Publications by authors named "Carla Maria Avesani"

56 Publications

Low hand grip strength is associated with worse functional capacity and higher inflammation in people receiving maintenance hemodialysis.

Nutrition 2021 Aug 30;93:111469. Epub 2021 Aug 30.

School of Nutrition, Federal University of Goiás, Goiania, Brazil. Electronic address:

Objectives: To evaluate the associations of hand grip strength (HGS) with body composition, functional capacity, muscle quality, and inflammatory markers in people receiving maintenance hemodialysis.

Methods: This is a cross-sectional study in people receiving maintenance hemodialysis. HGS was measured by hydraulic dynamometer on the upper limb without fistula. Participants were stratified into low or adequate HGS, based on population-specific cutoff points. Body composition was assessed by dual-energy X-ray absorptiometry, and functional capacity by the Short Physical Performance Battery and timed up-and-go tests. In addition, serum creatinine, interleukin-6 (IL-6), IL-10, tumor necrosis factor-α, and ultra-sensitive C-reactive protein (us-CRP) were measured before the dialysis session.

Results: A total of 67 participants (41.8% women, 58.2% male; ages 54.1 ± 11.7 y) were included. Those with low HGS had worse functional capacity than those with adequate HGS (timed up-and-go test, 10.7 ± 1.0 versus 8.5 ± 0.8 sec, respectively; P < 0.001). IL-6 and us-CRP were higher in those with low HGS than their counterparts (IL-6: 2.7 ± 0.3 versus 1.9 pg/mL, P = 0.03; us-CRP: 14.8 ± 3.0 versus 4.7 ± 1.9 mg/L, P = 0.03). Multiple linear regression analysis showed that appendicular lean mass, us-CRP, age, sex, and seven-point subjective global assessment score were associated with HGS.

Conclusions: Participants with low HGS showed higher inflammation and lower functional capacity. In addition to muscle mass, inflammation and nutritional status also affect HGS..
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http://dx.doi.org/10.1016/j.nut.2021.111469DOI Listing
August 2021

Low skeletal muscle mass by computerized tomography is associated with increased mortality risk in end-stage kidney disease patients on hemodialysis.

J Nephrol 2021 Oct 7. Epub 2021 Oct 7.

UO Nefrologia, Azienda Ospedaliera- Universitaria di Parma, Via Gramsci 14, 43100, Parma, Italy.

Background And Aims: Skeletal muscle (SM) area, as measured by abdominal CT at the level of the third lumbar vertebra (L3), has been proposed as a proxy of whole body muscle mass. However, population-specific reference values are lacking. In the present study we aimed at: (1) detecting low SM area on abdominal CT images in patients on hemodialysis by applying cut-offs derived from a group of healthy subjects, and (2) estimating the independent risk of all-cause mortality associated with low SM area.

Methods: We retrospectively enrolled 212 adult patients on hemodialysis, undergoing abdominal CT scan (study group), and 87 healthy kidney donors (reference group). We obtained the gender-specific 5th percentile values of the abdominal SM area distribution from both the whole control group and the subgroup of younger (29-60 years) subjects, which we used as reference cut-offs. Then we applied those cut-offs in the study group to identify patients with low SM area. We used survival and Cox regression analysis to evaluate the risk of all-cause mortality associated with low abdominal SM area.

Results: In the fully adjusted Cox regression analysis, the patients with low abdominal SM area had a higher risk of death than the patients with values above the reference cut-off derived in the subgroup of younger controls (adjHR = 1.79 (1.21; 2.67), P = 0.004).

Conclusions: Abdominal CT imaging can be used to detect low abdominal SM area in patients on hemodialysis by applying cut-offs derived from healthy subjects sharing a similar ethnic background. Low SM area as assessed by CT is independently associated with all-cause mortality in ESKD patients on hemodialysis.
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http://dx.doi.org/10.1007/s40620-021-01167-yDOI Listing
October 2021

Malnutrition and Sarcopenia Combined Increases the Risk for Mortality in Older Adults on Hemodialysis.

Front Nutr 2021 17;8:721941. Epub 2021 Sep 17.

Graduation Program in Food, Nutrition and Health, Nutrition Institute, Rio de Janeiro State University, Rio de Janeiro, Brazil.

Sarcopenia and malnutrition are highly prevalent in older adults undergoing hemodialysis (HD) and are associated with negative outcomes. This study aimed to evaluate the role of sarcopenia and malnutrition combined on the nutritional markers, quality of life, and survival in a cohort of older adults on chronic HD. This was an observational, longitudinal, and multicenter study including 170 patients on HD aged >60 years. Nutritional status was assessed by 7-point-subjective global assessment (7p-SGA), body composition (anthropometry and bioelectrical impedance), and appendicular skeletal muscle mass (Baumgartner's prediction equation). Quality of life was assessed by KDQoL-SF. The cutoffs for low muscle mass and low muscle strength established by the 2019 European Working group on sarcopenia for Older People (EWGSOP) were used for the diagnosis of sarcopenia. Individuals with a 7p-SGA score ≤5 were considered malnourished, individuals with low strength or low muscle mass were pre-sarcopenic, and those with low muscle mass and low muscle strength combined as sarcopenic. The sample was divided into four groups: sarcopenia and malnutrition; sarcopenia and no-malnutrition; no-sarcopenia with malnutrition; and no-sarcopenia and no-malnutrition. Follow-up for survival lasted 23.5 (12.2; 34.4) months. Pre-sarcopenia, sarcopenia, and malnutrition were present in 35.3, 14.1, and 58.8% of the patients, respectively. The frequency of malnutrition in the group of patients with sarcopenia was not significantly higher than in the patients without sarcopenia (66.7 vs. 51.2%; = 0.12). When comparing groups according to the occurrence of sarcopenia and malnutrition, the sarcopenia and malnutrition group were older and presented significantly lower BMI, calf circumference, body fat, phase angle, body cell mass, and mid-arm muscle circumference. In the survival analysis, the group with sarcopenia and malnutrition showed a higher hazard ratio 2.99 (95% CI: 1.23: 7.25) for mortality when compared to a group with no-sarcopenia and no-malnutrition. Older adults on HD with sarcopenia and malnutrition combined showed worse nutritional parameters, quality of life, and higher mortality risk. In addition, malnutrition can be present even in patients without sarcopenia. These findings highlight the importance of complete nutritional assessment in patients on dialysis.
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http://dx.doi.org/10.3389/fnut.2021.721941DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8484646PMC
September 2021

A Comparative Analysis of Nutritional Assessment Using Global Leadership Initiative on Malnutrition Versus Subjective Global Assessment and Malnutrition Inflammation Score in Maintenance Hemodialysis Patients.

J Ren Nutr 2021 Jul 27. Epub 2021 Jul 27.

Division of Renal Medicine and Baxter Novum, Department of Clinical Science, Technology and Intervention, Karolinska Institute, Stockholm, Sweden.

Objective: Malnutrition is a prevalent condition in maintenance hemodialysis (MHD) patients. This study aimed to evaluate the performance of the recently developed GLIM (Global Leadership Initiative on Malnutrition) in MHD by assessing the agreement, accuracy, sensitivity, specificity, and survival prediction of GLIM when compared to 7-point subjective global assessment (7p-SGA) and malnutrition inflammation score (MIS).

