A malnutrition-inflammation score is correlated with morbidity and mortality in maintenance hemodialysis patients

Construction and validation of a fall risk prediction model in elderly maintenance hemodialysis patients: a multicenter prospective cohort study

PURPOSE

To analyze the risk factors for falls in elderly maintenance hemodialysis patients, construct a nomogram prediction model and validate the application.

BACKGROUND

Elderly maintenance hemodialysis patients face a high risk of falls, and there are fewer and less effective fall-specific assessment tools.

METHOD

A total of 871 elderly hemodialysis patients from 9 hospitals in Chengdu City from October 2023 to December 2024 were selected as the study objects. Baseline characteristics and fall outcomes of patients in the fall group and non-fall group were recorded and compared through 6-month follow-up. Multivariable logistic regression analysis was employed to identify independent risk factors, and construct the nomogram prediction model and complete the internal verification of the model. 218 elderly maintenance hemodialysis patients from three other hospitals in Chengdu City were selected for a 6-month follow-up of falls from January to February 2024 to complete the external validation of the model.

RESULT

The incidence of falls in elderly maintenance hemodialysis patients was 31.96%, and logistic regression analysis showed that age, sex, visual impairment, intradialytic hypotension, cognitive impairment and depression were independent risk factors for falls. Both internal and external validation of the model demonstrated area under the curve greater than 0.80. Furthermore, calibration plots, the Hosmer-Lemeshow test, and clinical decision curves all demonstrated that the model had good calibration and clinical utility.

CONCLUSION

The nomogram constructed based on the above risk factors can provide scientific basis and practical tools for early clinical identification of high-risk groups of falls.

Impedance-derived phase angle as an indicator of physical function in maintenance hemodialysis patients

OBJECTIVES

Maintenance hemodialysis (MHD) patients often impairs physical function, leading to reduced quality of life and increased mortality. Phase angle (PhA), derived by bioelectrical impedance analysis, has been proposed as a predictor of sarcopenia, holds promise as a potential indicator of physical function. The aim of this study was to identify the association between PhA and physical function in MHD patients.

METHODS

This was a multicenter, cross-sectional study included MHD patients from seven dialysis centers from 2020 to 2021. Physical function was measured by handgrip strength (HGS), Short Physical Performance Battery (SPPB), 4-meter gait speed, and timed up and go test (TUGT). Nutritional status was assessed by malnutrition inflammation score (MIS). Body composition, including PhA at 50kHz, was measured by bioelectrical impedance analysis. Sarcopenia was diagnosed according to the 2019 update version of the Asian Working Group for Sarcopenia. Multivariable linear regression models were performed to determine the association between PhA and physical function.

RESULTS

A total of 864 patients (61% male, median age 63 years) were analyzed. The median PhA was 4.5 (interquartile range: 3.9-5.2)°. PhA was negatively associated with age, MIS, Charlson comorbidity index, extracellular water/total body water, visceral fat area, and TUGT, and positively associated with hemoglobin, serum albumin, body mass index, height, weight, skeletal muscle mass index (SMI), SPPB, 4-meter gait speed, and HGS. These associations were consistent across PhA values of whole body and five body segments-right arm, left arm, trunk, right leg, and left leg. Multivariable linear regression analyses indicated that PhA was independently associated with higher SPPB scores (β = 0.33, P < 0.001), faster gait speed (β = 0.29, P < 0.001), greater HGS (β = 0.28, P < 0.001) and shorter TUGT time (β = -0.20, P < 0.001) after fully adjusted for age, sex, spKt/V, dialysis vintage, Charlson comorbidity index, MIS and skeletal muscle index. Subgroup analyses confirmed the robust association of PhA with physical function across different patient characteristics including sarcopenia, malnutrition, age, sex, and diabetes.

CONCLUSIONS

Higher PhA was independently associated with better physical function in MHD patients. Our study suggested that PhA may serve as a non-invasive, reliable clinical indicator for assessing functional status in this population.

Assessing the Impact of Inflammation on Erythropoietin Resistance in Hemodialysis: The Role of the NLR

Background: The neutrophil-to-lymphocyte ratio (NLR) has emerged as a readily available marker of systemic inflammation and immune dysregulation. In patients undergoing hemodialysis, inflammation is a known contributor to erythropoietin resistance. However, the relationship between the NLR and the erythropoietin resistance index (ERI) has not been extensively characterized. Methods: A total of 317 hemodialysis patients were retrospectively evaluated and stratified into tertiles based on NLR levels. Biochemical, inflammatory, and anthropometric variables were compared across groups. Spearman's rank correlation was used to assess the relationship between the NLR and the ERI. Receiver operating characteristic (ROC) curve analysis was performed to evaluate the predictive ability of the NLR for erythropoietin resistance, defined as ERI > 10. Subsequently, linear and logistic regression models were employed to examine the independent association between the NLR and the ERI, adjusting for relevant covariates. Results: Higher NLR tertiles were significantly associated with increased CRP, lower serum iron, and elevated ERI (p = 0.002). Spearman's analysis revealed a modest but significant correlation between the NLR and the ERI (ρ = 0.31, p < 0.0001). ROC analysis identified an NLR threshold of 4.4 for detecting ERI > 10. In multivariable analysis, the NLR was independently associated with the ERI both as a continuous variable (β = 0.848, p = 0.046) and as a binary outcome (OR = 1.22, 95% CI: 0.95-1.24, p = 0.0021), while serum iron and hemoglobin also emerged as significant predictors. Conclusions: In this cohort of hemodialysis patients, a higher NLR was independently associated with increased erythropoietin resistance, suggesting its potential utility as an accessible inflammatory biomarker in anemia management. These findings add to the limited but growing body of evidence supporting the prognostic role of the NLR in dialysis populations and warrant further validation in prospective studies.

Sex-based variations in the nutritional and functional status of hemodialysis patients in Palestine: a cross-sectional study

INTRODUCTION

Hemodialysis affects patients' nutritional status in several ways, resulting in malnutrition, which, in turn, increases the rates of morbidity and mortality worldwide. The main aim of this study was to comprehensively examine the effect of sex-based differences on the nutritional status of Palestinian patients on hemodialysis.

METHODOLOGY

This study involved hemodialysis patients from An-Najah National University Hospital (NNUH) at Nablus/Palestine. A structured questionnaire was used in this study to collect data about sociodemographic data, medical history, lifestyle habits, and functional status, as well as nutritional status, which was assessed using 4 components (anthropometric measurements, biochemical data, clinical data, and dietary data). Patients' reports were reviewed to obtain laboratory values. The malnutrition-inflammation score was used to assess the prevalence of malnutrition. Data were analyzed using univariate and multivariate analysis.

RESULTS

A total of 188 hemodialysis patients participated in the study. The mean age was 57.8 ± 14.0 years, ranging from 19 to 86 years old. Females were more likely to experience nausea and headache during hemodialysis than men (p < 0.05). The findings also showed that the MIS score was significantly higher in women than in men. Biochemical findings revealed that female patients had significantly lower levels of blood urea nitrogen (p = 0.003), carbon dioxide (p = 0.020), ferritin levels (p = 0.025), and serum phosphate levels (p = 0.000). In addition, women had significantly lower intakes of total carbohydrate, total fat, saturated fat, monounsaturated fatty acids, water, vitamin B1, vitamin B2, vitamin B3, calcium, phosphate, sodium, and zinc, except for vitamin B12, which was higher in females. Furthermore, functional assessments indicated that males have significantly higher handgrip strength than females, while females represented more severe malnutrition compared to males.

CONCLUSION

Our data indicates that women have more severe malnutrition compared to men, suggesting the need to consider sex-based nutritional and functional differences in hemodialysis patients by healthcare professionals.

Association between Hemoglobin-albumin-lymphocyte-platelet score and all-cause or cardiovascular mortality in patients with diabetes or prediabetes: mediated effects of renal function

OBJECTIVE

Hemoglobin-albumin-lymphocyte-platelet (HALP) score is considered to be a comprehensive indicator of inflammation and nutrition. We aimed to investigate the relationship of HALP score and the risk of all-cause and cardiovascular disease (CVD) mortality in patients with diabetes (DM) or prediabetes (PDM).

METHODS

6,869 participants with DM or PDM from the National Health and Nutrition Examination Survey (NHANES) 2005 to 2018 were enrolled. The colleration of HALP score with all-cause and CVD mortality was evaluated using Kaplan-Meier, Cox regression and restricted cubic spline (RCS) methods. The predictive value of HALP score for mortality was evaluated by time-dependent-receiver-operating-characteristic (ROC) curves. Finally, subgroup and interaction analysis were performed.

RESULTS

1203 deaths from all-cause and 399 deaths from CVD were observed. Cox regression analyses showed that the HALP score was negatively correlated with both all-cause and CVD mortality risk. RCS curves showed a nonlinear relationship between HALP score and all-cause or CVD mortality risk, and both the dose-response curves are L-shaped. For all-cause mortality risk, the AUC was 0.805, 0.799, and 0.816 for 3, 5, and 10 years survival, respectively, and for CVD mortality risk, the AUC was 0.839, 0.850, and 0.837 for 3, 5, and 10 years of survival, respectively. Mediation analysis showed that serum creatinine and urea nitrogen partially mediate the relationship between HALP and mortality risk.

CONCLUSION

HALP score is negatively correlated with all-cause and CVD mortality risk, and serves as a valuable predictor of all-cause and CVD mortality risk in patients with DM or PDM.

CLINICAL TRIAL NUMBER

Not applicable.

Adherence to a Healthy Plant-Based Diet and Cardiovascular-Kidney-Metabolic Risk Factors in Patients with Moderate to Advanced Chronic Kidney Disease

OBJECTIVE

The confluence of cardiovascular-kidney-metabolic (CKM) risk factors and chronic kidney disease (CKD) elevates the risk for adverse cardiovascular and kidney outcomes. Mounting evidence has emerged on the benefits of plant-based diets for CKD management. However, whether the benefits are mediated by improved CKM health are unclear. In addition, there remain concerns about the risk of malnutrition and hyperkalemia associated with plant-based diets. The objective of this study was to assess the relationship between adherence to healthy plant-based diets and CKM syndrome, nutritional status, and serum potassium levels in patients with nondialysis CKD stages 3-5.

