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Changes in body fat mass in male hemodialysis patients: A comparison between diabetics and nondiabetics
Changes in Body Fat Mass in Male Hemodialysis Patients: A Comparison Between Diabetics and Nondiabetics Senji Okuno, MD, Eiji Ishimura, MD, Masao Kim, MD, Tsuyoshi Izumotani, MD, Tatsuyuki Otoshi, MD, Kiyoshi Maekawa, MD, Tomoyuki Yamakawa, MD, Hirotoshi Morii, MD, Masaaki Inaba, MD, and Yoshiki Nishizawa, MD ● Nutritional status is an important factor that affects morbidity and mortality of hemodialysis patients. We investigated 1-year changes in body fat mass of male patients undergoing hemodialysis (duration, 4.9 ⴞ 2.5 years). Fat mass of 217 male patients (age 60 ⴞ 13 years) was measured by dual x-ray absorptiometry twice in a 1-year interval. The patients consisted of 70 with diabetes mellitus and 147 without diabetes. At the second measurement compared with the first, a significant decrease in fat mass was observed in diabetic patients (12.1 ⴞ 4.4 kg versus 11.0 ⴞ 4.7 kg; P < 0.01); there were no significant changes in fat mass in nondiabetic patients (12.2 ⴞ 5.0 kg versus 11.9 ⴞ 4.9 kg; P ⴝ 0.15). Significant differences in percent fat mass changes per year were seen between diabetic and nondiabetic patients (P < 0.05). Protein catabolic rates of diabetic patients were significantly lower than those of nondiabetic patients (0.86 ⴞ 0.18 g/kg/d versus 0.93 ⴞ 0.19 g/kg/d; P < 0.05). In all patients, there was a significant correlation between protein catabolic rates and percent fat mass changes per year (r ⴝ 0.15; P < 0.05). These results showed that body fat mass was decreased significantly in 1 year in male diabetic patients with maintenance hemodialysis, suggesting poorer nutritional status in these patients. Poor protein intake may be one of the risk factors for the decrease in fat mass. Dual x-ray absorptiometry assessment of fat mass changes is suggested as a useful method to examine clinically the nutritional status of hemodialysis patients. © 2001 by the National Kidney Foundation, Inc. INDEX WORDS: Body fat mass; dual x-ray absorptiometry; nutritional status; hemodialysis; diabetes mellitus; protein catabolic rate.
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HE IMPORTANCE of nutritional status has been emphasized to affect morbidity and mortality in patients with end-stage renal disease.1-4 Several assessment methods for nutritional status have been reported to be of value in this population, such as serum albumin,1-6 subjective global assessment,7 anthropometric parameters,1,3,8-10 protein catabolic rate, and interdialytic weight gain.11 There is no gold standard parameter, however, which represents the absolute value for nutrition. Body composition measured by bioimpedance methods and dual x-ray absorptiometry (DXA) has been examined in this context,4,9,10,12-14 although the clinical applicability of these methods has not been well established. We recently reported that body fat mass increased significantly in the first year of maintenance hemodialysis, especially in patients with poor nutritional status, suggesting that nutriFrom the Kidney Center, Shirasagi Hospital; and Second Department of Internal Medicine, Osaka City University Medical School, Osaka, Japan. Address reprint requests to Eiji Ishimura, MD, Second Department of Internal Medicine, Osaka City University Medical School, 1-4-3, Asahi-machi, Abeno-ku, Osaka 5458585, Japan. e-mail: [email protected] © 2001 by the National Kidney Foundation, Inc. 0272-6386/01/3804-0144$35.00/0 doi:10.1053/ajkd.2001.27448 S208
tional status of end-stage renal failure is improved by initiation of hemodialysis.15 In the present study, we investigated 1-year changes in body fat mass of male hemodialysis patients with a duration of more than 1 year. We compared the fat mass change in patients with diabetes mellitus (DM) with that in patients without DM (non-DM) because survival of hemodialysis patients with DM is shorter than that of patients without DM. METHODS
Subjects A total of 217 male patients (mean age ⫾ SD, 60 ⫾ 13 years) with end-stage renal failure on maintenance hemodialysis at Shirasagi Hospital, Osaka, were enrolled in this study. The duration of hemodialysis was more than 1 year and less than 10 years (4.9 ⫾ 2.5 years). Causes of end-stage renal disease were DM in 70 patients and diseases other than DM in 147. All patients were advised regularly to consume food containing 35 kcal per kg ideal body weight. Patients underwent three 4-hour sessions of hemodialysis per week, using regulated cellulose membrane dialyzers and bicarbonate-buffered dialysate. All patients were free of significant acute illness throughout the study period. Blood was drawn for routine analysis before each hemodialysis session.
