Barbara Perez Vogt

Handgrip strength is an independent predictor of all-cause mortality in maintenance dialysis patients

BACKGROUND & AIMSnMuscle wasting is associated with mortality in dialysis patients. The measurement of muscle mass has some limitations, while muscle strength assessment is simple, safe and allows the recognition of patients at risk of progressing to poor outcomes related to malnutrition. The aim of this study is verify if handgrip strength (HGS) is associated with all-cause mortality in patients in maintenance haemodialysis (HD) and peritoneal dialysis (PD).nnnMETHODSnThis was an observational retrospective cohort study which included all patients in maintenance HD and PD from July 2012 to October 2014. Patients were followed-up until June 2015.nnnRESULTSnTwo-hundred sixty five patients were enrolled (218 HD and 47 PD) and they were followed for 13.4xa0±xa07.9 months. During the follow-up period, 53 patients (20%) have died, 36 patients (13.6%) have undergone renal transplantation, 13 patients (4.9%) have switched off dialysis method and 5 patients (1.9%) have transferred to another facility. The cut-off of HGS able to predict mortality was 22.5xa0kg for men and 7xa0kg for women. Using this cut-off to fit the Kaplan-Meier survival curve, the association of HGS with all-cause mortality for both genders was confirmed. Finally, in the multivariate analysis adjusted for demographic, clinical and nutritional variables, HGS remained significant predictor of mortality, independent of dialysis modality.nnnCONCLUSIONSnHGS cut-offs that predict mortality were 22.5xa0kg for men and 7xa0kg for women. HGS was associated with mortality independent of dialysis modality.

Are Nutritional Composed Scoring Systems and Protein-Energy Wasting Score Associated With Mortality in Maintenance Hemodialysis Patients?

OBJECTIVEnThe diagnostic of protein-energy wasting should be done using a tool that can predict clinically important outcomes, besides identifying malnutrition. This study investigated which nutritional composed scoring systems best predicts all-cause mortality in maintenance hemodialysis patients.nnnDESIGN AND METHODSnCohort study that included prevalent patients undergoing hemodialysis for at least 1xa0month. To assess nutritional status, Subjective Global Assessment (SGA), Malnutrition-Inflammation Score (MIS), and diagnostic criteria for protein-energy wasting proposed by the International Society of Renal Nutrition and Metabolism (ISRNM) were used. Patients were assessed in the moment of inclusion in the study (between July 2012 and December 2012) and followed prospectively to verify the occurrence of deaths.nnnRESULTSnA total of 163 patients were included, 54.6% were male, and mean age was 58.4xa0±xa015.5xa0years. During the follow-up period (15.5xa0±xa05.4xa0months), 29 patients died and 16 underwent kidney transplant. Kaplan-Meier survival curves and Cox proportional hazard analysis adjusted for age, gender, dialysis vintage, diabetes, and serum urea showed that SGA and MIS were predictors of all-cause mortality.nnnCONCLUSIONnOf the 3 investigated scoring systems, SGA and MIS predict mortality in a period of 15.5xa0±xa05.4xa0months of follow-up.

Anthropometric Indicators Predict Metabolic Syndrome Diagnosis in Maintenance Hemodialysis Patients

BACKGROUNDnObesity has been considered the key in metabolic syndrome (MetS) development, and fat accumulation may be responsible for the occurrence of metabolic abnormalities in hemodialysis patients. The use of gold-standard methods to evaluate obesity is limited, and anthropometric measures may be the simplest methods. However, no study has investigated the association between anthropometric indexes and MetS in these patients. Therefore, the aim was to determine which anthropometric indexes had the best association and prediction for MetS in patients undergoing hemodialysis.nnnMETHODSnCross-sectional study that included patients older than 18 years, undergoing hemodialysis for at least 3 months. Patients with liver disease and cancer or those receiving corticosteroids or antiretroviral therapy were excluded. Diagnostic criteria from Harmonizing Metabolic Syndrome were used for the diagnosis of MetS. Anthropometric indexes evaluated were body mass index (BMI); percent standard of triceps skinfold thickness and of middle arm muscle circumference; waist circumference (WC); sagittal abdominal diameter; neck circumference; waist-to-hip, waist-to-thigh, and waist-to-height ratios; sagittal index; conicity index; and body fat percentage.nnnRESULTSnNinety-eight patients were included, 54.1% male, and mean age was 57.8 ± 12.9 years. The prevalence of MetS was 74.5%. Individuals with MetS had increased accumulation of abdominal fat and general obesity. Waist-to-height ratio was the variable independently associated with MetS diagnosis (odds ratio, 1.21; 95% confidence interval, 1.09-1.34; P < .01) and that better predicts MetS, followed by WC and BMI (area under the curve of 0.840, 0.836, and 0.798, respectively, P < .01).nnnCONCLUSIONnWaist-to-height ratio was the best anthropometric predictor of MetS in maintenance hemodialysis patients.

