Clinical Significance of Nutritional Status, Inflammation, and Body Composition in Elderly Hemodialysis Patients-A Case-Control Study.

Nutritional and inflammatory disorders are factors that increase the risk of adverse clinical outcomes and mortality in elderly hemodialysis (HD) patients. This study aimed to examine nutritional and inflammation status as well as body composition in older adults on HD compared to matched controls. A case-control study was conducted on 168 older participants (84 HD patients (cases) and 84 controls) age- and sex-matched. Demographic, clinical, anthropometric, and laboratory parameters were collected from medical records. The primary outcome was nutritional status assessment using a combination of nutritional and inflammatory markers along with the geriatric nutritional risk index (GNRI). Sarcopenic obesity (SO) was studied by the combined application of anthropometric measures. Body composition and hydration status were assessed by bioelectrical impedance analysis (BIA). Univariate and multivariate regression analyses were performed to identify nutritional and inflammatory independent risk indicators in elderly HD patients and controls. A significantly high prevalence of nutritional risk measured by the GNRI was found in HD patients (32.1%) compared to controls (6.0%) (p < 0.001). Elderly HD patients were overweight and had lower percent arm muscle circumference, phase angle (PA), serum albumin (s-albumin), as well as higher percent extracellular body water (ECW%) and serum C-reactive protein (s-CRP) than controls (all at least, p < 0.01). SO was higher in HD patients (15.50%) than in controls (14.30%). By multi-regression analyses, age < 75 years (OR: 0.119; 95%CI: 0.036 to 0.388), ECW% (OR: 1.162; 95%CI: 1.061 to 1.273), PA (OR: 0.099; 95%CI: 0.036 to 0.271), as well as BMI, s-albumin ≥ 3.8 g/dL, and lower s-CRP were independently related between cases and controls (all at least, p < 0.05). Elderly HD patients had increased nutritional risk, SO, inflammation, overhydration, and metabolic derangements compared to controls. This study highlights the importance of identifying nutritional risk along with inflammation profile and associated body composition disorders in the nutritional care of elderly HD patients. Further studies are needed to prevent nutritional disorders in elderly HD patients.

Influencia del consumo crónico de estatinas en el estado de hidratación de personas mayores / Influence of chronic statin use on the hydration status of older people

Introducción: Las personas de edad avanzada en tratamiento crónico con fármacos son uno de los grupos de población con mayor riesgo de desarrollar alteraciones en el estado de hidratación. Uno de los fármacos más consumidos por este grupo de población y que pueden desencadenar la aparición de deshidratación son las estatinas. Sin embargo, hasta la fecha, estas interacciones no se han estudiado en profundidad. Objetivo: El objetivo del presente estudio fue evaluar la influencia del consumo crónico de estatinas sobre el estado de hidratación en personas de edad avanzada que acuden a la farmacia comunitaria. Métodos: Se llevó a cabo un estudio de casos y controles en voluntarios de edades comprendidas entre los 60 y 79 años residentes en Madrid, consumidores crónicos de estatinas (casos) y pacientes del mismo rango de edad, no consumidores de fármacos de forma crónica (controles). Resultados: El análisis de los datos generales de la población revelaron una elevada prevalencia de sobrepeso y obesidad, así como un elevado porcentaje de grasa corporal. Por su parte, el análisis de orina evidenció un mejor estado de hidratación de las mujeres frente a los hombres. Respecto al efecto de las estatinas en el estado de hidratación, se observó que los distintos parámetros analizados de los pacientes en tratamiento crónico con estatinas eran indicativos de deshidratación, frente al adecuado estado de hidratación de los pacientes sin tratamiento. Estos resultados se confirmaron con el análisis de la prevalencia de deshidratación en los distintos grupos. Conclusiones: Se concluye del presente estudio la importancia de monitorizar el consumo crónico de fármacos, como las estatinas, en las personas de edad avanzada, para evitar el desarrollo de patologías, incluyendo la aparición de deshidratación y sus complicaciones asociadas. Los farmacéuticos comunitarios como profesionales expertos en el medicamento son los profesionales más idóneos para llevar a cabo este seguimiento. (AU)

Introduction: Elderly people on chronic drug treatment are one of the population groups with the highest risk of developing alterations in hydration status. One of the drugs most consumed by this population group and that can trigger the onset of dehydration are statins. However, up to date, these interactions have not been studied in depth. Objective: The objective of this study was to evaluate the influence of chronic statin consumption on hydration status in elderly people attending the community pharmacy.Methods: A case-control study was conducted in volunteers aged between 60 and 79 years living in Madrid, chronic statin users (cases) and patients of the same age range, non-users of statin drugs. chronic form (controls). Results: Analysis of general population data revealed a high prevalence of overweight and obesity, as well as a high percentage of body fat. On the other hand, the urinalysis showed a better hydration status of women compared to men. Regarding the effect of statins on hydration status, it was observed that the different parameters analyzed in patients on chronic statin treatment were indicative of dehydration, compared to the adequate hydration status of patients without treatment. These results were confirmed by analyzing the prevalence of dehydration in the different groups. Conclusions: The importance of monitoring the chronic consumption of drugs, such as statins, in the elderly, to avoid the development of pathologies, including the appearance of dehydration and its associated complications, is concluded from the present study. Community pharmacists as expert professionals in the medication are the most suitable professionals to carry out this follow-up. (AU)

