7-point Subjective Global Assessment Research Articles

The safety of a low protein diet in older adults with advanced chronic kidney disease.

A low protein diet (LPD) is recommended to patients with advanced chronic kidney disease (CKD), whereas geriatric guidelines recommend a higher amount of protein. The aim of this study was to evaluate the safety of LPD treatment in older adults with advanced CKD. The EQUAL study is a prospective, observational study, including patients ≥65 years, incident estimated glomerular filtration rate <20 ml/min/1.73m², in six European countries with follow-up up till six years. Nutritional status was assessed by 7-point subjective global assessment (SGA) every 3-6 months. Prescribed diet (gram protein/kilogram/bodyweight) was recorded on every study visit; measured protein intake was available in three countries. Time to death and decline in nutritional status (SGA decrease by ≥2 points) were analysed using marginal structural models with dynamic inverse probability of treatment and censoring weights. Out of 1738 adults (631 prescribed LPD at any point during follow-up) there were 1319 with repeated SGA measurements of which 267 (20%) declined in SGA ≥ 2 points and 565 (32.5%) died. There was no difference in survival or decline in nutritional status for patients prescribed LPD ≤0.8 g/kg ideal bodyweight (Odds Ratio (OR) for mortality 1.15 (95% Confidence interval (CI) 0.86-1.55) and OR for decline in SGA 1.11 (95% CI 0.74-1.66) in the adjusted models. In patients prescribed LPD <0.6 g/kg ideal bodyweight, the results were similar. There was a significant interaction with LPD and higher age >75 years, lower SGA, and higher comorbidity burden for both mortality and nutritional status decline. In older adults with CKD approaching end-stage kidney disease, a traditional LPD prescribed and monitored according to routine clinical practice in Europe appears to be safe.

The correlation between serum growth differentiation factor 15 and malnutrition in patients with end-stage kidney disease on hemodialysis

Objective Malnutrition commonly occurs in patients undergoing maintenance hemodialysis. Early detection of malnutrition could allow early interventions to prevent later complications. At present, there are not many biomarkers with high predictive value of end-stage kidney disease (ESKD)-related malnutrition, especially for early malnutrition in hemodialysis patients, which needs more in-depth research. Therefore, we performed a cross-sectional study on 97 patients to identify biomarkers for malnutrition in hemodialysis patients. Research Methods & Procedures 7-point subjective global assessment (SGA) was applied to evaluate the nutritional status of patients on hemodialysis. Serum levels of growth differentiation factor 15 (GDF15), albumin, pre-albumin, c-reactive protein (CRP), tumor necrosis factor alpha (TNF-α), hemoglobin, low density lipoprotein-cholesterol, and high density lipoprotein-cholesterol were detected before hemodialysis. Logistic analysis and linear regression were used to analyze the association between GDF15 levels and the SGA score after adjustment for basic characteristics and laboratory findings. Results Among the 97 patients on hemodialysis, 51 had malnutrition (SGA < 6). There was no difference between the malnourished and well nourished (SGA ≥ 6) groups for dialysis duration, cholesterol, CRP, TNF-α, and hemoglobin. The malnutrition group had significantly lower grip strength (p < 0.05). GDF15 levels correlated negatively with the SGA score after adjustment for possible confounding factors [rho (male) = -0.312, rho(female)= -0.437;P(male) = 0.0181, P(female) = 0.005], and might contribute to the malnutritional status, the AUCs of GDF15 for malnutrition was 0.697 (p = 0.011) in male and 0.828 (p < 0.001) in female. Conclusions GDF15 is associated with malnutrition according to the SGA score in patients with ESKD on hemodialysis, suggesting that GDF15 might be involved in the pathogenesis of malnutrition patients with ESKD in this setting. Furthermore, GDF15 is likely to be a potential diagnostic biomarker for malnutrition according to the SGA score.

