Nutritional status assessment and body composition analysis in pre-end stage renal disease patients.

Malnutrition is a known risk factor for survival in renal failure patients. Of concern, a significant degree of malnutrition may develop in the predialysis period due to dietary restrictions and uremia. To further define this issue, we evaluated 25 predialysis patients using serum chemistries, body mass index (BMI), fat free mass (FFM), body cell mass (BCM), and protein appearance rate (PAR) as surrogates of nutritional status and compared their results to those obtained in established hemodialysis patients and recipients of living donor renal allografts during a nine-month observation period. Pre- dialysis patients had significantly (p<0.0001) higher body weight (28%), body mass index (26%), body cell mass (17%) and fat free mass (15%) than hemodialysis and transplant patients. Intracellular water content was similar in all groups. As many patients do not start dialysis until clearance values fall below 10 ml/min, it is possible that greater tissue mass losses occur in the weeks preceding initiation of dialytic therapy. Why renal transplant recipients fail to increase tissue mass may relate to the catabolic effects of immunosuppression. We conclude that the early stages of pre-end stage renal disease are associated with relatively good preservation of body cell mass.

Indirect measures of total body water may confound precise assessment of peritoneal dialysis adequacy.

Urea kinetic modeling (UKM) has yet to be optimized as a practical tool for assessing adequacy of therapy in continuous ambulatory peritoneal dialysis (CAPD) patients. Watson equation (WV) and 58% body weight (58%WT) estimates of total body water (TBW) are indirect measures likely to yield imprecise estimates of Kt/V. Bioelectrical impedance (BEI) measures body composition as a function of electrical conductance, minimizing fat contribution to TBW. TBW values were highest when measured as 58% WT and lowest when calculated from WV. These differences were most striking in patients with overweight body habitus. BEI-derived TBW correlated best with UKM values. The relationship between BEI-derived and anthropometrically derived TBW was best in patients of normal habitus. Kt/V values were highest when calculated from WV-derived volumes and significantly differed from Kt/V values calculated from BEI-derived and 58%WT volumes. When segregated by habitus, however, only in overweight patients was this pattern of clinical significance. Serial body weight, lean body mass, and TBW remained stable in patients of normal habitus. Overweight patients increased weight by 5%, lean mass by 2%, and TBW by 5%, 3%, and 2% when measured by 58%WT, WV, and BEI respectively. BEI measures of TBW exclude fat mass and thus strengthen the use of Kt/V for assessing dialysis adequacy in CAPD patients of all body weights.

Use of bioelectrical impedance for the nutritional assessment of chronic hemodialysis patients.

Although malnutrition poses a significant risk to the well-being of chronic hemodialysis patients, their nutritional assessment is usually empirical. We studied body composition by bioelectrical impedance (BEI) prospectively in 39 patients followed for 5-12 months. BEI correctly discriminated between underweight and overweight patients in terms of fat mass (21 +/- 5 vs. 34 +/- 10%; p = 0.002), lean body mass (78 +/- 4 vs. 67 +/- 10%; p = 0.004) and total body water (57 +/- 3 vs. 49 +/- 7%; p = 0.002), respectively. Serial body weights did not correlate with changes in lean body mass (LBM) as measured by BEI. While 28% of patients lost weight, 41% lost LBM. Most striking is the contrast between the patients who showed no change in LBM by BEI and those whose body weight remained neutral (3 vs. 28%). BEI is a most sensitive clinical tool for assessing changes in LBM in hemodialysis patients.