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OBJECTIVE: This study aimed to determine if adapted Global Leadership Initiative on Malnutrition (GLIM) criteria can diagnose overnutrition, in addition to undernutrition, in hemodialysis patients. Additionally, it compared the adapted GLIM criteria with the subjective global assessment (SGA) for diagnosing undernutrition. METHODS: A cross-sectional, descriptive study design with an analytical component was utilized. An interviewer-administered questionnaire was completed with 116 adult participants from 2 public renal units in Cape Town. Data collection included demographic, medical, and anthropometric information, incorporating the established SGA tool and the adapted GLIM criteria. RESULTS: Of the participants, 58% were female, with a mean age of 41.04 years (SD 10.6). The primary causes of renal failure were hypertension (38%) and glomerular disease (33%). The median weight was 64.74 kg (IQR 16.4), and the mean body mass index (BMI) was 25.44 kg/m2 (SD 4.66). The prevalence of obesity was 20%, and undernutrition was 4% by BMI. Participants from Groote Schuur Hospital had a higher mean BMI (26.40, SD 4.9) than those from Tygerberg Hospital (P = .0033). Abdominal obesity prevalence was 51%, with a mean waist circumference of 87.06 cm (SD 11.37). Using SGA parameters, undernutrition prevalence was 26%, with all classified as SGA-B, compared to 22% by adapted GLIM. Adapted GLIM classified 69.83% as malnourished (overnutrition 47% and undernutrition 22%). For undernutrition, the adapted GLIM had a sensitivity of 75% (CI 64.04, 85.96), specificity of 77.78% (CI 67.26, 88.3), positive predictive value of 69.23% (CI 57.55, 80.91), and negative predictive value of 82.35% (CI 72.71, 92.00). Among those diagnosed with overnutrition by adapted GLIM, 89% were classified as well-nourished by SGA. CONCLUSION: The adapted GLIM criteria effectively assessed overnutrition as well as undernutrition in hemodialysis patients. It identified a significant proportion of patients misclassified as well-nourished by SGA who were actually overnourished. The adapted GLIM showed good sensitivity and specificity for diagnosing undernutrition in this population.

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OBJECTIVE: Hungry bone syndrome (HBS) is a common complication after parathyroidectomy in dialysis patients with severe secondary hyperparathyroidism. The rapid decline in parathyroid hormone (PTH) levels diminishes bone resorption and accelerates bone formation. This causes a significant influx of calcium and phosphate into the bone, resulting in severe and prolonged hypocalcemia. While previous studies have established risk factors for HBS, the outcomes beyond the reduced recurrence rate of hyperparathyroidism have been largely unexplored. METHODS: This single-center retrospective study analyzed 322 cases in 314 dialysis patients who underwent parathyroidectomy between 2012 and 2022. The study examined baseline factors associated with HBS, adverse events, and clinical outcomes, including changes in blood pressure and hematologic and nutritional parameters over 3-12 months of follow-up, stratified by HBS status. RESULTS: Total parathyroidectomy was performed in 28 cases (8.7%), total parathyroidectomy with implantation in 98 cases (30.4%), and subtotal parathyroidectomy in 196 cases (60.9%). HBS occurred in 207 cases (64%). Independent predictors of HBS included male sex, lower serum calcium levels, higher PTH levels, and lack of active vitamin D treatment at baseline. Patients with HBS had longer hospital stays but did not experience an increase in other adverse events. Following parathyroidectomy, the HBS group showed a greater reduction in blood pressure and more significant increases in hemoglobin, total lymphocyte count, and serum creatinine. This group also saw a more substantial decrease in the proportions of patients with hemoglobin <11 g/dL and serum creatinine/body surface area <380 µmol/L/m2. Although the HBS group showed a more significant decline in PTH levels from baseline, similar proportions achieved the target PTH level by the end of the study. Serum calcium levels remained substantially lower in the HBS group throughout the follow-up, while serum phosphate and PTH levels were comparable. CONCLUSION: HBS was associated with more pronounced improvements in blood pressure, anemia, and nutritional parameters. The presence of HBS could indicate greater achievement in controlling hyperparathyroidism following parathyroidectomy.

