Malnutrition Inflammation Score Research Articles

Association between malnutrition-inflammation score and risk of subsequent self-reported bone fractures in prevalent kidney transplant recipients.

Kidney transplant recipients (KTR) have a 4-fold higher risk of fracture compared to the general population. Chronic inflammation and PEW syndrome are common in KTR and are associated with poor outcomes. We hypothesized that the Malnutrition-Inflammation Score (MIS), a validated measure of PEW, is associated with higher risk of bone fractures in KTR. This prospective cohort study included 839 prevalent KTR from a Central European academic center. MIS, a semiquantitative instrument of PEW, was calculated at the study entry. Self-reported history of fractures was recorded during the 2-year follow-up period. The association between MIS and bone fractures was examined in logistic regression analyses with adjustment for age, gender, eGFR, smoking habits, history of pre-transplant bone fractures, and acute rejection. Mean age was 51 ± 13years, and 56% of patients were males with median (interquartile range) transplant vintage 69 (38-112)months, estimated glomerular filtration rate 55 ± 21ml/min/1.73m2, and calculated MIS 3 (2-4) at enrollment. Fifty-five (7%) patients experienced self-reported bone fractures during the 2-year follow-up period. Higher MIS score showed linear association with increased risk of fracture. Each one-point higher MIS was associated with 23% higher risk of bone fractures (odds ratio (OR) and 95% CI 1.23, 1.12-1.34), which remained significant after multivariable adjustments (OR 1.17, 95% CI 1.06-1.29). The MIS is independently associated with new clinically detected bone fractures in prevalent KTR.

Influence of dietary protein intake on body composition in chronic kidney disease patients in stages 3–5: A cross-sectional study

IntroductionA controlled protein intake has shown beneficial effects to preserve renal function and nutritional status in chronic kidney disease (CKD) patients. This study aimed to analyze usual dietary protein intake and its potential contribution to body composition in CKD patients in stages 3–5. MethodCross-sectional study in 134 CKD patients in stages 3–5 (mean e-GFR: 19.4±8.7ml/min/1.73m2; males 68.7% and primary CKD etiology was diabetes mellitus, 35.8%). Demographic, clinical and nutritional parameters were evaluated. Normalized protein nitrogen appearance (nPNA), was used as a surrogate marker of dietary protein intake. The sample was classified into three nPNA groups (Gn): G1: <0.8g/kg/day; G2: 0.8–1g/kg/day and, G3: ≥1g/kg/day. Assessment of nutritional status using the malnutrition-inflammation score (MIS), anthropometric measures and laboratory parameters. Analysis of body composition and hydration status by bioelectrical impedance analysis (BIVA-101-RJL system). Statistical analysis by SPSS v.20. ResultsOverall mean nPNA values were 0.91±0.23g of protein/kg BW/day and only 32.1% had a dietary protein intake <0.8g of protein/kg BW/day. Most of the CKD patients (65.5%) were in stages 4 or 5. Prevalence of protein–energy–wasting (PEW) syndrome measured by MIS was 15%. By analyzing differences between nPNA groups, body weight (BW), BMI and triceps-skinfold (TSF) thickness were significantly higher in the group with nPNA ≥1g/kg BW/day (G3), whereas a significant inverse relationship was found with the percentages of body cell mass (BCM%), fat-free mass (FFM%), muscle mass (MM%) and phase angle (PA) in the group with the lowest nPNA (G1). Analysis of gender among subjects showed significant differences with BW, FFM%, TSF and mid-arm muscle circumference (MAMC%). Linear regression analysis showed that resistance, BCM%, MM%, and serum albumin were significant predictors of nPNA as a surrogate marker of daily protein intake (R=0.51; R2=0.29; R2 adjusted=0.23; p<0.001). ConclusionControlled protein intake is one of the cornerstones of treatment in CKD patients. A low protein intake in patients with CKD stages 3 and 4–5 was associated with loss of muscle mass in the advanced-CKD unit. The loss of muscle mass appears as an early indicator of nutritional comprised. Factors such, elderly age and loss of eGFR, showed lower protein intake and were associated with muscle loss, especially in women. Further longitudinal studies are required to evaluate the contribution of different protein intakes to uremic symptoms, nutritional status, body composition and CKD progression.

