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Blair C, Shields J, Mullan R, Johnston W, Davenport A, Fouque D, Kalantar-Zadeh K, Maxwell P, McKeaveney C, Noble H, Porter S, Seres D, Slee A, Swaine I, Witham M, Reid J. Exploring the lived experience of renal cachexia for individuals with end-stage renal disease and the interrelated experience of their carers: Study protocol. PLoS One 2022; 17:e0277241. [PMID: 36327348 PMCID: PMC9632830 DOI: 10.1371/journal.pone.0277241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 10/21/2022] [Indexed: 11/06/2022] Open
Abstract
Renal cachexia is an important consideration in the person-centred care that is needed in end-stage renal disease (ESRD). However, given that clinical guidelines relating to renal cachexia are largely absent, this is an unmet care need. To inform guidelines and future renal service planning, there is an urgency to understand individuals’ experiences of renal cachexia and the interrelated experiences of the carers in their lives. We report here the protocol for an interpretative phenomenological study which will explore this lived experience. A purposive sampling strategy will recruit individuals living with ESRD who have cachexia and their carers. A maximum of 30 participants (15 per group) dependent on saturation will be recruited across two nephrology directorates, within two healthcare trusts in the United Kingdom. Individuals with renal cachexia undergoing haemodialysis will be recruited via clinical gatekeepers and their carers will subsequently be invited to participate in the study. Participants will be offered the opportunity to have a face-to-face, virtual or telephone interview. Interviews will be audio-recorded, transcribed verbatim and analysed using interpretative phenomenological analysis. NVivo, will be used for data management. Ethical approval for this study was granted by the Office for Research Ethics Committees Northern Ireland (REC Reference: 22/NI/0107). Scientific evidence tends to focus on measurable psychological, social and quality of life outcomes but there is limited research providing in-depth meaning and understanding of the views of individuals with renal disease who are experiencing renal cachexia. This information is urgently needed to better prepare healthcare providers and in turn support individuals with ESRD and their carers. This study will help healthcare providers understand what challenges individuals with ESRD, and their carers face in relation to cachexia and aims to inform future clinical practice guidelines and develop supportive interventions which recognise and respond to the needs of this population.
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Affiliation(s)
- Carolyn Blair
- School of Nursing and Midwifery, Queen’s University Belfast, Belfast, United Kingdom
| | - Joanne Shields
- Regional Nephrology Unit, Belfast City Hospital, Belfast Health & Social Care Trust, Belfast, United Kingdom
| | - Robert Mullan
- Renal Unit, Antrim Area Hospital, Northern Health & Social Care Trust, Antrim, United Kingdom
| | - William Johnston
- Northern Ireland Kidney Patients Association, Belfast, United Kingdom
| | - Andrew Davenport
- UCL Department of Renal Medicine Royal Free Hospital University College London, London, United Kingdom
| | - Denis Fouque
- Division of Nephrology, Dialysis and Nutrition, Hôpital Lyon Sud and University of Lyon, Pierre-Bénite, France
| | - Kamyar Kalantar-Zadeh
- Irvine Division of Nephrology, Hypertension and Kidney Transplantation, University of California, Irvine, CA, United States of America
| | - Peter Maxwell
- Centre for Public Health, Queen’s University Belfast, Belfast, United Kingdom
| | - Clare McKeaveney
- School of Nursing and Midwifery, Queen’s University Belfast, Belfast, United Kingdom
| | - Helen Noble
- School of Nursing and Midwifery, Queen’s University Belfast, Belfast, United Kingdom
| | - Sam Porter
- Department of Social Sciences and Social Work, Bournemouth University, Poole, United Kingdom
| | - David Seres
- Institute of Human Nutrition and Department of Medicine, Columbia University Irving Medical Center, New York, NY, United States of America
| | - Adrian Slee
- Faculty of Medical Sciences, University College London, London, United Kingdom
| | - Ian Swaine
- School of Human Sciences, University of Greenwich, Greenwich, United Kingdom
| | - Miles Witham
- Campus for Ageing and Vitality, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Joanne Reid
- School of Nursing and Midwifery, Queen’s University Belfast, Belfast, United Kingdom
- * E-mail:
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Abstract
PURPOSE OF REVIEW Disease-related malnutrition has complex and multifactorial pathophysiology. It is common in patients with chronic kidney disease (CKD) and has a devastating impact on morbidity and mortality. Given the rising numbers of patients diagnosed with CKD, disease-related malnutrition is an escalating clinical challenge. This review summarises current knowledge in relation to the development, screening and treatments for disease-related malnutrition in CKD. RECENT FINDINGS New research has identified other potential causes for the development of malnutrition in CKD, including changes in taste and smell, and effects of polypharmacy. Screening and assessment studies have investigated different tools in relation to the new Global Leadership Initiative on Malnutrition (GLIM) criteria. Different modalities of low protein diets and the potential use of pre and probiotics are being explored. Furthermore, the importance of nutritional support, and possibly exercise during dialysis is being examined in terms of reducing anabolic resistance and catabolism. SUMMARY Further research is required to better understand the nuances of the pathophysiology of disease-related malnutrition in CKD. This work should inform not only consistent terminology and the application of assessment tools specific to disease-related malnutrition in CKD but also the development of novel interventions that reflect its multifaceted pathophysiology and impact.