METHOD

A total of 147 patients (median age 66 years) with CKD (median eGFR 23.1 mL/min/1.73 m2) were included. Responses to a food frequency questionnaire developed for the Asian population with CKD were used to calculate a healthy plant-based diet score (HPDS), which reflects higher consumption of plant foods and reduced intake of animal products and sugar. CKM risk factors included overweight/obesity, central obesity, high blood pressure, high triglycerides, and high blood glucose. Nutritional status was assessed using serum albumin and dietary energy and protein intake.

RESULTS

In logistic regression analyses, a higher HPDS was significantly associated with lower odds of all CKM risk factors and malnutrition. After adjusting for age, sex, comorbidities, lifestyle factors, and medications, a higher HPDS remained significantly linked to lower odds of overweight/obesity and central obesity, as well as higher odds of having a normal serum albumin level (≥ 3.8 g/dL), dietary protein intake (≥ 0.6 g/kg/day), and dietary energy intake (≥ 25 g/kg/day). No significant association was observed between HPDS and hyperkalemia.

CONCLUSIONS

In patients with moderate to advanced CKD, healthy plant-based diets were associated with a lower risk of CKM syndrome. Adherence to a healthy plant-based diet was more likely to achieve a better nutritional status and was not associated with risk of hyperkalemia.

Nutritional risk assessment in hemodialysis patients: A comparative analysis of modified creatinine index, geriatric nutritional risk index and simple protein-energy wasting score with malnutrition-inflammation score

BACKGROUND AND AIMS

Nutritional status has a great impact on the prognosis of maintenance hemodialysis patients. Therefore, its management should be a priority, and risk screening frequent and easily implemented, based on the biochemical and clinical routine parameters already available, when the use of more comprehensive tools is not possible. Many tools fit these simple criteria, namely the modified creatinine index, geriatric nutritional risk index, and simple protein energy wasting score. These scores are associated with mortality and morbidity risk in hemodialysis patients. This study aims to confirm that these scores are significantly associated with all-cause mortality and to compare them with malnutrition inflammation score.

METHODS

Historical cohort study of hemodialysis patients from 25 outpatient clinics. The nutritional and inflammation status was assessed at baseline with malnutrition-inflammation score, geriatric nutritional risk index, modified creatinine index, and simple protein-energy wasting score. Univariable and multivariable Cox additive regression models were used to analyse data. Partial likelihood ratio tests to compare the performance of non-nested Cox models were used.

RESULTS

We analysed 2322 patients, 59 % males, 31.7 % diabetic, with a median age of 70 years (P25 = 60, P75 = 79), during a median follow-up period of 45 months (P25 = 31; P75 = 45). All-cause mortality was observed in 778 patients (33.5 %). The median of the modified creatinine index was 19.9 mg/kg/day (P25 = 18.6, P75 = 23.2), and a higher index value was observed for the surviving patients (p < 0.001). Regarding geriatric nutritional risk score, a median of 106.6 (P25 = 99.4, P75 = 114.2) was observed, being significantly higher in the survival group (p < 0.001). Simple protein-energy wasting score lower values were more frequent in the group of deceased patients (p < 0.001). For the malnutrition-inflammation score the median was 6 (P25 = 4, P75 = 8), and 50.6 % of the patients had a score ≥6, with higher scores being more frequent in the deceased group (p < 0.001). Partial likelihood ratio tests showed that the malnutrition-inflammation score only fitted better than the model including simple protein-energy wasting score. All scores had a good discriminative performance with Harrell's C-statistic ranging from 0.71 to 0.73. Malnutrition-inflammation score and modified creatinine index models attained the highest values.

CONCLUSION

All the tools were significantly associated with mortality. The geriatric nutritional risk index was the score that performed most similarly to the malnutrition-inflammation score.

Investigating the complex relationship and influencing factors of frailty on nutritional status in maintenance hemodialysis patients

INTRODUCTION

Given the high prevalence and significant challenges of frailty, a state of increased vulnerability to adverse health outcomes, among maintenance hemodialysis (MHD) patients, this cross-sectional study aimed to investigate its prevalence and explore its association with nutritional status and other relevant factors.

METHODS

The study involved 290 MHD patients with an average age of 52.98 ± 13.65 years. Frailty assessments, nutritional evaluations, and medical status measurements were performed. Data analysis involved descriptive statistics, correlation analyses, and multivariate logistic regression.

RESULTS

Among the patients, 70.3% were identified with frailty (16.9% frail, 53.4% pre-frail). Frailty was more prevalent in female patients compared to males and correlated positively with age, marital status, caregiving needs, comorbidities, dialysis duration, and higher nutritional risk scores. Negative correlations were observed with serum albumin, hemoglobin, body weight, and height.

CONCLUSION

A significant prevalence of frailty was found in MHD patients, with notable associations to various demographic, clinical, and nutritional factors.

The Association Between Lifestyle and All-Cause Mortality in Patients Undergoing Maintenance Hemodialysis: A 3-year Prospective, Observational Study

Purpose

Lifestyle is one of the important factors affecting health. There are few studies that comprehensively analyze the impact of a combination of lifestyle factors on mortality in patients undergoing maintenance hemodialysis. So, to measure the association between lifestyle factors and mortality for patients undergoing maintenance hemodialysis.

Patients and Methods

A prospective, observational study design was employed. Through convenience sampling, the patients who are over 18 years old and have undergone dialysis for at least 3 months, from the hemodialysis center outpatient in two hospitals of Xi'an were selected. The questionnaires of this study include sociodemographic characteristics and lifestyle-related scales, such as nutrition, sleep and self-management scales. The differences between the deceased group and the surviving group were analyzed using the t-test or Mann-Whitney tests and chi-square tests. Logistic regression analysis was applied to identify the association between lifestyle factors and mortality.

Results

In this study, 286 patients who completed the questionnaire were screened. During the follow-up of this 3 years, patients who transferred to another hospital (n=31), kidney transplantation (n=6) and termination of dialysis (n=13) were excluded. Finally, 236 participants were tracked to the final outcome. Of these 236 patients, 66.95% were men. The proportion of patients under 60 years old is slightly higher than that of patients over 60 years old. More than half (64.83%) of the patients have a lower education level. And the main primary disease of ESRD was diabetic nephropathy (39.83%). Through a 3-year follow-up study, 73 patients died, accounting for 30.93%. The results showed that compared with surviving patients, deceased patients had significantly lower scores of self-management (Z=-2.09, P=0.036) and higher scores of malnutrition-inflammation score (Z=-2.31, P=0.021). Moreover, deceased patients had a significantly higher proportion of poor sleepers (χ2=4.38, P=0.036) and No exercise (χ2=5.16, P=0.023). However, there were no statistically significant differences in BMI, smoking history and drinking history between the two groups. In logistic analyses, age (χ2=19.63, P<0.001, OR=0.26, 95% CI=0.14~0.47) and self-management score (χ2=3.82, P=0.051, OR=1.03, 95% CI=1.00~1.06) were major factors related to mortality.

Conclusion

Self-management and age are closely related to the mortality rate of patients. And our study showed that the relationship between self-management and mortality is strongest, so doctors and nurses at dialysis centers should pay more attention to and actively improve self-management level of patients undergoing maintenance hemodialysis.

The 60:40 conundrum: are women with CKD discriminated after referral to a nephrology clinic?

Background

Epidemiological data show that chronic kidney disease (CKD) is more prevalent among females than males but the prevalence of women in dialysis is lower, as is their representation in nephrology trials. We aimed to test whether sex distribution varies at nephrology referral, inclusion in a trial, or at the starting of dialysis.

Methods

We evaluated patients' characteristics at the time of the first consultation in the Unit for the Care of Advanced CKD (UIRAV), at the inclusion in an observational study (PRO-RE-RE-PRO) and at the beginning of dialysis. Patient and renal survival analysis was performed in the pre-dialysis phase and after dialysis start. Reasons for denying participation to the proposed study and causes of death or withdrawal from follow-up and dialysis were likewise examined.

Results

During the period 2017-2023, 866 patients were referred to the UIRAV, 59% males and 41% females. Female patients were older, had lower comorbidity and were referred at the same eGFR than males. The same male/female proportion was observed in patients included in the PRO-RE-RE-PRO study and at dialysis start. Survival was significantly higher in females. Overall, distribution across sex remained stable over time.

Conclusions

Males and females are referred at similar eGFR levels, which appears to be the main reason for seeking nephrology care. Afterward, the ratio between males and females remains stable, suggesting that if a sex-selection bias exists, it should be sought before the first nephrology referral. However, further studies are needed to ensure that health equity is respected across sexes.

Evaluating the Oral Hygiene and Periodontal Status of Patients Undergoing Hemodialysis

Background Periodontal disease is a chronic inflammatory condition affecting the periodontium, which is induced by various pathogenic microorganisms. The severity and frequency of periodontal disease among patients undergoing hemodialysis are higher compared to healthy individuals. This study aimed to evaluate whether oral prophylaxis and proper oral hygiene maintenance help improve the periodontal condition of patients undergoing hemodialysis. Methodology In this study, 30 participants satisfying the inclusion criteria were selected. We assessed the oral hygiene (Oral Hygiene Index Simplified (OHI-S)) and the periodontal status (probing pocket depth (PPD) and clinical attachment level (CAL)) of the included participants. Non-surgical periodontal management comprising oral prophylaxis and oral hygiene maintenance instructions were provided one week before initiating hemodialysis. The patients were then re-examined after one and three months. At each visit, oral hygiene status and clinical periodontal examinations were performed, along with reinforcing oral hygiene instructions to all participants. Results The mean age of the study participants was 44.10 ± 5.02 years. Repeated-measures one-way analysis of variance was used to compare the mean OHI-S, CAL, and PPD at different periods (baseline, after one month, and after three months), followed by multiple comparison using Bonferroni test. There was a statistically significant improvement in oral hygiene status and periodontal parameters (PPD and CAL) after one month and three months (p < 0.001) while the patient continued with hemodialysis. Conclusions This study showed the potential benefits of oral prophylaxis, oral hygiene maintenance, and periodontal care in patients undergoing hemodialysis.

