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Anthropometric and body composition assessments provide important information about the nutritional status of dialysis patients. Anthropometric measurements describe body size, fatness, and leanness in dialysis patients and have been collected in the Modification of Diet in Renal Disease (MDRD) and HEMO studies. Dialysis patients present special problems for anthropometry, including decreased functional status and increased comorbidity, that challenge nutrition assessment methodology. Recumbent anthropometric techniques are recommended and stature is estimated from knee height. Measures of weight, stature, calf circumference, arm circumference, and triceps and subscapular skinfolds have recently been reported for dialysis patients, who tend to be shorter, lighter, and have less adipose tissue than healthy persons of the same age. The HEMO study anthropometric data provide a clinical reference for assessing the nutritional status of dialysis patients. The most common body composition methods used with dialysis patients are dual energy X-ray absorptiometry (DEXA), bioelectrical impedance, total body water (TBW), and prediction equations, but they are not recommended for assessment of predialysis patients, as estimates are best obtained postdialysis. The TBW volume used in calculating the dose of dialysis has commonly been predicted from the limited, out-of-date equations of Watson, based on nonrepresentative samples. New prediction equations are available for white, black, and Mexican American children and adults. Watson's data are not representative of the TBW of U.S. men and women. The greater TBW in non-Hispanic black men and women and Mexican American women reflects the greater levels of obesity in the U.S. population.
Semin Dial
PMID:Anthropometric and body composition assessment in dialysis patients. 1566 May 77

Although traditional risk factors for cardiovascular disease are common in dialysis patients, they alone cannot explain the unacceptably high prevalence of vascular disease in this patient group. Much recent interest has therefore focused on the role of various nontraditional cardiovascular risk factors, such as inflammation, wasting, obesity, vascular calcification, and oxidative stress. In addition, genetic factors such as single nucleotide polymorphisms (SNPs) may significantly influence the immune response, the levels of inflammatory markers and body composition, as well as the prevalence of vascular calcification in this patient group. While genetic variations in the tumor necrosis factor (TNF)-alpha-308 and interleukin (IL)-10 -1082 SNPs seem to be consistently associated with adverse clinical outcome in end-stage renal disease (ESRD) patients, the results regarding genetic variations in the IL-6 gene have been conflicting. To elucidate the respective role of DNA polymorphisms in the IL-6 and C-reactive protein (CRP) genes, as well as genes that encode vascular calcification inhibitors (such as fetuin-A, matrix Gla protein, and osteoprotegerin), sufficiently powered studies are needed in which both the protein product and the specific phenotype are determined. In addition, polymorphisms in genes related to body composition may be excellent candidates for analysis in the ESRD population, since nutritional parameters are strongly associated with adverse events in these patients. It seems conceivable that in the future, prognostic or predictive multigene DNA assays (which allow a simultaneous and rapid assessment of multiple genetic variants) will provide nephrologists with a more precise approach for the identification of "high-risk" ESRD patients and the development of accurate individualized treatment strategies.
Semin Dial
PMID:Gene polymorphism association studies in dialysis: the nutrition-inflammation axis. 1607 56

Several recent clinical trials using single modalities to correct the conventional cardiovascular risk factors in patients with chronic kidney disease (CKD) or to improve dialysis dose and techniques in maintenance dialysis patients have failed despite the high rate of cardiovascular mortality in these individuals. Protein-energy malnutrition and inflammation, two relatively common and concurrent conditions in CKD patients, have been implicated as the main cause of poor short-term survival in this population. The "malnutrition-inflammation-cachexia syndrome" (MICS) appears to be the main cause of worsening atherosclerotic cardiovascular disease in the CKD population. The MICS is associated with low serum cholesterol and homocysteine levels and leads to "cachexia in slow motion." Hence a reverse epidemiology of cardiovascular risk factors is observed in dialysis patients with a paradoxical association of obesity, hypercholesterolemia, and hyperhomocysteinemia with better survival. Correction of MICS can potentially ameliorate the cardiovascular epidemic in CKD patients. Because MICS is multifactorial, its correction will require an integral approach rather than a single intervention. The ongoing obsession with conventional cardiovascular risk factors largely reflecting overnutrition in a population that suffers from the short-term consequences of undernutrition and excessive inflammation may well be fruitless. Clinical trials focusing on the causes and consequences of MICS and its modulation using nutritional interventions may be the key to improving survival in these individuals.
Semin Dial
PMID:Recent advances in understanding the malnutrition-inflammation-cachexia syndrome in chronic kidney disease patients: What is next? 1619 Nov 72