Global Prevalence of Protein-Energy Wasting in Kidney Disease: A Meta-analysis of Contemporary Observational Studies From the International Society of Renal Nutrition and Metabolism

To better define the prevalence of protein-energy wasting (PEW) in kidney disease is poorly defined. We performed a meta-analysis of PEW prevalence from contemporary studies including more than 50 subjects with kidney disease, published during 2000-2014 and reporting on PEW prevalence by subjective global assessment or malnutrition-inflammation score. Data were reviewed throughout different strata: (1) acute kidney injury (AKI), (2) pediatric chronic kidney disease (CKD), (3) nondialyzed CKD 3-5, (4) maintenance dialysis, and (5) subjects undergoing kidney transplantation (Tx). Sample size, period of publication, reporting quality, methods, dialysis technique, country, geographical region, and gross national income were a priori considered factors influencing between-study variability. Two studies including 189 AKI patients reported a PEW prevalence of 60% and 82%. Five studies including 1776 patients with CKD stages 3-5 reported PEW prevalence ranging from 11% to 54%. Finally, 90 studies from 34 countries including 16,434 patients on maintenance dialysis were identified. The 25th-75th percentiles range in PEW prevalence among dialysis studies was 28-54%. Large variation in PEW prevalence across studies remained even when accounting for moderators. Mixed-effects meta-regression identified geographical region as the only significant moderator explaining 23% of the observed data heterogeneity. Finally, two studies including 1067 Tx patients reported a PEW prevalence of 28% and 52%, and no studies recruiting pediatric CKD patients were identified. By providing evidence-based ranges of PEW prevalence, we conclude that PEW is a common phenomenon across the spectrum of AKI and CKD. This, together with the well-documented impact of PEW on patient outcomes, justifies the need for increased medical attention.

Dietary inflammatory index and parameters of diet quality in normal weight and obese patients undergoing hemodialysis.

Better nutritional reserves are proposed as a mechanism for the protective role of obesity in hemodialysis. Little is known about the quality of diet as a major contributor to nutritional status, specifically body mass index and obesity. The aim of this study was to assess dietary inflammatory index (DII®) score and other parameters of diet in normal-weight and obese patients undergoing hemodialysis to understand whether there is a benefit for obese patients. This cross-sectional study included 85 hemodialysis patients (44 obese and 41 normal-weight). Four-day 24-h dietary recalls and anthropometric measurements were collected. DII, energy-adjusted DII (E-DII), dietary energy density (DED), mean adequacy ratio (MAR), and malnutrition inflammation score (MIS) were calculated. Median E-DII score (1 [0.29-1.47] versus 0.42 [0.12-1.27]; P = 0.047) was higher and DII score (1.18 [0.03-2.26] versus 1.79 [0.47-2.49]; P = 0.046) was lower in the obese group. Obese patients had higher DED (1.52 ± 0.23 versus 1.43 ± 0.28; P = 0.034) and lower MIS (6.3 ± 2.5 versus 10.5 ± 3.1; P < 0.001) compared with the normal weight group. There was no significant difference in MAR between groups (P = 0.358). E-DII had significant positive correlation with weight (r = 0.226; P = 0.037), triceps skinfold thickness (r = 0.239; P = 0.035), and DED (r = 0.227; P = 0.036). MAR had significant negative correlation with MIS (r = -0.287; P = 0.008). Observed higher diet inflammatory potential and energy density and lower wasting in the obese group, along with similar adequacy of nutrients intake between groups, indicates that lower wasting, but not other indicators of nutritional status, are involved in better prognosis of obese patients with hemodialysis. Further studies are required to assess the potential dietary factors involved in determining wasting in advanced kidney failure.

Prescribing Hemodialysis or Hemodiafiltration: When One Size Does Not Fit All the Proposal of a Personalized Approach Based on Comorbidity and Nutritional Status.