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OBJECTIVES: Anorexia is common in patients with chronic kidney disease (CKD) and could lead to protein-energy wasting (PEW). An altered sense of smell, a reflection of olfactory dysfunction, is a potential mechanism that exacerbates the impact of anorexia on PEW. In this study, we examined the extent of the altered sense of smell and its association with PEW in patients with moderate-to-advanced CKD. METHODS: We studied 139 individuals (34 healthy subjects- controls, 50 patients with stage 3-4 CKD, and 55 patients on maintenance hemodialysis (MHD)) using the odor identification test (Sniffin' Sticks odor screening test containing 12 different smells). The odor identification test was scored as either correct or incorrect, and each participant's total odor score was calculated. Malnutrition inflammation score (MIS) was used to assess PEW. RESULTS: Patients with CKD had higher C-reactive protein and lower serum albumin concentrations compared to healthy individuals. Total odor scores were different between groups, with controls having the highest scores and MHD patients having the lowest scores. A similar difference was observed in MIS, and MHD patients displayed the worst nutritional score (P ≤ .001). The number of participants with severe olfactory dysfunction (≤6 correct answers) was significantly higher in the CKD and MHD groups compared to the controls (P ≤ .01). There was an inverse trend between the total odor score and the MIS score for the study population. However, this relationship was not statistically significant (r = -0.124, P = .21). CONCLUSION: This cross-sectional study suggests that olfactory dysfunction, as assessed by the odor identification test, is altered in patients with advanced CKD, most notably in ones on MHD. Although the diminished sense of smell was observed alongside development of PEW, we explicitly noted that there is no statistically significant correlation.

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Background: Protein Energy Wasting (PEW) has high incidence in adult hemodialysis patients and refers to a state of decreased protein and energy substance. It has been demonstrated that PEW highly affects the quality of survival and increases the risk of death. Nevertheless, its diagnostic criteria are complex in clinic. To simplify the diagnosis method of PEW in adult hemodialysis patients, we previously established a novel clinical prediction model that was well-validated internally using bootstrapping. In this multicenter cross-sectional study, we aimed to externally validate this nomogram in a new cohort of adult hemodialysis patients. Methods: The novel prediction model was built by combining four independent variables with part of the International Society of Renal Nutrition and Metabolism (ISRNM) diagnostic criteria including albumin, total cholesterol, and body mass index (BMI). We evaluated the performance of the new model using discrimination (Concordance Index), calibration plots, and Clinical Impact Curve to assess its predictive utility. Results: From September 1st, 2022 to August 31st, 2023, 1,158 patients were screened in five medical centers in Shanghai. 622 (53.7%) hemodialysis patients were included for analysis. The PEW predictive model was acceptable discrimination with the area under the curve of 0.777 (95% CI 0.741-0.814). Additionally, the model revealed well-fitted calibration curves. The McNemar test showed the novel model had similar diagnostic efficacy with the gold standard diagnostic method (p > 0.05). Conclusion: Our results from this cross-sectional external validation study further demonstrate that the novel model is a valid tool to identify PEW in adult hemodialysis patients effectively.

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BACKGROUND: Chronic kidney disease (CKD) is characterized by structural abnormalities in nephrons, loss of functional nephrons, and impaired renal excretory function. A pro-vegetarian dietary pattern (PDP) is a gradual and progressive approach to vegetarianism. The current study aimed to assess the association between PDP and the odds of protein-energy wasting (PEW) and sarcopenia in patients with CKD. METHODS: The present cross-sectional study was conducted on kidney disease patients (n = 109) referred to two clinics in Shiraz, Iran. The diagnosis of sarcopenia and PEW was made according to the guidelines of the Asian Working Group for Sarcopenia (AWGS) and the International Society of Renal Nutrition and Metabolism (ISRNM) criteria, respectively. The participants' dietary intake was evaluated using a 168-item semi-quantitative food frequency questionnaire (FFQ). For PDP index calculation, plant and animal food sources were categorized into 12 subgroups. The association between sarcopenia and PEW with PDP was evaluated using logistic regression. RESULTS: The PDP was significantly associated with a lower risk of PEW in the second tertile compared to the first in the crude model (odds ratio (OR) = 0.225; confidence interval (CI): 0.055-0.915; p-value = 0.037). After adjusting for potential confounders, lower significant odds of PEW were observed in the second and last tertiles of PDP compared to the first (T2: OR = 0.194; CI: 0.039-0.962; p-value = 0.045, and T3: OR = 0.168; CI: 0.030-0.950; p-value = 0.044). In contrast, no significant relationship was observed between PDP and the odds of sarcopenia (p-value ˃ 0.05). CONCLUSIONS: Overall, the findings indicated that greater adherence to PDP was negatively associated with the odds of PEW. Additionally, the results showed no association between PDP and the odds of sarcopenia. Further studies are needed to support these findings.

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Using a system that incorporates a variety of food items rather than focusing on individual components can aid in assessing the inflammatory effects of a diet on disease outcomes such as chronic kidney disease (CKD). Therefore, we decided to investigate the association between dietary inflammatory index (DII) and the risk of protein-energy wasting (PEW) and sarcopenia in patients with CKD. In this cross-sectional study, 109 patients with CKD were selected from two clinics in Shiraz, Iran. The intake of individuals' diets was recorded using a validated 168-item food frequency questionnaire. Additionally, Asian Working Group for Sarcopenia (AWGS) guidelines were utilized to evaluate muscles' strength, mass, and function. Also, four International Society of Renal Nutrition and Metabolism (ISRNM) criteria (body mass index, intake of protein, albumin, and urine creatinine) were used  to diagnose PEW. Logistic regression was used to assess the association between DII and sarcopenia as well as PEW. The results showed that the intake of saturated fatty acids, trans fatty acids, niacin, beta-carotene, and vitamin C was significantly different between lower and higher DII groups. In the univariate model, higher odds of sarcopenia was observed by each unit increase in DII (odds ratio (OR) = 1.379, 95% confidence interval (CI): 1.042-1.824) and age (OR = 1.073, 95% CI: 1.017-1.132). Additionally, in the multivariate model, the association between DII and age with odds of sarcopenia remained significant (DII: OR = 1.379, 95% CI: 1.030-1.846 and age: OR = 1.063, 95% CI: 1.007-1.121). The current study suggests the possible role of pro-inflammatory foods in worsening muscle health, specifically sarcopenia, in CKD patients. Future longitudinal studies may reveal the causative nature of these correlations.

