The impact of malnutrition on mortality in patients on maintenance hemodialysis in Serbia

Numerous studies suggest a strong association between nutrition and clinical outcome in chronic hemodialysis (HD) patients. While determination of malnutrition is often based on objective measurements, such as biochemical parameters and anthropometric data, there is no single measurement that can reliably predict the risk for malnutrition or poor outcome. The aim of the present investigation was to determine the prevalence and severity of malnutrition among HD patients in a large university-affiliated HD center in Serbia, and to examine the relationship between various nutritional and nonnutritional factors, and the clinical outcome in the period of 20 months follow-up. The prospective observational cohort study included patients (n = 197) with more than 3 months on HD treatment before entering the study. Global nutritional status was evaluated by the dialysis malnutrition score (DMS). Body mass index (BMI), triceps skinfold thickness (TSF), mid-arm circumference (MAC), and mid-arm muscle circumference (MAMC), as well as several laboratory parameters and clinical examination, were recorded. Dose of HD and protein equivalence of nitrogen appearance normalized to ideal body weight (nPNA) were evaluated by the urea kinetic model. Mortality data were collected prospectively during the 20 months of follow-up. A moderate/severe degree of malnutrition was presented in 39.2% of female and 22.8% of male patients, while signs of mild malnutrition existed in 45.5% and 66.9% of patients, respectively. Kaplan-Meier survival analysis showed that in the entire group of patients with DMS score >10, the mortality rate was higher (log rank 5.61; P < 0.05) than in those with DMS score 相似文献   

A modified quantitative subjective global assessment of nutrition for dialysis patients.

BACKGROUND: Malnutrition, a predictor of increased mortality in dialysis patients, can be estimated using the subjective global assessment (SGA), a semiquantitative scale with three severity levels. This semiquantitative feature restricts the SGA's reliability and precision. METHODS: Using the components of the conventional SGA, we developed a fully quantitative scoring system (the dialysis malnutrition score) consisting of seven variables: weight change, dietary intake, gastrointestinal symptoms, functional capacity, comorbidity, subcutaneous fat and signs of muscle wasting. Each component was assigned a score from 1 (normal) to 5 (very severe). The sum of all seven components in this malnutrition score lies between 7 (normal) and 35 (severely malnourished). To evaluate nutritional status in chronic dialysis patients, anthropometric measurements including mid-arm circumference (MAC), triceps skin-fold thickness, calculated mid-arm muscle circumference (MAMC), body mass index (BMI, ratio of weight to square of height) and laboratory parameters were used. Forty-one patients (20 men and 21 women) were randomly selected from a pool of 120 haemodialysis patients. Patients were aged between 26 and 81 years (mean SD, 57 +/- 12 years) and had undergone haemodialysis for between 7 months and 12 years (mean +/- SD, 3.0 +/- 2.1 years). RESULTS: The malnutrition score of each patient was assessed by a dietitian within 5-20 min (12.0 +/- 3.5 min) with no knowledge of anthropometric findings. Pearson correlation coefficients between the malnutrition score and biceps skin-fold (r= -0.32) MAC (r= -0.55), MAMC (r= -0.66), BMI (r= -0.35), total iron-binding capacity (TIBC, r= -0.77), the serum albumin concentration (r= -0.36) and total protein (r= -0.33) were all significant, whereas the conventional SGA had significant correlation only with TIBC (r= -0.35) and MAMC (r= -0.37). Malnutrition score showed a significant correlation with age (r= +0.34) and years dialysed (r= +0.28). Multiple regression analysis showed a significant correlation between the malnutrition score and the combination of the MAMC, BMI, serum albumin concentration and TIBC (r= 0.81, P<0.001). There was no correlation between the malnutrition score and sex, urea reduction ratio, protein catabolic rate, and the absolute lymphocyte count. CONCLUSIONS: We conclude that our invented malnutrition score, which can be performed in minutes, reliably assesses the nutritional status of haemodialysis patients. We suggest that our malnutrition score may be superior to the SGA. More comparative and longitudinal studies are needed to confirm the validity of this scoring system in nutritional evaluation of dialysis patients.     

Nutritional parameters and mortality in incident hemodialysis patients.

