival were examined using Cox model to estimate death hazard ratios.

RESULT

A total of 794 patients were included in this study, 424 males and 370 females, with a mean age of 58.87 ± 16.02 years. Their mean normalize baseline dietary energy intake (nDEI) was 25.46 ± 6.72 kcal/kg/day, time average nDEI was 24.87 ± 4.74 kcal/kg/day. The median follow-up duration was 46.58 (27.38, 78.52) months in the overall cohort. Based on multivariate Cox proportional hazard analysis, age (HR = 1.056, 95% Cl = 1.047-1.065, p < 0.001), diabetes (HR = 1.364, 95% Cl = 1.114-1.671, p = 0.003), serum albumin (HR = 0.945, 95% Cl = 0.923-0.967, p < 0.001), blood sodium (HR = 0.973, 95% Cl = 0.954-0.992, p = 0.002), serum urea (HR = 0.974, 95% Cl = 0.953-0.994, p = 0.025), and baseline nDEI (HR = 0.980, 95% Cl = 0.964-0.996, p = 0.017) were significantly associated with mortality. Baseline DPI, BMI and time average nDEI were not related to PD patients' survival. When classified baseline nDEI into 4 groups (< 25 kcal/kg/day, 25-29.99 kcal/kg/day, 30-34.99 kcal/kg/day, and ≥ 35 kcal/kg/day), the univariate and multivariate Cox proportional hazard analysis showed that the patients with nDEI 30-34.99 kcal/kg/day had the lowest mortality risk (using the DEI < 25 kcal/kg/day group as reference, p < 0.05).

CONCLUSION

Our study revealed that DEI 30-34.99 kcal/kg/day might be beneficial to the long-term outcome for the Chinese PD population.

CLINICAL TRIAL NUMBER

Not applicable.

Association Between Peritoneal Glucose Absorption, Lipid Metabolism, and Cardiovascular Disease Risk in Nondiabetic Patients on Peritoneal Dialysis

BACKGROUND

Excessive sugar intake increases the energy metabolic burden and the risk of cardiovascular disease (CVD). Patients on peritoneal dialysis absorb much more glucose than the World Health Organization recommends, but the link to CVD is unclear.

OBJECTIVE

To identify the association between peritoneal glucose absorption, lipid metabolism, and CVD.

METHODS

We applied generalized additive mixed effects and mixed effects Cox proportional hazard models to evaluate the impact of peritoneal glucose absorption on lipid profiles and CVD risk. We performed subgroup analyses by using protein intake (normalized protein nitrogen appearance [nPNA] and normalized protein catabolic rate [nPCR] were used to assess protein intake) and high-sensitivity C-reactive protein (hs-CRP).

RESULTS

After multivariable adjustment, peritoneal glucose absorption per 10 g/d increase was associated with an increase in cholesterol of 0.145 (95% confidence interval [CI]: 0.086-0.204) mmol/L. No link with the total risk of CVD was observed; however, protein intake and hs-CRP levels affected the relationship between glucose absorption and CVD risk. Patients with values for nPNA and nPCR <1.0 g/(kg·d) were associated with a lower risk of CVD (hazard ratio [HR] 95% CI: 0.68 (0.46-0.98)) with glucose absorption per 10 g/d increase. While patients with hs-CRP levels ≥3 mg/d or values for nPNA or nPCR ≥1.0 g/(kg·d) were associated with a higher risk of CVD (HR 95% CI: 1.32 (1.07-1.63); 1.31 (1.02-1.68)) for glucose absorption per 10 g/d increase.

CONCLUSIONS

Our study found a positive correlation between peritoneal glucose absorption and lipid profiles. Increased glucose absorption was associated with a lower risk of CVD in lower protein intake patients and a higher risk of CVD in higher hs-CRP or protein intake levels in patients on peritoneal dialysis.

Current status and development trends in CKD with frailty research from 2000 to 2021: a bibliometric analysis

INTRODUCTION

The prevalence of chronic kidney disease (CKD) is gradually increasing in the elderly population. At the same time, frailty has become one of the research hotspots in the field of geriatrics. Bibliometric analyses help to understand the direction of a field. Therefore, this study aimed to analyze the status and emerging trends of frailty in CKD patients.

DATA AND METHODS

The Web of Science Core Collection (WoSCC) database was screened for relevant literature published between 1 January 2000 and 31 December 2021. Next, publications were analyzed for information including authors, journals, cited references, citing journals, institutions, countries and regions, high-frequency keywords and co-citations using VOSviewer, Microsoft Excel, and R software.

RESULTS

A total of 2223 articles were obtained, from which 613 relevant articles were selected based on title and abstract screening. There was an upward trend in the number of annual publications and Johansen KL was considered the most contributing author in the field. The Clinical Journal of the American Society of Nephrology was the most productive research journal. Johns Hopkins University is the most published organization. The United States is the global leader in the field and contributes the most to research. Research hotspots focus on epidemiological studies of frailty and frailty intervention.

CONCLUSIONS

This study presents a comprehensive bibliometric analysis of CKD and frailty research. Key findings highlight the current focus on early screening and assessment of frailty in CKD patients, as well as physical function interventions in frail patients.

The neutrophil percentage-to-albumin ratio is an independent risk factor for poor prognosis in peritoneal dialysis patients

AIM

This study aimed to investigate the predictive ability of the neutrophil percentage-to-albumin Ratio (NPAR) concerning all-cause mortality and cardio-cerebrovascular mortality in patients undergoing peritoneal dialysis (PD).

METHODS

We included a total of 807 PD patients from the Peritoneal Dialysis Center of the Second Affiliated Hospital of Soochow University between January 2009 and December 2019 in this study. Patients were categorized into three groups based on their baseline NPAR. The Kaplan-Meier method, multivariate Cox proportional hazard model, and Fine-Gray competing risk model were employed to examine the relationship between NPAR level and all-cause mortality and cardio-cerebrovascular mortality among PD patients. Furthermore, the ROC curve and calibration plots were utilized to compare the performance between NPAR and other conventional indicators.

RESULTS

The mean follow-up period was 38.2 months. A total of 243 (30.1%) patients passed away, with 128 (52.7%) succumbing to cardio-cerebrovascular diseases. The mortality rates of the Middle and High NPAR groups were significantly greater than that of the Low NPAR group (p < 0.001), and NPAR was independently associated with all-cause mortality and cardio-cerebrovascular mortality. Receiver Operating Characteristic (ROC) analysis indicated that the Area Under the Curve (AUC) of NPAR (0.714) was significantly superior to those of C-reactive protein (CRP) (0.597), neutrophil to lymphocyte ratio (NLR) (0.589), C-reactive protein to albumin ratio (CAR) (0.698) and platelet to lymphocyte ratio (PLR) (0.533).

CONCLUSION

NPAR served as an independent predictive marker for all-cause mortality and cardio-cerebrovascular mortality in PD patients. Moreover, NPAR demonstrated superior predictive potential compared to CRP, CAR, NLR, and PLR.

Gut Microbiota in Patients Receiving Dialysis: A Review

The human gut microbiota constitutes a complex community of microorganisms residing within the gastrointestinal tract, encompassing a vast array of species that play crucial roles in health and disease. The disease processes involved in chronic kidney disease (CKD) and end-stage kidney disease (ESKD) are now increasingly established to result in dysregulation of gut microbiota composition and function. Gut microbiota dysbiosis has been associated with poor clinical outcomes and all-cause mortality in patients with ESKD, particularly individuals receiving dialysis. Prior studies highlighted various factors that affect gut microbiota dysbiosis in CKD and ESKD. These include, but are not limited to, uraemic toxin accumulation, chronic inflammation, immune dysfunction, medications, and dietary restrictions and nutritional status. There is a lack of studies at present that focus on the evaluation of gut microbiota dysbiosis in the context of dialysis. Knowledge on gut microbiota changes in this context is important for determining their impact on dialysis-specific and overall outcomes for this patient cohort. More importantly, evaluating gut microbiota composition can provide information into potential targets for therapeutic intervention. Identification of specific microbial signatures may result in further development of personalised treatments to improve patient outcomes and mitigate complications during dialysis. Optimising gut microbiota through various therapeutic approaches, including dietary adjustments, probiotics, prebiotics, medications, and faecal transplantation, have previously demonstrated potential in multiple medical conditions. It remains to be seen whether these therapeutic approaches are effective within the dialysis setting. Our review aims to evaluate evidence relating to alterations in the gut microbiota of patients undergoing dialysis. A growing body of evidence pointing to the complex yet significant relationship which surrounds gut microbiota and kidney health emphasises the importance of gut microbial balance to improve outcomes for individuals receiving dialysis.

The advanced lung cancer inflammation index is associated with mortality in peritoneal dialysis patients

BACKGROUND

There is still a very high morbidity and mortality rate for patients undergoing peritoneal dialysis (PD). The advanced lung cancer inflammation index (ALI) has been demonstrated to be associated with the prognosis in multiple types of cancers. Like in cancer, systemic chronic low-grade inflammation is one of the distinguishing features of PD patients. Therefore, we aimed to investigate the relationships between the ALI and all-cause and cardiovascular disease (CVD) mortality in PD patients.

METHODS

Patients who started PD at Shaoxing People's Hospital between 1 January 2013 and 31 December 2020 (n = 277) were recruited and followed up until 1 July 2023. They were divided into high-ALI group and low-ALI group according to the median of ALI. Kaplan-Meier curves and multivariate Cox regression analyses were used to assess the associations between the ALI and all-cause and CVD mortality. Receiver operating characteristic (ROC) curves were constructed, and the area under the curve (AUC) was calculated to determine the predictive power of the ALI for all- cause and CVD mortality.

