Malnutrition Inflammation Score Research Articles

#5285 SERUM IRON AND NUTRITIONAL STATUS ARE ASSOCIATED IN PATIENTS WITH CHRONIC KIDNEY DISEASE

Abstract Background and Aims Both anemia and malnutrition are highly prevalent in patients with chronic kidney disease (CKD). Iron deficiency plays a significant role in anemia of CKD. However, whether iron deficiency contributes to malnutrition in CKD is unclear. Method We examined the association of iron status with nutritional status among patients with CKD stages 3–5 not yet on dialysis. The iron indices for assessing iron status included serum iron, serum ferritin, and transferrin saturation. Nutritional status was determined using body composition assessed by anthropometric measures and multi-frequency bioelectrical impedance, serum albumin, handgrip strength, Malnutrition Inflammation Score (MIS), and dietary protein and energy intake. We performed linear regression analyses to explore the cross-sectional association between iron status and different nutritional assessment tools. Results A total of 157 patients (age 64 ± 12 years; 93 men and 64 women; diabetes 39%) with CKD [estimated glomerular filtration rate (eGFR) 24.4 ± 13.4 ml/min/1.73 m2] were included. Patients were stratified as low (<70 μg/dL) or high (≥70 μg/dL) serum iron. Compared with patients with high serum iron (n = 104), patients with low serum iron (n = 53) were more likely to be female and had a significantly lower eGFR, hemoglobin, lean tissue index, serum albumin, handgrip strength, and dietary protein intake but a significantly higher MIS. In adjusted linear regression analyses, there was a significant association of serum iron with serum albumin, handgrip strength, and MIS (all adjusted P < 0.05). Serum ferritin was not associated with nutritional status, while the association between transferrin saturation and handgrip strength was only marginal (adjusted P = 0.044). Conclusion Higher serum iron is associated with better nutritional status in patients with CKD. Serum iron may be considered a complementary tool to assess nutritional status in CKD.

#2616 DIAGNOSTIC VALUE OF THE HANDGRIP STRENGTH IN DETECTING PROTEIN-ENERGY WASTING AMONG HEMODIALYSIS PATIENTS AT NATIONAL KIDNEY AND TRANSPLANT INSTITUTE

Abstract Background and Aims Protein energy wasting (PEW) is a syndrome of adverse nutritional and catabolic changes common among chronic kidney disease (CKD) patients. Handgrip strength (HGS) was one of the methods of screening PEW mentioned in Kidney Disease Outcomes Quality Initiative guidelines. However, only few studies determined the validity of HGS in detecting PEW among maintenance hemodialysis (MHD) patients. The study aimed to determine the diagnostic validity of HGS in detecting PEW among MHD patients in a tertiary government hospital, with the following specific objectives: to determine the prevalence of PEW among MHD patients, to compare the demographic and clinical profile by PEW status, to identify the optimal cut-off point of HGS pre- and post-HD sessions in detecting PEW by sex, and to determine the following diagnostic value parameters of HGS pre- and post-HD sessions in detecting PEW by sex in terms of discriminative ability, accuracy, sensitivity, specificity, positive predictive value and negative predictive value. Method Participants included in this cross-sectional study are randomly selected patients undergoing MHD in National Kidney and Transplant Institute (NKTI) from September to October, 2022. Diagnosis of PEW was based on the Malnutrition Inflammation Score (MIS) ≥5. HGS was measured using a dynamometer pre- and post-dialysis sessions. Results A total of 143 patients were included in the study, and 53% were diagnosed with PEW. Pre-HD and post-HD HGS have acceptable discriminative ability based on Area Under the Curve >0.70 in detecting PEW regardless of patient sex. In males, a post-hemodialysis cut-off of <17.9 showed 72% sensitivity and 71% specificity in detecting PEW. Meanwhile, a pre-hemodialysis cut-off of <18.6 in females showed 83% sensitivity and 65% specificity in detecting PEW. Conclusion PEW is common among MHD patients in NKTI. The diagnostic performance of HGS in detecting PEW was found to be acceptable in both males and females. While both pre- and post-HD measures can be used in males, only the pre-HD measures are recommended for females. HGS can, therefore, be used as a non-expensive, accurate and objective screening assessment tool in detecting PEW for MHD patients. External validation of the proposed HGS cut-off values is still recommended.

