[Show abstract][Hide abstract] ABSTRACT: Background In chronic kidney disease (CKD), multiple metabolic and nutritional abnormalities contribute to the impairment of skeletal muscle mass and function thus predisposing patients to the condition of sarcopenia. Herein, we investigated the prevalence and mortality predictive power of sarcopenia, defined by three different methods, in non-dialysis-dependent (NDD) CKD patients. Methods We evaluated 287 NDD-CKD patients in stages 3–5 [59.9 ± 10.5 years; 62% men; 49% diabetics; glomerular filtration rate (GFR) 25.0 ± 15.8 mL/min/1.73 m2]. Sarcopenia was defined as reduced muscle function assessed by handgrip strength (HGS
[Show abstract][Hide abstract] ABSTRACT: Background Home-based exercise has been shown to provide benefits in terms of physical capacity in the general population, but has been scarcely investigated in patients with chronic kidney disease (CKD). Aims To evaluate the impact of a home-based aerobic training on the cardiopulmonary and functional capacities of overweight non-dialysis-dependent patients with CKD (NDD-CKD). Methods Twenty-nine sedentary patients (55.1 ± 11.6 years, BMI = 31.2 ± 6.1 kg/m2, eGFR = 26.9 ± 17.4 mL/min/1.73 m2) were randomly assigned to a home-based exercise group (n = 14) or to a control group (n = 15) that remained without performing exercise. Aerobic training was performed three times per week for 12 weeks. A cardiopulmonary exercise test, functional capacity and clinical parameters were evaluated. Results A significant increase, ranging from 8.3 to 17 %, was observed in the cardiopulmonary capacity parameters, such as maximal ventilation (p = 0.005), VO2peak (p = 0.049), ventilatory threshold (p = 0.040) and respiratory compensation point (p p p p p p p = 0.042)] was also found in patients who were submitted to the exercise. Exercised patients experienced a decrease in systolic and diastolic blood pressure, average 10.6 % (p p = 0.007), respectively, and a trend toward improved renal function (p = 0.1). No change in any parameter was found in the control group during the follow-up. Conclusion The home-based aerobic exercise program was feasible, safe and effective for the improvement in the cardiopulmonary and functional capacities of overweight NDD-CKD patients.
International Urology and Nephrology 12/2014; 47(2). DOI:10.1007/s11255-014-0894-8 · 1.52 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Pericardial fat (PF) a component of visceral adipose tissue has been consistently related to coronary atherosclerosis in the general population. This study evaluated the association between PF and coronary artery calcification (CAC) in non-dialysis dependent chronic kidney disease (CKD) patients. This is a post-hoc cross sectional analysis of the baseline of a prospective cohort of 117 outward CKD patients without manifest coronary artery disease (age, 56.9±11.0 years, 64.1% males, 95.1% hypertensives, 25.2% diabetics, 15.5% ever smokers, CKD stage 2 to 5 with estimated glomerular filtration rate 36.8±18.1 ml/min). CAC scores, PF volume and abdominal visceral fat (AVF) areas were measured by computed tomography. The association of PF as a continuous variable with the presence of CAC was analyzed by multivariate logistic regression. CAC (calcium score >0) was present in 59.2% patients. Those presenting CAC were on average 10 years older, had a higher proportion of male gender (78.7% vs. 42.9%, p<0.001), and had higher values of waist circumference (95.9±10.7 vs. 90.2±13.2 cm, p = 0.02), PF volumes (224.8±107.6 vs. 139.1±85.0 cm3, p<0.01) and AVF areas (109.2±81.5 vs. 70.2±62.9 cm2, p = 0.01). In the multivariate analysis, adjusting for age, gender, diabetes, smoking and, left ventricular concentric hypertrophy, PF was significantly associated with the presence of CAC (OR: 1.88 95% CI: 1.03-3.43 per standard deviation). PF remained associated with CAC even with additional adjustments for estimated glomerular filtration rate or serum phosphorus (OR: 1.85 95% CI: 1.00-3.42, p = 0.05). PF is independently associated with CAC in non-dialysis dependent CKD patients.