RESULTS

During the median follow-up of 40.50 months (interquartile range, 26.42-59.77 months), a total of 55 patients died, 31 of whom died due to CVD. Kaplan-Meier curves revealed that patients in the low-ALI group had significantly lower cumulative and cardiovascular cumulative survival rates than did those in the high-ALI group (all P < 0.001). After we corrected for confounders, the risk of all-cause and CVD mortality was significantly greater in the low-ALI group than in the high-ALI group [hazard ratio (HR) 1.944, 95% confidence interval (CI) 1.068-3.540, P = 0.030, and HR 2.672, 95% CI 1.188-6.009, P = 0.017, respectively]. The predictive value of ALI (AUC = 0.708, 95% CI 0.630-0.786, P < 0.001) for all-cause mortality was superior to albumin (AUC = 0.644, 95% CI 0.556-0.726, P < 0.001), body mass index (AUC = 0.581, 95% CI 0.496-0.659, P = 0.069) and neutrophil-to-lymphocyte ratio (AUC = 0.675, 95% CI 0.596-0.754, P < 0.001).

CONCLUSION

A lower ALI is an independent risk factor for all-cause and cardiovascular mortality in PD patients. The ALI may be an effective indicator for predicting outcomes in PD patients.

Albumin-to-alkaline phosphatase ratio as a novel prognostic indicator in patients undergoing peritoneal dialysis: a propensity score matching analysis

Background

Though the albumin-to-alkaline phosphatase ratio (AAPR) is used as a biomarker in various diseases, little is known about its effect on outcomes after peritoneal dialysis (PD).

Methods

This multicenter retrospective study comprised 357 incident PD patients stratified according to the AAPR. Propensity score matching (PSM) was performed to identify 85 patients for a well-matched comparison of all-cause and cardiovascular mortality. Using Cox regression, we performed univariate and multivariate analyses to investigate the prognostic value of the AAPR and established a Kaplan-Meier curve-predicted nomogram to estimate expected overall survival (OS). We assessed the predictive accuracy using the concordance index (c-index).

Results

We found that the optimal cut-off of the AAPR to predict mortality was 0.36. In the present cohort of patients undergoing PD, a low AAPR strongly correlated with worse OS. In the multivariate analysis, the AAPR was shown to be an independent marker predicting reduced OS both before [hazard ratio (HR) 1.68, 95% confidence interval (CI) 1.08-2.60, P = 0.020] and after PSM (HR 1.96, 95% CI 1.06-3.62, P = 0.020). We also observed significant differences in OS in several subgroups, but not the group of patients with comorbidities. A nomogram was established to predict overall survival, with a c-index for prediction accuracy was 0.71 after PSM.

Conclusion

AAPR has potential as an independent prognostic biomarker in patients undergoing PD.

Association between sarcopenic obesity and mortality in patients on peritoneal dialysis: a prospective cohort study

Background

Whether sarcopenic obesity had unfavorable effect on survival of peritoneal dialysis (PD) patients is unknown. We aimed to investigate the association between sarcopenic obesity and survival in PD patients.

Methods

This was a prospective observational study. Eligible PD patients from November 2016 to December 2017 were enrolled and followed until August 31, 2023. Sarcopenia was defined following the recommendations of the Asian Working Group for Sarcopenia (AWGS) as low appendicular skeletal muscle mass index (ASMI) and handgrip strength (HGS). Obesity was defined using the percentage of body fat (PBF). Survival analysis was conducted using the Kaplan-Meier and log-rank test. The Cox regression and the cumulative incidence competing risk (CICR) analyzes were used to investigate the association between sarcopenic obesity and all-cause mortality.

Results

A total of 223 patients were enrolled with 133 (59.6%) males, a median age of 57.5 (44.6, 65.7) years, a median dialysis vintage of 20.3 (6.4, 57.7) months and 48 (21.5%) who had comorbid diabetes mellitus. Among them, 46 (20.6%) patients were sarcopenic, and 25 (11.2%) patients were diagnosed with sarcopenic obesity. After followed up for 51.6 (25.6, 73.9) months, the Kaplan-Meier curve showed the sarcopenic obesity (log-rank = 13.527, p < 0.001) group had significant lower survival rate compared to the nonsarcopenic non-obesity group. For multivariate analysis, the CICR method showed patients with sarcopenic obesity had significantly higher mortality rate (HR: 2.190, 95% CI: 1.011-4.743, p = 0.047) compared to those with nonsarcopenic non-obesity.

Conclusion

Sarcopenia is not uncommon in PD patients, with a considerable proportion having sarcopenic obesity. There is a significant association between sarcopenic obesity and an increased risk of mortality in PD patients.

Influencing factors of serum magnesium in CKD5 patients: A multicenter study in southern China

INTRODUCTION

Magnesium (Mg) disturbances are related to cardiac, bone, and renal patient mortality. In this study, we compared biochemical markers in hemodialysis (HD) and peritoneal dialysis (PD) patients and explored the influencing factors of serum Mg in stage 5 chronic kidney disease (CKD5) patients.

MATERIAL AND METHODS

All 598 patients with CKD5 from three medical centers in South China were recruited into this prospective cohort study from March 1, 2018, to January 31, 2021. Our study recorded the clinical characteristics and laboratory data of the patients.

RESULTS

Hemodialysis patients (0.99 ± 0.19 mmol/L) had a higher mean serum Mg level than PD patients (0.86 ± 0.20 mmol/L; p < 0.01). Regression analysis showed that only corrected calcium (Ca), phosphate (P), Ca/Mg, Ca × P, albumin (Alb), total protein and creatine (Cr) predicted Mg levels in CKD5 patients (p < 0.01). Ca/Mg predicts hypomagnesemia with 78% sensitivity and 85% specificity in CKD5 patients. The AUC value corresponding to Ca/Mg was 0.88.

CONCLUSIONS

This multicenter study in southern China showed that for all CKD5 patients, corrected Ca and Alb had a significant positive effect on serum Mg, while Ca/Mg had a significant negative effect on serum Mg. In 123 HD patients, Ca × P was positively associated with Mg while Ca/Mg and P were negatively associated with Mg. In 398 PD patients, Ca × P, Alb, and total protein were positively associated with Mg while Ca/Mg and P were negatively associated with Mg. In 77 non-dialysis patients, corrected Ca, Cr, and total protein were positively associated with Mg while Ca/Mg was negatively associated with Mg. Furthermore, Ca/Mg might be another useful technique to monitor blood Mg levels in CKD5 patients.

CLINICAL TRIAL REGISTRATION

ChiCTR1800014557.

Evolving peritoneal dialysis care in Chinese mainland from 2010 to 2020: Comparison data from two surveys

INTRODUCTION

Along with the peritoneal dialysis (PD)-favored policy in China and the implementation of more comprehensive PD management, PD has evolved in Chinese mainland over the last decade. Despite the existence of national registries and several provincial epidemiological descriptive studies, there was almost no national research on the changing trajectory in PD population. A comparison study, based on two national surveys that were 10 years apart, was conducted to reveal the evolvement of PD care in Chinese mainland.

METHODS

Two national surveys have been done respectively in 2010 and 2020 to capture the epidemiological status, application of different modalities, management of perioperative infection, and long-term complications among PD patients.

RESULTS

In the study with 730 participating hospitals (n = 14,912 PD patients) in 2010 and 746 hospitals (n = 101,537) in 2020, prevalent PD patients have increased in the past 10 years with increased numbers of PD patients in both secondary (average 5 ± 16 vs. 43 ± 41, p < 0.01) and tertiary hospitals (32 ± 53 vs. 153 ± 215, p < 0.01). Automated PD has been accessible in 0.4% of all hospitals, only in tertiary centers in 2010 and its application increased to 51% in 2020. PD centers have become more engaged in PD catheter placement, treated properly for the PD-related infection, and carried out the follow-up in compliance with the national protocols.

CONCLUSIONS

Our study indicates that over the past decade, the prevalent PD population has quickly expanded with increased APD availability in Chinese mainland. The management of PD patients has become better conforming to the guidelines and long-term follow-up of patients have remained stable. Further studies are warranted to evaluate whether the rapidly changing paradigm of PD could translate into the socio-economic benefits in the society.

Sex difference in the association among nutrition, muscle mass, and strength in peritoneal dialysis patients

Many peritoneal dialysis (PD) patients are malnourished, which leads to weakening owing to a decrease in muscle mass. However, this straightforward association could differ based on the sex of individuals. Further, studies on the sex-based association among nutrition, muscle mass, and strength would be helpful in choosing optimal interventions to improve the strength of patients on dialysis. The study aimed to assess the association between these three variables using mediation analysis. This retrospective study included prevalent PD patients (n = 199). Mediation analysis was conducted to investigate the effect of the appendicular lean mass (ALM) index on the association between the geriatric nutritional risk index (GNRI) and handgrip strength (HGS). The numbers of PD patients with a low ALM index, low HGS, or low GNRI score were 121 (60.8%), 109 (54.8%), and 70 (35.2%), respectively. The proportion of patients with a low ALM index was lower in females than in males, and those with a low HGS were less in patients without diabetes than that in those with diabetes. Patients ≥ 65 years old had a higher proportion of low ALM index or HGS than those < 65 years old. Low HGS was significantly associated with mortality in both sexes. In males, the HGS was correlated with the GNRI and ALM index; however, in females, partial correlation did not demonstrate an association among the GNRI, ALM index, and HGS. Mediation analysis showed that, in males, the GNRI was associated with HGS, and the association was partially mediated through the ALM index. These data reveal that the ALM index accounts for some, but not all, of the relationship between GNRI and HGS. There is not only a significant relationship between the ALM index and HGS, but also some direct relationship between GNRI and HGS. In females, there was no significant association between the GNRI or ALM index and HGS. These suggest that, for both sexes, nutritional supplementation and exercise should be recommended as the primary intervention for improving strength; however, other interventions for improving muscle quality could be considered as alternatives for maintaining strength in women undergoing PD.