Design And Methods: We investigated 2 cohorts: MHD (121 adults from Italy; 67 ± 16 years, 65% men, body mass index 25 ± 5 kg/m) and MHD (169 elderly [age > 60 years] from Brazil; 71 ± 7 years, 66% men, body mass index 25 ± 4 kg/m), followed for all-cause mortality for median 40 and 17 months, respectively. We applied the 2-step approach from GLIM: (1) screening and (2) confirming malnutrition by phenotypic and etiologic criteria. For 7p-SGA and MIS, a score ≤5 and ≥8, respectively, defined malnutrition.

Results: Malnutrition was present in 38.8% by GLIM, 25.6% by 7p-SGA, and 29.7% by MIS in the MHD cohort, and in 47.9% by GLIM, 59.8% by 7p-SGA, and 49.7% by MIS in the MHD cohort. Cohen's kappa coefficient (κ) showed only "fair" agreement between GLIM and SGA (MHD: κ = 0.26, P = .003; MHD: κ = 0.22, P = .003) and between GLIM and MIS (MHD: κ = 0.33, P < .001; MHD: κ = 0.25, P = .001). Cox regression analysis showed that all 3 methods were able to predict mortality in crude analysis; however in the adjusted model, the association seemed more consistent and stronger in magnitude for 7p-SGA and MIS.

Conclusion: In MHD patients, GLIM showed low agreement, sensitivity, and accuracy in identifying malnourished subjects by either 7p-SGA or MIS. Considering the specific wasting characteristics that predominate in MHD, the well-established 7p-SGA and MIS methods may be more useful in this clinical setting.
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http://dx.doi.org/10.1053/j.jrn.2021.06.008DOI Listing
July 2021

Phase angle as a marker for muscle abnormalities and function in patients with colorectal cancer.

Clin Nutr 2021 07 17;40(7):4799-4806. Epub 2021 Jun 17.

Postgraduate Program in Health and Behavior, Catholic University of Pelotas, Pelotas, Rio Grande do Sul, Brazil. Electronic address:

Background And Aims: Considering the applicability of phase angle (PhA) as a marker of muscle mass and function, we aimed to investigate whether PhA is a predictor of muscle abnormalities and function in patients with cancer.

Methods: In a sample of patients with colorectal cancer (CRC), PhA was obtained from measurements of resistance and reactance from bioelectrical impedance analysis. Computerized tomography imaging at the third lumbar vertebra was used to evaluate muscle abnormalities by quantifying skeletal muscle index (SMI) and skeletal muscle radiodensity (SMD). Muscle function was assessed by handgrip strength (HGS) and gait speed (GS).

Results: This cross-sectional study included 190 participants (X±SD), mean age 60.5 ± 11.3 years; 57% men; 78% had cancer stages III to IV. PhA was highly correlated with SMI (r = 0.70) and moderately correlated with HGS (r = 0.54). PhA explained 48% of the SMI variability (R = 0.485), 21% of the SMD variability (R = 0.214), 26% of HGS (R = 0.261) and 9.8% of GS (R = 0.098). In the multivariate model adjusted for age, sex, body mass index, performance status, comorbidities and cancer stage, 1-degree decrease in PhA was associated with low SMI (Odds Ratio (OR) = 6.56, 95% CI: 2.90-14.86) and with low SMI and HGS combined (OR = 11.10, 95% CI: 2.61-47.25). In addition, Receiving Operating Characteristics curve analysis showed that PhA had a good diagnostic accuracy for detecting low SMI, low SMI and SMD combined, low SMD and HGS and low SMI and HGS combined (AUC = 0.81, 95% CI: 0.74-0.88; AUC = 0.88, 95% CI: 0.81-0.95; AUC = 0.80, 95% CI: 0.70-0.91; AUC = 0.82, 95% CI: 0.74-0.89; respectively).

Conclusions: PhA was a predictor of muscle abnormalities and function and had a good diagnostic accuracy for detecting low muscle mass, low muscle mass and radiodensity, low muscle radiodensity and strength, and low muscle mass and strength in patients with CRC.
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http://dx.doi.org/10.1016/j.clnu.2021.06.013DOI Listing
July 2021

New predictive equations to estimate resting energy expenditure of non-dialysis dependent chronic kidney disease patients.

J Nephrol 2021 Aug 11;34(4):1235-1242. Epub 2021 Feb 11.

Nutrition Program, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil.

Background: Determination of resting energy expenditure (REE) is an important step for the nutritional and medical care of patients with chronic kidney disease (CKD). Methods such as indirect calorimetry or traditional predictive equations are costly or inaccurate to estimate REE of CKD patients. We aimed to develop and validate predictive equations to estimate the REE of non-dialysis dependent-CKD patients.

Methods: A database comprising REE measured by indirect calorimetry (mREE) of 170 non-dialysis dependent-CKD patients was used to develop (n = 119) and validate (n = 51) a new REE-predictive equation. Fat free mass (FFM) was assessed by anthropometry and by bioelectrical impedance (BIA).

Results: The multiple regression analysis generated three equations: (1) REE (kcal/day) = 854 + 7.4*Weight + 179*Sex - 3.3*Age + 2.1 *eGFR + 26 (if DM) (R = 0.424); (2) REE (kcal/day) = 678.3 + 14.07*FFM.ant + 54.8*Sex - 2*Age + 2.5*eGFR + 140.7* (if DM) (R = 0.449); (3) REE (kcal/day) = 668 + 17.1*FFM.BIA - 2.7*Age - 92.7*Sex + 1.3*eGFR - 152.3 (if DM) (R = 0.45). The estimated REE (eREE) was not different from the mREE (P = 0.181), a high ICC was found and the mean difference between mREE and eREE was not different from zero for the three equations in the validation group. eREE accuracy between 90 and 110% was observed in 55.3%, 62.5% and 61% of the patients for Eqs. (1), (2) and (3), respectively.

Conclusion: The equations showed acceptable accuracy for REE prediction making them a valuable tool to support practitioners to provide more reliable energy recommendations for this group of patients.
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http://dx.doi.org/10.1007/s40620-020-00899-7DOI Listing
August 2021

Medical Nutritional Therapy for Patients with Chronic Kidney Disease not on Dialysis: The Low Protein Diet as a Medication.

J Clin Med 2020 Nov 12;9(11). Epub 2020 Nov 12.

Department of Clinical and Biological Sciences, University of Torino, 10124 Torino, Italy.

