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Finco MG, Najafi B, Zhou H, Hamad A, Ibrahim R, Al-Ali F. Game-based intradialytic non-weight-bearing exercise training on gait speed and balance in older adults with diabetes: a single-blind randomized controlled trial. Sci Rep 2023; 13:14225. [PMID: 37648695 PMCID: PMC10469197 DOI: 10.1038/s41598-023-41290-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 08/24/2023] [Indexed: 09/01/2023] Open
Abstract
Older adults with diabetes receiving hemodialysis have impaired gait speed and balance compared to the general population, which have been associated with increased risks of falls and mortality. This study evaluated the effectiveness of a game-based intradialytic exercise training program (iExergame) on improving gait speed and balance. This was a single-blind randomized controlled trial. The intervention group (IG) received iExergame training using real-time audiovisual feedback with wearable inertial sensors. The control group (CG) received conventional training without any technology. Both trainings were intradialytic, non-weight-bearing, and used ankle range of motion. Gait and balance parameters were collected at baseline and 4-week follow-up. Data from 70 adults (age 64.2 ± 9.0 years) were analyzed. Compared to the CG, the IG showed greater changes between baseline and 4-week follow-up in several parameters. Gait parameters included faster speeds and longer stride lengths, particularly during dual task walking (p < 0.050). Balance parameters included reductions in center of mass (p = 0.004), ankle (p < 0.001), and hip (p = 0.010) sways during semi-tandem stance, particularly in users of assistive devices. iExergame training could improve gait speed and balance in this population and might be an option to increase intradialytic exercise adherence while reducing burdens of exercise administration.
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Affiliation(s)
- M G Finco
- Interdisciplinary Consortium on Advanced Motion Performance (iCAMP), Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Bijan Najafi
- Interdisciplinary Consortium on Advanced Motion Performance (iCAMP), Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.
| | - He Zhou
- Interdisciplinary Consortium on Advanced Motion Performance (iCAMP), Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Shenzhen Mass Medical Co., Ltd., Shenzhen, China
- Shanghai Dengding BioAI Co., Ltd., Shanghai, China
| | - Abdullah Hamad
- Department of Nephrology, Fahad Bin Jassim Kidney Center, Hamad General Hospital, Doha, Qatar
| | - Rania Ibrahim
- Department of Nephrology, Fahad Bin Jassim Kidney Center, Hamad General Hospital, Doha, Qatar
| | - Fadwa Al-Ali
- Department of Nephrology, Fahad Bin Jassim Kidney Center, Hamad General Hospital, Doha, Qatar
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Zemp DD, Giannini O, Quadri P, Rabuffetti M, Tettamanti M, de Bruin ED. Gait disorders in CKD patients: muscle wasting or cognitive impairment? A cross-sectional pilot study to investigate gait signatures in Stage 1-5 CKD patients. BMC Nephrol 2022; 23:72. [PMID: 35189838 PMCID: PMC8862207 DOI: 10.1186/s12882-022-02697-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 01/27/2022] [Indexed: 02/03/2023] Open
Abstract
Background Instrumental gait analysis in nephrology is widely neglected, although patients with chronic kidney disease (CKD) show brain changes due to cerebrovascular disease and metabolic disorders that can potentially influence gait quality. Our study assesses the association between CKD stages and gait parameters, to understand the prevalent status of brain related gait parameters (i.e. variability) and of performance related parameters (i.e. gait speed, stride length). We hypothesize that gait changes are detectable already in early stages of CKD. Methods Forty-five participants distributed in 5 CKD severity groups underwent an instrumental gait analysis via a triaxial accelerometer affixed to the lower trunk under single- and dual-task conditions. In addition to spatio-temporal parameters, variability and dual-task cost of gait were extracted. A battery of clinical assessments was conducted with the aim of helping to better explain the findings of the gait analysis. A correlation analysis was made to investigate a linear relation between gait parameters and CKD severity. Results Statistically significant correlations (Pearson correlation coefficient) with CKD severity were found for gait speed (p < 0.01, r = -0.55, 95% CI [-0.73;-0.30]), stride length ( p < 0.01, r = -0.40, 95% CI [-0.62;-0.12]), step length (p < 0.01, r = -0.41, 95% CI [-0.63;-0.13], coefficient of variance (CV) of step length (p = 0.01, r = 0.36, 95% CI [0.08;0.59]), gait regularity (p < 0.01, r = -0.38, 95% CI [-0.61;-0.10]), dual-task cost of gait speed (p < 0.01, r = 0.40, 95% CI [0.13;0.62]) and dual-task cost of stride time (p = 0.03, r = 0.32, 95% CI [0.03;0.57]). Adjustment for age and gender confirmed all results except for gait regularity. With increasing severity of renal failure, Handgrip strength, Time for the Expanded Timed Get Up and Go test, executive functions, haemoglobin, and haematocrit, worsen. Conclusions The correlation of CKD severity with spatio-temporal parameters (performance indices mainly relatable to peripheral functionality) and with variability of gait (related to central factors) supported by the results of the clinical assessments, suggests that gait disturbance in CKD patients is not only due to metabolic factors that lead to muscle wasting, but also to brain changes that affect motor control. This suggests that the treatment of renal disease should include cognitive aspects in addition to metabolic and functional factors. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-022-02697-8.
