DIALYSIS. PROTEIN-ENERGY WASTING, INFLAMMATION AND OXIDATIVE STRESS
0 Massimiliano Migliori
1 Renal Research Institute , New York, NY
2 Dipartimento Di Medicina Interna e Cerms, Università Di Torino , Torino , Italy
3 UOC Nefrologia e Dialisi USL12 Viareggio , Lido di Camaiore , Italy
4 Maastricht University Medical Center , Maastricht , The Netherlands
5 Fresenius Latin America , Buenos Aires , Argentina
6 Pontifical Catholic University of Parana , Curitiba , Brazil
7 Fresenius Medical Care , Bad Homburg , Germany
8 Department of Medicine, Imperial College London , London , United Kingdom
9 Hadassah-Hebrew University Medical Center , Jerusalem , Israel
10 Department of Nephrology, Arterial Hypertension , Dialysis and Transplantation, Zagreb , Croatia
11 University Hospital Centre Zagreb , Zagreb , Croatia
12 Nikolina Basic-Jukic
13 Fujita Health University School of Medicine , Toyoake , Japan
14 Karolinska Institutet , Stockholm , Sweden
15 Nagoya University Graduate School of Medicine , Nagoya, Aichi , Japan
16 Institute of Cancer Sciences, University of Glasgow , Glasgow , United Kingdom
17 Amsterdam University of Applied Sciences , Amsterdam , Netherlands
18 VU University Medical Center , Amsterdam , Netherlands
19 Trudeke Struijk-Wielinga
20 Medical University of Gdansk , Gdansk , Poland
21 Poznan University of Medical Sciences , Poznan , Poland
22 Hospital of Avellino , Avellino , Italy
23 Second University of Naples , Cercola (Naples) , Italy
24 Hans Mak Instituut , Naarden , Netherlands
25 Leiden University Medical Centre , Leiden , Netherlands
26 Academic Medical Centre , Amsterdam , Netherlands
End Stage Renal Disease (ESRD). Low density lipoproteins (LDL) are capable of absorbing and inactivating bacterial toxins (S Bhakdi) and human LDL can prevent endotoxin induced lethality in mice (Feingold). The second highest leading cause of death among ESRD patients after cardiovascular diseases is infectious. We conducted this analysis to explore the relationship between blood lipid composition and both cardiovascular and infectious outcomes. Methods: The MONitoring Dialysis Outcomes [MONDO] consortium consists of hemodialysis (HD) databases from Renal Research Institute [RRI] clinics in the US, Fresenius Medical Care [FMC] clinics in Europe, Asia Pacific, Latin America, KfH clinics in Germany, Imperial College in the UK, Hadassah Medical Center, Israel, Pontifical Catholic University of Parana, Brazil, and University of Maastricht, The Netherlands. Databases from RRI and FMC Europe [17 countries] were used to identify all patients with in-center treatments [1/2006-12/2012] who survived ≥12 months on HD. Only those with at least one record of HDL and LDL cholesterol, triglycerides, and neutrophils to lymphocyte ratio (NLR) in the first 12 months were selected (baseline period). The mean clinical and laboratory parameters were computed for the first 12 months and hospitalizations and clinical events (deaths and hospitalizations) were observed in months 13 to 24 (Followup period). Hospitalizations and mortality were classified as cardiovascular (CVD)-related or infectious-related and Poisson regression models were constructed to explore associations between baseline parameters and the number of CVD and infectious events in the follow up period. Results: We studied 22746 patients [FMC Europe 16911; RRI 5835]. Higher HDL was associated with fewer CVD deaths and hospitalizations (adjusted by NLR) while higher LDL was associated with less infectious deaths and hospitalizations but had no relationship to CVD outcomes. The association between HDL and CVD events was still significant when adjusted for NLR, a marker of inflammation (table 1). Results adjusted for CRP were similar although no CRP data was available for North America (results not shown).Adjusted for geographic region, age, gender, race, BMI, diabetic status, NLR and albumin Conclusions: Higher HDL is associated with fewer CVD events, while higher LDL is associated with fewer infectious deaths and hospitalizations. These data may contribute to the inverse association between LDL and mortality in the dialysis population SP643 Table 1. Poisson regression results © The Author 2014. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.
Introduction and Aims: Among the 600 to 700 mg of inorganic phosphate (Pi)
removed during a 4-hour hemodialysis session, a maximum of 10% could be extracted
from the extracellular space (1). The origin of the other 90% of removed Pi is unknown
and two hypothesis have been proposed being either the intracellular compartment or
bone. Spalding et al (2) hypothesized that Pi exchanges between intra and extracellular
compartments were diffusive, suggesting that the intracellular compartment could be
the main source of Pi removed during hemodialysis. Therefore, we proposed to test this
hypothesis during a hemodialysis session, by using Phosphorus (31P) Magnetic
Resonance Spectroscopy (MRS), which is the only tool allowing in vivo and dynamic
measurement of the intracellular Pi concentration as well as the other’s phosphate
metabolites such as Phosphocreatine (PCr) and ATP.
Methods: 3-hour hemodialysis sessions were performed in 6 pigs, after surgical
bi-nephrectomy, with a Prismaflex® generator and a M100® dialyser (Hospal). The
extra-corporal circulation blood flow was maintained between 100 and 150 mL/min.
31P MRS exams were performed with a 1.5T Siemens Sonata system using a surface
coil (20 cm) placed over the gluteal muscle region. 31P MR spectra (TR=10s,
TE=0.35ms) were acquired every 2’40” before, during and after dialysis. Blood samples
were obtained during the whole examination to measure plasma Pi concentrations.
Results: During the dialysis, the mean PCr/Pi ratio decreased significantly (-6.9%,
p<0.00001), while the Pi/βATP ratio increased (+22.2%, p<0.00001). Plasma Pi
concentration felt rapidly within 60 min from 2.30 ± 0.18 mmol/L to 1.65 ± 0.10
mmol/L (-28,08%, p=0.003) then plateaued.
Conclusions: This study demonstrated that intracellular Pi concentration did not
decrease in parallel with the extracellular Pi decrease as proposed (2). In contrast, the
intracellular Pi increase may reflect a cellular stress induced by hemodialysis and/or a
strong intracellular Pi production.1. Gallar P et al. Nefrologia, 27:46-52, 2007.2.
Spalding, et al. Kidney Int, 61:655-67, 2002.
HIGHER HDL CHOLESTEROL IS ASSOCIATED WITH LOWER
CARDIOVASCULAR EVENTS WHILE HIGHER LDL
CHOLESTEROL IS ASSOCIATED WITH LOWER INFECTIOUS
EVENTS IN A LARGE INTERNATIONAL POPULATION OF
Introduction and Aims: Lipid lowering agents have decreasing effect on all-cause
mortality as renal function declines losing statistical significance among patients with
POLYMETHYLMETHACRYLATE (PMMA) REDUCES SCD40L
PLASMA LEVELS IN HEMODIALYTIC PATIENTS. RESULTS
FROM A PRELIMINARY STUDY
Introduction and Aims: Soluble CD40L (sCD40L) is a well-known proinflammatory
and proatherogenic agent. The RISCAVID study demonstrated an increased
cardiovascular risk in patients with sCD40L serum levels exceeding 7.6 ng/ml. The aim
of our study was to evaluate the effect of different hemodialysis membranes on sCD40L
levels in hemodialytic patients (HD).
Methods: Twenty-three stable HD patients were randomized as follow: Group 1. Nine
patients were dialyzed for three months with Polyamide (PA) or polysulfone (PS)
membranes and then shifted (time 0) in polymethylmethacrylate (PMMA) membrane
for a further three months; Group 2. Six patients were dialyzed for three months with
PMMA membrane and subsequently shifted to PA / PS for a further three months;
Group 3 and 4, eight patients were maintained in PMMA or PA / PS membrane. We
measured the sCD40L serum levels (ELISA) at times 0, 30, 60 and 90 days.
Furthermore, to investigate inflammation and apoptosis induced by uremic serum in
vitro, HUVEC cells were incubated with serum of patients of group 1 and 2.
Results: In vivo study. The group 1 sCD40L serum levels were significantly reduced
after three months from 10.4±1.6 ng/ml) at time 0 to 5.2±0.9 ng/ml at time 90,
( p<0.001) below the threshold of 7.6 ng/ml. In group 2 sCD40L serum level increased
from 6.5±1.3 ng/ml to 7.8±1.7 ng/ml, but the difference was not statistically significant.
In groups 3 and 4 the levels of CD40L were stable. In vitro study. Less
pro-inflammatory (monocyte adhesion and ICAM -1 and E- seletin expression) and
proapoptotic (XTT and TUNEL) activity was detected in HUVEC cells incubated with
serum of patients from group 1 compared to group 2. These effects were reduced on
Poisson regression with risk of CVD events
Poisson regression with risk of infectious events
HUVEC treated with siRNA, confirming the role of sCD40L.
Conclusions: These preliminary data demonstrated an effect of the PMMA in the
reduction of circulating sCD40L, probably due to its adsorbitive properties. This effect
could reduce the cardiovascular risk in HD patients.
THE PROGRESS IN MALNUTRITION AND INFLAMMATORY
CONDITIONS AFFECT ON ADVERSE EVENTS AND
MORTALITY IN THE PATIENTS ON MAINTENANCE
Takahiro Kuragano1, Mana Yahiro1, Arithoshi Kida1, Yasuyuki Nagasawa1,
Yukiko Hasuike1, Masayoshi Nanami1 and Takashi Nakanishi1
1Hyogo College of Medicine, Nisinomiya, Japan
Introduction and Aims: In MHD, protein-energy malnutrition can be critical and is
one of the main causes of mortality. In MHD patients, nutritional and inflammatory
conditions could progress or regress during follow-up period, and may cause the
adverse events and premature mortality in MHD. However, few studies had reported
regarding the influence of changes in nutritional or inflammatory status on adverse
events or survival in MHD. In this study, we evaluated the relationship between the
changes in nutritional or inflammatory indexes and the adverse events or mortality.
Methods: Study design: Prospective, observational multi center study. Observational
period: 2 years. Subject and measurement: In 1086 MHD patients, blood levels of Hb,
albumin, prealbumin, high sensitive CRP (hCRP), were measured every 3 month. And
body mass index (BMI) is also evaluated.
Results: In logistic regression analysis, Hb ( p=0.008, Exp (β)=0.797) and pre-albumin
( p=0.001, Exp (β) =0.968) were selected as the significant predictors of the change in
BMI during the follow up period. Moreover, age ( p=0.003, Exp (β) =1.039) was
selected as a significant predictor of the change in serum albumin. In the time
dependent cox hazard model, in patients who were under 62 years old, there were no
significant changes in BMI and serum albumin levels during 2 years. On the other
hand, in the patients over 62 years old, BMI ( p=0.0025, from 21.4 ± 0.17 to 21.2 ±
0.17) and serum albumin ( p=0.0001, from 3.72 ± 0.015 to 3.66 ± 0.017 g/dL) levels
were significantly decreased during the follow-up period. Patients who showed the
decline in BMI were associated with the elevated risks for cerebro-cardiovascular
disease (CCVD) ( p=0.012, HR: 2.19) and hospitalization ( p=0.002, HR: 1.57).
Moreover, patients who showed the decline in serum albumin also associated with
higher risk for infectious disease ( p=0.001, HR: 1.55) and hospitalization ( p=0.049,
HR: 1.35). In addition, patients who showed the increase in hCRP had a higher risk for
CCVD ( p=0.023, HR: 0.44) and death ( p=0.023, HR: 0.32).
Conclusions: This study revealed that the downward trend of nutritionnal status was
prominent in elderly MHD. Furthermore, the progress in malnutrition and
inflammation could be associated with the several adverse events in MHD patients.
IMPACT OF PERIODONTAL DISEASE ON SURVIVAL OF
Liliana Garneata1,2, Oana Slusanschi1, Diana Ramona Dragomir2,
Alexandra Corbu-Stancu2, Carmen Barbulescu3 and Gabriel Mircescu1,2
1“Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania,
2“Dr Carol Davila” Teaching Hospital of Nephrology, Bucharest, Romania, 3“Dr
Carol Davila” Fresenius Nephrocare Dialysis Center, Bucharest, Romania
Introduction and Aims: Periodontal disease (PD) was reported as highly prevalent in
haemodialysis (HD) patients and was associated with inflammation-malnutrition
complex and higher mortality. We aimed to assess the extention of PD and its impact
on HD patients’ survival.
Methods: In this prospective single center observational study 263 stable HD patients
(age: 57 [50-65] years; 60% males; HD vintage 6.9 [6.2-7.6] years; primary kidney
disease: glomerulopathies in 34% cases, diabetic nephropathy in 11%) were enrolled
and followed for a median period of 24.6 months. Periodontal status was examined
according to WHO recommendations by a single examiner and quantified based on
loss of clinical attachment level (CAL): no/mild periodontitis (CAL<3mm), moderate
or severe periodontitis (CAL 3-4 mm or ≥5mm, respectively). Demografic data,
smoking status, haematologic data (haemoglobin, erythropoietin resistance index
ERI, defined as erythropoietin dose [mcg darbepoetinum/kg week]/haemoglobin [g/
dL]), dialysis adequacy (Kt/V), parameters of nutrition-inflammation (anthropometry,
biochemistry, serum C-reactive protein), as well as Davies co-morbidity score were
collected at baseline. Variables associated with PD status were evaluated in multinomial
regresssion. Survival analyses were conducted with the Kaplan-Meier method; log-rank
test was used for comparisons. Variables related to survival in multinomial analyses
were further evaluated in a multivariate Cox proportional hazard (CPH) model.
Results: Examination of oral health showed poor periodontal status in 75% of patients;
in 23% PD was severe. In multinomial regression, age, HD vintage, ERI and diabetic
status were retained in the model, but only lower Davies score and CRP levels allowed
for differention of mild and moderate from severe PD (OR 0.31 [0.12-0.78]) and 0.30
[0.14 to 0.66]; (0.49 [0.30 to 0.78]) and 0.55 [0.37 to 0.83], respectively; Cox&Snell r2
0.26; p=0.001). Patients with severe PD had the lowest median survival time (31.2
[27.7-34.8] months), as compared to those with moderate PD (50.5 [45.8-55.1]
months) and those with normal/mild PD (63.4 [59.8-67.0] months). In the
multivariate CPH model, higher co-morbidity score (HR 4.37 [2.61-7.33]; p<0.01) and
elevated CRP level (1.67 [1.21-2.30]; p<0.01) were the independent predictors of death.
Only patients with normal/mild PD had a survival advantage when ajusted for
Conclusions: Impaired periodontal health was highly prevalent in our cohort of HD
patients and it’s severity was related to age, dialysis vintage, diabetic status,
co-morbidities and inflammation, and was directly associated with reduced chances of
survival. However, the relationship between PD and the other co-morbidities in HD
patients remains unclear: periodontitis could be either another consequence of poor
health status, or add severity to the other co-morbidities. An interventional trial to
evaluate the influence of periodontal disease on hard end-points is required for
QUALITY OF LIFE IN HEMODIAFILTRATION WITH
ENDOGENOUS REINFUSION (HFR) VERSUS BICARBONATE
HEMODIALYSIS (BHD): CROSS-SECTIONAL MULTICENTRE
STUDY IN ITALY
Roberto Minutolo1, Silvio Borrelli1, Luca De Nicola1, Giuseppe Conte2 and
1Second University of Naples, Naples, Italy, 2Secon University of Naples, Naples,
Introduction and Aims: In hemodialysis (HD) patients, poor Health-related quality of
life (HRQoL) is frequent and it is associated with adverse outcome. It is well known
that HRQoL and nutritional status are strictly linked. However, whether amelioration
of chronic inflammation and improvement of nutritional status affect HRQoL remains
ill-defined. Hemofiltration with endogenous regeneration (HFR) is an alternative
dialysis technique that could reduce inflammation burden and malnutrition but it has
never been evaluated whether this translates into a beneficial effect on HRQoL.
Methods: We designed a cross-sectional multicentre study in order to compare the
HRQoL in patients treated with HFR versus BHD. We enrolled adult patients treated
for at least 6 months HFR, with life expectancy greater than six months and without
remarkable cognitive deficit. The recruited patients in HFR were matched for age,
gender, dialytic vintage and performance in activities of daily living (Barthel index)
with BHD treated patients. Demographic, clinical, laboratory and treatment data were
collected and SF-36 questionnaire for the assessment of QoL was administered.
Results: One hundred fourteen patients were enrolled (age 65.4±13.5 years; dialysis
vintage 5.4 (3.3-10.3) years; 53%males) from 18 dialysis non-profit centres in central
and southern Italy. As result of matching, no difference in age, gender, dialytic age and
Barthel index was found between HFR and BHD patients. KTV, hemoglobin and
serum albumin were similar between the two treatment groups. In HFR patients we
observed higher values of SF-36 physical component score than BHD patients, whereas
no significant difference emerged in the mental component score. In particular, as
described in table, HFR patients had a better Physical Functioning and Role Physical.
Conclusions: HFR is associated with a better physical component of HRQoL than
BHD, independently of age, gender, dialysis vintage and invalidity score.
SP647 Summary Component score and Eight Domains of SF-36 in HFR and BHD.
Physical Functioning Role Physical Bodily Pain General health
PROTIEN-ENERGY WASTING (PEW) IS PRESENT IN
HEMODIALYSIS PATIENTS ACROSS THE ALL BODY-MASS
INDEX GROUPS AND INCREASES WITH DIALYSIS VINTAGE
Introduction and Aims: Protein-energy wasting (PEW) is a state of decreased body
stores of protein and fat masses which arises from inadequate nutrient intake and
increased catabolism. Series of studies have described it as one of the main
non-traditional risk factors associated with poor prognosis and treatment outcome in
iii | Abstracts
chronic kidney disease (CKD) patients. It has been estimated that 18 to 75% of patients
on maintenance dialysis are malnourished. Nevertheless, PEW still stays greatly
neglected and often unrecognized. Evidence suggests that nutritional markers such as
hypoalbuminemia, low serum prealbumin and transferrin levels, and
malnutrition-inflammation score (MIS) ≥ 5, also correlate with mortality. Compared
to other traditional or non-traditional risk factors low serum albumin value is
doubtlessly the strongest predictor of mortality, their association linear and highly
progressive. As its levels are measured frequently, it is also one of the simplest and most
reliable markers of PEW. The aim of this study was to evaluate relationship between
body mass index and serum albumins in hemodialysis populatin, and to investigate
role of dialysis vintage in development of PEW.
Methods: 135 patients age ranging from 20 to 91 years were enrolled in the study. The
median time spent on treatment was 34 (2-413) months. Laboratory and clinical data
were obtained from the medical records and charts. The anthropometric
measurements were performed after dialysis session. MIS was individually taken.
