International Society Of Renal Nutrition And Metabolism Research Articles

The role of ultra-processed food consumption in protein-energy wasting and sarcopenia development in patients with chronic kidney diseases

BackgroundThe effect of ultra-processed foods (UPFs) on chronic kidney disease (CKD) has been studied in some studies. The present study aimed to investigate the association between UPF consumption and the risk of protein-energy wasting (PEW) and sarcopenia in patients with CKD in the Iranian population.MethodsThe current cross-sectional study included 110 patients with CKD referred to two clinics in Shiraz, Iran. The International Society of Renal Nutrition and Metabolism (ISRNM) criteria and the Asian Working Group for Sarcopenia (AWGS) guideline were considered for the diagnosis of PEW and sarcopenia, respectively. The valid semi-quantitative food frequency questionnaire was used to assess participants' dietary intake. The logistic regression was used to examine the association of UPFs with PEW and sarcopenia.ResultsWe observed no significant association between sarcopenia and PEW with UPFs in the crude model. After adjusting for confounders, we observed a significantly higher odds of sarcopenia in the upper versus lower median of UPF intake (odds ratio (OR) = 3.59, 95% confidence interval (CI): 1.02–12.62, P = 0.046).ConclusionsOur findings suggest a positive relationship between UPF intake and sarcopenia among CKD patients. Therefore, reducing the intake of UPFs may decrease the odds of sarcopenia in patients suffering from CKD.

Study on the correlation between bioelectrical impedance analysis index and protein energy consumption in maintenance dialysis patients

BackgroundProtein-energy wasting (PEW) has been reported to be pretty common in maintenance dialysis patients. However, the existing PEW diagnostic standard is limited in clinical use due to the complexity of it. Bioelectrical impedance analysis (BIA), as a non-invasive nutritional assessment method, can objectively and quantitatively analyze the changes of body tissue components under different nutritional states. We aim to explore the association between PEW and BIA and establish a reliable diagnostic model of PEW.MethodsWe collected cross-sectional data of 609 maintenance dialysis patients at the First Affiliated Hospital, College of Medicine, Zhejiang University. PEW was diagnosed according to International Society of Renal Nutrition and Metabolism (ISRNM) criteria. Among them, 448 consecutive patients were included in the training set for the establishment of a diagnostic nomogram. 161 consecutive patients were included for internal validation. 52 patients from Zhejiang Hospital were included for external validation of the diagnostic model. Correlation analysis of BIA indexes with other nutritional indicators was performed. Logistic regression was used to examine the association of BIA indexes with PEW. 12 diagnostic models of PEW in maintenance dialysis patients were developed and the performance of them in terms of discrimination and calibration was evaluated using C statistics and Hosmer–Lemeshow-type χ2 statistics. After comparing to existing diagnostic models, and performing both internal and external validation, we finally established a simple but reliable PEW diagnostic model which may have great value of clinical application.ResultsA total of 609 individuals from First Affiliated Hospital, College of Medicine, Zhejiang University and 52 individuals from Zhejiang Hospital were included. After full adjustment, age, peritoneal dialysis (compared to hemodialysis), subjective global assessment (SGA, compared to non-SGA) and water ratio were independent risk factors, while triglyceride, urea nitrogen, calcium, ferritin, BCM, VFA and phase angle were independent protective factors of PEW. The model incorporated water ratio, VFA, BCM, phase angle and cholesterol revealed best performance. A nomogram was developed according to the results of model performance. The model achieved high C-indexes of 0.843 in the training set, 0.841 and 0.829 in the internal and external validation sets, respectively, and had a well-fitted calibration curve. The net reclassification improvement (NRI) showed 8%, 13%, 2%, 38%, 36% improvement of diagnostic accuracy of our model compared with “PEW score model”, “modified PEW score model”, “3-index model”, “SGA model” and “BIA decision tree model”, respectively.ConclusionsBIA can be used as an auxiliary tool to evaluate PEW risk and may have certain clinical application value.