#3319 GOODRENAL: A FEASIBILITY STUDY OF AN INTRADIALYTIC HOLISTIC VIRTUAL-REALITY PLATFORM

Abstract Background and Aims People with advanced stages of chronic kidney disease (CKD) undergoing hemodialysis often suffer from comorbidities that together with malnutrition and frailty contribute to a sedentary lifestyle, and cognitive and emotional impairments. Intradialytic non-immersive virtual reality exercise programs may improve the health-related quality of life and physical function of people undertaking hemodialysis. The aim of the GoodRENal project was to test the feasibility of an intradialytic holistic virtual-reality platform designed to combine exercise with efforts to improve nutrition and psychological well-being as well as cognitive functioning and to assess the impact on physical, nutritional and psychological variables. Method People undergoing hemodialysis for at least 3 months who were medically stable, from Spain (Hospital de Manises), Sweden (Skane University Hospital and Karolinska Institutet), and Greece (Aristotle University of Thessaloniki) were selected and randomized into the GoodRENal intradialysis intervention group and a control group (usual care). The GoodRENal group was exposed to a platform that consisted of several Virtual Scenarios (games) for each one of the targeted treatment areas: Physical Activity, Nutritional Information, Psychological Well-being and Cognitive Functionality. Specifically, these scenarios (“games”) are aimed to make participants move (Physical Activity), learn aspects related to nutrition that they must follow (Nutritional Information), improve their psychological state (Psychological Well-being), and practice their cognitive abilities (Cognitive Functionality). The interaction with the Virtual Scenarios was designed to minimize “invasive” and “annoying” features by using a depth camera (AZURE Kinect), so that the patient, through the movement of their lower extremities (legs) was able to carry out the interaction. The control group carried out the usual care in the unit. The test battery included physical variables (lower-limb muscle strength, Sit-to-stand to sit test 10 repetitions, 4-meters gait speed, and 6-minute walking test), nutritional variables (short-form food question, 7-point subjective global assessment, body weight, and handgrip strength), psychological variables (depression and anxiety), and cognitive variables. Differences between groups (GoodRENal vs usual care) will be analyzed with a mixed ANOVA model for repeated measures. Results The study so far includes 55 participants (mean age 65.4 ± 13 years), 17 females, median time on hemodialysis 48 months). The program, which starts in 2023, will last 12 weeks, until the middle of May 2023. Conclusion The evaluation of the GoodRENal platform will show if this is a feasible holistic treatment for improving the physical, nutritional, psychological and cognitive condition of people undertaking hemodialysis.

#5405 MALNUTRITION DIAGNOSIS IN CKD PATIENTS

Abstract Background and Aims Malnutrition is a prevalent condition in patients with chronic kidney disease (CKD) receiving replacement therapy by peritoneal dialysis (PD). Geriatric nutritional risk index (GNRI) is an effective tool for screening nutritional status in maintenance hemodialysis patients. The purpose of this study was to determine the information content of GNRI for the diagnosis of protein-energy malnutrition in patients with CKD receiving replacement therapy with PD when compared to malnutrition inflammation score (MIS) and 7-point subjective global assessment (7p-SGA). Method A prospective cohort study included 222 adults PD-patients (man 100, female 112, age 44±14). All patients received continuous ambulatory peritoneal dialysis. Median duration PD before inclusion in the study was 12 months, the observation period of patients was 36 months. Nutritional status assessment included anthropometric (body mass index, triceps skinfold thickness, midupper arm muscular area) and biochemical (albumin, C-reactive protein, total iron-binding capacity, total cholesterol, hemoglobin and others) examinations as well as bioelectrical impedance analysis (BIA – fat mass). GNRI calculated according to the formula GNRI = 1.489 × albumin (g/dL)] + [41.7 × (body wt/ideal body wt)], where the ideal body weight for women is: height (cm)–100–[(height–152) × 0.2], ideal body weight for men is equal to: height (cm) -100 - [(height - 152) × 0.4]. We used MIS and 7p-SGA as a reference standard, a score ≥6 and ≤5, respectively, defined malnutrition. The cutoff of GNRI the diagnosis of malnutrition were derived from these ROC-analysis. Results Most of the individual nutritional indexes, including the anthropometric, biochemical and BIA indexes, were significantly (P&amp;lt;0.001) lower in the patients with MIS score ≥6 and 7p-SGA score ≤5, thus both nutritional screening tools were considered reasonable as a reference standard to determine the information content GNRI in PD-patients. The GNRI fluctuated in the range 66–126 (median 99), MIS score – 2–24 (median 7) and 7p-SGA score – 2–7 (median 5). The GNRI showed a significantly negative correlation with MIS (r = -0,708, p&amp;lt;0.0001) and a significantly positive correlation with 7p-SGA (r = 0.636, p&amp;lt;0.0001) (Fig. 1). The most accurate GNRI cutoff to identify a malnourished patient according to the MIS was ≤99 (Fig. 2). The frequency of malnutrition among the observed patients was 52.3% when using GNRI≤99, 55.9% when using MIS≥6 and 51.4% when using 7p-SGA≤5 (n.s.). The values for sensitivity and specificity with a GNRI of ≤99 in predicting malnutrition based on the MIS were 77.4% (95%CI 69.0-84.4%) and 79.6% (95%CI 70.3-87.1%) respectively. Positive predictive value and negative predictive value also had high scores respectively 73.7% (95%CI 64.9-80.9%) and 72.2 (95%CI 63.1-79.8%). The application of the GNRI to the PD-patients found significant (p&amp;lt;0.001) differences in the various nutrition-related indexes (anthropometric, biochemical and BIA) between the group with a GNRI≤99 and that with GNRI&amp;gt;99. Mortality from all causes among patients with GNRI&amp;gt;99 was one case per 54.9 patient-years, among patients with GNRI≤99 was one case per 29.7 patient-years. Conclusion In PD-patients GNRI closely correlates with MIS and 7p-SGA, characterized by high sensitivity and specificity. GNRI can be used to determine the nutritional status of PD patients.

