Supplementing Breakfast with a Vitamin D and Leucine-Enriched Whey Protein Medical Nutrition Drink Enhances Postprandial Muscle Protein Synthesis and Muscle Mass in Healthy Older Men.

Background: A promising strategy to help older adults preserve or build muscle mass is to optimize muscle anabolism through providing an adequate amount of high-quality protein at each meal.Objective: This "proof of principle" study investigated the acute effect of supplementing breakfast with a vitamin D and leucine-enriched whey protein medical nutrition drink on postprandial muscle protein synthesis and longer-term effect on muscle mass in healthy older adults.Methods: A randomized, placebo-controlled, double-blind study was conducted in 24 healthy older men [mean ± SD: age 71 ± 4 y; body mass index (in kg/m2) 24.7 ± 2.8] between September 2012 and October 2013 at the Unit of Human Nutrition, University of Auvergne, Clermont-Ferrand, France. Participants received a medical nutrition drink [test group; 21 g leucine-enriched whey protein, 9 g carbohydrates, 3 g fat, 800 IU cholecalciferol (vitamin D3), and 628 kJ] or a noncaloric placebo (control group) before breakfast for 6 wk. Mixed muscle protein fractional synthesis rate (FSR) was measured at week 0 in the basal and postprandial state, after study product intake with a standardized breakfast with the use of l-[2H5]-phenylalanine tracer methodology. The longer-term effect of the medical nutrition drink was evaluated by measurement of appendicular lean mass, representing skeletal muscle mass at weeks 0 and 6, by dual-energy X-ray absorptiometry.Results: Postprandial FSR (0-240 min) was higher in the test group than in the control group [estimate of difference (ED): 0.022%/h; 95% CI: 0.010%/h, 0.035%/h; ANCOVA, P = 0.001]. The test group gained more appendicular lean mass than the control group after 6 wk (ED: 0.37 kg; 95% CI: 0.03, 0.72 kg; ANCOVA, P = 0.035), predominantly as leg lean mass (ED: 0.30 kg; 95% CI: 0.03, 0.57 kg; ANCOVA, P = 0.034).Conclusions: Supplementing breakfast with a vitamin D and leucine-enriched whey protein medical nutrition drink stimulated postprandial muscle protein synthesis and increased muscle mass after 6 wk of intervention in healthy older adults and may therefore be a way to support muscle preservation in older people. This trial was registered at www.trialregister.nl as NTR3471.

Slight chronic elevation of C-reactive protein is associated with lower aerobic fitness but does not impair meal-induced stimulation of muscle protein metabolism in healthy old men.

Ageing impairs the muscle anabolic effect of food intake, which may explain muscle loss and an increased risk of sarcopenia. Ageing is also associated with low grade inflammation (LGI), which has been negatively correlated with muscle mass and strength. In rodents, the muscle anabolic resistance observed during ageing and sarcopenia has been ascribed to the development of the LGI. We aimed to investigate this relationship in humans. We studied protein metabolism and physical fitness in healthy elderly volunteers with slight chronic C-reactive protein. Two groups of healthy elderly volunteers were selected on the presence (or not) of a chronic, slight, elevation of CRP (Control: <1; CRP+: >2 mg l(-1) and <10 mg l(-1) , for 2 months). Body composition, short performance battery test, aerobic fitness and muscle strength were assessed. Whole body and muscle protein metabolism and the splanchnic extraction of amino acids were assessed using [(13) C]leucine and [(2) H]leucine infusion. The anabolic effect of food intake was measured by studying the volunteers both at the post-absorptive and post-prandial states. Slight chronic CRP elevation resulted in neither an alteration of whole body, nor skeletal muscle protein metabolism at both the post-absorptive and the post-prandial states. However, CRP+ presented a reduction of physical fitness, increased abdominal fat mass and post-prandial insulin resistance. Plasma cytokines (interleukin-1, interleukin-6, tumour necrosis factor α) and markers of endothelial inflammation (intercellular adhesion molecule, vascular cell adhesion molecule, selectins) were similar between groups. An isolated elevated CRP in healthy older population does not indicate an impaired skeletal muscle anabolism after food intake, nor an increased risk of skeletal muscle wasting. We propose that a broader picture of LGI (notably with elevated pro-inflammatory cytokines) is required to impact muscle metabolism and mass. However, an isolated chronic CRP elevation could predict a decrease in aerobic fitness and insulin resistance installation in elderly individuals.