Most consumed processed foods by patients on hemodialysis: Alert for phosphate-containing additives and the phosphate-to-protein ratio

BACKGROUND AND AIMSnHyperphosphatemia is common in patients with chronic kidney disease (CKD) stages IV and V because of decreased phosphorus excretion. Phosphatemia is closely related to dietary intake. Thus, a better understanding of sources of dietary phosphate consumption, absorption and restriction, particularly inorganic phosphate found in food additives, is key to prevent consequences of this complication. Our aims were to investigate the most commonly consumed processed foods by patients with CKD on hemodialysis, to analyze phosphate and protein content of these foods using chemical analysis and to compare these processed foods with fresh foods.nnnMETHODSnWe performed a cross-sectional descriptive analytical study using food frequency questionnaires to rank the most consumed industrialized foods and beverages. Total phosphate content was determined by metavanadate colorimetry, and nitrogen content was determined by the Kjeldahl method. Protein amounts were estimated from nitrogen content. The phosphate-to-protein ratio (mg/g) was then calculated. Processed meat protein and phosphate content were compared with the nutritional composition of fresh foods using the Brazilian Food Composition Table. Phosphate measurement results were compared with data from the Food Composition Tablexa0- Support for Nutritional Decisions. An α level of 5% was considered significant.nnnRESULTSnFood frequency questionnaires were performed on 100 patients (mean age, 59xa0±xa014 years; 57% male). Phosphate additives were mentioned on 70% of the product labels analyzed. Proteins with phosphate-containing additives provided approximately twice as much phosphate per gram of protein compared with that of fresh foods (pxa0<xa00.0001).nnnCONCLUSIONSnProtein and phosphate content of processed foods are higher than those of fresh foods, as well as phosphate-to-protein ratio. A better understanding of phosphate content in foods, particularly processed foods, may contribute to better control of phosphatemia in patients with CKD.

Malnutrition Inflammation Score cut-off predicting mortality in maintenance hemodialysis patients

BACKGROUNDnMalnutrition is a strong predictor of mortality on hemodialysis patients, especially when it is associated with inflammation. Malnutrition Inflammation Score (MIS) is a simple and low cost tool which assesses the presence of malnutrition associated with inflammation. Therefore, the aim is to evaluate if MIS is associated with mortality in patients on maintenance hemodialysis and establish a cut-off to predict mortality at different follow-up periods.nnnMETHODSnObservational retrospective cohort study including 215 patients on hemodialysis between July 2012 and June 2014, censored until November 2015. MIS was used to assess patients nutritional status at the moment they were enrolled in the study. They were followed for at least 18 months.nnnRESULTSnAt the end of 18 months, 38 (17.7%) deaths, 20 renal transplants (9.3%), four facilities transference (1.9%), three dialysis method change (1.4%) and one renal function recovery (0.5%) were observed. One hundred seventy one patients completed at least 24 months of follow-up, and during this additional period, there were five deaths and one renal transplant more. Score higher than 7 points was able to predict mortality for both follow-up periods using sensitivity and specificity analysis and ROC curves. Using this cut-off on Kaplan-Meier survival curve, it was possible to confirm the association of MIS with all-cause mortality at 18 months and 24 or more months of follow-up. Finally, Cox multivariate analysis adjusted for demographic, clinical and nutritional variables showed MIS as the only significant predictor of mortality.nnnCONCLUSIONnMIS is an independent predictor of mortality in hemodialysis patients.

Test–retest reliability, validation, and “minimal detectable change” scores for frequently reported tests of objective physical function in patients with non-dialysis chronic kidney disease

