Relationship between geriatric nutritional risk index and subpopulation lymphocyte counts in patients undergoing hemodialysis and peritoneal dialysis

We investigated the relationship between geriatric nutritional risk index (GNRI) and subpopulation lymphocyte counts (SLCs) in hemodialysis (HD) and peritoneal dialysis (PD) patients and evaluated whether they can be helpful in the diagnosis of malnutrition in these patients. We examined the GNRI and SLCs of 50 HD patients (mean: 55.8?±?12.7 years; 28 men and 22 women) and 16 Continuous Ambulatory Peritoneal Dialysis (CAPD) patients (mean: 49.8?±?14.5 years; 10 men and six women). The GNRI is calculated based on the serum albumin level, dry weight, and ideal body weight and uses the following equation: GNRI?=?[14.89?×?albumin (g/dL)]?+?[41.7?×?(weight/ideal body weight)]. SLCs were evaluated using flow cytometry. T-tests and χ² tests were performed to compare the two groups. Logistic regression analysis was performed for predicting malnutrition in dialysis patients. The average GNRI value was 100.1?±?8.4 in HD patients and 99.2?±?8.1 in PD patients, and no significant differences in GNRI or SLC were observed between the two groups. SLCs were higher in patients with higher GNRI (GNRI?≥?100) although there was no statistical difference. Logistic regression for predicting malnutrition according to GNRI revealed that age, female sex, and CD19 counts predicted malnutrition in HD and PD patients. These results suggest that GNRI and SLCs (especially CD19 count) may be significant nutritional markers in these patients.     

Discrepancies in Serum Albumin Measurements Vary by Dialysis Modality

Background.?Serum albumin level is an important prognostic marker in patients with chronic renal failure. However there are discrepancies in the methods of estimation of serum albumin. The objective of this study is to evaluate the magnitude of the discrepancy in the serum albumin levels as measured by Bromcresol Green (BCG) and Bromcresol Purple (BCP) dye methods in patients on hemodialysis (HD) and peritoneal dialysis (PD) and to ascertain the clinical determinants of the discrepancy (ΔSA = BCG-BCP; g/dL) in each of the modalities. Method.?We measured serum and plasma albumin levels by BCG and BCP methods in 19 adult HD patients and 18 adult PD patients treated in the dialysis units of the University of Colorado Health Sciences Center. Similar measurements were performed in 10 normal adult subjects. In all groups, paired blood samples were taken to estimate the albumin in both serum and plasma. Nephelometry (NM) was subsequently performed on the serum of 13 of the HD patients, 14 of the PD patients, and each of the 10 normal subjects. Results.?We found that for both the dye methods serum and plasma albumin levels are almost identical in each of the three subject groups. In the normal subjects serum albumin estimated by BCP is in good agreement with NM values but BCG overestimates the albumin levels. In the PD group the discrepancy between the BCG and BCP (ΔSA) is statistically significant with the BCG averaging 0.59 ± 0.12 g/dL more than the BCP. The BCG values are closer to those obtained by the “gold standard”, NM. In the HD group the ΔSA is significantly (p<0.001) less than in the PD group (0.34 ± 0.11 g/dL). As for PD, BCG values are closer to NM values. Increasing age, female gender, and higher dialysis adequacy are associated with higher ΔSA in the HD but not in the PD group. Utilizing linear regression analysis we developed equations for each dialysis modality to convert albumin measurements from one method to the other. Conclusion.?We confirm that a discrepancy exists between the commonly used dye methods (BCG and BCP) for serum albumin estimation. This discrepancy is significantly lower in HD patients than in PD patients. Nephrologists should be aware of this discrepancy and appropriate corrections should be made during quality improvement analysis.     

Hemoglobin predicts long-term survival in dialysis patients: a 15-year single-center longitudinal study and a correlation trend between prealbumin and hemoglobin

