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.     

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.     

The impact of malnutrition in morbidity and mortality in stable haemodialysis patients

Background: When assessed by single biochemical measurements, malnutrition in dialysis patients is associated with increased mortality, but there are few data evaluating abnormalities in anthropometry or composite nutritional scores and outcome. The aim of our study was to ascertain the prevalence and severity of malnutrition in 761 stable patients from 20 haemodialysis centres and its influence in morbidity and mortality after one year of follow-up. Methods: Malnutrition was estimated by scoring four anthropometric indexes; body mass index (BMI), triceps skinfold thickness (TSF), mid-arm circumference (MAC), and mid-arm muscle circumference (MAMC); three biochemical measurements; serum albumin, serum transferrin and total lymphocytes count; and clinical examination. Mortality and hospitalizations were collected prospectively during the year of follow-up. Results: A moderate/severe degree of malnutrition was presented by 51.6% of male and 46.3% of female patients. TSF was moderate-severely decreased in 41% without differences between males and females. MAMC was moderately decreased in 19.8% of males and in 8.1% of females (P <0.001). Multiple logistic regression analysis showed that the predictors of malnutrition were: age >65 years (OR=1.96, CI: 1.22-3.14), male sex (OR=1.85, CI: 1.24-3.07), comorbidity index (OR=1.23, CI: 1.03-1.45), time on dialysis (OR=1.13, CI: 1.08-1.18), duration of dialysis (OR=0.73, CI: 0.63-0.85) and PCR related to ideal body weight (OR=0.17, CI: 0.06-0.50). After 1 year of follow-up, data from 442 patients were available. A total of 68 patients died (15.4%) with cardiovascular diseases being the most frequent cause of death (57.3% of the cases). The predictors of mortality were: age (OR=1.06, CI: 1.03-1.09) cardiovascular disease (OR=2.13, CI: 1.19-3.83), neurological disease (OR=2.96, CI: 1.41-6.15) nephroangiosclerosis (OR=2.31, CI: 1.10-4.98) and total lymphocyte count (OR=0.93, CI: 0.87-0.98). Hospitalization was needed in 44% of patients. The comorbidity index, serum albumin and age were the predictive factors of hospitalization. Conclusions: Protein-calorie malnutrition is frequent in haemodialysis patients. Fat depletion predominated in both sexes. Duration of dialysis and protein catabolic rate related to ideal body weight was the only predictor which could be influenced by a nutritional intervention. Morbidity appeared to be influenced by the comorbidity index and age was the strongest predictor of mortality. The only nutritional measurements predictive of morbidity and mortality were serum albumin and total lymphocyte count respectively. Therefore, the influence of malnutrition in morbidity and mortality can not be definitively stated.     

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 status in type 2 diabetic patients requiring haemodialysis.

BACKGROUND: Type 2 diabetic patients with end-stage renal disease are often overweight (BMI > 24) at the start of dialysis therapy. However, there are very few reports in the literature concerning the nutritional status of these patients after prolonged haemodialysis treatment. Therefore, we compared nutritional parameters in type 2 diabetic patients and age-matched non-diabetic patients after at least 18 months of renal replacement therapy with haemodialysis. METHODS: In a cross-sectional study, we measured BMI, serum albumin, total protein, serum cholesterol and interdialytic weight gain (IWG), and performed a subjective global assessment (SGA) in 14 patients with type 2 diabetes and 16 non-diabetic patients (aged > or = 50 years, haemodialysis therapy > or = 18 months). Protein intake was estimated using the protein catabolic rate (PCR) and Kt/V was calculated to compare the dose of dialysis. RESULTS: BMI was significantly higher in patients with type 2 diabetes (30+/-7 vs 24+/-3, P<0.01). In contrast, the concentration of serum albumin was significantly lower (3180+/-499 mg/dl vs 3576+/-431 mg/dl, P<0.05), but six of the diabetic patients had signs of chronic inflammation. All other nutritional parameters did not differ between the two groups. In addition, there were no significant differences in the intake of protein (PCR 0.93+/-0.19 vs 0.92+/-0.22) and the dose of dialysis (Kt/V 1.13+/-0.19 vs 1.2+/-0.2). CONCLUSION: After > or = 18 months of haemodialysis therapy, the majority of type 2 diabetic patients (9/14) were still overweight (BMI > 24). The nutritional status of diabetic patients was similar to that of age-matched non-diabetic patients on prolonged haemodialysis, but serum albumin levels were significantly lower in diabetics. The lower albumin levels in the diabetic patients may be explained by a state of subclinical chronic inflammation.     

