The combination of malnutrition-inflammation and functional status limitations is associated with mortality in hemodialysis patients

Body Composition and Intradialytic Exercise in Kidney Disease: A Combined Analysis of the PEDAL and CYCLE-HD Randomised Controlled Trials

BACKGROUND

Haemodialysis patients are at high risk of myopenic obesity, necessitating effective nutritional status monitoring and intervention strategies. This combined analysis of two clinical trials (PEDAL trial and CYCLE-HD study) aimed to (i) determine the clinical utility of body mass index (BMI) in comparison to fat tissue index (FTI) and lean tissue index (LTI) and (ii) assess the effect of a 6-month intradialytic exercise intervention compared to usual care on FTI and LTI.

METHODS

A priori secondary endpoints in both trials included BMI, FTI and LTI. BMI was classified by World Health Organisation definitions (underweight, healthy, overweight or obese). FTI and LTI were determined by Bioelectrical Impedance Spectroscopy and classified by previous research evidence (FTI of 4-15 kg/m2 and LTI of 15-20 kg/m2 being associated with best survival). For aim (i), BMI was compared to FTI and LTI by correlation and classification. For aim (ii), changes over 6 months in FTI and LTI were compared between exercise intervention and control groups.

RESULTS

Across both studies, 298 and 209 participants had bioelectrical impedance spectroscopy measurement at baseline and 6 months, respectively. Mean (SD) age: 58 (15) years; BMI: 28.2(6.3) kg/m2; male: 65%. At baseline, only 47 of 298 participants (16%) had an FTI and LTI associated with best survival. BMI correlated with FTI (r = 0.79; p < 0.0001). However, 34% of participants were misclassified by BMI (e.g., 9% of patients were classified as obese by BMI yet FTI revealed their body composition was healthy). BMI did not correlate with LTI (p = 0.15), and 86% of participants were misclassified by BMI (e.g., 73% of patients were classified as healthy, overweight or obese by BMI yet LTI revealed they were myopenic). There was no difference between exercise intervention and control groups in mean change (95% CI) over 6 months for LTI (-0.3 [-1.1 to 0.4] kg/m2; p = 0.4) or FTI (0.2 [-0.7 to 1.0] kg/m2; p = 0.7).

CONCLUSIONS

Worryingly, only a minority (16%) of haemodialysis patients had both LTI and FTI within the range associated with best survival. Body composition misclassification using conventional BMI cut-offs was common: despite having healthy, overweight or even obese BMI, the majority (73%) of patients had hidden myopenia according to LTI. Six months of intradialytic aerobic exercise did not improve body composition. This study identified that common measures of nutritional status in haemodialysis patients such as BMI are misleading and that interventions other than intradialytic cycling are urgently required to target myopenic obesity.

The Severity of Carotid Calcifications, but Not Fibroblast Growth Factor 23, Is Associated with Mortality in Hemodialysis: A Single Center Experience

BACKGROUND

The study goal was to assess the mortality effect of carotid vascular calcifications (VC), of fibroblast growth factor 23 (FGF-23), mineral markers, and comorbidities in hemodialysis (HD) patients.

METHODS

The influence of carotid VC severity, FGF-23, laboratory markers, clinical features, and comorbidities on mortality was analyzed in a cohort of 88 HD patients. The follow-up period lasted 8 years. The cut-off value for carotid VC was 4 for all-cause and cardiovascular mortality.

RESULTS

Carotid VC, diabetes, low serum albumin, high serum C-reactive protein (CRP), and the presence of cardiovascular diseases are associated with all-cause and cardiovascular mortality. Carotid VC score over 4 was an independent predictor of all-cause and cardiovascular mortality, along with diabetes, low albumin, and high CRP. FGF-23 was not found to be predictable for the study outcomes.

CONCLUSIONS

The study documented in a cohort of patients prevalent in chronic HD that carotid VC predicts all-cause and cardiovascular mortality at 8 years and improves risk stratification, but FGF-23 is not associated with mortality. Other risk factors for all-cause and cardiovascular mortality were diabetes, inflammation, and malnutrition. However, future efforts are needed to assess whether a risk-based approach, including VC screening, improves survival.

