[Results of therapeutics strategy of protein-energy wasting in chronic hemodialysis: a prospective study during 12 months]. / Résultats des stratégies thérapeutiques au cours de la dénutrition en hémodialyse chronique: étude prospective sur 12 mois.

INTRODUCTION: Undernutrition (UN) in chronic hemodialysis (CHD) is a recurrent complication and constitutes a major public health problem. This work aims to evaluate the effects of our nutritional strategy (NS) developed among malnourished patients (pts) in CHD. This is a prospective observational study conducted for 12 months (M) in a cohort of 132 pts in CHD including 49 women, mean age 66 ± 16 years and the dialysis vintage 72 ± 74 months. This NS is based on the action of a multidisciplinary team; it provides for moderate UN pts one first phase of an optimization of protein and energy intake in the daily meals; then depending on the clinical course a second phase of oral supplementation at home. For severe UN pts, the optimization of daily meals and the oral supplements at home are reinforced with perdialytic oral supplementation. This modality was also prescribed for moderate UN pts with poor compliance at home. In case of loss of appetite, anorexia, gastrointestinal intolerance or inadequate oral intakes the relay is made by the intradialytic parenteral nutrition (IPN). Methods consist in the evaluation of the serum albumin (ALB), CRP, normalized PCR (nPCR), and Kt/V ratio of urea at baseline (day (D) 0) and at endpoint (M12). The ALB was measured by immunoturbidimetry. Three nutritional profiles were defined, severe UN if ALB ≤ 35 g/L, moderate UN if 35

Influence of inflammation on total energy expenditure in hemodialysis patients.

BACKGROUND AND OBJECTIVES: Studies show that inflammation can contribute to an increase in resting energy expenditure in patients with chronic kidney disease; however, findings about total energy expenditure (TEE) have not been reported. The aim of this study was to evaluate the effects of inflammation on TEE and physical activity energy expenditure in hemodialysis (HD) patients. DESIGN: This was a cross-sectional study. SETTING: This study was conducted from Hôpital Edouard Herriot, Lyon, France. PATIENTS: This study included 24 HD patients and 18 healthy subjects. MAIN OUTCOME MEASURE: TEE and step counts were measured over a 7-day period by the SenseWear Pro2 Armband in 24 HD patients (15 patients with C-reactive protein <5 mg/L, aged 67.0 ± 14.7 years, and 9 with C-reactive protein >5 mg/L, aged 69.0 ± 18.0 years) and compared with 18 healthy subjects (62.3 ± 15.3 years). RESULTS: Mean estimated TEE measured with SenseWear Pro2 Armband was significantly lower (25.5 ± 4.1 kcal/kg/day) in patients with inflammation when compared with those without inflammation (32.0 ± 6.7 kcal/kg/day) and with healthy subjects (31.8 ± 7.0 kcal/kg/day) (P = .012). There was a difference in the physical activity (step counts) between patient groups (P < .05). Healthy subjects and patients without inflammation walked more (8,107 ± 5,419 and 6,016 ± 3,752 steps/day, respectively) as compared with patients with inflammation (2,801 ± 2,754 steps/day, P = .001). CONCLUSION: Our findings suggest that patients with inflammation have a lower TEE when compared with healthy subjects and patients without inflammation. TEE is influenced by physical activity because patients with inflammation appear to be less active.

Obestatin and ghrelin interplay in hemodialysis patients.

OBJECTIVE: Compounds involved in the regulation of appetite and body composition appear to be of interest in chronic kidney disease. The purpose of this study was to analyze plasma obestatin and acyl and des-acyl ghrelin in patients on hemodialysis (HD). METHODS: Fifty patients on HD (56.0% women, mean age 62.2 ± 15.2 y) were studied. Blood samples were collected during fasting, before a regular HD session. Serum acyl and des-acyl ghrelin levels, leptin, and obestatin were measured using enzyme immunometric assay methods. Anthropometric parameters, appetite score, and food intake were recorded. RESULTS: Patients showed elevated serum leptin (34.1 ± 30 ng/mL), normal acyl ghrelin (137 ± 116.5 pg/mL), high des-acyl ghrelin (670 ± 479 pg/mL), and low obestatin (2.0 ± 1.4 ng/mL) levels compared with healthy volunteers. According to body mass index (BMI), patients with a BMI >23 kg/m(2) had significantly lower plasma obestatin. In contrast, leptin levels were increased and acyl ghrelin tended to be higher in these patients. There was a strong positive correlation between obestatin and des-acyl ghrelin (r = 0.56, P = 0.0001) and inverse correlations between obestatin and BMI (r = -0.40, P = 0.007), waist circumference (r = -0.38, P = 0.024), and C-reactive protein (r = -0.29, P = 0.048). By multivariate analysis, obestatin was independently and positively correlated with des-acyl ghrelin (P = 0.01), but not with C-reactive protein, BMI, or waist circumference. CONCLUSION: In summary, patients on HD exhibited increased plasma levels of des-acyl ghrelin, normal acyl ghrelin levels, and low obestatin levels. In lean patients, the obestatin and des-acyl ghrelin levels were increased, suggesting that these hormones may influence appetite and body composition in patients on HD.

New measurements of energy expenditure and physical activity in chronic kidney disease.

The accurate estimation of total daily energy expenditure (TEE) in chronic kidney patients is essential to allow the provision of nutritional requirements; however, it remains a challenge to collect actual physical activity and resting energy expenditure in maintenance dialysis patients. The direct measurement of TEE by direct calorimetry or doubly labeled water cannot be used easily so that, in clinical practice, TEE is usually estimated from resting energy expenditure and physical activity. Prediction equations may also be used to estimate resting energy expenditure; however, their use has been poorly documented in dialysis patients. Recently, a new system called SenseWear Armband (BodyMedia, Pittsburgh, PA) was developed to assess TEE, but so far no data have been published in chronic kidney disease patients. The aim of this review is to describe new measurements of energy expenditure and physical activity in chronic kidney disease patients.