Cardio-Renal Syndrome (CRS) is a condition, which is more frequently observed in clinical practice. The aim of this study is to explore nutritional status and intrarenal arterial stiffness in patients affected by CRS

Amoroso, D

Barbano, B

Cianci, R

Di Lazzaro Giraldi, G

Di Mario, F

GASPERINI ZACCO, MARIA LUDOVICA

Gigante, A

Laviano, A

Pofi, R

Rosato, E

Cardiorenal syndrome (CRS) describes the concurrent failure of cardiac and renal function, each influencing the other. Malnutrition and cachexia frequently develop in patients with heart failure or kidney failure. However, no information is currently available on the prevalence of malnutrition in CRS patients. We studied CRS patients admitted to an internal medicine ward during a 5-month period and evaluated their clinical characteristics and nutritional status. Malnutrition risk was assessed by using the validated screening tool NRS-2002 whilst body composition was assessed by bioimpedance analysis and muscle function was measured by handgrip (HG) strength. Cardiac mass was also recorded. Length of stay, hospital readmission and 6-month mortality were registered. During the study period, 22 CRS patients were studied. Twenty patients were diagnosed with either CRS type 1 or CRS type 5. In CRS patients, fat-free mass showed a trend toward representing a protective factor for 6-month mortality (OR=0.904; p=0.06). Also, fat-free mass correlated with HG strength and cardiac ejection fraction. Malnutrition risk was diagnosed in 45% of the patients, whereas 8 patients met the definition of cachexia. Even without statistical significance, CRS patients with malnutrition had lower BMI (Body Mass Index) (p=0.038) and fat-free mass (p= n.s.). However, CRS malnutrition was associated to higher 6-month mortality (p= 0.05), and appears to negatively influence the outcome in CRS (OR= 9; p= 0.06). Our results show that malnutrition is prevalent in CRS patients and influences the clinical outcome. The assessment of nutritional status, and particularly body composition, should be implemented in daily practice of patients with CRS

