[Nutritional and Functional assessment of peritoneal dialysis patients in the clinical practice: Report from MITO-DP Group]. / Valutazione Nutrizionale e Funzionale dei pazienti in dialisi peritoneale nella pratica clinica: l'esperienza del Gruppo Medico-Infermieristico Toscano di Dialisi Peritoneale (M.I.TO.-DP).

Nutritional abnormalities and physical inactivity are risk factors of increased morbidity and mortality in patients with ESRD. Identify and define malnutrition, in particular protein-energy depletion (PEW), is an important task in the management of renal patients. The aim of this multicenter observational study was to implement the assessment of nutritional status and functional capacity in patients on peritoneal dialysis, including tests and validated methods which are relatively easy to apply in daily clinical practice. The study includes all the 133 prevalent patients (80 m, 53 f, age 65 14 years), in peritoneal dialysis treatment (vintage 26 19 months) in 9 centers in Tuscany. We performed anthropometry, bioimpedance (BIA), clinical biochemistry, evaluation of habitual physical activity (RAPA tests) and performance (Sit-To-Stand test), appetite-evaluation questionnaire, and indices including the Malnutrition Inflammation Score (MIS), Geriatric Nutrition Risk Index (GNRI), Charlson comorbidity index, Barthel and Karnowsky index. The latter showed a condition of dependence in 7.2% and 19.7% of cases, respectively. Poor appetite was recorded in 48.2%. The majority of patients fell within the overweight / obesity range (51%) with waist circumference values associated with increased cardiovascular risk in 51% of males and 60% of females. At the BIA analysis, a BCMI <8 kg/m2 was detected in 39% of patients; an estimated protein intake <1.0 g / kg/d was found in 59% of cases; 34% of patients had serum albumin <3.5 g / dl; control of acidosis was good (bicarbonate 25.4 3.8 mM) but hyperphosphatemia was present in 64.6% of patients. A condition of sedentary or light physical activity was reported by 65.1% of patients, vigorous activity only by 11.9%. The 86.5% of patients able to perform the Sit-to-stand test reported a lower than the reference values for age and sex. A diagnosis of PEW was possible in 8% of our series, while a MIS score> 11, indicative of PEW, took place in 12.7% of cases. The values of the MIS correlated directly with age and the degree of comorbidity and inversely with the sit-to-stand test, RAPA tests and appetite level. The data in this study show that single tests indicative of malnutrition disorders are frequent to be found in our series of peritoneal dialysis patients. However, a diagnosis of PEW is quite infrequent. A large percentage of patients are overweight with increased abdominal adiposity, and reduced cell mass and protein intake below recommended levels; the level of habitual physical activity is low, and the level of physical capability is scarce. Therefore it is conceivable a nutritional counseling intervention to increase the intake of proteins, limiting the phosphorus and (when indicated) energy intake and to stimulating spontaneous physical activity or arranging assisted programs for functional rehabilitation. Close monitoring of the nutritional status and implementation of programs of adapted physical activity should have a prominent role in the clinical management of patients on peritoneal dialysis.

Assessment of habitual physical activity and energy expenditure in dialysis patients and relationships to nutritional parameters.