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Affiliation(s)
| | - Joanne Reid
- School of Nursing and Midwifery, Queens University Belfast, Northern Ireland, UK
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Noor H, Reid J, Slee A. Resistance exercise and nutritional interventions for augmenting sarcopenia outcomes in chronic kidney disease: a narrative review. J Cachexia Sarcopenia Muscle 2021; 12:1621-1640. [PMID: 34585539 PMCID: PMC8718072 DOI: 10.1002/jcsm.12791] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 08/02/2021] [Accepted: 08/23/2021] [Indexed: 12/25/2022] Open
Abstract
Sarcopenia is an age-related progressive muscle disease characterized by loss of muscle mass, muscle strength and physical performance with high prevalence in chronic kidney disease (CKD). CKD is associated with decreased muscle protein synthesis and muscle breakdown due to a number of factors including, the uremic inflammatory environment of the disease. CKD patients are highly sedentary and at risk of malnutrition which may exacerbate sarcopenia outcomes even further. Short and long-term exercise and nutritional interventions have been studied and found to have some positive effects on sarcopenia measures in CKD. This narrative review summarized evidence between 2010 and 2020 of resistance exercise (RE) alone or combined with nutritional interventions for improving sarcopenia outcomes in CKD. Due to lack of CKD-specific sarcopenia measures, the second European Working Group on Sarcopenia in Older People (EWGSOP2) definition has been used to guide the selection of the studies. The literature search identified 14 resistance exercise-based studies and 5 nutrition plus RE interventional studies. Muscle strength outcomes were increased with longer intervention duration, intervention supervision, and high participant adherence. Data also suggested that CKD patients may require increased RE intensity and progressive loading to obtain detectable results in muscle mass. Unlike muscle strength and muscle mass, physical performance was readily improved by all types of exercise in long or short-term interventions. Four studies used RE with high-protein nutritional supplementation. These showed significant benefits on muscle strength and physical performance in dialysis patients while non-significant results were found in muscle mass. More research is needed to confirm if a combination of RE and vitamin D supplementation could act synergistically to improve muscle strength in CKD. The current evidence on progressive RE for sarcopenia in CKD is encouraging; however, real-life applications in clinical settings are still very limited. A multidisciplinary patient-centred approach with regular follow-up may be most beneficial due to the complexity of sarcopenia in CKD. Long-term randomized control trials are needed to verify optimal RE prescription and explore safety and efficacy of other nutritional interventions in CKD.
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Affiliation(s)
- Hanaa Noor
- Division of Medicine, University College London, London, UK.,Diaverum Holding AB Branch, Riyadh, Saudi Arabia
| | - Joanne Reid
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Adrian Slee
- Division of Medicine, University College London, London, UK
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Abstract
Chronic kidney disease (CKD) has become a global health burden and is associated with increased morbidity and mortality. In particular, wasting is highly prevalent in later stages of the illness with muscle loss being a common problem. The aetiology and progression of this wasting is complex and multiple states have been identified linked to wasting in CKD. These include: ‘malnutrition’, ‘disease-related malnutrition’, ‘protein-energy wasting’, ‘cachexia’, ‘sarcopenia’, ‘frailty’ and ‘muscle wasting’. The purpose of this paper is to review these terms in the context of CKD. Common features include weight loss, loss of muscle mass and muscle function principally driven by CKD disease specific factors and inflammatory mediators. Disease-related malnutrition would appear to be a more appropriate term for CKD than malnutrition as it take in to consideration disease specific factors such as inflammation for example. Frailty is commonly associated with age-related decline in physiological function. Development of novel screening tools measuring across multiple domains of nutritional status, muscle and physical function may be useful in CKD. Research into potential treatments are currently underway with focus on multi-modal therapies including nutrition, resistance training and anabolic drugs such as myostatin blockade and selective androgen receptor modulators. A better understanding of different states and terms may help guide assessment and treatment opportunities for patients.