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Affiliation(s)
- Damiano D Zemp
- Institute of Human Movement Sciences and Sport, Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland.,Geriatric Service, Ospedale Regionale di Mendrisio, EOC, Mendrisio, Switzerland
| | - Olivier Giannini
- Department of Medicine, Ente Ospedaliero Cantonale, Bellinzona, Switzerland.,Division of Nephrology, Ente Ospedaliero Cantonale, Lugano, Switzerland.,Faculty of Biomedical Sciences, Università Della Svizzera Italiana, Lugano, Switzerland
| | - Pierluigi Quadri
- Geriatric Service, Ospedale Regionale di Mendrisio, EOC, Mendrisio, Switzerland.,Department of Medicine, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | | | - Mauro Tettamanti
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Eling D de Bruin
- Institute of Human Movement Sciences and Sport, Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland. .,Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden. .,OST - Eastern Swiss University of Applied Sciences, Department of Health, St. Gallen, Switzerland.
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Zemp DD, Giannini O, Quadri P, Rabuffetti M, Tettamanti M, de Bruin ED. Signatures of Gait Movement Variability in CKD Patients Scheduled for Hemodialysis Indicate Pathological Performance Before and After Hemodialysis: A Prospective, Observational Study. Front Med (Lausanne) 2021; 8:702029. [PMID: 34395481 PMCID: PMC8355421 DOI: 10.3389/fmed.2021.702029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 06/30/2021] [Indexed: 12/21/2022] Open
Abstract
Background: The frailty status of hemodialysis patients is well-known, but the role of the therapy in the frailty process is not yet clear. Nowadays gait analysis in nephrology is neglected, although gait performance is known to be related to frailty and kidney function. We hypothesized that gait quality and physical activity level is already affected before, and does not change because of the start of hemodialysis. Methods: Fourteen patients (72.3 ± 5.7 years old) in a pre-dialysis program underwent an instrumental gait analysis and their physical activity was monitored for a week. This protocol was repeated 3, 6, 12, and 24 months after the first hemodialysis session. Results: At baseline, our sample showed a conservative gait with pathologic gait variability, high dual-task cost, and a sedentary lifestyle. No statistically significant change was found in any parameter in the analyzed period, but there was a tendency toward an improvement of gait quality and physical activity in the first year of treatment, and a decline in the second year. Conclusion: Elderly patients in the pre-dialysis stage show a conservative gait, however variability was in a pathological range and did not change post-hemodialysis. This hints toward changes in the central nervous system due to the kidney disease. This finding suggests the importance of gait analysis in the early stages of renal disease in the diagnosis of changes in the nervous system due to kidney failure that affect gait. Early detection of these changes would potentially allow a prevention program tailored to this population to be developed.