BACKGROUND: Dialysis patients have much higher mortality rates than the general population. Anemia is a common complication of uremia and a major contributor to morbidity and mortality in dialysis patients. The benefits of anemia correction using recombinant human erythropoietin (rHuEPO) are well established. Optimum hemoglobin level for dialysis patients remain controversial. We have investigated the association of enrollment hemoglobin with long-term survival in hemodialysis (HD) and peritoneal dialysis (PD) patients. METHODS: We enrolled 529 HD and 326 PD patients from 1987 and followed them to April 2003. Demographics, enrollment, and clinical and laboratory data were recorded. The Kaplan-Meier method was used to compute observed survival, and the multivariate Cox regression analysis was used to identify the independent predictors of mortality risk. RESULTS: Mean ages of HD and PD patients were 60 +/- 16 (SD) and 54 +/- 16 (SD) years, respectively. Forty-seven percent of HD patients and 41% of PD patients were diabetic. Mean enrollment hemoglobin levels of HD and PD patients were 9.44 +/- 1.9 and 9.61 +/- 1.77 g/dL respectively. Cumulative 15 year observed survivals of HD (P = 0.05) and PD (P = 0.032) patients with hemoglobin levels greater or equal to 12 g/dL were higher than those with hemoglobin levels less than 12 g/dL. Hemoglobin <12 g/dL was a better predictor of mortality in nondiabetics than diabetics, particularly in HD patients. Both in HD and PD diabetic patients, hemoglobin was not a significant predictor of mortality. By Cox regression analysis, after adjusting for age, race, gender, and months on dialysis at enrollment, the relative risk of mortality of patients with hemoglobin <12 g/dL was 2.13-fold (P = 0.008) higher for HD and 1.85-fold (P = 0.06) higher for PD compared to those with hemoglobin >/=12 g/dL (P = 0.035). A logistic regression analysis revealed a strong inverse relationship between the hemoglobin level and the odds risk of death in HD (OR = 0.83, P = 0.008) and in PD (OR = 0.85, P = 0.02) patients. CONCLUSION: Enrollment hemoglobin is a predictor of long-term survival in HD and PD patients. Patients with hemoglobin levels that are higher than current treatment recommendations (>12 g/dL) may benefit from long-term survival. Survival of dialysis patients may be improved by better management of malnutrition and anemia.     

Effect of Dialysis Type on Serum Lipids,Apolipoproteins, and Lipoproteins

Aim. Dyslipidemia is common among patients with end-stage renal disease, whether treated by hemodialysis (HD) or peritoneal dialysis (PD). However, there are not enough data about the effect of dialysis type on serum lipoprotein (a) [Lp(a)], apolipoprotein (a) [Apo(a)], apolipoprotein (b) [Apo(b)], and lipid levels. The aim of this study was to determine the effect of dialysis type on serum lipid levels. Materials and Methods. This study enrolled 40 HD patients (20 men and 20 women, aged 48.1?±?17.6 years) and 69 PD patients (35 men and 34 women, aged 45.2?±?16.3 years). Serum lipid profile including total cholesterol (TC), low-density lipoprotein (LDL-C), high-density lipoprotein (HDL-C), triglyceride (TG), Apo(a), Apo(b), and Lp(a) were determined in HD and PD patients. Patients who have used statins within the last six months were not included in the study. Results. No significant differences in TC, LDL-C, HDL-C, TG, Apo(a), Apo(b), or Lp(a) serum levels were found between HD and PD patients. Serum TC, LDL-C, HDL-C, TG, Apo(a), Apo(b), and Lp(a) in HD and PD patients were 172.2?±?42.7 (mg/dL) vs. 181.0?±?53.0 (mg/dL), 97.2?±?36.2 (mg/dL) vs. 101.4?±?33.6 (mg/dL), 45.3?±?11.9 (mg/dL) vs. 41.4?±?11.1 (mg/dL), 144.7?±?71.8 (mg/dL) vs. 173.0?±?76.8 (mg/dL), 1.2?±?0.5 (g/L) vs. 1.0?±?0.2 (g/L), 0.9?±?0.3 (g/L) vs. 1.2?±?0.3 (g/L), and 43.1?±?40.6 (mg/dL) vs. 46.0?±?42.7 (mg/dL), respectively. Conclusion. The results of this study show that the maintenance CAPD treatment is associated with more pronounced alterations of the lipoproteins and lipid metabolism than those observed during HD treatment.     

