Interdialytic home systolic blood pressure variability increases all-cause mortality in hemodialysis patients

BACKGROUND

The association between Interdialytic home blood pressure variability (BPV) and the prognosis of patients undergoing maintenance hemodialysis (MHD) largely unknown.

HYPOTHESIS

We proposed the hypothesis that interdialytic home BPV exert effect on cardiac and all-cause mortality among individuals undergoing MHD.

METHODS

A total of 158 patients receiving MHD at the hemodialysis unit of Wuhan Fourth Hospital between December 2019 and August 2020 were included in this prospective cohort study. Patients were divided into tertiles according to the systolic BPV (SBPV), and the primary endpoints were cardiac and all-cause death. Kaplan-Meier analysis was used to assess the relationship between long-term survival and interdialytic home SBPV. In addition, Cox proportional hazards regression models were used to identify risk factors contributing to poor prognosis.

RESULTS

The risk of cardiac death and all-cause death was gradually increased in patients according to tertiles of SBPV (3.5% vs. 14.8% vs. 19.2%, p for trend = .021; and 11.5% vs. 27.8% vs. 44.2%, p for trend <.001). The Cox regression analysis revealed that compared to Tertile 1, the hazard ratios for all-cause mortality in Tertile 2 and Tertile 3 were 3.13 (p = .026) and 3.24 (p = .021), respectively, after adjustment for a series of covariates.

CONCLUSIONS

The findings revealed a positive correlation between increased interdialytic home SBPV and elevated mortality risk in patients with MHD.

Cross-Sectional Study on the Association between Dietary Patterns and Sarcopenia in Elderly Patients with Chronic Kidney Disease Receiving Conservative Treatment

Sarcopenia is a poor prognostic factor in patients with chronic kidney disease (CKD). Adequate dietary patterns are important for preventing sarcopenia; however, evidence regarding the underlying association between sarcopenia and diet is insufficient. Therefore, in this study, we aimed to investigate the association between sarcopenia and dietary patterns in CKD patients receiving conservative treatment. In this cross-sectional study, 441 patients with conservative CKD were examined using the Asian Working Group for Sarcopenia diagnostic criteria. CKD was defined as an eGFR of <60 mL/min/1.73 m2 present for >3 months. The participants were divided into sarcopenia and non-sarcopenia groups, and dietary patterns were compared between the two groups using the dietary variety score, a simple dietary survey method that investigates the weekly frequency of consumption of 10 food groups. Logistic regression analysis for CKD G3 showed that female sex (odds ratio (OR): 0.166, 95% confidence interval (CI): 0.086-0.320), increased body mass index (OR: 0.663, 95% CI: 0.590-0.745), and almost daily consumption of green/yellow vegetables (OR: 0.350, 95% CI: 0.176-0.695) were positively associated with non-sarcopenia. Although further prospective studies are required, the results suggest that low frequent consumption of vegetables is associated with sarcopenia in patients with CKD.

Computed tomography-determined skeletal muscle density predicts 3-year mortality in initial-dialysis patients in China

BACKGROUND

Skeletal muscle mass and quality assessed by computed tomography (CT) images of the third lumbar vertebra (L3) level have been established as risk factors for poor clinical outcomes in several illnesses, but the relevance for dialysis patients is unclear. A few studies have suggested a correlation between CT-determined skeletal muscle mass and quality at the first lumbar vertebra (L1) level and adverse outcomes. Generally, chest CT does not reach beyond L1. We aimed to determine whether opportunistic CT scan (chest CT)-determined skeletal muscle mass and quality at L1 are associated with mortality in initial-dialysis patients.

METHODS

This 3-year multicentric retrospective study included initial-dialysis patients from four centres between 2014 and 2017 in China. Unenhanced CT images of the L1 and L3 levels were obtained to assess skeletal muscle mass [by skeletal muscle index, (SMI), cm2 /m2 ] and quality [by skeletal muscle density (SMD), HU]. Skeletal muscle measures at L1 were compared with those at L3. The sex-specific optimal cutoff values of L1 SMI and L1 SMD were determined in relation to all-cause mortality. The outcomes were all-cause death and cardiac death. Cox regression models were applied to investigate the risk factors for death.

RESULTS

A total of 485 patients were enrolled, of whom 257 had both L1 and L3 images. Pearson's correlation coefficient between L1 and L3 SMI was 0.84 (P < 0.001), and that between L1 and L3 SMD was 0.90 (P < 0.001). No significant association between L1 SMI and mortality was observed (P > 0.05). Low L1 SMD (n = 280, 57.73%) was diagnosed based on the optimal cutoff value (<39.56 HU for males and <33.06 HU for females). Multivariate regression analysis revealed that the low L1 SMD group had higher risks of all-cause death (hazard ratio 1.80; 95% confidence interval 1.05-3.11, P = 0.034) and cardiac death (hazard ratio 3.74; 95% confidence interval 1.43-9.79, P = 0.007).

CONCLUSIONS

In initial-dialysis patients, there is high agreement between the L1 and L3 measures for SMI and SMD. Low SMD measured at L1, but not low SMI, is an independent predictor of both all-cause death and cardiac death.

Decreased intracellular water is associated with sarcopenic obesity in chronic haemodialysis patients

OBJECTIVE

To explore the association between intracellular water (ICW) and sarcopenic obesity in patients undergoing chronic haemodialysis (HD).

METHODS

A multicentre, cross-sectional study of 3354 adult chronic HD patients was conducted in 20 haemodialysis centres from June 1, 2021, to August 30, 2021. The diagnosis of sarcopenic obesity was made according to the revised Asian Working Group's definition of sarcopenia combined with obesity per the body fat percentage definition. Body composition was evaluated by a body composition monitor using bioimpedance spectroscopy. Multiple logistic regression models, stratified analyses, interactive analyses, and receiver-operating characteristic analyses were conducted.

RESULTS

A total of 752 patients were diagnosed with sarcopenic obesity among 3354 participants. The patients were grouped by sex-specific ICW median levels, and the prevalence of sarcopenic obesity was significantly higher in the low ICW group than in the high ICW group (41.3%vs 3.0%). Decreased ICW was significantly associated with sarcopenic obesity. The association remained statistically significant even after adjusting for dialysis vintage, age, body mass index, biochemical indicators, and various medical histories. The odds ratios of the low ICW group were much higher than those of the high ICW group in both males and females (P for trend < 0.001). The association was stable across subgroups, and the interaction analysis showed that age, body mass index and history of diabetes had interactive roles in the association between ICW and sarcopenic obesity (P for interaction < 0.05). Furthermore, the ICW cut-off values for identifying sarcopenic obesity were 19.1 kg and 14.5 kg for males and females, respectively.

CONCLUSION

Decreased ICW was an independent risk factor for sarcopenic obesity in chronic HD patients. The measurement of ICW by bioimpedance spectroscopy might be a non-invasive and valid means for identifying the risk of future sarcopenic obesity in HD patients.

Association of Intima-Media Thickness Measured at the Common Carotid Artery With Incident Carotid Plaque: Individual Participant Data Meta-Analysis of 20 Prospective Studies

Background The association between common carotid artery intima-media thickness (CCA-IMT) and incident carotid plaque has not been characterized fully. We therefore aimed to precisely quantify the relationship between CCA-IMT and carotid plaque development. Methods and Results We undertook an individual participant data meta-analysis of 20 prospective studies from the Proof-ATHERO (Prospective Studies of Atherosclerosis) consortium that recorded baseline CCA-IMT and incident carotid plaque involving 21 494 individuals without a history of cardiovascular disease and without preexisting carotid plaque at baseline. Mean baseline age was 56 years (SD, 9 years), 55% were women, and mean baseline CCA-IMT was 0.71 mm (SD, 0.17 mm). Over a median follow-up of 5.9 years (5th-95th percentile, 1.9-19.0 years), 8278 individuals developed first-ever carotid plaque. We combined study-specific odds ratios (ORs) for incident carotid plaque using random-effects meta-analysis. Baseline CCA-IMT was approximately log-linearly associated with the odds of developing carotid plaque. The age-, sex-, and trial arm-adjusted OR for carotid plaque per SD higher baseline CCA-IMT was 1.40 (95% CI, 1.31-1.50; I²=63.9%). The corresponding OR that was further adjusted for ethnicity, smoking, diabetes, body mass index, systolic blood pressure, low- and high-density lipoprotein cholesterol, and lipid-lowering and antihypertensive medication was 1.34 (95% CI, 1.24-1.45; I²=59.4%; 14 studies; 16 297 participants; 6381 incident plaques). We observed no significant effect modification across clinically relevant subgroups. Sensitivity analysis restricted to studies defining plaque as focal thickening yielded a comparable OR (1.38 [95% CI, 1.29-1.47]; I²=57.1%; 14 studies; 17 352 participants; 6991 incident plaques). Conclusions Our large-scale individual participant data meta-analysis demonstrated that CCA-IMT is associated with the long-term risk of developing first-ever carotid plaque, independent of traditional cardiovascular risk factors.

