Association of the malnutrition-inflammation score with anthropometry and body composition measurements in patients with chronic kidney disease

An Exploratory Study on a New Method for Nutritional Status Assessment in Patients with Chronic Kidney Disease

Malnutrition is a risk factor for disease progression and poor prognosis in chronic kidney disease (CKD). However, the complexity of nutritional status assessment limits its clinical application. This study explored a new method of nutritional assessment in CKD (stage 1-5) patients using the Subjective Global Assessment (SGA) as the gold standard and evaluated its applicability. The kappa test was used to analyze the consistency of the Renal Inpatient Nutrition Screening Tool (Renal iNUT) with SGA and protein-energy wasting. Logistic regression analysis was used to analyze the risk factors of CKD malnutrition and calculate the prediction probability of multiple indicators combined for the diagnosis of CKD malnutrition. The receiver operating characteristic curve of the prediction probability was drawn to evaluate its diagnostic efficiency. A total of 161 CKD patients were included in this study. The prevalence of malnutrition according to SGA was 19.9%. The results showed that Renal iNUT had a moderate consistency with SGA and a general consistency with protein-energy wasting. Age > 60 years (odds ratio, OR = 6.78), neutrophil-lymphocyte ratio > 2.62 (OR = 3.862), transferrin < 200 mg/dL (OR = 4.222), phase angle < 4.5° (OR = 7.478), and body fat percentage < 10% (OR = 19.119) were risk factors for malnutrition in patients with CKD. The area under the receiver operating characteristic curve of multiple indicators for the diagnosis of CKD malnutrition was 0.89 (95% confidence interval: 0.834-0.946, p < 0.001). This study demonstrated that Renal iNUT has good specificity as a new tool for the nutrition screening of CKD patients, but its sensitivity needs to be optimized. Advanced age, high neutrophil-lymphocyte ratio, low transferrin level, low phase angle, and low body fat percentage are risk factors for malnutrition in patients with CKD. The combination of the above indicators has high diagnostic efficiency in the diagnosis of CKD malnutrition, which may be an objective, simple, and reliable method to evaluate the nutritional status of patients with CKD.

From MIA to FIFA: The vicious matrix of frailty, inflammation, fluid overload and atherosclerosis in peritoneal dialysis

Cardiovascular disease (CVD) is a major cause of mortality and morbidity in peritoneal dialysis (PD) patients. Two decades ago, the common co-existence of malnutrition and systemic inflammation PD patients with atherosclerosis and CVD led to the proposed terminology of 'malnutrition-inflammation-atherosclerosis (MIA) syndrome'. Although the importance of malnutrition is well accepted, frailty represents a more comprehensive assessment of the physical and functional capability of the patient and encompasses the contributions of sarcopenia (a key component of malnutrition), obesity, cardiopulmonary as well as neuropsychiatric impairment. In recent years, it is also increasingly recognized that fluid overload is not only the consequence but also play an important role in the pathogenesis of CVD. Moreover, fluid overload is closely linked with the systemic inflammatory status, presumably by gut oedema, gastrointestinal epithelial barrier dysfunction and leakage of bacterial fragments to the systemic circulation. There are now a wealth of published evidence to show intricate relations between frailty, inflammation, fluid overload and atherosclerotic disease in patients with chronic kidney disease (CKD) and those on PD, a phenomenon that we propose the term 'FIFA complex'. In this system, frailty and atherosclerotic disease may be regarded as two patient-oriented outcomes, while inflammation and fluid overload are two inter-connected pathogenic processes. However, there remain limited data on how the treatment of one component affect the others. It is also important to define how treatment of fluid overload affect the systemic inflammatory status and to develop effective anti-inflammatory strategies that could alleviate atherosclerotic disease and frailty.