Patients were divided into 5 groups regarding the body mass index (BMI) values: < 20
kg/m2 malnourished, 20-25 kg/m2 properly nourished, 25.1-30 kg/m2 overweight, and
> 30 kg/m2 obese.
Results: The results show that 15.56% of our patients were nutritionally malnourished
despite carefully provided renal replacement therapy. As time spent on maintenance
hemodialysis was longer, BMI was lower and MIS had significantly increased - for
patients undergoing HD less than 2 years median BMI was 25.35 (16.62-51.7) kg/
m2and MIS 6.92while after 10 years of treatment it was 23.06 (16.73-29.93) kg/m2 and
MIS 10.13 ( p<0.05). Furthermore, median values of serum albumin were lower than
3.8 g/dl in all 5 analyzed groups. It was interesting to notice that serum albumin was
the highest in the group of malnourished patients according to the BMI (3.71 g/dl). On
the other hand, the lowest values were recorded in the group of overweight (3.54 g/dl).
When divided into two groups due to albumin value (lower and higher than 4 g/dl), it
could be seen that MIS was considerably higher in the group which measured lower
albumin values (8.79 versus 5.79). There was no significant difference in time spent on
HD (55 versus 54 months) regarding the serum albumin level.
Conclusions: Our results demonstrated that PEW cannot be exclusively linked to
malnourished patients - it is a major risk factor which extends to all patients, regardless
of the BMI. PEW was more common in patients with longer dialysis vintage. Complex
analysis like is MIS should be used to estimate malnutrition instead of the single
parameter like is albumin or BMI. Further efforts are needed to clearly define and
precisely establish diagnosis guidelines for this important condition. Although the ideal
therapy protocol still does not exist, active style of life and healthy nutritional habits, as
well as us of nutritional supplements when necessary, should be persistently promoted
in order to achieve better outcome and quality of life in this venerable population.
SERUM URIC ACID AS A CLINICALLY USEFUL NUTRITIONAL
MARKER AND PREDICTOR OF OUTCOME IN MAINTENANCE
Ilia Beberashvili1, Inna Sinuani1, Ada Azar1, Gregory Shapiro1, Leonid Feldman1,
Kobi Stav1, Judith Sandbank1 and Zhan Averbukh1
1Assaf Harofeh Medical Center, Zerifin, Israel
Introduction and Aims: The importance of serum uric acid (SUA) for maintenance
hemodialysis (MHD) population has not been well established. We hypothesized that
SUA levels may be associated with nutritional risk and consequently with adverse
clinical outcomes in MHD patients.
Methods: A two-year prospective cross-sectional study of MHD patients performed on
261 MHD outpatients (38.7% women) with a mean age of 68.6±13.6 years. Prospective
all-cause and cardiovascular (CV) hospitalization and mortality, nutritional scores
(malnutrition-inflammation score (MIS), and geriatric nutritional risk index (GNRI)),
hand-grip strength (HGS), and short form 36 (SF-36) quality-of-life (QoL) scores were
Results: SUA positively correlated with laboratory nutritional markers (albumin,
creatinine), with body composition parameters, with HGS (r=0.26, p<0.001) and with
GNRI (r=0.34, p<0.001). SUA negatively correlated with MIS (r=-0.33, p<0.001) and
interleukin 6 (r=-0.13, p=0.04). Patients in the highest SUA tertile had higher total
SF-36 scores ( p=0.04), higher physical functioning ( p=0.003) and role-physical
( p=0.006) SF-36 scales. For each 1.0 mg/dL increase in baseline SUA levels, the first
hospitalization hazard ratio (HR) was 0.79 (95% confidence interval (CI), 0.68 to 0.91)
and first CV event HR was 0.60 (95% CI, 0.44 to 0.82); all-cause death HR was 0.55
(95% CI, 0.43 to 0.72) and CV death HR was 0.55 (95% CI, 0.35-0.80). Associations
between SUA and mortality risk continued to be significant after adjustments for
various confounders including MIS and interleukin 6. Cubic spline survival models
confirmed linear trends.
Conclusions: In MHD patients, SUA is a good nutritional marker and associates with
body composition, muscle function, inflammation, and health-related QoL, upcoming
hospitalizations, as well as independently predicting all-cause and cardiovascular death risk.
IDPN IN PEW HEMODIALYSIS PATIENTS AS FIRST CHOICE
Elena Bruschetta1, Marco Righetti1, Francesca Colombo1, Nicola Palmieri1,
Mario Prencipe1, Oscar Bracchi1, Francesca Stefani1, Karen Amar1, Alfio Scalia1
and Ferruccio Conte1
1Uboldo Hospital, Cernusco s/N, Italy
Introduction and Aims: Protein energy wasting (PEW) is frequently diagnosed in
hemodialysis patients. Dietary counseling and oral nutritional supplements, even if
important tools to contrast PEW, are often discharged by the patients. Intradialytic
parenteral nutrition (IDPN) may be a useful support to improve malnutrition. So, we
designed a prospective trial analyzing the effects of IDPN, as first choice treatment, in
PEW dialysis patients.
Methods: A single center prospective, uncontrolled, interventional study has been
performed in our Renal Unit. PEW hemodialysis patients were submitted to thrice weekly
IDPN for at least a three months’ time. Primary outcomes were the effects of IDPN on
survival rate and nutritional parameters as albumin, transferrin, phosphorus, urea.
Results: 18 patients, 5 females and 13 males, with a mean age of 75,4 years (53-87) and a
Charlson Comorbidity Index of 11,5 (5,8-24,7) began IDPN. IDPN was performed for a
mean period of 142 days. 5 patients died after a brief mean time of 75 days. Table shows
nutritional parameters at baseline and after IDPN, nutritional parameters changing during
IDPN. KM survival analysis, considering 2 subgroups of patients split by the difference of
albumin values during IDPN showed that patients with higher increased of albumin levels
had a better survival rate ( p< 0,05).
Conclusions: IDPN improves all nutritional parameters in PEW hemodialysis patients.
Patients with a good outcome had a larger improvement of nutritional parameters as
compared with patients having a fatal outcome. IDPN may be a simple, first choice
treatment in PEW hemodialysis patients.
MALNUTRITION IN HAEMODIALYSIS PATIENTS ASSESSED
BY BODY COMPOSITION MONITOR
Jaroslav Rosenberger1,2, Maria Majernikova1, Viera Kissova3, Zuzana Straussova1
and Jan Boldizsar1
1FMC-Dialyzacne Sluzby, Piestany, Slovakia, 2University PJ Safarik, Kosice,
Slovakia, 3Teaching Hospital Nitra, Nitra, Slovakia
Introduction and Aims: Malnutrition is a known predictor of mortality in the
haemodialysis population. Body Composition Monitoring (BCM) is used mainly for
assessing overhydratation in haemodialysis patients, but it also offers the possibility of
evaluating nutrition status. This study explored whether malnutrition diagnosed by
BCM predicts mortality in prevalent haemodialysis patients. In addition, the effects of
enteral nutrition supplementation were evaluated as well.
Methods: A total sample consisted of 960 chronic haemodialysis participants with
baseline BCM measurement between 2008 and 2013. The observation period was up to
54 months follow-up. All data were retrieved from medical records. Nutrition status
was estimated by BCM; malnutrition was diagnosed as Lean Tissue Index (LTI) <10%
of the normal value. Cox regression was performed to analyse predictors of mortality.
Results: BCM-diagnosed malnutrition (HR 1.66;95%CI 1.1;2.44) was independent
predictor of mortality. Other significant predictors included higher age (HR 1.05;95%
CI 1.03;1.07), longer dialysis vintage (HR 1.00;95%CI 1.00;1.00), central venous
catheter use (HR 1.96;95%CI 1.28;2.99) and low serum albumin (HR 0.91;95%CI
0.87;0.95). 16.2% of patients received enteral supplementation. The use of supplements
was related neither to BMC-diagnosed malnutrition nor mortality; however in
stratified sample the BCM-diagnosed malnutrition remained significant predictor of
mortality only in patients not using enteral supplementation.
Conclusions: BCM-diagnosed malnutrition in chronic haemodialysis patients is an
independent predictor of mortality and is associated with a 1.66-fold higher risk of
dying compared with normal nutrition status. Nutritional supplementation is not
associated with decrease in mortality; however it was applied equally to malnourished
and normally nourished patients. In addition, when patients were stratified according
the nutritional supplementation, only those with malnutrition and without treatment
had increased mortality. Prospective study with proper design is necessary to evaluate
possible beneficial effects of enteral supplementation.
Changing during IDPN
changing during IDPN,
pts split by outcome (fatal vs. good)
RELATIONSHIP BETWEEN SERUM MAGNESIUM AND
NON-TRADITIONAL CARDIOVASCULAR RISK FACTORS IN
Gabriela Cobo1, Cristina Di Gioia1, Rosa Camacho1, Concepcion Garcia Lacalle1,
Olimpia Ortega1, Isabel Rodriguez1, Carmen Mon1, Milagros Ortiz1, Juan Herrero1,
Aniana Oliet1, Ana Vigil1 and Paloma Gallar1
1Hospital Severo Ochoa, Leganes, Spain
Introduction and Aims: CKD patients have a high incidence of cardiovascular
mortality. In the last years evidence has showed that non-traditional risk factors such
as inflammation, oxidative stress, malnutrition and anemia, play an important role in
all cause mortality. Additionally, recent studies have showed that low Mg levels are
predictors of overall mortality in hemodialysis patients. Although the importance of
this mineral has been particularly recognized due to its anti-atherosclerotic effect, the
pathway by which hypomagnesemia is associated with higher mortality in these group
of patients has not been has been poorly investigated. The aim of our study was to
analyze the relationship between serum Magnesium levels and non-traditional
cardiovascular risk factors in hemodialysis patients.
Methods: In a cross-sectional study including a total of 83 hemodialysis patients we
analyzed: serum magnesium levels (reference values: 1.58-2.55 mg/dl) and
non-traditional cardiovascular risk factors (NTCV). We divided NTCV in fourth
groups: a) Nutritional biochemical parameters: albumin, prealbumin b) Adipokins:
Adiponectin, Leptin, Resistin (X-MAP technology, BioRad, Madrid, Spain), c)
Inflammation parameters: CPR (Nephelometry), IL-6 and TNF-α, (X-MAP
technology, BioRad, Madrid, Spain), ESA resistance index, d) Body Composition
parameters: lean body mass, fat body mass, body cell mass, phase angle (assessed by
BCM Fresenius medical care).
Results: Mean age 64±12 years, 68% (57) were male, 36% (30%) diabetic and 23% (19)
had history of ischemic heart disease. Median age adjusted comorbidity index was 7
(5-9). Mean S-Mg level was 2.2±0.35 mg/dl (1.52-4.01). Only two patients (2.4%) had
S-Mg>2.55. Just one patient had hypomagnesemia considering the normal range
established in our center. However, 24% were in the low quartile range (<2mg). No
relation was found with age and there was no difference between genders or diabetics.
A strong relation was found with age-adjusted Charlson comorbidity index (ACCI)
( p=0,022). There was no correlation between biochemical nutritional parameters or
adipokines. In relation to inflammatory parameters, lower magnesium levels were
associated with lower hemoglobin level ( p=0,005) and more ESA resistance ( p=0,05).
Regarding CPR, a trend to higher CRP level in patients with lower mg was evident,
however this was not statistically significant ( p=0,097). There was no relation with
neither IL-6 nor TNF- α. Regarding body composition, higher magnesium levels were
related to more lean body mass ( p=0,004) and less fat body mass ( p=0,018). No
relation was found with phase angle. In a linear regression model, just age-adjusted
Charlson comorbidity index showed significant association with magnesium levels.
Conclusions: In our population, the incidence of hypomagnesemia is extremely low.
However, lower serum magnesium was associated with some non-traditional
cardiovascular risk factors like anemia and ESA resistance, and also with poor
THE ROLE OF SERUM MAGNESIUM (S-MG) AND CALCIUM
(S-CA) LEVELS IN THE ASSOCIATION BETWEEN
PROTEIN-ENERGY WASTING (PEW) AND MORTALITY IN
END-STAGE RENAL DISEASE (ESRD) PATIENTS
John Kyriazis1, Anastasia Markaki2, Katerina Kourtesi1, Marialena Kalymniou1,
Stamatios Vougazianos1, Periklis Kyriazis3 and Kostas Stylianou4
1General Hospital of Chios, Chios, Greece, 2Technological Educational Institute of
Crete, Heraklion, Greece, 3Charles University Prague. Faculty of Medicine In Pilsen,
Pilsen, Czech Republic, 4University Hospital of Heraklion, Heraklion, Greece
Introduction and Aims: PEW, which can be reliably assessed by the
malnutrition-inflammation score (MIS), is associated with adverse clinical outcomes in
ESRD patients. Low s-Mg and high s-Ca levels have been also consistently associated
with increased risk of morbidity and mortality in ESRD. Here, we examined a) whether
and to what extent s-Mg and s-Ca reflect the nutritional-inflammation status of ESRD
patients, as assessed by the MIS, and b) the interrelations between the altered mineral
metabolism, MIS and mortality in uremic patients.
Methods: One hundred and thirty six ESRD patients, 82 on hemodialysis and 54 on
peritoneal dialysis, after baseline assessment, including the MIS and other nutritional,
biochemical and anthropometric markers, were followed-up for all-cause mortality.
Since a higher score of the MIS (0 to 30) reflects a more severe degree of malnutrition
and inflammation, patients in the lower (0-4) and middle (5-7) tertiles of MIS were
defined as well nourished, whereas patients in the upper tertile (≥ 8) of MIS were
consider as malnourished.
Results: As compared to well nourished, malnourished patients were older, had longer
renal replacement therapy (RRT) vintage, higher prevalence of cardiovascular disease
(CVD), lower s-Mg (2.29 ± 0.27 vs. 2.49 ± 0.47 mg/dl; p<0.05) and higher s-Ca (9.46 ±
0.78 vs. 9.05 ± 0.76 mg/dl; p<0.01) levels, respectively. The MIS correlated inversely (all
rho >-0.210) with all the nutritional markers measured: serum albumin, transferrin,
creatinine and positively (r=0.210; p<0.05) with C-reactive protein (CRP). Also, the
MIS correlated inversely (all rho>-0.200) with anthropometric measurements: free fat
mass, mid-arm circumference and mid-arm muscle circumference. Multivariate
regression analysis (R2 = 0.320; p<0.001) identified s-Mg (Beta= -0.316; p<0.001) and
s-Ca (Beta =0.194; p<0.05) levels as significant independent predictors of the MIS, after
adjustment for sex, mode of dialysis, RRT vintage, age, CVD, diabetes, body mass
index, CRP and albumin. During a median follow-up period of 25 months, 35 deaths
occurred. Malnourished patients had increased all cause mortality [crude hazard ratio:
2.85 (95% CI, 1.42-5.69). Likewise, all-cause mortality increased by 23% (1.23
[1.12-1.36), for each unit increment in MIS. This MIS - mortality association persisted
even after adjustment for other risk factors, including age, diabetes and anemia.
However, this association lost its significance after adjusting for s-Ca and s-Mg, which
entered the final model as independent predictors of mortality in both analyses.
Conclusions: These data show for the first time that in the ESRD setting a) low s-Mg
and a high s-Ca levels appear to be reliable and robust markers of PEW and
inflammation, b) altered mineral metabolism may be a link between PEW and adverse
clinical outcomes and c) incorporation of s-Mg and s-Ca in a nutritional scoring
system can further improve its efficiency to predict outcomes in uremia, a possibility
that warrants further investigation.
HOW MUCH INCREASE IN MALNUTRITION-INFLAMMATION
SCORE (MIS) REALLY REFLECTS A PROGRESSION TOWARD
Hiroshi Tanaka1, Shoji Tsuneyoshi1, Miki Sawa1, Kiichiro Fujisaki1 and
1Hiroshima Red Cross Hospital and Atomic-Bomb Survivors Hospital, Hiroshima,
Introduction and Aims: Malnutrition, or protein-energy wasting (PEW), is regarded
to be one of the most common morbidity, which is associated with high mortality, in
dialysis population. Malnutrition-Inflammation Score (MIS), developed by
Kalantar-Zadeh (2001), is composed of 7 factors (dry weight loss, food intake, GI
symptoms, physical activities, comorbidities, fat and muscle) derived from subjective
global assessment (SGA) and additional 3 objective factors (body mass index, serum
albumin and total iron binding capacity). MIS has been regarded to be one of the most
efficient way to detect malnourished dialysis patients. However, MIS fluctuates over a
period of time in a single patient. It is unknown how much increase in MIS actually
reflects a progression toward malnutrition.
Methods: MIS has been performed semiannually by dialysis nurses to all the patients
on maintenance hemodialysis in a single dialysis center. Each 10 component of MIS
has 0-3 points with a higher point suggesting toward malnutrition; MIS is calculated as
a sum of those components, with a minimum (best) score of 0 and a maximum (worst)
score of 30. The patient who had at least 3 measurements were included in the present
analysis. Fluctuation of MIS was evaluated by standard deviations (SDs) of serial MIS
measurements in each patient. Background clinical factors which might influence MIS
fluctuation were analyzed. Statistical analysis were done using StatView 5.0 (SAS
Institute Inc.) for Macintosh.
Results: A total of 104 patients (age 67.7±13.1 years, m±SD, M:F = 69:35) were
included in the analysis, with their MIS of 6.49±3.70, standardized triceps skin fold
thickness 94.4±39.2% and standardized arm muscle area 99.4±20.8%. Multivariate
stepwise analysis showed that MIS fluctuated significantly if background status had
lower dry weight and lower serum albumin (P<0.001), supporting that MIS fluctuation
reflects progression to malnutrition at least partially. In patients with an average MIS
less than 8 (n=78), i.e., in those who would be regarded to be without PEW, SDs of MIS
were 1.62±0.71, significantly less than SDs in patients with MIS 8 or higher (n=26, 2.66
±1.11, P<0.001). Considering that 2SDs cover 95%, an increase in MIS beyond 2SDs (=
3.24) could be possibly regarded as a progression toward PEW. This hypothesis was
supported by the findings that the patients with an increase in MIS from an average of
the previous MIS by 3.5 or more (n=15) had significantly higher MIS (8.3±5.4 vs 6.2
±3.3, P=0.043) and a progressive decline in arm muscle area (-7.9±9.8% vs 2.4±14.8%,
P=0.011), compared with those whose increment were less (n=89).
Conclusions: Increase in MIS by 3.5 or more from an average of the previous MIS
measurements is likely to represent a true progression toward malnutrition rather than
a measurement error.
