Journal of Renal Nutrition最新文献

In end-stage-kidney-disease (ESKD) hyperphosphatemia occurs secondary to decreased renal elimination with continued intestinal absorption of dietary phosphate. Even in chronic kidney disease, glomerular filtration rate lower than 30 ml/min markedly decreases the filtration of inorganic phosphate and increases its serum level. Sevelamer, a non-calcium phosphate binder, is commonly used to control hyperphosphatemia. Available in two forms- sevelamer hydrochloride and sevelamer carbonate, it absorbs phosphate in the gastrointestinal tract and is known to have minimal adverse effects. These are limited to nausea, vomiting, flatulence, and metabolic acidosis, with infrequent significant adverse outcomes. We present a series of two patients with ESKD on sevelamer, with lower gastrointestinal bleeding and endoscopic findings of colonic mucosal injuries with histopathologic findings of sevelamer crystals deposition. Though reported in gastrology literature, nephrology reports show a paucity of discussion around this increasingly common adverse effect and the need for vigilance in ESKD.

Background: Protein-energy wasting (PEW) is the chronic kidney disease (CKD)-specific diagnosis encompassing malnutrition. PEW is associated with adverse outcomes, including those receiving peritoneal dialysis (PD). Identifying PEW requires accurate methods to improve diagnosis. The Global Leadership Initiative on Malnutrition (GLIM) criteria is focused on validating a global consensus for malnutrition diagnosis in adults in clinical settings. While the GLIM criteria has been extensively studied in other clinical populations, there is limited evidence about the agreement with PEW in the PD setting. The aim of this study was to assess the agreement, accuracy, sensitivity, and specificity of GLIM criteria in comparison to the malnutrition inflammation score (MIS), a widely used tool to diagnose PEW in patients on dialysis.

Methods: This was a cross-sectional study of patients undergoing PD. PEW was diagnosed using MIS score. Nutritional assessment was performed to identify malnutrition using GLIM criteria. Phenotypic criteria were assessed using low body mass index, low fat-free mass index, or low muscle strength. Etiology criteria were evaluated using high serum C-reactive protein or reduced food intake. The concordance between GLIM and MIS was evaluated by the Kappa test. A ROC-curve was used for identifying area under curve (AUC), sensitivity and specificity of GLIM.

Results: Patients undergoing PD (n=154) were included in the study. Participants had a median age of 40 (29-51) years and 46.7% were male. PEW/malnutrition was diagnosed using MIS score in 35.3% and in 27.3 % using the GLIM criteria. In comparison with MIS (used as the diagnostic reference), the sensitivity of GLIM was 65.8%, specificity 61.6 %, and AUC was 0.63. The weighted Kappa coefficient was (k 0.15, p=0.02.).

Conclusion: GLIM criteria did not perform better than MIS in diagnosing PEW/malnutrition in patients in PD. Future research to assess the association of GLIM criteria with clinical outcomes is needed.

Background and aims: Frailty is common among hemodialysis (HD) patients. Its assessment is usually based on clinical criteria. In the present work, we evaluated the interest of combining clinical frailty score and biomarkers to predict mortality of chronic HD patients. Four biomarkers were assessed: myostatin, insulin-like growth factor-1 (IGF-1), dehydroepiandrosterone sulfate (DHEA-S) and serum creatinine-to-cystastin C ratio (SCr/SCys).

Methods: Prevalent HD patients were enrolled from September 2016 to October 2017 in two centers in this observational prospective study and followed up for 5 years. Serum levels of myostatin, IGF-1, DHEA-S and SCr/SCys were measured at baseline. Frailty was assessed using Fried frailty score (≥3 indicates frailty). The ability to predict 5-year mortality was assessed by calculating Cox regression analyses and areas under the curve (AUC).

Results: We included 125 HD patients with the following characteristics: median age of 67 [53;78] years; 40 % of women; 41% of diabetics and median dialysis vintage of 30 [16;54] months. Among them, 46% were classified as "Frail" according to Fried score. Mortality rate at 5 years was 56%. The median follow up was 49 [19;60] months. Cox univariate analysis showed that higher age, frailty phenotype and decreased concentrations of myostatin, IGF-1, DHEA-S and SCr/SCys were associated with higher mortality. In multivariate analysis, only myostatin remained significant among the biomarkers. The AUC of Fried score and myostatin to predict mortality was significant and comparable: 0.72 (95% CI: 0.63 to 0.80) and 0.72 (95% CI: 0.64 to 0.80), respectively. Combining myostatin with Fried score improved significantly the AUC (AUC = 0.79, 95% CI: 0.71 to 0.86) compared to Fried score alone or myostatin alone (p=0.0049 and p=0.0035 respectively).