Incidence of Parkinson's disease and modifiable risk factors in Korean population: A longitudinal follow-up study of a nationwide cohort

Introduction

We aimed to investigate the incidence of Parkinson's disease (PD) by age and year for each sex as well as the modifiable risk factors for PD. Using data from the Korean National Health Insurance Service, 938,635 PD and dementia-free participants aged ≥40 years who underwent general health examinations were followed to December 2019.

Methods

We analyzed the PD incidence rates according to age, year and sex. To investigate the modifiable risk factors for PD, we used the Cox regression model. Additionally, we calculated the population-attributable fraction to measure the impact of the risk factors on PD.

Results

During follow-up, 9,924 of the 938,635 (1.1%) participants developed PD. The incidence of PD increased continuously from 2007 to 2018, reaching 1.34 per 1,000 person-years in 2018. The incidence of PD also increases with age, up to 80 y. Presence of hypertension (SHR = 1.09, 95% CI 1.05 to 1.14), diabetes (SHR = 1.24, 95% CI 1.17 to 1.31), dyslipidemia (SHR = 1.12, 95% CI 1.07 to 1.18), ischemic stroke (SHR = 1.26, 95% CI 1.17 to 1.36), hemorrhagic stroke (SHR = 1.26, 95% CI 1.08 to 1.47), ischemic heart disease (SHR = 1.09, 95% CI 1.02 to 1.17), depression (SHR = 1.61, 95% CI 1.53 to 1.69), osteoporosis (SHR = 1.24, 95% CI 1.18 to 1.30), and obesity (SHR = 1.06, 95% CI 1.01 to 1.10) were independently associated with a higher risk for PD.

Discussion

Our results highlight the effect of modifiable risk factors for PD in the Korean population, which will help establish health care policies to prevent the development of PD.

Cut points of the conicity index as an indicator of abdominal obesity in individuals undergoing hemodialysis: An analysis of latent classes

OBJECTIVES

Abdominal obesity favors the involvement of cardiometabolic complications in renal patients on hemodialysis. Thus, the aim of the study was to identify the cut-points of the conicity index in individuals undergoing hemodialysis.

METHODS

This was a cross-sectional study carried out with 953 individuals undergoing hemodialysis in clinics in a metropolitan region of southeastern Brazil. The conicity index was calculated using the following mathematical equation: waist circumference/0.109 × √weight/height. The receiver operating characteristic (ROC) curve was calculated from the analysis of latent classes by cross-validation through a latent variable of abdominal obesity. This latent variable was defined using the response pattern of the observed anthropometric variables considering the presence and absence of abdominal obesity: waist circumference, waist-to-height ratio, and body shape index. The cut-points identified were elucidated by the area under the curve (AUC), Youden index, sensitivity, and specificity.

RESULTS

The cut-points for the conicity index found for both sexes were similar, resulting in a cut-point for men of 1.275 (AUC, 0.921; Youden index, 0.666), with a sensitivity and specificity of 83% and 83.6%, and a cut-point for women of 1.285 (AUC, 0.921; Youden index, 0.679), with a sensitivity and specificity of 78.6% and 89.3%, respectively.

CONCLUSIONS

The conicity index showed high discriminatory power for the identification of abdominal obesity in hemodialysis patients, therefore it can be a simple and easily accessible tool to be incorporated into clinical practice in this population.

Sarcopenia and cardiovascular disease in patients with and without kidney disease: what do we know?

Cardiovascular disease (CVD) incidence is high in patients with chronic kidney disease (CKD) and is the most frequent cause of mortality in this population. Advanced age, hypertension, uremic toxins, endothelial dysfunction, atherosclerosis, hyperhomocysteinemia, oxidative stress, and inflammation are among the leading causes of increased CVD in advanced stages of CKD. Although defined as a decrease in muscle strength associated with aging, sarcopenia is also prevalent in CKD patients. Sarcopenia causes physical disability, low quality of life, and mortality. Regular exercise and nutritional supplementation may slow the progression of sarcopenia. Recent studies have shown that sarcopenia increases the risk of CVD and mortality in people with or without kidney disease. This review discusses the relationship between sarcopenia and CVD in light of the current literature.

Association of Body Fluid Volumes and Body Fat Distribution with Abnormal Ankle-Brachial Index

Background

Ankle-brachial index (ABI) is a simple, non-invasive and easy-to-obtain measure for the evaluation of atherosclerotic peripheral arterial disease (PAD). This study aimed to investigate the relationships between body fluid volumes, body composition, body fat distribution and ABI at a population perspective.

Results

Using the US National Health and Nutrition Examination Survey Data (NHANES) during 1999–2000, 2001–2002, and 2003–2004, adults ≥ 40 years old were eligible for inclusion. Univariate and multivariable linear and logistic regression analyses were performed to determine the associations between ABI, body fluid volume and body composition assessed by bioelectrical impedance analysis (BIA), and body fat distribution assessed by dual-energy X-ray absorptiometry (DEXA). After exclusion, the final analytic sample contained 1535 participants who were representative of totally 28,572,458 subjects in the US. After adjustments for relevant confounders, estimated fat mass was significantly and inversely associated with ABI (beta: − 0.0009, 95% CI = − 0.0015, − 0.0003). Total percent fat (beta: − 0.0024, 95% CI = − 0.0033, − 0.0014), trunk percent fat (beta: − 0.0016, 95% CI = − 0.0023, − 0.0009), and percent fat at the four limbs were also significantly and inversely associated with ABI (p < 0.001). In addition, subjects with higher estimated fat mass, total percent fat, trunk percent fat and higher percent fat at the four limbs were all significantly more likely to have abnormal ABI < 0.9. No significant association between parameters of body fluid volume and abnormal ABI was observed.

Conclusions

Estimated fat mass, total percent fat, trunk percent fat and percent fat at the four limbs were significantly and inversely associated with ABI. Subjects with abnormal ABI are more likely to have higher total percent fat, trunk percent fat and the limb fat. These findings fill the knowledge gap on the relationships between atherosclerosis and body fat distribution. Further well-designed prospective studies are needed to confirm the present findings.

Relationship between chronic kidney disease and sarcopenia

Few studies have investigated the relationship between sarcopenia and mild to moderate renal decline. This study aimed to investigate the relationship between chronic kidney disease (CKD) and sarcopenia. In total, 123 patients hospitalized with CKD and 57 healthy volunteers who underwent physical examination during the same period (control group) were analyzed. Body compositions were measured by dual-energy X-ray absorptiometry, and the relative appendicular skeletal muscle index (RASMI) was calculated. Muscular strength was evaluated using hydraulic hand dynamometer. Walking speed within 6 m was measured for muscular function assessment. Single-photon emission computed tomography was performed to measure the glomerular filtration rate of CKD patients, who were then divided into CKD1 (55 patients in CKD stages 1 and 2) and CKD2 (68 patients in CKD stages 3-5). RASMI showed a downward trend with CKD progression (P = 0.001). Multivariate logistic regression analysis showed that age and CKD progression were independent risk factors for sarcopenia. The morbidity of sarcopenia was significantly greater in CKD patients than in healthy volunteers, and the degree of muscle loss was closely related to CKD progression.

AGEs accumulation is related to muscle degeneration and vascular calcification in peritoneal dialysis patients

BACKGROUND

Patients with chronic kidney disease (CKD) are affected by dynapenia, sarcopenia, and vascular calcification. Advanced glycation end products (AGEs) may accumulate in peritoneal dialysis (PD) patients and favor sarcopenia via changes in collagen cross-linking, muscle protein breakdown, and the calcification of arterial smooth muscle cells via p38-MAPK activation. The aim of this study is to explore the relationships between AGEs, muscle degeneration, and coronary artery calcification.

METHODS

This was a clinical observational study in patients with CKD undergoing PD, in which serum and skin AGEs (AGEs-sAF), cumulative glucose load, muscle strength and functional tests, muscle ultrasounds with elastography, coronary artery calcium (CAC) quantification, and muscle density by multislice computed tomography were measured.

