Factors associated with variability in skeletal muscle radiodensity in patients with metastatic cancer.

OBJECTIVES: This study aimed to explore factors associated with skeletal muscle radiodensity (SMD) variability in patients with metastatic cancer. METHODS: This study included 393 patients (median age 61 y, 70% women) who had computed tomography (CT) scans within 30 days of inclusion in the study. SMD was evaluated from CT by averaging the Hounsfield unit value of the total muscle area. Skeletal muscle index (SMI), visceral adipose tissue index (VATI), subcutaneous adipose tissue index (SATI), and total adipose tissue index (TATI) were also assessed by CT. Additionally, age, sex, race/skin color, disease characteristics, comorbidities, inflammatory markers, handgrip strength (HGS), and body mass index (BMI) were recorded and evaluated in the linear regression analysis to identify factors associated with SMD variability. RESULTS: Multivariate explanatory models having SMD as an independent variable were performed and included BMI (model 1, r2 = 0.699), TATI (model 2, r2 = 0.712) or VATI and SATI (model 3, r2 = 0.706) in addition to age, race/skin color, tumor site, kidney disease, serum albumin, HGS, and SMI as dependent variables. For all models, lower SMD was associated with higher age, BMI, and adiposity measurements, kidney disease, White race/skin color, and lower serum albumin, HGS, and SMI. The primary tumor site also contributed to changes in SMD in all models, specifically those located in the gastrointestinal tract, gynecologic, and bone and connective tissue. CONCLUSION: In this group of patients with metastatic cancer, lower SMD was associated with older age, White race/skin color, and an overall worse clinical condition.

From ultra-processed foods towards healthy eating for CKD patients: a proposal of educational infographics.

Ultraprocessed food (UPF) is defined as industrialized, packaged and ready-to-eat food produced on a large scale, using sophisticated industrial machinery. Examples of UPFs include salty and sweet snacks, industrialized biscuits and packaged meals, processed meats and sugary drinks. Ultraprocessed food has a long-shelf life, is highly palatable, microbiologically safe, affordable and most of all, easy to consume. For these reasons, its consumption has been increasing worldwide, and is replacing healthy homemade meals. The main concern of this dietary shift is that UPFs come with the addition of salt, sugar, unhealthy fats, and several additives and taste enhancers that contain, among other substances, relevant quantities of potassium, phosphate and sodium. A large proportion of UPF in the diet may carry risks for patients with chronic kidney disease (CKD) since it can worsen blood pressure and glycemic control, and lead to constipation, hyperkalemia and hyperphosphatemia. Acknowledging the importance of UPF in kidney health implies integrating nutritional counseling with information on UPFs, and specific educational material can be helpful for patients, caregivers, and also for health care providers. We developed a set of 3 infographics dedicated to CKD patients, with information on how to identify UPFs, reasons for decreasing consumption, how to compose a healthy CKD plate and tips for reading food labels in supermarkets and grocery shops. We hope that this material can be useful in CKD outpatient clinics and dialysis centers as well as in general practitioners' offices, caring for early stage CKD.

Design and methodology of the SARCopenia trajectories and associations with adverse clinical outcomes in patients on HemoDialysis: the SARC-HD study.

BACKGROUND: Sarcopenia has been associated with adverse outcomes in patients with chronic kidney disease (CKD), particularly in those undergoing hemodialysis (HD). However, the trajectories across sarcopenia stages, their determinants, and associations with adverse clinical outcomes have yet to be comprehensively examined. METHODS: The SARC-HD is a multicenter, observational prospective cohort study designed to comprehensively investigate sarcopenia in patients on HD. Eligibility criteria include adult patients undergoing HD for ≥ 3 months. The primary objective is to investigate the trajectories of sarcopenia stages and their potential determinants. Secondary objectives include evaluating the association between sarcopenia and adverse clinical outcomes (i.e., falls, hospitalization, and mortality). Sarcopenia risk will be assessed by the SARC-F and SARC-CalF questionnaire. Sarcopenia traits (i.e., low muscle strength, low muscle mass, and low physical performance) will be defined according to the revised European Working Group on Sarcopenia in Older People and will be assessed at baseline and after 12 follow-up months. Patients will be followed-up at 3 monthly intervals for adverse clinical outcomes during 24 months. DISCUSSION: Collectively, we expect to provide relevant clinical findings for healthcare professionals from nephrology on the association between sarcopenia screening tools (i.e., SARC-F and SARC-CalF) with objective sarcopenia measurements, as well as to investigate predictors of trajectories across sarcopenia stages, and the impact of sarcopenia on adverse clinical outcomes. Hence, our ambition is that the data acquired from SARC-HD study will provide novel and valuable evidence to support an adequate screening and management of sarcopenia in patients on HD.