Comorbidity and nutritional status in adult with advanced chronic kidney disease influence the decision-making choice of renal replacement therapy modality: A retrospective 5-year study.

Background: Nutritional and inflammation status are significant predictors of morbidity and mortality risk in advanced chronic kidney disease (ACKD). To date, there are a limited number of clinical studies on the influence of nutritional status in ACKD stages 4-5 on the choice of renal replacement therapy (RRT) modality. Aim: This study aimed to examine relationships between comorbidity and nutritional and inflammatory status and the decision-making on the choice of RRT modalities in adults with ACKD. Methods: A retrospective cross-sectional study was conducted on 211 patients with ACKD with stages 4-5 from 2016 to 2021. Comorbidity was assessed using the Charlson comorbidity index (CCI) according to severity (CCI: ≤ 3 and >3 points). Clinical and nutritional assessment was carried out by prognosis nutritional index (PNI), laboratory parameters [serum s-albumin, s-prealbumin, and C-reactive protein (s-CRP)], and anthropometric measurements. The initial decision-making of the different RRT modalities [(in-center, home-based hemodialysis (HD), and peritoneal dialysis (PD)] as well as the informed therapeutic options (conservative treatment of CKD or pre-dialysis living donor transplantation) were recorded. The sample was classified according to gender, time on follow-up in the ACKD unit (≤ 6 and >6 months), and the initial decision-making of RRT (in-center and home-RRT). Univariate and multivariate regression analyses were carried out for evaluating the independent predictors of home-based RRT. Results: Of the 211 patients with ACKD, 47.4% (n = 100) were in stage 5 CKD, mainly elderly men (65.4%). DM was the main etiology of CKD (22.7%) together with hypertension (96.6%) as a CV risk factor. Higher CCI scores were significantly found in men, and severe comorbidity with a CCI score > 3 points was 99.1%. The mean time of follow-up time in the ACKD unit was 9.6 ± 12.8 months. A significantly higher CCI was found in those patients with a follow-up time > 6 months, as well as higher mean values of eGFR, s-albumin, s-prealbumin, s-transferrin, and hemoglobin, and lower s-CRP than those with a follow-up <6 months (all, at least p < 0.05). The mean PNI score was 38.9 ± 5.5 points, and a PNI score ≤ 39 points was found in 36.5%. S-albumin level > 3.8 g/dl was found in 71.1% (n = 150), and values of s-CRP ≤ 1 mg/dl were 82.9% (n = 175). PEW prevalence was 15.2%. The initial choice of RRT modality was higher in in-center HD (n = 119 patients; 56.4%) than in home-based RRT (n = 81; 40.5%). Patients who chose home-based RRT had significantly lower CCI scores and higher mean values of s-albumin, s-prealbumin, s-transferrin, hemoglobin, and eGFR and lower s-CRP than those who chose in-center RRT (p < 0.001). Logistic regression demonstrated that s-albumin (OR: 0.147) and a follow-up time in the ACKD unit >6 months (OR: 0.440) were significantly associated with the likelihood of decision-making to choose a home-based RRT modality (all, at least p < 0.05). Conclusion: Regular monitoring and follow-up of sociodemographic factors, comorbidity, and nutritional and inflammatory status in a multidisciplinary ACKD unit significantly influenced decision-making on the choice of RRT modality and outcome in patients with non-dialysis ACKD.

Omega-3 and Omega-6 Polyunsaturated Fatty Acid Intakes, Determinants and Dietary Sources in the Spanish Population: Findings from the ANIBES Study.