Differences in association between hypoalbuminaemia and mortality among younger versus older patients on haemodialysis

Background

Ageing often affects biomarker production. Yet, clinical/optimal thresholds to guide clinical decisions do not consider this. Serum albumin decreases with age, but hypoalbuminaemia is defined as serum albumin <4.0 g/dl. This study explores whether age might affect serum albumin levels and its association with mortality in haemodialysis patients.

Methods

COSMOS (Current Management of Secondary Hyperparathyroidism: a Multicentre Observational Study) is a prospective, open-cohort, observational study of haemodialysis patients followed for 3 years. Binary logistic and linear regression were used to analyse the association between age and hypoalbuminaemia or serum albumin (continuous). Cox proportional hazard multivariate regression was used to examine the relationship between hypoalbuminaemia and mortality in patients younger and older than 65 years. Time-dependent receiver operating characteristic (ROC) curves were used to assess the discriminatory ability of serum albumin and optimal thresholds for predicting mortality.

Results

The present analysis included 5585 patients. The odds of experiencing hypoalbuminaemia increased with age [adjusted odds ratios = 1.56(95%CI: 1.31-1.86), 1.89(95%CI: 1.59-2.24), 2.68(95%CI: 2.22-3.23) for 56-65, 66-75, and >75 years, respectively (reference ≤55 years; P value for trend: <0.001)]. Survival analysis showed that the association between hypoalbuminaemia and mortality was weaker in patients aged ≥65 compared to <65 years [hazard ratios: 1.36(95%CI: 1.17-1.57) and 1.81(95%CI:1.42-2.31) respectively; P value for interaction 0.004]. The ability of albumin levels to predict mortality was consistently higher in younger patients. Optimal albumin thresholds for predicting mortality were 3.7 g/dl in patients younger than 65 years and 3.5 g/dl in patients 65 years and older.

Conclusions

Ageing is accompanied by lower albumin levels, and the association between hypoalbuminaemia and mortality may be modified by age. Different clinical thresholds that consider age may better discriminate risks associated with hypoalbuminaemia.

Impact of Handgrip Strength on Survival in Hemodialysis Patients

Background: Hemodialysis patients face a high mortality risk, requiring effective clinical assessments. In these patients, muscle wasting due to protein-energy wasting (PEW) leads to increased frailty, which is strongly associated with worse outcomes, including higher mortality. As muscle mass declines, so does functional capacity, making regular assessment of both muscle mass and function critical for prognostic evaluation. Handgrip strength (HGS) offers a quick and reliable measure of muscle strength and functional capacity. In this study, we focused on the impact of HGS on survival in hemodialysis patients, analyzing its relationship with muscle mass and BMI. Methods: This retrospective cohort study included 408 dialysis patients (221 males, 187 females) who underwent bioimpedance spectroscopy (BIS) and HGS assessments between March 2021 and August 2023. Data collected included BIS profiles, HGS, dialysis status, age, complete blood count, blood chemistry, mortality, and CONUT scores. Results: Cox proportional hazards regression analysis revealed that lean tissue index (LTI) (HR 3.30, 95% CI 1.75-6.19), body mass index (BMI) (HR 2.65, 95% CI 1.17-6.01), and handgrip strength (HGS) (HR 4.22, 95% CI 2.05-8.70) were significant predictors of survival in the overall dialysis patient cohort. Gender-specific analysis showed that in males, both LTI (HR 4.81, 95% CI 1.89-12.23) and HGS (HR 5.45, 95% CI 2.18-13.61) significantly predicted survival. In females, HGS (HR 6.01, 95% CI 2.42-14.94) was a significant predictor, while LTI was also significant (HR 3.22, 95% CI 1.24-8.40, p = 0.017). In the multivariate Cox proportional hazards analysis, which adjusted for age, diabetes mellitus (DM), hypertension (HTN), BMI, fat tissue index (FTI), LTI, serum albumin, C-reactive protein (CRP), and CONUT score, HGS remained a significant predictor of survival in female dialysis patients (HR 2.77, 95% CI 1.00-7.65, p = 0.049). Conclusions: HGS has been identified as an important factor for survival in dialysis patients, particularly in female patients, independent of muscle mass and BMI.