Conclusion: Decreased concentrations of myostatin seem to be independently associated with higher risk of mortality. Combining Fried frailty score with myostatin concentration could improve the prediction of five-year mortality in chronic HD patients.

Objectives: To evaluate the associations between the quality of the diet and its components and microbial diversity and composition in peritoneal dialysis (PD) patients.

Design and methods: This cross-sectional study included PD patients for at least 3 months, aged 18-75 years and clinically stable. The Diet Quality Index (DQI), validated for the Brazilian population, is based on the energy density of 11 components ("sugar and sweets;" "beef, pork, and processed meat;" "refined grains and breads;" "animal fat;" "poultry, fish, and eggs;" "whole cereals, tubers, and roots;" "fruits"; "nonstarch vegetables;" "legumes and nuts;" "milk and dairy products;" and "vegetable oil"). A proportional score-based on the adequacy of the intake to Brazilian dietary guidelines-is calculated, and a final score ranged from 0 (worse) to 100 (better) is obtained. Fecal samples were collected at home, in a sterile material, kept refrigerated, and delivered to the clinic within 12 hours; α-diversity indices (Observed operational taxonomic units, Chao-1, Shannon's, Gini-Simpson's, Pielou eveness, and Faith phylogenetics) and microbial profile were determined by 16S ribosomal DNA with polymerase chain reaction-amplification and sequenced on an Illumina MiSeq platform.

Results: Forty-three participants were included (53.5% men, 52.4 ± 14.1 years, body mass index: 25.9 ± 4.1 kg/m², 30.2% had diabetes mellitus). DQI score was 50.5 (41.9-54.9). The lowest energy density was for the components "animal fat" and "whole cereals and breads, tubers, and roots," and the highest were for "refined grains and bread" and "beef, pork, and processed meat." Diversity indices and Enterorhabdus genus were directly associated with the energy density of the components "whole cereals and breads, tubers, and roots" and inversely with "refined grains and bread," after adjustments for age and diabetes.

Conclusions: Even low, the intake of whole cereals, tubers, and roots has the potential to positively influence the microbiota profile in PD patients.

Objective: Large language models (LLMs) have emerged as powerful tools with significant potential for quickly accessing information in the nutrition and health, as in many fields. Retrieval-augmented generation (RAG) has been included among artificial intelligence (AI) powered chatbot structures as a framework developed to increase the accuracy and ability of LLMs. This study aimed to evaluate the accuracy of LLMs (Generative Pre-trained Transformer 4, Gemini, and Llama) and RAG in determining dietary principles in chronic kidney disease.

Design and methods: The nutrition guideline published by the National Kidney Foundation in 2020 was used as an external information source in developed RAG model. Answers were obtained using 12 medical nutritional therapy prompts for chronic kidney disease by four chatbots. The accuracy of the 48 answers generated by the chatbots was evaluated with a 5-point Likert scale.

Results: The results showed that Gemini and RAG had the highest accuracy scores (median: 4.0), followed by Generative Pre-trained Transformer 4 (median: 2.5) and Llama (median: 1.5), respectively. When the accuracy scores were examined between the two chatbots, a significant difference was detected between all groups except Gemini and RAG.

Conclusion: These chatbots produced both completely correct answers and false information with potentially harmful clinical outcomes. Customization of LLMs in specific areas such as nutrition or the development of a nutrition-specific RAG framework by improving LLM structures with current guidelines and articles may be an important strategy to increase the accuracy of AI powered chatbots.

Objectives: The aim was to assess the intrarater and interrater reliability of the handheld dynamometry testing of lower limb muscles during hemodialysis.

Methods: This is a cross-sectional study including subjects undertaking hemodialysis for at least 3 months. Handheld dynamometer measurements of hip and ankle muscle strength (N) were registered on 4 different occasions, 2 trials by raters A and 2 by raters B, to evaluate the intrarater and interrater reliability. Bland-Altman plots were constructed to examine the agreement between raters by scoring the difference between raters against the mean of both raters' scores. The intraclass correlation coefficient was used to assess relative intrarater and interrater reliability. Absolute reliability was assessed with the minimal detectable change.

Results: Fifty-six participants (median age, 67 years) data showed high to very high relative reliability (intraclass correlation coefficients 0.75-0.98). Regarding the intrarater absolute reliability, minimal detectable change score 90% confidence interval values ranged from 27.0 to 41.6.5 N (0.14-0.26 N/kg m²) for hip muscles but increased for ankle muscles. Interrater values were wider. The mean difference between trials ranged narrowly across the two-time points for raters A (1.0-19.3 N) and for raters B (1.3 - 11.4 N). The mean difference between raters ranged from 2.4 to 13.5 N. The Bland-Altman plot revealed a systematic bias for raters A in ankle plantar flexion.

Conclusions: The assessment of the hip flexion and abduction strength during dialysis with a handheld dynamometer is reliable and safe. Normalized data provides more reliable results.