The multiple roles of polyunsaturated fatty acids (PUFA) in growth and general health are well documented. However, available intake data for the Spanish population are limited and lack gender and age considerations. Therefore, our goal was to assess dietary intake adequacy of omega-3 and omega-6 PUFA, their determinants and their major food sources among the Spanish population. Due to their influence on various beneficial functions attributed to omega-3 PUFA, combined intake adequacy with folic acid (FA), vitamin B12 and choline was also assessed. Intake data were obtained from the ANIBES cross-sectional study on a representative sample of the Spanish population (9-75 years; n = 2009), where dietary intake was analysed with a three-day dietary record. Median intake of total omega-3 PUFA stood at 0.81 g/day (0.56-1.19 g/day), with α-linolenic acid (ALA) at 0.61 g/day (0.45-0.85 g/day), eicosapentaenoic acid (EPA) at 0.03 g/day (0.01-0.12 g/day) and docosahexaenoic acid (DHA) at 0.06 g/day (0.0-0.20 g/day). Accordingly, 65% of the Spanish population showed insufficient intakes for total omega-3 PUFA; 87% for ALA, and 83% for combined EPA and DHA. Inadequate intakes were significantly higher in children, adolescents, and younger women of childbearing age (18-30 years). In contrast, inadequacy due to excessive intakes was almost negligible. Regarding omega-6 PUFA, total intake was 10.1 g/day (7.0-14.0 g/day), 10.0 g/day (6.9-13.9 g/day) for linoleic acid (LA) and 0.08 g/day (0.05-0.13 g/day) for arachidonic acid (AA). Non-compliance due to either insufficient or excessive intakes of LA stood at around 5% of the sample, with the elderly showing significantly higher degrees of inadequacy due to insufficient intakes (10%; p ≤ 0.05). Median omega-6 to omega-3 ratio was 12:1, and significantly higher in men compared to women (p ≤ 0.05); in children, adolescents and adults compared to the elderly (p ≤ 0.05); and in younger women of childbearing age compared to the older group (31-45 years) (p ≤ 0.001). Oils and fats and meat and meat products were the main dietary sources for the essential fatty acids LA and ALA, respectively. Meat and meat products were as well the main providers of AA, while fish and shellfish were almost exclusively the only sources of EPA and DHA. However, main food sources identified showed important differences across age groups. Finally, the total combined degree of inadequacy observed for omega-3 PUFA, FA, vitamin B12 and choline reached 21.3% of the ANIBES population. The observed degree of inadequacy of omega-3 PUFA intakes among the Spanish population makes it urgent to increase its consumption and to consider the need for supplementation. This should also be the main strategy for the optimization of the omega-6/omega-3 ratio, as the adequacy observed for omega-6 intakes is relatively acceptable. Additional improvement of the dietary intake of FA, vitamin B12 and choline could contribute to the beneficial effects of omega-3 PUFA.

Hearing Function and Nutritional Status in Aviation Pilots from Spain Exposed to High Acoustic Damage.

Noise-induced hearing loss is the most frequent and preventable occupational disease. Aviation pilots are a vulnerable population, as they spend many hours exposed to noise pollution in their working environment. Different studies suggest that certain dietary compounds may play a key role in the etiology and prevention of this pathology. We aimed to study the relationship linking auditory function, dietary intake, and some serum biomarkers in pilots, exposed to noise in the work environment. A total of 235 pilots, who undergo a periodic medical examination at the Centro de Instrucción de Medicina Aeroespacial (Madrid, SPAIN), were evaluated. Auditory function was assessed by tonal audiometry. Energy and nutrient intakes were estimated by 24 h recall (DIALTM program). Serum homocysteine (Hcy) was determined in a Cobas 6000TM multi-analyzer while folate, vitamin B12, and D were analyzed in a Cobas e411TM. The prevalence of hearing loss (HL) was 64.3%. HL was significantly related to age (r = 0.588, p ≤ 0.001) and flight hours (r = 0.283, p ≤ 0.001). A multiple linear regression model was used to assess the relationship among HL, flight hours, serum folate, and Hcy serum levels. HL was significantly (p < 0.050) associated with flight hours (ß = 0.246), serum folate (ß = −0.143), and serum Hcy (ß = 0.227). Nutritional interventions would be of great interest to monitor and slow down the HL progression in populations exposed to noise pollution in their workplace.

Nutritional Predictors of Mortality after 10 Years of Follow-Up in Patients with Chronic Kidney Disease at a Multidisciplinary Unit of Advanced Chronic Kidney Disease.

Nutritional monitoring in advanced chronic kidney disease (ACKD) units provides personalized care and improves clinical outcomes. This study aimed to identify mortality risk factors in chronic kidney disease (CKD) patients on nutritional follow-up in the multidisciplinary ACKD unit. A retrospective cross-sectional observational study was conducted in 307 CKD patients' stage 3b, 4−5 followed-up for 10 years. Clinical and nutritional monitoring was performed by malnutrition-inflammation score (MIS), biochemical parameters (s-albumin, s-prealbumin, and serum C-reactive protein (s-CRP), body composition measured by bioelectrical impedance analysis (BIA), anthropometry, and handgrip strength measurements. The sample was classified into non-survivors, survivors, and censored groups. Of the 307 CKD patients, the prevalence of protein-energy wasting (PEW) was 27.0% using MIS > 5 points, s-CRP > 1 mg/dL was 19.20%, and 27.18% died. Survivors had higher significant body cell mass (BCM%) and phase angle (PA). Survival analyses significantly showed that age > 72 years, MIS > 5 points, s-prealbumin ≤ 30 mg/dL, PA ≤ 4°, and gender-adjusted handgrip strength (HGS) were associated with an increased risk of mortality. By univariate and multivariate Cox regression, time on follow-up (HR:0.97), s-prealbumin (HR:0.94), and right handgrip strength (HR:0.96) were independent predictors of mortality risk at 10 years of follow-up in the ACKD unit. Nutritional monitoring in patients with stage 3b, 4−5 CKD helps to identify and treat nutritional risk early and improve adverse mortality prognosis.