Peritoneal albumin leakage: 2 year prospective cardiovascular event occurrence and patient survival analysis

Aim: High peritoneal transport status is a determinant of morbidity and mortality in peritoneal dialysis (PD) patients. It was hypothesized that 24 h peritoneal albumin leakage predicted 2 year prospective cardiovascular outcome and survival in patients receiving PD. Methods: Sixty‐six patients were included. A simplified peritoneal equilibration test was performed and 24 h peritoneal albumin leakage was calculated. Patients were followed up for 2 years. Patient outcome (alive or dead) and occurrence of a cardiovascular event were recorded. Results: During a 2 year follow‐up period, 10 (15.2%) patients had suffered from a cardiovascular event and seven (10.6%) patients had died. Patients who had suffered from a cardiovascular event during the follow up period were older (54.0 ± 9.4 years vs 44.3 ± 14.5 years, P = 0.025), had lower serum pre‐albumin concentrations (29.3 ± 10.0 g/dL vs 36.0 ± 9.2 g/dL, P = 0.034) and had higher 24 h peritoneal albumin leakage (median, 3.4 g/day (1.66–15.4 g/day) vs 2.4 g/day (0.76–7.31 g/day), P = 0.011) than patients who did not suffer from a cardiovascular event. In the Cox proportional hazards multivariate analysis of factors which differed significantly between patients with and without a cardiovascular event (age, serum pre‐albumin and 24 h peritoneal albumin leakage), only advanced age (hazards ratio, 1.083; 95% confidence interval, 1.023–1.147, P = 0.006) was an independent predictor of a cardiovascular event. Conclusion: In contrast to the hypothesis, 24 h peritoneal albumin leakage is not a predictor of 2 year prospective cardiovascular outcome and patient survival. Only advanced age independently predicts the occurrence of a cardiovascular event in patients receiving PD.     

Preoperative Nutritional Status of the Surgical Patients in Jeju

Background

To assess the preoperative nutritional status of patients with various disorders and to provide data for pre- and postoperative patient management plans, particularly in the elderly. There is no published information on age-matched and disease-matched preoperative nutritional/immunologic status for orthopedic patients, especially in the elderly, in Jeju.

Methods

In total, 331 patients with four categories of orthopedic conditions were assessed: 92 elective surgery patients, 59 arthroplasty patients, 145 patients with fractures, and 35 infection patients. Malnutrition was defined as body mass index (BMI) below 18 kg/m² of expected body weight (below 20% of normal), serum albumin/globulin ratio below 1.5 (normal range, 1.5 to 2.3), albumin level below 3.5 g/dL, total lymphocyte count below 1,500 cells/mm³, and lymphocyte/monocyte ratio below 5 versus 1.

Results

In 92 elective surgery patients, the average BMI was 23 kg/m², hemoglobin was 15 g/dL, lymphocytes (2,486 cells)/monocytes (465 cells) ratio was 6.1, and the albumin (4.4 g/dL)/globulin (2.5 g/dL) ratio as a protein quotient was 1.7. Among the 59 hip and knee arthroplasty patients, the average BMI was 25 kg/m², hemoglobin was 12 g/dL, lymphocytes (2,038 cells)/monocytes (391 cells) ratio was 6.6, and albumin (4.1 g/dL)/globulin (2.4 g/dL) ratio was 1.6. No subject showed malnutrition. Among the 145 fracture patients, the average BMI was 23 kg/m². The hemoglobin level was 13 g/dL, monocytes (495 cells)/lymphocytes (1,905 cells) ratio was 1 versus 4.6, and albumin (4.1 d/gL)/globulin (2.5 d/gL) ratio was 1.6. However, both ratios decreased after 70 years of age. Among the 17 of 35 infection patients, albumin levels were below 3.5 g/dL, the average BMI was 22 kg/m², lymphocytes (1,532 cells)/monocytes (545 cells) ratio was 2.4 versus 1, and albumin (3.0 g/dL)/globulin (3.3 g/dL) ratio was 0.9, while in 18 patients albumin levels were over 3.5 g/dL, the average BMI was 22 kg/m², hemoglobin was 12 g/dL, lymphocytes (1,998 cells)/monocytes (583 cells) ratio was 3 versus 1, and albumin/globulin ratio was 1.4. Thus, in the infection group, approximately 50% of the patients showed poor nutrition and immunosuppression.

Conclusions

It was found that nutritional and immune condition deteriorated gradually to some degree in elderly patients over 60 years of age.     