The role of interleukin-6 in the pathogenesis of protein-energy malnutrition in patients treated with haemodialysis

BACKGROUND. Protein-energy malnutrition (PEM) often develops in patients receiving long-term treatment with programmed haemodialysis (HD). Its main causes are decreased intake of basic nutrients, increased losses, disorders inherent to the terminal renal failure itself (including chronic inflammation), as well as the influence of factors associated with the HD procedure. THE AIM: to clarify the role of interleukin-6 (IL-6 ) in the pathogenesis of BEN in patients treated with programmed haemodialysis. PATIENTS AND METHODS. We examined 645 patients receiving HD treatment, including 300 men and 345 women aged 56.8±12.8 years, the duration of renal replacement therapy was 8.4±5.3 years. Nutritional status was assessed according to International Society of Renal Nutrition and Metabolism (ISRNM) recommendations. Serum IL-6 levels were determined by a three-step "sandwich" version of a solid phase enzyme immunoassay using mono- and polyclonal antibodies to IL-6 using a commercial kit "Interleukin-6-IFA-BEST" from Vector-Best, Russia, under the manufacturer's instructions. The reference values for IL-6 are 0-7 pg/ml. RESULTS. The prevalence of BEN was 24.9 % (160 patients). Mean IL-6 concentration was 6.47±2.64 pg/ml in patients without evidence of BEN, and 23.20±10.40 pg/ml in patients with BEN, p<0.001. Elevated IL-6 levels revealed statistically significantly lower levels of total protein, albumin, prealbumin, total cholesterol, transferrin and blood lymphocyte counts. Patients with elevated IL-6 levels were also characterized by statistically significantly lower values of body mass index, skeletal muscle mass index and skeletal muscle mass index. CONCLUSION. The results of this study suggest that the high prevalence of PEM in patients treated with HD is closely related to an imbalance of pro- and anti-inflammatory cytokines. An increase in the duration of renal replacement therapy is accompanied by an increase in serum IL-6 levels. Therefore, this cytokine can be considered as a therapeutic target for prevention and treatment of sarcopenia in dialysis patients.

An updated clinical prediction model of protein-energy wasting for hemodialysis patients.

Protein-energy wasting (PEW) is critically associated with the reduced quality of life and poor prognosis of hemodialysis patients. However, the diagnosis criteria of PEW are complex, characterized by difficulty in estimating dietary intake and assessing muscle mass loss objectively. We performed a cross-sectional study in hemodialysis patients to propose a novel PEW prediction model. A total of 380 patients who underwent maintenance hemodialysis were enrolled in this cross-sectional study. The data were analyzed with univariate and multivariable logistic regression to identify influencing factors of PEW. The PEW prediction model was presented as a nomogram by using the results of logistic regression. Furthermore, receiver operating characteristic (ROC) and decision curve analysis (DCA) were used to test the prediction and discrimination ability of the novel model. Binary logistic regression was used to identify four independent influencing factors, namely, sex (P = 0.03), triglycerides (P = 0.009), vitamin D (P = 0.029), and NT-proBNP (P = 0.029). The nomogram was applied to display the value of each influencing factor contributed to PEW. Then, we built a novel prediction model of PEW (model 3) by combining these four independent variables with part of the International Society of Renal Nutrition and Metabolism (ISRNM) diagnostic criteria including albumin, total cholesterol, and BMI, while the ISRNM diagnostic criteria served as model 1 and model 2. ROC analysis of model 3 showed that the area under the curve was 0.851 (95%CI: 0.799-0.904), and there was no significant difference between model 3 and model 1 or model 2 (all P > 0.05). DCA revealed that the novel prediction model resulted in clinical net benefit as well as the other two models. In this research, we proposed a novel PEW prediction model, which could effectively identify PEW in hemodialysis patients and was more convenient and objective than traditional diagnostic criteria.

MO937: Relationship Between Nutritional Status and Zonulin Level in Patients With End-Stage Renal Disease on Dialysis