Nutritional status and the risk of malnutrition in older adults with chronic kidney disease - implications for low protein intake and nutritional care: A critical review endorsed by ERN-ERA and ESPEN.

Increased life expectancy is posing unprecedented challenges to healthcare systems worldwide. These include a sharp increase in the prevalence of chronic kidney disease (CKD) and of impaired nutritional status with malnutrition-protein-energy wasting (PEW) that portends worse clinical outcomes, including reduced survival. In older adults with CKD, a nutritional dilemma occurs when indications from geriatric nutritional guidelines to maintain the protein intake above 1.0 g/kg/day to prevent malnutrition need to be adapted to the indications from nephrology guidelines, to reduce protein intake in order to prevent or slow CKD progression and improve metabolic abnormalities. To address these issues, the European Society for Clinical Nutrition and Metabolism (ESPEN) and the European Renal Nutrition group of the European Renal Association (ERN-ERA) have prepared this conjoint critical review paper, whose objective is to summarize key concepts related to prevention and treatment of both CKD progression and impaired nutritional status using dietary approaches, and to provide guidance on how to define optimal protein and energy intake in older adults with differing severity of CKD. Overall, the authors support careful assessment to identify the most urgent clinical challenge and the consequent treatment priority. The presence of malnutrition-protein-energy wasting (PEW) suggests the need to avoid or postpone protein restriction, particularly in the presence of stable kidney function and considering the patient's preferences and quality of life. CKD progression and advanced CKD stage support prioritization of protein restriction in the presence of a good nutritional status. Individual risk-benefit assessment and appropriate nutritional monitoring should guide the decision-making process. Higher awareness of the challenges of nutritional care in older adult patients with CKD is needed to improve care and outcomes. Research is advocated to support evidence-based recommendations, which we still lack for this increasingly large patient subgroup.

The association between low skeletal muscle mass and low skeletal muscle radiodensity with functional impairment, systemic inflammation, and reduced survival in patients with incurable cancer.

BACKGROUND AND AIMS: Factors associated with the concomitant occurrence of low muscle mass and low muscle radiodensity are unclear. This study investigated whether different skeletal muscle phenotypes are associated with functional impairment, serum inflammatory markers, and survival in patients with incurable cancer. METHODS: Three hundred and twenty-six patients (median age, 60 years; 67.5% female) who had abdominal or pelvic computed tomography (CT) scans up to 30 days before the initial assessment were enrolled in the study. CT images were used for the assessment of skeletal muscle index (SMI) and skeletal muscle radiodensity (SMD). Optimal stratification analysis was used to derive cohort-specific cutoff points to define SMI and SMD groups with a higher risk for mortality (SMI, males <45.0 cm2 /m2 and females <44.0 cm2 /m2 ; SMD, males <34 Hounsfield units [HU] and females <30 HU). Based on these cutoffs, participants were classified into four phenotypes: low-risk SMI + low-risk SMD, high-risk SMI + low-risk SMD, low-risk SMI + high-risk SMD, and high-risk SMI + high-risk SMD. RESULTS: Phenotypes with high-risk SMI or high-risk SMD, especially when combined, were associated with low handgrip strength, poor performance status, higher C-reactive protein, and lower serum albumin levels. The phenotypes with high-risk SMD, regardless of low-risk SMI (hazard ratio [HR], 1.74; 95% CI, 1.05-2.88) or high-risk SMI (HR, 1.99; 95% CI, 1.29-3.05) were associated with higher 90 days' mortality risk. CONCLUSION: In patients with incurable cancer, phenotype groups with high-risk SMI and high-risk SMD, particularly when combined, were associated with worse functional impairment and inflammation. Moreover, high-risk SMD was associated with increased mortality risk.

Transcription factor NRF2 as potential therapeutic target for preventing muscle wasting in aging chronic kidney disease patients.