Discrepancies in serum albumin measurements vary by dialysis modality

BACKGROUND: Serum albumin level is an important prognostic marker in patients with chronic renal failure. However there are discrepancies in the methods of estimation of serum albumin. The objective of this study is to evaluate the magnitude of the discrepancy in the serum albumin levels as measured by Bromcresol Green (BCG) and Bromcresol Purple (BCP) dye methods in patients on hemodialysis (HD) and peritoneal dialysis (PD) and to ascertain the clinical determinants of the discrepancy (deltaSA = BCG-BCP; g/dL) in each of the modalities. METHOD: We measured serum and plasma albumin levels by BCG and BCP methods in 19 adult HD patients and 18 adult PD patients treated in the dialysis units of the University of Colorado Health Sciences Center. Similar measurements were performed in 10 normal adult subjects. In all groups, paired blood samples were taken to estimate the albumin in both serum and plasma. Nephelometry (NM) was subsequently performed on the serum of 13 of the HD patients, 14 of the PD patients, and each of the 10 normal subjects. RESULTS: We found that for both the dye methods serum and plasma albumin levels are almost identical in each of the three subject groups. In the normal subjects serum albumin estimated by BCP is in good agreement with NM values but BCG overestimates the albumin levels. In the PD group the discrepancy between the BCG and BCP (deltaSA) is statistically significant with the BCG averaging 0.59 +/- 0.12 g/dL more than the BCP. The BCG values are closer to those obtained by the "gold standard", NM. In the HD group the deltaSA is significantly (p < 0.001) less than in the PD group (0.34 +/- 0.11 g/dL). As for PD, BCG values are closer to NM values. Increasing age, female gender, and higher dialysis adequacy are associated with higher deltaSA in the HD but not in the PD group. Utilizing linear regression analysis we developed equations for each dialysis modality to convert albumin measurements from one method to the other. CONCLUSION: We confirm that a discrepancy exists between the commonly used dye methods (BCG and BCP) for serum albumin estimation. This discrepancy is significantly lower in HD patients than in PD patients. Nephrologists should be aware of this discrepancy and appropriate corrections should be made during quality improvement analysis.     

Low levels of high-density lipoproteins are associated with acute kidney injury following revascularization for chronic limb ischemia

Abstract

Objectives: Perioperative acute kidney injury (AKI) is not uncommon, following revascularization. HDL has been shown to reduce organ injury in animal models. The aim of the study is to examine the association of HDL on AKI in patients undergoing revascularization for chronic limb ischemia. Methods: All patients who underwent revascularization between June 2001 and December 2009 were analyzed. Patients on dialysis and with incomplete data were excluded. Patients were grouped for HDL < or ≥40?mg/dL. Univariate and multivariate analysis were used to identify factors associated with AKI. Results: A total of 684 patients were included. Eighty-two (12.0%) patients developed postoperative AKI (15.7% in low HDL group vs. 6.3% in high HDL group, p?<?0.001). The AKI group were more likely to be older (71.5?±?10.1 vs. 68.0?±?10.8, p?=?0.01), ASA 4 class (26% vs. 14%, p?<?0.001), to have albumin <3?g/dL (59% vs. 32%, p?<?0.001), low HDL levels (79% vs. 58%, p?<?0.001), DM (61% vs. 44%, p?=?0.005), CAD (67% vs. 55%, p?=?0.003), preoperative chronic kidney disease (CKD) stage III–IV (55% vs.39%, p?<?0.001), to present with critical limb ischemia (82% vs. 63%, p?=?0.001), and to be on ACEI (67% vs. 51%, p?=?0.006). Multivariate logistic regression analysis showed low HDL (Odds Ratio (OR) 1.66 [1.23–2.24]) and serum albumin levels <3?g/dL (OR 1.66 [1.29–2.13], p?<?0.001) were independently associated with increased odds for developing AKI. Propensity score analyses showed low HDL was independently associated with increased odds of AKI (OR 2.4 (1.4–4.2)). Conclusions: AKI following revascularization is not uncommon (12.0%), and lower concentrations of HDL and serum albumin are associated with increased odds of postoperative AKI. There was also a trend of higher prevalence of AKI among those with pre-existing CKD.     