Measurements of Body Fat Mass Body fat mass was measured twice by DXA (QDR-4500; Hologic Inc, Waltham, MA), as previously described.15 The
American Journal of Kidney Diseases, Vol 38, No 4, Suppl 1 (October), 2001: pp S208-S211
DECREASING FAT MASS IN DM-HEMODIALYSIS
first measurement was carried out in 1997, and the second was performed in 1998 about 1 year after the first (1.0 ⫾ 0.2 years later). Body fat mass was expressed in kilograms. Reproducibility of the fat mass measurement expressed by the coefficient of variation was excellent, being less than 2% in hemodialysis patients.15,16
Statistics All values are expressed as the mean ⫾ SD unless otherwise stated. The differences in fat mass between the first and second DXA measurement were compared by paired Student’s t-tests, and differences in parameters between DM and non-DM patients were compared by unpaired Student’s t-tests. Correlation and linear regression analyses were used to examine the relationship between clinical parameters.
RESULTS
Patient Characteristics and Nutritional Parameters The clinical characteristics of DM patients are shown in Table 1, in which serum parameters were a mean of six measurements in the 3 months before the second DXA measurement. The DM and non-DM patients were similar with regard to age, hemodialysis duration, body mass index, and body fat mass at the first measurement. Serum albumin, creatinine, and cholesterol were significantly lower in DM patients than in non-DM patients. There were no significant differences in interdialytic weight gain between DM and non-DM patients. Protein catabolic rate Table 1.
Clinical Characteristics of Diabetes Mellitus Patients
Age (y) Duration of hemodialysis (y) Body mass index (kg/m2) Fat mess at the first measurement (kg) Interval of DXA measurement (y) Total protein (g/dL) Albumin (g/dL) Blood urea nitrogen (mg/dL) Creatinine (mg/dL) Cholesterol (mg/dL) Fasting plasma glucose (mg/dL) Interdialytic weight gain (%) Protein catabolic rate (g/kg/d) Kt/V
62 ⫾ 10 4.6 ⫾ 2.6 21.1 ⫾ 2.8 12.3 ⫾ 4.6 0.97 ⫾ 0.23 6.7 ⫾ 0.7 3.9 ⫾ 0.5* 72 ⫾ 12 10.5 ⫾ 2.2* 158 ⫾ 37† 126 ⫾ 43* 4.7 ⫾ 2.4 0.86 ⫾ 0.18† 1.02 ⫾ 0.17
NOTE. All values are expressed as mean ⫾ SD. *P ⬍ 0.01 compared with nondiabetic patients (unpaired Student’s t-test). †P ⬍ 0.05 compared with nondiabetic patients (unpaired Student’s t-test).
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of DM patients was significantly lower than that of non-DM patients (0.86 ⫾ 0.18 g/kg/d versus 0.93 ⫾ 0.19 g/kg/d; P ⬍ 0.05). Changes in Body Fat Mass In DM patients, compared with the first measurement, body fat mass at the second measurement was significantly lower (12.1 ⫾ 4.4 kg versus 11.0 ⫾ 4.7 kg; P ⬍ 0.01), although there were no significant differences in body fat mass in non-DM patients between the first and second measurements (12.2 ⫾ 5.0 kg versus 11.9 ⫾ 4.9 kg; P ⫽ 0.15) (Fig 1, left). Fat mass change between the two measurements in individual patients was calculated from the difference between the two divided by the first and expressed in percent. Because the interval between the first and second DXA measurements varied by patients, the percent changes in fat mass between the two measurements were assessed as percent per year. Percent changes in fat mass per year in DM patients were significantly greater than those in non-DM patients (⫺7.9 ⫾ 3.4%/y versus 0.1 ⫾ 1.9%/y in mean ⫾ SE; P ⬍ 0.05), showing a significantly greater decrease in fat mass in DM patients. Relationship Between Fat Mass Change and Clinical Parameters Although percent changes in fat mass per year had no significant correlation with body mass index, blood urea nitrogen, serum creatinine, cholesterol, or Kt/V, there was a significant positive correlation between percent fat mass change per year and protein catabolic rate in all subjects (r ⫽ 0.15; P ⬍ 0.05) (Fig 2). DISCUSSION
In the present study, we showed that body fat mass was decreased significantly in 1 year in male DM patients with maintenance hemodialysis (duration of ⬎1 year), although it was not decreased in non-DM patients. Of several clinical parameters, protein catabolic rate had a significant positive correlation with changes in fat mass, suggesting that poor protein intake may be one of the risk factors for the decrease in fat mass. Assessment of nutritional status is important because poor nutritional status contributes to high morbidity and mortality in dialysis patients.1-4 Although several assessment methods
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Fig 1. (Left) Fat mass in diabetes mellitus (DM) and non-DM patients. The open column represents the fat mass at the first measurement, and the closed column represents the fat mass at the second measurement 1 year later. A significant decrease in fat mass in DM patients was seen in 1 year. Error bars show SD. (Right) Percent change in fat mass per year in DM and non-DM patients. The open column represents the fat mass change in non-DM patients, and the dashed column represents the fat mass change in DM patients. There is a significant difference in fat mass change between DM and non-DM patients. Error bars show SE.
