Muscle Mass Assessed by Computed Tomography at the Third Lumbar Vertebra Predicts Patient Survival in Chronic Kidney Disease

OBJECTIVE: Muscle mass is a key element for the evaluation of nutritional disturbances in patients with chronic kidney disease (CKD). Low muscle mass is associated with increased morbidity and mortality. The assessment of muscle mass by computed tomography at the third lumbar vertebra region (CTMM-L3) is an accurate method not subject to errors from fluctuation in the hydration status. Therefore, we aimed at investigating whether CTMM-L3 was able to predict mortality in nondialyzed CKD 3-5 patients. METHODS: This is a prospective observational cohort study. We evaluated 223 nondialyzed CKD patients (60.3 ± 10.6 years; 64% men; 50% diabetics; glomerular filtration rate 20.7 ± 9.6 mLmin1.73 m2). Muscle mass was measured by CTMM-L3 using the Slice-O-Matic software and analyzed according to percentile adjusted by gender. Nutritional parameters, laboratory data, and comorbidities were evaluated, and mortality was followed up for 4 years. RESULTS: During the study period, 63 patients died, and the main cause of death was cardiovascular disease. Patients who died were older, had lower hemoglobin and albumin, as well as lower muscle markers. CTMM-L3 below the 25th percentile was associated with higher mortality according to the Kaplan-Meier curve (P = .017) and in Cox regression analysis (crude hazard ratio, 1.87 [95% confidence interval, 1.11-3.16]), also when adjusting for potential confounders (hazard ratio 1.83 [95% confidence interval 1.02-3.30]). CONCLUSION: Low muscle mass measured by computed tomography at the third lumbar vertebra region is an independent predictor of increased mortality in nondialyzed CKD patients.

Muscle Mass Assessed by Computed Tomography at the Third Lumbar Vertebra Predicts Patient Survival in Chronic Kidney Disease.

OBJECTIVE: Muscle mass is a key element for the evaluation of nutritional disturbances in patients with chronic kidney disease (CKD). Low muscle mass is associated with increased morbidity and mortality. The assessment of muscle mass by computed tomography at the third lumbar vertebra region (CTMM-L3) is an accurate method not subject to errors from fluctuation in the hydration status. Therefore, we aimed at investigating whether CTMM-L3 was able to predict mortality in nondialyzed CKD 3-5 patients. METHODS: This is a prospective observational cohort study. We evaluated 223 nondialyzed CKD patients (60.3 ± 10.6 years; 64% men; 50% diabetics; glomerular filtration rate 20.7 ± 9.6 mLmin1.73 m2). Muscle mass was measured by CTMM-L3 using the Slice-O-Matic software and analyzed according to percentile adjusted by gender. Nutritional parameters, laboratory data, and comorbidities were evaluated, and mortality was followed up for 4 years. RESULTS: During the study period, 63 patients died, and the main cause of death was cardiovascular disease. Patients who died were older, had lower hemoglobin and albumin, as well as lower muscle markers. CTMM-L3 below the 25th percentile was associated with higher mortality according to the Kaplan-Meier curve (P = .017) and in Cox regression analysis (crude hazard ratio, 1.87 [95% confidence interval, 1.11-3.16]), also when adjusting for potential confounders (hazard ratio 1.83 [95% confidence interval 1.02-3.30]). CONCLUSION: Low muscle mass measured by computed tomography at the third lumbar vertebra region is an independent predictor of increased mortality in nondialyzed CKD patients.

Concurrent validity of an appetite questionnaire in peritoneal dialysis.