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Affiliation(s)
- Damiano D Zemp
- Department of Health Sciences and Technology, Institute of Human Movement Sciences and Sport, ETH Zurich, Zurich, Switzerland.,Geriatric Service, Ente Ospedaliero Cantonale, Ospedale Regionale della Beata Vergine, Mendrisio, Switzerland
| | - Olivier Giannini
- Department of Internal Medicine, Ente Ospedaliero Cantonale, Mendrisio, Switzerland.,Service of Nephrology, Ente Ospedaliero Cantonale, Ospedale Regionale della Beata Vergine, Mendrisio, Switzerland.,Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Pierluigi Quadri
- Geriatric Service, Ente Ospedaliero Cantonale, Ospedale Regionale della Beata Vergine, Mendrisio, Switzerland.,Department of Internal Medicine, Ente Ospedaliero Cantonale, Mendrisio, Switzerland
| | | | - Mauro Tettamanti
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCSS, Milan, Italy
| | - Eling D de Bruin
- Department of Health Sciences and Technology, Institute of Human Movement Sciences and Sport, ETH Zurich, Zurich, Switzerland.,Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden.,OST - Eastern Swiss University of Applied Sciences, Department of Health, St. Gallen, Switzerland
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Risk factors for high fall risk in elderly patients with chronic kidney disease. Int Urol Nephrol 2021; 54:349-356. [PMID: 33966153 DOI: 10.1007/s11255-021-02884-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 05/01/2021] [Indexed: 12/29/2022]
Abstract
PURPOSE Patients with chronic kidney disease (CKD) usually represent an aging population, and both older age and CKD are associated with a higher risk of falling. Studies on risk factors among subjects with CKD are lacking. METHODS Records of outpatients from one geriatric clinic in Turkey were retrospectively reviewed. A result of ≥ 13.5 s on the timed up and go (TUG) test was accepted as a high risk of falls. Independent predictors of an increased risk of falls among subjects with CKD (estimated glomerular filtration rate of < 60 mL/min/1.73 m2) were identified using logistic regression models. RESULTS Patients with CKD (n = 205), represented the 20.2% of the entire cohort and was identified as an independent predictor of increased fall risk (OR 2.59). Within the CKD cohort, serum folic acid levels and frailty were independent predictors of an increased risk of falls. The CKD/fall risk group was older, had a lower median years of education, lower vitamin D levels, and lower serum folic acid levels than the CKD/non-fall risk group. In addition to higher serum creatinine and potassium levels, the only significant difference between patients with CKD/fall risk and a matched non-CKD/fall risk was a lower median folic acid level in the former group. CONCLUSIONS Frailty and low folic acid levels are independently associated with an increased risk of falls among elderly outpatients with CKD. Prevention of frailty may reduce the risk of falls in these subjects. Possible benefit of folic acid supplementation requires further studies.
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Yang YF, Huang CC, Chang CM, Lin HC. Effect of Whole-Body Vibration Training on Physical Fitness and Postural Control in Working-Age Patients on Haemodialysis. JOURNAL OF REHABILITATION MEDICINE. CLINICAL COMMUNICATIONS 2021; 4:1000045. [PMID: 33884147 PMCID: PMC8054743 DOI: 10.2340/20030711-1000045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 11/26/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To evaluate the effect of whole-body vibration training on working-age people on haemodialysis. DESIGN Consecutive case series study. SUBJECTS Seventeen working-age participants on maintenance haemodialysis were enrolled. METHODS A 12-week whole-body vibration training programme, including different postures, was designed. The study evaluated and compared physical fitness, including a list of tests such as the 5-repetition sit-to-stand test, hand grip test, 2-min step test, and 8-foot up-and-go test; modified Berg balance scale; static and dynamic balance function; and quality of life, using a quality of life questionnaire before and after the training. RESULTS All physical fitness parameters, except grip strength on the left side, improved after whole-body vibration training. For balance, the modified Berg balance scale demonstrated enhanced scores for equilibrium, with eyes closed on a stable surface and eyes open on an unstable surface, and movement velocity under the fast condition along the left and right directions (p=0.011). No significant improvements in quality of life were found. CONCLUSION Whole-body vibration exercise training enhanced physical fitness and static and dynamic balance control in working-age participants on haemodialysis.
