Normalized Protein Catabolic Rate Research Articles

Hepatitis B virus vaccine immune response and mortality in dialysis patients: a meta-analysis.

We performed a systematic review and meta-analysis to examine factors associated with HBV immune response in dialysis patients, and the association between the immune response to the HBV vaccine and mortality. Electronic databases were searched for studies of dialysis patients that compared the characteristics of HBV vaccine responders and non-responders. Mortality was also analyzed according to the vaccine immune response (defined by hepatitis B surface antibody titer > 10mIU/mL). Random-effects model meta-analyses were performed to compute a weighted mean difference (WMD), a pooled odds ratio (OR), and a pooled risk ratio (RR) between groups. We identified 61 studies with a total of 6628 dialysis patients who completed the course of HBV vaccination, 4582 responders (69%) and 2046 non-responders (31%). By meta-analysis, relative to non-responders, HBV vaccine responders had a higher dialysis adequacy as measured by Kt/V (WMD 0.08, P < 0.001), a higher serum albumin (WMD 0.12 gm/dL, P < 0.001), a higher normalized protein catabolic rate (WMD 0.12 gm/kg/day, P = 0.001), a higher hemoglobin (WMD 0.15 gm/L, P = 0.03), and a higher parathyroid hormone level (WMD 44pg/mL, P = 0.004). HBV vaccine responders were younger (WMD - 4.68years, P < 0.001), had been on dialysis for longer (WMD 2.60months, P < 0.001), were less likely to have diabetes mellitus (pooled OR 0.65, P < 0.001), and were less likely to carry the human leukocyte antigen (HLA) DR3 (pooled OR 0.38, P = 0.01). Compared to non-responders, HBV vaccine responders had lower risk for all-cause mortality (pooled RR 0.64, P < 0.001), and lower risk for cardiovascular-related mortality (pooled RR 0.74, P = 0.02). In dialysis patients, the lack of immune response to the HBV vaccine is associated with older age, diabetes mellitus, HLA-DR3 status, shorter time on dialysis, lower nutritional status, lower hemoglobin, lower PTH level, and lower dialysis adequacy. Tackling some of these modifiable factors might improve the HBV vaccine immune response.

Factors predicted with quality of life among hemodialysis patients in private hospital of Thailand

ABSTRACTBackground: The quality of life (QOL) among the end-stage renal disease patients is an essential component for assessing the success of treatment. This study aimed to determine the factors predicted with quality of life among hemodialysis patients in private hospital of Thailand.Method: This cross-sectional study was conducted by interviewing 188 Thai patients with end-stage renal disease (ESRD), who were on hemodialysis (HD) at Sanamchan Hospital Bangkok. Patients with stable hemodynamic status without any history of mental illness were included in this study. However, those who could not properly communicate were excluded. The descriptive statistics and the multiple linear regression were applied to identify the predictive factors of quality of life (QOL) scores in the end-stage renal disease (ESRD) patients on maintenance hemodialysis (HD). The QoL was assessed in three components including kidney disease component score (KDCS) physical component score (PCS) and mental component score (MCS).Findings: More than half of the participants (57%) in this research were male and (44%) were unemployed. The mean average systolic value of the participants was 157 (25.12 SD) mmHg and the diastolic blood pressure was 81 (5.85 SD) mmHg. Average hematocrit (Hct) was 30.95 (4.38 SD), Kt/v was 1.86 (0.96 SD), and average normalized protein catabolic rate (nPCR) was 1.12 (1.09 SD). The age, income, patients with more than three associated diseases, enough expenses for living, frequency of dialysis per week, and duration of treatment was statistically significant with the kidney disease component score (KDCS) (F = 6.28, p < 0.05). Furthermore, the age, income, patients with more than three associated diseases, hematocrit (Hct) and frequency of dialysis per week were the statistically significant with the physical component score (PCS) (F = 4.99, p < 0.05) while patients with more than three associated diseases and enough expenses for living were the statistically significant with the mental component score (MCS) (F = 3.30, p ≤ 0.05).Conclusion: Study concluded that the factors like; age, expenses for living, frequency of dialysis, patients with more than three associated diseases were had a positive impact on the quality of life among the end-stage renal disease patients coming for dialysis in private hospital of Thailand.