Increased muscle protein catabolism leading to muscle wasting is a prominent feature of the syndrome of protein-energy wasting (PEW) in patients with chronic kidney disease (CKD). PEW and muscle wasting are induced by factors such as inflammation, oxidative stress and metabolic acidosis that activate the ubiquitin-proteasome system, the main regulatory mechanism of skeletal muscle degradation. Whether deficiency of nuclear factor erythroid 2-related factor 2 (NRF2), which regulates expression of antioxidant proteins protecting against oxidative damage triggered by inflammation, may exacerbate PEW has yet to be examined in aging patients with CKD. This review focuses on the hypothesis that NRF2 is involved in the maintenance of muscle mass and explores whether sustained activation of NRF2 by non-pharmacological interventions using nutraceutical activators to improve redox homeostasis could be a plausible strategy to prevent skeletal muscle disorders, including muscle wasting, sarcopenia and frailty associated with PEW in aging CKD patients.

Low hand grip strength is associated with worse functional capacity and higher inflammation in people receiving maintenance hemodialysis.

OBJECTIVES: To evaluate the associations of hand grip strength (HGS) with body composition, functional capacity, muscle quality, and inflammatory markers in people receiving maintenance hemodialysis. METHODS: This is a cross-sectional study in people receiving maintenance hemodialysis. HGS was measured by hydraulic dynamometer on the upper limb without fistula. Participants were stratified into low or adequate HGS, based on population-specific cutoff points. Body composition was assessed by dual-energy X-ray absorptiometry, and functional capacity by the Short Physical Performance Battery and timed up-and-go tests. In addition, serum creatinine, interleukin-6 (IL-6), IL-10, tumor necrosis factor-α, and ultra-sensitive C-reactive protein (us-CRP) were measured before the dialysis session. RESULTS: A total of 67 participants (41.8% women, 58.2% male; ages 54.1 ± 11.7 y) were included. Those with low HGS had worse functional capacity than those with adequate HGS (timed up-and-go test, 10.7 ± 1.0 versus 8.5 ± 0.8 sec, respectively; P < 0.001). IL-6 and us-CRP were higher in those with low HGS than their counterparts (IL-6: 2.7 ± 0.3 versus 1.9 pg/mL, P = 0.03; us-CRP: 14.8 ± 3.0 versus 4.7 ± 1.9 mg/L, P = 0.03). Multiple linear regression analysis showed that appendicular lean mass, us-CRP, age, sex, and seven-point subjective global assessment score were associated with HGS. CONCLUSIONS: Participants with low HGS showed higher inflammation and lower functional capacity. In addition to muscle mass, inflammation and nutritional status also affect HGS..

Phase angle as a marker for muscle abnormalities and function in patients with colorectal cancer.

BACKGROUND AND AIMS: Considering the applicability of phase angle (PhA) as a marker of muscle mass and function, we aimed to investigate whether PhA is a predictor of muscle abnormalities and function in patients with cancer. METHODS: In a sample of patients with colorectal cancer (CRC), PhA was obtained from measurements of resistance and reactance from bioelectrical impedance analysis. Computerized tomography imaging at the third lumbar vertebra was used to evaluate muscle abnormalities by quantifying skeletal muscle index (SMI) and skeletal muscle radiodensity (SMD). Muscle function was assessed by handgrip strength (HGS) and gait speed (GS). RESULTS: This cross-sectional study included 190 participants (X±SD), mean age 60.5 ± 11.3 years; 57% men; 78% had cancer stages III to IV. PhA was highly correlated with SMI (r = 0.70) and moderately correlated with HGS (r = 0.54). PhA explained 48% of the SMI variability (R2 = 0.485), 21% of the SMD variability (R2 = 0.214), 26% of HGS (R2 = 0.261) and 9.8% of GS (R2 = 0.098). In the multivariate model adjusted for age, sex, body mass index, performance status, comorbidities and cancer stage, 1-degree decrease in PhA was associated with low SMI (Odds Ratio (OR) = 6.56, 95% CI: 2.90-14.86) and with low SMI and HGS combined (OR = 11.10, 95% CI: 2.61-47.25). In addition, Receiving Operating Characteristics curve analysis showed that PhA had a good diagnostic accuracy for detecting low SMI, low SMI and SMD combined, low SMD and HGS and low SMI and HGS combined (AUC = 0.81, 95% CI: 0.74-0.88; AUC = 0.88, 95% CI: 0.81-0.95; AUC = 0.80, 95% CI: 0.70-0.91; AUC = 0.82, 95% CI: 0.74-0.89; respectively). CONCLUSIONS: PhA was a predictor of muscle abnormalities and function and had a good diagnostic accuracy for detecting low muscle mass, low muscle mass and radiodensity, low muscle radiodensity and strength, and low muscle mass and strength in patients with CRC.