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Chronic kidney disease (CKD) encompasses diverse conditions such as congenital anomalies, glomerulonephritis, and hereditary nephropathies, necessitating individualized nutritional interventions. Early detection is pivotal due to the heightened risk of adverse outcomes, including compromised growth and increased healthcare costs. The nutritional assessment in pediatric CKD employs a comprehensive, multidisciplinary approach, considering disease-specific factors, growth metrics, and dietary habits. The prevalence of malnutrition, as identified through diverse tools and guidelines, underscores the necessity for regular and vigilant monitoring. Nutritional management strategies seek equilibrium in calorie intake, protein requirements, and electrolyte considerations. Maintaining a well-balanced nutritional intake is crucial for preventing systemic complications and preserving the remaining kidney function. The nuanced landscape of enteral nutrition, inclusive of gastrostomy placement, warrants consideration in scenarios requiring prolonged support, with an emphasis on minimizing risks for optimized outcomes. In conclusion, the ongoing challenge of managing nutrition in pediatric CKD necessitates continuous assessment and adaptation. This review underscores the significance of tailored dietary approaches, not only to foster growth and prevent complications but also to enhance the overall quality of life for children grappling with CKD.

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BACKGROUND: Pre-haemodialysis (HD) serum creatinine levels are reliable and inexpensive markers of muscle mass and important predictors of survival in patients with stable chronic HD. We aimed to assess whether changes in pre-HD serum creatinine levels during a 2-year period are linked to long-term patient survival. METHODS: We retrospectively analysed patients enrolled in a periodic HD quality assessment program. Of the 21 846 participants in the fourth HD quality assessment program, 13 765 were presented in the fifth, of which 10 299 eligible patients were included in this study. We assessed the change in serum creatinine levels over 2 years. The patients were categorized into the following three groups: stable group (patients with change in serum creatinine < 1 mg/dL during 2 years of HD, n = 5664), increasing group (patients with increase in serum creatinine ≥ 1 mg/dL, n = 2419) and decreasing group (patients with decrease in serum creatinine ≥ 1 mg/dL, n = 2216). RESULTS: The duration of HD at baseline was 62-83 months, with diabetic kidney disease being the most common cause of kidney failure in 36.4% of patients. The 5-year patient survival rates in the stable, increasing and decreasing groups were 69.1%, 71.3% and 66.8%, respectively. The decreasing group had poorer patient survival than the other two groups (P = 0.083 for stable vs. increasing group; P = 0.011 for stable vs. decreasing group; P < 0.001 for increasing vs. decreasing group). There was no significant difference in the cardiovascular event-free survival rate among the three groups. Multivariable Cox regression analyses revealed the highest hazard ratio (HR) for mortality in the decreasing group (HR 1.33, 95% confidence interval [CI] 1.21-1.45, P < 0.001 vs. stable group; HR 1.50, 95% CI 1.34-1.69, P < 0.001 vs. increasing group). The increasing group exhibited a lower risk of mortality than the stable group (HR 0.88, 95% CI 0.81-0.97, P = 0.008). Subgroup analyses based on age, HD vintage, sex, Charlson comorbidity index score, presence of diabetes and baseline serum creatinine level tertiles revealed that the decreasing group exhibited the highest mortality among all subgroups. CONCLUSIONS: Our results demonstrate that changes in pre-HD serum creatinine levels over 2 years of HD were associated with all-cause mortality in patients undergoing HD. This finding suggests a simple and promising approach for clinicians in the prognosis and management of patients undergoing HD.