The Association between Nutritional Markers and Heart Rate Variability Indices in Patients Undergoing Chronic Hemodialysis

The associations between nutritional markers and heart rate variability (HRV) are poorly addressed. This study aimed to evaluate whether malnutrition is associated with the altered autonomic nervous system (ANS) function. This cross-sectional study was conducted enrolling 175 patients (100 women, mean age 65.1 ± 12.9 years) receiving chronic hemodialysis in a teaching hospital from June to August 2010. We performed HRV measurements before and during the index hemodialysis and compared these HRV values between two groups categorized by the individual nutritional marker. By using the multivariate generalized estimating equation with adjustment, we exhibited the independent associations between HRV and poor nutritional status defined by serum albumin < 3.8 g/dL, total cholesterol < 100 mg/dL, body mass index < 23 kg/m2, bodyweight loss within six months > 10%, bodyweight loss within three months > 5%, and normalized protein catabolic rate < 1.1 g/kg BW/day. The current study disclosed ANS impairment in hemodialysis patients with poor nutritional status. The impaired ANS function might be a potential mechanism linking malnutrition to subsequent adverse prognoses in hemodialysis patients. Further investigations are warranted to confirm these findings and clarify the causal association among this complex issue.

Assessment of Hemodialysis Adequacy in Patients with End Stage Renal Disease in a Military Hospital of Dhaka, Bangladesh

Introduction: The burden of kidney disease patients requiring renal replacement therapy is increasing day by day. Hemodialysis (HD) constitutes the most common form of renal replacement therapy (RRT) worldwide. Determining the adequacy of hemodialysis, Urea kinetic modeling (UKM) is an important tool for this. The aim of this study was to determine hemodialysis adequacy by UKM.&#x0D; Material &amp; Methods: A total 137 patients were sampled in dialysis center of Combined Military Hospital (CMH) Dhaka. This was a cross sectional study. Data were collected from predialysis, postdialysis and next predialysis blood sample. Mean of adequacy parameters like single pool Kt/V (spKt/V), urea reduction ratio (URR), time average concentration of urea (TACurea) and normalized protein catabolic rate (NPCR) were calculated and compared between twice and thrice per week hemodialysis groups. Also compared adequacy variables between groups who achieved cutoff values and who did not achieve it.&#x0D; Results: One hundred (72.99%) patients were on 8 hours/week and 37 (27%) were on 12 hours/week hemodialysis session. Only 21(21%) and 16(43%) could achieve spKt/V cut off value among 8 hour and 12 hours group respectively. Eighty (58.39%) patients had URR &lt; 65% in this study. Blood flow e+250 ml/ min group had significantly better dialysis adequacy than blood flow &lt;250ml/min group, URR (81.31± 10.21 vs. 54.51 ± 11.52 and p-value &lt;0.001), spKt/V (1.99 ± 0.41 vs. 1.41 ± 0.31 pvalue&lt; 0.001) Thrice weekly hemodialysis group achieved better adequacy than twice weekly group.&#x0D; Conclusion: Frequency and blood flow of dialysis are strongly associated with adequacy of hemodialysis as evidenced by spKt/V and URR value. So to achieve hemodialysis adequacy, increasing the frequency of dialysis from two to three sessions per week is recommended.&#x0D; J Bangladesh Coll Phys Surg 2019; 37(4): 169-174

Test-Retest Reliability and Validity of the Nutrition-Specific Quality of Life Questionnaire

The purpose of this study is to test the Nutrition-Specific Quality of Life (NSQOL) questionnaire for test-retest reliability and validity in a sample of patients on maintenance hemodialysis (MHD). Test-retest reliability of the NSQOL questionnaire via two patient interviews and comparison of the NSQOL questionnaire to a comprehensive nutrition assessment performed by a registered dietitian nutritionist for validity testing. This study was conducted in one outpatient MHD center in Chicago, IL. Adults, aged 18years or older, treated with MHD for at least sixmonths prior to start of the study. A Spearman's correlation coefficient was used to determine test-retest reliability and a Cronbach's alpha was used to determine the internal consistency of the 2 NSQOL questionnaires. Validity testing was done by comparing the NSQOL questionnaire to the most recent comprehensive nutrition assessment. The sample consisted of 17 men (63%) and 10 women (37%), with a mean age of 60±13, who were mostly African American (63%) and Caucasian (26%). There was a significant correlation (P=.001) between the initial NSQOL interview and repeat NSQOL interview in all questions except for question 14 (P=.100). The NSQOL questionnaire was found to have excellent internal consistency with an α=0.900. No significant relationship was found among total NSQOL score and age, dialysis vintage, albumin, or normalized protein catabolic rate; however, older participants had lower total NSQOL questionnaire scores. Although not statistically significant, there was variability between NSQOL questionnaire score and nutritional status. The NSQOL questionnaire was found to be reliable and had high internal consistency in this sample of patients receiving MHD. The NSQOL questionnaire may be beneficial for monitoring nutrition quality of life changes in-between nutrition assessment intervals.

