Impact of Changes in Rectus Femoris Cross-Sectional Area Measured by Ultrasound on the Prognosis of Patients With Acute Heart Failure.

BACKGROUND: Low muscle mass in patients with acute heart failure (AHF) is associated with poor prognosis; however, this is based on a single baseline measurement, with little information on changes in muscle mass during hospitalization and their clinical implications. This study investigated the relationship between changes in rectus femoris cross-sectional area (RFCSA) on ultrasound and the prognosis of patients with AHF.Methods and Results: This is a retrospective evaluation of 284 AHF patients (mean [±SD] age 79.1±11.9 years; 116 female). RFCSA assessments at admission (pre-RFCSA), ∆RFCSA (i.e., the percentage change in RFCSA from admission to 2 weeks), and composite prognosis (all-cause death and heart failure-related readmission) within 1 year were determined. Patients were divided into 4 groups according to their median pre-RFCSA and ∆RFCSA after sex stratification: Group A, higher pre-RFCSA/better ∆RFCSA; Group B, higher pre-RFCSA/worse ∆RFCSA; Group C, lower pre-RFCSA/better ∆RFCSA; Group D, lower pre-RFCSA/worse ∆RFCSA. In the Cox regression analysis, with Group A as the reference, the cumulative event rate of Group C (hazard ratio [HR] 3.39; 95% confidence interval [CI] 0.71-16.09; P=0.124) did not differ significantly; however, the cumulative event rates of Group B (HR 7.93; 95% CI 1.99-31.60; P=0.003) and Group D (HR 9.24; 95% CI 2.57-33.26; P<0.001) were significantly higher. CONCLUSIONS: ∆RFCSA during hospitalization is useful for risk assessment of prognosis in patients with AHF.

Impact of sarcopenia and malnutrition on swallowing function utilizing ultrasonography in patients with acute heart failure: A retrospective cohort study.

BACKGROUND & AIMS: This study aimed to determine the impact of sarcopenia and nutritional risk on swallowing-related muscles by ultrasonography and dysphagia occurrence in older patients with acute heart failure (AHF) during hospitalization. METHODS: Patients with AHF aged ≥65 years without dysphagia (Food Intake LEVEL Scale [FILS] score ≥9) before admission were classified into four groups at admission: robust group, sarcopenia group (Asian Working Group for Sarcopenia 2019), nutritional risk group (geriatric nutritional risk index <92), and complicated group (with both sarcopenia and nutritional risk). Swallowing function (maximal hyoid displacement, geniohyoid muscle area and brightness, and maximal tongue pressure) and FILS were investigated from the medical records. RESULTS: In total, 131 patients with AHF (mean age 82.8 ± 7.1 years, 71 males) were enrolled during the study period; 33, 58, 5, and 35 were classified into the robust, sarcopenia, nutritional risk, and complicated groups, respectively. In the covariance analysis adjusted for age, sex, comorbidities, and cardiac function, the complicated group had significantly worse swallowing function than the sarcopenia and robust groups (P < 0.05). In the Cox proportional hazards model, in which event occurrence was defined as the first-time FILS score of ≥9 obtained during hospitalization, the sarcopenia group (hazard ratio [HR]: 0.83, 95 % confidence interval [CI]: 0.51-1.34, P = 0.438) and nutritional risk group (HR: 0.77, 95 % CI:0.25-2.32, P = 0.637) were not significantly different, but the complicated group (HR: 0.54, 95 % CI: 0.31-0.95, P = 0.033) had significantly lower cumulative event rates with the robust group as the reference. CONCLUSION: Sarcopenia and nutritional risk in older patients with AHF are risk factors for decreased swallowing function.

Effect of Electrical Muscle Stimulation on the Reduction of Muscle Volume Loss in Acute Heart Failure Patients.