Adherence to Caloric and Protein Recommendations in Older Hemodialysis Patients: A Multicenter Study.

Hemodialysis (HD) patients are characterized by malnutrition, which adversely affects their survival. The development of malnutrition is influenced, among other factors, by improper diet and the advanced age of patients. The study aimed to assess the nutritional status and adherence to dietary recommendations among older patients. The multicenter study included 179 stable HD patients. The nutritional status was assessed by a 7-point Subjective Global Assessment (SGA). Anthropometry and body composition was analyzed. The diet was assessed based on the 3-day food diary and the Food Frequency Questionnaire with 6 answers (FFQ-6). Blood laboratory tests were performed. Based on the 7-point SGA, malnutrition was diagnosed in 38.5% of HD patients. The decreased content of the muscle tissue (LTI < 14 kg/m2) was observed in 70.4% of the examined patients and the decreased concentration of s-albumin was observed in 44.1% of patients. Older patients had significantly lower LTI. 26% of patients consumed less than 25 kcal/kg body weight and less than 0.8 g protein/kg body weight. Older patients’ diets contained significantly fewer calories. There were significant differences between nutrient intake on a weekday with dialysis, a weekday without dialysis, and a weekend day without dialysis. The lowest intake of nutrients was observed on the day of dialysis. Nutritional education and the determination of whether food is permitted during hemodialysis are necessary to improve patients’ nutrition.

Commentary on the 2020 update of the KDOQI clinical practice guideline for nutrition in chronic kidney disease.

Commentary on the 2020 update of the KDOQI clinical practice guideline for nutrition in chronic kidney disease.

Comparison of Bioelectrical Impedance Vector Analysis (BIVA) to 7-point Subjective Global Assessment for the diagnosis of malnutrition.

Introduction:Bioelectrical impedance vector analysis (BIVA) is a non-invasive and low-cost strategy. The methods used to assess malnutrition in patients undergoing HD are still a challenge. The aim of the present study was to compare BIVA to 7-Point Subjective Global Assessment (7-point SGA) to identify malnutrition. We also investigated the sensitivity and specificity of the previously proposed cutoffs point for BIVA parameters.Methods:Patients of both sexes, over 20 years of age, on HD treatment were included. Anthropometric parameters, laboratory data, and bioelectrical impedance analysis (BIA) were evaluated. Values of resistance (R) and reactance (Xc) obtained by mono-frequency BIA were normalized to body height (H) to generate a graph of the bioimpedance vector with the BIVA software. The analysis of the area under the receiver operating curve ROC (AUC) was performed.Results:Among the included 104 patients, the mean age was 51.70 (±15.10) years, and 52% were male. The BIVA had a sensitivity of 35% for diagnosing malnutrition. The specificity of BIVA for identifying the well-nourished patients was 85.7%. The diagnostic accuracy between the BIVA and 7-point SGA was AUC=0.604; 95%CI 0.490-0.726, higher than the previously established cutoff values (AUC=0.514; 95%CI: 0.369-0.631). The 95% confidence ellipses did not overlap (p<0.05).Conclusion:Our study showed low accuracy of BIVA for diagnosing malnutrition using a 7-point SGA as a reference standard. However, it is a complementary method for assessing nutritional status as it provides data on cellularity and hydration, which are important aspects for the HD population.

Impact of malnutrition in surgically repaired hip fracture patients admitted for rehabilitation in a community hospital: A cohort prospective study.

Malnutrition is common and associated with adverse outcomes in geriatric patients with hip fractures. The study aims to evaluate the relationship between the nutritional status and rehabilitation efficiency and functional outcome on discharge in postoperative hip fracture patients. We prospectively evaluated 172 postoperative hip fracture patients who were admitted to the community hospital from November 2019 to November 2020. Nutritional status was assessed by the 7-point Subjective Global Assessment (SGA) within 48h of admission. Patients were assessed for rehabilitation efficiency and functional outcome at the end of their inpatient stay. There were 172 patients recruited with 100 (58.1%) malnourished and 72 (41.9%) well-nourished patients. Patients in the malnourished group were significantly older, needed walking aid assistance prior to sustaining hip fracture, cognitively impaired and had more comorbidities. Malnourished patients had lower rehabilitation efficiency scores (0.27, 95% CI -0.12 - 0.67 vs 1.32, 95% CI 0.88-1.76) and poorer functional outcomes on discharge (OR 21.5, 95% CI 2.45-188.7, p-value <0.001), after adjustment for pre- and post-fracture confounders. Malnutrition was present in more than half the postoperative hip fracture patients admitted to a community hospital in Singapore. This study showed that poor nutritional status is associated with significantly lower rehabilitation efficiency and functional outcome on discharge in hip fracture patients. Given the medical, social and economic stakes relating to hip fractures, it is essential to recognise and treat malnutrition in the hospital and community.