#4287 GASTROINTESTINAL SYMPTOMS IN PATIENTS RECEIVING HEMODIALYSIS: PREVALENCE, SEVERITY AND ASSOCIATED FACTORS

Abstract Background and Aims Gastrointestinal (GI) symptoms are common among patients with chronic renal failure, especially in those treated with maintenance hemodialysis (HD), and may adversely affect patients'' quality of life. A variety of GI symptoms has been reported, but previous studies present conflicting results regarding their association with age, sex, comorbidities, concomitant medications and dialysis modality. This study aimed to assess the prevalence and severity of GI symptoms in the maintenance HD population and explore possible associated factors. Method A total of 188 stable patients (55.3% male, 53.7% ≥65 years of age, age range 24–85, 30.9% with diabetes, 19.9% smokers) from three HD centres were enrolled in this observational cross-sectional study. Gastrointestinal symptoms were assessed by the self-administered Gastrointestinal Symptoms Rating Scale (GSRS). The scale includes 15 items graded by a 7-point Likert scale that can be grouped into five dimensions: abdominal pain syndrome, reflux syndrome, indigestion syndrome, diarrhoea syndrome, and constipation syndrome. A dimension score is calculated as the mean value of the items belonging to the specific syndrome, and the final score is the mean of dimension scores. Standard blood analyses, Kt/V, body mass index (BMI) and malnutrition-inflammation score (MIS) were determined in all patients. Other relevant demographic and clinical data were obtained from the patient's medical records. The results were analyzed with SPSS software, version 22 (IBM Corporation, New York, USA). Results The average BMI was 25.04±4.29. Half of the patients (50.3%) were overweight, 45.3% had normal weight, and 4.3% were underweight. The average MIS was 5.64±2.87. The average number of symptoms per patient was 4.01±3.20 (range 0 – 15). At least one GI symptom was reported by 84.6% of patients (33.0% reported 1 – 3 symptoms, and 49.5% reported 4 or more symptoms). The mean GSRS scores for eating dysfunctions were 1.59±1.08 for reflux, 1.74±0.98 for abdominal pain, 1.75±1.14 for constipation, 1.94±1.01 for indigestion, and 1.38±0.90 for diarrhoea. Total GSRS was 1.70±0.61. Elderly patients had a significantly lower overall number of GI symptoms (3.49±2.83 vs 4.57±3.51; p = 0.023), lower abdominal pain score (1.60±0.96 vs 1.91±1.09; p = 0.031), and indigestion score (1.74±0.85 vs 2.18±1.15; p = 0.005), but higher constipation (1.94±1.27 vs 1.54±0.96;p = 0.017) score than individuals under 65 years of age. Patients smoking cigarettes and those longer on HD had a significantly higher overall number of GI symptoms (3.44±0.56 vs 3.10±0.25; p = 0.035 and 3.78±2.99 vs 2.46±2.23; p = 0.016 respectively). Average abdominal pain score was significantly higher in non-diabetic (1.87±1.04 vs 1.44±0.75; p = 0.002) and underweight (2.62±1.51 vs 1.71±0.94 vs 1.65±0.90; p = 0.023) compared to diabetic, normal weight and overweight patients respectively. Patients taking ASA or NSAIDs had significantly higher total GSRS scores (1.84±0.72 vs 1.60±0.50; p = 0.016 and 1.88±0.64 vs 1.65±0.59; p = 0.044 respectively). Sex, dialysis adequacy and malnutrition-inflammation status were not significantly related to any of the GSRS dimensions. Conclusion The present study demonstrates a high prevalence of GI symptoms in maintenance HD patients and identifies age, cigarette smoking, diabetes, dialysis vintage, and certain medications as important elements to consider when addressing specific groups of GI symptoms in this population.