The Association between Iron Deficiency and Renal Outcomes Is Modified by Sex and Anemia in Patients with Chronic Kidney Disease Stage 1–4

Iron deficiency is prevalent in women and patients with chronic kidney disease (CKD). Iron deficiency is not only related to anemia but contributes to adverse consequences for the kidney as well. Whether iron status is associated with renal outcomes after considering sex and anemia in patients with CKD stage 1–4 is unclear. Thus, we investigated the association of iron or iron saturation with renal outcomes in a CKD cohort. During a follow-up of 8.2 years, 781 (31.2%) patients met the composite renal outcome of renal replacement therapy and a 50% decline in renal function. In linear regression, iron was associated with sex, hemoglobin (Hb), and nutritional markers. In a fully adjusted Cox regression model, the male patients with normal iron had a significantly decreased risk of renal outcomes (hazard ratio (HR) 0.718; 95% confidence interval (CI) 0.579 to 0.889), but the female patients did not exhibit this association. The non-anemic patients (Hb ≥ 11 g/dL) had a decreased risk of renal outcomes (HR 0.715; 95% CI 0.568 to 0.898), but the anemic patients did not. In the sensitivity analysis, transferrin saturation (TSAT) showed similar results. When comparing iron and TSAT, both indicators showed similar prognostic values. In conclusion, iron deficiency, indicated by either iron or iron saturation, was associated with poor renal outcomes in the male or non-anemic patients with CKD stage 1–4.

Malnutrition and Erythropoietin Resistance among Patients with End-Stage Kidney Disease: Where Is the Perpetrator of Disaster?

BACKGROUND

Hemodialyzed patients with poor erythropoietin response tend to have low volume of visceral adipose tissue and score high on malnutrition-inflammation score. This study investigates in-depth the role of leptin and chosen cytokines in the development of malnutrition-inflammation syndrome (MIS) and erythropoietin resistance.

METHODS

Eighty-one hemodialyzed patients with erythropoietin-treated anemia were enrolled in the study. Their body composition was measured. Erythropoietin resistance index was calculated. Blood samples for leptin, IL-6, IL-18, TNF-alpha, and IL-1-alpha serum levels were drawn.

RESULTS

Leptin showed negative correlation with erythropoietin resistance index (ERI), whilst IL-6 showed the opposite. IL-6 seemed to be linked more to HD parameters and vintage, while TNF-alpha and leptin were more dependent on body composition. IL-18 and IL-1-alpha did not affect nutritional parameters nor ERI.

CONCLUSION

Modulation of adipokine- and cytokine-related signaling is a promising target in tempering malnutrition in hemodialyzed, and thus achieving better outcomes in anemia treatment. Large clinical studies that target the inflammatory response in hemodialysis, especially regarding IL-6, TNF-alpha, and leptin, would be of great worth.

Phase angle and cellular health: inflammation and oxidative damage

Phase angle is a composite measure that combines two raw bioelectrical impedance analysis measures: resistance and reactance. Phase angle has been considered an indicator of cellular health, integrity, and hydration. As inflammation and oxidative stress can damage cellular structures, phase angle has potential utility in early detecting inflammatory and oxidative status. Herein, we aimed to critically review the current understanding on the determinants of phase angle and its relationship with markers of inflammation and oxidative stress. We also discussed the potential role of phase angle in detecting chronic inflammation and related adverse outcomes. Several factors have been identified as predictors of phase angle, including age, sex, extracellular to intracellular water ratio, and fat-free mass. In addition to these factors, body mass index (BMI) also seems to influence phase angle. Available data also show that lower phase angle values are correlated (negligible to high correlation coefficients) with higher c-reactive protein, tumour necrosis factor-α, interleukin-6, and interleukin-10 in studies involving the general and aging populations, as well as patients with chronic conditions. Although fewer studies have evaluated the relationship between phase angle and markers of oxidative stress, available data also suggest that phase angle has potential to be used as an indicator (for screening) of oxidative damage. Future studies including diverse populations and bioelectrical impedance devices are required to confirm the validity and accuracy of phase angle as a marker of inflammation and oxidative stress for clinical use.

Assessment of the Nutritional Status and Quality of Life in Chronic Kidney Disease and Kidney Transplant Patients: A Comparative Analysis

BACKGROUND

Chronic kidney disease (CKD) can significantly influence a patient's nutritional status, leading to malnutrition. Malnutrition is associated with an increase in morbidity and hospital admissions, as well as a decrease in functional status. All these factors impact emotional, physical, and psychosocial health, leading to a lower quality of life (QOL). The aim of the study was to assess the nutritional status and QOL in patients with CKD compared to patients after kidney transplantation and determine what factors influence nutritional status and QOL in this patient population.