Comprehensive malnutrition inflammation score as a marker of nutritional status in Chinese peritoneal dialysis patients

BACKGROUND: Malnutrition is common among peritoneal dialysis (PD) patients. However, the ideal marker of nutritional status in PD patients remained controversial. METHODS: We studied 165 unselected adult PD patients. We compared the comprehensive Malnutrition-Inflammation Score (MIS) and the 7-point Subjective Global Assessment (SGA) score. RESULTS: The mean age was 59.2 +/- 11.5 years. Seventy patients were male. MIS significantly correlated with the SGA score (r =-0.667, P < 0.001). Of the 165 patients, 132 (80.0%) had similar classification of nutritional status by SGA and MIS (Group I); 17 (10.3%) were classified as normal by SGA but moderately malnourished by MIS (Group II), while 16 (9.7%) were classified as normal by MIS but moderately malnourished by SGA (Group III). Group II had been dialysed longer than Group I (71.7 +/- 50.3 vs 40.7 +/- 37.5 months, P = 0.011). As compared with Group I, Group III was more likely to require helper for PD exchange (37.5%vs 9.7%, P = 0.004), marginally more likely to be diabetic (62.5%vs 35.6%, P = 0.085) and had a slightly higher Charlson's comorbidity score (6.13 +/- 1.78 vs 4.98 +/- 2.1, P = 0.085), although the latter two were not statistically significant. CONCLUSION: MIS has a reasonable correlation with the conventional SGA score in PD patients. Patients with limited self-care capability, diabetes and multiple comorbidities probably had worse score (i.e. worse nutrition) revealed by SGA than by MIS, while patients who had been dialysed longer had worse score revealed by MIS than by SGA.     

Correlates of habitual physical activity in chronic haemodialysis patients.

BACKGROUND: Results of physical performance tests may not reflect the level of habitual physical activity and health status of the dialysis patients. The aim of our study was to assess interdialytic spontaneous physical activity in chronic haemodialysis (HD) patients in relation to their nutritional status, severity of anaemia, inflammation and dialysis adequacy. METHODS: Sixty HD patients [27 female, 33 male; mean age 60+/-13 years, time on dialysis 46.2+/-62.1 months and body mass index (BMI) 25.1+/-4.7 kg/m2] without physical and neurological disabilities and 16 healthy individuals (10 female, six male, mean age 56+/-6 years, BMI 26.6+/-4.9 kg/m2) were enrolled into the study. In all patients, spontaneous daily physical activity was measured during 48 h between mid-week dialysis sessions by pedometers. Nutritional status was estimated by anthropometric methods (BMI and mid-arm muscle circumference) and serum albumin concentration. Additionally, body composition was estimated using a multifrequency phase-sensitive bioimpedance analysis (BIA). Severity of anaemia was determined by blood haemoglobin level and haematocrit value, and the presence of inflammatory state was determined by high sensitivity plasma C-reactive (CRP) protein measurements. RESULTS: The total number of steps during daily activities in dialysis patients and in healthy individuals was 6896+/-2357 vs 14 181+/-5383 per 48 h, respectively (P<0.001). Dialysis patients showed typical signs of malnutrition in the BIA, i.e. high extracellular mass/body cell mass index (1.17+/-0.28 in dialysis patients vs 0.97+/-0.1 in controls; P<0.001), low percentage cell mass (46.7+/-5.6 and 51.0+/-3.6, respectively; P = 0.002) and low phase angle (5.1+/-0.9 and 5.8+/-0.7, respectively; P = 0.006). Dialysis patients also showed lower serum albumin and blood haemoglobin and higher serum CRP levels than healthy controls. In dialysis patients, the number of steps taken positively correlated with body water (R = 0.28, P = 0.03), fat mass (r = 0.29, P = 0.04), BMI (R = 0.25, P = 0.04), lean body mass (R = 0.26, P = 0.04), intracellular water (r = 0.30, P<0.01), phase angle (R = 0.40, P = 0.002), serum albumin (R = 0.32, P = 0.01), haematocrit (R = 0.46, P = 0.001) and haemoglobin (R = 0.44, P = 0.001). Furthermore, the number of steps taken correlated significantly with mid-arm muscle circumference (r = 0.35, P = 0.006). A negative correlation was found between the number of steps and extracellular mass/body cell mass index (R = -0.37; P = 0.004). No significant relationships were found between the measures of physical activity and high sensitivity CRP or adequacy of dialysis. Multiple regression analysis revealed the independent associations between the number of steps taken by the patients and haemoglobin concentration, age, total body water, extracellular mass/body cell mass index and phase angle. CONCLUSIONS: Low habitual physical activity assessed in HD patients with simple portable pedometers is strongly related to several factors of major clinical importance in this population.     