Nutritional Assessment of Patients on Twice Weekly Maintenance Hemodialysis

Objective: To assess the magnitude of malnutrition in hemodialysis patients in Pakistan and identify contributing factors in order to facilitate timely interventions and improve their quality of life. Methodology: A cross-sectional descriptive study was conducted at the nephrology inpatient department of Fauji Foundation Hospital Rawalpindi from April to September 2021. The study included patients aged 15–60 years, of both genders, who had been on maintenance hemodialysis twice weekly for at least six months. Data was collected by structured performa, which included patients’ demographic details, including age, gender, level of education, and daily income; the cause and duration of CKD; duration and frequency of haemodialysis Malnutrition was assessed using the Malnutrition Inflammation Score (MIS) and categorized as mild, moderate, or severe. Results: Out of the 107 enrolled patients, 90 were included in the analysis. The study revealed that only one-third of the patients had normal nutritional status, while the rest exhibited varying degrees of malnutrition. Severe malnutrition was observed in 20% of the hemodialysis population. Female gender, lower education level, and lower income were strongly associated with severe malnutrition. Conclusion: The study highlights the need to improve literacy, raise awareness about chronic kidney disease (CKD), and enhance the financial status of hemodialysis patients. These interventions can significantly improve outcomes and quality of life in this population. The findings emphasize the importance of identifying high-risk patients early on and implementing appropriate interventions to improve nutritional status and overall well-being.

Frailty in hemodialysis patients: results of a screening program and multidisciplinary interventions.

The number of frail patients of advanced age with end-stage kidney disease (ESKD) undergoing hemodialysis is increasing globally. Here we evaluated a frailty screening program of ESKD patients starting hemodialysis, and subsequent multidisciplinary interventions. This was a prospective observational study of ESKD patients in a hemodialysis program. Patients were evaluated for frailty (Fried frail phenotype) before and after a 12-month period. Patients followed standard clinical practice at our hospital, which included assessment and multidisciplinary interventions for nutritional (malnutrition-inflammation score, protein-energy wasting), physical [short physical performance battery (SPPB)] and psychological status. A total of 167 patients (mean±standard deviation age 67.8±15.4 years) were screened for frailty, and 108 completed the program. At screening, 27.9% of the patients were frail, 40.0% pre-frail and 32.1% non-frail. Nutritional interventions (enrichment, oral nutritional supplements, intradialytic parenteral nutrition) resulted in stable nutritional status for most frail and pre-frail patients after 12 months. Patients following recommendations for intradialytic, home-based or combined physical exercise presented improved or stable in SPPB scores after 12 months, compared with those that did not follow recommendations, especially in the frail and pre-frail population (P=.025). A rate of 0.05 falls/patient/year was observed. More than 60% of frail patients presented high scores of sadness and anxiety. Frailty screening, together with coordinated interventions by nutritionists, physiotherapists, psychologists and nurses, preserved the health status of ESKD patients starting hemodialysis. Frailty assessment helped in advising patients on individual nutritional, physical or psychological needs.

Hemodialysis Serum Stimulates the TXNIP-eNOS-STAT3 Inflammatory Pathway In Vitro.

Endothelial dysfunction, vascular inflammation and accelerated atherosclerosis have been investigated extensively in patients with chronic kidney disease (CKD). These conditions, as well as protein-energy malnutrition and oxidative stress, impair kidney function and contribute to increased morbidity and mortality among patients with end-stage kidney disease undergoing hemodialysis (HD). TXNIP, a key regulator of oxidative stress, has been linked to inflammation and suppresses eNOS activity. STAT3 activation adds to endothelial cell dysfunction, macrophage polarization, immunity and inflammation. Therefore, it is critically involved in atherosclerosis. This study evaluated the effect of sera from HD patients on the TXNIP-eNOS-STAT3 pathway using an in vitro model of human umbilical vein endothelial cells (HUVECs). Thirty HD patients with end-stage kidney disease and ten healthy volunteers were recruited. Serum samples were taken at dialysis initiation. HUVECs were treated with HD or healthy serum (10% v/v) for 24 h. Then, cells were collected for mRNA and protein analysis. TXNIP mRNA and protein expression were significantly increased in HUVECs treated with HD serum compared to healthy controls (fold changes: 2.41 ± 1.84 vs. 1.41 ± 0.5 and 2.04 ± 1.16 vs. 0.92 ± 0.29, respectively), as were IL-8 mRNA (fold changes: 2.22 ± 1.09 vs. 0.98 ± 0.64) and STAT3 protein expression (fold changes: 1.31 ± 0.75 vs. 0.57 ± 0.43). The expression of eNOS mRNA and protein (fold changes: 0.64 ± 0.11 vs. 0.95 ± 0.24; 0.56 ± 0.28 vs. 4.35 ± 1.77, respectively) and that of SOCS3 and SIRT1 proteins were decreased. Patients' nutritional status, reflected by their malnutrition-inflammation scores, did not affect these inflammatory markers. This study showed that sera from HD patients stimulated a novel inflammatory pathway, regardless of their nutritional status.