METHODS

The study included 167 patients: 39 pre-dialysis patients-group 1; 65 dialysis patients-group 2; 63 kidney transplant patients-group 3. Patients completed the Kidney Disease Quality of Life questionnaire (KDQoL) and the Mini Nutritional Assessment questionnaire (MNA).

RESULTS

A comparative analysis of the QOL of patients in the three study groups showed no statistically significant differences in the overall KDQoL scores. Factors that affected quality of life included the designated group, determined by disease status, MNA score, patient age, and WHR. Nearly 1/3 of patients from groups 2 and 3 were at risk of malnutrition.

CONCLUSIONS

A systematic assessment of nutritional status and monitoring of QOL should be integrated into the standard management guidelines for CKD patients.

Nutritional and Hydration Status and Adherence to Dietary Recommendations in Dalmatian Dialysis Patients

Protein-energy wasting (PEW) is considered one of the major complications of chronic kidney disease (CKD), particularly in dialysis patients. Insufficient energy and protein intake, together with clinical complications, may contribute to the onset and severity of PEW. Therefore, the aim of the study was to analyze the differences in nutritional and hydration status and dietary intake among Dalmatian dialysis patients. Fifty-five hemodialysis (HD) and twenty peritoneal dialysis (PD) participants were included. For each study participant, data about body composition, anthropometric, laboratory, and clinical parameters were obtained. The Malnutrition Inflammation Score (MIS) and two separate 24-h dietary recalls were used to assess nutritional status and dietary intake. The Nutrient Adequacy Ratio (NAR) and Mean Adequacy Ratio (MAR) were calculated to compare actual dietary intake with recommended intake. Additionally, the estimated 10-year survival was calculated using the Charlson Comorbidity Index. The prevalence of malnutrition according to MIS was 47.3% in HD and 45% in PD participants. Significant differences in fat tissue parameters were found between HD and PD participants, whereas significant differences in hydration status and muscle mass parameters were not found. A significant difference in NAR between HD and PD participants was noticed for potassium and phosphorus intake, but not for MAR. MIS correlated negatively with anthropometric parameters, fat mass, visceral fat level and trunk fat mass, and iron and uric acid in HD participants, whereas no significant correlations were found in PD participants. The estimated 10-year survival correlated with several parameters of nutritional status in HD and PD participants, as well as nutrient intake in HD participants. These results indicate a high prevalence of malnutrition and inadequate dietary intake in the Dalmatian dialysis population which, furthermore, highlights the urgent need for individualized and structural nutritional support.

In Patients with Chronic Kidney Disease Advanced Glycation End-Products Receptors Isoforms (sRAGE and esRAGE) Are Associated with Malnutrition

Background: in patients with chronic kidney disease (CKD), the inflammatory and pro-oxidant milieu may contribute to malnutrition development. In this study, we investigated the relationship between inflammation, advanced glycation end-products (AGEs), and their receptors (RAGEs) with malnutrition in CKD patients. Methods: we evaluated 117 patients. AGEs were quantified by fluorescence intensity using a fluorescence spectrophotometer, soluble RAGEs isoforms, and inflammatory interleukins by ELISA. Malnutrition was assessed by a malnutrition inflammation score. Results: mean age was 80 ± +11 years, eGFR was 25 ± +11 mL/min/1.73 m2 and BMI was 28 ± 5 Kg/m2. Malnourished individuals were older, had lower estimated protein intake (nPCR 0.65 ± 0.2 vs. 0.8 ± 0.2 vs. 0.8 ± 0.3, p = 0.01), higher C reactive protein (CRP 0.6 ± 1 vs. 0.6 ± 0.7 vs. 0.17 ± 0.13, p = 0.02) and tumor necrosis factor α (TNF α 14.7 ± 8.7 vs. 15.6 ± 8 vs. 11.8 ± 5.8, p = 0.029). Malnourished patients had higher sRAGE (2813 ± 1477 vs. 2158 ± 1236 vs. 2314 ± 1115, p = 0.035) and esRAGE (648 [408–1049] vs. 476 [355–680] vs. 545 [380–730] p = 0.033). In the multivariate analysis, only sRAGE maintained its association with malnutrition (p = 0.02) independently of aging and inflammation. Conclusions: in CKD patients, RAGEs isoforms, but not AGEs, are associated with malnutrition, irrespective of systemic inflammation, aging, and renal function.

