Relationship Between Body Mass Index and Mortality in Adults on Maintenance Hemodialysis: A Systematic Review

Obesity measurement methods estimated mortality risk in patients undergoing hemodialysis: a systematic review and meta-analysis

PURPOSE

The impact of obesity on mortality risk in patients undergoing hemodialysis (HD) remains uncertain due to conflicting findings across obesity measurement methods. This study aimed to assess the obesity measurements influence mortality risk in HD populations.

METHODS

Systematic review and meta-analysis were conducted following PRISMA guidelines, registered on PROSPERO (CRD42023429943). Relevant observational studies analyzing mortality risk using obesity measurements in adult HD patients up to March 27, 2023 were included from multiple databases, including EMBASE, MEDLINE (OVID), and CINAHL (EBSCO). Pooled analyses with a random-effects model were performed using RevMan 5.4.

RESULTS

Twenty-three studies involving 381,580 subjects were reviewed. A meta-analysis of 15 studies in event-based analysis showed contrasting results between anthropometry and body composition analysis in predicting all-cause mortality. Obese patients indicated by body mass index (BMI) had a lower mortality risk than non-obese patients (RR = 0.73, 95% CI: 0.70-0.76, p < 0.001). In contrast, abdominal obesity measured by waist circumference (WC) or waist-to-hip ratio (WHR) increased mortality risk (RR = 1.35, 95% CI: 1.01-1.80, p = 0.04). Studies using bioelectrical impedance analysis (BIA) demonstrated an increased mortality risk for obese patients (RR = 1.22, 95% CI: 1.05-1.41, p = 0.009).

CONCLUSIONS

Obese patients undergoing HD exhibit different mortality risks depending on the methods of obesity measurement. The observed 'obesity paradox' in patients on HD, where lower mortality is seen with obesity measured by BMI, may reflect BMI's limitations in differentiating fat mass. More studies with other anthropometry and body composition analysis are needed to clarify this phenomenon.

Comparative effectiveness of nonpharmacological interventions for the nutritional status of maintenance hemodialysis patients: a systematic review and network meta-analysis

Objective

We aim to analyze the effects of different nonpharmacological interventions on the nutritional status of patients on maintenance hemodialysis (MHD).

Methods

Randomized controlled trials (RCTs) conducted up to October 12, 2023 were searched in the Cochrane Library, Chinese National Knowledge Infrastructure, Wan Fang Database, VIP databases, and China Biomedical Literature Database. R and Review Manager software were used for data analysis, the quality of the literature was assessed using the Cochrane Risk Bias Tool RoB2.0, the reliability of evidence was evaluated using Grading of Recommendations, Assessment, Development, and Evaluation guidelines, and sources of heterogeneity were explored through sensitivity analyses. This study was registered in PROSPERO with registration number CRD42023458187.

Results

A total of 54 studies met the criteria, 3,861 patients were enrolled in this study, and 11 interventions were explored. The results of the network meta-analysis (NMA) showed that dietary intervention is the best intervention in terms of improving patients' body mass index and serum albumin levels and health education is the best intervention in terms of improving patients' hemoglobin levels.

Conclusion

This NMA confirmed that different nonpharmacological interventions benefit the nutritional status of patients on MHD, providing novel insights for healthcare practitioners. However, high-quality RCTs should be designed to validate the stability of the level of evidence for different nonpharmacological interventions.

[Use of cinacalcet in secondary hyperparathyroidism: assessment of nutritional, lipid and inflammatory status in chronic kidney disease]

Introduction

Introduction: observations in cell lines suggest that the use of cinacalcet could be associated with increase in body fat, inflammatory state, and alteration in lipid metabolism. However, when scaling the model to the clinical level, the occurrence of these effects is unknown. Objectives: to analyze the effect of cinacalcet therapy on anthropometric, inflammatory and lipid parameters in renal patients with secondary hyperparathyroidism (SHPT). Methods: observational study with two approaches. The retrospective study included 89 patients who started cinacalcet treatment since 2018 with a maximum follow-up of 36 months. Body mass index (BMI) variables, waist circumference, tricipital skinfold, parathyroid hormone (PTH), and biochemical profile were analyzed. The prospective study included 52 patients who started cinacalcet treatment since 2020 with a 12-month follow-up. BMI, PTH, lipid profile, and PCR variables were analyzed. Results: in the retrospective study, BMI was 27 kg/m2, with 62 % overweight and 65 % of patients with high cardiovascular risk. Cinacalcet reduced PTH by 12 % after six months (p < 0.01) and serum calcium decreased by 3.4 % at the end of follow-up (p = 0.04). According to the prospective study, BMI was 26.8 kg/m2, with 60 % overweight. PTH decreased by 8.4 % after six months. Total cholesterol, LDL cholesterol, and triglycerides decreased by 6.8 %, 12.5 %, and 5.5 %, respectively, at the end of follow-up. Conclusions: the prevalent nutritional status is excess weight. In patients with SHPT, cinacalcet improves PTH control without causing changes in anthropometric, lipid, and inflammatory parameters.