A Comparative Analysis of Nutritional Assessment Using Global Leadership Initiative on Malnutrition Versus Subjective Global Assessment and Malnutrition Inflammation Score in Maintenance Hemodialysis Patients

Malnutrition is a prevalent condition in maintenance hemodialysis (MHD) patients. This study aimed to evaluate the performance of the recently developed GLIM (Global Leadership Initiative on Malnutrition) in MHD by assessing the agreement, accuracy, sensitivity, specificity, and survival prediction of GLIM when compared to 7-point subjective global assessment (7p-SGA) and malnutrition inflammation score (MIS). We investigated 2 cohorts: MHDltaly (121 adults from Italy; 67±16years, 65% men, body mass index 25±5kg/m2) and MHDBrazil (169 elderly [age>60years] from Brazil; 71±7years, 66% men, body mass index 25±4kg/m2), followed for all-cause mortality for median 40 and 17months, respectively. We applied the 2-step approach from GLIM: (1) screening and (2) confirming malnutrition by phenotypic and etiologic criteria. For 7p-SGA and MIS, a score ≤5 and ≥8, respectively, defined malnutrition. Malnutrition was present in 38.8% by GLIM, 25.6% by 7p-SGA, and 29.7% by MIS in the MHDItaly cohort, and in 47.9% by GLIM, 59.8% by 7p-SGA, and 49.7% by MIS in the MHDBrazil cohort. Cohen's kappa coefficient (κ) showed only "fair" agreement between GLIM and SGA (MHDItaly: κ = 0.26, P = .003; MHDBrazil: κ = 0.22, P = .003) and between GLIM and MIS (MHDItaly: κ= 0.33, P<.001; MHDBrazil: κ = 0.25, P = .001). Cox regression analysis showed that all 3 methods were able to predict mortality in crude analysis; however in the adjusted model, the association seemed more consistent and stronger in magnitude for 7p-SGA and MIS. In MHD patients, GLIM showed low agreement, sensitivity, and accuracy in identifying malnourished subjects by either 7p-SGA or MIS. Considering the specific wasting characteristics that predominate in MHD, the well-established 7p-SGA and MIS methods may be more useful in this clinical setting.

Combining hand grip strength with nutritional screening tools in elderly patients with chronic kidney disease

Malnutrition in vulnerable patient populations must be rapidly detected using techniques that are easy to incorporate into everyday clinical practice. The new recommendations defined the 7-point Subjective Global Assessment (SGA) as optimal for nutritional assessment in chronic kidney disease (CKD), while Geriatric Nutrition Risk Index (GNRI) demands additional examination in elderly. This study aimed to determine the accuracy of several concise tools used in the clinical practice and the correlation of this tools with functional method hand grip strength (HGS) in elderly patients with CKD. In this cross-sectional study, anthropometric and functional data for 50 elderly hemodialysis patients were analyzed using numerous survey-based tools for screening nutritional status (Malnutrition Screening Tool – MST, Nutritional Risk Screening 2002 - NRS2002, Malnutrition Universal Screening Tool - MUST, Mini Nutritional Assessment - MNA, GNRI), which we compared to the standard 7-point SGA nutritional assessment tool. The sensitivity, specificity, and accuracy of these tools for detecting malnutrition were compared with the standard by using receiver operating characteristic (ROC) curve analysis. 7-point SGA classified 36.6% of participants as well nourished, and 63.4% as mildly to moderately malnourished, while the simplest alternative methods showed lower accuracy, classifying much higher proportions of participants as well nourished (MST, 92.0%; NRS2002, 80.4%). MNA had the highest accuracy based on receiver operating characteristic curves. HGS correlated moderately with 7-point SGA (r = 0.331), MNA (r = 0.410), and GNRI (r = 0.320). Our small study suggests that MNA is the best tool for malnutrition risk screening in elderly with CKD. Combining HGS with concise tools, such as GNRI, may provide better results and unburden healthcare professionals.