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BACKGROUND: Excessive sugar intake increases the energy metabolic burden and the risk of cardiovascular disease (CVD). Patients on peritoneal dialysis absorb much more glucose than the World Health Organization recommends, but the link to CVD is unclear. OBJECTIVE: To identify the association between peritoneal glucose absorption, lipid metabolism, and CVD. METHODS: We applied generalized additive mixed effects and mixed effects Cox proportional hazard models to evaluate the impact of peritoneal glucose absorption on lipid profiles and CVD risk. We performed subgroup analyses by using protein intake (normalized protein nitrogen appearance [nPNA] and normalized protein catabolic rate [nPCR] were used to assess protein intake) and high-sensitivity C-reactive protein (hs-CRP). RESULTS: After multivariable adjustment, peritoneal glucose absorption per 10 g/d increase was associated with an increase in cholesterol of 0.145 (95% confidence interval [CI]: 0.086-0.204) mmol/L. No link with the total risk of CVD was observed; however, protein intake and hs-CRP levels affected the relationship between glucose absorption and CVD risk. Patients with values for nPNA and nPCR <1.0 g/(kg·d) were associated with a lower risk of CVD (hazard ratio [HR] 95% CI: 0.68 (0.46-0.98)) with glucose absorption per 10 g/d increase. While patients with hs-CRP levels ≥3 mg/d or values for nPNA or nPCR ≥1.0 g/(kg·d) were associated with a higher risk of CVD (HR 95% CI: 1.32 (1.07-1.63); 1.31 (1.02-1.68)) for glucose absorption per 10 g/d increase. CONCLUSIONS: Our study found a positive correlation between peritoneal glucose absorption and lipid profiles. Increased glucose absorption was associated with a lower risk of CVD in lower protein intake patients and a higher risk of CVD in higher hs-CRP or protein intake levels in patients on peritoneal dialysis.

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Protein-energy wasting and inflammation are major risk factors for complications in hemodialysis patients. As these risk factors are triggered by a pro-inflammatory state, oxidative stress and hemodynamic dysfunction, which overlap in hemodialyzed subjects, we aimed to assess the efficacy of a cost-effective and straightforward screening tool, the Prognostic Inflammatory and Nutritional Index (PINI), in regularly screening maintenance hemodialysis (MHD) patients, to detect early signs of inflammation and malnutrition. A 12-month follow-up was carried out on a cohort of 102 adult patients undergoing maintenance dialysis, during which the Prognostic Inflammatory and Nutritional Index (PINI) was calculated using the formula alpha1-Acid Glycoprotein (AGP) × C-reactive protein (CRP)/albumin (ALB) × transthyretin (TTR). A PINI score < 1 was considered normal. The patients were stratified based on their PINI score: 66 patients (64.70%) had a normal score, below 1, while 36 patients (35.30%) had a PINI score ≥ 1. Despite the absence of clinical evidence of inflammation at enrollment, the latter group exhibited higher levels of CRP. During the follow-up period, all patients with a PINI score ≥ 1 experienced at least one acute event, compared to only 6% of patients with a normal PINI score, which presented COVID-19 infection as an acute event. The evaluation of the PINI can effectively identify the silent malnutrition-inflammation syndrome and predict the risk of acute events. This straightforward test appears to be a rapid tool that is independent of the examiner's experience and subjectivity, thereby potentially reducing hospitalization costs.

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AIM: Protein-energy wasting (PEW) is a common syndrome in patients undergoing haemodialysis (HD) and is associated with poor prognosis. Bioelectrical impedance analysis (BIA)-derived phase angle (PA) is useful for predicting PEW, but sex and age need to be considered. We aimed to reveal sex-specific cut-off values of PA predicting PEW in HD patients aged ≥65. METHODS: This two-centre retrospective cohort study included patients on HD who underwent BIA. PEW was detected using the International Society of Renal Nutrition and Metabolism (ISRNM) criteria as a reference. The PA was measured using a multifrequency bioimpedance device. Sex-specific cut-off values of PA predicting PEW were detected by receiver-operator characteristic analysis. We investigated the association between PEW determined using sex-specific cut-off values for PA and all-cause mortality. RESULTS: This study included 274 patients undergoing HD, with a median age of 75 (70-80) years, mean PA of 3.8 ± 1.1° and PEW of 43%. Over a median follow-up duration of 1095 (400-1095) days, 111 patients died. Cut-off values of PA predicting PEW were as follows: female, 3.00° (sensitivity, 87.3%; specificity, 77.5%), and male, 3.84° (sensitivity, 77.6%; specificity, 71.4%). The kappa coefficient between sex-specific cut-off values of the PA and ISRNM criteria had a moderate coincidence level of 0.55. PEW detected by PA was independently associated with all-cause mortality (hazard ratio: 2.40; 95% confidence interval: 1.51-3.85; p < .001). CONCLUSIONS: Sex-specific cut-off values for PA in older HD patients may be useful as a screening tool for predicting PEW and mortality.

