Normalized Protein Catabolic Rate Research Articles

Risk factors associated with mortality among patients on maintenance hemodialysis: The Thailand Renal Replacement Therapy registry.

End-stage kidney disease (ESKD) has been increasing in prevalence across the world, including Thailand, and patients with ESKD on hemodialysis have a high mortality risk. A retrospective cohort study was performed across 855 hemodialysis centers in the Thailand Renal Replacement Therapy registry. The database and mortality data were analyzed. A total of 58 952 patients were included. The survival rates at 1, 3, and 5 years were 93.5%, 69.7%, and 41.2%, respectively. On multivariate analysis, factors such as aging, permanent catheter or arteriovenous graft, twice-weekly hemodialysis, low levels of urea reduction ratio, normalized protein catabolic rate, hemoglobin, transferrin saturation, serum albumin, LDL-cholesterol, intact-parathyroid hormone, uric acid, sodium, phosphate, and bicarbonate were significantly related to death. Mortality is high in ESKD patients on hemodialysis. Age, type of vascular access, twice-weekly hemodialysis, inadequate dialysis, low protein intake, anemia, abnormal electrolytes, and bone mineral disorders are associated with all-cause mortality.

#1277 Comparing advanced glycation end products removal in super high-flux hemodialysis versus high-volume hemodiafiltration: a randomized, crossover study

Abstract Background and Aims Expanded hemodialysis using super high-flux membrane, is a promising therapy for effectively clearing middle molecule uremic toxins. However, its impact on advanced glycation end products (AGEs), which is related to an increase in cardiovascular mortality [1], remains inconclusive. Previous studies demonstrated that AGEs increased over time in patients treated with high-flux hemodialysis (HD) [2, 3] while remaining stabilized in online hemodiafiltration (ol-HDF) [3]. This study aims to compare the longitudinal tissue AGEs measured by skin autofluorescence (SAF) between super high-flux hemodialysis (SHF-HD) and high-volume post-dilution ol-HDF. Method In this open-label prospective cross-over 24-week trial, twenty-two prevalent HD patients were randomly assigned to undergone two sequences of 24-week treatment periods: SHF-HD followed by high-volume postdilution ol-HDF or vice versa, with a 4-week wash-out period with high-flux HD between. SAF was measured at baseline and 24 weeks. Midweek pre-HD measurements of beta-2 microglobulin (B2M), serum albumin, normalized protein catabolic rate (NPCR) and Kt/V were obtained every 8 weeks. The amount of dialysate albumin was collected by continuous sampling of spent dialysate method and determined by immunoturbidimetric assay Results Seventeen out of twenty-two patients completed the study. At baseline, SAF levels (3.88 ± 0.14 vs 3.99 ± 0.14 AU, p = 0.463) and pre-HD B2M (22.66 ± 1.41 vs 21.09 ± 1.41 mg/L, p = 0.228) were similar between the SHF-HD and ol-HDF groups. After 24 weeks, SAF levels showed no significant change in SHF-HD (from 3.88 ± 0.14 to 3.91 ± 0.14 AU, p = 0.846) and ol-HDF (from 3.99 ± 0.14 to 3.95 ± 0.14 AU, p = 0.796), with a mean difference of change 0.06 (95% CI −0.34, 0.47, p = 0.75). Similarly, mid-week pre-HD serum B2M at 24 weeks exhibited no significant change in the SHF-HD group (22.66 ± 1.41 to 22.18 ± 1.47 mg/L, p = 0.722) and the ol-HDF group (21.09 ± 1.41 to 21.83 ± 1.45 mg/L, p = 0.577), with a mean difference of change −1.22 (95% CI −4.94, 2.49, p = 0.519). The spKt/V urea did not exhibit any notable differences. Furthermore, pre-HD levels of all small uremic toxins after the 24-week periods did not differ between both groups. Nutritional status measured by serum albumin and NPCR were comparable despite higher dialysate albumin loss in postdilution ol-HDF group (0.82 ± 0.04 vs 1.92 ± 0.12 g, p < 0.001 in SHF-HD and ol-HDF, respectively) Conclusion After 24 weeks of treatment, SHF-HD demonstrated levels of AGEs, pre-HD serum B2M, and serum albumin comparable to high-volume ol-HDF. If high-volume postdilution ol-HDF is not feasible, SHF-HD may serve as a valuable alternative treatment for stabilizing AGEs in chronic hemodialysis patients.