MO598COMPARISON OF GUT MICROBIOTA COMPOSITION BETWEEN PERITONEAL DIALYSIS PATIENTS AND HEALTHY HOUSEHOLD CONTACTS

Abstract Background and Aims According to some studies, it seems that advanced chronic kidney disease (CKD) has the potential to cause alterations in the composition of patients gut microbiota. Most of these data have been provided by comparing the microbiota profile between patients and healthy individuals. However, well-known factors that influence the microbiota composition such as age, environment and diet were not considered in the majority of these comparative studies. In the present study, we aimed to compare the gut microbiota composition between patients on peritoneal dialysis (PD) and age-paired healthy household contacts. Method This is a cross-sectional study. Patients undergoing automated PD for at least 3 months, aged 18 to 75 years and clinically stable were enrolled. Those who were using prebiotics, probiotics, symbiotics and antibiotics within a period of 30 days before the study, were not included. A healthy control group was composed by individuals living in the same home and with similar age of the patients. Participants received sterile materials to collect the feces sample and were instructed to keep it refrigerated and bring to the clinic within a period of 12h. To evaluate the microbial profile, 16S ribosomal DNA was PCR-amplified and sequenced on an IlluminaMiSeq platform. Diet was evaluated using a 3-day food record and the diet quality was analyzed by a Brazilian Diet Quality Index. Rome IV questionnaire was applied to diagnose constipation. Nutritional status was assessed by 7-point subjective global assessment (SGA) and body mass index (BMI). Fasting blood samples were collected and clinical data were obtained from interviewing the participants and from the patient’s charts. Data are presented in percentage, mean ± standard deviation or median (interquartile range). Results Twenty patients (PD group) and 20 healthy household contacts (control group) were studied. In PD group: 70% were men, 53.5 (48.2 - 66) years old, 50% had diabetes, BMI 25.9 ± 4.8 kg/m², 95% well-nourished, 40% constipated, 14 (5.2 – 43.5) months on dialysis and 80% had residual diuresis. In control group: 30% were men, 51.5 (46.2 - 59.7) years old, BMI 28.7 ± 3.5 kg/m² and 20% constipated. Except of sex (p = 0.01) and BMI (p = 0.04), there were no other differences between groups. Comparing dietary intake between groups, no difference was found in daily energy [PD: 20.8 ± 5.4 kcal/kg/d vs. control: 22.0 ± 5.6 kcal/kg/d, p = 0.51], protein (PD: 0.8 ± 0.2 g/kg/d vs. control: 0.9 ± 0.2 g/kg/d, p = 0.23) and fiber [PD: 14.1 (10.7 – 21.1) g/d vs. 13.7 (10.4 – 18.0) g/d, p = 0.85]. In addition, the Diet Quality Index was also not different between groups (PD: 52.3 ± 15.6 vs. control: 54.5 ± 14.8, p = 0.65). Regarding microbiota composition, no difference was found between groups in alfa diversity (Figure 1), beta diversity (p&amp;gt;0.05), and genera differential abundance (Figure 2). Conclusion In the present study, no difference in the gut microbiota composition was found between patients on PD and healthy household contacts sharing a similar environment and diet. This result suggests that CKD and PD seem not to alter significantly gut microbiota composition.

Associations Between Blood Trace Element Levels and Nutritional Status in Maintenance Hemodialysis

We aimed to investigate the associations between blood trace element levels and nutritional status in patients undergoing maintenance hemodialysis (MHD). This cross-sectional study included patients undergoing MHD who were treated at our center in September 2019. Clinical and demographic data and blood samples were collected before hemodialysis sessions, and the levels of manganese, lead, selenium, zinc, and copper were measured by inductively coupled plasma mass spectrometry. The Simplified Nutritional Appetite Questionnaire scale was used to assess patient appetite. Skinfold thickness, bicep circumference, upper arm muscle circumference, 7-point Subjective Global Assessment, Nutritional Risk Screening 2002 (NRS 2002), and Geriatric Nutritional Risk Index (GNRI) were used to assess patient nutritional status. Univariate and multivariate logistic regression analyses were performed to study the relationship between trace elements and nutritional indicators. In total, 118 patients (64 males and 54 females) were included, with a median dialysis vintage of 34.0months (16.0-54.5months) and an average age of 63.20±14.26years. Malnourished patients, as defined by the GNRI, Subjective Global Assessment, and NRS 2002, accounted for 28.0%, 49.2%, and 26.3% of enrolled patients, respectively. The multivariate binary logistic regression showed that higher blood copper levels were independently associated with nutritional risk defined as GNRI ≤91.2 (odds ratio [OR]=1.003, 95% confidence interval [CI] = 1.000-1.006; P=.020), whereas lower blood zinc levels (OR=0.634, 95% CI = 0.439-0.916; P=.015), blood zinc<4.220mg/L (OR=3.723, 95% CI = 1.274-10.879; P=.016), lower blood selenium levels (OR=0.959, 95% CI = 0.929-0.990; P=.010), and blood selenium<85μg/L (OR=5.568, 95% CI = 1.039-29.840; P=.045) were independently associated with a nutritional risk defined as NRS 2002≥3. Higher levels of blood copper and lower levels of blood zinc and selenium were independently associated with higher nutritional risk in MHD patients.

