Nutricion Clínica en tiempos de COVID-19 / Clinical Nutrition in times of COVID-19

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The risk of refeeding syndrome among severely malnourished tuberculosis patients in Chhattisgarh, India.

BACKGROUND: A secondary care hospital in rural India serving a highly tuberculosis (TB) and malnutrition endemic region. OBJECTIVE: In this study conducted on patients with chronic protein energy malnutrition (PEM) and TB, we sought to compare nurse-estimated vs. smartphone photograph analytic methods for assessing caloric intake and determine the incidence of refeeding hypophosphatemia (RH) and refeeding syndrome (RFS) in patients with TB. METHODS: Inpatients were prospectively enrolled. Baseline demographic, comorbidity and preadmission caloric data were collected. Nurse estimated caloric intake was compared with digital "before and after" meal images. Serum phosphorus was measured on days 1, 3 and 7 post admission. Patients with RH underwent further evaluation for RFS-associated findings. RESULTS: 27 patients were enrolled. 85% were at risk of RFS by National Institute for Health and Care Excellence (NICE) criteria. Significant discrepancy (>700 calories) was noted between nurse-estimated caloric intake compared to digital images. RH was found in 37% (10/27). None developed clinical RFS. CONCLUSIONS: Our study suggests more standardized methods of caloric intake are needed in resource-limited settings with high co-prevalence of PEM and TB. We noted that despite RH being common in inpatients with PEM+TB given high caloric diets, RFS was not detected.

Effects of Protein-Energy Wasting (PEW) and hyperphosphatemia on the prognosis in Japanese maintenance hemodialysis patients: A five-year follow-up observational study.

BACKGROUND & AIMS: In dialysis patients, malnutrition is a poor prognostic factor. In patients with chronic kidney disease (CKD), malnutrition is qualitatively different from general malnutrition, which is defined as "Protein-Energy Wasting (PEW)." Dietary therapy for the enhancement of PEW requires the aggressive intake of protein. Conversely, as protein intake and phosphorus intake correlate positively, increasing the protein intake increases the phosphorus intake, which is a poor prognostic factor in dialysis patients. One of the treatments for hyperphosphatemia in dialysis patients is the intake restriction of phosphorus by dietary counseling. However, protein uptake to maintain and augment the nutritional status and the protein intake restriction to correct hyperphosphatemia are contradictory treatments. Hence, this study aims to investigate the effects of PEW and hyperphosphatemia on the prognosis in hemodialysis patients. METHODS: We enrolled 60 outpatients who underwent maintenance hemodialysis for 6 months (May-November 2012) at Iga City General Hospital (Mie, Japan). In November 2012, we assessed the presence or absence of PEW and hyperphosphatemia in patients and evaluated the survival rate over the next 5 years. RESULTS: Overall, 10 patients (17%) were diagnosed as PEW. While 17 patients (28%) exhibited average phosphorus level >6.0 mg/dL (hyperphosphatemia). The 5-year survival rate was 30% in the PEW group, 66% in the non-PEW group, 57% in the hyperphosphatemia group, and 61% in the non-hyperphosphatemia group. A statistically significant difference existed between the PEW and non-PEW groups (P = 0.021). However, we observed no significant difference between the hyperphosphatemia and non-hyperphosphatemia groups. CONCLUSIONS: This study suggests that PEW affects the prognosis more than hyperphosphatemia in maintenance hemodialysis patients. The normalization of the serum phosphorus level by the protein intake restriction could prevent secondary hyperparathyroidism and vascular calcification. Conversely, restricting the protein intake poses a risk of malnutrition. In fact, early death occurred in patients with PEW in this study. Perhaps, patients with PEW should prioritize improving their nutritional status rather than controlling the serum phosphorus level.

The diagnosis and NUTRIC score of critically ill patients in enteral nutrition are risk factors for the survival time in an intensive care unit? / ¿El diagnóstico y la puntuación NUTRIC score en pacientes críticamente enfermos con nutrición enteral son factores de riesgo para el tiempo de supervivencia en una unidad de cuidados intensivos?

