Prevalence of osteosarcopenia and its association with mortality and fractures among patients undergoing hemodialysis.

INTRODUCTION: Osteosarcopenia is an age-related syndrome characterized by the coexistence of osteoporosis and sarcopenia. Little is known about the clinical implications of osteosarcopenia among patients undergoing hemodialysis. This study investigated the prevalence of osteosarcopenia and its association with all-cause mortality and fractures in this population. MATERIALS AND METHODS: This retrospective cohort study included outpatients undergoing hemodialysis in Japan. Sarcopenia was defined according to the recommendations of the Asian Working Group for Sarcopenia 2019. Osteoporosis was defined as a T-score of the calcaneus bone < - 2.5. We divided patients into three groups: robust (no osteoporosis or sarcopenia), osteoporosis or sarcopenia alone (osteoporosis without sarcopenia or sarcopenia without osteoporosis), and osteosarcopenia (osteoporosis and sarcopenia). Cox proportional-hazard and negative binomial regression models were used to estimate the associations between osteosarcopenia and all-cause mortality and fractures. RESULTS: Among the 328 patients (mean age, 65.5 ± 11.3 years; men, 59.1%), the prevalence of osteosarcopenia was 22.9%. During the follow-up period (1972 person-years), 131 deaths and 113 fractures occurred. Patients with osteoporosis or sarcopenia alone (hazard ratio 1.36; 95% confidence interval 0.85-2.18) and osteosarcopenia (hazard ratio 2.13; 95% confidence interval, 1.23-3.68) showed a higher risk of all-cause mortality than the robust group. Similar results were observed for the risk of fractures in patients with osteosarcopenia. CONCLUSIONS: Patients undergoing hemodialysis showed a high prevalence of osteosarcopenia, and osteosarcopenia was associated with a poor prognosis in this patient population. Assessing osteosarcopenia may be useful for accurate prognostic stratification of patients undergoing hemodialysis.

Reserved gait capacity and mortality among patients undergoing hemodialysis.

BACKGROUND: Patients undergoing hemodialysis (HD) have difficulty increasing their gait speed in daily life. The extent of the increase from the usual gait speed (UGS) to the maximum gait speed (MGS) is considered the reserved gait capacity (RGC). Little is known regarding the implications of RGC. This study aimed to investigate the association between RGC and all-cause mortality in patients undergoing HD. METHODS: In this retrospective study, we assessed the usual and maximum 10-m walking speed of outpatients who underwent HD between October 2002 and August 2021. RGC was defined as the ratio of MGS to UGS. Patients were divided into three groups according to the tertiles of RGC (low, moderate and high). A Cox proportional hazards regression model was used to examine the association between RGC and all-cause mortality. RESULTS: Of the 496 (median age 66.0 years; men 59%) participants, 186 patients died during the follow-up (incident ratio of 62.0 per 1000 person-years). The patients with moderate [hazard ratio (HR) 0.66, 95% confidence interval (CI) 0.46-0.94] and high (HR 0.44, 95% CI 0.30-0.65) RGC had a lower risk of mortality than the low RGC group. Furthermore, even when restricted to a population with only UGS <1.0 m/s, the group with high RGC still had a lower risk of mortality than those with low RGC (HR 0.55, 95% CI 0.33-0.94). CONCLUSIONS: Lower RGC was independently associated with an increased risk of all-cause mortality among patients on HD; high RGC had a survival advantage even with a slow UGS.

Comparison of the association between six different frailty scales and clinical events in patients on hemodialysis.

