Protein Nutrition and Malnutrition in CKD and ESRD

The value of bioimpedance analysis in the assessment of hydration and nutritional status in children on chronic peritoneal dialysis

Bioimpedance analysis (BIA)-body composition monitoring (BCM) has been used to evaluate the hydration and nutritional status of adults and children on dialysis. However, its clinical application still has challenges, so further exploration is valuable. We used BIA-BCM to evaluate the hydration and nutritional status of children undergoing chronic peritoneal dialysis from 1 July 2021 to 31 December 2022 in the Children's Hospital of Fudan University to explore the clinical value of this method. A total of 84 children on chronic peritoneal dialysis (PD) were included. In the PD group, 16 (19.05%) and 31 (36.90%) had mild and severe overhydration (OH), respectively; 41.27% (26/63) had a low lean tissue index (LTI). In the PD group, patients with relative OH (Re-OH) > 5.6% had significantly higher systolic blood pressure (SBP) and SBP z score (SBPz). Patients with LTI > 12% had significantly higher body mass index (BMI) and BMI z score (BMIz). Canonical correlation analysis indicated a linear relationship (ρ = 0.708) between BIA-BCM hydration and the clinical hydration indicator and a linear relationship (ρ = 0.995) between the BIA-BCM nutritional indicator and the clinical nutritional indicator. A total of 56% of children on chronic peritoneal dialysis had OH, and 41% had a low LTI. In PD patients, SBP and SBPz were correlated with BIA-BCM Re-OH, and BMI and BMIz were correlated with BIA-BCM LTI. BIA-BCM indicators have good clinical value in evaluating hydration and nutrition.

Innovative Treatments to Counteract Endothelial Dysfunction in Chronic Kidney Disease Patients

In chronic kidney disease (CKD) patients, several risk factors contribute to the development of endothelial dysfunction (ED), which can be described as an alteration in the cell structure or in the function of the endothelium. Among the well-known CKD-related risk factors capable of altering the production of endothelium-derived relaxing factors, we include asymmetric dimethylarginine increase, reduced dimethylarginine dimethylamine hydrolase enzyme activity, low-grade chronic systemic inflammation, hyperhomocysteinemia, oxidative stress, insulin resistance, alteration of calcium phosphorus metabolism, and early aging. In this review, we also examined the most important techniques useful for studying ED in humans, which are divided into indirect and direct methods. The direct study of coronary endothelial function is considered the gold standard technique to evaluate if ED is present. In addition to the discussion of the main pharmacological treatments useful to counteract ED in CKD patients (namely sodium-glucose cotransporter 2 inhibitors and mineralocorticoid receptor antagonist), we elucidate innovative non-pharmacological treatments that are successful in accompanying the pharmacological ones. Among them, the most important are the consumption of extra virgin olive oil with high intake of minor polar compounds, adherence to a plant-dominant, low-protein diet (LPD), an adaptive physical activity program and, finally, ketoanalogue administration in combination with the LPD or the very low-protein diet.

Pathogenic spectrum and risk factors of peritoneal dialysis-associated peritonitis: a single-center retrospective study

The present study aimed to explore the pathogenic spectrum and risk factors of peritoneal dialysis-associated peritonitis (Peritoneal dialysis associated peritonitis, PDAP) in Yongzhou, Hunan, China. The clinical and epidemiological data on regular peritoneal dialysis (Peritoneal dialysis, PD) between January 2016 and December 2020 in Yongzhou were collected for retrospective analysis. The related factors of peritonitis were evaluated by single-factor analysis, while risk factors of refractory PDAP were evaluated by multivariate logistic regression analysis.172/331 172 (51.9%) patients developed peritonitis. The risk factors of PDAP in PD patients included high C-reactive protein (C-reactive protein, CRP), low albumin(Albumin, ALB), low hemoglobin (Hemoglobin, Hb), low educational level (junior high school or lower), preference of spicy food, irregular diet, low annual household income, unfavorable fluid exchange conditions, unstable employment (including working as a farmer), and unfavorable humidity conditions (P < 0.05). 63/172 (36.6%) PDAP patients were intractable cases with a pathogenic bacteria positive rate of 74.60% in the peritoneal dialysate cultures, and 109/172 patients were non-intractable cases with a pathogenic bacteria positive rate of 53.21%. Gram-positive bacteria (G+) were detected in most of the dialysate cultures, with Staphylococcus epidermidis (S. epidermidis) as the most common type, while Escherichia coli (E. coli) was the most common Gram-negative bacteria (G-). Gram-positive bacteria were sensitive to vancomycin and linezolid, while G- bacteria were sensitive to imipenem and amikacin. Lifestyle, educational level, and environmental factors are the major contributors to PDAP in PD patients. Fungal and multi-bacterial infections are the major causes of death; PD is stopped for such patients.

Role of Nutrients in Pediatric Non-Dialysis Chronic Kidney Disease: From Pathogenesis to Correct Supplementation

Nutrition management is fundamental for children with chronic kidney disease (CKD). Fluid balance and low-protein and low-sodium diets are the more stressed fields from a nutritional point of view. At the same time, the role of micronutrients is often underestimated. Starting from the causes that could lead to potential micronutrient deficiencies in these patients, this review considers all micronutrients that could be administered in CKD to improve the prognosis of this disease.

Comprehensive geriatric assessment of older patients with renal disease: a cross-sectional survey

Multidimensional health function impairments are common in older patients with chronic kidney disease (CKD). The purpose of this study was to explore whether the risk or severity of geriatric syndrome increased with a decline in renal function. This survey was conducted for CKD patients aged  ≥ 60 years and hospitalized at West China Hospital of Sichuan University (Center of Gerontology and Geriatrics, Nephrology, and Endocrinology) and Chengdu Kangfu Kidney Disease Hospital from September 01, 2013 to June 30, 2014. Patients underwent multidimensional individualized assessments by trained doctors. Logistic regression analysis found that the risk of assisted walking (P = 0.001) and urinary incontinence (P = 0.039) increased with a decline in renal function. Regression analysis revealed that the scores of activities of daily living (P = 0.024), nutritional status (P = 0.000), total social support (P = 0.014), and objective support (P = 0.000) decreased with a decline in renal function.

Cardiovascular Consequences of Uremic Metabolites: an Overview of the Involved Signaling Pathways

The crosstalk of the heart with distant organs such as the lung, liver, gut, and kidney has been intensively approached lately. The kidney is involved in (1) the production of systemic relevant products, such as renin, as part of the most essential vasoregulatory system of the human body, and (2) in the clearance of metabolites with systemic and organ effects. Metabolic residue accumulation during kidney dysfunction is known to determine cardiovascular pathologies such as endothelial activation/dysfunction, atherosclerosis, cardiomyocyte apoptosis, cardiac fibrosis, and vascular and valvular calcification, leading to hypertension, arrhythmias, myocardial infarction, and cardiomyopathies. However, this review offers an overview of the uremic metabolites and details their signaling pathways involved in cardiorenal syndrome and the development of heart failure. A holistic view of the metabolites, but more importantly, an exhaustive crosstalk of their known signaling pathways, is important for depicting new therapeutic strategies in the cardiovascular field.

Association between controlling nutritional status score and chronic kidney disease in diabetic patients: a cross-sectional study based on the National Health and Nutrition Examination Survey

PURPOSE

This study aimed to explore the association between controlling nutritional status (CONUT) score and chronic kidney disease (CKD) in type-2 diabetes mellitus (T2DM) patients.

METHODS

This was a cross-sectional study based on the National Health and Nutrition Examination Survey (NHANES). The data on demographic characteristics, physical examination, lifestyle behaviors, comorbidities, medicine use, laboratory values, and energy were extracted. Nutritional status was assessed using CONUT score, and patients were divided into normal nutrition group and malnutrition group. Association between CONUT score and CKD in T2DM patients was assessed using logistic regression analysis, and odds ratio (OR) and 95% confidence intervals (CIs) were reported. Subgroup analysis based on age, body mass index (BMI), cardiovascular disease (CVD), diabetic retinopathy, and hyperlipidemia was performed.

RESULTS

A total of 4581 patients were finally included for analysis. In the adjusted model, high CONUT score was found to be associated with the high odds of CKD (OR = 1.28, 95% CI 1.05-1.56). Also, high CONUT score was associated with the high odds of CKD in T2DM patients with age ≥ 65 years, with BMI < 25 kg/m2, with BMI ≥ 25 kg/m2, without CVD, without diabetic retinopathy, with hyperlipidemia, or without hyperlipidemia (all P < 0.05).

CONCLUSIONS

Malnutrition was associated with the high odds of CKD in T2DM patients, indicating that actively monitoring the nutritional status is important for the management of CKD in T2DM patients.

Peritoneal dialysis fluids

There have been significant advances in the understanding of peritoneal dialysis (PD) in the last 40 years, and uptake of PD as a modality of kidney replacement therapy is increasing worldwide. PD fluids, therefore, remains the lifeline for patients on this treatment. Developing these fluids to be efficacious in solute clearance and ultrafiltration, with minimal adverse consequences to peritoneal membrane health and systemic effects is a key requirement. Since the first PD fluid produced in 1959, modifications to PD fluids have been made. Nonetheless, the search for that ideal PD fluid remains elusive. Understanding the components of PD fluids is a key aspect of optimizing the successful delivery of PD, allowing for individualized PD prescription. Glucose remains an integral component of PD fluids; however, its deleterious effects continue to be the impetus for the search of an alternative osmotic agent, and icodextrin remains the main alternative. More biocompatible PD fluids have been developed and have shown benefits in preserving residual kidney function. However, high cost and reduced accessibility remain deterrents to its widespread clinical use in many countries. Large-scale clinical trials are necessary and very much awaited to improve the narrow spectrum of PD fluids available for clinical use.