PLoS ONE 12/2014; 9(12):e114358. DOI:10.1371/journal.pone.0114358 · 3.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objectives
Subjective global assessment (SGA) has been demonstrated to be a reliable method for protein–energy wasting (PEW) evaluation in chronic kidney disease (CKD) patients on dialysis. Few data are available on PEW evaluation in nondialysis stages of CKD, and the validity of SGA has been scarcely investigated in this population. Herein, we aimed to evaluate in nondialysis-dependent CKD patients (NDD-CKD): (1) the prevalence of PEW by SGA; (2) the most common abnormalities of the SGA components; and (3) the agreement of SGA with the traditional anthropometric parameters.
Design and Subjects
This is a retrospective cross-sectional study including 922 NDD-CKD patients referred to the renal dietitians in the period of 2001 to 2012. Nutritional status was assessed by 7-point SGA. Body mass index (BMI), midarm circumference, midarm muscle circumference, and triceps skinfold thickness were available from 494 patients.
From the 922 patients, 58.6% were men, mean age was 63.8 ± 13.6 years, BMI was 27.7 ± 5.3 kg/m2. The majority of the patients were in CKD Stages 3 (48.9%) or 4 (40.3%). PEW (SGA ≤5) was present in 11% of the patients and 32% had signs of PEW (SGA 6). In the logistic regression analysis, the presence of comorbidities and worse renal function were independently associated with PEW. Among the SGA components, the most frequent abnormality in patients with PEW was muscle and fat wasting (88.6%). BMI, midarm circumference, midarm muscle circumference, and triceps skinfold thickness were lower across the worse SGA scores, and a moderate to good level of agreement was found between the anthropometric parameters and presence of PEW evaluated by SGA.
The prevalence of PEW was 11% in our unselected cohort of NDD-CKD patients. The physical examination component (muscle/fat wasting) was the most frequent alteration found in those patients. When compared with anthropometric parameters, 7-point SGA has shown to be a valid tool to assess PEW in NDD-CKD population.
[Show abstract][Hide abstract] ABSTRACT: The prevalence of obesity has markedly increased in patients with chronic kidney disease (CKD). Studies on the impact of exercise focusing on obese CKD patients are scarce. Therefore, we aimed to investigate the effect of aerobic exercise performed either in an exercise centre or at home on visceral fat in overweight non-dialysed CKD patients.
Twenty-seven sedentary men (52.1 ± 9.5 years, body mass index 30.4 ± 3.8 kg/m(2), estimated glomerular filtration rate (eGFR) 27.5 ± 11.6 mL/min) were randomly assigned to a centre-based exercise group (n = 10), home-based exercise group (n = 8) or control group (n = 9). The aerobic training was prescribed according to ventilatory threshold and performed three times per week during 12 weeks. Body composition was assessed by dual energy X-ray absorptiometry (DEXA) and the distribution of abdominal fat by computed tomography.
In the centre-based group, visceral fat and waist circumference decreased 6.4 ± 6.4 mm (P < 0.01) and 2.0 ± 2.3 cm (P = 0.03) and leg lean mass increased 0.5 ± 0.4 kg (P < 0.01). No significant changes were observed in the home-based group. Visceral fat increased 5.0 ± 4.4 mm in the control group (P = 0.01). In relation to the control, a group-by-time interaction was significant for visceral fat and waist circumference for both exercise groups and for leg lean mass for the centre-based group. Mean blood pressure decreased in both exercise groups (centre-based 13%, P < 0.01 and home-based 10%, P = 0.03) and eGFR increased 3.6 ± 4.6 mL/min (P = 0.03) in the centre-based group. These parameters remained unchanged in the control group.
Centre-based aerobic exercise is an effective approach to reduce visceral fat besides promoting relevant clinical benefits in male overweight CKD patients.
[Show abstract][Hide abstract] ABSTRACT: Recently, the adductor pollicis muscle thickness (APMT) has been suggested as a new nutritional marker in several population.
In view of the scarce data regarding the use of this marker in CKD patients, we aimed to evaluate APMT and its association with nutritional parameters in patients on hemodialysis.
We evaluated 73 hemodialysis patients (52.3 ± 17 years, without residual renal function). The APMT was assessed in the non vascular access arm by means of skinfold caliper. Body composition (bioelectrical impedance), handgrip strength (HGS, dynamometer), nutritional status (subjective global assessment), and laboratory parameters (creatinine, total protein and albumin) were also evaluated.
