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.

Wunderlich syndrome during antiplatelet drug therapy.

AIMS: Spontaneous hemorrhage in the kidney, also known as Wunderlich Syndrome, is a rare clinical problem. The most common cause of spontaneous renal hemorrhage is tumor. Other causes are rupture of a renal cyst, vasculitis, hydronephrosis, preeclampsia, and kidney infections. CASE HISTORY: A 67-year-old man was admitted complaining left flank colic pain. A contrast CT scan showed the presence of a subcapsular hematoma of the left kidney extending from the upper to the lower pole. He had no history of trauma and immunological screening tests for vasculitis were normal. His current therapy included acetylsalicylic acid (100 mg/daily) and lisinopril (20 mg/ daily). The patient was hospitalized for 4 days and his circulatory state remained stable. Nine months later an ultrasound examination showed complete resolution of the hematoma. One year later the patient was admitted again because of a spontaneous right calf hematoma and a thoroughly investigation of his coagulation pattern was carried out. Laboratory finding revealed a platelet defect, as the number of adenine nucleotides and other marker related to platelet activation were increased: ADP 1 mcM lack 2 masculine wave, ADP 2 mcM lack 2 masculine wave, Adrenalina 5 mcM lack 2 masculine wave, Adrenalina 10 mcM lack 2 masculine wave. Platelet activation markers: Gp53 in lysosomal membrane 0.48 Dpar (0 - 0.26). CONCLUSION: Our case describes the recurrence of spontaneous hemorrhages (perirenal and intramuscular hematoma) as a result of an underlying platelet aggregation defect worsened by administration of acetylsalicylic acid. In patients on antiplatelet treatment with a history of excessive bleeding a thorough investigation of coagulation status appears beneficial.

[Dialysis and quality of life: identifying and managing critical aspects]. / Terapia dialitica e qualitá di vita: individuare le aree di criticitá per orientare alla metodica più idonea.

Living with a chronic disease is for the patient a ''disease experience'' that also affects the psychosocial sphere and has a negative impact on perceived quality of life. To estimate the effect of dialysis on the perceived quality of life and to identify by means of a specific questionnaire the aspects that are compromised most. From our results it emerged that the examined patients had a sufficiently good total perception of quality of life, even though about 30% of the patients reported critical aspects related to daily life and, in some age groups, also related to dialysis method. This study confirms the importance of developing educational and supportive predialysis programs in order to identify and reduce the critical aspects.

Gastric pH, sevelamer hydrochloride and omeprazole.

AIMS: Sevelamer hydrochloride is a polymer containing multiple amines (40% amine hydrochloride) separated by one carbon from the polymer backbone, and it is not absorbed by the intestine. These amines are partially protonated and interact with phosphate molecules through ionic and hydrogen bonding, therefore reducing phosphate absorption and lowering serum phosphate concentration. Alterations of gastric pH, in particular excessive alkalinization, could interfere with sevelamer phosphate binding capacity. CASE HISTORY: A 30-year-old dialysis patient affected by secondary hyperparathyroidism started sevelamer treatment, 4.8 g/day, with a basal serum phosphate of 6.9 mg/dl. The patient was also treated with omeprazole (20 mg/day) because of chronic gastritis. Phosphate levels normalized (4.2 mg/dl), but after four months of follow-up serum phosphate unexpectedly increased to 7.2 mg/dl. We found out that in the same period she had autonomously increased the dosage of omeprazole to 80 mg/day, due to worsening of dyspepsia. Gastric pH measurement showed a median level of 4.1, rather than the normal values of 1 - 2, indicating excessive pharmacological alkalinization. When omeprazole was reduced to the correct dose of 20 mg/day, we observed a rapid decrease of phosphate levels. CONCLUSION: This case report highlights the influence of gastric pH on sevelamer phosphate binding capacity. The high dose of omeprazole and the consequent excessive increase in gastric pH was probably responsible for a decreased phosphate binding capacity of sevelamer. When patients taking appropriate doses of sevelamer do not respond to treatment, a potential interaction with drugs determining an increase of gastric pH should be considered.