#729 Application of ChatGPT to support nutritional recommendations for dialysis patients

Abstract Background and Aims The rising diversity of food preferences and the desire to provide better personalized care provide challenges to renal dietitians working in dialysis clinics. To address this situation, we explored the use of a Large Language Model (LLM), specifically, ChatGPT using the GPT-4 model (openai.com), to support nutritional advice given to dialysis patients. Method We applied a prompt that allows us to consider various factors that determine personalized dietary recommendations, menu options, and nutritional analysis. The prompt integrates several domains, including patient demographics (age, sex, race, and ethnicity) and food preferences (vegetarian, Indian, Latin American, Mediterranean, East Asian), laboratory data (levels of serum phosphate, potassium, albumin, calcium, and normalized protein catabolic rate), and clinical characteristics (height, BMI, comorbidities, and dialysis modality). Twenty virtual patients were created using Monte Carlo simulation in the statistical software R; we provided the characteristics of one randomly selected patient to ChatGPT (Fig. 1). The resulting daily recipe recommendations, cooking instructions, and nutritional analyses were reviewed and rated on a five-point Likert scale by an experienced renal dietitian. In addition, we entered the ChatGPT-generated recipes into an USDA-approved nutrient analysis software (ESHA research, Salem, OR, USA) for comparison. A pre-defined kidney-friendly recipe from the website of a large dialysis organization (Fresenius Medical Care (FMC), Waltham, MA, USA) was included for comparison as well. We were able to narrow down and personalize requests in a short dialogue with the bot, for example: “John is a hemodialysis patient. Age, years: 63.58; Height, cm: 181.52; BMI: 37.27; Serum albumin, g/dL: 3.08; Serum phosphate, mg/dL: 4.39; Serum potassium, mmol/L: 5.08; Total serum calcium, mg/dL: 8.63; nPCR, g/kg/day: 0.709; Sex: Male; Race/Ethnicity: Black; DM: No; CHF: No; Diet Restriction: No restriction; Food preferences: Latin American; Dialysis modality: HD; Budget: around $25. Can you create a one-day sample menu for this hemodialysis patient with recipes and nutritional analyses?” Results A daily menu comprising five recipes was created. The renal dietitian rated the recipes (2.9 on the 5-point Likert scale) and cooking instructions (4.8) as moderately satisfactory, but the nutritional analysis (2) was questionable. While ChatGPT's carbohydrate content estimation was relatively accurate, it underestimated calories by 36%, protein by 28%, and fat, phosphorus, potassium, and sodium by around 50% (Fig. 2A). Discrepancies observed with potassium may be partly explained by the analyses of raw vs. cooked ingredients (which may be altered by cooking techniques), unspecified portion sizes, and limited data for ChatGPT training (e.g., potassium is not a required nutrition label component). Interestingly, these discrepancies are much smaller with recipes garnered from the FMC website (Fig. 2B). The percentage differences between USDA's (=100%) and ChatGPT's estimations of recipes from different sources were shown in Fig. 2C. In addition, we explored the use of ChatGPT to create personalized dietary recommendations/menus in different languages, such as Mandarin. The translations, as judged by native speakers, were reliable. Conclusion While LLMs such as ChatGPT hold promise to provide personalized nutritional guidance to diverse populations of dialysis patients, we think that there is substantial room for improvement. Our findings underscore the importance of a critical approach and the need to assess qualitatively and quantitatively the output created by LLMs, especially regarding medical use cases.

#1067 The impact of hemodialysis (HD) versus hemodiafiltration (HDF) on the effect of intradialytic exercise: a multicentre cohort study

Abstract Background and Aims Diminished physical function in HD patients is a critical issue, necessitating strategic approaches to enhance the efficacy of exercise therapy. The differential impacts of HD and HDF on solute clearance, albumin loss, uremic conditions, and malnutrition could influence the success of exercise interventions. Presently, empirical evidence for this is lacking. This investigation explores how HD and HDF modalities influence the efficacy of exercise therapy administered during dialysis sessions. Method This study encompassed intradialytic resistance exercises, involving 414 patients with end-stage renal disease across 10 centers. Participants were voluntarily enlisted in an exercise regimen during their dialysis sessions. The intradialytic regimen comprised stretching and four types of resistance exercises utilizing elastic tubes, conducted thrice weekly over six months. Parameters such as 10-meter walking speed, knee extensor muscle strength, serum albumin levels (Alb), normalized protein catabolic rate (nPCR), and Creatinine Generation Rate (%CGR) were assessed pre-and post-intervention. Statistical analysis included propensity score matching to adjust for baseline characteristics, segregating patients into HD and HDF cohorts. Changes in the aforementioned indicators before and after intervention (Δ) were calculated. Analytical methods included paired t-tests for within-group comparisons and independent t-tests for between-group comparisons of Δ values. A 5% risk threshold was established for statistical significance. Ethical clearance was obtained from the Seirei Christopher University Ethics Committee. Results A propensity score matching yielded 70 matched pairs. There were no significant differences in baseline subject characteristics after propensity score matching. Within-group analyses in the HD group revealed significant improvements in 10-meter walking speed (1.42 ± 0.41→1.60 ± 0.46 m/s, p = 0.000), knee extensor strength (44.3 ± 14.7→49.6 ± 13.8%, p = 0.000), and a reduction in Kt/V (1.69 ± 0.32→1.64 ± 0.32, p = 0.006) after six months. The HDF group significantly enhanced 10-meter walking speed (1.54 ± 0.40→1.72 ± 0.40, p = 0.000), knee extensor muscle strength (51.7 ± 17.1→57.4 ± 17.7%, p = 0.000), nPCR (0.88 ± 0.15→0.94 ± 0.18, p = 0.009), and %CGR (106.3 ± 23.2→112.9 ± 25.2, p = 0.002) (pre to post value, respectively). There are no significant differences in other variables between pre- and post-values in each group. Comparative analysis between groups demonstrated a significantly lower ΔAlb (HD 0.04 ± 0.24 HDF −0.05 ± 0.27, p = 0.045)and a higher 7, p =0(HD 1.47 ± 18.2 HDF 6.65 ± 17.2, p = 0.004)in the HDF group compared to the HD group. Conclusion The study demonstrated a notable HDF group improvement in %CGR, an indicator of muscle mass, despite a decrease in albumin levels. This suggests that albumin loss due to HDF minimally affects the augmentation of physical function. The findings suggest integrating exercise therapy with HDF may positively influence protein consumption and muscle mass enhancement.