SUN-059 Significance of fibroblast growth factor-23 (FGF23) level in hemodialysis patients

Fibroblast growth factor-23 (FGF23) is a phosphaturic hormone, and its levels increases as kidney function declines. Increased levels of FGF23 occur primarily as a result of a net positive phosphate balance leading to increased renal phosphate excretion. Although FGF23 helps to prevent hyperphosphatemia, elevated circulating levels are independently associated with vascular dysfunction, left ventricular hypertrophy, and increased risk for death in patients with CKD. Because few studies have investigated parameters associated with FGF23 levels in hemodialysis (HD) patients, we examined the clinical significance of FGF23 cross-sectionally. One hundred and nineteen HD patients were enrolled. Their mean age was 68.3±10.9 years, and the mean duration of HD treatment was 9.4±8.7 years. Forty-seven patients had diabetes mellitus (DM) and twenty-three patients had heart diseases. We identified prospective studies reporting associations between FGF23 concentration and parameters. The level of FGF23 was significantly correlated with the levels of Ca (P=0.02), P (P=0.001), intact-PTH (P=0.017) and Mg (P=0.001). On the other hand, arteriosclerosis, aldosterone, β2-microglobulin, dialysis efficiency, medicine, body mass index (BMI), normalized protein catabolism rate (nPCR), arteriosclerosis score, bone density, heart echo findings, blood pressure (BP), carotid artery echo findings, and survival prognosis were not correlated with FGF23 levels. When the patients were divided in DM group and non-DM group, there were significant differences of age, HD duration, hemoglobin concentration, BMI and nPCR. In non-DM group, the level of FGF23 was correlated with left ventricular muscle mass index (LVMI). However, it was not correlated in DM group. The level of FGF23 was correlated with LVMI in non-DM hemodialysis patients. We suggested that FGF23 directly induced LVMI because there were no changes in the levels of aldosterone and BP.

The Effect of Protein Supplementation and Nutrition Counselling on Protein Catabolic Rates Among Persons with End-Stage Renal Disease on Maintenance Haemodialysis (P12-035-19)

ObjectivesTo compare the impact of protein supplementation versus nutrition education/counselling on protein intakes (indexed by normalized protein catabolic rates (nPCR)) among persons on maintenance haemodialysis. MethodsAn intervention study design was employed in this investigation. Participating dialysis centers were randomly selected and persons attending those centers were invited to participate in the study. Participants had anthropometry and biochemical variables recorded at baseline and on two occasion 1 month apart during each of the interventions. Persons in the intervention group (IVG) received a supplement containing 36 grams of whey protein daily for 6 weeks in. Following a 2-week washout period, they received personalized weekly nutrition education/counselling for an additional 6 weeks. The control group (NIVG) did not receive any supplementation or nutrition education/counselling. Both groups received received the routine facility care. Participation was voluntary. The study was approved by the Ethics Committee, The University of The West Indies. ResultsSixty-eight persons (IVG = 32; NIVG = 36) participated in the study. There was no significant difference in the mean nPCR between IVG and NIVG at baseline (0.84 ± 0.17 vs. 0.84 ± 0.17 mg/kg; P = 0.76). IVG had significantly higher mean nPCR than NIVG during protein supplementation (0.95 ± 0.21 vs. 0.78 ± 0.15 mg/kg; P < 0.001) and nutritional education/counselling (0.87 ± 0.17 vs. 0.79 ± 0.18 mg/kg; P = 0.02 phases of the study. Among IVG, protein supplementation (+Δ 12.8 ± 3.0 mg/kg (±S.E.) but not nutrition education/counselling (+Δ 2.8 ± 2.7 mg/kg; P = 0.32) resulted in a significant increase in mean nPCR compared to baseline.with no significant changes in biochemical variables. ConclusionsAmong participants nPCR increased significantly with protein supplementation but not nutrition education/counselling without adversely affecting biochemical variables. Funding SourcesGrant and Publication Fund, The University of The West Indies.