Relationship between immune nutrition index and all-cause and cause-specific mortality in U.S. adults with chronic kidney disease

Objective

The available evidence regarding the association of immune nutrition status with chronic kidney disease (CKD) is limited. Thus, the present study examined whether immunonutrition indices were associated with renal function and mortality among CKD individuals.

Research design and methods

This study enrolled 6,099 U.S. adults with CKD from the NHANES 2005-2018 database. Participants were matched with National Death Index records until 31 December 2019 to determine mortality outcomes. The time-dependent receiver operating characteristic was utilized to identify the most effective index among the prognostic nutritional index (PNI), system inflammation score (SIS), Naples prognostic score (NPS), and controlling nutritional status (CONUT) for predicting mortality. Cox regression models were employed to evaluate the associations of immunonutrition indices with mortality in participants with CKD.

Results

The PNI exhibited the strongest predictive power among the four indices evaluated and the restricted cubic spline analysis revealed a cutoff value of 51 for the PNI in predicting mortality. During a median follow-up of 72 months (39-115 months), a total of 1,762 (weighted 24.26%) CKD participants died from all causes. The Kaplan-Meier curve demonstrated a reduced risk of death for the subjects with a higher PNI compared to those in the lower group. Besides, after adjusting for multiple potential confounders, a higher PNI remained an independent predictor for lower risks of all-cause mortality (HR 0.80, 95%CI: 0.71-0.91, p < 0.001) and cardiovascular disease (CVD) mortality (HR 0.69, 95%CI: 0.55-0.88, p = 0.002) in individuals with CKD.

Conclusion

In CKD, a higher PNI level was significantly associated with lower mortality from all causes and CVD. Thus, the clinical utility of this immunonutrition indicator may facilitate risk stratification and prevent premature death among patients with CKD.

The body mass index change is associated with death or hemodialysis transfer in Japanese patients initiating peritoneal dialysis

A decreased body mass index (BMI) over time is associated with a poor prognosis for patients on hemodialysis. We aimed to examine whether this association also applies to patients with peritoneal dialysis (PD). BMI change was defined as the percentage change in the BMI between the time of PD catheter insertion and six months after its insertion. The association between the BMI change and all-cause mortality or PD discontinuation from six months after PD catheter insertion until October 2021 was investigated. This retrospective cohort study included 122 patients (aged 61.1 ± 12.1 years; 90 males) who underwent PD catheter insertion between January 2008 and March 2020. The median follow-up period was 43.1 (21.2-78.8) months. The median six-month percentage change in the BMI was -2.14 (-5.56-1.84)%, and patients were categorized into tertiles based on their BMI changes. The fully-adjusted Cox regression analysis revealed a significantly higher rate of PD discontinuation or all-cause mortality (hazard ratio (HR): 2.48; 95%; confidence interval (CI): 1.41-4.37) in patients with the lowest tertile (T1, BMI change: < -4.13%) compared to patients with the middle tertile (T2, BMI change: -4.13%-0.67%). The risk was not significantly higher in patients with the highest tertile (T3, BMI change: >0.67%) than those in the T2 group (HR: 1.18; 95% CI: 0.66-2.11). A decreased BMI over time is independently associated with HD transfer or all-cause mortality among patients initiating PD, which highlights the importance of the 6-month BMI change as a novel prognostic marker.

Geriatric Nutritional Risk Index as a Prognostic Factor for Renal Progression in Patients with Type 2 Diabetes Mellitus

The aim of this study was to evaluate whether the geriatric nutritional risk index (GNRI) is associated with chronic kidney disease (CKD) progression in patients with type 2 diabetes mellitus (DM). In total, 1100 patients with type 2 DM with a follow-up duration > 1 year were included in this longitudinal study. The risk of CKD progression was assessed according to GNRI quartiles. Patients in the lowest GNRI quartile exhibited a significantly lower estimated glomerular filtration rate (eGFR), compared with those in quartile four. Moreover, these patients had poorer glycemic control and lower hemoglobin levels, body mass index, and albumin levels. Additionally, they exhibited a greater annual decline in eGFR. Multivariate logistic regression analysis showed that old age (>60 years), baseline eGFR, the presence of proteinuria, the use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and low GNRI were significantly associated with CKD progression. GNRI may serve as a valuable predictive tool for identifying the risk of adverse renal outcomes in patients with type 2 DM. It may potentially serve as a more feasible measure for assessing the nutritional status of these patients, as well as for predicting their clinical outcomes.

Patient and Health Care Professional Perspectives on Addressing Obesity in ESKD

RATIONALE & OBJECTIVE

Obesity is common among patients with end-stage kidney disease (ESKD) and is a pervasive barrier to kidney transplantation. Patient perspectives about barriers to weight loss and patient and health care professionals' viewpoints about optimal obesity management in ESKD are needed.

STUDY DESIGN

Qualitative study using a descriptive phenomenological approach to understand ESKD patients' lived experiences with obesity and weight loss and patients' and health professionals' perceptions about optimal obesity care for ESKD patients.

SETTING & PARTICIPANTS

Between October 2020 and December 2021, we conducted 90-minute semistructured interviews with 40 ESKD patients with obesity (body mass index [BMI] ≥30kg/m2) and 60-minute interviews with 20 ESKD health care professionals.

ANALYTICAL APPROACH

Deductive and inductive thematic analysis of interviews.

RESULTS

Among patients with ESKD, the median age was 55 (IQR, 46-63) years, median BMI was 39.5 (IQR, 35.3-41.6) kg/m2, and median dialysis vintage was 5 (IQR, 3-8) years; 58% were female, and 46% were non-Hispanic White. Among health care professionals, 50% were renal dietitians, 20% were nephrologists, and the remainder were transplant professionals (surgeons, nephrologists, and dietitians). ESKD patients described unique weight loss challenges, including (1) conflicting tenets of "kidney-friendly" versus popular diets, (2) fatigue due to dialysis that affects dietary choices, and (3) perceived pressure and unrealistic expectations from health professionals to lose weight for kidney transplantation. Professionals and patients described a lack of transparent and honest communication about obesity and unclear roles and responsibilities for obesity counseling.

LIMITATIONS

Lack of caregiver perspectives and potential lack of transferability to overall dialysis population given overrepresentation of patients with severe obesity and previous weight loss surgery.

CONCLUSIONS

Obesity interventions for ESKD patients should be tailored to meet the unique challenges reported by patients with ESKD. Clarifying ESKD health professionals' roles and responsibilities for obesity care would help to ensure that patients have consistent and effective support to manage obesity.

PLAIN-LANGUAGE SUMMARY

Adults with coexisting obesity and end-stage kidney disease (ESKD) are often required to lose weight for kidney transplantation. Yet there is little knowledge about barriers to healthy weight loss in this population. In this study, we conducted interviews with 40 ESKD patients with coexisting obesity and 20 ESKD health care professionals to learn about opportunities to improve obesity-related health care in ESKD. Patients reported that fatigue and dialysis affected dietary choices, and fluid and food restrictions hampered weight loss. Professionals described a lack of training, comfort, and time to address obesity. Patients and professionals reported a lack of open communication about obesity management. Improving obesity-related education and clinical communication should be prioritized to improve care for patients with ESKD and obesity.

Dietary acid load in children with chronic kidney disease: its association with nutritional status and health-related quality of life

BACKGROUND

This study aimed to determine the dietary acid load of children with chronic kidney disease (CKD) and to evaluate the relationship between dietary acid load, nutritional status, and health-related quality of life (HRQOL).

METHOD

A total of 67 children aged 3-18 years with a diagnosis of CKD stages II-V were included in the study. Anthropometric measurements (body weight, height, mid-upper arm circumference, waist, and neck circumference) and 3-day food consumption records were taken to evaluate the nutritional status. The net endogenous acid production (NEAP) score was calculated to determine the dietary acid load. "Pediatric Inventory of Quality of Life (PedsQL)" was used to assess the participants' HRQOL.

RESULTS

The mean NEAP was 59.2 ± 18.96 mEq/day. Stunted and malnourished children had significantly higher NEAP than those who were not (p < 0.05). There were no significant differences in terms of HRQOL scores according to NEAP groups. The multivariate logistic regression analysis showed that waist circumference (OR: 0.890, 95% CI: 0.794-0.997), serum albumin (OR: 0.252, 95% CI: 0.068-0.929), and glomerular filtration rate (GFR) (OR: 0.985, 95% CI: 0.970-1.000) were negatively associated with high NEAP.

CONCLUSION

This study shows that a diet shifted in an acidic direction in children with CKD and a higher dietary acid load are associated with lower serum albumin, GFR, and waist circumference, but not HRQOL. These results suggest that dietary acid load might affect nutritional status and CKD progression in children with CKD. Future studies with larger samples are needed to confirm these results and to understand underlying mechanisms. A higher resolution version of the Graphical abstract is available as Supplementary information.