Dynamic serum albumin and outcome of peritoneal dialysis patients: A retrospective study in China

Introduction

Serum albumin levels at a single time point have been shown to predict mortality in peritoneal dialysis (PD) patients. However, we believe that the dynamic change in albumin after PD may be more significant. In this study, we investigated the relationship between dynamic serum albumin and the clinical outcome of patients undergoing continuous ambulatory peritoneal dialysis (CAPD).

Methods

The participants in this study enrolled 586 patients who underwent CAPD at the peritoneal dialysis center of Second Xiangya Hospital in China. We retrospectively reviewed medical records from January 1, 2010, to December 31, 2019. Baseline serum albumin (Alb), time-averaged albumin level (TA-ALB) and serum albumin reach rate (SR: defined as the percentage of serum albumin measurements that reached ≥ 35 g/L) were applied as the predictor variables. All-cause mortality and cardiovascular mortality were used as the outcome variables. Hazard function of all-cause mortality and cardiovascular mortality in the study participants were examined by using Cox proportional hazard regression models.

Results

Age (HR = 1.03, 95% CI 1.00–1.05), cardiovascular disease (HR = 1.80, 95% CI 1.07–3.03) and TA-ALB (HR = 0.92, 95% CI 0.85–0.99) were independent risk factors for all-cause mortality in PD patients. Patients with TA-ALB of <33 g/L (HR = 2.33, 95% CI 1.17–4.62) exhibited a higher risk for all-cause mortality than those with TA-ALB ≥ 36 g/L. Stratified SR showed a similar trend. Patients with a <25% SR exhibited a significantly increased risk for all-cause mortality (HR = 2.72, 95% CI, 1.24–5.96) by fully adjusted analysis. However, neither TA-ALB nor SR were associated with the risk of cardiovascular mortality after adjusted analysis.

Conclusion

This study demonstrated that age, cardiovascular disease, and TA-ALB were independent risk factors for all-cause mortality in PD patients. TA-ALB and SR can better predict the prognosis of PD patients than baseline Alb. Dynamic changes in Alb are more clinically significant than baseline Alb in predicting mortality risk.

Association of Albumin and Globulin with Mortality Risk in Incident Peritoneal Dialysis Patients

Background: Nutrition and inflammation have been implicated in predicting mortality in patients on peritoneal dialysis (PD). Serum albumin and globulin can be regarded for the nutritional and inflammatory status. However, there is lack of data to evaluate the synergistic effect of albumin and globulin on mortality prediction. Methods: In 554 patients initiating PD from January 2001 to July 2016, we divided them into four groups by the combination of two categories of low vs. high albumin and low vs. high globulin. The median values for albumin and globulin were chosen to classify them into low or high groups. Their associations with all-cause and cardiovascular (CV) mortality were examined in Cox regression models adjusted for confounding clinical and laboratory data. Results: Patients, 52.91 ± 15.2 years old and 47.8% men, had a median (interquartile range) value of 3.3 (2.9−3.8) g/dL for albumin and 2.8 (2.5−3.2) g/dL for globulin, respectively. Patients with low albumin and high globulin had the highest all-cause mortality and CV mortality, with adjusted hazard ratios of 3.87 (95% CI 1.83−8.20, p < 0.001) and 5.65 (95% CI 2.23−14.34, p < 0.001), respectively, compared with those with a high albumin and low globulin having the lowest mortality rate. Sensitivity analyses further confirmed this relationship. Conclusions: A patient profile of either low albumin or high globulin is linked to a higher risk for mortality, particularly for a profile of both low albumin and high globulin compared with one without either of them. Further studies are needed to explore the mechanisms underlying this phenomenon and how to improve clinical outcomes in those high-risk patients.

The relationship between the prognostic nutritional index and new-onset pneumonia in peritoneal dialysis patients

Purpose

As an indicator of nutrition and immunity, the prognostic value of the prognostic nutritional index (PNI) has been confirmed in various diseases. However, the relationship between PNI and the incidence of pneumonia in peritoneal dialysis (PD) patients remains unknown. The purpose of this study was to investigate the relationship between PNI and new-onset pneumonia in patients undergoing PD.

Methods

Thousand two hundred and nighty eight patients were enrolled in this multicenter retrospective study from February 1, 2010, to February 28, 2020. A total of 899 patients were included in the final statistical analysis. The patients were stratified into two groups by PNI quartiles. The primary endpoint was a new-onset pneumonia event. Cox regression model analysis was used to explore the association between PNI and the first occurrence of pneumonia.

Results

During a mean follow-up of 41.43 months, 147 patients developed new-onset pneumonia. Kaplan–Meier survival curves showed a significant difference in the incidence of the first presentation of pneumonia between the two groups, that patients in the low PNI group had a higher risk of pneumonia (P = 0.016). By adjusting for demographic parameters, comorbidities, and laboratory indicators, the Cox regression model showed that the high PNI group had less risk compared to the low PNI group (HR 0.479 95% CI 0.297–0.772, P = 0.003). There were no interactions in the subgroups as follows: diabetes, hypertension, age, and sex.

Conclusions

Low PNI levels were independently associated with the first occurrence of pneumonia in PD patients. PNI was an independent predictor of new-onset pneumonia in PD patients.

The impact of amino acid dialysate on anthropometric measures in adult patients on peritoneal dialysis: A systematic review and meta-analysis

BACKGROUND

Glucose-containing dialysate underpins peritoneal dialysis (PD) therapy. However, its use is associated with amino acid loss in the dialysis effluent, a risk factor for protein-energy wasting (PEW) in PD patients. Amino acid-based dialysis solutions (AAD) may ameliorate this loss. However, the evidence of clinical benefit in preventing PEW is unclear. The aim of this review was to assess the effect of AAD versus standard dialysis solutions (STD) on anthropometric measures and serum albumin.

METHODS

Studies up until 30 September 2020 were identified from databases including MEDLINE and Embase, using a prespecified protocol (PROSPERO - CRD42020209581). Studies evaluating adults on PD were included. Data pertaining to muscle mass (primary outcome), other anthropometric measures and serum albumin were extracted. A meta-analysis of the eligible studies was conducted.

RESULTS

A total of 6945 abstracts were reviewed, from which 14 studies (9 randomised and 5 non-randomised) were included. There was no significant difference in any of the anthropometric measures, between AAD and STD during follow-up. Serum albumin at 6 months was statistically lower with AAD compared to STD [mean difference = -0.89 (95%CI -1.77 to -0.01, p = 0.046)]. The quality of evidence was graded low for each outcome.

CONCLUSIONS

AAD may not alter anthropometric measures when compared to STD. The impact on serum albumin is uncertain, with an estimated difference that is unlikely to be of clinical value. These findings should be cautiously interpreted due to low quality of the evidence. Robust studies are needed to address the limitations in evidence.

Association Between Phase Angle and Sarcopenia in Patients Undergoing Peritoneal Dialysis

Introduction: There is limited data on the association between phase angle (PhA) and sarcopenia using both muscle strength and muscle mass in patients undergoing peritoneal dialysis (PD). We aimed to evaluate the association between PhA and sarcopenia in patients undergoing PD.

Methods: We enrolled prevalent patients undergoing PD (n = 200). The patients were divided into tertiles based on their PhA level: low (n = 66; 1.9–4°), middle (n = 68; 4.1–4.9°), and high tertiles (n = 66; 5–8°). PhA was measured by a bioimpedance analysis. Handgrip strength (HGS) was measured in all the patients. Body compositions were measured by dual energy x-ray absorptiometry (DXA).

Results: Handgrip strength (HGS) and/or lean mass indices showed poorer trends in the low tertile than in the other tertiles. PhA was positively associated with HGS and/or muscle mass index. Multivariate analyses showed that the patients in the low tertile had an odds ratio of 9.8 (p = 0.001) and 52.79 (p < 0.001) for developing sarcopenia compared with those in the middle and high tertiles, respectively. Subgroup analyses using these variables yielded results similar to those from the total cohort.

Conclusion: This study demonstrated that PhA is independently associated with muscle mass, strength, and sarcopenia in patients undergoing PD. This result suggests that PhA can be used as a valuable and simple predictor for identifying patients undergoing PD who are at risk of sarcopenia.

Nutritional predictors associated with malnutrition in continuous ambulatory peritoneal dialysis patients

BACKGROUND

Currently in China, out of the total dialysis population, approximately 20% represents continuous ambulatory peritoneal dialysis (CAPD) and almost half of CAPD patients was affected by malnutrition. This study aimed to investigate the association between nutritional predictors and malnutrition with 5.1 years of dialysis according to the subjective global assessment (SGA) in continuous ambulatory peritoneal dialysis (CAPD) patients.

METHODS

A cross-sectional study was conducted from April 2013 to May 2018 and included 70 CAPD patients. The relationship between anthropometric and biochemical parameters with malnutrition was assessed by multiple logistic regression analysis.

