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Understanding of the association between nutritional risk and clinical outcomes in hospitalised patients with overweight is still at an early stage. Given the lack of specific tools for the patient with overweight, the objective of this study was to compare two of the main general screening instruments for assessing nutritional risk in predicting clinical outcomes in a population of hospitalised patients with overweight. A retrospective study was carried out in a medium-sized hospital in Brazil, with patients ≥20 years old admitted between July 2017 and December 2019. Patients who were overweight and had records of Nutritional Risk Screening-2002 (NRS-2002) and Mini-Nutritional Assessment-Short Form (MNA-SF) in their medical files were included in the study. Clinical outcomes data (longer length of stay, readmission during the study period and mortality before the end of study or during hospitalisation) were obtained. The Kappa coefficient assessed agreement between both tools, and their performance for predicting outcomes was analysed using characteristic receiver operating curves (ROC). Data were collected from 643 patients. The prevalence of nutritional risk was 17.7% and 36.1% according to the NRS-2002 and MNA-SF (k = 0.390; p < 0.001), respectively. According to both tools, all clinical outcomes were significantly more common among individuals at nutritional risk (p < 0.05). Only the MNA-SF showed a significant percentage of predictions for readmission (57.2%) and death during hospitalisation (65.7%). For mortality until the end of the study, the area under the ROC curve was similar for MNA-SF (60.5%) and NRS-2002 (60.7%; p = 0.057). The MNA-SF detected a greater proportion of nutritional risk among hospitalised patients with overweight and better predicted all clinical outcomes compared to the NRS-2002 and should be used to screen patients with overweight for nutritional risk.
Assuntos
Desnutrição , Avaliação Nutricional , Humanos , Adulto Jovem , Adulto , Estado Nutricional , Desnutrição/diagnóstico , Estudos Retrospectivos , Sobrepeso/diagnósticoRESUMO
OBJECTIVE: The aim is to verify the association between nutritional status and muscle strength, considering handgrip strength (HGS) cutoffs associated with sarcopenia and mortality. METHODS: Cross-sectional analysis, including hemodialysis patients. Malnutrition Inflammation Score (MIS) was used to assess nutritional status. Muscle function was assessed by HGS, and the considered cutoffs were established by other studies. Cutoffs for sarcopenia diagnosis were 27 and 16 kg for males and females, respectively; cutoffs associated with mortality were 22 and 7 kg for males and females, respectively. Two binary logistic regression models were built, with HGS categorized according to the cutoff for sarcopenia and mortality as dependent variables. RESULTS: Of the 218 patients who were included, 56.9% were male, the mean age was 58.3 years, and 44.7% diabetic; 132 patients (60.6%) had HGS <27 or 16 kg. Age, prevalence of diabetes, and MIS were higher, creatinine and albumin were lower in patients with HGS below these values; 77 patients (35.2%) had HGS <22 or 7 kg. Age, male, and diabetes prevalence, CRP and MIS were higher, midarm muscle circumference (MAMC), creatinine, albumin, and urea were lower in patients with HGS below these values. In the logistic regression MIS (OR 1.202; 95% CI 1.073-1.347; P < .01), age, male, diabetes, and MAMC were associated with the risk of HGS below the cutoffs for sarcopenia. MIS (OR 1.322; 95% CI 1.192-1.467; P < .01), age, male, and diabetes were associated with the risk of HGS below the cutoffs associated with mortality. CONCLUSION: Worse nutritional status increases the risk of HGS below the cutoffs associated with sarcopenia and mortality in hemodialysis patients.
Assuntos
Diabetes Mellitus , Desnutrição , Sarcopenia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Força da Mão/fisiologia , Sarcopenia/epidemiologia , Estudos Transversais , Creatinina , Desnutrição/epidemiologia , Diálise Renal , Estado Nutricional , Inflamação , AlbuminasRESUMO
BACKGROUND: The objective of this study was to develop a new predictive equation of resting energy expenditure (REE) for acute kidney injury patients (AKI) on dialysis. MATERIALS AND METHODS: A cross-sectional descriptive study was carried out of 114 AKI patients, consecutively selected, on dialysis and mechanical ventilation, aged between 19 and 95 years. For construction of the predictive model, 80% of cases were randomly separated to training and 20% of unused cases to validation. Several machine learning models were tested in the training data: linear regression with stepwise, rpart, support vector machine with radial kernel, generalised boosting machine and random forest. The models were selected by ten-fold cross-validation and the performances evaluated by the root mean square error. RESULTS: There were 364 indirect calorimetry measurements in 114 patients, mean age of 60.65 ± 16.9 years and 68.4% were males. The average REE was 2081 ± 645 kcal. REE was positively correlated with C-reactive protein, minute volume (MV), expiratory positive airway pressure, serum urea, body mass index and inversely with age. The principal variables included in the selected model were age, body mass index, use of vasopressors, expiratory positive airway pressure, MV, C-reactive protein, temperature and serum urea. The final r-value in the validation set was 0.69. CONCLUSION: We propose a new predictive equation for estimating the REE of AKI patients on dialysis that uses a non-linear approach with better performance than actual models.