OBJECTIVE: To evaluate the impact of nutritional parameters at the time of initiation of hemodialysis (HD) on mortality. DESIGN: Retrospective study. SETTING: Dialysis Unit of the Federal University of Sao Paulo, Oswaldo Ramos Foundation. PATIENTS: Three hundred forty-four incident HD patients (60.5% male, 26% diabetic) with the first nutritional evaluation performed before completing 3 months of onset of HD were included. METHODS: The study consisted of baseline measurements of several nutritional parameters (triceps skinfold thickness [TSF], midarm muscle circumference [MAMC], body mass index [BMI], serum albumin, serum creatinine, and protein and energy intake assessed by 3-day food diary) and records of outcome (death) over a period of 10 years. RESULTS: Muscle and/or fat depletion was observed in 51% of the studied patients, according to the percent standard of MAMC and TSF, respectively. Presence of diabetes, age over 60 years, serum albumin < 3.5 g/dL, MAMC adequacy < 90%, protein intake < 1.0 g/kg/d, and energy intake < 25 kcal/kg/d were associated with worse survival. When patients were analyzed according to tertiles of dialysis vintage, BMI > or = 25 (calculated as kg/m2) had a negative impact on survival only in the highest tertile (> 2.45 years). Patients with BMI < 25 and MAMC adequacy > or = 90% showed the best survival over the study period, and those with BMI > or = 25 but MAMC adequacy < 90% had the worst survival (P = .004). In the multivariate survival analysis adjusting for diabetes, advanced age, and hypoalbuminemia, the reduced MAMC (P = .008) and the low energy intake (P = .03) were independent predictors of death in incident HD patients. CONCLUSIONS: Reduced MAMC and low energy intake at the beginning of chronic dialysis are risk factors for mortality. A negative effect of high BMI on survival was associated with reduced MAMC and longer dialysis vintage.     

A comparison of markers of myocardial injury and their relation to nutritional parameters in hemodialysis patients

Background: Serum cardiac troponin T (cTnT) is a valuable marker of ischemic heart disease (IHD) and left ventricular hypertrophy, as well as a mortality predictor in hemodialysis populations. We compared the value of cTnT, creatinine kinase (CK)-MB mass and myoglobin as mortality predictors in our hemodialysis patients and evaluated their relation to nutritional status. Methods: A total of 118 hemodialysis patients were prospectively studied from January 2004 to April 2013. Clinical and laboratory evaluations during the 12-month baseline period included the history of IHD, signs of left ventricular hypertrophy (LVH), Kt/V and serum cardiac markers together with the percentage of body fat (%fat), mid-arm circumference (MAC), mid-arm muscle circumference (MAMC), triceps skinfold (TSF) and BMI. Results: Underweight patients had significantly higher cTnT values (Mann–Whitney, p?p?p?p?p?p?Conclusion: Troponin T and CK-MB mass were significantly elevated in the underweight patient group. Troponin T was the only independent cardiac marker predictor of all cause mortality in our hemodialysis patients.     

Malnutrition is prevalent among hemodialysis patients in Jeddah, Saudi Arabia

Malnutrition (MN) in hemodialysis patients (HDP) is prevalent worldwide. How-ever, data regarding the nutritional status among HDP living in Jeddah, Saudi Arabia, is lacking. The purpose of this study was to detect MN in HDP at the Jeddah Kidney Center, with an inexpensive nutritional assessment protocol consisting of anthropometric body mass index (BMI), triceps skin fold (TSF), mid-arm muscle circumference (MAMC) and biochemical (albumin) blood measurements and the seven-point subjective global assessment (SGA). A cross-sectional study assessed 269 HDP for MN through a questionnaire, SGA and anthropometric and biochemical measurements. Spearman's rank correlation coefficients were determined between SGA and anthropometric and biochemical measurements as well as the relative odds of MN. Statistical significance was P <0.05. These HDP were 48.7% moderately and 6.3% severely malnourished. Albumin, BMI, TSF and MAMC correlated positively with the seven-point SGA (r s = 0.16, P = 0.007; r s = 0.33, P <0.001; r s = 0.29, P <0.001; and r s = 0.34, P <0.001, respectively). Those HDP who were female (Odds ratio [OR] = 2.04, P = 0.036), older (≥55 years) (OR = 1.70, P = 0.087), uneducated (OR = 1.80, P = 0.072), with a lower BMI (<18 kg/m2) (OR = 2.00, P = 0.077) and thinner TSF (OR = 1.45, P = 0.041) had a greater risk of MN. The high prevalence of MN was detected with an inexpensive protocol. Women with thinner TSF were more likely to be malnourished. The implementation of this protocol is warranted along with dietary education and counseling to decrease MN in HDP.     