Factors influencing survival according to elapsed time in peritoneal dialysis patients

The survival of patients undergoing peritoneal dialysis (PD) has improved over the past decade, but their mortality rate remains high. The aim of the current study was to identify correctable and uncorrectable factors influencing survival according to the elapsed time in patients undergoing PD. We retrospectively analyzed data from medical records of 118 patients who had undergone PD for >6 months. We analyzed laboratory findings at three time points (point of PD initiation, 6-month point of PD and 3-month point prior to death or last follow-up) during PD treatment and prescribed medications taken for >50% of the follow-up period. Three-year survival group was younger, had lower prevalence rates of ischemic heart disease (p?=?0.024) and heart failure (HF) (8.5% vs. 34.6%, p?=?0.003), higher serum albumin levels (albumin 2) at the 6-month point of PD, and higher serum albumin (albumin3) and creatinine (creatinine3) levels at the 3-month point prior to death or last follow-up than nonsurvival group. Patients without underlying HF, patients treated with angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers during the last 6 months (p?=?0.0042), and those having creatinine 3?>9.5 mg/dL (p?=?0.0029), and albumin 2 (p?=?0.0209) and albumin 3?>3.5 g/dL (p?=?0.0003) showed significantly higher survival curves. HF and albumin 3 were found to be independent factors for 3-year survival and long-term survival, respectively, by the multivariate Cox regression model. In conclusion, HF was useful information for predicting 3-year survival, and low serum albumin levels according to elapsed time should be corrected for survival of PD patients.     

Health-related quality of life,depression and mortality in peritoneal dialysis patients in Turkey: seven-year experience of a center

Introduction: Impairment of health-related quality of life (HRQoL) and being in a depressive mood were found to be associated with increased mortality in peritoneal dialysis (PD) patients. We aimed to investigate the association between HRQoL, depression, other factors and mortality in PD patients. Materials and methods: Totally 171 PD patients were included and followed for 7 years in this prospective study. Results: Of 171 PD patients, 45 (26.3%) deceased, 18 (10.5%) maintained on PD, 87 (50.9%) shifted to hemodialysis (HD) and 21 (12.3%) underwent transplantation. The most common cause of death was cardiovascular disease (32, 71.1%) followed by infection (6, 13.3%), cerebrovascular accident (5, 11.2%). The etiology of patients who shifted to HD was PD failure (41, 47.1%), peritonitis (33, 37.9%), leakage (6, 6.9%), catheter dysfunction (3, 3.4%), self willingness (4, 4.6%). Non-survivors were older than survivors (56.6?±?15.0 vs. 43.6?±?14.6, p?=?0.003). There were also statistically significant difference in terms of albumin, residual urine, presence of diabetes and co-morbidity. When the groups were compared regarding HRQoL scores, non-survivors had lower physical functioning (p?<?0.001), role-physical (p?=?0.0045), general health (p?=?0.004), role-emotional (p?=?0.011), physical component scale (PCS) (p?=?0.004), mental component scale (MCS) (p?=?0.029). Age, presence of residual urine, diabetes, albumin, PCS and MCS were entered in regression analysis. Decrease of 1?g/dL of albumin and being diabetic were found to be the independent predictors of mortality. Conclusions: Diabetes and hypoalbuminemia but not HRQOL scores were associated with higher mortality in PD patients after 7 years of following period.     

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.     

Malnutrition and inflammation in peritoneal dialysis patients

BACKGROUND: Malnutrition, cardiovascular disease, and heightened inflammation are highly prevalent in dialysis patients, and major contributors to morbidity and mortality. We have investigated the inter-relationship between malnutrition and inflammation, and their impact on morbidity and mortality in peritoneal dialysis (PD) patients. METHOD: We enrolled 63 PD patients beginning in November 2000, and measured C-reactive protein (CRP) and various nutritional markers, including prealbumin. RESULTS: CRP level was elevated in 29% of the PD patients. Diabetics had higher CRP than non-diabetics (24 vs. 9.3 mg/L, P = 0.016). Patients who were hospitalized during the study had higher enrollment CRP (16 vs. 12.5 mg/L, P = 0.05) and lower enrollment albumin (3.5 vs. 3.9 g/dL, P = 0.002), blood urea nitrogen (BUN) (40 vs. 49 mg/dL, P = 0.034), and protein catabolic rate (nPCR) (0.88 vs. 1.0 g/kg/day, P = 0.02) than those who were not hospitalized. Enrollment level of CRP was inversely correlated with nutritional markers prealbumin (r = -0.5, P < 0.0001) and creatinine (r =-0.35, P < 0.01). After adjusting for age, race, gender, diabetes, and CRP level, prealbumin continued to correlate with other nutritional markers. There was a trend toward association of elevated CRP with all-cause mortality in PD patients. CONCLUSION: It is useful to incorporate prealbumin and CRP in the regular assessment of PD patients, whose survival may be improved by better management of malnutrition and inflammation.     

