Study on the correlation between bioelectrical impedance analysis index and protein energy consumption in maintenance dialysis patients.

BACKGROUND: Protein-energy wasting (PEW) has been reported to be pretty common in maintenance dialysis patients. However, the existing PEW diagnostic standard is limited in clinical use due to the complexity of it. Bioelectrical impedance analysis (BIA), as a non-invasive nutritional assessment method, can objectively and quantitatively analyze the changes of body tissue components under different nutritional states. We aim to explore the association between PEW and BIA and establish a reliable diagnostic model of PEW. METHODS: We collected cross-sectional data of 609 maintenance dialysis patients at the First Affiliated Hospital, College of Medicine, Zhejiang University. PEW was diagnosed according to International Society of Renal Nutrition and Metabolism (ISRNM) criteria. Among them, 448 consecutive patients were included in the training set for the establishment of a diagnostic nomogram. 161 consecutive patients were included for internal validation. 52 patients from Zhejiang Hospital were included for external validation of the diagnostic model. Correlation analysis of BIA indexes with other nutritional indicators was performed. Logistic regression was used to examine the association of BIA indexes with PEW. 12 diagnostic models of PEW in maintenance dialysis patients were developed and the performance of them in terms of discrimination and calibration was evaluated using C statistics and Hosmer-Lemeshow-type χ2 statistics. After comparing to existing diagnostic models, and performing both internal and external validation, we finally established a simple but reliable PEW diagnostic model which may have great value of clinical application. RESULTS: A total of 609 individuals from First Affiliated Hospital, College of Medicine, Zhejiang University and 52 individuals from Zhejiang Hospital were included. After full adjustment, age, peritoneal dialysis (compared to hemodialysis), subjective global assessment (SGA, compared to non-SGA) and water ratio were independent risk factors, while triglyceride, urea nitrogen, calcium, ferritin, BCM, VFA and phase angle were independent protective factors of PEW. The model incorporated water ratio, VFA, BCM, phase angle and cholesterol revealed best performance. A nomogram was developed according to the results of model performance. The model achieved high C-indexes of 0.843 in the training set, 0.841 and 0.829 in the internal and external validation sets, respectively, and had a well-fitted calibration curve. The net reclassification improvement (NRI) showed 8%, 13%, 2%, 38%, 36% improvement of diagnostic accuracy of our model compared with "PEW score model", "modified PEW score model", "3-index model", "SGA model" and "BIA decision tree model", respectively. CONCLUSIONS: BIA can be used as an auxiliary tool to evaluate PEW risk and may have certain clinical application value.

Is There a Need to "Modernize" and "Simplify" the Diagnostic Criteria of Protein-Energy Wasting?

Protein energy wasting(PEW) is a term that most nephrologists used to define nutritional disorders in patients with acute kidney injury and chronic kidney disease. Although this nomenclature is well implemented in the field of nephrology, the use of other terms such as cachexia or malnutritionin the majority of chronic diseases can induce confusion regarding the definition and interpretation of these terms. There is ample evidence in the literature that the pathways involved in cachexia/malnutrition and PEW are common. However, in kidney diseases, there are pathophysiological conditions such as accumulation of uremic toxins, and the use of dialysis, which may induce a phenotypic specificity justifying the original term PEW. In light of the latest epidemiologic studies, the criteria for PEW used in 2008 probably need to be updated. The objective of this review is to summarize the main mechanisms involved in cachexia/malnutrition and PEW. We discuss the need to modernize and simplify the current definition and diagnostic criteria of PEW. We consider the interest of proposing a specific nomenclature of PEW for children and elderly patients with kidney diseases.

Deconstructing Disease-Related Malnutrition: A New Assessment Framework for Clinical Practice.

Protein-energy wasting (PEW) is a key cause of functional impairment and poor health outcomes in people with chronic kidney disease. While PEW can be mitigated with nutrition therapy, it is a complex myriad of disorders with numerous interacting etiologies and corresponding presentations, which make it difficult to diagnose and manage in practice. A variety of scoring rubrics have been developed to facilitate malnutrition assessment. Although these tools have greatly benefited the recognition and treatment of PEW, the typical format of grading specified PEW indicators has the potential to overlook or overstate highly relevant individual-specific factors. This review presents a simple framework for malnutrition assessment that can be used to complement and evaluate conventional assessment tools. Unlike standard tools, which are designed to identify and rate malnutrition risk and severity, the malnutrition framework is conceptual model that organizes PEW assessment into three distinct, but interacting facets of PEW risk: nutrient balance, nutrition status, and malnutrition risk. The new framework encourages critical thinking about PEW risk that may help clinicians plan and interpret assessments to efficiently and effectively manage this condition.

[Effect of hemoperfusion on protein energy wasting and long-term prognosis in patients on maintenance hemodialysis].