The prevalence of obesity is increasing among all Americans, including Native Hawaiians. Because obesity is a risk factor for major chronic diseases and shortens lifespan, it is important to develop and test interventions to prevent and reduce it. Traditional Hawaiian Diet (THD) programs, conducted over the last two decades, were examined in the context of national information on weight loss and obesity prevention programs. This review reveals that THD programs appeal to Native Hawaiians, especially the education about the health and cultural values of native foods and the support of peers. The majority of participants realize short-term weight loss and improvements in health, but few individuals sustain a significant weight loss. Most participants have difficulty adhering to the THD, citing barriers to accessing fresh, affordable produce and the lack of support systems and environments that embrace healthy eating. Any THD program offered in the future should address these barriers and engage participants for at least a year. This review includes a logic model that can be used to help program providers improve THD programs and increase the rigor of evaluation efforts. Additionally, public health professionals and Native Hawaiians should advocate for environmental changes that will support healthy lifestyles, for example: increase access by Native Hawaiians to the land and ocean; provide land for home, neighborhood and community gardening; support local farmers; remove junk-food vending machines from public buildings (including schools); improve school lunches; and mandate daily, enjoyable physical education classes in schools and after-school programs.
Pac Health Dialog 2004 Sep
PMID:The traditional Hawaiian diet: a review of the literature. 1628 10

Assessment of recent trends in the prevalence and incidence of cancer, and its associated risk and protective factors in the State of Hawai'i illustrate that there are definite ethnic, socio-economic, and geographic health disparities. Disparities in access to health care are reflected in decreased and under utilization of all types of preventive cancer screening tests and decreased proportions of people with health insurance coverage. Increases in obesity mirror U.S. national trends and disproportionately affect certain ethnic groups and those with low income. Tobacco use has increased among at-risk populations including: certain ethnic groups, those with low-income and/or low education and those in rural areas. Data that reveal continuing or worsening health disparities imply that either the old methods have not been effective and/or resources are not available or are not being applied to address such disparities. Promising methodologies and programmatic focuses to reduce health disparities are needed as mechanisms for improving the circumstances of at-risk populations. Community based participatory approaches are described here for cancer prevention, detection, and treatment programs that utilize culturally appropriate methods.
Pac Health Dialog 2004 Sep
PMID:Community based participatory approaches to address health disparities in Hawai'i: recent applications in cancer prevention, detection and treatment programs. 1628 97

There exists in the general population a complex and mostly positive relationship between adiposity and mortality risk. Because the dialysis population has a high prevalence of excess adiposity, in addition to a strikingly elevated mortality rate, the effects of obesity are of potential clinical importance. In contrast to the general population, the preponderance of data in dialysis, particularly hemodialysis patients, suggest that adiposity has a neutral or even protective association with mortality. Although methodological concerns exist with regards to confounding and survival bias, among others, the major limitation of this body of literature is its inability to establish causality. Thus, although obese dialysis patients, with certain exceptions, appear to live longer, there is no evidence to suggest that intentional weight loss adversely affects patient outcomes. In light of these limitations and the substantial body of literature implicating obesity as a pathophysiological state, it is currently premature to advocate for excess adiposity as being beneficial or intentional weight loss as dangerous. Decisions regarding optimal weight should be made by clinicians on an individual basis and with close supervision and follow-up. Efforts should be made to preserve lean mass during weight loss regimens by encouraging exercise and recommending sufficient protein consumption. Future research efforts in this area should focus on interventional trials designed to manipulate weight and measure outcomes, identifying potentially beneficial secretory products of adipose tissue, and documenting obesity's effects on quality of life and resource utilization in the dialysis setting.
Semin Dial
PMID:Adiposity in dialysis: good or bad? 1655 Dec 91

Uremic wasting is strongly associated with increased risk of death and hospitalization events in patients with advanced chronic kidney disease (CKD). Recent evidence indicates that patients with advanced chronic kidney disease are prone to uremic wasting due to several factors, which include the dialysis procedure and certain comorbid conditions, especially chronic inflammation and insulin resistance or deficiency. While the catabolic effects of dialysis can be readily avoided with intradialytic nutritional supplementation, there are no established alternative strategies to avoid the catabolic consequences of comorbid conditions other than treatment of their primary etiology. To this end, there is no indication that simply increasing dietary protein and energy intake above the required levels based on level of kidney disease is beneficial in patients with advanced chronic kidney disease. However, aside from the potential adverse effects such as uremic toxin production, dietary protein and energy intake in excess of actual needs might be beneficial in maintenance dialysis patients as it may lead to weight gain over time. Clearly, the role of obesity in advanced uremia needs to be examined in detail prior to making any clinically applicable recommendations, both in terms of ''low'' and ''high'' dietary protein and energy intake.
Semin Dial
PMID:Protein and energy intake in advanced chronic kidney disease: how much is too much? 1724 11