RESULTS

The prevalence of malnutrition in CAPD patients was 52.9%. Our result revealed a 7.05-fold increased odds of malnutrition for patients with protein equivalent of total nitrogen appearance normalized to body weight (nPNA) < 1.0 g/kg per day (d) versus patients with normal nPNA (confidence interval (CI) 1.33-37.34; p < 0.05). Patients whose normalized protein catabolic rate (nPCR) was <1.2 g/(kg/d) had a significant positive association with malnutrition versus patients with normal nPCR (adjusted odds ratio (OR) 7.99; p < 0.05). Patients with dietary protein intake (DPI) < 1.0 g/(kg/d) had a higher likelihood of malnutrition than those with normal DPI (OR 12.73; p < 0.05). CAPD patients with upper arm circumference (UAC) < 23.2 cm had a high risk of malnutrition versus patients with normal UAC (OR 12.99; p < 0.05).

CONCLUSIONS

Our study suggested a close association between nPNA, DPI, nPCR, and UAC and malnutrition in CAPD patients. Further studies can be warranted the use of these variables as predictors and a malnutrition consequence among Chinese CAPD patients.

Comparison of lean mass indices as predictors of mortality in incident peritoneal dialysis patients

Background

Few studies have considered optimal adjusted lean mass indices for prediction of clinical outcomes in peritoneal dialysis (PD) patients. We aimed to evaluate clinical variables using various adjusted indices in PD patients.

Methods

Total 528 incident PD patients were included. Lean mass was measured using dual energy X-ray absorptiometry. Appendicular lean mass (ALM) was calculated using the sum for both upper and lower extremities. Each ALM index was calculated using ALM per body weight (ALM/BW), height squared (ALM/Ht²), or body mass index (ALM/BMI). Limb/trunk lean mass (LTLM) ratio was defined as the sum for both upper and lower extremities divided by trunk lean mass.

Results

A total of 528 patients were analyzed men: 286, women: 242. In area under the receiver operating characteristic curve analyses, LTLM alone was associated with 1 year mortality. In the LTLM ratio, the cut-off value for 1-year mortality was ≤ 0.829 in men and ≤ 0.717 in women, respectively. In both sexes, LTLM ratio alone showed statistical significance in all-cause mortality in both univariate and multivariate Cox-regression analyses. Compared with other indices, the LTLM ratio was independent of edema and fat in both sexes. Edema- and C-reactive protein-adjusted correlation analysis showed that LTLM ratio alone was associated with serum albumin in men. Although statistical significance was not obtained for women, the correlation coefficient was highest for the LTLM ratio compared with other indices.

Conclusion

Among various indices using lean mass, LTLM ratio was independent of volume status and fat mass and was associated with mortality in incident PD patients.

Association between Prognostic Nutritional Index and Contrast-Associated Acute Kidney Injury in Patients Complicated with Chronic Kidney Disease and Coronary Artery Disease

Background

Contrast-associated acute kidney injury (CA-AKI) is a major adverse effect of coronary angiography (CAG). Patients with chronic kidney disease (CKD) and coronary artery disease (CAD) are at high risk of CA-AKI. This study aimed to investigate the association between prognostic nutritional index (PNI) and CA-AKI in this high-risk population.

Methods

This study enrolled a total of 4,391 patients. CA-AKI was defined as a serum creatinine increase ≥0.3 mg/dL or 50% from baseline within the first 48 hours following CAG. The PNI was calculated upon hospital admission: serum albumin (g/L) + 5 × total lymphocyte count (10⁹/L). PNI was analysed from the high level to low level as a continuous variable and categorical variable which was divided into four groups by quartile. Restricted cubic splines and logistic regression were applied.

Results

Overall, 13.09% (575/4391) of patients developed CA-AKI. PNI score was significantly lower in patients with CA-AKI than that in patients without CA-AKI (P < 0.01). The relationship between PNI score and CA-AKI was linear. A logistic regression model revealed that decreased PNI score was associated with increased risk of CA-AKI [per 1-point decrement; adjusted OR = 1.08, 95% CI, 1.05–1.09; compared with Quartile 1 (PNI ≥ 46.30), Quartile 4 (PNI < 37.90), adjusted OR = 1.88, 95% CI: 1.41–2.51; and Quartile 3 (37.90 ≤ PNI < 42.15), adjusted OR = 1.37, 95% CI: 1.02–1.84].

Conclusion

Our study indicated a negative linear relationship between PNI score and CA-AKI in patients undergoing CAG complicated with CKD and CAD. It suggested that malnutrition is associated with increased risk of CA-AKI in this population.

Changes in body composition in peritoneal dialysis patients after kidney transplantation

PURPOSE

Serial follow-up data of body composition from peritoneal dialysis (PD) initiation until 1 year after kidney transplantation (KT) would be useful in identifying pathologic or physiologic changes, related to each modality or during the exchange of the modality.

METHODS

Body composition analysis was performed 1 month after PD initiation, repeated annually, immediately before KT, 1 month and 1 year after KT (n = 43). Body composition analysis was performed using a bioimpedance analysis (BIA) machine. The body composition parameters measured using BIA included the water contents, fat mass index (FMI), appendicular muscle mass index (aMMI), and bone mineral content (BMC).

RESULTS

The aMMI values 1 month and 1 year after PD initiation, immediately before KT, and 1 month and 1 year after KT were 7.6 ± 1.5, 7.8 ± 1.4, 8.0 ± 1.4, 6.8 ± 0.9, and 7.0 ± 1.0 kg/m², respectively. The aMMI increased during the first year of PD (P = 0.029) and was maintained during the remaining period of PD (P = 0.413). The value decreased during the first month after KT (P < 0.001) and recovered during the first year after KT (P = 0.010). FMI increased during the first year of PD (P < 0.001) and was maintained during the remaining period of PD (P = 0.214). The value increased during the first year of KT (P < 0.001). BMC was stable during the PD period but decreased after KT. Body waters were maintained during PD and decreased after KT. The presence of low muscle mass (LMM) 1 month after PD initiation or 1 month after KT, was associated with development of LMM 1 year after KT.

CONCLUSION

Our study showed that body composition was significantly changed during the first year after PD or the first month after KT, as evidenced by a decrease in aMMI and BMC and an increase in FMI. Adequate interventions provided at these two points might help maintain proper body composition.

Superiority of albumin-globulin ratio over albumin to predict mortality in patients undergoing peritoneal dialysis

There is increasing evidence showing that albumin–globulin ratio (AGR) can predict the survival of patients in many types of malignancies. However, no study was done to explore the value of AGR in peritoneal dialysis (PD) patients. A total of 554 incident patients undergoing PD from January 2001 through July 2016 were enrolled for this retrospective observational study. The outcomes of interest were all-cause mortality and cardiovascular disease (CVD) mortality. Baseline patient’s socio-demographic data, pharmacotherapy, comorbidities, laboratory and PD-related parameters were collected and used in the multivariate Cox models. The predictive value of AGR on mortality risk was compared with other markers using area under the receiver operating characteristic curve (AUC) analysis. Among the study participants, there were 265 (47.83%) men and the mean follow-up time was 3.87 ± 3.15 years. Univariate Cox analysis showed that low AGR was significantly associated with worse outcomes in terms of all-cause and CVD mortality and it remained an independent predictor in the multivariate models. The fully adjusted hazard ratios for the low AGR group versus high AGR group were 2.12 (95% CI 1.34–3.35, p = 0.001) and 2.58 (95% CI 1.42–4.7, p = 0.002) for all-cause and CVD mortality, respectively. The predictive ability of AGR for mortality risk was superior to that of other biomarkers based on AUC calculations. In conclusion, low AGR was independently associated with higher all-cause and CVD mortality risks in patients undergoing PD.

Effects of dialysis modality choice on the survival of end-stage renal disease patients in southern China: a retrospective cohort study

BACKGROUND

The optimal choice of treatment, with hemodialysis (HD) or peritoneal dialysis (PD), for end-stage renal disease (ESRD) patients, is still controversial. Only a few studies comparing HD and PD have been conducted in China, which has the largest number of dialysis patients in the world.

METHODS

A retrospective cohort study was conducted on ESRD patients who began renal replacement treatment from January 1, 2012 to December 31, 2017 in Guangdong Provincial Hospital of Chinese Medicine. Propensity scoring match was applied to balance the baseline conditions and multivariate Cox regression analysis to compare the mortality between HD and PD patients, and evaluated the correlation between mortality and various baseline characteristics.

RESULTS

A total of 436 HD patients and 501 PD patients were included in this study, and PD patients had better survival than HD patients, but the difference was not statistically significant. For younger ESRD patients (≤60-year-old), the overall survival of PD was better than that of HD, but HD was associated with a lower risk of death in older patients (> 70-year-old). This difference was still significant after adjustment for a variety of confounding factors. Female gender, age at dialysis initiation, cardiovascular disease, cholesterol, and HD were risk factors of all-cause mortality in the younger subgroup, while PD was risk factor in the older subgroup.

CONCLUSION

PD may be a better choice for younger ESRD patients, and HD for the older patients.