Abstract BACKGROUND AND AIMS Protein energy wasting (PEW) is currently considered as one of the most important and independent predictors of an unfavourable prognosis in patients receiving haemodialysis treatment. The insufficient intake of nutrients and energy can be related to the ̏leaky gut̎ syndrome. Zonulin secretion has been shown to be dependent and is followed by an increase in gut permeability secondary to the disassembly of the protein ZO-1 from the tight junctional complex. Thus, the serum zonulin level may be considered as a biomarker of impaired intestinal barrier function. Тhe aim of our study was to evaluate the relationship between PEW and intestinal permeability, estimated by the level of serum zonulin, in patients receiving hemodialysis treatment. METHOD This was a case-control study involving 148 participants (123 haemodialysis patients and 25 control subjects). Patients diagnosed with infectious illness, unstable blood pressure, clinically active gastrointestinal disease, past history of abdominal operation and taking antibacterial, nonsteroidal anti-inflammatory and laxatives drugs were excluded. The presence of PEW was carried out by the International Society of Renal Nutrition and Metabolism (ISRNM) diagnostic criteria, which requires that patients meet at least one criterion in three of the four proposed categories: altered biochemical laboratory tests, loss of body mass, loss of muscle mass and decreased protein or energy intake. Bioimpedance measurements were obtained with an InBody720 equipment (Biospace, Korea). Plasma concentration of zonulin was assessed by ELISA using commercially available kit (BlueGene Biotech, Shanghai, China). RESULTS This study included 123 (75 men and 48 women) clinically stable patients undergoing haemodialysis in our centre. The average age was 59 years (49–67 years), and the mean duration of dialysis treatment was 36 (24–53) months. Given the absence of generally accepted reference values for serum zonulin levels, haemodialysis patients parameters were compared with the data of 25 healthy volunteers (13 men and 12 women) with an average age of 49 years (41.5–55). Zonulin level was significantly higher in the haemodialysis patients as compared with the healthy control 236.1 (190.3–310.9) ng/mL versus 190.6 (156.3–231.4) ng/mL, P < 0.01. Of the total population, 27 patients (22%) met the diagnostic criteria of PEW. The subgroup analysis between those with PEW and without PEW showed a statistically significant difference in serum zonulin concentration: 311.1 (282.6–406) versus 223.7 (182.8–271) ng/mL, respectively, P < 0.0001. Among subjects with PEW, there was a significant correlation between zonulin level and serum albumin (r = –0.404; P = 0.018), body mass index (r = –0.281; P = 0.021), body fat mass index (r = –0.55; P = 0.019), skeletal muscle mass index (r = –0.395; P = 0.007), erythrocyte sedimentation rate (r = 0.199; P = 0.04) and C-reactive protein (r = 0.642; P < 0.001). In the meantime, there was no significant interaction between zonulin and age, duration of dialysis treatment, Kt/V, shoulder muscle circumference, triceps skinfold, haemoglobin, total cholesterol, transferrin and lymphocyte levels (all P-values > 0.05). CONCLUSION Our study shows that PEW in haemodialysis patients could be associated with the increased intestinal permeability. Thus, different strategies that attenuate intestinal barrier disruption may be a potential therapeutic tool for the prevention and treatment of PEW. Limitation of the present study was the limited sample of participants, which probably influenced the significance of statistical tests. Further clinical studies are needed in a larger population as well as their prospective follow-up to enhance the understanding of this topic.

Nutrition and quality of life in chronic kidney disease patients: a practical approach for salt restriction.

The clinical practice guidelines (CPGs) for nutrition in chronic kidney disease (CKD) were updated after 20 years from the previous guidelines by the Kidney Disease Outcomes Quality Initiative (KDOQI). During this period, the severity of CKD was defined by eGFR and albuminuria by the organization Kidney Disease: Improving Global Outcomes (KDIGO). Main risk factors for CKD such as hypertension, hyperlipidemia, obesity, metabolic syndrome, and diabetes mellitus are closely related to lifestyle. Nutritional management is important to prevent and retard the progression of CKD. Members of the International Society of Renal Nutrition and Metabolism (ISRNM) reviewed the KDOQI CPG draft. ISRNM is an international scientific society comprising members of multiple subspecialties. ISRNM proposed the medical term protein-energy wasting (PEW), which is a keyword in renal nutrition. The prevalence of PEW among dialysis patients is high. The success of dietary therapy depends on adherence to the diet. It has to be palatable, otherwise eating habits will not change. To prevent the development and progression of CKD and PEW, regular consultation with an expert dietitian is required, especially regarding salt and protein restriction. Our cluster-randomized trial showed that intervention by a dietician was effective at retarding the progression of stage 3 CKD. In this review, I focus on salt (sodium) restriction and introduce tips for salt restriction and Japanese kidney-friendly recipes. Due to the lack of randomized controlled trials, nutritional management of CKD inevitably relies on expert opinion. In this regard, well-designed observational studies are needed. Too strict salt restriction may decrease quality of life and result in PEW.

Assessing Global Kidney Nutrition Care.

Nutrition intervention is an essential component of kidney disease management. This study aimed to understand current global availability and capacity of kidney nutrition care services, interdisciplinary communication, and availability of oral nutrition supplements. The International Society of Renal Nutrition and Metabolism (ISRNM), working in partnership with the International Society of Nephrology (ISN) Global Kidney Health Atlas Committee, developed this Global Kidney Nutrition Care Atlas. An electronic survey was administered among key kidney care stakeholders through 182 ISN-affiliated countries between July and September 2018. Overall, 160 of 182 countries (88%) responded, of which 155 countries (97%) answered the survey items related to kidney nutrition care. Only 48% of the 155 countries have dietitians/renal dietitians to provide this specialized service. Dietary counseling, provided by a person trained in nutrition, was generally not available in 65% of low-/lower middle-income countries and "never" available in 23% of low-income countries. Forty-one percent of the countries did not provide formal assessment of nutrition status for kidney nutrition care. The availability of oral nutrition supplements varied globally and, mostly, were not freely available in low-/lower middle-income countries for both inpatient and outpatient settings. Dietitians and nephrologists only communicated "sometimes" on kidney nutrition care in ≥60% of countries globally. This survey reveals significant gaps in global kidney nutrition care service capacity, availability, cost coverage, and deficiencies in interdisciplinary communication on kidney nutrition care delivery, especially in lower-income countries.