Electrical muscle stimulation (EMS) is expected to be considered as an add-on therapy for the usual rehabilitation of patients with chronic heart failure (HF). However, it remains unclear whether EMS can reduce muscle volume loss in patients with acute HF (AHF) immediately after hospitalization. Therefore, the aim of this study was to investigate if EMS could reduce the lower-limb muscle volume loss in patients with AHF. In this single-center, retrospective, observational study, lower-limb skeletal muscle volume, quadriceps muscle layer thickness, and clinical events (worsening HF or kidney function) were evaluated in 45 patients with AHF (mean age, 77.4 ± 11.6 years, 31 males). All patients underwent EMS on the right leg, in addition to usual rehabilitation, for 20 minutes per day, 5 days per week, for 2 weeks. A two-factor (time × leg) analysis of variance was performed to compare the difference between the right leg (usual rehabilitation and EMS) and left leg (usual rehabilitation only). The skeletal muscle mass decreased by 11.6% ± 19.7% from baseline in the right leg and by 20.4% ± 16.1% in the left leg (interaction; F = 4.54, P = 0.036). The quadriceps muscle layer thickness decreased by 10.2% ± 7.1% from baseline in the right leg and by 13.5% ± 6.0% in the left leg (interaction; F = 10.50, P = 0.002). No clinical events were related to EMS. Results showed that EMS combined with usual rehabilitation for patients with AHF has the potential to inhibit muscle volume loss.

Effects of electrical muscle stimulation in frail elderly patients during haemodialysis (DIAL): rationale and protocol for a crossover randomised controlled trial.

INTRODUCTION: The phenomenon of population ageing is accompanied by increases in the number of elderly haemodialysis patients worldwide. The incidence of frailty is high in the haemodialysis population and is associated with poor clinical outcome. Although several interventions have been developed for use in general haemodialysis patients, the efficacy of such rehabilitation programmes in frail elderly patients on haemodialysis has not been elucidated. Here, we examined whether electrical muscle stimulation (EMS) would show beneficial effects in frail elderly patients on haemodialysis. METHODS AND ANALYSIS: This is a randomised, two-period, controlled crossover trial, which will enrol 20 patients. Haemodialysis patients aged ≥65 years and defined as frail (ie, Short Physical Performance Battery score 4-9), will be randomly assigned to either group 1 (EMS intervention beginning in treatment period I, followed by reallocation as controls in treatment period II after a 5-week washout period) or group 2 (opposite schedule) in a 1:1 ratio. The two intervention periods will last 5 weeks each with an intervening washout period of 5 weeks. In the EMS intervention group, the treatment will be applied to the skeletal muscle of the entire lower extremity for 5 weeks, three times/week for 30-40 min during haemodialysis. The primary outcome of this study is the change in quadriceps isometric strength after the interventions. The secondary outcomes are the changes in physical function, physical activity, difficulty in activities of daily living, body composition, cognitive function, depressive symptoms, quality of life, blood test results and the clinical safety and feasibility of EMS therapy. ETHICS AND DISSEMINATION: This study has been approved by the institutional review board/ethics committee of Kitasato University Allied Health Sciences. This study will be reported in peer reviewed publications and at conference presentations. TRIAL REGISTRATION NUMBER: UMIN000032501.

Association between frailty and bone loss in patients undergoing maintenance hemodialysis.