Intradialytic oral nutrition effects on malnourished hemodialysis patients: a randomized trial

Oral nutritional supplementation (ONS) is recommended for malnourished hemodialysis patients when their nutritional intake remains inadequate to meet energy and protein requirements. Patients were randomized into two groups: the intradialytic ONS supplements (INTRA-ONS) group (N = 16) and the interdialytic ONS supplements (INTER-ONS) group (N = 16) for a duration of 12 weeks. Malnutrition inflammation score (MIS) and serum albumin levels were assessed. The total MIS decreased significantly in patients from both the INTRA-ONS group (- 6.13, 95% CI - 8.29 to - 3.96) and the INTER-ONS group (- 3.50, 95% CI - 5.56 to - 1.35). A significant difference in the change of MIS was observed between the two groups (- 3.06, 95% CI - 5.94 to - 0.17). No significant differences were observed between the groups concerning serum albumin levels, dietary intake, anthropometric measurements, or body weight. Intradialytic ONS demonstrates similar benefits on nutritional biomarkers but improves the MIS among malnourished ESRD patients compared to interdialytic ONS.Trial registration Thai Clinical Trials Registry (TCTR) identification number is TCTR20220322007: 16/09/2021.

Adipokines and Myokines as Markers of Malnutrition and Sarcopenia in Patients Receiving Kidney Replacement Therapy: An Observational, Cross-Sectional Study

Chronic kidney disease (CKD) is linked to an elevated risk of malnutrition and sarcopenia, contributing to the intricate network of CKD-related metabolic disorders. Adipokines and myokines are markers and effectors of sarcopenia and nutritional status. The aim of this study was to assess whether the adipokine-myokine signature in patients on kidney replacement therapy could help identify malnutrition and sarcopenia. The study involved three groups: 84 hemodialysis (HD) patients, 44 peritoneal dialysis (PD) patients, and 52 kidney transplant recipients (KTR). Mean age was 56.1 ± 16.3 years. Malnutrition was defined using the 7-Point Subjective Global Assessment (SGA) and the Malnutrition-Inflammation Score (MIS). Sarcopenia was diagnosed based on reduced handgrip strength (HGS) and diminished muscle mass. Concentrations of adipokines and myokines were determined using the enzyme-linked immunosorbent assay (ELISA). 32.8% of all study participants were identified as malnourished and 20.6% had sarcopenia. For malnutrition, assessed using the 7-Point SGA, in ROC analysis albumin (area under the curve (AUC) 0.67 was the best single biomarker identified. In dialysis patients, myostatin (AUC 0.79) and IL-6 (AUC 0.67) had a high discrimination value for sarcopenia, and we were able to develop a prediction model for sarcopenia, including age, albumin, adiponectin, and myostatin levels, with an AUC of 0.806 (95% CI: 0.721-0.891). Adipokines and myokines appear to be useful laboratory markers for assessing malnutrition and sarcopenia. The formula we propose could contribute to a better understanding of sarcopenia and potentially lead to more effective interventions and management strategies for dialysis patients.

The impact of malnutrition on the effectiveness of intradialytic exercise in hemodialysis patients: amulticenter cohort study

PURPOSE

Low physical function can be effectively improved via intradialytic exercise. However, the association between the effects of intradialytic exercise on physical function and malnutrition severity has not been studied extensively. This study aimed to investigate the impact of nutritional status severity on physical function in patients undergoing hemodialysis with low physical function to whom intradialytic exercise was prescribed.