Objective: to investigate whether the caloric and protein deficits, the diagnosis and the NUTRIC score, behaved as risk factors associated to the survival time. Methods: prospective study with 82 critically ill patients in intensive care unit (ICU), with exclusive enteral nutritional therapy (EENT). We investigated the calorie and protein deficiencies of EENT, the NUTRIC score, and the inflammatory-nutritional index by the C-reactive protein-CRP/albumin. The data were analyzed using the Chi-square, Fisher, Mann-Whitney, Kruskal-Wallis, univariate and multiple Cox regressions and the Kaplan-Meyer method. Results: in the univariate Cox regression, one-year increase in age increased the risk of death by 4.1% (p=0.0009; HR=1.041) and one-day increase with intercurrent events, by 1.8% (p = 0.0485; HR = 1.018). In the multiple Cox regression, the clinical diagnosis (p = 0.0462, HR = 2.091) and the NUTRIC score ≥ 5 (p < 0.0001; HR = 5.740) were the variables that together were associated with the survival time. The critical caloric and protein deficits did not behave as death risk factors in this population. Kaplan-Meier curves showed that the probability of survival in 40 days was 28.1% with clinical diagnosis and 40.2% with surgical diagnosis. The mean survival time with NUTRIC score ≥ 5 was 17.4 days. The probability of survival at 40 days was 72.8% with NUTRIC score < 5 and 6.4% with NUTRIC score ≥ 5. Conclusion: caloric and protein deficits are not risk factors for mortality. Only the diagnosis and the NUTRIC score were considered risk factors associated with the survival time

Objetivo: investigar si el déficit calórico y proteico, el diagnóstico y la puntuación nutricional se comportaron como factores de riesgo asociados al tiempo de supervivencia. Métodos: estudio prospectivo con 82 pacientes en estado crítico en la Unidad de Cuidados Intensivos (UCI), con terapia nutricional enteral exclusiva (EENT). Investigamos las deficiencias de calorías y proteínas de EENT, el puntuación NUTRIC y el índice inflamatorio-nutricional por la proteína C-reactiva-CRP / albúmina. Los datos se analizaron utilizando las regresiones de Chi-cuadrado, Fisher, Mann-Whitney, Kruskal-Wallis, univariadas y múltiples de Cox y el método de Kaplan-Meyer. Resultados: en la regresión de Cox univariada, el aumento de un año en la edad aumentó el riesgo de muerte en un 4,1% (p = 0,0009; HR = 1,041) y el aumento de un día con eventos intercurrentes, en un 1,8% (p = 0,0485; HR = 1,018). En la regresión múltiple de Cox, el diagnóstico clínico (p = 0,0462, HR = 2,091) y la puntuación nutricional ≥ 5 (p < 0,0001; HR = 5,740) fueron las variables que juntas se asociaron con el tiempo de supervivencia. Los déficits críticos de calorías y proteínas no se comportaron como factores de riesgo de muerte en esta población. Las curvas de Kaplan-Meier mostraron que la probabilidad de supervivencia en 40 días fue del 28,1% con diagnóstico clínico y del 40,2% con diagnóstico quirúrgico. El tiempo medio de supervivencia con puntuación NUTRIC ≥ 5 fue de 17,4 días. La probabilidad de supervivencia a los 40 días fue del 72,8% con una puntuación nutricional < 5 y del 6,4% con una puntuación NUTRIC ≥ 5. Conclusión: los déficits calóricos y proteicos no son factores de riesgo para la mortalidad. Solo el diagnóstico y la puntuación NUTRIC se consideraron factores de riesgo asociados con el tiempo de supervivencia

Phase angle and mid arm circumference as predictors of protein energy wasting in renal replacement therapy patients / Ángulo de fase y circunferencia media de brazo como predictores de desgaste proteico energético en pacientes con terapia renal sustitutiva

Objective: to analyze the association between phase angle (PA) and mid arm circumference (MAC) with protein energy wasting (PEW) in renal replacement therapy (RRT) patients. Methods: cross-sectional study. Hemodiafiltration (HDF) and automated peritoneal dialysis (PD) patients were enrolled in the study. MAC and body composition were measured using impedance bioelectric (BIA); PA, fat free mass (FFM), fat mass (FM) and ECW/TBW were obtained. Biochemical (serum albumin and cholesterol) and dietary data (energy and protein intake) were collected. Body mass index (BMI) was calculated. Patients were classified with PEW according to ISRNM criteria (low BMI, low albumin or cholesterol concentrations, low muscle mass and overhydration). Cut-off point of PA and MAC was obtained by ROC analysis. Logistic regression analysis was applied to evaluate the ability of both indicators to predict PEW. Results: sixty-nine patients were included in the study. Fifty-two (52%) were female. Thirty-nine (39%) patients had PEW. The ROC curve reveals that the optimal PA cut-off value for malnutrition risk was 4.64° with 77.8% sensitivity and 76.2% specificity. For MAC, a cut-off value of 29.6 cm shows a sensitivity of 66.6% and specificity of 69.0%. Both indicators showed significant association to PEW after multivariate adjustment. Conclusion: PEW is present almost in 39% of the RRT patients. PA and MAC are useful, simple and independents indicators for predicting PEW in Chronic Kidney disease patients on RRT