BACKGROUND: Frailty is associated with adverse outcomes in patients undergoing hemodialysis (HD). However, no study has used various frailty assessments in patients on HD to examine their association with clinical events. In this study, we investigated the association between clinical events and six frailty scales. METHODS: Outpatients who underwent HD between 2018 and 2020 were retrospectively enrolled. Frailty was defined using the Fried Frailty Phenotype, Study of Osteoporotic Fractures (SOF) Index, Short Physical Performance Battery (SPPB), Frail Screening Index, FRAIL scale and Clinical Frailty Scale. Outcomes were clinical events, including a composite of multiple (i.e. recurrent) all-cause hospitalizations, fractures and/or all-cause mortality. The association of clinical events and the frailty scales were investigated using negative binomial regression analysis. RESULTS: Fried Frailty Phenotype [incident rate ratio (IRR), 1.62; 95% confidence interval (CI), 1.49-1.76], SOF Index (IRR, 1.42; 95% CI, 1.10-1.83), SPPB (IRR, 1.79; 95% CI, 1.11-2.88) and Clinical Frailty Scale (IRR, 1.65; 95% CI, 1.04-2.61) were significantly associated with clinical events. However, Frail Screening Index (IRR, 1.38; 95% CI, 0.60-3.18) and FRAIL scale (IRR, 1.30; 95% CI, 0.88-1.92) showed no significant association with clinical events. CONCLUSIONS: Objective frailty assessments (SPPB) and medical staff impression-based frailty (Clinical Frailty Scale) may be useful prognostic predictors for patients on HD. Questionnaire-based frailty assessment should be carefully considered when used as a measurement of frailty.

The Association of Short Physical Performance Battery With Mortality and Hospitalization in Patients Receiving Hemodialysis.

OBJECTIVE: The Short Physical Performance Battery (SPPB) is recommended for evaluating physical performance in patients on hemodialysis (HD). However, the association between SPPB score and long-term health outcomes in these patients remains unclear. We examined the association of SPPB score with all-cause mortality, all-cause hospitalization, and cardiovascular hospitalization in patients on HD. DESIGN AND METHODS: This retrospective cohort study included 326 patients (median age, 68 years; 62% men) who received outpatient HD therapy. These patients were divided into 2 SPPB groups: low (SPPB ≤9) and high (SPPB >9). We investigated the association of SPPB score and their change over time with health outcomes using Cox regression analysis. RESULTS: Low SPPB score was associated with a higher risk for all-cause mortality (hazard ratio [HR]: 3.19, 95% confidence interval [95% CI]: 1.89-5.38), all-cause hospitalization (HR: 2.01, 95% CI: 1.44-2.82), and cardiovascular hospitalization (HR: 2.20, 95% CI: 1.45-3.35). Additionally, change in SPPB score over 1 year was associated with health outcomes. CONCLUSIONS: Lower SPPB score was significantly associated with a higher risk for all-cause mortality, all-cause hospitalization, and cardiovascular hospitalization. The SPPB may be a valuable indicator for risk stratification in patients on HD. Additionally, preventive treatments may be an effective management strategy in limiting the high mortality and hospitalization rates in patients with decreased SPPB score.

Trajectory of Serum Albumin Prior to Death in Patients Receiving Hemodialysis.

OBJECTIVE: Although some clinical expert guidelines recommend regular monitoring of serum albumin levels in patients undergoing maintenance hemodialysis, little is known about the serum albumin trajectory patterns over time, and it is unclear how the trajectory change before death. METHODS: We performed this retrospective study using data from 421 patients receiving hemodialysis in a dialysis facility. We divided patients into died and survived groups according to whether they died during the observation period. To compare the albumin trajectories during the observation period between the died and survived groups, linear mixed-effect models and a backward timescale from the year of death or study end were used. RESULTS: During the observation period (median, 5.1 years; maximum, 8.4 years), 115 patients receiving dialysis died. The serum albumin level showed steeper decline 3 years before death in the died group than in the survived group. The difference in albumin between the died and survived groups became apparent 3 years before death (difference, 0.08 g/dL; 95% confidence interval, 0.00-0.15 g/dL; P = .04), and the difference widened over time (difference at 1 year before death, 0.24 g/dL; 95% confidence interval, 0.14-0.33 g/dL; P < .001). Furthermore, in an analysis of albumin trajectories according to cause of death, the albumin level showed a downward trend regardless of the cause of death. CONCLUSION: The serum albumin trajectory differed between patients undergoing hemodialysis who died and who survived, supporting the importance of monitoring the albumin trajectory in clinical practice.

Comparative Analysis of Simplified, Objective Nutrition-Associated Markers in Patients Undergoing Hemodialysis.

