Bahar Gurlek Demirci

Reliability of bioelectrical impedance analysis in the evaluation of the nutritional status of hemodialysis patients - a comparison with Mini Nutritional Assessment.

INTRODUCTION Protein-energy wasting (PEW) is a strong predictive factor for morbidity and mortality in patients who have end-stage renal disease (ESRD). Mini Nutritional Assessment (MNA) is an important and confirmed tool to evaluate PEW that has been recommended by many guidelines. Bioelectrical impedance analysis (BIA) is a noninvasive technique for assessing body composition. The aim of the present study was to analyze the reliability of BIA in malnutrition diagnosis by comparing it with standard MNA in a group of 100 ESRD patients. METHODS One hundred ESRD patients who were medically stable and under dialysis treatment for at least 6 months were enrolled to the study. Monthly assessed serum creatinine, albumin, C-reactive protein (CRP), and lipid profiles from the last 6 months prior to the study were retrospectively collected. A standard Full-MNA and body composition analyses were applied to all patients. Body compositions were analyzed with the BIA technique using the Body Composition Analyzer (Tanita BC-420 MA; Tanita, Tokyo, Japan). Patients were classified into three groups according to MNA scores as PEW (n = 15, score <17), moderate PEW or risk group (n = 49, score 17-23.5), and well-nourished (n = 36, score ≥ 24) patients. RESULTS Mean duration of maintenance hemodialysis treatment was significantly shorter in the PEW group compared to both of the other groups described (P = .015). Well-nourished and risk groups had lower CRP and higher albumin levels compared to PEW patients; however, these values were statistically similar in these two groups (P = .018, .01, respectively). According to BIA findings, well-nourished patients had the highest fat ratio, fat mass, muscle mass, visceral fat mass, and fat-free mass compared to both moderate the PEW/risk and the PEW groups (P < .05). Risk group patients also had higher muscle mass, visceral fat mass, and fat-free mass values compared to the PEW group (P < .05). A correlation analysis revealed that MNA scores were positively correlated with albumin (P = .005), creatinine (P = .049), fat mass (P = .045), muscle mass (P = .001), visceral fat ratio (P = .007), and BMI (P = .047) and in negative correlation with CRP (r = -0.357, P = .0001) levels. CONCLUSIONS We recommend BIA as a complementary diagnostic tool to evaluate nutritional status of ESRD along with MNA, anthropometric measures, and classical biochemical markers.

Evaluation of Nutritional Status in Renal Transplant Recipients in Accordance with Changes in Graft Function

INTRODUCTION AND AIMS Renal transplantation (RT) is the ultimate treatment modality for end-stage renal disease (ESRD) patients. Malnutrition is a strong predictor of cardiovascular disease among ESRD patients. Body composition analysis using bioimpedance devices (BIA) is a useful noninvasive tool to detect malnutrition in this population. We investigated the impact of graft function on nutritional status and reliability of BIA to detect malnutrition in RT recipients. METHODS We evaluated retrospectively 189 RT recipients including 59 females, and of overall mean age of 38.3 ± 10.6 years who had a minimum posttransplant follow-up of 12 months. Body Composition Analyzer (Tanita BC-420MA) determinations were complemented with monthly assessments of biochemical parameters. Patients were divided into 3 groups according to glomerular filtration rate (GFR) levels: normal graft function/high GFR group (group 1, normal creatinine levels, no proteinuria and GFR ≥ 90 mL/min; n = 59); low renal function/low GFR group (normal or high creatinine levels with low GFR levels; group 2; GFR 89-60 mL/min; n = 87) and group 3, (GFR < 60 mL/min; n = 43). RESULTS Group 3 patients displayed significantly lower as well as hemoglobin albumin and calcium concentrations, with higher phosphorus and parathyroid hormone levels (P = .0001). They also showed significantly lower body weight (P = .0001), body mass index (P = .002), fat (P = .002) and muscle (P = .0001) contents as well as fat-free mass (P = .0001). Group 2 patients had significantly lower values compared with group 1 and higher values than group 3. GFR values positively correlated with albumin, fat, muscle, and fat-free mass (r = 0.337, 0.299, 0.281, 0.278, respectively; P = .0001). GFR values positively correlated with visceral fat ratio (r = 0.170; P = 0.02), body mass index (r = 0.253; P = .0001), and waist-hip ratio (r = 0.218; P = .006). CONCLUSION Loss of muscle and fat mass is an early sign of malnutrition among RT recipients. It is closely associated with loss of GFR. BIA is a noninvasive and reliable diagnostic tool that should be included in the follow-up of these patients for an early diagnosis of malnutrition-related complications.

