Malnutrition and Sarcopenia Combined Increases the Risk for Mortality in Older Adults on Hemodialysis

Aim: Sarcopenia and malnutrition are highly prevalent in older adults undergoing hemodialysis (HD) and are associated with negative outcomes. This study aimed to evaluate the role of sarcopenia and malnutrition combined on the nutritional markers, quality of life, and survival in a cohort of older adults on chronic HD. Methods: This was an observational, longitudinal, and multicenter study including 170 patients on HD aged >60 years. Nutritional status was assessed by 7-point-subjective global assessment (7p-SGA), body composition (anthropometry and bioelectrical impedance), and appendicular skeletal muscle mass (Baumgartner's prediction equation). Quality of life was assessed by KDQoL-SF. The cutoffs for low muscle mass and low muscle strength established by the 2019 European Working group on sarcopenia for Older People (EWGSOP) were used for the diagnosis of sarcopenia. Individuals with a 7p-SGA score 5 were considered malnourished, individuals with low strength or low muscle mass were pre-sarcopenic, and those with low muscle mass and low muscle strength combined as sarcopenic. The sample was divided into four groups: sarcopenia and malnutrition; sarcopenia and no-malnutrition; no-sarcopenia with malnutrition; and no-sarcopenia and no-malnutrition. Follow-up for survival lasted 23.5 (12.2; 34.4) months. Results: Pre-sarcopenia, sarcopenia, and malnutrition were present in 35.3, 14.1, and 58.8% of the patients, respectively. The frequency of malnutrition in the group of patients with sarcopenia was not significantly higher than in the patients without sarcopenia (66.7 vs. 51.2%; p = 0.12). When comparing groups according to the occurrence of sarcopenia and malnutrition, the sarcopenia and malnutrition group were older and presented significantly lower BMI, calf circumference, body fat, phase angle, body cell mass, and mid-arm muscle circumference. In the survival analysis, the group with sarcopenia and malnutrition showed a higher hazard ratio 2.99 (95% CI: 1.23: 7.25) for mortality when compared to a group with no-sarcopenia and no-malnutrition. Conclusion: Older adults on HD with sarcopenia and malnutrition combined showed worse nutritional parameters, quality of life, and higher mortality risk. In addition, malnutrition can be present even in patients without sarcopenia. These findings highlight the importance of complete nutritional assessment in patients on dialysis. (c) Copyright (c) 2021 Macedo, Amaral, Rodrigues, Santin and Avesani

Resting energy expenditure and its determinants in hemodialysis patients

Objective: Chronic kidney disease is associated with several metabolic disturbances that can affect energy metabolism. As resting energy expenditure (REE) is scarcely investigated in patients on hemodialysis (HD) therapy, we aimed to evaluate the REE and its determinants in HD patients.Design: Cross-sectional study.Setting: Dialysis Unit of the Nephrology Division, Federal University of São Paulo, Brazil.Subjects: the study included 55 patients ( 28 male, 41.4 +/- 12.6 years old) undergoing HD therapy thrice weekly for at least 2 months, and 55 healthy individuals pair matched for age and gender. Subjects underwent fasting blood tests, as well as nutritional assessment, and the REE was assessed by indirect calorimetry.Results: REE of HD patients was similar to that of pair-matched controls (1379 +/- 7272 and 1440 +/- 7259 kcal/day, respectively), even when adjusted for fat-free mass (P = 0.24). REE of HD patients correlated positively with fat-free mass (r = 0.74; P < 0.001) and body mass index (r = 0.37; P < 0.01), and negatively with dialysis adequacy (r = -0.46; P < 0.001). No significant univariate correlation was found between REE and age, dialysis vintage, serum creatinine, urea, albumin, bicarbonate, parathyroid hormone (PTH) or high-sensitivity C-reactive protein (CRP). in the multiple linear regression analysis, using REE as dependent variable, the final model showed that besides the well-recognized determinants of REE such as fat-free mass and age, PTH and CRP were the independent determinants of REE in HD patients (R-2 = 0.64).Conclusions: in this study, the REE of HD patients was similar to that of healthy individuals, even with the positive effect of secondary hyperparathyroidism and inflammation on REE of these patients.Universidade Federal de São Paulo, Div Nephrol, BR-04039000 São Paulo, BrazilUniversidade Federal de São Paulo, Nutr Program, São Paulo, BrazilUniversidade Federal de São Paulo, Div Nephrol, BR-04039000 São Paulo, BrazilUniversidade Federal de São Paulo, Nutr Program, São Paulo, BrazilWeb of Scienc