OBJECTIVE: Protein-energy wasting is prevalent among patients undergoing dialysis. Hence, identifying an optimal index is necessary for the comprehensive measurement of nutritional status. This study evaluated and compared the prognostic significance of the modified creatinine index (mCI) and geriatric nutritional risk index (GNRI), with the principal aim to identify markers that are more closely associated with clinical events in patients undergoing hemodialysis. METHODS: We performed a retrospective cohort study of 472 patients undergoing maintenance hemodialysis (mean age, 66.4 years; 62.9% males). We evaluated the mCI, GNRI, and their respective rates of change over a 1-year period. The outcome analysis included all-cause death, number and duration of all-cause hospitalizations, and number and duration of hospitalizations due to cardiovascular disease. In addition, we analyzed the associations of the mCI, GNRI, and their trajectories with clinical outcomes using Cox proportional hazard regression and negative binomial regression. RESULTS: Over a median 3.6-year follow-up, both the lower mCI (hazard ratio 3.00; 95% confidence interval 2.19, 4.09) and lower GNRI (hazard ratio 1.76; 95% confidence interval 1.45, 2.13) per 1 standard deviation decrease were associated with a higher risk of all-cause death. However, a lower mCI was consistently associated with a higher risk of hospitalization, whereas the GNRI was poorly associated with the risk of hospitalization after adjusting for covariates. Furthermore, although a decline in the mCI over time was associated with a higher risk of each adverse event, a significant association between the change in GNRI and clinical events was not detected. CONCLUSION: The mCI at one timepoint and its trajectory had consistently stronger associations with clinical events than the GNRI in patients undergoing hemodialysis. This study further emphasizes the importance of risk screening using a marker of nutritional status in patients undergoing hemodialysis.

Determinants of Health-Related Quality of Life and Physical Performance-Based Components of Frailty in Patients Undergoing Hemodialysis.

OBJECTIVES: Health-related quality of life (HRQoL) measures capture the patient's experience of the burden of chronic disease and are strongly associated with adverse health-related outcomes across multiple populations. The SF-36 score is the most widely used HRQoL measure among patients with end-stage renal disease. Current understanding of determinants of the physical component summary (PCS) and the mental component summary (MCS) and their association with objectively measured physical performance and activity is limited. METHODS: As an index of HRQoL, we prospectively examined the association of SF-36 and its component scores with physical function among 155 incident dialysis patients from the Hemodialysis Center. We investigated associations of HRQoL with the physical performance-based components of the frailty using multivariate linear and logistic regression after adjustment for confounders. Impaired physical performance was defined as having either slow usual gait speed or weak handgrip strength based on standardized and validated criteria derived from a large cohort study of older adults. RESULTS: The patients had a mean age of 65 ± 11 years, and 52.3% were male. After adjusting confounders, lower PCS was independently associated with decreased physical performance and reduced physical activity, but MCS was not associated. Among the PCS subscales, only physical functioning 10 (PF-10) was consistently associated with outcomes, and every 1 point increase in PF-10 score was associated with 4% lower odds of impaired physical performance (95% confidence interval 2-7, P = .01) after adjustment. CONCLUSIONS: SF-36, especially PF-10, is a valid surrogate that discriminates low physical performance and physical inactivity in the absence of formal physical function testing in patients on hemodialysis. The routine implementation of the PF-10 in clinical care has important clinical implications for medical management and therapeutic decision-making in patients undergoing hemodialysis.

Modified Creatinine Index and Clinical Outcomes of Hemodialysis Patients: An Indicator of Sarcopenia?