Subjects with APMT values above the median were in greater proportion black/ brown, younger and had higher HGS. The APMT correlated positively with HGS, albumin and body cell mass (%), and negatively with age. In the linear regression analysis adjusted for sex, age and length on hemodialysis, APMT was independently associated with HGS.
APMT was able to predict HGS in hemodialysis patients, suggesting APMT as a promising nutritional marker in this population.
Jornal Brasileiro de Nefrologia 09/2013; 35(3):177-184. DOI:10.5935/0101-2800.20130029
[Show abstract][Hide abstract] ABSTRACT: Background/objective:
Recent epidemiological data have shown that abdominal fat accumulation is associated with increased risk of cardiovascular events in patients with chronic kidney disease (CKD). This study aimed to investigate the association between visceral adiposity and coronary artery calcification (CAC) in CKD patients.
Cross-sectional study with 65 nondialyzed CKD male patients (59 ± 9 years, CKD stages 3 and 4). Abdominal fat compartments were assessed by computed tomography (CT) at L4-L5 level. Visceral to subcutaneous (V/S) fat ratio was calculated. Visceral obesity was defined as a V/S fat ratio greater than the median value of the sample study (>0.55). CAC was detected by multi-slice CT. CAC scores were calculated with the Agatston method.
CAC was present (calcium score >10 AU) in 66% of patients. In the group with visceral obesity, the CAC score was significantly higher. This group had lower adiponectin and higher leptin levels compared to patients without visceral obesity. In the whole sample, higher V/S fat ratio was associated with CAC score, independently of age, body mass index, diabetes, ionized calcium, smoking or renal function.
Our results show an association between visceral obesity and CAC in CKD patients, suggesting a deleterious effect of visceral fat in these patients. Increased visceral adiposity might enhance cardiovascular risk in this particular population.
European journal of clinical nutrition 03/2013; 67(6). DOI:10.1038/ejcn.2013.66 · 2.71 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective:
The malnutrition-inflammation score (MIS) is a nutritional scoring system that has been associated with muscle strength among dialysis patients. We aimed to test whether MIS is able to predict muscle strength in nondialysis-dependent chronic kidney disease (NDD-CKD) individuals.
Design and methods:
This was a cross-sectional study conducted at the Dante Pazzanese Institute of Cardiology, Hypertension, and Nephrology Division outpatient clinic. We evaluated 190 patients with NDD-CKD stages 2-5 (median 59.5 [interquartile range 51.4-66.9] years; 64% men). MIS was calculated without computing dialysis vintage to the scoring. HGS was assessed in the dominant arm. Anthropometric, laboratory, and body composition parameters were recorded.
A strong negative correlation was found between HGS and MIS (r = -0.42; P ≤ .001) in univariate analysis. In multivariate regressions, adjustment for age, sex, diabetes, glomerular filtration rate, body cell mass, and C-reactive protein did not materially diminish these relationships.
MIS shares strong links with objective measures of muscle strength in NDD-CKD patients.
[Show abstract][Hide abstract] ABSTRACT: Objectives:
This prospective study, conducted at the dialysis unit of the Nephrology Division, Federal University of Sao Paulo-Oswaldo Ramos Foundation, Brazil, aimed to evaluate whether waist circumference (WC) can predict adiponectin levels in patients undergoing peritoneal dialysis (PD).
Among 115 patients on PD at a single dialysis center who were evaluated at 6 and 12 months, 57% were men, 31% had diabetes, mean age was 52.8 ± 16.1 years, body mass index was 25 ± 4.3 kg/m(2), and dialysis vintage was 13 months (range: 5 - 33 months). We measured WC at the umbilicus level. Adiponectin was determined by an enzyme-linked immunosorbent assay.
At baseline, WC was inversely associated with adiponectin (r = -0.48, p < 0.01). After adjustment for sex, age, diabetes, peritoneal clearance, and residual renal function, WC was an independent determinant of serum adiponectin (β = -0.52; 95% confidence interval: -0.73 to -0.31; p < 0.001). In the prospective analysis, after adjustment for confounders, changes in WC predicted changes in adiponectin. For each unit increase in WC, adiponectin declined by 0.39 mg/L (p < 0.001).