RESULTS

27 patients aged 48±16 years, dialysis vintage of 27±17 months, had AGEs-sAF levels of 3.09±0.65 AU (elevated in 13 [87%] patients), grip strength levels of 26.2±9.2 kg (11 [42%] patients with dynapenia), gait speed of 1.04±0.3 m/s (abnormal in 14 [58%] patients) and "timed-up-and-go test" (TUG) of 10.5±2.2s (abnormal in 7 [26%] patients). Correlations between AGEs-sAF levels and femoral rectus elastography (R=-0.74; p=0.02), anterior-tibialis elastography (R= -0.68; p=0.04) and CAC (R=0.64; p=0.04) were detected. Cumulative glucose load correlated with femoral rectal elastography (R=-0.6; p=0.02), and serum glycated hemoglobin concentrations correlated with psoas muscle density (R= -0.58; p=0.04) and CAC correlated with psoas muscle density (R=0.57; p=0.01) and lumbar square muscle density (R=-0.63; p=0.005).

CONCLUSIONS

The study revealed associations between AGEs accumulation and lower muscle stiffness/density. Associations that linked muscle degeneration parameters with vascular calcification were observed.

Effects of Aerobic and Resistance Exercise Training on Carotid Intima-Media Thickness in Abdominal Obese Women

Aims: The purpose of this study was to investigate the effects of a 12-week aerobic and resistance training program on waist circumference (WC) and carotid intima-media thickness (CIMT) in abdominal obese middle-aged women. Methods: Subjects were 40 middle-aged women with abdominal obesity (WC >85 cm) but no specific diseases. Subjects were divided into a combined exercise group (aerobic and resistance exercise) and a control group that did not participate in any lifestyle modification. Carotid variables were measured using B-mode ultrasound. A treadmill exercise test was conducted to directly assess the peak oxygen uptake (VO₂peak). Differences in the carotid variables and relative changes between baseline and after 12 weeks were evaluated. Results: After 12 weeks, body weight (70.6 ± 7.8 to 65.6 ± 6.3 kg, P < 0.05), WC (88.8 ± 3.6 to 85.6 ± 3.1 cm, P < 0.01), total cholesterol (215.5 ± 38.4 to 188.2 ± 25.8 mmHg, P < 0.05), low-density lipoprotein cholesterol (150.5 ± 30.6 to 131.6 ± 22.3 mmHg, P < 0.05), triglycerides (164.5 ± 82.3 to 119.9 ± 60.6 mmHg, P < 0.01), VO₂peak (24.2 ± 6.2 to 28.7 ± 4.4 mL/kg/min, P < 0.01), and CIMT (0.61 ± 0.13 to 0.58 ± 0.12 mm, P < 0.05) were significantly improved in the combined exercise group but not in the control group; changes in CIMT were associated with changes in WC decrease (r = 0.41, P < 0.01) and VO₂peak (r = -0.53, P < 0.01). Conclusions: Combined exercise training in abdominal obese women decreased CIMT; these changes were also associated with reduced WC and improved VO₂peak.

Uremic Sarcopenia and Its Possible Nutritional Approach

Uremic sarcopenia is a frequent condition present in chronic kidney disease (CKD) patients and is characterized by reduced muscle mass, muscle strength and physical performance. Uremic sarcopenia is related to an increased risk of hospitalization and all-causes mortality. This pathological condition is caused not only by advanced age but also by others factors typical of CKD patients such as metabolic acidosis, hemodialysis therapy, low-grade inflammatory status and inadequate protein-energy intake. Currently, treatments available to ameliorate uremic sarcopenia include nutritional therapy (oral nutritional supplement, inter/intradialytic parenteral nutrition, enteral nutrition, high protein and fiber diet and percutaneous endoscopic gastrectomy) and a personalized program of physical activity. The aim of this review is to analyze the possible benefits induced by nutritional therapy alone or in combination with a personalized program of physical activity, on onset and/or progression of uremic sarcopenia.

Association Between sRAGE and Arterial Stiffness in Women with Systemic Lupus Erythematosus

BACKGROUND

sRAGE (soluble receptor for advanced glycation end products) is known to play a protective role in chronic inflammatory diseases, and has been found to be related to arterial stiffness in hypertensive or diabetic patients. This cross-sectional study was designed to study the potential association of sRAGE with arterial stiffness in systemic lupus erythematosus(SLE) patients.

METHODS

A total of 94 female SLE patients were enrolled. Brachial-ankle pulse wave velocity (baPWV) was measured by an automatic pulse wave analyzer. The patients were divided into two groups according to the baPWV values, those with values greater than 1400cm/s were placed in the high arterial stiffness group. Biochemical parameters were compared between the two groups. Linear and logistic regression analysis was used to observe the association between sRAGE and arterial stiffness in these patients.

RESULTS

Thirty-five patients were placed in the high arterial stiffness group in which sRAGE levels were lower (P<0.05). sRAGE levels were significantly related to baPWV(standardized β=1.18, P<0.01) by linear regression analysis. Multivariate logistic regression analysis showed that sRAGE, SLE duration, systolic blood pressure, and low-density lipoprotein cholesterol were independent predictors of arterial stiffness in these patients.

CONCLUSION

The results revealed that sRAGE was negatively associated with arterial stiffness in Chinese female SLE patients.

Presarcopenia Is an Independent Risk Factor for Carotid Atherosclerosis in Chinese Population with Metabolic Syndrome

PURPOSE

To investigate the impacts of skeletal muscle mass on carotid atherosclerosis in Chinese adults with metabolic syndrome (MetS).

METHODS

One hundred and ninety-five subjects with MetS had the waist-to-height ratio (WHTR)≥0.5 for all. One hundred and eighty-four subjects without MetS were divided into 2 groups: Non-Mets obese group (WHTR ≥ 0.5, n = 118) and Non-MetS control group (WHTR < 0.5, n = 66). All the groups had no difference in age. Appendicular skeletal muscle mass was acquired and skeletal muscle mass index (SMI) was calculated. Carotid intima-media thickness (IMT) was assessed by ultrasonography. Each group was stratified according to the presence or absence of presarcopenia.

RESULTS

While most parameters showed an increasing trend with WHTR and MetS in both genders, SMI and HDL-C showed a decreasing trend. The prevalence of carotid atherosclerosis showed the same increasing trend. Multivariate logistic regression analyses showed SBP and presarcopenia were both independent risk factors for carotid atherosclerosis in MetS (OR 1.026, P < 0.001; OR 2.788, P = 0.001, respectively). There was no significant difference in IMT among the three groups with preserved muscle mass whether the participants suffered from obesity or MetS, while there was a significant difference between the two groups with presarcopenia (in male P = 0.020, in female P = 0.009, respectively). The area under the ROC curve (AUC) was 0.641 (P<0.001) for presarcopenia.

CONCLUSION

Obesity was a risk factor for sarcopenia independent of age, especially in subjects with metabolic syndrome. In individuals with MetS, our findings suggest that presarcopenia may be an independent risk factor for atherosclerosis and appendicular skeletal muscle mass had potential protective effects for carotid atherosclerosis regardless of gender.

Investigating Physical and Nutritional Changes During Prolonged Intermittent Fasting in Hemodialysis Patients: A Prospective Cohort Study

OBJECTIVE

Studies investigating the health effects of prolonged intermittent fasting during Ramadan among Muslim patients on hemodialysis (HD) are limited and reported heterogeneous findings. This study aimed to evaluate the effects of intermittent fasting during Ramadan on nutritional and functional status of patients on maintenance HD.

DESIGN AND METHODS

This was a 12-week, multicenter, prospective observational study. The study setting included three HD centers. Adult Muslim patients, who were undergoing HD session thrice weekly and planned to fast during Ramadan, were screened for eligibility and recruited. Nutritional and functional status assessments were carried out 2 weeks before (V₀), at the fourth week of Ramadan (V₁), and 4 weeks after Ramadan (V₂). Nutritional status parameters included anthropometry (body mass index, interdialytic weight gain, waist circumference), body composition (mid-arm circumference, triceps skinfold, body fat percentage), blood biochemistry (albumin, renal profile, lipid profile, and inflammatory markers), blood pressure, dietary intake, and handgrip strength. Changes in nutritional and functional status parameters across study timepoints were analyzed using repeated-measures analysis of variance.

RESULTS

A total of 87 patients completed the study, with 68 patients (78.2%) reporting fasting ≥20 days. Ramadan fasting led to significant reductions (all P < .05) in body mass index, interdialytic weight gain, waist circumference, mid-arm circumference, fat tissue mass, and body fat percentage, but these were not accompanied by any significant change in lean tissue mass (P > .05). Significant improvement was observed in serum phosphate levels, but serum albumin, urea, and creatinine were also reduced significantly during Ramadan (P < .05). There were no significant changes in lipid profile and inflammatory markers. Interestingly, energy and protein intakes remain unchanged during Ramadan. Handgrip strength improved significantly during Ramadan and further improved after Ramadan.

CONCLUSION

Intermittent Ramadan fasting leads to temporary changes in nutritional status parameters and poses nondetrimental nutritional risk for patients on maintenance HD.