Medical Nutritional Therapy for Patients with Chronic Kidney Disease not on Dialysis: The Low Protein Diet as a Medication

The 2020 Kidney Disease Outcome Quality Initiative (KDOQI) Clinical Practice Guideline for Nutrition in chronic kidney disease (CKD) recommends protein restriction to patients affected by CKD in stages 3 to 5 (not on dialysis), provided that they are metabolically stable, with the goal to delay kidney failure (graded as evidence level 1A) and improve quality of life (graded as evidence level 2C). Despite these strong statements, low protein diets (LPDs) are not prescribed by many nephrologists worldwide. In this review, we challenge the view of protein restriction as an "option" in the management of patients with CKD, and defend it as a core element of care. We argue that LPDs need to be tailored and patient-centered to ensure adherence, efficacy, and safety. Nephrologists, aligned with renal dietitians, may approach the implementation of LPDs similarly to a drug prescription, considering its indications, contra-indications, mechanism of action, dosages, unwanted side effects, and special warnings. Following this framework, we discuss herein the benefits and potential harms of LPDs as a cornerstone in CKD management

Cytoplasmic and nuclear events controlling Tax-mediated activation of the NF-κB pathway: involvement of TAB2, IKKgamma/NEMO and calreticulin

The Tax oncoprotein of HTLV-1 initiates T-cell transformationby dysregulating cell cycle progression andinhibiting DNA damage responses. The subsequentgenomic instability might result in constitutive activationof the NF-B pathway observed in HTLV-1-transformedT lymphocytes. Our previous results indicatedthat differential modifications of Tax by ubiquitinationor sumoylation controlled its retention either in thecytoplasm or in the nucleus, respectively. Here we showthat Tax is targeted to pre-existing punctate cytoplasmicstructures which contain the TNF-receptor associatedprotein 2 (TAB2)

Diet and cancer: an epidemiological view

Recent data have shown that the prevalence of cancer in the world has significantly risen in the last century. Cancer epidemiologists believe that it is related to the industrialization and urbanization that occurred during this period. In fact, the cancer incidence and mortality observed in developed countries are higher than in non-developed countries. Moreover, some specific sites of cancer such as colon-rectum, prostate and female mama are more pronounced in developed countries, whereas others as stomach, esophagus and cervix are prevalent in non-developed countries. Different patterns of cancer are also observed among migrants when they migrate to a new country or region. Based on epidemiological data, the association between cancer and diet was analyzed, as well as the changes in some food intake patterns and how they can prevent some types of cancer in the future.Epidemiologistas que estudam câncer têm observado que a sua prevalência no mundo tem aumentado de maneira significativa no último século. Acredita-se que este resultado está relacionado, entre outros aspectos, com a industrialização e a urbanização ocorridas neste período. De fato, a morbi-mortalidade associada ao câncer observada em países desenvolvidos é maior do que em países em desenvolvimento. Além disso, algumas formas específicas de câncer, como o de cólon e reto, próstata e mama feminina, são mais freqüentes em países desenvolvidos, enquanto outras, como de estômago, esôfago e colo de útero têm maior incidência nos países em desenvolvimento. Padrões distintos de câncer também são observados entre indivíduos que emigram para um novo país ou região. Com base em estudos epidemiológicos, analisou-se a relação entre câncer e nutrição, e algumas modificações na alimentação que podem prevenir alguns tipos de cânceres.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Departamento de PediatriaUniversidade Federal de São Paulo (UNIFESP) Departamento de PediatriaUniversidade Santo Amaro Disciplina Saúde PúblicaUNIFESP, EPM, Depto. de PediatriaUNIFESP, Depto. de PediatriaSciEL

