Multiparametric renal function assessment in cirrhotic patients shows high prevalence of medically actionable changes in multiple modules.

AIM: Renal dysfunction is a common complication of cirrhosis, occurring either as part of multiorgan involvement in acute illness or secondary to advanced liver disease. To date, no study has comprehensively assessed multiple renal function parameters in hospitalized patients with cirrhosis through a multiparametric analysis of renal biochemistry markers. METHODS: We conducted a retrospective, observational study including all consecutive patients hospitalized with cirrhosis who underwent a 43-multiparametric renal function assessment between January 1, 2021, and June 30, 2023. RESULTS: All patients showed at least one of the following renal abnormalities: Kidney Disease: Improving Global Outcomes stage G2 or higher, sodium and/or chloride excretion fraction <1%, electrolyte-free water clearance <0.4 mL/min, or tubular maximum phosphate reabsorption capacity <0.8 mmol/L. The estimated glomerular filtration rate equations significantly overestimated the measured creatinine clearance with median differences of +14 mL/min/1.73 m2 (95% CI 6-29) and +9 mL/min/1.73 m2 (95% CI 2-15) for European Kidney Function Consortium equations, respectively. Notably, 54% and 39% of patients demonstrated estimated glomerular filtration rates exceeding 30% of the measured creatinine clearance when the Chronic Kidney Disease - Epidemiology Collaboration and European Kidney Function Consortium formulas were employed, respectively. Substantial discrepancies in Kidney Disease: Improving Global Outcomes stage assignments were observed between the estimated glomerular filtration rate- and measured creatinine clearance-based assessments. CONCLUSIONS: This study underscores the value of a multiparametric renal function assessment as a routine tool for evaluating renal function in patients with cirrhosis. A high prevalence of medically actionable renal abnormalities spanning multiple renal function modules, including alterations in glomerular function, salt and solute-free water excretion, and proximal tubule phosphate reabsorption, has been demonstrated in hospitalized patients with cirrhosis.

CT evaluation of bone fragility 2 years after bariatric surgery: an observational study.

INTRODUCTION: The objectives were to evaluate bone fragility on computed tomography (CT) in patients with obesity before and 2 years after bariatric surgery and to identify risk factors for a decrease in the scanographic bone attenuation coefficient of the first lumbar vertebra (SBAC-L1). MATERIALS AND METHODS: Patients with obesity who underwent bariatric surgery and CT before and 2 years (± 6 months) after bariatric surgery were included. SBAC-L1 was measured on CT with a fracture threshold at 145 HU. RESULTS: 78 patients were included, 85.9% women, mean age of 48.5 years (± 11.4); the mean BMI was 46.2 kg/m2 (± 7) before surgery and 29.8 kg/m2 (± 6.7) 2 years after surgery. There was a significant change in SBAC-L1 2 years after surgery (p = 0.037). In multivariate analysis, the risk factors for having an SBAC-L1 ≤ 145HU 2 years after bariatric surgery in those with an SBAC-L1 > 145HU before surgery were age and sex, with men and older patients having a higher risk (OR 32.6, CI 95% [1.86-568.77], and OR 0.85, CI 95% [0.74-0.98], respectively). CONCLUSION: SBAC-L1 was significantly lower two years after bariatric surgery. Men sex and older patients were the risk factors for having an SBAC-L1 below the fracture threshold 2 years after surgery.

Sugars and Gastrointestinal Health.

Sugar overconsumption is linked to a rise in the incidence of noncommunicable diseases such as diabetes, cardiovascular diseases, and cancer. This increased incidence is becoming a real public health problem that is more severe than infectious diseases, contributing to 35 million deaths annually. Excessive intake of free sugars can cause many of the same health problems as excessive alcohol consumption. Many recent international recommendations have expressed concerns about sugar consumption in Westernized societies, as current consumption levels represent quantities with no precedent during hominin evolution. In both adults and children, the World Health Organization strongly recommends reducing free sugar intake to <10% of total energy intake and suggests a further reduction to below 5%. Most studies have focused on the deleterious effects of Western dietary patterns on global health and the intestine. Whereas excessive dietary fat consumption is well studied, the specific impact of sugar is poorly described, while refined sugars represent up to 40% of caloric intake within industrialized countries. However, high sugar intake is associated with multiple tissue and organ dysfunctions. Both hyperglycemia and excessive sugar intake disrupt the intestinal barrier, thus increasing gut permeability and causing profound gut microbiota dysbiosis, which results in a disturbance in mucosal immunity that enhances infection susceptibility. This review aims to highlight the roles of different types of dietary carbohydrates and the consequences of their excessive intake for intestinal homeostasis.