Nutritional Status in Peritoneal Dialysis: Nutritional Guidelines, Adequacy and the Management of Malnutrition

The positive impact of nutritional status on the health and treatment adequacy of peritoneal dialyzed patients has been well established. Protein intake is an important factor used to stratify malnutrition, with inadequate intake leading to protein-energy wasting during the course of therapy. In this review, we discuss the recommendations made by nephrological societies regarding nutrition in this population of dialysis patients. Special attention is given to the intake of protein, and recommendations on the intake of micronutrients are also discussed. Furthermore, factors that may impair nutritional intake and balance are discussed, with mention of the innovative strategies utilized to combat them. In light of inconsistent recommendations that vary between each respective society, as well as a general lack of concise information, it is our intention to call for further research regarding nutritional recommendations in peritoneal dialysis (PD), as well as to advocate for clear and accessible information for patients.

Comparison of hemodialysis and peritoneal dialysis patients' dietary behaviors

Background

Nutritional factors are associated with high mortality and morbidity in dialysis patients, and protein-energy wasting is regarded as an important one. The modality of dialysis may affect patients’ dietary behavior and nutritional status, but no study has compared the dietary behavior, nutrient intake, and nutritional adequacy of hemodialysis (HD) and peritoneal dialysis (PD) patients.

Methods

From December 2016 to May 2017, a dietary behavior survey and Semi-quantitative Food Frequency Questionnaire (Semi-FFQ) were conducted on 30 HD patients and 30 PD patients in Ewha Womans University Mokdong Hospital, and laboratory parameters were obtained. The results of prevalent HD and PD patients were then compared.

Results

The mean age of HD patients was higher than that of PD patients; HD: 58.5 ± 9.1 years, PD: 49.3 ± 9.7 years (p = 0.001). In the dietary behavior survey, HD patients showed more appropriate dietary behavior patterns overall than PD patients. In the dietary intake analysis with the Semi-FFQ, energy intake was significantly lower in the PD group than in the HD group due to the lower intake of carbohydrates, fat, and protein. A comparison of nutrient intake-to-recommended allowance ratio between the HD and PD groups revealed that the HD group showed higher nutrient intake than the PD group. Serum albumin and potassium levels were significantly higher in HD than in PD patients.

Conclusion

According to this study, the dietary behavior and nutritional intake of prevalent PD patients were worse than those of HD patients.

Albumin-globulin ratio and mortality in patients on peritoneal dialysis: a retrospective study

Background

Albumin-globulin ratio (AGR), a variable based on serum albumin and non-albumin proteins, has been demonstrated as a predictor of mortality in patients with malignant neoplasm. The aim of this study was to evaluate the prognostic value of AGR on peritoneal dialysis (PD) patients.

Methods

We retrospectively analyzed 602 incident PD patients from January 1st, 2008, to December 31st, 2017, at our center and followed them until December 31st, 2018. Kaplan-Meier curves and multivariate Cox regression models were applied to analyze the association between AGR and all-cause of mortality and cardiovascular mortality.

Results

The median follow-up time was 32.17 (interquartile range = 32.80) months. During follow-up, 131 (21.8%) patients died, including 57 patients (43.5%) who died due to cardiovascular diseases. Kaplan-Meier curves showed that patients with AGR > 1.26 had better rates of survival than those with AGR ≤ 1.25 (p < 0.001). After adjusting for potential confounders, the lower AGR level was significantly associated with an increased all-cause and cardiovascular mortality [hazard ratio (HR): 1.57, 95% confidence interval (CI): 1.07–2.32, p = 0.022 and HR: 2.01, 95% CI: 1.10–3.69, p = 0.023 respectively].

Conclusions

Patients with a low AGR level had an increased all-cause and cardiovascular mortality. AGR may be a useful index in identifying patients on PD at risk for CVD and all-cause of mortality.

Education and Protein Supplementation Improve Nutritional Biomarkers among Hypoalbuminemic Peritoneal Dialysis Patients: A Quasi-Experimental Design

Protein-energy wasting is prevalent in peritoneal dialysis patients, which causes a heavy burden for individuals and healthcare systems. We aimed to investigate the effect of nutritional education, and/or protein supplementation on nutritional biomarkers in hypoalbuminemic peritoneal dialysis patients. A quasi-experimental study was conducted in two dialysis centers at Taipei Tzu Chi Hospital and Shin Kong Wu Ho-Su Memorial Hospital. Patients were allocated in three groups including control (n = 12), milk protein (n = 21) and soy protein (n = 20). All patients received dietary guidelines from dietitians and completed 3-day dietary records during monthly visits for consecutive three months. Nutrients were analyzed using Nutritionist Professional software. Blood urea nitrogen (BUN), creatinine, albumin, total protein, hemoglobin, serum calcium, phosphorus, sodium, and potassium were assessed monthly. Total cholesterol and triglycerides were measured every three months. After three-month intervention, protein intake (percent of total calories), and serum albumin were significantly increased in three groups. Protein, phosphorus intake, and BUN were increased in two intervention groups. Total serum protein increased in control and milk protein groups, and creatinine increased the control group. Serum phosphorus was not significantly changed. Nutritional education alone, or combined with protein supplementation, significantly improve protein intake, and nutritional status by increasing serum albumin, but not serum phosphorus in hypoalbuminemic peritoneal dialysis patients.

Lower Phase Angle Measured by Bioelectrical Impedance Analysis Is a Marker for Increased Mortality in Incident Continuous Ambulatory Peritoneal Dialysis Patients

OBJECTIVE

Phase angle (PA) determined by bioelectrical impedance analysis has been suggested to be a predictor of death in a variety of disease conditions, but its associations with outcomes have not yet been assessed in a large continuous ambulatory peritoneal dialysis (CAPD) patient cohort. The aim of the present study was to examine the association of PA with risks for all-cause and cardiovascular death in patients treated with CAPD.

METHODS

Incident CAPD patients were enrolled from January 1, 2010 to December 31, 2015 and were followed until December 31, 2017. Multifrequency bioelectrical impedance analysis was conducted in the morning with patients in a fasting state. Multivariable linear regression analyses were performed to study the relationships between PA and other variables. Cox proportional hazard models were used to evaluate the association between PA and mortality.

RESULTS

A total of 760 incident CAPD patients were enrolled in this study. Patients have a median PA value of 4.59° ranging from 2.30° to 7.22°. Aging, presence of diabetes mellitus, and fluid overload were independently associated with lower PA, whereas male sex, higher body mass index, higher serum levels of albumin and creatinine, and better residual renal function were independently associated with higher PA in a multivariable linear regression model. A total of 125 (16.4%) patients died during a median follow-up of 42 months. In the Cox model with adjustment for confounders, PA was significantly associated with all-cause and cardiovascular mortality in incident CAPD patients (hazard ratio, 0.584; 95% confidence interval, 0.403 to 0.844, P = .004; hazard ratio, 0.597; 95% confidence interval, 0.359 to 0.993, P = .047, respectively).

CONCLUSIONS

PA reflected a combined dimension of the illness including deranged hydration status and nutritional status. Lower PA was associated with both all-cause and cardiovascular death in patients with CAPD.

A telemonitoring system for nutritional intake in patients with chronic kidney disease receiving peritoneal dialysis therapy

Patients undergoing peritoneal dialysis (PD) therapy may present complications of protein-energy wasting, which may be partially produced by inadequate nutrition management and a protein or energy deficiency in the predialytic phase. Therefore, accurate monitoring of the nutrition status during PD therapy can prevent risk conditions in patients with chronic kidney disease (CKD). In this study, we present the analysis, design, and development of a telemonitoring system for the nutritional intake of patients with CKD receiving PD therapy. The proposed system consists of a mobile web application addressed to the nutrition specialist and a native Android application aimed at patients undergoing PD. Our system optimizes nutrition administration by providing services that allow the nutritionist to monitor the patient, assign a nutrition scheme based on the patient profile, manage intake phases and send recommendations to the patient. Furthermore, the system allows the patient to record the intake data daily, receive updates on diets generated by the nutritionist and communicate with the nutritionist through a consultation module. Finally, we performed a usability assessment of our system based on a laboratory study with two users: a nutritionist and a patient undergoing peritoneal dialysis treatment. Based on the obtained results, our telemonitoring system shows a favorable opinion in terms of usability from the perspectives of the patient and nutritionist.

Development of a risk prediction model for infection-related mortality in patients undergoing peritoneal dialysis

Background

Assessment of infection-related mortality remains inadequate in patients undergoing peritoneal dialysis. This study was performed to develop a risk model for predicting the 2-year infection-related mortality risk in patients undergoing peritoneal dialysis.

Methods

The study cohort comprised 606 patients who started and continued peritoneal dialysis for 90 at least days and was drawn from the Fukuoka Peritoneal Dialysis Database Registry Study in Japan. The patients were registered from 1 January 2006 to 31 December 2016 and followed up until 31 December 2017. To generate a prediction rule, the score for each variable was weighted by the regression coefficients calculated using a Cox proportional hazard model adjusted by risk factors for infection-related mortality, including patient characteristics, comorbidities, and laboratory data.

Results

During the follow-up period (median, 2.2 years), 138 patients died; 58 of them of infectious disease. The final model for infection-related mortality comprises six factors: age, sex, serum albumin, serum creatinine, total cholesterol, and weekly renal Kt/V. The incidence of infection-related mortality increased linearly with increasing total risk score (P for trend <0.001). Furthermore, the prediction model showed adequate discrimination (c-statistic = 0.79 [0.72–0.86]) and calibration (Hosmer–Lemeshow test, P = 0.47).

Conclusion

In this study, we developed a new model using clinical measures for predicting infection-related mortality in patients undergoing peritoneal dialysis.