There is no simple way to prescribe hemodialysis. Changes in the dialysis population, improvements in dialysis techniques, and different attitudes towards the initiation of dialysis have influenced treatment goals and, consequently, dialysis prescription. However, in clinical practice prescription of dialysis still often follows a “one size fits all” rule, and there is no agreed distinction between treatment goals for the younger, lower-risk population, and for older, high comorbidity patients. In the younger dialysis population, efficiency is our main goal, as assessed by the demonstrated close relationship between depuration (tested by kinetic adequacy) and survival. In the ageing dialysis population, tolerance is probably a better objective: “good dialysis” should allow the patient to attain a stable metabolic balance with minimal dialysis-related morbidity. We would like therefore to open the discussion on a personalized approach to dialysis prescription, focused on efficiency in younger patients and on tolerance in older ones, based on life expectancy, comorbidity, residual kidney function, and nutritional status, with particular attention placed on elderly, high-comorbidity populations, such as the ones presently treated in most European centers. Prescription of dialysis includes reaching decisions on the following elements: dialysis modality (hemodialysis (HD) or hemodiafiltration (HDF)); type of membrane (permeability, surface); and the frequency and duration of sessions. Blood and dialysate flow, anticoagulation, and reinfusion (in HDF) are also briefly discussed. The approach described in this concept paper was developed considering the following items: nutritional markers and integrated scores (albumin, pre-albumin, cholesterol; body size, Body Mass Index (BMI), Malnutrition Inflammation Score (MIS), and Subjective Global Assessment (SGA)); life expectancy (age, comorbidity (Charlson Index), and dialysis vintage); kinetic goals (Kt/V, normalized protein catabolic rate (n-PCR), calcium phosphate, parathyroid hormone (PTH), beta-2 microglobulin); technical aspects including vascular access (fistula versus catheter, degree of functionality); residual kidney function and weight gain; and dialysis tolerance (intradialytic hypotension, post-dialysis fatigue, and subjective evaluation of the effect of dialysis on quality of life). In the era of personalized medicine, we hope the approach described in this concept paper, which requires validation but has the merit of providing innovation, may be a first step towards raising attention on this issue and will be of help in guiding dialysis choices that exploit the extraordinary potential of the present dialysis “menu”.

Influence of dietary protein intake on body composition in chronic kidney disease patients in stages 3–5: A cross-sectional study

IntroductionA controlled protein intake has shown beneficial effects to preserve renal function and nutritional status in chronic kidney disease (CKD) patients. This study aimed to analyze usual dietary protein intake and its potential contribution to body composition in CKD patients in stages 3–5. MethodCross-sectional study in 134 CKD patients in stages 3–5 (mean e-GFR: 19.4±8.7ml/min/1.73m2; males 68.7% and primary CKD etiology was diabetes mellitus, 35.8%). Demographic, clinical and nutritional parameters were evaluated. Normalized protein nitrogen appearance (nPNA), was used as a surrogate marker of dietary protein intake. The sample was classified into three nPNA groups (Gn): G1: <0.8g/kg/day; G2: 0.8–1g/kg/day and, G3: ≥1g/kg/day. Assessment of nutritional status using the malnutrition-inflammation score (MIS), anthropometric measures and laboratory parameters. Analysis of body composition and hydration status by bioelectrical impedance analysis (BIVA-101-RJL system). Statistical analysis by SPSS v.20. ResultsOverall mean nPNA values were 0.91±0.23g of protein/kg BW/day and only 32.1% had a dietary protein intake <0.8g of protein/kg BW/day. Most of the CKD patients (65.5%) were in stages 4 or 5. Prevalence of protein–energy–wasting (PEW) syndrome measured by MIS was 15%. By analyzing differences between nPNA groups, body weight (BW), BMI and triceps-skinfold (TSF) thickness were significantly higher in the group with nPNA ≥1g/kg BW/day (G3), whereas a significant inverse relationship was found with the percentages of body cell mass (BCM%), fat-free mass (FFM%), muscle mass (MM%) and phase angle (PA) in the group with the lowest nPNA (G1). Analysis of gender among subjects showed significant differences with BW, FFM%, TSF and mid-arm muscle circumference (MAMC%). Linear regression analysis showed that resistance, BCM%, MM%, and serum albumin were significant predictors of nPNA as a surrogate marker of daily protein intake (R=0.51; R2=0.29; R2 adjusted=0.23; p<0.001). ConclusionControlled protein intake is one of the cornerstones of treatment in CKD patients. A low protein intake in patients with CKD stages 3 and 4–5 was associated with loss of muscle mass in the advanced-CKD unit. The loss of muscle mass appears as an early indicator of nutritional comprised. Factors such, elderly age and loss of eGFR, showed lower protein intake and were associated with muscle loss, especially in women. Further longitudinal studies are required to evaluate the contribution of different protein intakes to uremic symptoms, nutritional status, body composition and CKD progression.

Malnutrition associated with inflammation in the chronic renal patient on hemodialysis.

