Association of Ultrasound-Derived Metrics of the Quadriceps Muscle with Protein Energy Wasting in Hemodialysis Patients: A Multicenter Cross-Sectional Study.

This study aimed to assess muscle wasting and risk of protein energy wasting (PEW) in hemodialysis (HD) patients using an ultrasound (US) imaging method. PEW was identified using the ISRNM criteria in 351 HD patients. Quadriceps muscle thickness of rectus femoris (RF) and vastus intermedius (VI) muscles and cross-sectional area (CSA) of the RF muscle (RFCSA) were measured using US and compared with other physical measures. Associations of US indices with PEW were determined by logistic regression. Irrespective of gender, PEW vs. non-PEW patients had smaller RF, VI muscles, and RFCSA (all p < 0.001). US muscle sites (all p < 0.001) discriminated PEW from non-PEW patients, but the RFCSA compared to bio-impedance spectroscopy had a greater area under the curve (AUC, 0.686 vs. 0.581), sensitivity (72.8% vs. 65.8%), and specificity (55.6% vs. 53.9%). AUC of the RFCSA was greatest for PEW risk in men (0.74, 95% CI: 0.66-0.82) and women (0.80, 95% CI: 0.70-0.90) (both p < 0.001). Gender-specific RFCSA values (men < 6.00 cm2; women < 4.47 cm2) indicated HD patients with smaller RFCSA were 8 times more likely to have PEW (AOR = 8.63, 95% CI: 4.80-15.50, p < 0.001). The US approach enabled discrimination of muscle wasting in HD patients with PEW. The RFCSA was identified as the best US site with gender-specific RFCSA values to associate with PEW risk, suggesting potential diagnostic criteria for muscle wasting.

Noninvasive evaluation of muscle mass by ultrasonography of quadriceps femoris muscle in End-Stage Renal Disease patients on hemodialysis.

BACKGROUND & AIMS: Protein-Energy Wasting (PEW) is a pathological condition of renal patients with advanced Chronic Kidney Disease characterized by a progressive reduction of energy and protein assets. Nutritional status assessment, especially for what concerns muscle mass, is essential for both the identification of patients at risk for the development of PEW, as well as monitoring the effects of nutritional interventions. Ultrasound methods are easily applicable at the bedside for quantitative assessment of skeletal muscle. The present study was aimed at evaluating quadriceps rectus femoris thickness (QRFT) and quadriceps vastus intermedius thickness (QVIT) in patients on chronic hemodialysis. METHODS: This was a prospective observational study. Three groups of adult patients were studied: young healthy subjects, well-nourished hospitalized patients with normal renal function, and End-Stage Renal Disease patients on hemodialysis (ESRD-HD). QRFT and QVIT were measured at two sites bilaterally (8 measures/patient) and were compared between groups, and also between subgroups of ESRD-HD patients stratified on the basis of conventional nutritional status parameters. RESULTS: We enrolled 35 healthy subjects, 30 hospitalized patients, and 121 ESRD-HD patients on hemodialysis. QRFT and QVIT of ESRD patients on hemodialysis were lower than those of both control groups (P < 0.001). After stratifying ESRD patients into subgroups based on nutritional variable cut-offs commonly used to define PEW in this clinical setting (BMI [≥ 23 vs <23 kg/m2], albumin [≥3.8 vs <3.8 g/dL]) and malnutrition inflammation score (MIS) status (<6 vs ≥6), QRFT and QVIT of patients with worse nutritional status were significantly lower than those of well-nourished ESRD-HD patients (P value range: <0.001 to <0.05). CONCLUSION: Skeletal muscle ultrasound is a simple and easily applicable bedside technique in the dialysis units, and could represent an adequate tool for the identification of patients with reduced muscle mass.

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.

[Abdominal hemodynamic syndrome in patients with connective tissue dysplasia].

Implications of an protein-energy malnutrition are diagnosed for patients with a dysplasia of a connecting tissue more often than in population (in 69.9% of cases). One of mechanisms is depression of a volume abdominal blood flow against the structural changes of vascular system associated with a dysplasia of a connecting tissue.

Peritoneal dialysis with solutions containing amino acids plus glucose promotes protein synthesis during oral feeding.