Objectives: Anemia is a common complication associated with adverse outcomes in older patients undergoing hemodialysis (HD). They also tend to experience malnutrition, which can affect the course of anemia. We hypothesized that the optimal hemoglobin (Hb) level varies depending on nutritional status in older patients undergoing HD and aimed to investigate the association between Hb levels and mortality according to nutritional status.

Methods: This is an observational study utilizing a nationwide Japanese database from 2019 to 2021. This study included 95,771 patients aged ≥75 years undergoing HD thrice a week. The nutritional risk index for Japanese hemodialysis patients (NRI-JH) was calculated. The association between Hb levels and mortality was investigated using Cox regression analysis stratified by NRI-JH. A nonlinear relationship was investigated using restricted cubic spline analysis.

Results: During a median follow-up period of 24 months, 27,611 patients died. In the low-risk NRI-JH group, the risk of all-cause mortality was higher in the Hb categories of <9.0, 9.0-9.9, and ≥13 g/dL compared to the reference Hb category of 10-10.9 g/dL, with the adjusted hazard ratios and 95% confidence intervals of 1.45 (1.32-1.59), 1.15 (1.08-1.22), and 1.18 (1.07-1.29), respectively. In contrast, the impact of Hb levels on mortality was significantly attenuated in the high-risk NRI-JH group, with a mild increased risk in the <9.0 g/dL category (adjusted hazard ratio, 1.07; 95% confidence interval, 1.01-1.15).

Conclusion: Among older patients undergoing HD, the impact of Hb levels on mortality was attenuated in the high-risk NRI-JH group.

Objective: This large cohort study aimed to examine the overall associations of physical activity (PA) and estimated cardiorespiratory fitness (eCRF) with incident chronic kidney disease (CKD).

Methods: This study included a total of 274,292 participants (mean age, 37.9±8.0 years; 41% women) using data collected from the Kangbuk Samsung Health Study. The participants were categorized into three groups: PA (Inactive, Insufficiently active, and Active) and eCRF(Low, Middle, High). Furthermore, subgroup analyses were conducted to examine the differences in the risks of CKD incidence by age and sex. Cox proportional hazard models were used to calculate hazard ratios (HRs) and 95% confidence intervals (95% CIs).

Results: A total of 932 participants (0.34%) developed CKD. Physical activity level was not associated with CKD risk in the overall cohort. However, younger participants (<45 years) showed lower CKD risks, with hazard ratios (HRs) of 0.53 (95% CI: 0.36-0.79) and 0.73 (95% CI: 0.53-1.00) for insufficiently active and active individuals, respectively. Similarly, men exhibited reduced CKD risks, with HRs of 0.77 (95% CI: 0.59-1.00) and 0.81 (95% CI: 0.66-1.00) in these groups. Additionally, those in the high eCRF group had a 20% reduced CKD risk (HR, 0.80; 95% CI: 0.67-0.96) compared to the low eCRF group.

Conclusions: The associations between PA or eCRF and incident CKD showed differences according to age and sex.

Objectives: Medical nutrition therapy plays a crucial role in managing end-stage kidney disease. Nutrition education should be comprehensible, positive, and actionable. Storytelling can provide context, aid comprehension and retention of new information, and foster a sense of connection among patients. The study aimed to develop a video based on the "Healthy Eating in Kidney Disease" infographic and to test the knowledge of patients before and after watching the video. The study investigated the association between factors such as the number of years receiving dialysis, income, and education level on pre- and postvideo scores.

Methods: This experimental before-after study developed an animated nutrition education video based on the South African-based infographic "Healthy Eating for Kidney Disease" in collaboration with an animator and the researchers. The video was designed in animated format in English, Afrikaans, and isiXhosa. The developed video was used to test participants' knowledge by using the same questionnaire before and after watching the video.

Results: The developed video was tested on 125 participants undergoing peritoneal dialysis or hemodialysis. Participants had a mean age of 42.06 (±standard deviation 10.99) years. Predominantly, participants used isiXhosa (n = 62, 50.8%) as their primary language, followed by Afrikaans and English. Most participants (65.6%; n = 82) exhibited adequate prevideo knowledge scores, with a mean score of 67.73%. Postvideo, the majority (59.2%; n = 74) achieved good knowledge scores with a mean of 82.32%. Noteworthy improvements were observed in knowledge categories postintervention, reflecting a significant positive change (P < .001), with a mean increase of 14.59%.

Conclusion: The educational animated video for end-stage kidney disease patients was successfully developed and tested. The results indicated the video's effectiveness in enhancing participants' knowledge. Although no correlations emerged between knowledge scores and demographic factors, the study suggests that video-based education holds promise in encouraging behavioural changes and improving health outcomes.