The predictive value of temporal muscle thickness measured by ultrasonography for detecting moderate to severe malnutrition in chronic hemodialysis patients.

To determine the predictive value of temporal muscle thickness (TMT) measured by ultrasonography in the diagnosing of moderate to severe malnutrition in chronic hemodialysis (CHD) patients. Adult patients (> 18years) who had been on CHD for at least 3months were included in this cross-sectional study. Patients with infection or inflammatory disease, malignancy, malabsorption syndrome, history of surgery within the last 3months excluded. Demographic, anthropometric, laboratory parameters, and Malnutrition Inflammation Score (MIS) test results recorded. A total of 60 chronic hemodialysis (CHD) patients (median age: 66years, 46.7% female) and 30 healthy individuals (median age: 59.5years, 55% female) were examined. While there were no significant difference between the dry weight (70 vs 71kg) and body mass index (BMI) (25.8 vs 26kg/m2) of the CHD patients and healthy control group, we found that triceps skinfold thickness (TST) (16 vs 19mm) and left and right TMT (9.6 vs 10.7 and 9.8 vs 10.9mm) values were significantly lower in the CHD patients (p < 0.001). CHD patients were divided into two groups according to their MIS values as mild (MIS < 6) and moderate/severe malnutrition (MIS ≥ 6). Patients with moderate/severe malnutrition were older, predominantly female and with longer HD vintage. Left (8.8 vs 11mm) and right TMT (9.1 vs 11.2mm) values were lower in moderate/severe malnutrition group. In the correlation analysis, a negative correlation was found between TMT and age and MIS, and a positive correlation determined with dry weight, BMI, TST and serum uric acid. In the ROC curve analysis, we found that the optimal cut-off value of left and right TMT for predicting moderate/severe malnutrition were 10.05 and 10.45mm, respectively. Multivariate regression analysis showed that HD vintage, URR, and TMT values were independently associated with moderate/severe malnutrition. TMT value measured by ultrasonography in CHD patients can be used as a reliable, easily accessible and non-invasive diagnostic method for predicting moderate/severe malnutrition.

QEEG characteristics associated with malnutrition-inflammation complex syndrome.

End-stage renal disease (ESRD) has been linked to cerebral complications due to the comorbidity of malnutrition and inflammation, which is referred to as malnutrition-inflammation complex syndrome (MICS). The severity of this condition is clinically assessed with the malnutrition-inflammation score (MIS), and a cutoff of five is used to optimally distinguish patients with and without MICS. However, this tool is still invasive and inconvenient, because it combines medical records, physical examination, and laboratory results. These steps require clinicians and limit MIS usage on a regular basis. Cerebral diseases in ESRD patients can be evaluated reliably and conveniently by using quantitative electroencephalogram (QEEG), which possibly reflects the severity of MICS likewise. Given the links between kidney and brain abnormalities, we hypothesized that some QEEG patterns might be associated with the severity of MICS and could be used to distinguish ESRD patients with and without MICS. Hence, we recruited 62 ESRD participants and divided them into two subgroups: ESRD with MICS (17 women (59%), age 60.31 ± 7.79 years, MIS < 5) and ESRD without MICS (20 women (61%), age 62.03 ± 9.29 years, MIS ≥ 5). These participants willingly participated in MIS and QEEG assessments. We found that MICS-related factors may alter QEEG characteristics, including the absolute power of the delta, theta, and beta 1 bands, the relative power of the theta and beta 3 subbands, the coherence of the delta and theta bands, and the amplitude asymmetry of the beta 1 band, in certain brain regions. Although most of these QEEG patterns are significantly correlated with MIS, the delta absolute power, beta 1 amplitude asymmetry, and theta coherence are the optimal inputs for the logistic regression model, which can accurately classify ESRD patients with and without MICS (90.0 ± 5.7% area under the receiver operating characteristic curve). We suggest that these QEEG features can be used not only to evaluate the severity of cerebral disorders in ESRD patients but also to noninvasively monitor MICS in clinical practice.

Association between Cognitive Impairment and Malnutrition in Hemodialysis Patients: Two Sides of the Same Coin.