Objetivo: analizar la asociación entre el ángulo de fase (AF) y la circunferencia media del brazo (CMB) con la presencia de desgaste proteico energético (DPE) en pacientes en terapia de remplazo renal (TRR). Métodos: estudio transversal. Fueron incluidos pacientes en hemodiafiltración y en diálisis peritoneal automatizada. Se tomaron mediciones de CMB y de composición corporal utilizando bioimpedancia eléctrica (AF, masa libre de grasa, masa grasa y agua extracelular/agua corporal total). Se obtuvieron mediciones de albúmina y colesterol y se cuantificó el consumo dietético de energía y proteína. Se calculó el IMC. Se diagnosticó el DPE utilizando los criterios de ISRNM (bajo IMC, baja albúmina o colesterol, baja musculatura y sobrehidratación). Se evaluó la habilidad del AF y CMB para predecir DPE a través de una regresión logística. Se obtuvieron puntos de corte para ambos indicadores utilizando una prueba ROC. Se evaluó la habilidad del AF y CMB para predecir DPE a través de una regresión logística. Resultados: se incluyeron 69 pacientes en el estudio, el 52% de sexo femenino, y el 39% cumplieron criterios para DPE. El AF y el CMB predicen de forma adecuada el DPE según el análisis multivariado. Los puntos de corte obtenidos por la prueba ROC son < 4,64° para AF, con una sensibilidad del 77,8% y una especificidad del 76,2%, y < 29,6 cm para la CMB, con una sensibilidad del 66,6% y una especificidad del 69%. Conclusión: el DPE está presente en el 39% de pacientes en TRR. El AF y CMB son indicadores independientes, útiles y simples para predecir DPE en pacientes con enfermedad renal crónica en TRR

Nutritional recovery with a soybean diet impaired the glucagon response but did not alter liver gluconeogenesis in the adult offspring of rats deprived of protein during pregnancy and lactation.

Nutritional recovery of early malnutrition with a soybean diet reduces liver glycogen stores in the fed state and produces liver insulin resistance. We investigated whether nutritional recovery on a soybean flour diet alters hepatic gluconeogenesis in the adult offspring of rats deprived of protein during pregnancy and lactation. Male rats from mothers that were fed either 17% (C) or 6% (L) protein during pregnancy and lactation were maintained on a 17% casein (CC, n = 16 and LC, n = 17), 17% soybean flour (CS, n = 10 and LS, n = 10), or 6% casein (LL, n = 10) diet after weaning. The soybean diet reduced basal serum glucose (soybean diet, 5.6 ± 0.6 mmol/L vs. casein diet, 6.2 ± 0.6 mmol/L; p < 0.05) but increased alanine aminotransferase mRNA/GAPDH (soybean diet, 0.062 ± 0.038 vs. casein diet, 0.024 ± 0.011; p < 0.01), phosphoenolpyruvate carboxykinase mRNA/GAPDH (soybean diet, 1.53 ± 0.52 vs. casein diet, 0.95 ± 0.43; p < 0.05), and glycerokinase protein content (soybean diet, 0.86 ± 0.08 vs. casein diet, 0.75 ± 0.11; p < 0.05). The serum glucose concentration (recovered groups, 5.6 ± 0.5 mmol/L vs. control groups, 6.2 ± 0.7 mmol/L; p < 0.05) and phosphoenolpyruvate carboxykinase activity (recovered groups, 2.8 ± 0.6 µU/mg vs. control groups, 3.6 ± 0.6 µU/mg; p < 0.05) were decreased in rats subjected to protein restriction in early life. The glucose area under the curve during the pyruvate tolerance test did not differ among groups, whereas glucose area under the curve after glucagon infusion was reduced by early malnutrition (recovered groups, 4210 ± 572 mg/dL·40 min vs. control groups, 4493 ± 688 mg/dL·40 min; p < 0.001) and by the soybean diet (soybean diet, 3995 ± 500 mg/dL·40 min vs. casein diet, 4686 ± 576 mg/dL·40 min; p < 0.05). Thus, the soybean diet impaired the response to glucagon but did not alter gluconeogenesis.

Managing protein-energy wasting in hemodialysis patients: A comparison of animal- and plant-based protein foods.

Protein-energy wasting (PEW) is a major diet-related complication in hemodialysis (HD) patients. Nutrient-based dietary guidelines emphasize animal-based protein foods for preventing and managing PEW in HD patients. Although dietary protein intake is important for protein anabolism, other dietary factors contribute to PEW. In this article, we examine the diet-related etiologies of PEW in HD patients, and discuss how they may be affected differently by animal- and plant-based protein foods. In general, animal foods are superior sources of protein, but may contribute more to metabolic derangements that cause PEW. Given the potential mixed effects of animal-based protein foods on PEW, human research studies are needed to determine the impact of liberalizing the diet to allow plant-based protein foods on protein status.