The 2020 Kidney Disease Outcome Quality Initiative (KDOQI) Clinical Practice Guideline for Nutrition in chronic kidney disease (CKD) recommends protein restriction to patients affected by CKD in stages 3 to 5 (not on dialysis), provided that they are metabolically stable, with the goal to delay kidney failure (graded as evidence level 1A) and improve quality of life (graded as evidence level 2C). Despite these strong statements, low protein diets (LPDs) are not prescribed by many nephrologists worldwide. In this review, we challenge the view of protein restriction as an "option" in the management of patients with CKD, and defend it as a core element of care. We argue that LPDs need to be tailored and patient-centered to ensure adherence, efficacy, and safety. Nephrologists, aligned with renal dietitians, may approach the implementation of LPDs similarly to a drug prescription, considering its indications, contra-indications, mechanism of action, dosages, unwanted side effects, and special warnings. Following this framework, we discuss herein the benefits and potential harms of LPDs as a cornerstone in CKD management.
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http://dx.doi.org/10.3390/jcm9113644DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7697617PMC
November 2020

Strategies designed to increase the motivation for and adherence to dietary recommendations in patients with chronic kidney disease.

Nephrol Dial Transplant 2020 Nov 6. Epub 2020 Nov 6.

Nutrition Program, Federal University of São Paulo, São Paulo, Brazil.

Chronic kidney disease (CKD) often requires several dietary adjustments to control the disease-related disturbances. This is challenging for both patients and healthcare providers, and particularly for dietitians, who deal closely with the poor adherence to dietary recommendations. Factors associated with poor adherence within the CKD scenario and the need for a shift in the paradigm have already been indicated in several studies; however, rarely are any different and/or potential strategies actually formulated in order to change this paradigm. In this review, we aimed to explore the concepts and factors surrounding adherence to dietary recommendations in CKD and further describe certain potential strategies for a nutritional counseling approach. Such strategies, while poorly explored within CKD, have shown positive results in other chronic disease scenarios. It is timely, therefore, for healthcare providers to acquire these new counseling skills; nevertheless, this would require a rethinking of the traditional attitudes and approaches in order to build a partnership, based on a nonjudgmental and compassionate style in order to guide behavior change. The reflections presented in this review may contribute towards enhancing motivation and the adherence to dietary recommendations in CKD patients.
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http://dx.doi.org/10.1093/ndt/gfaa177DOI Listing
November 2020

Sarcopenia in chronic kidney disease: what have we learned so far?

J Nephrol 2021 Aug 2;34(4):1347-1372. Epub 2020 Sep 2.

Division of Renal Medicine and Baxter Novum, Department of Clinical Science, Technology and Intervention, Karolinska Institute, Stockholm, Sweden.

The term sarcopenia was first introduced in 1988 by Irwin Rosenberg to define a condition of muscle loss that occurs in the elderly. Since then, a broader definition comprising not only loss of muscle mass, but also loss of muscle strength and low physical performance due to ageing or other conditions, was developed and published in consensus papers from geriatric societies. Sarcopenia was proposed to be diagnosed based on operational criteria using two components of muscle abnormalities, low muscle mass and low muscle function. This brought awareness of an important nutritional derangement with adverse outcomes for the overall health. In parallel, many studies in patients with chronic kidney disease (CKD) have shown that sarcopenia is a prevalent condition, mainly among patients with end stage kidney disease (ESKD) on hemodialysis (HD). In CKD, sarcopenia is not necessarily age-related as it occurs as a result of the accelerated protein catabolism from the disease and from the dialysis procedure per se combined with low energy and protein intakes. Observational studies showed that sarcopenia and especially low muscle strength is associated with worse clinical outcomes, including worse quality of life (QoL) and higher hospitalization and mortality rates. This review aims to discuss the differences in conceptual definition of sarcopenia in the elderly and in CKD, as well as to describe etiology of sarcopenia, prevalence, outcome, and interventions that attempted to reverse the loss of muscle mass, strength and mobility in CKD and ESKD patients.
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http://dx.doi.org/10.1007/s40620-020-00840-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8357704PMC
August 2021

Development of muffins as dialysis snacks for patients undergoing hemodialysis: results of chemical composition and sensory analysis.

J Nephrol 2021 Aug 28;34(4):1281-1289. Epub 2020 Aug 28.

Graduation Program in Food, Nutrition and Health, Institute of Nutrition, Rio de Janeiro State University, R São Francisco Xavier, 524, Rio de Janeiro, RJ, 20550-900, Brazil.

Objective: This study aimed to develop two non-industrial food products as financially accessible options to prevent and treat malnutrition in hemodialysis (HD) patients. These food products were developed and intended for use as dialysis snacks.

Methods: This is a cross-sectional and multi-step study. First, 183 adult HD patients (55 ± 14 years; 50.8% males), replied to a questionnaire with their food preferences regarding taste (salty, sweet, bitter, sour) and consistency (liquid, solid, pasty) for a dialysis snack. Most patients preferred a food product with a solid consistency (90%) and a salty flavor (81.4%). Second, three muffin formulations of fine herbs were developed; one enriched with whey protein concentrate (WPC), a second with textured soy protein (TSP) and a third standard formulation without protein for comparison with the protein-enriched muffins, for which the chemical and nutritional compositions were analyzed. In the third step, 60 patients on HD (61 ± 15 years; 53% males) were enrolled in a sensory analysis by applying a 9-point structured hedonic scale, ranging from "extremely liked" (score 9) to "extremely disliked" (score 1).

Results: When compared with the standard formulation, the formulations enriched with WPC and TSP protein had a significantly higher amount of protein/serving (Standard: 5.9 ± 0.3 g vs WPC: 14.5 ± 0.9 g and TSP 10.8 ± 0.7 g; P < 0.05) but a lower amount of carbohydrate (Standard: 13.1 ± 2.2 g vs WPC: 5.6 ± 0.8 g and TSP 6.0 ± 1.2 g vs; P < 0.05). The mineral content/serving of the protein-enriched muffins was low in phosphorus (50 mg) and sodium (180 mg). The potassium content/serving was moderate for the WPC muffin (225.2 mg) and low for the TSP muffin (107.9 mg). The acceptability index (AI) for the enriched protein muffins was higher than 70% and similar to the standard formulation.

Conclusion: The muffins with fine herbs and enriched with protein were well-accepted by all patients and appropriate to serve as dialysis snacks for HD patients.
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http://dx.doi.org/10.1007/s40620-020-00831-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8357674PMC
August 2021

Nutritional management of kidney diseases: an unmet need in patient care.

J Nephrol 2020 10;33(5):895-897

Division of Nephrology, Dialysis and Transplantation, Department of Internal Medicine, IRCCS Ospedale Policlinico San Martino, University of Genova, Genova, Italy.

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http://dx.doi.org/10.1007/s40620-020-00829-7DOI Listing
October 2020

Comparative Analysis Between Computed Tomography and Surrogate Methods to Detect Low Muscle Mass Among Colorectal Cancer Patients.

JPEN J Parenter Enteral Nutr 2020 09 17;44(7):1328-1337. Epub 2019 Nov 17.

Nutrition Institute, Rio de Janeiro State University, Rio de Janeiro, Brazil.

Background: We aimed to evaluate the agreement between computed tomography (CT) and surrogate methods applied in clinical practice for the assessment of low muscle mass. In addition, we assessed the association between different muscle-assessment methods and nutrition status, as well as the prognostic value of low muscle mass on survival in patients with colorectal cancer (CRC).