Upper normal serum magnesium is associated with a reduction in incident death from fatal heart failure, coronary heart disease and stroke in non-dialysis patients with CKD stages 4 and 5

Background

Serum magnesium disturbances are common in patients with cardiovascular disease (CVD). However, the well-established link between low serum magnesium and nutritional or inflammatory disorders has limited its consideration as a non-traditional risk factor for mortality. This study aims to elucidate the relationship between serum magnesium concentrations and mortality due to fatal heart failure (HF), coronary heart disease (CHD) and stroke in non-dialysis patients with chronic kidney disease (CKD) stages 4 and 5.

Methods

A cohort of 1271 non-dialysis patients with CKD stages 4 and 5 was followed from 2008 to 2018. Patients with prior major adverse cardiovascular events (MACE) were excluded. Serum magnesium levels were stratified into tertiles and the primary outcomes were incidence rates of fatal HF, CHD and stroke. Secondary outcomes included composite MACE and all-cause mortality. Hazard ratios (HRs) were calculated using multivariate Cox regression, adjusting for demographics, comorbidities and biochemical parameters. E-values were used to assess the robustness of the results.

Results

Over the 10-year follow-up, 186 patients died. Higher serum magnesium levels were significantly associated with reduced mortality risk from HF [HR 0.49 (95% CI 0.27-0.89) for T2; HR 0.31 (95% CI 0.16-0.60) for T3] compared with the lowest tertile. Similar trends were observed for CHD and stroke mortality. The incidence rate of MACE per 1000 person-years was reduced from 68.2 in tertile 1 to 26.2 in tertile 2 and 16.8 in tertile 3. Secondary endpoints, including all-cause mortality and composite MACE, followed trends similar to the primary outcomes.

Conclusions

Higher serum magnesium concentrations were associated with lower risks of death from fatal HF, CHD and stroke in non-dialysis patients with CKD stages 4 and 5.

Factors associated with malnutrition inflammation score among hemodialysis patients: A cross-sectional investigation in tertiary care hospital, Palestine

Malnutrition is a prevalent complication in hemodialysis patients and is associated with increased mortality and morbidity. This study aimed to identify the risk factors associated with malnutrition among hemodialysis patients including patient's general characteristics, functional status, and dietary intake. This study involved hemodialysis patients in An-Najah National University Hospital at Nablus/Palestine. An interview-based questionnaire was used to collect data related to sociodemographic, lifestyle, hemodialysis, medical history, anthropometrics, biochemical indices, dietary data using 3-days diet recall, and functional status. Malnutrition-inflammation score tool (MIS) was used for malnutrition screening of the studied patients. The study involved 188 patients, with a mean age of 57.8±14 years. A total of 28.2% participants are reported malnourished. Malnutrition was significantly associated with being female (p = 0.001), unemployed (p = 0.009), nonsmoker or ex-smoker (p = 0.018). Patients with CVDs (p = 0.006), higher months on dialysis (p = 0.002), lower BMI (p = 0.018), and using catheter for dialysis access are more likely to develop malnutrition (p = 0.018). Furthermore, patients with poor functional status (poor handgrip strength (p<0.001), inability to walk (p<0.001), needing help in daily activity or in transfer (p<0.001)) were significantly associated with malnutrition. Additionally, malnutrition was significantly higher among patients who does not meet their recommended calorie intake (p = 0.008), whose sodium intake within recommendation (p = 0.049), patients with low levels of hemoglobin (p = 0.022), albumin (p<0.001), TIBC (p = 0.002), phosphate (p<0.001), and patients with higher levels of ferritin (p<0.001). Higher months on dialysis (Exp(B) = 1.02), unmet calorie intake (Exp(B) = 4.3), needing help in daily activities (Exp(B) = 0.238), and low albumin level (Exp(B) = 0.048) were the independent predictors of malnutrition. This study highlights the significant association between malnutrition and various demographic, clinical, functional, and dietary factors in hemodialysis patients, revealing the burden of malnutrition during HD. It also necessitates targeted intervention to address these risk factors and improve nutritional status and the overall health outcomes of HD patients.

The adductor pollicis muscle thickness is not associated with physical function, lean mass, and nutritional status in patients on maintenance hemodialysis

Background

The adductor pollicis muscle thickness (APMT) may be associated with the muscle strength in patients on hemodialysis. However, the association of APMT with other physical function assessment tests has not yet been tested. Moreover, because it is considered a good nutritional indicator and not influenced by fluid overload, the APMT may be associated with the muscle mass and nutritional status of these patients. Therefore, the objective was to assess the association of APMT with physical function, muscle mass and nutritional status in patients on hemodialysis.

Methods

The APMT was measured using a skinfold caliper between pollicis finger and index finger. Physical function was evaluated by handgrip strength (HGS), Short Physical Performance Battery (SPPB), the sit-to-stand test, gait speed test, and timed up and go (TUG). Appendicular muscle mass index (AMMI) was estimated using bioelectrical impedance. The nutritional status was evaluated by the Malnutrition Inflammation Score (MIS).

Results

Fifty-one patients were included, 60.8% men, mean age 58.4 ± 12.6 years. There were no significant correlations of APMT with physical function, muscle mass and nutritional status. Values of APMT were not different between the groups according to adequate physical function or muscle mass. In the multiple linear regression analysis adjusted for sex, age and diabetes, APMT was not significantly associated with physical function tests, as HGS (β = 0.101; p = 0.778), gait speed (β = -0.014; p = 0.180), SPPB (β = -0.054; p = 0.590), TUG (β = 0.202; p = 0.109), lean mass AMMI (β = 0.058; p = 0.147).

Conclusion

There were no associations of APMT with physical function, muscle mass and nutritional status in patients on hemodialysis. We suggest APMT should not be used in physical function and nutritional assessments of these patients.

Nutritional Status of Patients Starting on Peritoneal Dialysis: A Comparison Between Planned and Unplanned Dialysis Initiation

OBJECTIVE

A suboptimal dialysis initiation with insufficient or no planning before urgent start of dialysis remains a common problem associated with increased morbimortality. Whether nutritional markers differ between patients starting peritoneal dialysis (PD) in unplanned and planned modes has not yet been explored. Therefore, we aimed to evaluate whether the nutritional status at the start of dialysis differed between patients with unplanned and planned PD initiation.

METHODS

In this observational study comprising 47 adult patients starting PD (age 58 ± 15 years, 51% female), 29 patients had unplanned (starting dialysis up to 72 hours after peritoneal catheter implantation) and 18 planned (follow-up predialysis >90 days) dialysis initiation. Within 30 days of PD initiation, nutritional status was evaluated using anthropometric measurements, multifrequency bioelectrical impedance analysis, appetite assessment, handgrip strength, laboratory markers, and the malnutrition-inflammation score. Physical activity and performance were also evaluated.

RESULTS

Patients with an unplanned PD initiation had a higher frequency of diabetes, higher blood glucose, urea, and glycated hemoglobin levels, and lower hemoglobin and albumin levels. Furthermore, they had a lower calf circumference, slower gait speed, higher protein intake, and greater malnutrition-inflammation score, while their physical activity level and appetite did not differ.

CONCLUSION

Patients with an unplanned PD had unfavorable clinical and nutritional markers compared with those with planned PD. These findings indicate that a lack of follow-up prior to dialysis initiation can influence the clinical and nutritional statuses of patients, reinforcing the importance of conservative treatment prior to dialysis initiation.

Prognostic Features for Overall Survival in Male Diabetic Patients Undergoing Hemodialysis Using Elastic Net Penalized Cox Regression; A Machine Learning Approach

BACKGROUND

Diabetics constitute a significant percentage of hemodialysis (HD) patients with higher mortality, especially among male patients. A machine learning algorithm was used to optimize the prediction of time to death in male diabetic hemodialysis (MDHD) patients.

METHODS

This multicenter retrospective study was conducted on adult MDHD patients (2011-2019) from 34 HD centers affiliated with Shiraz University of Medical Sciences. As a special type of machine learning approach, an elastic net penalized Cox proportional hazards (EN-Cox) regression was used to optimize a predictive regression model of time to death. To maximize the generalizability and simplicity of the final model, the backward elimination method was used to reduce the estimated predictive model to its core covariates.

RESULTS

Out of 442 patients, 308 eligible cases were used in the final analysis. Their death proportion was estimated to be 28.2%. The estimated overall one-, two-, three-, and eight-year survival rates were 87.6%, 74.4%, 67.2%, and 53.9%, respectively. The EN-Cox regression model retained 14 (out of 35) candidate predictors of death. Five variables were excluded through backward elimination technique in the next step. Only 6 of the remaining 9 variables were statistically significant at the level of 5%. Body mass index (BMI)<25 kg/m2 (HR=2.75, P<0.001), vascular access type (HR=2.60, P<0.001), systolic blood pressure (1.02, P=0.003), hemoglobin (11≤Hb≤12.5 g/dL: HR=3.00, P=0.028 and Hb<11 g/dL: HR=2.95, P=0.021), dialysis duration in each session≥4hour (HR=2.95, P<0.001), and serum high-density lipoprotein cholesterol (HDL-C) (HR=1.02, P=0.022) had significant effects on the overall survival (OS) time.

CONCLUSION

Anemia, hypotension, hyperkalemia, having central venous catheter (CVC) as vascular access, a longer dialysis duration in each session, lower BMI and HDL-C were associated with lower mortality in MDHD patients.

The Association of Odor Identification With Nutritional Status and Systemic Inflammation in Patients With Advanced Chronic Kidney Disease

OBJECTIVES

Anorexia is common in patients with chronic kidney disease (CKD) and could lead to protein-energy wasting (PEW). An altered sense of smell, a reflection of olfactory dysfunction, is a potential mechanism that exacerbates the impact of anorexia on PEW. In this study, we examined the extent of the altered sense of smell and its association with PEW in patients with moderate-to-advanced CKD.