Energy and Protein Intake of Alzheimer's Disease Patients Compared to Cognitively Normal Controls: Systematic Review.

OBJECTIVES: Protein and energy malnutrition and unintended weight loss are frequently reported in patients with mild cognitive impairment (MCI) and Alzheimer's disease (AD). Possible underlying mechanisms include increased energy expenditure, altered uptake of nutrients, a reduced nutritional intake, or a combination of these 3. We aimed at systematically reviewing the literature to examine potential differences in energy and protein intake in patients with MCI and AD compared to controls as a possible mechanism for unintended weight loss. DESIGN: Systematic review and meta-analysis. SETTING: PubMed and Cochrane Electronic databases were searched from inception to September 2017 for case control studies. PARTICIPANTS: Patients with MCI or AD compared to cognitive healthy controls, all adhering to a Western dietary pattern. MEASUREMENTS: Energy and protein intake. RESULTS: The search resulted in 7 articles on patients with AD versus controls, and none on patients with MCI. Four articles found no differences in energy and protein intakes, 1 found higher intakes in patients with AD, and 1 article found lower intakes in patients with AD compared to controls. One article reported on intakes, but did not test differences. A meta-analysis of the results indicated no difference between patients with AD and controls in energy [-8 kcal/d, 95% confidence interval (CI): -97, 81; P = .85], or protein intake (2 g/d, 95% CI: -4, 9; P = .47). However, heterogeneity was high (I2 > 70%), and study methodology was generally poor or moderate. CONCLUSION: Contrary to frequently reported unintended weight loss, our systematic review does not provide evidence for a lower energy or protein intake in patients with AD compared to controls. High heterogeneity of the results as well as of participant characteristics, setting, and study methods was observed. High-quality studies are needed to study energy and protein intake as a possible mechanism for unintended weight loss and malnutrition in both patients with MCI and AD.

Precision Medicine for Nutritional Management in End-Stage Kidney Disease and Transition to Dialysis.

Chronic kidney disease (CKD) is a global public health burden. Dialysis is not only costly but may not be readily available in developing countries. Even in highly developed nations, many patients may prefer to defer or avoid dialysis. Thus, alternative options to dialysis therapy or to complement dialysis are needed urgently and are important objectives in CKD management that could have huge clinical and economic implications globally. The role of nutritional therapy as a strategy to slow CKD progression and uremia was discussed as early as the late 19th and early 20th century, but was only seriously explored in the 1970s. There is a revival of interest recently owing to encouraging data as well as the increase of precision medicine with an emphasis on a personalized approach to CKD management. Although part of the explanation for the inconclusive data may relate to variations in study design and dietary prescription, diversity in genetic make-up, variations in the non-nutritional management of CKD, intra-individual variations in responses to dietary and nondietary treatment, psychosocial factors, and dietary compliance issues, these all may contribute to the heterogeneous data and responses. This brings in the evolving concept of precision medicine, in which disease management should be tailored and individualized according not only to clinical manifestations but also to the genetic make-up and biologic responses to therapy, which may vary depending on genetic composition. Precision nutrition management also should take into account patient demographics, social, psychological, education, and compliance factors, which all may influence the therapeutic needs and responses to the nutritional therapy prescribed. In this review, we provide a novel concept of precision medicine in nutritional management in end-stage kidney disease with a transition to dialysis and propose how this may be the way forward for nutritional therapy in the CKD population.

Care home resident and staff perceptions of the acceptability of nutrition intervention trial procedures: a qualitative study embedded within a cluster randomised feasibility trial.

OBJECTIVES: To examine care home resident and staff perceptions of the acceptability of participating in a feasibility trial evaluating nutritional interventions in the treatment of malnutrition. DESIGN: Exploratory qualitative methodology was used to gather descriptions of resident and staff perceptions of trial procedures, using semi-structured interviews with residents and focus groups with staff. The interviews were used to explore individual perceptions of the acceptability of the assigned intervention and the outcomes measured. Focus groups were used to explore staff experiences of trial participation and perspectives of nutritional support interventions. SETTING: The study was embedded within a cluster randomised feasibility trial, which randomised six care homes to provide standard care (SC), food-based (FB) intervention or oral nutritional supplement (ONS) intervention to residents with, or at risk of, malnutrition. PARTICIPANTS: Residents in the trial with capacity to consent (n=7) formed the sampling frame for inclusion. Four agreed to be approached by the researcher and to take part in the individual interviews. All were women, representing two arms of the trial (ONS and SC). Twelve staff participated in six focus groups, one at each care home. All participants were women, representing all three arms of the trial. RESULTS: Major themes that emerged from both interviews and focus groups included the perceived acceptability of trial involvement, the value of residents completing participant-reported outcome measures and the challenges associated with outcomes measurement in this setting. Themes that emerged from the focus groups alone, included the importance of individualising an intervention, and the perceived value of FB and ONS interventions and dietetic input. CONCLUSIONS: Residents and staff perceived involvement in a trial evaluating nutritional interventions to be acceptable, although the challenges associated with research in this setting were acknowledged. Resident preferences were highlighted by staff as an important consideration when implementing a nutrition support plan. TRIAL REGISTRATION NUMBER: ISRCTN38047922.