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Reid J, Noble HR, Adamson G, Davenport A, Farrington K, Fouque D, Kalantar-Zadeh K, Mallett J, McKeaveney C, Porter S, Seres DS, Shields J, Slee A, Witham MD, Maxwell AP. Establishing a clinical phenotype for cachexia in end stage kidney disease - study protocol. BMC Nephrol 2018; 19:38. [PMID: 29439674 PMCID: PMC5812213 DOI: 10.1186/s12882-018-0819-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 01/17/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Surveys using traditional measures of nutritional status indicate that muscle wasting is common among persons with end-stage kidney disease (ESKD). Up to 75% of adults undergoing maintenance dialysis show some evidence of muscle wasting. ESKD is associated with an increase in inflammatory cytokines and can result in cachexia, with the loss of muscle and fat stores. At present, only limited data are available on the classification of wasting experienced by persons with ESKD. Individuals with ESKD often exhibit symptoms of anorexia, loss of lean muscle mass and altered energy expenditure. These symptoms are consistent with the syndrome of cachexia observed in other chronic diseases, such as cancer, heart failure, and acquired immune deficiency syndrome. While definitions of cachexia have been developed for some diseases, such as cardiac failure and cancer, no specific cachexia definition has been established for chronic kidney disease. The importance of developing a definition of cachexia in a population with ESKD is underscored by the negative impact that symptoms of cachexia have on quality of life and the association of cachexia with a substantially increased risk of premature mortality. The aim of this study is to determine the clinical phenotype of cachexia specific to individuals with ESKD. METHODS A longitudinal study which will recruit adult patients with ESKD receiving haemodialysis attending a Regional Nephrology Unit within the United Kingdom. Patients will be followed 2 monthly over 12 months and measurements of weight; lean muscle mass (bioelectrical impedance, mid upper arm muscle circumference and tricep skin fold thickness); muscle strength (hand held dynamometer), fatigue, anorexia and quality of life collected. We will determine if they experience (and to what degree) the known characteristics associated with cachexia. DISCUSSION Cachexia is a debilitating condition associated with an extremely poor outcome. Definitions of cachexia in chronic illnesses are required to reflect specific nuances associated with each disease. These discrete cachexia definitions help with the precision of research and the subsequent clinical interventions to improve outcomes for patients suffering from cachexia. The absence of a definition for cachexia in an ESKD population makes it particularly difficult to study the incidence of cachexia or potential treatments, as there are no standardised inclusion criteria for patients with ESKD who have cachexia. Outcomes from this study will provide much needed data to inform development and testing of potential treatment modalities, aimed at enhancing current clinical practice, policy and education.
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Affiliation(s)
- Joanne Reid
- School of Nursing and Midwifery, Queen's University Belfast Medical Biology Centre, 97 Lisburn Rd, Belfast, BT9 7BL, UK.
| | - Helen R Noble
- School of Nursing and Midwifery, Queen's University Belfast Medical Biology Centre, 97 Lisburn Rd, Belfast, BT9 7BL, UK
| | - Gary Adamson
- School of Psychology, Ulster University Magee Campus, Londonderry, BT48 7JL, UK
| | - Andrew Davenport
- UCL Centre for Nephrology, Royal Free Hospital, University College London, Pond Street, London, NW3 2QG, UK
| | - Ken Farrington
- East and North Hertfordshire University NHS Trust, Lister Hospital, Coreys Mill Lane, Stevenage, SG1 4AB, UK
| | - Denis Fouque
- Department of Nephrology, Université de Lyon, UCBL, Carmen, Centre Hospitalier Lyon Sud, F-69495, Pierre-Bénite, France
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, Pediatrics and Public Health, University of California, Los Angeles, USA
| | - John Mallett
- School of Psychology, Ulster University Magee Campus, Londonderry, BT48 7JL, UK
| | - C McKeaveney
- School of Nursing and Midwifery, Queen's University Belfast Medical Biology Centre, 97 Lisburn Rd, Belfast, BT9 7BL, UK
| | - S Porter
- Department of Social Sciences and Social Work, Bournemouth University, Poole, UK
| | - David S Seres
- Columbia University Medical Centre, NY Presbyterian Hospital, New York, USA
| | - Joanne Shields
- Regional Nephrology Unit, Belfast City Hospital, Belfast HSC Trust, Belfast, UK
| | - Adrian Slee
- UCL, Faculty of Medical Sciences, Gower St, Bloomsbury, London, WC1E 6BT, UK
| | - Miles D Witham
- School of Medicine, Ninewells Hospital, Dundee, DD1 9SY, UK
| | - Alexander P Maxwell
- School of Medicine, Dentistry and Biomedical Sciences, Queens University Belfast and Regional Nephrology Unit, Belfast City Hospital, Belfast HSC Trust, Belfast, UK
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Abstract
With aging and other muscle wasting diseases, men and women undergo similar pathological changes in skeletal muscle: increased inflammation, enhanced oxidative stress, mitochondrial dysfunction, satellite cell senescence, elevated apoptosis and proteasome activity, and suppressed protein synthesis and myocyte regeneration. Decreased food intake and physical activity also indirectly contribute to muscle wasting. Sex hormones also play important roles in maintaining skeletal muscle homeostasis. Testosterone is a potent anabolic factor promoting muscle protein synthesis and muscular regeneration. Estrogens have a protective effect on skeletal muscle by attenuating inflammation; however, the mechanisms of estrogen action in skeletal muscle are less well characterized than those of testosterone. Age- and/or disease-induced alterations in sex hormones are major contributors to muscle wasting. Hence, men and women may respond differently to catabolic conditions because of their hormonal profiles. Here we review the similarities and differences between men and women with common wasting conditions including sarcopenia and cachexia due to cancer, end-stage renal disease/chronic kidney disease, liver disease, chronic heart failure, and chronic obstructive pulmonary disease based on the literature in clinical studies. In addition, the responses in men and women to the commonly used therapeutic agents and their efficacy to improve muscle mass and function are also reviewed.
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