Methods: This is a cohort including 188 CRC patients with 17 months' follow-up (interquartile range: 12-23 months) for mortality. Low muscle mass was evaluated by corrected mid-upper arm muscle area (AMAc) and calf circumference, skeletal muscle mass by bioelectrical impedance analysis (BIA), muscle deficit by physical examination with the Patient-Generated Subjective Global Assessment (PG-SGA), and lumbar muscle cross-sectional area by CT (reference method).

Results: The prevalence of low muscle mass ranged from 9.6% to 54.3% according to the method used. The physical examination had the highest κ coefficient compared with CT. Low muscularity was associated with the presence of malnutrition, lower body fat, and low phase angle. The Cox regression models-adjusted for age, sex, and treatment 3 months before study inclusion-showed that severe muscle loss measured by BIA and CT and low muscle mass measured by PG-SGA predicted higher mortality rates.

Conclusions: Compared with CT, the physical examination had the best agreement to assess low muscle mass. Low muscle mass assessed by PG-SGA, BIA, and CT showed similar prognostic values for survival.
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http://dx.doi.org/10.1002/jpen.1741DOI Listing
September 2020

Dietary Patterns of Patients with Chronic Kidney Disease: The Influence of Treatment Modality.

Nutrients 2019 Aug 15;11(8). Epub 2019 Aug 15.

Department of Applied Nutrition, Nutrition Institute, Rio de Janeiro State University, Rio de Janeiro 20559-900, Brazil.

Background: We analyzed the dietary patterns of Brazilian individuals with a self-declared diagnosis of chronic kidney disease (CKD) and explored associations with treatment modality.

Methods: Weekly consumption of 14 food intake markers was analyzed in 839 individuals from the 2013 Brazil National Health Survey with a self-declared diagnosis of CKD undergoing nondialysis ( = 480), dialysis ( = 48), or renal transplant ( = 17) treatment or no CKD treatment ( = 294). Dietary patterns were derived by exploratory factor analysis of food intake groups. Multiple linear regression models, adjusted by sociodemographic and geographical variables, were used to evaluate possible differences in dietary pattern scores between different CKD treatment groups.

Results: Two food patterns were identified: an "Unhealthy" pattern (red meat, sweet sugar beverages, alcoholic beverages, and sweets and a negative loading of chicken, excessive salt, and fish) and a "Healthy" pattern (raw and cooked vegetables, fruits, fresh fruit juice, and milk). The Unhealthy pattern was inversely associated with nondialysis and dialysis treatment (β: -0.20 (95% CI: -0.33; -0.06) and β: -0.80 (-1.16; -0.45), respectively) and the Healthy pattern was positively associated with renal transplant treatment (β: 0.32 (0.03; 0.62)).

Conclusions: Two dietary patterns were identified in Brazilian CKD individuals and these patterns were linked to CKD treatment modality.
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http://dx.doi.org/10.3390/nu11081920DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6723967PMC
August 2019

Estimating resting energy expenditure of patients on dialysis: Development and validation of a predictive equation.

Nutrition 2019 Nov - Dec;67-68:110527. Epub 2019 Jun 14.

Nutrition Program, Universidade Federal de São Paulo, São Paulo, Brazil; Hospital do Rim-Fundação Oswaldo Ramos, São Paulo, Brazil; Division of Nephrology, Universidade Federal de São Paulo, São Paulo, Brazil. Electronic address:

Objectives: The aims of this study were to develop and validate a resting energy expenditure (REE) predictive equation in a cohort of patients on dialysis and to test the accuracy of two previously developed specific equations to estimate REE of these patients.

Methods: A database with REE measured by indirect calorimetry (IC) of 189 patients on hemodialysis and peritoneal dialysis was used to develop and validate the new equation. The sample including only patients on hemodialysis (n = 131) was used to test the accuracy of the specific REE dialysis equations by Vilar and Byham-Gray.

Results: Multiple regression analysis generated two equations: REE (kcal/d) = 957.02 - 8.08 × age + 11.07 × body weight + 136.4 (if men) (R = 0.515) (1) REE (kcal/d) = 624.6-4.8 × age + 20.6 × fat-free, ass-fat-free mass-8.65 (if men) (R = 0.512) (2) In the validation group, REE by both equations did not differ from the REE measured by IC. No bias was found in the Bland-Altman analysis and the intraclass correlation coefficient and P20 test showed good reliability with measured REE. Vilar's equation overestimated REE; whereas REE generated by Byham-Gray's equation did not differ from measured REE. Proportional and systematic biases were significant for both equations.

Conclusions: The new equations developed showed good accuracy and can be valuable to estimate energy needs of patients on dialysis. Byham-Gray's and Vilar's equations presented low to moderate performance to estimate REE of the patients on dialysis.
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http://dx.doi.org/10.1016/j.nut.2019.06.008DOI Listing
September 2020

Nutritional status of older patients on hemodialysis: Which nutritional markers can best predict clinical outcomes?

Nutrition 2019 09 20;65:113-119. Epub 2019 Mar 20.

Nutrition Institute, Rio de Janeiro State University, Rio de Janeiro, Brazil; Renal Medicine and Baxter Novum, CLINTEC, Karolinska Institutet, Stockholm, Sweden.

Objective: The aim of this study was to investigate nutritional status in older patients undergoing maintenance hemodialysis (MHD) to determine the prevalence of nutritional markers indicating protein-energy wasting (PEW) as assessed by subjective global assessment (SGA) and other methods, and to explore which nutritional markers can best predict clinical outcomes.

Methods: The study included 173 patients (median age 69 y; 65% men; 38% diabetes) undergoing MHD for >3 mo. Nutritional markers included SGA, malnutrition-inflammation score (MIS), geriatric nutritional risk index (GNRI), handgrip strength (HGS), midarm muscle circumference (MAMC), triceps skinfold thickness (SKF), calf circumference, and albumin. Associations between PEW (diagnosed by different measures and thresholds) and risk for hospitalization (by Poisson regression) and all-cause mortality (by Cox proportional hazards model) were analyzed.

Results: Depending on methods and thresholds used, the prevalence of nutritional markers indicatingPEW varied from 6.9% to 59.5%. In the Poisson models adjusted for age, sex, dialysis length, and diabetes, low SGA, HGS, albumin, and high MIS score were associated with high hospitalization events, whereas in the bivariate Cox regression models adjusted for the same variables, low SGA, GNRI, BMI, calf circumference, and high MIS score were associated with high hazard ratio (HR) for mortality. In addition, in the multivariate models, SGA showed the strongest association with mortality (HR, 2.32; 95% confidence interval [CI], 1.27-4.24) and together with MIS (HR, 2.09; 95% CI, 1.20-3.64), the highest values of C-statistics.

Conclusions: Among older MHD patients, the prevalence of nutritional markers indicating PEW varies substantially depending on methods applied. SGA, MIS, BMI, GNRI, calf circumference, and HGS predicted worse outcomes. SGA and MIS showed the strongest association with hospitalization and mortality risk in the adjusted models.
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http://dx.doi.org/10.1016/j.nut.2019.03.002DOI Listing
September 2019

Frailty is associated with myosteatosis in obese patients with colorectal cancer.

