Can Overnutrition Lead to Wasting?-The Paradox of Diabetes Mellitus in End-Stage Renal Disease Treated with Maintenance Hemodialysis

The correlation between protein energy wasting and the incidence of main adverse cardiovascular events in adult maintenance hemodialysis patients: a single-center retrospective cohort study

BACKGROUND

Protein energy wasting (PEW) is prevalent in adult maintenance hemodialysis (MHD) patients. Concurrently, cardiovascular diseases (CVD) remain a leading cause of mortality in MHD patients. However, the relationship between PEW and CVD in MHD patients remains unclear.

METHODS

We conducted a retrospective cohort study at Shanghai East Hospital. According to the inclusion and exclusion criteria, a total of 210 adult MHD patients were finally enrolled. Patients were categorized into two groups based on PEW diagnostic criteria, including 122 patients (58.1%) with PEW and 88 patients (41.9%) without PEW. We further analyzed the incidence of major adverse cardiovascular events (MACE) and all-cause mortality in one year, along with their risk factors.

RESULTS

MACE incidence was significantly higher in the PEW group compared with the non-PEW group (p = 0.015). Multivariate Cox regression showed PEW, CVD, high N-terminal pro-B-type natriuretic peptide (NT-proBNP) and low Kt/V urea were the risk factors of MACE. Age ≥ 65 years and high NT-proBNP were the risk factors of all-cause death. Among patients aged ≥ 65 years, PEW was associated with a higher risk of all-cause death (p = 0.043). Total cholesterol < 3.4 mmol/L, albumin < 38 g/L and prealbumin < 280 mg/L were the thresholds for MACE incidence in MHD patients with PEW.

CONCLUSION

Adult MHD patients with PEW had an increased risk of MACE and all-cause mortality. Strategies aimed at optimizing total cholesterol, albumin, and prealbumin levels may improve cardiovascular outcomes in adult MHD patients with PEW.

Association of Ankle-Brachial Index with Quality of Life and Survival Outcomes in Hemodialysis Patients

Background/Objectives: Ankle-brachial index (ABI) is frequently measured in hemodialysis patients due to their high cardiovascular risk, while its potential role as a screening tool for assessing overall physical function and health-related quality of life (QOL) remains unclear. This study aimed to evaluate the association of the ABI with QOL and survival in hemodialysis patients. Methods: This study included 346 hemodialysis patients, categorized into two groups based on their ABI (≤0.9 vs. >0.9). Clinical parameters, QOL (measured using SF-36 and KDQOL questionnaires), and survival outcomes were analyzed. Results: There were 66 (19.1%) patients with an ABI ≤ 0.9 in this study population. Patients with an ABI ≤ 0.9 exhibited significantly older ages, longer dialysis durations, higher prevalence of diabetes mellites and cardiovascular disease, elevated N-terminal pro-brain natriuretic peptide levels, and higher calcitriol use but lower phase angle, skeletal muscle mass index values, health-related QOL domains, and several kidney disease-specific QOL domains compared to those with an ABI > 0.9. Kaplan-Meier analysis revealed significantly higher cumulative mortality in the ABI ≤ 0.9 group (6.6 vs. 2.5 per 100 patient-years, p < 0.001). Conclusions: A low ABI is significantly associated with decreased QOL and higher mortality risk in hemodialysis patients. While traditionally used for PAD screening, the ABI may serve as a practical tool for predicting QOL decline and survival outcomes. Interestingly, the ABI was also linked to muscle attenuation and volume overload. ABI assessment could aid in early risk stratification and guide multidisciplinary interventions, including exercise programs, nutritional support, and cardiovascular risk management, to improve patient care and outcomes.

Dietary nutrient intake and nutritional status in maintenance hemodialysis patients: a multicenter cross-sectional survey

PURPOSE

To investigate the dietary nutrient intake of Maintenance hemodialysis (MHD) patients, identify influencing factors, and explore the correlation between dietary nutrient intake and nutritional and disease control indicators.