Patient-Reported Measures and Lifestyle Are Associated With Deterioration in Nutritional Status in CKD Stage 4-5: The EQUAL Cohort Study

The aim of this study was to explore the changes in nutritional status before dialysis initiation and to identify modifiable risk factors of nutritional status decline in older adults with advanced renal disease. The European Quality Study on treatment in advanced chronic kidney disease (EQUAL) is a prospective, observational cohort study involving six European countries. We included 1,103 adults >65years with incident estimated glomerular filtration rate <20mL/min/1.73 m2 not on dialysis, attending nephrology care. Nutritional status was assessed with the 7-point Subjective Global Assessment tool (7-p SGA), patient-reported outcomes with RAND-36 and the Dialysis Symptom Index. Logistic regression was used to estimate the associations between potential risk factors and SGA decline. The majority of the patients had a normal nutritional status at baseline, 28% were moderately malnourished (SGA ≤5). Overall, mean SGA decreased by -0.18 points/year, (95% confidence interval -0.21; -0.14). More than one-third of the study participants (34.9%) deteriorated in nutritional status (1 point decline in SGA) and 10.9% had a severe decline in SGA (≥2 points). The proportion of patients with low SGA (≤5) increased every 6months. Those who dropped in SGA also declined in estimated glomerular filtration rate and mental health score. Every 10 points decrease in physical function score increased the odds of decline in SGA by 23%. Lower physical function score at baseline, gastrointestinal symptoms, and smoking were risk factors for impaired nutritional status. There was an interaction between diabetes and physical function on SGA decline. Nutritional status deteriorated in more than one-third of the study participants during the first year of follow-up. Lower patient-reported physical function, more gastrointestinal symptoms, and current smoking were associated with decline in nutritional status.

An integrative approach to detect protein–energy wasting among chronic kidney disease maintenance hemodialysis patients

<br><b>Background:</b> Malnutrition is a major predictor of overall outcome in patients on hemodialysis. Regular and frequent evaluation of the nutritional status of these patients is advisable. <b>Aims and Objectives:</b> This study aimed to look at nutritional status of a hemodialysis cohort and to evaluate whether multiple assessment tools improve the detection of malnutrition in this cohort. <b>Materials and Methods:</b> A prospective study in two outpatient hemodialysis centers was conducted over 6 months. Stable patients without any irreversible organ damage and preserved cognitive function were included in the study. Data collected included demographics, comorbid conditions, and baseline laboratory investigations. The nutritional assessment tools included body mass index (BMI), 7-point Subjective Global Assessment, Global Leadership In Malnutrition (GLIM), handgrip strength, and body composition analysis. <b>Results:</b> A total of 121 subjects (77 males, 44 females) participated in the study. Based on BMI, only 14% were underweight. 7-point SGA detected 77 malnourished subjects, whereas according to GLIM criteria, all patients had some degree of malnutrition. Body composition analysis showed depleted total body protein mass in majority of patients. There was a correlation between total body protein mass and handgrip strength. The assessment tools showed some degree of correlation in patients who were malnourished. <b>Conclusions:</b> Use of a single assessment tool often underdiagnoses malnutrition in hemodialysis patients. An integrative approach using multiple evaluation tools may be beneficial in these groups of patients.<br>

Medical Nutrition Reimbursement in Singapore: Who Are the Patients Receiving MediFund Assistance? An Audit of Clinical Outcomes and Issues Pertaining to Reimbursement in a Public Hospital in Singapore.

Financial reimbursement (MediFund) of medical nutrition products (MNPs) was recently implemented in some of the public hospitals in Singapore for patients with financial difficulties. This study aimed to investigate the sustainability of this policy and the benefits conferred. We performed a 1-year retrospective audit of patients in a tertiary hospital who received MediFund. Demographics, presupport and postsupport clinical outcomes, and cost of support were determined and analyzed. A total of 129 patients received MediFund for MNPs. The median length of financial support was 115 days (interquartile range, 37-269). Overall, body mass index increased after nutrition support (20.9 ± 5.1 vs 20.4 ± 5.3; P = .012). There was a significant decrease in the number of malnourished patients (final, 55.1% vs initial, 86.8%; P < .001) and a significant increase in 7-point subjective global assessment scores (final, 4.9 ± 1.3 vs initial, 4.1 ± 1.3; P < .001) after MNP support. MNP adherence was high for 88.5% of patients who returned for follow-up appointments. Patients who defaulted follow-up appointments were more likely to have 30-day readmission (50% vs 19.5%; P < .001) and had higher mortality rates (35.7% vs 10.3%; P < .001). Total reimbursement of S $108,960 was provided to subsidize MNPs over 1 year. Supporting patients with financial difficulties led to an improvement in their nutrition status. Regular dietitian reviews of patients and monitoring compliance to consumption of MNPs are essential to ensure patients benefit from the support.

