Protein Catabolic Rate Research Articles

Relationship of serum magnesium level with body composition and survival in hemodialysis patients.

A relationship between serum magnesium (Mg) and body composition parameters has not been reported in hemodialysis (HD) patients. We aimed to clarify whether serum Mg has any association with body composition parameters, or survival in HD patients. This study included 215 consecutive maintenance HD patients. Laboratory data collection and postdialysis body composition analysis were performed at baseline. The patients were divided based on baseline serum Mg level tertiles (low, medium, and high Mg groups). Kaplan-Meier survival, logistic regression analyses and Cox proportional hazard analyses were conducted. Among all patients, the median age and dialysis vintage were 73 (65-81) years and 44 (8-96) months, respectively. The serum Mg levels were < 2.3, 2.3-2.5, and > 2.5 mg/dL for the low (n = 67), middle (n = 76), and high (n = 72) Mg groups, respectively. Compared to other groups, low Mg group showed significantly higher age and C-reactive protein levels, but lower serum albumin, normalized protein catabolic rates and frequency of on-line hemodiafiltration. The low, middle, and high Mg groups differed significantly regarding body cell mass (fat-free mass without bone mineral mass and extracellular water) index (BCMI): [5.6 (4.2-6.8), 6.0 (4.8-8.1), 6.7 (4.9-7.5) kg/m2 , respectively] and overhydration/extracellular water ratio (OH/ECW) [11.7 (4.5-21.9), 4.8 (1.0-14.1), 8.5 (-0.5-15.0) %, respectively] but not regarding body mass index, lean tissue index, fat tissue index. Hypomagnesemia was significantly associated with BCMI [odds ratio (OR) [95% confidence interval (CI)]: 0.85 [0.73-1.00] and OH/ECW (OR [95% CI]: 1.03 [1.01-1.05]), respectively. Kaplan-Meyer 3-year survival rates were 53.6%, 69.7%, and 71.7% in low, middle, and high Mg groups, respectively. However, hypomagnesemia was not significantly associated with 3-year all-cause mortality independent of age, serum albumin and C-reactive protein. Hypomagnesemia was associated with lower BCMI, more pronounced OH/ECW and poorer Kaplan-Meier 3-year cumulative survival, but was not an independent risk factor for mortality in HD patients.

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.

MIS and SGA Indices as Predictors of Mortality and Their Relationship with Nutrition Parameters in Hemodialysis Patients (P18-009-19)

ObjectivesTo compare the value of Subjective Global Assessment (SGA) and Malnutrition-Inflammation Score (MIS) for the prediction of mortality and examine their relationship with other nutritional parameters. MethodsNutrition status was assessed at baseline by SGA and MIS; albumin, protein catabolic rate (nPCR) were obtained from chart; 24-hr dietary recalls were used to estimate daily dietary protein intake (DPI) and dietary energy intake (DEI). Deaths were recorded for 12 months ResultsSeventy-seven participants receiving HD were included, with a mean age of 63.2 ± 14.2 years; 71.2% were male, 58.4% had diabetes and the average time on dialysis was 6.2 ± 4.2 years. The Mean ± SD of nPCR was 0.9 ± 0.2, albumin was 3.8 ± 0.3, DEI was 1867.3 ± 367.9 kcal/kg and DPI was 80.0 ± 15.8 gm/kg. MIS ≥ 6 and SGA > 1 were used as cut-off values to detect malnourished participants; 46% were malnourished by MIS vs. 35% by SGA. Albumin, nPCR, DPI and DEI were all inversely correlated with both indices (P < 0.05). Ten patients (13%) died of cardiovascular disease. Well-nourished participants with MIS < 6 lived longer (11.8 months, CI 95%, 11.6–12.1) than malnourished with MIS ≥ 6 (10.9 months, CI 95%, 10.1–11.7) (Log Rank P = 0.04). MIS was a significant predictor of mortality, while SGA did not reach significance (P = 0.264). ConclusionsMIS was a more sensitive index to detect malnutrition than SGA among HD patients. Only MIS was a significant predictor of mortality. Both indices were strongly correlated to the examined nutrition parameters. Funding SourcesNo funding sources.

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.