Nutritional assessment of children on haemodialysis: value of IGF-I, TNF-&agr; and IL-1{beta}

Background: Protein-energy malnutrition (PEM) is associated with increased morbidity and mortality in haemodialysis (HD) patients. Insulin-like growth factor I (IGF-I) has proved to be a sensitive marker of malnutrition, while interleukin-1 (IL-1{beta}) and tumour necrosis factor (TNF) have been found to be raised in catabolic states. Methods: We have investigated the nutritional status of 17 chronic renal failure (CRF) paediatric patients (8 boys, 9 girls) on maintenance HD. Eight predialysis CRF children (5 boys and 3 girls; mean creatinine 5.1±3.2 mg/dl) and 10 healthy children served as control groups. PEM was defined according to anthropometric measurements (triceps skinfold thickness (TST), mid-arm circumference (MAC), and mid-arm muscle circumference (MAMC). These were correlated with serum IGF-I, IL-1 TNF-&agr; transferrin, and albumin (all sampled before the HD session). Results: In the HD group, TST was reduced in 41.2% of the patients, whereas MAC and MAMC were reduced in 82.4 and 76.5% respectively. TST was depleted in only one of the predialysis CRF children. The degree of reduction in MAC and MAMC were 62.5 and 62.5% respectively. Median serum IGF-I level was decreased in both HD and predialysis CRF patients (205.1 interquartile range (IQR) 194.4 &mgr;g/l and 258.8 IQR 155.0 &mgr;g/l respectively) compared to the healthy children (418.0 IQR 310.5&mgr;g/l) (P=0.0009 and P=0.01 respectively). Within the HD group, IGF-I levels were lower in patients with malnutrition defined according to TST (145.0 IQR 125.5 &mgr;g/l) compared to children with normal TST (201.2 IQR 218.8 &mgr;g.l) (P=0.05). IGF-I levels of the HD patients with malnutrition according to TST was also lower than predialysis CRF patients and healthy children (P=0.04 and P=0.002 respectively). Serum IL-1{beta} was undetectable in all groups. Median serum TNF-&agr; levels were higher in HD and predialysis CRF patients compared to healthy children, albeit statistically insignificant. There was no correlation between TNF-&agr;, transferrin or albumin and anthropometric parameters. Conclusions: Our results support the high prevalence of malnutrition in CRF children, which becomes more pronounced when treatment by HD is initiated. We suggest that determination of IGF-I levels in childhood HD patients in conjunction with anthropometric measurements is useful for identification of malnutrition. We have not been able to demonstrate the catabolic effects of cytokines on this state of protein-energy malnutrition.     

维持性血液透析患者血清脂联素与营养状况的关系

目的探讨维持性血液透析患者血清脂联素与营养状况的关系。方法对81例维持性血液透析患者应用改良定量主观全面营养评估（MQSGA）法、血生化指标、人体指数学指标综合评估其营养状况,同时采用ELISA法测定血清脂联素水平,评估血清脂联素与营养状况之间的相关性。结果维持性血液透析患者营养不良患病率为69．1％。血清脂联素平均为（8．66±2．62）μg／ml,与MQSOA、肱三头肌皮褶厚度、上臂肌围、腰臀比、体重指数等营养指标成线性相关关系。结论维持性血液透析患者大多存在不同程度的营养不良,血清脂联素水平与营养指标相关,可作为评估血液透析患者营养不良的指标之一。     

High prevalence of malnutrition and inflammation in undialyzed patients with chronic renal failure in developing countries: a single center experience from eastern India

BACKGROUND: Malnutrition is common in patients with chronic renal failure (CRF), and its prevalence before the initiation of dialysis is poorly characterized in these patients in developing countries. There is a paucity of data on the quantification of malnutrition and inflammation in undialyzed patients of CRF from India. This study analyzed the prevalence and causes of malnutrition in patients with CRF before the initiation of dialysis treatment. MATERIAL AND METHODS: In the present study, assessments of nutritional and inflammatory status were carried out in patients with CRF. Serum albumin, body mass index (BMI), triceps skin fold thickness (TST), mid-arm muscle circumference (MAMC), and subjective global assessment (SGA) scoring were used for assessment of nutritional parameters. Serum C-reactive protein and serum ferritin level were used to assess the inflammatory state of the patient. RESULTS: Two hundred and three (146 male, 57 female) patients with CRF were included in the study from August 2004 to April 2006. Overall, the prevalence of malnutrition was 65% (131/203). The age of malnourished patients (93 male, 38 female) ranged from 11-82, with mean age of 52 +/- 12.68 years. The mean serum total protein and albumin were also significantly lower in patients with malnutrition in comparison to non malnourished cases (5.50 +/- 0.40 gm/dL vs. 5.74 +/- 0.38 gm/dL; p < 0.05, and 3.18 +/- 0.58 gm/dL vs. 3.68 +/- 0.55 gm/dL; p < 0.05). The C-reactive protein and serum ferritin were significantly elevated in the malnourished group as compared to non-malnourished patients (63% vs. 33%; p < 0.05, and 301.2 +/- 127.1 mg/dL vs. 212.7 +/- 124.9 mg/dL; p < 0.05). CONCLUSION: Thus, malnutrition was common in patients with CRF before the commencement of dialysis. These data indicate that an emphasis should be placed on the assessment and prevention or correction of malnutrition in patients with CRF because of its documented adverse effect on the outcome on maintenance dialysis.     