The association between six month intra-dialytic resistance training and muscle strength or physical performance in patients with maintenance hemodialysis: a multicenter retrospective observational study

BackgroundReduced muscle strength and physical performance are prevalent in patients of maintenance hemodialysis (MHD), and deleterious changes in these parameters are associated with increased mortality.MethodsThis retrospective observational study included 306 patients, who received a 6-month resistance exercise program during hemodialysis, three times per week on an outpatient basis. The training protocol consisted of two sets of 10 repetitions of knee extension, hip abduction, and hip flexion, using an elastic band in a sitting or supine position. Primary outcome measures included muscle strength, measured by percent knee extension muscle power to dry body weight (pKEMP-dBW), and physical performance, measured by short physical performance battery (SPPB). The adjusted mean differences in these variables during the 6 months were estimated using a multivariate linear regression model.ResultsThe mean age with standard deviation was 70 ± 11 years. One hundred and sixty patients (52.3%) were men and the dry weight was 55.6 ± 11.3 kg. Sarcopenia, defined as SPPB ≤8, was present in 21.4% patients. Their hemodialysis adequacy was acceptable, with a Kt/V of 1.65 ± 0.29, and their nutritional status was good, with a normalized protein catabolism rate of 0.89 ± 0.18 g/kg/day. During the 6 months, both pKEMP-dBW and SPPB showed a slight but significant increase with an adjusted mean difference of 2.8 (95% confidence interval 1.3–4.3, p < 0.001) and 0.6 (0.4–0.9, p < 0.001), respectively.ConclusionsSix-month resistance training was associated with improved muscle strength and physical performance in patients with MHD.

Evaluating haemodialysis patient's nutritional status: Body mass index or body cell mass index?

Evaluate which of two combinations of parameters based on International Society of Renal Nutrition and Metabolism recommendations could better identify patients with protein-energy wasting (PEW) and to compare the relationship of these two combinations with other clinical and body composition parameters. This was a multicentre longitudinal study with 24 months of follow-up. The PEW patients were characterized by: Group A (GA ) - normalized protein catabolic rate (nPCR) < 1.0 g/kg per day, albumin <3.8 g/dL and body cell mass index (BCMI) < 6.4 kg/m2 (n = 203); Group B (GB ) - nPCR <1.0 g/kg per day, albumin <3.8 g/dL and body mass index (BMI) <23 kg/m2 (n = 109). All the patients who did not meet these requirements were considered "well-nourished" (GA : n = 1818; GB : n = 3292). When compared to the well-nourished patients, PEW patients in the GA presented higher age, Kt/V, C-reactive protein, relative overhydration, fat tissue index (FTI); lower creatinine, albumin, nPCR, PTH, haemoglobin, phosphorus, calcium X phosphorus product, potassium, dry weight, BMI, BCMI, lean tissue index, %IDWG . In the GB , well-nourished patients FTI was significantly higher. In Cox analysis, the combination with BCMI was a strong independent predictor of mortality in these patients (hazard ratio: 1.48; confidence interval: 1.00-2.19; P = 0.048), even after adjustment. Although GB combination seemed to be also a predictor of death (hazard ratio: 2.67; confidence interval: 1.92-3.71; P < 0.001), when adjusted, the association remained no longer significant. A new combination of parameters including protein intake, albumin and BCMI demonstrated significant associations with other nutrition and inflammation parameters as well as with mortality.