Gasperini

Archivio della ricerca- Università di Roma La Sapienza

313and muscle wasting3. Recently cachexia has been proposed as a possible mechanism defining car-dio-renal cachexia syndromes (CRCS)4. CRCS can contribute to the worsening of cardiac and ki-dney functions and negatively influences clinical outcome.By exploring nutritional status in CRS patients and its relationship with intrarenal arterial stiff-ness, we aimed to assess whether anthropometric parameters correlate with renal resistive index (RRI) in CRS hospitalized patients.Patients and MethodsAdult patients admitted to our Department during five consecutive months and meeting the diagnosis of CRS were considered for inclusion in the study. The diagnosis of CRS was based on the criteria set in the ADQI Consensus Conference 20081. Patients unable to give informed consent, with cancer, gastrointestinal obstruction or dy-sphagia were excluded. At the moment of diagno-sis, patients underwent renal Doppler ultrasound, echocardiography and whole-body bioimpedance spectroscopy (BIS).Renal Doppler ultrasound (RDU) was perfor-med using a Toshiba Aplio Ultrasound System SSA-790 (Tokyo, Japan) equipped with convex 3.5-MHz probe. RRI was calculated as (peak systolic frequency shift-minimum diastolic fre-quency shift)/peak systolic frequency shift. All the ultrasound examinations were performed by the same-blinded physician in order to redu-ce variability in the assessment management of the study. The average of three measurements for each Doppler parameter of arcuate and interlobar arteries in both kidneys was calculated. RRI > 0.7 were considered pathologic5. Abstract. – OBJECTIVE: Cardio-Renal Syn-drome (CRS) is a condition, which is more fre-quently observed in clinical practice. The aim of this study is to explore nutritional status and intra-renal arterial stiffness in patients affected by CRS. PATIENTS AND METHODS: 14 consecutive CRS patients, screened for anthropometry, bio-chemistry, nutritional and metabolic status un-derwent renal Doppler ultrasound and whole-body bioimpedance spectroscopy (BIS).RESULTS: We found a positive correlation be-tween phase angle (PA) and CKD-EPI and MDRD (p=0.011 and p=0.007), and between body mass index and renal resistive index (RRI) (p=0.002). Finally, we found a negative correlation between fat-free mass and RRI (p=0.024).CONCLUSIONS: Body composition assess-ment may improve the care of patients with chronic kidney disease (CKD). Also, BIS may help identify changes in hydration status in CKD patients resulting as a significant predictor of mortality.Key Words: Cardiorenal syndrome, Renal resistive index, Bio-impedance spectroscopy, Cachexia, Malnutrition.IntroductionCardio-Renal Syndrome (CRS) describes a cardiac and renal dysfunction, where the acute or chronic failure of one of the two organs deter-mines acute or chronic insufficiency of the other organ1. CRS is a condition that is more frequently observed in the clinical practice and the identi-fication of predisposing trigger factors, such as infectious diseases, particularly in older adults, plays a key role in reducing morbidity and morta-lity2. Malnutrition and cachexia frequently deve-lop in patients with heart failure or kidney failure. Cachexia is clinically characterized by involun-tary weight loss, anorexia, reduced food intake, European Review for Medical and Pharmacological Sciences 2017; 20: 313-316A. GIGANTE1, F. DI MARIO2, B. BARBANO1, E. ROSATO1, G. DI LAZZARO GIRALDI1, R. POFI3, M.L. GASPERINI1, D. AMOROSO4, R. CIANCI1, A. LAVIANO11Department of Clinical Medicine, Sapienza University, Rome, Italy2Department of Internal Medicine and Medical Specialties, Sapienza University, Rome, Italy3Department of Experimental Medicine, Sapienza University of Rome, Italy 4Department of Emergency Medicine, Sapienza University, Rome, ItalyCorresponding Author: Antonietta Gigante, MD; e-mail: antonietta_gigante@yahoo.itNutritional status and intrarenal arterial stiffness in cardiorenal syndrome: a pilot studyA. Gigante, F. Di Mario, B. Barbano, E. Rosato, G. Di Lazzaro Giraldi, R. Pofi, M.L. Gasperini, et al. 314Echocardiography was performed with an ultrasound Toshiba Ultrasound System (Tokyo, Japan) equipped with a convex 2.5-3.5 MHz probe.Patients’ anthropometry [weight, height, body mass index (BMI), hand-grip (HG) stren-gth] and biochemistry were collected from charts and recorded. Also, patients were scree-ned for malnutrition by using the validated tool NRS-20026. Whole-body BIS was performed using an Impedimed multifrequency device (Impedi-med IMP SFB7, San Diego, CA, USA). All the subjects were in the supine position with four gel-type electrodes, two voltages and two cur-rent, pasted on the right foot and wrist. Two pairs of electrodes were placed: on the hand to foot for injecting current with a frequency from 4 kHz to 1 MHz, and on the wrist to ankle for measuring voltage. Data derived from these measurements included resistance, reactance, phase angle (PA) and impedance. Data were collected and processed using SPSS version 20 for Macintosh (SPSS Inc., Chicago, IL, USA). Correlations were used to assess the bivariate associations between va-riables, using Pearson correlation. Data are pre-sented as median (range). A p<0.05 was consi-dered statistically significant. ResultsDuring the study period, 14 patients were con-sidered for inclusion in the study: eight presen-ted an acute disorder and six manifested baseline characteristics typical of a chronic disease. Out of fourteen patients, 11 were males (78.6%) and 3 females (21.4%). The median age of the sam-ple was 77.5 years (37-92). In most of the patien-ts the reason for hospitalization was dyspnea. An abrupt increase of blood pressure, anemia, chest pain, fever of unknown origin, loss of con-sciousness and acute kidney injury were other remarkable causes. The baseline demographic, anthropometric and clinical characteristics are shown in Table I. In particular, we found a posi-tive correlation between