Frailty is associated with myosteatosis in obese patients with colorectal cancer.

BACKGROUND & AIMS: We aimed to explore the determinants of muscle fat infiltration and to investigate whether myosteatosis, assessed as muscle fat infiltration percentage (%MFI) and muscle attenuation from computed tomography (CT), is associated with frailty in a group of patients with colorectal cancer (CRC). METHODS: Cross sectional study including CRC patients. CT scan of the third lumbar vertebra was used to quantify body composition and the degree of %MFI (reported as percentage of fat within muscle area). Frailty was defined by Fried et al. (2001) as the presence of more than 3 criteria: unintentional weight loss, self-reported exhaustion, weakness (low handgrip strength), slow walking speed (gait speed) and low physical activity. Obesity was defined according to sex-and-age-specific body fat percentage (%BF) cutoff. RESULTS: A sample of 184 patients (age 60 ± 11 years; 58% men; 29% of patients with frailty) was studied. The sample was divided according to tertiles of MFI% (1st tertile 0 to 2.89%, n = 60; 2nd tertile ≥ 3.9-8.19%, n = 64; 3rd tertile ≥ 8.2-26%, n = 60). Age, females, body mass index, %BF, subcutaneous and visceral adipose tissue and the proportion of patients with frailty were significantly higher in the 3rd %MFI tertile. Phase angle and muscle attenuation were significantly lower in the 3rd %MFI tertile. The determinants of %MFI (r2 = 0.49), which was log transformed due to its normal distribution, were %BF (ß = 0.54; eß = 1.72; 95% CI: 0.032 to 0.051; P < 0.01), age (ß = 0.34; eß = 1.40; 95% CI: 0.016 to 0.032; P < 0.01) and gait speed (ß = -0.12; eß = 0.87; 95% CI: -0.84 to -0.001; P = 0.049). In addition, in obese patients (n = 74) presenting 4 or 5 frailty criteria increased the chance of having higher %MFI and lower muscle attenuation, after adjustment for sex, age and comorbidities when compared to none or 1 criteria. CONCLUSIONS: In a sample of CRC patients, %BF and gait speed were the determinants of %MFI. In addition, markers of myostetatosis were associated with frailty in the obese patients.

Comparative Analysis Between Computed Tomography and Surrogate Methods to Detect Low Muscle Mass Among Colorectal Cancer Patients.

BACKGROUND: We aimed to evaluate the agreement between computed tomography (CT) and surrogate methods applied in clinical practice for the assessment of low muscle mass. In addition, we assessed the association between different muscle-assessment methods and nutrition status, as well as the prognostic value of low muscle mass on survival in patients with colorectal cancer (CRC). METHODS: This is a cohort including 188 CRC patients with 17 months' follow-up (interquartile range: 12-23 months) for mortality. Low muscle mass was evaluated by corrected mid-upper arm muscle area (AMAc) and calf circumference, skeletal muscle mass by bioelectrical impedance analysis (BIA), muscle deficit by physical examination with the Patient-Generated Subjective Global Assessment (PG-SGA), and lumbar muscle cross-sectional area by CT (reference method). RESULTS: The prevalence of low muscle mass ranged from 9.6% to 54.3% according to the method used. The physical examination had the highest κ coefficient compared with CT. Low muscularity was associated with the presence of malnutrition, lower body fat, and low phase angle. The Cox regression models-adjusted for age, sex, and treatment 3 months before study inclusion-showed that severe muscle loss measured by BIA and CT and low muscle mass measured by PG-SGA predicted higher mortality rates. CONCLUSIONS: Compared with CT, the physical examination had the best agreement to assess low muscle mass. Low muscle mass assessed by PG-SGA, BIA, and CT showed similar prognostic values for survival.