Predictors of Skeletal Muscle Index for Patients Treated With Hemodialysis

ObjectiveThere is an increased risk of skeletal muscle mass (SMM) loss among patients with stage 5 chronic kidney disease (CKD) treated with maintenance hemodialysis (MHD). The reduced SMM considerably influences the development of protein-energy wasting (PEW). Patients who develop PEW have higher hospitalization and mortality rates than those without PEW. This study determined if key variables could predict SMM Index (SMM adjusted for height) in patients receiving MHD. MethodsWe conducted a secondary analysis of cross-sectional data obtained from the Rutgers Nutrition and Kidney Database (n=178). Data were utilized to calculate both SMM and SMM Index. Univariate and multiple linear regression models explored the relationship between SMM Index and the following variables: serum albumin (ALB), Kt/V, normalized protein catabolic rate (nPCR), serum creatinine (SCr), and urea reduction ratio (URR). ResultsMost participants were Black/African American (82.9%), male (59.1%), and obese (39%), with a mean age of 55.9 ± 11.9 years. The median SGA score was 5, indicating a lower risk of malnutrition. Participants had a mean SMM of 26.4kg and a median SMM Index of 8.9kg/m2. Univariate regression modeling found URR to be a significant predictor of SMM Index, with increases in the percentage of URR predicting lower SMM Index values. The adjusted regression modeling found similar results, with increases in URR percentage predicting declines in SMM Index. ConclusionThis study found that URR was a predictor of SMM Index in patients receiving MHD. Further research is required to explore these relationships and provide clinicians with a more extensive array of tools to recognize early signs of SMM loss to prevent the progression of PEW.

Assessing Cross-Sectional Association of Uremic Pruritus with Serum Heavy Metal Levels: A Single-Center Study

(1) Background: Uremic pruritus (UP) is a common and taxing symptom in patients on maintenance hemodialysis (MHD). We have previously shown that blood lead levels (BLLs) and blood aluminum levels (BALs) were separately positively associated with UP in MHD patients. We also found that blood cadmium levels (BCLs) were positively associated with all-cause mortality and cardiovascular-related mortality in MHD patients. We wondered whether there is any correlation between BCLs and UP after adjusting for BLLs and BALs. (2) Methods: Patients enrolled in this study were all from three hemodialysis (HD) centers at Chang Gung Memorial Hospital, Lin-Kou Medical Center, including both the Taipei and Taoyuan branches. Correlations between UP and BLLs, BALs, BCLs, and other clinical data were analyzed. (3) Results: Eight hundred and fifty-three patients were recruited. Univariate logistic regressions showed that diabetes mellitus, hepatitis B virus infection, hepatitis C virus infection, HD duration, hemodiafiltration, dialysis clearance of urea, normalized protein catabolic rate, non-anuria, serum albumin levels, log (intact-parathyroid hormone levels), total serum cholesterol levels, serum low-density lipoprotein levels, log (blood aluminum levels), and log (blood lead levels) were associated with UP. Although log BCLs were not significantly associated with UP (p = 0.136) in univariate analysis, we still included log BCLs in multivariate logistic regression to verify their effect on UP given that our aim in this study was to verify associations between serum heavy metals and UP. Multivariate logistic regressions showed that log BLLs (OR: 27.556, 95% CI: 10.912–69.587, p < 0.001) and log BALs (OR: 5.485, 95% CI: 2.985–10.079, p < 0.001) were positively associated with UP. The other logistic regression, which stratified BLLs and BALs into high and low BLLs and BALs, respectively, showed that high BLLs or high BALs (low BLLs and low BALs as reference) (OR: 3.760, 95% CI: 2.554–5.535, p < 0.001) and high BLLs and high BALs combined (low BLLs and low BALs as reference) (OR: 10.838, 95% CI: 5.381–21.828, p < 0.001) were positively correlated with UP. (4) Conclusions: BLLs and BALs were positively correlated with UP. BCLs were not correlated with UP. Clinicians should pay more attention to the environmental sources of lead and aluminum to prevent UP.