Nutritional markers in liver allograft recipients

BACKGROUND: Malnutrition is common in patients with end-stage liver disease considered for transplantation, but it is unclear whether this affects the outcome after transplantation. AIM.: To determine whether the severity of malnutrition in liver transplant candidates affects outcome after transplantation. METHODS: We did a prospective study of 61 patients with chronic liver disease accepted for transplantation. FINDINGS: The Child-Pugh and Model for End-Stage Liver Disease (MELD) score correlated significantly but weakly with the mid-arm circumference (MAC) (rho=-0.34 and -0.31, P=0.015 and 0.025, respectively) but not with hand-grip strength, triceps skin-fold thickness (TSFT), or mid-arm muscle circumference. The Child-Pugh score but not the MELD was significantly associated with intensive therapy unit stay but not eventual outcome; there was a weak but statistically significant correlation between death and MAC (rho=+0.29, P=0.04) and TSFT (rho=+0.25, P=0.02). CONCLUSIONS: These findings suggest that nutritional parameters and markers of disease severity do not correlate well with outcomes after transplantation.     

Serial monitoring of nutritional status in Chinese peritoneal dialysis patients by Subjective Global Assessment and comprehensive Malnutrition Inflammation Score

Aim: The Malnutrition Inflammation Score (MIS) has been proposed for the assessment of nutritional status in peritoneal dialysis (PD) patients. The MIS and the Subjective Global Assessment (SGA) for serial monitoring of nutritional status in PD patients were compared. Methods: The change in the MIS and SGA overall score of 59 PD patients (28 male) over 12 months was studied. Clinical factors relating to the discrepancy between the two instruments were explored. Results: The average patient age was 55.8 ± 9.7 years. Thirty of the 59 patients (50.8%) had exact agreement in the changed MIS and SGA scores. Cohen's κ score was 0.274, indicating a modest degree of agreement. For the detection of deterioration in nutritional status and using the MIS as the reference measure, the SGA had a sensitivity of 61.9% and specificity of 86.8%; serum ferritin level was substantially higher in the ones whose SGA did not detect a deterioration in nutrition (1464.1 ± 873.3 vs 800.5 ± 561.6 pmol/L, P = 0.046). For the detection of improvement in nutritional status, the SGA had a sensitivity of 45.8% and specificity of 82.9%; patients whose SGA did not detect an improvement in nutrition were dialyzed longer (53.8 ± 35.3 vs 27.6 ± 18.9 months, P = 0.038), had higher total iron binding capacity (TIBC) (45.6 ± 5.5 vs 38.2 ± 8.1 µmol/L, P = 0.015), had higher total Kt/V (2.02 ± 0.36 vs 1.75 ± 0.23, P = 0.048) and higher normalized protein nitrogen appearance (1.16 ± 0.25 vs 0.95 ± 0.23 g/kg per day, P = 0.048). Conclusion: The longitudinal changes in the MIS and SGA score have modest agreement with each other. However, PD patients with a longer duration of dialysis, higher serum ferritin, TIBC, total Kt/V or normalized protein nitrogen appearance tend to have discrepancies between the longitudinal changes in the MIS and SGA overall score.     