High fat mass, low muscle mass, and arterial stiffness in a population of free-living healthy subjects: The "al passo con la tua salute" project

INTRODUCTION

A progressive decline in lean body mass and increase in fat mass occur with aging, and result in progressive weakness and impaired mobility; these features are altogether landmarks of the ageing frailty syndrome. High-fat mass and low muscle mass are both associated with an increased risk of cardiovascular events and are supposed to be risk factors for arterial stiffness. Little data analyzing the relationship between body composition and cardio-ankle vascular index (CAVI) are currently available. The main objective of this study was to verify whether low muscle mass and/or high fat mass could be associated with arterial stiffness measured by CAVI.

METHODS

Data are from the cross-sectional assessment of the "Al passo con la tua salute", a clinical study aimed to promote physical function among free-living elderly subjects.After a screening interview and a clinical visit aimed to exclude ineligible persons, 52 volunteers were enrolled in the study. All underwent: clinical examination, physical performance assessment, an interview on lifestyle and dietary habits, and lastly, a blood sample collection after at least 8 hours of fasting.

RESULTS

CAVI was statistically significantly higher in those participants in the highest tertile of distribution for fat mass compared to all other subjects (P = .03). In those participants in the lowest tertile of distribution of muscle mass, compared to all other, CAVI was also statistically significant higher (P = .01) independently of age, sex, body mass index, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and systolic blood pressure.

CONCLUSIONS

Low muscle mass and high fat mass were landmarks in the frailty model of aging; therefore, it is not inconsistent that both clinical conditions might share with the "aging vessel" a common pathway, probably mediated through signaling network deregulation and/or through alteration of the balance between energy availability and energy demand.

Prevalence of dynapenic obesity and sarcopenic obesity and their associations with cardiovascular disease risk factors in peritoneal dialysis patients

Background

Dynapenic obesity and sarcopenic obesity increase cardiovascular disease (CVD) and mortality in nonuremic patients. The present study was designed to determine the prevalence of dynapenic obesity and sarcopenic obesity and their associations with CVD risk factors in peritoneal dialysis (PD) patients.

Methods

All eligible PD patients in Tehran peritoneal dialysis centers were included in this cross-sectional study. Skeletal muscle mass and fat mass were assessed using bioelectrical impedance analysis. Muscle strength and physical performance were determined using hand grip strength and a 4-meter walk gait speed test, respectively. In addition, a 5-mL blood sample was obtained from each patient.

Results

The prevalence of dynapenic obesity and sarcopenic obesity were 11.4% and 3.8% in PD patients, respectively. Serum high-sensitive C-reactive protein (hs-CRP), soluble intercellular adhesion molecule type 1, triglyceride, total cholesterol, and low-density lipoprotein cholesterol were significantly higher in PD patients with dynapenic obesity than in dynapenic nonobese and nondynapenic nonobese patients. Similarly, serum concentrations of CVD risk factors in PD patients with sarcopenic obesity were higher than in nonsarcopenic nonobese patients, but these differences were statistically significant only for serum hs-CRP and triglyceride. In addition, muscle strength and skeletal muscle mass percentage were negatively associated with markers of inflammation and dyslipidemia, whereas body fat percentage was positively associated with these CVD risk factors.

Conclusion

This study indicates that although the prevalence of dynapenic obesity and sarcopenic obesity are relatively low in PD patients, these disorders may be associated with CVD risk factors.

Sarcopenia and cardiovascular risk indices in patients with chronic kidney disease on conservative and replacement therapy

OBJECTIVE

Chronic kidney disease (CKD) is a condition with high cardiovascular mortality associated with emerging risk factors, including sarcopenia. Several mechanisms can affect muscle mass, such as vitamin D deficiency, low protein intake, physical inactivity, metabolic acidosis, and inflammation leading to a worsening of cardiovascular outcomes and cognitive function. We aimed to evaluate the prevalence of sarcopenia in CKD patients on conservative and replacement therapy and the associations between sarcopenia and markers of atherosclerosis, endothelial dysfunction, psychological and cognitive function.

METHODS

We enrolled CKD patients (stage 3/5 KDIGO [Kidney Disease: Improving Global Outcomes]) and hemodialysis, peritoneal dialysis, and post-kidney transplant patients. Clinical, laboratory and instrumental assessments, including bioimpedance analysis, hand-grip strength, intima media thickness, flow-mediated dilation, and epicardial adipose tissue, were performed in addition to analysis of psychological and cognitive status by the Montreal Cognitive Assessment, Mini-Mental State Examination, and Geriatric Depression Scale.

RESULTS

A total of 77 patients (43 male) with a mean age of 69.6 ± 9.85 y were studied. According to validated criteria (using bioimpedance analysis and hand-grip strength), the prevalence of sarcopenia was 49.4%. Sarcopenic patients had higher values of intima media thickness (P = 0.032) and epicardial adipose tissue (P = 0.012) and lower flow-mediated dilation (P = 0.002), total cholesterol (P = 0.005), and high-density lipoprotein cholesterol (P = 0.008) with respect to non-sarcopenic patients. We found higher Geriatric Depression Scale scores (P = 0.04) in sarcopenic patients, whereas we did not find differences between the two groups in Mini-Mental State Examination and Montreal Cognitive Assessment score.

CONCLUSION

Sarcopenia is highly prevalent in CKD/end stage renal disease patients and is associated with changes in early systemic indices of atherosclerosis and endothelial dysfunction, known as markers of worse prognosis.

Association of appendicular skeletal muscle mass with carotid intima-media thickness according to body mass index in Korean adults

OBJECTIVES

The combined effects of obesity and appendicular skeletal muscle (ASM) on atherosclerosis, especially in middleaged populations, remain poorly understood. This cross-sectional study investigated the effects of ASM on carotid intima-media thickness (IMT) according to body mass index (BMI) in middle-aged Korean adults.

METHODS

Herein, 595 men and 1,274 women aged 30-64 years completed questionnaires and underwent health examinations as part of the Cardiovascular and Metabolic Disease Etiology Research Center cohort. ASM was measured via bioelectrical impedance analysis and adjusted for weight (ASM/Wt). IMT was assessed using B-mode ultrasonography; highest quartile of IMT was defined as gender-specific top quartile of the IMT values. Higher BMIs was defined as a BMI over 25.0 kg/m2 .

RESULTS

Compared to the highest ASM/Wt quartile, the lowest ASM/Wt quartile was significantly associated with highest quartile of IMT in men with lower BMIs (adjusted odds ratio [aOR], 2.78; 95% confidence interval [CI], 1.09 to 7.13), but not in those with higher BMIs (aOR, 0.59; 95% CI, 0.24 to 1.91). In women, there was no significant association of low skeletal muscle mass with highest quartile of IMT, regardless of BMI.

CONCLUSIONS

Low appendicular skeletal muscle mass is associated with carotid arterial wall thickening in men with lower BMIs, but not in men with higher BMIs. Our findings suggest that the risk of atherosclerosis may be low in middle-aged Korean men with appropriate body weight and skeletal muscle mass maintenance.

Visceral, general, abdominal adiposity and atherogenic index of plasma in relatively lean hemodialysis patients

Background

Obesity is a well-established risk factor for atherosclerosis. However, it is unknown which measure of adiposity best relates to atherosclerosis in relatively lean maintenance hemodialysis (MHD) patients. We aimed to explore and compare the associations between different adiposity indices reflecting general, abdominal, visceral adiposity and arteriosclerosis risk with atherogenic index of plasma(AIP) in relatively lean MHD patients.

Methods

We conducted a multicenter, cross-sectional study in Guizhou Province, Southwest China. General/abdominal adiposity indices like body mass index (BMI), waist circumference(WC), waist-height ratio(WHtR), conicity index (Ci) and visceral obesity indices including visceral adiposity index (VAI), lipid accumulation product (LAP) and the hypertriglyceridemic waist phenotype (HW phenotype) were recorded. Univariate and multivariate linear regression models were used.

Results

All adiposity indices correlated positively with AIP in univariate analysis both in men and women except for Ci. After adjustment for age and traditional atherosclerosis risk factors, BMI, WC, WHtR, VAI and LAP still had associations with AIP both in men (β = 0.265, 0.153, 0.16, 0.788 and 0.74, respectively, all P < 0.001) and women (β = 0.34,0.199, 0.21, 0.83 and 0.74, respectively, all P < 0.001). After further adjustment for BMI, associations between AIP and VAI, LAP remained significant, but associations between WC, WHtR and AIP disappeared.

Conclusions

The HW phenotype, VAI, and LAP, validated and convenient markers of visceral obesity, were superior to classical anthropometric general/ abdominal adiposity indices for atherosclerosis risk assessment, especially in relatively lean MHD patients aged 40 years or older.

