Differences in the prevalence of sarcopenia in peritoneal dialysis patients using hand grip strength and appendicular lean mass: depends upon guideline definitions

Background Peritoneal dialysis (PD) patients with sarcopenia have increased risk of mortality. There is consensus that sarcopenia should combine assessments of muscle function and mass. We wished to determine the effect of using different operational definitions in PD patients. Methods Hand grip strength (HGS) and segmental bioimpedance derived appendicular lean mass (ALM) were measured and the prevalence of sarcopenia determined using the Foundation for the National Institutes of Health Sarcopenia Project (FNIH), European Working Group on Sarcopenia Older Persons (EWGSOP), and Asian Working Group on Sarcopenia (AWGS) definitions. Results We studied 155 PD patients, 95 men (61.3%), mean age 63.0 ± 14.9 years, 37.4% diabetic, treated by PD 9 (3–20) months with a HGS of 22.5 (15.5–30.2) kg, weight 73.6 ± 16.6 kg, % body fat 31.4 ± 4.2, and ALM index 7.52 ± 1.40 kg/m2. More patients were defined with muscle weakness using the EWGSOP compared to the FNIH criteria (X2 = 6.8, p = 0.009), whereas fewer patients met the EWGSOP criteria for muscle wasting compared to FNIH body mass index adjustment (X2 = 7.7, p = 0.006). However, when combining both criteria, there was no difference in the prevalence of sarcopenia between the different recommended definitions (11–15.5%). Conclusion We report a much lower prevalence of sarcopenia compared to studies in haemodialysis patients. Although there may be an element of patient selection bias, PD patients are not subject to changes in hydration and electrolytes with haemodialysis, which can affect HGS and muscle mass measurements. Using HGS and segmental bioimpedance we found similar prevalence of sarcopenia using EWGSOP, FNIH, AWGS definitions

Quality of life and willingness to pay for receiving hemodialysis in patients who received peritoneal dialysis in Thailand

This cross-sectional study was conducted to evaluate quality of life (QoL), willingness to pay (WTP) for receiving hemodialysis (HD), and factors influencing QoL in patients who received peritoneal dialysis (PD) in Thailand. Data of PD patients visiting secondary or tertiary hospitals from December 2020 through June 2021 were collected. EuroQoL EQ-5D-5L questionnaire was used to evaluate QoL. After the patients completed the questionnaire, they were interviewed using the contingent valuation method to derive their WTP for switching to HD. Patients randomly picked up one payment card as an initial price for receiving HD, then bidding by 100 Thai Baht (THB) up and down to reach the maximum affordable WTP amount. Multiple linear regression was used to identify factors affecting QoL. A total of 102 patients were included in this study. The mean age was 58 years. EQ-5D utility score was 0.71±0.32. Five variables were the factors that affect QoL included serum albumin, hospitalization, age, urine output, and hemoglobin level. Average WTP was 233±293 THB (7.2±9.0 USD) per HD session. Quality of life among these study patients was slightly higher than reported in Thai patients with low hemoglobin level. Treatment anemia to reach hemoglobin target and preservation of residual urine output might improve QoL. The average WTP for switching to HD among PD patients was only one-sixth of general billing price for HD

The effect of gender on survival for hemodialysis patients: Why don't women live longer than men?

Women in the general population have a survival advantage over men, but this advantage is not sustained in end‐stage kidney disease (ESKD) patients treated by hemodialysis. To understand why gender may affect survival we need to understand confounders which may affect dialysis practices. The current paradigm is to prescribe hemodialysis to achieve a target dialyzer urea clearance adjusted to total body water volume (Kt/Vurea). Estimated glomerular filtration calculated from serum creatinine is often used to determine when patients start dialysis; as creatinine generation rates are lower in women, this may potentially result in a lead time bias with male patients starting dialysis earlier than females. When hemodialysis dose is scaled to total body water (Kt/Vurea) women receive shorter dialysis session times. Scaling dialysis for body surface area may be more appropriate since urea generation (a surrogate for uremic toxin production) depends upon resting energy expenditure (ie, cellular metabolism) which reflects internal organ sizes. Resting energy expenditure is proportionally greater for smaller people. Women are generally smaller than men and as such have smaller sized internal organs. However, when comparing individuals, then internal organ size is best adjusted for using body surface area, not body water. The shorter, resultant dialysis session also results in lower middle molecule clearances, increases fluid removal rates and the risk of intra‐dialytic hypotension; the latter potentially results in earlier loss of residual renal function. Observational studies report that the association between survival and dialyzer Kt/Vurea is improved after adjustment for body surface area, or energy expenditure. These studies also demonstrated that the conventional prescription of hemodialysis based on current Kt/Vurea targets leads to less treatment delivered to women. These multiple consequences of the generally smaller size of women compared with men may account for the unexpectedly higher relative mortality for women. As such, prospective studies investigating alternative scaling parameters are required to confirm that increasing dialysis treatments for women improves survival