Malnutrition-Inflammation-Atherosclerosis Syndrome is very frequent in patients with chronic kidney disease on haemodialysis. In these patients, the inflammation associated with malnutrition is observed by the Malnutrition-Inflammation Score. To analyse the relationship between malnutrition-inflammation-atherosclerosis syndrome and anthropometric and biochemical parameters of patients on haemodialysis. A cross - sectional study was performed at the Haemodialysis Clinic of the Barão de Lucena Hospital, Recife, Brazil, between July and August 2016, with patients cared at the clinic for at least six months. Patients with amputees, hospitalized, visually impaired, HIV positive, with catheters in the neck, ascites and/or oedema, and those who were unable to provide information at the time of the interview were excluded. The patients were submitted to anthropometric evaluation for the classification of the nutritional status by waist circumference, neck circumference, body mass index, waist-to-hip ratio and waist-to-height ratio. Nutritional status related to inflammation was measured by the Malnutrition-Inflammation Score and nutritional status assessment using biochemical indicators that used urea, creatinine and albumin. Twenty-seven individuals of both genders, adults and elderly, aged 51.3 ± 13.3 years old participated in the study. The anthropometric evaluation showed that most of the population presented cardiovascular risk. The biochemical evaluation reported low frequencies of malnutrition. Malnutrition-Inflammation-Atherosclerosis syndrome was evidenced in 3.7% of the patients. The Malnutrition-Inflammation Score had a moderate negative correlation with body mass index, waist circumference, neck circumference, waist-to-height ratio and creatinine. The correlation seen among the parameters suggests that most of the parameters evaluated can be used as an indirect indicator of malnutrition-inflammation-atherosclerosis syndrome.

Malnutrition inflammation score: Screening tool to predict desnutrition in patients under hemodialysis

Rationale: Examine the utility of the Malnutrition Inflammation Score (MIS) tool in detection of nutritional risk and analyze the weight of each components in the presence of desnutrition among dialysis patients

Utility of malnutrition inflammation score (MIS) to predict mortality in hemodialysis patients

Utility of malnutrition inflammation score (MIS) to predict mortality in hemodialysis patients

Phosphate binders, appetite and nutritional status in maintenance hemodialysis patients.

The potential side effects of common phosphate binders are gastrointestinal in practice. We hypothesized that regular use of phosphate binders may be associated with decreased appetite, dietary intake and consequently, poor nutritional status. This was cross-sectional study of 78 patients (mean age 67.5±13.0, 34.6% women) undergoing maintenance hemodialysis (MHD) treatment. Participants were divided into three equal groups - sevelamer (n=25), lanthanum (n=24) and the control group (n=29). Eating motivation was assessed using visual analogue scales (VAS) and by a self-reported appetite assessment which was graded on a 5-point Likert scale. Main outcome measure was differences in VAS scores for appetite, dietary intake and nutritional status (malnutrition-inflammation score [MIS]) in the study groups. Appetite, dietary intake, biochemical nutritional markers, anthropometric measures and MIS were similar in the three groups. A statistically significant difference was observed in sensation of fullness between the groups: multivariable adjusted ORs in the sevelamer carbonate group was 4.90 (95% CI: 1.12 to 21.43), p=0.04 and in the lanthanum carbonate group was 5.18 (95% CI: 1.15 to 23.30), p=0.03 versus the control group. However, no linear association was observed between MIS scores and VAS scores for appetite in any study group. Regular use of these phosphate binders was not associated with anorexia, decreased dietary intake and nutritional status in the study population. Therefore, there is no preference in the choice of phosphate binders in MHD patients with hyperphosphatemia, even those who are at nutritional risk.

Decreased serum fatty acid binding protein 4 concentrations are associated with sarcopenia in chronic hemodialysis patients

BackgroundFatty acid binding protein 4 (FABP4) is found to play a role in skeletal muscle homeostasis. Since the dysregulation of FABP4 and sarcopenia are both highly prevalent in patients on chronic hemodialysis (HD), the correlation between them remains unknown. We aimed to examine this relationship in a cross-sectional study. MethodsA total of 120 chronic HD patients were recruited, and whose skeletal muscle mass, handgrip strength, and gait speed were assessed and blood samples were obtained. We grouped these participants into sarcopenia (n = 20) and non-sarcopenia groups according to European Working Group on Sarcopenia in Older People criteria. ResultsThe sarcopenia group exhibited lower weight (P < 0.001), height (P = 0.019), waist circumference (P < 0.001), body mass index (P < 0.001), body fat mass (P = 0.004), and lower serum triglycerides (P = 0.009), creatinine (P < 0.001), phosphorus (P = 0.013), intact parathyroid hormone (P = 0.012), and FABP4 concentrations (P = 0.005), and higher malnutrition–inflammation scores (MIS) (P = 0.031), urea reduction rates (P < 0.001), and fractional clearance index for urea (Kt/V) values (P < 0.001). Serum FABP4 concentrations (odds ratio (OR): 0.98, 95% confidence interval (CI): 0.96–0.99, P = 0.043), body fat mass (OR: 0.86, 95% CI: 0.77–0.97, P = 0.013), MIS (OR: 6.90, 95% CI: 1.31–36.36, P = 0.023), and Kt/V (each increase of 0.1, OR: 2.15, 95% CI: 1.29–3.57, P = 0.003) were independent predictors of sarcopenia in chronic HD patients. ConclusionsWe delineated the association between serum FABP4 concentrations and sarcopenia in chronic HD patients.