The Diagnosis of Protein Energy Wasting in Chronic Peritoneal Dialysis Patients Is Influenced by the Method of Calculating Muscle Mass. A Prospective, Multicenter Study.

Objective: To analyze the concordance and agreement between bioimpedance spectroscopy (BIS) and anthropometry for the diagnosis of protein energy wasting (PEW) in chronic peritoneal dialysis patients.Methods: Prospective, multi-center, observational study using multifrequency bioimpedance device (Body Composition Monitor -BCM®- Fresenius Medical Care) and anthropometry for the diagnosis of PEW as recommended by the International Society of Renal Nutrition and Metabolism (ISRNM). Cohen's kappa was the main test used to analyze concordance and a Bland-Altmann curve was built to evaluate the agreement between both methods.Results: We included 137 patients from three PD clinics. The mean age of the study population was 57.7 ± 14.9, 47.8% had diabetes, and 52.2% were male. We calculated the scores for PEW diagnosis at 3 and 6 months after the first collection (T3 and T6) and on average 40% of the study population were diagnosed with PEW. The concordance in the diagnosis of PEW was only moderate between anthropometry and BIS at both T3 and T6. The main factor responsible for our results was a low to moderate correlation for muscle mass in kilograms, with an r-squared (R2) of 0.35. The agreement was poor, with a difference of more than 10 kg of muscle mass on average and with more than a quarter of all cases beyond the limits of agreements.Conclusion: Current diagnosis of PEW may differ depending on the tools used to measure muscle mass in peritoneal dialysis patients.

Predicational ability of phase angle on protein energy wasting in kidney disease patients with renal replacement therapy: A cross-sectional study.

ObjectiveTo investigate the ability of phase angle (PA) and body composition for predicting protein energy wasting (PEW) in renal replacement therapy (RRT) patients.MethodsRenal replacement therapy (RRT) patients were enrolled in this study. Body composition was measured by direct segmental multi‐frequency biolectrical impedance analysis method (DSM‐BIA); phase angle (PA), fat‐free mass (FFM), fat mass (FM), mid‐arm circumference (MAC), WC (waist circumference), and ECW/TBW (extracellular water/total body water) were obtained. Biochemicals (serum albumin, triglyceride, and cholesterol) were tested. PEW patients were classified according to ISRNM (The International Society of Renal Nutrition and Metabolism) criteria. Cutoff value of PA and related variables was calculated by ROC analysis. The ability of body composition variables as indicators to predict PEW was evaluated.ResultsSixty‐four patients were enrolled in this study. Thirty‐three patients (52.6%) were males, and forty (62.5%) patients were diagnosed with PEW. The ROC curve showed that the optimal cutoff values of PA, FFMI (fat‐free mass index), MAC, WC, and BMI for PEW risk were 4.45°, 16.71, 29.7 cm, 86.4 cm, and 21.1 kg/m2, respectively. These indicators showed significant association with PEW; meanwhile, the PA and MAC can be used as the predictors for PEW with OR 6.333 (95% CI, 1.956–20.505) and 3.267 (95% CI, 1.136–9.394), respectively. Both groups have a lower BUN/Cr ratio (<20).ConclusionIn the RRT patients, over than 60% patients were diagnosed with PEW. PA, MAC, and other body composition can be used as the independent indicators for predicting PEW in renal replacement therapy kidney disease patients.

Resting metabolic rate and its adjustments as predictors of risk protein-energy wasting in hemodialysis patients.

