The impact of malnutrition in morbidity and mortality in stable haemodialysis patients

Marcén, R.; Jl, Teruel; Cal, Miguel A. de la; Gámez, C.

doi:10.1093/ndt/12.11.2324

Cited by 113 publications

(66 citation statements)

References 11 publications

(18 reference statements)

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“…The positive correlation between tHcy and markers of protein-energy nutritional status in maintenance dialysis patients may partially, but not fully, explain the paradoxical association between tHcy and mortality in these individuals. Diminished nutritional status, with or without inflammation, is a strong predictor of poor outcome in these individuals (24,(45)(46)(47)(48). Similar to our results, both Suliman et al (11) and Wrone et al (12) also reported significant correlations between tHcy and such nutritional markers as nPNA and serum concentrations of albumin, prealbumin, and creatinine.…”

Section: Discussionmentioning

confidence: 99%

A Low, Rather than a High, Total Plasma Homocysteine Is an Indicator of Poor Outcome in Hemodialysis Patients

Kalantar-Zadeh

Block

Humphreys

et al. 2004

Journal of the American Society of Nephrology

153

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Abstract. An increased level of total plasma homocysteine (tHcy) is a risk factor for poor cardiovascular outcome in the general population. However, a decreased, rather than an increased, tHcy concentration may predict poor outcome in maintenance hemodialysis (MHD) patients, a phenomenon referred to as reverse epidemiology. Associations were examined between tHcy level and markers of malnutrition-inflammation complex syndrome and 12-mo prospective hospitalization and mortality in 367 MHD patients, aged 54.5 Ϯ 14.7 (mean Ϯ SD) years, who included 199 men and 55% individuals with diabetes. tHcy was 24.4 Ϯ 11.8 mol/L, and 94% of the patients had hyperhomocysteinemia (tHcy Ͼ13.5 mol/L). tHcy had weak to moderate but statistically significant bivariate and multivariate correlations with some laboratory markers of nutrition (serum albumin, prealbumin, creatinine, and urea nitrogen) but no significant correlation with serum C-reactive protein or two proinflammatory cytokines (IL-6 and TNF-␣).During 12 mo of follow-up, 191 MHD patients were hospitalized, 37 died, nine underwent renal transplantation, and 38 transferred out. Hospitalization rates were significantly higher in patients with lower tHcy levels. Mortality rate in the lowest tHcy quartile (17.4%) was significantly higher compared with other three quartiles (6.5 to 9.8%; Kaplan-Meier P ϭ 0.04). Relative risk of death for the lowest tHcy quartile, even after adjustment for case-mix and serum albumin, was 2.27 (95% confidence interval, 1.14 to 4.53; P ϭ 0.02). Hence, tHcy may be a more exclusive nutritional marker in MHD patients with no association with inflammatory measures. Despite a very high prevalence of hyperhomocysteinemia in MHD patients, lower values of tHcy are paradoxically associated with increased hospitalization and mortality. The lowest tHcy quartile confers a twofold increase in risk of death independent of hypoalbuminemia. The nutritional feature of tHcy in MHD patients may explain its reverse association with outcome.In the general population, an increased level of total plasma homocysteine (tHcy) is a risk factor for increased cardiovascular events and mortality (1-4). In maintenance hemodialysis (MHD) outpatients, however, the association between tHcy and clinical outcome is inconsistent and even paradoxical. Some studies have shown a poor outcome in MHD patients with hyperhomocysteinemia (5-9). However, a few recent studies have suggested that a decreased, not an increased, tHcy concentration is related to a higher prevalence of cardiovascular disease and poor outcome in these individuals (10 -12). This seems to be due to the empirical association between a low tHcy and protein-energy malnutrition, which is per se a known risk factor for poor clinical outcome in dialysis patients (11,13,14). This recently described paradoxical association between tHcy and clinical outcome in dialysis patients has now been referred to as a possible component of the reversal of the cardiovascular risks (15-17). It is believed that both inflammation and protei...

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Section: Discussionmentioning

confidence: 99%

A Low, Rather than a High, Total Plasma Homocysteine Is an Indicator of Poor Outcome in Hemodialysis Patients

Kalantar-Zadeh

Block

Humphreys

et al. 2004

Journal of the American Society of Nephrology

153

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“…1 However, studies from Southern Europe had not found a significant benefit of a high BMI on survival. 13,14 Actually, there were significant variations in BMI within the 5 DOPPS I European countries, with the lowest in France and Italy (23.2 and 23.5 kg/m 2 , respectively), whereas it was higher in Germany (24.5 kg/m 2 ) ( Table 1). 5 In a large study from 9,714 patients from the United States and Europe, Leavey et al 3 have shown that the crude mortality rate decreased from 26.9 deaths per 100 patient years in the BMI Ͻ20 group to 14.1 deaths per 100 patient-years for the BMI Ն30 group.…”

Section: Body Mass Indexmentioning

confidence: 99%

Kidney Disease Outcomes Quality Initiative (K/DOQI) and the Dialysis Outcomes and Practice Patterns Study (DOPPS): Nutrition guidelines, indicators, and practices

