Journal of Renal Nutrition

Adductor Pollicis Muscle Thickness: A Promising Anthropometric Parameter for Patients With Chronic Renal Failure

2011-11-04

Introduction: Protein-calorie malnutrition is a prevalent disorder in chronic renal failure (CRF) and a major risk factor for increased mortality in hemodialysis (HD) patients. Although many methods have been used to assess malnutrition in CRF, the role of adductor pollicis muscle thickness (APMt) is not established yet.Aims: This study aimed to analyze the APMt in HD patients and to investigate the correlation between APMt and conventional anthropometric, laboratory, and bioelectrical impedance markers, as well as its association with mortality/morbidity in a period of 12 months of follow-up.Subjects and Methods: The study included 143 HD patients from a single facility. After dialysis, the dry weight, height, mid-arm circumference, triceps skinfold thickness, and APMt were measured. Subsequently, the body mass index, percentage of standard body weight, the mid-arm muscle circumference, and the mid-arm muscle area were calculated. Blood counts were performed for hemoglobin, creatinine, and albumin. Patients were also submitted to a single-frequency tetrapolar bioimpedance test for measuring resistance, reactance, phase angle, and percentage of body cell mass. The correlation between APMt and anthropometric, laboratory, and bioelectrical impedance parameters was calculated using Pearson’s linear correlation. Multiple linear regression analysis was used to select independent risk factors to death and hospitalizations in 6 and 12 months of follow-up, among parameters selected by univariate analysis.Results: Patients were aged 52.2 ± 16.6 years (20 to 83 years) on average, 58% were men, and mean dialysis vintage was 5.27 ± 5.12 years. APMt was 11.85 ± 1.63 mm (men, 12.34 ± 1.53; women, 11.19 ± 1.51; P < .0001). APMt was positively correlated with body mass index (r = 0.37; P < .0001), mid-arm circumference (r = 0.437; P < .0001), mid-arm muscle circumference (r = 0.494; P < .0001), mid-arm muscle area (r = 0.449; P < .0001), percentage of standard body weight (r = 0.355; P = .000), creatinine (r = 0.230; P = .006), albumin (r = 0.207; P = .013), percentage of body cell mass (r = 0.293; P = .000), and phase angle (r = 0.402; P < .0001), and negatively correlated with resistance (r = −0.403; P < .0001). The APMt ≤10.6 mm was associated with a 3.3 times greater risk of hospitalization within 6 months of follow-up (OR = 3.3, 95% CI: 1.13 to 9.66; P = .029) compared with patients with an APMt >10.6 mm. The APMt was not associated with risk of death at 6 and 12 months or hospitalization within 12 months of follow-up.Conclusion: This is the first study testing APMt as an anthropometric marker in HD patients. The parameter is easy to measure and does not seem to be significantly affected by variations in hydration status. The parameter was significantly correlated with markers reflecting the condition of the muscle compartment, but not with parameters estimating the fat mass. The determination of an APMt cutoff point for malnutrition in patients with CRF and its correlation with morbidity and mortality will require further investigation in clinical studies.

Examining Associations of Circulating Endotoxin With Nutritional Status, Inflammation, and Mortality in Hemodialysis Patients

2011-09-01

Objective: Lipopolysaccharide or endotoxin constitutes most part of the outer portion of the cell wall in the gram-negative bacteria. Subclinical endotoxemia could contribute to increased inflammation and mortality in hemodialysis (HD) patients. Endotoxin level and clinical effect are determined by its soluble receptor sCD14 and high-density lipoprotein. We examine the hypothesis that endotoxin level correlates with mortality.Methods: In this cohort study, endotoxin levels were measured in 306 long-term HD patients who were then followed up for a maximum of 42 months. Soluble CD14 and cytokines levels were also measured.Results: The mean (±SD) endotoxin level was 2.31 ± 3.10 EU/mL (minimum: 0.26 EU/mL, maximum: 22.94 EU/mL, interquartile range: 1.33 EU/mL, median: 1.27 EU/mL). Endotoxin correlated with C-reactive protein (r = 0.11, P < .04). On multivariate logistic regression analysis, high body mass index and low high-density lipoprotein (HDL) cholesterol levels were associated with higher endotoxemia (endotoxin below or above of median). In multivariate Cox regression analysis adjusted for case-mix and nutritional/inflammatory confounders, endotoxin levels in the third quartile versus first quartile were associated with a trend toward increased hazard ratio for death (hazard ratio: 1.83, 95% confidence interval: 0.93 to 3.6, P = .08).Conclusions: In this HD cohort, we found associations between endotoxemia and C-reactive protein, body composition, and HDL. Moderately high endotoxin levels tended to correlate with increased mortality than the highest circulating endotoxin level. Additional studies are required to assess the effect of endotoxemia on mortality in dialysis population.