BACKGROUND: Decreased appetite is a symptom often found in chronic kidney disease. Poor appetite may negatively affect food intake, what in long-term may contribute to the development of protein-energy malnutrition. METHODS: An Appetite and Food Satisfaction Questionnaire (AFSQ) was developed consisting of a question that assesses the level of appetite through a facial hedonic scale and five other questions adapted from the Buckner and Dwyer tool that assess some aspects related to food satisfaction. Each question received an arbitrary score of 0 to 3. The sum of the scores ranged from 0, the best, to 18, the worst condition. Nutritional status was assessed through seven-point SGA, bioelectrical impedance, anthropometry, and handgrip strength (HGS). RESULTS: Eighty-four patients on peritoneal dialysis (PD; 58.3% women, mean age 54.7 ± 14.2 years, and body mass index (BMI) of 26.0 ± 4.8 kg/m2) were evaluated. Median AFSQ score was 4.0 (1.0-6.8; median and IQ). Patients were divided into tertiles according to the AFSQ score. Comparing the third tertile (score ≥ 6) with the first tertile (score < 2), the prevalence of malnutrition was greater (32.1% vs. 6.7%, respectively, p = 0.005), HGS adequacy was lower (74.6% vs. 87.3%, p = 0.001), and body cell mass index (5.7% vs. 7.4%, p = 0.001) and lean BMI were lower (11% vs. 13.4%, p = 0.001) in the third tertile. CONCLUSION: Poor appetite and food satisfaction determined by the questionnaire was related to worse nutritional markers, indicating AFSQ as a valid easy-to-use tool to be applied as an initial screening to identify PD patients with potential risk of malnutrition.

Estimating resting energy expenditure of patients on dialysis: Development and validation of a predictive equation.

OBJECTIVES: The aims of this study were to develop and validate a resting energy expenditure (REE) predictive equation in a cohort of patients on dialysis and to test the accuracy of two previously developed specific equations to estimate REE of these patients. METHODS: A database with REE measured by indirect calorimetry (IC) of 189 patients on hemodialysis and peritoneal dialysis was used to develop and validate the new equation. The sample including only patients on hemodialysis (n = 131) was used to test the accuracy of the specific REE dialysis equations by Vilar and Byham-Gray. RESULTS: Multiple regression analysis generated two equations: REE (kcal/d) = 957.02 - 8.08 × age + 11.07 × body weight + 136.4 (if men) (R2 = 0.515) (1) REE (kcal/d) = 624.6-4.8 × age + 20.6 × fat-free, ass-fat-free mass-8.65 (if men) (R2 = 0.512) (2) In the validation group, REE by both equations did not differ from the REE measured by IC. No bias was found in the Bland-Altman analysis and the intraclass correlation coefficient and P20 test showed good reliability with measured REE. Vilar's equation overestimated REE; whereas REE generated by Byham-Gray's equation did not differ from measured REE. Proportional and systematic biases were significant for both equations. CONCLUSIONS: The new equations developed showed good accuracy and can be valuable to estimate energy needs of patients on dialysis. Byham-Gray's and Vilar's equations presented low to moderate performance to estimate REE of the patients on dialysis.

Muscle mass assessment by computed tomography in chronic kidney disease patients: agreement with surrogate method

Background/objectives Patients with chronic kidney disease (CKD) are subjected to muscle wasting. Therefore, it is important to investigate surrogate methods that enable the assessment of muscle mass loss in the clinical setting. We aimed to analyze the agreement between computed tomography (CT) and surrogate methods for the assessment of muscle mass in non-dialysis CKD patients. Subjects/methods Cross-sectional study including 233 non-dialysis patients on CKD stages 3 to 5 (61±11 years; 64% men; glomerular filtration rate 22 (14­33) mL/min/1.73m2). The muscle mass was evaluated by CT and bioelectrical impedance, skinfold thicknesses, midarm muscle circumference (MAMC), the predictive equations of Janssen and Baumgartner and the physical examination of muscle atrophy from the subjective global assessment. Results In males, the MAMC showed the best agreement with CT as indicated by the kappa test (k=0.57, P<0.01), sensitivity (S=68%), specificity (S=89%) and accuracy (area under the curve­AUC=0.78), followed by the Baumgartner equation (kappa=0.46, P<0.01; sensitivity=60%; specificity=87% and AUC=0.73). In female, the Baumgartner equation showed the best agreement with CT (kappa=0.43, P<0.01; sensitivity=57%; specificity=86% and AUC=0.71). (AU)

Muscle mass assessment by computed tomography in chronic kidney disease patients: agreement with surrogate methods.