Nutritional Risk of Candidates for Simultaneous Pancreatic-Kidney Transplantation-A Narrative Review

INTRODUCTION

Not much is known about the significance of nutritional status and support in transplant surgery, least of all in simultaneous pancreatic and kidney transplantation. Malnutrition in the context of simultaneous pancreatic-kidney transplantation seems to be complex and a still poorly investigated problem. Since SPKTX is highly qualified and also has a small volume procedure, it is difficult to obtain data from large cohorts of patients. The aim of this article is to gather existing evidence and information about the subject, as well as to elicit some questions and goals for the future.

METHODS

We searched through the Pub-Med database using the keywords "pancreas and kidney transplantation" combined with "nutritional risk", "nutritional status", "malnutrition", "nutritional intervention", and "frailty", finding a total of 4103 matching results. We then narrowed it down to articles written in English with the full text available. We also researched through the references of articles most accurately matching our researched terms.

RESULTS

There are numerous tools that have been investigated for the screening of malnutrition, such as the NRI index, PNI index, NLR, SGA scale, and NRS-2002 scale, each of which proved to be of some use in predicting patient outcomes in different surgical settings. Since all of them differed in components and assessed parameters and, in the absence of more sensitive or infallible indicators, the most reasonable approach seems to evaluate them jointly.

CONCLUSION

It is important to underline the necessity of nutritional screening and the subsequent introduction of adequate therapy while awaiting transplantation in an attempt to improve results. Considering the complexity of surgical procedures and the severity of underlying diseases with their intense metabolic components, the patient's nutritional status seems to significantly influence results. Consequently, nutritional risk assessments should be a part of the routine care of patients qualified for transplantation.

Autophagy Activation in Peripheral Blood Mononuclear Cells of Peritoneal Dialysis Patients

Introduction

The complete systemic deregulated biological network in patients on peritoneal dialysis (PD) is still only partially defined. High-throughput/omics techniques may offer the possibility to analyze the main biological fingerprints associated with this clinical condition.

Methods

We applied an innovative bioinformatic analysis of gene expression microarray data (mainly based on support vector machine (SVM) learning) to compare the transcriptomic profile of peripheral blood mononuclear cells (PBMCs) of healthy subjects (HS), chronic kidney disease (CKD) patients, and patients on PD divided into a microarray group (5 HS, 9 CKD, and 10 PD) and a validation group (10 HS, 15 CKD, and 15 PD). Classical well-standardized biomolecular approaches (western blotting and flow cytometry) were used to validate the transcriptomic results.

Results

Bioinformatics revealed a distinctive PBMC transcriptomic profiling for PD versus CKD and HS (n = 419 genes). Transcripts encoding for key elements of the autophagic pathway were significantly upregulated in PD, and the autophagy related 5 (ATG5) reached the top level of discrimination [-Log10 P-value = 11.3, variable importance in projection (VIP) score = 4.8, SVM rank:1]. Protein levels of ATG5 and microtubule associated protein 1 light chain 3 beta (LC3B), an important constituent of the autophagosome, validated microarray results. In addition, the incubation of PBMCs of HS with serum of patients on PD upregulated both proteins. Autophagy in PBMCs from patients on PD was attenuated by N-acetyl-cysteine or Resatorvid treatment.

Conclusions

Our data demonstrated, for the first time, that the autophagy pathway is activated in immune-cells of patients on PD, and this may represent a novel therapeutic target.

Glycemic index of a nutritional supplement designed for people with chronic kidney disease

The study was carried out to measure the glycemic index (GI) of an oral food supplement for people with CKD as well as on patients on maintenance dialysis. The study was conducted as per international protocols for testing GI, was approved by the local institutional ethics committee, and was registered with the Clinical Trial Registry of India (CTRI). This was a crossover randomized controlled study which enrolled 15 participants between the ages of 18 and 45 years. The participants were randomly allotted to one group that consumed either the reference food (27.5 g of glucose monohydrate) or 118 g of the nutritional supplement which contained 25 g of available carbohydrates. Fasting capillary blood samples as well as blood samples at different time intervals as per the GI protocol, after consumption of either the supplement or the reference food were taken from the participants. Each testing day was separated by a 3-day washout period. GI was calculated from the incremental area under the blood glucose response elicited by the nutritional supplement as a percentage of the response after the consumption of 25 g of glucose (27.5 g of glucose monohydrate) by the same participant using a standard formula. The GI of the nutritional supplement was calculated to be 10.3 ± 2.0 which is considered to be low as per international GI testing standards. The product was created to supplement the diet of people with CKD at different stages and to help prevent the progression from CKD to ESRD as well as the risk for CVD. This product was found to have a low GI which is desirable for people with CKD as well as diabetics in general who are at risk for developing CKD.

Associations between insulin-like growth factor-1 standard deviation score and overall nutritional parameters in patients with maintenance hemodialysis: a cross-sectional study

BACKGROUND

This study investigated the association between insulin-like growth factor-1 and nutritional status indicators in patients undergoing maintenance hemodialysis (MHD).

METHODS

Patients undergoing MHD for > 3 months were included in this single-center cross-sectional study in March 2021. Clinical, demographic, and body mass data and blood samples were collected before the hemodialysis sessions. Serum insulin-like growth factor-1 (IGF-1) levels were measured using a radioimmunoassay, and serum IGF-1 standard deviation score (SDS) was calculated for MHD patients according to age and sex. The nutritional status of patients was assessed using serum albumin, serum prealbumin, handgrip strength, pinching strength, upper arm muscle circumference, lean body mass, phase angle, seven-point subjective global assessment (SGA) score, and geriatric nutritional risk index (GNRI). The patients were divided into groups according to tertiles of serum IGF-1 SDS levels. Spearman correlation analyses and univariate and multivariate binary logistic regression analyses were used to determine the association between serum IGF-1 SDS and nutritional status parameters.

RESULTS

A total of 155 MHD patients (male: female = 90:65) were enrolled in the study, with a median dialysis vintage of 28.0 (11.0, 55.0) months, and an average age of 66 (65.5 ± 13.0) years. The median of IGF-1 SDS was - 0.1 (- 0.6 to 0.6). Compared to patients with higher IGF-1 SDSs, patients with lower IGF-1 SDSs had lower levels of serum ceruloplasmin (341.0 [287.5, 416.0] vs 395.0 [327.0, 451.0] vs 409.0 [349.5, 507.5], p = 0.002), serum albumin (34.7 ± 3.0 vs 37.0 ± 3.1 vs 37.8 ± 2.6, p < 0.001), serum prealbumin (270.3 [233.7, 327.8] vs 326.0 [279.3, 355.6] vs 363.0 [324.2, 398.2], p < 0.001), handgrip strength (13.8 [10.0, 20.7] vs 17.7 [10.7, 22.5] vs 23.3 [16.6, 27.8], p < 0.001), pinch strength (4.6 [3.9, 6.0] vs 4.9 (3.9, 6.9) vs 6.5 [4.7, 8.7], p = 0.002), phase angle (3.3 [3.0, 3.8] vs 3.9 [3.4, 4.7] vs 4.3 [3.6, 5.2, p < 0.001), modified Creatinine Index (83.1 ± 19.7 vs 93.1 ± 23.4 vs 113.9 ± 24.3, p < 0.001), intracellular water (14.5 ± 4.4 vs 16.1 ± 4.9 vs 16.9 ± 4.4, p = 0.031), higher extracellular water (26.9 ± 5.8 vs 25.7 ± 5.5 vs 25.1 ± 3.1, p = 0.042), and higher malnutrition risk as defined by GNRI (49.0% vs 15.7% vs 11.5%, p < 0.001) and SGA (53.9% vs 23.5% vs 7.7%, p < 0.001).

CONCLUSIONS

Lower IGF-1 SDSs are independently associated with higher malnutrition risk in patients with MHD.

Could cooling dialysate improve inflammatory and nutritional status of hemodialysis patients?

BACKGROUND

It has been shown that dialysate cooling (lowering the dialysate temperature to 0.5 °C below central body temperature) reduces the incidence of intradialytic hypotension. Other influences on hemodialysis patients, however, have not been adequately investigated. The purpose of this study was to determine the impact of individualized dialysate cooling on nutritional and inflammatory parameters in chronic hemodialysis (HD) patients.

METHODS

Seventy HD patients were separated into two groups: group A: (control group) standard dialysate temperature was 37 °C, and group B: (intervention group) dialysate temperature was 0.5 °C below core body temperature. In addition to routine laboratory tests, blood pressure, anthropometric measurements, inflammatory markers, and the malnutrition inflammation score (MIS) were calculated.

RESULTS

After six months of dialysate cooling, intradialytic hypotension episodes were much less prevalent in the intervention group (p = 0.001). Serum ferritin, transferrin saturation (TSAT), high sensitive C-reactive protein (HS-CRP), and Interleukin-6 (IL-6) reduced following dialysate cooling, whereas serum albumin rose. In the control group, IL-6 dropped but serum ferritin, TSAT, albumin, and HS-CRP rose. In both groups, hemoglobin levels dropped, and erythrocyte sedimentation rate (ESR) rose, both groups' midarm muscle circumference and MIS worsened.

CONCLUSION

Cold dialysate decreased intradialytic hypotension with no significant improvement of the nutritional and inflammatory surrogates. However, more studies including larger number of patients with longer duration of follow up are required to adequately assess its effect on inflammation and nutrition in chronic hemodialysis patients.