Summary of the 2018 ISN Frontiers Meeting: Kidney Disease and Cardiovascular Disease

International Society of Nephrology (ISN) Frontiers meetings build on the success of the ISN Nexus and Forefronts series by bringing together basic scientists, clinicians, and practitioners in a unique setting. This new event was organized to make more innovative science available to a global audience by removing regional barriers in accessing the latest knowledge. The first ISN Frontiers meeting was organized in partnership between the Japanese Society of Nephrology and the Japanese Society for Dialysis Therapy, which was held in Tokyo in February 2018. The meeting focused on the topic “Kidney Disease & Cardiovascular Disease,” which covered a broad range of scientific and clinical fields, including nephrology, cardiovascular diseases, dialysis, transplantation, chronic kidney disease (CKD)–mineral bone disease (MBD), diabetes, pediatric nephrology, nutrition, pharmacology, and nursing. A total of 1584 active physicians and scientists from 64 countries attended the meeting, and a number of leading physician scientists from different and related disciplines of clinical and basic research described and reviewed recent discoveries. This report summarizes the main highlights of the meeting lectures.

Low thigh muscle mass is associated with coronary artery stenosis among HIV-infected and HIV-uninfected men: The Multicenter AIDS Cohort Study (MACS)

BACKGROUND

HIV-infected individuals are at increased risk for both sarcopenia and cardiovascular disease. Whether an association between low muscle mass and subclinical coronary artery disease (CAD) exists, and if it is modified by HIV serostatus, are unknown.

METHODS

We performed cross-sectional analysis of 513 male MACS participants (72% HIV-infected) who underwent mid-thigh computed tomography (CT) and non-contrast cardiac CT for coronary artery calcium (CAC) during 2010-2013. Of these, 379 also underwent coronary CT angiography for non-calcified coronary plaque (NCP) and obstructive coronary stenosis ≥50%. Multivariable-adjusted Poisson regression was used to estimate prevalence risk ratios of associations between low muscle mass (<20th percentile of the HIV-uninfected individuals in the sample) and CAC, NCP and obstructive stenosis.

RESULTS

The prevalence of low thigh muscle mass was similar by HIV serostatus (20%). There was no association of low muscle mass with CAC or NCP. However, low thigh muscle mass was significantly associated with a 2.5-fold higher prevalence of obstructive coronary stenosis, after adjustment for demographics and traditional CAD risk factors [PR 2.46 (95% CI 1.51, 4.01)]. This association remained significant after adjustment for adiposity, inflammation, and physical activity. There was no significant interaction by HIV serostatus (p-interaction = 0.90).

CONCLUSIONS

In this exploratory analysis, low thigh muscle mass was significantly associated with subclinical obstructive coronary stenosis. Additional studies involving larger sample sizes and prospective analyses are needed to confirm the potential utility of measuring mid-thigh muscle mass for identifying individuals at increased risk for obstructive CAD who might benefit from more aggressive risk factor management.

Gender-specific associations of skeletal muscle mass and arterial stiffness among peritoneal dialysis patients

Decreased skeletal muscle has been identified as a relevant factor for arterial stiffness but has not been thoroughly investigated in peritoneal dialysis (PD) patients. The aim of this study was to investigate the relationship between skeletal muscle and arterial stiffness in PD patients. A cross-sectional study of 658 prevalent PD patients with a mean brachial-ankle pulse wave velocity (baPWV) of 1714 (±501) cm/s and mean skeletal muscle mass of 26.6 (±5.4) kg was performed. Skeletal muscle mass level was significantly higher in males than in females. When examining skeletal muscle mass as a continuous variable, skeletal muscle mass was significantly associated with baPWV in fully adjusted linear regression models in total patients [standardized coefficients (β), −0.181; 95% confidence interval (95% CI), −0.276 to −0.056; P = 0.003] or female patients (β, −0.119; 95% CI, −0.350 to −0.015; P = 0.03) but not in male patients (β, −0.117; 95% CI, −0.300 to 0.011; P = 0.07). Furthermore, in females, a significant association between the middle or highest tertile of skeletal muscle mass and baPWV was found in fully adjusted models (β, −0.123; 95% CI, −0.204 to −0.008; P = 0.03; β, −0.140; 95% CI, −0.228 to −0.016; P = 0.02, respectively). In conclusion, decreased skeletal muscle mass was independently associated with increased baPWV in PD patients, and this association was significant in females but not in males.

Positive correlation of serum leptin levels and peripheral arterial stiffness in patients with type 2 diabetes

Objective:

Leptin plays a pathophysiologic role in the pathogenesis of aortic dysfunction and peripheral arterial stiffness (PAS). Our aim was to evaluate the risk factors for developing PAS and the association of leptin and PAS in patients with type 2 diabetes mellitus (DM).

Materials and Methods:

Fasting blood samples were obtained for biochemical data and leptin determinations from 105 patients with type 2 DM. In this study, we applied an automatic pulse wave analyzer (VaSera VS-1000) to measure the brachial-ankle pulse wave velocity (baPWV); a baPWV value >14.0 m/s on either side was considered high PAS.

Results:

Seventy-five patients (71.4%) had high PAS and they included a higher percentage of patients with hypertension (P < 0.001), older age (P < 0.001), and a higher body fat mass (P = 0.043), systolic blood pressure (P < 0.001), diastolic blood pressure (P = 0.016), serum blood urea nitrogen (P = 0.003), and leptin level (P < 0.001), and lower height (P = 0.027) and glomerular filtration rate (P < 0.001) compared with type 2 DM patients with low PAS. After adjusting for factors significantly associated with PAS in these patients by multivariate logistic regression analysis, age (β = 0.470, adjusted R² change = 0.279; P < 0.001), logarithmically transformed leptin (log-leptin, β = 0.259, adjusted R² change = 0.085; P = 0.001), and hypertension (β = 0.197, adjusted R² change = 0.031; P = 0.011) were significant independent predictors of PAS in type 2 DM patients.

Conclusion:

The serum leptin level could be a predictor of PAS in type 2 DM patients.

Effects of 24-Week Aerobic and Resistance Training on Carotid Artery Intima-Media Thickness and Flow Velocity in Elderly Women with Sarcopenic Obesity

Aim: Sarcopenic obesity (SO) is closely associated with cardiovascular disease (CVD) in elderly women. Increases in body fat and decreases in muscle mass are closely associated with increased carotid intima-media thickness (CIMT). The aim of this study was to examine the influence of a 24-week aerobic and resistance training program on carotid parameters in SO.

Methods: Fifty elderly women (74.1 ± 6.1 years) with SO were randomly divided into an exercise group and a control group. The exercise group performed combined exercise over 24 weeks, consisting of resistance and aerobic training for 50–80 min, 5 times a week. Carotid variables were measured using B-mode ultrasound. The differences in the carotid variables and the relative changes between baseline and after 24 weeks were evaluated.

Results: In the analysis of variance (ANOVA) results, CIMT (p = 0.013), systolic flow velocity (p = 0.007), diastolic flow velocity (p = 0.006), and wall shear rate (p = 0.010) showed significant interactions. In paired t-test results of the exercise group, CIMT significantly decreased (p < 0.01) and systolic flow velocity (p < 0.01), diastolic flow velocity (p < 0.001), and wall shear rate (p < 0.05) significantly increased after 24 weeks.

Conclusion: The 24-week combined exercise effectively decreased CIMT and increased carotid flow velocity and wall shear ratio. Therefore, combined exercise is thought to contribute to the improvement of the risk of CVD in elderly women with SO.

Waist circumference as a predictor of mortality in peritoneal dialysis patients: a follow-up study of 48 months

Body-fat gain is a common finding among peritoneal dialysis (PD) patients, and the accumulation of adipose tissue occurs predominantly in the abdominal area. Waist circumference (WC) is a reliable marker of abdominal obesity and its association with worse outcomes has been demonstrated in non-dialysis and haemodialysis patients. We aimed at investigating whether WC measurements as well as the changes over time in WC were able to predict mortality in PD patients. This prospective study included 109 patients undergoing PD (57 % male, age 52 (sd 16) years, 32 % diabetics, 48 % BMI≥25 kg/m2). WC was measured at the umbilicus level (empty abdominal cavity), and values >88 cm for women and >102 cm for men were considered high. Nutritional status and laboratory parameters were also evaluated. WC was measured at baseline and after 6 months, and mortality was registered during a period of 48 months. High WC was observed in 55 % of women and in 23 % of men at baseline. After 6 months, 61 % of the patients showed an increased WC. At the end of the study, twenty-seven deaths were registered. A significant increase in WC was observed only in the non-survivor group. In the Cox regression analysis adjusting for sex, age, duration on dialysis, diabetes, BMI, serum albumin and C-reactive protein, high WC at baseline as well as the 6-month increase in WC were independently associated with mortality. This study demonstrated that a high WC and the increase over time in WC were both predictors of mortality in PD patients.

