Agreement between the EWGSOP2 and SDOC consensuses for sarcopenia in patients receiving hemodialysis: Findings of a cross sectional analysis from the SARC-HD study.

BACKGROUND: Differences in definitions and operational diagnoses for sarcopenia create difficulties in understanding the epidemiology of the disease. We examined the prevalences of sarcopenia using the revised European Working Group on Sarcopenia in Older People (EWGSOP2) and the Sarcopenia Definitions and Outcomes Consortium (SDOC) consensuses and analyzed their level of agreement in patients receiving hemodialysis. METHODS: Data from the SARCopenia trajectories and associations with clinical outcomes in patients receiving hemodialysis (SARC-HD) multicenter study in Brazil were analyzed. Muscle strength was assessed using handgrip strength, muscle mass by calf circumference, and physical performance by the 4-m gait speed test. Sarcopenia was diagnosed according to both the EWGSOP2 (low muscle strength plus low muscle mass) and the SDOC (low muscle strength plus low physical performance). The Cohen kappa statistic was used to determine the level of agreement between the consensuses. RESULTS: 838 patients (57.8 ± 15.0 years; 61% men) from 19 dialysis units were included. We found similar prevalences of sarcopenia between the consensuses (EWGSOP2, n = 128, 15.3%; SDOC, n = 105, 12.5%) but with weak agreement (50 of 233 patients, 21.5%; κ = 0.34, 95% CI 0.25-0.43). Agreement was also weak within age categories (≥60 years, κ = 0.34; <60 years, κ = 0.15; both P < 0.001). Of the 51 patients diagnosed by the EWGSOP2 criterion as having severe sarcopenia, all but 1 (98.0%) met the SDOC criterion for sarcopenia (κ = 0.61, 95% CI 0.52-0.70). Low muscle strength was more frequently diagnosed using the SDOC than with the EWGSOP2 (52.3% vs 25.9%). CONCLUSION: We found a weak agreement between the EWGSOP2 and SDOC consensuses for the diagnosis of sarcopenia in patients receiving hemodialysis. Although still weak, agreement was marginally better for older patients. These findings highlight the importance of a global and standardized conceptual diagnosis of sarcopenia.

The 10-Item Physical Function Scale as a Sarcopenia Screening Tool for Patients on Hemodialysis.

OBJECTIVE: We investigated the accuracy of the 10-item Physical Function (PF-10) questions of the SF-36 quality of life questionnaire as a sarcopenia screening tool among patients on hemodialysis. METHODS: A cross-sectional, multicenter study that included adult patients on hemodialysis. The revised European Working Group on Sarcopenia in Older People was used to diagnose sarcopenia. The 10 questions about daily activities from the SF-36 quality of life questionnaire were used to appoint the PF-10, where the final score could range from 10 to 30, and the lower the worse the physical function. The PF-10 accuracy to identify confirmed sarcopenia (low muscle strength + low muscle mass) was assessed through a receiver operating characteristic curve and the cutoff was calculated using the Youden index. RESULTS: One hundred eighty-five patients were included (median 59 years; 45% female). Prevalence of confirmed sarcopenia was 31.4%. The median PF-10 score was 23 (interquartile range: 17-27) and a significant association with all sarcopenia measurements was found (all P < .05). The best cutoff calculated from the receiver operating characteristic curve was ≤26 points (area under the curve = 0.69, 95% confidence interval 0.61-0.77) with sensitivity and specificity of 96.6% and 71.0%, respectively. Moreover, patients with ≤26 points (n = 133, 72%) had a higher prevalence of low muscle strength by handgrip (53 vs. 19%; P < .001) and 5-time sit-to-stand (41 vs. 10%; P < .001), low gait speed (44 vs. 19%; P = .002), confirmed sarcopenia (39 vs. 11%; P < .001), and severe sarcopenia (26 vs. 4%; P = .001), but not low muscle mass (49 vs. 35%; P = .08), in comparison with those >26 points (n = 52, 28%). CONCLUSION: The PF-10 may be a useful physical dysfunction and sarcopenia screening tool in patients on hemodialysis. A PF-10 threshold of around 26 points appeared to display the fairest accuracy for diagnosing sarcopenia.

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.

Effects of Exercise on Inflammatory Markers in Individuals with Chronic Kidney Disease: A Systematic Review and Meta-Analysis.