Randomized prospective comparison between erythropoietin and androgens in CAPD patients

BACKGROUND: Anemia and malnutrition are significant complications in peritoneal dialysis (PD) patients. Previous studies in hemodialysis have shown that androgens are effective as therapy for anemia; however, this has not been tested in a randomized prospective trial in PD patients. Furthermore, the anabolic properties of androgens may exert additional benefits on the nutritional status in this population. METHODS: Twenty-seven stable male patients over 50 years who were under maintenance continuous ambulatory peritoneal dialysis (CAPD) therapy were randomized to receive recombinant human erythropoietin (rHuEPO; N = 14) or nandrolone decanoate (ND; 200 mg/week IM; N = 13) as therapy for anemia. The evolution of hematologic parameters and the impact on both nutritional anthorpometric and biochemical variables were evaluated after six months of treatment. RESULTS: Hemoglobin and hematocrit experienced similar increases in both groups: from 8.5 +/- 0.9 g/dL and 25.8 +/- 2.7% to 11.7 +/- 0.6 g/dL and 34.7 +/- 1.6% (P < 0.001) in patients receiving rHuEPO, and from 8.9 +/- 0.8 and 27 +/- 2.2% to 11.8 +/- 0.4 g/dL and 35.1 +/- 1.5% (P < 0.001) in subjects treated with ND. At the end of the study, out of the diverse nutritional variables included in this investigation, only weight and body mass index significantly increased in the rHuEPO group. Conversely, both anthropometric [weight, body mass index, triceps skinfold, mid-arm circumference (MAC) and mid-arm muscle circumference (MAMC)] and biochemical parameters (serum total proteins, albumin, prealbumin and transferrin) were significantly increased in patients treated with ND. In this group, serum urea nitrogen, urea net excretion and protein equivalent of nitrogen appearance significantly decreased. These facts, together with an increase in serum creatinine and no changes in dietary intake during the study, suggest a rise in muscle mass related to an anabolic effect of nandrolone decanoate. Interestingly, serum levels of insulin-like growth factor type 1 (IGF-1) increased in patients on the androgen group compared to subjects treated with rHuEPO. Moreover, there was a positive and significant correlation between the rise in IGF-1 concentrations and the increase in hemoglobin, hematocrit, MAC and MAMC. CONCLUSIONS: Androgens therapy improved the anemia in elderly male CAPD patients in a similar manner to that observed with rHuEPO. Furthermore, compared with rHuEPO, androgen administration was associated with beneficial effects on nutritional status. The mechanism of action of androgens on hematologic and nutritional parameters might be mediated, at least in part, by IGF-1.     

High Prevalence of Malnutrition and Inflammation in Undialyzed Patients with Chronic Renal Failure in Developing Countries: A Single Center Experience from Eastern India

Background. Malnutrition is common in patients with chronic renal failure (CRF), and its prevalence before the initiation of dialysis is poorly characterized in these patients in developing countries. There is a paucity of data on the quantification of malnutrition and inflammation in undialyzed patients of CRF from India. This study analyzed the prevalence and causes of malnutrition in patients with CRF before the initiation of dialysis treatment. Material and Methods. In the present study, assessments of nutritional and inflammatory status were carried out in patients with CRF. Serum albumin, body mass index (BMI), triceps skin fold thickness (TST), mid-arm muscle circumference (MAMC), and subjective global assessment (SGA) scoring were used for assessment of nutritional parameters. Serum C-reactive protein and serum ferritin level were used to assess the inflammatory state of the patient. Results. Two hundred and three (146 male, 57 female) patients with CRF were included in the study from August 2004 to April 2006. Overall, the prevalence of malnutrition was 65% (131/203). The age of malnourished patients (93 male, 38 female) ranged from 11–82, with mean age of 52 ± 12.68 years. The mean serum total protein and albumin were also significantly lower in patients with malnutrition in comparison to non malnourished cases (5.50 ± 0.40 gm/dL vs. 5.74 ± 0.38 gm/dL; p < 0.05, and 3.18 ± 0.58 gm/dL vs. 3.68 ± 0.55 gm/dL; p < 0.05). The C-reactive protein and serum ferritin were significantly elevated in the malnourished group as compared to non-malnourished patients (63% vs. 33%; p < 0.05, and 301.2 ± 127.1 mg/dL vs. 212.7 ± 124.9 mg/dL; p < 0.05). Conclusion. Thus, malnutrition was common in patients with CRF before the commencement of dialysis. These data indicate that an emphasis should be placed on the assessment and prevention or correction of malnutrition in patients with CRF because of its documented adverse effect on the outcome on maintenance dialysis.     