Prediction of Mortality and Hospitalization Risk Using Nutritional Indicators and Their Changes Over Time in a Large Prevalent Hemodialysis Cohort

Malnutrition and protein-energy wasting are associated with morbidity and mortality in hemodialysis patients. Existing nutritional scores rely primarily on cross-sectional data. Using readily available nutritional indicators, we developed models to predict the risk of mortality and hospitalization in prevalent hemodialysis patients. In this retrospective study, we constructed prediction models of 1-year mortality and hospitalization using generalized linear models, generalized additive models (GAM), classification tree, and random forest models. The models were compared using area under the receiver-operating characteristics curve (AUC) and calibration curves. Model predictors included nutritional and inflammation indicators, demographics, comorbidities, and slopes of all continuous variables over 6months. Patients were randomly split in the ratio 2:1:1 into training, testing, and validation cohorts, respectively. We included patients with hemodialysis vintage ≥1year from Fresenius Medical Care North America clinics from July 2011 to December 2012 (N=21,802 in mortality analysis; N=13,892 in hospitalization analysis).The outcome variables were 1-year mortality and hospitalization. For mortality prediction, GAM was the best model (AUC = 0.85, 95% confidence interval = 0.83-0.86), comprised of neutrophil-to-lymphocyte ratio slope, serum bicarbonate slope, and vintage as nonlinear predictors, and age, serum albumin, and creatinine as linear predictors. For hospitalization prediction, GAM was also the best model (AUC = 0.70, 95% confidence interval= 0.62-0.79) and included neutrophil-to-lymphocyte ratio slope, bicarbonate slope, volume of urea distribution, vintage, and phosphate slope as nonlinear predictors, in addition to albumin, congestive heart failure, age, phosphate, equilibrated normalized protein catabolic rate, and creatinine as linear predictors. Both models demonstrated good calibration, with mild overestimation of hospitalization risk at the highest risk interval. The GAM model can accurately predict the risk of mortality and hospitalization. Application of these prediction models could inform allocation of nutritional interventions to patients at highest nutritional risk.

Factors Associated With Withdrawal From Dialysis Therapy in Incident Hemodialysis Patients Aged 80 Years or Older

ObjectivesAmong kidney disease patients ≥80 years progressing to end-stage renal disease, there is growing interest in conservative nondialytic management approaches. However, among those who have initiated hemodialysis, little is known about the impact of withdrawal from dialysis on mortality, nor the patient characteristics associated with withdrawal from dialysis. Study designHistorical cohort study. Setting and participantsWe examined 133,162 incident hemodialysis patients receiving care within a large national dialysis organization from 2007 to 2011. MeasuresWe identified patients who withdrew from dialysis, either as a listed cause of death or censor reason. Incidence rates and subdistribution hazard ratios for withdrawal from dialysis as well as 4 other censoring reasons were examined across age groups. In addition, demographic and clinical characteristics associated with withdrawal from dialysis therapy among patients ≥80 years old was assessed using logistic regression analysis. ResultsAmong 17,296 patients aged ≥80 years, 10% of patients withdrew from dialysis. Duration from the last hemodialysis treatment to death was 10 [interquartile range 6-16] days in patients with available data. Withdrawal from dialysis was the second and third most common cause of death among patients aged ≥80 years and <80 years, respectively. Among patients ≥80 years, minorities were much less likely than non-Hispanic whites to stop dialysis. Other factors associated with higher odds of dialysis withdrawal included having a central venous catheter compared to an arteriovenous fistula at dialysis start, dementia, living in mid-west regions, and less favorable markers associated with malnutrition-inflammation-cachexia syndrome such as higher white blood cell counts and lower body mass index, albumin, and normalized protein catabolic rate. Conclusion/ImplicationsAmong very-elderly incident hemodialysis patients, dialysis therapy withdrawal exhibits wide variations across age, race and ethnicity, regions, cognitive status, dialysis vascular access, and nutritional status. Further studies examining implications of withdrawal from dialysis in older patients are warranted

One-Year Historical Cohort Study of the Phosphate Binder Sucroferric Oxyhydroxide in Patients on Maintenance Hemodialysis