Objective: To explore the effect of hemoperfusion (HP) combined with hemodialysis (HD) (HD+HP) on protein energy wasting (PEW) and long-term prognosis in patients on maintenance HD (MHD). Methods: A prospective multicenter cohort study was conducted. Adult MHD patients who completed PEW assessment and underwent regular dialysis between July 2015 and July 2021 at 23 hemodialysis centers in Guizhou Province were selected. Demographic characteristics, physical indicators, laboratory indicators, 3-day diet diary and HP treatment data of the subjects were collected. The patients were divided into different groups according to the presence or absence of HP, the frequency of HP treatment and the type of cartridge, and then relevant indicators were compared. Multivariate logistic regression model and Cox proportional regression model were used to analyze the influence of HP treatment on PEW risk in MHD patients. Meanwhile, Kaplan-Meier method was used to plot the survival curve. Results: A total of 4 623 MHD patients (2 789 males and 1 834 females) aged (53.7±15.9) years were included in the study, with a median dialysis age of 64.3 (44.3, 92.3) months. There were 3 429 (74.2%) MHD patients treated with HD+HP, and 1 194 patients (25.8%) were not treated with HP. According to the 2008 diagnostic criteria of the International Society for Renal Nutrition and Metabolism (ISRNM), the incidence of PEW was 26.0% (1 204/4 623). Multivariate logistic regression analysis showed that female (OR=2.48, 95%CI: 1.55-3.95, P<0.001), diabetes (OR=1.75, 95%CI: 1.08-2.83, P=0.024) and high-sensitivity C-reactive protein (hs-CRP) (OR=1.02, 95%CI: 1.01-1.03, P=0.003) were risk factors for PEW, while treatment with HD+HP (OR=0.51, 95%CI: 0.31-0.87, P=0.012) and elevated triglyceride levels (OR=0.62, 95%CI: 0.48-0.80, P<0.001) were protective factors. Cox hazard ratio regression showed that among different HP treatment frequencies and cartridge types, 2 times/month (HR=0.40, 95%CI: 0.17-0.95, P=0.037), 3 times/month (HR=0.44, 95%CI: 0.23-0.85, P=0.014), 4 times/month (HR=0.54, 95%CI: 0.34-0.85, P=0.008), HA130 (HR=0.57, 95%CI: 0.36-0.89, P=0.014) and HA230 (HR=0.30, 95%CI: 0.15-0.63, P=0.001) had protective effects on the occurrence of PEW in MHD patients. The all-cause mortality rate was 11.3% (521/4 623) at 33 (24, 48) months of follow-up. Kaplan-Meier analysis showed that patients undergoing 4 times/month HP treatment (χ2=36.78, P<0.001) and using HA230 (χ2=9.46, P=0.002) had the highest survival rate. Conclusion: Treatment with HD+HP is a protective factor for PEW in patients with MHD, and 4 times/month HP treatment or HA230 significantly reduces the risk of PEW and all-cause mortality in patients with MHD.

The ability of the Global Leadership Initiative on Malnutrition (GLIM) to diagnose protein-energy malnutrition in patients requiring vascular surgery: a validation study.

Identifying nutritional deficits and implementing appropriate interventions in patients requiring vascular surgery is challenging due to the paucity of appropriate screening and assessment tools in this group. This retrospective study aimed to determine the validity of the Global Leadership Initiative on Malnutrition (GLIM) in identifying protein-energy malnutrition (PEM) in inpatients admitted to a vascular surgery unit, using the PG-SGA as the comparator. Diagnostic accuracy and consistency were determined between the GLIM and the Patient-Generated Subjective Global Assessment (PG-SGA) global rating. The GLIM determination was made retrospectively using the relevant parameters collected at baseline in the original study. Two hundred and twenty-four (70·1 % male) participants were included. The prevalence of PEM was 28·6 % on GLIM and 17 % via the PG-SGA. Compared with the PG-SGA, the GLIM achieved sensitivity of 73·7 % and specificity of 80·6 %; however positive predictive value was 43·7 % indicating that the GLIM over-diagnosed malnutrition compared with the PG-SGA. Kappa reached 0·427 indicating moderate diagnostic consistency. Due to the absence of an ideal instrument and the complexity of malnutrition often seen in this group which extends beyond PEM to significant micronutrient deficiencies, further work is required to determine the most appropriate instrument in this patient group, and how micronutrient status can also be included in the overall assessment given the critical role of micronutrients in this group.

Interactive effects of vitamin D and serum uric acid concentration on protein-energy wasting in maintenance hemodialysis patients.