Cognitive impairment and malnutrition are prevalent in patients on hemodialysis (HD), and they negatively affect the outcomes of HD patients. Evidence suggests that cognitive impairment and malnutrition may be associated, but clinical studies to assess this association in HD patients are lacking. The aim of this study was to evaluate the association between cognitive impairment evaluated by the Montreal Cognitive Assessment (MoCA) score and nutritional status evaluated by the malnutrition inflammation score (MIS) in HD patients. We enrolled 84 HD patients (44 males and 40 females; age: 75.8 years (63.5-82.7); HD vintage: 46.0 months (22.1-66.9)). The MISs identified 34 patients (40%) as malnourished; the MoCa scores identified 67 patients (80%) with mild cognitive impairment (MCI). Malnourished patients had a higher prevalence of MCI compared to well-nourished patients (85% vs. 70%; p = 0.014). MoCa score and MIS were negatively correlated (rho:-0.317; p < 0.01). Our data showed a high prevalence of MCI and malnutrition in HD patients. Low MoCA scores characterized patients with high MISs, and malnutrition was a risk factor for MCI. In conclusion, it is plausible that MCI and malnutrition are linked by common sociodemographic, clinical, and biochemical risk factors rather than by a pathophysiological mechanism.

Evaluation of the efficacy of using gnri and mis as a predictor of mortality in elderly hemodialysis patients.

Malnutrition is one of the most common geriatric syndromes in hemodialysis (HD) patients. Although there is no gold standard for evaluating nutritional status in HD patients, the Subjective Global Assessment (SGA), Geriatric Nutritional Risk Index (GNRI), and Malnutrition-Inflammation Score (MIS) are widely used in clinical settings. To examine the efficacy of using Geriatric Nutritional Risk Index (GNRI) and Malnutrition-Inflammation Score (MIS) as a predictor of mortality in elderly hemodialysis patients. A retrospective cohort study was carried out in Malatya Training and Research Hospital's Hemodialysis Unit between July 2018 and August 2022. Two hundred seventy-four elderly hemodialysis patients were included in the study. Demographic characteristics, laboratory parameters, and anthropometric measurements of the patients were reviewed. Statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS) version 16.0 software (SPSS Inc., Chicago, IL, USA). Logistic regression analysis was performed to identify independent predictors of mortality. The mean age of 83 patients who died was 70.00 ± 8.39 years and 47 (56.6%) of these patients were male. All-cause death occurred in 69 (71.1%) of 97 patients with an MIS of ≥6. All-cause death occurred in 24 (54.5%) of 44 patients with a GNRI score of <91.2. Accordingly, MIS (P < 0.001, OR = 1.376 [0.163-0.392]), GNRI (P = 0.001, OR = -0.431 [1.189-1.990]), and age (P = 0.021, OR = 0.109 [0.818-0.984]) were found to be independent predictors of all-cause mortality. GNRI and MIS are important predictors of increased risk of mortality from all causes in elderly HD patients.

Multiple factors influencing mortality in hemodialysis patients.

Both decreased food intake and elevated inflammation contribute to malnutrition in hemodialysis (HD) patients. Malnutrition, inflammation, anthropometric measurements, and other comorbidity factors were investigated in this study as potential indicators of mortality in HD patients. By measuring geriatric nutritional risk index (GNRI), malnutrition inflammation score (MIS), and prognostic nutritional index (PNI), 334 HD patients' nutritional status was assessed. Through the use of four different models and logistic regression analysis, the predictors of each individual's survival status were examined. The models were matched using the Hosmer-Lemeshow test. On the survival of patients, the effects of malnutrition indices in Model 1, anthropometric measurements in Model 2, blood parameters in Model 3, and sociodemographic characteristics in Model 4 were investigated. Five years later, 286 individuals were still on hemodialysis. Patients who had a high GNRI value had a lower mortality rate in Model 1. The body mass index (BMI) value of the patients was found to be the best predictor of mortality in Model 2, and it was found that patients with high muscle percentage had a lower mortality risk. The difference in urea level measured at the beginning and end of hemodialysis was found to be the most potent predictor of mortality in Model 3, although C-reactive protein (CRP) level was also discovered to be one of the best predictors for this model. The final model, Model 4, revealed that mortality was lower in women than in men and that income status was a reliable predictor of mortality estimation. The best indicator of mortality in hemodialysis patients is the malnutrition index.

Body Composition Parameters Correlate to Depression Symptom Levels in Patients Treated with Hemodialysis and Peritoneal Dialysis.