Nutritional Status, Body Composition, and Inflammation Profile in Older Patients with Advanced Chronic Kidney Disease Stage 4-5: A Case-Control Study.

Nutritional status is a predictor of adverse outcomes and mortality in patients with advanced chronic kidney disease (ACKD). This study aimed to explore and evaluate risk factors related to nutritional status, body composition, and inflammatory profile in patients with ACKD compared with age- and sex-matched controls in a Mediterranean cohort of the Spanish population. Out of 200 volunteers recruited, 150 participants (64%) were included, and a case-control study was conducted on 75 ACKD patients (stages 4−5), matched individually with controls at a ratio of 1:1 for both age and sex. At enrolment, demographic, clinical, anthropometric, and laboratory parameters were measured. Bioimpedance analysis (BIA) was used to assess both body composition and hydration status. ACKD patients had lower body cell mass (BCM%), muscle mass (MM%) phase angle (PA), s-albumin, and higher C-reactive protein (s-CRP) than controls (at least, p < 0.05). PA correlated positively with BCM% (cases: r = 0.84; controls: r = 0.53, p < 0.001), MM% (cases: r = 0.65; controls: r = 0.31, p < 0.001), and inversely with s-CRP (cases: r = −0.30, p < 0.001; controls: r = −0.31, p = 0.40). By univariate and multivariate conditional regression analysis, total body water (OR: 1.186), extracellular mass (OR: 1.346), s-CRP (OR: 2.050), MM% (OR: 0.847), PA (OR: 0.058), and s-albumin (OR: 0.475) were significantly associated among cases to controls. Nutritional parameters and BIA-derived measures appear as prognostic entities in patients with stage 4−5 ACKD compared to matched controls in this Mediterranean cohort.

A Descriptive Analysis of Macronutrient, Fatty Acid Profile, and Some Immunomodulatory Nutrients in Standard and Disease-Specific Enteral Formulae in Europe.

Foods for special medical purposes (FSMPs) are commercially available formulations used as a source of nutrition when administered orally or by tube feeding. This study examines, for the first time, the nutritional composition of enteral formulae (EFs) according to European nutritional guidelines. We developed a descriptive study on 118 EFs from 2020 to 2021. Formulae were classified as standard (SFs) and disease-specific (DSF). According to the protein-energy content, SFs were classified into G1, normoprotein-normocaloric; G2, normoprotein-hypercaloric; G3, hyperproteic-normocaloric; and G4, hyperproteic-hypercaloric. Disease-related formulae for metabolic stress, renal, cancer, pulmonary, diabetes, malabsorption, and surgery were studied. Macronutrient distribution, fatty acid profile (monounsaturated [MUFA], polyunsaturated [PUFA], saturated [SFA]), derived fat quality indexes, and immuno-modulatory nutrients (omega-3, eicosapentaenoic acid [EPA], docosahexaenoic acid [DHA], arginine and nucleotides) per 1,500 kcal infused were calculated. In total, 53% were SFs, mainly normoproteic (G1, G2) with higher carbohydrate contents in normocaloric vs. hypercaloric SFs. The most balanced fatty acid profiles (MUFA: 17.7%; PUFA: 6.8%; SFA: 9.5%) belonged to G1. The PUFA/MUFA ratio: ≥0.5 was in 85.7% with a higher proportion of EPA+DHA (46%) vs. omega-3 (15.8%) in SFs. In DSFs (46.9%), higher carbohydrate content (>50%) was in malabsorption and surgery, whereas high-fat content (>50%) was in pulmonary and renal formulae. DSFs had higher SFA vs. MUFA content, except for diabetes. EPA and DHA were added in 45.5% (cancer, malabsorption, and surgery). Only 12.7% of DSFs had arginine and nucleotides. A higher proportion of SFs was found, in line with current European guidelines. Results highlighted a wide intra-group variability of nutrients among the formula selected. These findings are useful to evaluate the nutritional composition of EFs from a preventive and/or therapeutic perspective in clinical settings.

Iron Supplementation at the Crossroads of Nutrition and Gut Microbiota: The State of the Art.