This study demonstrates that WC is associated with adiponectin and, more importantly, that this simple marker of central adiposity was able to predict changes in adiponectin levels over time.
[Show abstract][Hide abstract] ABSTRACT: Cardiovascular complications remain the main cause of mortality in patients with chronic kidney disease (CKD). Adiponectin is an adipose tissue-derived protein that carries important cardioprotective properties. We aimed at investigating the determinants of adiponectin levels in CKD patients.
This prospective observational study included 98 CKD patients [glomerular filtration rate (GFR) 36.1+-14.4 ml/min, 56.5+-10.4 y, 63% male, 31% diabetics, and body mass index (BMI) 27.1+-5.2 kg/m²]. Evaluation of adiponectin (imunoenzimatic assay), laboratory parameters, nutritional status (subjective global assessment), total body fat (dual x-ray energy absorptiometry), and visceral and subcutaneous abdominal fat (computed tomography) was performed at baseline and after 12 months.
Adiponectin correlated with GFR (r = -0.45; p < 0.001), proteinuria (r = 0.21; p = 0.04), BMI (r = -0.33; p < 0.01), and visceral fat (r = -0.49; p < 0.001). In the linear regression analysis, the determinants of adiponectin levels were sex (female β = 3.8; p < 0.01), age (β = 0.14; p = 0.03), GFR (β = -0.15; p < 0.01) and visceral fat (β = -0.04; p < 0.001) (R² = 0.41). After 12 months, a progression of the disease was evidenced by the reduction of GFR (-1.6+-6.3 ml/min; p = 0.01) and increase of proteinuria (0.3+-0.8 g/d; p < 0.01). An accumulation of visceral fat was observed, from 97+-73 cm² to 111+-82 cm² (p < 0.001), with a concomitant reduction of adiponectin concentration, from 27.6+-7.5 mg/l to 22.2+-11.6 mg/l (p < 0.001). Body weight, BMI, total body fat, and subcutaneous abdominal fat remained unchanged. After adjustments for the baseline determinants of adiponectin, the increase in visceral fat was independently associated with overtime decrease in adiponectin levels (β = -0.04; p = 0.025; R² = 0.21).
Age, sex, renal function and visceral fat were independently associated with adiponectin levels in nondialyzed CKD patients. However, variation in visceral fat was the only predictor of variation in adiponectin levels over 12 months.
Jornal Brasileiro de Nefrologia 09/2012; 34(3):259-65. DOI:10.5935/0101-2800.20120007
[Show abstract][Hide abstract] ABSTRACT: Hypovitaminosis D is highly prevalent among patients with chronic kidney disease (CKD) and has been associated with poor outcome. We aimed to test the effect of a protocol of cholecalciferol supplementation on the restoration of vitamin D status and on parathyroid hormone (PTH) levels in patients with CKD.
This was a prospective interventional study of 6 months. Forty-five CKD patients (stages 3 and 4) with 25-hydroxyvitamin D deficiency [25(OH)D <15 ng/ml] were included. Patients received a weekly dose of 50,000 IU of cholecalciferol during 3 months, and 50,000 IU/month thereafter for those who had achieved 25(OH)D ≥30 ng/ml.
At 3 months, 78% of the patients restored their vitamin D status. At 6 months, only 43% of those patients maintained adequate vitamin D status. PTH decreased at 3 months (p = 0.02) but returned to baseline levels after 6 months. Fibroblast growth factor 23 increased at 3 months (p = 0.001) and returned to initial levels at 6 months. No changes were found in serum 1,25(OH)(2)D, ionized calcium and phosphorus.
A weekly dose of 50,000 IU of cholecalciferol for 3 months restored the vitamin D status of most patients and led to a reduction in PTH. The monthly dose of 50,000 IU appears not to be sufficient to maintain the levels of 25(OH)D.
Annals of Nutrition and Metabolism 08/2012; 61(1):74-82. DOI:10.1159/000339618 · 2.62 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background and aim:
Cardiovascular disease is the leading cause of death among patients with chronic kidney disease (CKD). Although there is emerging evidence that excess visceral fat is associated with a cluster of cardiometabolic abnormalities in these patients, the impact of visceral obesity evaluated by a gold-standard method on future outcomes has not been studied. We aimed to investigate whether visceral obesity assessed by computed tomography was able to predict cardiovascular events in CKD patients.