Antioxidant status and the risk of elevated C-reactive protein 12 years later.

BACKGROUND/AIMS: Low-grade inflammation is an independent risk factor for cardiovascular disease. Relationships between the antioxidant status and inflammatory biomarkers could give new insights into cardiovascular disease prevention. We investigated long-term associations between the antioxidant nutrient (vitamin C, α-tocopherol, ß-carotene) status and C-reactive protein (CRP) in a population-based cohort. METHODS: Subjects included in the French SU.VI.MAX trial study who had available data on baseline (1994-1995) blood nutrient concentrations and CRP measurements 12 years later (2007-2009) were included. Associations between baseline antioxidant circulating concentrations and elevated CRP (>3 mg/l) were investigated in multivariate logistic regression models. Subgroup analyses were performed according to gender, supplementation group of the initial trial, smoking status, and alcohol intake. RESULTS: Serum α-tocopherol (n = 2,060) and vitamin C (n = 1,719) concentrations [odds ratio (OR) and 95% confidence interval (95% CI) quintile 5 vs. 1: OR 1.10 (95% CI 0.71-1.73), p for trend = 0.533, vs. OR 0.79 (95% CI 0.48-1.29), p for trend = 0.121, respectively] were not associated with elevated CRP concentrations. The ß-carotene status (n = 2,048) was inversely associated with elevated CRP [adjusted OR quintile 5 vs. 1: OR 0.61 (95% CI 0.38-0.98), p for trend = 0.01]. Subgroup analyses showed that associations were stronger in women (p for trend = 0.004), never smokers (p for trend = 0.009) and subjects in the supplementation group (p for trend = 0.002). CONCLUSIONS: Our results suggest that the ß-carotene status may be inversely associated with low-grade inflammation in the long term.

Prevention and treatment of protein energy wasting in chronic kidney disease patients: a consensus statement by the International Society of Renal Nutrition and Metabolism.

Protein energy wasting (PEW) is common in patients with chronic kidney disease (CKD) and is associated with adverse clinical outcomes, especially in individuals receiving maintenance dialysis therapy. A multitude of factors can affect the nutritional and metabolic status of CKD patients requiring a combination of therapeutic maneuvers to prevent or reverse protein and energy depletion. These include optimizing dietary nutrient intake, appropriate treatment of metabolic disturbances such as metabolic acidosis, systemic inflammation, and hormonal deficiencies, and prescribing optimized dialytic regimens. In patients where oral dietary intake from regular meals cannot maintain adequate nutritional status, nutritional supplementation, administered orally, enterally, or parenterally, is shown to be effective in replenishing protein and energy stores. In clinical practice, the advantages of oral nutritional supplements include proven efficacy, safety, and compliance. Anabolic strategies such as anabolic steroids, growth hormone, and exercise, in combination with nutritional supplementation or alone, have been shown to improve protein stores and represent potential additional approaches for the treatment of PEW. Appetite stimulants, anti-inflammatory interventions, and newer anabolic agents are emerging as novel therapies. While numerous epidemiological data suggest that an improvement in biomarkers of nutritional status is associated with improved survival, there are no large randomized clinical trials that have tested the effectiveness of nutritional interventions on mortality and morbidity.

Dietary patterns and risk of elevated C-reactive protein concentrations 12 years later.