BACKGROUND/OBJECTIVES: Patients with chronic kidney disease (CKD) are subjected to muscle wasting. Therefore, it is important to investigate surrogate methods that enable the assessment of muscle mass loss in the clinical setting. We aimed to analyze the agreement between computed tomography (CT) and surrogate methods for the assessment of muscle mass in non-dialysis CKD patients. SUBJECTS/METHODS: Cross-sectional study including 233 non-dialysis patients on CKD stages 3 to 5 (61 ± 11 years; 64% men; glomerular filtration rate 22 (14-33) mL/min/1.73 m2). The muscle mass was evaluated by CT and bioelectrical impedance, skinfold thicknesses, midarm muscle circumference (MAMC), the predictive equations of Janssen and Baumgartner and the physical examination of muscle atrophy from the subjective global assessment. RESULTS: In males, the MAMC showed the best agreement with CT as indicated by the kappa test (k = 0.57, P < 0.01), sensitivity (S = 68%), specificity (S = 89%) and accuracy (area under the curve-AUC = 0.78), followed by the Baumgartner equation (kappa = 0.46, P < 0.01; sensitivity = 60%; specificity = 87% and AUC = 0.73). In female, the Baumgartner equation showed the best agreement with CT (kappa = 0.43, P < 0.01; sensitivity = 57%; specificity = 86% and AUC = 0.71). CONCLUSIONS: The MAMC and Baumgartner equation showed the best agreement with CT for the assessment of muscle mass in non-dialysis CKD patients.

Intramuscle fat infiltration in non-dialysis CKD: clinical determinants and association with mortality

BACKGROUND: Intramuscle fat infiltration (IFI) is an important feature of aging currently understood as a cause of muscle weakness in elderly. Compared to healthy controls, IFI has been reported elevated in chronic kidney disease (CKD) patients. Its determinants and consequences, however, are unknown. METHODS: Cross-sectional study with mortality follow-up of 195 nephrology-referred patients with non-dialysis CKD stages 3-5. Mean age was 60±11 years, 61% were men and glomerular filtration rate (creatinine clearance) was 25±12 ml/min/1.73 m2 . We used computed tomography (CT) scan (Slice-O-Matic software version 5.0) of the third lumbar vertebra to quantify the degree of IFI (reported as % of fat within muscle area). Muscles evaluated by CT were psoas, transversus abdominis, rectus abdominis, external and internal obliques, erector spinae and quadratus lumborum. Coronary artery calcification score (CAC) was evaluated by CT, muscle strength by dynamometry (handgrip strength, HGS) and shown as standard values to normative tables. RESULTS: IFI was higher in women than in men (9.7±6 vs 6.3±4%, P 0.05), and was positively correlated (Spearman test) with age (rho =0.37), Charlson comorbidity score (rho=0.19), CAC (r=0.16) and CT-derived visceral (rho=0.37) and subcutaneous fat (rho =0.57). IFI was negatively associated with HGS (rho=-0.25) and CT-derived skeletal muscle mass (rho=-0.37)...(AU)

Association of Sarcopenia With Nutritional Parameters, Quality of Life, Hospitalization, and Mortality Rates of Elderly Patients on Hemodialysis.