Frailty is significantly associated with bone loss in the general population. However, it is unclear whether this association also exists in patients undergoing hemodialysis who have chronic kidney disease-mineral and bone disorder (CKD-MBD). This study aimed to assess the association between frailty and bone loss in patients undergoing hemodialysis. This cross-sectional study included 214 (90 women, 124 men) Japanese outpatients undergoing maintenance hemodialysis three times per week, with a mean age of 67.1 years (women) and 66.8 years (men). Frailty was defined based on criteria set forth by the Cardiovascular Health Study (CHS)-19 (21.1%) women and 47 (37.9%) men were robust, 41 (45.6%) women and 43 (34.7%) men were pre-frail, and 30 (33.3%) women and 34 (27.4%) men were frail. For bone mass, quantitative ultrasound (QUS) parameters (speed of sound, broadband ultrasound attenuation, stiffness index) of the calcaneus were measured. The association between frailty and QUS parameters was determined separately for women and men using multivariate analysis of covariance (ANCOVA), with adjustments for clinical characteristics including age, body mass index, hemodialysis vintage, diabetes, current smoking, serum albumin, phosphate, corrected calcium, intact parathyroid hormone, and medication for CKD-MBD (vitamin D receptor activator, calcimimetics). ANCOVA revealed that all QUS parameters declined significantly with increasing levels of frailty in both sexes (P < 0.05). In conclusion, frailty (as defined by CHS criteria) should be considered a risk factor for bone loss in patients undergoing hemodialysis.

Utility of Regular Management of Physical Activity and Physical Function in Hemodialysis Patients.

BACKGROUND/AIMS: Several clinical practice guidelines recommend regular assessment of physical activity and physical function as part of routine care in hemodialysis patients. However, there is no clear evidence to support these recommendations. We investigated whether the proportion of attendance at a regular program for management of physical activity and physical function can predict all-cause mortality and cardiovascular events in hemodialysis patients. METHODS: This retrospective cohort study consisted of 266 hemodialysis patients participating in the management program at least once. Participants were tracked for 3 years after their first attendance at the management program to determine their attendance proportion. The main study outcomes included all-cause mortality and a composite of fatal and nonfatal cardiovascular events. RESULTS: Median patient age was 64.5 (interquartile range, 56.8 - 72.0) years, 45% were women, and the median time on hemodialysis was 35.5 (interquartile range, 12.0 - 114.3) months at baseline. Sixty-five patients died over a median follow-up of 79 months. The incidence of cardiovascular events was 60 over a median follow-up of 68 months. Even after adjusting for any of the prognostic models, participants who attended ≤ 75% of sessions (n = 140) had higher risks of mortality (hazard ratio (HR), 1.79; 95% confidence interval (CI): 1.00 - 3.36; P = 0.049) and cardiovascular events (HR, 1.84; 95% CI: 1.07 - 3.48; P = 0.03) than those attending > 75% of sessions (n = 126). CONCLUSION: Hemodialysis patients in whom physical activity and physical function could be assessed more regularly had better prognosis than those with only intermittent assessment.

Combined Contribution of Reduced Functional Mobility, Muscle Weakness, and Low Serum Albumin in Prediction of All-Cause Mortality in Hemodialysis Patients: A Retrospective Cohort Study.

OBJECTIVES: The combined effects of reduced functional mobility, muscle weakness, and low serum albumin on mortality in hemodialysis patients have not been clarified. Here, we examined the associations of reduced functional mobility, muscle weakness, and low serum albumin-both alone and in combination-with all-cause mortality in hemodialysis patients. METHODS: A total of 490 patients treated between July 2010 and October 2016 were enrolled retrospectively in this study. The independent prognostic effect of the combination of reduced functional mobility, muscle weakness, and low serum albumin on survival was estimated by Cox proportional hazard regression analysis. We calculated the increases in predictive capacity by combining the associations of reduced functional mobility, muscle weakness, and low serum albumin in comparison to each component alone based on the receiver-operating characteristic curves, continuous net reclassification improvement (NRI), and integrated discrimination improvement (IDI). RESULTS: The final study population consisted of 314 hemodialysis patients, and 56 patients died during the 6.5-year follow-up period. The high Combined score group showed a significantly lower cumulative survival rate than the low Combined score group (hazard ratio, 3.30; 95% confidence interval, 1.59-6.87; P = .001). Both NRI and IDI suggested that the addition of Combined score to patient characteristics improved discrimination of patients at high risk of mortality (NRI, 0.038 95% CI: 0.096 - 0.064, P < .001 IDI, 0.029 95% CI: 0.004 - 0.055, P = .025). CONCLUSIONS: The combined assessment of reduced functional mobility, muscle weakness, and low serum albumin was associated with poorer prognosis in patients on hemodialysis. The results presented here indicated that the combination of reduced functional mobility, muscle weakness, and low serum albumin is useful for accurate prediction of prognosis in hemodialysis patients.