Serum prealbumin is higher in peritoneal dialysis than in hemodialysis: a meta-analysis

BACKGROUND: Although not widely appreciated, the reported concentration of serum prealbumin, like that of serum cholesterol, tends to be higher in patients on peritoneal dialysis (PD) than on hemodialysis (HD), despite the substantial loss of protein during PD. METHODS: The mean difference in serum prealbumin was quantified by meta-analysis of the mean differences found in six cohorts with both PD and HD patients (set 1; N = 639) using a fixed-effects model, and meta-analysis of the mean prealbumin values reported in 23 cohorts of unselected dialysis patients on a single modality (set 2; 9 PD cohorts, 14 HD cohorts; N = 12,256) using a mixed model. For comparison, the mean difference in serum albumin concentration between PD and HD also was estimated in sets 1 and 2 using the same methods. RESULTS: In set 1, the mean prealbumin difference (PD-HD) in the individual cohorts ranged from 3.6 to 14.7 mg/dL (P < 0.05 in five cohorts), and the weighted mean difference was 5.4 mg/dL (95% CI, 3.8 to 7.0 mg/dL). In set 2, weighted mean prealbumin was 8.1 mg/dL (95% CI, 5.2 to 10.9 mg/dL) higher in PD than in HD in the entire data set, and 6.9 mg/dL (95% CI, 5.2 to 8.6 mg/dL) higher in a sensitivity analysis that excluded two outlying HD studies. By contrast, weighted mean serum albumin concentration was significantly lower in PD than in HD in both sets 1 and 2; the mean difference was 0.25 g/dL (95% CI, 0.14 to 0.36 g/dL) in set 1 and 0.28 g/dL (95% CI, 0.14 to 0.42 g/dL) in set 2. CONCLUSIONS: Serum prealbumin level is approximately 6 mg/dL higher in PD than HD, perhaps due to the stimulation of hepatic synthesis by PD albumin loss, while serum albumin is approximately 0.3 g/dL lower in PD. Different reference ranges and clinical targets (such as, K/DOQI guidelines) are needed for PD and for HD.     

Peritoneal and hemodialysis: I. Differences in patient characteristics at initiation

BACKGROUND: Comparisons of mortality outcomes between peritoneal dialysis (PD) and hemodialysis (HD) patients have shown varying results, which may be caused by the unequally distributed clinical conditions of patients at initiation. To address this issue, we evaluated the clinical characteristics of 105,954 patients at the initiation of PD and HD, using the U.S. national incidence data on treated end-stage renal disease from the Medical Evidence Form, 1995 to 1997. METHODS: A general linear model was used to analyze differences of age, albumin, creatinine, blood urea nitrogen (BUN), and hematocrit; categorical data analysis to evaluate body mass index (BMI), grouped into four categories: < 19, 19-25 (< 25), 25-30 (< 30), and 30+; and logistic regression to assess the likelihood of initiating PD versus HD. Diabetics (DM) were analyzed separately from non-diabetics (NDM). Explanatory variables in the logistic regression included incidence year, race, gender, age, BMI, albumin, creatinine, BUN, and hematocrit. Race included white and black. Age was categorized into four groups: 20-44, 45-64, 65-74, and 75+.RESULTS: At the initiation of dialysis PD patients were approximately 6 years younger (P < 0.0001) than HD patients. PD patients also had higher (P < 0.0001) albumin (+0.35 g/dL for DM and +0.23 g/dL for NDM) and hematocrit (+1.64% for DM and +1.71% for NDM) levels, and lower (P < 0.04) BUN (-8.75 mg/dL for DM and -5.24 mg/dL for NDM) and creatinine (-0.51 mg/dL for DM and -0.23 mg/dL for NDM) levels than HD patients. Whites had a higher (P < 0.0001) likelihood of starting PD than blacks, and patients with BMI <19 had a lower (P < 0.0001) chance of beginning on PD. CONCLUSION: PD patients had favorable clinical conditions at the initiation of dialysis, which should be taken into consideration when comparing dialysis outcomes between the two modalities.     