Dietary Interventions in Liver Cirrhosis.

Liver cirrhosis is associated with significant nutritional risks that often result in serious hepatic complications and poor survival rates. Diet is an important but underutilized aspect in the treatment modality of cirrhosis. Therefore, the aims of this review are to ascertain nutritional risks associated with its pathophysiology and to summarize existing evidence that support dietary recommendations for managing this patient population. Alterations in substrate utilization for energy production is a main feature of liver cirrhosis, resulting in increased catabolism of protein stores and a predisposition toward protein-energy malnutrition, even in the early stages of the disease. The body of evidence suggests that a high energy and protein (>1.2 g/kg body weight/d) diet consumed frequently and late in the evening is effective in improving nutritional status of these patients and has been associated with improved hospitalization and mortality rates. The use of branched-chain amino acid supplementation shows promise in reducing cirrhosis-related complications but are currently limited by adverse gastrointestinal symptoms and poor palatability. Furthermore exploration of dietary manipulation of branched-chain amino acid warrants further examination. Evidence is also accumulating that protein intake should not be restricted in patients with hepatic encephalopathy with earlier studies of protein restriction neglecting to account for the relative increase in fermentable fiber which would reduce the absorption of ammonia into the portal system in a way similar to supplementation with lactulose. Finally, a major finding of this review is the need to improve the quality and quantity of dietary intervention studies for patients with liver cirrhosis, particularly with the use of partial or whole dietary sources. In conclusion, dietary management of cirrhosis is not a one-size fits all approach but should be implemented earlier on in the treatment algorithm to improve the clinical prognosis of cirrhosis.

Colesteatoma congénito gigante en paciente octogenario / Giant congenital cholesteatoma in an octogenarian patient

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[Impact of the adjunction of boiled-egg during the chronic hemodialysis session on the nutrition state]. / Impact du renforcement de la prise en charge nutritionnelle du patient en hémodialyse chronique par ajout d'œufs durs en collation.

Denutrition for chronic hemodialysed patients is common and severe, often the first step of many complication and comorbidities. This work was aimed to study the impact of the adjunction of hard-boiled egg during six months, at the time of the hemodialysis session, if the classic nutritional support with oral nutritional supplements and intradialytic parenteral nutrition has failed. Required criteria were: Albuminemia, prealbuminemia and Moreau and Gaudry's score. Thirty-six patients have been included. During the six months, the following nutritional parameters have improved: Moreau and Gaudry's score decreased of 0.27, C reactive protein of 9.44 mg/L. Albuminemia improved of 3.53 g/L in average, pre-albuminemia of 0.2 g/L, and normalized Protein catabolic rate of 0.01 g/kg/day. Half of the patients were successful to stop the intradialytic parenteral nutrition. Protein adjunction with hard-boiled egg during chronic hemodialysis session, on top of the classic dietetic support has improved nutritional patient status.

Changes in susceptibility to life-threatening infections after treatment for complicated severe malnutrition in Kenya.

Background: Goals of treating childhood severe acute malnutrition (SAM), in addition to anthropometric recovery and preventing short-term mortality, include reducing the risks of subsequent serious infections. How quickly and how much the risk of serious illness changes during rehabilitation are unknown but could inform improving the design and scope of interventions. Objective: The aim of this study was to investigate changes in the risk of life-threatening events (LTEs) in relation to anthropometric recovery from SAM. Design: This was a secondary analysis of a clinical trial including 1778 HIV-uninfected Kenyan children aged 2-59 mo with complicated SAM, enrolled after the inpatient stabilization phase of treatment, and followed for 12 mo. The main outcome was LTEs, defined as infections requiring rehospitalization or causing death. We examined anthropometric variables measured at months 1, 3, and 6 after enrollment in relation to LTEs occurring during the 6 mo after each of these time points. Results: Over 12 mo, there were 823 LTEs (257 fatal), predominantly severe pneumonia and diarrhea. At months 1, 3, and 6, 557 (34%), 764 (49%), and 842 (56%) children had a weight-for-height or -length z score (WHZ) ≥-2, respectively, which, compared with a WHZ <-3, was associated with lower risks of subsequent LTEs [adjusted HRs (95% CIs): 0.50 (0.40, 0.64), 0.30 (0.23, 0.39), and 0.23 (0.16, 0.32), respectively]. However, children with a WHZ ≥-2 at 1, 3, and 6 mo still had 39 (95% CI: 32, 47), 26 (95% CI: 22, 32), and 15 (95% CI: 12, 20) LTEs/100 child-years of observation during the following 6 mo. WHZ at study enrollment predicted subsequent WHZ but not the risk of LTEs. Changes in height-for-age z score did not predict LTEs. Conclusions: Anthropometric response was associated with a rapid and substantial reduction in risk of LTEs. However, reduction in susceptibility lagged behind anthropometric improvement. Disease events, together with anthropometric assessment, may provide a clearer picture of the effectiveness of interventions. Robust protocols for detecting and treating poor anthropometric recovery and addressing broader vulnerabilities that complicated SAM indicates may save lives. This trial was registered at www.clinicaltrials.gov as NCT00934492.