Impact of nutritional status on heart failure mortality: a retrospective cohort study.

BACKGROUND: Chronic heart failure (CHF) is one of the most common causes of mortality in industrialized countries despite regular therapeutic advances. Numerous factors influence mortality in CHF patients, including nutritional status. It is known that malnutrition is a risk factor for mortality, whereas obesity may play a protective role, a phenomenon dubbed the "obesity paradox". However, the effect of the obesity-malnutrition association on mortality has not been previously studied for CHF. Our aim was to study the effect of nutritional status on overall mortality in CHF patients. METHODS: This retrospective, multicenter study was based on a French nationwide database (PMSI). We included all CHF patients aged ≥18 years admitted to all public and private hospitals between 2012 and 2016 and performed a survival analysis over 1 to 4 years of follow-up. RESULTS: Malnutrition led to a significant decrease in life expectancy in CHF patients when compared with normal nutritional status (aHR=1.16 [1.14-1.18] at one year and aHR=1.04 [1.004-1.08] at four years), obese, and obese-malnutrition groups. In contrast, obesity led to a significant increase in life expectancy compared with normal nutritional status (aHR=0.75 [0.73-0.78] at one year and aHR=0.85 [0.81-0.90] at four years), malnutrition, and obese-malnutrition groups. The mortality rate was similar in patients presenting both malnutrition and obesity and patients with normal nutritional status. CONCLUSIONS: Our results indicate that the protective effect on mortality observed in obese CHF patients seems to be linked to fat massincrease. Furthermore, malnourished obese and normal nutritional status patients had similar mortality rates. Further studies should be conducted to confirm our results and to explore the physiopathological mechanisms behind these effects.

Low resilience in severe obesity: marker of adverse childhood experiences and current psychological disorders.

PURPOSE: Psychological disorders, early-age psychological traumas and eating disorders may contribute to the development of severe obesity in vulnerable individuals. Resilience may serve a protective role against binge eating disorder or depression. The current study aimed to investigate the relationship between adverse childhood experiences (ACE), resilience, and current psychological disorders. It also examined whether resilience plays a protective role in this pathway in a cohort of patients seeking bariatric surgery. METHODS: Two hundred patients (153 women, 47 men) with severe obesity scheduled for bariatric surgery at the CHRU Nancy were included between September 2016 and April 2017. Participants completed the Resilience Scale for Adults (RSA) questionnaire and underwent a structured interview on ACE and current psychological disorders. RESULTS: Mean total RSA score was 5.16 ± 0.87. The most frequent ACE were emotional neglect (90.5%) and emotional abuse (61%); 96% reported at least one ACE; 67% presented at least one current psychological disorder, the most frequent being anxiety (36%) and BED (35%). The number of psychological disorders, cumulative ACE and age explained 19.5% of the variance in total RSA score (p < 0.0001; adjusted R2 = 0.19). The association of cumulative ACE and number of psychological disorders was mediated by resilience. CONCLUSION: Our findings suggest that resilience is a relevant component of the psychosocial phenotype of severe obesity in bariatric surgery candidates. Resilience seems to play a partly mediation role in the relationship between ACE and psychological disorders. Low resilience becomes a marker that underscores the necessity to examine in greater depth ACE and psychological disorders. LEVEL OF EVIDENCE: Level III, cohort analytic study.

Important issues in proposing autonomy training in home parenteral nutrition for short bowel syndrome patients: a qualitative insight from the patients' perspectives.