ABSTRACT Physical function is an important outcome in chronic kidney disease (CKD). We aimed to establish the reliability, validity, and the “minimal detectable change” (MDC) of several common tests used in renal rehabilitation and research. In a repeated measures design, 41 patients with CKD not requiring dialysis (stage 3b to 5) were assessed at an interval of 6 weeks. The tests were the incremental shuttle walk test (ISWT), “sit-to-stand” (STS) test, estimated 1 repetition maximum for quadriceps strength (e1RM), and VO2peak by cardiopulmonary exercise testing (CPET). Reliability was assessed using intraclass correlation coefficient and Bland–Altman analysis, and absolute reliability by standard error of measurement and MDC. The ISWT, STS-60, e1RM, and CPET had “good” to “excellent” reliability (0.973, 0.927, 0.927, and 0.866), respectively. STS-5 reliability was poor (0.676). The MDC is ISWT, 20 m; STS-5, 7.5 s; STS-60, 4 reps; e1RM, 6.4 kg; VO2peak, 2.8 ml/kg/min. There was strong correlation between the ISWT and VO2peak (r = 0.73 and 0.74). While there was poor correlation between the STS-5 and e1RM (r = 0.14 and 0.47), better correlation was seen between STS-5 and ISWT (r = 0.55 and 0.74). In conclusion, the ISWT, STS-60, e1RM, and CPET are reliable tests of function in CKD. The ISWT is a valid means of exercise capacity. The MDC can help researchers and rehabilitation professionals interpret changes following an intervention.

Twelve weeks of supervised exercise improves self-reported symptom burden and fatigue in chronic kidney disease: a secondary analysis of the ‘ExTra CKD’ trial

Abstract Background Chronic kidney disease (CKD) patients experience a high symptom burden including fatigue, sleep difficulties, muscle weakness and pain. These symptoms reduce levels of physical function (PF) and activity, and contribute to poor health-related quality of life (HRQoL). Despite the gathering evidence of positive physiological changes following exercise in CKD, there is limited evidence on its effect on self-reported symptom burden, fatigue, HRQoL and physical activity. Methods Thirty-six patients [meanu2009±u2009SD 61.6u2009±u200911.8u2009years, 22 (61%) females, estimated glomerular filtration rate: 25.5u2009±u20097.8u2009mL/min/1.73 m2] not requiring renal replacement therapy underwent 12 weeks (3 times/week) of supervised aerobic exercise (AE), or a combination (CE) of AE plus resistance training. Outcomes included self-reported symptom burden, fatigue, HRQoL and physical activity. Results Exercise reduced the total number of symptoms reported by 17% and had favourable effects on fatigue in both groups. AE reduced the frequency of ‘itching’, ‘impotence’ and ‘shortness of breath’ symptoms, and the intrusiveness for symptoms of ‘sleep disturbance’, ‘loss of muscular strength/power’, ‘muscle spasm/stiffness’ and ‘restless legs’. The addition of resistance exercise in the CE group saw a reduction in ‘loss of muscular strength/power’. No changes were seen in subjective PF or physical activity levels. AE increased self-efficacy for physical activity. Conclusions Supervised exercise had favourable effects on symptom frequency and intrusiveness, including substantial improvements in fatigue. Although the intervention did not improve self-reported physical activity levels, AE increased patients’ self-efficacy for physical activity. These favourable changes in self-reported outcomes support the important role of exercise in CKD.

Response to the letter “Handgrip strength may not accurately reflect the overall nutritional status of patients”

Department of Clinical Medicine Faculdade de Medicina de Botucatu UNESP Univ Estadual Paulista

Influence of different dialysis modalities in the measurement of resting energy expenditure in patients with acute kidney injury in ICU

BACKGROUNDnCurrently, the execution of indirect calorimetry, which is considered the gold standard for measuring energy expenditure, is not indicate during dialysis, and it may interfere on nutritional therapy of these patients. This study aimed to evaluate the resting energy expenditure (REE) in patients with severe acute kidney injury treated by different modalities of dialysis and to identify whether dialysis influences on REE.nnnMETHODSnThis was a prospective cohort study that evaluated patients admitted in intensive care units with diagnosis of acute kidney injury AKIN-3, mechanically ventilated, and submitted to conventional hemodialysis (CHD), extended hemodialysis (EHD) or high volume peritoneal dialysis (HVPD). Indirect calorimetry was performed at pre dialysis time and during the dialysis procedure. Parameters that could change REE were also evaluated.nnnRESULTSnOne-hundred patients undergoing 290 dialysis sessions were evaluated, with mean age 60.3xa0±xa017 years, 69% were male and 74% have died. There was no significant difference between REE of predialysis time and during dialysis time (2156xa0±xa0659xa0kcal vs. 2100xa0±xa0634xa0kcal, respectively, pxa0=xa00.15). No difference was observed in the REE before and during dialysis of different modalities. There were no differences between parameters pre and during dialysis of each modality. There was only a difference in norepinephrine dose, which was higher in pre dialysis time in HVPD and EHD modalities, compared with CHD modality. Moreover, during dialysis time, EHD modality had significantly higher VAD compared to other dialysis modalities.nnnCONCLUSIONnThe three evaluated modalities did not change REE. Indirect calorimetry can be performed during dialysis procedures and there was no difference between ventilation parameters, sedatives use, body temperature and VAD in both moments.