Background: The purpose of the present study was to explore the association between resting metabolic rate (RMR) and protein-energy wasting (PEW) risk in Chinese hemodialysis patients by age and gender subgroup.Methods: RMR and body composition (body cell mass (BCM) and fat mass) of 774 patients undergoing hemodialysis were estimated by bio-electrical impedance analysis (BIA). Anthropometric data were collected by a standard measurement protocol, and the upper arm muscle circumference (AMC) was calculated. Biochemical nutritional and dialysis parameters were obtained. Linear regression analysis was used to analyze the relationship among RMR, body composition and nutritional factors.Results: The mean age was 54.96 ± 15.78 years. RMR level in patients was 1463.0 (1240.5, 1669.0) kcal/d. In multiple linear regression models, BCM, left calf circumference (LCC), fat mass were the determinants association with RMR (P<0.001). Among the patients in the sample, 133 (17.2%) had been diagnosed with PEW per International Society of Renal Nutrition and Metabolism (ISRNM) criteria and 363 (46.9%) were being at risk PEW. The area under the receiver-operating characteristic curve (AUC) of RMR for predicting risk PEW was greater than RMR/BCM and RMR/body surface area (BSA). When the cutoff of RMR was 1481 kcal/d it had the higher sensitivity and specificity (82 and 42%), and the AUC was 0.68 in elderly maintenance hemodialysis (MHD) patients (P<0.001). After adjustment for potential confounders, lowest RMR quartile level (<1239) increased the risk of PEW (OR = 4.71, 95% CI: 1.33–16.64, P=0.016) in all patients.Conclusions: Older patients with PEW have a lower RMR reduction. RMR and RMR/BCM may play the role in objective screening to detect risk PEW in MHD patients, especially in males.

Status of Nutrition in Hemodialysis Patients Survey (SNIPS): Nutrition Intake in Obese and Overweight vs. Healthy Weight Patients.

Elevated body mass index (BMI) has been associated with improved survival and fewer hospitalizations in hemodialysis patients; however, it is not clear that dietary intake is associated with increased BMI in hemodialysis patients. The present analysis was designed to compare energy and macronutrient intake and distribution, as well as compliance with the International Society of Renal Nutrition and Metabolism (ISRNM) dietary guidelines, by body weight status (overweight/obese vs. normal weight) in hemodialysis patients. The status of nutrition in hemodialysis patients survey (SNIPS) cohort is a cross-sectional study including a representative sample of individuals on hemodialysis treated in hospital dialysis centers throughout Israel. Of the 375 patients eligible for the current analysis, 60.1% had BMI ≥ 25 kg/m2 (overweight/obese). For each participant, the following measures were recorded: dietary intake, blood biochemistry, anthropometric and hemodynamic measures. These were compared by body weight status. Compared to their normal-weight counterparts, overweight/obese hemodialysis patients did not differ by energy and macronutrient intake, distribution of these nutrients in the diet. Regardless of body weight status, hemodialysis patients have poor compliance with ISRNM dietary guidelines.

Bioelectrical impedance analysis-derived phase angle as a determinant of protein-energy wasting and frailty in maintenance hemodialysis patients: retrospective cohort study

BackgroundPhase angle (PA), measured by bioelectrical impedance analysis (BIA) has been studied as indicator of nutritional status or muscle function in hemodialysis (HD) patients. It remains unclear if the phase angle is associated protein-energy wasting (PEW) or frailty, which are common complication in hemodialysis patients. The aim of this study is to determine whether BIA-derived PA is a marker of PEW or frailty in HD patients.MethodsThis retrospective observational study included 116 adult HD patients (35% female, 64 ± 12 years of age) in a single dialysis center. Patients were classified according to the PA quartiles into four groups; 1) first quartile: PA < 3.7°, 2) second quartile: PA 3.7–4.1°, 3) third quartile: PA 4.2–4.9°and 4) forth quartile: PA ≥ 5.0°. International Society of Renal Nutrition and Metabolism (ISRNM) criteria and Japanese version of Cardiovascular Health Study (J-CHS) criteria were used to identify PEW and frailty.ResultsThe lower PA group was associated with a greater risk of PEW (35% vs. 24% vs. 21% vs. 3%; p = 0.032), frailty (59% vs. 40% vs. 21% vs. 3%; p < 0.001). In multivariate logistic regression analysis, the first quartile group was at a significantly greater risk of both PEW and frailty compared with the fourth quartile group after adjusting for other confounding factors.ConclusionsLower PA was associated with a greater risk of PEW and frailty in HD patients.

Relationship of dietary and serum zinc and leptin levels with protein energy wasting in haemodialysis patients.

This study was carried out to evaluate the relationship between dietary and serum zinc and leptin levels with protein-energy wasting (PEW) in haemodialysis patients. The study was conducted on 80 volunteer patients aged 19-65years who received haemodialysis treatment three times a week for at least 1year. Anthropometric measurements and body composition analyses were performed. Blood samples were collected for serum zinc and leptin and other biochemical parameters. Food consumption of the patients was recorded for 3 days. Malnutrition-inflammation score (MIS) was calculated for all patients. PEW was assessed according to the criteria recommended by the International Society of Renal Nutrition and Metabolism (ISRNM). According to the ISRNM criteria, 38.1% of male patients and 36.8% of female patients were diagnosed with PEW. The median serum leptin levels of patients with PEW [9.0 (16.9) ng/mL] were significantly lower than those without PEW [20.7 (38.5) ng/mL] (p < 0.05). Dietary zinc intake in patients with PEW was significantly lower than that in patients without PEW (p < 0.05). However, there was no significant difference in serum zinc levels between the patients with and without PEW. In the multivariate analyses, dietary and serum zinc and leptin was associated with PEW. After controlling for several confounding factors these associations disappeared. Dietary zinc intake and serum leptin levels were inversely correlated with MİS. There was no relationship between serum leptin and dietary and serum zinc in these patients. Dietary zinc intake and serum zinc and leptin concentration were not associated with PEW. Low serum leptin levels might be the outcome rather than the cause of PEW in haemodialysis patients.