The Diet and Haemodialysis Dyad: Three Eras, Four Open Questions and Four Paradoxes. A Narrative Review, Towards a Personalized, Patient-Centered Approach

The history of dialysis and diet can be viewed as a series of battles waged against potential threats to patients' lives. In the early years of dialysis, potassium was identified as "the killer", and the lists patients were given of forbidden foods included most plant-derived nourishment. As soon as dialysis became more efficient and survival increased, hyperphosphatemia, was identified as the enemy, generating an even longer list of banned aliments. Conversely, the "third era" finds us combating protein-energy wasting. This review discusses four questions and four paradoxes, regarding the diet-dialysis dyad: are the "magic numbers" of nutritional requirements (calories: 30-35 kcal/kg; proteins > 1.2 g/kg) still valid? Are the guidelines based on the metabolic needs of patients on "conventional" thrice-weekly bicarbonate dialysis applicable to different dialysis schedules, including daily dialysis or haemodiafiltration? The quantity of phosphate and potassium contained in processed and preserved foods may be significantly different from those in untreated foods: what are we eating? Is malnutrition one condition or a combination of conditions? The paradoxes: obesity is associated with higher survival in dialysis, losing weight is associated with mortality, but high BMI is a contraindication for kidney transplantation; it is difficult to limit phosphate intake when a patient is on a high-protein diet, such as the ones usually prescribed on dialysis; low serum albumin is associated with low dialysis efficiency and reduced survival, but on haemodiafiltration, high efficiency is coupled with albumin losses; banning plant derived food may limit consumption of "vascular healthy" food in a vulnerable population. Tailored approaches and agreed practices are needed so that we can identify attainable goals and pursue them in our fragile haemodialysis populations.

Central obesity and risks of cardiovascular events and mortality in prevalent hemodialysis patients

BACKGROUND

To date, no attempt has been made to assess the best anthropometric method for defining abdominal adiposity in hemodialysis (HD) patients or to determine whether the quantity of intra-abdominal fat relates to morbidity and mortality in that population. We aimed to describe the prevalence of central obesity in HD patients and to investigate the relationship between central obesity assessed by anthropometric variables, and composite outcomes, cardiovascular morbidity and mortality among HD patients and whether this parameter correlates with intra-abdominal fat assessed by computed tomography scan (CT scan).

METHODS

The procedures followed were in accord with the ethical standards of the committee on human experimentation of our institution. Informed oral consent was obtained from all patients. This was a cross-sectional study of 120 prevalent HD patients. Anthropometric measurements including body mass index, conicity index (Ci), waist-hip ratio (WHR), waist circumference (WC), waist-to-height ratio (WHtR), and visceral adiposity index (VAI) were recorded. Visceral and subcutaneous abdominal fat were assessed by CT scan. Comorbidity was scored for both the Charlson comorbidity index (CCI) and Davies comorbidity index.

RESULTS

Twenty-eight patients (23.3%) were centrally obese based on anthropometry. By linear regression analysis, Ci, WHR, and VAI were predictors of CT assessed central obesity; p 0.042, 0.001, and 0.010, respectively. On assessment of the relationship between the abdominal obesity and the comorbidity indices, there was a positive significant correlation between Ci and CCI (p 0.025) and Davies score (p 0.002) which are predictors of mortality. During the mean follow-up period (3.2 years), 56 patients reached the composite outcome; eight patients died and 48 experienced CV events. Central obesity measured by anthropometry was a predictor of composite outcomes, cardiovascular morbidity, and mortality in HD patients by regression analysis and cox regression model. Only WC and WHtR did not predict mortality.

CONCLUSION

Ci, WHR, and VAI are cheap alternatives for accurate assessment of morbidity and mortality risk in centrally obese prevalent HD patients.

Characterization of deficits across the spectrum of motor abilities in dialysis patients and the impact of sarcopenic overweight and obesity

BACKGROUND & AIMS

Physical performance deficits in kidney failure predict mortality and quality of life. We aimed to quantify deficits in multiple motor abilities, investigate associations of lean and fat tissue content with test results and analyzed performance of sarcopenic individuals with adipose tissue excess.

METHODS

Ninety hemodialysis patients and 140 healthy controls performed 6-minute walk test, gait speed measurement, sit-to-stand and time up and go tests, upper extremity handgrip and tapping tests, Stork balance and forward bend flexibility tests. Human Activity Profile questionnaire was used to assess habitual activity. Body composition was measured by bioimpedance analysis.

RESULTS

Relative performance deficit of dialysis patients in age, sex, height and comorbidity adjusted estimated marginal means was largest for balance and flexibility (-52 and -33%), followed by lower extremity deficits in sit-to-stand, time up and go and 6-minute walk tests (-29, -19 and -15%, respectively), p < 0.05 for all comparisons. Upper extremity performance was less affected. Lean tissue index associated significantly positively with five and fat tissue index associated significantly negatively with two out of nine tests. Sarcopenic overweight and obese individuals exhibited significant deficits mainly in lower extremity tests with worse composite lower extremity score when compared to other categories of body composition.

CONCLUSIONS

Patients with hemodialysis treated kidney failure have largest functional deficits in balance, flexibility and lower extremity functions. Lean and fat mass associate oppositely with physical performance measures and individuals at unfavorable extremes of these indices express significantly impaired lower extremity functions.

Lower thigh muscle mass is associated with all-cause and cardiovascular mortality in elderly hemodialysis patients

BACKGROUND/OBJECTIVES

Higher body mass index appears protective in hemodialysis patients, although it remains to be determined which component of muscle or fat mass is primarily associated with this survival advantage.

SUBJECTS/METHODS

Eighty-one hemodialysis patients in our institution were prospectively followed from July 2011 to August 2015. Muscle and fat mass were evaluated by measuring the cross-sectional areas of the thigh and abdomen using computed tomography. The relationship between muscle and fat mass, and all-cause and cardiovascular mortality was studied using the Kaplan-Meier analyses and multivariate Cox proportional hazard models.

RESULTS

During more than 4 years of follow-up, 26 patients (32%) died. In the Kaplan-Meier curve analyses, lower thigh muscle mass was significantly associated with all-cause and cardiovascular mortality (log-rank test, P<0.01 and P<0.001, respectively), but there was no such association with thigh fat, abdominal muscle and fat mass levels. In multivariate Cox proportional hazard models, each 0.1 cm²/kg increase in the thigh muscle area adjusted by dry weight was associated with an estimated 22% lower risk of all-cause mortality (95% confidence interval (95% CI), 0.64-0.95, P<0.05) and a 30% lower risk of cardiovascular mortality (95% CI, 0.54-0.90, P<0.01).

CONCLUSIONS

Lower thigh muscle mass is significantly associated with all-cause and cardiovascular mortality in hemodialysis patients. Our findings indicate the importance of focusing on the muscle mass of lower extremities to predict the clinical outcomes of hemodialysis patients.

Serum Sclerostin as an Independent Marker of Peripheral Arterial Stiffness in Renal Transplantation Recipients: A Cross-Sectional Study

Wnt/β-catenin signaling pathway is thought to be implicated in the development of arterial stiffness and vascular calcification. As a Wnt signaling pathway inhibitor, it is interesting to investigate whether sclerostin or dickkopf-1 (DKK1) level is correlated with arterial stiffness in renal transplant (RT) recipients. Fasting blood samples were obtained for biochemical data, sclerostin, DKK1, and osteoprotegerin (OPG) determinations. In this study, we applied automatic pulse wave analyzer (VaSera VS-1000) to measure brachial-ankle pulse wave velocity and either sides of brachial-ankle pulse wave velocity value, which greater than 14.0 m/s was determined as high arterial stiffness. Among 68 RT recipients, 30 patients (44.1%) were in the high arterial stiffness group. Compared with patients in the low arterial stiffness group, patients in the high arterial stiffness group had higher prevalence of hypertension (P = 0.002), diabetes (P < 0.001), metabolic syndrome (P = 0.025), longer posttransplant duration (P = 0.005), higher systolic blood pressure (P < 0.001) and diastolic blood pressure (P = 0.018), and higher fasting glucose (P = 0.004), total cholesterol (P = 0.042), blood urea nitrogen (P = 0.020), phosphorus (P = 0.042), and sclerostin levels (P = 0.001). According to our multivariable forward stepwise linear regression analysis, age (β = 0.272, P = 0.014), phosphorus (β = 0.308, P = 0.007), and logarithmically-transformed OPG (log-OPG; β = 0.222, P = 0.046) were positively associated with sclerostin levels, and multivariate logistic regression analysis, sclerostin (odds ratio 1.052, 95% confidence interval 1.007-1.099, P = 0.024), and posttransplant duration (odds ratio 1.024, 95% confidence interval 1.004-1.045, P = 0.019) were the independent predictors of peripheral arterial stiffness in RT recipients. In this study, serum sclerostin level, but not DKK1, was proved to be involved in the pathogenetic process of peripheral arterial stiffness in RT recipients.