Síndrome de desgaste proteico energético en la enfermedad renal crónica avanzada: prevalencia y características clínicas específicas / Protein-energy wasting syndrome in advanced chronic kidney disease: prevalence and specific clinical characteristics

Introducción: El desgaste proteico energético (DPE) se asocia a mayor mortalidad y difiere dependiendo del estadio de la enfermedad renal y de la técnica de diálisis. Su prevalencia en pacientes sin diálisis se encuentra poco estudiada y oscila entre el 0 y el 40,8%. Objetivo: Evaluar el estado nutricional según criterios de DPE y por valoración global subjetiva (VGS) de un colectivo de pacientes españoles con enfermedad renal crónica avanzada (ERCA). Pacientes y métodos: Estudio transversal de 186 pacientes (101 hombres) con edad media de 66,1±16 años. Se realizó evaluación nutricional mediante: VGS, criterios de DPE, registro dietético de 3 días, parámetros antropométricos y bioimpedancia vectorial. Resultados: Un 30,1% presentaba DPE, con diferencias significativas entre hombres y mujeres (22,8 vs. 33,8%; p<0,005) y un 27,9% tenía valores de VGS en rangos de desnutrición. Sin diferencia entre los 2 métodos estudiados. Los hombres presentaron mayores niveles de proteinuria, porcentaje de masa muscular e ingesta de nutrientes. Las mujeres tuvieron mayores niveles de colesterol total, HDL y porcentaje de masa grasa. Las características de los pacientes con DPE fueron: bajos valores de albúmina y recuento total de linfocitos, elevada proteinuria, baja masa grasa, baja masa muscular y cociente Na/K elevado. El análisis multivariante mostró asociación de DPE con proteinuria (OR: 1,257; IC 95%: 1,084-1,457; p=0,002), porcentaje de ingesta lipídica (OR: 0,903; IC 95%: 0,893-0,983; p=0,008), recuento total de linfocitos (OR: 0,999; IC 95%: 0,998-0,999; p=0,001) y el índice de masa celular (OR: 0,995; IC 95%: 0,992-0,998). Conclusión: Existe malnutrición en población española con ERCA, medida por diferentes herramientas. Consideramos conveniente adecuar nuevos elementos diagnósticos a los criterios de DPE (AU)

Introduction: Protein-energy wasting (PEW) is associated with increased mortality and differs depending on the chronic kidney disease (CKD) stage and the dialysis technique. The prevalence in non-dialysis patients is understudied and ranges from 0 to 40.8%. Objective: To evaluate the nutritional status of a group of Spanish advanced CKD patients by PEW criteria and subjective global assessment (SGA). Patients and methods: Cross-sectional study of 186 patients (101 men) with a mean age of 66.1±16 years. The nutritional assessment consisted of: SGA, PEW criteria, 3-day dietary records, anthropometric parameters and bioelectrical impedance vector analysis. Results: The prevalence of PEW was 30.1%, with significant differences between men and women (22.8 vs. 33.8%, p < 0.005), while 27.9% of SGA values were within the range of malnutrition. No differences were found between the 2methods. Men had higher proteinuria, percentage of muscle mass and nutrient intake. Women had higher levels of total cholesterol, HDL and a higher body fat percentage. The characteristics of patients with PEW were low albumin levels and a low total lymphocyte count, high proteinuria, low fat and muscle mass and a high Na/K ratio. The multivariate analysis found PEW to be associated with: proteinuria (OR: 1.257; 95% CI: 1.084-1.457, p=0.002), percentage of fat intake (OR: 0.903; 95% CI: 0.893-0.983, p=0.008), total lymphocyte count (OR: 0.999; 95% CI: 0.998-0.999, p=0.001) and cell mass index (OR: 0.995; 95% CI: 0.992-0.998). Conclusion: Malnutrition was identified in Spanish advanced CKD patients measured by different tools. We consider it appropriate to adapt new diagnostic elements to PEW criteria (AU)

From Treating Childhood Malnutrition to Public Health Nutrition.