Assessment of nutritional status in CAPD patients: serum albumin is not a useful measure

INTRODUCTION: In CAPD patients serum albumin is frequently used as an index of nutritional status, although it is recognized that hypoalbuminaemia may be caused by many factors. We have further examined the relationship between serum albumin and nutrition. METHODS: Nutritional status was assessed by biochemistry, anthropometry, mid-arm muscle circumference, muscle strength (hand grip and back), and lean body mass (from anthropometry, creatinine kinetics and bioimpedance) in a group of 76 stable CAPD patients. Correlations between biochemical and nutritional parameters were sought and data were compared between patient groups defined by serum albumin (> or = 37 vs < 37 g/l on two occasions 2 months apart) and separately according to subjective global assessment score (normal nutrition, A vs mild to moderate, B, and severe, C, malnutrition). RESULTS: In patients with a low SGA score, actual body weight, body mass index, mid-arm muscle circumference, lean body mass, subscapular skinfold thickness, hand grip strength (males and females) and iliac and triceps skinfold thicknesses and back strength (females only) were all significantly less than in patients with a normal SGA score. In contrast, none of these variables differed in either gender when patients were compared according to serum albumin. Serum albumin was correlated with serum creatinine (r = 0.45, P = 0.01), daily urine protein excretion (r = -0.42, P = 0.02) and uncorrected weekly creatinine clearance (r = -0.39) in females, but not with any index of body composition in either gender. CONCLUSION: Whilst SGA identified a patient group with significantly abnormal body mass, muscle mass and muscle strength, serum albumin did not. Serum albumin is not a useful marker of malnutrition in stable patients on CAPD.      

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.     

Effects of ultrapure dialysis fluid on nutritional status and inflammatory parameters.

BACKGROUND: Malnutrition and chronic systemic inflammatory response syndrome not only coexist in uraemia, but may also have a bi-directional cause-and-effect relationship. To evaluate the role of dialysate-related cytokine induction in inflammatory response and nutritional status, we conducted a prospective comparison of two dialysis fluids differing in their microbiological quality. METHODS: Forty-eight early haemodialysis patients were assigned to either treatment with conventional (potentially microbiologically contaminated) or on-line produced ultrapure dialysis fluid. Study parameters were bacterial growth, markers of systemic inflammation (C-reactive protein (CRP) and interleukin 6), and parameters of nutritional status (estimated dry weight, upper mid-arm muscle circumference, serum albumin concentration, insulin-like growth factor 1, leptin, and protein catabolic rate). Patients were followed for 12 months. RESULTS: There were no statistically significant differences in demographic and treatment characteristics, degree of bacterial contamination of the dialysate, markers of systemic inflammation, or parameters of nutritional status among the two treatment groups at recruitment. Changing from conventional to ultrapure dialysis fluid reduced significantly the levels of IL-6 (19+/-3 pg/ml to 13+/-3 pg/ml) and CRP (1.0+/- 0.4 mg/dl to 0.5+/-0.2 mg/dl), and resulted in significant increases in estimated dry body weight, mid-arm muscle circumference, serum albumin concentration, levels of the humoral factors, and in protein catabolic rate after 12 months. Continuous use of conventional dialysis fluid (median 40-60 c.f.u./ml) was not associated with significant alterations in markers of inflammation (IL-6 21+/-4 pg/ml vs 24+/-6 pg/ml, CRP 0.9+/-0.3 mg/dl vs 1.1+/-0.4 mg/dl) or of nutritional status at any time of the study. All differences in systemic inflammation and nutritional parameters observed during the study period (from recruitment to month 12) were significant between the two patient groups. CONCLUSIONS: Cytokine induction by microbiologically contaminated dialysis fluid has a negative impact on nutritional parameters of early haemodialysis patients. The microbiological quality of the dialysis fluid represents an independent determinant of the nutritional status in addition to known factors, such as dose of dialysis and biocompatibility of the dialyser membrane. Ultrapure dialysis fluid adds to the cost of the dialytic treatment, but may improve the nutritional status in long-term haemodialysis patients.     