RESUMO
Acute kidney injury (AKI) is a frequent and serious condition with high mortality. The presence of hypermetabolism may be a factor related to poorer prognosis. This study evaluated the resting energy expenditure (REE) of intensive care unit (ICU) patients with severe AKI using indirect calorimetry (IC) and identified factors associated with metabolism categories. Patients were evaluated through measurement of REE and estimation of basal energy expenditure (BEE) using the Harrisâ»Benedict equation. Metabolism categories were as follows: hypermetabolism (REE/BEE > 1.3) and hypometabolism (REE/BEE < 0.9). The metabolism categories were compared using ANOVA and the chi-square test. Variables were analyzed by multiple logistic regression tests. Also, survivors and non-survivors were compared using Student’s t-tests along with Cox regression tests. Kaplanâ»Meier survival curves were also performed. We evaluated 124 patients with a mean age of 61.08 ± 16.6 years. Sixty-four patients were hypermetabolic (62%) and 18 were hypometabolic (14%). Vasoactive drug (VAD) dose and younger age were independently associated with hypermetabolism. The survival analysis was not associated with metabolism categorization. In conclusion, patients with severe AKI are mostly hypermetabolic and hypermetabolic patients of a lower age receiving treatment with higher VAD doses. The only factors associated with death were protein intake and VAD dose.
Assuntos
Injúria Renal Aguda/patologia , Estado Terminal , Metabolismo Energético , Adulto , Idoso , Dieta/normas , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Sódio na DietaRESUMO
BACKGROUND: Chronic kidney disease is worldwide recognized as a public health problem due to high rates of morbidity and mortality. At the end stage of the disease, which the glomerular filtration rate is equal or less than15 ml/min/1.73 m2, dialysis initiation is usually indicated. In the absence of a consensus on the best time of beginning, the aim of this study was to identify clinical and nutritional factors associated with clinical outcomes with the start of dialysis and death. METHODS: In a prospective cohort of 82 patients, clinical (underlying renal disease, renal survival time, systolic and diastolic blood pressure, estimated glomerular filtration rate) and nutritional data (protein intake, anthropometry, bioelectrical impedance test, and strength handgrip) were collected. We used mean and standard deviation ormedian and association of the variables with the outcome entry into dialysis or death, and a Cox regression model was applied. Statistical significance wasp< 0.05.RESULTS: Fifty-eight patients were included in group 1G1 (without dialysis)and 24 patients in group 2G2(dialysis). The groups were different in blood urea nitrogen (p= <0.001), serum creatinine (p= 0.003), estimated glomerular filtration rate (p= 0.002), and serum phosphorus (p= 0.002). After multivariate analysis, only serumalbumin (HR 0.342,p= 0.004) and glomerular filtration rate (HR 0.001,p= 0.001) were associated with entry into dialysis and death. CONCLUSIONS: We concluded that lower levels of serum albumin and glomerular filtration rate values are associated with entry into dialysis or death.
Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Insuficiência Renal Crônica/complicações , Insuficiência Renal Crônica/metabolismo , Insuficiência Renal Crônica/terapia , Barreira de Filtração Glomerular/anormalidades , Albumina Sérica/análiseRESUMO
BACKGROUND: The determination of resting energy expenditure (REE) in critically ill patients could prevent complications such as hypo- and hyper alimentation. This study aims to describe the REE in septic patients with and without acute kidney injury (AKI) and compare the REE estimated by the Harris-Benedict equation (HB) with the REE measured by indirect calorimetry (IC). METHODS: Prospective and observational study was performed. Septic patients older than 18 years, undergoing mechanical ventilation, with or without AKI defined by KDIGO criteria, and admitted to the Intensive Care Unit of University Hospital from Brazil were included. The REE was estimated by HB equation and measured by the IC within72 h after the diagnosis of sepsis and 7 days after the initial measure. RESULTS:Sixty-eight patients were evaluated, age was 62.5 ± 16.6 years, 64.7% were male, 63.2% had AKI, and SOFA was9.8 ± 2.35. The measured REE was 1857.5 ± 685.32 kcal, while the estimated REE was 1514.8 ± 356.72 kcal, with adequacy of 123.5 ± 43%. Septic patients without AKI (n= 25) and with AKI (n= 43) had measured REE statistically higher than the estimated one (1855.0 (1631.752052.75) vs. 1551.0 kcal (1349.01719.25),p= 0.007 and 1868.0(1219.52364.75) vs. 1388.0 kcal (1254.01665.5),p= 0.026, respectively). There was no significant difference between the two groups (with and without AKI) in measured and estimated REE (p= 0.63 and 0.64, respectively). There was no significant difference in evolutional REE (1845.95 ± 658.27 kcal vs. 1809.54 ± 755.08 kcal, p=0.86).CONCLUSIONS: The REE measured by IC was significantly higher than that estimated by HB equation in both septic with and without AKI. There was no significant difference in REE between the septic patients with and without AKI, suggesting that AKI does not influence the energy metabolism of septic patients.
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Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Injúria Renal Aguda , Metabolismo Energético/fisiologia , Sepse/metabolismoRESUMO
This study aimed to explore the role of high-volume peritoneal dialysis (HVPD) in cardiorenal syndrome (CRS) type 1 patients in relation to metabolic and fluid control and outcome. Sixty-four patients were treated by HVPD (prescribed Kt/V = 0.50/session), flexible catheter and cycler. Mean age was 68.8 ± 15.4 years, 54.7% needed intravenous inotropic agents and/or intravenous vasodilators, 31.2% were on mechanical ventilation, acute coronary syndrome (ACS) was the main cause of acute disease heart failure (ADHF) 48.3%, median left ventricular ejection fraction (LVEF) was 38% and the main dialysis indications were uremia and hypervolemia. Blood ureic nitrogen and creatinine levels stabilized after 4 sessions at around 50 and 4 mg/dL, respectively. Negative fluid balance (FB) and ultrafiltration (UF) increased progressively and stabilized around 2.6 L and -2.5 L/day, respectively. Weekly-delivered Kt/V was 3.0 ± 0.42, and 32.8% died. There was a significant difference between the survivors (S) and non-survivors (NS) in age (71.4 ± 15.7 vs 63.6 ± 17.6, p < 0.001), main diagnosis of ADHF (ACS: 76.2 vs 34.8%, p = 0.04), mechanical ventilation (52.4 vs 20.1%, p = 0.03), fluid overload (FO) at predialysis moment (52.4 vs 25.6%, p = 0.04), and FB and UF from the 2nd to 5th dialysis session. In conclusion, HVPD treatment was effective in CRS type 1 patients, allowing adequate metabolic and fluid control. Age, ACS, FO and positive FB after 2 HVPD sessions were higher in NS patients.
Assuntos
Síndrome Cardiorrenal/terapia , Diálise Peritoneal/métodos , Idoso , Idoso de 80 Anos ou mais , Brasil , Síndrome Cardiorrenal/mortalidade , Síndrome Cardiorrenal/fisiopatologia , Feminino , Humanos , Testes de Função Renal , Masculino , Pessoa de Meia-Idade , Diálise Peritoneal/efeitos adversos , Estudos Prospectivos , Fatores de Risco , Taxa de Sobrevida , Resultado do Tratamento , Equilíbrio HidroeletrolíticoRESUMO
INTRODUCTION: It is needed for nutrition prescription correct estimate of resting energy expenditure (REE), which is a challenge given the possible daily variation in critically ill patients with acute kidney injury (AKI). OBJECTIVE: To evaluate the daily variability of REE measured by indirect calorimetry (IC) in patients with AKI and dialysis indication and identify clinical variables associated with REE. METHODS: The REE was measured on the time of dialysis indication and the subsequent four days. We also evaluated parameters that can influence the REE. The daily differences were analyzed by generalized linear model for repeated measures. We also used Spearman correlation and multiple linear regression. RESULTS: There were 301 IC measurements in 114 patients, mean age of 60.65 ± 16.9 years and 68.4% were male. The average REE was 2081 ± 645 kcal, rising on day 5 (2270 ± 556 kcal) compared to the days 2 and 3 (2022 ± 754; 2022 ± 660 kcal, respectively, p = 0,04). When normalized to weight, there was no significant difference in REE (kcal/kg/day) during follow-up. REE was positively correlated with total leukocyte count, C-reactive protein, minute volume (MV), fraction of inspired oxygen (FiO2) urea nitrogen appearance (UNA), weight and height and inversely with age. After multiple regression, MV, FiO2, weight and age are correlated independently with REE. CONCLUSION: Patients with AKI have REE stable. The REE was associated independently with FiO2, MV, body weight and age. Thus, ventilatory parameters should be evaluated each day for the necessary dietary changes may be made.