Peritoneal dialysis (PD) patients present an extremely high mortality rate, but the mechanisms mediating the increased risk of mortality observed in this group of patients are still largely unknown, which limits the perspective of effective therapeutic strategies. The leading hypothesis that tries to explain this high mortality risk is that PD patients are exposed to a number of traditional risk factors for cardiovascular disease (CVD) already at the onset of their chronic kidney disease (CKD), since many of these risk factors are common to both CVD and CKD. Of particular importance, chronic inflammation recently emerged as an important novel risk factor related to multiple complications of CKD. There are many stimuli of the inflammatory response in CKD patients, such as fluid overload, decreased cytokine clearance, presence of uremia-modified proteins, presence of chronic infections, metabolic disturbances (including hyperglycemia), obesity. Many of these factors are related to PD. Latin America has made some progress in economic issues; however, a large portion of the population is still living in poverty, in poor sanitary conditions, and with many health-related issues, such as an increasing elderly population, low birth weights, and increasingly high energy intake in the adult population, which, in combination with changes in lifestyle, has provoked an increase in the prevalence of obesity, diabetes, and CVD. Therefore, in Latin America, there seems to be a peculiar situation combining high prevalence of low education level, poor sanitary conditions, and poverty with increases in obesity, diabetes, and sedentary lifestyle. Since inflammation and mortality risk are intimately related to both sides of those health issues, in this review we aim to analyze the peculiarities of inflammation and mortality risk in the Latin-American PD population.
Perit Dial Int
PMID:Inflammation in peritoneal dialysis: a Latin-American perspective. 1746 89

The prevalence of obesity in peritoneal dialysis (PD) populations has risen dramatically since the mid-1980s. This epidemic has been driven by the increased prevalence of obesity in the general population, the increased risk of progression of chronic kidney disease to end-stage renal failure (ESRF) in obese subjects, the reduced probability of listing obese dialysis patients for renal transplantation, a paradoxical enhanced survival in at least some obese populations on dialysis as compared with non-obese ESRF patients, and a possible adipogenic effect of excessive peritoneal glucose absorption in PD. Although obesity has consistently been associated with improved outcomes in hemodialysis, conflicting results have been seen in PD. In general, an elevated body mass index (BMI) has been associated with a neutral or deleterious impact on PD outcomes, and the relationship appears to be explained predominantly by fat mass. Risk is also elevated in patients with a low BMI, such that the "optimal BMI" appears to lie between 20 kg/m2 and 25 kg/m2. The mechanisms underpinning the harmful effect of obesity appear to include increased peritonitis rate, proinflammatory effects, and a more rapid decline of residual renal function in obese patients. No proof exists that weight reduction engenders an improvement in outcome in PD patients, but the available studies suggest that cautious weight reduction is advisable. A few studies have demonstrated that clinically important and sustained weight reduction can be successfully achieved through a combination of individual meal plans, regular exercise, and substitution of icodextrin for dextrose in the once-daily long dwell.
Perit Dial Int 2007 Jun
PMID:What is the optimal fat mass in peritoneal dialysis patients? 1755 14

The increasing rates in incidence and prevalence of chronic kidney disease (CKD) are important challenges for health systems around the world, and are even more significant for undeveloped countries. In Mexico the prevalence of CKD seems to be similar to that in highly developed nations, with diabetes as the leading cause of CKD; however, human and economic resources seem to be insufficient for treatment needs. This is reflected in the unacceptably high mortality rates and in noncompliance with established standards and guidelines. Several measures need to be taken to improve this picture, such as more efficient programs for the prevention of obesity, diabetes, and hypertension. Organizing a national registry of patients with CKD is now a pressing need, as is a continuous search for additional funding and budgets to increase the number of qualified nephrologists and specialized nurses and to continue the much-needed research on CKD.
Perit Dial Int
PMID:Chronic kidney disease and dialysis in Mexico. 1760 47


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