RANDOMIZED CONTROLLED TRIAL ON THE EFFECTS OF A
SIX-MONTH INTRA-DIALYTIC PHYSICAL ACTIVITY
PROGRAM AND ADEQUATE NUTRITIONAL SUPPORT ON
PROTEIN-ENERGY WASTING, PHYSICAL FUNCTIONING AND
QUALITY OF LIFE IN CHRONIC HEMODIALYSIS PATIENTS
Dan Hristea1, Anne Paris1, Gaëlle Lefrançois1, Christelle Volteau2,
Corneliu Savoiu1, Sophie Ozenne1, Angelo Testa1, Stéphanie Coupel1,
Isabelle Bertho1, Marie Claude Legall1, Justine Magnard3 and
1ECHO Association, Nantes, France, 2Biometrics, CHU, Nantes, France,
3University of Nantes, Nantes, France
Introduction and Aims: Protein-energy wasting (PEW) is common in hemodialysis
patients and is a powerful predictor of adverse outcomes. The aims of this randomized
iii | Abstracts
controlled trial were to investigate the effects of a six-month intradialytic physical
activity program in addition to an adapted nutritional support on protein-energy
wasting (PEW), physical functioning and quality of life in chronic hemodialysis
Methods: All 210 patients of 2 dialysis units in Nantes (France) were screened for the
presence of PEW according to the criteria of the ISRNM. Eligible patients were then
randomly assigned either to a nutrition and exercise group (N+EX) or to a nutrition
only group (N). In both groups, the prescription of nutritional supplements (oral or, in
case of intolerance, IV) was adapted according to the dietary records, in order to reach
goals set by the European Guidelines for Nutrition in terms of protein and energy
intake. In addition, N+EX group engaged in a 6-months progressive submaximal
intradialytic cycling exercise program. Primary outcome was to compare the number of
patients having reached remission of PEW in N+EX vs. N group by 6 months.
Secondary outcomes assessed the effects of intradialytic exercise on functional
performances (six-minute walk test (6MWT), quiet standing postural control, and
maximal quadriceps strength), body composition (estimated by bio-impedance
spectroscopy) and self-reported health-related quality of life (SF-36 score).
Results: Twenty-one eligible patients (11 men) consented to participate and were
randomized: 11 N vs. 10 N+EX. Mean age and dialysis vintage (years) were: 71.0
(range 52-89) and 8.6 (0.8-23.8) in N+EX, and 69.9 (51-93), 11.3 (1.3-25.7) in N
respectively. Six patients in N+EX and nine patients in N completed the 6 months of
the study. Causes of drop-out were: kidney transplantation (1 N+EX), death due to
comorbidities (1 N, 1N+EX), intercurrent disease (2 N+EX) and withdrawal of consent
(1 N). No serious adverse effects directly related to exercise occurred. There was no
significant difference in the number of patients having reached remission of PEW
between the two groups. Two of 6 patients in N+EX and 4 of 9 patients in N had no
longer all criteria of PEW, but only one patient in N had normal albumin, prealbumin
and LTI at the end of the study. No significant changes were observed between groups
over time in measures of serum-albumin, -prealbumin, C-reactive protein, body mass
index, lean- and fat-tissue index or quadriceps force. There were statistically significant
and clinical meaningful increases in self- assessed quality of life (SF36 mean score
+61%) and in the 6MWT (+ 42%) in N+Ex while these parameters declined in N. The
postural control (assessed by the quantity of postural sway) worsened over time in N
and remained stable in N+EX.
Conclusions: The results of this study, made in a limited number of patients, could not
show an additive effect of combining intradialytic exercise and nutritional support in
the treatment of PEW. However this strategy seems safe, well accepted and increases
significantly physical performances and quality of life in this frail population of dialysis
patients. Further larger-scale studies are necessary in order to investigate long term
DETERMINANTS OF PLASMA OXIDIZED LDL IN
Cristina Capusa1,2, Irina Stoian1, Carmen Barbulescu3, Catrinel Santimbrean3,
Dana Dumitru2 and Gabriel Mircescu1,2
1“Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania,
2“Dr Carol Davila” Teaching Hospital of Nephrology, Bucharest, Romania, 3“Carol
Davila” Fresenius Nephrocare Dialysis Center, Bucharest, Romania
Introduction and Aims: Oxidized low-density lipoproteins (oxLDL) were involved in
the development and progression of atherosclerosis and could contribute to the
increased cardiovascular risk in end-stage renal disease patients. Hence, we aimed to
assess the relationships between plasma oxLDL, parameters of serum oxidative stress
and plasma lipids status in hemodialysis (HD) patients.
Methods: Oxidized LDL (competitive ELISA), lipid peroxidation and plasma
antioxidant defence markers (serum thiobarbituric acid reactive substances - TBARS,
arylesterase activity of serum paraoxonase - PON, plasma total free thiols - PtSH,
serum total and residual antioxidant activity - TAA, RAA; spectrophotometry), lipide
profile (total cholesterol - C, HDL-cholesterol, LDL-cholesterol and triglycerides - TG),
serum albumin and uric acid were assessed in fifty-two stable, non-diabetic chronic
HD patients (54% males, 51 [42; 57] years, 77 [3; 134] months dialysis vintage),
without overt inflammation (C-reactive protein <10mg/L). Atherogenic index of
plasma (AIP, logarithm of the molar TG/HDL-C ratio) was calculated as surrogate of
lipoprotein particle size. Data are presented as median [quartile 1; quartile 3].
Comparisons among subgroups defined by tertiles of oxLDL, Spearman correlation
and multiple linear regression using log-transformed variables were performed.
Results: Median oxLDL was 1.7 [1.5; 1.8]U/ml. Subjects in the highest oxLDL tertile
(n=18) had lower PtSH (1.8 [1.6; 2.0] vs. 2.1 [1.8; 2.2] mcmol/g protein, p=0.02), but
higher HD vintage (116 [80; 159] vs. 64 [22; 93] months, p=0.01), serum cholesterol
(208 [194; 223] vs. 171 [161; 179] mg/dl, p<0.01), TG (174 [144; 218] vs. 89 [76; 134]
mg/dl, p<0.01), LDL-C (132 [116; 142] vs. 104 [93; 113] mg/dl, p<0.01), AIP (0.6 [0.5;
0.8] vs. 0.3 [0.3; 0.4] mg/dl, p<0.01) and uric acid (6.7 [6.2; 6.8] vs. 5.9 [5.4; 6.6] mg/dl,
p<0.01) as compared to those in the lowest tertile (n=16). Also, oxLDL was positively
associated with cholesterol, LDL-C, TG and AIP (rs=0.63, 0.54, 0.53 and 0.47,
respectively, p<0.001), dialysis vintage (rs=0.31, p=0.02), and uric acid (rs=0.34,
p=0.01), while inversely with PON (rs= -0.31, p=0.03) and PtSH (rs= -0.35, p=0.01).
However, multiple linear regression analysis, a model that explains 59% of oxLDL
variation, retained only total cholesterol (t ratio=7.1, p<0.001), HDL-C (t ratio= -3.2,
p=0.002), uric acid (t ratio=3.0, p=0.004), and TAA (t ratio= -2.3, p=0.03) as
independent predictors. No significant correlations with TBARS were found.
Conclusions: The plasma lipid status, i.e. increased amount of substrate for oxidation
along with decreased antiatherogenic component, appears as essential for an increased
level of oxLDL in long-vintage HD patients. Also, higher uric acid seems to favor LDL
oxidation in this clinical setting. Oxidative stress parameters had weaker influence, only
the reduced extracellular antioxidant capacity being an independent contributor to the
increase in oxLDL. Therefore, on might speculate on the need to address metabolism
abnormalities in the management of HD patients.
IS TELOMERE ATTRITION LINKED TO INTERLEUKIN 6
LEVELS BUT NOT WHITE BLOOD CELL COUNTS IN
JAPANESE DIALYSIS PATIENTS?
Introduction and Aims: Inflammation is a risk factor in end-stage renal disease
(ESRD) patients ( pts) who undergo accelerated atherosclerosis and vascular aging. It
has previously been reported that reduced telomere length (TL) is associated with
inflammatory markers in uremic Caucasian pts undergoing regular hemodialysis. Here,
we sought to verify if TL is linked to systemic inflammation also in Japanese ESRD pts,
at baseline and after 1 year of dialysis.
Methods: We enrolled 59 Japanese dialysis pts (31 males, mean age 60±12 years) who
had just started renal replacement therapy (RRT) from June 2007 to July 2013 at two
affiliated hospitals in Aichi prefecture, Japan. This study is a sub-analysis of the
ongoing prospective Nagoya Immune System in ESRD study. In this study, TL was
determined in peripheral blood leukocytes using a standard Q-PCR methodology.
Results: Leukocyte TL (T/S) negatively correlated with age at baseline (R2=0.13,
t=-2.93, P=0.0043) and 1 year after RRT (R2=0.11, t=-2.72, P=0.0086) and there was a
mean TL reduction of 8.6% (median 14.4%) within the first year following RRT. The
degree of any TL shortening was unaffected by adjustment for age, gender, diabetes and
smoking habit. Longer TL at baseline was associated with the lower IL-6 levels at
baseline (R2=0.09, t=-2.46, P=0.02), as well as with IL-6 levels (R2=0.10 t=-2.48,
P=0.02) and CRP levels after 1 year (R2=0.10, t=-2.37, P=0.02). There was no
association between the degree of TL shortening during 1 year and these inflammatory
markers. Higher white blood cell count (WBC) was significantly associated with longer
TL 1 year after follow up (R2=0.15, t=3.20, P=0.002) and the degree of TL shortening
relative to baseline TL (R2=0.07, t=-2.01, P=0.048).
Conclusions: We confirm that TL correlates inversely with IL-6 levels, in Japanese
ESRD pts, as WBC correlated positively with TL. We hypothesize that leukocyte
telomere attrition reflect a shortened life span for leukocytes in the uremic milieu and
that longer leukocyte TL in pts with healthy productive WBC may be reflective of more
robust biological ageing in these pts.
FLUCTUATION OF SERUM HIGH SENSITIVITY C-REACTIVE
PROTEIN TO ABUMIN RATIOS IS AN INDEPENDENT
MORTALITY RISK IN CLINICALLY STABLE HEMODIALYSIS
Jyh-Chang Hwang1, Ming-Yan Jiang1, Yi-Hua Lu1 and Charn-Ting Wang1
1Chi Mei Medical Center, Tainan, Taiwan
Introduction and Aims: High sensitive C-reactive protein to albumin ratio (CRP/alb)
predicts mortality risk in patients with acute kidney injury. Rather than a fix value, this
marker varies dynamically. This study was conducted to evaluate whether fluctuation
of this marker was associated with long-term outcome in the clinically stable
hemodialysis (HD) patients.
Methods: CRP/alb was regularly checked every other month for each clinically stable
outpatient in the year 2008. Based on the “slope of trend equation” derived from 5-6
CRP/alb ratios, a total of 282 HD patients treated in a center were enrolled and divided
into quartiles. Group1:≦-1.43: n=69; group2:>-1.43≦0: n=68, group 3:>0≦0.18: n=73;
and group 4:>0.18: n=74. The observation period started from 1st January 2009 to 31st
Results: Those patients with fluctuant CRP/alb (Groups 1+4) showed a worse long-term
survival ( p=0.019) and longer 5-year hospitalization stay than their counterparts
(Groups 2+3) (38.5±14.3 vs. 16.8±22.5days, p<0.001). Groups 1+4 was associated with
older age (OR=1.03, 95%CI=1.01-1.05), and high prevalence of congestive heart failure
(OR=2.11, 95%CI= 1.02-4.36). Fluctuation (i.e., standard deviation) of CRP/alb was
associated with male gender (r=0.17, p=0.003), Davies co-morbidity score (r=0.16,
p=0.03), and baseline hs-CRP (r=0.39, p<0.001). By multivariate Cox proportional
methods, fluctuation of CRP/alb (HR:1.05, 95%CI:1.01-1.09) rather than baseline CRP/
alb was an independent factor for prediction of long-term mortality after adjusting for
age, sex, diabetes, HD vintage, and co-morbidities.
Conclusions: HD patients with exaggerated variation of hs-CRP/alb ratios are
characterized by old age, and more co-morbid conditions, and tended to have longer
subsequent hospitalization stay and higher long-term mortality rate. Precedent variation
of CRP/Alb is an independent risk factor for predicting long-term morality in clinically
stable HD patients.
HANDGRIP STRENGTH PREDICTS SURVIVAL IN CHRONIC
Terry Ting-Yu Chiou1, Yueh-Ting Lee1, Hwee-Yeong Ng1 and Chien-Te Lee1
1Kaohsiung Chang Gung Memorial Hospital and Chang-Gung University College
of Medicine, Kaohsiung, Taiwan
Introduction and Aims: Poor muscle quality had been associated with mortality in
hemodialysis (HD) patients. Handgrip strength (HGS) is a reproducible and easily
performed test that correlates with lean body mass. It may predict malnutrition and
renal outcomes in CKD patients, and circulatory congestion in peritoneal dialysis
patients. However, how well can HGS predict mortality in HD patients has not been
Methods: 188 stable HD patients (78 males) were enrolled in the study from January to
December 2009. For each patient, baseline HGS was measured by grip dynamometer,
and mid-arm muscle circumference (MAMC) and triceps skinfold thickness (TST)
were measured with standard plastic tape and Lange Skinfold Caliper. Baseline
biochemical data as well as demographic features were reviewed and collected.
Results: Average patient age was 60±11 year-old. 27% had diabetes and 24% had
cardiovascular disease. During the mean follow-up period of 47 months, 34 (17 males)
out of 188 patients died. Univariate analysis showed that survivors had significantly
higher HGS, serum albumin, Kt/v, nPCR, and lower waist circumference, IL-6, hsCRP.
The two groups did not differ significantly in age, HD vintage, hemoglobin, serum
phosphate, BMI, MAMC and TST. Survivors also had less diabetes (23%  vs. 47%
, p=0.006) and cardiovascular disease (41%  vs. 62% , p=0.036). Cox
regression hazards analysis identified higher HGS (HR 0.891, 95% CI 0.838-0.948;
p<0.001) and Kt/v (HR 0.086, 95% CI 0.018-0.421; p=0.002) as the only two significant
independent predictors for better survival in hemodialysis patients. HGS was
significantly lower in female (19.6±6.3 vs. 28.4±10.4kg [male], p<0.001) and diabetic
(19.3±8.0 vs. 24.1±9.2kg [non-diabetic], p=0.007) patients. For female patients, a HGS
less than 17kg had a positive predictive value (PPV) of 39% and negative predictive
value (NPV) of 96% for predicting mortality. For male patients, a HGS less than 26kg
had a PPV 29% and NPV 84% for predicting mortality.
Conclusions: Handgrip strength provides a good marker for survival in HD patients,
independent of age, DM, cardiovascular disease, and serum albumin.
TYPE OF RENAL REPLACEMENT THERAPY (HEMODIALYSIS
VS PERITONAL DIALYSIS) DOES NOT AFFECT CYTOKINE
GENE EXPRESSION AND CLINICAL PARAMETERS OF RENAL
Dorota Kaminska1, Katarzyna Koscielska-Kasprzak1, Pawel Chudoba1,
Oktawia Mazanowska1, Marcelina Zabinska1, Miroslaw Banasik1,
Maria Boratynska1, Agnieszka Lepiesza1, Krzysztof Korta1 and Marian Klinger1
1Wroclaw Medical University, Wrocław, Poland
Introduction and Aims: Patients with end-stage renal disease suffer from immune
disturbances, caused by uremic toxins and influenced by dialysis treatment. It is not
clear whether type of renal replacement therapy (RRT) affects gene profiles in patients
on active transplant waiting list. The aim of the study was to investigate pre-transplant
blood cytokine and apoptosis related gene expression in patients on hemodialysis (HD)
and peritoneal dialysis (PD).
Methods: 87 renal transplant candidates (aged 16-72y., mean 47y., 34F/53M) were
included in the study. Among them 66 patients were treated with hemodialysis and 21
patients with peritoneal dialysis. They were on RRT from 1 to 192 mth, mean 25 mth.
The peripheral blood samples were obtained with PAXgene blood RNA tubes, RNA
was isolated with PAXgene Blood RNA kit (PreAnalytics) and reversely transcribed
with high capacity RNA to cDNA kit (Applied Biosystems). The peripheral blood gene
expression of caspase-3, Fas, p53, FoxP3, IFN-gamma, IL-2, IL-6, IL-8, IL-10, IL-18,
NGAL, TGF-beta, and TNF-alpha were assessed just before transplantation with the
real-time PCR on custom-designed low density arrays (Taqman).
Results: The mean serum expression of examined genes showed no significant
differences between the PD and HD with the exception of FAS, which expression was
increased 1.3x in PD patients compared to HD group ( p<0.05). There was a trend to
increased level of pro-inflammatory cytokines expression in PD group. The clinical
inflammatory parameters (CRP, albumin, cholesterol, haemoglobin levels) did not
differ between the groups. Only pre-transplant serum uric acid concentration was
significantly higher in PD group (6.8 vs 5.4 mg/dL, p<0.05).
Conclusions: Type of the renal replacement therapy exert no effect on cytokine gene
expression as well as inflammatory clinical parameters.
PROVIDING IN BETWEEN MEALS DURING DIALYSIS
TREATMENT DAYS CONTRIBUTES TO AN ADEQUATE
PROTEIN ENERGY INTAKE IN HEMODIALYSIS PATIENTS
Introduction and Aims: Reduced protein intake and imbalance between protein
synthesis and degradation during maintenance hemodialysis treatment are causes of
protein-energy wasting, and predicts morbidity and mortality. The aim of this intervention
study is to achieve adequate protein- and energy intake on days of dialysis treatment.
Methods: Adult hemodialysis patients in a university hospital, receiving three times per
week dialysis treatment, were offered a choice out of seven different in-between meals (± 15
g protein, 240 kcal) during a six week intervention, combined with education focused on
adequate protein-energy intake. Indirect calorimetry and physical activity level were
measured to provide daily energy needs. 24 hour recall was completed for two dialysis days
both before and after intervention.
Results: 23 patients (11 men) were enrolled. Age: 55.4±12.7 years (mean ± SD), BMI: 24.5
±4.4 kg/m2. Before intervention the protein intake was 1.0 g/kg bodyweight (82±37% of
protein requirements) and the energy intake 25±10 kcal/kg bodyweight (85±26% of energy
requirements). Both protein and energy intake were significantly below requirements
( p=0.01). 35% of the patients achieved their protein goal, 39% of the patients achieved
their energy goal. After intervention the protein intake significantly improved to 1.2±0.5 g/
kg bodyweight ( p=0.002) and the energy intake significantly improved to 29±10 kcal/kg
bodyweight ( p=0.005). 61% of the patients achieved their protein goal, 67% of the patients
their energy goal. Patients preferred in-between meals of regular foods instead of protein
Conclusions: Protein- and energy intake on days of dialysis treatment is insufficient in two
out of three hemodialysis patients. This significantly improves by providing an in-between
meal combined with education during dialysis treatment.