Changes in geriatric nutritional risk index and risk of major adverse cardiac and cerebrovascular events in incident peritoneal dialysis patients

Background

Geriatric nutritional risk index (GNRI) is a validated nutritional assessment method, and lower GNRI values are closely associated with adverse clinical outcomes in dialysis patients. This study investigated the impact of changes in GNRI during the first year of dialysis on cardiovascular outcomes in incident peritoneal dialysis (PD) patients.

Methods

We reviewed medical records in 133 incident PD patients to determine GNRI at the start of PD and after 12 months. Patients were categorized into improved (delta GNRI > 0) and worsening/stationary (delta GNRI ≤ 0) groups. The primary outcome was major adverse cardiac and cerebrovascular events (MACCEs).

Results

During a mean follow-up of 51.1 months, the primary outcome was observed in 42 patients (31.6%). The baseline GNRI at PD initiation was not significantly associated with MACCEs (log-rank test, P = 0.40). However, the cumulative event-free rate was significantly lower in the worsening or stationary GNRI group than in the improved group (log-rank test, P = 0.004). Multivariate Cox analysis revealed that a worsening or stationary GNRI was independently associated with higher risk for MACCEs (hazard ratio, 2.47; 95% confidence interval, 1.15–5.29; P = 0.02). In subgroup analysis, patients with worsening or stationary GNRI were at significantly greater risk for MACCEs in both the lower (P = 0.04) and higher (P = 0.01) baseline GNRI groups.

Conclusion

Baseline GNRI was not associated with MACCEs, but patients with deteriorating or stationary nutritional status were at significantly greater risk for MACCEs, suggesting that serial monitoring of nutritional status is important to stratify cardiovascular risk in incident PD patients.

High serum adiponectin is associated with anemia development in chronic kidney disease: The results from the KNOW-CKD study

BACKGROUND

Adiponectin is an adipokine secreted by adipocytes. A low adiponectin level is a significant risk factor of diabetes mellitus and cardiovascular disease. Recent studies have shown that adiponectin is negatively associated with hematopoiesis and predicts the development of anemia in the general population. In chronic kidney disease (CKD) patients, circulating adiponectin level is paradoxically elevated and the role of adiponectin is complex. Therefore, we evaluated the relationship between adiponectin and anemia in these patients.

METHODS

This prospective longitudinal study included 2113 patients from the KNOW-CKD study (KoreaN cohort study for Outcome in patients With CKD), after excluding 125 without data on adiponectin levels. Hemoglobin levels were measured yearly during a mean follow-up period of 23.7 months. Anemia was defined as hemoglobin levels of <13.0 and 12.0 g/dL for men and women, respectively.

RESULTS

Mean patient age was 53.6 ± 12.2 years, and 1289 (61%) were men. The mean estimated glomerular filtration rate (eGFR) was 50.4 ± 30.2 mL min^-1 1.73 m^-2. Serum adiponectin level was inversely associated with body mass index, eGFR, log-transformed C-reactive protein, and positively with Charlson comorbidity index, urine protein to creatinine ratio, and high density lipoprotein cholesterol. In addition, serum adiponectin level was also negatively correlated with hemoglobin level and reticulocyte production index in both men and women. In multivariable linear regression analysis after adjustment of multiple confounders, adiponectin was negatively associated with hemoglobin (men, β = -0.219, P < .001; women, β = -0.09, P = .025). Among 1227 patients without anemia at baseline, 307 newly developed anemia during the follow-up period. In multivariable Cox regression analysis after adjustment of confounders, high adiponectin level was significantly associated with an increased risk of incident anemia (per 1 µg/mL increase, hazard ratio, 1.02; 95% confidence interval 1.01-1.04; P = .001).

CONCLUSIONS

A high serum adiponectin level is independently associated with a low hemoglobin level and predicts the development of anemia in patients with CKD. These findings reveal the potential role of adiponectin in CKD-related anemia.

Low prognostic nutritional index associated with cardiovascular disease mortality in incident peritoneal dialysis patients

PURPOSE

The prognostic nutritional index (PNI), a variable based on serum albumin concentration and total lymphocyte count in peripheral blood, is reported as a predictor of mortality in a variety of malignant tumor population. This study is aimed to evaluate whether PNI has prognostic value in patients on peritoneal dialysis (PD).

METHODS

This was a single-center, retrospective observational cohort study conducted in incident PD patients from January 1, 2006 to June 30, 2014, and followed until June 30, 2015. The associations of PNI levels with mortality were evaluated by Kaplan-Meier method and Cox proportional hazards models.

RESULTS

A total of 345 patients were included in this study. Median PNI level at baseline was 40.7 (range: 18.8-75.5) for all patients. During follow-up, 59 (17.1%) died during follow-up, among which 31 (52.5%) were due to cardiovascular diseases (CVD). In crude analysis, the patients with low PNI had a significant increase risk of CVD and all-cause mortality [hazard ratio (HR) 3.07, 95% confidence interval (CI) 1.51-6.25 and HR 2.18, 95% CI 1.28-3.72, respectively)]. After adjusting age, Davies comorbidity score, hemoglobin and leukocytes, the patients with low PNI still had a significant increased risk of CVD mortality (HR 2.37, 95% CI 1.10-5.12). However, there was no significant difference in risk of all-cause mortality (HR 1.72, 95% CI 0.97-3.06).

CONCLUSIONS

Low PNI at initiation of PD was independently associated with an increased CVD mortality.

Comparative Study on Trace Element Excretions between Nonanuric and Anuric Patients Undergoing Continuous Ambulatory Peritoneal Dialysis

Few studies have been reported on alterations of trace elements (TE) in peritoneal dialysis patients. Our objective was to investigate and assess the characteristics of daily TE excretions in continuous ambulatory peritoneal dialysis (CAPD) patients. This cross-sectional study included 61 CAPD patients (nonanuric/anuric: 45/16) and 11 healthy subjects in Wuhan, China between 2013 and 2014. The dialysate and urine of patients and urine of healthy subjects were collected. The concentrations of copper (Cu), zinc (Zn), selenium (Se), molybdenum (Mo), and arsenic (As) in dialysate and urine were determined using inductively coupled plasma mass spectrometer (ICP-MS). Various clinical variables were obtained from automatic biochemical analyzer. Daily Cu, Zn, Se, and Mo excretions in nonanuric patients were higher than healthy subjects, while arsenic excretion in anuric patients was lower. A strong and positive correlation was observed between Se and Mo excretion in both dialysate (β = 0.869, p < 0.010) and urine (β = 0.968, p < 0.010). Furthermore, the clinical variables associated with Se excretion were found to be correlated with Mo excretion. Our findings indicated that nonanuric CAPD patients may suffer from deficiency of some essential TEs, while anuric patients are at risk of arsenic accumulation. A close association between Se and Mo excretion was also found.

Chronic Kidney Disease-Mineral Bone Disorder in the Elderly Peritoneal Dialysis Patient

PURPOSE

The purpose of this paper was to review the literature concerning the treatment of chronic kidney disease-mineral bone disorder (CKD-MBD) in the elderly peritoneal dialysis (PD) patient.

RESULTS

Chronic kidney disease-mineral bone disorder is a major problem in the elderly PD patient, with its associated increased fracture risk, vascular calcification, and accelerated mortality fracture risk. Peritoneal dialysis, however, bears a lower risk than hemodialysis (HD). The approach to CKD-MBD prophylaxis and treatment in the elderly PD patient is similar to other CKD patients, with some important differences. Avoidance of hypercalcemia, hyperphosphatemia, and hyperparathyroidism is important, as in other CKD groups, and is generally easier to attain. Calcium-free phosphate binders are recommended for normocalcemic and hypercalcemic patients. Normalization of vitamin D levels to > 75 nmol/L (> 30 pg/L) and low-dose active vitamin D therapy is recommended for all patients. Hyperparathryoidism is to be avoided by using active vitamin D and cinacalcet. Particular attention should be paid to treating protein malnutrition. Fracture prophylaxis (exercise, use of walkers, dwelling modifications) are important. Hypomagnesemia is common in PD and can be treated with magnesium supplements. Vitamin K deficiency is also common and has been identified as a cause of vascular calcification. Accordingly, warfarin treatment for this age group is problematic.

CONCLUSION

While treatment principles are similar to other dialysis patient groups, physicians should be aware of the special problems of the elderly group.

APPETITE PREDICTS INTAKE AND NUTRITIONAL STATUS IN PATIENTS RECEIVING PERITONEAL DIALYSIS

BACKGROUND

Sub-optimal nutrition status is common amongst patients receiving peritoneal dialysis (PD) and leads to poor clinical outcome. This population experiences multi-factorial challenges to achieving optimal nutritional status, particularly driven by inadequate intake.

OBJECTIVES

The aim of this investigation was to identify factors associated with inadequate protein intake and sub-optimal nutritional status in patients undergoing PD.

DESIGN/PARTICIPANTS

This was a cross-sectional study of 67 adult patients receiving PD (mean age 59 ± 14 years; 57% male) within a single centre. Participants were consecutively recruited and interviewed by renal dietitians, collecting: Subjective Global Assessment (SGA); quality of life (using EQ-5D); dietary intake (via dietary interview); and appetite (using Appetite and Diet Assessment Tool). Participant demographics were obtained via survey or medical charts. Main outcome measures were inadequate dietary protein intake (<1.1 g/kg adjusted body weight/day) and malnutrition (as defined by SGA rating B or C).

RESULTS

Overall, 15 (22%) patients were malnourished and 29 (43%) had inadequate protein intake. Poor appetite (anorexia) was reported in 62% (18/29) of participants with inadequate protein malnourished patients reported anorexia versus 12 (23%) of the well-nourished patients (p = 0.0001).