BACKGROUND AND AIM: Assessment of physical activity level and of energy expenditure is important in the clinical and nutritional care of dialysis patients, but it is not so easy to accomplish. The SenseWear™ Armband (SWA) is a novel multisensory device that is worn on the upper arm and collects a variety of physiologic data related to physical activity. Thus, duration and intensity of physical activity is recorded and expressed as METs (Metabolic Equivalent Task), and energy expenditure is estimated. The aim of our study was to assess interdialytic spontaneous physical activity in stable chronic hemodialysis (HD) patients and the relation to nutritional status and dietary nutrient intake. PATIENTS AND METHODS: In 50 stable patients on maintenance hemodialysis treatment and 33 normal subjects (control group), level of spontaneous physical activity and estimated daily energy expenditure was assessed by SWA and related to biochemistry and anthropometry data, bioelectric impedance vector analysis, and energy and nutrient intake information coming from a 3-day food recall. RESULTS: In respect to controls, HD patients showed lower mean daily METs value (1.3 ± 0.3 vs. 1.5 ± 0.2, p < 0.01), a lower time spent on activities > 3 METs (89 ± 85 vs. 143 ± 104 min/day, p < 0.05), lower number of steps per day (5,584 ± 3,734 vs. 11,735 ± 5,130, p < 0.001), resulting in a lower estimated energy expenditure (2,190 ± 629 vs. 2,462 ± 443 Kcal/day, p < 0.05). 31 out of the 50 HD patients (62%) had a mean daily value < 1.4 METs and hence were defined as sedentary. They differed from the active patients for higher age (63 ± 12 vs. 54 ± 12 y, p < 0.01), lower energy intake (26.1 ± 6.4 vs. 32.4 ± 11.3 Kcal/day, p < 0.05) and lower phase angle (5.5 ± 1.0 vs. 6.3 ± 0.9, p < 0.05). SWA-based estimation of daily energy expenditure was negatively related to age (r = -0.31, p < 0.05), whereas positive relations were observed with BMI (r = 0.51, p < 0.001), phase angle (r = 0.40, p < 0.01), serum phosphate (r = 0.49, p < 0.001) and albumin (r = 0.41, p < 0.01). The mean daily METs values were strongly related to normalized energy intake (r = 0.47, p < 0.001) and also to protein intake (r = 0.33, p < 0.05) and to phase angle (r = 0.38, p < 0.01). Multiple regression analysis showed that energy intake and dietary protein intake were independently related to the intensity of physical activity. CONCLUSION: Our findings indicate that poor physical activity is highly prevalent in stable dialysis patients even when free from physical or neurological disabilities or severe comorbid conditions. The level and intensity of physical activity is positively related to body composition and to dietary nutrient intake. This confirms the strong interrelationship between exercise and nutrition, which in turn are associated with survival, rehabilitation and quality of life in dialysis patients.

Food intake and nutritional status in stable hemodialysis patients.

This is a cross-sectional, multicenter, controlled study aiming to evaluate changes of actual dietary nutrient intake in 94 stable hemodialysis patients in respect to 52 normal subjects and guideline recommendations, and to assess the prevalence of signs of malnutrition. Energy and nutrients intake assessment was obtained by a three-day period food recall. Anthropometric and biochemical parameters of nutrition, bioelectric impedance vector analysis, and subjective global assessment (SGA) have been performed to assess nutritional status. SGA-B was scored in 5% of the patients. Body mass index < 20 Kg/m(2), serum albumin <35 g/L, nPNA < 1.0 g/Kg, and phase angle <4.0 degrees were detected in 16.3%, 16%, 23%, and 8.0 % of patients, respectively. HD patients showed a lower energy and protein intake in respect to controls, but no difference occurred when normalized per ideal body weight (29.3 +/- 8.4 vs. 29.5 +/- 8.4 Kcal/Kg i.b.w./d and 1.08 +/- 0.35 vs. 1.12 +/- 0.32 Kcal/Kg i.b.w. /d, respectively). Age was the only parameter that inversely correlates with energy (r = -0.35, p < 0.001) and protein intake (r = -0.34, p < 0.001). This study shows that in stable dialysis patients, abnormalities of nutritional parameters are less prevalent than expected by analysis of dietary food intake. Age is the best predictor of energy and protein intake in the dialysis patients who ate less than normal people, but no difference emerged when energy and protein intakes were normalized for body weight. These results recall the attention for individual dietetic counseling in HD patients, and also for a critical re-evaluation of their dietary protein and energy requirements.

Extradural endoscopic dissection of the anterior skull base.

A study was conducted from February 29, 1996, to March 28, 1996, at the University of Brno's Pathology Institute in the Czech Republic to explore the possible application of craniofacial intracranial endoscopic techniques through minimal skin incisions and trephines in fresh cadavers (3 to 12 hours old). Through the trephines the dura was totally dissected from the bone. After this dissection a standard bicoronal incision and a full craniotomy was performed to assess the integrity of the meninges. This minimally invasive dissection of the skull base with the aid of an endoscope is characterized by fewer skin incisions, thereby avoiding the exposure of subcutaneous tissue, muscle, cranial bone, and meninges. We find that it is possible to accomplish an accurate and extensive intracranial dissection with the aid of an endoscope. The potential of this technique is important for craniofacial surgery as well as for neurosurgery. The objectives of this study were [1] to explore endoscopically the craniofacial anatomy to determine the best approach and the optimal method for dissecting endocranial structures, and [2] to achieve a safer and more accurate dissection of the skull base, evaluating advantages of endoscopic surgery as an alternative method for the treatment of craniofacial and neurosurgical pathologies.