Physical Activity Dose for Hemodialysis Patients: Where to Begin? Results from a Prospective Cohort Study.

OBJECTIVE: Greater physical activity is associated with lower risk of mortality in persons with kidney disease; however, little is known about the appropriate dose of physical activity among hemodialysis patients. Here detected the minimum level of habitual physical activity to help inform interventions aimed at improving outcomes in the dialysis population. DESIGN: The design was prospective cohort study. SUBJECTS: Clinically stable outpatients in a hemodialysis unit from October 2002 to March 2014 were assessed for their eligibility to be included in this 7-year prospective cohort study. We used the Youden index to determine the optimal cutoff points for physical activity. The prognostic effect of physical activity on survival was estimated by Cox proportional hazards regression analysis. The number of steps per nondialysis day was recorded by accelerometer at study entry. MAIN OUTCOME MEASURE: The main outcome measure was all-cause mortality. RESULTS: There were 282 participants who had a mean age of 65 ± 11 years and 45% were female. A total of 56 deaths occurred during the follow-up period (56 months [interquartile range: 29-84 months]). The cutoff value for the physical activity discriminating those at high risk of mortality was 3,752 steps. After adjustment for the effect of confounders, the hazard ratio in the group of <4,000 steps was 2.37 (95% confidence interval: 1.22-4.60, P = .01) compared with the others. CONCLUSIONS: Engaging in physical activity is associated with decreased mortality risk among hemodialysis patients. Our findings of a substantial mortality benefit among those who engage in at least 4,000 steps provide a basis for as a minimum initial recommendation kidney health providers can provide for mobility disability-free hemodialysis patients.

Exercise Training in Elderly People Undergoing Hemodialysis: A Systematic Review and Meta-analysis.

INTRODUCTION: Previous reviews have indicated the effectiveness of exercise in people undergoing hemodialysis. However, these analyses did not take into account whether the subjects were elderly. We performed a systematic review of the effects of exercise training in elderly people undergoing hemodialysis and updated the evidence of exercise for people undergoing hemodialysis by adding recent research data. METHODS: We searched 8 electronic databases up to June 2016. Inclusion criteria were as follows: randomized controlled trial, English publication, subjects aged 18 and older undergoing hemodialysis, evaluation of physical function as an outcome of exercise intervention. We defined elderly as age 60 years and older. The main outcomes were exercise tolerance (peak/maximum oxygen consumption) and walking ability (6-minute walk distance). Secondary outcomes were lower extremity muscle strength and quality of life. RESULTS: After screening of 10,923 references, 30 comparisons were entered into the analysis. However, because we found only 1 study in which elderly subjects were treated, we could not perform a meta-analysis for these people. For the general population undergoing hemodialysis, supervised exercise training was shown to significantly increase peak/maximum oxygen consumption (standard mean difference, 0.62; 95% confidence interval 0.38-0.87; P < 0.001), 6-minute walk distance (standard mean difference, 0.58; 95% confidence interval 0.24-0.93; P < 0.001), lower extremity muscle strength (standard mean difference, 0.94; 95% confidence interval 0.67-1.21; P < 0.001), and quality of life (standard mean difference, 0.53; 95% confidence interval 0.52-0.82; P < 0.001). DISCUSSION: Our analysis on the effectiveness of exercise training in elderly people undergoing hemodialysis as compared with nonelderly people was somewhat inconclusive. Future studies should be carried out for elderly people to identify the most favorable exercise program for this population.

Changes in physical activity and risk of all-cause mortality in patients on maintence hemodialysis: a retrospective cohort study.