Methods and results:
We studied 113 nondialyzed CKD patients [60% men; 31% diabetics; age 55.3 ± 11.3 years; body mass index (BMI) 27.2 ± 5.3 kg/m(2); estimated glomerular filtration rate (GFR) 33.7 ± 13.6 ml/min/1.73 m(2)]. Visceral and subcutaneous abdominal fat were assessed by computed tomography at L4-L5. Visceral to subcutaneous fat ratio >0.55 (highest tertile cut-off) was defined as visceral obesity. Cardiovascular events including acute myocardial infarction, angina, arrhythmia, uncontrolled blood pressure, stroke and cardiac failure were recorded during 24 months. Cardiovascular events were 3-fold higher in patients with visceral obesity than in those without visceral obesity. The Kaplan-Meier analysis indicated that patients with visceral obesity had shorter cardiovascular event-free time than those without visceral obesity (P = 0.021). In the univariate Cox analysis, visceral obesity was associated with higher risk of cardiovascular events (hazard ratio = 3.4; 95% confidence interval = 1.1-10.5; P = 0.03). The prognostic power of visceral obesity for cardiovascular events remained significant after adjustments for sex, age, diabetes, previous cardiovascular disease, smoking, sedentary lifestyle, BMI, GFR, hypertension, dyslipidemia and inflammation.
Visceral obesity assessed by computed tomography was a predictor of cardiovascular events in CKD patients.
[Show abstract][Hide abstract] ABSTRACT: Sarcopenia is strongly associated to aging and can be defined as a decrease in muscle mass, strength and muscle quality. Hemodialysis (HD) patients are exposed to several factors that lead to a loss of muscle mass, which in turn can accelerate the development of sarcopenia. We aimed to evaluate the prevalence of sarcopenia and to compare the nutritional and inflammatory profile of sarcopenic and non-sarcopenic elderly patients on HD. Seventy-four elderly patients on HD (68.9% male; age: 69.3 ±6.4 years) were included. Sarcopenia was defined by a handgrip strength (HGS) <10th percentile of a Brazilian population-based reference study. Obesity was defined as body fat % (sum of skinfold thicknesses) above the median values for men (≥26%) and women (≥39%); abdominal obesity as waist circumference ≥102 cm in men and ≥88 in women and inflammation (ultra sensitive C-reactive protein -CRP) as CRP ≥10 mg/L. Sarcopenia was observed in 41% of the patients. No significant difference was observed between Sarcopenic (n= 30; Male 67%; Age 69 ±6.2 years; BMI 24.5 ±4.9 kg/m2) and non-sarcopenic (n= 44; Male 73%; Age 69.7 ±6.6 years; BMI: 26.2 ±4.5 kg/m2) groups, as shown below:
Sarcopenic Group (n= 30)Non-Sarcopenic Group (n= 44)Diabetes (n; %)12 (40)13 (30)Obesity (n; %)13 (43)24 (55)Abdominal Obesity (n; %)10 (33)21 (48)Inflammation (n; %)8 (27)9 (20)Full-size tableTable optionsView in workspaceDownload as CSV
In conclusion, sarcopenia is highly prevalent in elderly HD patients and the inflammatory profile of sarcopenic and non-sarcopenic patients is similar. In addition, these results show that sarcopenia does not exclude the occurrence of increased adiposity, as shown by the elevated frequency of obesity and abdominal obesity in the elderly sarcopenic group.
[Show abstract][Hide abstract] ABSTRACT: Body fat gain is a common finding among peritoneal dialysis (PD) patients, and the accumulation of adipose tissue occurs predominantly in the abdominal area. Waist circumference (WC) is a reliable marker of abdominal obesity and its association with worse outcomes has been demonstrated in nondialysis and hemodialysis patients. Herein, we aimed at investigating whether WC measurements as well as the overtime changes in WC were able to predict mortality in PD patients.This prospective study included 109 prevalent PD patients [57% male, age 52±16 years, 32% diabetics, 48% BMI ≥25 kg/m2]. WC was measured at umbilicus level (empty abdominal cavity) at baseline and after 6 months. WC measurements >88 cm for women and >102 cm for men were considered as increased. Nutritional status and laboratory parameters were also evaluated. Mortality was registered during a period of 48 months.At baseline, increased WC was observed in 55.3% of women and 22.6% of men. A total of 60.5% of the PD patients increased WC after 6 months. Patients who died during the follow-up (nonsurvival group, n=27) were older than the survivor group. A significant increase in WC was observed in the former group. In the cox regression analysis adjusting for sex, age, length on PD, diabetes, BMI, serum albumin and C-reactive protein, increased WC at baseline was associated with mortality. Adjusting for confounders, 6-month increase in WC was also a predictor of mortality in these patients. Increased WC at baseline and overtime changes in WC were both associated with mortality in PD patients.