Gastrointestinal Symptoms and Nutritional Status in Women and Men on Maintenance Hemodialysis

2011-11-10

Objective: The main objective was to investigate whether the prevalences of nausea, vomiting, diarrhea, and reduced appetite varied by gender in maintenance hemodialysis (MHD) patients. We also evaluated whether these symptoms explain female–male difference in nutritional status.Design: Cross section of baseline data of the Prospective Study of the Prognosis in Chronic Hemodialysis Patients.Setting: Dialysis units in the city of Salvador, Brazil.Patients: Three hundred ninety-seven men and 287 women with more than three months on MHD.Predictor Variable: Gender.Outcome Measures: The patient’s self-reported nausea, vomiting, diarrhea, and reduced appetite. The malnutrition–inflammation score (MIS) was used to assess nutritional status.Results: The prevalence of symptoms was 24.3% for reduced appetite, 19.7% for nausea, 12.3% for vomiting, and 3.5% for diarrhea. In a logistic regression model with adjustments for age, diabetes, congestive heart failure, hemoglobin, albumin, Kt/V, and years on dialysis, women were found to have significantly higher odds of reduced appetite (odds ratio [OR] = 1.97), nausea (OR = 1.90), and vomiting (OR = 2.21). MIS was 5.41 ± 3.18 for women and 4.66 ± 3.28 for men (P = .002) corresponding to a percentage difference of 13.86%. The female-male difference reduced by more than half after excluding the gastrointestinal symptoms component and by approximately 65% after excluding both the gastrointestinal symptoms and the dietary intake components from the MIS.Conclusions: The results suggest that the prevalences of nausea, vomiting, and reduced appetite are higher in women than in men on MHD. These gastrointestinal symptoms and perhaps their detrimental effects on dietary intake may partially explain a poorer nutritional status in MHD women.

Protective and Therapeutic Effects of Licorice in Rats With Acute Tubular Necrosis

2011-11-02

Objectives: Various protective and therapeutic effects such as antioxidant, anti-inflammatory, anticancer, antihistaminic, and antibacterial effects have been depicted for licorice. However, its biological effects in the kidney are still not clear. Therefore, we aimed to investigate the efficiency of licorice in rats with gentamicin (GM)-induced acute tubular necrosis.Design and Methods: Rats were randomized into the control group (only saline for 12 days), licorice group (licorice for 12 days), GM group (GM for 12 days), GM + licorice group, and licorice-treated GM group (licorice for 12 days after taking GM for 12 days). Blood urea, creatinine, and uric acid levels were measured and histopathological analyses of the kidneys were performed. The oxidative side of oxidant-antioxidant balance was evaluated by detecting lipid peroxidation (LPO) and total peroxide levels, and antioxidative side was determined by measuring total antioxidant capacity (TAC) and reduced glutathione (GSH) levels in plasma and kidney tissues.Results: The oxidant-antioxidant balance seemed to be shifted to the oxidative side in the GM group when compared with the control and GM + licorice groups. In GM group, biochemical profiles showed a remarkable increase in blood uric acid, urea, and creatinine levels, and depletion of renal tissue and plasma TAC and GSH levels. In addition, histopathologic studies revealed severe acute tubular necrosis, congestion, and hyaline casts, verifying GM-induced nephrotoxicity. Licorice was effective in reduction of blood urea, creatinine, and uric acid levels, and also effective in decreasing the tubular necrosis score. Licorice treatment also significantly reduced LPO and total peroxide levels, and increased TAC and GSH levels in both renal tissue and blood. Moreover, these changes in rats subjected to the combined therapy (GM + licorice) were significantly less than those of GM group.Conclusions: Licorice ameliorates GM-induced nephrotoxicity and oxidative damage by scavenging oxygen free radicals, decreasing LPO, and improving antioxidant defense.