A 2 year experience of a nutritional support service: prospective study of 229 non-intensive care patients receiving parenteral nutrition

During a 2 year period, 229 non-intensive care patients received total parenteral nutrition (TPN) for a mean of 23.2 days. Nutritional parameters of weight, triceps skin-fold thickness (TSF), mid-arm muscle circumference (MAMC), total lymphocyte count (TLC), serum albumin and serum transferrin were measured prior to commencement of TPN and then at weekly intervals. All parameters showed an upward trend during the period of TPN. This was small and not statistically significant for weight, TSF, MAMC and albumin; the trends were greater and statistically significant for transferrin (P = 0.001) and TLC (P = 0.002). In contrast, in the 14.4% of patients who died, albumin, transferrin and TLC all fell. Patients who died had a significantly lower initial albumin (P = 0.05), transferrin (P = 0.04) and TLC (P = 0.04). The last values obtained in patients who died were very significantly lower for albumin (P less than 0.001), transferrin (P less than 0.001) and TLC (P = 0.003). Single-lumen tunnelled subclavian catheters had a significantly lower incidence of catheter sepsis (4.8%) compared with double-lumen (17.4%) and triple-lumen (13.7%) catheters (P = 0.01). There was also a greater incidence of mechanical and thrombotic complications with multiple-lumen catheters compared with single-lumen catheters (P = 0.02). This study shows that the nutritional indices albumin, transferrin and TLC have prognostic significance. Single-lumen rather than multiple-lumen catheters should be used for administration of TPN whenever possible.     

Near infra-red interactance for nutritional assessment of dialysis patients.

BACKGROUND: Malnutrition is a common problem in dialysis patients and may affect up to one-third of patients. Near-infrared interactance (NIR) is a novel approach to estimate body composition and per cent total body fat. METHODS: We used near-infrared interactance (Futrex 5000) to estimate the body composition including body fat percentage, as well as subjective global assessment (SGA), anthropometric measurements including mid-arm circumference (MAC), triceps and biceps skinfold thickness, calculated mid-arm muscle circumference (MAMC), body mass index (BMI), and laboratory values. NIR score, SGA assessment and anthropometric parameters were measured shortly after the end of a dialysis session. NIR measurement was made by placing a Futrex sensor on the nonaccess upper arm for several seconds. Serum albumin, transferrin (reflected by total iron binding capacity), and total cholesterol concentrations were performed as well. RESULTS: Thirty-four patients (20 men and 14 women) were selected from a pool of 120 haemodialysis patients. Their ages ranged from 26 to 86 years (58+/-14 years). Time on dialysis ranged from 8 months to 19 years (4.5+/-4.6 years). NIR scores were significantly different in three SGA groups: (A) well-nourished, 32.5+/-6.9%; (B) mildly to moderately malnourished, 29.2+/-5.3%; and (C) severely malnourished, 23.2+/-10.2% (P<0.001). Pearson correlation coefficients (r) between the NIR score and nutritionally relevant parameters were significant (P<0.001) for body mass index (r=+0.81), mid-arm circumference (r=+0.74), triceps skin fold (r=+0.54), biceps skin fold (r=+0.55), and mid-arm muscle circumference (r=+0.54). An inverse correlation was also found between NIR and years dialysed (r=-0.49, P=0.004), denoting a lesser body fat percentage according to NIR for patients dialysed longer. NIR was correlated with serum transferrin (r=+0.41, P=0.016) and cholesterol (r=+0.39, P=0.022) and marginally with serum albumin (r=+0.29, P=0.097). CONCLUSIONS: We conclude that NIR, which can be performed within seconds, may serve as an objective indicator of nutritional status in haemodialysis patients. More comparative and longitudinal studies are needed to confirm the validity of NIR measurements in nutritional evaluation of dialysis patients.     