Gut microbiota has received significant attention owing to its decisive role in human health and disease. Diet exerts a significant influence on the variety and number of bacteria residing in the intestinal epithelium. On the other hand, as iron is a key micronutrient for blood formation and oxygen supply, its deficiency is highly prevalent worldwide. In fact, it is the most common cause of anemia and thus, iron supplementation is widespread. However, there is concern due to some potential risks linked to iron supplementation. Therefore, we have reviewed the available evidence of the effects that iron supplementation exerts on the gut microbiota as well as its potential benefits and risks. The compiled information suggests that iron supplementation is potentially harmful for gut microbiota. Therefore, it should be performed with caution, and by principle, recommended only to individuals with proven iron deficiency or iron-deficiency anemia to avoid potential adverse effects. In any case, large and long-term population studies are urgently needed to confirm or refute these results, mainly focused on vulnerable populations.

The Extracellular Mass to Body Cell Mass Ratio as a Predictor of Mortality Risk in Hemodialysis Patients.

The extracellular mass/body cell mass ratio (ECM/BCM ratio) is a novel indicator of nutritional and hydration status in hemodialysis (HD) patients. This study aimed to explore the ECM/BCM ratio as a predictor of mortality risk with nutritional-inflammatory markers in HD patients. A prospective observational study was conducted in 90 HD patients (male: 52.2%; DM: 25.60%). Clinical and biochemical parameters [serum albumin, serum C-reactive protein (s-CRP), interleukine-6 (IL-6)] were analysed and bioelectrical impedance analysis (BIA) was performed. Protein-energy wasting syndrome (PEW) was diagnosed using malnutrition-inflammation score (MIS). Based on BIA-derived measurements, the ECM/BCM ratio with a cut-off point of 1.20 was used as a PEW-fluid overload indicator. Comorbidity by Charlson index and hospital admissions were measured. Out of 90 HD patients followed up for 36 months, 20 patients (22.22%) died. PEW was observed in 24 survivors (34.28%) and all non-survivors. The ECM/BCM ratio was directly correlated with MIS, s-CRP, Charlson index and hospital admissions but was negatively correlated with phase angle and s-albumin (all, p < 0.001). Values of the ECM/BCM ratio ≥ 1.20 were associated with higher probability of all-cause mortality (p = 0.002). The ECM/BCM ratio ≥ 1.20, IL-6 ≥ 3.1 pg/mL, s-CRP and s-albumin ≥ 3.8 g/dL and Charlson index were significantly associated with all-cause mortality risk in multivariate adjusted analysis. This study demonstrates that the ECM/BCM ratio ≥ 1.20 as a nutritional marker and/or fluid overload indicator had a significant prognostic value of death risk in HD patients.

Nutritional interventions in older people with COVID-19: an overview of the evidence.

Older people are a high-risk group for coronavirus disease 2019 (COVID-19) because of a range of factors, including age-related changes in anatomical pulmonary and muscle function, decreased immunity and increased inflammation. These factors partly explain why older people with COVID-19 experience more severe symptoms and higher mortality than younger adults and are more likely to require nutritional support. Furthermore, there is an association between suboptimal nutritional status and poorer recovery from COVID-19. Therefore, nutritional interventions are an important aspect of care for older people with COVID-19. All members of the multidisciplinary team, including dietitians and nurses, need to assess, treat and prevent nutritional deficiencies in older people with COVID-19. This literature review provides an overview of the evidence regarding the role of nutritional interventions in the treatment of, and recovery from, COVID-19 in older people.

Effects of Supplementation with Folic Acid and Its Combinations with Other Nutrients on Cognitive Impairment and Alzheimer's Disease: A Narrative Review.

Cognitive impairment and Alzheimer's Disease, among other cognitive dysfunctions, has been recognized as a major public health problem. Folic acid is a well-known essential nutrient whose deficiency has been linked to neurocognitive dysfunctions, owing to hyperhomocysteinemia, an independent risk factor for cardio- and cerebrovascular diseases, including cognitive impairment, Alzheimer's Disease, and vascular dementia. However, to date, there is certain controversy about the efficacy of vitamin supplementation in patients with these pathologies. Therefore, we have reviewed the available dietary intervention studies based on folic acid, either alone or in combination with different vitamins or nutrients into the progression of Alzheimer's Disease and Cognitive impairment, highlighting the cognition and biochemical markers employed for the evaluation of the disease progression. Undeniably, the compiled information supports the potential benefits of vitamin supplementation in these pathologies, especially relevant to the aging process and quality of life, although more research is urgently needed to confirm these positive findings.

Effect of oral administration of docohexanoic acid on anemia and inflammation in hemodialysis patients: A randomized controlled clinical trial.