Clinical risk factors for peritoneal dialysis withdrawal at different dialysis duration

Background The duration of patients maintained on peritoneal dialysis (PD) varied. This study investigated the clinical risk factors for PD withdrawal at different dialysis duration. Methods Patients who initiated PD from 1994 to 2011 were recruited and followed for at least 10 years until 2021. Patients were grouped into four groups according to dialysis duration or time on treatment (TOT) when withdrew PD. Results A cohort of 586 patients were enrolled (mean age of 54.9 years, median dialysis duration or TOT of 47.9 months). Patients who maintained PD for longer than 10 years were younger, with lower prevalence of diabetes, lower serum C-reactive protein (CRP) level and white blood cell (WBC) count, higher serum albumin and pre-albumin level, higher normalized protein catabolic rate (nPCR) and residual kidney function, and more common use of renin–angiotensin system inhibitors (RASi) at baseline (p < 0.05 for all). Peritonitis related death and ultrafiltration failure related HD transferring increased along with time on PD (p < 0.001). Old age, diabetes, low serum albumin, high WBC count, hypertensive nephropathy, and nonuse of RASi were associated with increased risk of non-transplantation related PD withdrawal (p < 0.05 for all). Low baseline CRP and use of RASi were independent predictors for long-term PD maintenance (p < 0.05 for all). Conclusions Long-term PD patients demonstrated young age, low prevalence of diabetes, better nutrition status, absence of inflammation, better residual kidney function, and higher proportion of RASi usage at baseline. Absence of inflammation and use of RASi were independently associated with long-term PD maintenance.

Comparative Analysis of Tools for Assessment of Protein–Energy Wasting in Chronic Kidney Disease Patients on Maintenance Hemodialysis

Abstract Background: Patients with chronic kidney disease have muscle wasting, sarcopenia, and cachexia that contribute to frailty and morbidity. The present study assessed the prevalence of protein–energy wasting in dialysis-dependent chronic kidney disease population and evaluated the validity of various nutritional assessment tools in diagnosing protein–energy wasting. Materials and Methods: All patients above 18 years undergoing dialysis for more than 3 months without any active infection or malignancy were included in our study. Data from anthropometric measurements, dietary assessment, and blood investigations were collected. Protein–energy wasting was assessed by the International Society of Renal Nutrition and Metabolism 2008 criteria. Diagnostic validity of the nutritional assessment tools to predict protein–energy wasting was estimated by area under the curve, sensitivity, specificity, and accuracy statistics. Results: A total of 146 patients were studied. The prevalence of protein–energy wasting was 56.8%. Protein–energy wasting was significantly associated with socioeconomic status, hospitalization days, and catheter days. Normalized protein catabolism rate had the highest sensitivity (90.4%) for predicting protein–energy wasting. Malnutritional inflammatory score had the highest area under the curve (0.858), specificity (82.5%), and accuracy (82.2%). Mid-upper arm circumference, Dialysis Malnutrition Score, and albumin were also found to be significant predictors of protein–energy wasting. Conclusion: Lack of advanced equipment in suburban and rural centers to detect protein–energy wasting in India can be overcome by using the various stand-alone and combination nutrition assessment tools which have been validated in the present study.

Association of extracellular water/total body water ratio with protein-energy wasting and mortality in patients on hemodialysis

Bioimpedance analysis-assessed extracellular water/total body water (ECW/TBW) ratio may be a marker for mortality and poor nutritional status in hemodialysis patients. In 193 maintenance hemodialysis patients, we retrospectively investigated the relationships among ECW/TBW ratio, mortality, and protein-energy wasting (PEW). Four components—body mass index, normalized protein catabolic rate, normalized serum creatinine level, and serum albumin level—constitute the simple PEW score; this score was calculated based on the positive number of items concerning malnutrition among these four components. A score ≥ 3 indicated PEW. Patients were stratified by an ECW/TBW ratio cut-off value (0.40) and by PEW versus non-PEW status. The simple PEW score, cardiothoracic ratio, and log-transformed C-reactive protein level were independently correlated with the ECW/TBW ratio. Eighty-four patients died during follow-up (median 4.3 years). After adjustments for sex, age, hemodialysis vintage, histories of cardiovascular events and diabetes, and C-reactive protein level, a higher ECW/TBW ratio and PEW were independently related to elevated risks of all-cause death. Adding the ECW/TBW ratio to a baseline risk model including PEW significantly increased C-statistics from 0.788 to 0.835. In conclusion, the ECW/TBW ratio may be an indicator of PEW and may be a predictor of death even accounting for PEW, in hemodialysis patients.

Effects of Oral Sodium Bicarbonate Supplementation on Protein Metabolism and Inflammation in Iraqi Hemodialysis Patients: An Open-Label Randomized Controlled Trial.

