The Prevalence Of Protein Energy Wasting And Prognosis Analysis Of Patients With Hemodialysis In A Hospital Of Guiyan

Background: Protein energy wasting is common among maintenance hemodialysis(MHD)patients and indicate the presence of wasting and abnormalities in protein–energy nutritional status can also be induced by inflammatory processes.Simply stated,malnutrition refers to abnormalities induced by an inadequate diet,whereas wasting refers to abnormalities that cannot be corrected solely by increasing the diet.For example,pure malnutrition can be associated with reduced serum albumin concentrations,but marked reductions are unusual,while the presence of inflammation is frequently associated with a decrease in serum albumin,where marked reductions are common.Inflammation may also be associated with an increase in protein catabolism that is presumably related to the elaboration of catabolic or antianabolic proinflammatory cytokines.Thus,malnutrition refers to the presence of a low-nutrient intake or,at least,an intake that is inadequate for the nutritional needs of the individual.PEW is the basis on malnutrition,an increase in proinflammatory cytokines such as tumor necrosis factor-a and interleukin-6 may cause loss of protein stores and also can induce anorexia with reduced nutrient intake.The difference is that inflammation or other problems associated with loss of kidney function(for example,metabolic acidosis or impaired insulin/insulin-like growth factor-1 signaling pathways)can impair protein anabolism independently of whether adequate nutrition is present.According to the survey,the United States 20%-80% of dialysis patients have PEW,Spain 52.5% of dialysis patients have PEW,from China's Guangzhou data show that MHD patients PEW incidence was 38.4%.Results from the DOPPS study showed that approximately 25% of MHD patients had severe PEW with an annual mortality rate of 30%..Data from North America showed that albumin lower than 35 g/L was associated with a 2-fold increase in death and hospitalization risk,compared to higher than 40 g/d L albumin level in this population.A project for the United States dialysis population from the base case showed 1400 lives saved,6000 hospitalizations averted,and $36 million in Medicare cost savings resulting from a reduction of totally 20,000 hospital days.Therefore,early detection and intervention for PEW could improve the quality of life and survival of MHD patients.In 2008,the International Society of Renal Nutrition and Metabolism(ISRNM)experts recommends that four main and established categories be recognized for the diagnosis of PEW: biochemical criteria,low body weight,reduced total body fat or body weight,a decrease in muscle mass,and low protein or energy intakes.Hence,accurate assessment of PEW is the key to reduce the incidence of PEW,reduce the mortality rate in patients with MHD.Nevertheless,the optimal method for determining muscle mass in these patients is debatable.Although dual-energy x-ray absorptiometry(DEXA)is considered a reference method for assessing body composition,very few dialysis clinics have direct access to DEXA machines.Therefore,developing and testing equations that can estimate muscle mass based on routinely available clinical and nutritional measures that correlate with PEW is of paramount clinical relevance.Objective: According to the diagnostic criteria for PEW established by ISRNM in 2008,a single center prospective study was conducted on patients with MHD at the hemodialysis center of Guizhou Provincial People's Hospital,and the prevalence of PEW in MHD patients was investigated.A comprehensive nutritional assessment was performed on maintenance hemodialysis patients by means of dietary survey,anthropometry,laboratory examination,and bioelements impedance analysis(BIA).For 1 year follow-up,we recorded survival,death and cause of death,compared the survival rate and mortality rate of PEW patients and non PEW patients.Carry on the correlation analysis between survival rate and age,PEW,diabetes,hemoglobin,creatinine level,history of cardiovascular disease.Methods : This cross-sectional observational study involved 298 patients from hemodialysis centers of Guizhou People's Hospital.Through collecting questionnaires(include gender,age,height,weight,smoking history,medical insurance category,family income,dialysis time,dialysis,primary cause,etc)and SGA questionnaire,physical measurement(include the arm circumference,triceps skinfold thickness,handgrip strength),bioelectrical impedance analysis(including phase angle,lean body mass,fat mass,etc),various laboratory datas(include HGB,LC,ALB,PA,Ca,P,BUN,CREA,i PTH,CRP,ect)and diet survey to evaluate the current nutrition status.We investigate the prevalence of PEW by using the diagnosis criteria of PEW recommended the International Society of Renal Nutrition(2008)and analysis its determinants in MHD.Follow-up for 1 year,count the survival rate in hemodialysis patients,analysis of causes of death and related risk factors.Results:1.The occurrence rate of protein-energy wasting(PEW)in patients with maintenance hemodialysis was 51.7%(154/298).2.Compared PEW group and no-PEW group,handgrip strength(HGS)in the no-PEW group was higher than PEW group significantly,24.7±9.0kg vs.19.4±8.3kg,P <0.001.There were no significant difference of MAC,TSF and LCF in two groups(P >0.05)3.The occurrence rate of Sarcopenia in patients with maintenance hemodialysis was 43.9%,and 61.0% in the PEW group.4.Lean body mass(LBM)and fat mass(FM)in the no-PEW group was significantly higher in no-PEW group than PEW group,51.2±9.6Kg vs 46.0±10.4Kg and 14.3±7.4Kg vs10.8±6.9Kg,P <0.001.There were no significant difference in phase angel(PA)between two groups(P >0.05).5.The independent factors associated with PEW were lean body mass(LBM)and fat mass(FM)in the multivariate logistic regression.6.Follow up observation for 1 years,there were 29 patients(9.7%)died.The main course of death was cardiovascular and cerebrovascular diseases,which resulted in 15 deaths(51.7%),malnutrition 5 deaths(17.2%)and infections 4 deaths(13.8%).7.Kaplan-Meier survival curve analysis revealed that the overall mortality rate in the PEW group was higher as compared with the no-PEW group(P = 0.019).8.The independent factors associated with death were age(OR= 0.101,95% CI 0.027 ~0.378,P = 0.001)?PEW(OR= 3.618,95% CI 1.110~11.792,P = 0.033)?diabetes(OR= 2.811,95% CI1.059~7.464,P = 0.038)?hemoglobin level(OR= 4.451,95% CI 1.719 ~11.524,P = 0.002)in the multivariate logistic regression.9.Cox regression analysis showed that PEW(HR = 4.173,95% CI 1.023 ~ 17.023,P = 0.046)was independent risk factors of death in MHD patients.Conclusion:1.The occurrence rate of PEW in patients with MHD was 51.7%.2.Protein energy wasting in hemodialysis patients,the handgrip strength(HGS)was significantly decreased.3.The occurrence rate of Sarcopenia in patients with maintenance hemodialysis was 43.9%,and 61% in the PEW group.4.LBM and FM loss are an independent risk factor for PEW in patients with MHD.5.The 1 year survival rate of patients with MHD was 90.3%,and death rate was 9.7%.The survival rate in patients undergoing PEW was significantly lower than patient's non-PEW.6.The main cause of death in MHD patients are cardiovascular and cerebrovascular diseases?malnutrition and infections.7.PEW?older age?diabetes and lower hemoglobin level were cause higher death risk in MHD patients.8.The overall survival rate in patients undergoing PEW was 4.17 times as compared with patient's no-PEW.