PA and renal function, as expressed by estimated glomerular filtrate rate (eGFR) evaluated by CKD-EPI and MDRD (p=0.011 and p=0.007 respectively). Moreover, we found a positive correlation between BMI and RRI (p=0.002) and a negative correlation between fat-free mass (%) and RRI (p=0.024) (Figure 1).DiscussionOur study shows that in CRS patients, RRI correlates positively with BMI and negatively with fat-free mass. In patients with metabolic syndrome, it is well known that intra-renal resi-stances are elevated at an early stage and asso-ciated with a dysregulated production of fat-de-rived hormones and cytokines7. Furthermore, we found that eGFR showed a positive correla-tion with PA. PA is a bedside reliable tool for nutritional assessment based on conductivity properties of body tissues representing an indicator of cell membrane integrity and a prognostic indicator Figure 1. Correlation between mean RRI and BMI and between RRI and Fat Free Mass (%).Nutritional status and intrarenal arterial stiffness in cardiorenal syndrome: a pilot study315in many clinical situations8. These data, when comprehensively evaluated, seem to point at a protective role of improved nutritional status in determining renal function. This is in agre-ement with previous studies in different clini-cal settings, highlighting the close relationship between preserved muscle mass and favorable outcome9. Additionally, it may be helpful to in-tervene in the early CRS by drugs that act on outcome at multiple levels (heart, kidney, ves-sels)10. In particular, the divergent correlations of RRI with BMI and fat-free mass suggest that sarcopenic obesity, i.e., concurrent large fat mass and low muscle mass, may negatively inf luence outcome also in CRS patients. The-refore, considering the role of specialized nu-trition therapy to ameliorate nutritional status, body composition assessment has the potential to improve the care of CKD patients. Further-more, BIS may help to identify changes in hy-dration status in CKD patients not fully appre-ciated by clinical or biochemical assessment resulting as a significant predictor of mortality in these patients.ConclusionsOur study strongly encourages the initiation of larger trials to assess the RRI and BIS in course of CRS to help monitoring therapy.Ethical StatementThe study protocol was designed according to the cri-teria set in the Declaration of Helsinki and was ap-proved by the Ethics Committee at our institution.Conflict of InterestThe authors declare no conflicts of interest.References 1) Ronco c, Mccullough P, AnkeR SD, AnAnD I, ASPRo-Monte n, BAgShAw SM, BelloMo R, BeRl t, BoBek I, cRuz Dn, DAlIento l, DAvenPoRt A, hAAPIo M, hIllege h, houSe AA, kAtz n, MAISel A, MAnkAD S, zAnco P, MeBAzAA A, PAlAzzuolI A, Ronco F, ShAw A, SheInFelD g, SonI S, veScovo g, zAMPeRettI n, Po-nIkowSkI P. Acute Dialysis Quality Initiative (ADQI) consensus group. Cardio-renal syndromes: re-port from the consensus conference of the Acute Dialysis Quality Initiative. Eur Heart J 2010; 31: 703-711. 2) gIgAnte A, lIBeRAtoRI M, gASPeRInI Ml, SARDo l, DI MARIo F, DoRellI B, BARBAno B, RoSAto e, RoSSI FAnellI F, AMoRoSo A. Prevalence and clinical features of patients with the cardiorenal syndrome admitted to an internal medicine ward. Cardiorenal Med 2014; 4: 88-94. 3) ARgIléS JM, BuSquetS S, SteMMleR B, lóPez-SoRIAno FJ. Cancer cachexia: understanding the molecular basis. Nat Rev Cancer 2014; 14: 754-762.Table I. Demographic, anthropometric and clinical characteristics in patients affected by CRS. Median value Max MinCreatinine (mg/dl) 1.55 7.8 1.1eGFR CKD-EPI (ml/min/1.73 m2)  40 66 7eGFR MDRD (ml/min/1.73 m2)  43 69 8Azotemia (mg/dl) 57.2 308.0 35.0Hemoglobin (g/dl) 11 16.5 8.1Uric acid (mg/dl) 7.6 11.6 4.7Albumin (mg/dl) 3.1 4 1.6PCR (ng/ml) 50850 208800 500BMI (kg/m2) 28.5 33.1 20.2BSA (m2) 1.9 2.3 1.7NRS 2002 2 4 1HG right (kg) 18 33 9HG left (kg) 18 33 4Phase angle 5.8 8.6 3.3Fat free mass (kg) 55.4 68.6 35.7Fat free mass (%) 64.9 97.6 54.9EF (%) 50 60 40Cardiac mass 215.9 339.6 114Cardiac mass/BSA 117.5 172.4 49.78RRI 0.79 0.96 0.63A. Gigante, F. Di Mario, B. Barbano, E. Rosato, G. Di Lazzaro Giraldi, R. Pofi, M.L. Gasperini, et al. 316 4) cIcoIRA M, AnkeR SD, Ronco c. Cardio-renal cachexia syndromes (CRCS): pathophysio-logical foundations of a vicious pathological circle. J Cachexia Sarcopenia Muscle 2011; 2: 135-142. 5) PARolInI c, noce A, StAFFolAnI e, gIARRIzzo gF, co-StAnzI S, SPlenDIAnI g. Renal resistive index and long-term outcome in chronic nephropathies. Ra-diology 2009; 252: 888-896. 6) konDRuP J, RASMuSSen hh, hAMBeRg o, StAngA z. Ad hoc ESPEN working group. Nutritional risk screening (NRS 2002): a new method based on an analysis of controlled clinical trials. Clin Nutr 2003; 22: 321-336. 7) BuSceMI S, veRgA S, BAtSIS JA, cottone S, MAttInA A, Re A, ARnone M, cItARDA S, ceRASolA g. Intra-renal hemodynamics and carotid intima-media thick-ness in the metabolic syndrome. Diabetes Res Clin Pract 2009; 86: 177-185. 8) noRMAn k, wIRth R, neuBAueR M, eckARDt R, StoBäuS n. The bioimpedance phase angle predicts low muscle strength, impaired quality of life, and in-creased mortality in old patients with cancer. J Am Med Dir Assoc 2015; 16: 173.e17-22. 9) veASey RoDRIgueS h, BARAcoS ve, wheleR JJ, PARSonS hA, hong DS, nAIng A, Fu S, FAlchoock g, tSIMBeRI-Dou AM, PIhA-PAul S, chISholM g, kuRzRock R. Body composition and survival in the early clinical trials setting. Eur J Cancer 2013; 49: 3068-3075. 10) Peng DF, tAng Sy, hu yJ, chen J, Peng X, huAng q. Comparison of valsartan and benazepril when combined with atorvastatin in protecting patients with early cardio-renal syndrome (CRS). Eur Rev Med Pharmacol Sci 2015; 19: 1264-1271.

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Nutritional status and intrarenal arterial stiffness in cardiorenal syndrome: a pilot study

Nutritional status and intrarenal arterial stiffness in cardiorenal syndrome: a pilot study

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