Differences among Total and In Vitro Digestible Phosphorus Content of Meat and Milk Products

Heini Karp, Päivi Ekholm, Virpi Kemi, Tero Hirvonen, Christel Lamberg-Allardt — 2011-10-07

Objective: Meat and milk products are important sources of dietary phosphorus (P) and protein. The use of P additives is common both in processed cheese and meat products. Measurement of in vitro digestible phosphorus (DP) content of foods may reflect absorbability of P. The objective of this study was to measure both total phosphorus (TP) and DP contents of selected meat and milk products and to compare amounts of TP and DP and the proportion of DP to TP among different foods.Methods: TP and DP contents of 21 meat and milk products were measured by inductively coupled plasma optical emission spectrometry (ICP-OES). In DP analysis, samples were digested enzymatically, in principle, in the same way as in the alimentary canal before the analyses. The most popular national brands of meat and milk products were chosen for analysis.Results: The highest TP and DP contents were found in processed and hard cheeses; the lowest, in milk and cottage cheese. TP and DP contents in sausages and cold cuts were lower than those in cheeses. Chicken, pork, beef, and rainbow trout contained similar amounts of TP, but slightly more variation was found in their DP contents.Conclusions: Foods containing P additives have a high content of DP. Our study confirms that cottage cheese and unenhanced meats are better choices than processed or hard cheeses, sausages, and cold cuts for chronic kidney disease patients, based on their lower P-to-protein ratios and sodium contents. The results support previous findings of better P absorbability in foods of animal origin than in, for example, legumes.

Association Between Circulating Electronegative Low-Density Lipoproteins and Serum Ferritin in Hemodialysis Patients: A Pilot Study

2011-07-11

Background: Iron supplementation is a common recommendation to chronic kidney disease patients undergoing hemodialysis (HD). However, iron excess is closely associated with lipid peroxidation and, it is well known that electronegative low-density lipoproteins (LDL[−]) are present at higher plasma concentrations in diseases with high cardiovascular risk such as chronic kidney disease. Thus, the aim of this study was to investigate whether ferritin levels are associated with LDL(−) levels in HD patients.Design: This was a cross-sectional study.Setting: This study was conducted from a private clinic in Rio de Janeiro, Brazil.Patients: The study included 27 HD patients and 15 healthy subjects.Methods and Procedures: Twenty-seven HD patients (14 men, 58.6 ± 10 years, 62.2 ± 51.4 months on dialysis, and body mass index: 24.4 ± 4.2 kg/m2) were studied and compared with 15 healthy individuals (6 men, 53.8 ± 15.4 years, body mass index: 24.5 ± 4.3 kg/m2). Serum LDL(−) levels were measured using the enzyme-linked immunosorbent assay method; ferritin levels by commercially available kits, and tumor necrosis factor-α, interleukin-6, monocyte chemoattractant protein-1, and plasminogen activator inhibitor-1 were determined with a multiplex assay kit manufactured by R&D Systems.Results: The HD patients presented higher LDL(−) and tumor necrosis factor-α levels (0.15 ± 0.13 U/L and 5.9 ± 2.3 pg/mL, respectively) than healthy subjects (0.07 ± 0.05 U/L and 2.3 ± 1.3 pg/mL, respectively) (P = .0001). The mean ferritin level in HD patients was 1,117.5 ± 610.4 ng/mL, and 90% of patients showed ferritin levels exceeding 500 ng/mL. We found a positive correlation between LDL(−) and ferritin in the patients (r = 0.48; P = .01), and ferritin was a significant contributor to LDL(−) concentrations independent of inflammation.Conclusions: Excess body iron stores for HD patients was associated with signs of increased oxidative stress, as reflected by increased LDL(−) levels in HD patients.

Effect of Hemodialysis and Diet on the Exhaled Breath Methanol Concentration in Patients With ESRD

Hyun Ji (Julie) Lee, Madeleine V. Pahl, Nosratola D. Vaziri, Donald R. Blake — 2011-11-21

Objectives: End-stage renal disease (ESRD) causes accumulation of nitrogenous waste products and acid-base, mineral, fluid, and electrolyte disorders, which are partially corrected by hemodialysis (HD). While the effects of ESRD and dialysis on body fluid composition are well known, the effects on composition of expired breath are uncertain. Methanol is produced from unabsorbable complex carbohydrates by the colonic microbiome. Dietary restrictions of fruits and vegetables aimed at limiting potassium intake lower the intake of dietary fibers; the reduced fiber intake can in turn reduce production of methanol and its appearance in the exhaled breath. In this study, we investigated the inter- and intradialytic changes in the breath methanol levels.Design and Method: Ten ESRD patients were studied during HD procedures at 3- and 2-day interdialytic intervals. On each occasion, 20 exhaled breath and room air samples were collected using evacuated canisters. Ten age-matched normal subjects served as controls. The samples were analyzed on a unique 6-column/detector gas chromatography system.Results: Seven ESRD patients consuming renal diet had lower methanol concentration (90 ± 29 ppbv) than the 3 patients consuming high-fiber diet (340 ± 48 ppbv, P ≤ .0006) and the 10 controls consuming unrestricted diets (202 ± 80 ppbv, P ≤ .001). HD significantly lowered breath methanol (60% ± 12%), paralleling the fall in serum urea concentration (70% ± 6%). The predialysis methanol concentration was slightly higher at 3-day than the 2-day interdialytic intervals.Conclusion: Dietary restriction of fruits and vegetables lowers methanol production by the gut microbial flora in ESRD patients. Perhaps, methanol is a reliable breath biomarker to monitor individuals’ daily fiber intake. Breath methanol is dramatically reduced by HD, reflecting its efficient removal.