Impact of Extremes of Body Mass Index (BMI) in End-Stage Renal Disease (ESRD) Patients

The principal objective of this systematic review is to determine the prognosis of end-stage renal disease (ESRD) patients on maintenance hemodialysis with high body mass index (BMI) and study the potential mechanisms behind it. PubMed and Google Scholar electronic databases covering the period of the last 30 years 1992 to 2022 are searched thoroughly and a total of 11 articles were finally selected for the study. Reference lists of included papers are also searched. Each paper was examined by two independent evaluators who also extracted data from full papers. The quality of the selected studies was assessed by different quality assessment tools and only moderate- to high-quality papers are included.

In this systematic review, we studied different mechanisms explaining the obesity paradox in patients on maintenance hemodialysis, i.e., hemodynamic stability, the concentration of TNF-α receptors, neurohumoral response, role of inflammation, blood pressure, etc. also, the effect of age, gender, duration of treatment, acetyl-ghrelin on obesity paradox have been considered in our paper. This systematic review demonstrates the evidence of an inverse relationship between BMI and all-cause mortality in ESRD patients on maintenance hemodialysis.

Vegetarian diet in dialysis patients: A significant gap between actual intake and current nutritional recommendations

ABSTRACT

Nutritional status is a predictor of mortality and morbidity in dialysis patients. This study aimed to assess dietary behaviors in dialysis patients compared to the recommendations of the Kidney Disease Outcomes Quality Initiative.Ninety five dialysis patients recruited from a hospital completed a 24-hour dietary recall questionnaire. Body weight, energy requirements, protein requirements, albumin, normalized protein catabolic rate, and 25(OH) vitamin D levels were measured.Of the 95 patients, 11 (11.6%) were below the desirable body mass index range, 59 (62.1%) were within the desired range, and 25 (26.3%) were above the desired range. However, only 32.7% of patients met the target energy intake, 29.5% reached the protein intake target, and 20.0% had adequate vitamin D concentrations. Vegetarian patients had lower energy, protein, fat, vitamin D intake, lower body mass index, serum blood urea nitrogen, creatinine, phosphate, normalized protein catabolic rate, and vitamin D status than the omnivorous patients (P < .05). After adjusting for age, sex, and body weight, vegetarianism was an independent risk factor for severe vitamin D deficiency (<10 ng/ml, P < .01).Most dialysis patients do not meet their dietary recommendations or goals. The risk of a vegetarian diet may outweigh the benefits in dialysis patients. Careful consideration of dietary behaviors is required for dialysis patients to prevent malnutrition, more so in vegetarians.

Association of Body Mass Index and Waist Circumference with All-Cause Mortality in Hemodialysis Patients

In this study based on a large nationally representative sample of Korean adults, we investigated the potential associations of the body mass index (BMI) and waist circumference (WC) with mortality in patients undergoing hemodialysis. We obtained the data of 18,699 participants >20 years of age who were followed up with for 4 years and for whom BMI and WC information were available, using a nationally representative dataset from the Korean National Health Insurance System. Patients were stratified into five levels by their baseline BMI and into six levels by their WC (5-cm increments). A total of 4975 deaths occurred during a median follow-up period of 48.2 months. Participants with a higher BMI had a lower mortality rate than those with a lower BMI. In a fully adjusted Cox regression analysis, being overweight and obese was associated with a significantly lower relative risk of all-cause mortality relative to the reference group. Conversely, the mortality rate was higher among participants with a high WC than among those with a low WC. Participants with the highest WC had a higher risk of mortality, while those with the lowest WC level had a significantly lower risk of mortality. In conclusion, all-cause mortality was positively associated with WC, a measure of abdominal obesity, and inversely associated with BMI, a measure of body volume, in patients undergoing hemodialysis.