METHODS

We studied 139 individuals (34 healthy subjects- controls, 50 patients with stage 3-4 CKD, and 55 patients on maintenance hemodialysis (MHD)) using the odor identification test (Sniffin' Sticks odor screening test containing 12 different smells). The odor identification test was scored as either correct or incorrect, and each participant's total odor score was calculated. Malnutrition inflammation score (MIS) was used to assess PEW.

RESULTS

Patients with CKD had higher C-reactive protein and lower serum albumin concentrations compared to healthy individuals. Total odor scores were different between groups, with controls having the highest scores and MHD patients having the lowest scores. A similar difference was observed in MIS, and MHD patients displayed the worst nutritional score (P ≤ .001). The number of participants with severe olfactory dysfunction (≤6 correct answers) was significantly higher in the CKD and MHD groups compared to the controls (P ≤ .01). There was an inverse trend between the total odor score and the MIS score for the study population. However, this relationship was not statistically significant (r = -0.124, P = .21).

CONCLUSION

This cross-sectional study suggests that olfactory dysfunction, as assessed by the odor identification test, is altered in patients with advanced CKD, most notably in ones on MHD. Although the diminished sense of smell was observed alongside development of PEW, we explicitly noted that there is no statistically significant correlation.

Change in adiposity indices after 1 year of peritoneal dialysis: a single-center cohort study

Background

Weight gain is common after starting peritoneal dialysis (PD). Several adiposity indices have been developed recently as potential indicators of visceral adiposity and lipid accumulation. We aim to investigate the prevalence and prognostic implications of the change in adiposity indices after 1 year of PD.

Methods

We recruited 110 patients treated with PD for 12 months. Adiposity indices, including triglyceride glucose index, lipid accumulation product, visceral adiposity index and conicity index, were measured at baseline and then 1 year after PD started. The relation between their changes (Δ) and other clinical and biochemical parameters, as well as survival and hospitalization rates were analyzed.

Results

After 1 year of PD, more than half of the patients had increased adiposity indices. The change in adipose tissue mass significantly correlated with the concomitant changes in triglyceride glucose index (ΔTyGI) (r = 0.25, P  = .01), lipid accumulation product (ΔLAP) (r = 0.27, P  = .007) and visceral adiposity index (ΔVAI) (r = 0.26, P  = .01). ΔTyGI significantly correlated with the change in insulin resistance as represented by homeostasis model assessment of insulin resistance (HOMA-IR) (r = 0.22, P  = .02), while ΔLAP and change in conicity index (ΔCI) correlated with the changes in various anthropometric parameters. However, no indices variation was associated with patient survival, technique survival or hospitalization rate.

Conclusions

Increased adiposity indices were common after 1 year of PD. The changes in adiposity indices had variable correlation with the change in adipose tissue mass, insulin resistance and anthropometric parameters. Further studies are required to identify simple metabolic parameters with a prognostic impact that could be suitable for serial monitoring.

The Surprise Question in Hemodialysis, Frailty, Nutrition, Patient-reported Quality of Life, and All-Cause Mortality: The Osaka Dialysis Complication Study (ODCS)

Rationale & Objective

A response "no" (SQ-No) to the surprise question (SQ) of whether a clinician would be surprised if a dialysis patient died in the next 6 months is associated with a higher risk of all-cause death. It is uncertain what domains are intuitively assessed with the SQ. We hypothesized that the SQ would assess the patient's frailty, malnutrition, or patient-perceived health-related quality of life in a cohort of patients on maintenance hemodialysis.

Study Design

Cohort study.

Setting & Participants

A multicenter study including 994 patients on maintenance hemodialysis in Japan.

Predictors

(1) SQ answered by nurses; (2) frailty by modified Cardiovascular Health Study criteria; (3) malnutrition as evaluated by Geriatric Nutritional Risk Index (GNRI); and (4) patient-perceived health-related quality of life examined by the 36-Item Short Form Health Survey (SF-36) physical component summary (PCS).

Outcomes

All-cause mortality.

Analytical Approach

Cox proportional hazard models.

Results

Median age and dialysis vintage were 66 and 5.9 years, respectively, 35.8% were women, and 39.6% had diabetic kidney disease. The prevalence of SQ-No and frailty was 19.7% and 45.9%. Median GNRI and SF-36 PCS scores were 96.3 and 36.9, respectively. During the 5-year follow-up, 247 patients died. SQ-No, being frail, low GNRI, and low SF-36 PCS were each significant predictors of a higher risk for mortality independent of potential confounders. SQ-No remained a significant predictor after further adjustment for frailty or GNRI, but SQ-No was no longer significant when adjusted for SF-36 PCS.

Limitations

We did not assess the agreement of responses to the SQ between different raters.

Conclusions

The predictive ability of the SQ was closely related to SF-36 PCS in hemodialysis patients. Nurses' answer to the SQ appears to assess the physical domain of patient-perceived health-related quality of life rather than objectively assessed frailty or malnutrition.

Intradialytic Parenteral Nutrition in Patients on Hemodialysis: A Multicenter Retrospective Study

BACKGROUND AND OBJECTIVE

To evaluate the effectiveness and safety of intradialytic parenteral nutrition (IDPN) on different nutritional outcomes.

METHODS

This was a retrospective analysis for a "routinely collected data bank" in a multicenter cohort, conducted on consecutive malnourished or at-risk of malnutrition patients with chronic kidney disease on hemodialysis who underwent IDPN with a three-in-one parenteral nutrition formula for a period ≥ 2 weeks. The primary endpoint was the mean change in the malnutrition inflammation score (MIS) score between baseline and the last follow-up visit on IDPN.

RESULTS

Fifty-six patients were included. The mean age was 72.4 ± 12.0 years, and 24 (42.9%) were women. In the overall study sample, MIS significantly decreased from 16.4 (95%CI: 15.3-17.65) at baseline to 14.3 (95%CI: 12.8-15.8) at the last follow-up visit on IDPN (p = 0.0019). Fifteen (26.8%) patients achieved a MIS reduction ≥ 5 points after IDPN. As compared to baseline, IDPN significantly reduced the proportion of patients with protein-energy wasting (PEW) (89.3% versus 66.1%, respectively, p = 0.0023). Regarding analytical parameters, serum albumin (p = 0.0003) and total proteins (p = 0.0024) significantly increased after IDPN administration. Throughout the study's follow-up period, 45 (80.4%) patients reported experiencing some type of adverse event.

CONCLUSIONS

IDPN was associated with a significant improvement in the nutritional profile. Notably, our research found that the administration of IDPN over a duration > 3 months significantly improved the nutritional status of patients evaluated by the MIS test.

Malnutrition-Inflammation Score of Patients with Chronic Kidney Disease from Early Stage to Initiation of Dialysis

Background: The malnutrition-inflammation score (MIS) is a practical and accessible tool for evaluating protein energy wasting (PEW) in patients on dialysis. However, the severity of PEW at each stage of chronic kidney disease (CKD), especially with late dialysis initiation, is unclear. Methods: We evaluated the MIS of 3659 patients with CKD stages 1-5 and the changes in their MIS results at baseline and at the time before dialysis initiation. Patients were defined to have PEW if they had a subjective global assessment (SGA) rating of C or lower. Results: The MIS increased substantially over a follow-up period of 6.12 years for 1124 patients just starting dialysis, with 49.3% having an MIS of 8. The pre-dialysis MIS was associated with baseline MIS, age, cardiovascular disease, and cancer. The prevalence of PEW based on an SGA rating of C or lower increased from 10.5% at baseline to 61.2% immediately before dialysis. The prevalence of PEW based on an MIS of ≥8 increased from 28.5% at baseline to 49.3% immediately before dialysis. In CKD stage 5 patients, 29.4% had PEW based on an MIS of 8 or less, and 11.6% had an SGA rating of C. The MIS was revealed to be associated with renal function, nutritional markers, and cardiometabolic disease (diabetes or cardiovascular disease). Conclusions: In conclusion, the MIS increased as CKD progressed to stages 4 and 5, as well as just prior to dialysis. Our study identified patients who required PEW assessment on the basis of their MIS results.

Independent Association Between Malnutrition Inflammation Score and C Reactive Protein/Albumin Ratio in Hemodialysis Patients

Introduction

This study aimed to investigate the relationship between the Malnutrition Inflammation Score (MIS) and the C-reactive protein/albumin ratio (CAR) in patients undergoing hemodialysis (HD).

Materials and Methods

Sixty-six End-Stage Renal Disease (ESRD) patients on maintenance hemodialysis were recruited for the study. Malnutrition Inflammation Score, biochemical parameters, and C-reactive protein/albumin ratio were analyzed.

Results

The mean age of the participants was 56.47 ± 17.3 years. A statistically significant positive correlation was found between the CRP/albumin ratio and MIS ≥7 (r = 0.413, p = 0.026), CRP and MIS ≥7 (r = 0.388, p = 0.038) and a negative correlation between albumin and MIS (r = -0.511, p = 0.005). Additionally, MIS was negatively correlated with hemoglobin (r = -0.412, p = 0.026) and creatinine (r = -0.568, p = 0.001), while a positive correlation was found between MIS and ferritin (r = 0.584, p = 0.001) for MIS ≥7. A multiple regression ANOVA model confirmed a significant association between CAR, CRP, albumin, and MIS (F = 6.432, p = 0.002), with significant contributions from CAR (p = 0.003), albumin (p = 0.008), and CRP (p = 0.003).

Conclusion

Our study is the first to show an independent association between CAR and MIS in hemodialysis patients. The CRP/albumin ratio can serve as a valuable indicator of malnutrition in this population, providing a reliable tool for assessing nutritional status.

Relationship between HALP and PNI score with 1-month mortality after CABG

Background

Coronary heart disease (CHD) is the most common cause of cardiovascular disease (CVD). CHD is among the most common causes of mortality and morbidity world wide. In addition, CHD is one of the most important causes of health expenditures world wide. Today, coronary artery bypass grafting (CABG) operations are a widely used surgical procedure and have an important place in the treatment of CHD. Many scoring systems have been evaluated to estimate the risk of mortality and morbidity. 30-day mortality rates after CABG have been reported as 1-4% in large-scale studies.