Clin Nutr 2020 02 22;39(2):484-491. Epub 2019 Feb 22.

Department of Applied Nutrition, Nutrition Institute, Rio de Janeiro State University, Rio de Janeiro, Brazil; Graduation Program in Nutrition, Food and Health, Nutrition Institute, Rio de Janeiro State University, Rio de Janeiro, Brazil.

Background & Aims: We aimed to explore the determinants of muscle fat infiltration and to investigate whether myosteatosis, assessed as muscle fat infiltration percentage (%MFI) and muscle attenuation from computed tomography (CT), is associated with frailty in a group of patients with colorectal cancer (CRC).

Methods: Cross sectional study including CRC patients. CT scan of the third lumbar vertebra was used to quantify body composition and the degree of %MFI (reported as percentage of fat within muscle area). Frailty was defined by Fried et al. (2001) as the presence of more than 3 criteria: unintentional weight loss, self-reported exhaustion, weakness (low handgrip strength), slow walking speed (gait speed) and low physical activity. Obesity was defined according to sex-and-age-specific body fat percentage (%BF) cutoff.

Results: A sample of 184 patients (age 60 ± 11 years; 58% men; 29% of patients with frailty) was studied. The sample was divided according to tertiles of MFI% (1st tertile 0 to 2.89%, n = 60; 2nd tertile ≥ 3.9-8.19%, n = 64; 3rd tertile ≥ 8.2-26%, n = 60). Age, females, body mass index, %BF, subcutaneous and visceral adipose tissue and the proportion of patients with frailty were significantly higher in the 3rd %MFI tertile. Phase angle and muscle attenuation were significantly lower in the 3rd %MFI tertile. The determinants of %MFI (r = 0.49), which was log transformed due to its normal distribution, were %BF (β = 0.54; e = 1.72; 95% CI: 0.032 to 0.051; P < 0.01), age (β = 0.34; e = 1.40; 95% CI: 0.016 to 0.032; P < 0.01) and gait speed (β = -0.12; e = 0.87; 95% CI: -0.84 to -0.001; P = 0.049). In addition, in obese patients (n = 74) presenting 4 or 5 frailty criteria increased the chance of having higher %MFI and lower muscle attenuation, after adjustment for sex, age and comorbidities when compared to none or 1 criteria.

Conclusions: In a sample of CRC patients, %BF and gait speed were the determinants of %MFI. In addition, markers of myostetatosis were associated with frailty in the obese patients.
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http://dx.doi.org/10.1016/j.clnu.2019.02.026DOI Listing
February 2020

Food Consumption in Chronic Kidney Disease: Association With Sociodemographic and Geographical Variables and Comparison With Healthy Individuals.

J Ren Nutr 2019 07 24;29(4):333-342. Epub 2018 Dec 24.

Nutrition Institute, Rio de Janeiro State, University, Rio de Janeiro, Brazil. Electronic address:

Objective: To describe the food consumption of individuals with chronic kidney disease (CKD) per sociodemographic and geographical characteristics and CKD treatment. In addition, we compared the food consumption of individuals with and without CKD.

Methods: Cross-sectional study using data from the National Health Survey (Brazil 2013) that included 60,202 individuals. Food consumption was evaluated with the following food intake markers: (1) regular consumption of fruit, vegetables, beans, milk, sugar-sweetened beverages (SSBs), sweets, red meat, and chicken; (2) weekly intake of fish; and (3) consumption of meat or chicken with excess fat, excess salt, and alcoholic beverage. The prevalence of these indicators was described per sociodemographic (gender, age, educational level, and race/skin color) and geographical (location of residence and geographical regions) variables in CKD and non-CKD individuals. Unadjusted and multiple logistic regression models, adjusted by sociodemographic and geographical variables, were applied.

Results: 60,202 individuals were divided into 5 groups: (1) non-CKD (n 5 59,363), (2) non-dialysis-dependent (n 5 480), (3) dialysis (n 5 48), (4) renal transplanted (n 5 17), and (5) untreated CKD (n 5 294). Age, education level, and geographic region were associated with food markers. Comparisons among those with CKD by treatment group showed that the dialysis group had a lower regular consumption of beans, alcoholic beverages, and salt in excess. Upon further comparisons with the non-CKD group, the CKD group (especially that in dialysis) showed a significantly lower regular consumption of beans, red meat, SSBs, salt in excess, and alcoholic beverages. Except for SSBs, this difference was maintained after adjustment.

Conclusions: Food consumption of the CKD individuals is influenced by sociodemographic and geographical characteristics. Food groups of which patients are normally advised to limit their dietary intake were those with the greatest difference between individuals with and without CKD and among the CKD treatments.
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http://dx.doi.org/10.1053/j.jrn.2018.10.010DOI Listing
July 2019

Association of Sarcopenia With Nutritional Parameters, Quality of Life, Hospitalization, and Mortality Rates of Elderly Patients on Hemodialysis.

J Ren Nutr 2018 05;28(3):197-207

Nutrition Institute, Rio de Janeiro State University, Rio de Janeiro, Brazil. Electronic address:

Objective: This study aimed to assess whether diminished muscle mass, diminished muscle strength, or both conditions (sarcopenia) are associated with worse nutritional status, poor quality of life (QoL), and hard outcomes, such as hospitalization and mortality, in elderly patients on maintenance hemodialysis (MHD).

Design And Subjects: This is a multicenter observational longitudinal study that included 170 patients on MHD (age 70 ± 7 years, 65% male) from 6 dialysis centers.

Main Outcome Measure: The European Working Group on Sarcopenia in Older People defines sarcopenia as the presence of both low muscle mass by appendicular skeletal + low muscle function by handgrip strength. This study evaluated the clinical and nutritional status (laboratory, anthropometry, dual-energy X-ray absorptiometry, 7-point subjective global assessment) and QoL (Kidney Disease Quality of Life) at baseline. Hospitalization and mortality were recorded during 36 months.

Results: Reduced muscle mass was observed in 64% of the patients, reduced muscle strength in 52%, and sarcopenia in 37%. The group with sarcopenia was older, had a higher proportion of men and showed worse clinical and nutritional conditions when compared with patients without sarcopenia. Although reduced muscle mass was strongly associated with poor nutritional status, low muscle strength was associated with worse QoL domains. In the multivariate Cox analyses adjusted by age, gender, dialysis vintage, and diabetes mellitus, low muscle strength alone and sarcopenia were associated with higher hospitalization, and sarcopenia was a predictor of mortality.

Conclusion: In conclusion, in this sample, comprised of elderly patients on MHD, sarcopenia was associated with worse nutritional and clinical conditions and was a predictor of hospitalization and mortality.
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http://dx.doi.org/10.1053/j.jrn.2017.12.003DOI Listing
May 2018

Muscle mass assessment by computed tomography in chronic kidney disease patients: agreement with surrogate methods.

Eur J Clin Nutr 2019 01 20;73(1):46-53. Epub 2018 Mar 20.

Nutrition Graduate Program in Food, Nutrition and Health, Nutrition Institute, Rio de Janeiro State University, Rio de Janeiro, Brazil.