Indoxyl Sulfate, a Uremic Endotheliotoxin

Chronic kidney disease (CKD) is associated with a high prevalence of cardiovascular diseases. During CKD, the uremic toxin indoxyl sulfate (IS)—derived from tryptophan metabolism—accumulates. IS is involved in the pathophysiology of cardiovascular complications. IS can be described as an endotheliotoxin: IS induces endothelial dysfunction implicated in cardiovascular morbidity and mortality during CKD. In this review, we describe clinical and experimental evidence for IS endothelial toxicity and focus on the various molecular pathways implicated. In patients with CKD, plasma concentrations of IS correlate with cardiovascular events and mortality, with vascular calcification and atherosclerotic markers. Moreover, IS induces a prothrombotic state and impaired neovascularization. IS reduction by AST-120 reverse these abnormalities. In vitro, IS induces endothelial aryl hydrocarbon receptor (AhR) activation and proinflammatory transcription factors as NF-κB or AP-1. IS has a prooxidant effect with reduction of nitric oxide (NO) bioavailability. Finally, IS alters endothelial cell and endothelial progenitor cell migration, regeneration and control vascular smooth muscle cells proliferation. Reducing IS endothelial toxicity appears to be necessary to improve cardiovascular health in CKD patients.

Low lean tissue mass can be a predictor of one-year survival in hemodialysis patients

Purpose: Nutritional status has a significant impact on the outcomes in the dialysis population. The aim of this study was to evaluate the association between body composition and a one-year survival of hemodialysis patients.

Methods: Forty-eight patients with chronic kidney disease stage V treated with hemodialysis for more than three months were included. Body composition was assessed by bioimpedance spectroscopy (Body Composition Monitor, Fresenius Medical Care). Blood samples for serum creatinine, serum albumin, serum prealbumin, high sensitivity C-reactive protein (hsCRP), interleukin 6 (IL-6), insulin-like growth factor 1(IGF-1) concentrations were taken before the midweek dialysis session.

Results: Over the course of a one-year observation, seven patients died. We observed a significantly lower lean tissue index (LTI) (p = .013) and higher IL-6 (p = .032) and hsCRP levels (p = .011) among the patients who died. The remaining biochemical markers did not differ between these two groups. Kapplan–Meier analysis revealed a worse survival rate in patients with sarcopenia (lower than the 10th percentile for their age and gender) in comparison with those with normal LTI. However, it was not of statistical significance (p = .055). LTI inversely correlated with age and IL-6 and positively with IGF-1.

Conclusions: Sarcopenia defined as decreased LTI, is a relatively common condition among patients undergoing maintenance hemodialysis, it can also be associated with a lower one-year survival rate. Decreased lean tissue mass can be associated with old age, lower IGF-1 levels and higher IL-6 levels. Body composition assessment may provide prognostic data for hemodialysis patients.

Association Between Sleep Duration, Quality and Body Mass Index in the Korean Population

STUDY OBJECTIVES

Mounting evidence indicates that sleep disturbance contributes to the increased risk for cardiometabolic diseases. Obesity and underweight are also closely linked to cardiometabolic risk. Thus, the objective of this study was to examine the association between sleep duration, quality, and body mass index (BMI) categories.

METHODS

Using data from a cohort of 107,718 Korean individuals (63,421 men and 44,297 women), we conducted cross-sectional analysis with sex subgroup analysis. Sleep duration was classified into 3 groups-short (< 7 hours), normal (7-9 hours) and long sleep (> 9 hours)-and Pittsburgh Sleep Quality Index (PSQI) score was used to divide sleep quality into 2 groups-poor (PSQI > 5) and good sleep (PSQI ≤ 5). Compared to normal sleep and good sleep quality, adjusted odds ratios of short and long sleep and poor sleep for BMI categories were calculated. BMI categories included underweight (BMI < 18.5 kg/m²), overweight (BMI 23 to < 25 kg/m²), obesity (BMI 25 to < 30 kg/m²) and severe obesity (BMI ≥ 30 kg/m²).

RESULTS

Short sleep duration had the dose-dependent relationship with obesity categories from overweight to severe obesity, and inverse relationship with underweight (adjusted odds ratios [95% confidence intervals] for underweight, overweight, obesity, and severe obesity versus normal weight; 0.88 [0.82-0.94], 1.15 [1.11-1.20], 1.31 [1.26-1.37], 1.70 [1.54-1.85]). Poor sleep quality was significantly associated with severe obesity in male subgroup (1.16 [1.05-1.27]) and with obesity (1.18 [1.10-1.25]) and severe obesity in female subgroup (1.66 [1.40-1.98]).

CONCLUSIONS

Short sleep duration and poor sleep quality was more positively associated with obesity across BMI than underweight.