Objectives

The aim of our study was to evaluate the relationship between 1-month mortality in patients undergoing CABG and the Hemoglobin, albumin, lymphocyte, platelet index (HALP score) and Prognostic nutritional index (PNI) calculated using laboratory data in the preoperative period.

Methods and design

A total of 239 patients who underwent CABG were evaluated retrospectively. Preoperative biochemical and hemogram values, demographic characteristics, comorbidities, HALP score and PNI values of the patients were recorded. The patients were divided into two groups: Exitus group (n = 51) and survival group (n = 188). The data of the two groups were compared, mainly HALP score and PNI.

Results

It was observed that 51 of 239 patients (21.3%) developed exitus during the 30-day follow-up after CABG. When demographic data are compared; advanced age, female gender, history of DM (Diabetes Mellitus), history of HL (hyperlipidemia) and smoking were found to be associated with mortality. When laboratory data are compared; high troponin levels, low hemoglobin, low lymphocyte and low albumin levels were found to be associated with mortality. Low HALP score (p < 0.001) and low PNI (p < 0.001) were also found to be associated with mortality. In univariate and multivariate regression analysis; advanced age, history of DM, HALP score and PNI were found to be independent predictors of 30-day mortality after CABG. It was determined that a cut-off value of 0.29 for the HALP score and 39.1 for PNI had found, respectively, 81 and 79% sensitivity and 82 and 80% specificity.

Conclusion

Preoperatively measured HALP score and PNI can be used to predict 1-month mortality after CABG.

Growth hormone in pediatric chronic kidney disease: more than just height

Recombinant human growth hormone therapy, which was introduced in the 1980s, is now routine for children with advanced chronic kidney disease (CKD) who are exhibiting growth impairment. Growth hormone usage remains variable across different centers, with some showing low uptake. Much of the focus on growth hormone supplementation has been on increasing height because of social and psychological effects of short stature. There are, however, numerous other changes that occur in CKD that have not received as much attention but are biologically important for pediatric growth and development. This article reviews the current knowledge about the multisystem effects of growth hormone therapy in pediatric patients with CKD and highlights areas where additional clinical research is needed. We also included clinical data on children and adults who had received growth hormone for other indications apart from CKD. Ultimately, having robust clinical studies which examine these effects will allow children and their families to make more informed decisions about this therapy.

Prognostic role of nutritional and inflammatory indicators for patient survival and death with functional graft in living kidney transplant recipients

BACKGROUND

The clinical importance of nutrition and inflammation in patients with end-stage renal disease is well established. In this study, we investigated the role of nutritional and inflammatory indicators in the patient outcomes of living donor kidney transplant recipients.

METHODS

We included 204 consecutive patients who underwent kidney transplantation at our institute between 2003 and 2022. We retrospectively reviewed medical charts to obtain clinical information. Six nutritional indicators and two inflammatory indicators were assessed. Patient outcomes were investigated, and predictive factors were explored.

RESULTS

The median patient age and follow-up period were 48 years and 99 months, respectively. The cohort included patients with preoperative malnutrition and microinflammation. No significant differences in graft survival were identified according to nutritional and inflammatory indicators, whereas the survival index, controlled nutritional status, and C-reactive protein levels were associated with patient survival. The survival index was an independent indicator of survival and death in patients with functioning grafts (P = 0.047 and P = 0.013, respectively). Furthermore, the C-reactive protein level could distinguish between low and high mortality risks in patients with good nutrition (P = 0.019).

CONCLUSIONS

Our findings suggest that nutrition and inflammation indicators play important roles in predicting outcomes in living donor kidney transplantation recipients. Further research is warranted to establish optimal management strategies.

Association between protein energy wasting and peritoneal membrane transport in peritoneal dialysis

Introduction

Background: fast peritoneal transport (FT) has been associated with peritoneal albumin loss and protein energy wasting (PEW); however, this relationship has not been fully studied. Aim: the aim of this study was to analyze the differences in nutritional parameters between fast-transport peritoneal membrane (FT-PET) and slow-transport peritoneal membrane (ST-PET), and analyze the association between FT-PET and PEW in peritoneal dialysis (PD) patients. Methods: a cross-sectional study of patients on PD. Peritoneal transport characteristics were assessed using the peritoneal equilibration test (PET). Malnutrition inflammation score (MIS) was used for PEW identification. Clinical and biochemical characteristics between patients with and without PEW were assessed. Association between FT-PET status and PEW were evaluated using univariate and multivariate logistic regression. Results: a total of 143 patients were included. FT-PET group showed a higher prevalence of hypoalbuminemia, edema, lower phase angle, lower energy intake, and higher values of MIS score. FT-PET was significantly associated with PEW on univariate (OR: 3.5, 95 % CI: 1.56-7.83, p = 0.002) and multivariate models (OR: 2.6, 95 % CI: 1.02-6.6, p = 0.04). This association was maintained in patients where baseline PET was performed after initiating PD therapy (OR: 6.2, 95 % CI: 1.01-38.6, p = 0.04). Conclusion: FT-PET is associated with PEW evaluated by MIS score. Clinical trials to study nutritional interventions personalized to peritoneal-membrane transport characteristics should be designed.

Association between malnutrition-inflammation score (MIS) and quality of life in elderly hemodyalisis patients

INTRODUCTION

The malnutrition-inflammation process is one of the main causes of morbidity and mortality in patients with chronic kidney disease (CKD), influencing quality of life. The aim of this study was to identify the inflammatory and nutritional status of elderly hemodialysis (HD) and its association with quality of life.

METHODS

This study was carried out in health services in three different cities. The Malnutrition-Inflammation Score (MIS) was used to assess the inflammatory and nutritional status, with anthropometric measurements, protein status, lean mass and function. The quality of life was assessed using KDQOL-SFTM. Data were analyzed using multivariate analysis and the Poisson model to evaluate the factors that increased the risk of developing malnutrition and inflammation.

RESULTS

The MIS identified a 52.2% prevalence of malnutrition and inflammation in the population. In univariate analysis, most KDQOL-SFTM domains presented higher scores for nourished elderly. Anthropometric measures associated with muscle mass and functionality were lower in the malnourished elderly. Multivariate modeling revealed a higher nutritional risk of 50.6% for women and older age, since with each additional year of life the risk of malnutrition increased by 2.4% and by 0.4% with each additional month on HD. Greater arm muscle circumference (AMC) and higher serum albumin were factors for reducing malnutrition by 4.6% and 34.7%, respectively.

CONCLUSION

Higher serum albumin and preserved AMC have been shown to be good indicators of better nutritional status. Higher MIS was associated with poorer quality of life, older age, lower income and education, longer time on dialysis, and presence of comorbidities.

A Comparative Analysis of the SARC-F Questionnaire and the Malnutrition-Inflammation Score for Sarcopenia Risk Assessment and Negative Outcome Probability in Chronic Hemodialysis Patients

Background/Objectives: Protein-energy wasting (PEW) and sarcopenia are common in chronic hemodialysis (HD) patients, leading to numerous complications and increased mortality. This study aimed to compare the reliability of the SARC-F (Strength, Assistance in walking, Rise from a chair, Climb stairs, and Falls) and the Malnutrition-Inflammation Score (MIS) in assessing sarcopenia and predicting negative outcomes in HD patients. Methods: This cross-sectional study enrolled 109 HD patients. Nutritional assessments were performed, and blood samples were taken for routine blood laboratory investigations. The MIS was used as a scoring system to represent the severity of PEW, while the SARC-F was applied as an indicator of sarcopenia risk and general functional capacity. A multivariable logistic regression was conducted to analyze the association of several predictors with a negative cross-sectional outcome (death). Results: Patients with SARC-F scores ≥ 4 and MISs ≥ 6 were older, had significantly lower albumin and prealbumin levels, and more severe anemia. They were also more likely to report weight loss and poor appetite. A higher MIS was closely associated with unfavourable nutritional status according to the International Society of Renal Nutrition and Metabolism (ISRNM) criteria for PEW. However, in 71.25% of patients with satisfactory functional capacity (SARC-F scores 0-3), some form of PEW was still observed. After performing logistic regression modelling, only the MIS remained strongly associated with the probability of a negative outcome. Conclusions: The SARC-F alone often did not correspond to an increased sarcopenia risk or clear clinical and biochemical indicators of PEW in HD patients. When assessing nutritional risk in this group, it is recommended to use more detailed tools, such as the MIS, to ensure the accurate identification of those at the highest risk for negative outcomes.

Asymmetric dimethylarginine serum concentration in normal weight and obese CKD patients treated with hemodialysis

INTRODUCTION

Asymmetric dimethylarginine (ADMA), a cardiovascular risk factor, increases in renal failure. The aim of this study was to investigate ADMA levels in normal weight and obese patients on hemodialysis.

METHODS

In this cross-sectional study, 43 normal weight and 43 obese patients on regular hemodialysis were examined. Malnutrition-inflammation score (MIS), anthropometry, circulating ADMA, lipid profiles including triglycerides (TG), total cholesterol (TC), low-density lipoprotein (LDL), high-density lipoprotein (HDL) and lipid ratios, glucose homeostasis parameters, blood pressure, and high-sensitivity C-reactive protein (hs-CRP) were assessed.

RESULTS

Serum levels of ADMA were significantly lower in the obese compared to the normal weight patients (10268.2 ± 10092.4 vs. 13765.2 ± 9951.3 ng/l, P = 0.03). At the same time MIS score (6.1 ± 2.4 vs. 10.7 ± 3.2, P < 0.001), systolic blood pressure (119 ± 26.8 vs. 134.2 ± 24.7 mmHg, P = 0.018) and mean arterial pressure (91.3 ± 18.6 vs. 100.9 ± 15.9 mmHg, P = 0.028) were significantly lower in the obese than the normal weight group. Fasting blood glucose (P = 0.045), TG/HDL (P = 0.03), TC/HDL (P = 0.019), and LDL/HDL (P = 0.005) ratios, and hs-CRP (P = 0.015) levels were significantly higher in the obese than in the normal weight group.

CONCLUSION

Circulating ADMA was significantly lower in obese than in normal weight patients on hemodialysis, which was concomitant with lower MIS, indicating a better nutritional inflammatory status, and lower blood pressure.