Predictive Factors for Achieving the Recommended AUA Daily Urine Production in Patients With Nephrolithiasis.

ObjectiveTo identify factors that predict kidney stone patient's ability to produce 2.5 L urine volume per day on metabolic evaluation.Patients and MethodsIn a retrospective chart review, the first analysis evaluated initial 24-hour urine collections with respect to those who achieved or did not achieve a urine volume of 2.5 L/day. The second analysis evaluated those who achieved or did not achieve a daily urine volume of 2.5 L on their subsequent collection. Several variables were assessed.ResultsPatients’ initial collections (n=1100) that achieved 2.5 L/day (n=274) were of younger age and had a higher body mass index, increased urine sodium, phosphorus, calcium levels, increased protein catabolic rate, and decreased supersaturation of calcium oxalate. In the second analysis (n=273), decreased supersaturation of calcium oxalate, increased urine urea nitrogen level, and increased protein catabolic rate were observed in subsequent collections with a urine volume of 2.5 L/day or more. Patients with a diagnosis of hyponatremia were less likely to achieve 2.5 L/day urine volume. Collection date, other comorbidities, and diuretic use were not associated with achieving 2.5 L/day urine volume. Patients’ mean creatinine per kilogram for all study cohorts were within the range of adequate collection.ConclusionPredictive factors for a urine volume of 2.5 L/day or more include increased fluid intake, higher salt and animal protein diet, elevated body mass index, and male sex. Patients with these factors may require interventions other than hydration recommendations to optimize their prevention of future kidney.

Serum myokine (myostatin and IGF-1) measurement as predictors in hemodialysis patients

BackgroundAlthough individuals undergoing maintenance hemodialysis are a major sarcopenic population, there are few methods to assess their skeletal muscle mass conveniently. Here, we investigated the usefulness of serum myostatin and insulin-like growth factor-1 (IGF-1) measurements for the evaluation of skeletal muscle mass.MethodsWe examined 117 patients undergoing conventional hemodialysis. The serum myostatin level and IGF-1 level were measured once and compared to clinical parameters (especially skeletal muscle mass-related factors) in hemodialysis patients.ResultsThe myostatin levels were positively correlated with body cell mass, arm muscle circumference, basal metabolic rate, creatinine, creatinine phosphokinase, and albumin and negatively correlated with body fat rate, arm circumference–arm muscle circumference, age, and C-reactive protein (CRP). The IGF-1 levels were positively correlated with body cell mass, body mass index, arm muscle circumference, arm circumference–arm muscle circumference, blood urea nitrogen, creatinine, protein catabolism rate, transferrin, cholesterol, and triglyceride, and negatively with age and human atrial natriuretic polypeptide.ConclusionsOur findings indicate that serum myostatin might be a useful biomarker for predicting muscle mass and serum IGF-1 might be a useful predictor of nutritional status in hemodialysis patients.

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.

Modeled Daily Ingested, Absorbed and Bound Phosphorus: New Measures of Mineral Balance in Hemodialysis Patients

Background: Control of predialysis serum phosphorus in hemodialysis patients is challenging. We explored the utility of a novel kinetic phosphorus modeling program. Methods: As part of a quality assurance program, urea kinetic modeling results were combined with those from phosphorus kinetic modeling to compute modeled daily ingested phosphorus (DIP) and components making up this metric, including absorbed, bound, and nonabsorbed, nonbound phosphorus. Results: In 182 hemodialysis patients, DIP averaged 1,089 ± 348 mg/day in men and 934 ± 292 in women (p < 0.002) and correlated substantially with body weight. DIP/kg bodyweight (12.8 ± 3.40 mg/kg) was not significantly different between the sexes. Prescribed equivalent binder dose (EBD) was 4.98 ± 3.61 and 4.53 ± 3.02 g/day in men and women, respectively (p NS). Protein catabolic rate (PCR) was significantly higher in men (64.4 ± 18) g/day vs. women (48.2 ± 15.6, p < 0.001), and the DIP/PCR ratio was 17.4 ± 4.81 in men vs. 20.1 ± 5.76 in women (p < 0.001). Presence of residual kidney function was associated with a lower prescribed EBD dose (4.08 ± 2.62 vs. 5.38 ± 3.81 g/day, p < 0.01). Self-reported poor binder compliance was associated with higher DIP or DIP/kg as well as higher prescribed EBD. In anuric patients, DIP/kg was increased in patients consuming diets with high phosphate additive content and those reporting poor compliance with the prescribed dose of phosphate binders. Conclusions: The combination of urea kinetic and phosphorus modeling can be used to estimate measures related to phosphorus intake. High DIP/PCR or DIP/kg body weight values in anuric patients suggest consumption of a diet high in phosphorus additives or noncompliance with the prescribed amount of phosphorus binders.