Diagnostic Accuracy of Bioelectrical Impedance Analysis Parameters for the Evaluation of Malnutrition in Patients Receiving Hemodialysis.

In the absence of a gold standard technique for assessing nutrition status in patients receiving hemodialysis (HD), we aimed to determine the diagnostic accuracy of single-frequency (50 kHz) bioelectrical impedance analysis parameters, resistance/height (R/H), reactance/height (Xc/H), and impedance/height (Z/H), and their cutoff points for malnutrition. The reference standards, Subjective Global Assessment (SGA), Malnutrition Inflammation Score, and Nutritional Risk Screening 2002, were performed at baseline and then once a year for 2 years. At least 2 assessments for each reference standard were performed during the monitoring period, and those patients who were assessed as malnourished on at least 2 consecutive occasions were classified as malnourished. A total 101 patients receiving HD were evaluated. R/H and Z/H demonstrated low to moderate accuracy to diagnose malnutrition in men and low accuracy in women, whereas the accuracy of Xc/H was uncertain. The cutoff points of bioelectrical impedance vector analysis (BIVA) parameters, determined based on the SGA to maximize sensitivity and specificity simultaneously, were: R/H ≥330.05 and ≥420.92 ohms/m for men and women, respectively; Z/H ≥332.71 and ≥423.19 ohms/m for men and women, respectively. In men, sensitivity based on the cutoff points of R/H and Z/H together ranged from 73% to 89% and specificity ranged from 49% to 50%. In women, sensitivity ranged from 58% to 80% and specificity from 48% to 55%. BIVA parameters demonstrated low to moderate accuracy in men and low accuracy in women for the diagnosis of malnutrition.

Noninvasive evaluation of muscle mass by ultrasonography of quadriceps femoris muscle in End-Stage Renal Disease patients on hemodialysis

Protein-Energy Wasting (PEW) is a pathological condition of renal patients with advanced Chronic Kidney Disease characterized by a progressive reduction of energy and protein assets. Nutritional status assessment, especially for what concerns muscle mass, is essential for both the identification of patients at risk for the development of PEW, as well as monitoring the effects of nutritional interventions. Ultrasound methods are easily applicable at the bedside for quantitative assessment of skeletal muscle. The present study was aimed at evaluating quadriceps rectus femoris thickness (QRFT) and quadriceps vastus intermedius thickness (QVIT) in patients on chronic hemodialysis. This was a prospective observational study. Three groups of adult patients were studied: young healthy subjects, well-nourished hospitalized patients with normal renal function, and End-Stage Renal Disease patients on hemodialysis (ESRD-HD). QRFT and QVIT were measured at two sites bilaterally (8 measures/patient) and were compared between groups, and also between subgroups of ESRD-HD patients stratified on the basis of conventional nutritional status parameters. We enrolled 35 healthy subjects, 30 hospitalized patients, and 121 ESRD-HD patients on hemodialysis. QRFT and QVIT of ESRD patients on hemodialysis were lower than those of both control groups (P<0.001). After stratifying ESRD patients into subgroups based on nutritional variable cut-offs commonly used to define PEW in this clinical setting (BMI [≥ 23 vs <23kg/m2], albumin [≥3.8 vs <3.8g/dL]) and malnutrition inflammation score (MIS) status (<6 vs ≥6), QRFT and QVIT of patients with worse nutritional status were significantly lower than those of well-nourished ESRD-HD patients (P value range: <0.001 to <0.05). Skeletal muscle ultrasound is a simple and easily applicable bedside technique in the dialysis units, and could represent an adequate tool for the identification of patients with reduced muscle mass.