THE EFFECT OF PROTEIN PERMEABLE MEMBRANE ON
HUMAN MERCAPTALBUMIN (HMA) IN HAEMODIALYSIS
Kenji Tsuchida1, Daisuke Hirose1, Jun Minakuchi1, Shu Kawashima1 and
1Kawashima Hospital, Tokushima City, Japan, 2Oita University, Oita City, Japan
Introduction and Aims: Oxidative stress is believed to play an important role in the
pathogenesis of critical clinical conditions, such as end stage renal disease or cardiovascular
diseases. Healthy adults have about 70-80% of the human mercaptalbumin (HMA), 25%
of the human nonmercaptalbumin (HNA). In patients with renal dysfunction, the fraction
of HNA in maternal plasma was about twice as high as in control plasma. Oxidative
damage of albumin may impair its function. The aim of study is to investigate the effect of
protein permeable membrane on human mercaptalbumin (HMA)/ human
non-mercaptalbumin(HNA) in haemodialysis patients.
Methods: Dialysis carried out for 6 months with protein-nonleaking dialysis
membrane (PNLD group: in the range of 1.0g/dialysis session), and with
protein-leaking dialysis membrane (PLD group: in the range of 9.1g/dialysis session).
Of 18 patients on HD, the PNLD group (5 male, 3 female, mean age: 65.3 years, 156
months HD duration, serum albumin level 37.0g/L) consisted of 8 patients, and the
PLD group (4 male, 6 female, mean age: 61.3, 132 months HD duration, serum
albumin level 38.0g/L) consisted of 10 patients. The treatment conditions were as
follows: HD: 4hours at QB 250mL/min, and QD total 500mL/min. The FB 210Ueco
(Triacetate membrane; Nipro Co., Ltd., Osaka, Japan) was used for PNLD, and
FB-210FHeco (Triacetate membrane; Nipro Co., Ltd., Osaka, Japan) for PLD. Blood
samples for biochemical data were collected monthly, before and after dialysis session.
Determination was made of the following parameters: Serum; total protein, albumin
(BCG method), HMA/HNA ratio of albumin by using high-performance liquid
chromatography, and normalized protein catabolic rate (nPCR), geriatric nutritional
risk index (GNRI), and creatinine index (CreIND) were calculated.
Results: In the PLD group, both serum albumin (from 38.0 to 34.0g/L) and total
protein (from 63.0 to 58.0g/L) decrease after 6 months. However, HMA/HNA ratio of
albumin significantly increases in the PLD group. In the PNLD group, serum albumin
and total proteins have not changed during observation periods, and there are not
significantly changes HMA/HNA ratio of albumin. GNRI, nPCR, and CreIND have
not changed in both groups during observation periods.
Conclusions: In HD patients, oxidative stress, and HNA accumulation can be treated
by using different approaches, but it is of primary importance to improve the overall
quality of the dialysis therapy. Dialysis using protein-leaking dialysismembrane is
effective of increase of HMA. In fact, albumin is the most abundant proteinaceous
solute removed by dialysis using a PLD, and might significantly contribute to the
mechanism proposed above to sustain a large solute accumulation and the
inflammatory loop in patients with ESRD.
USEFULNESS OF BIOELECTRICAL IMPEDANCE ANALYSIS
FOR ASSESSING NUTRITIONAL STATUS IN HEMODIALYSIS
Jung Eun Lee1, Gi Young Yun2, Hoon Young Choi2, Songmi Lee3, Woojeong Kim3,
In Young Jo3, Sung Kyu Ha2, Hyung Jong Kim4 and Hyeong Cheon Park2
1Yongin Severance Hospital, Yonsei University College of Medicine, Yongin,
Republic of Korea, 2Gangnam Severance Hospital, Yonsei University College of
Medicine, Seoul, Republic of Korea, 3Gangnam Severance Hospital, Seoul,
Republic of Korea, 4Bundang CHA Medical Center, CHA University, Seongnam,
Republic of Korea
iii | Abstracts
Introduction and Aims: Nutritional status in dialysis patients should be evaluated
comprehensively through a variety of indicators such as body mass index (BMI),
muscle mass, protein intake, edema and body function. However, assessment of body
composition and muscle mass is not being practically because of the hassle of measure
and high cost. Bioelectrical impedance analysis (BIA) is a non-invasive and low cost
method which easily able to evaluate body composition. The aim of this study is to
evaluate the relationship between various indicators by BIA and nutritional status in
hemodialysis (HD) patients.
Methods: We prospectively enrolled 61 HD (male 35, mean age 60±12 years, 30 of
them diabetic) patients. In 60 patients of them, we measured various data;
anthropometric data such as BMI, triceps skinfold (TSF), mid-arm circumference
(MAC), mid-arm muscle circumference (MAMC), handgrip strength; laboratory data
such as total protein, albumin, total iron-binding capacity (TIBC), hemoglobin, total
cholesterol, blood urea nitrogen (BUN), creatinine, high sensitivity C-reactive protein
(hsCRP) ; BIA data such as phase angle (PhA), fat free mass (FFM), body cell mass
(BCM), total body water (TBW), extra cellular water (ECW)/total body water (TBW)
ratio; and traditional nutritional assessment method for dialysis patients like
malnutrition-inflammation score (MIS).
Results: In men, the MAC, MAMC, handgrip strength, BUN, creatinine, MIS, PhA,
FFM, BCM, TBW was higher, and total cholesterol and ECW/TBW ratio was lower
than those of woman. In correlation analysis between PhA, which is one of BIA
markers, and various nutritional markers, PhA was positively associated with BMI,
MAC, MAMC, handgrip strength, BUN, creatinine, albumin and TIBC ( p<0.05). But,
PhA was negatively associated with hsCRP and MIS ( p<0.01). The FFM, BCM, and
TBW measured by BIA were positively associated with BMI, MAC, MAMC, handgrip
strength, and negatively associated with hsCRP and MIS ( p<0.01). ECF/TBW ratio was
negatively associated with MAC, MAMC, handgrip strength, TIBC, BUN, and
creatinine. In univariate analysis, MAC, MAMC, handgrip strength, PhA, ECF/TBW,
hsCRP and MIS were associated with serum albumin, which is a traditional nutritional
marker ( p<0.05). In multivariate analysis, PhA and hsCRP were independently
associated with serum albumin level.
Conclusions: The PhA, FFM, BCM, TBW and ECW/TBW ratio measured by BIA were
highly associated with traditional markers of nutritional status in HD patients. Among
them, PhA well reflected nutritional status in hemodialysis patients. Therefore, our
results indicated that the measurements of BIA might be a clinically useful method for
assessing nutritional status in HD patients.
YKL-40: A NEW URAEMIC TOXIN?
Massimiliano Migliori1, Alessia Scatena2, Vincenzo Cantaluppi3, Alberto Rosati4,
Francesco Pizzarelli5 and Vincenzo Panichi2
1Ospedale USL12 Toscana, Lido di Camaiore, Lucca, Italy, 2USL12 Toscana, Lido
di Camaiore, Lucca, Italy, 3Università Di Torino, Torino, Italy, 4USL 2 Lucca,
Toscana, Lucca, Italy, 5Ospedale Firenze Osma, Firenze, Italy
Introduction and Aims: In the last few years there has been a growing number of
publications concerning YKL-40, a 40 Kd glycoprotein mainly produced by
inflammatory and cancer cells. YKL-40 regulates vascular endothelial growth factor
and has a role in inflammation, angiogenesis, cell proliferation and differentiation.
Recently has been established that serum YKL-40 has a prognostic impact on all-cause
mortality in patients with hearth failure and has been introduced as a marker of
inflammation in different clinical situations, also in chronic kidney disease. The aim of
this study was to investigate serum YKL-40 concentrations in chronic renal failure
patients (CKD5) in conservative therapy and in dialysis therapy compared to healthy
subjects and to explore its relationships with interleukin-6 (IL-6), C-reactive protein
(CRP), and Hepcidin (HEP). Furthermore we investigated if YKL-40 serum levels are
influenced by different dialysis techniques.
Methods: The study population included low inflamed hemodialytic patients (N =13),
CKD5 patients not receiving dialysis (N=6) and healthy subjects (N = 6). HD patients
were treated in bicarbonate hemodialysis (BHD) with low flux polysulphone (PS)
membrane group for six months. At the end they were shifted in On-line
hemodiafiltration (OL-HDF) group with high flux PS membranes and exchange
volume > 20 litres. Serum was collected at the end of each treatment period. Routine
laboratory analysis, IL-6 and CRP levels were determined by local laboratory, instead
hepcidin (HEP) and YKL-40 serum concentration was centrally determined by ELISA
kit (DRG Instruments GmbH, Germany and Quidel Corporation San Diego, USA,
respectively). Resistance to EPO was determined as ERI (weekly ESA dose/Kg/
Hemoglobin). Data were analyzed using X² Test e Mann-Whitney test and Spearman’s
correlation coefficient. The null-hypothesis was rejected when p<0.05.
Results: YKL-40 serum levels were significantly higher in CKD5 and HD patients
respect to healthy controls (437.6±83 ng/ml and 389.48±110.3 vs 72.7±8.3 ng/ml,
p<0.01). Difference between CKD5 and HD was not statistically significant. Moreover,
YKL-40 levels were lower in OL-HDF (374.25±112.6 ng/ml) than in BHD (404.7
±110.23 ng/ml) but the difference was not statistically significant ( p=0.20). In HD
patients YKL-40 was significantly related ( p=0.036) with ERI but not with CRP, IL-6,
Conclusions: YKL-40 serum levels were increased in patients affected by chronic renal
failure. In low inflamed HD patients YKL-40 was not related to CRP and IL-6, but
demonstrated a positive relation with ERI. This data suggest that YKL-40 in HD was
enhanced also by a mechanism independent by inflammation and may act as an
CUTOFF VALUE OF SERUM PROCALCITONIN AS
DIAGNOSTIC BIOMARKER OF INFECTION IN END-STAGE
RENAL DISEASE PATIENTS
Byung Chul Shin1, Hyun Lee Kim1 and Jong Hoon Chung1
1Chosun University Hospital, Gwangju, Republic of Korea
Introduction and Aims: Serum procalcitonin (PCT) levels are low levels in healthy
individuals but are elevated in patients with a serious bacterial infection or sepsis.
Although serum PCT reflects severity of infection, it has been shown it is increased in
chronic renal failure patients and in dialysis patients without an infection. In this study,
we examined the ability of serum PCT concentration to diagnose infections in
end-stage renal disease (ESRD) patients, and sought to an appropriate threshold level
Methods: Serum PCT levels were measured in ESRD patients on antibiotic therapy for
a suspected bacterial infection (iESRD group, n=21), and compared with those of
ESRD patients on hemodialysis without any sign of infection (cESRD group, n=20).
Receiver operating characteristic curve analysis was performed to determine a cut-off
value for the diagnosis of an infection or systemic inflammatory response syndrome
Results: Mean serum PCT concentration of the iESRD group was significantly higher
than in the cESRD group (2.95±3.67 ng/mL vs. 0.50±0.49 ng/mL, p=0.006), but serum
PCT concentrations were not correlated with severity of infection. The optimized
threshold level derived for serum PCT was 0.75 ng/mL rather than 0.5 ng/mL currently
used, and this threshold demonstrated a sensitivity and specificity of 76.2% and 80.0%
for infection and of 100% and 60.6% for SIRS, respectively as compared with a cutoff of
Conclusions: The study suggests that serum PCT at a cut-off value of 0.75 ng/mL is an
appropriate indicator of infection in ESRD patients.
ASSESSMENT OF APPETITE AND NUTRITIONAL STATUS IN
Introduction and Aims: Hemodialysis patients frequently experience loss of appetite
(anorexia), which increases in severity during the dialysis treatment and may lead to
protein-energy wasting. Appetite in patients on chronic hemodialysis (HD) may be
depressed constantly or may fluctuate up and down over time. When constantly fair/
poor, appetite has been shown to be associated with older age, more comorbidities, and
more hospitalizations and might be predicts survival. The aim of the study was to
determine the appetite in patients on chronic HD and the correlation between appetite
and the other parameters of nutritional status.
Methods: 89 HD patients (mean age 64.8±13.6) were evaluated for the appetite and the
nutritional status. Appetite was assess by SNAQ (Short Nutritional Assessment
Questionnaire). The nutritional status was determinated by a Subjective Global
Assessment (SGA) method, serum albumin concentration and anthropometric
measurements. The adequacy of dialysis treatment was estimated by Kt/V.
Results: Appetite was decreased (very poor, poor or average) in 37,1% of patients,
28,1% patients declared bad food tastes and 7,8% eating normally less than three meals
a day. SGA indicated that 44.9% of patients were mild malnourished, 3.3% were severe
malnourished. Low s-albumin level was observed in 46.6% patients. No correlation
between appetite and SGA and s-albumin was noticed. The multifactorial regression
analysis indicated that age of patients was factor significantly influenced on appetite in
Conclusions: Decreased appetite and abnormal taste are important problems in
hemodialysis patients increases with age of patients. SNAQ may be usefull in practice
for quickly estimation of appetite and risk of malnutrition. HD patients need thorough
nutritional/appetite evaluation to prevent of protein-energy wasting.
OXIDATIVE STRESS MARKERS IN CKD 5D PATIENTS
Mykola Kolesnyk1, Natalia Stepanova1, Lesya Korol1, Mykola Kulizkyi1,
Olena Ablogina1 and Ludmila Migal1
1State Institution «Institute of Nephrology of the National Academy of Medical
Sciences», Kyiv, Ukraine
Introduction and Aims: Oxidative stress is resulted by the imbalance in production of
free radicals and antioxidant activity. It is wide-spread opinion that in dialysis patients
oxidative stress is associated with chronic inflammation. We identified that only few
cross sectional studies described the markers of lipid peroxidation and antioxidant
status of different dialysis modalities. The objective of our investigation was to compare
the oxidative stress degree in three groups of patients using different dialysis
techniques: a) continuous ambulatory peritoneal dialysis (CAPD), b) hemodialysis
(HD) three times / week, and c) haemodiafiltration (HDF) three times / week.
Methods: We examined several serum markers of oxidative stress as follows:
malondialdehyde (MDA), ceruloplasmin (CP) and transferrin (TF) in 47 dialysis
patients (18 CAPD patients, 15 HD patients, and 14 HDF patients), aged 31 to 70 years
(mean 49.3±12.7 years). There were two diabetics in each group. All patients were
examined before a dialysis session. Patients received dialysis treatment more than 12
months. The statistical analysis was performed using MedCalc.
Results: Oxidative stress was detected in each of the three groups. The MDA level was
the highest in HD patients in compared with HDF patients (P=0.88) and patients of
CAPD group (P=0.03) (Table). Antioxidant proteins CP and TF did not differ
significantly between HD and HDF groups (P=0.9 and P=0.5, respectively). But, the
patients of CAPD group showed the highest level of TF (P=0.03 in compared with HD
patients). The CP concentration was significantly higher in patients on HDF compared
with CAPD (P<0.001).
Conclusions: In CKD 5D patients we identified the different type of lipid peroxidation
and antioxidant defenses. However, the oxidative stress is a common event in end stage
renal diseases, regardless of the kind of dialysis technique.
SP667 Mean Values of Oxidative Stress Markers in CKD 5D Patients (* P<0.05 for
CAPD versus HD)
Markers of oxidative stress
EFFECT OF BCAA-CONTAINING FOOD IN IMPROVING THE
MALNUTRITION OF ELDERLY HEMODIALYSIS PATIENTS
Introduction and Aims: In recent years, the number of elderly patients on long-term
dialysis has increased, resulting in a higher incidence of malnutrition in these patients.
This study investigated whether the continuous ingestion of food containing Branched
Chain Amino Acid (BCAA; valine, leucine, isoleucine) can improve the nutritional
state of elderly patients on dialysis suffering from malnutrition.
Methods: 26 hemodialysis patients (12 men, 14 wemen) were chosen from a total of 57
people subjected to dietary management in our hospital and nursing home. They were
not undergoing tube feeding, and their Alb was under 3.5 g/dl. The patients were
divided in two groups: those who were able to continue consuming galette-like food
containing BCAA (4000 mg/portion) for 9 months (Group C; 6 subjects, average age:
81.4 ± 4.8 years, average number of years on dialysis: 9.0 ± 4.1 years) and those
consumed foods for only 3 months and then stopped (Group I; 20 subjects, average age
78.9 ± 6.2 years, average number of years on dialysis: 6.8 ± 4.4 years). We performed
comparative studies of BCAA concentration in the blood, Alb, hs-CRP and appetite
before and at 3 and 9 months after the onset of biscuit consumption.
Results: During the 3-month period between February and May 2013, the subjects
tried consuming the foods containing BCAA, and they did not have to pay for the
foods. However, subjects in Group I stopped consuming BCAA foods after 3 months
because they were required to pay for the foods from that moment on. The daily
average amount of BCAA ingested by subjects in Group C was 3828.7 mg, whereas that
in Group I during the first 3 months was 2075.9 mg. All subjects consumed one food
per meal; they broke the foods into pieces and softened by placing them into hot water
before consuming. In Group C, BCAA concentration in the blood showed significantly
high values, as can be seen from the following data (the values are in nmoL/mL).
February 2013: valine 176.1 ± 44.2; leucine 88.2 ± 30.7; isoleucine 60.2 ± 20.8. May
2013: valine 296.4 ± 120.0; leucine 219.0 ± 124.2; isoleucine 117.0 ± 67.2. November
2013: valine: 231.9 ± 73.7; leucine 162.1 ± 91.5; isoleucine 91.2 ± 53.3. February 2013:
BCAA 324.5 ± 90.0; Fischer ratio 2.8 ± 0.6. May 2013: BCAA 632.4 ± 308.6; Fischer
ratio 5.5 ± 2.3. November 2013: BCAA 485.2 ± 217.4; Fischer ratio 4.3 ± 1.4. The
corresponding values for subjects in Group I after 3 months of foods consumption
were significantly higher, as can be seen from the following data: valine increased from
194.7 ± 49.7 to 232.6 ± 58.2; leucine increased from 88.2 ± 30.7 to 135.9 ± 56.2; and
isoleucine increased from 60.2 ± 20.8 to 77.4 ± 34.0 nmoL/mL. However, 6 months
after the patients stopped consuming BCAA foods (i.e., at November 2013), valine
decreased to 181.6 ± 48.7, leucine decreased to 100.4 ± 31.9, and isoleucine decreased
to 84.5 ± 80.7 nmoL/mL. No significant differences were observed for Alb, hs-CRP, or
Conclusions: It is difficult to supply a sufficient amount of BCAA only through meals
to elderly hemodialysis patients suffering from malnutrition; therefore, providing
BCAA-containing food to patients who are able to orally ingest food effectively
improves their nutritional state. In addition, BCAA concentration decreased after the
subjects in the group I stopped eating BCAA foods; this shows that the regular
consumption of BCAA-containing food adjusts the amino acid balance, which is
necessary for protein synthesis in the body. However, the cost of BCAA-containing
food makes it difficult to continue their consumption.