This study aimed to explore the influence of the interaction between vitamin D level and blood uric acid level on protein-energy wasting (PEW) in patients with Maintenance hemodialysis (MHD), in order to provide a solution for disease prevention. For this aim, a total of 150 patients with maintenance hemodialysis aged 30-79 years in a hospital were included in the study. The logistic regression model was used to analyze the relationship between vitamin D level, blood uric acid level and PEW, and the additive interaction was evaluated by calculating the relative excess risk ratio (RERI) attributive ratio (AP) and synergy index (S) of the interaction. Finally, the ROC curve was drawn to evaluate the diagnostic value of vitamin D level and blood uric acid level for PEW. In this study, the detection rate of PEW was 68%, low vitamin D level was 57.33%, and high blood uric acid level was 64.67%. Compared with non-low vitamin D levels, the PEW risk was OR=16.794, 95%CI: 4.973-60.356; Compared with those without high uric acid levels, the PEW risk was OR=7.599, 95%CI: 2.460-23.468. However, there was no multiplicative interaction between the two on PEW risk (OR=0.345, 95%CI: 0.060-1.983, P=0.233). In the additive interaction analysis, the PEW risk OR=43.992,95%CI: 12.795-151.253, higher than those with only high uric acid levels or only low vitamin D levels, the combination of the two had a summative interaction with PEW risk, with a RERI of 20.599 (95%CI: -26.158-67.356) API was 0.468 (-0.159-1.095) and S was 1.920 (0.569-6.483). In conclusion, both vitamin D deficiency and high uric acid levels were associated with an increased risk of PEW in MHD patients, and low vitamin D and high uric acid levels had a summative interaction with protein-energy expenditure risk.

Evolving Concepts on Inflammatory Biomarkers and Malnutrition in Chronic Kidney Disease.

While patient care, kidney replacement therapy, and transplantation techniques for chronic kidney disease (CKD) have continued to progress, the incidence of malnutrition disorders in CKD appears to have remained unchanged over time. However, there is now a better understanding of the underlying pathophysiology according to the disease background, disease stage, and the treatment received. In CKD patients, the increased production of proinflammatory cytokines and oxidative stress lead to a proinflammatory milieu that is at least partially responsible for the increased morbidity and mortality in this patient population. New insights into the pathogenic role of innate immunity and the proinflammatory cytokine profile, characterized, for instance, by higher levels of IL-6 and TNF-α, explain some of the clinical and laboratory abnormalities observed in these patients. In this article, we will explore currently available nutritional-inflammatory biomarkers in distinct CKD populations (hemodialysis, peritoneal dialysis, transplantation) with a view to evaluating their efficacy as predictors of malnutrition and their involvement in the common proinflammatory process. Although there is a direct relationship between inflammatory-nutritional status, signs and symptoms [e.g., protein-energy wasting (PEW), anorexia], and comorbidities (e.g., atheromatosis, atherosclerosis), we are in need of clearly standardized markers for nutritional-inflammatory assessment to improve their performance and design appropriate bidirectional interventions.

Prevalence of Protein-Energy Wasting in Dialysis Patients Using a Practical Online Tool to Compare with Other Nutritional Scores: Results of the Nutrendial Study.

This cross-sectional study aims to explore the prevalence of protein-energy wasting (PEW) in dialysis patients in Catalonia, Spain, using a new and practical online tool which enables rapid calculation and comparison with other nutritional scores. METHODS: A web tool (Nutrendial) was created to introduce different variables and automatically calculate PEW, Malnutrition inflammation Score (MIS) and Subjective Global Assessment (SGA) in 1389 patients (88% in haemodialysis (HD)), 12% in peritoneal dialysis (PD) from different regions of Catalonia. RESULTS: A prevalence of 23.3% (26% HD, 10.2% PD) of PEW was found, with a mean MIS score of 6 and SGA score of C in 7% of the patients. ROC analysis showed MIS as the best nutritional score to diagnose PEW (AUC 0.85). Albumin delivered lower diagnostic precision (AUC 0.77) and sensitivity (66%). A cut off point of 7 (86% sensitivity and 75% specificity) for MIS and 3.7 mg/dL for albumin were found to predict the appearance of PEW in this population. SGA B or C showed an 87% sensitivity and 55% specificity to diagnose PEW. Very low nutritional intervention (14%) was recorded with this tool in patients with PEW. CONCLUSIONS: This new online tool facilitated the calculation of PEW, enabling different professionals-including nephrologists, dieticians and nurses-to efficiently obtain insights into the nutritional status of the Catalonian dialysis population and implement the required nutritional interventions. MIS is the score with more sensitivity to diagnose PEW.

Effects of oral non-protein calorie supplements on nutritional status among maintenance hemodialysis patients with protein-energy wasting: a multi-center randomized controlled trial.