Soluble Toll-like Receptor 4: A New Player in Subclinical Inflammation and Malnutrition in Hemodialysis Patients

OBJECTIVE

Toll-like receptor 4 (TLR4) promotes inflammation in hemodialysis patients (HD). A soluble form of extracellular TLR4 (sTLR4) has been recently characterized, which showed the ability to attenuate TLR4 signalling. In this study, we describe the sTLR4 profile in regular HD patients.

SUBJECTS

In a cross-sectional study we enrolled forty prevalent HD patients (68.2 ± 16.3 years, twenty-five males) with a median dialysis vintage of 41 months. Nineteen patients were undergoing standard bicarbonate HD (BHD) and 21 patients on-line hemodiafiltration (HDF). Ten healthy sex-matched subjects constituted the controls (C).

INTERVENTION

Before and after the HD session, serum was tested for sTLR4 levels by ELISA. Moreover, clinical and biochemical data were collected, including body mass index, albumin, and C-reactive protein (CRP) levels. Body composition was expressed as a 3-compartment model, providing lean tissue index and fat tissue index (FTI).

MAIN OUTCOME MEASURE

Describe the profile of sTLR4 in HD patients, evaluating the correlations among sTLR4 levels and the main clinical characteristics, inflammatory and nutritional parameters.

RESULTS

Patients with subclinical inflammation (i.e., high CRP levels without clinical symptomatology) presented higher sTLR4 levels (0.42 ± 0.25 ng/mL) with respect to both C and not inflamed HD patients (0.23 ± 0.19 ng/mL, P < .05). There was a significant direct correlation between predialysis sTLR4 and body mass index, FTI (r = 0.55), and CRP levels (r = 0.52) and inverse correlation with lean tissue index and albumin (r = -0.4). In multivariate analysis, sTLR4 resulted directly associated with FTI (P = .038). Notably, sTLR4 levels resulted higher in bicarbonate hemodialysis versus hemodiafiltration (0.37 ± 0.18 vs. 0.19 ± 0.21 ng/mL, P < .05).

CONCLUSIONS

sTLR4 correlates with inflammatory and nutritional parameters, presenting as a new potential player in modulating subclinical inflammation in HD patients.

Obesity and the risk of cardiovascular and all-cause mortality in chronic kidney disease: a systematic review and meta-analysis

Background

Obesity is a risk factor for cardiovascular disease and death in people without chronic kidney disease (CKD), but the effect of obesity in people with CKD is uncertain.

Methods

Medline and Embase (from inception to January 2015) were searched for cohort studies measuring obesity by body mass index (BMI), waist:hip ratio (WHR) and/or waist circumference (WC) and all-cause and cardiovascular mortality or events in patients with any stage of CKD. Data were summarized using random effects models. Meta-regression was conducted to assess sources of heterogeneity.

Results

Of 4065 potentially eligible citations, 165 studies ( n = 1 534 845 participants) were analyzed. In studies that found a nonlinear relationship, underweight people with CKD (3-5) on hemodialysis experienced an increased risk of death compared with those with normal weight. In transplant recipients, excess risk was observed at levels of morbid obesity (>35 kg/m 2 ). Of studies that found the relationship to be linear, a 1 kg/m 2 increase in BMI was associated with a 3 and 4% reduction in all-cause and cardiovascular mortality in patients on hemodialysis, respectively {adjusted hazard ratio [HR] 0.97 [95% confidence interval (CI) 0.96-0.98] and adjusted HR 0.96 (95% CI 0.92-1.00)}. In CKD Stages 3-5, for every 1 kg/m 2 increase in BMI there was a 1% reduction in all-cause mortality [HR 0.99 (95% CI 0.0.97-1.00)]. There was no apparent association between obesity and mortality in transplanted patients or those on peritoneal dialysis. Sparse data for WHR and WC did not allow further analyses.

Conclusions

Being obese may be protective for all-cause mortality in the predialysis and hemodialysis populations, while being underweight suggests increased risk, but not in transplant recipients.

Obesity and listing for renal transplantation: weighing the evidence for a growing problem

A 56-year-old female patient was referred to the transplant assessment clinic in July 2016. She started haemodialysis in 2012 for renal failure due to urinary tract infections. She is doing very well on dialysis and has an excellent exercise tolerance without shortness of breath or angina. She has had no infections since starting dialysis and no other comorbidity, except well-controlled hypertension and hyperparathyroidism requiring treatment with cinacalcet. Clinical examination is essentially normal except for truncal obesity with height 167 cm and weight 121 kg, giving her a body mass index of 43.4. Can she be listed for a renal transplant? If not, which target weight should be given to the patient before she can be transplant listed? Which interventions, if any, should be recommended to achieve weight loss?