for nutritional status have been reported to be of value, there is no gold standard parameter. DXA can measure bone mineral content, fat mass, and fat-free soft tissue mass (lean body mass) separately; the estimation of body fat mass is relatively precise and, importantly in dialysis patients, is unaffected by hydration status.9,14,17 Although body fat mass was increased significantly in the first year of maintenance hemodialysis in our previous study,15 we found no significant increase in body fat mass in patients with a longer dialysis duration of more than 1 year
(4.9 ⫾ 2.5 years) in the present study. Fat mass in DM patients significantly decreased in 1 year, although fat mass in non-DM patients did not show significant changes. In DM patients in the present study, serum albumin, cholesterol, creatinine, and protein catabolic rate, all of which are considered to be nutritional parameters, were significantly lower than in non-DM patients. These findings suggest that DM patients in the present study are of poorer nutritional status. Decreasing fat mass in DM patients in the present study suggests that poor nutritional status is a
Fig 2. Correlations between percent change in fat mass per year and protein catabolic rate in all patients. There was a significant correlation between fat mass change and protein catabolic rate (r ⴝ 0.15; P < 0.05).
DECREASING FAT MASS IN DM-HEMODIALYSIS
cause of fat mass decrease in 1 year in these patients. A significant positive correlation between the percent changes in fat mass per year and protein catabolic rate was observed. This result also suggests that a decrease in the fat mass reflects poorer nutritional status. Morbidity and mortality in hemodialysis patients with DM are higher than in non-DM patients, and survival in hemodialysis patients with DM is reported to be generally shorter than in non-DM patients.18 One of the reasons for the higher mortality and poorer prognosis in DM patients is considered to be malnutritional status in DM patients.1,2,4,19 Factors contributing to malnutrition in DM patients in the present study are unknown. A lower protein catabolic rate in DM patients suggests that the intake of food or absorption of nutrients from the gastrointestinal tract in DM patients may be lower because lower protein catabolic rate can reflect decreased intake or absorption. The lower food intake or absorption may be caused by diabetic gastroenteropathy or decreased daily activity in these patients.20 In conclusion, we showed that body fat mass was decreased significantly in 1 year in male DM patients undergoing maintenance hemodialysis. Decreasing fat mass is suggested to represent poor nutritional status and decreased nutritional uptake (intake and absorption) in DM patients. DXA assessment of body fat mass is a useful method to examine clinically the fine changes in nutritional status of hemodialysis patients. REFERENCES 1. Qureshi AR, Alvestrand A, Danielsson A, DivinoFilho JC, Gutierrez A, Lindholm B, Bergstrom J: Factors predicting malnutrition in hemodialysis patients: A crosssectional study. Kidney Int 53:773-782, 1998 2. Kaysen GA, Stevenson FT, Depner TA: Determinants of albumin concentration in hemodialysis patients. Am J Kidney Dis 29:658-668, 1997 3. Marcen R, Teruel JL, de la Cal MA, Gamez C, and Spanish Cooperative Study of Nutrition in Hemodialysis: The impact of malnutrition in morbidity and mortality in stable haemodialysis patients. Nephrol Dial Transplant 12: 2324-2331, 1997 4. Ikizler TA, Wingard RL, Harvell J, Shyr Y, Hakim RM: Association of morbidity with markers of nutrition and inflammation in chronic hemodialysis patients: A prospective study. Kidney Int 55:1945-1951, 1999