Consenso brasileiro de fragilidade em idosos: conceitos, epidemiologia e instrumentos de avaliação / Brazilian consensus on frailty in older people: concepts, epidemiology and evaluation instruments

O objetivo do presente trabalho foi descrever as definições conceitual e operacional da síndrome de fragilidade recomendadas pelo Consenso Brasileiro de Fragilidade em Idosos. Em 2015, uma força-tarefa composta de especialistas brasileiros em envelhecimento humano conduziu uma revisão bibliográfica sobre fragilidade em idosos no Brasil e estabeleceu um consenso acerca dos principais achados por meio de reuniões periódicas. No total, 72 artigos foram incluídos para análise, entre os quais, uma revisão sistemática, duas discussões conceituais, duas descrições metodológicas, quatro estudos longitudinais focando mortalidade e piora do perfil de fragilidade, oito estudos de adaptação transcultural e 55 estudos transversais ou de prevalência. Quarenta e cinco estudos (62,5%) utilizaram a escala de fragilidade do Cardiovascular Health Study (EFCHS), dos quais sete (15,2%) usaram pontos de corte não ajustados para a amostra e 17 (36,9%) modificaram pelo menos um dos cinco itens que compõem o instrumento. A prevalência de fragilidade variou entre 6,7 e 74,1%. Quando utilizada a EFCHS, a ampla variação de prevalência ­ de 8 a 49,3% ­ dependeu dos pontos de corte empregados para classificar as alterações na velocidade de marcha e na força de preensão palmar, bem como do cenário de investigação. Os estudos foram baseados em quatro grandes modelos conceituais de fragilidade. A fragilidade em idosos representa um estado de vulnerabilidade fisiológica e não deve ser confundida com incapacidades ou multimorbidades. Na população brasileira, a prevalência de fragilidade ainda não está adequadamente estimada, e os pontos de corte dos itens que compõem as escalas de fragilidade devem ser adaptados aos parâmetros dessa população.

The aim of the present study was to describe the conceptual and operational definitions of the frailty syndrome recommended by the Brazilian Consensus on Frailty in Older People. In 2015, a task force consisting of Brazilian specialists on human aging conducted a bibliographical review on frailty among older people in Brazil and established a consensus on the main findings through periodic meetings. A total of 72 articles were included in the analysis, comprising one systematic review, two conceptual discussions, two methodological descriptions, four longitudinal studies focusing on mortality and worsening of the frailty profile, eight cross-cultural adaptation studies, and 55 cross-sectional or prevalence studies. Forty-five studies (62.5%) used the Cardiovascular Health Study (CHS) frailty scale, of which seven (15.2%) used unadjusted cut-off points for their samples and 17 (36.9%) modified at least one of the five items of the instrument. The prevalence of frailty varied between 6.7 and 74.1%. When the CHS frailty scale was used, the wide range of prevalence ­ from 8 to 49.3% ­ depended on the cut-off points used to classify changes in gait speed and handgrip strength, as well as the research setting. The studies were based on four major conceptual models of frailty. Frailty in older people represents a state of physiological vulnerability and should not be confused with disabilities or multi-morbidities. In the Brazilian population, the prevalence of frailty has not yet been adequately estimated, and the cut-off points of the items of the frailty scales should be adapted to the parameters of this population.

Factors Associated with Sarcopenia in Patients with Colorectal Cancer.

Introduction; Sarcopenia are frequently observed in cancer patients and was associated with poor prognosis. Objectives; to determine the association of nutritional status, body composition, and clinic parameters with sarcopenia in patients with colorectal cancer (CRC). Methods; We conducted a cross-sectional study of 197 patients with CRC. The sarcopenia elements, including lumbar skeletal muscle index (SMI), handgrip strength, and gait speed were measured. The SMI was assessed by computed tomography at third lumbar vertebra. Phase angle (PA), serum albumin (SAlb), muscle attenuation (MA), and the scored patient-generated subjective global assessment (PG-SGA) were also evaluated. Univariate and multivariate analysis of factors associated with sarcopenia were performed. Results; Sarcopenia was present in 29 of 195 patients (15%) and was significantly correlated with advance age, lower body mass index (BMI), SAlb, PA, MA, higher PG-SGA score, and malnutrition (PG-SGA B). In univariate analysis, age, BMI, SAlb, PA, MA, PG-SGA score, and malnutrition (PG-SGA B) were associated with sarcopenia. Multivariable analysis revealed that BMI, SAlb, PA, MA, and PG-SGA score were independent predictors of sarcopenia. Conclusion; BMI, SAlb, PA, MA, and PG-SGA score were independent predictors of sarcopenia in patients with CRC.