Inflammation mediates several chronic diseases. Micronutrients can act on inflammation, either through modulating cytokine production or by scavenging by-products of activated white cells. Identifying dietary patterns (DP) reflecting these mechanisms and relating them to inflammation is of interest. The objective of the study was to identify DP specifically associated with intakes of nutrients potentially involved in inflammatory processes in a middle-aged population and investigate long-term associations between these DP and C-reactive protein (CRP) status assessed several years later. Subjects included in the Supplementation in Vitamins and Mineral Antioxidants 2 cohort study, having available data on dietary assessment carried out in 1994-5 and CRP measurement in 2007-9, were included in the analysis. DP were extracted with reduced rank regression (RRR), using antioxidant micronutrients and PUFA as response variables. Associations between CRP measurements >3 mg/l and extracted DP were then examined with logistic regression models providing OR and 95% CI. A total of 2031 subjects (53·2% women, mean follow-up duration: 12·5 years) were included in the analyses. Of the four extracted DP, a DP with high loading values of vegetables and vegetable oils, leading to high intakes of antioxidant micronutrients and essential fatty acids, was significantly and negatively associated with risk of elevated CRP (OR 0·88; 95% CI 0·78, 0·98). Conversely, a DP reflecting a high n-6:n-3 fatty acid intake ratio was positively and significantly associated with elevated CRP (adjusted OR 1·15; 95% CI 1·00, 1·32). DP extracted with RRR provide support for further exploration of relationships between dietary behaviour and inflammation.

Body composition and muscle strength at the end of ICU stay are associated with 1-year mortality, a prospective multicenter observational study.

BACKGROUND & AIMS: After a prolonged intensive care unit (ICU) stay patients experience increased mortality and morbidity. The primary aim of this study was to assess the prognostic value of nutritional status, body mass composition and muscle strength, as assessed by body mass index (BMI), bioelectrical impedance analysis (BIA), handgrip (HG) test, and that of the biological features to predict one-year survival at the end of a prolonged ICU stay. METHODS: This was a multicenter prospective observational study. Survivor patients older than 18 years with ICU length of stay >72 h were eligible for inclusion. BIA and HG were performed at the end of the ICU stay. Malnutrition was defined by BMI and fat-free mass index (FFMI). The primary endpoint was one-year mortality. Multivariable logistic regression was performed to determine parameters associated with mortality. RESULTS: 572 patients were included with a median age of 63 years [53.5; 71.1], BMI of 26.6 kg/m2 [22.8; 31.3], SAPS II score of 43 [31; 58], and ICU length of stay of 9 days [6; 15]. Malnutrition was observed in 142 (24.9%) patients. During the 1-year follow-up after discharge, 96 (18.5%) patients died. After adjustment, a low HG test score (aOR = 1.44 [1.11; 1.89], p = 0.01) was associated with 1-year mortality. Patients with low HG score, malnutrition, and Albuminemia <30 g/L had a one-year death rate of 41.4%. Conversely, patients with none of these parameters had a 1-year death rate of 4.1%. CONCLUSION: BIA to assess FFMI, HG and albuminemia at the end of ICU stay could be used to predict 1-year mortality. Their ability to identify patients eligible for a structured recovery program could be studied.

Multimodal nutritional rehabilitation improves clinical outcomes of malnourished patients with chronic respiratory failure: a randomised controlled trial.