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5. Goldwasser P, Kaldas AI, Barth RH: Rise in serum albumin and creatinine in the first half year on hemodialysis. Kidney Int 56:2260-2268, 1999 6. Bologa RM, Levine DM, Parker TS, Cheigh JS, Serur D, Stenzel KH, Rubin AL: Interleukin-6 predicts hypoalbuminemia, hypocholesterolemia, and mortality in hemodialysis patients. Am J Kidney Dis 32:107-114, 1998 7. Kalantar-Zadeh K, Kleiner M, Dunne E, Ahern K, Nelson M, Koslowe R, Luft FC: Total iron-binding capacityestimated transferrin correlates with the nutritional subjective global assessment in hemodialysis patients. Am J Kidney Dis 31:263-272, 1998 8. Kopple JD, Zhu X, Lew NL, Lowrie EG: Body weightfor-height relationships predict mortality in maintenance hemodialysis patients. Kidney Int 56:1136-1148, 1999 9. Lukaski HC: Validation of body composition assessment techniques in the dialysis population. ASAIO J 43:251255, 1997 10. Uribarri J, Leibowitz J, Dimaano F: Caloric intake in a group of peritoneal dialysis patients. Am J Kidney Dis 32:1019-1022, 1998 11. Richard AS, Ronald PC, Mary ER, Joan CS: Interdialytic weight gain and nutritional parameters in chronic hemodialysis patients. Am J Kidney Dis 25:579-583, 1995 12. Dumler F: Use of bioelectric impedance analysis and dual-energy X-ray absorptiometry for monitoring the nutritional status of dialysis patients. ASAIO J 43:256-260, 1997 13. Woodrow G, Oldroyd B, Turney JH, Tompkins L, Brownjohn AM, Smith MA: Whole body and regional body composition in patients with chronic renal failure. Nephrol Dial Transplant 11:1613-1618, 1996 14. Stenver DI, Gotfredsen A, Hilsted J, Nielsen B: Body composition in hemodialysis patients measured by dualenergy x-ray absorptiometry. Am J Nephrol 15:105-110, 1995 15. Ishimura E, Okuno S, Kim M, Yamamoto T, Izumotani T, Otoshi T, Shoji T, Inaba M, Nishizawa Y: Increasing body fat mass in the first year of hemodialysis. J Am Soc Nephrol 12:1921-1926, 2001 16. Nishizawa Y, Shoji T, Tanaka S, Yamashita M, Morita A, Emoto M, Tabata T, Inoue T, Morii H: Plasma leptin level and its relationship with body composition in hemodialysis patients. Am J Kidney Dis 31:655-661, 1998 17. Svendsen OL, Haarbo J, Hassager C, Christiansen C: Accuracy of measurements of body composition by dualenergy x-ray absorptiometry in vivo. Am J Clin Nutr 57:605608, 1993 18. US Renal Data System: USRDS 1999 Annual Data Report. Bethesda, MD, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 1999 19. Miller DG, Levine S, Bistrian B: Diagnosis of protein caloric malnutrition in diabetic patients on hemodialysis and peritoneal dialysis. Nephron 33:127-132, 1988 20. Ishimura E, Nishizawa Y, Inaba M, Matsumoto N, Emoto M, Kawagishi T, Shoji S, Okuno S, Kim M, Miki T, Morii H: Serum levels of 1,25-dihydroxyvitamin D, 24,25dihydroxyvitamin D, and 25-hydroxyvitamin D in nondialyzed patients with chronic renal failure. Kidney Int 55:10191027, 1999
T
HE IMPORTANCE of nutritional status has been emphasized to affect morbidity and mortality in patients with end-stage renal disease.1-4 Several assessment methods for nutritional status have been reported to be of value in this population, such as serum albumin,1-6 subjective global assessment,7 anthropometric parameters,1,3,8-10 protein catabolic rate, and interdialytic weight gain.11 There is no gold standard parameter, however, which represents the absolute value for nutrition. Body composition measured by bioimpedance methods and dual x-ray absorptiometry (DXA) has been examined in this context,4,9,10,12-14 although the clinical applicability of these methods has not been well established. We recently reported that body fat mass increased significantly in the first year of maintenance hemodialysis, especially in patients with poor nutritional status, suggesting that nutriFrom the Kidney Center, Shirasagi Hospital; and Second Department of Internal Medicine, Osaka City University Medical School, Osaka, Japan. Address reprint requests to Eiji Ishimura, MD, Second Department of Internal Medicine, Osaka City University Medical School, 1-4-3, Asahi-machi, Abeno-ku, Osaka 5458585, Japan. e-mail: [email protected] © 2001 by the National Kidney Foundation, Inc. 0272-6386/01/3804-0144$35.00/0 doi:10.1053/ajkd.2001.27448 S208