Inadequate food intake plays an important role in the development of malnutrition. Recently, an increased rate of protein anabolism was shown in fasting state in patients who were on automated peritoneal dialysis with combined amino acids (AA) and glucose (G) dialysate serving as a source of both proteins and calories. This study investigated the effects of such a dialysis procedure in the daytime in the fed state in patients who were on continuous ambulatory peritoneal dialysis (CAPD). A crossover study was performed in 12 CAPD patients to compare, at 7-d intervals, a mixture of AA (Nutrineal 1.1%) plus G (Physioneal l.36 to 3.86%) versus G only as control dialysate. Whole-body protein turnover was studied by primed constant intravenous infusion of (13)C-leucine during the 9-h dialysis. For meeting steady-state conditions during whole-body protein turnover, frequent exchanges with a mixture of AA plus G were done using an automated cycler. Fed-state conditions were created by identical liquid hourly meals. Using AA plus G dialysate, as compared with the control, rates of protein synthesis increased significantly (2.02 +/- 0.08 versus 1.94 +/- 0.07 mumol leucine/kg per min [mean +/- SEM]; P = 0.039). Rates of protein breakdown and net protein balance did not differ significantly between AA plus G and G. In conclusion, dialysate that contains AA plus G also improves protein synthesis in fed CAPD patients. The use of such a mixture may contribute to long-term improvement of the nutritional status in malnourished CAPD patients with deficient food intake.

The effect of malnutrition on kidney size in children.

Malnutrition is a widespread disorder in children, and ultrasonography is the method of choice to estimate kidney dimensions. Previously, kidney sizes had been studied in healthy newborns and in pediatric patients; however, kidney sizes were not investigated sufficiently in malnourished children. The study group consisted of 74 children with energy malnutrition (marasmus), and the control group consisted of 47 healthy children. Kidney sizes were mesaured by the same radiologist using ultrasonography. The mean age of the marasmic group was 29.6 +/- 14.0 months. Malnourished children had significantly lower kidney length and renal volume but higher relative kidney volume (cm3/body weight) compared with controls (P < 0.05). The mean length and volume of left kidney were higher than those of right kidney in both marasmic and control groups (P < 0.05). The strongest positive correlations were found between body height and kidney length, depth and volume in marasmic group. Regression analysis revealed that height and age of marasmic children had a significant effect on kidney volume; however, only body height had an effect on kidney length. In conclusion, malnourished children had smaller kidney sizes, and body height was the main determinant of their kidney length and volume. The potential long-term detrimental consequences of poor renal growth in malnutrition need to be investigated.

Body fat mass and lean mass as predictors of survival in hemodialysis patients.

A higher body mass index (BMI) is a predictor of better survival in hemodialysis patients, although the relative importance of body fat and lean mass has not been examined in the dialysis population. We performed an observational cohort study in 808 patients with end-stage renal disease on maintenance hemodialysis. At baseline, fat mass was measured by dual-energy X-ray absorptiometry and expressed as fat mass index (FMI; kg/m2). Lean mass index (LMI) was defined as BMI minus FMI. During the mean follow-up period of 53 months, 147 deaths, including 62 cardiovascular (CV) and 85 non-CV fatal events, were recorded. In univariate analysis, LMI was not significantly associated with CV or non-CV death, whereas a higher FMI was predictive of lower risk for non-CV death. Analyses with multivariate Cox models, which took other confounding variables as covariates, indicated the independent associations between a higher LMI and a lower risk of CV death, as well as between a higher FMI and a lower risk of non-CV death. These results indicate that increased fat mass and lean mass were both conditions associated with better outcomes in the dialysis population.

Ultrasonographic gastric emptying in protein energy malnutrition: effect of type of meal and nutritional recovery.