Clinical efficacy and feasibility of whey protein isolates supplementation in malnourished peritoneal dialysis patients: A multicenter, parallel, open-label randomized controlled trial

Poor dietary intake is commonly associated with malnutrition in the dialysis population and oral nutritional supplementation is strategized to redress dietary inadequacy. Knowledge on clinical efficacy of whey protein supplementation (WPS) as an option to treat malnutrition in continuous ambulatory peritoneal dialysis (CAPD) patients is limited. This multicenter, parallel, open-label, randomized controlled trial investigated the clinical efficacy of WPS in 126 malnourished CAPD patients with serum albumin <40g/L and body mass index (BMI) <24kg/m2. Patients randomized to the intervention group (IG, n=65) received protein powder (27.4g) for 6 months plus dietary counseling (DC) while the control group (CG, n=61) received DC only. Anthropometry, biochemistry, malnutrition-inflammation-score (MIS), dietary intake inclusive of dialysate calories, handgrip strength (HGS) and quality of life (QOL) were assessed at baseline and 6 months. Clinical outcomes were assessed by effect size (Cohen's d) comparisons within and between groups. Seventy-four patients (n=37 per group) completed the study. Significantly more IG patients (59.5%) achieved dietary protein intake (DPI) adequacy of 1.2g/kg per ideal body weight (p<0.001) compared to CG (16.2%) although difference in the adequacy of dietary energy intake between groups was non-significant (p>0.05). A higher DPI paralleled significant increases in serum urea (mean Δ: IG=+2.39±4.36mmol/L, p=0.002, d=0.57 vs CG=-0.39±4.59mmol/L, p>0.05, d=0.07) and normalized protein catabolic rate, nPCR (mean Δ: IG=+0.11±0.14g/kg/day, p<0.001, d=0.63 vs CG=+0.001±0.17g/kg/day, p>0.05, d=0.09) for IG compared to CG patients. Although not significant, comparison for changes in post-dialysis weight (mean Δ:+0.64±1.16kg vs+0.02±1.36kg, p=0.076, d=0.58) and mid-arm circumference (mean Δ:+0.29±0.93cm vs-0.12±0.71cm, p=0.079, d=0.24) indicated trends favoring IG vs CG. Other parameters remained unaffected by treatment comparisons. CG patients had a significant decline in QOL physical component (mean Δ=-6.62±16.63, p=0.020, d=0.47). Using changes in nPCR level as a marker of WPS intake within IG, 'positive responders' achieved significant improvement in weight, BMI, skinfold measures and serum urea (all p<0.05), while such changes within 'negative responders' were non-significant (all p>0.05). A single macronutrient approach with WPS in malnourished CAPD patients was shown to achieve DPI adequacy and improvements in weight, BMI, skin fold measures, serum urea and nPCR level. CLINICAL TRIAL REGISTRY: www.clinicaltrials.gov (NCT03367000).

Intradialytic Aerobic Exercise in the United Arab Emirates: a Descriptive Study

Aim: Intradialytic exercise (IDE) improves hyperphosphatemia management in hemodialysis (HD) patient in addition to other clinical outcomes. The aim of the study is to present the strategies needed to integrate such a protocol in an HD unit in UAE and patients’ baseline characteristics.Methods: The largest HD unit in Sharjah emirate was chosen. All eligible patients (n=57) in the unit were included. Patients were stable adults HD patients who served as their own controls. The intervention included an aerobic low intensity IDE of 45 minutes per HD session, tailored to each patient’s fitness scale (BORG scale) for 6 months. Patients were educated on the importance of exercise. Outcome measures were barriers to exercise, serum phosphorus (P), urea reduction ratio (URR), malnutrition inflammation score, quality of life (QOL using euroqol5) collected at baseline and post intervention.Results: A total of 41 patients completed the study, 61% were males; 90.2%, 53.7% and 14.6% suffered from hypertension, diabetes and cardiovascular disease respectively. Hypherphosphatemia was prevalent among 75% of the patients with a mean of 5.76 ± 1.66 mg/dl. Mean age was 48 ± 14.37 years, BMI 24.98 ± 6.09 kg/m2, URR 71.88 ± 8.52%, and Kt/v 1.32 ± 1.09. The main barrier to exercise was identified to be fatigue on HD days by 58.5% of patients, followed by fear of getting hurt (36.6%). Finally, 80.4% of patients were mildly malnourished and QOL scale was 65.02% ± 18.54. Conclusion: Our study highlighted the widespread of hyperphosphatemia and malnutrition in our sample. The IDE regimen, if proven effective in future studies, could be integrated in the routine practice and may improve patients’ outcomes.