A fuzzy based dietary clinical decision support system for patients with multiple chronic conditions (MCCs)

Due to the multifaceted nature of Multiple Chronic Conditions (MCCs), setting a diet for these patients is complicated and time-consuming. In this study, a clinical decision support system based on fuzzy logic was modeled and evaluated to aid dietitians in adjusting the diet for patients with MCCs. Mamdani fuzzy logic with 1144 rules was applied to design the model for MCCs patients over 18 years who suffer from one or more chronic diseases, including obesity, diabetes, hypertension, hyperlipidemia, and kidney disease. One hundred nutrition records from three nutrition clinics were employed to measure the system's performance. The findings showed that the diet set by nutritionists had no statistically significant difference from the diet recommended by the fuzzy model (p > 0.05), and there was a strong correlation close to one between them. In addition, the results indicated a suitable model performance with an accuracy of about 97%. This system could adjust the diet with high accuracy as well as humans. In addition, it could increase dietitians' confidence, precision, and speed in setting the diet for MCCs patients.

Prevalence and prognostic value of malnutrition in patients with acute coronary syndrome and chronic kidney disease

Background

Malnutrition is a rising global health issue associated with unfavorable outcomes of a variety of disorders. Currently, the prevalence and prognostic significance of malnutrition to patients with acute coronary syndrome (ACS) and chronic kidney disease (CKD) remained largely unclear.

Methods

A total of 705 patients diagnosed with ACS and CKD in the First Affiliated Hospital of Wenzhou Medical University between 2013 and 2021 were included in this retrospective cohort study. Malnutrition was assessed by the Controlling Nutritional Status (CONUT), the Geriatric Nutritional Risk Index (GNRI), and the Prognostic Nutritional Index (PNI), respectively. The relationships between malnutrition and all-cause mortality and major cardiovascular events (MACEs) were analyzed.

Results

During a median follow-up of 31 months, 153 (21.7%) patients died, and 165 (23.4%) had MACEs. The prevalence of malnutrition was 29.8, 80.6, and 89.8% for the PNI, CONUT, and GNRI, respectively. All the malnutrition indexes were correlated with each other (r = 0.77 between GNRI and PNI, r = -0.72 between GNRI and CONUT, and r = -0.88 between PNI and CONUT, all p < 0.001). Compared with normal nutrition, malnutrition was independently associated with an increased risk for all-cause mortality (adjusted hazard ratio for moderate and severe degrees of malnutrition, respectively: 7.23 [95% confidence interval (CI): 2.69 to 19.49] and 17.56 [95% CI: 5.61 to 55.09] for the CONUT score, 2.18 [95% CI: 0.93 to 5.13] and 3.16 [95% CI: 1.28 to 7.79] for the GNRI, and 2.52 [95% CI: 1.62 to 3.94] and 3.46 [95% CI: 2.28 to 5.25] for the PNI score. p values were lower than 0.05 for all nutritional indexes, except for moderate GNRI p value = 0.075). As for MACEs, similar results were observed in the CONUT and PNI. All the risk scores could improve the predictive ability of the Global Registry of Acute Coronary Events (GRACE) risk score for both all-cause mortality and MACEs.

Conclusion

Malnutrition was common in patients with ACS and CKD regardless of the screening tools used, and was independently associated with all-cause mortality and MACEs. Malnutrition scores could facilitate risk stratification and prognosis assessment.

Dialysis in Pregnancy: An Update Review

Chronic kidney disease and end-stage kidney disease (ESKD) are important public health problems with increased rates of morbidity, mortality, and social costs. Pregnancy is rare in patients with ESKD, with reduced fertility rates in women undergoing dialysis. Although current advances have led to an increase in live births in pregnant dialysis patients, this modality still has an increased risk of multiple adverse events in pregnant women. Despite these existing risks, large-scale studies investigating the management of pregnant women on dialysis are lacking, resulting in the absence of consensus guidelines for this patient group. In this review, we aimed to present the effects of dialysis during pregnancy. We first discuss pregnancy outcomes in dialysis patients and the development of acute kidney injury during pregnancy. Then, we discuss our recommendations for the management of pregnant dialysis patients, including the maintenance of pre-dialysis blood urea nitrogen levels, the ideal frequency and duration of hemodialysis sessions, as well as the modality of renal replacement therapies, the difficulty of maintaining peritoneal dialysis in the third trimester of pregnancy, and optimization of prepregnancy modifiable risk factors. Finally, we present our recommendations for future studies investigating dialysis among pregnant patients.

A novel model of adenine-induced chronic kidney disease-associated gastrointestinal dysfunction in mice: The gut-kidney axis

Although constipation is a common complication of chronic kidney disease (CKD), there is no animal model that can be used to study the association between renal impairment and gastrointestinal function without interfering with the gastrointestinal tract of the model. Therefore, we determined whether adenine could induce CKD in association with gastrointestinal dysfunction. Six-week-old ICR mice were intraperitoneally injected with saline, 25, 50, or 75 mg adenine/kg body weight for 21 days. Blood urea nitrogen (BUN), plasma creatinine, and renal histopathology were evaluated. Defecation status was evaluated from defecation frequency and fecal water content. Colonic smooth muscle contraction was measured by the organ bath technique, and transepithelial electrical resistance (TEER) was measured using an Ussing chamber. In the 50 mg/kg treatment group, BUN and creatinine were significantly increased compared with control, and inflammatory cell infiltration, glomerular necrosis, tubular dilatation, and interstitial fibrosis were observed in renal tissues. Mice in this group also showed a significant decrease in defecation frequency, fecal water content, colonic motility index, and TEER. Overall, 50 mg/kg of adenine was the best dose to induce CKD with associated constipation and intestinal barrier impairment. Therefore, this adenine administration model can be recommended for CKD-associated gastrointestinal dysfunction research.

A Perfluorocarbon-Coated ZrP Cation Exchanger with Excellent Ammonium Selectivity and Chemical Stability: An Oral Sorbent for End-Stage Kidney Disease (ESKD)

An oral sorbent to remove NH₄⁺ within the small intestine of end-stage kidney disease (ESKD) patients could reduce blood urea levels and diminish their dialysis treatment burden. But current sorbent materials like amorphous zirconium phosphate particles Zr(HPO₄)₂·H₂O (ZrP) lack the selectivity to remove NH₄⁺ in water solution with other competing ions. Our previous work found that a gas-permeable, hydrophobic polydimethylsiloxane (PDMS) coating on ZrP improved the material's selectivity for NH₄⁺. However, a competing ion Ca²⁺ was still removed by PDMS-coated ZrP sorbent, and the permeability of the PDMS coating to Ca²⁺ was increased after low-pH stomach-like condition exposure. An alternative hydrophobic and gas permeable coating has been investigated─perfluorooctyltriethoxysilane (FOTS). The coating was attached in place of PDMS to a tetraethyl orthosilicate-coated ZrP surface. Surface atomic composition analysis and scanning electron microscopy observation verified the successful application of the FOTS coating. Water contact angle analysis validated the FOTS coating was hydrophobic (145.0 ± 3.2°). In vitro competing ion studies indicated the FOTS coating attached to ZrP increased NH₄⁺ removal by 53% versus uncoated ZrP. FOTS offers complete selectivity for NH₄⁺ over Ca²⁺ with similar NH₄⁺ capacity as the previous PDMS coating. Moreover, FOTS-coated ZrP maintained NH₄⁺ removal capacity and selectivity after the acid exposure study, indicating excellent acid resistance while NH₄⁺ selectivity of ZrP-PDMS decreased by 72%. The results suggested that FOTS-coated ZrP is promising as an oral sorbent for ESKD patients.

Protein energy wasting in pre-dialysis chronic kidney disease patients in Benin City, Nigeria: A cross-sectional study

INTRODUCTION

Protein energy wasting (PEW) is common among chronic kidney disease (CKD) patients, especially those with advanced stage. It worsens frailty, sarcopenia and debility in CKD patients. Despite the importance of PEW, it is not routinely assessed during management of CKD patients in Nigeria. The prevalence of PEW and its associated factors were determined in pre-dialysis CKD patients.

METHODS

This was a cross-sectional study that involved 250 pre-dialysis CKD patients and 125 age- and sex- matched healthy controls. Body mass index (BMI), subjective global assessment (SGA) scores and serum albumin levels were used in PEW assessment. The factors associated with PEW were identified. P-value of < 0.05 was taken as significant.

RESULTS

The mean age of CKD and control group were 52.3±16.0 years and 50.5±16.0 years, respectively. The prevalence of low BMI, hypoalbuminaemia and malnutrition defined by SGA in pre-dialysis CKD patients were 42.4%, 62.0% and 74.8%, respectively. The overall prevalence of PEW among the pre-dialysis CKD patients was 33.3%. On multiple logistic regression, the factors associated with PEW in CKD were being middle aged (adjusted odds ratio: 12.50; confidence interval: 3.42-45.00; p <0.001), depression (adjusted odds ratio: 2.34; confidence interval: 1.02-5.40; p = 0.046) and CKD stage 5 (adjusted odds ratio: 12.83; confidence interval: 3.53-46.60; p <0.001).

CONCLUSION

PEW is common in pre-dialysis CKD patients and it was associated with middle age, depression and advanced CKD. Early intervention aimed at addressing depression in early stages of CKD may prevent PEW and improve overall outcome in CKD patients.