Individuals with chronic kidney disease (CKD) have a systemic inflammatory state. We assessed the effects of exercise on inflammatory markers in individuals with CKD. An electronic search was conducted, including MEDLINE. Experimental clinical trials that investigated the effects of exercise on inflammatory markers in individuals with CKD at all stages were included. Meta-analyses were conducted using the random-effects model and standard mean difference (SMD). Subgroup analyses were performed for resistance, aerobic, and combined exercise interventions. Twenty-nine studies were included in the meta-analyses. Exercise interventions showed significant reductions in C-reactive protein (CRP) (SMD: -0.23; 95% CI: -0.39 to -0.06), interleukin (IL)-6 (SMD: -0.35; 95% CI: -0.57, -0.14), and tumor necrosis factor-alpha (TNF-α) (SMD: -0.63, 95% CI: -1.01, -0.25) when compared with the controls. IL-10 levels significantly increased (SMD: 0.66, 95% CI: 0.09, 1.23) with exercise interventions. Resistance interventions significantly decreased CRP (SMD: -0.39, 95% CI: -0.69, -0.09) and TNF-α (SMD: -0.72, 95% CI: -1.20, -0.23) levels, while increasing IL-10 levels (SMD: 0.57, 95% CI: 0.04, 1.09). Aerobic interventions only significantly reduced IL-6 levels (SMD: -0.26, 95% CI: -0.51, -0.01). No significant changes in any inflammatory markers were observed with combined exercise interventions. Exercise interventions are effective as an anti-inflammatory therapy in individuals with CKD compared to usual care control groups. Resistance interventions seem to promote greater anti-inflammatory effects.

Intradialytic resistance training for short daily hemodialysis patients as part of the clinical routine: a quasi-experimental study.

Background and purpose: Hemodialysis patients have chronic systemic inflammation, musculoskeletal impairments, and body composition changes from several factors and exercise may attenuate. We evaluated the effects of an intradialytic resistance training program on body composition, physical function, and inflammatory markers in patients under short daily hemodialysis treatment. Materials and methods: A quasi-experimental study in clinical routine was conducted over eight months. Measures of physical function (handgrip strength, five-time sit-to-stand, timed-up and go, and gait speed), body composition (by bioelectrical impedance), and inflammatory markers (interleukin [IL]-1 beta, IL-6, IL-8, IL-10, IL-12p70, and tumor necrosis factor-α) were assessed at baseline as well as at four and eight months past continued intervention. Patients underwent two intradialytic resistance training sessions per week supervised by exercise professionals. Results: A total of 18 patients (62 ± 14 years; 55.6% ≥ 60 years; 44% female) were included. Significant increases in body mass index and basal metabolic rate were found at four and eight months compared to baseline. For physical function, timed-up and go performance improved at four and eight months compared to baseline. The other body composition and physical function measures, as well as all inflammatory markers, did not significantly change over time. Conclusion: A supervised intradialytic resistance training program for patients on short daily hemodialysis treatment, as part of the clinical routine, may induce modest changes in body mass index, basal metabolic rate, and timed-up and go performance.

Implementing a resistance training programme for patients on short daily haemodialysis: A feasibility study.

BACKGROUND: Kidney failure patients receiving haemodialysis experience protein-energy wasting, muscle mass loss and physical function impairment. Intradialytic exercise interventions seem to modify these features, but they are often not implemented as a clinical routine. OBJECTIVE: To investigate the feasibility of implementing a supervised intradialytic resistance training programme as a clinical routine for patients receiving short daily haemodialysis. DESIGN: A prospective longitudinal study. PARTICIPANTS: Eighteen patients in a supervised intradialytic resistance training programme for 8 months. MEASUREMENTS: It consisted of a warm-up, lower- and upper-limb resistance exercises and a cool-down. Patients performed the resistance training during the first half of haemodialysis, twice a week, supervised by exercise physiologists and physiotherapists. The feasibility was assessed by the total and partial adherences, the reasons for refusing or for not exercising and the intradialytic complications. RESULTS: From a total of 953 potential exercise sessions, 759 were performed, with a 79.6% adherence rate. In the first 9 weeks, the adherence rate was 86.6% and the lowest rate was in the 19-27 weeks (73.5%). The main intradialytic complication during exercise sessions was hypotension (n = 31; 4.1%). The highest number of complications was reported during the first 9 weeks (n = 27; 9.1%). The main reasons for refusing or for not performing the intradialytic exercise sessions were clinical complications previous to exercise time (n = 63; 32.5%) and self-reported indisposition (n = 62; 32.0%). CONCLUSIONS: The intradialytic resistance training programme, supervised by exercise physiologists and physiotherapists, had very low complications, achieved a high long-term adherence rate and showed to be feasible as a clinical routine for patients receiving short daily haemodialysis.