Objective:The high pill burden of many phosphate binders (PBs) may contribute to increased prevalence of hyperphosphatemia and poor nutritional status observed among patients undergoing maintenance hemodialysis therapy. We examined the real-world effectiveness of sucroferric oxyhydroxide (SO), a PB with low pill burden, in managing serum phosphorus in patients with prevalent hemodialysis over a 1-year period.Design:Historical cohort analyses of de-identified electronic medical records.Subjects:In-center hemodialysis patients switched from another PB to SO therapy as part of routine care with 12 months of uninterrupted SO prescriptions recorded, and documented serum phosphorus levels were eligible for inclusion. Clinical data were extracted from a pharmacy service, FreseniusRx, database and Fresenius Kidney Care clinical data warehouse.Main outcome measures:Comparisons were made between the 91-day period before SO initiation (i.e., baseline) and the 4 consecutive 91-day intervals of SO treatment (Q1-Q4). Clinical measures included achievement of target phosphorus levels (#5.5 mg/dL) and mean number of PB pills/day.Results:Among 530 analyzed patients, the proportion achieving target serum phosphorus levels increased by >100% 1 year after switching to SO therapy, that is, from 17.7% at baseline to 24.5%, 30.5%, 36.4%, and 36.0% at Q1 through Q4, respectively (P < .0001 for all). Reductions in serum phosphorus were observed at all follow-up timepoints (P <.0001), irrespective of baseline PB. From a mean baseline PB pill burden of 8.5 pills/day, patients experienced an average 50% pill burden reduction during SO treatment (P <. 0001). Phosphorus-attuned albumin and phosphorus-attuned protein intake (normalized protein catabolic rate) improved significantly after transition to SO (P < .0001). The effectiveness of SO was evident in prespecified subgroups of interest (i.e., black/African-American patients, Hispanic/Latino patients, and women).Conclusion:Among patients on hemodialysis, switching to SO resulted in a 2-fold greater likelihood of achieving target phosphorus levels while halving daily PB pill burden. Increases in phosphorus-attuned albumin and protein intake suggest improved nutritional status.

Correlation between Aortic Calcification Score and Biochemical Parameters in Hemodialysis Patients.

The purpose of this study was to determine the correlation between aortic calcification and demographic and biochemical parameters in hemodialysis patients. Calcification scores of the aortic arch and abdominal aorta were determined from multi-slice computed tomography scans and evaluated according to the Agatston score. The associations between demographic and biochemical parameters and aortic calcification score were determined. In total, 190 patients were included in the study. There was a significant positive correlation between aortic calcification scores and age, duration of hemodialysis, cardiothoracic ratio, normalized protein catabolic rate, brachial-ankle pulse wave velocity (baPWV), serum markers of mineral metabolism, and inflammation. A significant negative correlation was found between aortic calcification scores and platelet count. Multivariate analysis showed that age, duration of hemodialysis, baPWV, phosphate, calcium and phosphate (Ca×P) product, parathyroid hormone, and C-reactive protein levels were independent risk factors for calcification of the aortic arch, while baPWV and Ca×P product were independent risk factors for calcification of the abdominal aorta. Key Messages: Aortic calcification scores correlate with age, duration of hemodialysis, and several biochemical parameters of inflammation and mineral metabolism.

Association of serum angiopoietin-2 with malnutrition, inflammation, atherosclerosis and valvular calcification syndrome and outcome in peritoneal dialysis patients: a prospective cohort study

BackgroundTo examine serum angiopoietin-2 (Angpt-2) in relation to malnutrition, inflammation, atherosclerosis and cardiac valvular calcification, so-called MIAC syndrome and its predictive role in outcomes of peritoneal dialysis (PD) patients.MethodsA prospective observational study was conducted in 324 chronic PD patients. Biochemical analysis was performed at baseline for serum angiopoietins, albumin and high sensitive C-reactive protein (hs-CRP) and echocardiography was done to detect cardiac valvular calcification. Primary study end points were fatal or nonfatal cardiovascular events and mortality.ResultsThe median of serum Angpt-2 levels was 5.44 ng/mL (interquartile range, 3.41–7.85). Across the three tertiles of serum Angpt-2, a significant trend effect was observed for body mass index, normalized protein catabolic rate, calcium × phosphorus product, hs-CRP, brain natriuretic peptide, lower-density lipoprotein cholesterol, left ventricular ejection fraction, total weekly urea clearance and residual renal function (all p < 0.05). Serum Angpt-2 showed a significant increase across the four groups of patients with increasing components of MIAC syndrome (p < 0.001). There were 77 deaths and 57 cardiovascular events. High serum Angpt-2 was an independent predictor of fatal and nonfatal cardiovascular events in PD patients (p = 0.02), however serum Angpt-2 was not an independent predictor of all-cause mortality (p = 0.3).ConclusionsSerum Angpt-2 showed close association with valvular calcification, atherosclerosis, inflammation and malnutrition, having significant independent prognostic value and is useful for cardiovascular event stratification in chronic PD patients. Angpt-2 might be a potential mediator of increased cardiovascular risk in patients undergoing PD treatment.