A Difference Between Day and Night: Protein Intake Improves After the Transition From Conventional to Frequent Nocturnal Home Hemodialysis

2011-11-07

Background: Malnutrition is an important cause of the excessive morbidity and mortality rate of dialysis patients. Frequent nocturnal home hemodialysis (NHHD) has many benefits compared with conventional thrice-weekly hemodialysis (CHD), due to the virtual absence of dietary restrictions and a much higher overall dialysis efficiency. In this observational study, we investigated whether these benefits of NHHD translate into an improved nutritional intake, with a special emphasis on protein intake.Methods: We prospectively assessed the effect of the transition of CHD to NHHD on nutritional intake (5-day dietary intake journal), normalized protein catabolic rate, and anthropometric parameters in 15 consecutive patients who started NHHD in our center between 2004 and 2009 and completed at least 8 months of follow-up. Data were collected before the transition from CHD to NHHD and 4 and 8 months after the transition.Results: Protein intake, as measured by both dietary intake journal and normalized protein catabolic rate, increased significantly after the transition from CHD to NHHD. Accordingly, phosphate intake increased significantly; however, serum phosphate levels did not increase, despite negligible phosphate binder use during NHHD. Body mass index and upper arm muscle circumference did not change significantly.Conclusion: The transition from CHD to NHHD has a positive effect on nutritional intake, in particular, protein intake. NHHD should be considered in malnourished patients on CHD.

Vitamin C Affects the Expression of Hepcidin and Erythropoietin Receptor in HepG2 Cells

Ping-Fang Chiu, Shun-Yao Ko, Chia-Chu Chang — 2012-01-09

Backgrounds: Hepcidin modulates the de novo absorption of iron from the duodenum and the recycling of iron released from the reticuloendothelial system. In patients with chronic renal failure, administration of higher doses of erythropoietin (EPO) or vitamin C (Vit C) can correct the functional iron deficiency. While EPO-regulated hepcidin expression within hepatocytes has been recently identified, the relation between vitamin C with hepcidin expression is still uncertain.Methods: Hepcidin-producing HepG2 cells (a human liver carcinoma cell line) were cultured with 50- to 100-μg/mL vitamin C or 0.25- to 1.0-U/mL EPO for 6 hours. Reverse transcription polymerase chain reaction was performed for quantitative measurements of hepcidin, EPO, and EPO receptor (EPOR) expression.Results: EPO and vitamin C inhibited hepcidin expression within HepG2 cells; the EPO effect was dose dependent. EPO downregulated EPOR and vitamin C and upregulated EPOR. However, vitamin C had little effect on the expression of EPO.Conclusions: EPO is capable of downregulating EPOR when it acts early. Vitamin C directly inhibits hepcidin expression within HepG2 cells. Moreover, by enhancing EPOR production, vitamin C may correct the downregulating EPOR from EPO, which has additional effect with EPO in treating anemia.

A Milestone

Lisa Gutekunst — 2012-05-01

Today is January 31, 2012, and it marks a milestone in my life. Today, the Food and Drug Administration announced the approval of a drug that will treat the underlying cause of cystic fibrosis (CF). Although the medication, Kalydeco (ivacaftor, Vertex Pharmaceuticals Cambridge, MA), will treat only a handful of the estimated 30,000 people with the disease, this is the first milestone on the path to a cure. The treatment will be costly; the company that developed the medication, Vertex Pharmaceuticals, estimates it will cost approximately $300,000 a year to “cure” the disease. But I know first hand what the $300,000 will buy.

May Meeting Announcements

2012-05-01

May 9-13, 2012 National Kidney Foundation (NKF) Spring Clinical Meetings, Washington, DC. Visit www.kidney.org or call 800-622-9010. May 24-27, 2012 49th European Renal Association/European Dialysis and Transplant Association (ERA–EDTA) Congress, Paris, France. Visit www.era-edta.org or call +40-721-280246.