Association of Body Mass Index with Clinical Outcomes in Non-Dialysis-Dependent Chronic Kidney Disease: A Systematic Review and Meta-Analysis

BACKGROUND

Previous studies have not shown a consistent link between body mass index (BMI) and outcomes such as mortality and kidney disease progression in non-dialysis-dependent chronic kidney disease (CKD) patients. Therefore, we aimed to complete a systematic review and meta-analysis study on this subject.

METHODS

We searched MEDLINE, EMBASE, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Cochrane Central Register of Controlled Trials (CENTRAL), and screened 7,123 retrieved studies for inclusion. Two investigators independently selected the studies using predefined criteria and assessed each study's quality using the Newcastle-Ottawa quality assessment scale. We meta-analyzed the results based on the BMI classification system by the WHO.

RESULTS

We included 10 studies (with a total sample size of 484,906) in the systematic review and 4 studies in the meta-analyses. The study results were generally heterogeneous. However, following reanalysis of the largest reported study and our meta-analyses, we observed that in stage 3-5 CKD, being underweight was associated with a higher risk of death while being overweight or obese class I was associated with a lower risk of death; however, obesity classes II and III were not associated with risk of death. In addition, reanalysis of the largest available study showed that a higher BMI was associated with an incrementally higher risk of kidney disease progression; however, this association was attenuated in our pooled results. For earlier stages of CKD, we could not complete meta-analyses as the studies were sparse and had heterogeneous BMI classifications and/or referent BMI groups.

CONCLUSION

Among the group of patients with stage 3-5 CKD, we found a differential association between obesity classes I-III and mortality compared to the general population, indicating an obesity paradox in the CKD population.

Association of Body Mass Index With Mortality in Peritoneal Dialysis Patients: A Systematic Review and Meta-Analysis

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BACKGROUND

Although higher body mass index (BMI) is associated with better outcomes in hemodialysis patients, the relationship in peritoneal dialysis (PD) patients is less clear. We aimed to synthesize the results from all large and high-quality studies to examine whether underweight, overweight, or obesity is associated with any significantly different risk of death in peritoneal dialysis patients. ♦

METHODS

We searched MEDLINE, EMBASE, Web of Science, CINAHL, and Cochrane CENTRAL, and screened 7,123 retrieved studies for inclusion. Two investigators independently selected the studies using predefined criteria and assessed each study's quality using the Newcastle-Ottawa Quality Assessment Scale. We meta-analyzed the results of the largest studies with no overlap in their data sources. ♦

RESULTS

We included 9 studies (n = 156,562) in the systematic review and 4 studies in the meta-analyses. When examined without stratifying studies by follow-up duration, the results of the studies were inconsistent. Hence, we pooled the study results stratified based upon their follow-up durations, as suggested by a large study, and observed that being underweight was associated with higher 1-year mortality but had no significant association with 2- and 3- to 5-year mortalities. In contrast, being overweight or obese was associated with lower 1-year mortality but it had no significant association with 2-, and 3- to 5-year mortalities. ♦

CONCLUSION

Over the short-term, being underweight was associated with higher mortality and being overweight or obese was associated with lower mortality. The associations of body mass with mortality were not significant over the long-term.

Importance of simultaneous evaluation of multiple risk factors for hemodialysis patients' mortality and development of a novel index: dialysis outcomes and practice patterns study

BACKGROUND

For hemodialysis (HD) patients, many risk factors for death are associated with each other intricately. However, they are often considered separately in clinical settings. We evaluated the maintenance HD patients' risk of death within one year from multiple risk factors simultaneously considering their interrelationships using a novel index (survival index, SI) for HD patients in the United States developed using data from the Dialysis Outcomes and Practice Patterns Study (DOPPS).

METHODS

We analyzed data from 3899 and 3765 patients to develop and validate SI, respectively. To predict death within one year, candidate models were developed using logistic regression models. The final model was determined by comparing the accuracy among the models for the prediction of deaths.