METHODS

This was a multicenter cross-sectional study. A dietary survey was conducted using a three-day dietary record method, and a self-designed diet management software was utilized to calculate the daily intake of dietary nutrients. The nutritional status and disease control indicators were assessed using subjective global assessment, handgrip strength, blood test indexes, and dialysis adequacy.

RESULTS

A total of 382 MHD patients were included in this study. Among them, 225 (58.9%) and 233 (61.0%) patients' protein and energy intake did not meet the recommendations outlined in the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative Clinical Practice Guideline for Nutrition in Chronic Kidney Disease (2020 update). The average protein and energy intake for these patients were 0.99 ± 0.32 g/kg/d and 29.06 ± 7.79 kcal/kg/d, respectively. Multiple linear regression analysis showed that comorbidity-diabetes had a negative influence on normalized daily energy intake (nDEI = DEI / ideal body weight) (B = -2.880, p = 0.001) and normalized daily protein intake (nDPI = DPI / ideal body weight) (B = -0.109, p = 0.001). Pearson correlation analysis revealed that dietary DPI (r = -0.109, p < 0.05), DEI (r = -0.226, p < 0.05) and phosphorus (r = -0.195, p < 0.001) intake were statistically correlated to Kt/V; dietary nDPI (r = 0.101, p < 0.05) and sodium (r = -0.144, p < 0.001) intake were statistically correlated to serum urea nitrogen; dietary DPI (r = 0.200, p < 0.001), DEI (r = 0.241, p < 0.001), potassium (r = 0.129, p < 0.05), phosphorus (r = 0.199, p < 0.001), and fiber (r = 0.157, p < 0.001) intake were statistically correlated to serum creatinine; dietary phosphorus (r = 0.117, p < 0.05) and fiber (r = 0.142, p < 0.001) intake were statistically correlated to serum phosphorus; dietary nDPI (r = 0.125, p < 0.05), DPI (r = 0.135, p < 0.05), nDEI (r = 0.116, p < 0.05), DEI (r = 0.125, p < 0.05), potassium (r = 0.148, p < 0.001), and phosphorus (r = 0.156, p < 0.001) intake were statistically correlated to subjective global assessment scores; dietary nDPI (r = 0.215, p < 0.001), DPI (r = 0.341, p < 0.001), nDEI (r = 0.142, p < 0.05), DEI (r = 0.241, p < 0.001), potassium (r = 0.166, p < 0.05), phosphorus (r = 0.258, p < 0.001), and fiber (r = 0.252, p < 0.001) intake were statistically correlated to handgrip strength in males; dietary fiber (r = 0.190, p < 0.05) intake was statistically correlated to handgrip strength in females.

CONCLUSIONS

The dietary nutrient intake of MHD patients need improvement. Inadequate dietary nutrient intake among MHD patients could have a detrimental effect on their blood test indexes and overall nutritional status. It is crucial to address and optimize the dietary intake of nutrients in this patient population to enhance their health outcomes and well-being.

The association between physical activity and cardiovascular events, tumors and all-cause mortality in patients with maintenance hemodialysis with different nutritional status