Assuntos
Injúria Renal Aguda/metabolismo , Injúria Renal Aguda/terapia , Metabolismo Energético , Diálise Renal , Ritmo Circadiano , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de TempoRESUMO
Abstract Introduction: It is needed for nutrition prescription correct estimate of resting energy expenditure (REE), which is a challenge given the possible daily variation in critically ill patients with acute kidney injury (AKI). Objective: To evaluate the daily variability of REE measured by indirect calorimetry (IC) in patients with AKI and dialysis indication and identify clinical variables associated with REE. Methods: The REE was measured on the time of dialysis indication and the subsequent four days. We also evaluated parameters that can influence the REE. The daily differences were analyzed by generalized linear model for repeated measures. We also used Spearman correlation and multiple linear regression. Results: There were 301 IC measurements in 114 patients, mean age of 60.65 ± 16.9 years and 68.4% were male. The average REE was 2081 ± 645 kcal, rising on day 5 (2270 ± 556 kcal) compared to the days 2 and 3 (2022 ± 754; 2022 ± 660 kcal, respectively, p = 0,04). When normalized to weight, there was no significant difference in REE (kcal/kg/day) during follow-up. REE was positively correlated with total leukocyte count, C-reactive protein, minute volume (MV), fraction of inspired oxygen (FiO2) urea nitrogen appearance (UNA), weight and height and inversely with age. After multiple regression, MV, FiO2, weight and age are correlated independently with REE. Conclusion: Patients with AKI have REE stable. The REE was associated independently with FiO2, MV, body weight and age. Thus, ventilatory parameters should be evaluated each day for the necessary dietary changes may be made.
Resumo Introdução: É imprescindível a correta estimativa do gasto energético de repouso (GER), que pode apresentar considerável variação diária no paciente crítico com lesão renal aguda (LRA). Objetivo: Avaliar a variabilidade diária do GER medido por calorimetria indireta (CI) em pacientes com LRA e indicação dialítica e identificar as variáveis clínicas associadas ao GER. Métodos: O GER foi medido no dia da indicação do procedimento dialítico e nos quatro dias subsequentes. Também foram avaliados parâmetros que podem influenciar o GER. As diferenças diárias foram analisadas pelo modelo linear generalizado para medidas repetidas, com distribuição gama, além da correlação de Spearman e regressão linear múltipla. Resultados: Foram 301 medidas de CI realizadas em 114 pacientes, com idade de 60,65 ± 16,9 anos e 68,4% do sexo masculino. O GER médio foi de 2081 ± 645 Kcal, com aumento no dia 5 (2270 ± 556 Kcal), quando comparado aos dias 2 e 3 (2022 ± 754; 2022 ± 660 kcal, respectivamente, p = 0,04); quando normalizado para peso, não houve diferença significante no GER (kcal/kg/dia) durante o acompanhamento. GER correlacionou-se positivamente com temperatura corporal, contagem total de leucócitos, proteína C reativa, volume minuto (VM), fração inspirada de oxigênio (FiO2), aparecimento de nitrogênio ureico (UNA), peso corporal e estatura e inversamente com idade. Após a regressão linear múltipla, somente VM, FiO2 e peso corporal e idade se correlacionaram independentemente. Conclusão: Pacientes com LRA dialíticos apresentam GER estável. O GER foi associado independentemente com FiO2, VM, peso e idade. Assim, requisitos ventilatórios precisam ser avaliados diariamente para que alterações necessárias na prescrição dietética sejam feitas.
Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Diálise Renal , Metabolismo Energético , Injúria Renal Aguda/metabolismo , Injúria Renal Aguda/terapia , Fatores de Tempo , Estudos Prospectivos , Ritmo CircadianoRESUMO
BACKGROUND: Currently, the execution of indirect calorimetry, which is considered the gold standard for measuring energy expenditure, is not indicate during dialysis, and it may interfere on nutritional therapy of these patients. This study aimed to evaluate the resting energy expenditure (REE) in patients with severe acute kidney injury treated by different modalities of dialysis and to identify whether dialysis influences on REE. METHODS: This was a prospective cohort study that evaluated patients admitted in intensive care units with diagnosis of acute kidney injury AKIN-3, mechanically ventilated, and submitted to conventional hemodialysis (CHD), extended hemodialysis (EHD) or high volume peritoneal dialysis (HVPD). Indirect calorimetry was performed at pre dialysis time and during the dialysis procedure. Parameters that could change REE were also evaluated. RESULTS: One-hundred patients undergoing 290 dialysis sessions were evaluated, with mean age 60.3 ± 17 years, 69% were male and 74% have died. There was no significant difference between REE of predialysis time and during dialysis time (2156 ± 659 kcal vs. 2100 ± 634 kcal, respectively, p = 0.15). No difference was observed in the REE before and during dialysis of different modalities. There were no differences between parameters pre and during dialysis of each modality. There was only a difference in norepinephrine dose, which was higher in pre dialysis time in HVPD and EHD modalities, compared with CHD modality. Moreover, during dialysis time, EHD modality had significantly higher VAD compared to other dialysis modalities. CONCLUSION: The three evaluated modalities did not change REE. Indirect calorimetry can be performed during dialysis procedures and there was no difference between ventilation parameters, sedatives use, body temperature and VAD in both moments.
Assuntos
Injúria Renal Aguda/terapia , Metabolismo Basal , Diálise Peritoneal , Diálise Renal , Injúria Renal Aguda/complicações , Injúria Renal Aguda/metabolismo , Injúria Renal Aguda/fisiopatologia , Idoso , Metabolismo Basal/efeitos dos fármacos , Temperatura Corporal , Brasil , Calorimetria Indireta , Estudos de Coortes , Estado Terminal/terapia , Feminino , Humanos , Hipnóticos e Sedativos/uso terapêutico , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Norepinefrina/uso terapêutico , Diálise Peritoneal/efeitos adversos , Estudos Prospectivos , Diálise Renal/efeitos adversos , Respiração Artificial , Índice de Gravidade de Doença , Fatores de Tempo , Vasoconstritores/uso terapêuticoRESUMO
Patients on intensive care present systemic, metabolic, and hormonal alterations that may adversely affect their nutritional condition and lead to fast and important depletion of lean mass and malnutrition. Several factors and medical conditions can influence the energy expenditure (EE) of critically ill patients, such as age, gender, surgery, serious infections, medications, ventilation modality, and organ dysfunction. Clinical conditions that can present with EE change include acute kidney injury, a complex disorder commonly seen in critically ill patients with manifestations that can range from minimum elevations in serum creatinine to renal failure requiring dialysis. The nutritional needs of this population are therefore complex, and determining the resting energy expenditure is essential to adjust the nutritional supply and to plan a proper diet, ensuring that energy requirements are met and avoiding complications associated with overfeeding and underfeeding. Several evaluation methods of EE in this population have been described, but all of them have limitations. Such methods include direct calorimetry, doubly labeled water, indirect calorimetry (IC), various predictive equations, and, more recently, the rule of thumb (kcal/kg of body weight). Currently, IC is considered the gold standard.
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Calorimetria/métodos , Estado Terminal , Metabolismo Energético/fisiologia , Descanso/fisiologia , Injúria Renal Aguda/metabolismo , Algoritmos , Feminino , Humanos , Masculino , Necessidades Nutricionais , Valor Preditivo dos TestesRESUMO
Summary Patients on intensive care present systemic, metabolic, and hormonal alterations that may adversely affect their nutritional condition and lead to fast and important depletion of lean mass and malnutrition. Several factors and medical conditions can influence the energy expenditure (EE) of critically ill patients, such as age, gender, surgery, serious infections, medications, ventilation modality, and organ dysfunction. Clinical conditions that can present with EE change include acute kidney injury, a complex disorder commonly seen in critically ill patients with manifestations that can range from minimum elevations in serum creatinine to renal failure requiring dialysis. The nutritional needs of this population are therefore complex, and determining the resting energy expenditure is essential to adjust the nutritional supply and to plan a proper diet, ensuring that energy requirements are met and avoiding complications associated with overfeeding and underfeeding. Several evaluation methods of EE in this population have been described, but all of them have limitations. Such methods include direct calorimetry, doubly labeled water, indirect calorimetry (IC), various predictive equations, and, more recently, the rule of thumb (kcal/kg of body weight). Currently, IC is considered the gold standard.