Low Graft Function and Ongoing Hyperparathyroidism Are Closely Related to Post-Transplantation Osteoporosis

INTRODUCTION Renal transplantation (RT) is the gold standard therapy for chronic renal failure. Immunosuppressive drug choice, malnutrition, adynamic bone disease and hyperparathyroidism are important factors impacting the development of posttransplant osteoporosis. Body composition analysis with bioimpedance devices (BIA) is a useful noninvasive tool to detect malnutrition among the RT population. We investigated the effects of graft function, immunosuppressive drug regimens and biochemical characteristics on bone mineral density of RT patients as well as the reliability of BIA measurements to diagnose osteoporosis. METHODS One hundred three recipients with a minimum of 12 months post-RT follow-up underwent body composition analysis using the Tanita Analyzer. The last 6 months of monthly biochemical parameters and glomerular filtration rates (GFR) as well as drug regimens were collected retrospectively from patient charts. Patients were divided into 2 groups, according to their femoral neck and lumbal T scores, as osteoporosis (n = 42) and control groups (n = 61). RESULTS The mean GFR of osteoporotic patients was significantly lower (P = .04) and parathyroid hormone (PTH) levels significantly higher (P = .002). According to BIA, osteoporotic patients showed lower bone mass, fat mass, visceral fat ratio, muscle mass, waist-hip ratios, and body mass index values (P < .05). Correlation analysis revealed GFR to negatively correlate with PTH (r = -0.231, P = .010) and positively with femur t scores (r = 0.389, P = .0001) as well as with BIA findings (P = .0001). In contrast, PTH levels in negatively correlated with lumbar and femoral neck t scores (r = -0.22, -0.4 and P = .026, .0001, respectively) but not with BIA findings including bone mass. CONCLUSION Changes in bone density after RT were affected by graft function. The rapid loss of bone mineral density emphasizes the need for prevention started in the early posttransplant period. BMD measurements provided a guide for treatment and for subsequent evaluation.

High-Grade Proteinuria as a Cardiovascular Risk Factor in Renal Transplant Recipients

BACKGROUND Proteinuria is a marker of graft damage and is closely associated with a higher risk of morbidity, mortality, and cardiovascular disease in kidney transplant recipients (KTRs). Arterial stiffness is a well-known predictor of vascular calcification and systemic arteriosclerosis. In our study, we aimed to investigate the association between proteinuria and graft/patient survival and to determine whether proteinuria may be a predictor for cardiovascular disease in our KTR population. METHODS Ninety KTRs (31 women; age, 38.7 ± 11 years, with 45.9 ± 9.6 months post-transplantation period) with normal graft functions in the 3 to 5 years of the post-transplantation period were enrolled. All patients were evaluated for their standard clinical (age, sex, and duration of hemodialysis) parameters. High-grade proteinuria was defined as proteinuria >500 mg/day in the 24-hour urine collection. All patients were evaluated by means of pulse-wave velocity (PWV) measurement at the initiation of the study. RESULTS Patients were divided into 2 groups: group 1 (high-grade proteinuria) patients with ≥500 mg/24 hours (n = 30) and group 2 (low-grade proteinuria) patients with <500 mg/24 hours (n = 60). High-grade proteinuria was correlated with higher PWV measurements and lower estimated glomerular filtration levels. Proteinuria appears to precede the elevation of serum creatinine and thus may be a useful marker of renal injury and may also be a contributing factor on deterioration of the graft. CONCLUSIONS High-grade (>500 mg/day) proteinuria in KTRs is strongly associated with poor graft survival and increased risk of cardiovascular events. In our study, we proved the significant difference between high-grade and low-grade proteinuric patients, and we suggest 500 mg/day as the threshold of proteinuria in KTR population.