Aplicabilidade da avaliação global subjetiva e malnutrition inflammation score na avaliação do estado nutricional na doença renal crônica / Applicability of subjective global assessment and malnutrition inflammation score in the assessment of nutritional status on chronic kidney disease

Até o momento, não há um método único capaz de diagnosticar com fidedignidade a condição nutricional do paciente com doença renal crônica (DRC). Por essa razão, tem se recomendado o emprego de vários marcadores nutricionais. A avaliação global subjetiva (AGS) se baseia na história física e no exame clínico do paciente e, desde sua criação, novas versões foram elaboradas. A partir da AGS, foi criado o malnutrition inflammation score (MIS), composto por 70% das questões comuns à AGS acrescido de questões objetivas do estado nutricional. Como muitas modificações foram feitas na forma original da AGS e o emprego tanto da AGS quanto do MIS em pacientes com DRC aumentou significativamente na prática clínica, este trabalho tem como objetivo fazer uma revisão sobre a aplicabilidade desses métodos para avaliação do estado nutricional em pacientes com DRC.

Up to now, there is no single method that provides complete and unambiguous assessment of the nutritional status in chronic kidney disease (CKD). Therefore, it has been recommended the use of many nutritional markers. The subjective global assessment (SGA) contains questions regarding the clinical history and physical examination. Subsequently, other versions of the SGA were developed. The malnutrition inflammation score (MIS) was also developed from the original version of the SGA and consists of 70% of the items common to SGA in addition to objective questions. Since many modifications were proposed in the original form of SGA, the use of these questionnaires in CKD patients has increased substantially in clinical practice. Therefore, this paper aims to review the applicability of the SGA and MIS when applied to assess the nutritional status of CKD patients.

Adaptação transcultural para o português de instrumentos de avaliação do estado nutricional de pacientes em diálise / Cross-cultural adaptation to Portuguese of tools for assessing the nutritional status of patients on dialysis

Introdução: A avaliação global subjetiva de 7 pontos (AGS-7p) e o malnutrition inflammation score (MIS) constituem métodos de avaliação nutricional comumente empregados em pacientes em diálise. Ambos foram desenvolvidos na língua inglesa, de forma que é necessária a tradução para o português. O processo de adaptação transcultural garante a equivalência semântica e de mensuração de instrumentos traduzidos. Objetivo: Realizar a adaptação transcultural para o português da AGS-7p e do MIS. Métodos: A equivalência semântica foi feita pelo método da retrotradução e pela avaliação do grau de similaridade entre o instrumento original em inglês e o retraduzido do português para o inglês (retrotradução). A avaliação da equivalência de mensuração foi feita pela medida de confiabilidade interna (α de Cronbach) e pela reprodutibilidade interavaliador (dois avaliadores). Para tanto, 101 pacientes idosos em hemodiálise (HD) foram avaliados. Resultados: Ambos os instrumentos apresentaram alto grau de similaridade semântica e próximo ao valor máximo (AGS-7p 96,8 ± 7,8 e MIS 99,6 ± 1,4). A consistência interna apresentou valor de α de Cronbach para a AGS-7p de 0,72 e para o MIS de 0,53. A reprodutibilidade interavaliador da AGS-7p foi moderada e para e do MIS foi forte (coeficiente intraclasse = 0,74 [95% IC: 0,58; 0,84] e 0,88 [95% IC: 0,81; 0,93], respectivamente). Conclusão: A AGS-7p e MIS traduzidos para o português estão aptos para o emprego em pacientes idosos em HD. Estudos que testem a aplicabilidade dessas versões em pacientes adultos em HD e em diálise peritoneal devem ser feitos. .