Combe

McCullough

Asano³

et al. 2004

American Journal of Kidney Diseases

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• Background: Nutritional markers are important predictors of morbidity and mortality in dialysis patients. The Clinical Practice Guidelines for Nutrition in Chronic Renal Failure provides guidelines for assessing nutritional status that were evaluated using data from the Dialysis Outcomes and Practice Patterns Study (DOPPS). Methods: The level of various nutritional markers (serum albumin, modified subjective global assessment, serum creatinine, normalized protein catabolic rate [nPCR], and body mass index) were described for representative samples of patients and facilities from 7 countries (France, Germany, Italy, Spain, Japan, United Kingdom, and United States) participating in the DOPPS. Results: A strong inverse association was observed between mortality and serum albumin, with a mortality risk 1.38 times higher for patients with serum albumin concentration less than 3.5 g/dL (35 g/L). There were significant differences by country in the proportion of moderately and severely malnourished patients as determined by the modified subjective global assessment score. In the US sample, severely and moderately malnourished patients had a higher mortality risk compared with those not malnourished, 33% and 5% higher, respectively. An inverse relationship exists between serum creatinine concentration and mortality, with a mortality risk 60% to 70% higher in the lowest quartile group compared with the highest quartile group in Europe and the United States. Levels of nPCR varied significantly between European countries, and there was no association between mortality and nPCR in US data. After adjustment for demographic and comorbidity factors, the mortality risk decreased as body mass index increased in both US and European samples. Conclusion: DOPPS data highlight the importance of routine assessment of nutritional status, using multiple parameters, in clinical practice to improve patient care. Am J Kidney Dis 44(S2):S39-S46.

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“…Marcen et al 25 encontraram uma associação entre desnutrição e linfopenia em pacientes submetidos à hemodiálise. Alguns fatores, entre eles, deficiência de zinco 26 podem causar linfopenia em pacientes renais crônicos.…”

Section: Discussão E Conclusõesunclassified

Estado nutricional de pacientes com insuficiência renal crônica em hemodiálise no Amazonas

Valenzuela¹,

Giffoni²,

Cuppari³

et al. 2003

Rev. Assoc. Med. Bras.

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RESUMO -OBJETIVO. Estudar a ingestão alimentar e o estado INTRODUÇÃOPacientes com insuficiência renal crônica em programa de hemodiálise sofrem, com frequência, de anormalidades nutricionais. Bergstrom et al. 1 referem que 10% a 70% dos pacientes mantidos em hemodiálise e 18% a 56% dos pacientes em CAPD apresentam algum sinal de desnutrição. Prevalência semelhante tem sido observada em nosso meio, onde 69% das mulheres e 79% dos homens evidenciaram diminuição importante de parâ-metros antropométricos 2 .O impacto da desnutrição sobre a morbidade e mortalidade desses pacientes tem sido amplamente estudado 3 . Vários estudos demonstraram que a baixa adequação de peso e a reduzida concentração sérica de albumina e colesterol aumentam o risco de mortalidade nessa população 3,4,5 .Diversos fatores podem ser responsáveis pela desnutrição nesses pacientes, entre eles a anorexia com conseqüente redução do consumo alimentar tem sido apontada como uma das principais causas 6,7,8 . Além disso, outras condições como distúrbios gastrointestinais, acidose metabólica, fatores associados ao procedimento dialítico, distúrbios hormonais, doenças associadas ou intercorrentes (diabetes mellitus, insuficiência cardíaca e infecções) podem também contribuir na fisiopatogênese dessa desnutrição 9 .Conhecer e caracterizar adequadamente o estado nutricional de uma população em diálise é fundamental tanto para a prevenção da desnutrição quanto para intervir apropriadamente nos pacientes que já se apresentam desnutridos. Assim, o objetivo do presente trabalho foi caracterizar o estado nutricional de pacientes com insuficiência renal crônica em hemodiálise em um centro de diálise do Amazonas. MÉTODOSForam estudados 165 pacientes em hemodiálise, na Clínica Renal de Manaus, durante o período de 01/3/1999 a 15/4/1999. Foram incluídos no estudo pacientes maiores de 18 anos de idade, em programa de hemodiálise há pelo menos três meses, e que não apresentavam intercorrências clínicas. Foram excluídos aqueles em uso de corticosteróides, com infecções recentes (< 3 meses), tuberculose em tratamento, doença intestinal, alcoolismo crônico, HIV, doenças malignas, insuficiência cardíaca e pulmonar grave e insucessos de transplante renal nos últimos seis meses. Os pacientes foram submetidos a uma avaliação nutricional, realizada por nutricionista treinada, que constou de medidas antropométricas, laboratoriais e de consumo alimentar. O registro alimentar de três dias foi a técnica empregada para avaliar a ingestão mé-dia de energia, proteína, lipídio, carboidrato, cálcio e fósforo. Os três dias compreendiam um dia em que o paciente se submetia a hemodiálise e dois dias sem o procedimento, excluindo-se sábado e domingo. Além disso, foi analisada a freqüência de consumo dos seguintes grupos alimentares: carnes, laticínios e ovos, cereais e leguminosas e frutas e hortaliças. Os dados coletados da avaliação nutricional foram armazenados e tratados utilizando-se um sistema computadorizado, o "Sistema de apoio à decisão em nutrição -versão 2.5" do Centro de In...

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The impact of malnutrition in morbidity and mortality in stable haemodialysis patients

Cited by 113 publications

References 11 publications

A Low, Rather than a High, Total Plasma Homocysteine Is an Indicator of Poor Outcome in Hemodialysis Patients

A Low, Rather than a High, Total Plasma Homocysteine Is an Indicator of Poor Outcome in Hemodialysis Patients

Kidney Disease Outcomes Quality Initiative (K/DOQI) and the Dialysis Outcomes and Practice Patterns Study (DOPPS): Nutrition guidelines, indicators, and practices

Estado nutricional de pacientes com insuficiência renal crônica em hemodiálise no Amazonas

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