老龄维持性血液透析患者营养不良及炎症状态的临床分析

目的：营养不良是维持性血液透析（MHD）患者主要并发症,老龄血透患者一般预后更差,死亡风险更高,其原因是否与老龄患者具有更严重的营养不良和炎症状态有关。本课题研究对象为年龄≥65周岁的老龄MHD患者,临床观察其MIS,MQSGA,人体测量学指标,生化指标及炎症因子水平,并与非老龄MHD患者进行比较研究。方法：选取2007年11月～2008年4月在我院门诊行MHD的36例老龄患者（年龄≥65周岁）为研究对象,64例非老龄（年龄〈65周岁）MHD患者为对照。观察指标：（1）营养不良指标：包括营养不良-炎症评分、改良SGA评分和白蛋白水平。（2）人体测量学指标：包括体重指数（BMI）、肱三头肌皮褶厚度（TSF）、上臂围（MAC）、上臂肌围（MAMC）等。（3）生化指标和血常规：包括血浆总蛋白（TPRO）、白蛋白（Alb）、转铁蛋白（TF）、总胆固醇（TC）、肾功能、铁蛋白（Ft）、未饱和铁（UIBC）等,及血红蛋白（Hb）、红细胞（RBC）等。（4）炎症指标：包括血清超敏C反应蛋白（hs-CRP）、白细胞介素-6（IL-6）、肿瘤坏死因子-α（TNF-α）等。结果：老龄组平均年龄（75.19±8.26）岁。以MQSGA标准：老龄组中营养不良者为91.67%,非老龄组为70.31%。老龄组MIS评分（9.19±5.73）高于非老龄组（6.38±4.51）;按照MIS营养不良程度划分：老龄组55.56%为轻度营养不良,36.11%为中度营养不良,8.33%为重度营养不良。老龄组血浆白蛋白、转铁蛋白、肌酐、未饱和铁和总铁结合力低于非老龄组（P〈0.05）,而铁蛋白水平显著高于非老龄组。两组总胆固醇、血常规（Hb、RBC和红细胞压积）水平,差异无统计学意义。两组的中臂围、中臂肌围、TSF均较健康对照组明显下降,但组间差异无统计学意义。两组CRP、IL-6、和TNF-α水平均显著高于正常人群。老龄组透析前后IL-6和透前TNF-α均高于非老龄组（P〈0.05）。结论：老龄MHD患者具有较高的营养不良发生率,且营养不良程度更重;MHD患者具有较高的炎症因子水平,与非老龄患者比较,老龄患者具有较高水平血清IL-6。     

Evaluation of nutrition assessment tools compared with body cell mass for the assessment of malnutrition in chronic kidney disease.

OBJECTIVE: We compared the subjective global assessment (SGA) and a range of SGA-based assessment tools with body cell mass (BCM) in patients with stage IV and V predialysis chronic kidney disease (CKD). STUDY DESIGN: This was a cross-sectional, observational study. SETTING: The study took place at a public tertiary hospital predialysis outpatient clinic. PATIENTS: A total of 56 consecutive consenting patients with CKD (61% were male; age [mean +/- standard deviation] 70.2 +/- 11.6 years; glomerular filtration rate 22.2 +/- 6.8 mL/min). MAIN OUTCOME MEASURE: Nutrition status was the main outcome measure. RESULTS: In this population, the prevalence of malnutrition was 19.6% (n = 11, SGA B; no C ratings). Malnutrition was associated with lower BCM (mean BCM, 26.3 vs. 33.4 kg, P = .007, measured by total body potassium), body weight (64.8 vs. 76.1 kg, P = .042), body mass index (23.7 vs. 27.6 kg/m(2), P = .015), and greater weight loss over the previous 6 months (-6.2 vs. -0.1 kg, P = .004). BCM had a weak relationship with 7-point SGA (P = .267), malnutrition inflammation score (r = -0.27 P = .063), and patient-generated SGA (r = -0.27 P = .060). There was no association for either measure of nutrition status (SGA or BCM) with albumin, glomerular filtration rate, or C-reactive protein. CONCLUSION: SGA in its original form most accurately delineated malnutrition by depleted BCM and is the most appropriate tool for cross-sectional assessment of nutrition status in patients with predialysis CKD.     