OBJECTIVE: Sarcopenia (especially muscle mass assessed using gold standard techniques) has been suggested as a poorer predictor of mortality than muscle function in patients undergoing hemodialysis. Appropriate methods to estimate muscle mass for use as a good predictor of clinical outcomes remain to be established. We investigated whether the modified creatinine index (mCI), which is a surrogate marker of muscle mass, could predict mortality and cardiovascular (CV) hospitalizations independent of muscle function and other confounders in patients on hemodialysis. DESIGN AND METHODS: In this retrospective study, outpatients (n = 542; mean age, 65.3 years; 60% men; median dialysis vintage, 29 months; mean BMI, 22.0 kg/m2) undergoing hemodialysis were investigated. The mCI, handgrip strength, and gait speed were assessed and related to all-cause mortality and a composite of CV hospitalizations and all-cause mortality. Cox proportional and mixed-effects negative binomial models were fit for mortality and the composite outcomes. RESULTS: Patients were followed up for a median 3 years (interquartile range: 1.5-5.7). Each per SD increase of mCI (HR:0.63, 95% CI:0.62-0.65), handgrip strength (HR:0.51, 95% CI:0.48-0.54), and gait speed (HR:0.60, 95% CI:0.56-0.64) were significantly associated with lower all-cause mortality rates after adjusting for covariates. The mCI was consistently found to be an independent predictor of mortality after additional adjustment for handgrip strength or gait speed. Furthermore, sarcopenic conditions [i.e., lower mCI, and lower handgrip strength (HR:3.79, 95% CI:2.09-6.87) or slower gait speed (HR:4.20, 95% CI:2.38-7.41)] were significantly associated with a higher risk of mortality after adjusting for covariates. Associations of mCI with multiple CV hospitalizations and mortality were similar to those between mCI and mortality. CONCLUSION: The mCI was a good predictor of clinical outcomes and was comparable to muscle function, including handgrip strength and gait speed. The mCI is likely to provide additional diagnostic and prognostic values for sarcopenia in patients on hemodialysis.

Impact of Physical Activity on Dialysis and Nondialysis Days and Clinical Outcomes Among Patients on Hemodialysis.

OBJECTIVE: Patients undergoing hemodialysis (HD) have different physical activity (PA) patterns on HD and non-HD days. Nonetheless, whether these differences are associated with clinical outcomes remains unclear. We examined the association of PA levels on HD and non-HD days with cardiovascular (CV) hospitalizations and mortality. METHODS: Outpatients undergoing HD from 2002 to 2019 were retrospectively enrolled. The number of steps performed over 3 HD days and 4 non-HD days was recorded via accelerometry. Outcomes were all-cause mortality and a composite of CV hospitalizations and mortality. Patients were divided into two groups, each according to the median number of steps performed on HD (2371 steps/day) and non-HD days (3752 steps/day). Further, we categorized them into 4 groups according to each median values: "more active on HD/more active on non-HD (MM)," "more active on HD/less active on non-HD (ML)," "less active on HD/more active on non-HD (LM)," and "less active on HD/less active on non-HD (LL)." Cox and mixed-effects Poisson regression models were used for these outcomes. RESULTS: We analyzed 512 patients (median follow-up, 3.4 years). Higher PA on HD (hazard ratio [HR], 0.59; 95% confidence interval [CI], 0.54-0.65), and non-HD (HR, 0.84; 95% CI, 0.80-0.88) was associated with lower mortality risk, respectively. Further, the ML group (HR, 1.20; 95% CI, 1.13-1.28), LM group (HR, 1.82; 95% CI, 1.53-2.17), and LL group (HR, 1.83; 95% CI, 1.65-2.02) had higher mortality risks than the MM group. Associations of PA with multiple CV hospitalizations and mortality were similar to those between PA and mortality. CONCLUSIONS: Higher PA on HD and non-HD days was associated with lower risks of CV hospitalizations and mortality. However, higher PA levels on either HD or non-HD days alone did not improve clinical outcomes.

Trajectory of Lean Body Mass Assessed Using the Modified Creatinine Index and Mortality in Hemodialysis Patients.

RATIONALE & OBJECTIVE: Although a declining body mass index (BMI) is associated with higher mortality in patients on hemodialysis, BMI cannot distinguish lean body mass from fat mass. It remains unclear whether changes over time in lean body mass are associated with mortality. We examined the prognostic significance of changes in the modified creatinine index, a proxy for lean body mass. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: Outpatients (n=349; mean age, 67.4 years; 60% men) undergoing maintenance hemodialysis 3 times a week at a treatment center. PREDICTOR: Modified creatinine index and BMI trajectories over a 1-year period. OUTCOMES: All-cause mortality. ANALYTICAL APPROACH: We calculated the percentage of change in modified creatinine index and BMI over a 1-year period. Patients were categorized according to change in modified creatinine index/BMI: no decline (≥0%) or decline (<0%). Kaplan-Meier and Cox proportional hazard analyses were performed to examine whether modified creatinine index and BMI trajectories were associated with mortality. RESULTS: During follow-up (median, 1,157 days), 79 patients died. Decreasing modified creatinine index (HR, 1.31; 95% CI, 1.11-1.54) and BMI (HR, 1.25; 95% CI, 1.01-1.54) over time, measured as continuous variables and expressed per 1-standard deviation decrease, were independently associated with higher risk for all-cause mortality. The decline in modified creatinine index/no decline in BMI group (HR, 2.14; 95% CI, 1.04-4.45) and the decline in modified creatinine index/decline in BMI group (HR, 3.05; 95% CI, 1.58-5.90) had higher rates of mortality compared to the no decline in modified creatinine index/decline in BMI group. LIMITATIONS: The absence of a direct measure of lean body and fat mass and limited generalizability to non-Japanese hemodialysis populations. CONCLUSIONS: The modified creatinine index trajectory is independently associated with mortality and provides additional prognostic information to the BMI trajectory in patients on hemodialysis.