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Affiliation(s)
- Ya-Fei Yang
- Department of Nephrology, China Medical University Hospital, Taichung, Taiwan, ROC
- Department of Medicine, China Medical University, Taichung, Taichung, Taiwan, ROC
| | - Chiu-Ching Huang
- Department of Nephrology, China Medical University Hospital, Taichung, Taiwan, ROC
- Department of Medicine, China Medical University, Taichung, Taichung, Taiwan, ROC
| | - Chia-Ming Chang
- Department of Physical Therapy and Graduate Institute of Rehabilitation Science, China Medical University, Taichung, Taiwan, ROC
| | - Hsiu-Chen Lin
- Department of Physical Therapy and Graduate Institute of Rehabilitation Science, China Medical University, Taichung, Taiwan, ROC
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Fourier-Based Footfall Placement Variability in Parkinson's Disease. BIOMED RESEARCH INTERNATIONAL 2019; 2019:2689609. [PMID: 31183365 PMCID: PMC6515172 DOI: 10.1155/2019/2689609] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 04/09/2019] [Accepted: 04/15/2019] [Indexed: 11/24/2022]
Abstract
The current investigation examined whether Parkinson's patients (PD) have greater Fourier-based footfall placement gait with the greatest mobility dysfunction variability (FPV) than the age and gender matched control group and that variability would be the greatest in the PD participants with the greatest mobility dysfunction indexed Hoehn/Yahr scale. 35 persons undergoing PD and 30 age-matched controls participated in this investigation. Participants repeated two trials' normal walking and average and variability parameters of gait were measured using a 3.66 m electronic walkway. FPV was quantified as a change in the center of pressure during gait. Persons with PD were divided into two groups based on Hoehn/Yahr scale. Overall, persons with PD had smaller average performance indexed by mean and greater gait variability than controls as indexed by CV and Fourier-based variability (p's<0.05). Moreover, PD with higher mobility dysfunction had not only greater variability in traditional parameters but also greater Fourier-based variability than nonfallers with MS (p<.001) with higher effect size (η2=0.37 vs.0.18-0.29). These observations highlight the fact that footfall placement variability is related to mobility dysfunction in PD. Further study is necessary to determine contributing factors to an increased FPV and whether targeted interventions such as exercise can reduce FPV.
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Kistler BM, Khubchandani J, Wiblishauser M, Wilund KR, Sosnoff JJ. Epidemiology of falls and fall-related injuries among middle-aged adults with kidney disease. Int Urol Nephrol 2019; 51:1613-1621. [PMID: 31165398 DOI: 10.1007/s11255-019-02148-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 04/10/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE Comorbidities, such as kidney disease (CKD), increase the likelihood of falls and fall-related injuries. Despite the focus of most research in this population on older adults, falls are a significant cause of injury throughout adulthood. Therefore, we aimed to describe the epidemiology of falls in middle-aged adults with kidney diseases. METHODS We analyzed falls and fall-related injuries among middle-aged adults (45-65 years old) with and without CKD included in the 2014 Behavioral Risk Factor Surveillance System (BRFSS) utilizing multivariate logistic regression and complex sample survey data analysis procedures. RESULTS Middle-aged adults with CKD were more likely to suffer a fall (2.30, 95% CI 2.07-2.55) and a fall-related injury (1.54, 95% CI 1.32-1.80) compared to those without CKD. However, only the increased likelihood for falls remained significant after correction for multiple demographic, health, lifestyle, and comorbid conditions (AOR 1.22, 95% CI 1.08-1.39). Among adults with CKD, general health status, smoking, and total comorbidity scores were significant predictors of falls and fall-related injuries (p < 0.05 for all). Furthermore, individual comorbidities such as COPD, asthma, depressive disorders, stroke, and arthritis also predicted falls and fall-related injuries (p < 0.05 for all). CONCLUSION Middle-aged adults with CKD were more likely than those without CKD to fall and suffer a fall-related injury. However, injury risk did not remain elevated after accounting for differences between groups. The presence of comorbidities, especially depressive disorders, was associated with increased odds for falls and fall-related injuries. Given the high prevalence of depression among adults with CKD, the relationship between depression and falls warrants further examination.
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Affiliation(s)
- Brandon M Kistler
- Department of Nutrition and Health Science, Ball State University, 2000 W University Avenue, Muncie, Indiana, USA.