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The potential threshold for dietary energy intake (DEI) that might prevent protein-energy wasting (PEW) in chronic kidney disease (CKD) is uncertain. The subjects were non-dialysis CKD patients aged ≥ 14 years who were hospitalised from September 2019 to July 2022. PEW was measured by subjective global assessment. DEI and dietary protein intake (DPI) were obtained by 3-d diet recalls. Patients were divided into adequate DEI group and inadequate DEI group according to DEI ≥ 30 or < 30 kcal/kg/d. Logistic regression analysis and restricted cubic spline were used in this study. We enrolled 409 patients, with 53·8 % had hypertension and 18·6 % had diabetes. The DEI and DPI were 27·63 (sd 5·79) kcal/kg/d and 1·00 (0·90, 1·20) g/kg/d, respectively. 69·2 % of participants are in the inadequate DEI group. Malnutrition occurred in 18·6 % of patients. Comparing with patients in the adequate DEI group, those in the inadequate DEI group had significantly lower total lymphocyte count, serum cholesterol and LDL-cholesterol and a higher prevalence of PEW. For every 1 kcal/kg/d increase in DEI, the incidence of PEW was reduced by 12·0 % (OR: 0·880, 95 % CI: 0·830, 0·933, P < 0·001). There was a nonlinear curve relationship between DEI and PEW (overall P < 0·001), and DEI ≥ 27·6 kcal/kg/d may have a preventive effect on PEW in CKD. Low DPI was also significantly associated with malnutrition, but not when DEI was adequate. Decreased energy intake may be a more important factor of PEW in CKD than protein intake.

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OBJECTIVE: The Subjective Global Assessment (SGA) is a validated tool for identifying nutritional status in patients receiving maintenance dialysis (MHD), but it is not without limitations. Current research identifies additional clinical characteristics such as phase angle (PhA) associated with SGA. This study aimed to assess the overall correlation between PhA and SGA; associations between PhA and SGA by body mass index (BMI), and to identify clinical characteristics associated with SGA. DESIGN AND METHODS: This is a secondary analysis of the Rutgers Nutrition & Kidney Database, which enrolled participants from four primary studies that included adults diagnosed with chronic kidney disease who were receiving MHD. Multivariable binary logistic regression analyses were conducted to estimate odds ratio (OR) and corresponding 95% confidence intervals. RESULTS: The study sample included 60.0% males with 81.1% of the sample identifying as African American. Additionally, 38.9% were obese according to the BMI classification, and 57.0% were moderately malnourished. Patients with obesity had 44% lower odds of being moderately malnourished (OR=0.56, 95% CI= 0.37, 0.85). In the model adjusted for age and ethnicity and other clinical characteristics, increasing PhA values by one unit was associated with 28% lower odds (OR= 0.72, 95% CI= 0.53, 0.97) of being moderately malnourished while increasing waist circumference (WC) values by one unit was associated with 12% higher odds (OR= 1.12; 95% CI= 1.06, 1.19) of being moderately malnourished than well-nourished. In this fully adjusted model, increasing FFM (OR= 0.95, 95% CI=0.91, 0.99) and FM (OR = 0.92, 95% CI= 0.87, 0.97) by 1 kg was also associated with a 5% and 8% lower odds of being moderately malnourished, respectively. CONCLUSION: PhA and SGA were significantly associated only among patients classified as obese. PhA, WC, FM, and FFM were identified as potential clinical determinants of SGA. Patients receiving MHD and who have obesity may benefit from utilizing SGA along with WC, PhA, FM, and FFM to assess nutritional status.

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Protein energy wasting(PEW)is common in maintenance hemodialysis(MHD)patients,and it is associated with a variety of adverse clinical outcomes,including weight loss and increased protein catabolism.There are many studies on health interventions for MHD patients through nutrition strategies,exercise patterns and the combination of both.This article reviews the pathogenesis,diagnostic criteria and intervention measures of PEW,aiming to provide a reference for early clinical diagnosis,identification and intervention of PEW.

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OBJECTIVE: Loss of muscle mass and sarcopenia are common in chronic kidney disease (CKD) and end-stage renal disease (ESRD), and sarcopenia can worsen insidiously in patients with advancing CKD. The temporal dynamics of sarcopenia in patients with progressive loss of kidney function, and its association with future outcomes, is unclear. METHODS: In a contemporary national cohort of incident ESRD US veterans, we selected 661 patients who had at least 2 24-hour urine creatinine (24hrUC) measurements, a surrogate of muscle mass, performed during the 3-year prelude period prior to ESRD transition. We estimated 24hrUC slopes in mixed effects models. To assess the temporal dynamics of pre-ESRD changes in 24hrUC and its association with changing eGFR, we separately fitted in mixed effects models a penalized spline regression of 24hrUC on time and on eGFR. We examined the association of 24hrUC slopes with postdialysis all-cause mortality using Cox models adjusted for confounders. RESULTS: The mean slope of 24hrUC versus time was -78 mg/year (95% confidence interval: -102 to -54), with a steeper decline noted in the last year prior to ESRD. More severe decreases in 24hrUC were associated with higher all-cause mortality: a 100 mg/year decrease in 24hrUC was associated with a multivariable adjusted death hazard ratio of 1.41 (95% confidence interval: 1.00-1.98, P = .05). CONCLUSION: Patients with advanced CKD lose a substantial proportion of their muscle mass each year during pre-ESRD prelude. Loss of muscle mass accelerates near ESRD transition, and more loss of muscle mass is associated with higher mortality after ESRD transition.