Association between frailty and bone loss in patients undergoing maintenance hemodialysis.

Frailty is significantly associated with bone loss in the general population. However, it is unclear whether this association also exists in patients undergoing hemodialysis who have chronic kidney disease-mineral and bone disorder (CKD-MBD). This study aimed to assess the association between frailty and bone loss in patients undergoing hemodialysis. This cross-sectional study included 214 (90 women, 124 men) Japanese outpatients undergoing maintenance hemodialysis three times per week, with a mean age of 67.1 years (women) and 66.8 years (men). Frailty was defined based on criteria set forth by the Cardiovascular Health Study (CHS)-19 (21.1%) women and 47 (37.9%) men were robust, 41 (45.6%) women and 43 (34.7%) men were pre-frail, and 30 (33.3%) women and 34 (27.4%) men were frail. For bone mass, quantitative ultrasound (QUS) parameters (speed of sound, broadband ultrasound attenuation, stiffness index) of the calcaneus were measured. The association between frailty and QUS parameters was determined separately for women and men using multivariate analysis of covariance (ANCOVA), with adjustments for clinical characteristics including age, body mass index, hemodialysis vintage, diabetes, current smoking, serum albumin, phosphate, corrected calcium, intact parathyroid hormone, and medication for CKD-MBD (vitamin D receptor activator, calcimimetics). ANCOVA revealed that all QUS parameters declined significantly with increasing levels of frailty in both sexes (P < 0.05). In conclusion, frailty (as defined by CHS criteria) should be considered a risk factor for bone loss in patients undergoing hemodialysis.

Utility of Regular Management of Physical Activity and Physical Function in Hemodialysis Patients.

BACKGROUND/AIMS: Several clinical practice guidelines recommend regular assessment of physical activity and physical function as part of routine care in hemodialysis patients. However, there is no clear evidence to support these recommendations. We investigated whether the proportion of attendance at a regular program for management of physical activity and physical function can predict all-cause mortality and cardiovascular events in hemodialysis patients. METHODS: This retrospective cohort study consisted of 266 hemodialysis patients participating in the management program at least once. Participants were tracked for 3 years after their first attendance at the management program to determine their attendance proportion. The main study outcomes included all-cause mortality and a composite of fatal and nonfatal cardiovascular events. RESULTS: Median patient age was 64.5 (interquartile range, 56.8 - 72.0) years, 45% were women, and the median time on hemodialysis was 35.5 (interquartile range, 12.0 - 114.3) months at baseline. Sixty-five patients died over a median follow-up of 79 months. The incidence of cardiovascular events was 60 over a median follow-up of 68 months. Even after adjusting for any of the prognostic models, participants who attended ≤ 75% of sessions (n = 140) had higher risks of mortality (hazard ratio (HR), 1.79; 95% confidence interval (CI): 1.00 - 3.36; P = 0.049) and cardiovascular events (HR, 1.84; 95% CI: 1.07 - 3.48; P = 0.03) than those attending > 75% of sessions (n = 126). CONCLUSION: Hemodialysis patients in whom physical activity and physical function could be assessed more regularly had better prognosis than those with only intermittent assessment.

Physical Activity Dose for Hemodialysis Patients: Where to Begin? Results from a Prospective Cohort Study.