Precision Dialysis: Leveraging Big Data and Artificial Intelligence

The long-term mortality of patients with kidney failure remains unacceptably high. There are a multitude of reasons for the unfavorable status quo of dialysis care, such as the inadequate and suboptimal pattern of uremic toxin removal resulting in a metabolic and hemodynamic "roller coaster" induced by thrice-weekly in-center hemodialysis. Innovation in dialysis delivery systems is needed to build an adaptive and self-improving process to change the status quo of dialysis care with the aim of transforming it from being reactive to being proactive. The introduction of more physiologic and smart dialysis systems using artificial intelligence (AI) incorporating real-time data into the process of dialysis delivery is a realistic target. This would enable machine learning from both individual and collective patient treatment data. This has the potential to shift the paradigm from the practice of population-driven, evidence-based data to precision medicine. In this review, we describe the different components of an AI system, discuss the studied applications of AI in the field of dialysis, and outline parameters that can be used for future smart, adaptive dialysis delivery systems. The desired output is precision dialysis; a self-improving process that has the ability to prognosticate and develop instant and individualized predictive models.

Comparative Analysis of Tools for Assessment of Protein-Energy Wasting in Chronic Kidney Disease Patients on Maintenance Hemodialysis

Background

Patients with chronic kidney disease have muscle wasting, sarcopenia, and cachexia that contribute to frailty and morbidity. The present study assessed the prevalence of protein-energy wasting in dialysis-dependent chronic kidney disease population and evaluated the validity of various nutritional assessment tools in diagnosing protein-energy wasting.

Materials and Methods

All patients above 18 years undergoing dialysis for more than 3 months without any active infection or malignancy were included in our study. Data from anthropometric measurements, dietary assessment, and blood investigations were collected. Protein-energy wasting was assessed by the International Society of Renal Nutrition and Metabolism 2008 criteria. Diagnostic validity of the nutritional assessment tools to predict protein-energy wasting was estimated by area under the curve, sensitivity, specificity, and accuracy statistics.

Results

A total of 146 patients were studied. The prevalence of protein-energy wasting was 56.8%. Protein-energy wasting was significantly associated with socioeconomic status, hospitalization days, and catheter days. Normalized protein catabolism rate had the highest sensitivity (90.4%) for predicting protein-energy wasting. Malnutritional inflammatory score had the highest area under the curve (0.858), specificity (82.5%), and accuracy (82.2%). Mid-upper arm circumference, Dialysis Malnutrition Score, and albumin were also found to be significant predictors of protein-energy wasting.

Conclusion

Lack of advanced equipment in suburban and rural centers to detect protein-energy wasting in India can be overcome by using the various stand-alone and combination nutrition assessment tools which have been validated in the present study.

Association between TMSE/MoCA and MIS/NAF in ESKD patients undergoing hemodialysis: a cross-sectional study

BACKGROUND

Both cognitive impairment and malnutrition are common in hemodialysis (HD) patients and are associated with increased hospitalization rates, infection, poor clinical outcomes, and mortality. The study investigated the association between cognitive and nutrition status among end-stage kidney disease (ESKD) patients undergoing hemodialysis.

METHODS

In this cross-sectional study, we enrolled 115 patients with ESKD who underwent regular hemodialysis (HD). Data collection included the use of screening tools for mild cognitive impairment (MCI), specifically Thai Mental State Examination (TMSE) and Montreal Cognitive Assessment (MoCA). In addition, we collected data using nutritional screening tools including Malnutrition Inflammation Score (MIS) and Nutrition Alert Form (NAF). Our primary outcome was to demonstrate whether there was a relationship between TMSE/MoCA and MIS/NAF scores in this population. Secondary outcomes were a prevalence of MCI and malnutrition status in ESKD patients, an association between TMSE and MoCA with other surrogate nutritional markers, and factors affecting MCI in such patients.

RESULTS

A total of 109 patients undergoing HD completed our protocol. Their mean age was 63.42 (± 15.82) years, and 51.38% were male. Mean TMSE and MoCA were 23.98 (± 5.06) points and 18.3 (± 6.40) points, respectively. The prevalence of TMSE ≤ 23 and MoCA ≤ 24 were 39.45% and 83.49%, respectively. TMSE had a statistically significant negative correlation with MIS (R2 = 0.16, p < 0.001) and NAF. MoCA also negatively correlated with MIS and NAF. The age, total educational year, the status of whether having a caregiver, serum albumin, serum phosphorus level, handgrip strength, and lean mass tissue were correlated with TMSE.

CONCLUSION

Nutritional parameters, including MIS score, NAF score, serum albumin, lean tissue mass, and lean tissue index, significantly correlate with TMSE and MoCA.

Frailty Is Associated with Malnutrition-Inflammation Syndrome in Older CKD Patients

Patients affected by chronic kidney disease (CKD) are generally considered to be frailer than those with preserved renal function. We cross-sectionally evaluated the associations between frailty, malnutrition-inflammation syndrome and circulating inflammatory cytokines in 115 older individuals with advanced CKD. As for frailty definition, we adopted Fried's frailty phenotype (FP), while malnutrition-inflammation syndrome was assessed using the Malnutrition-Inflammation Score (MIS) and circulating inflammatory cytokines (IL-6; TNFα; MCP-1). A total of 48 patients were frail, and mean eGFR was comparable in both frail and non-frail patients (24 ± 10 vs. 25 ± 11 mL/min/1.73 m2; p = 0.63). Frail patients had higher MIS (6 [4-11] vs. 4 [3-5]; p < 0.0001) but cytokine concentrations were comparable in both groups. At multivariate regression, FP was independently associated with MIS, age, gender and pre-albumin but not with cytokines. However, we found some associations between inflammatory cytokines and some specific frailty criteria: weight loss and slowness were associated with MCP-1 (respectively p = 0.049 and p < 0.0001) and weakness with IL-6 (p = 0.005); in conclusion, in older patients with advanced CKD, frailty is strictly associated with malnutrition-inflammation syndrome but not with circulating inflammatory cytokines.

Lower extremity function and cardiovascular disease risk in hemodialysis patients: A multicenter cross-sectional study

Physical performance in hemodialysis patients declines and serves as a cardiovascular disease (CVD) incidence and mortality predictor. However, lower extremity function's role remains unclear. This study aimed to quantify the association between lower extremity function and CVD risk in hemodialysis patients. This was a multicenter cross-sectional study enrolling 868 participants (532 males, 336 females) from seven hemodialysis centers in Shanghai, China. Patients were divided into three groups per lower extremity function, evaluated by short physical performance battery (SPPB) scores: 0-6, 7-9, and 10-12. Upper extremity function was quantified through grip strength assessment. CVD risk was assessed using the Framingham Risk Score. Approximately 35% of hemodialysis patients had impaired lower extremity function (SPPB score < 10). Participants with high SPPB scores had stronger handgrip and lower Framingham CVD risk scores than those with low and moderate SPPB scores (p < 0.05). After adjusting clinical confounders, SPPB was independently associated with CVD risk, as a categorized variable (odds ratio: 0.577, 95% confidence interval [CI]: 0.388-0.857, p = 0.006) and as a continuous variable (odds ratio: 0.858, 95% CI: 0.772-0.953, p = 0.004). An SPPB score < 10 predicted an increased CVD risk (area under curve: 0.649, 95% CI: 0.599-0.699, p < 0.001). Causality between physical performance and CVD risk was not considered. Some upper limb results may not be generalizable to peritoneal dialysis and kidney transplant patients. Lower extremity function was significantly associated with CVD risk in hemodialysis patients. Further studies are needed to explore the long-term relationship between lower extremity function and CVD risk.

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.

Clinical Factors and Biomarkers Associated with Depressive Disorders in Older Patients Affected by Chronic Kidney Disease (CKD): Does the Advanced Glycation End Products (AGEs)/RAGE (Receptor for AGEs) System Play Any Role?

Depressive disorders are highly prevalent among subjects suffering from chronic kidney disease (CKD). The aim of the present study is to evaluate clinical and biochemical factors associated with depressive disorders in a sample of older CKD patients, with a focus on advanced glycation end products (AGEs) and their soluble receptors (sRAGEs). A total of 115 older subjects affected by CKD (stages 3 to 5, not in dialysis) were selected for this study. These patients were divided into two groups according to the presence of depressive disorders defined by a score ≥ 10 on the 30-item Geriatric Depression Scale (GDS). The two groups were compared by independent sample t tests for continuous variables and χ2 tests for qualitative ones. Significant variables at univariate analyses were then inserted as predictors of a binary logistic regression model, with the presence or absence of depressive disorders as a dependent variable. The binary logistic regression model showed that patients with concomitant depressive disorders were more frequently of female gender (p < 0.01) and had lower MCP1 (p < 0.01) and AGE circulating levels (p < 0.01) than their counterparts. Depressive disorders in older CKD patients are more prevalent in women and seem to be inversely associated with systemic inflammation and circulating AGEs.

Association of Handgrip Strength and Nutritional Status in Non-Dialysis-Dependent Chronic Kidney Disease Patients: Results from the KNOW-CKD Study

Handgrip strength (HGS) is suggested as an indirect assessment of nutritional status in chronic kidney disease (CKD) patients, but evidence is limited for non-dialysis-dependent CKD (NDD-CKD) patients. This cross-sectional study included 404 patients from the Phase II KoreaN Cohort Study for Outcome in Patients With CKD. HGS, measured twice in each hand, was the exposure, and malnutrition status was defined by a malnutrition-inflammation score (MIS) of 6 or higher. A logistic regression analysis adjusted for age, sex, diabetes mellitus (DM), hypertension, CKD stages, smoking, overhydration, education, and income status was used to assess malnutrition risk. The predictability of HGS for malnutrition was evaluated using the area under the curve (AUC). Patients with lower HGS were older, had a higher prevalence of DM, and lower estimated glomerular filtration rate. Higher HGS was significantly associated with lower malnutrition risk after adjustment (per 1 standard deviation increase, adjusted odds ratio, 0.47 [0.30-0.75]). Subgroup analyses showed no significant interaction between HGS and malnutrition risk across age, sex, DM, and CKD stage. HGS showed fair predictability for malnutrition in men (AUC 0.64 [0.46-0.83]) and women (AUC 0.71 [0.55-0.86]). In conclusion, HGS is a useful diagnostic indicator of malnutrition in NDD-CKD patients.