Relation of protein energy wasting to carotid intima media thickness in hemodialysis patients.

Carotid intima media thickness (CIMT) can reflect the degree of atherosclerosis and cardiovascular risk in hemodialysis patients. Factors such as advanced age, male gender, family history, and smoking can increase the risk of CIMT. In hemodialysis (HD) patients, lower serum albumin level was found to be correlated with higher CIMT. This study aimed to evaluate the relation between CIMT and protein energy wasting (PEW) diagnosed according to the diagnostic criteria of International Society of Renal Nutrition and Metabolism (ISRNM) expert panel in HD patients. This study involved 45 HD patients who were divided into two groups according to the diagnostic criteria for PEW proposed by the ISRNM expert panel including group with PEW (11 patients) and group without PEW (34 patients). Caloric intake was evaluated by food frequency questionnaire for 3 days. Subjective global assessment (SGA) and malnutrition inflammation score (MIS) were fulfilled. Anthropometric measurements, as well as body composition, was evaluated by electrical bioimpedance analysis. Doppler ultrasonography was used to assess CIMT that was significantly higher in patients with PEW (p = 0.030). CIMT had significant positive correlation to age, SGA, and MIS (p = 0.008, 0.002, and 0.003, respectively). Significant negative correlation was observed between CIMT and serum albumin. Multiple linear regression analysis revealed that serum albumin was the only predictor of mean CIMT. In conclusion, CIMT seems to be related to malnutrition in HD patients. Low serum albumin was the only predictor of CIMT.

P1579PREVALENCE OF PROTEIN-ENERGY WASTING IN HEMODIALYSIS PATIENTS IN THE EUROPEAN REGION OF THE RUSSIAN FEDERATION

Abstract Background and Aims One of the complications of hemodialysis therapy (HD) is the development of protein-energy wasting (PEW), which is an independent predictor of morbidity and mortality in this cohort of patients. The prevalence of PEW in hemodialysis patients in different regions of the world varies from 15% to 75% but has not been practically studied in the Russian Federation. To assess the prevalence of protein-energy wasting in hemodialysis patients in the European region of the Russian Federation. Method 645 hemodialysis patients were examined in 9 hemodialysis centers in 5 regions of the European part of the Russian Federation. Among the patients there were 345 women and 300 men, the average age was 56.8 ± 12.8 years. The duration of hemodialysis therapy was 8.4 ± 5.3 years. The diagnosis of PEW was established in accordance with the criteria: biochemical criteria (serum albumin &amp;lt; 3.8 g per 100 ml; serum prealbumin (transthyretin) &amp;lt; 30 mg per 100 ml; serum cholesterol &amp;lt; 100 mg per 100 ml); low body weight, reduced total body fat, or weight loss; a decrease in muscle mass; and low protein or energy intakes. The level of blood albumin was determined using the BCG method (bromocresol green). Estimation of protein and calorie intake was performed using 3-day food diaries filled out by patients. Results Insufficient protein intake according to the International Society of Renal Nutrition and Metabolism (ISRNM) recommendations was observed in 5.5 % of patients, calories in 4.1 %, combined deficiency in protein and calorie intake in 2.7% of patients. The prevalence of PEW was 51.2 %. The relationship between age and gender was not identified. The lowest prevalence of PEW is observed in patients with a hemodialysis therapy experience of fewer than 5 years (25,4 %) and gradually increasing by 2.5 times in patients with survival rates on HD for more than 10 years (χ2 = 22,580 р = 0.0001). Conclusion The prevalence of protein-energy wasting in hemodialysis patients in the European region of the Russian Federation is 51,2 %.