BACKGROUND: In chronic respiratory failure (CRF), body composition strongly predicts survival. METHODS: A prospective randomised controlled trial was undertaken in malnourished patients with CRF to evaluate the effects of 3 months of home rehabilitation on body functioning and composition. 122 patients with CRF on long-term oxygen therapy and/or non-invasive ventilation (mean (SD) age 66 (10) years, 91 men) were included from eight respiratory units; 62 were assigned to home health education (controls) and 60 to multimodal nutritional rehabilitation combining health education, oral nutritional supplements, exercise and oral testosterone for 90 days. The primary endpoint was exercise tolerance assessed by the 6-min walking test (6MWT). Secondary endpoints were body composition, quality of life after 3 months and 15-month survival. RESULTS: Mean (SD) baseline arterial oxygen tension was 7.7 (1.2) kPa, forced expiratory volume in 1 s 31 (13)% predicted, body mass index (BMI) 21.5 (3.9) kg/m2 and fat-free mass index (FFMI) 15.5 (2.4) kg/m2. The intervention had no significant effect on 6MWT. Improvements (treatment effect) were seen in BMI (+0.56 kg/m2, 95% CI 0.18 to 0.95, p=0.004), FFMI (+0.60 kg/m2, 95% CI 0.15 to 1.05, p=0.01), haemoglobin (+9.1 g/l, 95% CI 2.5 to 15.7, p=0.008), peak workload (+7.2 W, 95% CI 3.7 to 10.6, p<0.001), quadriceps isometric force (+28.3 N, 95% CI 7.2 to 49.3, p=0.009), endurance time (+5.9 min, 95% CI 3.1 to 8.8, p<0.001) and, in women, Chronic Respiratory Questionnaire (+16.5 units, 95% CI 5.3 to 27.7, p=0.006). In a multivariate Cox analysis, only rehabilitation in a per-protocol analysis predicted survival (HR 0.27, 95% CI 0.07 to 0.95, p=0.042). CONCLUSIONS: Multimodal nutritional rehabilitation aimed at improving body composition increased exercise tolerance, quality of life in women and survival in compliant patients, supporting its incorporation in the treatment of malnourished patients with CRF. Clinical Trial number NCT00230984.

Quantification of lean tissue losses during cancer and HIV infection/AIDS.

PURPOSE OF REVIEW: Cancer and HIV infection/AIDS are associated with an increased risk of undernutrition and cachexia. During the past decade, patients became older, frequently overweight or obese and sedentary, conditions which are likely to result in fat-free mass (FFM) loss. This review sustains the hypothesis that FFM measurement should be implemented in routine clinical practice, to optimize the management of cancer and AIDS, as well as disease-related undernutrition. RECENT FINDINGS: Undernutrition and FFM loss are associated with worse clinical outcome and increased therapy toxicity in cancer and AIDS patients. The emergence of the concept of sarcopenic obesity in cancer patients, a condition associated with decreased survival, demonstrates the necessity to assess their body composition with easily available methods, such as dual energy X-ray absorptiometry, computerized tomography and bioelectrical impedance analysis. FFM measurement could be helpful for guiding the choice of both disease-specific and nutritional therapies and for evaluating their efficacy and putative toxicity. SUMMARY: FFM measurement at different steps of disease course could allow improving the guidance and efficacy of both cancer and HIV/AIDS-specific and nutritional therapies. The repeated measurement of FFM could allow reducing undernutrition-related morbidity, mortality and global healthcare costs, and could improve response and tolerance towards therapy, and quality of life.

Multimodal approach to malnutrition in malnourished maintenance hemodialysis patients.

Chronic organ failures, including chronic kidney disease, cardiac failure, and chronic pulmonary disease, share a common phenotype which is characterized by a high prevalence of anorexia, inflammation, oxidative stress, insulin resistance, hypogonadism, and anemia. Because of the systemic dimension of organ failure, such a phenotype results in a decrease in body mass, in addition to alterations of body composition and abnormal muscle structure, metabolism, and performance. The response of both protein-energy wasting and muscle disease to nutritional support given alone was shown to be limited both in chronic kidney disease and chronic pulmonary disease. Data are needed to evaluate the effects of an integrated management taking into account the different factor of muscle anabolism: nutrition support, endurance exercise, and, in selected patients, other anabolic agents such as androgens and omega-3 fatty acids.

Day and night changes in energy expenditure of patients on automated peritoneal dialysis.

