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.

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)

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.

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.

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.

Diagnostic validation and prognostic significance ofthe Malnutrition-Inflammation Score in nondialyzed chronickidney disease patients

Malnutrition and inflammation are highlyprevalent and intimately linked conditions in chronic kidneydisease (CKD) patients that lead to a state of protein-energywasting (PEW), the severity of which can be assessed by theMalnutrition-Inflammation Score (MIS). Here, we appliedMIS and validated, for the first time, its ability to grade PEWand predict mortality in nondialyzed CKD patients.Methods. We cross-sectionally evaluated 300 CKD stages 3–5patients [median age 61 (53–68) years; estimated glomerularfiltration rate 18 (12–27) mL/min/1.73 m2; 63% men] referredfor the first time to our center. Patients were followed during amedian 30 (18–37) months for all-cause mortality.Results. A worsening in MIS scale was associated withinflammatory biomarkers increase (i.e. alpha-1 acidglycoprotein, fibrinogen, ferritin and C-reactive protein) aswell as a progressive deterioration in various MIS-independentindicators of nutritional status based on anthropometrics, dynamometry,urea kinetics and bioelectric impedance analysis.A structural equation model with two latent variables (assessingsimultaneously malnutrition and inflammation factors)demonstrated good fit to the observed data. During a followup,71 deaths were recorded; patients with higher MIS were atincreased mortality risk in both crude and adjusted Coxmodels.Conclusions. MIS appears to be a useful tool to assess PEW innondialyzed CKD patients. In addition, MIS identified patientsat increased mortality risk.

Malnutrition-inflammation score is associated with handgrip strength in nondialysis-dependent chronic kidney disease patients.

OBJECTIVE: The malnutrition-inflammation score (MIS) is a nutritional scoring system that has been associated with muscle strength among dialysis patients. We aimed to test whether MIS is able to predict muscle strength in nondialysis-dependent chronic kidney disease (NDD-CKD) individuals. DESIGN AND METHODS: This was a cross-sectional study conducted at the Dante Pazzanese Institute of Cardiology, Hypertension, and Nephrology Division outpatient clinic. We evaluated 190 patients with NDD-CKD stages 2-5 (median 59.5 [interquartile range 51.4-66.9] years; 64% men). MIS was calculated without computing dialysis vintage to the scoring. HGS was assessed in the dominant arm. Anthropometric, laboratory, and body composition parameters were recorded. RESULTS: A strong negative correlation was found between HGS and MIS (r = -0.42; P ≤ .001) in univariate analysis. In multivariate regressions, adjustment for age, sex, diabetes, glomerular filtration rate, body cell mass, and C-reactive protein did not materially diminish these relationships. CONCLUSIONS: MIS shares strong links with objective measures of muscle strength in NDD-CKD patients.

Malnutrition-Inflammation Score is Associated With Handgrip Strength in Nondialysis-Dependent Chronic Kidney Disease Patients

Objective: The malnutrition-inflammation score (MIS) is a nutritional scoring system that has been associated with muscle strengthamong dialysis patients. We aimed to test whether MIS is able to predict muscle strength in nondialysis-dependent chronic kidney disease(NDD-CKD) individuals.Design and Methods: This was a cross-sectional study conducted at the Dante Pazzanese Institute of Cardiology, Hypertension, andNephrology Division outpatient clinic. We evaluated 190 patients with NDD-CKD stages 2-5 (median 59.5 [interquartile range 51.4-66.9]years; 64% men). MIS was calculated without computing dialysis vintage to the scoring. HGS was assessed in the dominant arm. Anthropometric,laboratory, and body composition parameters were recorded.Results: A strong negative correlation was found between HGS and MIS (r520.42; P # .001) in univariate analysis. In multivariateregressions, adjustment for age, sex, diabetes, glomerular filtration rate, body cell mass, and C-reactive protein did not materially diminishthese relationships.Conclusions: MIS shares strong links with objective measures of muscle strength in NDD-CKD patients.