| | - Jagdish Khubchandani
- Department of Nutrition and Health Science, Ball State University, 2000 W University Avenue, Muncie, Indiana, USA
| | - Michael Wiblishauser
- School of Education, Health Professions and Human Development, University of Houston-Victoria, Victoria, Texas, USA
| | - Kenneth R Wilund
- Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Champaign, Illinois, USA
| | - Jacob J Sosnoff
- Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Champaign, Illinois, USA
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Abstract
BACKGROUND People with Chronic Kidney Disease (CKD) often present with prevalent gait impairment and high fall rates, particularly in advanced CKD stages. Gait impairment and its consequences is associated with increased hospital admission, institutionalization, and greater need for health care. The objective of this systematic review was to evaluate the quality of studies investigating CKD patients' gait characteristics at different CKD stages, to highlight areas of agreement and contradiction between studies reporting aspects of gait in CKD, and to discuss and emphasize gait parameters associated with fall risk. METHODS We performed a literature search of trials in CINAHL (EBSCO), Cochrane Library, EMBASE, Medline (EBSCO), PEDro, PubMed, and Scopus databases from their inception to June 30th 2018 using a two-stage process for the identification of studies. We retrieved English-, German-, Italian-, Spanish-, Portuguese and Dutch-language articles for review. Methodological quality of randomized and non-randomized studies was assessed with an adapted version of the Downs and Black checklist. RESULTS Thirty-one studies (22 cross-sectional with 3901 participants) and 9 longitudinal intervention studies (1 randomized control trial, 5 controlled clinical trials and 3 one-group pre-post-test; with 659 participants) were considered. The studies revealed a primary emphasis on gait speed measures within clinical tests, and a neglect of spatiotemporal gait variables. Most of the studies showed that CKD progression is associated with slowing of walking speed. No studies analysed the relation between gait parameters and fall risk. CONCLUSIONS There was a paucity of studies investigating aspects of gait quality in patients with CKD. In the majority of studies, only gait speed is analysed as a performance indicator. The relation between gait parameters and fall risk in CKD is not investigated. We formulate several recommendations to fill the current research gap, encourage the use of standardized gait analysis protocols that include assessment of spatiotemporal parameters in clinical care of patients with CKD, aimed at prevention of mobility decline and falls risk.
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Kistler BM, Khubchandani J, Jakubowicz G, Wilund K, Sosnoff J. Falls and Fall-Related Injuries Among US Adults Aged 65 or Older With Chronic Kidney Disease. Prev Chronic Dis 2018; 15:E82. [PMID: 29935079 PMCID: PMC6016407 DOI: 10.5888/pcd15.170518] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Introduction Falls are among the leading causes of injury and death among adults aged 65 or older. People with chronic kidney disease (CKD) are at increased risk of falling and of having a serious injury from falls. However, information is limited about risk factors for falls and fall-related injuries among people with CKD. Methods We performed a secondary analysis of 157,753 adults (6.1% with CKD) aged 65 or older surveyed in the 2014 Behavioral Risk Factor Surveillance System. Results People with CKD were at increased risk of falls (odds ratio [OR] = 1.81; 95% confidence interval [CI], 1.63–2.01) and fall-related injuries (OR = 1.50; 95% CI, 1.27–1.78) even after adjusting for differences in demographic characteristics, health conditions, and lifestyle factors (P < .05 for all). Among people with CKD, women, people diagnosed with diabetes, diabetes duration, and arthritis were all significant predictors of falls and fall-related injuries (P < .05 for all). Lifestyle factors, such as engaging in recent exercise (adjusted odds ratio [AOR] = 0.68; 95% CI, 0.56–0.81) and limited physical function (assessed as difficulty in climbing stairs) (AOR = 2.84; 95% CI, 2.30–3.44), were most closely associated with falls and fall-related injuries. Conclusion Adults aged 65 or older with CKD were at increased risk of falling and of suffering an injury as a result of a fall compared with adults in the same age range without CKD. Potentially modifiable factors such as physical function and recent exercise were most closely related to reduced risk for falls and fall-related injuries and may be an appropriate target for fall prevention and rehabilitation programs in people with CKD.
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Affiliation(s)
- Brandon M Kistler
- Department of Nutrition and Health Science, 2000 W University Ave, Ball State University, Muncie, IN 47304.
| | - Jagdish Khubchandani
- Department of Nutrition and Health Science, Ball State University, Muncie, Indiana
| | - Gina Jakubowicz
- Department of Nutrition and Health Science, Ball State University, Muncie, Indiana
| | - Kenneth Wilund
- Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana, Illinois
| | - Jacob Sosnoff
- Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana, Illinois
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Fitschen PJ, Biruete A, Jeong J, Wilund KR. Efficacy of beta-hydroxy-beta-methylbutyrate supplementation in maintenance hemodialysis patients. Hemodial Int 2016; 21:107-116. [DOI: 10.1111/hdi.12440] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Peter J. Fitschen
- Division of Nutritional Sciences; University of Illinois; Urbana Illinois USA
| | - Annabel Biruete
- Division of Nutritional Sciences; University of Illinois; Urbana Illinois USA
| | - Jinny Jeong
- Department of Kinesiology and Community Health; University of Illinois; Urbana Illinois USA
| | - Kenneth R. Wilund
- Division of Nutritional Sciences; University of Illinois; Urbana Illinois USA
- Department of Kinesiology and Community Health; University of Illinois; Urbana Illinois USA
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