INFLUENCE OF PERSISTENT OVERHYDRATION ON
HEMODIALYZED PATIENTS' CARDIOVASCULAR
COMPLICATIONS AND NUTRITIONAL DETERIORATION
Introduction and Aims: Patients with end-stage renal disease on maintenance
hemodialysis (HD) are at increased risk of fluid imbalance leading to persistent
overhydration which influences crucial vital parameters and long-term survival
prognosis. The aim of the study was to assess the impact of HD patients’ hydration
state on cardiovascular (CV) injury and nutritional condition.
Methods: The study comprised 304 patients (198 M, 106 F) undergoing chronic HD
who were divided into 3 subgroups with regard to overhydration to body weight ratio
(OH). GrA consisted of 89 pts (53 M, 36 F; mean age 60.9±11.2) with OH<1.5%. GrB
featured 102 pts (64 M, 38 F; mean age 62.1±11.9) with OH 1.5-3.5% while GrC - 81
pts (49 M, 32 F; mean age: 59.2±13.1) with OH>3.5%. Analyzed parameters included
OH and nutritional state parameters (NS): Body Mass Index (BMI), Lean Tissue Index
(LTI) and Fat Tissue Index (FTI) measured with bioimpedance analysis (using BCM),
subjective global assessment (SGA), serum albumin (alb), cardiac troponin T (cTnT),
and hemoglobin (Hb).
Results: Our study revealed a significant negative influence of OH% on CV risk
markers represented by cTnT elevation (GrA vs. GrB vs. GrC: 0.053±0.039 vs. 0.068
±0.045 vs. 0.108±0.071 ng/ml; p<0.001) and NS parameters including: alb (4.04±0.37
vs. 4.02±0.32 vs. 3.73±0.40 g/dl; p<0.001), SGA (9.16±2.50 vs. 8.48±2.02 vs. 9.85±2.41;
p<0.05), BMI (28.68±4.55 vs. 26.61±3.66 vs. 24.31±3.17 kg/m2; p<0.001), and FTI
(15.98±5.16 vs. 14.15±3.65 vs. 10.74±3.26 kg/m2; p<0.001). Furthermore, increase of
OH% was related with reduction of residual daily diuresis (1171±65 vs. 1141±588 vs.
335±363 ml; p<0.001) and Hb concentration (11.29±1.27 vs. 11.06±1.07 vs. 10.42±1.17
Conclusions: Persistent overhydration is a negative risk factor for nutritional condition
impairment, which is a component of malnutrition-atherosclerosis-inflammation
(MIA) syndrome developing in subjects undergoing maintenance HD. Moreover, OH
has an impact on the incidence rate of CV complications, which are the most common
cause of death in this group of patients.
iii | Abstracts
IMMUNE RESPONSE DETERIORATION BY SLEEP
DISTURBANCE AND LONGER DIALYSIS VINTAGE IN
Galina Severova Andreevska1, Lada Trajceska1, Saso Gelev1, Pavlina Dzekova1,
Gjulsen Selim1 and Aleksandar Sikole1
1University Clinic of Nephrology, Skopje, Republic of Macedonia
Introduction and Aims: This study aimed to assess whether sleep disturbance is
associated with immune response and could predict magnitude of antibody response to
the novel antigene of Hepatitis B in vaccinated dialysis patients.
Methods: We prospectively studied the evolution of HBsAg antibody (HBsAb) after
primary vaccination (three doses; Engerix B, 40 pg i.m at 0, one and 6 months) in 91
seronegative dialysis patients from 2009 to 2012. Also, we assessed dialysis adequacy
(Kt/V), predialysis albumin and CRP before vaccination and the anti-HBs titer one
month after completed vaccination.
Results: The mean age was 57.65± 12.94, dialysis vintage 47.23±54.63 months and 54%
were men. 21(23%) patients were non-responders (HBsAb100 IU/L). HBsAb titer
showed no association with age, serum albumin Kt/V and CRP ( p>0.05). The
regression analysis showed that dialysis vintage and presence of sleep disturbance were
strongly and inversely associated with immune response (β=-0.309, p=o.o1; β=-0.252,
p=0.008, respectively). In the multivariate model the presence of sleep disturbance and
longer vintage predicted lower antibody level, explaining 16% of the population.
Conclusions: Dialysis patients should be vaccinated against Hepatitis B as soon as
possible at start, or in predialysis period of the disease. Sleep disturbance negatively
affects immune response.
VITAMIN D DEFICIENCY IS PREDICTED BY AGE, GENDER
AND CARDIAC FUNCTION IN DIALYSIS PATIENTS
Lada Trajceska1, Galina Severova Andreevska1, Irena Rambabova Busletik1,
Saso Gelev1, Svetlana Pavleska Kuzmanovska1, Pavlina Dzekova Vidimiski1,
Gjulsen Selim1 and Aleksandar Sikole1
1University Clinic of Nephrology, Skopje, Republic of Macedonia
Introduction and Aims: Vitamin D deficiency is almost universal in patients with
kidney disease especially during the winter, and in black race. This study aimed to
identifier risk factors for nutritional vitamin D deficiency in the dialysis population.
Methods: We routinely measured clinical and demographic factors that could identify
patients who are deficient in vitamin D. The study cohort consisted of 80 dialysis
patients. Patients receiving any kind of Vitamin D preparations 6 months prior the
study were excluded. Using logistic regression modeling, with vitamin D deficiency as
the dependent variable, we generated predictive models from routinely determined
clinical and demographic data.
Results: Vitamin D deficiency, defined as 25-hydroxyvitamin D levels of less than 30
ng/mL, was present in 88% of the study population. In the Univariate analysis the
younger age, female gender, lower albumin level (serum albumin levels ≤ 3.5 g/dL),
higher CRP, and lower Heart Ejection Fraction, were strongly associated with lower
levels of Vitamin D (β=0.292, p=0.014, β=0.260, p=0.015, β=0.198, p=0.05, β=-0.179,
p=0.045, β=0.243, p=0.031), respectively. Furthermore, the higher required
Erythropoietin dose was significantly associated to lower Vitamin D levels (β = -0.184,
p=0.05). In the final model as mightiest predictors of vitamin D deficiency remained
female sex, gender and Cardiac function (β=0.426, p=0.001, β=0.278, p=0.016, β=0.301,
Conclusions: Clinical factors predict low 25-hydroxyvitamin D levels, further study are
needed to prove the clinical benefit of the deficiency correction. The inflammation,
nutrition and Cardio-Vascular comorbidities should be of prior interest.
EFFECT OF HIGHER CONVECTION ON THE CHRONIC
INFLAMMATORY MARKERS: COMPARISON BETWEEN
MIDDILUTION AND TRADITIONAL POST-DILUTION
Introduction and Aims: Chronic inflammation is widely diffuse in maintenance
haemodialysis (HD) patients and is associated with poor survival. Middilution (MID)
is a novel dialytic technique that could improve inflammatory status by increasing
convective clearance. However this topic is unknown. The aim of this prospective
cross-over study was to compare the effect of an higher to a lower convection rate on
inflammatory biomarkers in HD patients.
Methods: After a 1 month run-in period of bicarbonate dialysis, chronic HD patients
were shifted with a cross-over design to a higher convection treatment by Middilution
(MID) or a lower convection treatment by post-dilution hemodiafiltration (HDF). Each
study period of 4 months was followed by 1 month of HD and the total duration of the
study was 9 months. Primary outcome was the change of serum levels of C reactive
Protein (CRP), IL-6, IL-1, IL-10, TGF-β, TNF-α, β2-Microglobulin, albumin and
prealbumin, monthly assessed, during four months of each treatment. Repeated
Measures ANOVA or Friedman test was performed according the distribution of each
Results: Ten HD patients were enrolled (age:64.9±12.6 years; dialytic vintage: 10.6
(2.7-16.2) years; 70% males). Mean convection volume was 40.6±2.6 L/session (of
which 26.5±1.7 L/session in post-dilution) in MID and 16.8±2.1 L/session in HDF. In
MID we registered a reduction of CRP from 11.3 [3.2-31.0] to 3.1[1.4-14.4] mg/L
(P=0.007), IL-6 from 12.7 [5.0-29.7] to 8.3 [4.4-14.0] pg/mL (P=0.003), TGF-β from
10.6[7.4-15.6] to 7.4[5.9-9.3] ng/mL (P=0.001) and β2-Microglobulin from 39.0±9.4 to
30.1±9.1 mg/L (P<0.0001). In HDF a significant reduction of CRP from 8.5 [3.2-31.0]
to 4.6 [3.2-31.0] mg/L ( p=0.037) and β2-Microglobulin from 39.4±9.3 to 30.1±9.1 mg/
L was detected (P<0.0001). In MID the percentage changes of serum CRP and IL-6
were correlated with post-dilutional convective volume [R=0.73 (P=0.018) and R=0.71
Conclusions: MID is associated with an attenuation of inflammatory pattern that
seems to be correlated with higher convective volume.
NEUTROPHI˙L TO LYMPHOCYTE AND PLATELET TO
LYMPHOCYTE RATIO: A NOVEL MARKERS OF
INFLAMMATION IN CHRONIC HAEMODIALYSIS PATIENTS
Elbis Ahbap1, Ekrem Kara1, Taner Basturk1, Tamer Sakaci1, Yener Koc1,
Tuncay Sahutoglu1, Cuneyt Akgol1, Mustafa Sevinc1, Zuhal Atan Ucar1 and
1Sisli Etfal Educational and Research Hospital, Istanbul, Turkey
Introduction and Aims: Neutrophil-to-Lymphocyte Ratio (NLR) and
Platelet-to-Lymphocyte Ratio (PLR) are new potential markers to determine
inflammation in end-stage renal disease (ESRD) patients. The association between
malnutrition, inflammation and appetite with PLR and NLR are lacking in
hemodialysis (HD). Hence, we aimed to determine the relationship between PLR and
NLR with malnutrition, inflammation and appetite in ESRD patients.
Methods: One-hundred patients receiving HD for ≥3 months in the dialysis unit of
Sisli Etfal Educational and Research Hospital were enrolled in this cross-sectional
study. Patients with hospitalization, major surgery, obvious infections, inflammatory
disease, end stage liver disease, metastatic malignancies and malabsorbsion syndromes
were excluded. To determine malnutrition and inflammation status, malnutrition
inflammation score, hs-CRP and TNF-α levels were obtained from all patients.
Results: Mean age of 100 patients (Male/Female: 52/48) were 52.3±17.4 years. Group 1
(MIS ≤ 2), group 2 (MIS: 2-8) and group 3 (MIS > 8) consisted of 9, 64, 27 patients,
respectively. Mean duration time on HD were less in group 1 ( p=0.035). There were no
differences regarding age, gender, ethiology, delivered dialysis dose between the groups.
As expected, Group 3 (MIS > 8) patients had lower dry weight ( p=0.008), BMI
( p=0.002), triceps scinfold thickness (mm) ( p=0.002), predialysis serum urea
( p=0.020), creatinine ( p=0.004), phosphorus ( p=0.015), CaxP ( p=0.008), prealbumin
( p=0.001), albumin ( p=0.001), TIBC ( p=0.001) which means worse nutritional status.
There were no significant difference between 3 groups about leptin, leptin/BMI,
hs-CRP, TNF-α and NLR but PLR was founded significantly higher in group 3
compared to group 1 ( p=0.007). NLR and PLR were positively correlated with hs-CRP
( p=0.001, r=+0.333 and p=0.008, r=+0.262, respectively) and negatively correlated
with transferrin saturation (%) ( p=0.001, r=-0.418 and p=0.002, r=-0.309,
respectively). There were no significant corellation between NLR and PLR with MIS,
serum leptin levels.
Conclusions: NLR and PLR seems to be positively correlated with inflammation
parameters in chronic HD population. PLR but not NLR were significantly high in
malnourished group with MIS > 8.
RANDOMIZED PROSPECTIVE STUDY OF HIGH CUT-OFF
DIALYZER MEMBRANES TO REDUCE INFLAMMATION IN
CHRONIC HEMODIALYSIS PATIENTS: THE PERCI-I TRIAL
Matthias Girndt1, Roman Fiedler1, Peter Martus2, Michael Pawlak3, Markus Storr4,
Torsten Boehler4, Markus Templin3, Bogusz Trojanowicz1, Christof Ulrich1,
Marcus Glomb1, Kristin Liehr1, Kristin Werner4, Daniel Zickler5 and Ralf Schindler5
1Martin-Luther-University Halle, Halle, Germany, 2Eberhard-Karls-University
Tübingen, Tübingen, Germany, 3NMI Technology Transfer GmbH, Reutlingen,
Germany, 4Gambro Dialysatoren GmbH, Hechingen, Germany, 5Charite-Virchow
Clinic, Berlin, Germany
Introduction and Aims: Chronic hemodialysis patients suffer from enhanced
cardiovascular morbidity and mortality, part of which may be caused by systemic
inflammation. It is hypothesized that inflammation is promoted by the lack of
clearance for immunoactive proteins within the molecular weight range of 15-45 kD,
substances that are effectively cleared by the kidneys in healthy individuals. High
cut-off (HCO) dialyzer membranes have an enhanced clearance for these molecules,
however, their chronic use may be limited by albumin losses. Short pilot studies have
suggested that treatment for three weeks may be tolerable and effective regarding the
reduction of inflammation.
Methods: The “Permeability Enhancement to Reduce Chronic Inflammation (PERCI)”
Study I is a prospective bi-centric randomized open-label cross-over trial comparing a
combination of the high cut-off dialyzer HCO1100 and the low-flux dialyzer PF14L
(HCO/LF) with a PF210H high-flux membrane (HF) for treatment of chronic
hemodialysis patients. The HCO and LF dialyzer were applied in series to achieve
adequate urea clearance. Patients were treated for three weeks (9 dialysis sessions).
After a subsequent two week wash-out period patients were switched from study
treatment to comparator or vice versa. Blood was sampled at adequate time points
preand post dialysis to detect a broad panel of plasma cytokine concentrations. Primary
end-point was the quantity of CD162 expression on circulating monocytes indicating
inflammatory activation. Further, transcription of inflammation associated genes was
measured by qPCR in leucocytes. This work was supported by the German Federal
Ministry of Education and Research (BMBF, FKZ 13N11796-99).
Results: Treatment with HCO/LF was well tolerated for three weeks. A preliminary
safety evaluation showed that both treatments were safe. The primary end point was
missed; HCO dialysis did not reduce the expression of CD162 on monocytes. However,
mRNA for IL-6 and TNF-a as well as plasma concentrations of soluble TNF receptors
were significantly reduced by HCO treatment. There was a clear signal that
antiinflammatory effects were more pronounced at week 3 than at week 2. Serum
albumin decreased by 5,7 g/l during HCO treatment while remaining stable in the
control group. None of the patients needed albumin replacement.
Conclusions: While the primary end point of reduction of the proinflammatory
marker CD162 on monocytes was missed, the trial gives clear hints that
antiinflammatory effects of HCO treatment are achievable. Most likely, prolonged
treatment might lead to stronger effects. However, albumin losses seem to be
prohibitive. The trial justifies the development of more selective membranes with
similar clearance of immunoactive proteins and much less albumin loss.
BIOIMPEDANCE PHASE ANGLE AS A PARAMETER OF THE
NUTRITIONAL STATUS FOR HEMODIALYSIS PATIENTS
Konstantin Aleksandrovich Vishnevskii1,2, Roman Pavlovich Gerasimchuk1 and
Alexander Yurievich Zemchenkov1
1St.-Petersburg State Healthcare Institution «City Mariinsky Hospital»,
St.-Petersburg, Russian Federation, 2First Pavlov State Medical University,
St.-Petersburg, Russian Federation
Introduction and Aims: There are sufficient evidences of the necessity to monitor the
nutritional status of dialysis patients. For this purpose there are special methods of
physical examination, laboratory markers and questionnaires. Additional procedure for
diagnostic the violations of nutritional status in screening mode is the bioimpedance
analysis, which is a direct method and almost free from human errors. Phase Angle
(PA) is the most accurate parameter in assessing the nutritional status by
bioimpedance, because its value is determined by the potential of cell membranes and,
therefore, provides insight into the nutritional status at the cellular level. The aim of
this study was to determine the adequacy of the assessment of nutritional status for
hemodialysis (HD) patients by using the PA.
Methods: Total 66 HD patients were included in the study. The mean age was 60±14
years, mean duration of renal replacement therapy was 68±57 months. Bioimpedance
measurement was performed on phase-sensitive bioimpedance analyzer
NutriGuard-M (Data Input GmbH), at the start of the HD and 15 minutes after the
HD. PA was determined at a frequency of 50 kHz and analyzed in each bioimpedance
dimension. The upper arm muscle area and triceps skinfold were measured before HD.
Serum albumin, phosphorus, C-reactive protein (CRP) were determined before dialysis
as biochemical markers of nutritional status. Also the calculation of the protein
catabolic rate (nPCR) was performed.
Results: The following average values of the PA were obtained: before HD 5,2±1,2º,
after HD 5,9±1,2º. There was an inverse correlation between the PA and the patient's
age (before HD r = - 0,65, p<0.001; after HD r = - 0,60, p<0.001) and CRP (before HD
r = - 0,31, p<0.05; after HD r = - 0,26, p<0.05). Also revealed positive direct correlation
between the PA and the serum albumin level (before HD r = 0,43; p<0.001, after HD r
= 0,56, p<0.001), serum phosphate level (before HD r = 0,35, p<0,01), nPCR (before
HD r = 0,41, p<0.001; after HD r = 0,27, p<0.05) and the upper arm muscle area
(before HD r = 0,31, p<0.05; after HD r = 0,26, p<0.05). Stepwise regression analysis
with the exception of the variables confirmed the independent effect of age, CRP,
serum albumin, nPCR and upper arm muscle area to the level of the PA.
Conclusions: Bioimpedance PA is appropriate parameter in the integrated assessment
of the nutritional status for hemodialysis patients and it can be used as a screening
marker of the nutritional disorders.