RATIONALE: Automated peritoneal dialysis (APD) treatment for end-stage kidney disease affords patients a degree of autonomy in everyday life. Clinical investigations of their energy expenditure (EE) are usually based on resting EE, which could mask day and night variations in EE. The aim of this study, therefore, was to compare the components of EE in APD patients and healthy control (C) subjects. MATERIAL AND METHOD: Patients treated with APD for more than 3 months were compared with C volunteers matched for age and lean body mass (LBM). Biochemical analyses were performed and body composition was determined by DEXA to adjust EE to LBM. Total EE, its different components and respiratory quotients (RQ) were measured by a gas exchange method in calorimetric chambers. Spontaneous total and activity-related EE (AEE) were also measured in free-living conditions over 4 days by a calibrated accelerometer and a heart rate monitor. RESULTS: APD (n = 7) and C (n = 7) patients did not differ in age and body composition. REE did not differ between the two groups. However, prandial increase in EE adjusted for dietary energy intake was higher in APD patients (+57.5 ± 12.71 kcal/h) than in C subjects (+33.8 ± 10.5 kcal/h, p = 0.003) and nocturnal decrease in EE tended to be lower in APD patients undergoing dialysis sessions (- 4.53 ± 8.37 kcal/h) than in subjects (- 11.8 ± 7.69 kcal/h, p = 0.059). Resting RQ (0.91 ± 0.09 vs 0.81 ± 0.04, p = 0.032) and nocturnal RQ (0.91 ± 0.09 vs 0.81 ± 0.04, p = 0.032) were significantly higher in APD patients, indicating a preferential use of glucose substrate potentially absorbed across the peritoneum. AEE was lower in APD patients (595.9 ± 383.2 kcal/d) than in C subjects (1205.2 ± 370.5 kcal/d, p = 0.011). In contrast, energy intakes were not significantly different (1986 ± 465 vs 2083 ± 377 kcal/d, p = 0.677). CONCLUSION: Although the two groups had identical resting EE, APD patients had a higher prandial increase in EE, a lower activity-related EE and higher resting and nocturnal RQ than healthy subjects.

Assessment of body protein: energy status in chronic kidney disease.

The prevalence of protein-energy malnutrition progressively increases during the evolution of chronic kidney disease (CKD). As a consequence, it has been reported that 40% of patients present with symptoms of undernutrition at the entrance to chronic dialysis treatment. In patients established on maintenance hemodialysis, the prevalence of malnutrition varies from 20% to 60% according to which indicators of nutritional status are used. Protein-energy malnutrition is associated with an increase in overall and cardiovascular death risks both in CKD patients not yet on dialysis and in dialysis patients. Given the impact of protein-energy wasting on the outcome of CKD patients, screening malnutrition and monitoring protein-energy status appear of primary importance. Therefore, scientific and professional societies or foundations have developed guidelines for the assessment of nutritional status as well as for the treatment of malnourished CKD patients. Recently, an expert panel recommended the term protein-energy wasting for loss of body protein mass and fuel reserves. According to these recommendations, protein-energy wasting should be diagnosed if 3 characteristics are present (low serum levels of albumin, transthyretin, or cholesterol), reduced body mass (low or reduced body mass or fat mass or weight loss with reduced intake of protein and energy), and reduced muscle mass (muscle wasting or sarcopenia, reduced mid-arm-muscle circumference). The present article addresses the methods for assessing protein-energy status, their specificities regarding the CKD staging, and the criteria for choosing among these methods when managing the follow-up evaluation of CKD patients. The practical implications of nutritional parameters for the management of CKD patients are illustrated by a case presentation.

Use of a renal-specific oral supplement by haemodialysis patients with low protein intake does not increase the need for phosphate binders and may prevent a decline in nutritional status and quality of life.

BACKGROUND: Protein-energy wasting is a frequent and debilitating condition in maintenance dialysis. We randomly tested if an energy-dense, phosphate-restricted, renal-specific oral supplement could maintain adequate nutritional intake and prevent malnutrition in maintenance haemodialysis patients with insufficient intake. METHODS: Eighty-six patients were assigned to a standard care (CTRL) group or were prescribed two 125-ml packs of Renilon 7.5(R) daily for 3 months (SUPP). Dietary intake, serum (S) albumin, prealbumin, protein nitrogen appearance (nPNA), C-reactive protein, subjective global assessment (SGA) and quality of life (QOL) were recorded at baseline and after 3 months. RESULTS: While intention to treat analysis (ITT) did not reveal strong statistically significant changes in dietary intake between groups, per protocol (PP) analysis showed that the SUPP group increased protein (P < 0.01) and energy (P < 0.01) intakes. In contrast, protein and energy intakes further deteriorated in the CTRL group (PP). Although there was no difference in serum albumin and prealbumin changes between groups, in the total population serum albumin and prealbumin changes were positively associated with the increment in protein intake (r = 0.29, P = 0.01 and r = 0.27, P = 0.02, respectively). The SUPP group did not increase phosphate intake, phosphataemia remained unaffected, and the use of phosphate binders remained stable or decreased. The SUPP group exhibited improved SGA and QOL (P < 0.05). CONCLUSION: This study shows that providing maintenance haemodialysis patients with insufficient intake with a renal-specific oral supplement may prevent deterioration in nutritional indices and QOL without increasing the need for phosphate binders.