BACKGROUND: This analysis sets out an overview of an IUNS presentation of a European clinician's assessment of the challenges of coping with immediate critical clinical problems and how to use metabolic and a mechanistic understanding of disease when developing nutritional policies. SUMMARY: Critically ill malnourished children prove very sensitive to both mineral and general nutritional overload, but after careful metabolic control they can cope with a high-quality, energy-rich diet provided their initial lactase deficiency and intestinal atrophy are taken into account. Detailed intestinal perfusion studies also showed that gastroenteritis can be combatted by multiple frequent glucose/saline feeds, which has saved millions of lives. However, persisting pancreatic islet cell damage may explain our findings of pandemic rates of adult diabetes in Asia, the Middle East and Mexico and perhaps elsewhere including Africa and Latin America. These handicaps together with the magnitude of epigenetic changes emphasized the importance of a whole life course approach to nutritional policy making. Whole body calorimetric analyses of energy requirements allowed a complete revision of estimates for world food needs and detailed clinical experience showed the value of redefining stunting and wasting in childhood and the value of BMI for classifying appropriate adult weights, underweight and obesity. Lithium tracer studies of dietary salt sources should also dictate priorities in population salt-reduction strategies. Metabolic and clinical studies combined with meticulous measures of population dietary intakes now suggest the need for far more radical steps to lower the dietary goals for both free sugars and total dietary fat unencumbered by flawed cohort studies that neglect not only dietary errors but also the intrinsic inter-individual differences in metabolic responses to most nutrients. Key Messages: Detailed clinical and metabolic analyses of physiological responses combined with rigorous dietary and preferably biomarker of mechanistic pathways should underpin a new approach not only to clinical care but also to the development of more radical nutritional policies.

Improving nutrition care and intake for older hospital patients through system-level dietary and mealtime interventions.

BACKGROUND & AIMS: Interventions such as oral nutritional supplements (ONS), fortified meals and mid-meals, feeding assistants and Protected Mealtimes have shown some impact on nutritional intake in research studies, but embedding them in practise remains challenging. This study monitored nutritional intake of older medical inpatients as dietary and mealtime interventions were progressively implemented into routine practise. METHODS: Series of three prospectively evaluated patient cohorts allowed comparison of nutritional intake of 320 consented medical inpatients aged 65 + years: cohort 1 (2007-8), cohort 2 (2009) and cohort 3 (2013-14) as nutrition care interventions were progressively introduced and embedded. Interventions focused on 'assisted mealtimes', fortified meals and mid-meals, and ONS. Energy and protein intake were calculated from visual plate waste of individual meal and mid-meal components on day 5 of admission. Nutrition care processes were evaluated by mealtime audits of diet type, assistance and interruptions on the same day. One-way ANOVA and chi square tests were used for comparison between cohorts. RESULTS: Significant, progressive improvements in energy and protein intake were seen between cohorts (energy: cohort 1: 5073 kJ/d; cohort 2: 5403 kJ/d; cohort 3: 5989 kJ/d, p = 0.04; protein: cohort 1: 48 g/d, cohort 2: 50 g/d, cohort 3: 57 g/d, p = 0.02). Greater use of fortified meals and mid-meals and sustained improvements in mealtime assistance likely contributed to these improvements. CONCLUSIONS: Multi-faceted system-level approach to nutrition care, including changes to dietary and mealtime care processes, was associated with measureable and sustained improvements in nutritional intake of older inpatients over a seven year period.

Hormonal Correlates and Predictors of Nutritional Recovery in Malnourished African Children.

Background: Malnourished children show variable growth responses to nutritional rehabilitation. We aimed to investigate whether these differences could be explained by variations in growth and energy-regulating hormones. Methods: Quasi-experimental study: Children aged 6-24 months in rural Gambia were recruited to controls if weight-for-height z-score (WHZ) > -2 (n = 22), moderate acute malnutrition if WHZ < -2 and > -3 (n = 18) or severe acute malnutrition if WHZ < -3 (n = 20). Plasma hormone and salivary CRP levels were determined by ELISA. Results: In univariable analyses, increases in weight-for-age z-score (WAZ) in malnourished children were positively correlated with insulin (F-ratio 7.8, p = 0.006), C-peptide (F-ratio 12.2, p < 0.001) and cortisol (F-ratio 5.0, p = 0.03). In multivariable analysis, only baseline C-peptide (F-ratio 7.6, p = 0.009) predicted the changes in WAZ over 28 days of interventions. Conclusion: In rural Gambian, malnourished children, although it cannot be used in isolation, baseline C-peptide was a predictor of future response to rehabilitation.