The effect of correcting metabolic acidosis on protein metabolism in hemodialysis patients is controversial. To study the effects of oral sodium bicarbonate on protein metabolism and markers of inflammation in acidotic hemodialysis patients. Patients and Methods. An open-label randomized controlled trial was conducted at a single center. Sixty-six clinically stable adult hemodialysis patients were recruited with an average predialysis serum bicarbonate level of <22 mmol/l and a dialysate bicarbonate concentration of 35 mmol/l. Forty-nine participants have completed the study. Oral sodium bicarbonate tablets of 500 mg were given daily in the intervention group (n = 25) for 12 weeks versus the standard of care in the control group (n = 24). Outcomes compared intervention versus nonintervention in both groups at equivalent time points (0 and 3 months). The clinical data, anthropometry, dialysis adequacy, albumin, normalized protein catabolism rate, blood gas analysis, and bicarbonate were recorded at 0 and 3 months. In addition, muscle mass and handgrip strength were measured. Finally, IL-6 as a marker of inflammation was measured at randomization and three months. Serum bicarbonate and pH increased significantly from 17.57 ± 3.34 mmol/L to 20.69 ± 2.54 mmol/L and from 7.26 ± 0.06 to 7.34 ± 0.04, respectively (p < 0.0001). Serum albumin was significantly higher in the intervention group at three months than in the control group, 4.11 ± 0.45 vs. 3.79 ± 0.47 (p value 0.011). Serum potassium significantly decreased in the intervention group at three months compared to the control group, 5.00 ± 0.43 mEq/l vs. 5.33 ± 0.63 mEq/l (p value 0.03). Muscle strength expressed as handgrip has improved significantly in the intervention group at three months compared to the control group, 45.01 ± 19.19 vs. 33.93 ± 15.06 (p value 0.03). The IL-6 values were less in the intervention group at 3 months with a p value of 0.01. The interdialytic weight of the intervention group at three months was 2.42 ± 0.64 compared to the 2.20 ± 1.14 control group, but this did not reach statistical significance (p value of 0.4). The composite of (albumin + nPCR) at three months was achieved in 59.18% of the intervention group compared to 14.28% with a p value of 0.01. Correcting metabolic acidosis in hemodialysis patients improved serum albumin and nPCR without hypokalemia or significant interdialytic weight gain. This was particularly evident in patients with minimal inflammation with low IL-6 values.

Seasonal variation in predialysis systolic blood pressure and cardiovascular events in patients on maintenance hemodialysis.

Predialysis systolic blood pressure (SBP) in patients on hemodialysis (HD) consistently followed a seasonal pattern, reaching a peak in winter and nadir in summer, similar to blood pressure in the general population. However, the relationship between seasonal variations in predialysis SBP and clinical outcomes is still under-investigated in Japanese patients on HD. This retrospective cohort study included 307 Japanese patients undergoing HD for >1 year in three dialysis clinics and evaluated the association between the standard deviation (SD) of predialysis SBP and clinical outcomes, including major adverse cardiovascular events (MACEs; cardiovascular death, nonfatal myocardial infarction or unstable angina, stroke, heart failure, and other severe cardiovascular events requiring hospitalization) with 2.5 years follow-up. The SD of predialysis SBP was 8.2 (6.4-10.9) mmHg. In the model fully adjusted for the SD of predialysis SBP, predialysis SBP, age, sex, HD vintage, Charlson comorbidity index, ultrafiltration rate, renin-angiotensin system inhibitors, corrected calcium, phosphorus, human atrial natriuretic peptide, C-reactive protein, albumin, hemoglobin, body mass index, normalized protein catabolism rate, and intradialytic SBP decline, Cox regression analyses showed that a higher SD of predialysis SBP (per 10 mmHg) was significantly associated with increased MACE risk (hazard ratio [HR], 1.89; 95% confidence interval [95% CI], 1.07-3.36) and all-cause hospitalization (HR, 1.57; 95% CI, 1.07-2.30). Therefore, greater seasonal variations in predialysis SBP were associated with worse clinical outcomes, including MACEs and all-cause hospitalization. Whether interventions to reduce seasonal variations in predialysis SBP will improve the prognosis of Japanese patients on HD must be investigated further.

Validation of formulas calculating normalized protein catabolic rate in patients undergoing home hemodialysis.

Depner and Daugirdas developed a simplified formula to estimate the normalized protein catabolic rate in patients on twice- or thrice-weekly hemodialysis (JASN, 1996). The aim of our work was to establish formulas in more frequent schedules and validate them in home-based hemodialysis patients. We realized that the structure of Depner and Daugirdas' normalized protein catabolic rate formulas has a general meaning and can be expressed as PCRn = C0/[a + b*(Kt/V) + c/(Kt/V)] + d, where C0 is pre-dialysis blood urea nitrogen, Kt/V is dialysis dose,a, b, c, dare the specific coefficients for each combination of home-based hemodialysis schedules and the day of blood sampling. The same applies to the formula that adjusts C0 (C'0) for residual kidney clearance of blood water urea (Kru) and urea distribution volume (V): C'0 = C0*[1 + (a1 + b1/(Kt/V))*Kru/V]. On this basis, we computed the six coefficients (a, b, c, d, a1, b1) for each of the 50 possible combinations and simulated a total of 24,000 weekly dialysis cycles using the Daugirdas Solute Solver software recommended by the KDOQI 2015 guidelines. From the associated statistical analyses we obtained 50 sets of coefficient values, which were validated comparing the paired normalized protein catabolic rate values (i.e., those estimated with our formulas with those modeled with Solute Solver) in 210 datasets of27patients on home-based hemodialysis. The mean values ± SD were 1.06 ± 0.262 and 1.07 ± 0.283g/kg/day, respectively, with a mean difference of 0.004 ± 0.034g/kg/day (p = 0.11). The paired values were highly correlated (R2 = 0.99). In conclusion, even if the coefficient values were validated in a relatively small sample of patients, they allow an accurate estimation of normalized protein catabolic rate in home-based hemodialysis patients.