Introduction: The 7 point subjective global assessment (7p-SGA) and the malnutrition inflammation score (MIS) are tools commonly applied for the assessment of nutritional status in dialyzed patients. Both were developed in English and require translation to Portuguese to be applied in Brazil. The cross-cultural equivalence process ensures semantic and measurement equivalence of a translated tool. Objective: To perform the cross-cultural adaptation to Portuguese of the 7p-SGA and MIS. Methods: Semantic equivalence was performed by the back-translation method and by assessing the degree of similarity between the original instrument and that back-translated from Portuguese to English (Back-translation). The assessment of the equivalence measurement was made by evaluating the intern reliability (Cronbach's α) and interobserver reliability (two observers). One-hundred and one elderly patients on hemodialysis (HD) were included. Results: Both instruments showed a high degree of semantic similarity with results close to the maximum value (7p-SGA 96.8 ± 7.8 and MIS 99.6 ± 1.4). The intern consistency showed a Cronbach's α value for 7p-SGA of 0.72 and of 0.53 for MIS. The interobserver reproducibility of 7p-SGA was moderate (intraclass coefficient [ICC] = 0.74 [95% CI: 0.58; 0.84]), while for MIS was strong (ICC = 0.88 [95% CI: 0.81; 0.93]). Conclusion: The 7p-SGA and MIS translated into Portuguese can be applied for assessing the nutritional status of elderly patients on HD. Studies testing the applicability of these instruments in adult patients on HD and in peritoneal dialysis should yet be performed. .

Estimativa das necessidades energéticas em pacientes com doença renal crônica / Estimating the energy requirement of chronic kidney disease patients

Estabelecer as necessidades energéticas de pacientes com doença renal crônica é importante para que se possam tratar os distúrbios nutricionais encontrados nessa população. Segundo os guias de condutas voltados ao cuidado nutricional de pacientes com essa doença, a recomendação energética pode variar entre 30 e 40kcal/kg/dia. Contudo, trabalhos que avaliaram os componentes do gasto energético nos pacientes com doença renal crônica sugerem que as necessidades energéticas dessa população podem diferir do valor recomendado acima, a depender da condição clínica (presença de comorbidades), da modalidade de tratamento empregado e do nível de atividade física. Dessa forma, o presente trabalho tem como objetivo fazer uma revisão dos estudos sobre o gasto energético de pacientes com doença renal crônica, com o intuito de abordar as seguintes questões: (1) as atuais recomendações de energia para pacientes com doença renal crônica estão adequadas? (2) qual equação de predição poderia ser empregada para estimar as necessidades energéticas desse grupo de pacientes? Assim, esta revisão busca auxiliar o nutricionista ao estimar as necessidades energéticas de pacientes com doença renal crônica.

Estimating the energy requirement of patients with chronic kidney disease is highly important for treating the nutritional disorders often seen in this population. According to the specific guidelines for patients with chronic kidney disease, the currently recommended daily energy intake varies from 30 to 40kcal/kg/day. However, studies that investigated energy expenditure components of patients with chronic kidney disease suggested that the energy requirement may differ from the one proposed earlier, depending on overall clinical condition (i.e. presence of comorbidities), treatment modality and level of physical activity. With this perspective in mind, the present study aims to review the studies assessing energy expenditure focusing on two themes: (1) is the current energy recommendation for patients with chronic kidney disease adequate? (2) which predictive equation can be used when estimating the energy requirements of this population? Therefore, this review aims to help dietitians to estimate the energy needs of chronic kidney disease patients.

Can renal nutrition education improve adherence to a low-protein diet in patients with stages 3 to 5 chronic kidney disease?

OBJECTIVE: Low adherence is frequently observed in patients with chronic kidney disease (CKD) who are following a low-protein diet. We have evaluated whether a specific nutrition education program motivates patients with CKD who do not yet receive dialysis to reduce their protein intake and whether such a program improves adherence to a low-protein diet over and above standard dietary counseling. DESIGN AND METHODS: This was a randomized controlled clinical trial conducted at the CKD outpatient clinic at Pedro Ernesto University Hospital, Rio de Janeiro, Brazil. SUBJECTS: This study included adult patients with an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m(2) who were receiving conservative treatment. Participants had received their first referrals to a renal dietitian. INTERVENTION: Patients were randomized to a normal counseling group (individualized dietary program: 0.6 to 0.75 g protein/kg/day or 0.6 to 0.8 g/kg/day for patients with diabetes and 25 to 35 kcal/kg/day with sodium restriction) or an intense counseling group (same dietary program plus nutrition education materials). The nutrition education material included 4 different actions to improve patient knowledge and understanding of the low-protein and low-sodium diet. Both groups were followed by means of individual monthly visits to the outpatient clinic for 4 months. MAIN OUTCOME MEASURE: We looked for a change in protein intake from baseline values as well as the adherence rate, assessed as a 20% decrease of the initial protein intake (by 24-hour food recall). RESULTS: Eighty-nine patients completed the study (normal counseling n = 46; intense counseling n = 43). The number of patients who adhered to a low-protein diet was high but did not differ between groups (in the last visit 69% vs. 48%; P = .48; intense vs. normal counseling, respectively). The reduction in protein intake from baseline values was greater for the intense counseling group compared with the normal counseling group (at the last visit, -20.7 g/day [-30.9%] vs. -10.5 g/day [-15.1%], intense vs. normal counseling, respectively; P = .04). CONCLUSION: An intense nutrition education program contributed to reducing protein intake in patients with stage 3 to 5 CKD over and above our standard dietary counseling. Nutritional education programs are effective in increasing patient adherence to protein intake recommendations.