Factors associated with systolic hypertension in peritoneal dialysis patients

BACKGROUND: Hypertension is common in peritoneal dialysis (PD) patients and associated with adverse outcomes. Besides solute clearance, PD convective clearance is used to control extracellular water (ECW) volume and sodium balance. Previous studies have reported on hypertension in PD patients treated with continuous ambulatory peritoneal dialysis (CAPD) using hypertonic glucose dialysates. However, increasing numbers of PD patients are now treated with automated peritoneal dialysis (APD) and icodextrin dialysates. As such, we wished to explore factors associated with systolic blood pressure (SBP) in a modern cohort to identify targets to improve blood pressure control in PD patients. METHODS: We retrospectively reviewed the results from PD patients attending for peritoneal membrane assessment who had corresponding bioimpedance ECW and brain natriuretic peptide (NT-proBNP) measurements. RESULTS: We studied 510 PD patients: 317 (72.2%) male, 216 (42.4%) diabetics, median age 59 (47–72) years, and 51% treated by APD with a day-time icodextrin exchange. Mean systolic blood pressure (SBP) was 140 ± 24.8 mmHg. SBP was independently associated with 4-hour dialysate to plasma creatinine ratio (β = 29.5 (95% confidence limits 11.4–47.5, p = 0.001), N-terminal brain natriuretic peptide [β = 11.9 (7.2–16.7), p < 0.001], and daily urine sodium excretion [β = 1.7 (1.0–2.3), p < 0.001]. CONCLUSION: In the era of APD cyclers and icodextrin, SBP is associated with increased NT-proBNP, a marker of ECW expansion, and faster peritoneal transport, a risk factor for a positive sodium balance, and increased urinary sodium suggestive of higher dietary sodium intake. Patients should be encouraged to restrict sodium intake and PD prescriptions targeted to control ECW to improve SBP control

Estimating Dietary Protein Intake in Peritoneal Dialysis Patients: The Effect of Ethnicity

Kidney dialysis patients with sarcopenia have increased mortality. Clinical guidelines recommend peritoneal dialysis (PD) patients have a target daily protein intake to prevent sarcopenia. Protein intake is estimated from total daily urea losses in urine and peritoneal dialysate to assess the protein equivalent of nitrogen appearance rate adjusted for body weight (nPNA). Dietary habits differ among ethnic groups, so we reviewed nPNA and body com - position in a multi-ethnic PD population. Body composition was measured with multifrequency bioimpedance in 598 patients (301 white, 136 black, 123 South-Asian, and 38 Asian-Pacific). South-Asians had a lower nPNA compared with white and black indi - viduals (Randerson 0.80 ± 0.21 vs 0.88 ± 0.24 and 0.85 ± 0.24g/kg/ day, Blumenkrantz 0.97 ± 0.14 vs 1.04 ± 0.22 and 0.99 ± 0.22 g/kg/ day, Bergström 0.87 ± 0.4 vs 0.95 ± 0.24 and 0.92 ± 0.24 g/kg/day all p < 0.001). South-Asians had lower weights (68.9 ± 14.9 vs 74.4 ± 16.6 and 73.5 ± 16.3 kg, p < 0.001), and although of similar body mass index (25.9 ± 4.9 vs 28.5 ± 4.9 and 26.5 ± 5.2 kg/m 2), had both lower skeletal muscle and appendicular muscle mass indexed for height (9.08 ± 1.45 vs 9.89 ± 1.62 and 10.1 ± 1.85, p < 0.001; and 6.95 ± 1.39 vs 7.68 ± 1.48 and 7.67 ± 1.58 kg/m2 p < 0.01). South-Asian patients had a lower calculated basal metabolic rate (BMR) (1,358 ± 218 vs 1,487 ± 257 and 1,489 ± 271 kcal/day, p < 0.001). Asian PD patients, particularly South-Asians, have lower dietary protein intakes when calculated by nPNA. However, South-Asians had lower measured muscle mass and calculated BMR. As such, dietary protein intake targets derived from studies in 1 ethnic group are not necessarily applicable for all patients, as those with less muscle mass and lower BMR may well need less daily protein intake to maintain homeostasis

CRYPTOCOCCAL MENINGITIS IN HIV-INFECTED PATIENTS AT CHIANG MAI UNIVERSITY HOSPITAL: A RETROSPECTIVE STUDY

Abstract. Cryptococcal meningitis (CM) is a common central nervous system infection in HIV-infected patients. This study aimed to determine treatment outcomes among HIV-infected patients who had cryptococcal meningitis and to determine predictors of death. We conducted a retrospective cohort study among HIV-infected patients receiving care at Chiang Mai University Hospital from January 1, 2005 to December 31, 2010. We studied 79 patients; 45 (57.0%) were male and the mean age was 35.1±7.2 years. Eleven patients (13.9%) had previous opportunistic infection. The most common presenting symptoms were headache (63 patients, 79.8%), fever (49 patients, 62.0%), and altered consciousness (21 patients, 26.6%). The median CD4+ cell count was 20 cells/mm 3 [Interquartile range (IQR) 10, 53]. The in-hospital, 90-day, and 1-year mortality rates were 24.1%, 32.4%, and 52.2%, respectively. The CM attributable in-hospital, 90-day and 1-year mortality rates were 13.9%, 20.3%, and 23.2%, respectively. Predictors associated with a 1-year mortality were a high cerebrospinal (CSF) cryptococcal antigen titer (&gt;1:10,000) [Odds Ratio (OR) =7.08, 95% confidence interval (CI): 1.62-31.00, p=0.009], and altered consciousness at presentation (OR=5.27; 95% CI: 1. 16-24.05; p=0.032). Cryptococcal meningitis is an important cause of death in HIV-infected patients. HIV-infected patients with a low CD4+ cell count, a headache, fever and altered consciousness should be investigated for CM and those with a high CSF cryptococcal antigen titer are at high risk for mortality