#5941 SERUM LEPTIN AND MALNUTRITION IN PERITONEAL DIALYSIS PATIENTS: A CONNECTION YET TO BE FOUND

Abstract Background and Aims Leptin is a hormone responsible for the modulation of the satiety signals and that it is known for being increased in patients undergoing Peritoneal Dialysis (PD) treatment. Nevertheless, conclusions about its role in the malnutrition associated with this technique remains to be done. Our study aimed to characterize the nutritional state of a Portuguese program of PD and to establish the impact that leptin levels had on it. Method A cross-sectional study was performed involving 28 patients of a PD program. To characterize the patients’ nutritional status we collected the following data: anthropometric measurements (weight, body mass index (BMI), fat tissue index and lean tissue index using Fresenius ® Body Composition Monitor), analytical values (albumin, total proteins, total cholesterol, high-density lipoprotein cholesterol, low-density cholesterol, triglycerides, leptin serum levels), protein metabolism (normalized protein catabolic rate (nPCR), normalized dialysate protein loss (nEPL), normalized urine protein loss (nUPL), normalized total protein loss (nTPL) and normalized dietary protein requirement (nDPR)) and peritoneal dialysis adequacy (total, renal and peritoneal kT/v; total, renal and peritoneal creatinine clearance). The collected data were statistically analyzed and correlations were made using Mann-Whitney U test and Spearman test, depending on the variable type. Results 7 (25%) patients were females, and the mean age was 59.5 years old (± 14.31). The mean dialysis vintage was 27.04 months (± 20.14) and the majority (n=23, 82,1%) preformed automated peritoneal dialysis (APD). Regarding the nutritional status, the mean BMI, FTI and LTI was 26.64 kg/m2 (±4.39), 14.24 kg/m2 (±5.47) and 11.62 kg/m2 (±2.52) respectively. 57.1% (n=16) had serum albumin below 3.5 mg/dL, with a mean phosphorus of 5.01mg/dl (±0.72) and a mean leptin of 28.58ng/mL (±28.44). The serum leptin was 5.4 times higher than the adjusted value for BMI in the population without kidney disease. The adjusted serum leptin for BMI was different between sex (U=15, P = .001) and it was positively correlated with total (ρ=0.47, P = .012) and high-density lipoprotein (HDL) cholesterol (ρ=0.535, P = .003). It was not associated with the protein metabolism (nPCR, nEPL, nUPL, nTOL and nDPR), albumin or total proteins and PD adequacy. Conclusion Leptin values independent of BMI are significantly higher amongst patients on PD. Alike the healthy population, women on PD are also prone to have higher serum leptin values. Although studies are still controversial about the association between this hormone and cholesterol, in this population there is a positive correlation. As so, hyperleptinaemia cannot yet be associated with the malnutrition that is generally present amongst PD patients, but it must be considered as a contribute to the already known increased cardiovascular risk.

Factors affecting presenteeism in workers with nocturnal hemodialysis: A two-center cross-sectional study.

Presenteeism and work dysfunction in dialysis patients should be assessed to improve disease management and work productivity. Therefore, this study aimed to investigate the prevalence and factors surrounding presenteeism and work dysfunction in workers with nocturnal hemodialysis. This multicenter cross-sectional study included 42 workers with nocturnal hemodialysis. Presenteeism was measured in patients using the Work Functioning Impairment Scale (WFun), employment status, exercise habit, and exercise self-efficacy (SE). The WFun score was 12.5 ± 6.3 points, and patients with mild presenteeism were 12 (28.6%), moderate was 2 (4.8%), and severe was 1 (2.4%). Multiple regression analysis, which was adjusted for few confounding factors, showed that WFun had a significant relationship with lower exercise SE (r = -0.32) and normalized protein catabolism rate (r = 0.31). Working patients with nocturnal hemodialysis had presenteeism and a significant correlation with exercise SE and nPCR. This study provides a framework to prevent work dysfunction in nocturnal hemodialysis patients.

Correlation of Serum Asprosin Levels With Normalized Protein Catabolic Rate in Patients Receiving Peritoneal Dialysis Treatment.