The current research focuses on the effects of nutritional supplementation and exercise on dialysis patients, but whether physical activity (PA) can reduce the risk of adverse outcomes for patients with different nutritional status is not clear. The maintenance hemodialysis (MHD) patients were recruited from April 2021 to April 2022. The information of PA was obtained from the international physical activity questionnaire (IPAQ). The outcomes were cardiovascular death, myocardial infarction, stroke, heart failure, atrial fibrillation, tumor and all-cause death. We used COX proportional risk model to estimate the association between PA and the outcomes of MHD patients. Patients are classified into two groups based on geriatric nutritional risk index (GNRI) and classified by age, and we used COX proportional risk model to estimate the association of PA and outcomes in subgroups. The isotemporal substitution model (ISM) was used to estimate the effects of replacing light physical activity (LPA) with moderate physical activity (MPA) or vigorous physical activity (VPA) on risk of cardiovascular events, tumors, and all-cause death in different subgroups. The effects of PA on ankle-brachial index (ABI) and body fat content were analyzed in different IPAQ groups. A total of 241 maintenance hemodialysis patients were included, 105 peoples developed cardiovascular death, myocardial infarction, stroke, heart failure, atrial fibrillation, tumor and all-cause death (43.6%). The median follow-up time was 12 months. MPA reduced the risk of outcome in MHD patients or high GNRI patients (40% vs 39%).In MHD patients who was under 65 years with high GNRI, MPA reduced cardiovascular death, myocardial infarction, stroke, heart failure, atrial fibrillation, tumor and all-cause death by 55%.PA reduced the risk of cardiovascular event by 65%, but did not reduce the risk of tumor or all-cause death. Replacing LPA with VPA did not improve clinical outcomes. It actually increases the risk of heart failure 0.4%. MPA reduced the risk of cardiovascular death, myocardial infarction, stroke, heart failure, atrial fibrillation, tumor, all-cause death in MHD patients under 65 years, while VPA had no health benefit.Trial registration: ChiCTR210050998.

Influences of trans-theoretical model-based diet nursing intervention on sarcopenia and quality of life in maintenance hemodialysis patients

OBJECTIVE

to explore the influences of a trans-theoretical model-based diet nursing intervention on sarcopenia and quality of life in maintenance hemodialysis patients.

METHODS

the clinical data of 243 patients with maintenance hemodialysis (MHD) admitted to our hospital from January 2019 to August 2020 were retrospectively analyzed. A 1:1 orientation score matching (PSM) method was adopted, and patients with different intervention methods were matched based on gender, age, education time, dialysis age, body mass index, underlying diseases, annual income, and whether they were malnourished. Finally, 82 cases were included in the control group (routine nursing and dietary guidance) and 80 cases in the intrevention group (dietary nursing intervention based on the trans-theoretical model), respectively.

RESULTS

After PSM, 82 cases in the control group and 80 cases in the intrevention group were included in the study. After the intervention, the incidence of sarcopenia, the extracellular water rate (ECF/TBF) value, and the malnutrition rate of the intrevention group were lower than those of the control group (p < 0.05); the scores of self-care, facing difficulties, potassium intake management, salt intake management, fluid restriction management, the levels of serum albumin, prealbumin and transferrin were all higher than those of the control group (p < 0.05); the SF-36 Concise Health Scale score of the intrevention group was higher than that of the control group (p < 0.05). The 1-year survival rate in the intrevention group (95.00 %) was higher than that in the control group (85.37 %) (p < 0.05).

CONCLUSION

a TTM-based diet nursing intervention can help improve the dietary management behavior of MHD patients, prevent malnutrition, reduce the incidence of sarcopenia, and improve their quality of life and survival rate.

Bioelectrical Impedance Analysis for the Assessment of Body Composition in Sarcopenia and Type 2 Diabetes

Sarcopenia is emerging as a severe complication in type 2 diabetes (T2DM). On the other hand, it has been documented that nutritional aspects, such as insufficient protein or total energy intake, increase sarcopenia risk. The analysis of body composition is a relevant approach to assess nutritional status, and different techniques are available. Among such techniques, bioelectrical impedance analysis (BIA) is particularly interesting, since it is non-invasive, simple, and less expensive than the other techniques. Therefore, we conducted a review study to analyze the studies using BIA for body composition analysis in T2DM patients with sarcopenia or at risk of catching it. Revised studies have provided important information concerning relationships between body composition parameters (mainly muscle mass) and other aspects of T2DM patients’ conditions, including different comorbidities, and information on how to avoid muscle mass deterioration. Such relevant findings suggest that BIA can be considered appropriate for body composition analysis in T2DM complicated by sarcopenia/muscle loss. The wide size of the patients’ cohort in many studies confirms that BIA is convenient for clinical applications. However, studies with a specific focus on the validation of BIA, in the peculiar population of patients with T2DM complicated by sarcopenia, should be considered.