Protein-energy wasting (PEW) is prevalent in maintenance hemodialysis (MHD) patients, and is one of the major risk factors for poor outcomes and death. This study aimed to investigate the effects of non-protein calorie supplements on the nutritional status of MHD patients with PEW. MHD patients with PEW were enrolled in this multi-center, open-label, randomized controlled trial. Then, they were randomly assigned to the intervention group to receive the non-protein calorie supplements containing 280 kcal of energy every day for 6 months or the control group to complete all aspects of the study without receiving supplements. Patients in both groups received dietary counselling from dietitians. Data on nutritional assessments, anthropometric measurements, blood analysis and dietary recall were collected at the baseline and at six months from both groups. Statistical analyses were performed using analysis of covariance (ANCOVA) adjusted for sex and baseline values. Ninety-two MHD patients completed the study. A significant increase in the subjective global assessment (SGA) score was found in the intervention group compared with the control group (4.88 ± 1.41 vs. 4.40 ± 1.16, p = 0.044). The ratio of PEW patients (diagnosed with SGA ≤5) in the intervention group (61.2%) was also significantly lower than that in the control group (83.7%) (p < 0.001). Moreover, significant improvements in body mass index (20.81 ± 2.46 kg m-2vs. 19.51 ± 2.60 kg m-2, p < 0.001), nutrition risk screening 2002 (2.45 ± 1.40 vs. 3.12 ± 1.37, p = 0.038), mid-upper arm circumference (23.30 ± 2.78 cm vs. 21.75 ± 2.87 cm, p = 0.001), and mid-arm muscle circumference (20.51 ± 2.32 cm vs. 19.06 ± 2.92 cm, p = 0.005) were observed in the intervention group compared with the control group. Patients in the intervention group took in more dietary energy than the control group (26.96 ± 4.75 kcal per kg body weight per day vs. 24.33 ± 2.68 kcal per kg body weight per day, p < 0.001). In conclusion, non-protein calorie supplements may improve the nutritional status of MHD patients with PEW.

Severity of protein-energy wasting and obesity are independently related with poor quality of life in peritoneal dialysis patients / La severidad del desgaste energético-proteico y la obesidad se relacionan independientemente con la mala calidad de vida en pacientes de diálisis peritoneal

Protein-energy wasting (PEW) and poor health-related quality of life (HRQoL) are independently associated with morbi-mortality in continuous ambulatory peritoneal dialysis (CAPD). PEW may reduce HRQoL; however, we hypothesized HRQoL is affected differentially by PEW degrees or by individual criteria of nutritional status.Aim: To evaluate HRQoL according to PEW severity and nutritional status indicators in CAPD.This is a cross-sectional study in 151 patients. Subjective global assessment (SGA) was employed, and nutritional status classified as normal, mild-moderate PEW, and severe PEW. HRQoL was evaluated using Kidney Disease Quality of Life Short Form™, including physical (PCS), mental (MCS) and kidney disease (KDCS) components, and their subscales. Dietary intake, anthropometric and biochemical variables were measured.Forty-six percent of patients were well-nourished, 44% had mild-moderate PEW, and 10% severe PEW. Compared with well-nourished patients, those with mild-moderate (p=0.06) and severe (p=0.005) PEW had lower HRQoL score [68 (52–75), 55 (45–72), 46 (43–58), respectively]. PCS, MCS, and KDCS and their subscales had lower values as PEW was more severe. Patients with obesity and hypoalbuminemia had significantly lower HRQoL overall and component scores than their counterparts. Dietary intake was not associated with quality of life. In multivariate analysis obesity, PEW (by SGA), hypoalbuminemia, and low educational level predicted poor HRQoL (χ2 58.2, p<0.0001).As conclusion, PEW severity was related with worse HRQoL, either as overall score or in every component or subscale in CAPD patients. Poor HRQoL was predicted independently by PEW severity and obesity; additional predictors were hypoalbuminemia and low education. (AU)

El desgaste proteico-energético (DEP) y la mala calidad de vida relacionada con la salud (CVRS) se asocian de forma independiente con la morbimortalidad en diálisis peritoneal continua ambulatoria (DPCA). El DEP puede reducir la CVRS; sin embargo, planteamos la hipótesis de que la CVRS se ve afectada de forma independiente por los grados de DEP o por los criterios individuales del estado nutricional. Objetivo : Evaluar la CVRS de acuerdo a la gravedad de la DEP e indicadores del estado nutricional en DPCA.Este es un estudio transversal en 151 pacientes. Se empleó la evaluación global subjetiva (EGS) y el estado nutricional se clasificó como normal, DEP leve-moderada y DEP grave. La CVRS se evaluó mediante el uso del cuestionario Kidney Disease Quality of Life Short Form™, incluidos los componentes físicos (PCS), mentales (MCS) y de enfermedad renal (KDCS) y sus subescalas. Se midieron la ingesta dietética, las variables antropométricas y bioquímicas.El 46% de los pacientes tenía un estado nutricional normal, el 44% tenía DEP leve-moderada y el 10% DEP grave. En comparación con los pacientes bien nutridos, aquellos con DEP leve-moderada (p=0,06) y grave (p=0,005) tenían una puntuación de CVRS más baja (68 [52-75], 55 [45-72], 46 [43-58], respectivamente). Igualmente, la PCS, MCS y KDCS y sus subescalas tuvieron valores más bajos, conforme la DEP fue más severa. Los pacientes con obesidad e hipoalbuminemia tenían puntuaciones de CVRS general y de sus componentes significativamente más bajas que sus contrapartes. La ingesta dietética no se asoció con la calidad de vida. En el análisis multivariado la obesidad, el DEP (por EGS), la hipoalbuminemia y el bajo nivel educativo predijeron una mala CVRS (χ2 58,2; p<0,0001).En conclusión, la gravedad del DEP se relacionó con una peor CVRS, ya sea como puntuación global o en cada componente o subescala de los pacientes con DPCA. ... (AU)