Are prediction equations reliable for estimating resting energy expenditure in chronic kidney disease patients?

BACKGROUND: The determination of resting energy expenditure (REE) is the primary step for estimating the energy requirement of an individual. Although numerous equations have been formulated for predicting metabolic rates, there is a lack of studies addressing the reliability of those equations in chronic kidney disease (CKD). Thus, the aim of this study was to evaluate whether the main equations developed for estimating REE can be reliably applied for CKD patients. METHODS: A total of 281 CKD patients (124 non-dialysis, 99 haemodialysis and 58 peritoneal dialysis) and 81 healthy control individuals were recruited. Indirect calorimetry and blood sample collection were performed after a 12-h fasting. Two most traditionally used equations for estimating REE were chosen for comparison with the REE measured by indirect calorimetry: (i) the equation proposed by Harris and Benedict, and (ii) the equation proposed by Schofield that is currently recommended by the FAO/WHO/UNU. RESULTS: Schofield's equation exhibited higher REE [1492±220 kcal/day (mean±SD)] in relation to Harris and Benedict's equation (1431±214 kcal/day; P<0.001), and both prediction equations showed higher REE in comparison with the reference indirect calorimetry (1352±252 kcal/day; P<0.001). In patients with diabetes, inflammation or severe hyperparathyroidism, the REE estimated by the Harris and Benedict equation was equivalent to that measured by indirect calorimetry. The intraclass correlation of the REE measured by indirect calorimetry with the Schofield's equation was r=0.48 (P<0.001) and with the Harris and Benedict's equation was r=0.58 (P<0.001). According to the Bland and Altman analysis, there was a large limit of agreement between both prediction equations and the reference method. Acceptable prediction of REE (90-110% adequacy) was found in 47% of the patients by using the Harris and Benedict's equation and in only 37% by using the Schofield's equation. CONCLUSIONS: The most traditionally used prediction equations overestimated the REE of CKD patients, and the errors were minimized in the presence of comorbidities. There is a need to develop population-specific equations in order to adequately estimate the energy requirement of these patients.

Prospective evaluation of waist circumference and visceral adipose tissue in patients with chronic kidney disease.

BACKGROUND: Waist circumference (WC), a simple anthropometric measure, is associated with visceral adipose tissue (VAT) in cross-sectional studies, and thus has been used as a surrogate marker for VAT. However, associations between changes over time in WC and VAT have not been studied in chronic kidney disease (CKD) patients. METHODS: This prospective study included 87 nondialysis-dependent CKD patients (54 males, 56.2 +/- 10.4 years, BMI 27.3 +/- 5.1, GFR 35.9 +/- 14.6 ml/min/1.73 m(2)). VAT area was measured by computed tomography (CT) and WC was measured at the umbilicus level at baseline and after 12 months. RESULTS: Changes in WC correlated significantly but weakly with changes in VAT (r = 0.26, p = 0.016), likely due to a substantially smaller change in WC compared to changes in VAT. This was also reflected by a kappa coefficient of 0.26, i.e. indicative of poor agreement between WC and CT measurements in regards to quantification of changes in VAT. Likewise, the receiver operating characteristic curve analysis identified WC as poor predictor of changes in VAT (area under the curve = 0.62). CONCLUSION: Anthropometric measurement of WC is poorly correlated with changes in VAT measured by CT in nondialysis-dependent CKD patients. Therefore, caution should be taken when using WC as a surrogate marker of VAT changes in this population.

Waist circumference and visceral fat in CKD: a cross-sectional study.