tional status of end-stage renal failure is improved by initiation of hemodialysis.15 In the present study, we investigated 1-year changes in body fat mass of male hemodialysis patients with a duration of more than 1 year. We compared the fat mass change in patients with diabetes mellitus (DM) with that in patients without DM (non-DM) because survival of hemodialysis patients with DM is shorter than that of patients without DM. METHODS
Subjects A total of 217 male patients (mean age ⫾ SD, 60 ⫾ 13 years) with end-stage renal failure on maintenance hemodialysis at Shirasagi Hospital, Osaka, were enrolled in this study. The duration of hemodialysis was more than 1 year and less than 10 years (4.9 ⫾ 2.5 years). Causes of end-stage renal disease were DM in 70 patients and diseases other than DM in 147. All patients were advised regularly to consume food containing 35 kcal per kg ideal body weight. Patients underwent three 4-hour sessions of hemodialysis per week, using regulated cellulose membrane dialyzers and bicarbonate-buffered dialysate. All patients were free of significant acute illness throughout the study period. Blood was drawn for routine analysis before each hemodialysis session.
Measurements of Body Fat Mass Body fat mass was measured twice by DXA (QDR-4500; Hologic Inc, Waltham, MA), as previously described.15 The
American Journal of Kidney Diseases, Vol 38, No 4, Suppl 1 (October), 2001: pp S208-S211
DECREASING FAT MASS IN DM-HEMODIALYSIS
first measurement was carried out in 1997, and the second was performed in 1998 about 1 year after the first (1.0 ⫾ 0.2 years later). Body fat mass was expressed in kilograms. Reproducibility of the fat mass measurement expressed by the coefficient of variation was excellent, being less than 2% in hemodialysis patients.15,16
Statistics All values are expressed as the mean ⫾ SD unless otherwise stated. The differences in fat mass between the first and second DXA measurement were compared by paired Student’s t-tests, and differences in parameters between DM and non-DM patients were compared by unpaired Student’s t-tests. Correlation and linear regression analyses were used to examine the relationship between clinical parameters.
RESULTS
Patient Characteristics and Nutritional Parameters The clinical characteristics of DM patients are shown in Table 1, in which serum parameters were a mean of six measurements in the 3 months before the second DXA measurement. The DM and non-DM patients were similar with regard to age, hemodialysis duration, body mass index, and body fat mass at the first measurement. Serum albumin, creatinine, and cholesterol were significantly lower in DM patients than in non-DM patients. There were no significant differences in interdialytic weight gain between DM and non-DM patients. Protein catabolic rate Table 1.
Clinical Characteristics of Diabetes Mellitus Patients
Age (y) Duration of hemodialysis (y) Body mass index (kg/m2) Fat mess at the first measurement (kg) Interval of DXA measurement (y) Total protein (g/dL) Albumin (g/dL) Blood urea nitrogen (mg/dL) Creatinine (mg/dL) Cholesterol (mg/dL) Fasting plasma glucose (mg/dL) Interdialytic weight gain (%) Protein catabolic rate (g/kg/d) Kt/V
62 ⫾ 10 4.6 ⫾ 2.6 21.1 ⫾ 2.8 12.3 ⫾ 4.6 0.97 ⫾ 0.23 6.7 ⫾ 0.7 3.9 ⫾ 0.5* 72 ⫾ 12 10.5 ⫾ 2.2* 158 ⫾ 37† 126 ⫾ 43* 4.7 ⫾ 2.4 0.86 ⫾ 0.18† 1.02 ⫾ 0.17
NOTE. All values are expressed as mean ⫾ SD. *P ⬍ 0.01 compared with nondiabetic patients (unpaired Student’s t-test). †P ⬍ 0.05 compared with nondiabetic patients (unpaired Student’s t-test).