Clinical practice guideline on undernutrition in chronic kidney disease

Background “Malnutrition” describes both over and undernutrition. In the UK, the National Institute for Health and Care Excellence (NICE) define malnutrition as “a state in which a deficiency of nutrients such as energy, protein, vitamins and minerals causes measurable adverse effects on body composition, function or clinical outcome” in their Clinical Guideline (CG 32) [1] and Quality Standard (QS24) [2]. These guidelines suggest that patients at high risk of malnutrition should be screened and referred for specialist support if it is present. Patients with kidney failure face a number of challenges to their nutritional balance [3]. Uraemia itself inhibits appetite and reduces nutrient intake. Dialysis treatments result in the loss of small amounts of nutrients too. There are also other factors that tend to promote protein breakdown over protein synthesis. These include acidosis, insulin resistance and chronic inflammation. This latter factor can coexist with extensive atherosclerotic disease in a particularly toxic combination that is associated with increased mortality risk [3]. The International Society of Renal Nutrition and Metabolism (ISRNM), recommend the term protein energy wasting (PEW) to describe the undernutrition that is prevalent in renal failure populations [4], though more than one underlying cause may present in any individual. Protein energy wasting is described in 20–40% of patients with stage 4–5 chronic kidney disease (CKD) [3]. It is a more frequent finding in dialysis patients where it is described in 28–54% [5] and is associated with reduced survival, poor healing, infection risk, impaired functional ability and reduced quality of life [3].

MON-119 APPLICATION OF GENDER SPECIFIC ULTRASONOGRAPHY CUT-OFFS TO DETERMINE RISK OF PROTEIN ENERGY WASTING IN HEMODIALYSIS PATIENTS

Muscle depletion in hemodialysis (HD) patients associates with protein energy wasting (PEW) but quantification of muscle mass is challenging in the outpatient HD setting. Quadriceps muscle thickness assessment by ultrasound imaging (UI) offers a potential surrogate measure for muscle mass, and we aimed to determine the applicability of gender specific UI cut-off values for identifying risk of PEW in HD patients. PEW risk assessment used the criteria set by International Society of Renal Nutrition and Metabolism (ISRNM), namely body mass index (BMI) <23 kg/m2, reduction >10% in mid-arm muscle circumference (MAMC) in relation to the 50th percentile of reference population, serum albumin <38 g/dL and dietary energy intake (DEI) <25 kcal/kg ideal body weight (IBW). Using a portable UI device, we measured the cross-sectional area of the quadriceps muscle namely rectus femoris (RFCSA) in 351 Malaysian HD patients participated in the on going multi-centered Palm Tocotrienol in Chronic Hemodialysis (PaTCH) screening study. Using receiving operating characteristic analysis, derived RFCSA cut-off values to identify patients at risk of PEW were <6.00 cm2 for men and <4.47 cm2 for women. Differences for PEW criteria and various nutritional parameters were examined based on gender specific categorization (men: <6.00cm2 vs >6.00cm2 and women: <4.47cm2 vs >4.47cm2). Mann-Whitney’s U tested continuous data while Chi-square tested categorical data. Both men (62%, p<0.001) and women (77%, p=0.003) with smaller RFCSA had a higher prevalence of PEW. As per PEW criteria, both men and women with smaller RFCSA had significantly poorer BMI (men: 21.08, IQR: 19.11-23.74kg/m2 vs 25.10, IQR: 22.96-27.50kg/m2, p<0.001; women: 20.54, IQR: 18.29-22.85 kg/m2 vs 25.49, IQR: 22.83-28.85 kg/m2, p<0.001) and MAMC (men: 22.74, IQR: 20.41-24.75cm vs 24.76, IQR: 23.58-26.36cm, p<0.001; women: 19.38 IQR: 17.73-22.45cm vs 23.57, IQR: 21.34-25.39cm, p<0.001). DEI was significantly lower only in men with RFCSA<6.00cm2 (22.53, IQR: 19.09-27.66kcal/kg IBW vs 25.67, IQR: 22.46-30.43kcal/kg IBW, p<0.001) but not in women (23.64, IQR: 20.16-29.34kcal/kg IBW vs 24.35, IQR: 20.90-28.18kcal/kg IBW, p>0.05). Irrespective of gender, significantly lower muscle and fat mass, handgrip strength, and higher Malnutrition-Inflammation Score (all p<0.05) were observed in patients with smaller RFCSA. Using gender-specific RFCSA cut-offs, the UI method enabled differential PEW identification based on ISRNM criteria, yet factoring heterogeneous body compositional differences mediated by gender.