Serum levels of the adipokine zinc-alpha2-glycoprotein (ZAG) predict mortality in hemodialysis patients

Wasting has been associated with increased cardiovascular and all-cause mortality in chronic kidney disease (CKD). We investigated whether serum zinc-alpha2-glycoprotein (ZAG), a potent cachectic and lipid-mobilizing factor that is increased in patients with CKD, predicts clinical outcomes in patients on chronic hemodialysis. We quantified serum ZAG at baseline in a prospective cohort of 252 patients undergoing maintenance hemodialysis. Serum ZAG concentrations were inversely associated with serum albumin, creatinine, and triglycerides and, conversely, positively associated with age. Although ZAG is strongly linked to protein energy wasting (PEW) in patients with cancer, higher ZAG concentrations were not associated with PEW in our cohort. During a mean study follow-up of 954 days, 49 patients died and 62 patients experienced a cardiovascular event. Kaplan-Meier analysis revealed a significant correlation between serum ZAG concentrations and all-cause mortality and cardiovascular events. In separate multivariable Cox regression models, serum ZAG concentrations remained significantly associated with all-cause mortality and cardiovascular events after adjustment for demographic factors (age, sex, and dialysis vintage), metabolic parameters (serum albumin, prealbumin, triglycerides, cholesterol, normalized protein catabolic rate, and body mass index), and cardiovascular risk factors (diabetes, dyslipidemia, history of cardiovascular disease, smoking, and diuretic use as a proxy of residual renal function). Thus, serum ZAG appears to be a strong and independent predictor of mortality and cardiovascular events in patients with end-stage renal disease. Further studies are necessary to confirm this association and to elucidate the underlying mechanisms.

Eliminating the need for routine monthly postdialysis serum urea nitrogen measurement: A method for monitoring Kt/V and normalized protein catabolic rate using conductivity determined dialyzer clearance.

Many dialysis machines can compute dialyzer sodium clearances at multiple time points during a dialysis treatment using conductivity. For a given treatment, the average dialyzer sodium clearance (K), when combined with treatment time (t), and the estimated urea distribution volume (V, usually based on either anthropometry or bioimpedance), can be used to estimate Kt/V, an important measure of hemodialysis adequacy. While this conductivity-derived value for Kt/V correlates moderately with Kt/V calculated from predialysis and postdialysis serum urea nitrogen (SUN) values (urea reduction ratio, URR), the ultrafiltration volume, and session length it is, unfortunately, not sufficiently accurate to replace URR-based Kt/V. Here we underline the potential utility of an alternative method to estimate Kt/V (a variant of a technique originally proposed by Gotch and Levin and their colleagues) using conductivity-derived sodium clearance (K) that does not require routine measurement of the postdialysis SUN but which should closely track Kt/V computed in the usual fashion. The increased accuracy with the new method is explained by the use of a patient-specific value of V, which is an average value calculated from several dialysis sessions where both conductivity dialyzer clearance and predialysis and postdialysis SUN have been measured. Once this patient-specific conductivity/URR-based value for V has been determined, it can be used to calculate Kt/V for subsequent treatments in which conductivity-based dialyzer clearances are measured, but around which predialysis and postdialysis SUN values have not been obtained. (If the predialysis SUN values for such a subsequent treatment are also measured, then a normalized protein catabolic rate that closely tracks the value from conventional urea modeling, can also be determined.) By reducing the number of postdialysis SUN measurements needed to monitor hemodialysis adequacy this new method of estimating Kt/V by conductivity should save staff time and laboratory costs, increase patient and staff safety, and decrease error rates associated with improper postdialysis blood sampling technique.

The impact of residual renal function on quality of life in patients with peritoneal dialysis .