[Prevalence of malnutrition and absolute and functional iron deficiency anemia in nondialysis-dependent chronic kidney disease and hemodialysis Algerian patients]

In chronic kidney disease, anemia and malnutrition coupled with inflammation as malnutrition-inflammation complex syndrom are common and considered as morbidity-mortality factors. The link between these two factors has been described at length in the literature highlighting an association of malnutrition with iron deficiency considered itself as one of the causes of anemia in chronic kidney disease (non-dialysis and hemodialysis). Our study aims to know the prevalence of these two factors in a population of chronic kidney disease (non-dialysis and hemodialysis) of Algiers and to highlight the possible associations between them.

PATIENTS AND METHODS

This is a multicentre, cross-sectional and descriptive study carried out over a period of 6months (August 2018 to January 2019). Anemia and malnutrition were assessed by various biological and clinical tools such as the malnutrition inflammation score and the International Society of Renal Nutrition and Metabolism criteria. Statistical tests were performed on the R studio software, considering P<0.05 as a statistically significant value.

RESULTS

Two hundred and nine patients on chronic kidney disease were included (90 non dialysis and 119 hemodialysis). The median age was 70 (IQR=16) for non dialysis and 56 (IQR=16.5) for hemodialysis. The prevalence of anemia was 66.66% (n=60) in non dialysis and 70.58% (n=84) in hemodialysis. Absolute iron deficiency anemia was higher in non dialysis (48.33%; n=29) while functional iron deficiency anemia was higher in hemodialysis (34.52%; n=29). The prevalence of malnutrition by malnutrition inflammation score was relatively low. Only functional iron deficiency anemia was associated with malnutrition.

CONCLUSION

The prevalence of anemia was higher in Algerian chronic kidney disease (non-dialysis and hemodialysis) unlike malnutrition which remains associated with functional iron deficiency anemia.

The impact of nutritional status on health-related quality of life in hemodialysis patients

Malnutrition is frequent in hemodialysis (HD) patients. Nutritional deficiencies may negatively impact quality of life (QOL). This study examines the utility of the Malnutrition-Inflammation Score (MIS) in detecting nutritional risk (NR) and assesses the correlation between nutritional status and QOL in dialysis patients upon starting a nutritional intervention program (NIP). One hundred and twenty patients were included in this cross-sectional study. The MIS was used to detect NR and the Kidney Disease Quality of Life (KDQOL-SF) instrument version 1.2 was used to assess QOL. 62% of patients were found to be at NR (MIS > 5). Nutritional status was significantly correlated with all generic QOL sub-scales. On a multiple linear regression analysis, malnutrition showed the highest level of explanation in the Kidney Disease Summary Component which explained 28.9% of the variance; the Physical Component Summary which explained 33% of the variance; and the Mental Component Summary which explained 21.5% of the variance. Malnutrition was found to be the most significant predictor of impaired scores on the KDQOL-SF. The use of MIS to identify patients at NR and a nutritional assessment to detect malnutrition in its early stages are important given the effects a NIP can have on improving QOL in HD patients.