Cardiovascular and All-Cause Mortality Is Affected by Serum Magnesium and Diet Pattern in a Cohort of Dialysis Patients

Background: Hypomagnesaemia is associated with an increased overall mortality in patients with chronic kidney disease on dialysis (CKD-5D). Mediterranean-style diet (MD), having a high magnesium content, can serve as a form of dietary magnesium supplementation. We examined whether there is a potential link between increased Mediterranean Diet score (MDS) and elevated serum magnesium (sMg) to assess its impact on reducing mortality risk in CKD-5D patients. Methods: In this multi-center prospective observational study, 117 CKD-5D patients (66 on hemodialysis and 51 on peritoneal dialysis) with a mean age of 62 ± 15 years were studied for a median follow-up period of 68 months. After baseline assessment, including measurement of sMg and MDS, all patients were followed up for cardiovascular (CV) and all-cause mortality. Results: Forty deaths occurred, 58% of which were cardiovascular. Patients who were above the median value of sMg (2.2 mg/dL) had a 66% reduction in CV (crude HR, 0.34; 95% CI, 0.11-0.70), and 49% reduction in all-cause (crude HR, 0.51; 95% CI, 0.27-0.96) mortality, even after adjustment for age, malnutrition inflammation score, left ventricular mass index, peripheral vascular disease and diabetes. Similar results were obtained when sMg was analyzed as a continuous variable. sMg was associated directly with MDS (r = 0.230; p = 0.012). Conclusions: Higher sMg levels are strongly and independently associated with reduced CV and all-cause mortality in CKD-5D patients. A strong correlation exists between MDS and sMg. Elevated sMg levels, achieved through MD adherence, can significantly reduce CV mortality, implicating MD as a mediator of the association between sMg and CV mortality.

Malnutrition as a potential predictor of mortality in chronic kidney disease patients on dialysis: A systematic review and meta-analysis

BACKGROUND & AIMS

Malnutrition, a significant problem in patients with chronic kidney disease (CKD), is linked to lower health-related quality of life, longer and more frequent hospital admissions, worse functional capacity, and higher levels of morbidity. However, the extent of its impact on mortality is poorly elucidated. This systematic review and meta-analysis aimed to investigate the impact of malnutrition on mortality among CKD patients on dialysis.

METHODS

This meta-analysis was designed and performed in accordance with the PRISMA guidelines (CRD42023394584). A systematic electronic literature search was conducted in PubMed, ScienceDirect, and Embase to identify relevant cohort studies. The studies that reported nutritional status and its impact on mortality in patients were considered for analysis. The generic inverse variance method was used to pool the hazard ratio effect estimates by employing a random effects model. The Newcastle-Ottawa scale was used for the quality assessment. The statistical analysis was performed by utilizing RevMan and CMA 2.0.

RESULTS

A total of 29 studies that comprised 11,063 patients on dialysis whose nutritional status was evaluated were eligible for quantitative analysis. Based on a comparison between the "malnutrition" category and the reference "normal nutrition status" category, the results showed that the overall pooled hazard risk (HR) for mortality was (HR 1.49, 95% CI: 1.36-1.64, p < 0.0001). According to the subgroup analysis, the hemodialysis subgroup had greater mortality hazards (HR 1.53; 95% CI 1.38-1.70, p < 0.0001), compared to the peritoneal dialysis subgroup (HR 1.26; 95% CI 1.15-1.37, p < 0.00001). Additionally, the overall incidence of mortality was explored but the authors were unable to combine the results due to limitations with the data.

CONCLUSION

The findings conclude that malnutrition is a strong predictor of mortality among patients on dialysis, with the hemodialysis subgroup having a higher mortality hazard compared to the peritoneal dialysis subgroup. The results of this study will advocate for early nutritional evaluation and timely dietary interventions to halt the progression of CKD and death.

Prevalence and factors associated with the correlation between malnutrition and pain in hemodialysis patients

Malnutrition and pain are common in patients with chronic kidney disease who undergo hemodialysis. Although both pain and malnutrition are associated with increased morbidity and mortality, few studies have explored the correlation between pain and nutritional status. This study aimed to investigate the factors associated with pain intensity in patients undergoing hemodialysis, focusing on the risk of malnutrition. This was a cross-sectional study conducted at a regional dialysis center in a large tertiary hospital. Convenience sampling was used to recruit adult patients who had undergone hemodialysis for more than three months. An interviewer-administered questionnaire was used to gather sociodemographic and clinical data related to dialysis status, comorbidities, and body mass index (BMI). Pain severity and pain interference with functioning domains of the Brief Pain Index (BPI) were used to assess pain, and the malnutrition inflammation score (MIS) was used to assess nutritional status. Descriptive and inferential statistics were used to report the findings. The data were analyzed using the 25th version of the Statistical Package for the Social Sciences (IBM-SPSS) software. Of the final sample of 230 patients, 63.0% were males and 37.0% were females, with an average age of 58.3 years. Almost one-third of the participants had a BMI within the normal range (33.9%), and nearly one-third had a BMI within the underweight range (33.9%). Slightly more than half had a normal nutritional status or mild malnutrition (54.8%), while just under half had moderate or severe malnutrition (45.2%). The prevalence of pain was 47.0%. At the multivariate level, the severity of pain was associated with malnutrition (p < 0.001). Pain interference with function was associated with marital status (p = 0.045), number of comorbidities (p = 0.012), and malnutrition (p < 0.001). The MIS was positively correlated with both the severity of pain and the interference score. Pain and malnutrition were found to be prevalent in patients undergoing hemodialysis. Pain severity was associated with malnutrition, and pain interference was associated with malnutrition, marital status, and the number of comorbidities. Hemodialysis treatment should follow a patient-tailored approach that addresses pain, nutritional status, and associated chronic conditions. In addition, pain assessment and management should be included in the curriculum of nephrology training programs.

Trajectory of mid-arm subcutaneous fat, muscle mass predicts mortality in hemodialysis patients independent of body mass index

Although decreasing body mass index (BMI) is associated with higher mortality risk in patients undergoing hemodialysis (HD), BMI neither differentiates muscle and fat mass nor provides information about the variations of fat distribution. It remains unclear whether changes over time in fat and muscle mass are associated with mortality. We examined the prognostic significance of trajectory in the triceps skinfold (TSF) thickness and mid-upper arm circumference (MUAC). In this multicenter prospective cohort study, 972 outpatients (mean age, 54.5 years; 55.3% men) undergoing maintenance HD at 22 treatment centers were included. We calculated the relative change in TSF and MUAC over a 1-year period. The outcome was all-cause mortality. Kaplan-Meier, Cox proportional hazard analyses, restricted cubic splines, and Fine and Gray sub-distribution hazards models were performed to examine whether TSF and MUAC trajectories were associated with all-cause mortality. During follow-up (median, 48.0 months), 206 (21.2%) HD patients died. Compared with the lowest trajectory group, the highest trajectories of TSF and MUAC were independently associated with lower risk for all-cause mortality (HR = 0.405, 95% CI 0.257-0.640; HR = 0.537; 95% CI 0.345-0.837; respectively), even adjusting for BMI trajectory. Increasing TSF and MUAC over time, measured as continuous variables and expressed per 1-standard deviation decrease, were associated with a 55.7% (HR = 0.443, 95% CI 0.302-0.649), and 97.8% (HR = 0.022, 95% CI 0.005-0.102) decreased risk of all-cause mortality. Reduction of TSF and MUAC are independently associated with lower all-cause mortality, independent of change in BMI. Our study revealed that the trajectory of TSF thickness and MUAC provides additional prognostic information to the BMI trajectory in HD patients.

Early Detection of Inflammation and Malnutrition and Prediction of Acute Events in Hemodialysis Patients through PINI (Prognostic Inflammatory and Nutritional Index)

Protein-energy wasting and inflammation are major risk factors for complications in hemodialysis patients. As these risk factors are triggered by a pro-inflammatory state, oxidative stress and hemodynamic dysfunction, which overlap in hemodialyzed subjects, we aimed to assess the efficacy of a cost-effective and straightforward screening tool, the Prognostic Inflammatory and Nutritional Index (PINI), in regularly screening maintenance hemodialysis (MHD) patients, to detect early signs of inflammation and malnutrition. A 12-month follow-up was carried out on a cohort of 102 adult patients undergoing maintenance dialysis, during which the Prognostic Inflammatory and Nutritional Index (PINI) was calculated using the formula alpha1-Acid Glycoprotein (AGP) × C-reactive protein (CRP)/albumin (ALB) × transthyretin (TTR). A PINI score < 1 was considered normal. The patients were stratified based on their PINI score: 66 patients (64.70%) had a normal score, below 1, while 36 patients (35.30%) had a PINI score ≥ 1. Despite the absence of clinical evidence of inflammation at enrollment, the latter group exhibited higher levels of CRP. During the follow-up period, all patients with a PINI score ≥ 1 experienced at least one acute event, compared to only 6% of patients with a normal PINI score, which presented COVID-19 infection as an acute event. The evaluation of the PINI can effectively identify the silent malnutrition-inflammation syndrome and predict the risk of acute events. This straightforward test appears to be a rapid tool that is independent of the examiner's experience and subjectivity, thereby potentially reducing hospitalization costs.