EFFECT OF AGING IN THE PERCEPTION OF HEALTH
RELATED QUALITY OF LIFE, DIALYSIS ADEQUACY, IRON
STATUS, INFLAMMATION AND NUTRITIONAL MARKERS IN
END STAGE RENAL DISEASE PATIENTS UNDER ONLINE
Alexandra Moura1, José Madureira2, Pablo Alija2, João Carlos Fernandes2, José
Gerardo Oliveira3, Martin Lopez4, Madalena Filgueiras5, Leonilde Amado6,
Maria Sameiro-Faria6, Vasco Miranda6, Margarida Vieira1, Alice Santos-Silva7,8 and
1Instituto de Ciências da Saúde, Universidade Católica Portuguesa, Porto,
Portugal, 2Nefroserve, Barcelos, Portugal, 3Centro Hospitalar do Porto, Porto,
Portugal, 4CHF, Felgueiras, Portugal, 5CHD, Gondomar, Portugal, 6Nephrocare,
Maia, Portugal, 7Faculdade de Farmácia, Universidade do Porto, Porto, Portugal,
8IBMC, Porto, Portugal
Introduction and Aims: A high proportion of dialysis patients are older, raising a
major challenge to health care systems, as they often show several comorbidities, poor
functional status, depression and they often avoid personal and social involvement.
There is a lack of information about the effect of aging in patients’ perception of health
quality of life (HRQOL), and in clinical and analytical characteristics of dialysis
patients, particularly in end-stage renal disease (ESRD) patients under
online-hemodiafiltration (OL-HDF). We aimed to evaluate how aging could influence
patients’ perception of HRQOL, as well as, the effect of aging on dialysis adequacy and
in hematological, iron status, inflammatory and nutritional markers.
Methods: In this transversal study were enrolled 322 ESRD patients under OL-HDF
(59.63% males; 64.9 ± 14.3 years old). Data about comorbidities, hematological data,
iron status, dialysis adequacy, nutritional and inflammatory markers were collected
iii | Abstracts
from patient’s records. Moreover, HRQOL score, by using the Kidney Disease Quality
of Life-Short Form (KDQOL-SF), were assessed.
Results: Analyzing the results according to quartiles of age, significant differences were
found for some parameters evaluated by the KDQOL-SF instrument, namely for work
status, physical functioning and role-physical, which decreased with increasing age. We
also found a higher proportion of diabetic patients, a decrease in creatinine, iron,
albumin serum levels, transferrin saturation and nPCR, with increasing age. Moreover,
significant negative correlations were found between age and MCHC (r=-0.190;
p=0.001), iron (r=-0.207; p<0.001), transferrin saturation (r=-0.166; p=0.004), albumin
(r=-0.190; p<0.001), nPCR (r=-0.191; r=0.001), work status (r=-0.199; p<0.001),
physical functioning (r=-0.323; p<0.001) and role-physical (r=-0.182; p=0.001).
Conclusions: In conclusion, our results showed that aging is associated with a
decreased work status, physical functioning and role-physical, with a decreased dialysis
adequacy, iron availability and nutritional status, and with diabetes and with the use of
central venous catheter, as the vascular access. The knowledge of these changes
associated with aging, which have impact in the quality of life of the patients, could be
useful in their management.
EXTRACELLULAR WATER CONTENT (ECW) CORRELATES
WITH PLASMA PROINFLAMMATORY CYTOKINES
CONCENTRATION AND PROCALCITONIN IN CRITICALLY ILL
Wojciech Zaluska1, Edyta Kotlinska-Hasiec Kotlinska-Hasiec1, Alicja Zaluska1,
Ziemowit Rzecki1, Przemyslaw Zadora1 and Wojciech Dabrowski1
1Med. University of Lublin, Lublin, Poland
Introduction and Aims: Tissue edema is one of the most important symptoms of
inflammation. It depends on degree of inflammation and plasma proinflammatory
cytokine concentrations. The aim of this study was to assess the relationships between
total body water (TBW), extracellular body water (ECW) and volume excess (VE), and
plasma vascular endothelial growth factor (VEGF), tumour necrosis factor alpha
(TNFα), histamine and interleukin 1β, 6, 17α and 23 and capillary leak index (CLI) in
critically ill patients.
Methods: Adult critically ill patients with acute kidney injury (AKI) were studied.
Patients were divided into: treated with continuous furosemide infusion (furosemide
group) and treated with continuous veno-venous haemofiltration (CVVH group). VE,
TBW and ECW were measured using whole body bioimpedance. CLI was calculated as
CRP/plasma albumin All parameters were measured at three consecutive days: the day
of admission into Intensive Care Unit (ICU), 24 and 48 hours after the admission into
Results: Forty patients were studied. 23 were treated with furosemide infusion and 17
with CVVH. In furosemide group: VE correlated with IL-17α ( p < 0.001, r = 0.43) and
CLI ( p < 0.001, r = 0.5), TBW correlated with VEGF ( p < 0.001, r = 0.54) and IL-17α
( p < 0.001, r = 0.43) and ECW correlated with VEGF ( p < 0.001, r = 0.47). In CVVH
group: VE correlated with TNFα ( p < 0.001, r = 0.46), TBW correlated with VEGF ( p
< 0.01, r = 0.47) and ECW correlated with VEGF ( p < 0.01, r = 0.47) and TNFα ( p <
0.01, r = 0.43). In both groups, changes in VE, TBW and ECW didn’t correlate with
Conclusions: Changes in TBW, ECW and VE correspond with plasma VEGF and
pro-inflammatory cytokines concentration in critically ill patients.
IMROVEMENT OF THE CLINICAL, NUTRITIONAL AND
INFAMMATORY PARAMETERS DURING HIGH FLUX
Aleksandar Sikole1, Lada Trajceska1, Vili Amitov1, Irena R Busletik1,
Pavlina Dzekova1, Gjulsen Selim1, Galina Severova Andreevska1 and Saso Gelev1
1University Clinic of Nephrology, Skopje, Republic of Macedonia
Introduction and Aims: We aimed to investigate the beneficial effect of high-flux
(HFHD) vs. low-flux (LFHD) dialysis on clinical findings in dialysis patients.
Methods: Comparative analysis on dialysis and laboratory data was done in one arm
crossover study. 65 patients were dialyzed 2 years on Low Flux and then crossed on
High Flux dialysis for 2 years. Patients mean age was 53.86 ± 11.49 years, vintage 87.00
± 72.82 months and 30 (46%) were men. The patients scored their appetite from 1 to 5
in subjective assessment.
Results: The assignment to HFHD had no significant effect on Kt/V, dialysis time or
for the presence of fistulas ( p=0.418, p=0.885, p=0.321, respectively). Urea Reduction
ratio rose significantly ( p= 0.02). In the HFHD the mean appetite score improved
significantly from 3.66 to 4.17. In spite of this significant appetite improvement, the
other nutritional indices as Body weight, Body mass index, Inter-dialytic weight gain,
total proteins, albumin and creatinin were not altered by the change of dialysis
treatment. The Hemoglobin level significantly rose from 115 to 118 g per liter in the
HFHD. The mean weekly dose of Erythropoietin dosage did not change, neither did
the mean Erythropoietin dosage per kilogram of body weight ( p>0.05). The
Erythropoietin treatment index of resistance (Epo dosage divided by body weight and
per gram of hemoglobin), declined and achieved borderline significance (0.41 ± 0.37
vs. 0.38 ± 0.37, p=0.057). The level of total lipids significantly declined in the HFHD
period from 7.92 to 7.43 g/L. The total cholesterol did not change. The protective
High-Density Lipids significantly rose from 0.96 to 1.16 and the Low-Density Lipids
significantly declined from 2.61 to 2.38 mmol/L ( p<0.05). The total calcium level
significantly improved from 2.11 to 2.17 mmol /L. The phosphorous level did not
change in spite the better appetite. The PTH remained steady and there was significant
increase in Alcal Phosphatase activity. The mean predialysis sodium and potassium
level did not change significantly. In respect of enzymes, the Aspartate
Aminotransferase did not change, neither did the Alnine Aminotransferase activity.
We observed significant improvement in the leucocyte number and CRP level (6.82 ±
1.63 vs. 6.24 ± 1.62, p=0.0001; 5.60 ± 5.14 vs. 4.40 ± 3.96, p=0.014), respectively.
Conclusions: High Flux Dialysis had beneficiall effects on the nutritional, clinical and
inflammatory parameters in dialysis patients.
NUTRITIONAL EVALUATION FOR DIALYSIS PATIENTS: BODY
MASS CELL (BCM) ANALYSIS DOES NOT REPLACE
TRADITIONAL ANTHROPOMETRIC EVALUATION
Valeria Aicardi Spalloni1, Vincenzo La Milia2, Selena Longhi3, Leano Volo2,
Lucia Del Vecchio2, Giuseppe Pontoriero2 and Francesco Locatelli2
1Inta Institute of Nutrition and Food Technology of the Chilean University, Santiago,
Chile, 2A. Manzoni Hospital, Lecco, Italy, 3A. Manzoni Hospital, Lecco, Italy
Introduction and Aims: Since malnutrition is a mortality risk factor in dialysis
patients, periodical evaluation of nutritional status is of importance. However, the use
of traditional measurements (brachial circumference, skinfolds, etc) is challenging and
it requires an expert dietician. Body Cell Mass (BCM) measured with bioimpedance is
an easier and more standardised method to assess nutritional and hydration status.
Methods: We evaluated the nutritional status of 150 dialysis patients (mean age 67.5 ±
14.6 years; F/M=55/88; HD/PD=115/28) with traditional anthropometric parameters
and BCM. The same dietician performs all the measurements. Seven patients with
major amputations were excluded from the study.
Results: 39 patients (27%) showed decreased Lean Body Mass (BLM) during
traditional anthropometric analysis; in 19 (13%) the BLM loss was severe. 81 patients
(57%) had decreased Fat Body Mass (BFM); in 27 (19%) of them the FBM loss was
severe. Conversely, 14 patients (10%) showed increased BFM, 8 (6%) of which were
obese.8 patients (6%) had a severe loss of both BLM and BFM. At logistic regression
analysis, BLM loss was directly related to age and male gender but not to dialysis
modality (HD vs PD) (chi2 = 0.003); the decrease of BFM was not related to any of
these parameters. Nutritional parameters measured with BCM - Lean Tissue Index
(Kg/m2) for BLM and Fat Tissue Index (Kg/m2) for BFM - were not predictive of BLM
and BFM losses: The area under the ROC curve (AUC) was of 0.64 and 0.75 for BLM
reduction with LTI and FTI, respectively. (Figure 1).
Conclusions: In dialysis patients malnutrition is quite common along BFM and BLM
losses and it is not influenced by dialysis modality. New methods based on
bioimpedance seem not to be a valid alternative to traditional anthropometric
parameters in the evaluation of nutritional status in dialysis patients.
MALNUTRITION IN HAEMODIALYSIS AND IN PERITONEAL
DIALYSIS: WHAT IS THE BETTER TREATMENT?
Francesca Martino1, Elisa Scalzotto2, Valentina Corradi2, Federico Nalesso3,
Monica Zanella3 and Alessandra Brandolan3
1S Bortolo Hospital, Vicenza, Italy, 2International Renal Research Institute (IRRIV),
Vicenza, Italy, 3San Bortolo Hospital, Vicenza, Italy
Introduction and Aims: Malnutrition is a common feature in end stage renal disease
and is a predictor of cardiovascular mortality in this kind of patients. Furthermore, the
type of dialysis could have an impact on malnutrition state for different reasons. The
aim of the study was to compare haemodialysis (HD) and peritoneal dialysis (PD)
patients to evaluate the presence of malnutrition in both dialysis modalities.
Methods: We performed a retrospective cross sectional study. We analysed the
SP680 Nutritional marker in haemodialysis and peritoneal dialysis
conditions of the patients such as age, type of dialysis, diabetes, presence of urine
output, BMI, albumin, haemoglobin, CRP, total cholesterol, HDL, LDL, and
triglycerides. Finally, we evaluated the pharmacological treatment such as statins,
insulin, and oral hypoglycaemic agents. All continuous variables were reported as the
median values and interquartile range (IQR). All categorical variables were reported as
percentage. Kruskal Wallis test, and Pearson’s chi-square test were used to compare
continuous and categorical variables, as appropriate. All reported p-values were two
sided, and statistical significance was set at p <0.05. Statistical analysis was performed
with SPSS version 20.0.
Results: We analysed 212 patients: 44.3% in haemodialysis and 55.7% in peritoneal
dialysis. 57.6% were male. About 20% were diabetic; we observed a non-significant
difference between the two groups (PD 24.6% versus HD 19.2 p=0.09). On the other
hand we observed a higher prevalence of urine output in PD patients (PD 77.1% versus
HD 28.7% p<0.001). We found a statistically significant difference for all markers of
malnutrition; specifically BMI, cholesterol, triglycerides and haemoglobin were higher
in peritoneal dialysis patients, while albumin, and CRP were higher in HD patients.
Finally, treatment with statins and insulin was different in the two groups. All details
reported in following table.
Conclusions: HD and PD had a different nutritional pattern. No clear advantage or
disadvantage was related with dialysis modalities in our dialysis population.
BODY COMPOSITION AND MORTALITY IN HEMODIALYSIS
Ana Pérez De José1, Soraya Abad1, Almudena Vega1, Javier Reque1,
Borja Quiroga1 and Juan Manuel López-Gómez1
1Hospital Gregorio Marañón, Madrid, Spain
Introduction and Aims: In contrast to the general population, obesity has generally
been associated with improved survival among chronic hemodialysis patientsWe still
don´t know which component of body composition (fat or lean) is more associated with
the observed obesity paradox. The aim of the study is to determine whether muscle
mass, fat tissue or both are associated with longer survival among hemodialysis
Methods: The study group consisted of 217 patients on maintenance haemodialysis.
Patients were prospectively followed-up for 5 years. Demographic data and mortality
were prospectively collected. Body composition was assessed by bioimpedance
spectroscopy (BIS). To set the cutoff point at which mortality increases patients were
categorized initially in tertiles according to lean tissue index (LTI) and fat tissue index
(FTI). Then they were categorized into two groups coinciding the cutting point of FTI
with the median and for LTI with the lower tertile. Mortality was analysed with Kaplan
Meier and Cox regression models was used to evaluate the relationship between
measures of body composition with mortality after adjustments for demographic data.
Results: In Kaplan Meier analysis mortality at 5 years followed-up is associated with
higher FTI (log rank p<0.013) and lower LTI (log rank p=0.013). Mortality is increased
in patients with FTI > 12.6 Kg/m2and LTI < 10,2 Kg/m2. In the multivariate Cox
model, adjusted for age and sex FTI an independent predictor of mortality (HR 1.735,
95%CI 1.060-2.840, p=0.028). The cox regression model for LTI does not meet criteria
of proportionality of risk, so it is broken into 2 models one for less than 3 years of
follow-up in which there are no significant differences and one for the patients with
more than 3 years follow-up in which the group with LTI <10.2 Kg/m2have higher
mortality (HR 2.267, 95% CI 1.230-2.267).
Conclusions: FTI determined by bioimpedance is an early and independent predictor
of mortality in hemodialysis patients at 5 years followed-up. LTI is an independent
predictor of mortality from the 3 years follow-up in the studied hemodialysis patients.
EXERCISE TRAINING, NUTRITIONAL PARAMETERS, BODY
COMPOSITION AND HORMONAL ANABOLIC SYSTEM IN
Vicent Esteve Simo1, Veronica Duarte Gallego1, Fatima Moreno Guzman1,
Miquel Fulquet Nicolas1, Monica Pou Potau1, Anna Saurina Sole1, Jose Carneiro
Oliveira1 and Manel Ramirez De Arellano Serna1
1Consorci Sanitari Terrassa, Terrassa, Spain
Introduction and Aims: Haemodialysis (HD) patients are characterized by great
muscle wasting, decreased physical function and poor quality of life. Scarce studies
about the relation of physical exercise with body composition and the hormonal
anabolic system in HD patients have been published. The aim of the study was to
analize if an intradialysis training program could improve muscular strength, body
composition, nutritional parameters and the hormonal anabolic system in these
Methods: A 12 weeks single-center prospective study. HD patients were assigned into
exercise training (ET) or control group (C). ET included a combined physical fitness
using balls, weights, elastic bands and cycle movements in the first two hours of HD
session. C receieved standard HD care. Analized data:1.-Biochemical nutritional data
(albumin, prealbumin, ferritin and C Reactive Protein, CRP) and lipid profile
(triglycerids, total cholesterol and fractions).2.- Muscular data: Maximum length
quadriceps strength(MLQS) and hand-grip dominant arm (HG).3.-Functional capacity
tests:“Sit to stand to sit" (STS10) and “six-minutes walking test”(6MWT).4.-Body
composition determined by electrical biompedance (BIA). 5.- Anabolic Hormones
system: Insulin Growth Factor-I (IGF-I), Insulin Growth Factor Binding Protein 3
(IGFBP-3) and ratio IGF-I/IGFBP-3.
Results: 34 patients included: 53% men. Mean age 72.2 years and 60.5 months on
HD.20 were on ET and 14 on C group. In contrast with C group, ET group significally
(*p<0,05) improves in MLQS* (15.2 ± 9.9 vs 18.3 ± 11.6 kg), HG* (24.6 ± 14.3 vs 26.1 ±
14.2 kg), STS10* (23.8 ± 2.5 vs 20.1 ± 8.1 seg), 6MWT* (15%, 370 vs 435 m), body fat
percentage (FAT)* (26.4 ± 15.1 vs 25.3 ± 15.5) and musculoskeletal tissue percentage*
(31.7 ± 8.5 vs 32.9 ± 8.2) at the end of the study. However, ET group lowered IGF-I
(155±20.7 vs 150±19.4ng/ml) and increases IGF-I/IGFBP-3 ratio (38.7 ± 18.9 vs 41.8 ±
4.9); while in C group, an increase in IGF-I levels (125.9 ± 15.8 vs 132.7 ± 14.2 ng/ml)
and lower IGF-I/IGFBP-3 ratio (34.1 ± 14.5 vs 28.8 ± 6.8) were observed, althought did
not reach statistical significance. No relevant changes in nutritional parameters and in
the IGFBP-3 levels were observed in both groups.
Conclusions: 1.-Although exercise training was beneficial in terms of physical
function, muscular strength and body composition, we did not found relevant changes
on serum biochemical data and the hormonal anabolic system in our HD patients.
2.Nevertheless, the results observed regarding the anabolic hormonal system, as
described in the literature, could reflect a favorable anabolic neuromuscular adaptation
in these patients.