OBJECTIVES: The standard treatment for short bowel syndrome is home parenteral nutrition. Patients' strict adherence to protocols is essential to decrease the risk of complications such as infection or catheter thrombosis. Patient training can even result in complete autonomy in daily care. However, some patients cannot or do not want too much responsibility. However, doctors often encourage them to acquire these skills. Based on qualitative investigations with patients, we wanted to document issues of importance concerning perceptions of autonomy in daily care. METHODS: Semistructured interviews were conducted with 13 adult patients treated by home parenteral nutrition using a maximum variation sampling strategy. We proceeded to a thematic analysis following an inductive approach. RESULTS: After achieving clinical management of symptoms, a good quality of life is within the realm of possibility for short bowel syndrome patients with home parenteral nutrition. In this context, achieving autonomy in home parenteral nutrition could be a lever to sustain patients' quality of life by providing better life control. However, counterintuitively, not all patients aim at reducing constraints by reaching autonomy in home parenteral nutrition. First, they appreciate the social contact with the nurses, which is particularly true among patients who live alone. Second, they can feel safer with the nurse's visits. Regaining freedom was the main motivation for patients in the training program and the main benefit for those who were already autonomous. CONCLUSIONS: Medical teams should consider patients' health locus of control (internal or external) for disease management to support them concerning the choice of autonomy in daily care for parenteral nutrition.

DXA evaluation of bone fragility 2 years after bariatric surgery in patients with obesity.

Purpose: The primary objective was to evaluate bone fragility on dual X-ray absorptiometry (DXA) in patients with obesity before and 2 years after bariatric surgery. The secondary objective was to identify risk factors for the development of a bone mineral density ≤ -2 SD at 2 years. Methods: This descriptive study included patients with obesity who underwent DXA before and 2 years (±6 months) after bariatric surgery. The BMD and the T-score were assessed at the lumbar spine, femoral neck and total hip. Data on body composition on DXA were also collected. The diagnosis of osteoporosis was retained for a T-score ≤ - 2.5 SD at any measured location. Osteopenia, or low bone mass, was defined by -2.5 SD < T-score ≤ -1 SD. Results: Among the 675 included patients, 77.8 % were women, with a mean age of 49.5 years (±11.1). After bariatric surgery, there were significantly more patients with osteoporosis: 3.6 % vs. 0.9 % (p = 0.0001). Multivariate analysis revealed that the risk factors for developing a bone mineral density ≤ -2 SD 2 years after bariatric surgery in patients with normal BMD before surgery were age and lower lean and fat mass before the surgery (OR = 1.07, 95%CI = [1.03-1.12], OR = 0.83, 95%CI = [0.77-0.91], OR = 1.08, 95%CI = [1.02-1.15], respectively). Conclusion: There was a significantly higher prevalence of osteoporosis and low bone mass 2 years after bariatric surgery. Older age and lower lean and fat mass at baseline were risk factors for the development of a BMD ≤ -2SD at 2 years.

[Update of guidelines of the AFSOS, SFRO, SFH, SFNCM, SFCE, GFRP for the management of radio-induced nausea and vomiting]. / Actualisation du référentiel AFSOS, SFRO, SFH, SFNCM, SFCE, GFRP : nausées et vomissements radio-induits.

BACKGROUND: Radiation-induced nausea and vomiting have mutiple clinical consequences: delay or refusal of irradiation (decreased antineoplastic efficacy of irradiation), altered quality of life, dehydration, malnutrition, interruption of treatment, decompensation of comorbidities and aspiration. These guidelines aim at defining good clinical practices for management of radiation-induced nausea and vomiting (RINV). METHODS: AFSOS, SFRO, SFH, SFNEP, SFCE and GFRP applied an expert consensus methodology to propose updated guidelines. RESULTS: RINV are underdiagnosed and undertreated. Assessment of the emetogenic risk depends on two main factors: 1) the irradiated anatomical localization and 2) the associated concomitant chemotherapy. In case of exclusive radiotherapy, primary antiemetic prophylaxis depends on the emetogenic risk of irradiated anatomical localization. Primary antiemetic prophylaxis is initiated at the onset of irradiation and continues until 24h after the end of the irradiation. In the case of concomitant radiochemotherapy, the emetogenic risk is generally higher for chemotherapy and the primary antiemetic prophylaxis corresponds to that of chemo-induced nausea and vomiting. In the case of persistence of these symptoms, subject to a well-conducted treatment, a rigorous diagnostic procedure must be carried out before being attributed to radiotherapy and precise evaluation of their impact. Remedial treatments are less well codified. CONCLUSION: It is essential to know and good management practices for radiation-induced nausea and vomiting.