A Preliminary Report on the Functioning and Data Collection Capabilities of a Web-based Nutrition Algorithm for Patients With Chronic Kidney Disease

Rosa K. Hand, Janeen León, Lillian Cuppari, Alison Leah Steiber — 2011-08-12

Objective: The purpose of this study was to test the functional and data collection capabilities of an online nutrition algorithm for patients with chronic kidney disease by comparing dietitian-selected nutrition diagnoses, etiologies, and interventions in hemodialysis (HD) patients with and without diabetes mellitus (DM).Design: Data were collected using an online nutrition screening tool and algorithm for HD patients based on the American Dietetic Association’s Nutrition Care Process.Setting: Data were collected by dietitians in the United States, New Zealand, Australia, and Brazil.Patients: Patients undergoing HD under the care of a participating dietitian and who were deemed at nutrition risk at visit 1 were eligible to participate. Other inclusion criteria included age >19 years, able to speak and write English, and not receiving hospice care or the international equivalent. Data were available on 26 patients (50% males, 39% with DM). Mean baseline values were as follows: age, 56.3 years; body mass index, 28.2 kg/m2; and serum albumin (bromocresol green), 36.8 g/L (3.68 g/dL). There were no statistically significant differences between DM and non-DM patients except in mean hemoglobin A1C.Main Outcome Measure: Differences in the frequency of selection of diagnoses, etiology, and intervention categories were compared.Results: The algorithm is under continuous development using input from participating dietitians, but its use was generally considered feasible. The initial data analysis showed that the algorithm is an effective method for collecting data on HD patients. In this small cohort, patients with and without DM had similar dietitian-selected nutrition diagnoses and etiologies, but had statistically significant differences in the dietitian-selected nutrition interventions that were selected most frequently. Health Care Team Referral was selected more often in DM patients (P < .003) and Recommendation of Specific Foods was selected more often in non-DM patients (P < .0170).Conclusion: This preliminary analysis shows that the algorithm can be used as both a clinical and a data collection tool. The test analysis, although small in sample size, showed interesting differences in the care of DM and non-DM HD patients.

Nutrition Label Reading Tips for CKD Patients (English and Korean)

Haewook Han — 2012-05-01

Ask yourself how many servings are there per container? How many servings am I eating? Serving sizes are provided in familiar units like cups or pieces.

Choosing a Bread That Will Fit the Chronic Kidney Disease Diet: An Emphasis on Sodium and Phosphorus

Kristin Sheridan — 2012-05-01

There are many data showing blood pressure is aggravated by sodium, and if consumed in excess, lowering the intake of sodium may lower blood pressure. In dialysis patients, limiting sodium assists with controlling interdialysis weight gain and fluid control. Both Kidney Disease Outcomes Quality Initiative guidelines and the Dietary Guidelines for Americans, 2010 report the need for limiting dietary sodium intake. In fact, the Dietary Guidelines state the following:

Masthead

2012-05-01

Editorial Board

2012-05-01

Journal of Renal Nutrition

Adductor Pollicis Muscle Thickness: A Promising Anthropometric Parameter for Patients With Chronic Renal Failure

Examining Associations of Circulating Endotoxin With Nutritional Status, Inflammation, and Mortality in Hemodialysis Patients

Gastrointestinal Symptoms and Nutritional Status in Women and Men on Maintenance Hemodialysis

Protective and Therapeutic Effects of Licorice in Rats With Acute Tubular Necrosis

Differences among Total and In Vitro Digestible Phosphorus Content of Meat and Milk Products

Association Between Circulating Electronegative Low-Density Lipoproteins and Serum Ferritin in Hemodialysis Patients: A Pilot Study

Effect of Hemodialysis and Diet on the Exhaled Breath Methanol Concentration in Patients With ESRD

A Difference Between Day and Night: Protein Intake Improves After the Transition From Conventional to Frequent Nocturnal Home Hemodialysis

Vitamin C Affects the Expression of Hepcidin and Erythropoietin Receptor in HepG2 Cells

A Milestone

May Meeting Announcements

A Preliminary Report on the Functioning and Data Collection Capabilities of a Web-based Nutrition Algorithm for Patients With Chronic Kidney Disease

Nutrition Label Reading Tips for CKD Patients (English and Korean)

Choosing a Bread That Will Fit the Chronic Kidney Disease Diet: An Emphasis on Sodium and Phosphorus

Masthead

Editorial Board

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