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of DM patients was significantly lower than that of non-DM patients (0.86 ⫾ 0.18 g/kg/d versus 0.93 ⫾ 0.19 g/kg/d; P ⬍ 0.05). Changes in Body Fat Mass In DM patients, compared with the first measurement, body fat mass at the second measurement was significantly lower (12.1 ⫾ 4.4 kg versus 11.0 ⫾ 4.7 kg; P ⬍ 0.01), although there were no significant differences in body fat mass in non-DM patients between the first and second measurements (12.2 ⫾ 5.0 kg versus 11.9 ⫾ 4.9 kg; P ⫽ 0.15) (Fig 1, left). Fat mass change between the two measurements in individual patients was calculated from the difference between the two divided by the first and expressed in percent. Because the interval between the first and second DXA measurements varied by patients, the percent changes in fat mass between the two measurements were assessed as percent per year. Percent changes in fat mass per year in DM patients were significantly greater than those in non-DM patients (⫺7.9 ⫾ 3.4%/y versus 0.1 ⫾ 1.9%/y in mean ⫾ SE; P ⬍ 0.05), showing a significantly greater decrease in fat mass in DM patients. Relationship Between Fat Mass Change and Clinical Parameters Although percent changes in fat mass per year had no significant correlation with body mass index, blood urea nitrogen, serum creatinine, cholesterol, or Kt/V, there was a significant positive correlation between percent fat mass change per year and protein catabolic rate in all subjects (r ⫽ 0.15; P ⬍ 0.05) (Fig 2). DISCUSSION
In the present study, we showed that body fat mass was decreased significantly in 1 year in male DM patients with maintenance hemodialysis (duration of ⬎1 year), although it was not decreased in non-DM patients. Of several clinical parameters, protein catabolic rate had a significant positive correlation with changes in fat mass, suggesting that poor protein intake may be one of the risk factors for the decrease in fat mass. Assessment of nutritional status is important because poor nutritional status contributes to high morbidity and mortality in dialysis patients.1-4 Although several assessment methods
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Fig 1. (Left) Fat mass in diabetes mellitus (DM) and non-DM patients. The open column represents the fat mass at the first measurement, and the closed column represents the fat mass at the second measurement 1 year later. A significant decrease in fat mass in DM patients was seen in 1 year. Error bars show SD. (Right) Percent change in fat mass per year in DM and non-DM patients. The open column represents the fat mass change in non-DM patients, and the dashed column represents the fat mass change in DM patients. There is a significant difference in fat mass change between DM and non-DM patients. Error bars show SE.
for nutritional status have been reported to be of value, there is no gold standard parameter. DXA can measure bone mineral content, fat mass, and fat-free soft tissue mass (lean body mass) separately; the estimation of body fat mass is relatively precise and, importantly in dialysis patients, is unaffected by hydration status.9,14,17 Although body fat mass was increased significantly in the first year of maintenance hemodialysis in our previous study,15 we found no significant increase in body fat mass in patients with a longer dialysis duration of more than 1 year
(4.9 ⫾ 2.5 years) in the present study. Fat mass in DM patients significantly decreased in 1 year, although fat mass in non-DM patients did not show significant changes. In DM patients in the present study, serum albumin, cholesterol, creatinine, and protein catabolic rate, all of which are considered to be nutritional parameters, were significantly lower than in non-DM patients. These findings suggest that DM patients in the present study are of poorer nutritional status. Decreasing fat mass in DM patients in the present study suggests that poor nutritional status is a
Fig 2. Correlations between percent change in fat mass per year and protein catabolic rate in all patients. There was a significant correlation between fat mass change and protein catabolic rate (r ⴝ 0.15; P < 0.05).