Assessment of dynapenia and undernutrition in primary care, a systematic screening study in community medicine.

Screening for sarcopenia is a growing public health issue since associated with functional alterations and an increase in morbidity and mortality. OBJECTIVE: To analyze the prevalence of decreased muscle strength (dynapenia) in patients aged 18 to 74 in community medicine, as measured in the general practitioner's office, and to assess the prevalence of undernutrition in this population. METHOD: Muscle strength was measured with a Hand Grip (HG) dynamometer according to European recommended thresholds and French guidelines. Malnutrition was defined according to the GLIM criteria. RESULTS: Of 341 patients, 303 were evaluated (89%): mean age was 47.8 ± 17.4 years, including 51.2% women, 103 with an acute disease (AD) and 200 with a chronic disease (CD). 23.5% were below the 10th percentile threshold in the CD group and 19.4% in the AD group. For these patients, muscle age, evaluated on the median values for age, was higher by 39.3 ± 15.2 years for men and by 41.5 ± 13.6 years for women. Maximum HG values were significantly correlated with changes in International Physical Activity Questionnaire (IPAQ) score (F = 10.22; p = 0.0017) and weight changes (%) (F = 5.30; p = 0.0227) in women only, regardless of age, BMI, disease, professional status or type of work (manual or not); 19.1% suffered from malnutrition (10.9% Stage 1 and 8.3% Stage 2), with 20.0% in the CD group and 17.4% in the AD group. CONCLUSION: This study highlights the feasibility of screening for sarcopenia in primary care community medicine. The prevalence of dynapenia in the studied population (nearly one in 5 patients) and the observed higher-than-expected undernutrition (17.5%) justify their screening for appropriate management care. CLINICAL TRIAL REGISTRATION: NCT04451694; referred to as "observational research", "non-interventional", or « non-RIPH ¼.

Food avoidance and fasting in patients with inflammatory bowel disease: Experience from the Nancy IBD nutrition clinic.

BACKGROUND: Patients with inflammatory bowel disease (IBD) consider that their diet is important for controlling symptoms and frequently ask their physician for additional guidance on this matter. The objectives of the present study of patients with IBD were to characterize the prevalence of exclusion diets and fasting and to identify associated risk factors. METHODS: Using an anonymous questionnaire, we screened patients attending our IBD nutrition clinic between November 2021 and April 2022 for exclusion diets. The avoidance of a food category completely was defined as total exclusion and avoidance most of the time was defined as partial exclusion. We also asked patients whether they fasted totally, intermittently, or partially. RESULT: A total of 434 patients with IBD were included. On inclusion, 159 patients (36.6%) totally excluded at least one food category and 271 (62.4%) partially excluded at least one food. Intermittent, total, or partial fasting was reported by 30.8% of the patients. Disease activity (odds ratio (OR) [95% confidence interval] = 1.7 [1.1-2.7], p = 0.0130) and treatment with a small-molecule or an investigational drug (OR = 4.0 [1.5-10.6], p = 0.0059) were independently associated with an exclusion diet. A history of stenosis (OR = 2.0 [1.2-3.2], p = 0.0063) and active disease (OR = 1.9 [1.2-3.1], p = 0.0059) were associated with fasting. CONCLUSION: In this real-world study, approximately two-thirds of our patients with IBD reported the partial or total exclusion of at least one food category and one third reported fasting. A systematic nutritional evaluation might improve clinical management and quality of care for patients with IBD both Crohn's disease and ulcerative colitis.

Effectiveness of salvage catheters in home parenteral nutrition: A single-center study and systematic literature review.