Background/objectives: Patients with chronic kidney disease (CKD) are subjected to muscle wasting. Therefore, it is important to investigate surrogate methods that enable the assessment of muscle mass loss in the clinical setting. We aimed to analyze the agreement between computed tomography (CT) and surrogate methods for the assessment of muscle mass in non-dialysis CKD patients.

Subjects/methods: Cross-sectional study including 233 non-dialysis patients on CKD stages 3 to 5 (61 ± 11 years; 64% men; glomerular filtration rate 22 (14-33) mL/min/1.73 m). The muscle mass was evaluated by CT and bioelectrical impedance, skinfold thicknesses, midarm muscle circumference (MAMC), the predictive equations of Janssen and Baumgartner and the physical examination of muscle atrophy from the subjective global assessment.

Results: In males, the MAMC showed the best agreement with CT as indicated by the kappa test (k = 0.57, P < 0.01), sensitivity (S = 68%), specificity (S = 89%) and accuracy (area under the curve-AUC = 0.78), followed by the Baumgartner equation (kappa = 0.46, P < 0.01; sensitivity = 60%; specificity = 87% and AUC = 0.73). In female, the Baumgartner equation showed the best agreement with CT (kappa = 0.43, P < 0.01; sensitivity = 57%; specificity = 86% and AUC = 0.71).

Conclusions: The MAMC and Baumgartner equation showed the best agreement with CT for the assessment of muscle mass in non-dialysis CKD patients.
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http://dx.doi.org/10.1038/s41430-018-0130-1DOI Listing
January 2019

Factors Associated with Sarcopenia in Patients with Colorectal Cancer.

Nutr Cancer 2018 Feb-Mar;70(2):176-183. Epub 2018 Jan 19.

c Nutrition Institute, Rio de Janeiro State University (UERJ) , Rio de Janeiro , Brazil.

Introduction; Sarcopenia are frequently observed in cancer patients and was associated with poor prognosis. Objectives; to determine the association of nutritional status, body composition, and clinic parameters with sarcopenia in patients with colorectal cancer (CRC). Methods; We conducted a cross-sectional study of 197 patients with CRC. The sarcopenia elements, including lumbar skeletal muscle index (SMI), handgrip strength, and gait speed were measured. The SMI was assessed by computed tomography at third lumbar vertebra. Phase angle (PA), serum albumin (SAlb), muscle attenuation (MA), and the scored patient-generated subjective global assessment (PG-SGA) were also evaluated. Univariate and multivariate analysis of factors associated with sarcopenia were performed. Results; Sarcopenia was present in 29 of 195 patients (15%) and was significantly correlated with advance age, lower body mass index (BMI), SAlb, PA, MA, higher PG-SGA score, and malnutrition (PG-SGA B). In univariate analysis, age, BMI, SAlb, PA, MA, PG-SGA score, and malnutrition (PG-SGA B) were associated with sarcopenia. Multivariable analysis revealed that BMI, SAlb, PA, MA, and PG-SGA score were independent predictors of sarcopenia. Conclusion; BMI, SAlb, PA, MA, and PG-SGA score were independent predictors of sarcopenia in patients with CRC.
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http://dx.doi.org/10.1080/01635581.2018.1412480DOI Listing
April 2019

Elderly patients on hemodialysis have worse dietary quality and higher consumption of ultraprocessed food than elderly without chronic kidney disease.

Nutrition 2017 Sep 19;41:73-79. Epub 2017 Apr 19.

Graduate program in Food, Nutrition and Health, Nutrition Institute, Rio de Janeiro State University, Rio de Janeiro, Brazil; Department of Applied Nutrition, Nutrition Institute, Rio de Janeiro State University, Rio de Janeiro, Brazil. Electronic address:

Objectives: The multiple dietary restrictions recommended to patients on hemodialysis (HD), coupled with conditions imposed by aging, may lead to poor dietary quality in these patients. The aim of this study was to investigate the dietary quality and consumption of ultraprocessed food by elderly patients on HD and those without chronic kidney disease (CKD). Additionally, diets on the day of dialysis and on nondialysis days were evaluated.

Methods: This was a cross-sectional study conducted with 153 noninstitutionalized elderly patients on HD (Elder-HD) and 47 non-CKD elderly (Elder-Healthy) aged ≥60 y. From a 3-d food record, the dietary quality was assessed using the Brazilian Healthy Eating Index Revised (BHEI-R) and the energy contribution of food-processing groups.

Results: Compared with the Elder-Healthy group, the Elder-HD group showed a lower total BHEI-R score (P < 0.05). On the weekdays, the Elder-HD group showed lower scores (P < 0.05) of whole fruit, dark green vegetables and legumes, meat, eggs, and legumes, whereas total cereals showed a higher score (P < 0.05). When furthering the analysis on the Elder-HD group, although the total BHEI-R score did not differ among the days assessed, the components whole fruit, dark green vegetables, and legumes had lower scores (P < 0.05) on the day of dialysis, and the opposite was observed for milk and dairy products. Moreover, the Elder-HD showed a higher (P < 0.05) contribution of processed and ultraprocessed foods and lower (P < 0.05) contribution of natural or minimally processed foods.

Conclusion: The Elder-HD group showed poorer dietary quality and higher consumption of processed and ultraprocessed foods than the Elder-Healthy group. Moreover, when compared with the nondialysis day, these patients exhibited worse dietary quality, on the day of dialysis.
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http://dx.doi.org/10.1016/j.nut.2017.03.013DOI Listing
September 2017

Nutritional assessment of elderly patients on dialysis: pitfalls and potentials for practice.

Nephrol Dial Transplant 2017 Nov;32(11):1780-1789

Nutrition Institute, Rio de Janeiro, Brazil.

The chronic kidney disease (CKD) population is aging. Currently a high percentage of patients treated on dialysis are older than 65 years. As patients get older, several conditions contribute to the development of malnutrition, namely protein energy wasting (PEW), which may be compounded by nutritional disturbances associated with CKD and from the dialysis procedure. Therefore, elderly patients on dialysis are vulnerable to the development of PEW and awareness of the identification and subsequent management of nutritional status is of importance. In clinical practice, the nutritional assessment of patients on dialysis usually includes methods to assess PEW, such as the subjective global assessment, the malnutrition inflammation score, and anthropometric and laboratory parameters. Studies investigating measures of nutritional status specifically tailored to the elderly on dialysis are scarce. Therefore, the same methods and cutoffs used for the general adult population on dialysis are applied to the elderly. Considering this scenario, the aim of this review is to discuss specific considerations for nutritional assessment of elderly patients on dialysis addressing specific shortcomings on the interpretation of markers, in addition to providing clinical practice guidance to assess the nutritional status of elderly patients on dialysis.
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http://dx.doi.org/10.1093/ndt/gfw471DOI Listing
November 2017

Performance of subjective global assessment and malnutrition inflammation score for monitoring the nutritional status of older adults on hemodialysis.

Clin Nutr 2018 04 3;37(2):604-611. Epub 2017 Feb 3.