Apelin and nutritional status in children on dialysis

Background: We aimed to evaluate whether serum apelin could reflect the nutritional status of children on dialysis. Methods: Twelve patients on peritoneal dialysis (PD) and 20 patients on hemodialysis (HD) were enrolled. Patients received individualized diet for six months. Anthropometric and laboratory indices were measured at onset and the end of the study. Results: The anthropometric indices were all significantly lower in patients than in controls whereas similar in PD and HD patients. The protein catabolic rate (nPCR), height, mid-arm circumference (MAC), triceps skinfold thickness (TSF), arm muscle area (AMA) and arm fat area (AFA) z scores were significantly increased in dialysis patients after nutritional intervention. Weight z scores statistically increased in HD group whereas did not statistically change in PD group. Serum albumin levels were significantly improved in PD and HD patients. Apelin levels were similar in PD, HD and control groups. Post nutritional apelin values did not differ in each dialysis groups. On multivariate analysis, apelin was independently associated with age, weight, ESR and TG. Conclusions: Apelin seems to be not a useful indicator for monitoring the nutritional status in children on dialysis. However, the close link of apelin with inflammatory and lipid parameters suggested that apelin might be a novel target for slowing the atherogenic process in pediatric dialysis patients.     

维持性血液透析患者营养状况的评价

目的：评价维持性血液透析(MHD）患的营养状况。方法：对57例维持性血透患进行人体测量、生化指标的测定、饮食评估、主观综合营养评估(SGA)及综合性营养评估(GNA)。结果：不同指标评估营养不良的发生率分别为：三头肌皮皱厚度(TSF)66．7％，上臂中段肌肉周径(MAMC)33．3％，白蛋白(Alb)31．6％，前白蛋白(PA)45．6％，转铁蛋白(TRF)63．2％，饮食蛋白摄入(DPI)33．3％，SGA38．6％，GNA47．4％。各项指标均属正常仅占14，0％。依据GNA评分，营养不良组与营养良好组进行比较，Alb、PA、蛋白分解率(nPCR)、DPI、SGA评分均有统计学差异。结论：综合评价结果表明86．0％透析患存在不同程度的营养不良。GNA对血透患具有良好的营养评价作用。对MHD患进行常规的营养评价及合理的营养指导对预后有重要意义。     

Association between nutrition and peripheral artery disease in continuous ambulatory peritoneal dialysis patients

Objective To investigate the association between nutrition and peripheral artery disease (PAD) in continuous ambulatory peritoneal dialysis (CAPD) patients. Methods One hundred and two stable CAPD patients from a single center were enrolled in this cross-sectional study. Automatic ankle-brachial index (ABI) measuring system was applied to examine ABI. Patients were divided into PAD group (ABI＜0.9) and non-PAD group (ABI≥0.9). Clinical data were collected. Biochemical parameters were detected. Nutritional status was evaluated by serum albumin, handgrip strength (HGS) and subjective global assessment (SGA). Logistic regression analysis was performed to estimate the association of PAD with each nutritional marker as well as other potential risk factors. Results The incidence of PAD was 23.53% (24/102). ABI was significantly lower in patients with malnutrition as compared to those without malnutrition [(0.72±0.21) vs (1.04±0.14), P＜0.01]. Compared with non-PAD patients, serum albumin (P＜0.01), HGS (P＜0.01), diastolic blood pressure (P＜0.05), serum creatine (P＜0.05)、blood urine nitrogen (P＜0.01) were significantly decreased, but age (P＜0.01), the incidence of malnutrition [SGA, P＜0.01], diabetic status (P＜0.01), cardiovascular disease history (P＜0.01) were significantly increased in PAD patients. Logistic regression analysis showed that serum albumin (OR=0.762, 95％CI：0.611-0.948, P=0.015), HGS (OR=0.988, 95％CI：0.979-0.997, P=0.013) were independent protective factors for PAD, malnutrition [(SGA), OR=21.101, 95％CI：5.008-88.901, P＜0.01] was independent risk factor for PAD in CAPD patients. Conclusions The PAD incidence of CAPD patients in our center is 23.53%. Nutrition is independent factor associated with PAD in CAPD patients.     