RESULTS

The model included age; body mass index; serum creatinine, albumin, total cholesterol and phosphorus levels; history of cardiovascular diseases; and arteriovenous fistula use. SI showed a higher accuracy in predicting death (c-statistic, 0.739) than geriatric nutritional risk index (0.647) and serum albumin level (0.637). The probability of death predicted on the basis of SI matched the observed number of deaths. Cox proportional hazard models for time-dependent SI showed that patients with low SI had a higher risk of death than patients with high SI [reference, Group 4 (26.1≤SI)]; Group 1 (SI<12.7), adjusted hazard ratio, 7.97 (95% CI, 5.02, 12.65); Group 2 (12.7≤SI<19.0), 3.18 (95% CI, 1.96, 5.16); Group 3 (19.0≤SI<26.1), 2.20 (95% CI, 1.33, 3.66).

CONCLUSION

Results of this study suggest that the simultaneous evaluation of multiple risk factors can more accurately assess patients' prognosis and identify patients at an increased risk of death than single factors.

Body mass index and mortality in kidney transplant recipients: a systematic review and meta-analysis

BACKGROUND

A higher body mass index (BMI) seems to be linked to survival advantage in maintenance hemodialysis patients. However, it is uncertain if this 'obesity survival paradox' is also observed in kidney transplant recipients. Hence, we systematically reviewed the literature on the impact of pre-transplantation BMI on all-cause mortality in this population.

METHODS

We searched MEDLINE, EMBASE, Web of Science, CINAHL, and Cochrane CENTRAL for relevant studies up to July 2013. Two investigators independently selected the studies using predefined criteria, abstracted the data from the included studies, and independently assessed each study's quality using the Newcastle-Ottawa Quality Assessment Scale. In addition to the qualitative synthesis, we quantitatively pooled the results of the studies with clinical, methodological, and statistical homogeneity.

RESULTS

We screened 7,123 records, from which we included 11 studies (with a total of 305,392 participants) in this systematic review and 4 studies in the meta-analyses. In the only study that included children, obesity was linked to higher mortality in children of 6-12 years old. For adults, our meta-analyses indicated that compared to normal BMI, underweight [Hazard Ratio (HR): 1.09; 95% Confidence Interval (CI): 1.02-1.20], overweight (HR: 1.07; 95% CI: 1.04-1.12), and obese (HR: 1.20; 95% CI: 1.14-1.23) levels of BMI were associated with higher mortality.

CONCLUSION

The presence of the obesity survival paradox is unlikely in kidney transplant recipients since both extremes of pre-transplantation BMI are linked to higher mortality in this population.

Anthropometrics Identify Wasting in Patients Undergoing Surgery for Encapsulating Peritoneal Sclerosis

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INTRODUCTION

Encapsulating peritoneal sclerosis (EPS) is a serious complication of peritoneal dialysis in which gastrointestinal (GI) symptoms reduce appetite and dietary intake. Adequate nutrition is important, especially if surgery is required. Although the incidence of EPS is low, the present report is able to detail preoperative nutrition status and treatment in a large cohort of patients from a national EPS referral center. ♦

METHODS

Of 51 patients admitted to this EPS specialist center hospital for their first peritonectomy in the study period, 50 had a preoperative dietetic assessment, and 49 underwent upper-arm anthropometry. ♦

RESULTS

Mean body mass index (BMI) was 20.6 kg/m(2). Mean weight loss was 14% of body weight in the preceding 6 months, with 35 of 50 patients losing more than 10%. On anthropometry, 25 of 49 patients were below the 5th percentile for mid-arm circumference (MAC), 17 of 49 were below for triceps skinfold thickness (TSF), and 21 of 49 were below for mid-arm muscle circumference (MAMC). Mean handgrip strength (HGS) was 60% of normal, with 43 of 49 patients being below 85% of normal. Appetite was poor in 21 of 50 patients, and 37 of 50 had upper and 40 of 50 had lower GI symptoms. By subjective global assessment, 27 of 51 patients were graded as severely malnourished, and 5 of 51, as well-nourished. Mean serum albumin was 28 g/L and did not correlate with BMI, MAC, TSF, MAMC, or HGS. In most patients, C-reactive protein was elevated (mean: 111 mg/L). Preoperative parenteral nutrition was given to 46 of 51 patients for a mean of 21 days. ♦

DISCUSSION

Our findings demonstrate the poor nutrition status of patients admitted for EPS surgical intervention. Anthropometrics reveal depleted fat and lean body mass in EPS patients, which might be a result of anorexia and inflammation, and the reason that albumin was not an accurate marker of nutrition. Poor nutrition status is likely to negatively affect outcome in this patient group. ♦

CONCLUSIONS

Early recognition of GI symptoms may herald a diagnosis of EPS. Optimization of preoperative nutrition status with intensive nutrition support is needed.