OBJECTIVE AND DESIGN: The earlier reports of disturbed gastric motility in protein energy malnutrition (PEM) point out to its possible contribution in the difficulties faced during nutritional rehabilitation. This study was thus designed to assess the ultrasonographic gastric emptying time (GET) using 20 ml/kg body weight of both liquid and semisolid meals, in 27 patients suffering from PEM as well as in 15 healthy matching infants to delineate any defect present, its degree in different types of PEM and the effect of nutritional rehabilitation. PATIENTS: The patients were recruited from the in-patient department of Children's Hospital, Ain Shams University, Cairo, Egypt. They were divided into three groups: 10 marasmic infants, 10 marasmic kwashiorkor (marasmic KWO) and seven kwashiorkor (KWO) cases. Ultrasonographic GET assessment was carried out within 72 h of admission and 30+/-7 days after nutritional rehabilitation. RESULTS: The gastric half-emptying time T(1/2) of both liquid and semisolid meals was markedly prolonged in patients with marasmus and marasmic KWO. It was more delayed for the semisolid than the liquid meals. This delay was reversible after nutritional rehabilitation of the patients, indicating that it was secondary to the malnourished status. On the other hand, T(1/2) of both liquid and semisolid meals showed no statistically significant delay in the KWO group and nutritional rehabilitation added no further to the results. CONCLUSION: PEM, especially marasmus and marasmic KWO, causes a delay in GET, which is reversible on nutritional recovery. This must be considered during nutritional rehabilitation of such patients to decrease the duration of their hospitalization and thus decrease the morbidity in PEM.

Anasarca and small bowel obstruction secondary to endometriosis.

Intestinal involvement by endometriotic tissue occurs in up to 37% of patients with endometriosis. The vast majority of patients do not experience symptoms related to the gastrointestinal tract. In particular, the complications of intestinal obstruction and malabsorption secondary to endometriosis are exceedingly uncommon. We present a 42-year-old woman with intestinal obstruction, protein-losing enteropathy, and anasarca secondary to endometriosis. She had a 1-year history of watery diarrhea, bloating, and abdominal pain with a 30-lb weight-loss over 3 months. She had no previous history of endometriosis, and laboratory investigations showed severe hypoalbuminemia, hypokalemia, and metabolic acidosis. Abdominal x-rays revealed air-fluid levels and dilated loops of small bowel. She underwent surgical resection with primary anastomosis. Pathologic evaluation showed extensive endometriosis of the small bowel and appendix, which resulted in complete obstruction. Segments of ileum also demonstrated moderate-to-marked blunting of the villi. Postoperatively, the patient had a slow recovery with resolution of anasarca and a gradual increase in her weight. This report illuminates the rare, yet significant, complications of intestinal endometriosis, including small bowel obstruction, the development of a protein-losing enteropathy, and anasarca. One should consider the possibility of intestinal endometriosis in the differential diagnosis of bowel obstruction in women of childbearing age.

[Nutritional status and clinical score of 95 patients examined by radiovideoscopy for deglutition]. / Etat nutritionnel et score clinique de 95 patients explorés en radiovidéoscopie de la déglutition.

Ninety five consecutive patients were examined. One performed swallowing videoradioscopy, swallowing clinical score calculation and nutritional assessment with four different methods: Body Mass Index (BMI), arm muscle circumference, dual frequency bioelectrical impedance analysis and serum albumin level. The easiest and the most reliable method for nutritional assessment, comparing to the others, was BMI, where only weight ant height were necessary to measure. So, the prevalence of protein-energy malnutrition was 24.2%, unlinked neither with the presence of videoradioscopy swallowing disorders nor with clinical swallowing score level. The score level was inversely correlated with the presence of videoradioscopy swallowing disorders, and correlated with feeding types: the highest for per os normal feeding, the lowest for patients with parenteral nutrition. The presence of videoradioscopy swallowing disorders was inversely correlated with feeding types. Swallowing clinical score was validated.

The computed axial tomography of the brain in protein energy malnutrition.

Forty consecutive new cases of protein energy malnutrition were evaluated clinically and biochemically; in addition, the brain morphology was assessed by computed tomography within 24 hours of admission. Cerebral shrinkage was shown in six of 14 (42.9%) cases of marasmus, ten of 14 (71.4%) cases of kwashiorkor, and 11 of 12 (91.7%) cases of marasmic-kwashiorkor. Ventricular dilatation was demonstrated in 57.1% of marasmus cases, 71.4% of kwashiorkor cases and 91.7% of patients suffering from marasmic-kwashiorkor. However, none of the subjects studied showed any changes in the brain stem or cerebellum. Only ten returned 2 months after nutritional rehabilitation for repeat tomograms. None of these repeat tomograms showed any residual morphological changes. The study demonstrated that the brain is affected in all types of malnutrition, albeit in different proportions, but these changes are completely reversible.