Protein - energy wasting of haemodialysis patients

To assess the prevalence of protein - energy wasting (PEW) of haemodialysis patients (HD). A total of 645 patients receiving treatment with programmatic bicarbonate HD for 8.4±5.3 years, including 345 women and 300 men, the average age was 56.8±12.8 years. Nutritional status was assessed using the method recommended by the Ministry of Health of the Russian Federation (MHRF) (accounting form № 003/U), as well as the method proposed by the International Society of Renal Nutrition and Metabolism (ISRNM). The nature of the change in appetite was determined by the Appetite and diet assessment tool (ADAT) and KDQOL-SF (version 1.3). Evaluation of the adequacy of the diet was performed using filled in patients for 3 days food diaries. A decrease in appetite was recorded in no more than 5% of patients, while these changes were of a persistent, lasting nature. Inadequate intake of essential nutrients, taking into account the recommendations of the ERBP, was found in 9.7% of patients, while inadequate intake of protein was noted. The prevalence of PEW by the method of MHRF was 75.3%, by the method of ISRNM the prevalence of PEW was 51.2%. There were no statistically significant differences between the patient groups depending on age and the presence of PEW according to the MHRF method (χ2=7.072; p=0.069). Similar data were obtained for the method of diagnostics PEW ISRNM. Statistically significant differences between groups of patients were obtained depending on the duration of HD and the presence of PEW according to the MHRF method (χ2=22.580; r=0.0001). The prevalence of PEW by the MHRF method increases with increasing duration of HD (Rs=0.184; p=0.0001). Similar data were obtained for the method of diagnosis of PEW ISRNM. The prevalence of PEW in haemodialysis patients was 51.2% according to the ISRNM method and 75.3% according to the MHRF method.

Association of low serum parathyroid hormone with protein-energy wasting in maintenance hemodialysis patients

Objective: To examine the relationship between low serum parathyroid hormone (PTH) and protein-energy wasting (PEW) in patients who underwent maintenance hemodialysis (MHD) treatment. Methods: A cross-sectional study was conducted in MHD patients between June 2015 and August 2017 in 11 MHD centers from Guizhou province. Body composition and physical parameters were measured, clinical data and other related laboratory values were collected according to the medical record system. Participants were assigned to low serum PTH group (PTH<150 ng/L), target PTH group (150 ng/L≤ PTH ≤300 ng/L) and high serum PTH group (PTH>300 ng/L). Multivariate logistic regression analysis was used to analyze the relationship between low serum PTH and risk of PEW, which was diagnosed according to the diagnostic criteria recommened by the International Society of Renal Nutrition and Metabolism (ISRNM). Results: A total of 873 MHD patients (488 males and 385 females) were included in the final analysis, with a mean age of 55.0 (44.0, 67.0) years and a mean hemodialysis duration of 31.0(17.0, 54.0) months. In unadjusted model, low serum PTH group was associated with PEW (OR=2.12, 95% CI: 1.26-3.54, P=0.004), when compared with high serum PTH group. After adjustment for age and sex, low serum PTH group was still significantly associated with PEW (OR=2.09, 95% CI: 1.23-3.52, P=0.006). Further adjustment for diabetes and hypertension, the correlation between low serum PTH group and PEW was still significant (OR=2.02, 95% CI: 1.04-3.90, P=0.037). However, the correlation was not observed in target PTH group and high serum PTH group. Conclusion: Low serum PTH was associated with risk of PEW, regardless of age, sex, history of diabetes and hypertension, and thus it might be a promising indicator of PEW in MHD patients.

Diagnosis and prevalence of protein-energy wasting and its association with mortality in Japanese haemodialysis patients.

The International Society of Renal Nutrition and Metabolism (ISRNM) has proposed the diagnostic criteria for protein-energy wasting (PEW). We studied Japanese haemodialysis (HD) patients to verify the diagnostic method, especially with respect to the body mass index (BMI) criterion, as well as the prevalence of PEW and its association with mortality. Japanese patients receiving maintenance HD at three outpatient clinics in Tokyo (n = 210) were enrolled, and prospectively followed-up for 3 years. PEW was diagnosed at baseline, according to the four categories (serum chemistry, body mass, muscle mass and dietary intake) recommended by the ISRNM. For the category of body mass, we select a body mass index (BMI) and set up three thresholds, <18.5, <20.0 and <23.0 kg/m2 , as the diagnostic criterion. The patients who satisfied at least three out of the four categories were diagnosed as PEW. Protein-energy wasting, when the threshold of a BMI among the diagnostic criteria was defined as <18.5 kg/m2 , was recognized as an independent risk factor for mortality. However, PEW was not recognized as a risk factor when the BMI diagnostic criterion was set at <20.0 or <23.0 kg/m2 . Overall, 14.8% of the patients had PEW. The survival rate of PEW patients was significantly lower than that of non-PEW patients (log rank, P < 0.001). The diagnosis algorithm of PEW proposed by an expert panel of the ISRNM strongly associates with mortality. However, given differences in body size in Japan, we suggest to revise the BMI criterion from <23.0 kg/m2 to <18.5 kg/m2 .