OBJECTIVE: This study aimed to assess whether diminished muscle mass, diminished muscle strength, or both conditions (sarcopenia) are associated with worse nutritional status, poor quality of life (QoL), and hard outcomes, such as hospitalization and mortality, in elderly patients on maintenance hemodialysis (MHD). DESIGN AND SUBJECTS: This is a multicenter observational longitudinal study that included 170 patients on MHD (age 70 ± 7 years, 65% male) from 6 dialysis centers. MAIN OUTCOME MEASURE: The European Working Group on Sarcopenia in Older People defines sarcopenia as the presence of both low muscle mass by appendicular skeletal + low muscle function by handgrip strength. This study evaluated the clinical and nutritional status (laboratory, anthropometry, dual-energy X-ray absorptiometry, 7-point subjective global assessment) and QoL (Kidney Disease Quality of Life) at baseline. Hospitalization and mortality were recorded during 36 months. RESULTS: Reduced muscle mass was observed in 64% of the patients, reduced muscle strength in 52%, and sarcopenia in 37%. The group with sarcopenia was older, had a higher proportion of men and showed worse clinical and nutritional conditions when compared with patients without sarcopenia. Although reduced muscle mass was strongly associated with poor nutritional status, low muscle strength was associated with worse QoL domains. In the multivariate Cox analyses adjusted by age, gender, dialysis vintage, and diabetes mellitus, low muscle strength alone and sarcopenia were associated with higher hospitalization, and sarcopenia was a predictor of mortality. CONCLUSION: In conclusion, in this sample, comprised of elderly patients on MHD, sarcopenia was associated with worse nutritional and clinical conditions and was a predictor of hospitalization and mortality.

Home-based versus center-based aerobic exercise on cardiopulmonary performance, physical function, quality of life and quality of sleep of overweight patients with chronic kidney disease.

BACKGROUND: The association between chronic kidney disease (CKD) and obesity can decrease the patients' cardiopulmonary capacity, physical functioning and quality of life. The search for effective and practical alternative methods of exercise to engage patients in training programs is of great importance. Therefore, we aimed to compare the effects of home-based versus center-based aerobic exercise on the cardiopulmonary and functional capacities, quality of life and quality of sleep of overweight non-dialysis-dependent patients with CKD (NDD-CKD). METHODS: Forty sedentary overweight patients CKD stages 3 and 4 were randomly assigned to an exercise group [home-based group (n = 12) or center-based exercise group (n = 13)] or to a control group (n = 15) that did not perform any exercise. Cardiopulmonary exercise test, functional capacity tests, quality of life, quality of sleep and clinical parameters were assessed at baseline, 12 and 24 weeks. RESULTS: The VO2peak and all cardiopulmonary parameters evaluated were similarly improved (p < 0.05) after 12 and 24 weeks in both exercise groups. The functional capacity tests improved during the follow-up in the home-based group (p < 0.05) and reached values similar to those obtained in the center-based group. The benefits achieved in both exercise groups were also reflected in improvement of quality of life and sleep (p < 0.05). No differences were observed between the exercise groups, and no changes in any of the parameters investigated were found in the control group. CONCLUSION: Home-based aerobic training was as effective as center-based training in improving the physical and functional capabilities, quality of life and sleep in overweight NDD-CKD patients.

Waist circumference as a predictor of mortality in peritoneal dialysis patients: a follow-up study of 48 months.

Body-fat gain is a common finding among peritoneal dialysis (PD) patients, and the accumulation of adipose tissue occurs predominantly in the abdominal area. Waist circumference (WC) is a reliable marker of abdominal obesity and its association with worse outcomes has been demonstrated in non-dialysis and haemodialysis patients. We aimed at investigating whether WC measurements as well as the changes over time in WC were able to predict mortality in PD patients. This prospective study included 109 patients undergoing PD (57 % male, age 52 (sd 16) years, 32 % diabetics, 48 % BMI≥25 kg/m2). WC was measured at the umbilicus level (empty abdominal cavity), and values >88 cm for women and >102 cm for men were considered high. Nutritional status and laboratory parameters were also evaluated. WC was measured at baseline and after 6 months, and mortality was registered during a period of 48 months. High WC was observed in 55 % of women and in 23 % of men at baseline. After 6 months, 61 % of the patients showed an increased WC. At the end of the study, twenty-seven deaths were registered. A significant increase in WC was observed only in the non-survivor group. In the Cox regression analysis adjusting for sex, age, duration on dialysis, diabetes, BMI, serum albumin and C-reactive protein, high WC at baseline as well as the 6-month increase in WC were independently associated with mortality. This study demonstrated that a high WC and the increase over time in WC were both predictors of mortality in PD patients.