Associated factors of cardiac valve calcification and its prognostic effects among patients with chronic kidney disease: a systematic review and meta-analysis

Background

Cardiac valve calcification (CVC) is highly prevalent and a risk factor for adverse outcomes in patients with chronic kidney disease (CKD). This meta-analysis aimed to investigate the risk factors for CVC and association between CVC and mortality in CKD patients.

Method

Three electronic databases including PubMed, Embase, and Web of Science were searched for relevant studies up to November 2022. Hazard ratios (HR), odds ratios (OR), and 95% confidence intervals (CI) were pooled using random-effect meta-analyses.

Results

22 studies were included in the meta-analysis. Pooled analyses showed that CKD patients with CVC were relatively older, had a higher body mass index, left atrial dimension, C-reaction protein level, and a declined ejection fraction. Calcium and phosphate metabolism dysfunction, diabetes, coronary heart disease, and duration of dialysis were all predictors for CVC in CKD patients. The presence of CVC (both aortic valve and mitral valve) increased the risk of all-cause and cardiovascular mortality in CKD patients. However, the prognostic value of CVC for mortality was not significant anymore in patients with peritoneal dialysis.

Conclusion

CKD patients with CVC had a greater risk of all-cause and cardiovascular mortality. Multiple associated factors for development of CVC in CKD patients should be taken into consideration by healthcare professionals to improve prognosis.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/, identifier [CRD42022364970].

Metabolomics profiling distinctively identified end-stage renal disease patients from chronic kidney disease patients

Chronic kidney disease (CKD) is a serious public health problem characterized by progressive kidney function loss leading to end-stage renal disease (ESRD) that demands dialysis or kidney transplantation. Early detection can prevent or delay progression to ESRD. The study aimed to gain new insights into the perturbed biochemical reactions and to identify novel distinct biomarkers between ESRD and CKD. Serum samples of 32 patients with ESRD (n = 13) and CKD (n = 19) were analyzed using chemical isotope labeling liquid chromatography-mass spectrometry metabolomics approach. A total of 193 metabolites were significantly altered in ESRD compared to CKD and were mainly involved in aminoacyl-tRNA biosynthesis, branched-chain amino acid (BCAA) biosynthesis, taurine metabolism, and tryptophan metabolism. Three kynurenine derivatives, namely, 2-aminobenzoic acid, xanthurenic acid, and hydroxypicolinic acid were upregulated in ESRD compared to CKD due to the significant decrease in glomerular filtration rate with the progression of CKD to ESRD. N-Hydroxy-isoleucine, 2-aminobenzoic acid, and picolinic acid yielded AUC > 0.99 when analyzed using Receiver Operating Characteristic (ROC) analysis. Our findings suggest that inhibiting the kynurenine pathway might be a promising target to delay CKD progression and that metabolites with high discriminative ability might serve as potential prognostic biomarkers to monitor the progression of CKD to ESRD or used in combination with current markers to indicate the status of kidney damage better.

Effect of oral nutritional supplementation combined with impedance vectors for dry weight adjustment on the nutritional status, hydration status and quality of life in patients on chronic hemodialysis: A pilot study

BACKGROUND & AIMS

Protein energy wasting frequently affect hemodialysis patients and contribute to the development of overhydration. The objective of this study was to assess the effect of oral nutritional supplementation (ONS) combined with bioelectrical vector analysis (BIVA) on the nutritional and hydration status and the quality of life (QoL) in hemodialysis (HD) patients.

METHODS

Thirty-two chronic HD patients were included in a 6-month randomized pilot study. Patients in SUPL group received a simultaneous intervention consisting of a personalized diet, 245 mL/d ONS and dry weight adjustment through BIVA. Patients in CON group received a personalized diet and dry weight adjustment by BIVA. Anthropometrical, biochemical, dietary, QoL, handgrip strength (HGS) and bioimpedance measurements were performed. Malnutrition Inflammation Score (MIS) was applied.

RESULTS

At the end of the intervention, moderate undernutrition decreased by 43.8% in SUPL group while in CON group, severe undernutrition increased by 13% (p < 0.04 between groups). In the adjusted covariance analysis, SUPL compared to CON group, increased HGS (Δ 2.8 Kg vs Δ -1.8 Kg, p = 0.003), serum albumin (Δ 0.29 g/dL vs Δ -0.03 g/dL, p = 0.04) and serum transferrin (Δ 4.7 mg/dL vs Δ -0.7 mg/dL, p = 0.0007). The increase in QoL was significantly higher in SUPL group. Dry weight was achieved in 100% of patients in SUPL and 95% in CON group.

CONCLUSIONS

ONS combined with BIVA for dry weight adjustment, improved nutritional status, QoL and achieved dry weight in HD patients.

Frailty and Age-Associated Assessments Associated with Chronic Kidney Disease and Transplantation Outcomes

Background. Frailty is often defined as a decrease in physiological reserve and has been shown to be correlated with adverse health outcomes and mortality in the general population. This condition is highly prevalent in the chronic kidney disease (CKD) patient population as well as in kidney transplant (KT) recipients. Other age-associated changes include sarcopenia, nutrition, cognition, and depression. In assessing the contributions of these components to patient outcomes and their prevalence in the CKD and KT patient population, it can be determined how such variables may be associated with frailty and the extent to which they may impact the adverse outcomes an individual may experience. Objectives. We sought to perform a systematic literature review to review published data on frailty and associated age-associated syndromes in CKD and KT patients. Results. Over 80 references pertinent to frailty, sarcopenia, nutrition, cognition, or depression in patients with CKD or KT were identified. Systematic review was performed to evaluate the data supporting the use of the following approaches: Fried Frailty, Short Physical Performance Battery, Frailty Index, Sarcopenia Index, CT scan quantification of muscle mass, health-related quality of life, and assessment tools for nutrition, cognition, and depression. Conclusion. This report represents a comprehensive review of previously published research articles on this topic. The intersectionality between all these components in contributing to the patient’s clinical status suggests a need for a multifaceted approach to developing comprehensive care and treatment for the CKD and KT population to improve outcomes before and after transplantation.

A Rare Case of Postoperative Encephalopathy in Twin

The clinical picture of encephalopathy invites a broad differential with multiple etiologies. It is with judicious history, hospital course, lab testing, and imaging that the ultimate cause is identified. We present a unique case of identical twins who share a similar clinical presentation of postoperative encephalopathy. The striking similarities in both twins suggest a genetic component requiring further research to identify patients who are genetically predisposed.

Nitric Oxide Levels as a Marker of Intradialytic Hypertension in End-Stage Renal Disease Patients

Intradialytic hypertension (IDH) is an important emerging complication in hemodialysis patients. No study has examined the diagnostic markers of various risk factors for the occurrence of IDH in chronic hemodialysis patients. Therefore, our study aimed to assess the use of nitric oxide (NO) as a marker of IDH among end-stage renal disease patients. The patients were divided into two groups: Group I (40 patients) with IDH and Group II (40 patients) without IDH. For all participants, a full medical history was taken, followed by laboratory examinations to measure the level of NO and a clinical examination. The dose of erythropoietin per week, the level of intact parathyroid hormone, and platelet count were significantly higher in Group I than in Group II, whereas the mean level of NO (2.10 ± 1.23 pmol/L) was highly significantly lower in patients with IDH (P < 0.001). Multivariate analysis showed that hypertension (odds ratio: 1.824, 95% confidence interval: 1.273-2.982) and the level of NO (odds ratio: 1.68, 95% confidence interval: 1.13-2.97) were independent risk factors for IDH. The receiver operating characteristic curve showed that the cutoff point of NO was 2.52 μmol/L to differentiate between cases with and without IDH (area under the curve = 0.844). Our findings support previous research regarding the involvement of endothelial dysfunction and a higher sodium level in the pathogenesis of IDH. We also found that the NO level had a good diagnostic value for the occurrence of IDH at a cutoff of 2.52 μmol/L.

Association between Cognitive Impairment and Malnutrition in Hemodialysis Patients: Two Sides of the Same Coin

Cognitive impairment and malnutrition are prevalent in patients on hemodialysis (HD), and they negatively affect the outcomes of HD patients. Evidence suggests that cognitive impairment and malnutrition may be associated, but clinical studies to assess this association in HD patients are lacking. The aim of this study was to evaluate the association between cognitive impairment evaluated by the Montreal Cognitive Assessment (MoCA) score and nutritional status evaluated by the malnutrition inflammation score (MIS) in HD patients. We enrolled 84 HD patients (44 males and 40 females; age: 75.8 years (63.5-82.7); HD vintage: 46.0 months (22.1-66.9)). The MISs identified 34 patients (40%) as malnourished; the MoCa scores identified 67 patients (80%) with mild cognitive impairment (MCI). Malnourished patients had a higher prevalence of MCI compared to well-nourished patients (85% vs. 70%; p = 0.014). MoCa score and MIS were negatively correlated (rho:-0.317; p < 0.01). Our data showed a high prevalence of MCI and malnutrition in HD patients. Low MoCA scores characterized patients with high MISs, and malnutrition was a risk factor for MCI. In conclusion, it is plausible that MCI and malnutrition are linked by common sociodemographic, clinical, and biochemical risk factors rather than by a pathophysiological mechanism.