Physical activity and energy expenditure in haemodialysis patients: an international survey

Background. The assessment of physical activity and energy expenditure is relevant to the care of maintenance haemodialysis (MHD) patients. In the current study, we aimed to evaluate measurements of physical activity and energy expenditure in MHD patients from different centres and countries and explored the predictors of physical activity in these patients. Methods. In this cross-sectional multicentre study, 134 MHD patients from four countries (France, Switzerland, Sweden and Brazil) were included. The physical activity was evaluated for 5.0 ± 1.4 days (mean ± SD) by a multisensory device (SenseWear Armband) and comprised the assessment of number of steps per day, activity-related energy expenditure (activity-related EE) and physical activity level (PAL). Results. The number of steps per day, activity-related EE and PAL from the MHD patients were compatible with a sedentary lifestyle. In addition, all parameters were significantly lower in dialysis days when compared to non-dialysis days (P < 0.001). The multivariate regression analysis revealed that diabetes and higher body mass index (BMI) predicted a lower PAL and older age and diabetes predicted a reduced number of steps. Conclusions. The physical activity parameters of MHD patients were compatible with a sedentary lifestyle. This inactivity was worsened by aging, diabetes and higher BMI. Our results indicate that MHD patients should be encouraged by the health care team to increase their physical activit

Energy expense in rest for diabetic patients with chronic kidney fsilure

No diabetes mellitus (DM) mal controlado ocorre elevacao taxa da neoglicogenese que, alem de aumentar o catabolismo proteico, possui um alto custo energetico e promove elevacao gasto energetico em repouso (GER). Pouco se sabe sobre metabolismo energetico e proteico quando a patologia renal e diabetica estao associadas. Assim o objetivo deste estudo foi o d verificar se pacientes renais cronicos diabeticos apresentam GE aumentado, quando este e comparado com o de renais cronicos nao diabeticos. Para tanto foram estudados pacientes na fase pre-dialitica, que foram divididos em um grupo chamado d IRCDiabetes formado por 24 pacientes renais cronicos diabeticos, outro, composto por 24 pacientes renais cronicos nao diabeticos pareados de acordo com o sexo, a idade e o grau de funcao renal. GER foi medido atraves da calorimetria indireta de circuito aberto, apos O jejum de 12 horas. Os pacientes tambem foram avaliados em relacao ao seu estado nutricional, por meio de parametros antropometricos e bioquimicas. A composicao corporal foi estimada atraves de densltometria de duplo foton. Ja a inGestão alimentar, por registro alimentar de 4 dias, e a taxa do catabolismo proteico (PCR) foi estimada pela formula de Sargent e Gotch. A maioria dos pacientes estudados nao apresentou sinais indicativos de desnutricao energetico-proteica. O grupo IRCDiabetes apresentou uma media de massa corporal magra (MCM) semelhante a do IRCControle (respectivamente 75,1 kg n1O,6 versus 75,4 kg n8,86) . A analise dos registros alimentares demonstrou que a inGestão energetica (kcal/kg/dia) nao diferiu de forma significante entre os grupos e que, em media, se encontrava abaixo do recomendado para esta populacao (IRCDiabetes 23,4 n5, versus IRCControle 24,8 n6,9). Em relacao a inGestão proteic observou-se que, tanto aquela estimada pelo registro alimenta quanto a revelada pelo PCR, foi significantemente maior no grup IRCDiabetes (inGestão proteica de O,89 n O,20 g/kg/dia no grupo IRCDiabetes versus O,76 nO,25 g/kg/dia no grupo IRCControle; p@O,02. PCR de I,21 nO,32 g/kg/dia no grupo IRCDiabetes versus 1,03 n O,22 g/kg/dia; p = O,02). Alem disto esteve acima do recomendado em ambos os grupos. O GER dos diabetico s - foi significantemente maior do que o de renais cronicos nao diabeticos, tanto no seu valor absoluto (kcal/dia) (respectivamente 1538 n 230 versus 1339 n 315; p = O,O09), quanto no ...(au)BV UNIFESP: Teses e dissertaçõe