A practical approach to dietary interventions for nondialysis-dependent CKD patients: the experience of a reference nephrology center in Brazil.

This paper describes the 30-year experience on nutritional management of non-dialysis dependent chronic kidney disease (CKD) patients in a public outpatient clinic located in the city of São Paulo, Brazil. A team of specialized dietitians in renal nutrition is responsible to provide individual dietary counseling for patients on stages 3 to 5 of CKD. Two different types of nutrition care protocols are employed depending on the level of renal function. For patients with CKD stage 3 a simplified nutritional assessment is performed and the main dietary focus is on the control of protein intake particularly from animal sources. A more complete nutritional assessment as well as a detailed dietary plan focusing not only on the control of protein but also on energy supply and on specific micronutrients is provided for patients on stages 4 or 5 of CKD. Practical approaches and tools used by the dietitians in our clinic for improving patient´s adherence to protein, sodium and potassium restriction while maintaining a healthy diet are described in detail in the sections of the article.

Effect of cholecalciferol on vitamin D-regulatory proteins in monocytes and on inflammatory markers in dialysis patients: A randomized controlled trial.

BACKGROUND & AIMS: Hypovitaminosis D and inflammation are highly prevalent among patients undergoing dialysis, and the association of both conditions with worse survival has been well recognized. Although a potential role for vitamin D in the immune system has been suggested, the effect of the treatment of hypovitaminosis D on the modulation of the inflammatory response remains unclear. The aim of this study was to investigate the effect of the restoration of the vitamin D status on the expression of vitamin D-regulatory proteins in monocytes and on circulating inflammatory markers in dialysis patients. METHODS: In this randomized double-blind placebo-controlled 12-week trial, 38 patients on dialysis with serum 25-hydroxyvitamin D [25(OH)D] <20 ng/mL were randomized either to the cholecalciferol group (n = 20; 50,000 IU of cholecalciferol twice weekly) or to the control group (n = 18; 50 drops of a placebo solution twice weekly). The expression of vitamin D receptor (VDR), CYP27B1, CYP24A1 and interleukin-6 (IL-6) in monocytes was determined by flow cytometry. Serum concentrations of 25(OH)D, interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α) and C-reactive protein (CRP) were measured. The trial is registered at ClinicalTrials.gov #NCT01974245. RESULTS: After 12 weeks, the serum 25(OH)D increased from 14.3 ± 4.7 ng/mL to 43.1 ± 11.0 ng/mL (p < 0.05) in the cholecalciferol group and did not change in the control group (13.9 ± 4.2 ng/mL to 13.5 ± 4.3 ng/mL; p = 0.56). In monocytes, while CYP27B1 expression and VDR expression increased in the cholecalciferol group (p < 0.05), CYP27B1 expression did not change, and VDR expression decreased in the control group (p < 0.05). There were no changes in IL-6 and CYP24A1 expression in both groups. Serum concentration of IL-6 and CRP decreased from 8.1 ± 6.6 pg/mL to 4.6 ± 4.1 pg/mL (p < 0.05) and from 0.50 (0.10-1.27) mg/dL to 0.28 (0.09-0.62) mg/dL (p < 0.05), respectively only in the cholecalciferol group. Assessed overtime, the treatment group differences in 25(OH) D, PTH, CRP and IL-6, CYP27B1 and VDR remained significant. CONCLUSIONS: Restoration of vitamin D status of patients undergoing dialysis promoted upregulation of CYP27B1 and VDR expression in monocytes and a decrease in circulating inflammatory markers.