The Relation of Serum Dehydroepiandrosterone Sulfate Level to Protein Energy Wasting in Hemodialysis Patients.

Protein-energy wasting (PEW) is a major risk for morbidity and mortality in hemodialysis (HD) patients. The change in the concentration of dehydroepiandrosterone sulfate (DHEA-S) may play a role in PEW. The aim of this work was to study the possible relationship between serum DHEA-S levels and various nutritional and inflammatory parameters in a cohort of HD patients. In total, 78 HD patients (47 males and 31 females) were included in this crosssectional observational study. In addition to taking their history, clinical examinations, and routine laboratory investigations, the nutritional status was assessed, and their serum DHEA-S was measured. Nutritional status was assessed by anthropometric measures, bioelectrical impedance analysis, malnutrition inflammation scores, and subjective global assessments. A diagnosis of malnutrition was made based on the recommendations of the International Society of Renal Nutrition and Metabolism. The relationship between DHEA-S and various nutritional parameters was analyzed. Eighteen patients (23.1%) suffered from PEW. Those with PEW had a longer duration of HD (P = 0.04), and lower serum levels of creatinine (P = 0.003), hemoglobin (P = 0.01), albumin (P <0.0001), cholesterol (P = 0.02), and DHEA-S (P = 0.01). Among the variables, serum DHEA-S levels were significant predictors of PEW in this cohort (odds ratio: 0.976; 95% confidence interval: 0.954-1.0; P = 0.04). PEW is frequently encountered in HD patients. Decreased serum DHEA-S levels were associated with PEW in male HD patients. Further studies are needed to assess the effect of hormone supplementation on this serious disorder in HD patients.

Malnutrition screening and diagnosis tools: Implications for practice.

Despite the prevalence of protein-calorie malnutrition (PCM) in acute-care hospitals and long-term care centers, a national and global consensus on nutrition screening and malnutrition diagnosis is lacking. PCM is associated with various acute and chronic complications, such as impaired wound healing, increased risk for infection, debility, and increased risk for rehospitalization. The consequences of PCM are also incredibly costly to both the patient and the healthcare facility. The purpose of this paper is to identify nutrition screening tools and malnutrition diagnosis tools currently being utilized in acute-care healthcare centers across the United States.

Development of a protein energy malnutrition screening tool for older Thais in public residential homes.

OBJECTIVE: This study aimed to develop and validate protein energy malnutrition (PEM) screening tool for older adults in public residential homes, and to test its practicality. DESIGN: This cross-sectional study consisted of two phases: tool development/validation and tool practicality evaluation. In Phase 1, the questionnaire was developed based on literature review and tested for content validity. Older residents were interviewed using this questionnaire to identify potential PEM risk factors. A 24-h recall was used to collect dietary data, and body composition and serum albumin were measured. In Phase 2, practicality of new PEM screening tool was evaluated by intended users. Data were analysed by χ2 test, Fisher's exact test, t-test, Mann-Whitney U test and multiple logistic regression. Akaike Information Criterion (AIC) was used to estimate the best fit model. SETTING: Four public residential homes in central region, Thailand. PARTICIPANTS: 249 older residents residing in public residential homes and eight intended users. RESULTS: 26·9 % had PEM (serum albumin <3·5 g/dl). According to multiple logistic regression and AIC values, PEM predictors were having pressure ulcer, experiencing significant weight loss and taking ≥ 9 types of medicine daily. These predictors were included in PEM screening tool. Regarding the tool performance test, area under the ROC curve was 0·8 (P < 0·001) with sensitivity and specificity of 83·9 and 45·5 %, respectively. For its practicality, eight intended users reported that it was useful and easy to use. CONCLUSIONS: New screening tool may be capable of identifying PEM in older residents, and further testing is required before being recommended for use.

Independent Determinants of Appetite Impairment among Patients with Stage 3 or Higher Chronic Kidney Disease: A Prospective Study.