BACKGROUND & AIMS: Docohexanoic acid (DHA), a dietary n-3 polyunsaturated fatty-acid omega-3 (n-3, PUFA), showed potential beneficial effects in reducing all-cause mortality in hemodialysis (HD) patients. This randomized trial aimed to analyze whether DHA supplementation was a modulator of erythropoietin (EPO) response and inflammation in hemodialysis (HD) patients. METHODS: In this controlled clinical trial, 52 HD patients were randomized to either DHA supplementation (650 mg DHA/3 times/wk/post-HD session) or controls (usual care), with 8-weeks of follow-up. The primary outcome was to determine the correction of anemia measured by changes in the erythropoiesis-resistance index (ERI) to keep the hemoglobin level at recommended target value. Secondary outcomes include changes in inflammatory biomarkers: serum C-reactive protein, total homocysteine (tHcy) and expression of miR-146a. Laboratory measures were determined at baseline and at 8-weeks after the DHA supplementation or usual care in controls. Linear regression analysis was used to assess the effect of DHA supplementation, adjusting for baseline values and intervention. RESULTS: Forty-two HD patients (men: 69%; aged:66.7 ± 15.5 yrs; DM:19%), completed this study. The DHA effect significantly decreased EPO doses (-4158.7 UI/weekly; CI95%:-8123.7 to 193,6; p = 0.04), ERI (-9.25 UI weekly/kg BW/g/dL; CI95%:-15.5 to -2.9; p = 0.006), tHcy (-5.1 µmol/L; CI95%:-9.7 to -0.3; p = 0.03), and levels of miR-146a (-1.43; CI95%:-2.7 to -0.19; p = 0.03) in regression model. No adverse effects were found. CONCLUSION: The DHA supplementation enhances anemia management and attenuates inflammation response in this controlled trial in HD patients, when provided as coadjutant therapy together with usual medical care. REGISTERED UNDER CLINICALTRIALS. GOV IDENTIFIER NUMBER: 04536636.

Clinical evaluation of an evidence-based method based on food characteristics to adjust pancreatic enzyme supplements dose in cystic fibrosis.

BACKGROUND: Patients with cystic fibrosis (CF) and pancreatic insufficiency need pancreatic enzyme replacement therapy (PERT) for dietary lipids digestion. There is limited evidence for recommending the adequate PERT dose for every meal, and controlling steatorrhea remains a challenge. This study aimed to evaluate a new PERT dosing method supported by a self-management mobile-app. METHODS: Children with CF recruited from 6 European centres were instructed to use the app, including an algorithm for optimal PERT dosing based on in vitro digestion studies for every type of food. At baseline, a 24h self-selected diet was registered in the app, and usual PERT doses were taken by the patient. After 1 month, the same diet was followed, but PERT doses were indicated by the app. Change in faecal fat and coefficient of fat absorption (CFA) were determined. RESULTS: 58 patients (median age 8.1 years) participated. Baseline fat absorption was high: median CFA 96.9%, median 2.4g faecal fat). After intervention CFA did not significantly change, but range of PERT doses was reduced: interquartile ranges narrowing from 1447-3070 at baseline to 1783-2495 LU/g fat when using the app. Patients with a low baseline fat absorption (CFA<90%, n=12) experienced significant improvement in CFA after adhering to the recommended PERT dose (from 86.3 to 94.0%, p=0.031). CONCLUSION: the use of a novel evidence-based PERT dosing method, based on in vitro fat digestion studies incorporating food characteristics, was effective in increasing CFA in patients with poor baseline fat absorption and could safely be implemented in clinical practice.

Extracellular mass to body cell mass ratio as a potential index of wasting and fluid overload in hemodialysis patients. A case-control study.

BACKGROUND & AIMS: Extracellular mass-to-body cell mass ratio (ECM/BCM ratio) which differentiates the proportion between intraextracellular compartments, could be a nutrition index of being wasted overloaded in hemodialysis (HD) patients. This study aimed to describe a cut-off point of the ECM/BCM ratio and, to find out the relationship between the nutritional-hydration status and this ratio in HD patients. METHODS: A case-control study was carried out in 64 HD patients individually age-gender-matched to controls. Demographic, clinical and laboratory parameters were recorded. Bioelectrical impedance analysis was used to estimate ECM/BCM ratio as an indicator of the nutritional hydration status. Receiver operator characteristic (ROC) curve analysis was applied to determine the optimal cut-off point for identification of ECM/BCM ratio. An univariate and multivariate conditional logistic regression for the ECM/BCM ratio ≥1.20 was performed. RESULTS: Median of ECM/BCM ratio was 1.50 (IQR:0.66) in HD patients, whereas 0.87 (IQR: 0.35) was found in controls (p < 0.001). HD-patients had lower body weight, serum albumin (s-albumin) and higher serum C-reactive protein (s-CRP) than controls. By ROC curve analysis, a cut-off point of 1.20 for the ECM/BCM ratio best discriminates to be wasted-overhydrated (sensitivity: 81.2%; specificity: 87.5%). Conditional logistic regression showed that for each 10%, ECM/BCM ratio increase the probability of developing fluid overload was increased 63% (OR: 1.63; 95% CI, 1.15-2.29), whereas an inverse association with s-albumin (OR: 0.15; 95% CI, 0.03-0.61) and other nutritional indicators were found. CONCLUSIONS: The ECM/BCM ratio appears as a sensitive index that discriminates nutritional and/or hydration status in HD patients compared with age-gender-matched-controls. ECM/BCM ratios ≥1.20 are indicators of wasting and fluid overload in HD patients.