BACKGROUND: A previous cohort study indicated a significant association of lower baseline level of physical activity in hemodialysis patients with elevated risks of mortality. However, there have been no reports regarding the association between changes in physical activity over time and mortality in hemodialysis patients. This study was performed to examine the prognostic significance of physical activity changes in hemodialysis patients. METHODS: This retrospective cohort study was performed in 192 hemodialysis patients with a 7-year follow-up. The average number of steps taken per non-dialysis day was used as a measure of physical activity. Forty (20.8%) patients had died during the follow-up period. The percentage change in physical activity between baseline and 12 months was determined, and patients were divided into three categories according to changes in physical activity. A decrease or increase in physical activity > 30% was defined as becoming less or more active, respectively, while decrease or increase in physical activity < 30% were classified as stable. RESULTS: Forty seven (24.5%), 51 (26.6%), and 94 (49.0%) patients were classified as becoming less active, becoming more active, and stable, respectively. The hazard ratio on multivariate analysis in patients with decreased physical activity was 3.68 (95% confidence interval, 1.55-8.78; P < 0.01) compared to those with increased physical activity. CONCLUSIONS: Reductions in physical activity were significantly associated with poor prognosis independent of not only patient characteristics but also baseline physical activity. Therefore, improved prognosis in hemodialysis patients requires means of preventing a decline in physical activity over time.

Evaluating the effectiveness of exercise training on elderly patients who require haemodialysis: study protocol for a systematic review and meta-analysis.

INTRODUCTION: As the average age of haemodialysis patients rapidly increases around the world, the number of frail, elderly patients has increased. Frailty is well known to be an indicator of disability and a poor prognosis for haemodialysis patients. Exercise interventions have been safely and successfully implemented for middle-aged or younger patients undergoing haemodialysis. However, the benefits of exercise interventions on elderly patients undergoing haemodialysis remain controversial. The main objective of this study is to systematically review the effects of exercise training on the physical function, exercise capacity and quality of life of elderly patients undergoing haemodialysis, and to provide an update on the relevant evidence. METHODS AND ANALYSES: Published randomised controlled trials (RCTs) that assessed the effectiveness of exercise training on haemodialysis patients with respect to physical function, exercise tolerance and quality of life will be included. Bibliographic databases include MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, CINAHL, Web of Science, PsycINFO and PEDro. The risk of bias of the included RCTs will be assessed using the Cochrane Collaboration's tool and TESTEX. The primary outcome will be physical function and exercise tolerance. This review protocol is reported according to the PRISMA-P 2015 checklist. Statistical analysis will be performed using review manager software (RevMan V.5.3, Cochrane Collaboration, Oxford, England). ETHICS AND DISSEMINATION: Ethical approval is not required because this study does not include confidential personal data nor does it perform interventions on patients. This review is expected to inform readers on the effectiveness of exercise training in elderly patients undergoing haemodialysis. Findings will be presented at conferences and submitted to a peer-reviewed journal for publication. PROSPERO REGISTRATION NUMBER: CRD42015020701.

Determinants of Slow Walking Speed in Ambulatory Patients Undergoing Maintenance Hemodialysis.