3-Carboxy-4-methyl-5-propyl-2-furanpropanoic acid (CMPF) induces cell death through ferroptosis and acts as a trigger of apoptosis in kidney cells

Ferroptosis is a cell death mechanism characterized by intracellular iron accumulation and lipid peroxidation. Effects of uremic toxins on ferroptosis in the kidney are not well understood. We investigated whether protein-bound uremic toxins induce ferroptosis, resulting in cell death, using the bilateral ureteral obstruction (BUO) mouse model and kidney cells. In BUO mice, we observed elevated lipid peroxidation, increased iron concentration, and decreased glutathione peroxidase 4 (GPX4) expression. Levels of transferrin receptor 1 and system Xc-, which are involved in iron transport and storage, were also elevated, while those of ferritin heavy and light chains (FHC and FLC) were reduced. Treatment of HK-2 and NRK49F kidney cells with CMPF decreased GSH levels and the expression of GPX4, FHC, and FLC, and increased levels of ROS, lipid peroxidation, and intracellular iron concentration. CMPF-induced and erastin-induced decreases in GPX4 levels and increases in Bax and cytochrome C levels were counteracted by ferrostatin-1 pretreatment. However, GPX4 mRNA levels, protein abundance, or promoter activity were not restored by Z-VAD-FMK, a multi-caspase inhibitor. These results suggest that ferroptosis induced by CMPF treatment induces apoptosis, and inhibition of ferroptosis reduces apoptosis, suggesting that ferroptosis plays a role in triggering cell death by apoptosis.

Prognostic nutritional index as a risk factor for diabetic kidney disease and mortality in patients with type 2 diabetes mellitus

AIMS

Microinflammation and malnutrition are common in individuals with type 2 diabetes mellitus (T2DM). We aimed to validate whether prognostic nutritional index (PNI) may increase the risk of diabetic kidney disease (DKD) and all-cause mortality in T2DM patients.

METHODS

This retrospective cohort study was based on the National Health and Nutrition Examination Survey (NHANES) and National Death Index (NDI) 2013-2018 database. A total of 14,349 eligible subjects were included, and 2720 of them were with T2DM. PNI was assessed by the 5 × lymphocyte count (10⁹/L) + serum albumin (g/L). The Logistic and Cox regression analyses were conducted to investigate the risk factors of DKD and mortality in T2DM patients.

RESULTS

For 14,349 participants represented 224.7 million noninstitutionalized residents of the United State, the average PNI was 53.72 ± 0.12, and the prevalence of T2DM was 14.89%. T2DM patients had a lower level of PNI and dietary protein intake, a higher risk of mortality, kidney injury, anemia, arterial hypertension and hyperuricemia, compared with non-T2DM subjects. DKD occurred in 35.06% of diabetic participants and a higher PNI was independently related with a lower risk of DKD (OR 0.64, 95% CI 0.459-0.892, p = 0.01) in T2DM after multivariate adjustment. During a median follow-up of 46 person-months (29-66 months), a total of 233 T2DM individuals died from all causes (mortality rate = 8.17%). Subjects with T2DM who had a higher PNI showed a lower risk of all-cause mortality (HR 0.60, 95% CI 0.37-0.97, p = 0.036).

CONCLUSIONS

PNI, as a marker of immunonutrition, correlated with the incidence of DKD, and was an independent predictor for all-cause mortality in participants with T2DM. Thus, PNI may conduce to the risk stratification and timely intervention of T2DM patients.

Relationship between gut microbiota and nutritional status in patients on peritoneal dialysis

Malnutrition is a common complication in the dialysis population, both hemodialysis and peritoneal dialysis (PD). We report our exploratory study on the characteristics of intestinal microbiota and nutritional status in PD patients. The nutritional status of our PD patients were evaluated, and their feces were collected for 16S rRNA gene V3-V4 regions amplification and high-throughput sequencing. The characteristics and differences of microbiota between the well-nourished (W) and malnourished (M) groups were compared. We studied the genera and the operational taxonomic units (OTUs) within the genus of our patients, initially comparing the malnourished and the well- nourished groups and later on reanalyzing the whole group using these OTUs. At the OTU level, 6 bacteria were significantly correlated with the serum albumin level. The abundances of 2 OTUs (OTU208 Lachnospiraceae_incertae_sedi and OTU4 Bacteroides) were more in W group. Meanwhile, 4 OTUs (OTU225 Akkermansia, OTU87 Megasphaera, OTU31 Peptostreptococcaceae_incertae_sedi and OTU168 Clostridium_sensu_strictu) displayed higher abundance among individuals in M group. Notably, the OTU168 Clostridium_sensu_stricto was the only bacteria that significantly correlated with serum albumin (r = - 0.356, P = 0.05), pre-albumin (r = - 0.399, P = 0.02), and SGA (r = 0.458, P = 0.01). The higher the OTU168 Clostridium_sensu_strictu, the lower serum albumin and pre-albumin and a higher score of SGA signifying a worse nutritional status. Our preliminary findings suggested a relationship between the nutrition status and microbiota in PD patients. Our results provide a basis for further exploration of the interactions between malnutrition and intestinal flora in PD patients with potential interventions using probiotics and prebiotics.

Effects of propolis on inflammation markers in patients undergoing hemodialysis: A randomized, double-blind controlled clinical trial

BACKGROUND AND AIMS

Several studies have been performed in vitro and in animals showing that propolis (a resin made by bees) has excellent anti-inflammatory properties, but no study has been performed in patients with chronic kidney disease (CKD) on hemodialysis (HD). The present study aimed to evaluate the effects of propolis supplementation on inflammatory markers in patients with CKD on HD.

METHODS

This is a longitudinal, double-blind, placebo-controlled trial with patients randomized into two groups: propolis (4 capsules of 100 mg/day containing concentrated and standardized dry EPP-AF® green propolis extract) or placebo (4 capsules of 100 mg/day containing microcrystalline cellulose, magnesium stearate and colloidal silicon dioxide) for two months. Routine parameters were analyzed using commercial kits. The plasma levels of inflammatory cytokines were evaluated by flow luminometry.

RESULTS

Forty-one patients completed the follow-up, 21 patients in the propolis group (45 ± 12 years, 13 women, BMI, 22.8 ± 3.7 kg/m²) and 20 in the placebo group (45.5 ± 14 years, 13 women, BMI, 24.8 ± 6.8 kg/m²). The obtained data revealed that the intervention with propolis significantly reduced the serum levels of tumour necrosis factor α (TNFα) (p = 0.009) as well as had the tendency to reduce the levels of macrophage inflammatory protein-1β (MIP-1β) (p = 0.07). There were no significant differences in the placebo group.

CONCLUSION

Short-term EPP-AF® propolis dry extract 400 mg/day supplementation seems to mitigate inflammation, reducing the plasma levels of TNFα and MIP-1β in patients with CKD on HD. This study was registered at clinicaltrials.gov (NCT04411758).

Analysis of malnutrition factors for inpatients with chronic kidney disease

Objective

Malnutrition is a common complication of Chronic Kidney Disease (CKD), and it is the risk factor of CKD prognosis. This study aim to evaluate the nutritional status of inpatients with CKD by using the Subjective Global Assessment (SGA), and to analyze the related factors of malnutrition; and to provide effective reference for early detection of malnutrition status in patients with CKD and timely nutrition intervention.

Methods

A total of 426 patients (238 male patients, 188 female patients) aged 62.62 ± 14.61 and 61.14 ± 14.82, respectively admitted to the Nephrology Department of Wannan Medical College from February 2020 to December 2020 were selected and included in to this study by convenience sampling. 426 patients with CKD were evaluated by SGA. Human body weight, hemoglobin (Hb), total protein (TP), albumin (ALB), pre-albumin (PA), qualitative analysis of urinary protein and other laboratory indexes were collected and measured. The correlation between malnutrition and age, education, gender, diet, CKD stage and other factors was analyzed by spearman correlation analysis.

Results

The incidence of malnutrition was 85.7% among 426 patients with CKD. Gender, age, education level, CKD stage, diabetes mellitus, weight loss and reduced food intake were related to SGA nutritional assessment (P < 0.05). The expression levels of ALB, PA and Hb in the malnutrition group were significantly lower than those in the normal group (P < 0.05). The degree of malnutrition in CKD patients was significant negatively correlated with the expression levels of ALB (r = -0.188), PA (r = -0.262) and Hb (r = -0.176) (P < 0.05). The multivariate Logistic regression analysis model showed that female (OR = 2.155), ≥60 years old (OR = 7.671), weight loss (OR = 10.691), reduced food intake (OR = 28.953), moderate and severe serum ALB expression (OR = 3.391 and 8.326) were risk factors for malnutrition in patients with CKD (P < 0.05). Malnutrition was correlated with the results of qualitative examination of urinary protein (r = 0.268, P < 0.05).

Conclusion

Gender, age, weight loss, reduced food intake, serum ALB expression were independently associated with malnutrition in patients with chronic kidney disease, Hence, the medical staff should take timely and effective nutrition intervention for the patients with malnutrition, delay the renal function damage of patients with CKD and improve the quality of life of patients. Inpatients with CKD, especially women, should increase their dietary intake, maintain normal weight and improve their nutritional status.

Probiotics, Prebiotics, and Synbiotics for Patients on Dialysis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

The current systematic review and meta-analysis investigated the effects of probiotic, prebiotic, and synbiotic administration on inflammation, metabolic parameters, nutritional status, and uremic toxin in dialysis patients.