Therapeutic effects of oral nutritional supplementation during hemodialysis

BACKGROUND: Protein-calorie malnutrition is common in chronic hemodialysis (CHD) patients and correlates with morbidity and mortality in these patients. There are limited trials evaluating the efficacy of oral nutritional supplementation in malnourished CHD patients. METHODS: Eighty-five CHD patients with evidence of malnutrition were included in this prospective study. Patients were followed for a 3-month baseline period during which they received conventional nutrition counseling. This was followed by an intervention period, during which an oral nutritional supplement specifically formulated for CHD patients was given over a period of 6 months. An important element of this study was that the nutritional supplement was provided during dialysis to ensure compliance. Serial measurements of nutritional parameters including concentrations of serum albumin, prealbumin, transferrin as well as body mass index (BMI) and subjective global assessment (SGA) were obtained during the 9-month period. RESULTS: The nutritional parameters did not change during the 3-month baseline period. Following administration of oral supplementation during hemodialysis, there were significant increases in concentrations of serum albumin (from 3.33 +/- 0.32 g/dL at baseline, to 3.65 +/- 0.26 g/dL at month 6, P < 0.0001) and serum prealbumin (from 26.1 +/- 8.6 mg/dL at baseline, to 30.7 +/- 7.4 mg/dL at month 6, P = 0.002). Mean SGA score increased 14% by the end of the study (P = 0.023). Although BMI and estimated dry weight increased also, these changes were not statistically significant. Serum transferrin did not change during the study period. CONCLUSION: Oral nutritional supplementation given during hemodialysis improves nutritional markers in malnourished CHD patients.     

Intradialytic amino acids supplementation in hemodialysis patients with malnutrition: results of a multicenter cohort study.

OBJECTIVE: Prospective evaluation of the effect of 6-month-long intradialytic amino acids (AA) supplementation on selected nutritional variables in malnourished hemodialysis (HD) patients. DESIGN: Multicenter, prospective, (nonrandomized, noncontrolled) observational study. SETTING: Thirty-one HD units affiliated with academic centers and tertiary-care hospitals. PATIENTS: Adult patients treated by HD for at least 6 months. Inclusion criteria were: serum albumin concentration < or =39 g/L and at least 4% loss of body weight during the last 6 months in otherwise stable HD patients. From a cohort of 133 patients who were enrolled, 97 (54 men and 43 women) were eligible for the analysis. INTERVENTION: Intradialytic AA supplementation with 500 mL 10% solution per HD session for a period of 6 months. MAIN OUTCOME MEASURES: Serum albumin concentration, modified Subjective Global Assessment (SGA) score, body mass index (BMI), mid-arm circumference (MAC), and total lymphocyte count. Measurements were recorded at baseline and after 3 and 6 months of AA supplementation. RESULTS: Serum albumin concentration increased significantly from the mean 32.5 +/- 4.6g/L at baseline to 36.4 +/- 4.8 g/L at 3 months (P <.001) and 37.1 +/- 4.8 g/L at final observation (P <.001 versus baseline). Significant correlation was observed between frequency of AA supplementation and serum albumin increase (r = 0.41; P <.0001). Rate of improvement negatively correlated significantly with baseline concentration of serum albumin (r = - 0.42; P <.0001). SGA score significantly improved from median of 16 points at baseline to 12 points at 3 months (P <.01) and 11 points at 6 months (P <.01 versus baseline), and this improvement also correlated with the frequency of AA supplementation. Small yet significant increase of MAC was observed at 6 months (from baseline 24.1 +/- 4.3 to 24.8 +/- 4.8 cm; P <.01), whereas BMI remained unchanged. CONCLUSION: Intradialytic AA supplementation improves selected nutritional parameters of HD patients with malnutrition. The improvement depends on the intensity of supplementation.     