Avaliação de métodos para identificar desnutrição energético-protéica de pacientes em hemodiálise / Assessment of methods to identify protein-energy wasting in patients on hemodialysis

INTRODUÇÃO: O método capaz de melhor identificar desnutrição energético-protéica (DEP) em pacientes em hemodiálise (HD) ainda se mantém em debate. Logo, avaliamos o estado nutricional de pacientes em HD por diferentes métodos e verificamos qual deles identificava o maior número de pacientes com DEP. MÉTODOS: Quinze pacientes em HD (52,7 ± 10 anos; 33,3 por cento Masculino). O estado nutricional foi avaliado por medidas antropométricas, pela avaliação subjetiva global (ASG), por albumina plasmática e pelo consumo alimentar (recordatório de 24 horas). A gordura corporal foi avaliada por antropometria. O critério de diagnóstico de DEP preconizado pela International Society of Renal Nutrition and Metabolism (ISRNM) foi empregado. RESULTADOS: Observou-se que o índice de massa corporal esteve dentro da normalidade (24,2 ± 4,4 kg/m²). Ao avaliar a condição nutricional pela adequação da circunferência muscular do braço CMB) e da prega cutânea de tríceps (PCT) notou-se que a adequação da CMB esteve dentro dos parâmetros de normalidade (102,6 ± 13 por cento), ao passo que a adequação da PCT esteve abaixo da normalidade (Feminino: 75,3 ± 40,4 por cento; Masculino: 73,5 ± 20,6 por cento). Contudo, o percentual de gordura corporal esteve elevado (Feminino: 34,5 ± 7,3 por cento; Masculino: 23,6 ± 4,2 por cento). Com relação à ASG, a maioria dos pacientes (n = 12) apresentou algum grau de desnutrição e este constituiu o método que identificou o maior número de pacientes com DEP. Ao empregar os critérios da ISRNM, notou-se que apenas dois pacientes apresentaram DEP. CONCLUSÃO: Todos os pacientes avaliados encontravam-se com DEP por algum dos métodos utilizados. A ASG foi o método que, isoladamente, conseguiu detectar o maior número de pacientes com DEP.

INTRODUCTION: The method capable of best identifying protein-energy wasting (PEW) in hemodialysis (HD) patients is controversial. Thus, we assessed the nutritional status of HD patients by use of different methods and verified which one identified the highest number of patients with PEW. METHODS: The study assessed the nutritional status of 15 HD patients (age: 52.7 ± 10.1 years; males: 33.3 percent) by use of anthropometric measurements, subjective global assessment (SGA), serum albumin, and dietary intake (24-hour food recall). Body fat was assessed by use of anthropometry. The International Society of Renal Nutrition and Metabolism (ISRNM) criteria were used to diagnose PEW. RESULTS: The body mass index (24.2 ± 4.4 kg/m²) and the percentage of standard value for mid-arm muscle circumference were within the normal limits (102.6 ± 13 percent). Nevertheless, the percentage of standard value for triceps skinfold was below the normal limits (females, 75.3 ± 40.4 percent; and males, 73.5 ± 20.6 percent), although a high body fat percentage was observed (females, 34.5 ± 7.3 percent; males, 23.6 ± 4.2 percent). When assessing the nutritional status by use of SGA, most patients (80 percent, n = 12) were malnourished, and SGA was the method that identified the highest number of patients with PEW. By using the ISRNM criteria, PEW was diagnosed in only two patients. CONCLUSION: All patients were diagnosed with PEW by use of one of the methods studied. The SGA was the method that, in isolation, could detect the greatest number of patients with PEW.