Residual renal function (RRF) is a crucial factor that plays an important role in peritoneal dialysis (PD) patients, but whether RRF influences the quality of life (QOL) of PD patients is still controversial. The aims of this study were to explore the effects of RRF on QOL in patients with continuous ambulatory peritoneal dialysis (CAPD) and analyze the related factors that might affect patients' QOL. All 120 adult patients in this study received regular CAPD treatment for at least 3 months. Patients were divided into two groups: an RRF group (residual glomerular filtration (rGFR) ≥ 1 mL×min-1×(1.73m2)-1) and a non-RRF group (rGFR ≥ 1 mL×min-1×(1.73m2)-1). The Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) was used as a reference to calculate the scores of CAPD patients for assessing their QOL. Multiple- and single-linear regression analysis was performed to analyze correlation degree of several SF-36-related indexes. The indexes of age, gender, cause of disease, complication, body mass index (BMI), systolic and diastolic blood pressure (SBP and DBP), hemoglobin (HB), cholesterol, triglycerides, high- and low-density lipoprotein, normalized protein catabolic rate (nPCR), and cardiothoracic ratio (CTR) showed no difference between the two groups (RRF and non-RRF). Comparing with RRF group, the patients without RRF showed a significant difference on indexes of PD duration, urine volume, ultrafiltration volume, dialysis dose, serum albumin, potassium, Kt/V (urea reduction ratio), creatinine, calcium, phosphate, C-reactive protein (CRP), and parathyroid hormone (PTH). Single-linear regression analysis that achieved total score of SF-36 showed no correlation with rGFR, but there was a correlation of SF-36 score with CRP, creatinine, CTR, albumin, and ultrafiltration volume. These results suggested that there was no correlation between RRF and QOL in CAPD patients, but chronic inflammation, fluid overload, and malnutrition were considered as the main factors that affect patients' QOL. .

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).

Impact du renforcement de la prise en charge nutritionnelle du patient en hémodialyse chronique par ajout d’œufs durs en collation

Denutrition for chronic hemodialysed patients is common and severe, often the first step of many complication and comorbidities. This work was aimed to study the impact of the adjunction of hard-boiled egg during six months, at the time of the hemodialysis session, if the classic nutritional support with oral nutritional supplements and intradialytic parenteral nutrition has failed. Required criteria were: Albuminemia, prealbuminemia and Moreau and Gaudry's score. Thirty-six patients have been included. During the six months, the following nutritional parameters have improved: Moreau and Gaudry's score decreased of 0.27, C reactive protein of 9.44 mg/L. Albuminemia improved of 3.53 g/L in average, pre-albuminemia of 0.2 g/L, and normalized Protein catabolic rate of 0.01 g/kg/day. Half of the patients were successful to stop the intradialytic parenteral nutrition. Protein adjunction with hard-boiled egg during chronic hemodialysis session, on top of the classic dietetic support has improved nutritional patient status.

Twice-Weekly Hemodialysis and Clinical Outcomes in the China Dialysis Outcomes and Practice Patterns Study

IntroductionIn China, a quarter of patients are undergoing 2-times weekly hemodialysis. Using data from the China Dialysis Outcomes and Practice Patterns Study (DOPPS), we tested the hypothesis that whereas survival and hospitalizations would be similar in the presence of residual kidney function (RKF), patients without RKF would fare worse on 2-times weekly hemodialysis.MethodsIn our cohort derived from 15 units randomly selected from each of 3 major cities (total N = 45), we generated a propensity score for the probability of dialysis frequency assignment, estimated a survival function by propensity score quintiles, and averaged stratum-specific survival functions to generate mean survival time. We used the proportional rates model to assess hospitalizations. We stratified all analyses by RKF, as reported by patients (urine output <1 vs. ≥1 cup/day).ResultsAmong 1265 patients, 123 and 133 were undergoing 2-times weekly hemodialysis with and without evidence of RKF. Over 2.5 years, adjusted mean survival times were similar for 2- versus 3-times weekly dialysis groups: 2.20 versus 2.23 and 2.20 versus 2.15 for patients with and without RKF (P = 0.65). Hazard ratios for hospitalization rates were similar for 2- versus 3-times weekly groups, with (1.15, 95% confidence interval = 0.66−2.00) and without (1.10, 95% confidence interval 0.68−1.79]) RKF. The normalized protein catabolic rate was lower and intradialytic weight gain was not substantially higher in the 2- versus 3-times weekly dialysis group, suggesting greater restriction of dietary sodium and protein.ConclusionIn our study of patients in China’s major cities, we could not detect differences in survival and hospitalization for those undergoing 2- versus 3-times weekly dialysis, regardless of RKF. Our findings indicate the need for pragmatic studies regarding less frequent dialysis with associated nutritional management.