BACKGROUND & AIMS: There are sparse data regarding the rate of catheter salvage and long-term effectiveness of antibiotic lock treatment outcome after central line-associated bloodstream infections (CLABSI). Objectives were to analyze the effectiveness of central venous catheter (CVC) rescue strategy and its impact on catheter lifespan. Secondary objective included effectiveness of taurolidine+4% citrate in primary prevention, compared to a secondary prevention strategy, by analyzing infection incidence during two successive periods. METHOD: Real-life 5-year observational study assessing CLABSI occurrence and CVC salvage outcomes in adult patients requiring Home Parenteral Nutrition (HPN) managed in a single-center Intestinal Failure Unit. RESULTS: Over the 5-year period, there were 106 confirmed infections (63/143 patients (44%)). Infection incidence was 0.92/1000 catheter-days. Incidence was 1.02/1000 catheter-days during the taurolidine+4% citrate period while lower at 0.84/1000 catheter-days (p = 0.034) during the systematic taurolidine lock period. Of the total number of infections, 89 CVCs were immediately removed and 17 were salvaged. The success rate of catheter salvage with antibiotic lock was 82.4%, with 53% remaining CLABSI-free at one year. The salvage strategy extended catheter lifespan by a median 165 days (IQR 50-214). However, the rate of new infection was significantly higher in instances of salvage (71.4%) vs. removal (36%). Parenteral Nutrition (PN) ≥12 months (p = 0.002), PN (vs. hydroelectrolytic support) (p = 0.028) and self-management by patients (p = 0.049) were independent risk factors of CLABSI. CONCLUSION: Catheter salvage appears to be an effective long-term strategy with >50% of CVCs remaining CLABSI-free at one year and a prolonged catheter life, although may expose to a more frequent and earlier infection recurrence. CLINICAL TRIAL REGISTRATION: Cohort approved by the French CNIL (National Committee for Data Protection, authorization number CNIL 2015-25). referred to as "observational research", "non-interventional", or « non-RIPH ¼.

Prevalence of Osteoporosis Assessed by DXA and/or CT in Severe Obese Patients.

The primary objective was to evaluate bone fragility prevalence on dual X-ray absorptiometry (DXA) and computed tomography (CT) in patients with severe obesity. The secondary objective was to evaluate the risk factors for bone fragility. This monocentric study was conducted in patients with grade 2 and 3 obesity. Bone mineral density (BMD) and T-score were studied on DXA, and the scanographic bone attenuation coefficient of L1 (SBAC-L1) was measured on CT. Among the 1386 patients included, 1013 had undergone both DXA and CT within less than 2 years. The mean age was 48.4 (±11.4) years, 77.6% were women, and the mean BMI was 45.6 (±6.7) kg/m². Eight patients (0.8%) had osteoporosis in at least one site. The mean SBAC-L1 was 192.3 (±52.4) HU; 163 patients (16.1%) were under the threshold of 145 HU. Older age (OR[CI95] = 1.1 [1.08-1.16]), lower BMD on the femoral neck and spine (OR[CI95] = 0.04[0.005-0.33] and OR[CI95] = 0.001[0.0001-0.008], respectively), and higher lean mass (OR[CI95] = 1.1 [1.03-1.13]) were significantly associated with an SBAC-L1 ≤ 145 HU in multivariate analysis. Approximately 16% of patients with severe obesity were under the SBAC-L1 threshold, while less than 1% were classified as osteoporotic on DXA.

Taste of Fat and Obesity: Different Hypotheses and Our Point of View.

Obesity results from a temporary or prolonged positive energy balance due to an alteration in the homeostatic feedback of energy balance. Food, with its discriminative and hedonic qualities, is a key element of reward-based energy intake. An alteration in the brain reward system for highly palatable energy-rich foods, comprised of fat and carbohydrates, could be one of the main factors involved in the development of obesity by increasing the attractiveness and consumption of fat-rich foods. This would induce, in turn, a decrease in the taste of fat. A better understanding of the altered reward system in obesity may open the door to a new era for the diagnosis, management and treatment of this disease.

[Nutritionnal complications and patients follow-up after bariatric surgery]. / Complications nutritionnelles de la chirurgie bariatrique et surveillance des patients opérés.