The aim of this study was to investigate the determinants of depression and nutritional status and their associations in patients treated with hemodialysis (HD) and peritoneal dialysis (PD) and the differences according to the type of treatment. There were fifty-three patients treated with maintenance HD and twenty patients treated with PD enrolled in this cross-sectional study. Body composition, anthropometric parameters, and clinical and laboratory parameters were collected for each participant. Depression was assessed with the Beck Depression Inventory II (BDI-II) and risk of malnutrition with the Malnutrition Inflammation Score (MIS). The results suggest a positive association between the level of depression and the percentage of fat mass and obesity parameters in PD and HD participants. Muscle mass and fat-free mass in HD, phase angle (PhA), and serum albumin levels in PD were negatively associated with the value of BDI-II. Participants treated with HD were found to have higher levels of pessimism and loss of interest in sex compared with PD. There is a need to integrate multidisciplinary psychological and nutritional assessment into the usual care of dialysis patients.

Association of the malnutrition-inflammation score with physical function and functional disability in elderly patients with chronic kidney disease.

To describe nutritional status and inflammation of elderly patients with chronic kidney disease and to confirm the association between a Malnutrition-Inflammation Score and physical func-tion and functional disability. A total of 221 chronic kidney disease patients (aged ≥60 years) were included. A Malnutrition-Inflammation Score was used to assess malnutrition and inflammation. Physical function was assessed using the SF-12. Functional status was evaluated using basic activities of daily living and instrumental activities of daily living. Thirty percent of participants had a Malnutrition-Inflammation Score ≥6, which denoted poor nutritional status. Participants with a Malnutrition-Inflammation Score ≥6 had decreased concentration of hemoglobin, albumin, prealbumin, handgrip strength and walking speed and increased concentration of inflammatory markers, including CRP, IL-6 and fibrinogen. Physical function and physical component summary were lower and basic activities of daily living dependence and instrumental activities of daily living dependence were higher among patients with higher Malnutrition-Inflammation Score than those with a lower Malnutrition-Inflammation Score. The Malnutrition-Inflammation Score was an independent risk factor for physical function and instrumental activities of daily living dependence. The elderly chronic kidney disease patients with a high Malnutrition-Inflammation Score had a decreased physical function and an increased risk of functional instrumental activities of daily living dependence.

Effect of oral nutritional supplementation combined with impedance vectors for dry weight adjustment on the nutritional status, hydration status and quality of life in patients on chronic hemodialysis: A pilot study

Protein energy wasting frequently affect hemodialysis patients and contribute to the development of overhydration. The objective of this study was to assess the effect of oral nutritional supplementation (ONS) combined with bioelectrical vector analysis (BIVA) on the nutritional and hydration status and the quality of life (QoL) in hemodialysis (HD) patients. Thirty-two chronic HD patients were included in a 6-month randomized pilot study. Patients in SUPL group received a simultaneous intervention consisting of a personalized diet, 245mL/d ONS and dry weight adjustment through BIVA. Patients in CON group received a personalized diet and dry weight adjustment by BIVA. Anthropometrical, biochemical, dietary, QoL, handgrip strength (HGS) and bioimpedance measurements were performed. Malnutrition Inflammation Score (MIS) was applied. At the end of the intervention, moderate undernutrition decreased by 43.8% in SUPL group while in CON group, severe undernutrition increased by 13% (p<0.04 between groups). In the adjusted covariance analysis, SUPL compared to CON group, increased HGS (Δ 2.8Kg vs Δ-1.8Kg, p=0.003), serum albumin (Δ 0.29g/dL vs Δ-0.03g/dL, p=0.04) and serum transferrin (Δ 4.7mg/dL vs Δ-0.7mg/dL, p=0.0007). The increase in QoL was significantly higher in SUPL group. Dry weight was achieved in 100% of patients in SUPL and 95% in CON group. ONS combined with BIVA for dry weight adjustment, improved nutritional status, QoL and achieved dry weight in HD patients.