Nutrition Institute, Rio de Janeiro State University, Rio de Janeiro, Brazil. Electronic address:

Background & Aims: Studies assessing the performance of 7-point subjective global assessment (7p-SGA) and malnutrition inflammation score (MIS) to assess longitudinal changes in nutritional status are lacking. Thus, we aimed to investigate whether longitudinal changes in 7p-SGA and MIS were associated with changes in objective parameters of nutritional status, as well as to evaluate the prognostic value of 7p-SGA and MIS on hospitalization events.

Methods: One hundred and four patients aged ≥60 years (70.2% male, age: 70.9 ± 6.9 years) on maintenance hemodialysis were studied. The 7p-SGA, MIS and objective parameters of nutritional status (anthropometrics, muscle strength, body cell mass and phase angle assessed by bioelectrical impedance analysis - BIA, albumin, creatinine and C-reactive protein) were assessed at baseline and 12 months after the enrollment. Follow-up for hospitalization events were carried out at 13.0 (interquartile range: 3.0; 21.0) months after the first year of enrollment.

Results: Analysis of repeated measures, stratified by gender, and adjusted for age and dialysis vintage, showed that for men, a 1-unit change in 7p-SGA was significantly associated (P < 0.05) with changes in all anthropometrics, muscle strength and BIA parameters. For women, changes in 7p-SGA were associated with most of the anthropometrics, muscle strength and BIA parameters. Similarly, for both genders, changes in MIS were associated with changes in most anthropometric, muscle strength, BIA measurements, albumin (only for men), and creatinine (only for women). In addition, when assessed by 7p-SGA, patients with a declining nutritional status had a higher relative risk (RR) of hospitalization events [RR: 2.08 (95 CI: 1.44-2.99; P < 0.001)] and length of hospital stay (days) [RR: 3.73 (95 CI: 3.29-4.22; P < 0.001)].

Conclusions: Longitudinal changes in 7p-SGA and MIS were associated with changes in most of the objective parameters tested during 12 months of follow-up. Furthermore, a declining 7p-SGA score predicted a greater number of hospitalization events and days of hospital stay.
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http://dx.doi.org/10.1016/j.clnu.2017.01.021DOI Listing
April 2018

A practical approach to dietary interventions for nondialysis-dependent CKD patients: the experience of a reference nephrology center in Brazil.

BMC Nephrol 2016 07 16;17(1):85. Epub 2016 Jul 16.

Nutrition Program and Division of Nephrology, Federal University of São Paulo, São Paulo, Brazil.

This paper describes the 30-year experience on nutritional management of non-dialysis dependent chronic kidney disease (CKD) patients in a public outpatient clinic located in the city of São Paulo, Brazil. A team of specialized dietitians in renal nutrition is responsible to provide individual dietary counseling for patients on stages 3 to 5 of CKD. Two different types of nutrition care protocols are employed depending on the level of renal function. For patients with CKD stage 3 a simplified nutritional assessment is performed and the main dietary focus is on the control of protein intake particularly from animal sources. A more complete nutritional assessment as well as a detailed dietary plan focusing not only on the control of protein but also on energy supply and on specific micronutrients is provided for patients on stages 4 or 5 of CKD. Practical approaches and tools used by the dietitians in our clinic for improving patient´s adherence to protein, sodium and potassium restriction while maintaining a healthy diet are described in detail in the sections of the article.
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http://dx.doi.org/10.1186/s12882-016-0282-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4947314PMC
July 2016

Sensitivity and Specificity of Body Mass Index as a Marker of Obesity in Elderly Patients on Hemodialysis.

J Ren Nutr 2016 Mar;26(2):65-71

Graduate Program in Food, Nutrition and Health, Nutrition Institute, Rio de Janeiro State University, Rio de Janeiro, Brazil; Department of Applied Nutrition, Nutrition Institute, Rio de Janeiro State University, Rio de Janeiro, Brazil. Electronic address:

Objectives: Diagnosing obesity by body mass index (BMI) may not be reliable in elderly individuals due to the changes in body composition. We aimed to analyze the accuracy of BMI thresholds by World Health Organization (WHO) and Nutrition Screening Initiative (NSI) to diagnose obesity in elderly patients on hemodialysis (HD).

Design: Multicenter cross-sectional study.

Setting: Six dialysis facilities.

Subjects: 169 elderly on chronic HD (70.4 ± 7.1 years; 63.9% men).

Main Outcome Variable: Total body fat percentage (BF%) was assessed by the sum of skinfold thicknesses and abdominal fat by waist circumference (WC). Both were used as reference to test the specificity and sensitivity of BMI thresholds (WHO: ≥30 kg/m(2); NSI: >27 kg/m(2)).

Results: The prevalence of obesity according to NSI-BMI, WHO-BMI, BF%, and WC thresholds were 31%, 13%, 27%, and 29.6% in men, respectively, and 36%, 15%, 13%, and 75% in women. Compared to BF%, the sensitivity of NSI-BMI was moderate (65.5%) for men and high (100%) for women, whereas that of WHO-BMI was low (31%) for men and high (87.5%) for women. Compared with WC, NSI-BMI had good (75%) sensitivity for men and moderate (47.8%) for women, whereas WHO-BMI had moderate (43.8%) sensitivity for men and low (19.6%) for women. The best agreement with BF% was observed for NSI-BMI in men (kappa = 0.46) and for WHO-BMI in women (kappa = 0.80). For WC, the best agreement was for WHO-BMI for men (kappa = 0.63) and NSI-BMI for women (kappa = 0.31).

Conclusions: BMI thresholds do not accurately diagnose adiposity in elderly on HD. Therefore, using BMI may lead to misclassifications in this segment population.
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http://dx.doi.org/10.1053/j.jrn.2015.09.001DOI Listing
March 2016

Concurrent and Predictive Validity of Composite Methods to Assess Nutritional Status in Older Adults on Hemodialysis.

J Ren Nutr 2016 Jan 24;26(1):18-25. Epub 2015 Aug 24.

Department of Applied Nutrition, Nutrition Institute, Rio de Janeiro State University, Rio de Janeiro, Rio de Janeiro, Brazil. Electronic address:

Objective: To assess the performance of subjective global assessment (SGA), malnutrition inflammation score (MIS), and mini nutritional assessment short-form (MNA-SF) in older adults on hemodialysis (HD) by evaluating their concurrent and predictive validity.

Design: An observational and prospective study including older adults on HD.

Setting: Six dialysis units.

Subjects: We assessed 137 HD patients aged ≥60 years (71.7% male, 70.2 ± 7.2 years).

Main Outcome Measures: The nutritional status was assessed by 7-point SGA, MIS and MNA-SF, and by objective methods. Patients were followed up for 14.5 (8; 26.3) months (median and interquartile) to assess survival.

Results: Protein energy wasting (PEW) was present in 63% of the patients when assessed by SGA, in 77% by MIS, and in 26% by MNA-SF. Most objective parameters of patients classified with PEW were lower (P < .05) than those from patients classified as well-nourished by SGA, MIS, and MNA-SF. In addition, the hazard of death was higher for patients classified as PEW by SGA (hazard ratio 2.63 [95% confidence interval 1.14-6.00]), MIS (5.13 [1.19-13.7]), and MNA-SF (2.53 [1.34-4.77]) in comparison to well-nourished patients.