Prevalence and clinical outcome associated with preexisting malnutrition in acute renal failure: a prospective cohort study

Malnutrition is a frequent finding in hospitalized patients and is associated with an increased risk of subsequent in-hospital morbidity and mortality. Both prevalence and prognostic relevance of preexisting malnutrition in patients referred to nephrology wards for acute renal failure (ARF) are still unknown. This study tests the hypothesis that malnutrition is frequent in such clinical setting, and is associated with excess in-hospital morbidity and mortality. A prospective cohort of 309 patients admitted to a renal intermediate care unit during a 42-mo period with ARF diagnosis was studied. Patients with malnutrition were identified at admission by the Subjective Global Assessment of nutritional status method (SGA); nutritional status was also evaluated by anthropometric, biochemical, and immunologic parameters. Outcome measures included in-hospital mortality and morbidity, and use of health care resources. In-hospital mortality was 39% (120 of 309); renal replacement therapies (hemodialysis or continuous hemofiltration) were performed in 67% of patients (206 of 309); APACHE II score was 23.1+/-8.2 (range, 10 to 52). Severe malnutrition by SGA was found in 42% of patients with ARF; anthropometric, biochemical, and immunologic nutritional indexes were significantly reduced in this group compared with patients with normal nutritional status. Severely malnourished patients, as compared to patients with normal nutritional status, had significantly increased morbidity for sepsis (odds ratio [OR] 2.88; 95% confidence interval [CI], 1.53 to 5.42, P < 0.001), septic shock (OR 4.05; 95% CI, 1.46 to 11.28, P < 0.01), hemorrhage (OR 2.98; 95% CI, 1.45 to 6.13, P < 0.01), intestinal occlusion (OR 5.57; 95% CI, 1.57 to 19.74, P < 0.01), cardiac dysrhythmia (OR 2.29; 95% CI, 1.36 to 3.85, P < 0.01), cardiogenic shock (OR 4.39; 95% CI, 1.83 to 10.55, P < .001), and acute respiratory failure with mechanical ventilation need (OR 3.35; 95% CI, 3.35 to 8.74, P < 0.05). Hospital length of stay was significantly increased (P < 0.01), and the presence of severe malnutrition was associated with a significant increase of in-hospital mortality (OR 7.21; 95% CI, 4.08 to 12.73, P < 0.001). Preexisting malnutrition was a statistically significant, independent predictor of in-hospital mortality at multivariable logistic regression analysis both with comorbidities (OR 2.02; 95% CI, 1.50 to 2.71, P < 0.001), and with comorbidities and complications (OR 2.12; 95% CI, 1.61 to 2.89, P < 0.001). Malnutrition is highly prevalent among ARF patients and increases the likelihood of in-hospital death, complications, and use of health care resources.     

甲氧氯普胺加入腹透液中对腹膜透析患者食欲及营养状况的影响

目的：探讨甲氧氯普胺加入腹透液中对腹膜透析患者食欲及营养状况的影响。方法：将食欲明显减退的腹膜透析患者为研究对象,随机分成观察组52例和对照组52例,两组常规治疗相同,观察组予甲氧氯普胺注射液10 mg/d加入腹透液中,疗程为4周。比较两组治疗前和治疗后3月的食欲和血白蛋白、体重指数（BMI）、中臂围、中臂肌围、肱三头肌皮褶厚度（TSF）、改良定量主观整体评估（MQSGA）等营养指标的差别。结果：（1）观察组总有效率（90.39%）显著高于对照组（69.23%）,差异有统计学意义（P〈0.05）;（2）观察组治疗后白蛋白、BMI、中臂围、中臂肌围和TSF均较治疗前显著升高,MQSGA较治疗前显著下降,差异均有统计学意义（P〈0.05）;对照组治疗后白蛋白较治疗前显著升高,MQSGA较治疗前显著下降,差异均有统计学意义（P〈0.05）;治疗后,观察组白蛋白显著高于对照组,MQSGA显著低于对照组,差异均有统计学意义（P〈0.05）;（3）两组均未见明显药物不良反应。结论：甲氧氯普胺加入腹透液中可改善腹膜透析患者食欲和营养状况。     