RELATI˙ONSHI˙P BETWEEN RELATI˙VE INTERDIALYTIC
WEIGHT GAIN WITH SERUM LEPTIN LEVELS, NUTRITION
AND INFLAMMATION IN CHRONIC HAEMODIALYSIS
Elbis Ahbap1, Ekrem Kara1, Taner Basturk1, Yener Koc1, Tamer Sakaci1,
Tuncay Sahutoglu1, Mustafa Sevinc1, Zuhal Atan Ucar1 and Abdulkadir Unsal1
1Sisli Etfal Educational and Research Hospital, Istanbul, Turkey
Introduction and Aims: Excessive RIDWG(%) is an important factor for long-term
poor cardiovascular outcomes. On the other hand it may be an index of good appetite
and nutritional status. The aim of this study was to assess the relationship between
RIDWG(%) and appetite, nutrition, inflammation parameters in HD patients and
determine short term survival.
Methods: One-hundred, anuric HD patients were enrolled in this prospective study
between January 2013 to January 2014. Patients with hospitalization, major surgery,
obvious infections, inflammatory disease, end stage liver disease, metastatic
malignancies and malabsorbsion syndromes were excluded. MIS, leptin, hs-CRP and
TNF-α levels were obtained from all patients.
Results: Mean age of 100 patients (Male/Female: 52/48) were 52.3±17.4 years. Group 1
(RIDWG≤ %3), group 2 (RIDWG=%3-%5) and group 3 (RIDWG> %5) consisted of
10, 47, 43 patients, respectively. There were no differences regarding gender, duration
on HD, ethiology, dialysis dose, dry weight, systolic and diastolic blood pressures
between the groups. Group 3 patients were younger ( p=0.011) with lower BMI
( p=0.014). No significant difference determined between groups about nutrition and
inflammation parameters including MIS, serum albumin, prealbumin, triceps scinfold
thickness, hs-CRP and TNF-α. Leptin and Leptin/BMI levels were significantly lower
in group 3 ( p=0.001). RIDWG(%) were negatively corelated with age ( p=0.001, r=
-0.371), BMI ( p=0.001, r= -0.372), leptin ( p=0.001, r= -0.369), leptin/BMI ( p=0.001,
iii | Abstracts
r=-0.369). After adjusment for BMI in the lineer regression analyse, leptin/BMI
remained significantly correlated with RIDWG(%) ( p=0.024, r=0.427, R²=0.183, %95
CI lower: -1.674, upper: -0.119). Eight patients died during the follow-up period. There
were no differance between the groups about 1 year survival rates (group 1, 2 and 3
were%71.4, %91.1 and%95, respectively ( p=0.105).
Conclusions: Altough higher RIDWG(%) seems to be related with low leptin levels,
there were no link with malnutrition, inflammation and short-term survival.
PROTEIN ENERGY WASTING IS A RISK FACTOR FOR
INFECTIOUS COMPLICATIONS IN BOTH HEMODIALYSIS AND
PERITONEAL DIALYSIS PATIENTS
Introduction and Aims: Protein-energy wasting (PEW) has been linked to impaired
immune function in both peritoneal dialysis (PD) and haemodialysis (HD) patients. In
general, PD patients carry a higher baseline risk of infections compared with HD
patients. It is however unknown whether nutritional status may influence this infection
risk. The objective of our study was to investigate the association between nutritional
status and risk of infectious complications in both HD and PD patients. We
hypothesized that PEW is more common in HD patients, but stronger associated with
infections in PD patients.
Methods: In a prospective multi-center cohort study of incident dialysis patients
(NECOSAD), the 7-point Subjective Global Assessment of nutritional status (SGA)
was assessed every six months during follow-up. From this cohort, detailed
information on infectious complications was retrospectively collected in 5 hospitals
from the start of dialysis until modality switch, transplantation, death, or loss to follow
up until 3 years of follow up. PEW was defined as an SGA of 1-5. Incidence rate ratios
(IRR) of infection associated with PEW at baseline were calculated with Poisson
regression considering all infections in 3 years of follow-up. In addition,
time-dependent Cox regression was used to estimate short-term risks of a first
infection associated with PEW within 6 months, using HD patients with a normal
nutritional status as reference. Models were adjusted for age, sex, ethnicity, primary
kidney disease, smoking and comorbidity.
Results: This analysis included 452 patients with complete medical records, of whom
285 initially started on HD and 167 on PD. Thirty-four percent of HD patients and
17% of PD patients suffered from PEW at the start of dialysis. In 3 years of follow up
the incidence rate of infection was 0.46/ HD year and 0.68/ PD year. Both HD
(Adjusted IRR: 1.37; 95% CI: 0.98, 1.91) and PD patients (1.35; 1.00, 1.81) suffering
from PEW showed an increased risk of infection compared with patients with a normal
nutritional status. Compared with HD patients with a normal nutritional status
(reference group), short-term adjusted hazard ratios of infection were 1.48 (95% CI:
1.08, 2.04) for PD patients with a normal nutritional status, 1.79 (1.27, 2.51) for HD
patients with PEW, and 2.80 (1.80, 4.36) for PD patients with PEW.
Conclusions: Protein energy wasting was associated with an increased risk of infection
in both HD and PD patients. Routine screening of nutritional status is important in all
AGE, NUTRITION AND HEMODIALYSIS
Konstantina Trigka1, Konstantinos Chouchoulis1, Carlos Guido Musso2,
Maria Kaza1, Aikaterini Mpimpi1, Crhisula Pipili1, Ilias Kyritsis1 and
1Kyanus Stayros, Patra, Greece, 2Hospital Italiano, Buenos Aires, Argentina
Introduction and Aims: Incidence of elderly receiving hemodialysis (HD) is
increasing. Mortality co-morbidities and malnutrition are main burdens. We evaluated
the presence of elderly in HD, survival rate, nutritional status and possible correlations
Methods: We evaluated 69 patients who were initiated HD at >70 years, on HD >2
months between 1.1.2009-1.9.2013. They were divided in 3 groups: > 70, >80 and >90
years old and compared according to survival (Kaplan-Meier) and nutrition (Geriatric
Nutritional Risk Index-GNRI). Also investigated correlations with depression, QOL,
dialysis dose and clinic-laboratory parameters by applying Geriatric Depression Scale,
BDI, SF-36, Kt/V and co-morbidity-CCI.
Results: 69 patients (70.4% of all incident patients) aged <70 started HD in the
observed period. (Median age 82 ± 5 years, 60.9% males. 40 (58%) deceased after 28
±27 months on HD, median age (M.A) while initiation HD 81±5 years and M.A of
death 83±4. Main cause of death: myocardial infarct. 29 (42%) are alive, M.A 84±5,
52% males, 41% diabetics. 43±38 months on HD. M.A on initiation HD 81±6 years.
45% have AVF and 52% catheter. Main renal diseases: arterial hypertension (34%) and
diabetic nephropathy (21%). 6.4% receive two HD sessions weekly. Statistical
significance was found between age groups and dialysis modality, since patients >80
years were mostly on conventional HD, whereas patients <80 on HD, HDF and on line.
More AVFs were reported in90 years) 40%. Expected survival 26.3% for the 2nd year,
5.3% for the 3rd, 21.1% for the 4th and 47.4% for the 5th year. No correlation found
with sex, creatinin entering HD, osteodystrophy, anemia, ESRD causes, vascular access,
cardiovascular disease, HD shift, diabetes, CCI, COPD and smoking. Most elderly HD
patients preserved good nutrition. 8.3% had low and 4.7% moderate GNRI. Increasing
age correlated with lower GNRI values, since mean GNRI for 70-79 years old was 108.2
±10.7and for >80 years old 112.2 ±12.9. Statistical difference observed among nutrition,
gender and ESRD cause, with females having higher GNRI scores and AKI and FSGN
may predispose poorer nutrition. Peripheral vascular disease, diabetes and COPD
patients were better nourished. Higher PTH levels, lower hematocrit (Hct) and QOL
parameters regarding bodily pain, vitality and mental health related to moderate GNRI.
No statistical difference was found with depression (BDI, GDS), cardiac disease, CCI,
mortality and kt/v.
Conclusions: Elderly patients represented the majority of our patients. Initiation HD
in older age (>80) is not contradictive, as there was no big difference in survival curves
of the 3 age groups. Survival rate in 90 years old was similar to octogenarians. Mortality
rate increased in the first 3 years. Prevalence of co-morbidities was similar with aging.
GNRI is a simple tool for predicting malnutrition risk. Deteriorated nutrition
correlates with QOL, increasing age, PTH and lower hct in elderly HD patients but not
with depression or CCI.
HIGHER aspartate aminotransferase LEVELS ARE
ASSOCIATED with HIGHER ALL-CAUSE MORTALITY in
MAINTENANCE HEMODialysis Patients
Elani Streja1, Sepideh Rezakhani1, Connie M Rhee1 and Kam Kalantar-Zadeh1
1UC Irvine Medical Center, Orange, CA
Introduction and Aims: In Maintenance Hemodialysis (MHD) patients, liver disease
is a comorbidity that may be associated to poor survival. Some studies have observed
positive association between elevated liver enzymes and mortality risk in MHD patients
but to date, the relationship between Aspartate Aminotransferase (AST) and all-cause
mortality risk in MHD patients has not been well studied. We hypothesized that higher
levels of AST would be associated with increased all-cause mortality in MHD patients.
Methods: In this study we analyzed a database of 114,267 DaVita MHD patients
followed up to 8 years (2001-2009) to examine the association of AST with all-cause
mortality. We used baseline AST levels in fractional polynomial models with adjusted
for case mix covariates plus surrogates of malnutrition and inflammation (MICS)
Results: The patient’s average age was 61±15 year old with 45% being female, 32%
blacks and 57% diabetics. We found a significant positive association between
increasing AST levels above 20U/L and all-cause mortality even after adjustment for
case mix plus MICS covariates. In fully adjusted models, AST levels ≥80 U/L, are
associated with highest risk of mortality with a Hazard Ratio of 1.70 (95% confidence
interval 1.56 to 1.85; P <0.0001)
Conclusions: In MHD patients, increasing levels of serum AST above 20 U/L are
associated with a linear increased risk of all-cause mortality even after adjustment for
MICS markers. Further studies are needed to confirm findings and determine
mechanistic pathways of the AST─mortality association.
EFFECT OF ALBUMIN ON ASSOCIATION OF SERUM
CHOLESTEROL AND MORTALITY IN HEMODIALYSIS
Elani Streja1, Megha Doshi1, Connie Rhee1, Csaba Kovesdy2, Hamid Moradi1 and
1UC Irvine Medical Center, Orange, CA, 2Memphis VA Medical Center, Memphis,
Introduction and Aims: In contrast to the general population, studies have found an
inverse or non-significant association of serum total cholesterol and mortality in
chronic hemodialysis (HD) patients, also known as a “lipid paradox”. We hypothesize
that the association between cholesterol and mortality in HD patients may be modified
by serum albumin levels.
Methods: Across 4 categories of serum albumin (ALB) levels (4.0 g/dL), we examined
the associations of cholesterol with 6-yr (2001-2007) all-cause mortality among 53,041
adult HD patients. We used continuous time-dependent cholesterol in restricted cubic
spline models adjusted for case-mix and markers of the malnutrition-inflammation
Results: Patients were 62±16 years old and included 45% women, 31% blacks, and 55%
diabetics. There were 12,505 patients ALB 4.0 g/dL. Using restricted cubic splines with
2 degrees of freedom, we found no significant associations between both lower and
higher levels of cholesterol with all-cause mortality in HD patients in any strata of ALB
Conclusions: Hence, HD patients with better nutritional status, or serum albumin
level ≥4.0g/dL demonstrate an exception to the lipid paradox where higher levels
cholesterol appear associated with increased all-cause mortality.
HANDGRIP STRENGTH AS A PREDICTOR OF DEATH IN
INCIDENT HEMODIALYSIS PATIENTS OF DIFFERENT AGE
GROUPS: A 6-YEAR COHORT STUDY
Marina A Dantas1, Lucas L Resende1, Luciana F Silva2, Cacia M Matos1, Gildete
B Lopes1 and Antonio Alberto Lopes1
1Universidade Federal da Bahia, Salvador, Brazil, 2Universidade do Estado da
Bahia, Salvador, Brazil
Introduction and Aims: We have previously shown evidence that a single measure of
handgrip strength (HGS) by a dynamometer could help to identify maintenance
hemodialysis (MHD) patients at higher risk of malnutrition (J Ren Nutr
2011;21:235-45). There is also evidence that lower HGS is associated with higher
mortality risk in MHD patients. However, it is not clear if there is association between
HGS and mortality in incident MHD patients and if a possible association is similar
between patients of different age groups. The main objective was to investigate if HGS
was similarly associated with mortality between patients of two different age groups
(<60 and ≥60 yr) on hemodialysis for less than 6 months.
Methods: Prospective cohort (from 2006 to 2012) of 176 adult patients (68 women,
108 men; 133 aged <60 yr and 43 ≥60 yr) with less than six months on dialysis enrolled
in the Prospective Study of the Prognosis of Chronic Hemodialysis Patients
(PROHEMO) developed in 4 clinics in Salvador, BA, Brazil. A research ethics
committee approved the study protocol and all patients provided informed consent to
participate. HGS was measured at baseline using a dynamometer (Takei Scientific
Instruments, Japan). HGS was categorized into low and high groups based on sex-age
specific median values (18 kg for women <60 yr, 13 kg for women ≥60 yr, 30 kg for
men <60 yr and 22.7 kg for men ≥60 yr). Cox’s proportional hazard models specific for
patients with ages <60 yr and ≥60 yr were used to estimate hazard ratio (HR) of the
association between HGS and all-cause death and the respective 95% confidence
interval (CI). To investigate the potential statistical interactive effect of age with HGS
on the hazard of death, a model was developed that included a coefficient of interaction
HGS*age (<60 yr and ≥60 yr). The hazard ratio (HR) was adjusted for age, sex,
diabetes, heart failure, albumin, creatinine and blood hemoglobin.
Results: The mean age of the 176 patients was 49.3±15.0 years, 82.4% non-white and
34.1% diabetic. There were 59 deaths during a median follow-up of 3.4 years. Death
rate per 100 person-years was 11.0 in the whole cohort and was higher in patients with
HGS below the median (18.7 versus 5.9; P<0.001). In the Cox model adjusted for all
covariates, the HR of death was higher in patients with HGS below the median, both
for patients aged <60 yr (HR=3.35, 95% CI=1.43-7.41) and ≥60 yr (HR=2.37, 95%
CI=0.94-5.99). The P value for interaction age*HGS was not statistically significant
Conclusions: By using sex-age specific median cutoffs for HGS, these results from
PROHEMO provide evidence that HGS is a useful tool to identify incident MHD
patients of different age groups who are at higher risk of death
iii | Abstracts
SGA AND SERUM ALBUMIN ARE GOOD PREDICTORS OF
DEATH IN MALNOURISHED HEMODIALYSIS PATIENTS
Bojan Knap1, Miha Arnol1, Jadranka Buturovic1, Rafael Ponikvar1 and Andrej Bren1
1University Clinical Centre Ljubljana, Ljubljana, Slovenia
Introduction and Aims: Many patients with end-stage renal disease are malnourished,
and cross-sectional studies have shown that markers of malnutrition may predict
death. In this study, we investigated the association of Subjective Global Nutritional
Assessment (SGA) and serum albumin with mortality in a single hemodialysis center.
Methods: In our study 39 out of 183 hemodialysis patients (21.3%) showed results of
malnutrition. Nutritional intervention and observation were started in the
malnourished group. We observed patient survival rate in the next 50 months. Classical
parameters for evaluation of nutritional status such as SGA, body weight, and routine
biochemical parameters were analyzed. SGA values less than 21 and serum albumin
less than 30 g/l are critical for prognosis of malnourished patients.
Results: In a 50-month follow-up study of 39 malnourished patients, 25 patients (64%)
died despite nutritional intervention and intensive therapy. The causes of death were
cardiovascular event in 9 pts (36%), sepsis in 7 pts (28%) cachexia in 5 pts (20%), and
cancer in 4 pts (16%). Only 10 pts had SGA > 21 and 6 of these pts (60%) survived.
Twenty-nine pts had SGA value 21 and 24% in patients with SGA < 21 ( p = 0.05). In
13 pts with albumin 30 g/l (56%; p = 0.009).
Conclusions: SGA value less than 21 and serum albumin less than 30 g/l are good
predictors of death in malnourished hemodialysis patients. This assessment tool is
beneficial for hemodialysis patients who are at an increased risk of
malnutrition-associated mortality. Early diagnosis, nutritional intervention and
therapy of basic illness are very important for improving nutritional status and survival
in malnourished dialysis pts.
PROGNOSTIC VALUE OF COMBINED EVALUATION OF
NUTRITION AND HYDRATION WITH BIVA METHOD IN
CHRONIC DIALYSIS PATIENTS: A 2 YEARS OUTCOME
Marta Codognotto1 and Paola Piasentin2
1University of Padova, Italy, Italy, 2University of Padova, Padova, Italy
Introduction and Aims: Malnutrition identification is crucial for a correct patient
handling. Despite the use of the Subjective Global Assessment (SGA) is recommended
by K/DQQI for evaluating the nutrition state in the hemodialysis patient. Furthermore
patient hydration cannot be evaluated with SGA. In a former cross-sectional study,
Piccoli et al. (2013) demonstrated that bioelectrical impedance vector analysis (BIVA)
is a potential instrument for evaluating hydration and nutrition status in the chronic
hemodialysis patient. They furthermore demonstrated that impedance vector
distribution is associated with the nutrition SGA score. The aims of the current study
were: to evaluate whether a significant relationship within hydration and nutrition
status, measured by BIVA, and mortality at 24 month could be; to evaluate whether a
significant relationship within nutrition status, measured by SGA, and mortality could
Methods: The study was conducted on 73 patients undergoing chronic hemodialysis
three times a week at the Padova University Hospital, who survived after the former
study. All the patients were classified into three groups, on the basis of their SGA score:
BIVA was performed before and after hemodialysis. The impedance vector components
of resistance (R) and reactance (Xc) in Ohm were transformed into bivariate Z scores Z
(R)=(R-mean R)/SD) and Z(Xc)=(Xc-meanXc)/SD) [Piccoli et al, Nutrition 18:153,
2002]. Uremia causes and comorbidities were investigated; furthermore laboratoristc
and clinic nutrition parameters, ultrafiltration, weight and blood pressure before and
after hemodyalisis were analyzed.
Results: The mean vector position of the well nourished patients was at the lower pole
of the 50% tolerance elipse; the mean vector position of the patients in group SGA-B
was into the 75% tolerance elipse; the mean vector position of malnourished patients
(SGA-C) was out of the 95% tolerance elipse. For each group the "slope of migration"
was calculated: it is the angle of the vector migration during the dialysis session (Fig 1).