CONCLUSION

Anorexia was a key risk factor for inadequate protein intake and malnutrition in patients undergoing PD. These findings highlight a need to closely monitor patients with appetite disturbances.

Change of Nutritional Status Assessed Using Subjective Global Assessment Is Associated With All-Cause Mortality in Incident Dialysis Patients

Subjective global assessment (SGA) is associated with mortality in end-stage renal disease (ESRD) patients. However, little is known whether improvement or deterioration of nutritional status after dialysis initiation influences the clinical outcome. We aimed to elucidate the association between changes in nutritional status determined by SGA during the first year of dialysis and all-cause mortality in incident ESRD patients. This was a multicenter, prospective cohort study. Incident dialysis patients with available SGA data at both baseline and 12 months after dialysis commencement (n = 914) were analyzed. Nutritional status was defined as well nourished (WN, SGA A) or malnourished (MN, SGA B or C). The patients were divided into 4 groups according to the change in nutritional status between baseline and 12 months after dialysis commencement: group 1, WN to WN; group 2, MN to WN; group 3, WN to MN; and group 4, MN to MN. Cox proportional hazard analysis was performed to clarify the association between changes in nutritional status and mortality. Being in the MN group at 12 months after dialysis initiation, but not at baseline, was a significant risk factor for mortality. There was a significant difference in the 3-year survival rates among the groups (group 1, 92.2%; group 2, 86.0%; group 3, 78.2%; and group 4, 63.5%; log-rank test, P < 0.001). Multivariate Cox regression analysis revealed that the mortality risk was significantly higher in group 3 than in group 1 (hazard ratio [HR] 2.77, 95% confidence interval [CI] 1.27-6.03, P = 0.01) whereas the mortality risk was significantly lower in group 2 compared with group 4 (HR 0.35, 95% CI 0.17-0.71, P < 0.01) even after adjustment for confounding factors. Moreover, mortality risk of group 3 was significantly higher than in group 2 (HR 2.89, 95% CI 1.22-6.81, P = 0.02); there was no significant difference between groups 1 and 2. The changes in nutritional status assessed by SGA during the first year of dialysis were associated with all-cause mortality in incident ESRD patients.

Baseline higher peritoneal transport had been associated with worse nutritional status of incident continuous ambulatory peritoneal dialysis patients in Southern China: a 1-year prospective study

The aim of the present study was to investigate the relationship between baseline peritoneal transport types and nutritional status in Chinese continuous ambulatory peritoneal dialysis (CAPD) patients. In the present single-centre, prospective study, incident CAPD patients were included from 15 April 2010 to 31 December 2011 and were followed up for 12 months. According to the results of baseline peritoneal equilibration test, patients were divided into lower peritoneal transport group (lower transporters) and higher peritoneal transport group (higher transporters). Nutritional status was evaluated by both subjective global assessment (SGA) and protein-energy wasting (PEW) score. The body composition parameters were assessed by body impedance analysis. A total of 283 CAPD patients were included in the study, of which 171 (60.4 %) were males with a mean age of 47.0 (sd 14.9) years. Compared with lower transporters (n 92), higher transporters (n 181) had lower levels of serum albumin (37.1 (sd 4.3) v. 39.6 (sd 4.3) g/l, P< 0.001), serum pre-albumin (356 (sd 99) v. 384 (sd 90) mg/l, P= 0.035), phase angle (6.15 (sd 0.39) v. 6.27 (sd 0.47)°, P< 0.05) and higher rate of malnutrition defined by SGA (52.5 v. 25.0%, P< 0.001) and PEW score (37.0 v. 14.1 %, P< 0.001) at 1-year of follow-up. Baseline higher peritoneal transport, analysed by multivariate binary logistic regressions, was independently associated with malnutrition (SGA mild to moderate and severe malnutrition: OR 3.43, 95% CI 1.69, 6.96, P< 0.01; PEW: OR 2.40, 95% CI 1.08, 5.31, P= 0.03). It was concluded that baseline higher peritoneal transport was independently associated with worse nutritional status of CAPD patients in Southern China.

Association of Body Mass Index with Patient-Centered Outcomes in Children with ESRD

Obesity is associated with less access to transplantation among adults with ESRD. To examine the association between body mass index at ESRD onset and survival and transplantation in children, we performed a retrospective analysis of children ages 2-19 years old beginning RRT from 1995 to 2011 using the US Renal Data System. Among 13,172 children, prevalence of obesity increased from 14% to 18%, whereas prevalence of underweight decreased from 12% to 9% during this period. Over a median follow-up of 7.0 years, 10,004 children had at least one kidney transplant, and 1675 deaths occurred. Risk of death was higher in obese (hazard ratio [HR], 1.17; 95% confidence interval [95% CI], 1.03 to 1.32) and underweight (HR, 1.26; 95% CI, 1.09 to 1.47) children than children with normal body mass indices. Obese and underweight children were less likely to receive a kidney transplant (HR, 0.92; 95% CI, 0.87 to 0.97; HR, 0.83; 95% CI, 0.78 to 0.89, respectively). Obese children had lower odds of receiving a living donor transplant (odds ratio, 0.85; 95% CI, 0.74 to 0.98) if the transplant occurred within 18 months of ESRD onset. Adjustment for transplant in a time-dependent Cox model attenuated the higher risk of death in obese but not underweight children (HR, 1.09; 95% CI, 0.96 to 1.24). Lower rates of kidney transplantation may, therefore, mediate the higher risk of death in obese children with ESRD. The increasing prevalence of obesity among children starting RRT may impede kidney transplantation, especially from living donors.

Hyponatremia Predicts New-Onset Cardiovascular Events in Peritoneal Dialysis Patients

Background and Aim

Cardiovascular (CV) disease is the leading cause of morbidity and mortality in patients on peritoneal dialysis (PD). Hyponatremia was recently shown to be a modifiable factor that is strongly associated with increased mortality in PD patients. However, the clinical impact of hyponatremia on CV outcomes in these patients is unclear.

Methods

To determine whether a low serum sodium level predicts the development of CV disease, we carried out a prospective observational study of 441 incident patients who started PD between January 2000 and December 2005. Time-averaged serum sodium (TA-Na) levels were determined to investigate the ability of hyponatremia to predict newly developed CV events in these patients.

Results

During a mean follow-up of 43.2 months, 106 (24.0%) patients developed new CV events. The cumulative incidence of new-onset CV events after the initiation of PD was significantly higher in patients with TA-Na levels ≤ 138 mEq/L than in those with a TA-Na > 138 mEq/L. After adjustment for multiple potentially confounding covariates, an increase in TA-Na level was found to be associated with a significantly lower risk of CV events (subdistribution hazard ratio per 1 mEq/L increase, 0.90; 95% confidence interval, 0.83–0.96; p = 0.003). Patients with a TA-Na ≤ 138 mEq/L had a 2.31-fold higher risk of suffering a CV event.

Conclusions

These results provide evidence of a clear association between low serum sodium and new-onset CV events after dialysis initiation in PD patients. Whether the correction of hyponatremia for this indication provides additional protection for the development of CV disease in these patients remains to be addressed in interventional studies.

Lower plasma visceral protein concentrations are independently associated with higher mortality in patients on peritoneal dialysis

Protein-energy wasting (PEW) is strongly associated with high mortality in continuous ambulatory peritoneal dialysis (CAPD) patients. However, its clinical assessment has not been well defined. The aim of the present study was to investigate the relationship between combined nutritional indicators and mortality in CAPD patients. In the present retrospective cohort study, a total of 885 incident CAPD patients were enrolled. Nutritional status at the initiation of CAPD was assessed by BMI and biochemical indices (serum albumin, prealbumin, transferrin, creatinine and total cholesterol). The primary outcome was all-cause mortality. Principal components factor analysis was used to identify the combined nutritional parameters. Their association with mortality was examined by multivariable-adjusted Cox models. The mean age was 47·4 (SD 14·8) years, 59·2 % (n 524) were male and 24·6 % (n 218) were diabetic. Of the total patients, 130 (14·7 %) had BMI < 18·5 kg/m², 439 (49·6 %) had albumin < 38 g/l ( < 3·8 g/dl), 303 (34·2 %) had prealbumin < 300 mg/l ( < 30 mg/dl), 404 (45·6 %) had transferrin < 2 g/l ( < 200 mg/dl), 501 (56·6 %) had total cholesterol < 5·2 mmol/l ( < 200 mg/dl) and 466 (52·7 %) had creatinine < 707 μmol/l ( < 8 mg/dl). Overall, three components such as visceral proteins, muscle-mass surrogate and BMI were extracted, which explained 69·95 % of the total variance of the nutritional parameters. After adjusting for demographic variables, co-morbid conditions, Hb, TAG and high-sensitivity C-reactive protein, the factor score of visceral proteins including albumin, prealbumin and transferrin was independently associated with mortality (hazard ratio 0·73, 95 % CI 0·60, 0·89; P= 0·002). Lower visceral protein concentrations may be independently associated with higher mortality in incident CAPD patients. Simultaneous measurements of serum albumin, prealbumin and transferrin could be helpful to monitor PEW.

Hyponatremia as a predictor of mortality in peritoneal dialysis patients

BACKGROUND AND AIM

Hyponatremia is common in patients with chronic kidney disease and is associated with increased mortality in hemodialysis patients. However, few studies have addressed this issue in peritoneal dialysis (PD) patients.