METHODS

The participants were patients with decreased mobility [walking speed < 1.0 m/s and/or Short Physical Performance Battery (SPPB) < 12] who had been undergoing hemodialysis thrice a week for 6 months and performing intradialytic exercise program. Patients were divided into groups based on the Geriatric Nutritional Risk Index (GNRI) [Non-malnutrition group (GNRI > 98), Gentle/slim malnutrition group (GNRI ≤ 98, GNRI ≥ 92), Mild malnutrition group (GNRI < 92, GNRI ≥ 82), Severe malnutrition group (GNRI < 82)]. The primary outcomes were Grip strength, isometric knee extension strength (IKES), SPPB, and 10-m walking speed measured at baseline and at 6 months. Statistical analyses were performed using a linear mixed-effects model with the intention-to-treat analysis, including within-group analysis and between-group comparison.

RESULTS

A total of 805 participants were included in the study. Within-group comparisons showed significantly improved IKES, 10-m walking speed, and SPPB improved, except in the Severe malnutrition group. Grip strength significantly improved in the Gentle/slim and mild malnutrition groups. Between-group comparison with controls showed that the improvement in Grip strength was significantly bigger in the Gentle/slim malnutrition group [0.98 (0.15 to 1.82) kg] than in the non-malnutrition group. However, IKES in the Severe malnutrition group [- 5.14 (- 9.18 to - 1.10) %] less significantly improve than that in the non-malnutrition group. No significant differences were found in the other indices.

CONCLUSION

In patients with severe malnutrition, the changes in IKES scores resulting from Intradialytic exercise were significantly smaller than those observed in non-malnourished patients. Therefore, it is necessary to initiate suitable nutritional and exercise therapy based on the severity of malnutrition.

Evaluation of laboratory values affecting mortality of end-stage renal disease patients: a competing risks approach

BACKGROUND

Chronic Kidney Disease (CKD) is a prevalent and life-threatening situation recognized as an emerging health issue. The present study aimed to evaluate the effect of demographic and laboratory parameters on the survival of patients with End-Stage Renal Disease (ESRD) in a hemodialysis (HD) center in Iran.

MATERIALS AND METHODS

This study was conducted on patients receiving chronic HD in Iran Helal Pharmaceutical and Clinical Complex between 2014 and 2018. The survival time was considered as the time interval between HD initiation and death. Receiving kidney transplantation was regarded as a competing risk, and an improper form of two-parameter Weibull distribution was utilized to simultaneously model the time to both death and renal transplantation. The Bayesian approach was conducted for parameters estimation.

RESULTS

Overall, 29 (26.6%) patients expired, and 19 (17.4%) received kidney transplants. The male gender was related to poor survival, having nearly 4.6 folds higher hazard of mortality (90% HPD region: 1.36-15.49). Moreover, Serum calcium levels [Formula: see text]9.5 mg/dL (adjusted Sub-hazard ratio (S-HR)=2.33, 90% HPD region: 1.05-5.32) and intact parathyroid hormone (iPTH) [Formula: see text]150 pg/mL (adjusted S-HR = 2.56, 90% HPD region: 1.09-6.15) were associated with an elevated hazard of mortality. The cumulative incidence function (CIF) for transplantation was greater than death in the first two years of the study. Subsequently, the CIF for death exceeded transplantation in the following two years. The 4-year cumulative incidence of death and kidney transplantation was 63.7% and 36.3%, respectively.

CONCLUSION

Male gender, hypercalcemia, and hypoparathyroidism were associated with worse outcomes. Correcting mentioned laboratory parameters may improve patients' survival in the HD population.

Association of Hyperkalemia and Hypokalemia with Patient Characteristics and Clinical Outcomes in Japanese Hemodialysis (HD) Patients