Protein-energy wasting, as well as overweight and obesity, is a long-term risk factor for mortality in chronic hemodialysis patients

INTRODUCTION

In patients with end-stage renal disease on chronic hemodialysis (HD), protein-energy wasting (PEW) is very common and is associated with increased morbidity and mortality. Evaluation of nutritional status should be performed regularly in all such patients, using multiple methods. In this study, we analyzed the influence of several nutritional markers on long-term (5 years) survival of HD patients in one center. This is the first study on the long-term influence of nutritional status on mortality in dialysis patients ever conducted in Romania.

MATERIALS AND METHODS

We included all prevalent HD patients in our center. Those with ongoing acute illnesses and with inflammation (C-reactive protein ≥ 6.0 mg/l) were excluded. In the remaining subjects (N = 149, 82 males, mean age 55 years old), we performed the following measurements of nutritional status: estimation of dietary protein intake by normalized protein equivalent of nitrogen appearance (nPNA), subjective global assessment (SGA), body mass index (BMI), tricipital skinfold thickness, mid-arm circumference, assessment of body composition by bioelectrical impedance analysis (BIA), and pre-dialysis serum creatinine, albumin, and total cholesterol. We used receiver operating characteristic curves to determine the cutoff points for most of the variables, and we applied the Kaplan-Meier estimator and the Cox's proportional hazards model (stepwise method) to analyze the influence of these variables on survival.

RESULTS

In univariate analysis, general factors including age ≥ 65 years, male gender, dialysis vintage ≥ 2 years, and the presence of diabetes and heart failure were all significant predictors of mortality. Among nutritional parameters, BMI ≥ 25 kg/m(2), SGA-B (mild PEW), nPNA < 1.15 g/kg per day, and the BIA-derived phase angle (PhA) <5.58° were also significantly associated with reduced survival. All of these factors maintained statistical significance in multivariate analysis, except for male gender and heart failure.

CONCLUSION

We showed that low values of SGA, nPNA, and PhA independently predict mortality in HD patients. In conjunction with an earlier study, we demonstrated that the relative risk of death associated with these markers is highest during the first year of monitoring and it decreases in the following 4 years, although it still remains significantly increased. On the other hand, overweight and obesity were also associated with lower survival after 5 years, whereas this association was not apparent after 1 year.

Performance of the Cockcroft-Gault, MDRD and CKD-EPI Formulae in Non-Valvular Atrial Fibrillation: Which one Should be Used for Risk Stratification?

Background: Renal dysfunction is a strong predictor of adverse events in patients with atrial fibrillation (AF). The Cokcroft-Gault, Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease-Epidemiology Collaboration (CKD-EPI) equations are available for estimating the glomerular filtration rate (GFR). No comparisons between these equations have yet been performed in patients with non-valvular AF concerning their mid-term prognostic performance. Methods: Cross-sectional study of 555 consecutive patients with non-valvular AF undergoing transesophageal echocardiogram. We tested the prognostic performance of the aforementioned GFR estimation formulae, namely their ability to predict all-cause mortality (primary endpoint) and major cardiac adverse or ischemic cerebrovascular events (secondary endpoints) during an average follow-up of 24 months. Results: Regarding the primary endpoint, Cockcroft-Gault (AUC=0.749±0.028) was superior to both MDRD (AUC=0.624±0.039) and CKD-EPI (AUC=0.641±0.034) [p<0.001 both comparisons] while CKD-EPI was superior to MDRD (p=0.011). Cockcroft-Gault was marginally superior to both MDRD (AUC=0.673±0.049 vs. AUC=0.586±0.054, p=0.041) and CKD-EPI (AUC=0.673±0.049 vs. AUC=0.604±0.054, p=0.063) in the prediction of ischemic cerebrovascular events, while no difference was found between CKD-EPI and MDRD. Concerning AUC for prediction of MACE, Cockcroft-Gault was superior to MDRD (p=0.009) and CKD-EPI (p=0.012), while CKD-EPI was similar to MDRD (p=0.215). Multivariate predictive models consistently included Cockcroft-Gault formula along with CHADS₂, excluding the other two equations. Measures of reclassification revealed a significant improvement in risk stratification for all studied endpoints with Cockcroft-Gault instead of CKD-EPI. Conclusions: In patients with non-valvular AF, the Cockcroft-Gault more appropriately classified individuals with respect to risk of all-cause mortality, ischaemic cerebrovascular event and major adverse cardiac event.

