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Journal of Renal Nutrition, Vol 23, No 2 (March), 2013: pp 150-153 150 1. DIAGNOSIS OF SARCOPENIA IN CHRONIC KIDNEY DISEASE: COMPARISON OF 3 METHODS Raíssa Antunes, Antonio C. Cordeiro, Carla M. Avesani, Fernanda C. Amparo, Celso Amodeo, Lilian Cuppari, Maria A. Kamimura. Federal University of São Paulo, São Paulo, Brazil. Dante Pazzanese Institute of Cardiology, São Paulo, Brazil. Sarcopenia is a condition characterized by both loss of muscle mass and decline of muscle function or strength, and it has been associated with negative outcomes. Although a number of abnormalities in chronic kidney disease (CKD) may predispose the development of sarcopenia, it has been poorly investigated in this population, and remains largely undiagnosed and undertreated due to the lack of a universally accepted methodology. This study aimed to compare 3 methods for diagnosing sarcopenia in non- dialyzed (ND) CKD patients. We cross-sectionally evaluated 278 ND-CKD stage 2-5 patients (eGFR 19.4±9.6ml/min; 60.5±10.2years; 63% men; 49% diabetics; BMI 29.3±5.8kg/m²). Sarcopenia was defined as reduced handgrip strength (<30th percentil of a population-based reference adjusted for sex and age) associated with: A) reduced skeletal muscle mass index (<10.76kg/m² men; <6.76kg/m² women) estimated by bioelectrical impedance analysis; B) presence of muscle atrophy by subjective global assessment or C) midarm muscle circumference adequacy <90%. The prevalence of sarcopenia was 6.8% by method A, 9.7% by method B and 10.1% by method C (p<0.01). The kappa agreement between the methods were 0.44 (A vs B), 0.48 (A vs C) and 0.70 (B vs C). Age, gender, diabetes, nPNA and 25- hidroxivitamin D did not differ between sarcopenic patients when compared to those without sarcopenia, as assessed by the 3 methods. Patients diagnosed with sarcopenia by the 3 methods had lower BMI, body cell mass and phase angle. Serum albumin, hemoglobin and eGFR were lower in sarcopenic patients diagnosed by methods B and C, whereas the levels of C-reactive protein were increased only among patients with sarcopenia evaluated by method B. In conclusion, the frequency of sarcopenia in non- dialyzed CKD patients differed when evaluated by the 3 methods. Sarcopenia defined as reduced handgrip strength and presence of muscle atrophy by subjective global assessment (method B) was better associated with the nutritional and clinical abnormalities. 3. EFFECTS OF CHANGING FROM CONVENTIONAL TO HOME HD, THE IRISH EXPERIENCE Oonagh Deeney, Patrick O’Kelly, Peter J. Conlon, Annette Butler, Jane Ormond, Beaumont Hospital, Dublin, Ireland Whether more intensive dialysis improves outcomes remains controversial. This prospective audit monitored the effect of changing from conventional 3 times a week haemodialysis (HD) to a home HD programme. Nutritional status was assessed, at baseline and 12 months, through weight, Body Mass Index (BMI), Subjective Global Assessment and reported appetite. Pre-dialysis serum levels of Ur, Cr, K, PO - 4 , Corrected calcium (Corr Ca 2+) , PTH and Alkaline phosphatase (Alk Phos) were recorded at baseline and monthly for 1 year. Mineral bone disorder medications & doses were recorded at baseline and study end. The first 15 patients enrolled in our home HD programme were included in this audit. 47% (n=7) performed HD x 4 days/week, 40% (n=6) on alternate days and 13% (n=2) performed HD > 4 days/week. The mean increase in HD hours over 14 days was 8.4 hrs (+/- 8.5). A significant increase in dry weight & BMI was observed over the 12 month period, before: 69.05kg & after: 72.54 kg (P= 0.007) and 23.46kg/m 2 to 24.17kg/m 2 (P=0.0021) respectively. A significant reduction in pre dialysis Ur (P= 0.004) and Cr (P= 0.001) and an increase in serum Corr Ca (P= 0.018) was observed. 