Multifaceted Nutritional Disorders in Elderly Patients Undergoing Dialysis

Advances in medicine have resulted in increased longevity, which has consequently led to unexpected geriatric syndromes, such as frailty and sarcopenia. Patients with end-stage kidney disease, especially those receiving dialysis treatment, often show characteristic reductions in body protein and energy storage, termed protein energy wasting (PEW). Therefore, maintenance of nutritional condition has a key role in defending against both geriatric syndromes and PEW, which share several components in elderly individuals undergoing hemodialysis. To counteract the development of an undesirable condition, nutritional evaluation is indispensable. In addition to simple measurements of body mass index, and serum albumin and creatinine, a composite nutritional assessment including a malnutrition inflammation score is useful, although subjective elements are included and a well-trained examiner is required. On the other hand, the geriatric nutritional risk index and nutritional risk index for Japanese hemodialysis patients (NRI-JH) are objective tools, and easy to use in clinical settings. Undernutrition is closely related to infectious events and the results of an infection are often serious in elderly patients, even those with survival, with large medical costs incurred. Together with appropriate nutritional evaluation, it is necessary to clarify the underlying relationship of PEW with infection for improvement of prognosis in affected elderly individuals.

Malnutrition and Erythropoietin Resistance among Patients with End-Stage Kidney Disease: Where Is the Perpetrator of Disaster?

Hemodialyzed patients with poor erythropoietin response tend to have low volume of visceral adipose tissue and score high on malnutrition-inflammation score. This study investigates in-depth the role of leptin and chosen cytokines in the development of malnutrition-inflammation syndrome (MIS) and erythropoietin resistance. Eighty-one hemodialyzed patients with erythropoietin-treated anemia were enrolled in the study. Their body composition was measured. Erythropoietin resistance index was calculated. Blood samples for leptin, IL-6, IL-18, TNF-alpha, and IL-1-alpha serum levels were drawn. Leptin showed negative correlation with erythropoietin resistance index (ERI), whilst IL-6 showed the opposite. IL-6 seemed to be linked more to HD parameters and vintage, while TNF-alpha and leptin were more dependent on body composition. IL-18 and IL-1-alpha did not affect nutritional parameters nor ERI. Modulation of adipokine- and cytokine-related signaling is a promising target in tempering malnutrition in hemodialyzed, and thus achieving better outcomes in anemia treatment. Large clinical studies that target the inflammatory response in hemodialysis, especially regarding IL-6, TNF-alpha, and leptin, would be of great worth.

Evaluation of malnutrition and inflammation after total parathyroidectomy in patients on maintenance dialysis.

To evaluate the effect of total parathyroidectomy (tPTx) on malnutrition and inflammation in patients on maintenance dialysis (MHD) having secondary hyperparathyroidism (SHPT). Twenty-five patients on MHD having SHPT who were being treated with tPTx were selected, and changes in their general condition (dry body mass), parathyroid hormone (PTH) and calcium levels, nutrition state (hemoglobin, hematocrit, serum albumin, and total iron binding capacity), and inflammatory status [serum C-reactive protein (CRP), interleukin-6 (IL-6), tumor necrosis factor (TNF-α), and the malnutrition-inflammation score (MIS)] were observed at 12, 24, and 36months postoperatively. Compared with the preoperative period, the dry body mass increased at 12, 24, and 36months postoperatively (P < 0.01), hemoglobin, hematocrit, and serum albumin increased significantly (P < 0.01), whereas calcium, phosphorus, and PTH levels decreased significantly (P < 0.01). Serum CRP, IL-6, and TNF-α levels were significantly decreased at 12, 24, and 36months after surgery (P < 0.01). Furthermore, MIS was reduced as well but to a lesser extent (P < 0.01). tPTx effectively reduced MIS in maintenance dialysis patients, and the alleviated malnutrition and improved inflammatory status may contributed to improving the quality of life of patients on MHD with SHPT.

Oral energy supplementation improves nutritional status in hemodialysis patients with protein-energy wasting: A pilot study.