Serum Creatinine Modifies Associations between Body Mass Index and Mortality and Morbidity in Prevalent Hemodialysis Patients

Background

High body mass index (BMI) is paradoxically associated with better outcomes in hemodialysis (HD) patients. This study aimed to examine whether serum creatinine (Cr), a marker of muscle mass, could modify the association between BMI, and mortality and morbidity in prevalent HD patients.

Methods

A retrospective study was conducted using a nationwide database from the registry of the Japanese Society for Dialysis Therapy. A total of 119,099 patients were selected (age: 65±12 years; median time on HD: 5.6 years; male: 62%), and we examined the association of basal BMI with mortality and morbidity after a 1-year period. Patients were stratified either by BMI into 4 groups or by serum Cr levels into 3 tertiles. Odds ratio (OR) [95% confidence interval] was calculated by multivariate logistic regression analysis.

Results

Higher BMI did not predict a higher 1-year total mortality. However, when we stratified the patients by serum Cr levels, the risk of cardiac death became significantly higher in obese patients with the lowest Cr levels, in both males (OR 2.82 [1.51–5.27], p<0.01) and females (OR 2.00 [1.03–3.90], p<0.05). The risk of new cerebral infarction was also higher in obese male patients within the lowest Cr tertile. In contrast, there was a significantly lower risk of cardiac, cerebrovascular, and infection-related death in non-obese patients with higher levels of Cr. Higher serum Cr was also related to a lower risk of cardiovascular events and hip fracture in non-obese HD patients.

Conclusions

The obesity paradox was found to be present in HD patients only when obesity was defined by BMI. Decreased serum Cr levels were found to be positively associated with clinical poor outcomes in all BMI groups. Thus, irrespective of BMI, the evaluation of serum Cr levels is important to predict mortality and morbidity in patients receiving regular HD.

Mortality and complications after hip fracture among elderly patients undergoing hemodialysis

BACKGROUND

Osteoporotic hip fractures cause high mortality and morbidity in elderly adults. Compared to the general population, subjects with end-stage renal disease and hemodialysis often develop mineral bone disorders and have a higher risk for hip fractures.

METHODS

We conducted a matched cohort study design and used competing risk analysis to estimate the cumulative incidence of the complication rate. Subjects aged greater than 60 years with hip fracture were selected from Taiwan's National Health Insurance Research Database covering a period from 1997 to 2007, and these subjects were followed up until 2009. We used the Kaplan-Meier method to estimate the overall survival and used the log-rank test and multiple Cox proportional hazards model to explore the risk factors for survival. The cumulative incidence of the first complication was estimated using competing risk analysis.

RESULTS

Among hemodialysis subjects, the three-month, one-year, two-year and five-year mortality rates were 17.3 %, 37.2 %, 51.5 %, and 80.5 %, respectively; the one-year and five-year cumulative incidences of the first surgical complication were 14.2 % and 20.6 %, respectively; and the three-month cumulative incidence of the first medical complication was 24.1 %. Hemodialysis subjects presented a 2.32 times (95 % CI: 2.16-2.49) higher hazard ratio of overall death, 1.15 times (95 % CI: 1.01-1.30) higher sub-hazard ratio (sub-HR) of surgical complications, and 1.35 times (95 % CI: 1.21-1.52) higher sub-HR of the first medical complication than non-hemodialysis controls.

CONCLUSIONS

The overall mortality and complication rates of hemodialysis subjects after surgery for hip fracture were significantly higher than those of non-hemodialysis subjects. Further prospective studies which include important risk factors are necessary to more precisely quantify the adjusted effect of hemodialysis.

Arterial Stiffening and Clinical Outcomes in Dialysis Patients

Cardiovascular disease (CVD) is an important cause of morbidity and mortality in dialysis patients. Brachial-ankle pulse wave velocity (baPWV) is more efficient to handily assess arteriosclerosis than aortic PWV. The cardio-ankle vascular index (CAVI) is also a novel blood pressure-independent arterial stiffness parameter. In dialysis patients, both baPWV and CAVI are increased compared to general subjects. Several studies have demonstrated that increased baPWV is associated with carotid atherosclerosis and diastolic left ventricular dysfunction in hemodialysis (HD) patients. In addition, higher baPWV is related to all-cause and cardiovascular (CV) mortality. CAVI is similarly associated with CVD. However, baPWV is superior to CAVI as a predictor of CV outcomes in HD patients. Besides these outcomes, a close relationship exists between sarcopenia, abdominal visceral obesity and arterial stiffening. Reduction of thigh muscle mass is inversely correlated with baPWV and CAVI in males. Abdominal fatness is also associated with increased arterial stiffness in females. These observations provide further evidence of higher risk of CV events in HD patients with sarcopenic obesity. In addition, arterial stiffness is associated with cerebral small vessel disease and decreased cognitive function in the elderly. However, it is unknown whether arterial stiffness may be useful as an early indicator of cognitive decline in dialysis patients. Because dialysis patients are at risk of developing dementia, more studies are needed to elucidate the causal link between arterial stiffness and cognitive impairment.

Influence of body fatness distribution and total lean mass on aortic stiffness in nonobese individuals

BACKGROUND

Subjects with normal body mass index but high body fat percentage have higher cardiovascular risk than subjects with normal weight and low fat mass. However, the association of fat distribution and lean mass with carotid-femoral pulse wave velocity (cfPWV) among nonobese apparently healthy individuals has never been assessed.

METHODS

In 136 nonobese volunteers (mean age = 45±9 years; 57% women) without manifest cardiovascular disease, cfPWV was measured by applanation tonometry. Fat and lean mass were measured by dual-energy x-ray absorptiometry.

RESULTS

In univariate analysis, total fat (r = 0.17; P < 0.01), trunk fat (r = 0.27; P < 0.01), and trunk/total fat ratio (r = 0.32; P < 0.01) were correlated with cfPWV. After adjustment for age and mean arterial pressure, only central fat distribution (trunk/total fat ratio) was significantly associated with cfPWV. In the fully adjustment model, there was a significant interaction between fat distribution and lean mass. When the study sample was grouped by fat distribution and total lean mass medians, subjects with central fat distribution and low lean mass (group 4) had higher log-transformed cfPWV than the noncentral fat/low lean mass group (group 2) (0.89, 95% confidence interval (CI) = 0.86-0.92 vs. 0.85, 95% CI = 0.83-0.87; P < 0.01) or the noncentral fat/high lean mass group (group 1) (0.89, 95% CI = 0.86-0.92 vs. 0.84, 95% CI = 0.81-0.87; P < 0.01) after adjustments. Aortic stiffness increased from group 1 to group 4 (P for linear trend < 0.001).

CONCLUSIONS

Among normal weight individuals without manifest cardiovascular disease, the combination of central fat distribution and low lean mass is associated with higher cfPWV. These factors are more closely related to cfPWV than total fat mass.

Serum leptin levels positively correlate with peripheral arterial stiffness in kidney transplantation patients

BACKGROUND

Leptin is a protein predominantly produced by adipocytes that plays a pathophysiologic role in the pathogenesis of hypertension and cardiovascular diseases. The aim of this study was to evaluate the relationship between fasting serum leptin levels and peripheral arterial stiffness among kidney transplant (KT) patients.

METHODS

Fasting blood samples were obtained from 74 KT patients. Brachial-ankle pulse wave velocity (baPWV) was measured in the right or left brachial artery to the ankle segments using an automatic pulse wave analyzer (VaSera VS-1000). Plasma leptin levels were measured using a commercial enzyme-linked immunosorbent assay kit. In this study, left or right baPWV values of less than 14.0 m/s were used to define the high arterial stiffness group.

RESULTS

Forty KT patients (54.1%) were defined in high arterial stiffness group. Hypertension (P < .010), diabetes (P < .010), age (P = .010), KT duration (P = .013), triglyceride levels (P = .016), systolic blood pressure (P < .001), waist circumference (P = .031), and leptin level (P < .001) were higher, whereas serum high-density lipoprotein cholesterol level (P = .030) was lower in the high arterial stiffness group compared with the low arterial stiffness group. Multivariate logistic regression analysis showed that leptin (odds ratio, 1.033; 95% CI, 1.004-1.062; P = .023), KT duration (odds ratio, 1.023; 95% CI, 1.004-1.044; P = .020), and high-density lipoprotein cholesterol level (odds ratio, 0.925; 95% CI, 0.872-0.982; P = .010) were the independent predictors of peripheral arterial stiffness in KT patients.