Impact of hemodialysis session on handgrip strength.

INTRODUCTION: Handgrip strength (HGS) is a simple and reliable method with a good predictive clinical value for assessing muscle function of patients undergoing hemodialysis (HD). However, there is no consensus regarding the appropriate moment for performing the HGS measurement since the performance of the HGS can be influenced by fluid, electrolyte and blood pressure changes that affect patients on HD. OBJECTIVE: To investigate the impact of the dialysis session on the HGS in patients undergoing HD. METHODS: This is a cross-sectional study with 156 patients [57.7% male, median age of 56.5 (42-67) years old, 28.8% diabetes, mean BMI of 24.75 ± 4.5 kg/m2 and HD vintage of 38 (19.25 to 72.75) months]. Measures of HGS were performed with a dynamometer during the initial minutes of the HD session and at the end of the session. The values obtained were compared with a national standard reference. Clinical, demographic and laboratory data were collected from medical records. RESULTS: A significant reduction of HGS was observed after the HD session (28.6 ± 11.4 kg to 27.7 ± 11.7 kg; p < 0.01). The prevalence of patients with HGS below the 30th percentile increased from 44.9% to 55.1% (p < 0.01). The decrease in blood pressure during dialysis was the only factor associated with the reduction of HGS. CONCLUSION: These findings show that the HD procedure affects negatively the HGS.

Impacto da sessão de hemodiálise na força de preensão manual / Impact of hemodialysis session on handgrip strength

Resumo Introdução: A força de preensão manual (FPM) é um método simples, confiável e com bom valor preditivo para avaliar a função muscular de pacientes submetidos à hemodiálise (HD). Porém, ainda não existe um consenso a respeito do momento mais apropriado para a aferição da medida, já que o desempenho da FPM pode ser influenciado pelas flutuações hidroeletrolíticas e de pressão arterial que acometem esses pacientes. Objetivo: Investigar o impacto da sessão de diálise sobre a FPM em pacientes submetidos à HD. Métodos: Trata-se de um estudo transversal com 156 pacientes [57,7% homens, idade mediana de 56,5 (42-67) anos, 28,8% diabéticos, IMC médio de 24,75 ± 4,5 kg/m2 e tempo em HD de 38 (19,25-72,75) meses]. Foram realizadas aferições da FPM com um dinamômetro nos minutos iniciais e ao término da sessão de HD. Os valores obtidos foram comparados com um padrão de referência nacional. Dados clínicos, demográficos e laboratoriais foram coletados do prontuário médico. Resultados: Foi observada uma redução significante da FPM após a sessão de HD (28,6 ± 11,4 kg para 27,7 ± 11,7 kg; p < 0,01). A prevalência de pacientes com FPM abaixo do percentil 30 aumentou de 44,9% para 55,1% (p < 0,01). A redução da pressão arterial durante a diálise foi o único fator que se associou com a redução da FPM. Conclusão: Os achados mostram que o processo de HD influencia negativamente a FPM.

Abstract Introduction: Handgrip strength (HGS) is a simple and reliable method with a good predictive clinical value for assessing muscle function of patients undergoing hemodialysis (HD). However, there is no consensus regarding the appropriate moment for performing the HGS measurement since the performance of the HGS can be influenced by fluid, electrolyte and blood pressure changes that affect patients on HD. Objective: To investigate the impact of the dialysis session on the HGS in patients undergoing HD. Methods: This is a cross-sectional study with 156 patients [57.7% male, median age of 56.5 (42-67) years old, 28.8% diabetes, mean BMI of 24.75 ± 4.5 kg/m2 and HD vintage of 38 (19.25 to 72.75) months]. Measures of HGS were performed with a dynamometer during the initial minutes of the HD session and at the end of the session. The values obtained were compared with a national standard reference. Clinical, demographic and laboratory data were collected from medical records. Results: A significant reduction of HGS was observed after the HD session (28.6 ± 11.4 kg to 27.7 ± 11.7 kg; p < 0.01). The prevalence of patients with HGS below the 30th percentile increased from 44.9% to 55.1% (p < 0.01). The decrease in blood pressure during dialysis was the only factor associated with the reduction of HGS. Conclusion: These findings show that the HD procedure affects negatively the HGS.