OBJECTIVE: Greater physical activity is associated with lower risk of mortality in persons with kidney disease; however, little is known about the appropriate dose of physical activity among hemodialysis patients. Here detected the minimum level of habitual physical activity to help inform interventions aimed at improving outcomes in the dialysis population. DESIGN: The design was prospective cohort study. SUBJECTS: Clinically stable outpatients in a hemodialysis unit from October 2002 to March 2014 were assessed for their eligibility to be included in this 7-year prospective cohort study. We used the Youden index to determine the optimal cutoff points for physical activity. The prognostic effect of physical activity on survival was estimated by Cox proportional hazards regression analysis. The number of steps per nondialysis day was recorded by accelerometer at study entry. MAIN OUTCOME MEASURE: The main outcome measure was all-cause mortality. RESULTS: There were 282 participants who had a mean age of 65 ± 11 years and 45% were female. A total of 56 deaths occurred during the follow-up period (56 months [interquartile range: 29-84 months]). The cutoff value for the physical activity discriminating those at high risk of mortality was 3,752 steps. After adjustment for the effect of confounders, the hazard ratio in the group of <4,000 steps was 2.37 (95% confidence interval: 1.22-4.60, P = .01) compared with the others. CONCLUSIONS: Engaging in physical activity is associated with decreased mortality risk among hemodialysis patients. Our findings of a substantial mortality benefit among those who engage in at least 4,000 steps provide a basis for as a minimum initial recommendation kidney health providers can provide for mobility disability-free hemodialysis patients.

Combined Contribution of Reduced Functional Mobility, Muscle Weakness, and Low Serum Albumin in Prediction of All-Cause Mortality in Hemodialysis Patients: A Retrospective Cohort Study.

OBJECTIVES: The combined effects of reduced functional mobility, muscle weakness, and low serum albumin on mortality in hemodialysis patients have not been clarified. Here, we examined the associations of reduced functional mobility, muscle weakness, and low serum albumin-both alone and in combination-with all-cause mortality in hemodialysis patients. METHODS: A total of 490 patients treated between July 2010 and October 2016 were enrolled retrospectively in this study. The independent prognostic effect of the combination of reduced functional mobility, muscle weakness, and low serum albumin on survival was estimated by Cox proportional hazard regression analysis. We calculated the increases in predictive capacity by combining the associations of reduced functional mobility, muscle weakness, and low serum albumin in comparison to each component alone based on the receiver-operating characteristic curves, continuous net reclassification improvement (NRI), and integrated discrimination improvement (IDI). RESULTS: The final study population consisted of 314 hemodialysis patients, and 56 patients died during the 6.5-year follow-up period. The high Combined score group showed a significantly lower cumulative survival rate than the low Combined score group (hazard ratio, 3.30; 95% confidence interval, 1.59-6.87; P = .001). Both NRI and IDI suggested that the addition of Combined score to patient characteristics improved discrimination of patients at high risk of mortality (NRI, 0.038 95% CI: 0.096 - 0.064, P < .001 IDI, 0.029 95% CI: 0.004 - 0.055, P = .025). CONCLUSIONS: The combined assessment of reduced functional mobility, muscle weakness, and low serum albumin was associated with poorer prognosis in patients on hemodialysis. The results presented here indicated that the combination of reduced functional mobility, muscle weakness, and low serum albumin is useful for accurate prediction of prognosis in hemodialysis patients.

Changes in physical activity and risk of all-cause mortality in patients on maintence hemodialysis: a retrospective cohort study.

BACKGROUND: A previous cohort study indicated a significant association of lower baseline level of physical activity in hemodialysis patients with elevated risks of mortality. However, there have been no reports regarding the association between changes in physical activity over time and mortality in hemodialysis patients. This study was performed to examine the prognostic significance of physical activity changes in hemodialysis patients. METHODS: This retrospective cohort study was performed in 192 hemodialysis patients with a 7-year follow-up. The average number of steps taken per non-dialysis day was used as a measure of physical activity. Forty (20.8%) patients had died during the follow-up period. The percentage change in physical activity between baseline and 12 months was determined, and patients were divided into three categories according to changes in physical activity. A decrease or increase in physical activity > 30% was defined as becoming less or more active, respectively, while decrease or increase in physical activity < 30% were classified as stable. RESULTS: Forty seven (24.5%), 51 (26.6%), and 94 (49.0%) patients were classified as becoming less active, becoming more active, and stable, respectively. The hazard ratio on multivariate analysis in patients with decreased physical activity was 3.68 (95% confidence interval, 1.55-8.78; P < 0.01) compared to those with increased physical activity. CONCLUSIONS: Reductions in physical activity were significantly associated with poor prognosis independent of not only patient characteristics but also baseline physical activity. Therefore, improved prognosis in hemodialysis patients requires means of preventing a decline in physical activity over time.