67 % had no change in phosphate binder dose and in fact 20% required an increased dose. However, a dose reduction or discontinuation was seen of 50% of Alfacalcidol, 60% of Cinacalcet and 75% of Paricalcitol prescription. Changing from conventional HD to a more intensive home HD regimen was seen to have a significantly positive outcome in pre dialysis Ur and Cr and increased dry weight & BMI. However, due to the high baseline of this group there was little opportunity to observe if this was in conjunction with a marked improvement in reported appetite. Further research is required to identify if weight gain is related to muscle or adipose tissue. However, as the mean BMI remained within the healthy range this increase was not felt to be a negative outcome. These findings are similar to other research which demonstrates little evidence of improved phosphate control with short daily HD. However, the observed reduced prescription of vitamin D analogue medications is beneficial in reducing pill burden and may also have a financial benefit in the long term. 4. THE BENEFIT OF IN-CENTER ORAL PROTEIN SUPPLEMENTATION ON HEMODIALYSIS PATIENTS Malak El-Rahi, Wadi Suki, Oluyemi Odunusi, The Methodist Hospital, Houston TX, USA In addition to continuous education regarding dietary modifications for patients on chronic hemodialysis, in-center oral protein supplementation program was established at an affiliated facility, in the aim of improving their nutrition status. Between October 2009 and August 2012, 82 patients were enrolled based on the inclusion criteria of having a sustained albumin level < 3.5 mg/dl. The mean value of their albumin levels was 3.6 mg/dl at 2 months prior to the start date, 3.4 mg/dl at 1 month prior, and 3.2 mg/dl at the start date. This decreasing trend necessitated our intervention by supplementing different forms of either protein bars or liquacel; based on patient preference, during each hemodialysis session. As albumin levels were checked monthly thereafter, the mean of the peak albumin values reached by the 82 patients was 3.73 mg/dl within an average time of 6.5 months. Actually, 35.4% reached an albumin level > 4 mg/dl within an average of 7 months, whereas 59.8% reached an albumin level > 3.8 mg/dl within almost 4 months. Fifteen patients managed to graduate from the program as they maintained an albumin level > 4 mg/dl, and 5 other patients refused to stay in the program. Of these 20 patients, 65% failed to maintain their albumin levels > 3.8 mg/dl after discontinuation. Two patients who dropped their levels below 3.5 mg/dl agreed to be re-enrolled in the program and their albumin levels improved back up to > 3.8 mg/dl. In conclusion, our data emphasizes the significant impact of in- center oral protein supplementation on improving hypoalbuminemia in patients on chronic hemodialysis with high risk of malnourishment, and thus higher mortality. 2. AEROBIC EXERCISE: AN EFFECTIVE INTERVENTION TO REDUCE VISCERAL FAT IN OBESE MEN WITH CKD. Flavia Baria, Maria Ayako Kamimura, Danilo Takashi Aoike, Mariana Leister Rocha, Adriano Ammirati, Lilian Cuppari. São Paulo, São Paulo, Brazil. This is a randomized controlled study that aimed to assess the impact of aerobic exercise on visceral fat of overweight CKD patients. Nineteen sedentary men with CKD (52.7r10.3 years, eGFR 26.8r11.2 mL/min, BMI 30.2r3.9 kg/m² were included. Patients were assigned to aerobic exercise group (EG=10) or control group (CG=9). The aerobic training was conducted on a treadmill at the ventilatory threshold three times per week during 12 weeks. The CG patients remained without practicing exercise during follow up. Visceral and subcutaneous fat were assessed by computed tomography, and body fat and lean body mass by DEXA. Waist circumference was measured at the umbilicus level. At the end of 12 weeks, a decrease in both visceral fat (113.1r24.1 to 106.6r22.8 mm, p<0.01) and waist circumference (106.8r16.7 to 104.9r16.0 cm, p=0.02) was observed in EG while in CG no change was observed. Lean body mass increased only in EG (52.5r5.4 to 53.7r5.6 kg, p<0.01), which was due to the increase in the leg fat-free mass (18.0r1.3 to 18.5r1.6 kg, p=0.01). Body weight, subcutaneous fat and body fat mass did not change in both groups. Renal function (eGFR 25.8r8.7 to 29.3r8.6 mL/min, p=0.04) and mean blood pressure (97.7r7.4 to 84.7r5.6 mmHg, p<0.01) improved in the EG. There was a significant group-by-time interaction for waist circumference, visceral fat, leg lean body mass, eGFR, and mean blood pressure. Our results indicate that aerobic exercise is an effective approach to reduce visceral fat besides increasing lean body mass in male CKD patients.