Resumo Os pacientes em cuidados intensivos apresentam alterações sistêmicas, metabólicas e hormonais, que podem afetar adversamente a condição nutricional e levar à rápida e importante depleção da massa magra e desnutrição. Vários fatores e situações clínicas podem exercer influência sobre o gasto energético (GE) de pacientes críticos, como idade, sexo, cirurgias, infecções graves, medicamentos, modalidade ventilatória e disfunção de órgãos. Dentre as condições clínicas que podem cursar com alteração do GE, encontra-se a lesão renal aguda (LRA), distúrbio complexo comumente observado em pacientes críticos, com manifestações que podem variar de mínimas elevações na creatinina sérica até insuficiência renal com necessidade dialítica. Dessa forma, essa população crítica apresenta necessidades nutricionais complexas e a determinação do gasto energético de repouso (GER) torna-se essencial para o ajuste da oferta nutricional e para o planejamento de uma nutrição adequada, assegurando que as necessidades energéticas sejam atingidas e evitando as complicações associadas à hiper ou hipoalimentação. Diversos métodos de avaliação do GE nessa população foram descritos, mas todos apresentam limitações. Dentre eles, destacam-se a calorimetria direta, a água duplamente marcada, a calorimetria indireta (CI), diversas equações preditivas e, mais atualmente, a regra de bolso (kcal/kg de peso). Atualmente, a CI é eleita o método padrão-ouro.
Assuntos
Humanos , Masculino , Feminino , Descanso/fisiologia , Calorimetria/métodos , Estado Terminal , Metabolismo Energético/fisiologia , Algoritmos , Valor Preditivo dos Testes , Injúria Renal Aguda/metabolismo , Necessidades NutricionaisRESUMO
BACKGROUND: There are multiple equations for predicting resting energy expenditure (REE), but how accurate they are in severe acute kidney injury (AKI) patients is not clear. Our aim was to determine if predictive equations for estimated REE accurately reflect the requirements of AKI patients. METHODS: We included in this prospective and observational study AKI patients AKIN-3 assessed by indirect calorimetry (IC). Bland-Altman, intraclass correlation coefficient and precision (percentagem of predicted values within 10% of measured values) were performed to compare REE by equations with REE measured by IC. RESULTS: IC was applied in 125 AKI patients. The mean age was 62.5 ± 16.6 and 65.6% were male. Mean REE measured was 2,029.11 ± 760.4 kcal/day. There were low precision, and poor agreement between measured and predicted REE by the Harris-Benedict (HB), Mifflin, Ireton-Jones, Penn state, American College of Chest Physicians, and Faisy equations. HB without using injury factor was the least precise (18% of precision). Modified Penn state equation had the best precision, although the precision rate was only 41%. For all equations, the limits of agreement range were large leading to the potential under or overfeeding of individual patients. CONCLUSION: None of these equations accurately estimated measured REE in severe AKI patients and most of them underestimated energy needs.
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Injúria Renal Aguda/metabolismo , Metabolismo Basal , Estado Terminal , Metabolismo Energético , Modelos Biológicos , Necessidades Nutricionais , Injúria Renal Aguda/fisiopatologia , Injúria Renal Aguda/terapia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Calorimetria Indireta , Feminino , Hospitais de Ensino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Reprodutibilidade dos Testes , Índice de Gravidade de Doença , Adulto JovemRESUMO
BACKGROUND & AIMS: Muscle wasting is associated with mortality in dialysis patients. The measurement of muscle mass has some limitations, while muscle strength assessment is simple, safe and allows the recognition of patients at risk of progressing to poor outcomes related to malnutrition. The aim of this study is verify if handgrip strength (HGS) is associated with all-cause mortality in patients in maintenance haemodialysis (HD) and peritoneal dialysis (PD). METHODS: This was an observational retrospective cohort study which included all patients in maintenance HD and PD from July 2012 to October 2014. Patients were followed-up until June 2015. RESULTS: Two-hundred sixty five patients were enrolled (218 HD and 47 PD) and they were followed for 13.4 ± 7.9 months. During the follow-up period, 53 patients (20%) have died, 36 patients (13.6%) have undergone renal transplantation, 13 patients (4.9%) have switched off dialysis method and 5 patients (1.9%) have transferred to another facility. The cut-off of HGS able to predict mortality was 22.5 kg for men and 7 kg for women. Using this cut-off to fit the Kaplan-Meier survival curve, the association of HGS with all-cause mortality for both genders was confirmed. Finally, in the multivariate analysis adjusted for demographic, clinical and nutritional variables, HGS remained significant predictor of mortality, independent of dialysis modality. CONCLUSIONS: HGS cut-offs that predict mortality were 22.5 kg for men and 7 kg for women. HGS was associated with mortality independent of dialysis modality.