The Role of Malnutrition in Ninety-Day Outcomes After Total Joint Arthroplasty

BackgroundResearch has linked malnutrition to more complications in total joint arthroplasty (TJA) patients. The role of preoperative albumin in predicting length of stay (LOS) and 90-day outcomes remains understudied. Often, an albumin cut-off ≤3.5 g/dL is used as proxy for malnutrition, although this value remains understudied. This preoperative level may be missing some patients at risk for adverse events post TJA.MethodsTJA patients at a single institution from 2013 to 2018 were reviewed for preoperative albumin level. In total, 4047 cases (total knee arthroplasty: 2058; total hip arthroplasty: 1989) had available data, including 90-day readmissions, 90-day emergency department (ED) visits, and postoperative LOS.ResultsAbout 5.6% experienced a readmission and 9.6% had at least one ED visit within 90 days. Overall prevalence of malnutrition was 3.6%, and this cohort experienced a longer average LOS (3.5 vs 2.2 days, P < .0001) and was more likely to experience a readmission (16% vs 5%, P < .0001) or ED visit (18% vs 9%, P = .0005). Additionally, albumin ≤3.5 g/dL was correlated with more frequent discharge to skilled nursing facility/rehab (30.8% vs 14.7%, P < .0001), increased risk for 90-day readmission with univariable (odds ratio [OR] 1.79, P < .0001) and multivariable logistic regression (OR 1.55, P < .0001), and increased risk for 90-day ED visits with univariable (OR 1.62, P < .0001) and multivariable regression (OR 1.35, P < .0001). The optimal albumin cut-off was 3.94 g/dL in a univariable model for 90-day readmission.ConclusionScreening for malnutrition may serve a role in preoperative evaluation. An albumin cutoff value of 3.5 g/dL may miss some at-risk patients.     

Nutrition counseling impacts serum albumin levels.

OBJECTIVE: To determine the difference in the rate of change of serum albumin levels between protein-energy malnourished patients who receive intensive dietary counseling and patients who receive a special oral liquid nutritional supplement (Nepro; Ross Products, Division Abbott Laboratories, Columbus, OH). DESIGN: Participants with serum albumin values < or =3.5 g/dL (bromocresol green) or 3.2 g/dL (bromocresol purple) and a Mini Nutrition Assessment (MNA) Malnutrition score < or =23.5 were randomized to the supplement group (Nepro) or the nonsupplement group with intensive dietary counseling. PATIENTS: Forty-one hemodialysis patients 18 years and older who had been on dialysis for at least 6 months. INTERVENTION: Participants were randomly assigned to supplement (26) or nonsupplement (14) groups. MAIN OUTCOME MEASURES: Albumin levels. STATISTICAL ANALYSES PERFORMED: Analysis of variance and chi2 tests, linear regression. RESULTS: After adjustment for demographic and clinical characteristics, the rate of change in serum albumin level was significantly greater among patients randomized to dietary counseling alone than among those who received oral supplements. These preliminary results suggest that intensive nutritional counseling may be of greater benefit than nutritional supplements alone in the management of protein-energy malnutrition in patients on hemodialysis. These preliminary findings should be confirmed by a larger full-scale trial.     

The pre-transplant anemic condition is independent of long-term outcome in living-related kidney transplantation

The relationship between pre-transplant Hemoglobin (Hb) concentration and long-term outcome of living-related kidney transplantation is far from well addressed. A retrospective cohort study was conducted by reviewing the medical profile of the patients who received living-related kidney transplantations at our center from January 2006 to January 2013. Patients were divided into two groups: high Hb group (≥10?g/dL) and low Hb group (<10?g/dL). Cox regression model was utilized to analyze the effect of pre-transplant hemoglobin concentration on the patient and graft survival. About 422 patients were of Hb level <10?g/dL (78.30?±?14.18?g/dL), 280 were >10?g/dL (116.2?±?14.43?g/dL) (p?p?=?0.096; and 4.04% vs. 2.14%, p?=?0.165, respectively). Cox regression model revealed that pre-transplant Hb level <10?g/dL was independent of increased overall mortality (HR?=?3.379; 95% CI: 0.706–17.172) and increased death censored allograft failure risk (HR?=?1.556; 95% CI: 0.595–4.069). Pre-transplant Hb concentration <10?g/dL is independent of poor long-term outcome of living-related kidney transplantation.     