Protein-energy wasting (PEW) is an important complication resulting from chronic kidney disease (CKD). Appetite impairment contributes significantly to PEW in these patients, but risk factors associated with having appetite impairment in patients with CKD remain elusive. Patients with an estimated glomerular filtration rate <60 mL/min/1.73 m2 for ≥2 times at least three months apart were prospectively enrolled during 2017, with their demographic features, comorbidities, anthropometric parameters, physical and performance indices, functional status, frailty, sensory organ integrity, and laboratory data collected. Their appetite status was measured using the Council on Nutrition Appetite Questionnaire (CNAQ). We examined independent determinants of appetite impairment in these CKD patients using multiple regression analyses. Among 78 patients with CKD, 42.3% had CNAQ-identified impaired appetite. Those with an impaired appetite also had poorer physical performance, a higher degree of functional impairment, higher frail severities, lower serum sodium levels, less intact oral cavity, and a trend toward having less intact nasal structures than those without. Multiple regression analyses revealed that a higher frail severity, in the forms of increasing Study of Osteoporotic Fractures (SOF) scores (odds ratio (OR), 2.74; 95% confidence interval (CI), 1.15-6.57) and a less intact nasal structure (OR, 0.96; 95% CI, 0.92-0.995) were associated with a higher probability of having an impaired appetite, while higher serum sodium (OR, 0.76; 95% CI, 0.6-0.97) correlated with a lower probability. Based on our findings, in patients with CKD, the severity of frailty, serum sodium, and nasal structural integrity might modify appetite status. Therapies targeting these factors might be beneficial for appetite restoration in patients with CKD.

Overcoming protein-energy malnutrition in older adults in the residential care setting: A narrative review of causes and interventions.

Malnutrition, in particular protein-energy malnutrition, is a highly prevalent condition in older adults, and is associated with low muscle mass and function, and increased prevalence of physical frailty. Malnutrition is often exacerbated in the residential care setting due to factors including lack of dentition and appetite, and increased prevalence of dementia and dysphagia. This review aims to provide an overview of the available literature in older adults in the residential care setting regarding the following: links between sarcopenia, frailty, and malnutrition (in particular, protein-energy malnutrition (PEM)), recognition and diagnosis of malnutrition, factors contributing to PEM, and the effectiveness of different forms of protein supplementation (in particular, oral nutritional supplementation (ONS) and protein-fortified foods (PFF)) to target PEM. This review found a lack of consensus on effective malnutrition diagnostic tools and lack of universal requirement for malnutrition screening in the residential care setting, making identifying and treating malnutrition in this population a challenge. When assessing the use of protein supplementation in the residential care setting, the two primary forms of supplementation were ONS and PFF. There is evidence that ONS and PFF increase protein and energy intakes in residential care setting, yet compliance with supplementation and their impact on functional status is unclear and conflicting. Further research comparing the use of ONS and PFF is needed to fully determine feasibility and efficacy of protein supplementation in the residential care setting.

Avaliação do estado nutricional em relação à presença de cárie dentária em crianças de 4 a 6 anos do município de Cajamar - São Paulo / Evaluation of the nutritional status in relation to the presence of dental caries in children aged 4 to 6 years in the city of Cajamar - São Paulo

Este artigo tem como objetivo avaliar o estado nutricional em relação à presença de cáries dentárias em crianças de 4 a 6 anos de idade, do município de Cajamar, São Paulo. Trata-se de estudo transversal com crianças entre 4 a 6 anos (n=1642), acompanhadas pelo Programa Saúde na Escola (PSE) do Município de Cajamar, São Paulo. A classificação do estado nutricional foi baseada no Índice de Massa Corporal (IMC) e a avaliação das condições bucais, por meio do índice ceo-d e critério para Risco de Cárie. A análise do estado nutricional, faixa etária e sexo conforme o número de cáries, foi feita por meio dos testes Mann-Whitney U e Kruskal-Wallis (p<0,05). Observou-se maior prevalência de meninos entre 4 a 6 anos. Em todas as faixas etárias a prevalência de excesso de peso foi de aproximadamente 30% e eutrofia em torno de 70%. 65% (n=1068) das crianças não apresentavam risco de cárie (A) e 28,8% (n=475), alto risco (D, E e F). Das 1162 crianças sem cáries, 0,2% eram magras (n=2), 67,2% (n=781) eutróficas e 32,7% (n=380) possuíam excesso de peso. A frequência de 1 a 5 cáries maior entre meninas e de 6 ou mais cáries, entre meninos. Segundo estado nutricional, o número médio do número de cáries foi de 2,17 para magreza, 0,93 para eutrofia e 0,65 para excesso de peso (p<0,010). Conclui-se que houve diferença entre número cáries e estado nutricional, na qual crianças com déficit nutricional apresentavam maior número de cáries dentárias comparadas às eutróficas ou com excesso de peso, sugerindo-se a inclusão do estado nutricional na avaliação odontológica.