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Força da Mão , Falência Renal Crônica/terapia , Mortalidade , Diálise Peritoneal , Diálise Renal , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Estimativa de Kaplan-Meier , Transplante de Rim , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Avaliação Nutricional , Estado Nutricional , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Adulto JovemRESUMO
Peritoneal dialysis (PD) should be considered a suitable method of renal replacement therapy in acute kidney injury (AKI) patients. This study is the largest cohort providing patient characteristics, clinical practice, patterns and their relationship to outcomes in a developing country. Its objective was to describe the main determinants of patient and technique survival, including trends over time of PD treatment in AKI patients. This was a Brazilian prospective cohort study in which all adult AKI patients on PD were studied from January/2004 to January/2014. For comparison purposes, patients were divided into 2 groups according to the year of treatment: 2004-2008 and 2009-2014. Patient survival and technique failure (TF) were analyzed using the competing risk model of Fine and Gray. A total of 301 patients were included, 51 were transferred to hemodialysis (16.9%) during the study period. The main cause of TF was mechanical complication (47%) followed by peritonitis (41.2%). There was change in TF during the study period: compared to 2004-2008, patients treated at 2009-2014 had relative risk (RR) reduction of 0.86 (95% CI 0.77-0.96) and three independent risk factors were identified: period of treatment at 2009 and 2014, sepsis and age> 65 years. There were 180 deaths (59.8%) during the study. Death was the leading cause of dropout (77.9% of all cases) mainly by sepsis (58.3%), followed cardiovascular disease (36.1%). The overall patient survival was 41% at 30 days. Patient survival improved along study periods: compared to 2004-2008, patients treated at 2009-2014 had a RR reduction of 0.87 (95% CI 0.79-0.98). The independent risk factors for mortality were sepsis, age >70 years, ATN-ISS > 0.65 and positive fluid balance. As conclusion, we observed an improvement in patient survival and TF along the years even after correction for several confounders and using a competing risk approach.
Assuntos
Injúria Renal Aguda/mortalidade , Injúria Renal Aguda/terapia , Diálise Peritoneal/efeitos adversos , Diálise Renal/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Brasil/epidemiologia , Causas de Morte/tendências , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Diálise Peritoneal/instrumentação , Estudos Prospectivos , Diálise Renal/instrumentação , Fatores de Risco , Análise de Sobrevida , Resultado do TratamentoRESUMO
During the 1970s and 1980s, peritoneal dialysis (PD) was widely accepted as the standard treatment for acute kidney injury (AKI). However, advances in the techniques of extracorporeal blood purification gradually reduced its use, making PD an underused modality in this context. Although PD for AKI is an underutilized modality worldwide, it is frequently used in developing countries because of its lower cost and minimal infrastructure requirements. Recent studies have shown that PD administered continuously through a flexible catheter and cycler is an effective treatment in AKI because it ensures adequate fluid status and metabolic control. However, the use of PD in AKI has several limitations, such as the need for an intact peritoneal cavity and, in emergency situations such as severe fluid overload and severe hyperkalemia, an efficacy that is lower than that with extracorporeal blood purification techniques. Metabolic, infectious, and mechanical disorders related to PD are also limitations.Among the metabolic complications of PD are hyperglycemia, hypernatremia, protein loss into the dialysate, and hypercatabolism. Hyperglycemia is caused by the use of dialysate containing high concentrations of glucose. Hypernatremia is a result of short dialysate dwell times during the rapid exchanges of high-volume PD. Protein loss into the dialysate can reach 48 g daily, worsening the nutrition status of patients already depleted by AKI. Severe hypercatabolism caused by PD remains controversial and occurs because PD methods cannot provide an adequate dialysis dose for AKI patients.Few studies have assessed the metabolic implications of PD in AKI patients. Evaluation of these implications is relatively simple, imposes no additional costs, and can provide information about the severity of the disease. Evaluation could also guide the selection of therapeutic, dialytic, and nutrition measures, preventing metabolic complications. The present manuscript describes the metabolic implications of PD and reviews the literature on how to prevent metabolic complications.