Correlation of serum lead levels with inflammation, nutritional status, and clinical complications in hemodialysis patients

The aim of this study was to determine blood lead level (BLL) in hemodialysis (HD) patients and their relation with high-sensitivity C-reactive protein (hsCRP) and albumin which are inflammatory and nutritional biomarkers, respectively, and clinical complications. A total of 93 patients, who were dialyzed at least for 3 months, were included in the study. Blood samples were collected before HD and BLL was measured and categorized as three equal groups: low normal (BLL??10.6?μg/dL). All patients had normal BLL, 9.7?±?3.4?g/dL. Patients with abnormal hsCRP level (>3?mg/L) had higher BLL than other patients (16.4?±?0.8 vs. 11.5?±?2.7?mg/L, p?=?0.003). Patients with BLL > 10.6?μg/dL had significantly lower hemoglobin, ferritin, iron, and albumin levels and higher hsCRP and intact parathyroid hormone (iPTH) levels than the patients with BLL?< 8?μg/dL. In addition, BLL revealed a significant positive correlation with duration of dialysis. We concluded that BLL associated to inflammation, malnutritional status, iron-deficiency condition, and high iPTH level in HD patients.     

Normalized protein catabolic rate versus serum albumin as a nutrition status marker in pediatric patients receiving hemodialysis.

BACKGROUND: Protein-energy malnutrition occurs commonly in patients receiving hemodialysis (HD). Although serum albumin (sAlb) is recommended to monitor nutrition status in patients receiving HD, many processes unrelated to nutrition status can affect albumin concentrations. METHODS: We previously showed normalized protein catabolic rate (nPCR) to be superior to sAlb to reflect improvement in nutrition status in pediatric patients receiving maintenance HD after treatment with intradialytic parenteral nutrition for severe protein-energy malnutrition. We now compare nPCR and sAlb as nutrition status markers for pediatric patients on HD irrespective of current nutrition status. RESULTS: Forty-four patients comprising 840 months of HD provision were assessed. nPCR was higher for younger patients. Mean nPCR values were significantly lower for adolescent patients with persistent weight loss of at least 2% for at least 3 consecutive months versus patients without persistent weight loss (1.03 +/- 0.29 g/kg/d vs. 1.15 +/- 0.27 g/kg/d, P < .002), and the odds for developing persistent weight loss were four times greater for adolescent patients with nPCR less than 1 g/kg/d. No association between nPCR and weight loss was observed for younger patients. Mean sAlb levels were greater than 4 g/dL for all patient age groups and did not demonstrate a clinically significant difference between patients with or without weight loss. CONCLUSION: We suggest that nPCR may be useful for monthly nutrition status in adolescent patients receiving maintenance HD and that adolescents with nPCR less than 1 g/kg/d may be at increased risk for subsequent weight loss.     

Effects of acetate-free citrate-containing dialysate on metabolic acidosis, anemia, and malnutrition in hemodialysis patients

Previously, dialysate contained small amounts of acetate as an alkaline buffer. Recently, acetate‐free dialysate (A[?]D) has been available. We evaluated the clinical effect of A(?)D over acetate‐containing dialysate (A(+)D) on acid–base balance, anemia, and nutritional status in maintenance hemodialysis (MHD) patients. Twenty‐nine patients on MHD were treated with A(+)D for 4 months (first A(+)D), switched to A(?)D for 4 months, and returned to A(+)D for the next 4‐month period (second A(+)D). Metabolic acidosis: Serum bicarbonate (HCO3^‐) levels did not change in patients with normal HCO3^‐ levels (≥20 mEq/L) throughout the study. Meanwhile, in patients with initially low HCO3^‐ levels, it was significantly increased during the A(?)D period only. Anemia: In patients with target hemoglobin (Hb) ≥10 g/dL, Hb levels were maintained during the study period, even if the dose of erythropoiesis‐stimulating agents (ESAs) decreased. In patients with low Hb levels, it was significantly increased in the A(?)D period without increasing ESA or iron doses. Nutritional Condition: In patients with normal albumin levels (≥3.8 g/dL), albumin did not change throughout the study period. However, in patients with lower albumin levels, it was significantly increased during the A(?)D period. These improvements in metabolic acidosis, anemia, and nutrition in the A(?)D period completely dissipated during the second A(+)D period. Hemodialysis (HD) with A(?)D may improve a patient's clinical status with intractable metabolic acidosis, hyporesponsiveness to ESA, and malnutrition that were not normalized in HD with A(+)D.