Background: Protein-energy wasting (PEW) is highly prevalent in hemodialysis (HD) patients, which is associated with poor quality of life, complications, and an increased risk of mortality. A prospective study in HD patients with 2months of oral energy supplements (OESs) was performed. Methods: A total of 37 HD patients with PEW were finally enrolled in this prospective study and were randomized into the OES group (n = 19), which received oral energy supplementation (300kcal) and dietary recommendations, while patients in the non-OES group (n = 18) received only dietary recommendations. The study duration was 2months. The nutritional status of the patients was evaluated by laboratory indexes, body composition parameters, and the modified quantitative subjective global assessment (MQSGA) and malnutrition-inflammation score (MIS). Quality of life was evaluated by the Short Form Health Survey Questionnaire (SF-36). Results: After 2months of therapy, a significant increase in serum albumin [39.6 (37.6-45.8) vs. 43.4 (39.1-46.7) g/L; p = 0.018], hemoglobin (101.0 ± 13.6g/L vs. 111.8 ± 11.7g/L; p = 0.042), and dietary energy intake (29.17 ± 3.22kcal/kg/day vs. 33.60 ± 2.72kcal/kg/day, p < 0.001) was observed in the comparisons of baseline in the OES group. Moreover, the OES group demonstrated significant amelioration in MQSGA [9 (8-13) vs. 8 (7-12), p < 0.001] and MIS [5 (3-10) vs. 3 (2-8), p < 0.001], physical functioning (p < 0.001), and mental health (p = 0.046) subsections of SF-36 compared with the baseline. No electrolyte disorders or dyslipidemia were observed in the OES group. Conclusion: OES in HD patients with PEW can significantly ameliorate energy supply, nutritional status, anemia, and quality of life.

Consistency of MIS with other malnutrition screening tools among adult and elderly hemodialysis patients

Background and aimMalnutrition and inflammation commonly occur concomitantly among hemodialysis patients. Malnutrition inflammation score (MIS) is a tool that helps clinical and nutritional evaluation of patients regardless of age. This study aimed to determine the best approach by comparing different tools/indices to evaluate the malnutrition and inflammation status of patients having hemodialysis treatment regarding their age and to examine the clinical benefits and consistency of MIS with other malnutrition tools. MethodsThe study was conducted with a sample of 140 hemodialysis patients (70 adults and 70 elderly patients). The biochemical data of the patients were retrospectively obtained, and the research dietitian conducted the anthropometric measures. In addition to MIS, 7 point-SGA (7p-SGA), Nutrition Risk Index (NRI) for adults, and Mini Nutritional Assessment (MNA), Geriatric Nutritional Risk Index (GNRI) for elderly patients were used. The model's discriminatory power was examined by receiver operating characteristics curve analysis. ResultsPatients who were “at-risk” according to MIS had significantly lower scores of 7p-SGA and NRI than those who had “no risk” (p<0.001). Moreover, those who are “at-risk” have significantly lower MNA scores than those who are not (p=0.002). Among adult patients, MIS displayed lower sensitivity but higher specificity with NRI than 7p-SGA. However, for elderly patients, MIS showed fair sensitivity and specificity with MNA but the highest sensitivity with GNRI. ConclusionAlthough different screening tools are available to screen malnutrition among dialysis patients regarding their age, MIS might be more clincally useful as it is more susceptible to assess both malnutrition and inflammation that occur concomitantly.

Response to Treatment with Erythropoietin in Chronic Kidney Disease Patients with Protein Energy Wasting in Homa Bay Teaching and Referral Hospital, Kenya

Anemia is one of the major causes of morbidity in Chronic Kidney Disease (CKD). There are many causes of anemia in CKD, but the main cause is erythropoietin deficiency. CKD patients on hemodialysis have a high protein-energy wasting (PEW) prevalence that may explain Erythropoietin's (EPO) hypo-responsiveness. This study aimed to evaluate the response to EPO treatment in CKD patients with PEW in Homa County Teaching and Referral Hospital. The study was a retrospective medical chart review of patients on hemodialysis in 2018 and 2019 at Homa Bay County Teaching and Referral Hospital. The patients were classified according to PEW diagnostic using the Subjective Global Assessment tool and the Malnutrition Inflammation score tools. PEW prevalence was 41.2% while the prevalence for anemia was 85.3%. The mean hemoglobin at the onset of EPO treatment for patients with PEW and patients without PEW was 8.71 ± 1.82 and 9.53±1.90 g/dl while the final mean hemoglobin was 9.35±1.95 and 10.7±1.86 g/dl respectively. Differences between groups with PEW and groups without PEW were analyzed considering their responsiveness and a statistically significant improvement was recorded in patients without PEW after EPO administration (p-value=0.04). The relative risk of EPO resistance, considering 95 % confidence interval, was 0.3 with a range of 0.109 – 0.825. The risk of poor response to EPO treatment was reduced to 30 % in patients without PEW. This study concluded that PEW contributes to poor response to EPO treatment in hemodialysis patients. It is therefore important to correct wasting in these patients to improve response to EPO treatment. Key words: Anaemia, Erythropoietin, Protein Energy Wasting, Chronic Kidney Disease