METHODS

Up to June 2021, publications were searched in Cochrane Library, PubMed, EMBASE, and Web of Science databases. The protocol was submitted to the International Prospective Register of Systematic Reviews and was approved.

RESULTS

This meta-analysis included 18 randomized controlled trials which were eligible. This meta-analysis discovered that probiotic, prebiotic, and synbiotic supplements could reduce C-reactive protein (standardized mean difference (SMD), -0.38; 95% confidence interval (CI), -0.68 to -0.08; P = .01), interleukin 6 (SMD, -0.48; 95% CI, -0.76 to -0.20; P = .00), and indoxyl sulfate (SMD, -0.24; 95% CI, -0.48 to -0.01; P = .045) and increase high-density lipoprotein cholesterol (SMD, 0.25; 95% CI, 0.03 to 0.46; P = .025) compared with the control group but had no significant influence on tumor necrosis factor α, albumin, hemoglobin, triglyceride, total cholesterol, low-density lipoprotein cholesterol, calcium, phosphorus, uric acid, or p-cresyl sulfate in dialysis patients.

CONCLUSIONS

Probiotic, prebiotic, and synbiotic administration could reduce C-reactive protein, interleukin 6, and indoxyl sulfate and increase high-density lipoprotein cholesterol in dialysis patients. To better examine the impact, large-scale, long-term, controlled diets and well-designed randomized controlled trials are needed.

Relationships between Sclerostin, Leptin and Metabolic Parameters in Non-Dialysis Chronic Kidney Disease Males

Sclerostin is an inhibitor of the Wnt-beta-catenin pathway. The relationship between sclerostin and adipose tissue or between sclerostin and nutritional status has been the subject of research interest in the last decade. Sclerostin concentrations are elevated in patients with chronic kidney disease (CKD). Leptin is an adipocytokine which inhibits food intake by stimulating the satiety center in the hypothalamus. Leptin concentrations rise with the reduction of eGFR (glomerular filtration rate). The aim of this study was to investigate the possible association between sclerostin and leptin, between sclerostin and selected poor prognostic factors of CKD progression, and between sclerostin and nutritional parameters in non-dialysis CKD male patients. 101 men with non-dialysis CKD stage 3-5 were included in the study. Bioimpedance spectroscopy (BIS) was used to measure body composition. Blood samples were drawn to measure the serum concentrations of sclerostin, leptin, creatinine, hemoglobin (Hgb), parathormone (PTH), inflammatory markers, and markers of nutritional status. We also measured homeostatic model assessment of insulin resistance (HOMA-IR) as well as blood pressure. We observed a significant, positive relationship between sclerostin and age, leptin, and glycated hemoglobin (HgbA1c) concentrations. A significant, negative association was observed between sclerostin and eGFR. Sclerostin is associated with leptin in non-dialysis CKD male patients. Sclerostin is also related to metabolic disturbances such as hyperglycemia in this population.

Phase Angle Association with Dietary Habits and Metabolic Syndrome in Diabetic Hypertensive Patients: A Cross-Sectional Study

Phase angle (PhA) levels are often lower than normal because both disease-specific parameters and disease-related inflammatory status, metabolic syndrome (MetS) included, can affect PhA. Therefore, the aim of this cross-sectional study was to compare body composition, metabolic profile and dietary patterns of participants with arterial hypertension (AH), type 2 diabetes mellitus (T2DM) and MetS with regard to PhA values. A total of 208 participants were included, of whom 53.6% were males. For each participant, data about body composition and anthropometric parameters, clinical and laboratory parameters, as well as food frequency questionnaire (FFQ) and Mediterranean Diet Serving Score (MDSS) were obtained. MC-780 Multi Frequency Segmental Body Mass Analyzer (Tanita) was used to assess body composition. Furthermore, waist-to-hip ratio (WHR) and waist-to-height ratio (WHtR) were calculated. The results showed that 75 (36.06%) participants had low PhA values and 133 (63.94%) had high PhA values. Participants with higher PhA values had significantly higher body fat percentage (p = 0.04), fat-free mass (kg; p < 0.001), muscle mass (kg; p < 0.001), skeletal muscle mass (% and kg; p < 0.001), sarcopenic index (SMI; p < 0.001) and mid-upper arm circumference (MUAC; p = 0.04), as well as lower fat mass percentage (p = 0.04). Regarding food frequency consumption, significantly higher intakes of red meat (p = 0.003), poultry (p = 0.02) and fast food (p = 0.003) were noticed in participants with higher PhA values. Adherence to the Mediterranean Diet (MeDi) was exceptionally low in both groups of participants, with significantly higher fish intake noticed in participants with high PhA (p = 0.03). In conclusion, our results showed that body composition could be the indicator of PhA in MetS as well as overall low adherence to the MeDi principles. These findings highlight the importance of adequate nutritional strategies and novel approaches to maintaining optimal body composition and adopting proper eating habits within the framework of one’s disease.

A high neutrophil to lymphocyte ratio is associated with poor nutritional status in chronic kidney disease patients

We aimed to investigate the relationship between the neutrophil to lymphocyte ratio (NLR) and nutritional parameters in chronic kidney disease (CKD) patients. In this cross-sectional study, 187 non-dialysis CKD patients were enrolled. Daily dietary energy intake (DEI) and daily dietary protein intake (DPI) were assessed by 3-d dietary records. Protein-energy wasting (PEW) was defined as Subjective Global Assessment (SGA) class B and C. Spearman correlation analysis, logistic regression analysis and receiver operating characteristic (ROC) curve analysis were performed. The median NLR was 2·51 (1·83, 3·83). Patients with CKD stage 5 had the highest NLR level. A total of 19·3 % (n 36) of patients suffered from PEW. The NLR was positively correlated with SGA and serum P, and the NLR was negatively correlated with BMI, waist and hip circumference, triceps skinfold thickness, mid-arm muscle circumference, DPI and Hb. Multivariate logistic regression analysis adjusted for DPI, DEI, serum creatinine, blood urea nitrogen, uric acid and Hb showed that a high NLR was an independent risk factor for PEW (OR = 1·393, 95 % CI 1·078, 1·800, P = 0·011). ROC analysis showed that an NLR ≥ 2·62 had the ability to identify PEW among CKD patients, with a sensitivity of 77·8 %, a specificity of 62·3 % and an AUC of 0·71 (95 % CI 0·63, 0·81, P < 0·001). The NLR was closely associated with nutritional status. NLR may be an indicator of PEW in CKD patients.

In-Depth Analysis of the Extracorporeal Proteome Adsorbed to Dialysis Membranes during Hemodialysis

Used hemodialysis membranes (HD-M) are a valuable reservoir of biological information. Proteins bind to HD-M, but whether this process depends on the type of membrane or patient factors or selectively affects specific protein classes has not been adequately elucidated. State-of-the-art proteomics techniques are capable of identifying and quantifying this therapy-specific subproteome to enable the analysis of disease- or membrane-induced pathophysiologies. We demonstrate the feasibility of the deep proteomic characterization of the extracorporeal proteome adsorbed to HD-M. A shotgun proteomics approach using nano-flow liquid chromatography coupled to mass-spectrometry identified 1648 unique proteins eluted by a chaotropic buffer from the HD-M of eight patients. In total, 995 proteins were present in all eluates; a more stringent approach showed that a core proteome of 310 proteins could be identified independently in all samples. Stability of the dialyzer proteome was demonstrated by a >90% re-identification rate on longitudinal samples of a single patient. The core proteome showed an overrepresentation of pathways of hemostasis and the immune system, and showed differences in membrane materials (polysulfone vs. helixone). This study demonstrates that optimized conditions combined with high-performance proteomics enable the in-depth exploration of the subproteome bound to HD-M, yielding a stable core proteome that can be exploited to study patient-specific factors and improve hemodialysis therapy.

Current Status and Future of Artificial Kidney in Humans

The number of patients needing renal replacement therapy (RRT) is increasing rapidly with an increase in lifestyle diseases such as diabetes, hypertension, and metabolic syndrome. Kidney transplantation, whenever feasible, is the most preferred mode of RRT. However, there is a growing shortage of donor kidneys for transplantation. While dialysis is partially able to perform the filtration and excretion function of the kidneys, it is still not able to perform the other renal tubular and endocrine functions of a normal kidney and has quality-of-life issues with significant long-term morbidity. The need of the hour is to develop an ideal artificial kidney that would be wearable or implantable and would be able to perform the complete excretory, filtration, tubular, endocrine, and metabolic functions of the kidney while preserving the quality of life and minimizing complications. In this review, we discuss the characteristics of an ideal artificial kidney, the challenges of developing such a device, a brief description of the past and current work on this topic, and what the artificial kidney of the future should look like.