SP690 Figure 1.: Z-score graph of the mean vectors with 95% confidence ellipseds pre
and post dialysis for the SGA group (SGA-A, SGA-B and SGA-C). The slopte of the
mean vectors identifies the variable “slope”.
SP690 Figure 2.: The cumulative survival curves for the variable slope (median 0.57)
indicate an apparent worsening of the prognosis in group 0, with values less than or
equal to the slope of the median (P = 0.001). The survival rate at 24 months is 52.3% in
SGA-C versus 79.7% in SGA-A.
The mean vector migration of SGA-C group showed reduced gradient (slope) and little
migration during the dialysis session. The survival analysis showed that the SGA
classification was associated with mortality: patients in the SGA-C group, severely
malnourished, in fact, have a poorer prognosis compared to groups A and B, with
24-month survival of 35% (P <0.001). In addition, the analysis of the survival curves
showed that values of Z (Xc0 / H) less than -1.2 and slope values of less than 0.57,
indicating sarcopenia, are associated with a significantly worse prognosis, with survival
at 24 months, respectively, equal to 57% and 52% (P = 0.02 and P = 0.001) (Fig 2).
Conclusions: This study has been demonstrated that BIVA allowed to find sarcopenic
patients, showing worse prognosis, by observing impedance vector migration slope.
A SURVEY ON PROTEIN ENERGY WASTING DIALYSIS
Ferruccio Conte1, Marco Righetti1, Aurelio Limido2 and ociety Of Nephrology On
Behalf Of The Lombardy Section Of The Italian S
1Uboldo Hospital, Cernusco s/N, Italy, 2Fatebenefratelli Hospital, Milano, Italy
Introduction and Aims: Protein energy wasting (PEW) dialysis patients are frequently
diagnosed. Malnutrition is strictly related to morbidity and mortality of dialysis
patients. The nutritional status assessment and the clinical approach to PEW dialysis
patients are two important steps in our clinical practice. International guidelines on
nutrition may be a useful instrument for everyday clinical practice. So, we performed a
survey with the aim to detect the most used diagnostic criteria and treatments of PEW
Methods: We performed a simple test comprising 16 multiple answer questions. 72%
of Dialysis Units of our Region, exactly 34 of 47 Units, answered to the questionnaire.
A total of 5395 dialysis patients were analyzed.
Results: International guidelines for nutritional assessment are rarely used in our
Dialysis Units. Nephrologists prefer a simple evaluation because of lacking time.
Malnutrition is frequently detected: dialysis patients with serum albumin levels below
3,5 g/dl were 691 (21,5%), 222 (14,6%), and 217 (32,6%); respectively for hospital
hemodialysis patients, limited care hemodialysis patients and peritoneal dialysis
patients. PEW hemodialysis patients are frequently switched from bicarbonate dialysis
to hemodiafiltration, submitted to multivitamin B supplementation, and treated with
oral nutritional supplements and IDPN. A large part of Dialysis Units (68%) submitted
at least 1 patient to intradialytic parenteral nutrition (IDPN) and, moreover, 100 of 913
(11%) PEW hemodialysis patients have been submitted to IDPN in the last year. The
mean number of treated patients in every single Dialysis Unit was equal to 4,3 and at
least 10 patients have been treated in three Dialysis Units.
Conclusions: PEW is an important, rising syndrome. Nephrologists and nurses have
unfortunately a few time to spend for it. International guidelines are too much complex
to be followed. So, a simple consensus statement on nutrition in PEW dialysis patients
may be useful for daily clinical practice. Participating Centers: Bergamo “Gavazzeni”,
Bollate, Brescia, Castellanza “Multimedica”, Cernusco s/N, Chiari, Cinisello Balsamo,
Como, Cremona, Desio, Esine, Lecco, Legnano-Magenta, Lodi, Manerbio-Desenzano,
Mantova, Melegnano, Milano Fatebenefratelli, Milano Humanitas, Milano Policlinico,
Milano Sacco, Milano San Carlo, Milano San Paolo, Milano San Raffaele, Monza San
Gerardo, Pavia Maugeri, Sesto San Giovanni “Multimedica”, Sondrio, Tradate,
Treviglio, Varese, Vimercate, Voghera, Zingonia.
THE IMPACT OF ALBUMIN LOOSING TREATMENT ON
SURVIVAL OF HAEMODIALYSIS PATIENTS
Kenji Tsuchida1, Hiroyuki Michiwaki1, Jun Minakuchi1, Shu Kawashima1 and
1Kawashima Hospital, Tokushima City, Japan, 2Oita University, Oita City, Japan
Introduction and Aims: Protein-bound uraemic toxins play an important role in
uraemic complication. But haemodialysis(HD) cannot efficiently remove the
protein-bound uraemic toxins because of their high albumin-binding property. The
object of present study is to investigate the effectiveness of albumin loosing treatment
on survival of HD patients.
Methods: A retrospective study was designed. Clinical recordings from all patients
initiated on HD between April 2005 and March 2013 in the dialysis center of
Kawashima hospital, Tokushima, Japan. Patients were classified according in three
groups by albumin loosing 1g< group, 1≤ <3g group and 3g≤ group during one HD
session. There are not statistically significant differences in patient’s baseline
characteristics (age, gender, HD duration, eKt/V, Hb, serum albumin level) between
these groups. Survival probability was generated using the Kaplan-Meier method.
Results: Data from 702 patients were included in the analysis. Albumin loosing 1g<
group (serum albumin level 35.3+/-3.1g/L) consisted of 142 patients, 1≤ <3g group
(serum albumin level 35.5+/-3.3g/L) consisted of 455 patients, and 3g≤ group (serum
albumin level 36.6+/-2.6g/L) consisted of 105 patients. The 1-, 2-, 3-, 5-, and 7-year
patient survival rates were 98%, 92%, 86%, 67%, and 54% for 1g< group, and 97%,
94%, 89%, 81%, and 70% for 1≤ <3g group, and 99%, 98%, 95%, 92%, and 88% for 3g≤
group. The patient survival rates were significantly lowest for the albumin loosing 3g≤
group among the three groups.
Conclusions: To increase the clearance of middle-to-large molecules, synthetic
membranes with high water permeability (high-flux membranes) were introduced
recently. But these membranes have a risk of albumin loosing. There are a lot of uremic
toxins, especially protein-bound solute with biological activities, and it is difficult to
remove these solutes without albumin loosing treatment. We have choice of the
albumin loosing treatment without hypoalbuminemia. In conclusion, the results of this
study suggested that the albumin loosing HD treatment plays an important role in the
outcome of chronic HD patients.
HIGH PROTEIN DIET ALTERS THE METABOLIC STATUS OF
MICE COMPARABLE TO CHANGES IN UREMIC TOXIN
LEVELS OBSERVED IN RENAL FAILURE PATIENTS
Henricus A. Mutsaers1, Jitske Jansen1, Petra H. Van Den Broek1, Vivienne
G. Verweij1, Lambertus P. Van Den Heuvel1, Joost G. Hoenderop1 and
1Radboudumc, Nijmegen, The Netherlands
Introduction and Aims: Many of the well-studied uremic toxins originate from the
diet and are generated in the colon due to protein fermentation by intestinal bacteria.
Breakdown of tyrosine and phenylalanine results in the formation of phenylacetic acid,
phenol and p-cresol, which is subsequently metabolized into p-cresyl sulfate and
p¬-cresyl glucuronide. On the other hand, bacterial metabolism of tryptophan results
in the formation of indole which can give rise to diverse indolic uremic solutes,
including indoxyl sulfate and indole-3-acetic acid. Here, we examined the impact of a
high protein diet on the plasma concentration of a variety of uremic toxins to obtain
insight into the interplay between dietary protein and uremic solutes.
Methods: Wild type (WT) Friend leukemia virus B (FVB) mice were provided either a
control (21% crude protein; n=10) diet or a high protein (HP; 45% crude protein;
n=10) diet for 21 days, after which mice were sacrificed and uremic toxins were
measured by liquid chromatography-tandem mass spectrometry.
Results: Mice fed the HP diet showed higher plasma levels of the phenol-derived
metabolites phenylacetic acid (1.9 ± 0.3 μM, p=0.01), phenyl sulfate (3.9 ± 0.8 μM,
p=0.0061), phenyl glucuronide (0.2 ± 0.05 μM, p=0.0095), p-cresyl glucuronide (1.6 ±
0.3 μM, p=0.0093) and hippuric acid (0.1 ± 0.01 μM, p=0.0002) compared to mice
provided with control diet (1.1 ± 0.1 μM, 1.4 ± 0.3 μM, 0.03 ± 0.007 μM, 0.7 ± 0.1 μM
and 0.04 ± 0.008 μM, respectively). In addition, we observed a reduction in tryptophan
concentration (HP: 93 ± 11 μM vs. control: 127 ± 5 μM, p=0.011) as well as an 1.2 fold
increase in indoleamine 2,3-dioxygenase (IDO) activity (P=0.0389). Furthermore, in
mice fed the HP diet, indoxyl sulfate levels significantly increased from 3.6 ± 0.7 μM
(control) to 7.1 ± 1.7 μM ( p=0.033). In contrast, p-cresyl sulfate and kynurenic acid
levels remained unaltered, and kynurenine and indole-3-acetic acid concentrations
diminished. In addition, mice on the HP diet developed significant polyuria (HP: 0.8 ±
0.2 mL/18 h vs. control: 0.3 ± 0.04 mL/18 h; p=0.025), implying the presence of renal
Conclusions: A HP diet alters the metabolic status of mice comparable to changes
observed in chronic kidney disease patients. This supports the hypothesis that
managing the levels of dietary protein intake in patients may be of key importance
since high protein intake will augment uremic toxin levels, whereas a restriction in
dietary protein might cause protein-energy wasting.
DIETARY PATTERN ANALYSIS IN A RESIDENT POPULATION
AS A KEY FOR TAILORING THE APPROACH TO LOW-PROTEIN
DIETS IN CKD PATIENTS
Roberta Clari1, Elena Mongilardi1, Federica Neve Vigotti1, Stefania Scognamiglio1,
Valentina Consiglio1, Marta Nazha1, Paolo Avagnina1 and Giorgina Piccoli1
1University of Torino, Torino, Italy
Introduction and Aims: Even if Low-protein diets are commonly cited as milestones
in the treatment of CKD, for delaying progression of chronic renal diseases and for
postponing dialysis, their use varies widely across the world. A common idea is that
this variability is mainly due to the different baseline dietary patterns, which favors the
diet in the Mediterranean Countries, as compared with the Northern ones;
furthermore, the increasing use of canned, processed and pre-cooked food may further
impair the application of such diets. In spite of the tenet that the diet results in CKD
are linked with the baseline diet patterns of the overall population, few studies assessed
the baseline dietary habits as a tool for understanding and improving compliance on
low-protein diets in CKD patients. Aim of the study was to assess the main dietary
patterns of the families of patients attending the Nephrology Unit of a Northern Italian
University Hospital, in the neighborhood of a one million inhabitants city.
Methods: Semi-structured questionnaires (30 items) were built, tested, and given for
three months to the patients attending the Nephrology Unit in a setting where
compliance to low-protein diets is high, and over 90% of the patients with CKD stages
4-5 not on dialysis perform at least one trial period on a protein restricted diet
(different schemas, 0.6 to 0.3 g/Kg/day of proteins).
Results: Overall, 202 questionnaires were gathered; the answers came from 101 males,
101 females, median age 63 years (range: 19-101); as for the working status, 46.5% were
retired. Family members were in different CKD stages (stage 1 to dialysis); 13.5% were
on a low-protein diet, while in 66.8% no diet had been prescribed. The baseline dietary
habits followed a Mediterranean pattern in most of the families, as 48.2% of the
families eat pasta or rice at least once a day, while only 15.9% eat pasta only
iii | Abstracts
occasionally. Furthermore, only 17.4% of the families eat meat every day. Most of the
families (65%) eat vegetables at each meal. As for the setting and preparation, 35.8% of
the cases always eat at home, while about a further 50% eat out of home more twice a
week (mainly at work). Markets are still the main source of fresh vegetables in 94.7% of
the cases, but 75.1% of the cases also shop regularly in the supermarkets. The use of
pre-cooked, frozen or canned food was limited, and almost 25% of the families
systematically avoided all types of processed food.
Conclusions: In the area under study, most of the families follow a Mediterranean
dietary pattern and conserve the habit of buying and cooking food every day at home.
These habits are more pronounced in the older families, in which more commonly a
family member is affected by severe CKD. This may be one of the reasons why, as
compared with the literature, we experienced an easier switch to low protein diets in
our patients. Comparisons with settings in which prepared, canned or processed food
are widely used, and where the baseline dietary pattern is richer in red meat are needed
for testing this hypothesis.
USE OF THE STANDARD URINE PHOSPHATE ASSAY FOR
MEASURING THE PHOSPHATE CONTENT OF BEVERAGES:
VALIDATION AND VARIATION
Seán J. Costelloe1, Julienne Freeman1, David F. Keane2,2,3, Elizabeth J. Lindley2,2,3
and Douglas Thompson1
1Leeds Teaching Hospitals NHS Trust (LTHNT), Leeds, United Kingdom, 2LTHNT,
Leeds, United Kingdom, 3NIHR Devices for Dignity Healthcare Technology
Co-Operative, Sheffield, United Kingdom
Introduction and Aims: Hyperphosphataemia is strongly associated with
cardiovascular morbidity and mortality in patients with chronic kidney disease.
Control of serum phosphate is particularly challenging for haemodialysis patients as
phosphate generated by an adequate protein intake cannot be removed with standard
treatment regimes. Binders that reduce absorption of phosphate can have unwanted
side-effects and are often an intolerable pill burden. Beverages can contain phosphate
in a form that is readily absorbed and are often consumed between meals, without a
binder. Manufacturers are obliged to declare use of additives, including phosphoric
acid in colas, but not the amount added. The phosphate present in beer and wine is not
mentioned on the label as it is not added. For patients on low phosphate diets (26-32
mmol/day), it would help to know which types or brands of beverages are higher in
Methods: The inorganic phosphate concentration in samples of thirty-two soft drinks,
beers, ciders, and wines was measured with and without spikes of a solution containing
a known amount of phosphate (as H2NaPO4). Samples were measured in duplicate
using the reaction between inorganic phosphate and ammonium molybdate on a
Siemens Advia analyser. The blue compound formed was quantified by absorbance at
340/658 nm. The measured increase in phosphate concentration in the spiked samples
was compared with the expected increase to see if the beverages contained anything
that would enhance or diminish the assay signal. A difference of <20% was deemed
acceptable. Fourteen additional beverages were tested as standard urine samples
(without spikes) to further investigate variation between brands.
Results: Recovery of phosphate spikes varied from 84.8 to 90.9% for soft drinks, from
82.2 to 103.5% for beers, and ciders, and from 80.5 to 86.1% for wines, indicating that
our standard urine phosphate assay can accurately measure the phosphate
concentration in these beverages. There was considerable variation in the phosphate
concentrations measured. Soft drinks that did not contain phosphoric acid had
undetectable levels (<0.03 mmol/L), whilst colas contained 3.2 to 5.0 mmol/L. The
ciders tested had concentrations of 1.8 to 2.6 mmol/L, which was lower than the beers
(2.7 to 8.1 mmol/L) and the wines (3.6 to 9.9 mmol/L).
Conclusions: The BDA Renal Nutrition Group recommends a minimum protein
intake for haemodialysis patients of 1.1 g/kg ideal weight/day, i.e. 77 g/day for a 70 kg
patient. Using the figures in Daugirdas et al. (Sem Dial 2011), this will lead to a
phosphate load of about 26 mmol/day. Conventional dialysis removes about 100 mmol
phosphate/week. This leaves an anuric patient with about 12 mmol/day of excess
phosphate for which 4 to 12 binder tablets (depending on the type and size) will be
required. This substantial pill burden is needed simply to manage the phosphate
generated from adequate protein ingestion. Any extra mmols of phosphate from
beverages will add to this burden and/or lead to high serum phosphate levels. We have
shown that this assay for inorganic phosphate in urine, which is based on the
phosphomolybdate method and is similar to the methods used in the vast majority of
hospital laboratories, can give accurate measurements of phosphate in a range of
beverages. The information the assay provides can enable patients to compare locally
available beverages and avoid or limit their intake of those with high phosphate
ASSOCIATION BETWEEN IGF-1 AND NUTRITIONAL STATUS
IN PATIENTS WITH CHRONIC KIDNEY DISEASE
Gun Woo Kang1, In Hee Lee1 and Ki Sung Ahn1
1Catholic University of Daegu School of Medicine, Daegu, Republic of Korea
Introduction and Aims: Insulin-like growth factor-1 (IGF-1) is the key mediator of the
anabolic actions of growth hormone. In previous studies, IGF-1 has been associated
with an increased risk of cardiovascular disease. Limited studies in patients receiving
dialysis suggest that serum IGF-1 correlates with markers of nutrition, compared to
serum albumin and serum transferrin. And, the association between serum IGF-1
levels and renal function is not clear. The aim of this study was to investigate the
nutritional status and renal function according to serum IGF-1 levels in patients with
chronic kidney disease (CKD).
Methods: The 165 patients with CKD from the Daegu Catholic University Medical
Center were assessed from January 2010 to November 2012. Serum IGF-1 levels were
compared with demographics features, clinical data including nutritional markers and
renal function. CKD was defined as an estimated glomerular filtration rate (eGFR) of <
60 mL/min/1.73 m2. Patients on renal replacement therapy for CKD were excluded
from this study. Statistical significance between IGF-1 and nutritional markers, and
renal function was assessed by univariate and multivariate logistic regression analysis.
Results: The mean of IGF-1 was 174.1±99.1 ng/mL. The variables showed significant
association with IGF-1 were age (r=-0.231, p=0.003), eGFR (r=0.210, p=0.007),
albumin (r=0.229, p=0.003), apolipoprotein A1 (r=0.161, p=0.042), prealbumin
(r=0.399, p<0.001), body surface area (r=0.202, p=0.009), triceps skin-fold thickness
(r=0.175, p=0.024), %fat using dual energy x-ray absorptiometry (DEXA) (r=0.333,
p<0.001). Multiple regression showed that prealbumin ( p=0.009), %fat ( p=0.015) were
independently associated with IGF-1. However, there were no significant associateion
between IGF-1 and eGFR ( p=0.094).
Conclusions: These results suggest that serum IGF-1 levels are reduced in CKD
patients with malnutrition. However, we didn’t find a correlation between IGF-1 and
eGFR. We should consider that IGF-1 is the important factor of nutritional status in