Prevalence and relevance of cachexia as diagnosed by two different definitions in patients undergoing hemodialysis: A retrospective and exploratory study.

OBJECTIVE: Cachexia is present in various chronic diseases and is associated with decreased quality of life and increased risk of morbidity and mortality. However, evidence regarding the association of cachexia with prognosis in patients undergoing hemodialysis is limited. We assessed cachexia using two definitions and compared prevalence, functional impairment, and prognostic impact in patients undergoing hemodialysis. METHODS: We enrolled outpatients undergoing hemodialysis at two centers retrospectively. We assessed cachexia using the conventional cachexia (Evans' criteria) and the Asian Working Group for Cachexia (AWGC) criteria. The study examined all-cause mortality and functional status (Clinical Frailty Scale and short physical performance battery). We used Cox proportional hazards model to examine the association with prognosis, and logistic regression analysis to examine the association with functional impairment. RESULTS: Among 367 patients (mean age, 67 years; 63 % male), cachexia prevalence, as defined by Evans' criteria and AWGC, was 21.3 % and 35.2 %, respectively. Cachexia as defined by Evans' criteria was associated with an increased risk of all-cause mortality (hazard ratio [HR], 95 % confidence interval [CI]: 1.81, 1.02-3.23). Also, cachexia as defined by AWGC criteria showed suggestive association with increasing mortality (HR, 95 % CI: 1.56, 0.90-2.70). Similar results were seen between cachexia and functional impairment. CONCLUSIONS: Among patients on hemodialysis, cachexia was highly prevalent and was associated with poor prognosis and functional impairment. Detecting cachexia in earlier stages may be useful for risk stratification in this population.

Association between Physical Frailty and Sleep Disturbances among Patients on Hemodialysis: A Cross-Sectional Study.

INTRODUCTION: Among patients on hemodialysis (HD), physical frailty and sleep disturbances are not only common but also associated with adverse outcomes. The aim of this study was to evaluate the association between physical frailty and sleep disturbances in patients on HD. METHODS: This cross-sectional study was conducted from June 2017 to March 2021, with outpatients receiving HD 3 times a week at two dialysis facilities in Japan. Sleep disturbances were identified with the Athens Insomnia Scale (AIS). Physical frailty was defined using the Fried Frailty Phenotype. Patients were classified as "non-frailty (number of frailty components: 0-2)" or "frailty (3-5)." We examined the association of sleep disturbances with physical frailty and its components by performing a logistic regression analysis. RESULTS: We analyzed 360 patients (mean age 65.6 years; 62% men). Eighty-one patients (23%) were classified into the group with frailty, and the mean AIS score was 5.2 ± 4.2 points. After adjusting for clinical characteristics, increasing the AIS score per 1 point was associated with higher odds of physical frailty (odds ratio, 1.12; 95% confidence interval, 1.05-1.20; p < 0.01). As for the frailty components, exhaustion, low physical activity, and weak grip strength showed an association with sleep disturbances (all p < 0.05). CONCLUSIONS: Sleep disturbances were independently associated with physical frailty in patients on HD. Future studies are warranted to investigate the causality between physical frailty and sleep disturbances in this population.

Concomitant sarcopenia and undernutrition: Impact on clinical outcomes in patients undergoing hemodialysis.