Obesity in patients undergoing dialysis and kidney transplantation

Obesity poses a major challenge for nephrologists and patients alike, and its prevalence among patients with kidney disease is increasing at least as fast as in the general population. Although the body mass index (BMI) is the most commonly used measurement of excess adiposity, it has important limitations that can be ameliorated by incorporating other markers of body composition. The influence of obesity on outcomes in patients undergoing dialysis and kidney transplantation is of great interest. Although the preponderance of epidemiologic data suggests that, at least in patients undergoing dialysis, obesity has a neutral or protective effect on mortality, although this has not been confirmed in interventional studies needed to establish causality. The effect of obesity on other important outcomes such as quality of life has yet to be determined, and much less information on obesity and outcomes is available in the kidney transplantation population. Similarly, research on the optimal strategies and effects of weight loss in dialysis and kidney transplantation patients is at a nascent stage.

Nutritional status and clinical outcome of children on continuous renal replacement therapy: a prospective observational study

BACKGROUND

No studies on continuous renal replacement therapy (CRRT) have analyzed nutritional status in children. The objective of this study was to assess the association between mortality and nutritional status of children receiving CRRT.

METHODS

Prospective observational study to analyze the nutritional status of children receiving CRRT and its association with mortality. The variables recorded were age, weight, sex, diagnosis, albumin, creatinine, urea, uric acid, severity of illness scores, CRRT-related complications, duration of admission to the pediatric intensive care unit, and mortality.

RESULTS

The sample comprised 174 critically ill children on CRRT. The median weight of the patients was 10 kg, 35% were under percentile (P) 3, and 56% had a weight/P50 ratio of less than 0.85. Only two patients were above P95. The mean age for patients under P3 was significantly lower than that of the other patients (p = 0.03). The incidence of weight under P3 was greater in younger children (p = 0.007) and in cardiac patients and in those who had previous chronic renal insufficiency (p = 0.047). The mortality analysis did not include patients with pre-existing renal disease. Mortality was 38.9%. Mortality for patients with weight < P3 was greater than that of children with weight > P3 (51% vs 33%; p = 0.037). In the univariate and multivariate logistic regression analyses, the only factor associated with mortality was protein-energy wasting (malnutrition) (OR, 2.11; 95% CI, 1.067-4.173; p = 0.032).

CONCLUSIONS

The frequency of protein-energy wasting in children who require CRRT is high, and the frequency of obesity is low. Protein-energy wasting is more frequent in children with previous end-stage renal disease and heart disease. Underweight children present a higher mortality rate than patients with normal body weight.

Cardio-renal cachexia syndromes (CRCS): pathophysiological foundations of a vicious pathological circle

Cardio-renal syndromes (CRS) are defined as disorders of the heart and kidney whereby acute or chronic dysfunction in one organ may induce acute or chronic dysfunction of the other. CRS have been classified into five categories, where types 2 and 4 represent respectively chronic cardio-renal and chronic reno-cardiac syndromes. In these conditions, the chronic disorder of either the heart or kidney has been shown to induce some degree of cachexia. At the same time, cachexia has been proposed as a possible mechanism contributing to the worsening of such pathological organ cross talk. Common pathogenetic mechanisms underlie body wasting in cachectic states of different chronic heart and kidney diseases. In these circumstances, a vicious circle could arise, in which cachexia associated with either heart failure or chronic kidney disease may contribute to further damage of the other organ. In chronic CRS, activation of the immune and neuroendocrine systems contributes to the genesis of cachexia, which in turn can negatively affect the heart and kidney function. In patients with cardiac sustained activation of the immune and neuroendocrine systems and oxidative stress, renal vascular resistance can increase and therefore impair renal perfusion, leading to worsening kidney function. Similarly, in renal cachexia, increased levels of pro-inflammatory cytokines can cause progressive left ventricular systolic dysfunction, myocardial cell death, endothelial dysfunction and increased myocardial fibrosis, with consequent impairment of the chronic reno-cardiac syndrome type 4. Thus, we speculate that the occurrence of different types of chronic CRS could represent a fundamental step in the genesis of cachexia, being renal and cardiac dysfunction closely related to the occurrence of systemic disorders leading to a final common pathway. Therefore, the heart and kidney and cachexia represent a triad causing a vicious circle that increases mortality and morbidity: In such circumstances, we may plausibly talk about cardio-renal cachexia syndrome. Complex interrelations may explain the transition from CRS to cachexia and from cachexia to CRS. Identification of the exact mechanisms occurring in these conditions could potentially help in preventing and treating this deadly combination.