BACKGROUND: In the general population, waist circumference was noted to be a reliable predictor of visceral fat. In addition, increased waist circumference was strongly associated with risk factors for cardiovascular disease. In patients with chronic kidney disease (CKD), the association of waist circumference with visceral fat was never tested. STUDY DESIGN: Cross-sectional study. SETTING & PARTICIPANTS: 122 patients with CKD not yet on dialysis therapy (75 men; diabetes mellitus, 30%; age, 55.3 +/- 11.3 years; body mass index, 27.1 +/- 5.2 kg/m(2); estimated glomerular filtration rate, 35.4 +/- 15.2 mL/min/1.73 m(2)) were studied. PREDICTOR: Waist circumference. OUTCOMES & MEASUREMENTS: Anthropometry, abdominal visceral fat measured by means of computed tomography, and cardiovascular disease risk factors. RESULTS: Waist circumference strongly correlated with visceral fat (r = 0.75 for men, r = 0.81 for women; P < 0.01). kappa Statistic was 0.56, indicating relatively good agreement between methods. Body mass index showed a lower correlation coefficient (r = 0.68 for men, r = 0.76 for women; P < 0.01) and poor agreement (0.36) with visceral fat in comparison to waist circumference. In men, waist circumference and visceral fat similarly correlated with high-density lipoprotein cholesterol level, triacylglycerol level, and Homeostasis Model Assessment Index (P < 0.05). In women, waist circumference correlated with age, C-reactive protein level, and Homeostasis Model Assessment Index, whereas visceral fat also correlated with low-density lipoprotein cholesterol and triacylglycerol levels (P < 0.05). LIMITATIONS: Findings are restricted to patients with CKD not yet on dialysis therapy from a single center. CONCLUSIONS: Waist circumference was strongly associated with visceral fat in patients with CKD. Associations between waist circumference and cardiovascular disease risk factors were similar to those observed for visceral fat, particularly in men. These findings suggest that waist circumference may be a simple and inexpensive tool to be used in epidemiological studies.

Serum and cellular interleukin-6 in haemodialysis patients: relationship with energy expenditure.

BACKGROUND: Inflammation is a highly prevalent condition among end-stage renal disease (ESRD) patients and it has been implicated with several metabolic derangements. Considering the harmful effect of hypermetabolism on nutritional status and clinical outcomes of ESRD patients, we aimed to investigate the relationship between proinflammatory cytokine interleukin-6 (IL-6) and energy expenditure in this population. METHODS: This cross-sectional study enrolled 80 adult haemodialysis patients for the evaluation of serum IL-6 and energy expenditure. The production of IL-6 by peripheral blood mononuclear cells (PBMCs) (spontaneous and endotoxin-stimulated production) was examined in a subgroup of 30 haemodialysis patients and in 11 healthy control subjects. IL-6 was measured by immunoenzymatic assay. The resting energy expenditure was evaluated by means of indirect calorimetry. Body composition was assessed by bioelectrical impedance analysis and skinfold thicknesses. RESULTS: Serum IL-6 [6.3 (2.2-163.5) pg/ml] correlated positively with age (R = 0.26; P = 0.02) and C-reactive protein (R = 0.31; P < 0.01). Resting energy expenditure correlated positively with lean body mass (R = 0.68; P < 0.001) and BMI (R = 0.44; P < 0.001), and negatively with Kt/V (R = -0.37; P < 0.01). In the multivariate analysis, controlling for age and lean body mass, serum IL-6 was positively associated with resting energy expenditure (n = 80; beta = 2.4; P = 0.01). The production of IL-6 by PBMCs did not reach statistically significant differences between patients and controls [spontaneous production 6541 (96-7739) pg/ml vs 3410 (50-7806) pg/ml, respectively; and stimulated production 6530 (579-7671) pg/ml vs 5304 (1527-7670) pg/ml, respectively]. IL-6 secreted by monocytes showed no association with either serum IL-6 or resting energy expenditure. CONCLUSION: Serum IL-6 was associated with an increase of energy expenditure in haemodialysis patients.

Resting energy expenditure in peritoneal dialysis patients.