Factors Influencing Hemoglobin Variability and Its Association with Mortality in Hemodialysis Patients

Purpose We aimed to investigate the factors influencing hemoglobin variability with inflammatory and nutritional parameters and its associations with all-cause mortality among hemodialysis patients. Methods One hundred and sixty-nine patients during the entire 12 months were enrolled into the study. Fasting plasma glucose, creatinine, calcium, phosphorus, alkaline phosphatase, parathyroid hormone (PTH), C-reactive protein (CRP), serum iron, serum iron-binding capacity, and transferrin saturation were analyzed. We defined six groups: low, target range, high, low-amplitude fluctuation with low hemoglobin levels, low-amplitude fluctuation with high hemoglobin levels, and high-amplitude fluctuation. Body mass index (BMI), malnutrition-inflammation score (MIS), and Charlson Comorbidity Index were evaluated. Results Hemoglobin variability was significantly correlated with age, platelet count, and number of hospitalization instances and inversely correlated with erythropoietin dose per body surface area. The coefficient of variation of hemoglobin showed a correlation with MIS and ferritin. The absolute level of hemoglobin showed a negative correlation between PTH, CRP, MIS, number of hospitalization instances and a positive correlation with albumin and BMI. High, low, and target-range groups showed survival advantage compared to the other three groups. In regression analysis, age, CRP levels, MIS, and BMI were the predictors of mortality. Conclusion Inflammation and duration of anemia were the major predictors of hemoglobin variability. High-amplitude fluctuation predicts high mortality; on the contrary low-amplitude fluctuations is related to better survival. MIS was independently associated with mortality. This trial is registered with NCT03454906.

Fibromyalgia syndrome in chronic hemodialysis patients is associated with depression, hypoalbuminemia and inflammation

Objectives: Fibromyalgia syndrome (FMS) is an entity that presents with wide-spread chronic pain in musculoskeletal system , disturbed sleep, reduced mental functioning and depressed mood . We aimed to determine the incidence of FMS in our hemodialysis patients and to evaluate the association between FMS, depression and inflammation in patients ongoing hemodialysis. Methods: Among 169 patients, 140 patients were enrolled into our study. Twenty-nine patients were excluded according to exclusion criteria. Demographic characteristics including age, sex, body mass index, duration of dialysis, the etiology of end stage renal disease, the dialysis adequacy (Kt/V) were also recorded. All patients were evaluated through 2010 ACR preliminary diagnostic criteria including widespread pain index (WPI) and total symptom severity. All subjects completed Beck depression inventory (BDI) to determine psychological status. Results: Among 140 hemodialysis patients, 76 (54.2%) patients presented chronic widespread pain and 20 patients (14.2%) met the 2010 ACR criteria for FMS. Patients were divided into FMS (n = 20; 14.2%) and non-FMS (n = 120; 85.8%) groups. FMS group had significantly higher serum C-reactive protein levels and lower serum albumin levels when compared to non-FMS group. BDI (31.4 ± 1.4 vs 14.8 ± 0.6, p < 0.005), WPI (11.2 ± 0.7 vs 2.8± 0.2, p = 0.002) and symptom severity (7.3 ± 0.3 vs 3.7 ± 0.1, p < 0.005) scores were significantly higher in FMS group. Conclusions: The FMS itself and the related symptoms were correlated with depression in maintenance hemodialysis patients. Besides, inflammation and perhaps malnutrition-inflammation sydrome may trigger FMS in this population.