Conclusions: The prevalence of PEW varied depending on the tool applied. SGA, MIS, and MNA-SF had good concurrent and predictive validity for the assessment of nutritional status, but SGA and MIS were likely to perform better than MNA-SF.
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http://dx.doi.org/10.1053/j.jrn.2015.07.002DOI Listing
January 2016

Food intake assessment of elderly patients on hemodialysis.

J Ren Nutr 2015 May 6;25(3):321-6. Epub 2015 Jan 6.

Department of Applied Nutrition, Nutrition Institute, Rio de Janeiro State University, Rio de Janeiro, Brazil. Electronic address:

Objective: To investigate whether the dietary intake of elderly patients on hemodialysis (HD) is lower than that of elderly individuals with normal renal function. In addition, we also assessed whether the dietary intake of elderly on HD is lower on the dialysis day (DD) than on nondialysis days (non-DD).

Design: A cross-sectional and observational study including elderly on HD and non-chronic kidney disease (non-CKD) elderly.

Subjects: We assessed 54 noninstitutionalized elderly patients on HD (study group) and 47 non-CKD elderly (control group) aged ≥60 years.

Main Outcome Measures: All participants had their dietary intake assessed by 3-day food diaries. As a sensitivity analysis, we also assessed the dietary intake in the adequate reporters, which were identified when the ratio-energy intake-to-estimated basal metabolic rate-was above 1.27 (Goldberg index).

Results: When comparing dietary intake between the study and control groups, adjusted for sex and underreporting, it was noted that only the intake of protein (β: -9.9; P: .01) and phosphorus (β: -104; P: .04) were significantly lower in the study group. In addition, when furthering the analysis in the study group by comparing DD with non-DD, it was observed that energy (18 ± 7 vs. 21 ± 8 kcal/kg/day), protein (0.8 ± 0.4 vs. 1.0 ± 0.4 g/kg/day), lipids (41 ± 20 vs. 48 ± 23 g/day), potassium (1371 ± 587 vs. 1540 ± 484 mg/day), and phosphorous intake (647 ± 312 vs. 789 ± 287 mg/day), but not carbohydrate (155 ± 54 vs. 167 ± 55 g/day) and calcium (470 ± 345 vs. 518 ± 333 g/day) were significantly lower on DDs than on non-DDs, respectively.

Conclusions: Except for protein and phosphorous, energy and nutrient intake of elderly patients on HD are similar to that of non-CKD elderly. In addition, the dietary intake is lower on DDs, highlighting the importance of focusing efforts to improve nutritional intake mainly during the day of dialysis treatment.
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http://dx.doi.org/10.1053/j.jrn.2014.10.007DOI Listing
May 2015

Pros and cons of body mass index as a nutritional and risk assessment tool in dialysis patients.

Semin Dial 2015 Jan-Feb;28(1):48-58. Epub 2014 Aug 4.

Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Center for Molecular Medicine, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.

Obesity is a problem of serious concern among chronic kidney disease (CKD) patients; it is a risk factor for progression to end-stage renal disease and its incidence and prevalence in dialysis patients exceeds those of the general population. Obesity, typically assessed with the simple metric of body mass index (BMI), is considered a mainstay for nutritional assessment in guidelines on nutrition in CKD. While regular BMI assessment in connection with the dialysis session is a simple and easy-to-use monitoring tool, such ease of access can lead to excess-of-use, as the value of this metric to health care professionals is overestimated. This review examines BMI as a clinical monitoring tool in CKD practice and offers a critical appraisal as to what a high or a low BMI may signify in this patient population. Topics discussed include the utility of BMI as a reflection of body size, body composition and body fat distribution, diagnostic versus prognostic performance, and consideration of temporal trends over single assessments.
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http://dx.doi.org/10.1111/sdi.12287DOI Listing
October 2015

Comparative associations of muscle mass and muscle strength with mortality in dialysis patients.

Clin J Am Soc Nephrol 2014 Oct 29;9(10):1720-8. Epub 2014 Jul 29.

Divisions of Renal Medicine and Baxter Novum, and Center for Molecular Medicine, Karolinska Institute, Stockholm, Sweden;

Background And Objectives: Reduced muscle mass and strength are prevalent conditions in dialysis patients. However, muscle strength and muscle mass are not congruent; muscle strength can diminish even though muscle mass is maintained or increased. This study addresses phenotype and mortality associations of these muscle dysfunction entities alone or in combination (i.e., concurrent loss of muscle mass and strength/mobility, here defined as sarcopenia).

Design, Setting, Participants, & Measurements: This study included 330 incident dialysis patients (203 men, mean age 53±13 years, and mean GFR 7±2 ml/min per 1.73 m(2)) recruited between 1994 and 2010 and followed prospectively for up to 5 years. Low muscle mass (by dual-energy x-ray absorptiometry appendicular mass index) and low muscle strength (by handgrip) were defined against young reference populations according to the European Working Group on Sarcopenia in Older People.

Results: Whereas 20% of patients had sarcopenia, low muscle mass and low muscle strength alone were observed in a further 24% and 15% of patients, respectively. Old age, comorbidities, protein-energy wasting, physical inactivity, low albumin, and inflammation associated with low muscle strength, but not with low muscle mass (multivariate ANOVA interactions). During follow-up, 95 patients (29%) died and both conditions associated with mortality as separate entities. When combined, individuals with low muscle mass alone were not at increased risk of mortality (adjusted hazard ratio [HR], 1.23; 95% confidence interval [95% CI], 0.56 to 2.67). Individuals with low muscle strength were at increased risk, irrespective of their muscle stores being appropriate (HR, 1.98; 95% CI, 1.01 to 3.87) or low (HR, 1.93; 95% CI, 1.01 to 3.71).

Conclusions: Low muscle strength was more strongly associated with aging, protein-energy wasting, physical inactivity, inflammation, and mortality than low muscle mass. Assessment of muscle functionality may provide additional diagnostic and prognostic information to muscle-mass evaluation.
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http://dx.doi.org/10.2215/CJN.10261013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4186520PMC
October 2014

Applicability of subjective global assessment and malnutrition inflammation score in the assessment of nutritional status on chronic kidney disease.

J Bras Nefrol 2014 Apr-Jun;36(2):236-40

Universidade do Estado do Rio de Janeiro.

Up to now, there is no single method that provides complete and unambiguous assessment of the nutritional status in chronic kidney disease (CKD). Therefore, it has been recommended the use of many nutritional markers. The subjective global assessment (SGA) contains questions regarding the clinical history and physical examination. Subsequently, other versions of the SGA were developed. The malnutrition inflammation score (MIS) was also developed from the original version of the SGA and consists of 70% of the items common to SGA in addition to objective questions. Since many modifications were proposed in the original form of SGA, the use of these questionnaires in CKD patients has increased substantially in clinical practice. Therefore, this paper aims to review the applicability of the SGA and MIS when applied to assess the nutritional status of CKD patients.
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http://dx.doi.org/10.5935/0101-2800.20140034DOI Listing
June 2016
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