围手术期营养支持对外科病人预后的影响

目的:分析围手术期营养支持与术后并发症和死亡率的关系。方法:采用多项营养评价指标测定4642例外科非急诊住院病人的营养状况,按是否接受围手术期营养支持分组,分析营养状况及术后死亡率和并发症的影响。结果:就各项指标分别进行营养评价,得出我院普外科非急诊病人营养不良的发生率分别是:体重指数(BMI)21.0%,三头肌皮褶厚度(TSF)50.2%,上臂围(AC)20.3%,上臂肌围(AMC)21.4%,血清白蛋白(ALB)24.5%,前白蛋白(PA)35.3%,总淋巴细胞(TLC)55.5%,主观全面评价法(SGA)38.4%。823例(17.7%)属接受正规围手术期营养支持组,3819例(82.3%)病人属未接受围手术期营养支持组。两组间的并发症发生率及死亡率相比,不存在统计学差异(14.3%比11.3%,P=0.062;2.4%比2.1%,P=0.126)。而若以两组中呈中、重度营养不良者作比较,则围手术期非营养支持组病人的并发症发生率及死亡率却明显高于接受营养支持组者(25.4%比14.5%,P=0.003;5.4%比2.8%,P=0.014),且住院时间也明显延长(24.2d比17.6d,P=0.042)。结论:围手术期营养支持对营养状况良好病人的预后无影响,但能降低呈中、重度营养不良病人的术后死亡率和并发症发生率,并缩短其住院时间。     

High‐calcium dialysate: A factor associated with inflammation,malnutrition and mortality in non‐diabetic maintenance haemodialysis patients

Aim: Chronic inflammation, which is common in dialysis patients, often causes malnutrition and even protein‐energy wasting. However, the association of high‐calcium dialysate with malnutrition and/or inflammation in non‐diabetic maintenance haemodialysis patients remains unclear. This study investigated the possible adverse effects of high‐calcium dialysate and mortality in this population. Methods: A total of 717 non‐diabetic haemodialysis patients participated in this 2 year prospective study. The subjects were categorized into three subgroups based on whether dialysate calcium concentrations were high (3.5 mEq/L), standard (3.0 mEq/L) or low (2.5 mEq/L). Demographic, haematological, nutritional and inflammatory markers, biochemical and dialysis‐related data were obtained for cross‐sectional analysis. Causes of death and mortality rates were also analyzed for each subgroup. Results: Patients with high‐calcium dialysate (n = 82) had a higher incidence of malnutrition and inflammation (61.0% vs 44.1% and 43.9%, respectively) than those with standard‐ and low‐calcium dialysate (n = 528 and 107). Backward stepwise multiple regression analysis revealed that high‐calcium dialysate was negatively correlated with nutritional index, serum albumin levels, but positively associated with the inflammatory marker of serum ferritin levels. At the end of the 2 year follow up, 45 patients had died. Cox multivariate analysis demonstrated that high‐calcium dialysate was a significant associated factor (relative risk 2.765; 95% confidence interval 1.429–5.352) for 2 year all‐cause mortality in these patients. Conclusion: The analytical results indicate that high‐calcium dialysate is associated with malnutrition and inflammation as well as 2 year mortality in non‐diabetic maintenance haemodialysis patients and the findings suggest that this population, even those with optimal mineral balance, should avoid high‐calcium dialysate.     

Total body nitrogen predicts long-term mortality in haemodialysis patients - a single-centre experience

Background: It has been estimated that 30-50% of adult haemodialysis patients have moderate to severe malnutrition. We have previously shown that estimation of total body nitrogen, expressed as a nitrogen index (NI) by in vivo neutron activation analysis (IVNAA) is an accurate tool for estimating total body protein in dialysis patients. It is not clear whether the nitrogen index is predictive of mortality and morbidity in dialysis patients. Methods: We studied the long-term predictive value of nutritional assessment by IVNAA and serum albumin on mortality and morbidity (including infection episodes requiring hospital admission, ischaemic heart disease (IHD), cerebrovascular or peripheral vascular disease (PVD). Seventy-six chronic haemodialysis patients were initially studied between 1989 and 1991, with a minimum follow-up of 5 years. The mean age of the patients was 48.3 years (range 21-76). Patients were divided into two groups, group I, n=22, had a NI⩽0.8 (NI⩽0.8 represents protein malnutrition) and group II, n=54, had a NI>0.8. Results: Fifteen patients in group II died in the follow-up period compared to nine from group I (P<0.05), but NI⩽0.8 did not predict vascular or infective morbidity. Serum albumin⩽35 g/day did predict over all mortality (P<0.05) as well as infection episodes (P<0.001). When patients above the age of 50 years were analysed, NI did predict mortality (P<0.05) but serum albumin did not, while the age of >50 itself was a strong predictor of mortality (P<0.001). Conclusion: We conclude that NI⩽0.8 is predictive of long-term mortality. This reinforces the view that low body protein stores are predictive of increased mortality in dialysis patients and that the serum albumin is predictive of mortality because of its reflection of protein stores. Key words: haemodialysis; mortality; nutrition; total body nitrogen