Sarcopenia in chronic kidney disease on conservative therapy: prevalence and association with mortality.

BACKGROUND: In chronic kidney disease (CKD), multiple metabolic and nutritional abnormalities contribute to the impairment of skeletal muscle mass and function thus predisposing patients to the condition of sarcopenia. Herein, we investigated the prevalence and mortality predictive power of sarcopenia, defined by three different methods, in non-dialysis-dependent (NDD) CKD patients. METHODS: We evaluated 287 NDD-CKD patients in stages 3-5 [59.9 ± 10.5 years; 62% men; 49% diabetics; glomerular filtration rate (GFR) 25.0 ± 15.8 mL/min/1.73 m(2)]. Sarcopenia was defined as reduced muscle function assessed by handgrip strength (HGS <30th percentile of a population-based reference adjusted for sex and age) plus diminished muscle mass assessed by three different methods: (i) midarm muscle circumference (MAMC) <90% of reference value (A), (ii) muscle wasting by subjective global assessment (B) and (iii) reduced skeletal muscle mass index (<10.76 kg/m² men; <6.76 kg/m² women) estimated by bioelectrical impedance analysis (BIA) (C). Patients were followed for up to 40 months for all-cause mortality, and there was no loss of follow-up. RESULTS: The prevalence of sarcopenia was 9.8% (A), 9.4% (B) and 5.9% (C). The kappa agreement between the methods were 0.69 (A versus B), 0.49 (A versus C) and 0.46 (B versus C). During follow-up, 51 patients (18%) died, and the frequency of sarcopenia was significantly higher among non-survivors. In crude Cox analysis, sarcopenia diagnosed by the three methods was associated with a higher hazard for mortality; however, only sarcopenia diagnosed by method C remained as a predictor of mortality after multivariate adjustment. CONCLUSIONS: The prevalence of sarcopenia in CKD patients on conservative therapy varies according to the method applied. Sarcopenia defined as reduced handgrip strength and low skeletal muscle mass index estimated by BIA was an independent predictor of mortality in these patients.

Impact of home-based aerobic exercise on the physical capacity of overweight patients with chronic kidney disease.

BACKGROUND: Home-based exercise has been shown to provide benefits in terms of physical capacity in the general population, but has been scarcely investigated in patients with chronic kidney disease (CKD). AIMS: To evaluate the impact of a home-based aerobic training on the cardiopulmonary and functional capacities of overweight non-dialysis-dependent patients with CKD (NDD-CKD). METHODS: Twenty-nine sedentary patients (55.1 ± 11.6 years, BMI = 31.2 ± 6.1 kg/m(2), eGFR = 26.9 ± 17.4 mL/min/1.73 m(2)) were randomly assigned to a home-based exercise group (n = 14) or to a control group (n = 15) that remained without performing exercise. Aerobic training was performed three times per week for 12 weeks. A cardiopulmonary exercise test, functional capacity and clinical parameters were evaluated. RESULTS: A significant increase, ranging from 8.3 to 17 %, was observed in the cardiopulmonary capacity parameters, such as maximal ventilation (p = 0.005), VO2peak (p = 0.049), ventilatory threshold (p = 0.040) and respiratory compensation point (p < 0.001), of the exercise group. A simultaneous improvement in the functional capacity tests [6-min walk test (p < 0.001), time up and go test (p < 0.001), arm curl test (p < 0.001), sit and stand test (p < 0.001), 2-min step test (p < 0.001) and back scratch test (p = 0.042)] was also found in patients who were submitted to the exercise. Exercised patients experienced a decrease in systolic and diastolic blood pressure, average 10.6 % (p < 0.001) and 9.2 % (p = 0.007), respectively, and a trend toward improved renal function (p = 0.1). No change in any parameter was found in the control group during the follow-up. CONCLUSION: The home-based aerobic exercise program was feasible, safe and effective for the improvement in the cardiopulmonary and functional capacities of overweight NDD-CKD patients.