Serum Obestatin: A Biomarker of Cardiovascular and All-Cause Mortality in Hemodialysis Patients

Background: Recent experimental studies have suggested that obestatin, a proposed anorexigenic gut hormone and a physiological opponent of acyl-ghrelin, has protective cardiovascular effects. We tested the hypothesis that obestatin is independent of inflammatory mediators and/or acyl-ghrelin in predicting outcomes of the maintenance hemodialysis (MHD) population. Methods: It was a 6-year cohort study on 261 MHD patients. Obestatin, acyl-ghrelin, adipokines (leptin and adiponectin), markers of inflammation and nutrition, prospective all-cause and cardiovascular mortality were studied. Results: During the follow-up, 160 patients died in total, with 74 deaths due to cardiovascular causes. For each ng/mL increase in baseline obestatin level in fully adjusted models (including malnutrition-inflammation score, Interleukin-6 [IL-6], adipokines and acyl-ghrelin), the hazard for death from all causes was 0.90 (95% CI 0.81–0.99) and for cardiovascular death 0.85 (95% CI 0.73–0.99). However, these associations were more robust in the subgroup of patients aged above 71 years: 0.85 (95% CI 0.73–0.98) for all-cause death and 0.66 (95% CI 0.52–0.85) for cardiovascular death. An interaction between high IL-6 (above median) and low obestatin (below median) levels for increased risk of all-cause mortality (synergy index [SI] 5.14, p = 0.001) and cardiovascular mortality (SI 4.81, p = 0.02) emerged in the development of multivariable adjusted models. Interactions were also observed between obestatin, Tumor necrosis factor-alpha, adipokines and acyl-ghrelin, which were associated with mortality risk. Conclusion: Serum obestatin behaves as a biomarker for cardiovascular and all-cause mortality in MHD patients. The prognostic ability of obestatin in this regard is independent of inflammation, nutritional status, acyl-ghrelin’s and adipokines’ activity and is modified by age being very prominent in patients older than 71 years.

Bioimpedance Spectroscopy as a Practical Tool for the Early Detection and Prevention of Protein-Energy Wasting in Hemodialysis Patients

To evaluate whether body composition monitor (BCM) could be a practical instrument for nephrologists to assess nutritional status in patients on hemodialysis (HD) and whether it is more effective in identifying patients at highest risk of developing protein-energy wasting (PEW) alone or in combination with other tools currently used for that purpose. Observational cross-sectional study in 91 HD patients (60±14years, 70.3% male, 24±4.1kg/m2 body mass index) from 2 different locations. Nutritional status was evaluated by anthropometric methods (biceps and triceps skinfold thickness, waist circumference, and arm muscular circumference), biochemical nutritional markers, malnutrition-inflammation score (MIS), and BCM. The patients were grouped into those with and without PEW by using classical criteria and then classified as being adequately or inadequately nourished according to a BCM flow chart to detect those requiring preferential nutritional intervention. A multivariate approach was used to calculate the risk of developing PEW. Anthropometric measurements revealed significantly lower body mass index (<23kg/m2; odds ratios [OR]=13.3 and P=0.001) and arm muscular circumference<p10 (OR=34, P<0.001) in the PEW group. MIS was above 5 in all the patients classified as having PEW. BCM showed that fat tissue index < p10 was significantly lower in this group (OR=1.52), and a decision tree using the lean tissue index < p10, fat tissue index<p10, and extracellular water>15% revealed that 42.9% of the patients would need nutritional monitoring. On multivariate analysis, insufficient nutritional status detected by BCM decision tree was an independent prognostic factor for developing PEW. About 9.89% of the patients were classified as PEW, with MIS > 5, and insufficient nutritional status detected by BCM required preferential nutritional intervention. BCM is a practical instrument for nephrologists to assess nutritional status in patients on HD and is useful for the early prevention and detection of PEW, as is able to identify differences in body composition, predict clinically important outcomes, and classify patients requiring preferential nutritional intervention.

Relationship between Nutritional Status and Gastrointestinal Symptoms in Geriatric Patients with End-Stage Renal Disease on Dialysis.