The determination of whole blood magnesium concentration in uremics on chronic dialysis.

The determination of whole blood magnesium concentration (MgT) was investigated in uremics on chronic dialysis with a broad range of hematocrit (Ht) and of plasma magnesium concentration (MgP). In view of the inverse correlation between erythrocyte magnesium concentration (MgC) and Ht in dialyzed uremics, as shown in our previous paper, it was possible to derive a formula which expressed MgT in terms of MgP and Ht. By exploring the predictive power of this formula, it can be concluded that MgT can be calculated directly from MgP and Ht.

The investigation of the relationship between whole blood potassium concentration and hematocrit in uremic patients undergoing hemodialysis.

The correlation between whole blood potassium (K) concentration and hematocrit (Ht) was investigated in chronically dialyzed uremics with a broad range of Ht. This correlation was found to be represented by a curve and its form was derived by the manipulation of the formula concerning the inverse relationship between erythrocyte K concentration and Ht. These findings show that in dialyzed patients the whole blood K concentration can be correctly predicted from any Ht value, despite their wide range of plasma K concentration.

Investigation of the correlation between total blood potassium concentration and hematocrit.

The correlation between whole blood potassium concentration (Kt) and hematocrit (Ht) was investigated in subjects with a broad range ofHt. This relationship was found to be represented by a curve, and its form was derived by the manipulation of the formula concerning the inverse correlation between Ht and erythrocyte potassium concentration (Kc).

Serum levels of PTH, Mg, Ca, inorganic phosphate and alkaline phosphatases in uraemic patients on differentiated Mg dialysis.

The serum levels of PTH, Mg, Ca, inorganic phosphate (Pi) and alkaline phosphatases (AlkPase) were determined in 22 uraemic patients on chronic haemodialysis with different Mg levels in th dialysate, in an attempt to clarify the pathogenesis of uraemic osteodystrophy. Baseline levels of all the considered parameters were obtained over a four month period whilst on standard Mg concentration in the dialysis solution (1.5 mEq/L). Patients were then divided into three groups: 10 patients were dialysed for six months with 0.5mEq/L of Mg, seven patients with 1.5mEq/L and five patients with 2.5mEq/L in the dialysate. At the end of the six months with differentiated Mg dialysis, the three groups had significantly different Mg serum levels, whereas no significant changes were observed in the PTH and Ca serum levels. All the patients on high-Mg dialysis showed a significant reduction of the Pi serum levels, whereas a significant increase of AlkPase was observed in the low-Mg dialysis group. The overall results obtained in the present study indicate a possible beneficial effect of low-Mg dialysis on the progression of uraemic osteodystrophy of patients on maintenance haemodialysis.

The relationship between Ht and erythrocyte potassium concentration in patients on regular hemodialysis.

Plasma and erythrocyte potassium (K) concentrations were measured in uremics of chronic dialysis and in a control group composed of healthy persons and of patients with anemia due to causes other than renal failure. The behavior of the erythrocyte K content in uremics did not differ from that of the control group and in both cases a close inverse relationship was present between hematocrit and erythrocyte K concentration, irrespective of its plasma level. These findings suggest that the red blood cell count, rather than renal failure, may affect the erythrocyte K content.

The relationship between hematocrit and erythrocyte magnesium concentration in patients on regular hemodialysis.

Plasma and erythrocyte magnesium (Mg) concentrations were measured in uremics on regular hemodialysis, in healthy persons and in patients with anemia due to causes other than renal failure. The mean plasma Mg concentration was found to be significantly higher in the uremic patients than in other subjects. The erythrocyte Mg concentration in anemic uremics and in nonuremic anemics was found to be higher than in normal subjects and a close inverse relationship was found between this figure and the hematocrit. It seems reasonable to argue that anemia, rather than renal failure, is related to the high concentration of Mg in erythrocytes.