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Background: Malnutrition and protein-energy wasting (PEW) are nutritional complications of advanced chronic kidney disease (CKD) that contribute to morbidity, mortality, and decreased quality of life. No previous studies have assessed the effect of oral nutritional supplements (ONSs) on patient-reported symptom burden among patients with non-dialysis CKD (CKD-ND) who have or are at risk of malnutrition/PEW. Objective: The objective of this study was (1) to quantify the associations between baseline nutritional parameters and patient-reported symptom scores for wellbeing, tiredness, nausea, and appetite and (2) to compare the change in symptom scores among patients prescribed ONS with patients who did not receive ONS in a propensity-score-matched analysis. Design: This study conducted observational cohort analysis using provincial registry data. Setting: This study was done in multidisciplinary CKD clinics in British Columbia. Patients: Adult patients >18 years of age with CKD-ND entering multidisciplinary CKD clinics between January 1, 2010-July 31, 2019 who had at least 2 Edmonton Symptom Assessment System Revised: Renal (ESASr:Renal) assessments. Measurements: The measurements include nutrition-related parameters such as body mass index (BMI), serum albumin, serum phosphate, serum bicarbonate, neutrophil-to-lymphocyte ratio (NLR), and ESASr:Renal scores (overall and subscores for wellbeing, tiredness, nausea, and appetite). Methods: Multivariable linear regression was applied to assess associations between nutritional parameters and ESASr:Renal scores. Propensity-score matching using the greedy method was used to match patients prescribed ONS with those not prescribed ONS using multiple demographic, comorbidity, health care utilization, and temporal factors. Linear regression was used to assess the association between first ONS prescription and change in ESASr:Renal overall score and subscores for wellbeing, tiredness, nausea, and appetite. Results: Of total, 2076 patients were included. Higher baseline serum albumin was associated with lower overall ESASr:Renal score (-0.20, 95% confidence interval [CI] = -0.40 to -0.01 per 1 g/L increase in albumin), lower subscores for tiredness (-0.04, 95% CI = -0.07 to -0.01), nausea (-0.03, 95% CI = -0.04 to -0.01), and appetite (-0.03, 95% CI = -0.06 to -0.01). Higher BMI was associated with higher overall ESASr:Renal score (0.32, 95% CI = 0.16 to 0.48 per 1 kg/m2 increase in BMI), higher symptom subscores for wellbeing (0.02, 95% CI = 0.00 to 0.04) and tiredness (0.05, 95% CI = 0.02 to 0.07). Higher baseline NLR was associated with higher overall score (0.21, 95% CI = 0.03 to 0.39 per 1 unit increase in NLR), higher symptom subscores for wellbeing (0.03, 95% CI = 0.01 to 0.05) and nausea (0.03, 95% CI = 0.02 to 0.05). In the propensity-score-matched analysis, there were no statistically significant associations between ONS prescription and change in overall ESASr:Renal (beta coefficient for change in ESASr:Renal = 0.17, 95% CI = -2.64 to 2.99) or for subscores for appetite, tiredness, nausea, and wellbeing. Limitations: Possible residual confounding. The ESASr:Renal assessments were obtained routinely only in patients with G5 CKD-ND and/or experiencing significant CKD-related symptoms. Conclusions: This exploratory observational analysis of patients with advanced non-dialysis CKD demonstrated BMI, serum albumin, and NLR were modestly associated with patient-reported symptoms, but we did not observe an association between ONS use and change in ESASr:Renal scores.