This article aims at evaluating the nutritional status in relation to the presence of dental caries in children aged 4 to 6 years in the city of Cajamar, in the state of São Paulo. It is a cross-sectional study with children aged 4 to 6 years (n=1642) accompanied by the School Health Program of the City of Cajamar, São Paulo. The nutritional status classification was based on the Body Mass Index (BMI) and the evaluation of oral conditions, through the ceo-d index, and criteria for risk for caries. The analysis of the nutritional status, age, and sex according to the number of caries was made through the Mann-Whitney U and Kruskal-Wallis tests (p<0.05). A higher prevalence was observed among boys aged 4 to 6 years. In all age groups, there was a prevalence of 30% of overweight children, and eutrophy of approximately 70%. A total of 65% (n=1068) of the children presented no risk of caries (A), whereas 28.8% (n=475) showed high risk (D, E, and F). Among the 1162 children with no caries, 0.2% were thin (n=2); 67.2% (n=781) eutrophic; and 32.7% (n=380) were overweight. Girls presented a higher frequency of 1 to 5 caries while boys presented frequency of having 6 or more caries. According to the nutritional status, the average number of caries was 2.17 for thin individuals; 0.93 for eutrophic individuals; and 0.65 for overweight individuals (p<0.010). It could be concluded that there was a difference between the number of caries and the nutritional status, in which children with nutritional deficit presented a higher number of dental caries when compared to eutrophic or overweight ones, suggesting the inclusion of the nutritional status in the dental evaluation.

Easy clinical predictor for low BCAA to tyrosine ratio in chronic liver disease patients with hepatocellular carcinoma: Usefulness of ALBI score as nutritional prognostic marker.

BACKGROUND/AIM: Low branched-chain amino acid (BCAA) to tyrosine ratio (BTR) is known as an indicator of amino acid imbalance. We elucidated usefulness of newly developed albumin-bilirubin (ALBI) score as alternative methods of BTR in patients with naïve hepatocellular carcinoma (HCC) retrospectively. MATERIALS/METHODS: In 842 patients with HCC and without BCAA supplementation (71 years, male 614, Child-Pugh A:B:C = 689:116:37), relationships among BTR and clinical features were evaluated. Of those, 438 patients, with Milan criteria HCC, treated curatively were divided into the high-BTR (>4.4) (n = 293) and low-BTR (≤4.4) (n = 145) groups. The prognostic value of BTR was evaluated using inverse probability weighting (IPW) with propensity score. RESULTS: The low-BTR group showed worse prognosis than the other (3-, 5-, 10-year overall survival rates: 88.9% vs. 86.3%/70.5% vs. 78.1%/38.1% vs. 52.3%, respectively; p < 0.001). Multivariate Cox-hazard analysis adjusted for IPW showed elderly (≥65 years) HR 2.314, p = 0.001), female gender (HR 0.422, p < 0.001), ECOG PS ≥2 (HR 3.032, p = 0.002), low platelet count (HR 1.757, p = 0.010), and low BTR (≤4.4) (HR 1.852, p = 0.005) to be significant prognostic factors. Both serum albumin level (r = 0.370, p < 0.001) and ALBI score (r = -0.389, p < 0.001) showed a significant relationship with BTR. Child-Pugh class B, modified ALBI grade (mALBI) 2a, and mALBI 2b predictive values for BTR were 3.589, 4.509, and 4.155 (AUC range: 0.735-0.770), respectively, while the predictive value of ALBI score for low-BTR (≤4.4) was -2.588 (AUC 0.790). CONCLUSION: ALBI score -2.588 was a predictor for low-BTR (≤4.4), which was prognostic factors for early HCC patients, and at least patients with mALBI 2b might have an amino acid imbalance.

Revisión crítica de los criterios GLIM / A critical review of the GLIM criteria

La desnutrición relacionada con la enfermedad es un síndrome frecuente en la práctica clínica, en el que se observa la mutua relación entre enfermedad y desnutrición. Es una forma específica de desnutrición con causas distintas a la pobreza y a problemas sociales que dificultan la distribución de alimentos. La inflamación, la anorexia, los cambios en composición corporal o en requerimientos energéticos y proteicos contribuyen al desarrollo de la desnutrición relacionada con la enfermedad. Esta se asocia a un aumento de morbilidad, mortalidad y gasto económico. Existen numerosas herramientas para identificar a pacientes con riesgo de desnutrición, pero hasta ahora no existía un consenso generalizado sobre los criterios diagnósticos de desnutrición. Los criterios GLIM proporcionan un sistema diagnóstico que ha sido aceptado por las principales sociedades científicas internacionales en el campo de la nutrición clínica. En este artículo describimos su desarrollo, su aplicación en distintas poblaciones de enfermos y su comparación con otros criterios o herramientas diagnósticas diferentes que contribuyen a su validación. Esto permite señalar las ventajas y limitaciones que se han descrito hasta ahora con el uso de los criterios GLIM