Background Peritoneal dialysis patients are malnourished due to loss of protein in the dialysate and inadequate dialysis, although they take additional calories every day during treatment. Many parameters are used to assess nutritional status, with normalized protein catabolic rate (nPCR) being one of the most common. Asprosin, a novel adipokine secreted by adipose tissue, peaks during fasting and induces hepatic glucose release through the activation of the G-protein-cAMP-PKA pathway, which has been indicated to have a curative effect on chronic inflammation. In this study, we aimed to investigate the relationship between asprosin levels and nutritional parameters in patients receiving peritoneal dialysis treatment as well as to investigate the applicability of more practical tests. Methodology A total of 70 peritoneal dialysis patients, 35 female (59%) and 24 male (41%), were included in the study. The mean age of the patients was 53 ± 14 years (range = 18-80 years), and the median peritoneal dialysis duration was 31.5 months (range = 20-56.2 months). The most common etiologic cause was hypertension(37%). Patients over 18 years of age who had been receiving peritoneal dialysis treatment for at least 24 months were included in the study. The correlation between patients' nPCR levels and serum asprosin, body mass index, and lipids was evaluated. Results The correlation between the level of nPCR and the serum asprosin level, body mass index, and lipids was evaluated. Patients with nPCR <0.815 were considered malnourished, and factors affecting malnutrition were determined by univariate analysis. Among the factors affecting malnutrition according to univariate analysis, those with p-value <0.05 were analyzed by multivariate analysis. Low asprosin level was one of the independent factors affecting malnutrition in patients (Exp(B) = 0.944, 95% confidence interval (CI) = 0.896-0.994). Other independent factors affecting malnutrition were Kt/V (Exp(B) = 0.018, 95% CI = 0.001-0.550) and residual renal function (Exp(B) = -0.004, 95% CI = 0.993-0.999). Conclusions There is a need for more accessible tests and reliable parameters to evaluate dialysis and nutritional deficiency in peritoneal dialysis patients. One possible hormone that could serve as a guide is asprosin.

High Protein Whole Food Snack and Albumin Outcomes in Patients With Dialysis-Dependent Chronic Kidney Disease

Protein-energy wasting is common among patients on hemodialysis (HD). This study sought to define effects that a novel, post-HD, high-calorie, high-protein whole food snack had on patients' serum albumin (serum alb), serum phosphorus and equilibrated normalized protein catabolic rate (enPCR). A 12-month (6months intervention, 6months pre/post data collection), single-center, unblinded study was conducted. Participants (n=67) consumed, ad libitum, a whole food snack post-HD for 6 treatments each month. Upon analysis, regression models identified relationships between serum alb and whole food snack consumption across follow up. Predefined effect size anticipated was + 0.2g/dL. Patients were stratified by high (≥4g/dL) or low (<4g/dL) mean serum alb during a 3-month baseline period. Paired t-tests compared mean per patient difference in serum alb, enPCR and serum phosphorus from baseline to each month of follow up, stratified by high (≥640 g) or low (<640 g) consumption of the whole food snack (a priori caloric estimation). Linear regression models showed positive associations between higher serum alb and enPCR with higher whole food snack consumption across follow up (all P<.05). Assessments from baseline to each follow-up month show some increases in serum alb, yet t test comparisons were not significant. No significant changes were seen in serum phosphorus levels during follow-up. Albeit the catabolic effects of HD are well-known, effective nutritional interventions are scarce. Results showed that providing a whole food snack post-HD to individuals with serum alb <4.0g/dL may be beneficial but further studies are recommended.

PS-C18-6: THE IMPACT OF ANTIHYPERTENSIVE DRUG USE ON INTRADIALYTIC BLOOD PRESSURE DECLINE CONSIDERING SEASONAL VARIATION: A RETROSPECTIVE COHORT STUDY

Objective: Risk factors of intradialytic systolic blood pressure decline remain less understood. We aimed to identify clinical and laboratory predictors of intradialytic systolic blood pressure decline, considering its seasonal variation. Design and method: In a retrospective cohort of 47,219 hemodialysis sessions from 307 patients undergoing hemodialysis for 1 year in three dialysis clinics, seasonal variation and intradialytic systolic blood pressure decline predictors (predialysis systolic blood pressure - nadir intradialytic systolic blood pressure) were assessed using cosinor analysis and linear mixed models adjusted for baseline/monthly hemodialysis-related variables, respectively. Results: Intradialytic systolic blood pressure decline was highest and lowest in the winter and summer, respectively, following a clear seasonal pattern. In both models adjusted for baseline and monthly hemodialysis-related parameters, calcium channel blocker use was associated with a smaller decline (-4.58 [95% confidence interval (CI), -5.84 to -3.34], P &lt; 0.001; -3.66 [95% CI, -5.69 to -1.64], P &lt; 0.001) and alfa blocker use, with a greater decline (3.25 [95% CI, 1.53–4.97], P &lt; 0.001; 3.57 [95% CI, 1.08–6.06], P = 0.005). Baseline and monthly serum phosphorus levels were positively correlated with a decline (1.55 [95% CI, 0.30–2.80], P = 0.02; 0.59 [95% CI, 0.16–1.00], P = 0.007) and baseline and monthly normalized protein catabolic rate, inversely correlated (-22.41 [95% CI, -33.53 to -11.28], P &lt; 0.001; 9.65 [95% CI, 4.60–14.70], P &lt; 0.001) Conclusions: Calcium channel blocker use, alfa blocker avoidance, and serum phosphorus-lowering therapy may attenuate intradialytic systolic blood pressure decline and should be investigated in prospective trials.