Shared decision making in elderly patients with kidney failure

'Elderly' is most commonly defined as an individual aged 65 years or older. However, this definition fails to account for the differences in genetics, lifestyle and overall health that contribute to significant heterogeneity among the elderly beyond chronological age. As the world population continues to age, the prevalence of chronic diseases, including chronic kidney disease (CKD), is increasing and CKD frequently progresses to kidney failure. Moreover, frailty represents a multidimensional clinical entity highly prevalent in this population, which needs to be adequately assessed to inform and support medical decisions. Selecting the optimal treatment pathway for the elderly and frail kidney failure population, be it haemodialysis, peritoneal dialysis or conservative kidney management, is complex because of the presence of comorbidities associated with low survival rates and impaired quality of life. Management of these patients should involve a multidisciplinary approach including doctors from various specialties, nurses, psychologists, dieticians and physiotherapists. Studies are mostly retrospective and observational, lacking adjustment for confounders or addressing selection and indication biases, making it difficult to use these data to guide treatment decisions. Throughout this review we discuss the difficulty of making a one-size-fits-all recommendation for the clinical needs of older patients with kidney failure. We advocate that a research agenda for optimization of the critical issues we present in this review be implemented. We recommend prospective studies that address these issues, and systematic reviews incorporating the complementary evidence of both observational and interventional studies. Furthermore, we strongly support a shared decision-making process matching evidence with patient preferences to ensure that individualized choices are made regarding dialysis vs conservative kidney management, dialysis modality and optimal vascular access.

Role of composite objective nutritional indexes in patients with chronic kidney disease

Malnutrition persists as one of the most severe symptoms in patients with chronic kidney disease (CKD) globally. It is a critical risk factor for cardiovascular and all-cause mortality in patients with CKD. Readily available objective indicators are used to calculate composite objective nutritional assessment indexes, including the geriatric nutritional risk index, prognostic nutritional index, and controlling nutritional status score. These indexes offer a straightforward and effective method for evaluating nutritional status and predicting clinical outcomes in patients with CKD. This review presents supporting evidence on the significance of composite nutritional indexes.

A simple score for malnutrition-inflammation complex syndrome (MICS) is associated with the risk of mortality in Japanese patients undergoing maintenance hemodialysis

INTRODUCTION

Malnutrition-inflammation complex syndrome (MICS) is highly prevalent in patients undergoing hemodialysis. We determined the prognostic value of the Simple MICS score, calculated using a combination of age, body mass index, and serum concentrations of albumin, creatinine, and C-reactive protein.

METHODS

We retrospectively recruited 218 Japanese patients undergoing maintenance hemodialysis. The primary outcome was all-cause mortality, and the main exposure was the Simple MICS score. Cox proportional hazard regression analysis and logistic regression analysis were used to characterize the relationship between the Simple MICS score and mortality.

RESULTS

During a median 4.4-year follow-up period, 56 patients died. Multivariable-adjusted models showed that a higher Simple MICS score was associated with higher risks of mortality. The predictability for all-cause mortality of the Simple MICS score was significantly better than conventional nutrition-related indices.

CONCLUSION

The Simple MICS score can be used to stratify mortality risk in patients undergoing maintenance hemodialysis.

Association of Frailty With Nutritional Status in Patients With Chronic Kidney Disease

OBJECTIVES

Frailty is commonly observed in patients with chronic kidney disease (CKD) and is associated with adverse outcomes. Protein-energy wasting (PEW), a state of decreased body stores of protein and energy fuels, may be associated with frailty. However, few data are available on the possible association between frailty and PEW in CKD.

METHODS

We examined the association between frailty and nutritional status assessed using anthropometric and body composition measurements, serum albumin, handgrip strength, the Malnutrition Inflammation Score (MIS), and dietary protein and calorie intake in a cross-sectional analysis of nondialysis patients with CKD stages 3-5. Body composition was assessed using multifrequency bioelectrical impedance. Frailty was defined as a Clinical Frailty Scale ≥4. We performed logistic regression with different nutrition assessment tools as the main predictors and age, sex, comorbidity, estimated glomerular filtration rate (eGFR), and hemoglobin as covariates.

RESULTS

A total of 157 patients (93 men and 64 women; mean age 64 years; diabetes prevalence 38.9%) with CKD (eGFR 24.4 ± 13.4 mL/min/1.73 m2) were included. Overall, 29.3% of patients were frail. Patients with frailty were older and had a significantly higher fat tissue index and MIS but a significantly lower lean tissue index, eGFR, hemoglobin value, serum albumin value, handgrip strength value, and dietary protein intake. In multivariate logistic regression analyses, a higher body mass index category (odds ratio [OR], 1.54; 95% confidence interval [CI], 1.03-2.31), higher fat tissue index (OR, 1.15; 95% CI, 1.03-1.28), larger waist circumference (OR, 1.05; 95% CI, 1.01-1.09), reduced handgrip strength (OR, 2.70; 95% CI, 1.17-6.21), PEW defined by MIS ≥5 (OR, 3.49; 95% CI, 1.35-9.01), and dietary protein intake ≤0.8 g/kg/day (OR, 2.70; 95% CI, 1.18-6.19) were associated with higher odds of frailty.

CONCLUSION

Frailty is associated with nutritional status in patients with CKD. A comprehensive nutrition assessment may allow the implementation of strategies to prevent or reduce frailty.

Analysis of influencing factors on quality of life in patients with chronic kidney disease undergoing maintenance haemodialysis

Objective

To investigate and analyse the quality of life (QoL) of patients with chronic kidney disease (CKD) undergoing maintenance haemodialysis (MHD), explore influencing factors and provide a basis for formulating corresponding intervention measures.

Methods

A cross-sectional study was conducted on 190 patients with CKD undergoing MHD in hospital between March 2021 and March 2022. A general information questionnaire and the Kidney Disease Quality of Life Short Form were used to collect data. The QoL scores of patients with CKD undergoing MHD were calculated and compared by t-test and analysis of variance. Pearson correlation analysis was used to analyse the correlation between QoL scores and related factors. Stepwise multiple linear regression analysis was used to screen the influencing factors of QoL.

Results

The total score of QoL of patients with CKD undergoing MHD was 59.32 ± 11.67, and the scores of physical component summary, mental component summary and kidney disease component summary were 50.21 ± 9.32, 48.76 ± 10.81 and 66.34 ± 12.76, respectively. The QoL scores of patients with CKD undergoing MHD were significantly different in age, education level, marital status, employment status, monthly income, dialysis frequency, dialysis duration and complications (p < 0.05). The QoL scores were positively correlated with education level, monthly income and dialysis frequency, and negatively correlated with age, dialysis duration and blood phosphorus level (p < 0.05). Stepwise multiple linear regression analysis showed that age, education level, employment status, dialysis frequency, dialysis duration and blood phosphorus level were the main influencing factors of QoL (p < 0.05).

Conclusion

The QoL of patients with CKD undergoing MHD is low, and it is affected by multiple factors. We suggest that healthcare workers should pay attention to the physical and mental health of patients with CKD undergoing MHD, provide individualised and comprehensive nursing interventions and improve their QoL.

Geriatric Nutritional Risk Index and First-Year Mortality in Incident Hemodialysis Patients

OBJECTIVE

The Geriatric Nutritional Risk Index is a simple nutritional screening method, and this study aimed to investigate the association between the initial Geriatric Nutritional Risk Index and all-cause mortality in incident patients in the first year after the initiation of hemodialysis.

MATERIALS AND METHODS

This study is a retrospective cohort study and used the Korean Renal Data System database. Patients who were eligible for Geriatric Nutritional Risk Index assessment and underwent hemodialysis from January 2016 to December 2019 were included. The primary outcome was all-cause mortality, and outcome evaluation was performed in December 2020. A Cox proportional hazard model was used to analyze the association between the Geriatric Nutritional Risk Index and mortality.

RESULTS

A total of 10,545 patients were included, and the mean age was 63.9 ± 3.7 years. The patients were divided into four groups by the quartile of the Geriatric Nutritional Risk Index with a mean value of 96.2 ± 8.2. During the study period, 545 (5.2%) deaths occurred. The surviving patients had higher Geriatric Nutritional Risk Index values than ones who died in the first year of hemodialysis initiation (96.6 ± 7.5 vs. 88.2 ± 9.3, p < 0.001). Quartile 1 (Geriatric Nutritional Risk Index < 91.8) showed a significantly increased risk of all-cause (Hazard Ratio: 2.56; 95% Confidence Interval: 2.13-3.09; p < 0.001) and cardiovascular mortality (Hazard Ratio: 22.29; 95% Confidence Interval: 1.71- 3.08; p < 0.001) at the first year in comparison with Quartile 4 (Geriatric Nutritional Risk Index ≥ 101.3). In areas under the receiver-operating characteristic curves of all-cause mortality, the Geriatric Nutritional Risk Index model improved predictive values, compared to the baseline model. The area with the Geriatric Nutritional Risk Index model was significantly higher than the one with a model including albumin or body mass index (p < 0.001).

CONCLUSIONS

These findings suggest that a low Geriatric Nutritional Risk Index (<91.8) is associated with first-year all-cause and cardiovascular mortality in patients who start hemodialysis and may be a useful and reproducible tool for assessing prognoses in this population.

Effect of Creatine Supplementation on Body Composition and Malnutrition-Inflammation Score in Hemodialysis Patients: An Exploratory 1-Year, Balanced, Double-Blind Design

Hemodialysis has a detrimental effect on fat-free mass (FFM) and muscle strength over time. Thus, we aimed to evaluate the effect of creatine supplementation on the body composition and Malnutrition-Inflammation Score (MIS) in patients with chronic kidney disease (CKD) undergoing hemodialysis. An exploratory 1-year balanced, placebo-controlled, and double-blind design was conducted with hemodialysis patients (≥18 years). The creatine group (CG) received 5 g of creatine monohydrate and 5 g of maltodextrin per day and the placebo group (PG) received 10 g of maltodextrin per day. MIS and body composition were analyzed at three time points: pre, intermediate (after 6 months), and post (after 12 months). After 6 months, 60% of patients on creatine experienced an increase in FFM compared to a 36.8% increase for those on placebo. Moreover, 65% of patients on creatine increased their skeletal muscle mass index (SMMI) compared to only 15.8% for those on placebo. Creatine increased intracellular water (ICW) in 60% of patients. MIS did not change after the intervention. In the CG, there was an increase in body weight (p = 0.018), FFM (p = 0.010), SMMI (p = 0.022). CG also increased total body water (pre 35.4 L, post 36.1 L; p = 0.008), mainly due to ICW (pre 20.2 L, intermediate 20.7 L, post 21.0 L; p = 0.016). Long-term creatine supplementation in hemodialysis patients did not attenuate the MIS, but enhanced FFM and SMMI, which was likely triggered by an increase in ICW.