[Show abstract][Hide abstract] ABSTRACT: This is a randomized controlled study that aimed to assess the impact of aerobic exercise on visceral fat of overweight CKD patients. Twenty-six sedentary patients in stages 3–4 of CKD (73% men; 52.3±8.6 years, BMI 30.6±4.3 kg/m2) were included. Patients were assigned to aerobic exercise group (EG; n=13) or control group (CG; n=13). The aerobic training was conducted on a treadmill at the ventilatory threshold three times per week during 12 weeks. The CG patients remained without practicing exercise during follow up. Visceral and subcutaneous fat were assessed by computed tomography, and lean body mass (LBM) by DEXA. At the end of 12 weeks, visceral fat decreased 5% in EG and increased 3% in CG (p=0.02). Waist circumference decreased 1.5% in EG and increased 0.8% in CG (p=0.02). No changes were observed in body weight and subcutaneous fat. LBM tended to increase in EG and decrease in CG (p=0.09). In addition, blood pressure decreased (p<0.01) despite no change in body weight, 24 h urinary sodium and antihypertensive medication. Our results suggest aerobic exercise as an effective approach to reduce visceral fat while maintaining lean body mass in CKD patients.
[Show abstract][Hide abstract] ABSTRACT: Subjective Global Assessment (SGA) is a well-recognized and valid tool for diagnosing malnutrition in chronic kidney disease (CKD). SGA is based on components as weight change, dietary intake change, gastrointestinal symptoms, functional capacity, comorbidities related to nutritional condition and physical examination. Herein, we aimed at investigating which SGA alteration was the most prevalent in patients in the nondialysis stages of CKD. Seven-hundred and three patients were studied (91% CKD stages III and IV, eGFR 34.1±13.7 mL/min, 64±13.3 years, 58% men, 45% diabetics, BMI 27.9±7.4 kg/m2). Each of the SGA components was scored from 1 to 7 according to the severity, and values ≤ 5 were considered as abnormal. Malnutrition was observed in 11.5% of the patients, of which 10.5% mild to moderately malnourished (score of 3–5) and 0.7% severely malnourished (score of 1 or 2). The frequency of alterations in the SGA components is demonstrated below:
As can be seen dietary intake change was the most frequent alteration among the SGA components in nondialysis CKD patients.
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[Show abstract][Hide abstract] ABSTRACT: We tested the hypothesis that home-based exercise (HE) was similarly effective to the in center exercise (CE) on CR and FC. This is a randomized controlled study that included 35 sedentary patients (23 men; 53±8.1 years, BMI 30.7±4.2 kg/m2, creatinine clearance 30.9±4.2 mL/min; DM 23%). Patients were randomly assigned to HE (n=11), CE (n=12) or control (CO, n=12) groups. CE and HE underwent to an identical exercise program, three times per week during 12 weeks. The CO group remained without practicing exercise during follow up. The CE patients trained on a treadmill while the HE patients were instructed how to perform the training at home and were monitored by phone once a week. The training resulted in increase 20% and 19% in maximal ventilation (p<0.05), 14.5% and 11% in speed of VO2peak (p<0.01), 25.7% and 17.5% in speed of ventilatory threshold (p<0.01) and 20% and 17.2% in speed of respiratory compensation point (p<0.001) only in CE and HE groups respectively. In the exercise groups, improvement in functional capacity tests such as 2-min step (p<0.01), sit-stand (p<0.001) and arm curl (p<0.001) was observed. Blood pressure decreassed only in the exercise groups (p<0.01), in conclusion HE promoted similarly effective that CE and can be effectively applied for this particular group of patients.