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.

Carbohydrate and Lipid Prescription, Administration, and Oxidation in Critically Ill Patients With Acute Kidney Injury: A Post Hoc Analysis

In a prospective multicenter study on adult patients with acute kidney injury (AKI) receiving enteral and/or parenteral nutrition, administered carbohydrates and lipids were compared to the prescribed amounts, as well as to substrate utilization data derived from indirect calorimetry measurements. Resting energy expenditure (REE) was measured by indirect calorimetry. Nitrogen excretion was obtained from the protein catabolic rate calculated from urinary urea nitrogen when available and by urea kinetic-based methods in patients on renal replacement therapy. Fat and carbohydrate oxidations were derived from Frayn formulas. Ninety-two REE measurements were available in 35 critically ill patients with AKI (16 on renal replacement therapy). The mean lipid oxidation rate was 101g/24 h (standard deviation [SD] 73.8), whereas prescribed lipids were 67g/24 h (SD 32; P<.001). Carbohydrate utilization was derived from the same REE measurements yielding a mean carbohydrate oxidation of 105.8g/24 h (SD 131.8), thus, much lower than the prescribed carbohydrates (186.7g/24 h; SD 74.3; P<.001). The amount of fat and carbohydrates administered correlated to the prescribed amount (r=0.896 and r=0.829, respectively). Further analysis showed that this nutritional pattern was independent from the presence of sepsis. Our study suggests that critically ill patients with AKI do not receive an amount of carbohydrate and lipids adequate to support their needs on the basis of measured substrate utilization data. Thus, current nutritional approach in these patients, based on commercial formulas, should be challenged with measured substrate utilization-guided nutritional support.

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.

The state of nutrition care in outpatient hemodialysis settings in Malaysia: a nationwide survey

BackgroundThis study aimed to assess the situational capacity for nutrition care delivery in the outpatient hemodialysis (HD) setting in Malaysia by evaluating dietitian accessibility, nutrition practices and patients’ outcomes.MethodsA 17-item questionnaire was developed to assess nutrition practices and administered to dialysis managers of 150 HD centers, identified through the National Renal Registry. Nutritional outcomes of 4362 patients enabled crosscutting comparisons as per dietitian accessibility and center sector.ResultsDedicated dietitian (18%) and visiting/shared dietitian (14.7%) service availability was limited, with greatest accessibility at government centers (82.4%) > non-governmental organization (NGO) centers (26.7%) > private centers (15.1%). Nutritional monitoring varied across HD centers as per albumin (100%) > normalized protein catabolic rate (32.7%) > body mass index (BMI, 30.7%) > dietary intake (6.0%). Both sector and dietitian accessibility was not associated with achieving albumin ≥40 g/L. However, NGO centers were 36% more likely (p = 0.030) to achieve pre-dialysis serum creatinine ≥884 μmol/L compared to government centers, whilst centers with dedicated dietitian service were 29% less likely (p = 0.017) to achieve pre-dialysis serum creatinine ≥884 μmol/L. In terms of BMI, private centers were 32% more likely (p = 0.022) to achieve BMI ≥ 25.0 kg/m2 compared to government centers. Private centers were 62% less likely (p < 0.001) while NGO centers were 56% less likely (p < 0.001) to achieve serum phosphorus control compared to government centers. Patients from centers with a shared/visiting dietitian had 35% lower probability (p < 0.001) to achieve serum phosphorus levels below 1.78 mmol/L compared to centers without access to a dietitian.ConclusionsThere were clear discrepancies in nutritional care in Malaysian HD centers. Changes in stakeholder policy are required to ensure that dietitian service is available in Malaysian HD centers.