[Radiology in the 3d World, illness, hunger, violence]. / Radiologie in der 3. Welt, Krankheit, Hunger, Gewalt.

Parasitoses, perinatal X-ray diagnostics, hunger, war, and torture produce X-Ray findings that are hardly known in Western and Central Europe. X-ray diagnostics in the 3rd world are often decisive for the diagnosis due to the lack of other methods. X-ray diagnostics offers many possibilities but is often not available or available only for few.

Cardiac function in malnourished children.

The cardiovascular status of severely malnourished children was characterized before, during, and after nutritional rehabilitation. In most children with third-degree malnutrition, cardiac mass was decreased on admission to the hospital and recovered subsequent to nutritional therapy. All children had echocardiographic and Doppler measurements indicative of impaired ventricular function which significantly improved during the course of hospitalization, as evidenced in part by the change in fractional shortening (P = 0.015), mean velocity of circumferential fiber shortening (P = 0.038), and systolic time interval (P = 0.030). We conclude that children with primary third-degree malnutrition not only have cardiac muscle wasting, but also have inherent ventricular dysfunction as the result of severe malnutrition that responds to nutritional therapy. Particular care with fluid administration is imperative in the first week of therapy, when heart function is the most compromised.

[Alimentary, metabolic and toxic osteopathies in adults]. / Alimentäre, metabolische und toxische Osteopathien bei Erwachsenen.

Skeletal changes in deficient or badly balanced nutrition (alimentary osteopathies) and osseous changes accompanying chronic disease of internal organs and metabolic disorders (metabolic osteopathies) are discussed. Basically, the classical generalised skeletal changes such as osteoporosis, osteomalacia, fibroosteoclacia and sclerosis of the bone can occur in their pure form or as a combination of two ore more of these disorders. Finally the exogenic toxic osteopathies are discussed, nowadays fluorosis being the most important. Other external factors may be drugs such as methotrexate and antiepileptic medications.

Cerebral atrophy in infants with protein energy malnutrition.

Central nervous system manifestations are common in infants suffering from protein energy malnutrition. Computed tomography was used to search for pathology in the brain that might explain these symptoms. Subjects were 40 infants with protein malnutrition. All had mental symptoms. The bifrontal index was taken as the best parameter for measuring central atrophy, and the width of the sylvian fissure was used as the parameter for cortical atrophy. Ventricular dilatation and widened sylvian fissure of various degrees were found in every patient. The severity of atrophy correlated with the duration of the illness.

A radiographic method of quantifying protein-calorie undernutrition.

Estimation of midarm adipose tissue and muscle by the anthropometric technique is based on the idealized assumption that the arm and its muscle compartments are circular, and that fat is distributed evenly around the arm. We examined the validity of these assumptions by computerized axial tomography of the midarm in 21 subjects ranging from 65 to 255% of ideal body weight. Computerized axial tomography identified three errors inherent in the anthropometric method: 1) The arm and its muscle compartment were rarely circular, but resembled instead an ellipse and "cloverleaf", respectively; 2) fat was distributed asymmetrically around the arm, and furthermore when triceps skinfold was less than 5 mm, no fat was radiographically detectable, and 3) muscle are calculated by the anthropometric method includes bone area. Since bone area was not influenced by nutritional status, anthropometric "muscle area" underestimated the degree of muscle atrophy in undernutrition. Despite these limitations, in subjects 60 to 120% of ideal body weight anthropometric estimates of midarm muscle area (MAMA) and fat area did not differ greatly from the radiographic values. Anthropometric MAMA was consistently greater than the radiographic value by 15 to 25%, while midarm fat area agreed within +/- 10%. The error in the anthropometric MAMA could be nearly eliminated by two types of correction: expressing MAMA as a percentage of normal, and correcting for bone content by subtracting midarm bone area (6.3 and 4.7 cm2 for men and women). In subjects greater than 150% ideal body weight, however, anthropometric estimates of MAMA and midarm fat area differed from the radiographic values by greater than 50% even after the above two types of correction. Midarm computerized axial tomography scan provides an accurate alternative to the anthropometric method for estimating midarm muscle and fat in these obese individuals.