Association of subjective global assessment of nutritional status with gut microbiota in hemodialysis patients: a case-control study.

Protein-energy wasting (PEW) is prevalent and associated with adverse outcomes in patients with chronic kidney disease (CKD). However, the pathogenesis of PEW in CKD patients has not been fully identified. The gut microbiota has been implicated in the regulation of host metabolism and energy balance. Therefore, we aimed to explore the association between nutritional status and the composition of the gut microbiota in hemodialysis patients. Gut microbial diversity and taxonomy were examined in 88 hemodialysis patients with PEW (n = 22) and normal nutritional status (n = 66) who were matched 1:3 for age and sex. Nutritional status was assessed by using the 7-point subjective global assessment (SGA) score (1-3 = severe PEW; 4-5 = moderate PEW and 6-7 = normal nutrition). The gut microbiota was assessed by 16S ribosomal RNA gene sequencing. Patients with normal nutritional status had a significantly higher body mass index and physical activity and serum albumin levels, but significantly lower levels of inflammatory cytokines than patients with PEW. The most striking finding was that the α-diversity of the gut microbiota was significantly lower in patients with PEW. In a multivariate analysis, the SGA score was independently and positively associated with α-diversity (P = 0.049). Patients with or without PEW were different with respect to the principal coordinate analysis of β-diversity. Notably, the relative abundance of Faecalibacterium prausnitzii, a butyrate-producing bacteria, was markedly reduced in patients with PEW. In hemodialysis patients, PEW assessed with the SGA was associated with gut dysbiosis.

Association of Sarcopenia With Nutritional Parameters, Quality of Life, Hospitalization, and Mortality Rates of Elderly Patients on Hemodialysis

This study aimed to assess whether diminished muscle mass, diminished muscle strength, or both conditions (sarcopenia) are associated with worse nutritional status, poor quality of life (QoL), and hard outcomes, such as hospitalization and mortality, in elderly patients on maintenance hemodialysis (MHD). This is a multicenter observational longitudinal study that included 170 patients on MHD (age 70±7years, 65% male) from 6 dialysis centers. The European Working Group on Sarcopenia in Older People defines sarcopenia as the presence of both low muscle mass by appendicular skeletal+low muscle function by handgrip strength. This study evaluated the clinical and nutritional status (laboratory, anthropometry, dual-energy X-ray absorptiometry, 7-point subjective global assessment) and QoL (Kidney Disease Quality of Life) at baseline. Hospitalization and mortality were recorded during 36months. Reduced muscle mass was observed in 64% of the patients, reduced muscle strength in 52%, and sarcopenia in 37%. The group with sarcopenia was older, had a higher proportion of men and showed worse clinical and nutritional conditions when compared with patients without sarcopenia. Although reduced muscle mass was strongly associated with poor nutritional status, low muscle strength was associated with worse QoL domains. In the multivariate Cox analyses adjusted by age, gender, dialysis vintage, and diabetes mellitus, low muscle strength alone and sarcopenia were associated with higher hospitalization, and sarcopenia was a predictor of mortality. In conclusion, in this sample, comprised of elderly patients on MHD, sarcopenia was associated with worse nutritional and clinical conditions and was a predictor of hospitalization and mortality.

Prevalence and Risk of Protein-Energy Wasting Assessed by Subjective Global Assessment in Older Adults With Advanced Chronic Kidney Disease: Results From the EQUAL Study

Prevalence and risk factors for protein-energy wasting (PEW) are poorly studied in the nondialysis, older population with advanced chronic kidney disease (CKD). Our aim was to evaluate the prevalence of PEW in advanced stage CKD patients aged greater than 65years. Furthermore, we aimed to describe risk factors for PEW in the overall study population and among obese individuals. Prospective observational cohort study. The EQUAL study, a European Quality Study on treatment in advanced chronic kidney disease, is a multicenter prospective observational cohort study in six European countries. We included patients aged ≥65 years with incident glomerular filtration rate <20mL/min/1.73m2 not on dialysis attending nephrology care. PEW was assessed by 7-point Subjective Global Assessment (7-p SGA). In general, the study cohort (n=1,334) was overweight (mean body mass index [BMI] 28.4kg/m2). The majority of the patients had a normal nutritional status (SGA 6-7), 26% had moderate PEW (SGA 3-5), and less than 1% had severe PEW (SGA 1-2). Muscle wasting and loss of fat tissue were the most frequent alterations according to the SGA subscales, especially in those aged >80years. The prevalence of PEW was higher among women, increased with age, and was higher in those with depression/dementia. PEW was the most common in those with underweight (BMI <22kg/m2), 55% or normal weight (BMI 22-25kg/m2), 40%. In obese individuals (BMI >30kg/m2), 25% were diagnosed with protein wasting. Risk factors for SGA ≤5 in obese people were similar to those for the overall study population. This European multicenter study shows that the prevalence of PEW is high in patients with advanced CKD aged >65years. The risk of PEW increases substantially with age and is commonly characterized by muscle wasting. Our study suggests that focus on nutrition should start early in the follow-up of older adults with CKD.