Assessing gastro-intestinal related quality of life in cystic fibrosis: Validation of PedsQL GI in children and their parents.

BACKGROUND: Most patients with cystic fibrosis (CF) suffer from pancreatic insufficiency, leading to fat malabsorption, malnutrition and abdominal discomfort. Until recently, no specific tool was available for assessing gastro-intestinal related quality of life (GI QOL) in patients with CF. As the Horizon2020 project MyCyFAPP aims to improve GI QOL by using a newly designed mobile application, a sensitive and reliable outcome measure was needed. We aimed to study the applicability of the existing child-specific Pediatric Quality of Life Inventory, Gastrointestinal Symptoms Scales and Module (PedsQL GI) in children with CF. METHODS: A multicenter, prospective observational study was performed in 6 European centers to validate the PedsQL GI in children with CF during 3 months. RESULTS: In total, 248 children and their parents were included. Within-patient variability of PedsQL GI was low (24.11), and there was reasonable agreement between children and parents (ICC 0.681). Nine of 14 subscales were informative (no ceiling effect). The PedsQL GI and the median scores for 4 subscales were significantly lower in patients compared to healthy controls. Positive associations were found between PedsQL GI and age (OR = 1.044, p = 0.004) and between PedsQL GI and BMI z-score (OR = 1.127, p = 0.036). PedsQL GI correlated with most CFQ-R subscales (r 0.268 to 0.623) and with a Visual Analogue Scale (r = 0.20). CONCLUSIONS: PedsQL GI is a valid and applicable instrument to assess GI QOL in children with CF. Future research efforts should examine the responsiveness of the CF PedsQL GI to change in the context of clinical interventions and trials.

The Relative Contribution of Food Groups to Macronutrient Intake in Children with Cystic Fibrosis: A European Multicenter Assessment.

BACKGROUND: Optimal nutrition for children with cystic fibrosis (CF) improves prognosis and survival, but an increased caloric intake recommendation for this population raises concerns about the nutrient profile of their diets. OBJECTIVE: Our aim was to assess the relative contribution of food groups to the total macronutrient intake of European pediatric patients with CF. DESIGN: We conducted a cross-sectional study in which the participants recorded dietary intake from 2016 to 2017. Specifically developed nutritional composition databases were used to obtain nutritional data, including macronutrients and food groups, according to previously standardized criteria. PARTICIPANTS/SETTING: Two hundred and seven pediatric patients with CF from six European centers were involved in the My App for Cystic Fibrosis self-management project. MAIN OUTCOME MEASURES: Participants reported dietary intake with a detailed 4-day food record. STATISTICAL ANALYSIS PERFORMED: Descriptive analyses of nutrient intake, food group consumption, and dietary origin of macronutrients were conducted with R software. RESULTS: Similar patterns were found in nutrient and food group intake; both sugar and saturated fatty acids contributed >10% each to the total daily energy intake in all the centers. Large mean and median percent differences were observed in the intake of other nutrient and food groups, because sweets and snacks were consumed once or twice a day, and fruit and vegetables were consumed two or three times a day. Milk, meat, sweets and snacks, and oils were the main sources of fat in all centers. CONCLUSIONS: Study findings indicated less than optimal nutrient profiles, especially for sugars and saturated fatty acids, resulting from the high consumption of meat, dairy, and processed products and low consumption of fish, nuts, and legumes. These results can serve as a basis for future tailored interventions that target improved adherence to nutritional recommendations for patients with CF.

Clinical validation of an evidence-based method to adjust Pancreatic Enzyme Replacement Therapy through a prospective interventional study in paediatric patients with Cystic Fibrosis.

