Preface : “Practical Research on Gamification in Education (2)”

<p>(A) Areas under the curves (AUC) of receiver operating characteristics (ROC) in 746 patients for pentosidine in relation to all-cause mortality.(B) Areas under the curves (AUC) of receiver operating characteristics (ROC) in 746 patients for pentosidine in relation to CVD-mortality.</p

Clinical global assessment of nutritional status as predictor of mortality in chronic kidney disease patients

<div><p>Background</p><p>The value of subjective global assessment (SGA) as nutritional assessor of protein-energy wasting (PEW_SGA) in chronic kidney disease (CKD) patients depends on its mortality predictive capacity. We investigated associations of PEW_SGA with markers of nutritional status and all-cause mortality in CKD patients.</p><p>Methods</p><p>In 1031 (732 CKD1-5 non-dialysis and 299 dialysis) patients, SGA and body (BMI), lean (LBMI) and fat (FBMI) body mass indices, % handgrip strength (% HGS), serum albumin, and high sensitivity C-reactive protein (hsCRP) were examined at baseline. The five-year all-cause mortality predictive strength of baseline PEW_SGA and during follow-up were investigated.</p><p>Results</p><p>PEW_SGA was present in 2% of CKD1-2, 16% of CKD3-4, 31% of CKD5 non-dialysis and 44% of dialysis patients. Patients with PEW_SGA (n = 320; 31%) had higher hsCRP and lower BMI, LBMI, FBMI, %HGS and serum albumin. But, using receiver operating characteristics-derived cutoffs, these markers could not classify (by kappa statistic) or explain variations of (by multinomial logistic regression analysis) presence of PEW_SGA. In generalized linear models, SGA independently predicted mortality after adjustments of multiple confounders (RR: 1.17; 95% CI: 1.11–1.23). Among 323 CKD5 patients who were re-assessed after median 12.6 months, 222 (69%) remained well-nourished, 37 (11%) developed PEW_SGA de novo, 40 (12%) improved while 24 (8%) remained with PEW_SGA. The latter independently predicted mortality (RR: 1.29; 95% CI: 1.13–1.46).</p><p>Conclusions</p><p>SGA, a valid assessor of nutritional status, is an independent predictor of all-cause mortality both in CKD non-dialysis and dialysis patients that outperforms non-composite nutritional markers as prognosticator.</p></div

All-cause mortality risk for death occurring within 60 months based on imputed follow-up^a data in 323 incident dialysis patients, adjusted for all confounders, and expressed as relative risk ratio (95% CI).

<p>All-cause mortality risk for death occurring within 60 months based on imputed follow-up<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0186659#t005fn002" target="_blank">^a</a> data in 323 incident dialysis patients, adjusted for all confounders, and expressed as relative risk ratio (95% CI).</p

Baseline demographic and biochemical characteristics of 1031 CKD patients according to presence of malnutrition defined as SGA score >1.

<p>Baseline demographic and biochemical characteristics of 1031 CKD patients according to presence of malnutrition defined as SGA score >1.</p

Comparative analysis of metabolites in inflamed (hsCRP ≥10 mg/L) and non-inflamed (hsCRP < 10 mg/L) CKD 3–5 patients (<i>n</i> = 179).

<p>Higher hsCRP levels associated with higher TMAO levels and decreased betaine levels. Values are expressed as median (10^th -90^th percentile). P-values analyzed by Kruskal–Wallis’ one-way ANOVA, followed by Dunn’s multiple comparison test.</p

Kaplan-Meier analysis of TMAO levels and all-cause mortality in CKD 3–5 patient (<i>n</i> = 179).

<p>Data presented as tertiles. CKD patients with the highest TMAO levels (Combined middle (32.2–75.2 μM/L) + high tertile (>72.2 μM/L)) had a significantly lower survival compared with patients in the lowest TMAO tertile.</p

Kaplan—Meier plot for all-cause mortality of the four groups of patients according to the nutritional status change assessed by SGA.

<p>Abbreviations: Group 1 _WN-WN, patients who remained well-nourished during follow up; Group 2 _MN-WN, patients who were improved with nutritional status during follow up; Group 3 _WN-MN, patients who developed PEW_SGA during the follow-up; Group 4 _MN-MN, patients who remained with PEW_SGA at baseline and at follow-up.</p

Nutritional markers at baseline and after a median follow-up of 12.6 months in four groups^a defined by changes in SGA.

<p>Nutritional markers at baseline and after a median follow-up of 12.6 months in four groups<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0186659#t004fn002" target="_blank">^a</a> defined by changes in SGA.</p

Increasing plasma levels of TMAO in CKD patients stage 3 (<i>n</i> = 30), stage 4 (<i>n</i> = 28) and stage 5 (<i>n</i> = 116) compared to healthy controls (<i>n</i> = 80).

<p>Values are expressed as median (10^th -90^th percentile). P-values analyzed by Kruskal–Wallis’ one-way ANOVA, followed by Dunn’s multiple comparison test.</p

Restrictive lung disorder is common in patients with kidney failure and associates with protein-energy wasting, inflammation and cardiovascular disease

<div><p>Background</p><p>Cardiovascular disease (CVD), protein-energy wasting (PEW), and inflammation are common interrelated features of chronic kidney disease (CKD). Less is known about lung dysfunction in CKD and its possible role in this context. We evaluated lung function and its association with estimated glomerular filtration rate (GFR), CVD, PEW, and inflammation in individuals with normal to severely reduced GFR.</p><p>Methods</p><p>In 404 individuals with GFR category G1 (n = 31; GFR >90mL/min/1.73 m²), G2 (n = 46), G3 (n = 33), G4 (n = 49) and G5 (n = 245; GFR<15mL/min/1.73 m²), pulmonary function was assessed by spirometry. Obstructive (OLD) and restrictive (RLD) lung dysfunction was defined based on forced vital capacity (FVC), forced expiratory volume in the first second (FEV₁) and peak expiratory flow (PEF), expressed as percentages of predicted values (þV₁, %FVC and %PEF, respectively). PEW was evaluated by subjective global assessment, handgrip strength (HGS) and lean body mass index (LBMI), and inflammation by interleukin-6 and high sensitivity C-reactive protein.</p><p>Results</p><p>RLD (defined as FEV₁/FVC ≥ 0.70 and %FVC<80) associated with GFR and was present in 36% of G5 and 14% of G1-4 individuals. OLD (FEV₁/FVC<0.70) was less common with similar prevalence among G1-4 (9%) and G5 (11%) individuals. Notably, 64% of those with concomitant presence of PEW, inflammation and clinical signs of CVD had RLD while 79% of those lacking these complications had normal lung function. In multivariate logistic regression analysis, RLD associated with CVD, PEW and inflammation, after adjusting for Framingham’s CVD risk score, serum albumin, and GFR category.</p><p>Conclusions</p><p>RLD is a common complication in patients with advanced CKD, especially in those with concomitant presence of CVD, inflammation and PEW. RLD appears to be an integral albeit scarcely explored consequence of pulmonary-renal interactions in CKD patients.</p></div