Nutritional supplementation in adult patients on hemodialysis.

At the beginning of the 1980s, nutritional status appeared as a key element of quality of life, health care requirements, and survival during chronic renal failure. In patients on dialysis, malnutrition is a major determinant of survival, and its management appears to be a key element in terms of outcome. Recommendations for the nutritional management of patients on hemodialysis have been elaborated by the National Kidney Foundation (NKF) and the European Society of Parenteral and Enteral Nutrition (ESPEN).

[Diabetic patients survival rates in dialysis]. / Survie des diabétiques en dialyse.

Since the beginning of the eighties, the prevalence and incidence of diabetes have been increasing in dialysis units. In France, type 2 diabetes accounts for approximately 90% of diabetic hemodialysis patients. Among the etiologies of renal failure, diabetes is characterized by increased hospitalization rates and reduced quality of life, transplantation rates and survival. In dialysis patients, diabetes mellitus enhances the main factors leading to an increase in cardiovascular and non-cardiovascular deaths: inflammation, dyslipidemia, hypertension, increased energy expenditure, oxidative stress and plasma assymetrical dimethylarginine. The prevention of these complications includes the control of blood glucose, plasma lipids, hypertension, and anemia. The role of antioxidant therapies remains to be evaluated.

Fat-free mass at admission predicts 28-day mortality in intensive care unit patients: the international prospective observational study Phase Angle Project.

PURPOSE: Phase angle as measured by bioelectrical impedance analysis reflects fat-free mass. Fat-free mass loss relates to worse prognosis in chronic diseases. Primary aim of this study was: to determine the association between fat-free mass at intensive care unit admission and 28-day mortality. METHODS: Ten centres in nine countries participated in this multicentre prospective observational study. The inclusion criteria were age >18 years; expected length of stay >48 h; absence of pacemaker, heart defibrillator implant, pregnancy and lactation. Fat-free mass was assessed by measurement of the 50-kHz phase angle at admission. The primary endpoint was 28-day mortality. The area under the receiver operating characteristic curve (AUC) was used to assess prediction of 28-day mortality by fat-free mass at ICU admission. The variables associated with 28-day mortality were analysed by means of multivariable logistic regression. RESULTS: Of the 3605 patients screened, 931 were analysed: age 61 ± 16 years, male 60 %, APACHE II 19 ± 9, body mass index 26 ± 6, day 1 phase angle 4.5° ± 1.9°. Day 1 phase angle was lower in patients who eventually died than in survivors (4.1° ± 2.0° vs. 4.6° ± 1.8°, P = 0.001). The day 1 phase angle AUC for 28-day mortality was 0.63 [0.58-0.67]. In multivariable analysis, the following were independently associated with 28-day mortality: age (adjusted odds ratio (aOR) 1.014 [95 % confidence interval 1.002-1.027], P = 0.03), day 1 phase angle (aOR 0.86 [0.78-0.96], P = 0.008), APACHE II (aOR 1.08 [1.06-1.11], P < 0.001), surgical patient (aOR 0.51 [0.33-0.79], P = 0.002), and admission for other diagnosis (aOR 0.39 [0.21-0.72], P = 0.003). A multivariable combined score improved the predictability of 28-day mortality: AUC = 0.79 [0.75-0.82]. CONCLUSION: Low fat-free mass at ICU admission is associated with 28-day mortality. A combined score improves mortality predictability. TRIAL REGISTRATION: NCT01907347 ( http://www.clinicaltrials.gov ).