Gastrointestinal symptoms (GIS) are common in patients with end-stage renal disease (ESRD) and are associated with nutritional risks resulting from low food intake. Little is known about the relationship between GIS and malnutrition in geriatric patients with ESRD. The main objective of this study was to determine the relationship between nutritional status and severity of GIS in geriatric patients on dialysis therapy. Clinically-stable geriatric patients (older than 60 years old) who were dialysis outpatients were included in this cross-sectional study. The severity of GIS was assessed using the Gastrointestinal Symptoms Questionnaire (GSQ, short version), with patients classified into three groups: mild, moderate, and severe. Nutritional status was evaluated with the Malnutrition Inflammation Score (MIS), anthropometric assessment, biochemical parameters, and bioelectrical impedance. Descriptive statistics were used and differences between groups were analyzed with ANOVA and Kruskal Wallis, with a p < 0.05 considered to indicate significance. Fifty patients completed the study; the median age was 67 years old. Twenty-three patients were on hemodialysis (HD) and 27 were on peritoneal dialysis (PD). No significant differences were found according to dialysis modality, presence of diabetes, or gender. Ninety percent of patients had at least one GIS. Poorer nutritional status (evaluated by MIS) was related to a higher severity of GIS. There were no significant differences with other nutritional parameters. Our study showed a high prevalence of GIS in geriatric patients. There were no differences in observed GIS values that were attributed to dialysis modality, gender, or presence of type 2 diabetes mellitus (DM2). Severe GIS values were associated with poorer nutritional status determined by MIS, however, there was no association with anthropometry, biochemical values, or bioimpedance vector analysis.

253 Impact of Race and Ethnicity Upon Malnutrition Inflammation Score and Mortality Risk in a Prospective Hemodialysis Cohort

253 Impact of Race and Ethnicity Upon Malnutrition Inflammation Score and Mortality Risk in a Prospective Hemodialysis Cohort

Inflammation and nutritional status assessment by malnutrition inflammation score and its outcome in pre-dialysis chronic kidney disease patients

Malnutrition-inflammation complex syndrome (MICS), hyperhomocysteinemia, calcium and phosphate levels derangement have been predicted as important contributing factors for the progression of cardiovascular burden. Among patients with earlier stage of CKD, hypoalbuminaemia and inflammation deliberated as non-traditional cardiovascular risk factors, which add more burden to circulatory disease, mortality and rapid advancement to CKD stage 5. The aim of the study is to evaluate inflammation and nutritional status of CKD patients not on dialysis using Malnutrition inflammation score (MIS) and to verify the association with mortality in the follow-up period. In this prospective cohort study 129 (66 males, 63 females) pre-dialysis CKD patients enrolled between June 2013 to August 2014 and censored until March 2017. Malnutrition and Inflammation assessed using Malnutrition inflammation score. Blood urea nitrogen, serum creatinine, albumin, Interleukin - 6, highly sensitive C reactive protein (hsCRP), total cholesterol and anthropometric data were analyzed. The Malnutrition inflammation score in pre-dialysis CKD patients ranged from 0 to 18 with the median score of two. During 36 or more months of follow-up, there were 30 (23.2%) deaths, 35 (27%) patients initiated on hemodialysis, one (0.7%) patient was initiated on peritoneal dialysis, two (1.4%) patients underwent renal transplantation and two (1.4%) patients were lost for follow-up. In this study, 33% had varying degree of malnutrition and inflammation. Patients who had MIS ≥7 had significant increase in IL-6 (p=0.003) and HsCRP levels (p<0.001) when compared with other tertiles of MIS. ROC curve analysis of MIS showed 56.5% sensitivity and 81% specificity in predicting death rate (AUC 0.709; 95% CI 0.604-0.815, p<0.001). Kaplan-Meier survival analysis showed MIS ≥7 had a strong association (log rank test, p<0.001) with mortality during 36 and more months of follow-up time. In unadjusted analyses, MIS (HR 1.140; 95% CI 1.054-1.233; p<0.05) and HsCRP (HR 2.369; 95% CI 1.779-3.154; p<0.001) found to be predictors of mortality. MIS and HsCRP remained predictors of mortality even after adjustments. This study shows MIS is an important factor that determines mortality in pre-dialysis CKD patients during 36 and more months of follow-up time. Patients with MIS ≥7 have high risk for mortality and needs close monitoring. In clinical setting application of MIS has a greater utilization in pre-dialysis CKD patients. Further research with longitudinal assessment of MIS and its association with outcomes are warranted. Pre-dialysis CKD patients should be assessed for their nutritional status and inflammation using MIS regularly to prevent malnutrition and its associated complications through appropriate medical and nutritional intervention.