Factors Affecting Insulin Resistance and Its Relation to Vitamin D Status and Clinical Nutritional Parameters in Dialysis Patients: A Single-center Indian Study.

The aim of this study was to measure insulin resistance (IR) in dialysis patients and its relation to Vitamin D status and nutritional parameters. We included patients on maintenance dialysis, both hemodialysis and peritoneal dialysis (HD and PD). IR was measured by homeostatic model assessment (HOMA)-IR index defined as fasting serum insulin (μU/L) × fasting blood sugar (mmol/L)/22.5. Baseline Vitamin D levels were measured by chemiluminescence immunoassay (CLIA) method. HOMA-IR index correlated with nutritional parameters such as 7-point subjective global assessment (SGA) and anthropometric measures, for example, body fat percentage, lean body weight (LBW), mid-arm circumference (MAC), and mid-arm muscle circumference (MAMC). A total of 55 patients were studied, of them 74.55% were male with mean age of the study population being 37.44 ± 14.96 years. The prevalence values of Vitamin D deficiency <30 ngm/ml, <20 ngm/ml, and <10 ngm/ml levels were 96.36%, 70.91%, and 23.64%, respectively. Mean HOMA-IR index was 3.14 ± 3.86. The correlation of HOMA-IR with Vitamin D was negative (r = −0.140, 95% confidence interval [CI] = −0.397–0.138 and P = 0.309); however, in subgroup analysis, patients with Vitamin D level <20 ng/ml had significantly high IR compared to those with Vitamin D >20 ng/ml, i.e., 3.74 ± 4.37 and 1.67 ± 1.47, respectively (P = 0.018). The other measured parameter which had a significant positive correlation with IR was serum uric acid (r = 0.303, 95% CI = 0.021–0.534, and P = 0.025). In nutritional assessment, body mass index, MAC, and MAMC had statistically significant positive correlation with HOMA-IR index (P ≤ 0.001, 0.004, and 0.004, respectively) unlike SGA (P = 0.480). The mode of dialysis did not have a significant effect on IR (HD vs. PD, P = 0.227). The majority of the patients on maintenance dialysis are Vitamin D deficient. Low Vitamin D level, especially <20 ng/ml, muscle mass, and high serum uric acid level are likely to have more IR in dialysis-dependent patients.

The use of bioelectrical impedance phase angle for predicting protein-energy wasting in hemodialysis patients

Objective To evaluate the use of bioelectrical impedance phase angle (PhA) for predicting protein-energy wasting (PEW) in hemodialysis patients. Methods This cross-sectional study involved 144 patients who were on maintenance hemodialysis (MHD) in the blood purification centers of two tertiary hospitals in Guangzhou, where the body impedance analysis (BIA) was performed after the hemodialysis procedure and the prevalence of protein-energy wasting (PEW) was investigated by the 7-point subjective global assessment (SGA) among. Nutritional indices of the patients with PEW were compared with the well-nourished patients to identify independent variables that can predict PEW and determine the cut-off value of PhA as a predictor. Results The patients with PEW had significantly lower PhA values than the Non-PEWpatients(t=8.68, P=0.00). PhA was positively related with the nutritional indices reflecting function of body proteins or muscles, such as serum albumin(rs=0.25, P=0.00), prealbumin(rs=0.31, P=0.00), free fat mass index(rs=0.25, P=0.00), and mid-arm muscle circumference(rs=0.44, P=0.00). However, the correlations of PhA with fat mass(rs=0.04, P=0.66)and body fat percentage(rs=-0.04, P=0.66)were no statistical significance. Multivariate logistic regression analysis revealed that PhA(OR=4.48, P=0.00) and body mass index (OR=1.59, P=0.00)were independent predictors of PEW, but PhA was more potent than BMI. Receiver operating characteristic curve analysis suggested that the optimum PhA cut-off point for predicting PEW was 4.6. Conclusion PhA can be a useful independent predictor for PEW in hemodialysis patients and its cut-off value is 4.6. Key words: Hemodialysis; Protein-energy wasting; Bioelectrical impedance analysis; Phase angle