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      The Impact of New Comorbidities on Nutritional Status in Continuous Ambulatory Peritoneal Dialysis Patients

      , ,

      Blood Purification

      S. Karger AG

      Malnutrition, Comorbidity, Continuous ambulatory peritoneal dialysis

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          Abstract

          Objective: To study the prevalence and risk factors for malnutrition in a peritoneal dialysis (PD) center with an active PD program. Methods: We assessed the nutritional status in 205 continuous ambulatory peritoneal dialysis (CAPD) patients, including stable and unstable patients, by subjective global assessment (SGA), dietary diaries and biochemistry index. Serum C-reactive protein (CRP) levels were examined as inflammatory marker. Fluid status including extracellular water (ECW), intracellular water, and total body water (TBW) was evaluated by multiple-frequency bioelectrical impedance analysis and brachial blood pressure was measured. New comorbidities included systemic infection, congestive heart failure and trauma that occurred within 1 month or less. Cardiovascular disease (CVD) was recorded too. Dialysis adequacy and residual renal function were calculated by a standard technique. Results: Based on SGA, 15.6% of our CAPD patients were malnourished. The malnourished patients had advanced age, higher CRP and ECW/TBW levels than normally nourished patients (age: 68.78 ± 11.92 vs. 59.26 ± 13.46 years, p = 0.001; CRP: 11.98 ± 20.22 vs. 5.56 ± 8.30 mg/l, p = 0.004; ECW/TBW: 0.55 ± 0.16 vs. 0.52 ± 0.04, p = 0.049). Patients with malnutrition were more prone to have CVD (53.13 vs. 31.79%, p = 0.004) and new comorbidities (65.62 vs. 4.62%, p = 0.023). Multivariate analysis showed new comorbidities, mostly systemic infection, which were associated with nutritional status (p < 0.001). Both ECW/TBW and new comorbidities were associated with serum CRP, CVD and malnutrition (p < 0.001–0.05). In contrast, some traditional factors which were recognized as contributing to malnutrition such as residual renal function, dialysis adequacy, metabolic acidosis, total protein loss, diabetes and Charlson indexes were not different between normally nourished and malnourished patients in the present study. Conclusions: Our results suggest that only 15.6% of patients were malnourished in our PD program. Old age, inflammation, CVD, fluid overload and new comorbidities were all associated with malnutrition, with new comorbidities, mostly systemic infections, being the most significant risk factor. However, many traditional factors such as residual renal function, dialysis adequacy and diabetes were not.

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          Most cited references 14

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          Strong association between malnutrition, inflammation, and atherosclerosis in chronic renal failure.

          Atherosclerotic cardiovascular disease and malnutrition are widely recognized as leading causes of the increased morbidity and mortality observed in uremic patients. C-reactive protein (CRP), an acute-phase protein, is a predictor of cardiovascular mortality in nonrenal patient populations. In chronic renal failure (CRF), the prevalence of an acute-phase response has been associated with an increased mortality. One hundred and nine predialysis patients (age 52 +/- 1 years) with terminal CRF (glomerular filtration rate 7 +/- 1 ml/min) were studied. By using noninvasive B-mode ultrasonography, the cross-sectional carotid intima-media area was calculated, and the presence or absence of carotid plaques was determined. Nutritional status was assessed by subjective global assessment (SGA), dual-energy x-ray absorptiometry (DXA), serum albumin, serum creatinine, serum urea, and 24-hour urine urea excretion. The presence of an inflammatory reaction was assessed by CRP, fibrinogen (N = 46), and tumor necrosis factor-alpha (TNF-alpha; N = 87). Lipid parameters, including Lp(a) and apo(a)-isoforms, as well as markers of oxidative stress (autoantibodies against oxidized low-density lipoprotein and vitamin E), were also determined. Compared with healthy controls, CRF patients had an increased mean carotid intima-media area (18.3 +/- 0.6 vs. 13.2 +/- 0.7 mm2, P or = 10 mg/liter). Malnourished patients had higher CRP levels (23 +/- 3 vs. 13 +/- 2 mg/liter, P < 0.01), elevated calculated intima-media area (20.2 +/- 0.8 vs. 16.9 +/- 0.7 mm2, P < 0.01) and a higher prevalence of carotid plaques (90 vs. 60%, P < 0.0001) compared with well-nourished patients. During stepwise multivariate analysis adjusting for age and gender, vitamin E (P < 0.05) and CRP (P < 0.05) remained associated with an increased intima-media area. The presence of carotid plaques was significantly associated with age (P < 0.001), log oxidized low-density lipoprotein (oxLDL; P < 0.01), and small apo(a) isoform size (P < 0.05) in a multivariate logistic regression model. These results indicate that the rapidly developing atherosclerosis in advanced CRF appears to be caused by a synergism of different mechanisms, such as malnutrition, inflammation, oxidative stress, and genetic components. Apart from classic risk factors, low vitamin E levels and elevated CRP levels are associated with an increased intima-media area, whereas small molecular weight apo(a) isoforms and increased levels of oxLDL are associated with the presence of carotid plaques.
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            Are there two types of malnutrition in chronic renal failure? Evidence for relationships between malnutrition, inflammation and atherosclerosis (MIA syndrome).

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              Inflammatory mediators in chronic heart failure: an overview.

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                Author and article information

                Journal
                BPU
                Blood Purif
                10.1159/issn.0253-5068
                Blood Purification
                S. Karger AG
                0253-5068
                1421-9735
                2006
                December 2006
                21 December 2006
                : 24
                : 5-6
                : 517-523
                Affiliations
                Institute of Nephrology, Peking University First Hospital, Beijing, China
                Article
                96472 Blood Purif 2006;24:517–523
                10.1159/000096472
                17077624
                © 2006 S. Karger AG, Basel

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                Page count
                Figures: 3, Tables: 4, References: 24, Pages: 7
                Product
                Self URI (application/pdf): https://www.karger.com/Article/Pdf/96472
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