The effects of a high-protein, high-calorie, fiber- and fructo-oligosaccharide-enriched enteral formula on nutritional status, bowel habits and tolerance: Safety and Effectiveness of Enteral Nutrition in elderly Spanish patients (SENS Study) / Fórmula enteral hiperproteica e hipercalórica, enriquecida en fibra y en fructooligosacáridos: efecto sobre el estado nutricional, hábitos gastrointestinales y tolerancia en pacientes ancianos españoles (Estudio SENS)

Background: Enteral nutrition (EN) is an effective nutritional intervention for patients at risk of malnutrition or malnourished. However, complications such as gastrointestinal intolerance, hyperglycemia or refeeding syndrome can be triggered by EN. Aim: To investigate the effects of a tube feeding formula (TFF) on patients' nutritional status, biochemical status, bowel habits and safety. Methodology: Observational, prospective and multicenter study. Patients ≥ 18 years, undernourished or at nutritional risk, who were prescribed a high-calorie, high-protein, fiber-fortified TFF were included. Patients were evaluated over a period of eight weeks (baseline [V1], four weeks [V2] and eight weeks [V3]). Results: A statistically significant increase in weight (1.5 kg), body mass index (0.6 kg/m2) and nutritional intake (59.7 kcal/day) was observed between V1 and V2. Between V1 and V3, there was a statistically significant decrease in the percentage of individuals with abnormal biochemical markers for glucose, potassium, total protein and albumin. The number of patients’ bowel movements remained stable throughout the study with a mean of 1.1 daily bowel movements. Conclusion: The TFF was safe and well tolerated, improving patients’ nutritional status without altering patients' bowel habits (AU)

Introducción: la nutrición enteral es una intervención efectiva para pacientes desnutridos o en riesgo de sufrir desnutrición. Sin embargo, puede desencadenar complicaciones como intolerancia gastrointestinal, hiperglicemia o síndrome de realimentación. Objetivo: investigar los efectos de una fórmula de nutrición enteral por sonda en el estado nutricional y bioquímico, hábitos gastrointestinales y seguridad de los pacientes. Metodología: estudio observacional, prospectivo y multicéntrico. Se incluyeron pacientes ≥ 18 años, desnutridos o en riesgo de desnutrición, tributarios de recibir una fórmula de nutrición enteral hipercalórica, hiperproteica, y rica en fibra y fructooligosacáridos. Los pacientes fueron evaluados durante 8 semanas en 3 visitas (V1, inicial; V2, 4 semanas; V3, 8 semanas). Resultados: entre V1 y V2 se observó un incremento estadísticamente significativo en peso (1,5 kg), índice de masa corporal (0,6 kg/m2) e ingesta calórica (59,7 kcal/día). Entre V1 y V3, existió un descenso en el porcentaje de pacientes con valores anormales de glucosa, potasio, proteína total y albúmina. Los hábitos intestinales se mantuvieron estables durante el estudio (1,1 deposiciones diarias de media). Conclusión: la fórmula fue segura, tolerada, y mejoró el estado nutricional del paciente sin alterar los hábitos intestinales (AU)

Protein blend ingestion before allogeneic stem cell transplantation improves protein-energy malnutrition in patients with leukemia.

Severe protein-energy malnutrition (PEM) and skeletal muscle wasting are commonly observed in patients with acute leukemia. Recently, the ingestion of a soy-whey protein blend has been shown to promote muscle protein synthesis (MPS). Thus, we tested the hypothesis that the ingestion of a soy-whey blended protein (BP) may improve the PEM status and muscle mass in acute leukemia patients. In total, 24 patients from the same treatment group were randomly assigned to the natural diet plus soy-whey blended protein (BP) group and the natural diet only (ND) group. Our data showed that protein and energy intake decreased significantly (P < .05) after transplantation in both groups. In the absence of the BP intervention, dramatic decreases in muscle-related indicators (i.e., anthropometric variables, muscle strength and serum protein) were observed in the majority (>50%) of the patients. However, 66% of the patients who ingested the BP before transplantation showed obvious increases in arm muscle area. The gripping power value (△post-pre or △post-baseline) was significantly higher in the BP group than in the ND group (P < .05). The ingestion of the BP also increased the levels of serum albumin, globulin and serum total protein to different extents. Notably, the average time to stem cell engraftment was significantly shorter for patients in the BP group (12.2 ± 2.0 days) than for patients in the ND group (15.1 ± 2.9 days). Collectively, our data supported that soy-whey protein can improve PEM status and muscle mass in leukemia patients.