This study aimed to examine the characteristics and clinical outcomes of Japanese hemodialysis patients with dyskalemia. A retrospective study was conducted using a large Japanese hospital group database. Outpatients undergoing thrice-a-week maintenance hemodialysis were stratified into hyperkalemia, hypokalemia, and normokalemia groups based on their pre-dialysis serum potassium (sK) levels during the three-month baseline period. Baseline characteristics of the three groups were described and compared for the following outcomes during follow-up: all-cause mortality, all-cause hospitalization, major adverse cardiovascular events (MACE), cardiac arrest, fatal arrythmia, and death related to arrhythmia. The study included 2846 eligible patients, of which 67% were men with a mean age of 65.65 (SD: 12.63) years. When compared with the normokalemia group (n = 1624, 57.06%), patients in the hypokalemia group (n = 313, 11.00%) were older and suffered from malnutrition, whereas patients in the hyperkalemia group (n = 909, 31.94%) had longer dialysis vintage. The hazard ratios for all-cause mortality and MACE in the hypokalemia group were 1.47 (95% confidence interval [CI], 1.13–1.92) and 1.48 (95% CI, 1.17–1.86), respectively, whereas that of death related to arrhythmia in the hyperkalemia group was 3.11 (95% CI, 1.03–9.33). Thus, dyskalemia in maintenance hemodialysis patients was associated with adverse outcomes, suggesting the importance of optimized sK levels.

Influence of Malnutrition on the Improvement of Physical Function by Intradialytic Resistance Exercise in Patients Undergoing Hemodialysis

OBJECTIVE

Intradialytic exercise improves physical function. However, malnutrition may be an essential factor affecting the effectiveness of exercise to improve physical function. Few studies of the relationship between malnutrition and the effectiveness of intradialytic exercise to improve physical function exist. Therefore, this study investigated malnutrition at the beginning of intradialytic exercise and how it affects the subsequent improvement in physical function.

METHODS

Patients who performed intradialytic exercise for 12 months were enrolled in this study. A Geriatric Nutritional Risk Index of 91.2 was defined as malnutrition. Patients were assigned to 2 groups using propensity score matching to adjust for confounding factors. Physical function outcomes were handgrip strength, isometric knee extension strength, short physical performance battery, and 10-m walking speed; these were compared at baseline, 3 months, 6 months, and 12 months. The 2 groups were further divided into another 2 groups as per whether the nutritional status had improved after 12 months; therefore, a total of 4 groups were analyzed.

RESULTS

After matching, the data of 154 patients in each group were analyzed. During the intragroup comparison, isometric knee extension strength, short physical performance battery, and 10-m walking speed improved significantly in both groups after intradialytic exercise was started compared with before intradialytic exercise was started. However, there was no significant improvement in handgrip strength in the malnutrition group. There were no significant differences in any of the physical function measurements or changes from the baseline values among the 4 groups divided as per subsequent recovery of the nutritional status.

CONCLUSION

Malnutrition may not impact the effectiveness of intradialytic exercise to improve lower-leg physical function. Its effect on the improvement of handgrip strength requires further investigation.

Consistency of MIS with other malnutrition screening tools among adult and elderly hemodialysis patients

BACKGROUND AND AIM

Malnutrition and inflammation commonly occur concomitantly among hemodialysis patients. Malnutrition inflammation score (MIS) is a tool that helps clinical and nutritional evaluation of patients regardless of age. This study aimed to determine the best approach by comparing different tools/indices to evaluate the malnutrition and inflammation status of patients having hemodialysis treatment regarding their age and to examine the clinical benefits and consistency of MIS with other malnutrition tools.

METHODS

The study was conducted with a sample of 140 hemodialysis patients (70 adults and 70 elderly patients). The biochemical data of the patients were retrospectively obtained, and the research dietitian conducted the anthropometric measures. In addition to MIS, 7 point-SGA (7p-SGA), Nutrition Risk Index (NRI) for adults, and Mini Nutritional Assessment (MNA), Geriatric Nutritional Risk Index (GNRI) for elderly patients were used. The model's discriminatory power was examined by receiver operating characteristics curve analysis.

RESULTS

Patients who were "at-risk" according to MIS had significantly lower scores of 7p-SGA and NRI than those who had "no risk" (p<0.001). Moreover, those who are "at-risk" have significantly lower MNA scores than those who are not (p=0.002). Among adult patients, MIS displayed lower sensitivity but higher specificity with NRI than 7p-SGA. However, for elderly patients, MIS showed fair sensitivity and specificity with MNA but the highest sensitivity with GNRI.