NUTRITIONNAL COMPLICATIONS AND PATIENTS FOLLOW-UP AFTER BARIATRIC SURGERYBariatric surgery is the most consistently effective method for sustained weight reduction and can result in a substantial improvement in overall survival in patients with severe obesity. Complex mechanisms underlying metabolic benefits could also drive preventable, but potentially life-threatening, long-term nutritional complications. Consequently, physicians should be familiar with the lifelong monitoring of patients after bariatric surgery and the potential long-term complications in this paradoxical situation where the long-awaited weight loss can lead to severe nutritional complications.

COMPLICATIONS NUTRITIONNELLES DE LA CHIRURGIE BARIATRIQUE ET SURVEILLANCE DES PATIENTS OPÉRÉS La chirurgie bariatrique est le traitement le plus efficace en termes de perte pondérale durable et de réduction de la morbi-mortalité en cas d'obésité sévère. Cependant, les modifications profondes de la physiologie digestive qui sous-tendent ces bénéfices métaboliques peuvent entraîner des carences nutritionnelles qui peuvent induire des complications sévères et irréversibles. La population des patients bariatriques étant en constante augmentation, tout médecin peut être amené à prendre un charge un patient opéré. Il devrait donc connaître les principes de la surveillance à vie et les possibles complications à long terme dans cette situation si paradoxale où la perte de poids tant attendue peut aussi s'associer à des carences potentiellement sévères.

Low-frequency Coding Variants Associated With Body Mass Index Affect the Success of Bariatric Surgery.

CONTEXT: A recent study identified 14 low-frequency coding variants associated with body mass index (BMI) in 718 734 individuals predominantly of European ancestry. OBJECTIVE: We investigated the association of 2 genetic scores (GS) with i) the risk of severe/morbid obesity, ii) BMI variation before weight-loss intervention, iii) BMI change in response to an 18-month lifestyle/behavioral intervention program, and iv) BMI change up to 24 months after bariatric surgery. METHODS: The 14 low-frequency coding variants were genotyped or sequenced in 342 French adults with severe/morbid obesity and 574 French adult controls from the general population. We built risk and protective GS based on 6 BMI-increasing and 5 BMI-decreasing low-frequency coding variants that were polymorphic in our study. RESULTS: While the risk GS was not associated with severe/morbid obesity status, BMI-decreasing low-frequency coding variants were significantly less frequent in patients with severe/morbid obesity than in French adults from the general population. Neither the risk nor the protective GS was associated with BMI before intervention in patients with severe/morbid obesity, nor did they affect BMI change in response to a lifestyle/behavioral modification program. The protective GS was associated with a greater BMI decrease following bariatric surgery. The risk and protective GS were associated with a higher and lower risk of BMI regain after bariatric surgery. CONCLUSION: Our data indicate that in populations of European descent, low-frequency coding variants associated with BMI in the general population also affect the outcomes of bariatric surgery in patients with severe/morbid obesity.

Management of Central Venous Catheters in Children and Adults on Home Parenteral Nutrition: A French Survey of Current Practice.

Although central venous catheter (CVC)-related thrombosis (CRT) is a severe complication of home parenteral nutrition (HPN), the amount and quality of data in the diagnosis and management of CRT remain low. We aimed to describe current practices regarding CVC management in French adult and pediatric HPN centers, with a focus on CVC obstruction and CRT. Current practices regarding CVC management in patients on HPN were collected by an online-based cross-sectional survey sent to expert physicians of French HPN centers. We compared these practices to published guidelines and searched for differences between pediatric and adult HPN centers' practices. Finally, we examined the heterogeneity of practices in both pediatric and adult HPN centers. The survey was completed by 34 centers, including 21 pediatric and 13 adult centers. We found a considerable heterogeneity, especially in the responses of pediatric centers. On some points, the centers' responses differed from the current guidelines. We also found significant differences between practices in adult and pediatric centers. We conclude that the management of CVC and CRT in patients on HPN is a serious and complex situation for which there is significant heterogeneity between HPN centers. These findings highlight the need for more well-designed clinical trials in this field.