U-Shaped Association between Waist-to-Hip Ratio and All-Cause Mortality in Stage 3-5 Chronic Kidney Disease Patients with Body Mass Index Paradox

The obesity paradox, referring to the association of high body mass index (BMI) with low all-cause mortality risk, is found in patients with chronic kidney disease (CKD). Central obesity is associated with metabolic syndrome and may have better prognostic value than BMI for all-cause mortality. Whether central obesity is associated with all-cause mortality in cases of obesity paradox in CKD patients remains unknown. We included 3262 patients with stage 3–5 CKD, grouped into five quintiles (Q1–5) by waist-to-hip ratio (WHR). Low WHR and BMI were associated with malnutrition and inflammation. In Cox regression, high BMI was not associated with all-cause mortality, but BMI < 22.5 kg/m² increased the mortality risk. A U-shaped association between central obesity and all-cause mortality was found: WHR Q1, Q4, and Q5 had higher risk for all-cause mortality. The hazard ratio (95% confidence interval) of WHR Q5 and Q1 for all-cause mortality was 1.39 (1.03–1.87) and 1.53 (1.13–2.05) in male and 1.42 (1.02–1.99) and 1.28 (0.88–1.85) in female, respectively. Waist-to-height ratio and conicity index showed similar results. Low WHR or low BMI and high WHR, but not high BMI, are associated with all-cause mortality in advanced CKD.

Exploring the potential role of phase angle as a marker of oxidative stress: A narrative review

Chronic conditions including non-communicable diseases have become increasingly prevalent in the past decade. Proinflammatory cytokines are associated with the development of several pathologies, their prognoses, and their associated mortality. Chronic inflammation is also associated with oxidative stress whereby reactive oxygen species (ROS) induce cellular injury and, thus, by doing so, initiate inflammatory signaling. Phase angle (PhA) is a measurable body composition parameter obtained using bioelectrical impedance analysis (BIA). PhA is considered an indicator of cellular health and integrity and is also related to inflammatory markers and inflammation. Given the association among oxidative stress, cell damage, and inflammation that may in turn be associated with low PhA values, it is expected that PhA could mirror oxidative stress. In this hypothesis-generating, narrative review we summarize the current knowledge regarding the potential relationship between PhA and oxidative stress and their interrelationship in chronic conditions.

Consensus on the standard terminology used in the nutrition care of adult patients with chronic kidney disease

This nutrition consensus document is the first to coordinate the efforts of three professional organizations - the Brazilian Association of Nutrition (Asbran), the Brazilian Society of Nephrology (SBN), and the Brazilian Society of Parenteral and Enteral Nutrition (Braspen/SBNPE) - to select terminology and international standardized tools used in nutrition care. Its purpose is to improve the training delivered to nutritionists working with adult patients with chronic kidney disease (CKD). Eleven questions were developed concerning patient screening, care, and nutrition outcome management. The recommendations set out in this document were developed based on international guidelines and papers published in electronic databases such as PubMed, EMBASE(tm), CINHAL, Web of Science, and Cochrane. From a list of internationally standardized terms, twenty nutritionists selected the ones they deemed relevant in clinical practice involving outpatients with CKD. The content validity index (CVI) was calculated with 80% agreement in the answers. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework was used to assess the strength of evidence and recommendations. A total of 107 terms related to Nutrition Assessment and Reassessment, 28 to Diagnosis, nine to Intervention, and 94 to Monitoring and Evaluation were selected. The list of selected terms and identified tools will be used in the development of training programs and the implementation of standardized nutrition terminology for nutritionists working with patients with chronic kidney disease in Brazil.

Significance of Adipose Tissue Maintenance in Patients Undergoing Hemodialysis

In the general population, obesity is known to be associated with adverse outcomes, including mortality. In contrast, high body mass index (BMI) may provide a survival advantage for hemodialysis patients, which is known as the obesity paradox. Although BMI is the most commonly used measure for the assessment of obesity, it does not distinguish between fat and lean mass. Fat mass is considered to serve as an energy reserve against a catabolic condition, while the capacity to survive starvation is also thought to be dependent on its amount. Thus, fat mass is used as a nutritional marker. For example, improvement of nutritional status by nutritional intervention or initiation of hemodialysis is associated with an increase in fat mass. Several studies have shown that higher levels of fat mass were associated with better survival in hemodialysis patients. Based on body distribution, fat mass is classified into subcutaneous and visceral fat. Visceral fat is metabolically more active and associated with metabolic abnormalities and inflammation, and it is thus considered to be a risk factor for cardiovascular disease and mortality. On the other hand, subcutaneous fat has not been consistently linked to adverse phenomena and may reflect nutritional status as a type of energy storage. Visceral and subcutaneous adipose tissues have different metabolic and inflammatory characteristics and may have opposing influences on various outcomes, including mortality. Results showing an association between increased subcutaneous fat and better survival, along with other conditions, such as cancer or cirrhosis, in hemodialysis patients have been reported. This evidence suggests that fat mass distribution (i.e., visceral fat and subcutaneous fat) plays a more important role for these beneficial effects in hemodialysis patients.