Walking ability is significantly lower in hemodialysis patients compared to healthy people. Decreased walking ability characterized by slow walking speed is associated with adverse clinical events, but determinants of decreased walking speed in hemodialysis patients are unknown. The purpose of this study was to identify factors associated with slow walking speed in ambulatory hemodialysis patients. Subjects were 122 outpatients (64 men, 58 women; mean age, 68 years) undergoing hemodialysis. Clinical characteristics including comorbidities, motor function (strength, flexibility, and balance), and maximum walking speed (MWS) were measured and compared across sex-specific tertiles of MWS. Univariate and multivariate logistic regression analyses were performed to examine whether clinical characteristics and motor function could discriminate between the lowest, middle, and highest tertiles of MWS. Significant and common factors that discriminated the lowest and highest tertiles of MWS from other categories were presence of cardiac disease (lowest: odds ratio [OR] = 3.33, 95% confidence interval [CI] = 1.26-8.83, P<0.05; highest: OR = 2.84, 95% CI = 1.18-6.84, P<0.05), leg strength (OR = 0.62, 95% CI = 0.40-0.95, P<0.05; OR = 0.57, 95% CI = 0.39-0.82, P<0.01), and standing balance (OR = 0.76, 95% CI = 0.63-0.92, P<0.01; OR = 0.81, 95% CI = 0.68-0.97, P<0.05). History of fracture (OR = 3.35, 95% CI = 1.08-10.38; P<0.05) was a significant factor only in the lowest tertile. Cardiac disease, history of fracture, decreased leg strength, and poor standing balance were independently associated with slow walking speed in ambulatory hemodialysis patients. These findings provide useful data for planning effective therapeutic regimens to prevent decreases in walking ability in ambulatory hemodialysis patients.

Relationship between lower extremity muscle strength and all-cause mortality in Japanese patients undergoing dialysis.

BACKGROUND: Skeletal muscle wasting is common and insidious in patients who are undergoing hemodialysis. However, the association between lower extremity muscle strength and all-cause mortality remains unclear in this population. OBJECTIVE: The purpose of this study was to investigate the prognostic significance of lower extremity muscle strength on 7-year survival in a cohort of patients who were clinically stable and undergoing hemodialysis. DESIGN: A prospective cohort study was conducted. METHODS: A total of 190 Japanese outpatients who were undergoing maintenance hemodialysis 3 times per week at a hemodialysis center were followed for up to 7 years. Lower extremity muscle strength was evaluated using a handheld dynamometer at the time of patient enrollment in the study. Muscle strength data were divided by dry weight and expressed as a percentage. A Cox proportional hazards regression model was used to assess the contribution of lower extremity muscle strength to all-cause mortality. RESULTS: The median age (25th and 75th percentiles) of this study population was 64 years (57 and 72 years), 53.2% of the patients were women, and the time on hemodialysis was 39.0 months (15.9 and 110.5 months) at baseline. During a median follow-up of 36.0 months, there were 30 deaths. With a multivariate Cox model, the hazard ratio in the group with a knee extensor strength of <40% was 2.73 (95% confidence interval=1.14-6.52) compared with that in the ≥40% group. LIMITATIONS: This was a small-scale observational study, and the mechanisms underlying the higher mortality risk in patients with poor muscle strength undergoing hemodialysis than in other patients undergoing hemodialysis remain to be elucidated. CONCLUSIONS: Decreased lower extremity muscle strength was strongly associated with increased mortality risk in patients undergoing hemodialysis.

Association of habitual physical activity measured by an accelerometer with high-density lipoprotein cholesterol levels in maintenance hemodialysis patients.

After confirming the relationship between high-density lipoprotein cholesterol (HDL-C) levels and mortality in hemodialysis patients for study 1, we investigated the effect of physical activity on their HDL-C levels for study 2. In study 1, 266 hemodialysis patients were monitored prospectively for five years, and Cox proportional hazard regression confirmed the contribution of HDL-C to mortality. In study 2, 116 patients were recruited after excluding those with severe comorbidities or requiring assistance from another person to walk. Baseline characteristics, such as demographic factors, physical constitution, primary kidney disease, comorbid conditions, smoking habits, drug use, and laboratory parameters, were collected from patient hospital records. An accelerometer measured physical activity as the number of steps per day over five consecutive days, and multiple regression evaluated the association between physical activity and HDL-C levels. Seventy-seven patients died during the follow-up period. In study 1, we confirmed that HDL-C level was a significant predictor of mortality (P = 0.03). After adjusting for patient characteristics in study 2, physical activity was independently associated with HDL-C levels (adjusted R (2) = 0.255; P = 0.005). In conclusion, physical inactivity was strongly associated with decreased HDL-C levels in hemodialysis patients.