Dialyzer membrane permeability and survival in hemodialysis patients.

BACKGROUND: We previously showed that nutritional protein concentrations were predictive of outcome, whereas variables reflecting body composition and dialysis dose were not, in a 30-month prospective follow-up of 1,610 hemodialysis patients. Information on dialysis membrane and erythropoietin use had to be evaluated in an additional follow-up. METHODS: A subset of 650 patients from the initial cohort of 1,610 was analyzed for survival in a 2-year extension of follow-up. Detailed data were collected: demographics; cause of renal failure; time on dialysis therapy; type of membrane; erythropoietin treatment; body mass index (BMI); predialysis albumin, prealbumin, and bicarbonate levels; and outcome. Normalized protein catabolic rate (nPCR), dialysis adequacy, and lean body mass were computed from predialysis and postdialysis urea and creatinine values. RESULTS: Patient characteristics were age of 61 +/- 16 years, 58% men, BMI of 22.7 +/- 4.4 kg/m2 , time on dialysis therapy of 102 +/- 73 months, and 8.8% had diabetes. Dialysis parameters were duration of 247 +/- 31 minutes, Kt/V of 1.4 +/- 0.3, and nPCR of 1.2 +/- 0.3 g/kg/d. Albumin level was 3.73 +/- 0.53 g/dL (37.3 +/- 5.3 g/L), and prealbumin level was 31 +/- 8 mg/dL. The survival rate was 78.7% after 2 years. Survival was influenced by age, presence of diabetes, use of high-flux membrane, and serum albumin level, but not other variables, including Kt/V and prealbumin level. Two-year variations in values for urea, creatinine, and weight were predictive of survival in univariate, but not multivariate, analyses. CONCLUSION: In patients on dialysis therapy for a long period, better survival was observed when high-flux dialysis membranes were used.

Energy expenditure, spontaneous physical activity and with weight gain in kidney transplant recipients.

BACKGROUND & AIMS: Alterations in energy metabolism could trigger weight gain after renal transplantation. METHODS: Nineteen transplanted non-diabetic men, 53 ± 1.6 years old, receiving calcineurin inhibitors but no corticosteroids were studied. They were compared with nine healthy men matched for height, age and lean body mass. Daily energy expenditure and its components (sleeping, basal and absorptive metabolic rates) were analyzed for 24 h in calorimetric chambers and for 4 days in free living conditions using calibrated accelerometry. Other variables known to influence energy expenditure were assessed: body composition, physical activity, 4-day food intake, drug consumption, serum C-reactive protein, interleukin-6, thyroid and parathyroid hormones, and epinephrine. Transplant recipients who gained more than 5% body weight after transplantation (n = 11, +11.0 ± 1.5 kg) were compared with those who did not (n = 8) and with the controls. RESULTS: Weight gain compared with non-weight gain patients and controls exhibited higher fat mass without change in lean body mass. Daily, sleeping and resting energy expenditure adjusted for lean body mass was significantly higher in non-weight gain (167.1 ± 4.2 kJ/kg/lean body mass/24 h, P < 0.05) compared with weight gain patients (147.4 ± 3.6) and controls (146.1 ± 4.6). Weight gain compared with controls and non-weight gain subjects had lower free living physical activity and a higher consumption of antihypertensive drugs and ß-blockers. CONCLUSIONS: After kidney transplantation, weight gain patients were characterized by lower adjusted energy expenditure, reduced spontaneous physical activity but a more sedentary life style and a trend toward a higher energy intake explaining the reason they gained weight. The nWG KTR had increased resting and sleeping EE which protected them from weight gain. Such hypermetabolism was also observed in 24-h EE measurements. By comparison with the nWG patients, the WG transplant recipients were characterized by higher ß-blocker consumption. These data could be helpful in the prevention of weight gain in kidney transplant recipients.

Survival of patients with chronic respiratory failure on long-term oxygen therapy and or non-invasive ventilation at home.