Seasonal variations in nutritional status and oxidative stress in patients on hemodialysis: Are they related?

OBJECTIVE

Seasonal variations in body composition and parameters that reflect nutritional status are well established in patients on hemodialysis (HD). However, to our knowledge, no study has assessed the changes in oxidative stress (OS). The aims of this study were to assess seasonal variations in OS, body composition, and other nutritional parameters.

METHODS

Seasonal variations in fat tissue mass (FTM), fat tissue index (FTI), adipose tissue mass (ATM), lean tissue mass (LTM), lean tissue index (LTI), body cell mass (BCM), overhydration (OH) volume, and OS (blood levels of derivatives of reactive oxygen metabolites [d-ROMs], thiobarbituric reactive substances, plasma protein reduced thiol content [THIOLS], and ferric reducing ability of plasma) were assessed in 45 patients on HD, 70 y of age (60.5-76.5 y).

RESULTS

FTM (P < 0.001), FTI (P < 0.001), and ATM (P < 0.001) significantly increased, whereas LTI (P < 0.001), LTM (P < 0.001), BCM (P < 0.001), and OH volume (P = 0.004) significantly decreased over the season. Additionally, significant seasonal variations in the levels of d-ROMs (P = 0.02) and THIOLS (P = 0.02) were found. Levels of d-ROMs were found to be a significant predictor of LTM and BCM (β = -0.57; 95% confidence interval [CI], -1.08 to -0.06; P = 0.03; β = -0.04; 95% CI, -0.075 to -0.006; P = 0.02). Furthermore, hip circumference was found to be the most significant predictor of the level of d-ROMs (β = 2.66; 95% CI; 0.28-5.04; P = 0.03) and waist-to-height ratio (β = 251; 95% CI, 16.6-477.2; P = 0.03) and serum prealbumin levels of THIOLS (β = 263; 95% CI, 6.8-521.1; P = 0.04).

CONCLUSION

These results suggest seasonal variations in OS in patients on HD and a possible interaction between OS and nutritional status in these patients.

Physiologically based pharmacokinetic model of renally cleared antibacterial drugs in Chinese renal impairment patients

To preliminarily develop physiologically based population models for Chinese renal impairment patients and to evaluate the prediction performance of new population models by renally cleared antibacterial drugs. First, demographic data and physiological parameters of Chinese renal impairment patients were collected, and then the coefficients of the relative demographic and physiological equation were recalibrated to construct the new population models. Second, drug‐independent parameters of ceftazidime, cefodizime, vancomycin, and cefuroxime were collected and verified by Chinese healthy volunteers, Caucasian healthy volunteers, and Caucasian renal impairment population models built in Simcyp. Finally, the newly developed population models were applied to predict the plasma concentration of four antibacterial drugs in Chinese renal impairment patients. The new physiologically based pharmacokinetic (PBPK) population models can predict the main pharmacokinetic parameters, including area under the plasma concentration–time curve extrapolated to infinity (AUC_inf), renal clearance (CL_r), and peak concentration (C_max), of ceftazidime, cefodizime, vancomycin, and cefuroxime following intravenous administrations with less than twofold error in mild, moderate, and severe Chinese renal impairment patients. The accuracy and precision of the predictions were improved compared with the Chinese healthy volunteers and Caucasian renal impairment population models. The PBPK population models were preliminarily developed and the first‐step validation results of four antibacterial drugs following intravenous administration showed acceptable accuracy and precision. The population models still need more systematic validation by using more drugs and scenarios in future studies to support their applications on dosage recommendation for Chinese renal impairment patients.