Older Women Who Practiced Physical Exercises before the COVID-19 Pandemic Present Metabolic Alterations and Worsened Functional Physical Capacity after One Year of Social Isolation

Background: Because the consequences of the lifestyle changes in older adults associated with the social isolation imposed in response to the COVID-19 pandemic are not fully understood, here, we investigated the effects of one year of social isolation imposed by COVID-19 on the metabolic parameters and functional physical capacity of older women who regularly practiced physical exercises before the pandemic. Methods: Systemic lipid and protein profiles, estimated creatinine clearance (ECC), and functional physical capacity (FPC) were assessed before (January-February 2020) and 12 months after social isolation in 30 older women (mean age 73.77 ± 6.22) who were engaged in a combined-exercise training program for at least 3 years before the COVID-19 pandemic. Results: In this group, we observed increased plasma levels of triglycerides and creatinine, an increase in the time necessary to perform gait speed and time-up-and-go tests, and reduced muscle strength assessed by the handgrip test and ECC post-COVID-19 pandemic relative to values recorded pre-pandemic. In addition, we observed significant correlations (both negative and positive) between anthropometric, some metabolic parameters, and physical tests. Conclusion: One year of interruption of physical exercise practice imposed in response to the COVID-19 pandemic significantly altered some systemic metabolic parameters and worsened ECC and FPC in older women.

Prognostic Nutritional Index as a Predictor of Diabetic Nephropathy Progression

Malnutrition and immunologic derangement were not uncommon in patients with chronic kidney disease (CKD). However, the long-term effects of prognostic nutritional index (PNI), an immunonutrition indictor, on renal outcomes in patients with diabetic nephropathy (DN) and type 2 diabetes mellitus (T2DM) are unknown. In this retrospective cohort study, 475 patients with T2DM and biopsy-confirmed DN from West China Hospital between January 2010 and September 2019 were evaluated. PNI was evaluated as serum albumin (g/L) + 5 × lymphocyte count (109/L). The study endpoint was defined as progression to end-stage renal disease (ESRD). The Cox regression analysis was performed to investigate the risk factors of renal failure in DN patients. A total of 321 eligible individuals were finally included in this study. The patients with higher PNI had a higher eGFR and lower proteinuria at baseline. Correlation analysis indicated PNI was positively related eGFR (r = 0.325, p < 0.001), and negatively correlated with proteinuria (r = −0.68, p < 0.001), glomerular lesion (r = −0.412, p < 0.001) and interstitial fibrosis and tubular atrophy (r = −0.282, p < 0.001). During a median follow-up of 30 months (16−50 months), the outcome event occurred in 164(51.09%) of all the patients. After multivariable adjustment, each SD (per-SD) increment of PNI at baseline was associated with a lower incidence of ESRD (hazard ratio, 0.705, 95% CI, 0.523−0.952, p = 0.023), while the hypoalbuminemia and anemia were not. For the prediction of ESRD, the area under curves (AUC) evaluated with time-dependent receiver operating characteristics were 0.79 at 1 year, 0.78 at 2 years, and 0.74 at 3 years, respectively, and the addition of PNI could significantly improve the predictive ability of the model incorporating traditional risk factors. In summary, PNI correlated with eGFR and glomerular injury and was an independent predictor for DN progression in patients with T2DM. Thus, it may facilitate the risk stratification of DN patients and contribute to targeted management.

Developing a Selective Zirconium Phosphate Cation Exchanger to Adsorb Ammonium: Effect of a Gas-Permeable and Hydrophobic Coating

A sorbent with a high enough capacity for NH₄⁺ could serve as an oral binder to lower urea levels in end-stage kidney disease (ESKD) patients. A hydrogen-loaded cation exchanger such as zirconium phosphate Zr(HPO₄)₂·H₂O (ZrP) is a promising candidate for this application. However, the NH₄⁺ binding selectivity versus other ions must be improved. Here, we have developed a gas-permeable and hydrophobic surface coating on an amorphous form of ZrP using tetraethyl orthosilicate and methoxy-terminated polydimethylsiloxane. The hydrophobic coating serves as a barrier to ions in water solution from reaching the ion-exchanger's surface. Meanwhile, its gas-permeable nature allows for gaseous ammonia transfer to the cation exchanger. In vitro studies were designed to replicate the small intestine's expected ion concentrations and exposure time to the sorbent. The effectiveness of the coating was measured with NH₄⁺ and Ca²⁺ solutions and uncoated ZrP as the negative control. X-ray photoelectron spectroscopy and scanning electron microscopy measurements show that the coating successfully modifies the surface of the cation exchanger─ZrP. Water contact angle studies indicate that coated ZrP is hydrophobic with an angle of (149.8 ± 2.5°). Simulated small intestine solution studies show that the coated ZrP will bind 94% (±11%) more NH₄⁺ than uncoated ZrP in the presence of Ca²⁺. Meanwhile, Ca²⁺ binding decreases by 64% (±6%). The nearly fourfold increase in NH₄⁺ selectivity can be attributed to the gas-permeable and hydrophobic coating applied on the ZrP surface. This work suggests a novel pathway to develop a selective cation exchanger for treating ESKD patients.

The relationship between the prognostic nutritional index and new-onset pneumonia in peritoneal dialysis patients

Purpose

As an indicator of nutrition and immunity, the prognostic value of the prognostic nutritional index (PNI) has been confirmed in various diseases. However, the relationship between PNI and the incidence of pneumonia in peritoneal dialysis (PD) patients remains unknown. The purpose of this study was to investigate the relationship between PNI and new-onset pneumonia in patients undergoing PD.

Methods

Thousand two hundred and nighty eight patients were enrolled in this multicenter retrospective study from February 1, 2010, to February 28, 2020. A total of 899 patients were included in the final statistical analysis. The patients were stratified into two groups by PNI quartiles. The primary endpoint was a new-onset pneumonia event. Cox regression model analysis was used to explore the association between PNI and the first occurrence of pneumonia.

Results

During a mean follow-up of 41.43 months, 147 patients developed new-onset pneumonia. Kaplan–Meier survival curves showed a significant difference in the incidence of the first presentation of pneumonia between the two groups, that patients in the low PNI group had a higher risk of pneumonia (P = 0.016). By adjusting for demographic parameters, comorbidities, and laboratory indicators, the Cox regression model showed that the high PNI group had less risk compared to the low PNI group (HR 0.479 95% CI 0.297–0.772, P = 0.003). There were no interactions in the subgroups as follows: diabetes, hypertension, age, and sex.

Conclusions

Low PNI levels were independently associated with the first occurrence of pneumonia in PD patients. PNI was an independent predictor of new-onset pneumonia in PD patients.

Compliance of NKF KDOQI 2020 nutrition guideline recommendations with other guideline recommendations and protein energy wasting criteria in hemodialysis patients

INTRODUCTION

Nutrition in hemodialysis patients is important in decreasing complications, improving quality of life, and preventing of malnutrition. Recommendations of the guidelines are taken into consideration while prescribing a nutrition therapy plan for patients. However, the recommendations may differ between the guidelines. It was aimed to compare the newly published National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI) guideline with previous reported two guideline recommendations and protein energy wasting criteria in this study.

MATERIALS AND METHODS

Fifty-five maintenance hemodialysis patients between the ages of 18-65 were included in the study. Daily energy intake and daily protein intake of these patients were evaluated by three different nutrition guidelines; NKF KDOQI-2000, 2020 and European Best Practice Guidelines-2007. In addition, protein energy wasting was determined by using anthropometric measurements, biochemical findings and food intake of the patients.

RESULTS

When the inadequacy rate in dietary daily energy intake and daily protein intake of the patients evaluated by NKF KDOQI-2000 recommendations, it was found to be higher than the rates in other two recommendations (P<0.05). Based on criteria, protein energy wasting was detected in 29.1% of the patients. While the NKF KDOQI-2020 daily energy intake recommendation was not consistent with other guideline recommendations, it seems highly compatible with protein energy wasting recommendations such as albumin, body mass index, mid-upper arm circumference, energy, and protein intake. While NKF KDOQI-2020 daily protein intake recommendation complies with European Best Practice Guidelines-2007 recommendations, the level of agreement with protein energy wasting criteria is very low.

CONCLUSION

Inadequate protein intake is still an ongoing problem in hemodialysis patients. NKF KDOQI-2020 guidelines provide a more suitable and applicable daily energy intake recommendation for patients compared to the previous guidelines.

Association between Vitamin Intake and Chronic Kidney Disease According to a Variant Located Upstream of the PTGS1 Gene: A Cross-Sectional Analysis of Shika Study

Chronic kidney disease (CKD) patients have been advised to take vitamins; however, the effects have been controversial. The individual differences in developing CKD might involve genetic variants of inflammation, including variant rs883484 located upstream of the prostaglandin-endoperoxide synthase 1 (PTGS1) gene. We aimed to identify whether the 12 dietary vitamin intake interacts with genotypes of the rs883484 on developing CKD. The population-based, cross-sectional study had 684 Japanese participants (≥40 years old). The study used a validated, brief, self-administered diet history questionnaire to estimate the intake of the dietary vitamins. CKD was defined as estimated glomerular filtration < 60 mL/min/1.73 m2. The study participants had an average age of 62.1 ± 10.8 years with 15.4% minor homozygotes of rs883484, and 114 subjects had CKD. In the fully adjusted model, the higher intake of vitamins, namely niacin (odds ratio (OR) = 0.74, 95% confidence interval (CI): 0.57−0.96, p = 0.024), α-tocopherol (OR = 0.49, 95% CI: 0.26−0.95, p = 0.034), and vitamin C (OR = 0.97, 95% CI: 0.95−1.00, p = 0.037), was independently associated with lower CKD tendency in the minor homozygotes of rs883484. The results suggested the importance of dietary vitamin intake in the prevention of CKD in middle-aged to older-aged Japanese with minor homozygous of rs883484 gene variant.