Contexte: La malnutrition et la dénutrition protéino-énergétique (DPÉ) sont des complications nutritionnelles de l'insuffisance rénale chronique (IRC) de stade avancé qui contribuent à la morbidité, à la mortalité et à la diminution de la qualité de vie associées à la maladie. Aucune étude n'a évalué l'effet des suppléments nutritionnels administrés par voie orale (SNO) sur le fardeau des symptômes autodéclarés par les patients non dialysés atteints d'IRC (IRC-ND) et souffrant de malnutrition/DPÉ ou risquant d'en souffrir. Objectifs: (1) Quantifier les associations entre les paramètres nutritionnels initiaux et les scores des symptômes autodéclarés en lien avec le bien-être, la fatigue, les nausées et l'appétit. (2) Comparer, dans une analyse des scores de propension appariés, la variation des scores associés aux symptômes des patients ayant reçu une ordonnance de SNO par rapport aux patients n'en ayant pas reçu. Conception: Analyse de cohorte observationnelle à partir des données du registre provincial. Cadre: Cliniques multidisciplinaires d'IRC en Colombie-Britannique. Sujets: Des patients adultes atteints d'IRC-ND admis entre le 1er janvier 2010 et le 31 juillet 2019 dans des cliniques multidisciplinaires d'IRC avec au moins deux évaluations selon l'Échelle d'évaluation Edmonton pour l'insuffisance rénale (ESASr:renal­Edmonton Symptom Assessment System Revised: Renal). Mesures: Les paramètres liés à la nutrition: indice de masse corporelle (IMC), albumine sérique, phosphate sérique, bicarbonate sérique, rapport neutrophiles/lymphocytes (RNL), ainsi que les scores ESASr:renal (scores globaux et scores secondaires pour le bien-être, la fatigue, les nausées et l'appétit). Méthodologie: La régression linéaire multivariable a servi à évaluer les associations entre les paramètres nutritionnels et les scores ESASr:renal. Une correspondance des scores de propension par la méthode Greedy a été utilisée pour apparier des patients ayant reçu ordonnance de SNO avec des patients n'en ayant pas reçu selon plusieurs facteurs démographiques, les comorbidités, l'utilisation des soins de santé et des facteurs temporels. La régression linéaire a servi à évaluer l'association entre la première ordonnance de SNO et la variation des scores globaux et des scores secondaires de l'ESASr:renal pour le bien-être, la fatigue, les nausées et l'appétit. Résultats: Au total, 2 076 patients ont été inclus à l'étude. Un taux d'albumine sérique plus élevé à l'inclusion était associé à un score ESASr:rénal global plus faible (-0,20 [IC 95 %: -0,40 à -0,01 pour 1 g/L d'augmentation de l'albumine]) et à des scores secondaires plus faibles pour la fatigue (-0,04 [IC 95 %: -0,07 à -0,01]), les nausées (-0,03 [IC 95 %: -0,04 à 0,01]) et l'appétit (0,03 [IC 95 %: -0,06 à -0,01]). Un IMC plus élevé était associé à un score ESASr:renal global plus élevé (0,32 [IC 95 %: 0,16 à 0,48 par augmentation de 1 kg/m2 de l'IMC]), des scores secondaires de symptômes plus élevés pour le bien-être (0,02 [IC 95 %: 0,00 à 0,04]) et la fatigue (0,05 [IC 95 %: 0,02 à 0,07]). Un RNL initial plus élevé était associé à un score ESASr:renal global plus élevé (0,21 [IC 95 %: 0,03 à 0,39 par unité d'augmentation du RNL]), des scores secondaires de symptômes plus élevés pour le bien-être (0,03 [IC 95 %: 0,01 à 0,05]) et les nausées (0,03 [IC 95 %: 0,02 à 0,05]). Dans l'analyse des scores de propension appariés, aucune association statistiquement significative n'a été observée entre une ordonnance de SNO et une variation significative dans les scores globaux de l'ESASr:renal (coefficient bêta de variation de l'ESASr:rénal: 0,17 [IC 95 %: -2,64 ­ à 2,99]) ou les scores secondaires pour l'appétit, la fatigue, les nausées et le bien-être. Limites: Possibilité de facteurs de confusion résiduels. Les évaluations ESASr:renal ont été effectuées de routine uniquement pour les patients atteints d'IRC-ND G5 et/ou présentant des symptômes importants liés à l'IRC. Conclusion: Cette analyse observationnelle exploratoire portant sur des patients atteints d'IRC avancée non dialysés a démontré que l'IMC, l'albumine sérique et le RNL étaient associés de façon modeste aux symptômes autodéclarés. Toutefois, aucune association n'a été observée entre une ordonnance de SNO et une variation des scores ESASr:renal.

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Serum levels of butyrylcholinesterase (BChE) are commonly used to assess liver function. Its levels have been reported to be significantly lower in patients undergoing dialysis. To the best of our knowledge, this is the first report of hereditary heterozygous BChE deficiency in a patient undergoing dialysis. Medical staff involved in the care of patients with BChE deficiency should be aware of anesthetic usage, because prolonged neuromuscular paralysis following the administration of succinylcholine or mivacurium may occur. However, in the heterozygotes, BChE activity is not completely absent. Therefore, differentiating patients undergoing dialysis is challenging. A 52-year-old man underwent living-related kidney transplantation for focal segmental glomerulosclerosis at 22 years of age. As the renal function gradually worsened, the patient began to receive combined hemodialysis and peritoneal dialysis therapy. No problems with anesthesia were observed in past surgeries. The patient's BChE levels fluctuated between 76 and 170 U/L (reference range: 198-495 U/L); however, they had never been previously investigated. We suspected hereditary heterozygous BChE deficiency because the patient's sister was also diagnosed with it. DNA sequencing revealed a heterozygous missense mutation (Gly365Arg) and a K-variant (Ala539Thr). Patients on dialysis with low serum BChE levels often present with low albumin levels which may be overlooked as malnutrition. Thus, BChE deficiency should be suspected in patients on dialysis with unexplained low serum BChE levels. In the case of heterozygous BChE deficiency, the reference value is low, and continuous monitoring is crucial.