Exercise guide to help on arteriovenous fistula maturation and maintenance.

BACKGROUND: The arteriovenous fistula is the main vascular access in hemodialysis. Arteriovenous fistula access is generally evaluated by a vascular surgeon after 2 weeks of its surgery, however, exercise programs may begin earlier for improving outcomes. Therefore, we propose this guide with simple, but potentially effective exercises, using low-cost materials that can be safely performed by the patients at home or in the dialysis center. It also provides to the dialysis staff team a starting point for implementing an upper-limb exercise program that may facilitate arteriovenous fistula maturation and maintenance. METHODS: This exercise routine for arteriovenous fistula maturation can be performed three to four times a day, every day, from 2 to 4 weeks. After its maturation, it can be performed on every non-dialysis day for conventional treatment and every other day, before dialysis, for short daily treatment. CONCLUSIONS: Based on the available evidence, we have gathered some exercises, in a very easy and understandable language, that may potentially help arteriovenous fistula maturation and maintenance for hemodialysis patients.

SARC-F and SARC-CalF are associated with sarcopenia traits in hemodialysis patients.

BACKGROUND: The SARC-F questionnaire assesses sarcopenia risk. The addition of a calf circumference measurement, known as SARC-CalF, has been recently proposed. We investigated possible associations of SARC-F and SARC-CalF with sarcopenia traits in patients undergoing hemodialysis. METHODS: Thirty patients (17 men; 57 ± 15 years) were enrolled. Sarcopenia risk was assessed by SARC-F (≥4) and SARC-CalF (≥11). Probable (low muscle strength or low skeletal muscle mass [SMM]) and confirmed (both) sarcopenia were diagnosed as recommended by the revised European Working Group on Sarcopenia in Older People. Muscle strength was assessed by handgrip strength (HGS) and five-time sit-to-stand test (STS-5), and physical performance was evaluated by gait speed. SMM was assessed by bioelectrical impedance. RESULTS: Sarcopenia risk by the SARC-F and SARC-CalF were found in 23% (n = 7) and 40% (n = 12) patients, respectively. The SARC-F and SARC-CalF were both associated with physical function, but not with SMM. Probable sarcopenia by HGS was associated with SARC-F and SARC-CalF. Moreover, both showed moderate Kappa agreement with slowness and probable sarcopenia by HGS and/or STS-5, but only SARC-CalF with probable sarcopenia by HGS. A larger sensitivity was found for SARC-CalF than SARC-F in detecting probable sarcopenia by HGS (70% vs 30%) and by HGS and/or STS-5 (63% vs 44%). CONCLUSION: SARC-F and SARC-CalF are associated with sarcopenia traits in patients undergoing hemodialysis. SARC-CalF seems to be more strongly associated with sarcopenia traits and present a higher sensitivity for probable sarcopenia than SARC-F, as it adds a direct measurement.

Intradialytic isometric handgrip exercise does not cause hemodynamic instability: A randomized, cross-over, pilot study.

Hemodialysis (HD) patients experience hemodynamic instability and intradialytic exercise seems to attenuate it. This study aimed to verify the acute hemodynamic response to different intradialytic handgrip exercise intensities in HD patients. In a randomized, cross-over, experimental pilot study, eight patients completed two experimental sessions and one control in random order: (a) regular HD; (b) low-intensity isometric handgrip exercise; and (c) moderate-intensity isometric handgrip exercise. BP and heart rate variability were recorded immediately before and every 15 minutes. Isometric handgrip exercise protocols, regardless of the intensity, did not lead to significant changes in hemodynamic stability, nor when compared to the control condition (P > .05). The systolic BP and double product significantly increased immediately after the moderate-intensity protocol (122.0 ± 15.9 vs 131.3 ± 19.8, P < .05; 9094.7 ± 1705.7 vs 9783.0 ± 1947.9, P < .05, respectively) but returned to the pre-exercise values 10 minutes later. We conclude that intradialytic isometric handgrip exercise does not induce hemodynamic instability at low and moderate intensities.