CONCLUSIONS

Serum fasting leptin level was positively associated with peripheral arterial stiffness among KT patients.

Sarcopenia, and its association with cardiometabolic and functional characteristics in Taiwan: results from I-Lan Longitudinal Aging Study

AIM

Sarcopenia is a well-recognized geriatric syndrome, which is associated with a variety of adverse outcomes. The present study aimed to evaluate the prevalence of sarcopenia and its associative clinical characteristics in Taiwan.

METHODS

Data of the I-Lan Longitudinal Aging Study (ILAS) were retrieved for this study. Sarcopenia was defined according to the European Working Group on Sarcopenia in Older People criteria, and comparisons of demographic characteristics, physical performance, body composition, cardiometabolic profiles and functionality indicators were carried out.

RESULTS

Overall, data of 1008 participants (mean age 65.2 ± 9.3 years, male 50.6%) were retrieved for analysis. The cut-off value of relative appendicular skeletal muscle was 7.0 kg/m(2) for men and 5.9 kg/m(2) for women. Sarcopenia was significantly related to low body mass index, smaller waist circumference, poor nutrition and poor cognition. The mean carotid intima-media thickness and cardiometabolic parameters showed no statistically significant findings.

CONCLUSIONS

The present paper showed the epidemiology of sarcopenia, and the strong connection to functionality indicators. However, sarcopenia was not associated with cardiometabolic risk or carotid intima media thickness in the present study.

Visceral adiposity index and risks of cardiovascular events and mortality in prevalent hemodialysis patients

Background

The visceral adiposity index (VAI) is a newly-derived measure of visceral adiposity with well-validated predictive power for cardiovascular (CV) outcomes in the general population. However, this predictability has not been investigated in hemodialysis patients, and whether VAI is superior to waist circumference (WC) and waist-to-height ratio (WHtR) in predicting CV outcomes and survival in hemodialysis patients remains unknown.

Methods

We performed a prospective study including 464 prevalent hemodialysis patients. The composite outcome was the occurrence of death and CV events during follow-up. Using multivariate Cox regression analysis, VAI, WC and WHtR were tested for the predictive power of outcomes. To evaluate the predictive performance of the VAI, WC and WHtR, time-dependent receiver operating characteristic curve (ROC) analysis was performed.

Results

VAI, WC and WHtR positively correlated with each other. Patients with a higher VAI (tertile 3 vs. tertile 1, adjusted hazard ratio (HR), 1.65; 95% confidence interval (CI), 1.12-2.42; tertile 2 vs. tertile 1, adjusted HR, 1.52; 95% CI, 1.1-2.18) had more composite outcomes. VAI had a similar predictive power of all-cause mortality to WC and WHtR, but superior predictive power of composite and CV outcomes to WC when analyzed by a stepwise forward likelihood ratio test. In time-dependent ROC analysis, VAI, WC and WHtR showed similar predictive performance for outcomes.

Conclusion

VAI is an optimal method to measure visceral adiposity to assess long-term CV outcomes and all-cause mortality in prevalent hemodialysis patients. VAI may provide a superior predictive power of CV outcomes to WC and WHtR.

Trial registration

ClinicalTrials.gov NCT01457625

ACE inhibitors, statins and thiazides: no association with change in grip strength among community dwelling older men and women from the Hertfordshire Cohort Study

BACKGROUND

vascular disease has been postulated to contribute to muscle dysfunction in old age. Previous studies examining the effects of cardiovascular drugs on muscle function have shown conflicting results. We therefore examined the association of angiotensin converting enzyme (ACE) inhibitor, thiazide and statin use with decline in grip strength in a well-characterised cohort.

METHODS

we analysed prospectively collected data from the Hertfordshire Cohort Study (HCS). For each medication, participants were divided into no baseline use/no use at follow-up, baseline use/no use at follow-up, no baseline use but use at follow-up and use at baseline and follow-up. For each group, annualised decline in grip strength (kg per year) was calculated, then adjusted for baseline age, height, weight, baseline grip strength, indices of ischaemic heart disease and hypertension. Analyses were conducted separately for males and females.

RESULTS

639 participants were included in the analysis, mean age 65 years. 321 (50%) were male; mean follow-up time was 4.4 years. There were no differences in baseline grip between baseline users and non-users of any drug class. Adjusted grip strength change per year was similar for each group of ACE inhibitor use (P > 0.05). Similar analyses revealed no significant between-group differences for statin or thiazide use. Analysis of dropout rates by medication use revealed no evidence of selection bias.

CONCLUSION

use of ACE inhibitors, statins or thiazides was not associated with differences in grip strength decline in healthy older people in the HCS.

Managing sarcopenia and its related-fractures to improve quality of life in geriatric populations

Sarcopenia, an aging-induced generalized decrease in muscle mass, strength, and function, is known to affect elderly individuals by decreasing mobile function and increasing frailty and imbalance that lead to falls and fragile fractures. Sarcopenia is a known risk factor for osteoporotic fractures, infections, and early death in some specific situations. The number of patients with sarcopenia is estimated to increase to 500 million people in the year 2050. Sarcopenia is believed to be caused by multiple factors such as disuse, malnutrition, age-related cellular changes, apoptosis, and genetic predisposition; however, this remains to be determined. Various methods have been developed, but no safe or effective treatment has been found to date. This paper is a review on the association between sarcopenia and its related-fractures and their diagnoses and management methods to prevent fractures.

Hypoadiponectinemia correlates with arterial stiffness in kidney transplantation patients

BACKGROUND

Adiponectin is a fat-derived hormone produced and secreted exclusively by adipocytes that have anti-atherosclerotic effects. The aim of this study was to evaluate the relationship between fasting serum adiponectin levels and arterial stiffness among kidney transplant (KT) patients.

METHODS

Fasting blood samples were obtained from 69 KT patients. Brachial-ankle pulse wave velocity (baPWV) was measured in the right or left brachial artery to the ankle segments using an automatic pulse wave analyzer. Plasma adiponectin levels were measured using a commercial enzyme-linked immunosorbent assay kit. Left or right baPWV values of >14.0 m/s were used to define the high arterial stiffness group.

RESULTS

Thirty-five KT patients (35/69; 50.7 %) were defined in high arterial stiffness group. Diabetes (P = 0.013), smoking (P = 0.001), KT duration (P < 0.001), body weight (P = 0.013), waist circumference (P = 0.013), body mass index (P = 0.001), fasting glucose (P = 0.013), systolic blood pressure (P < 0.001), diastolic blood pressure (P = 0.008), and pulse pressure (P = 0.003) were higher, while serum adiponectin level (P = 0.004) was lower in high arterial stiffness group compared with low arterial stiffness group. Multivariate logistic regression analysis showed that adiponectin (odds ratio 0.90, 95 % confidence interval 0.81-0.99, P = 0.034) was still the independent predictors of arterial stiffness among the KT patients.

CONCLUSION

Serum fasting adiponectin level was inversely associated with arterial stiffness among KT patients.

Prevalence of sarcopenia in elderly maintenance hemodialysis patients: the impact of different diagnostic criteria

The prevalence of sarcopenia on elderly maintenance hemodialysis (MHD) has been scarcely investigated.

OBJECTIVES

To investigate the prevalence of decreased muscle mass and strength alone or combined (true sarcopenia) in elderly patients on MHD according to different methods and cutoff limits. Additionally, we evaluated the agreement between dual energy x-ray absorptiometry (DXA) and surrogate methods for the assessment of muscle mass.

DESIGN

Observational and cross-sectional study.

PARTICIPANTS

Non-institutionalized 102 elderly (age > 60 years) patients on MHD.

MEASUREMENTS

Sarcopenia was considered when the patient fit one criteria for low muscle mass assessed by DXA, bioelectrical impedance (BIA), sum of skinfold thicknesses (SKF), calf circumference and mid-arm muscle circumference (MAMC) and one for low muscle strength evaluated by handgrip dynamometer.

RESULTS

Decreased muscle strength was found in 85% of the patients. The prevalence of decreased muscle mass varied from 4 to 73.5% and of sarcopenia (decreased muscle mass and strength combined) from 4 to 63%, depending on the method and cutoff limit applied. A small percentage of patients (2 to 15%) were classified as sarcopenic by more than one diagnostic criteria. The agreement between DXA and the surrogate methods to assess muscle mass showed better kappa coefficients with BIA (r=0.36; P<0.01) and SKF (r=0.40; P<0.01).

CONCLUSION

A wide prevalence of sarcopenia is observed depending on the method and cutoff limit applied. This may limit extrapolate on to clinical practice. BIA and SKF were the surrogate methods to assess muscle mass with the best concordance with DXA in elderly MHD patients.