BACKGROUND: A method to adjust Pancreatic Enzyme Replacement Therapy in Cystic Fibrosis is not currently available. OBJECTIVES: To assess the in vivo efficacy of a method to adjust the dose of enzymatic supplement in CF extrapolated from previous in vitro digestion studies (theoretical optimal dose, TOD). Secondly, to assess how individual patient characteristics influence the expected coefficient of fat absorption (CFA) and thus to identify an individual correction factor to improve TOD. METHODS: A prospective interventional study in 43 paediatric patients with CF from 5 European centres. They followed a 24h fixed diet with the theoretical optimal dose for each meal. Faecal collection was carried out between colorimetric markers in order to include all the faeces corresponding to the fixed diet. Beta regression models were applied to assess the associations of individual patient characteristics with the CFA. RESULTS: Median CFA was 90% (84, 94% 1st, 3rd Q.) with no significant differences among centres. Intestinal transit time was positively associated with CFA (p = 0.007), but no statistical associations were found with and age, gender, phenotype or BMI. Regression model showed no improvement of the in vitro predicted theoretical optimal dose when taking individual patient characteristics into account. CONCLUSION: Strict adherence to the theoretical optimal dose of enzymatic supplement for a prescribed meal, led to median CFA levels at the clinical target of 90% with a low variability between patients. The proposed method can be considered as a first approach for an evidence-based method in PERT dosing based on food characteristics. Results have to be confirmed in free dietary settings.

Nutritional status, nutrient intake and use of enzyme supplements in paediatric patients with Cystic Fibrosis; a European multicentre study with reference to current guidelines.

BACKGROUND: The New European guidelines have established the most updated recommendations on nutrition and pancreatic enzyme replacement therapy (PERT) in CF. In the context of MyCyFAPP project - a European study in children with CF aimed at developing specific tools for improvement of self-management - the objective of the current study was to assess nutritional status, daily energy and macronutrient intake, and PERT dosing with reference to these new guidelines. METHODS: Cross sectional study in paediatric patients with CF from 6 European centres. SD-scores for weight-for-age (WFA), height-for-age (HFA) and body mass index-for-age (BMI) were obtained. Through a specific 4-day food and enzyme-dose record, energy and macronutrients intake and PERT-use (LU/g lipids) were automatically calculated by the MyCyFAPP system. Comparisons were made using linear regression models. RESULTS: The lowest quartiles for BMI and HFA were between 0 and -1SD in all the centres with no significant differences, and 33.5% of the patients had a SD-score <0 for all three parameters. The minimum energy intake recommendation was not reached by 40% of the children and mean nutrients intake values were 14%, 51% and 34% of the total energy for protein, carbohydrates and lipids respectively. When assessed per centre, reported PERT doses were in the recommended range in only 13.8% to 46.6% of the patients; from 5.6% up to 82.7% of children were above the recommended doses and 3.3% to 75% were below. CONCLUSION: Among the 6 centres, a large variability and inconsistency with new guidelines on nutrition and PERT-use was found. Our findings document the lack of a general criterion to adjust PERT and suggest the potential benefit of educational and self-managerial tools to ensure adherence to therapies, both for clinical staff and families. They will be taken into account when developing these new tools during the next stages of MyCyFAPP Project.

Usefulness of the conicity index together with the conjoint use of adipocytokines and nutritional-inflammatory markers in hemodialysis patients

Abdominal fat has been recognized as the most hormonally active tissue secreting a variety of adipocytokines and, therefore, potentially contributing to inflammation. The conicity index (Cindex) has been considered a valuable indicator of central obesity. This study aims to relate plasma concentrations of leptin, adiponectin, interleukin-6 (IL-6), and serum C-reactive protein (CRP) with Cindex values in hemodialysis (HD) patients. Cross-sectional study in 45 HD patients (55.6 % men; DM 20 %; mean age, 68.1 year). Cindex and nutritional-inflammatory markers were used for the abdominal fat depot assessment. Patients were classified as having a low or high median Cindex (MCindex): low group (men, <1.39; women, <1.33) and high group (men, ≥1.39; women, ≥1.33). A combination of plasma leptin, IL-6, adiponectin, and CRP was used to design an inflammatory index (Iindex) while a protein-energy wasting index (PEWindex) was calculated from the Iindex plus the malnutrition-inflammation score (MIS). Waist circumference (WC) and Cindex but not BMI were significantly higher in men than in women (p < 0.01). The MCindex was significantly associated with the adipocytokine profile (CRP, leptin, and adiponectin). Patients with a high MCindex had a higher Iindex and PEWindex (p < 0.01). ROC curve analyses measured by area under the curve (AUC) were 0.69 and 0.68 (p < 0.05), for the Cindex and MCindex, respectively, demonstrating the usefulness of the Cindex as an abdominal fat mass biomarker able for wasting-inflamed HD patients. These findings in HD patients underscore the importance of incorporating the evaluation of one abdominal fat indicator, such as the Cindex and an inflammatory biomarker such as the IL-6 and CRP, in substitution of the BMI, in current clinical practice (AU)

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