Disease-related malnutrition (DRM) is a frequent syndrome in clinical practice, in which the mutual relationship between disease and malnutrition is observed. It is a specific form of malnutrition with causes other than poverty and social problems that make it difficult food production and distribution. Inflammation, anorexia, changes in body composition or in energy and protein requirements contribute to the development of DRM. This is associated with an increase in morbidity, mortality and economic expenditure. There are numerous tools to identify patients at risk of malnutrition, but until now there was no general consensus on the diagnostic criteria for malnutrition. The GLIM criteria provide a diagnostic system that has been accepted by the main international scientific societies in the field of clinical nutrition. In this article we describe its development, its application in different populations of patients and its comparison with other criteria or different diagnostic tools that contribute to its validation. This makes it possible to point out the advantages and limitations that have been described so far with the use of the GLIM criteria

Fibroblast growth factor 21 and protein energy wasting in hemodialysis patients.

INTRODUCTION: Protein energy wasting (PEW) is the most important risk factor for morbidity and mortality in hemodialysis patients. Inadequate dietary protein intake is a frequent cause of PEW. Recent studies have identified fibroblast growth factor 21 (FGF21) as an endocrine protein sensor. This study aims to investigate the potential of FGF21 as a biomarker for protein intake and PEW and to investigate intradialytic FGF21 changes. METHODS: Plasma FGF21 was measured using an enzyme-linked immunoassay. Complete intradialytic dialysate and interdialytic urinary collections were used to calculate 24-h urea excretion and protein intake. Muscle mass was assessed using the creatinine excretion rate and fatigue was assessed using the Short Form 36 and the Checklist Individual Strength. RESULTS: Out of 59 hemodialysis patients (65 ± 15 years, 63% male), 39 patients had a low protein intake, defined as a protein intake less than 0.9 g/kg/24-h. Patients with a low protein intake had nearly twofold higher plasma FGF21 compared to those with an adequate protein intake (FGF21 1370 [795-4034] pg/mL versus 709 [405-1077] pg/mL;P < 0.001). Higher plasma FGF21 was associated with higher odds of low protein intake (Odds Ratio: 3.18 [1.62-7.95] per doubling of FGF21; P = 0.004), independent of potential confounders. Higher plasma FGF21 was also associated with lower muscle mass (std ß: -0.34 [-0.59;-0.09];P = 0.009), lower vitality (std ß: -0.30 [-0.55;-0.05];P = 0.02), and more fatigue (std ß: 0.32 [0.07;0.57];P = 0.01). During hemodialysis plasma FGF21 increased by 354 [71-570] pg/mL, corresponding to a 29% increase. CONCLUSION: Higher plasma FGF21 is associated with higher odds of low protein intake in hemodialysis patients. Secondarily, plasma FGF21 is also associated with lower muscle mass, less vitality, and more fatigue. Lastly, there is an intradialytic increase in plasma FGF21. FGF21 could be a valuable marker allowing for objective assessment of PEW.

Protein Energy Wasting in Children With Chronic Kidney Disease and End-Stage Kidney Disease: An Observational Study.

OBJECTIVES: Protein energy wasting (PEW), a specific nutritional comorbidity associated with increased mortality, is underrecognized in children with chronic kidney disease (CKD). The aim of this study was to determine the burden and factors associated with PEW and assess the utility of parameters used to diagnose PEW in children with CKD and End stage kidney disease (ESKD). METHODS: Children between 2 and 18 years of age with CKD stages 2-5 were recruited over 30 months. Parameters of PEW assessed included body mass index for height, mid-upper arm circumference, height for age, appetite, serum albumin, cholesterol, transferrin, and C-reactive protein. Based on number of criteria fulfilled in each subject, PEW was further stratified as mild, standard, and modified PEW. RESULTS: One hundred twenty-three children (male:female 3:1, 73 in CKD stages 2-4, 50 with ESKD) were recruited. PEW was observed in 58% (47% in CKD stages 2-4 vs. 73% ESKD, P = .035). Longer duration and severity of disease was associated PEW. Reduced appetite (P = .001, P = .04), low mid-upper arm circumference (P = .000, P = .006), and low body mass index for height (P = .000, P = .007) were useful criteria to diagnose PEW in CKD stages 2-4 and ESKD, while most children did not meet biochemical criteria. Inflammation observed in 47% was higher in those with ESKD [CKD stages 2-4: 72 (39%) vs. ESKD: 29 (59%), P = .02] but was associated with PEW only in CKD stages 2-4. CONCLUSION: PEW was highly prevalent in children with CKD and ESKD. Appetite and anthropometry measures were more useful than biochemical criteria for diagnosis of PEW. Whereas inflammation was common, it was associated with PEW only in CKD stages 2-4. Pediatric CKD and ESKD may need exclusive diagnostic criteria for PEW based on anthropometry, appetite, and inflammation.