Diagnostic validation and prognostic significance of the Malnutrition-Inflammation Score in nondialyzed chronic kidney disease patients.

BACKGROUND: Malnutrition and inflammation are highly prevalent and intimately linked conditions in chronic kidney disease (CKD) patients that lead to a state of protein-energy wasting (PEW), the severity of which can be assessed by the Malnutrition-Inflammation Score (MIS). Here, we applied MIS and validated, for the first time, its ability to grade PEW and predict mortality in nondialyzed CKD patients. METHODS: We cross-sectionally evaluated 300 CKD stages 3-5 patients [median age 61 (53-68) years; estimated glomerular filtration rate 18 (12-27) mL/min/1.73 m(2); 63% men] referred for the first time to our center. Patients were followed during a median 30 (18-37) months for all-cause mortality. RESULTS: A worsening in MIS scale was associated with inflammatory biomarkers increase (i.e. alpha-1 acid glycoprotein, fibrinogen, ferritin and C-reactive protein) as well as a progressive deterioration in various MIS-independent indicators of nutritional status based on anthropometrics, dynamometry, urea kinetics and bioelectric impedance analysis. A structural equation model with two latent variables (assessing simultaneously malnutrition and inflammation factors) demonstrated good fit to the observed data. During a follow-up, 71 deaths were recorded; patients with higher MIS were at increased mortality risk in both crude and adjusted Cox models. CONCLUSIONS: MIS appears to be a useful tool to assess PEW in nondialyzed CKD patients. In addition, MIS identified patients at increased mortality risk.

Pericardial fat is associated with coronary artery calcification in non-dialysis dependent chronic kidney disease patients.

Pericardial fat (PF) a component of visceral adipose tissue has been consistently related to coronary atherosclerosis in the general population. This study evaluated the association between PF and coronary artery calcification (CAC) in non-dialysis dependent chronic kidney disease (CKD) patients. This is a post-hoc cross sectional analysis of the baseline of a prospective cohort of 117 outward CKD patients without manifest coronary artery disease (age, 56.9 ± 11.0 years, 64.1% males, 95.1% hypertensives, 25.2% diabetics, 15.5% ever smokers, CKD stage 2 to 5 with estimated glomerular filtration rate 36.8 ± 18.1 ml/min). CAC scores, PF volume and abdominal visceral fat (AVF) areas were measured by computed tomography. The association of PF as a continuous variable with the presence of CAC was analyzed by multivariate logistic regression. CAC (calcium score > 0) was present in 59.2% patients. Those presenting CAC were on average 10 years older, had a higher proportion of male gender (78.7% vs. 42.9%, p < 0.001), and had higher values of waist circumference (95.9 ± 10.7 vs. 90.2 ± 13.2 cm, p = 0.02), PF volumes (224.8 ± 107.6 vs. 139.1 ± 85.0 cm3, p<0.01) and AVF areas (109.2 ± 81.5 vs. 70.2 ± 62.9 cm2, p = 0.01). In the multivariate analysis, adjusting for age, gender, diabetes, smoking and, left ventricular concentric hypertrophy, PF was significantly associated with the presence of CAC (OR: 1.88 95% CI: 1.03-3.43 per standard deviation). PF remained associated with CAC even with additional adjustments for estimated glomerular filtration rate or serum phosphorus (OR: 1.85 95% CI: 1.00-3.42, p = 0.05). PF is independently associated with CAC in non-dialysis dependent CKD patients.