CONCLUSION

Although different screening tools are available to screen malnutrition among dialysis patients regarding their age, MIS might be more clincally useful as it is more susceptible to assess both malnutrition and inflammation that occur concomitantly.

Increased Predialysis Extracellular to Intracellular Water Ratio Is Associated With Sarcopenia in Hemodialysis Patients

OBJECTIVE

To explore the association between fluid overload, evaluated by a new fluid overload indicator, the bioelectrical impedance analysis-derived whole-body extracellular to intracellular water ratio (ECW/ICW), and sarcopenia in maintenance hemodialysis (MHD) patients.

METHODS

A multicenter, cross-sectional study that included 3320 adult MHD patients was conducted in 20 hemodialysis centers of Guizhou Province, Southwest China from June 1, 2020, to September 30, 2020. The diagnosis of sarcopenia was based on the Asian Working Group's definition of sarcopenia. Multiple logistic regression models, stratified analyses, and interactive analyses were conducted.

RESULTS

A total of 3196 participants were included in the final analysis. The prevalence of sarcopenia was 36.2% in the total population. The prevalence of sarcopenia was increased with increasing quartiles of ECW/ICW (18.1%, 33.3%, 37.8%, and 55.4% for the first, second, third, and fourth quartiles, respectively). Increased ECW/ICW was significantly associated with sarcopenia. The association remained statistically significant even after adjusting for age, sex, body mass index (BMI), dialysis vintage, C-reactive protein, and various medical histories. The odds ratios were 2.11 (1.41, 3.14), 1.83 (1.22, 2.76), and 3.45 (2.21, 5.39) for ECW/ICW quartiles 2-4, respectively (P for trend <.001). The interaction analysis showed that history of diabetes had an interactive role in the association between ECW/ICW and sarcopenia (P for interaction = .034). The association stably existed across subgroups and was more prominent in older patients and those with higher BMI and a history of diabetes.

CONCLUSIONS

Elevated ECW/ICW was associated with increased sarcopenia risk independent of BMI, prealbumin, C-reactive protein, and other potential confounders in MHD patients. The association was more prominent in older patients and those with higher BMI and a history of diabetes, suggesting that controlling volume balance may help to reduce the occurrence of sarcopenia in these populations.

Prognostic value of creatinine-to-cystatin c ratio in patients with type 2 diabetes mellitus: a cohort study

BACKGROUND

The serum creatinine-to-cystatin C ratio (Scr/Scys) has been suggested as a surrogate marker of muscle mass and a predictor of adverse outcomes in many diseases. However, the prognostic value of Scr/Scys in patients with type 2 diabetes mellitus (T2DM) is unknown. The aim of this study is to assess the prognostic value of Scr/Scys in patients with T2DM.

METHODS

In this retrospective observational study, we enrolled 3668 T2DM patients undergoing coronary angiography (CAG). Serum creatinine (Scr) and serum cystatin C (Scys) levels were measured at admission. The study population was separated into low muscle mass (low-MM) and normal muscle mass (normal-MM) groups by Scr/Scys cut-off point. The association between muscle mass and long-term all-cause mortality was examined using Cox regression analysis.

RESULTS

During a median follow-up of 4.9 (3.0-7.1) years, a total of 352 (9.6%) patients died. The mortality was higher in patients with low-MM as compared with patients with normal-MM (11.1% vs. 7.3%; p < 0.001). Low muscle mass was associated with increased risk for long-term all-cause mortality, regardless of whether Scr/Scys were used as a continuous variable (adjusted hazard ratio: 1.08 [95% confidence interval (CI) 1.03 to 1.13]; p = 0.009) or a categorial variable (adjusted hazard ratio: 1.36 [95% CI 1.03 to 1.75]; p = 0.021).

CONCLUSION

Low muscle mass assessed by Scr/Scys was associated with increased risk of long-term all-cause mortality in diabetic patients.