Assuntos
Injúria Renal Aguda/mortalidade , Injúria Renal Aguda/terapia , Doenças Metabólicas/etiologia , Diálise Peritoneal/efeitos adversos , Injúria Renal Aguda/diagnóstico , Feminino , Humanos , Hiperglicemia/epidemiologia , Hiperglicemia/etiologia , Hiperglicemia/terapia , Hipernatremia/epidemiologia , Hipernatremia/etiologia , Hipernatremia/terapia , Hipoproteinemia/etiologia , Hipoproteinemia/mortalidade , Hipoproteinemia/terapia , Masculino , Doenças Metabólicas/mortalidade , Doenças Metabólicas/terapia , Diálise Peritoneal/métodos , Prognóstico , Medição de Risco , Análise de SobrevidaRESUMO
OBJECTIVE: The objective of this study was to perform a nutritional assessment of acute kidney injury patients and to identify the relationship between nutritional markers and outcomes. METHOD: This was a prospective and observational study. Patients who were hospitalized at the Hospital of Botucatu School of Medicine were evaluated between January 2009 and December 2011. We evaluated a total of 133 patients with a clinical diagnosis of acute kidney injury and a clinical presentation suggestive of acute tubular necrosis. We explored the associations between clinical, laboratory and nutritional markers and in-hospital mortality. Multivariable logistic regression was used to adjust for confounding and selection bias. RESULTS: Non-survivor patients were older (67 ± 14 vs. 59 ± 16 years) and exhibited a higher prevalence of sepsis (57.1 vs. 21.4%) and higher Acute Tubular Necrosis-Individual Severity Scores (0.60 ± 0.22 vs. 0.41 ± 0.21) than did survivor patients. Based on the multivariable analysis, laboratorial parameters such as blood urea nitrogen and C-reactive protein were associated with a higher risk of death (OR: 1.013, p=0.0052; OR: 1.050, p=0.01, respectively), and nutritional parameters such as low calorie intake, higher levels of edema, lower resistance based on bioelectrical impedance analysis and a more negative nitrogen balance were significantly associated with a higher risk of death (OR: 0.950, p=0.01; OR: 1.138, p=0.03; OR: 0.995, p=0.03; OR: 0.934, p=0.04, respectively). CONCLUSIONS: In acute kidney injury patients, a nutritional assessment seems to identify nutritional markers that are associated with outcome. In this study, a low caloric intake, higher C-reactive protein levels, the presence of edema, a lower resistance measured during a bioelectrical impedance analysis and a lower nitrogen balance were significantly associated with risk of death in acute kidney injury patients.
Assuntos
Injúria Renal Aguda/metabolismo , Injúria Renal Aguda/mortalidade , Avaliação Nutricional , Injúria Renal Aguda/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/análise , Nitrogênio da Ureia Sanguínea , Proteína C-Reativa/análise , Impedância Elétrica , Ingestão de Energia , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Estudos Prospectivos , Fatores de RiscoRESUMO
OBJECTIVE: The objective of this study was to perform a nutritional assessment of acute kidney injury patients and to identify the relationship between nutritional markers and outcomes. METHOD: This was a prospective and observational study. Patients who were hospitalized at the Hospital of Botucatu School of Medicine were evaluated between January 2009 and December 2011. We evaluated a total of 133 patients with a clinical diagnosis of acute kidney injury and a clinical presentation suggestive of acute tubular necrosis. We explored the associations between clinical, laboratory and nutritional markers and in-hospital mortality. Multivariable logistic regression was used to adjust for confounding and selection bias. RESULTS: Non-survivor patients were older (67±14 vs. 59±16 years) and exhibited a higher prevalence of sepsis (57.1 vs. 21.4%) and higher Acute Tubular Necrosis-Individual Severity Scores (0.60±0.22 vs. 0.41±0.21) than did survivor patients. Based on the multivariable analysis, laboratorial parameters such as blood urea nitrogen and C-reactive protein were associated with a higher risk of death (OR: 1.013, p = 0.0052; OR: 1.050, p = 0.01, respectively), and nutritional parameters such as low calorie intake, higher levels of edema, lower resistance based on bioelectrical impedance analysis and a more negative nitrogen balance were significantly associated with a higher risk of death (OR: 0.950, p = 0.01; OR: 1.138, p = 0.03; OR: 0.995, p = 0.03; OR: 0.934, p = 0.04, respectively). CONCLUSIONS: In acute kidney injury patients, a nutritional assessment seems to identify nutritional markers that are associated with outcome. In this study, a low caloric intake, higher C-reactive protein levels, the presence of edema, a lower resistance measured during a bioelectrical impedance analysis and a lower nitrogen balance were significantly associated ...