BACKGROUND: Sarcopenia and undernutrition are crucial in the cycle of frailty in patients requiring hemodialysis therapy, and their deleterious clinical consequences are well documented. However, little attention has been directed towards examining their combined impact on clinical outcomes. OBJECTIVE: This study aimed to elucidate the effects of concomitant sarcopenia and undernutrition on clinical outcomes in patients undergoing hemodialysis. METHODS: This prospective cohort study recruited outpatients undergoing hemodialysis from four facilities. Sarcopenia was diagnosed according to the criteria of the Asian Working Group for Sarcopenia, 2019. Undernutrition was determined using the Geriatric Nutritional Risk Index, with a score of <92 classified as undernutrition. Patients were classified into four groups according to the presence or absence of sarcopenia and undernutrition. Cox proportional hazards analysis was used to assess the independent association between concomitant sarcopenia and undernutrition, all-cause mortality, and cardiovascular (CV) events after adjusting for baseline characteristics. RESULTS: We included 450 patients in this analysis. Of the 450 patients, 69 (15.3%) had concomitant sarcopenia and undernutrition. The mean follow-up period was 1067 days, and there were 61 deaths and 60 CV events. The cumulative survival rate was significantly lower in the sarcopenia with undernutrition group (P = 0.011). The overlap of sarcopenia and undernutrition was significantly associated with a risk of mortality (hazard ratio 2.10; 95% confidence interval 1.05-4.21; P = 0.037). However, no association was observed between the co-occurrence of sarcopenia and undernutrition and the risk of CV events. CONCLUSIONS: Concomitant sarcopenia and undernutrition were significantly associated with an increased mortality risk among patients undergoing hemodialysis. This finding reaffirms the importance of managing sarcopenia and undernutrition in patients undergoing hemodialysis in daily clinical practice.

Association of habitual physical activity measured by an accelerometer with high-density lipoprotein cholesterol levels in maintenance hemodialysis patients.

After confirming the relationship between high-density lipoprotein cholesterol (HDL-C) levels and mortality in hemodialysis patients for study 1, we investigated the effect of physical activity on their HDL-C levels for study 2. In study 1, 266 hemodialysis patients were monitored prospectively for five years, and Cox proportional hazard regression confirmed the contribution of HDL-C to mortality. In study 2, 116 patients were recruited after excluding those with severe comorbidities or requiring assistance from another person to walk. Baseline characteristics, such as demographic factors, physical constitution, primary kidney disease, comorbid conditions, smoking habits, drug use, and laboratory parameters, were collected from patient hospital records. An accelerometer measured physical activity as the number of steps per day over five consecutive days, and multiple regression evaluated the association between physical activity and HDL-C levels. Seventy-seven patients died during the follow-up period. In study 1, we confirmed that HDL-C level was a significant predictor of mortality (P = 0.03). After adjusting for patient characteristics in study 2, physical activity was independently associated with HDL-C levels (adjusted R (2) = 0.255; P = 0.005). In conclusion, physical inactivity was strongly associated with decreased HDL-C levels in hemodialysis patients.

Effects of anthropometric changes on hospitalization and mortality among patients on hemodialysis.

BACKGROUND: Low values for anthropometric indicators are risk factors for adverse clinical outcomes among patients on hemodialysis. Nonetheless, little is known about the association between the trajectory of anthropometric indicators and prognosis. We examined the association between a one-year change in anthropometric indicators and hospitalization and mortality in patients undergoing hemodialysis. METHODS: This retrospective cohort study collected data on five anthropometric indicators from patients undergoing maintenance hemodialysis: body mass index, mid-upper arm circumference, triceps skinfold, mid-arm muscle circumference, and calf circumference. We calculated their trajectories over one year. The outcomes were all-cause death and the number of all-cause hospitalizations. Negative binomial regressions were used to examine these associations. RESULTS: We included 283 patients (mean age, 67.3 years; 60.4% males). During the follow-up period (median, 2.7 years), 30 deaths and 200 hospitalizations occurred. Body mass index (incident rate ratio [IRR]: 0.87; 95% confidence interval [CI] 0.85-0.90), mid-upper arm circumference (IRR: 0.94; 95% CI 0.88-0.99), triceps skinfold (IRR: 0.92; 95% CI 0.84-0.99), and mid-arm muscle circumference (IRR: 0.99; 95% CI 0.98-0.99) increases over one year were associated with a lower risk of all-cause hospitalizations and death regardless of their value at any one point in time. However, the calf circumference trajectory was not associated with clinical events (IRR: 0.94; 95% CI 0.83-1.07). CONCLUSIONS: Body mass index, mid-upper arm circumference, triceps skinfold, and mid-arm muscle circumference trajectories were independently associated with clinical events. Routinely assessing these simple measures in clinical practice may provide additional prognostic information for managing patients undergoing hemodialysis.