BACKGROUND & AIMS: Chronic respiratory failure (CRF) is the common fate of respiratory diseases where systemic effects contribute to outcomes. In a prospective cohort of home-treated patients with CRF, we looked for predictors of long-term survival including respiratory, nutritional and inflammatory dimensions. METHODS: 637 stable outpatients with CRF, 397 men, 68 ± 11 years, on long-term oxygen therapy and/or non-invasive ventilation from 21 chest clinics were enrolled and followed over 53 ± 31 months. CRF resulted from Chronic Obstructive Pulmonary Disease (COPD) in 48.5%, restrictive disorders 32%, mixed (obstructive and restrictive patterns) respiratory failure 13.5%, bronchiectasis 6%. Demographic characteristics, smoking habits, underlying respiratory diseases, forced expiratory volume in one second (FEV1), forced vital capacity (FVC), arterial blood gases, 6-min walking distance (6MWD), hemoglobin, body mass index (BMI), serum albumin, transthyretin, C-reactive protein (CRP), history of respiratory assistance, antibiotic and oral corticosteroid use during the previous year were recorded. RESULTS: 322 deaths occurred during the follow-up. One-, five- and 8-year actuarial survival was 89%, 56% and 47%. By Cox univariate analysis, age, respiratory disease, PaO2, PaCO2, FEV1/FVC, BMI, 6MWD, activity score, type and length of home respiratory assistance, smoking habits, oral corticosteroid and antibiotic uses, albumin, transthyretin, hemoglobin and CRP levels were associated with survival. Multivariate analysis identified eight independent markers of survival: age, FEV1/FVC, PaO2, PaCO2, 6MWD, BMI, serum transthyretin, CRP ≥ 5 mg/l. CONCLUSIONS: In CRF, whatever the underlying diseases, besides the levels of obstructive ventilatory defect and gas exchange failure, 6MWD, BMI, serum transthyretin and CRP ≥ 5 mg/l predicted long-term survival identifying potential targets for nutritional rehabilitation.

C-reactive protein and body mass index predict outcome in end-stage respiratory failure.

STUDY OBJECTIVE: To determine the predictive factors of morbidity and mortality in patients with end-stage respiratory disease. DESIGN: Prospective, multicenter cohort study. SETTING: Thirteen outpatient chest clinics within the Association Nationale de Traitement à Domicile de l'Insuffisance Respiratoire. PARTICIPANTS: Stable adult patients with chronic respiratory failure receiving long-term oxygen therapy and/or home mechanical ventilation (n = 446; 182 women and 264 men; aged 68.5 +/- 12.1 years [+/- SD]); Respiratory diseases were COPD in 42.8%, restrictive disorders in 36.3%, mixed respiratory failure in 13.5%, and bronchiectasis in 7.4%. Recruitment was performed during the yearly examination. Patients with neuromuscular diseases and sleeping apnea were excluded. MEASUREMENTS AND RESULTS: Hospitalization days and survival were recorded during a follow-up of 14.3 +/- 5.6 months. Body mass index (BMI), serum albumin, and transthyretin levels were considered for their predictive value of outcome, together with demographic data, underlying respiratory disease, respiratory function, hemoglobin, C-reactive protein, smoking habits, oral corticosteroid use, and antibiotic treatment courses. Overall, 1.8 +/- 1.7 hospitalizations (cumulative stay, 17.6 +/- 27.1 days) were observed in 254 of 446 patients (57%). Independent predictors of hospitalization were oral corticosteroids, FEV(1), and plasma C-reactive protein. One-year and 2-year cumulative survivals were 93% and 69%, respectively. Plasma C-reactive protein, BMI, Pao(2) on room air, and oral corticosteroids independently predicted survival in multivariate analysis. CONCLUSION: Besides established prognosis factors such as FEV(1) and Pao(2), nutritional depletion as assessed by BMI and overall systemic inflammation as estimated by C-reactive protein appear as major determinants of hospitalization and death risks whatever the end-stage respiratory disease. BMI and C-reactive protein should be included in the monitoring of chronic respiratory failure. Oral corticosteroids as maintenance treatment in patients with end-stage respiratory disease are an independent risk factor of death, and should be avoided in most cases.