The Relationship of Uremic Toxin Indoxyl Sulfate and Intestinal Elimination Mechanisms in Hemodialysis Patients

Introduction: High indoxyl sulfate (IS) concentration is a serious problem for patients with CKD increasing the risk of cardiovascular diseases and CKD progression. Thus, the methods of decreasing the toxin concentrations are highly desired. The study aimed to discover the role of selected intestine-related factors on IS concentration. Methods: We evaluated the impact of ABCG2 and ABCC2 polymorphisms influencing activity and protein intake by normalized protein catabolic rate. Additionally, we examined the relation of IS and uric acid (UA) that can share common elimination transporters. A monocentric, prospective, open cohort pilot study was performed on 108 patients undergoing dialysis treatment. Results: The positive effect of residual diuresis on the reduction of IS levels was confirmed (p = 0.005). Also, an increase in IS depending on the dietary protein intake was confirmed (p = 0.040). No significant correlation between ABC gene polymorphisms was observed either, suggesting the negligible role of ABCG2 and ABCC2 in the elimination of IS in small bowel. The significant difference was observed for UA where ABCG2 421C>A (rs72552713) gene polymorphism was higher (505.3 μmol/L) in comparison with a wild-type genotype (360.5 μmol/L). Conclusion: No evidence of bowel elimination pathway via ABCC2 and ABCG2 transporters was found in renal replacement therapy patients.

Long-term body composition changes in patients undergoing hemodialysis: a single-center retrospective study

BackgroundPatients undergoing dialysis experience substantial decreases in muscle mass and functional muscle weakness. Muscle mass loss in patients undergoing hemodialysis is an independent predictor of survival, so muscle mass maintenance is essential for continued hemodialysis. This study examined longitudinal changes in the body composition of patients undergoing hemodialysis in different dialysis periods.MethodsWe retrospectively analyzed body composition measurements obtained by bioelectrical impedance analysis (BIA) using the same measuring instrument. The dialysis periods were 1–10 years from the start of hemodialysis for group A (n = 25), 10–20 years for group B (n = 22), and 20–30 years for group C (n = 9). The initial and final measurements of each group were compared. Furthermore, the nutritional status based on the inflammation and nutritional indicators obtained during the measurement period of each group was examined.ResultsMuscle mass did not significantly decrease in groups A and B but did decrease in group C (P < 0.05). In all groups, the extracellular water-to-total body water ratio (ECW/TBW) significantly increased (P < 0.001). C-reactive protein in groups A and B increased; however, the median initial and final values were < 0.2 mg/dL, and no changes were observed in group C. Furthermore, the median normalized protein catabolic rate was 0.86–1.05 g/kg/day, and there was no difference in the initial or final rates. The mean energy and protein daily intakes were 30–32 kcal/ideal body weight (IBW) kg/day and 1.1 g/IBW kg/day, respectively.ConclusionsIn patients undergoing hemodialysis, even if the muscle mass values are maintained, the possibility of a substantial decrease in muscle mass cannot be ruled out when ECW/TBW increases. Control of inflammation and nutritional intake may help minimize muscle mass loss caused by continued hemodialysis in patients.

Severe hyperparathyroidism is associated with nutritional impairment in maintenance hemodialysis patients.

Severe hyperparathyroidism predicts poor outcomes in patients with kidney failure. Mechanisms underlying the relationship between high parathyroid hormone (PTH) and decreased survival other than bone loss are largely unexplored. Recent evidence suggests the role of excess PTH in adipose tissue browning resulting in protein-energy wasting. The present retrospective observational study examined nutritional status among patients receiving maintenance hemodialysis with different degree of hyperparathyroidism. Seven hundred forty-five patients were categorized into four groups according to PTH levels: group 0, < 200; group 1, 200–599; group 2, 600–1,499; and group 3, ≥1,500 pg/ml. Group 0 was excluded because of the relationship between low PTH with aging and malnutrition. Patients in groups 1 and 2 were matched to group 3 by propensity score yielding 410 patients in the final analysis. Nutritional parameters at baseline and the preceding 1 and 2 years were examined. At baseline, lower serum albumin, creatinine/body surface area (Cr/BSA), height in female and higher percentage of patients with serum albumin < 38 g/L were observed in group 3 compared to groups 1 and 2. Higher PTH level was independently associated with serum albumin < 38 g/L and Cr/BSA < 380 μmol/L/m2. The longitudinal decline in serum albumin and Cr/BSA and the increase in the frequency of patients with serum albumin < 38 g/L were observed among patients in group 3. Between group comparisons confirmed a significant decline in serum albumin and Cr/BSA in association with an increase in the proportion of patients with serum albumin < 38 g/L and Cr/BSA < 380 μmol/L/m2 in group 3 compared to groups 1 and 2. Weight loss was more significant and was of greater magnitude among patients in group 3 compared to groups 1 and 2. Normalized protein catabolic rate in 3 groups were comparable. There was no significant difference in any of the nutritional parameters between groups 1 and 2. In conclusion, patients receiving maintenance hemodialysis with severe hyperparathyroidism showed deterioration of nutritional status compared to patients with moderate hyperparathyroidism and patients with PTH level in the recommended range. These findings support the role of extreme PTH level in protein-energy wasting emphasizing the importance of early management of hyperparathyroidism.