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BACKGROUND: The effect of ultra-processed foods (UPFs) on chronic kidney disease (CKD) has been studied in some studies. The present study aimed to investigate the association between UPF consumption and the risk of protein-energy wasting (PEW) and sarcopenia in patients with CKD in the Iranian population. METHODS: The current cross-sectional study included 110 patients with CKD referred to two clinics in Shiraz, Iran. The International Society of Renal Nutrition and Metabolism (ISRNM) criteria and the Asian Working Group for Sarcopenia (AWGS) guideline were considered for the diagnosis of PEW and sarcopenia, respectively. The valid semi-quantitative food frequency questionnaire was used to assess participants' dietary intake. The logistic regression was used to examine the association of UPFs with PEW and sarcopenia. RESULTS: We observed no significant association between sarcopenia and PEW with UPFs in the crude model. After adjusting for confounders, we observed a significantly higher odds of sarcopenia in the upper versus lower median of UPF intake (odds ratio (OR) = 3.59, 95% confidence interval (CI): 1.02-12.62, P = 0.046). CONCLUSIONS: Our findings suggest a positive relationship between UPF intake and sarcopenia among CKD patients. Therefore, reducing the intake of UPFs may decrease the odds of sarcopenia in patients suffering from CKD.

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OBJECTIVES: The aim of the present study was to assess the dietary intake and nutritional status of patients with chronic kidney disease (CKD) stage 4-5 according to the presence of diabetes. METHODS: This observational and cross-sectional study included adult patients with CKD stage 4-5 referred to a nephrology unit, between October 2018 and March 2019. Daily dietary intake was evaluated by 24-hour dietary inquiry and urine excretion. Nutritional status was assessed by measuring body composition using bioimpedance analysis and muscle function using handgrip strength. Undernutrition was considered using the protein energy wasting score. RESULTS: A total of 75 CKD patients were included, 36 (48%) of whom had diabetes; median age (interquartile range) was 71 (60-80) years. The median weight-adjusted dietary energy intake (DEI) was 22.6 (19.1-28.2) kcal/kg/day and the mean weight-adjusted dietary protein intake (DPI) was 0.86 ± 0.19 g/kg/day. There was no significant difference in DEI and DPI between patients with diabetes and those without, except for weight-adjusted DPI which was significantly lower in diabetic patients (P = .022). In univariate analysis, diabetes was associated with weight-adjusted DPI (coefficient [95% confidence interval] -0.237 [-0.446; -0.004] kcal/kg/day; P = .040), but this association did not remain significant in multivariate analysis. Nutritional status did not differ significantly between diabetic and nondiabetic patients except for lean tissue mass, which was lower in diabetic patients (P = .046). The proportion of patients with protein energy wasting was not significantly different between diabetic and nondiabetic patients (13.9% vs. 10.2%, respectively). CONCLUSIONS: In the present cohort, DPI and DEI were not significantly different between diabetic and nondiabetic CKD patients. Diabetes was not found to be associated with dietary intakes in CKD stage 4-5 patients.

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OBJECTIVES: Frailty is commonly observed in patients with chronic kidney disease (CKD) and is associated with adverse outcomes. Protein-energy wasting (PEW), a state of decreased body stores of protein and energy fuels, may be associated with frailty. However, few data are available on the possible association between frailty and PEW in CKD. METHODS: We examined the association between frailty and nutritional status assessed using anthropometric and body composition measurements, serum albumin, handgrip strength, the Malnutrition Inflammation Score (MIS), and dietary protein and calorie intake in a cross-sectional analysis of nondialysis patients with CKD stages 3-5. Body composition was assessed using multifrequency bioelectrical impedance. Frailty was defined as a Clinical Frailty Scale ≥4. We performed logistic regression with different nutrition assessment tools as the main predictors and age, sex, comorbidity, estimated glomerular filtration rate (eGFR), and hemoglobin as covariates. RESULTS: A total of 157 patients (93 men and 64 women; mean age 64 years; diabetes prevalence 38.9%) with CKD (eGFR 24.4 ± 13.4 mL/min/1.73 m2) were included. Overall, 29.3% of patients were frail. Patients with frailty were older and had a significantly higher fat tissue index and MIS but a significantly lower lean tissue index, eGFR, hemoglobin value, serum albumin value, handgrip strength value, and dietary protein intake. In multivariate logistic regression analyses, a higher body mass index category (odds ratio [OR], 1.54; 95% confidence interval [CI], 1.03-2.31), higher fat tissue index (OR, 1.15; 95% CI, 1.03-1.28), larger waist circumference (OR, 1.05; 95% CI, 1.01-1.09), reduced handgrip strength (OR, 2.70; 95% CI, 1.17-6.21), PEW defined by MIS ≥5 (OR, 3.49; 95% CI, 1.35-9.01), and dietary protein intake ≤0.8 g/kg/day (OR, 2.70; 95% CI, 1.18-6.19) were associated with higher odds of frailty. CONCLUSION: Frailty is associated with nutritional status in patients with CKD. A comprehensive nutrition assessment may allow the implementation of strategies to prevent or reduce frailty.

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