Nutrition and quality of life in chronic kidney disease patients: a practical approach for salt restriction

The clinical practice guidelines (CPGs) for nutrition in chronic kidney disease (CKD) were updated after 20 years from the previous guidelines by the Kidney Disease Outcomes Quality Initiative (KDOQI). During this period, the severity of CKD was defined by eGFR and albuminuria by the organization Kidney Disease: Improving Global Outcomes (KDIGO). Main risk factors for CKD such as hypertension, hyperlipidemia, obesity, metabolic syndrome, and diabetes mellitus are closely related to lifestyle. Nutritional management is important to prevent and retard the progression of CKD. Members of the International Society of Renal Nutrition and Metabolism (ISRNM) reviewed the KDOQI CPG draft. ISRNM is an international scientific society comprising members of multiple subspecialties. ISRNM proposed the medical term protein-energy wasting (PEW), which is a keyword in renal nutrition. The prevalence of PEW among dialysis patients is high. The success of dietary therapy depends on adherence to the diet. It has to be palatable, otherwise eating habits will not change. To prevent the development and progression of CKD and PEW, regular consultation with an expert dietitian is required, especially regarding salt and protein restriction. Our cluster-randomized trial showed that intervention by a dietician was effective at retarding the progression of stage 3 CKD. In this review, I focus on salt (sodium) restriction and introduce tips for salt restriction and Japanese kidney-friendly recipes. Due to the lack of randomized controlled trials, nutritional management of CKD inevitably relies on expert opinion. In this regard, well-designed observational studies are needed. Too strict salt restriction may decrease quality of life and result in PEW.

Disease-related malnutrition in chronic kidney disease

PURPOSE OF REVIEW

Disease-related malnutrition has complex and multifactorial pathophysiology. It is common in patients with chronic kidney disease (CKD) and has a devastating impact on morbidity and mortality. Given the rising numbers of patients diagnosed with CKD, disease-related malnutrition is an escalating clinical challenge. This review summarises current knowledge in relation to the development, screening and treatments for disease-related malnutrition in CKD.

RECENT FINDINGS

New research has identified other potential causes for the development of malnutrition in CKD, including changes in taste and smell, and effects of polypharmacy. Screening and assessment studies have investigated different tools in relation to the new Global Leadership Initiative on Malnutrition (GLIM) criteria. Different modalities of low protein diets and the potential use of pre and probiotics are being explored. Furthermore, the importance of nutritional support, and possibly exercise during dialysis is being examined in terms of reducing anabolic resistance and catabolism.

SUMMARY

Further research is required to better understand the nuances of the pathophysiology of disease-related malnutrition in CKD. This work should inform not only consistent terminology and the application of assessment tools specific to disease-related malnutrition in CKD but also the development of novel interventions that reflect its multifaceted pathophysiology and impact.

Status of Nutrition in Hemodialysis Patients Survey (SNIPS): Nutrition Intake in Obese and Overweight vs. Healthy Weight Patients

Elevated body mass index (BMI) has been associated with improved survival and fewer hospitalizations in hemodialysis patients; however, it is not clear that dietary intake is associated with increased BMI in hemodialysis patients. The present analysis was designed to compare energy and macronutrient intake and distribution, as well as compliance with the International Society of Renal Nutrition and Metabolism (ISRNM) dietary guidelines, by body weight status (overweight/obese vs. normal weight) in hemodialysis patients. The status of nutrition in hemodialysis patients survey (SNIPS) cohort is a cross-sectional study including a representative sample of individuals on hemodialysis treated in hospital dialysis centers throughout Israel. Of the 375 patients eligible for the current analysis, 60.1% had BMI ≥ 25 kg/m2 (overweight/obese). For each participant, the following measures were recorded: dietary intake, blood biochemistry, anthropometric and hemodynamic measures. These were compared by body weight status. Compared to their normal-weight counterparts, overweight/obese hemodialysis patients did not differ by energy and macronutrient intake, distribution of these nutrients in the diet. Regardless of body weight status, hemodialysis patients have poor compliance with ISRNM dietary guidelines.