OBJECTIVES: This study aimed to evaluate whether resting energy expenditure (REE) of patients undergoing peritoneal dialysis (PD) therapy differs from that of healthy individuals, as well as to investigate the factors associated with REE in this sample of patients. DESIGN: Cross-sectional study. SETTING: Dialysis Unit of the Nephrology Division, Federal University of Sao Paulo-Oswaldo Ramos Foundation, Brazil. SUBJECTS AND METHODS: The study examined the REE of 37 patients (20 males, age 44.5 +/- 13 years) undergoing PD therapy. Only patients older than 18 years, on PD for at least 3 months, without catabolic illness, and with normal thyroid function were included. Patients were pair matched for age and gender with 37 healthy individuals. REE was measured by indirect calorimetry. Body composition was assessed by dual-energy x-ray absorptiometry in the patients and by bioelectrical impedance in the healthy individuals. RESULTS: The REE of PD patients was similar to that of pair-matched controls (1372 +/- 266 and 1453 +/- 252 kcal/day respectively, p = 0.13) even when adjusted for lean body mass and gender (p = 0.56). The REE of PD patients was positively correlated with lean body mass (r = 0.60, p < 0.01), fat mass (r = 0.43, p < 0.01), body mass index (r = 0.60, p < 0.01), serum glucose (r = 0.36, p < 0.05), and protein equivalent of nitrogen appearance (PNA; r = 0.42, p < 0.01). There were no correlations between REE and glucose absorption, dialysis-related parameters, C-reactive protein, and energy or protein intake by 3-day food diary. In the multiple linear regression analysis, using REE as the dependent variable, the final model showed that lean body mass and female gender were determinants of REE in PD patients (R(2) = 0.44). When separate analysis by gender was performed, REE correlated directly with body fat in female patients (r = 0.70, p < 0.01) but not in male patients (r = 0.29, p = 0.21). On the other hand, lean body mass was significantly correlated with REE in male patients (r = 0.78, p < 0.01) but not in female patients (r = 0.47, p = 0.06). CONCLUSIONS: This study showed that REE of PD patients did not differ from that of healthy individuals. The strong association between body fat and REE in female patients remains to be further investigated.

Inflammation is associated with increased energy expenditure in patients with chronic kidney disease.

BACKGROUND: Inflammation, a clinical condition observed in patients with chronic kidney disease (CKD), may be related to increased resting energy expenditure (REE). OBJECTIVES: The main objective was to investigate the relation between inflammation and REE in patients with CKD who are not undergoing dialysis. We also aimed to analyze whether a decrease in C-reactive protein (CRP) would result in a reduction in REE. DESIGN: This study enrolled 132 patients with CKD who were not undergoing dialysis, who had creatinine clearance from 5 to 65 mL.min(-1).1.73 m(-2), and who were 53.6 +/- 16 y old; 82 (62.1%) were men. Twenty-nine patients had clinical signs of infection. REE was measured by using indirect calorimetry, and inflammation was evaluated by using high-sensitivity CRP measurement. Patients were divided according to tertiles of CRP with the following intertertile ranges: first tertile, CRP < or = 0.14 mg/dL (n = 43); second tertile, CRP 0.15-0.59 mg/dL (n = 46); and third tertile, CRP > or = 0.60 mg/dL (n = 43). REE was measured before and after treatment in 10 patients who had inflammation or infection. RESULTS: After adjustment for age, sex, and lean body mass, the REE of the third (1395 kcal/d; P = 0.02) and second (1355 kcal/d; P = 0.04) tertiles was significantly higher than that of the first tertile (1286 kcal/d). In the multiple linear regression analysis (n = 132), the independent determinants of REE were lean body mass, CRP, and age (R2 = 0.55). After treatment of infection in a subgroup of 10 patients, it was observed that a significant reduction in CRP concentration was accompanied by a significant reduction of 174 +/- 165 kcal that accounted for 13% of the initial REE. CONCLUSION: This study showed that inflammation is associated with increased REE in patients with CKD.