Dietary Fiber Intake: Its Relation With Glycation End Products and Arterial Stiffness in End-Stage Renal Disease Patients

OBJECTIVE We aimed to analyze the relationship between the effect of total dietary fiber intake on C-reactive protein (CRP) and on oxidative stress parameters such as serum advanced glycation end products (AGEs), superoxide dysmutase (SOD), malondialdehyde, and arterial stiffness by pulse wave velocity (PWv) in maintanace hemodialysis (MHD) patients. METHODS Among 650 MHD patients, 128 were selected according to inclusion criteria. The dietary survey was performed with a 3-day dietary history. Dietary fiber level was adjusted for total energy intake by the residual method. Patients were stratified by quartiles of adjusted dietary fiber (ADF) level as group 1 (n = 32) (ADF: <8.86 g/day), group 2 (n = 35) (ADF: 8.86-12.50 g/day), group 3 (n = 31) (ADF: 12.51-15.90 g/day), and group 4 (n = 30) (ADF: ≥15.91 g/day). Monthly assessed biochemical parameters including serum hemoglobin, albumin, CRP, calcium, phosphorus, and lipid profile levels were recorded. Serum AGEs, SOD, and malondialdehyde levels were determined by ELISA method. The PWv was determined from pressure tracing over carotid and femoral arteries. RESULTS Patients in group 3 and 4 had significantly lower CRP and AGE than those in group 1 and 2. Mean serum SOD level and PWv were significantly higher in group 4. In regression analysis, ADF intake was the unique predictor for both AGE (r2 = 0.164, P = 0.017) and CRP levels (r2 = 0.238, P = 0.01). CONCLUSION Present data show that dietary fiber intake is independently correlated with inflammation and oxidative stress. In addition, decreased fiber intake results in impaired arterial stiffness. Thus, adequate fiber intake could prevent cardiovascular events and inflammatory processes in patients undergoing MHD.

Assessment of volume status with cardiovascular risk factors in hemodialysis patients

INTRODUCTION: Chronic fluid overload is a common issue in patients undergoing hemodialysis. In present study, we aimed to investigate fluid volume parameters by bioimpedance analysis (BIA) and their relationship to hemodynamic parameters as systolic and diastolic blood pressure, pulse wave velocity (PWv), PP, cardiac index (CI) and cardiac output (CO) in patients ongoing hemodialysis. METHODS: One hundred end stage renal disease patients who were medically stable and undergoing dialysis treatment for at least 3 months were enrolled to the study. Body compositions were analyzed with the BIA technique (BCM, Fresenius) that estimates systolic and diastolic blood pressure, body mass index (BMI) lean tissue index (LTI), extracellular volume (ECW), intracellular volume (ICW), lean tissue mass (LTM) and phase angle levels. PWv, pulse pressure, CI, CO, systolic pressure augmentation (AIx) and total vascular resistance (TVR) were evaluated with PWv analysis monitor (Mobil-O-Graph). RESULTS: The mean age was 47.5 ± 16.2. Ultrafiltration volume and overhydration frequency were positively correlated with systolic blood pressure, ECW, ICW, BMI (p<0.05) and hemodynamic parameters as PWv, PP, CO, TVR, CI and AIx (p<0.001), and negatively correlated with LTI (p <0.05). PP, CO, TVR, CI, AIx, Kt/V, E/I and phi50 were the predictors of pulse wave velocity (p<0.05). Systolic blood pressure, PP, CO, TVR, CI, AIx, PWv, ECW, ICW and E/I were the predictors of overhydration (p<0.001). DISCUSSION and CONCLUSION: Present study concluded that overhydration is associated with increased PWv, systolic blood pressure, PP and vascular resistance