METHODS

This prospective observational study included a total of 441 incident patients who started PD between January 2000 and December 2005. Using time-averaged serum sodium (TA-Na) levels, we aimed to investigate whether hyponatremia can predict mortality in these patients.

RESULTS

Among the baseline parameters, serum sodium level was positively associated with serum albumin (β = 0.145; p = 0.003) and residual renal function (RRF) (β = 0.130; p = 0.018) and inversely associated with PD ultrafiltration (β = -0.114; p = 0.024) in a multivariable linear regression analysis. During a median follow-up of 34.8 months, 149 deaths were recorded. All-cause death occurred in 81 (55.9%) patients in the lowest tertile compared to 37 (25.0%) and 31 (20.9%) patients in the middle and highest tertiles, respectively. After adjusting for multiple potentially confounding covariates, increased TA-Na level was associated with a significantly decreased risk of all-cause (HR per 1 mEq/L increase, 0.79; 95% CI, 0.73-0.86; p<0.001) and infection-related (HR per 1 mEq/L increase, 0.77; 95% CI, 0.70-0.85; p<0.001) deaths.

CONCLUSIONS

This study showed that hyponatremia is an independent predictor of mortality in PD patients. Nevertheless, whether correcting hyponatremia improves patient survival is unknown. Future interventional studies should address this question more appropriately.

Is hypoalbuminemia a prognostic risk factor for contrast-induced nephropathy in peritoneal dialysis patients?

Objective

Residual renal function (RRF) is an important predictor of outcome in peritoneal dialysis (PD) patients. Hypoalbuminemia was found to be an independent risk factor for the development of acute kidney injury. We investigated the possibility of an association between serum albumin levels and the development of iodine contrast media-induced nephropathy (CIN) in PD patients.

Methods

A total of 103 PD patients who underwent invasive angiographies with exposure to iodine contrast media (ICM) were reviewed retrospectively. All patients received 0.9% saline intravenously at a rate of 75 mL per hour for 12 hours prior, during, and 12 hours after exposure to ICM. Acetylcysteine was given orally at a dose of 600 mg twice daily, on the day before and on the day of exposure to ICM. The nonionic, low-osmolar contrast agent iopromide was used at a mean dose of 75.0±15.2 mL. The changes in RRF from baseline to 1 week and 4 weeks after exposure to ICM were recorded. Outcomes of patients with serum albumin levels <3.8 g/dL and those with serum albumin levels ≥3.8 g/dL were compared. A reduction >30% in RRF at 7 days after exposure to ICM was considered CIN.

Results

CIN developed in 27.2% (28/103) of patients. Of the 103 patients, 59.2% (61) had serum albumin levels <3.8 g/dL. Of those, 37.7% (23/61) developed CIN, compared with 11.9% (5/42) of those with serum albumin levels ≥3.8 g/dL (P=0.004). After adjustment for all tested variables in a logistic regression with a stepwise selection model, serum albumin level at exposure to ICM was found to be the most powerful predictor of the development of CIN (odds ratio =4.5; confidence interval =1.5–13.0; P=0.006).

Conclusion

PD patients with serum albumin levels <3.8 g/dL should be monitored carefully when exposed to ICM. Serum albumin level may be considered a potential therapeutic target in the prevention of CIN and preservation of RRF in PD patients.

Intraperitoneal fluid overestimates hydration status assessment by bioimpedance spectroscopy

BACKGROUND

Bioimpedance spectroscopy (BIS) is a valuable tool to assess nutrition and volume status in peritoneal dialysis (PD) patients. However, data about the influence of intraperitoneal fluid on body composition measures are conflicting, and there is no clear consensus about whether the abdomen should be drained before the procedure. We designed a comparison study to detect the influence of intra-abdominal fluid on BIS results.

METHODS

We performed 73 pairs of BIS measurements in 34 stable PD patients, first with the peritoneum filled with a 1.36% glucose dialysate solution and then after the solution was drained. Patients stayed in the supine position for 10 minutes before the BIS procedure, and the electrodes were not moved between measures. Clinical and demographic data were collected, as were analytic parameters of nutrition and volume status.

RESULTS

Fluid overload is overestimated when BIS is performed with a full abdomen (1.82 ± 1.73 L vs 1.64 ± 1.68 L, p = 0.043). We also found a spurious overestimation in extracellular water (16.40 ± 3.21 L vs 16.24 ± 3.16 L, p < 0.001) and in relative overhydration (8.29% ± 6.96% vs 7.14% ± 6.79%, p = 0.017). No differences in intracellular water or parameters of nutrition were found. We observed negative correlations for the extracellular water overestimation with age (r = -0.245, p = 0.037), serum B-type natriuretic peptide (r = -0.366, p = 0.036), body mass index (r = -0.248, p = 0.035), and lean tissue index (r = -0.427, p = 0.001). The difference in extracellular water correlated only with body mass index (r = -0.259, p = 0.039). We also found that, assessed at 50 KHz, whole-body impedance (-4.52 ± 8.37, p = 0.001) and phase angle (-0.08 ± 0.23 degrees, p = 0.002) were both lower when BIS was performed in patients with a full abdomen.

CONCLUSIONS

Fluid overload is overestimated by BIS when performed in patients with dialysate in the peritoneum. The observed differences are greater in younger, more poorly nourished, or less overhydrated patients. If more precise results are required, we suggest that the abdomen be drained before BIS is performed.

A low serum bicarbonate concentration as a risk factor for mortality in peritoneal dialysis patients

BACKGROUND AND AIM

Metabolic acidosis is common in patients with chronic kidney disease and is associated with increased mortality in hemodialysis patients. However, this relationship has not yet been determined in peritoneal dialysis (PD) patients.

METHODS

This prospective observational study included a total of 441 incident patients who started PD between January 2000 and December 2005. Using time-averaged serum bicarbonate (TA-Bic) levels, we aimed to investigate whether a low serum bicarbonate concentration can predict mortality in these patients.

RESULTS

Among the baseline parameters, serum bicarbonate level was positively associated with hemoglobin level and residual glomerular filtration rate (GFR), while it was negatively associated with albumin, C-reactive protein (CRP) levels, peritoneal Kt/V urea, and normalized protein catabolic rate (nPCR) in a multivariable linear regression analysis. During a median follow-up of 34.8 months, 149 deaths were recorded. After adjustment for age, diabetes, coronary artery disease, serum albumin, ferritin, CRP, residual GFR, peritoneal Kt/V urea, nPCR, and percentage of lean body mass, TA-Bic level was associated with a significantly decreased risk of mortality (HR per 1 mEq/L increase, 0.83; 95% CI, 0.76-0.91; p < 0.001). In addition, compared to patients with a TA-Bic level of 24-26 mEq/L, those with a TA-Bic level < 22 and between 22-24 mEq/L conferred a 13.10- and 2.13-fold increased risk of death, respectively.

CONCLUSIONS

This study showed that a low serum bicarbonate concentration is an independent risk factor for mortality in PD patients. This relationship between low bicarbonate levels and adverse outcome could be related to enhanced inflammation and a more rapid loss of RRF associated with metabolic acidosis. Large randomized clinical trials to correct acidosis are warranted to confirm our findings.

Effects of peritoneal dialysis on protein metabolism

Protein-energy wasting is relatively common in renal patients treated with haemodialysis or peritoneal dialysis (PD) and is associated with worse outcome. In this article, we review the current state of our knowledge regarding the effects of PD on protein metabolism and the possible interactions between PD-induced changes in protein turnover and the uraemia-induced alterations in protein metabolism. Available evidence shows that PD induces a new state in muscle protein dynamics, which is characterized by decreased turnover rates and a reduced efficiency of protein turnover, a condition which may be harmful in stress conditions, when nutrient intake is diminished or during superimposed catabolic illnesses. There is a need to develop more effective treatments to enhance the nutritional status of PD patients. New approaches include the use of amino acid/keto acids-containing supplements combined with physical exercise, incremental doses of intraperitoneal amino acids, vitamin D and myostatin antagonism for malnourished patients refractory to standard nutritional therapy.

Diminished appetite predicts mortality of Chinese peritoneal dialysis patients

BACKGROUND

Many maintenance dialysis patients experience a common cluster of symptoms, including diminished appetite (anorexia). This symptom has been associated with reduced quality of life and increased mortality in this population.

AIM

The aim of this study was to determine whether diminished appetite is a significant predictor of negative clinical outcomes in patients on peritoneal dialysis (PD).

METHOD

A longitudinal prospective study was conducted in 98 patients receiving PD in Beijing, China. Clinical characteristics, nutritional and inflammatory marker levels, and related peritoneal treatment information were collected. The appetite status and serum albumin levels were assessed initially and reevaluated monthly during the first year of follow-up. All patients were followed for nearly 5 years or until death. Data were collected about mortality, hospitalization, and peritonitis.

RESULTS

The mean age of participants was 60.3 ± 14.4, and 22.8% reported diminished appetite. At baseline, female sex, cardiovascular disease, and prealbumin level were the significant predictors of appetite. The average length of follow-up was 39 (range: 2-57) months. The Kaplan-Meier survival curve showed the survival rate was lower in patients reporting diminished appetite than for patients reporting normal appetite. Multivariate analysis indicated that diminished appetite, diabetes, ferritin, and serum albumin levels were independent predictors of mortality.

CONCLUSION

Self-reported appetite was a predictor of clinical characteristics and outcome for patients receiving PD. Conducting appetite evaluation periodically is recommended as a nursing strategy to improve care for these patients.