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.     

Nutritional profile and inflammatory status of hemodialysis patients

BACKGROUND: Malnutrition and abnormal inflammatory markers are prominent features of the uremic syndrome, but associations and repercussions are somewhat controversial. OBJECTIVE: To determine nutritional and clinical profile of hemodialysis patients, aiming at potential diagnostic recommendations for stable subjects with elevated C-reactive protein. MATERIAL AND METHOD: Design: Prospective observational cross-sectional clinical study in a stable chronic hemodialysis population; Setting: Renal and Nutritional Service of a mid-size charity academic hospital; Patients: Subjects (n=44) were analyzed concerning nutritional status and C-reactive protein. Some displayed acute infections (Group I, n=9) and others did not (Group II, n=35). Age was 47.0 +/- 16.9 years with 63.6% males. Body mass index (BMI) was 22.2 +/- 3.9 kg/m2, calorie intake was 1262 +/- 601 kcal/day (20.7 +/- 6.7 kcal/kg/day), and protein ingestion was 74.3 +/- 16.6 g protein/day (1.2 g/kg/day); Intervention: No nutritional supplement or artificial modality of alimentation was employed in this series; Main outcome measures: Subjective global assessment and C-reactive protein. RESULTS: Malnutrition estimated by subjective global assessment (SGA) was very common (>90%), despite acceptable BMI and serum albumin. C-reactive protein was moderately elevated in 40.9% and was positively associated with SGA and negatively with plasma proteins. Comorbidities were associated positively with extracellular water and negatively with reactance (bioimpedance). When infected versus non-infected cases were analyzed, 100% of the former displayed high CRP concentrations in contrast with 22.9% of remaining patients. CONCLUSIONS: (1) Malnutrition profile was rather unique, with relatively favorable objective findings (body mass index, serum albumin) and more deranged SGA; (2) Bioimpedance analysis suggested that phase angle could be used as an indicator of nutritional status; (3) Creactive protein was negatively associated with plasma proteins; (4) Infected subjects, although few and displaying moderate clinical troubles, were responsible for most C-reactive protein determinations above 8 mg/L; (5) Investigation of occult infectious foci is advised in these circumstances.     

Oral sodium bicarbonate for the treatment of metabolic acidosis in peritoneal dialysis patients: a randomized placebo-control trial

Acidosis causes malnutrition in peritoneal dialysis (PD) patients. The effect of oral bicarbonate in PD patients with Kt/V <2.1 has not been studied. We randomly assigned 60 PD patients with acidosis and Kt/V <2.1 to oral sodium bicarbonate (0.9 g thrice daily) or placebo. Patients were followed for 12 mo. We compared their nutritional status, including subjective global assessment (SGA) score and normalized protein nitrogen appearance (NPNA), hospitalization and all-cause mortality. Treatment with oral bicarbonate resulted in a higher plasma bicarbonate level at 4 wk (27.8 +/- 2.6 versus 24.7 +/- 3.9 mmol/L, P = 0.002), and the difference persisted until 52 wk. Bicarbonate treatment had a significant effect on the change in overall SGA score (repeated measures ANOVA, P = 0.0003). The overall SGA score of the treatment group was higher than the placebo group at 24 wk (5.07 +/- 0.94 versus 4.40 +/- 1.00, P = 0.015), and the difference persisted thereafter. NPNA rose in the treatment group (1.17 +/- 0.32 to 1.28 +/- 0.26 g/kg per d, P = 0.034), but declined in placebo group (1.13 +/- 0.25 to 1.03 +/- 0.28 g/kg per d, P = 0.054). The treatment group had a shorter hospitalization than the placebo group (8.4 +/- 17.7 versus 16.8 +/- 21.7 d/yr; P = 0.02). Mortality was not significantly different. Although our trial has limited statistical power, we find that in PD patients with mild acidosis and Kt/V <2.1, oral sodium bicarbonate probably improve nutritional status and reduce the duration of hospitalization.     

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