Diagnosis of Sarcopenia in Chronic Kidney Disease: Comparison of 3 Methods

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Page 1: Diagnosis of Sarcopenia in Chronic Kidney Disease: Comparison of 3 Methods

1. DIAGNOSIS OF SARCOPENIA IN CHRONIC KIDNEY DISEASE: COMPARISON OF 3 METHODS Raíssa Antunes, Antonio C. Cordeiro, Carla M. Avesani, Fernanda C. Amparo, Celso Amodeo, Lilian Cuppari, Maria A. Kamimura. Federal University of São Paulo, São Paulo, Brazil. Dante Pazzanese Institute of Cardiology, São Paulo, Brazil. Sarcopenia is a condition characterized by both loss of muscle mass and decline of muscle function or strength, and it has been associated with negative outcomes. Although a number of abnormalities in chronic kidney disease (CKD) may predispose the development of sarcopenia, it has been poorly investigated in this population, and remains largely undiagnosed and undertreated due to the lack of a universally accepted methodology. This study aimed to compare 3 methods for diagnosing sarcopenia in non-dialyzed (ND) CKD patients. We cross-sectionally evaluated 278 ND-CKD stage 2-5 patients (eGFR 19.4±9.6ml/min; 60.5±10.2years; 63% men; 49% diabetics; BMI 29.3±5.8kg/m²). Sarcopenia was defined as reduced handgrip strength (<30th percentil of a population-based reference adjusted for sex and age) associated with: A) reduced skeletal muscle mass index (<10.76kg/m² men; <6.76kg/m² women) estimated by bioelectrical impedance analysis; B) presence of muscle atrophy by subjective global assessment or C) midarm muscle circumference adequacy <90%. The prevalence of sarcopenia was 6.8% by method A, 9.7% by method B and 10.1% by method C (p<0.01). The kappa agreement between the methods were 0.44 (A vs B), 0.48 (A vs C) and 0.70 (B vs C). Age, gender, diabetes, nPNA and 25-hidroxivitamin D did not differ between sarcopenic patients when compared to those without sarcopenia, as assessed by the 3 methods. Patients diagnosed with sarcopenia by the 3 methods had lower BMI, body cell mass and phase angle. Serum albumin, hemoglobin and eGFR were lower in sarcopenic patients diagnosed by methods B and C, whereas the levels of C-reactive protein were increased only among patients with sarcopenia evaluated by method B. In conclusion, the frequency of sarcopenia in non-dialyzed CKD patients differed when evaluated by the 3 methods. Sarcopenia defined as reduced handgrip strength and presence of muscle atrophy by subjective global assessment (method B) was better associated with the nutritional and clinical abnormalities.

3. EFFECTS OF CHANGING FROM CONVENTIONAL TO HOME HD, THE IRISH EXPERIENCE Oonagh Deeney, Patrick O’Kelly, Peter J. Conlon, Annette Butler,Jane Ormond, Beaumont Hospital, Dublin, Ireland

Whether more intensive dialysis improves outcomes remainscontroversial. This prospective audit monitored the effect ofchanging from conventional 3 times a week haemodialysis (HD) toa home HD programme. Nutritional status was assessed, at baselineand 12 months, through weight, Body Mass Index (BMI),Subjective Global Assessment and reported appetite. Pre-dialysisserum levels of Ur, Cr, K, PO-

4, Corrected calcium (Corr Ca2+),PTH and Alkaline phosphatase (Alk Phos) were recorded atbaseline and monthly for 1 year. Mineral bone disordermedications & doses were recorded at baseline and study end. Thefirst 15 patients enrolled in our home HD programme wereincluded in this audit. 47% (n=7) performed HD x 4 days/week,40% (n=6) on alternate days and 13% (n=2) performed HD > 4days/week. The mean increase in HD hours over 14 days was 8.4hrs (+/- 8.5). A significant increase in dry weight & BMI wasobserved over the 12 month period, before: 69.05kg & after: 72.54kg (P= 0.007) and 23.46kg/m2 to 24.17kg/m2 (P=0.0021)respectively. A significant reduction in pre dialysis Ur (P= 0.004)and Cr (P= 0.001) and an increase in serum Corr Ca (P= 0.018)was observed. 67 % had no change in phosphate binder dose and infact 20% required an increased dose. However, a dose reduction ordiscontinuation was seen of 50% of Alfacalcidol, 60% ofCinacalcet and 75% of Paricalcitol prescription.

Changing from conventional HD to a more intensive home HDregimen was seen to have a significantly positive outcome in predialysis Ur and Cr and increased dry weight & BMI. However, dueto the high baseline of this group there was little opportunity toobserve if this was in conjunction with a marked improvement inreported appetite. Further research is required to identify if weightgain is related to muscle or adipose tissue. However, as the meanBMI remained within the healthy range this increase was not felt tobe a negative outcome. These findings are similar to other researchwhich demonstrates little evidence of improved phosphate controlwith short daily HD. However, the observed reduced prescriptionof vitamin D analogue medications is beneficial in reducing pillburden and may also have a financial benefit in the long term.

4. THE BENEFIT OF IN-CENTER ORAL PROTEIN SUPPLEMENTATION ON HEMODIALYSIS PATIENTS Malak El-Rahi, Wadi Suki, Oluyemi Odunusi, The Methodist Hospital, Houston TX, USA In addition to continuous education regarding dietary modifications for patients on chronic hemodialysis, in-center oral protein supplementation program was established at an affiliated facility, in the aim of improving their nutrition status. Between October 2009 and August 2012, 82 patients were enrolled based on the inclusion criteria of having a sustained albumin level < 3.5 mg/dl. The mean value of their albumin levels was 3.6 mg/dl at 2 months prior to the start date, 3.4 mg/dl at 1 month prior, and 3.2 mg/dl at the start date. This decreasing trend necessitated our intervention by supplementing different forms of either protein bars or liquacel; based on patient preference, during each hemodialysis session. As albumin levels were checked monthly thereafter, the mean of the peak albumin values reached by the 82 patients was 3.73 mg/dl within an average time of 6.5 months. Actually, 35.4% reached an albumin level > 4 mg/dl within an average of 7 months, whereas 59.8% reached an albumin level > 3.8 mg/dl within almost 4 months. Fifteen patients managed to graduate from the program as theymaintained an albumin level > 4 mg/dl, and 5 other patients refused to stay in the program. Of these 20 patients, 65% failed to maintain their albumin levels > 3.8 mg/dl after discontinuation. Two patients who dropped their levels below 3.5 mg/dl agreed to be re-enrolled in the program and their albumin levels improved back up to > 3.8 mg/dl. In conclusion, our data emphasizes the significant impact of in-center oral protein supplementation on improving hypoalbuminemia in patients on chronic hemodialysis with high risk of malnourishment, and thus higher mortality.

2. AEROBIC EXERCISE: AN EFFECTIVE INTERVENTION TO REDUCE VISCERAL FAT IN OBESE MEN WITH CKD. Flavia Baria, Maria Ayako Kamimura, Danilo Takashi Aoike, Mariana Leister Rocha, Adriano Ammirati, Lilian Cuppari. São Paulo, São Paulo, Brazil. This is a randomized controlled study that aimed to assess the impact of aerobic exercise on visceral fat of overweight CKD patients. Nineteen sedentary men with CKD (52.7 10.3 years, eGFR 26.8 11.2 mL/min, BMI 30.2 3.9 kg/m² were included. Patients were assigned to aerobic exercise group (EG=10) or control group (CG=9). The aerobic training was conducted on a treadmill at the ventilatory threshold three times per week during 12 weeks. The CG patients remained without practicing exercise during follow up. Visceral and subcutaneous fat were assessed by computed tomography, and body fat and lean body mass by DEXA. Waist circumference was measured at the umbilicus level. At the end of 12 weeks, a decrease in both visceral fat (113.1 24.1to 106.6 22.8 mm, p<0.01) and waist circumference (106.8 16.7 to 104.9 16.0 cm, p=0.02) was observed in EG while in CG no change was observed. Lean body mass increased only in EG (52.5 5.4 to 53.7 5.6 kg, p<0.01), which was due to the increase in the leg fat-free mass (18.0 1.3 to 18.5 1.6 kg, p=0.01). Body weight, subcutaneous fat and body fat mass did not change in both groups. Renal function (eGFR 25.8 8.7 to 29.3 8.6 mL/min, p=0.04) and mean blood pressure (97.7 7.4 to 84.7 5.6 mmHg, p<0.01) improved in the EG. There was a significant group-by-time interaction for waist circumference, visceral fat, leg lean body mass, eGFR, and mean blood pressure. Our results indicate that aerobic exercise is an effective approach to reduce visceral fat besides increasing lean body mass in male CKD patients.

Journal of Renal Nutrition, Vol 23, No 2 (March), 2013: pp 150-153150