DECREASING FAT MASS IN DM-HEMODIALYSIS
cause of fat mass decrease in 1 year in these patients. A significant positive correlation between the percent changes in fat mass per year and protein catabolic rate was observed. This result also suggests that a decrease in the fat mass reflects poorer nutritional status. Morbidity and mortality in hemodialysis patients with DM are higher than in non-DM patients, and survival in hemodialysis patients with DM is reported to be generally shorter than in non-DM patients.18 One of the reasons for the higher mortality and poorer prognosis in DM patients is considered to be malnutritional status in DM patients.1,2,4,19 Factors contributing to malnutrition in DM patients in the present study are unknown. A lower protein catabolic rate in DM patients suggests that the intake of food or absorption of nutrients from the gastrointestinal tract in DM patients may be lower because lower protein catabolic rate can reflect decreased intake or absorption. The lower food intake or absorption may be caused by diabetic gastroenteropathy or decreased daily activity in these patients.20 In conclusion, we showed that body fat mass was decreased significantly in 1 year in male DM patients undergoing maintenance hemodialysis. Decreasing fat mass is suggested to represent poor nutritional status and decreased nutritional uptake (intake and absorption) in DM patients. DXA assessment of body fat mass is a useful method to examine clinically the fine changes in nutritional status of hemodialysis patients. REFERENCES 1. Qureshi AR, Alvestrand A, Danielsson A, DivinoFilho JC, Gutierrez A, Lindholm B, Bergstrom J: Factors predicting malnutrition in hemodialysis patients: A crosssectional study. Kidney Int 53:773-782, 1998 2. Kaysen GA, Stevenson FT, Depner TA: Determinants of albumin concentration in hemodialysis patients. Am J Kidney Dis 29:658-668, 1997 3. Marcen R, Teruel JL, de la Cal MA, Gamez C, and Spanish Cooperative Study of Nutrition in Hemodialysis: The impact of malnutrition in morbidity and mortality in stable haemodialysis patients. Nephrol Dial Transplant 12: 2324-2331, 1997 4. Ikizler TA, Wingard RL, Harvell J, Shyr Y, Hakim RM: Association of morbidity with markers of nutrition and inflammation in chronic hemodialysis patients: A prospective study. Kidney Int 55:1945-1951, 1999
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5. Goldwasser P, Kaldas AI, Barth RH: Rise in serum albumin and creatinine in the first half year on hemodialysis. Kidney Int 56:2260-2268, 1999 6. Bologa RM, Levine DM, Parker TS, Cheigh JS, Serur D, Stenzel KH, Rubin AL: Interleukin-6 predicts hypoalbuminemia, hypocholesterolemia, and mortality in hemodialysis patients. Am J Kidney Dis 32:107-114, 1998 7. Kalantar-Zadeh K, Kleiner M, Dunne E, Ahern K, Nelson M, Koslowe R, Luft FC: Total iron-binding capacityestimated transferrin correlates with the nutritional subjective global assessment in hemodialysis patients. Am J Kidney Dis 31:263-272, 1998 8. Kopple JD, Zhu X, Lew NL, Lowrie EG: Body weightfor-height relationships predict mortality in maintenance hemodialysis patients. Kidney Int 56:1136-1148, 1999 9. Lukaski HC: Validation of body composition assessment techniques in the dialysis population. ASAIO J 43:251255, 1997 10. Uribarri J, Leibowitz J, Dimaano F: Caloric intake in a group of peritoneal dialysis patients. Am J Kidney Dis 32:1019-1022, 1998 11. Richard AS, Ronald PC, Mary ER, Joan CS: Interdialytic weight gain and nutritional parameters in chronic hemodialysis patients. Am J Kidney Dis 25:579-583, 1995 12. Dumler F: Use of bioelectric impedance analysis and dual-energy X-ray absorptiometry for monitoring the nutritional status of dialysis patients. ASAIO J 43:256-260, 1997 13. Woodrow G, Oldroyd B, Turney JH, Tompkins L, Brownjohn AM, Smith MA: Whole body and regional body composition in patients with chronic renal failure. Nephrol Dial Transplant 11:1613-1618, 1996 14. Stenver DI, Gotfredsen A, Hilsted J, Nielsen B: Body composition in hemodialysis patients measured by dualenergy x-ray absorptiometry. Am J Nephrol 15:105-110, 1995 15. Ishimura E, Okuno S, Kim M, Yamamoto T, Izumotani T, Otoshi T, Shoji T, Inaba M, Nishizawa Y: Increasing body fat mass in the first year of hemodialysis. J Am Soc Nephrol 12:1921-1926, 2001 16. Nishizawa Y, Shoji T, Tanaka S, Yamashita M, Morita A, Emoto M, Tabata T, Inoue T, Morii H: Plasma leptin level and its relationship with body composition in hemodialysis patients. Am J Kidney Dis 31:655-661, 1998 17. Svendsen OL, Haarbo J, Hassager C, Christiansen C: Accuracy of measurements of body composition by dualenergy x-ray absorptiometry in vivo. Am J Clin Nutr 57:605608, 1993 18. US Renal Data System: USRDS 1999 Annual Data Report. Bethesda, MD, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 1999 19. Miller DG, Levine S, Bistrian B: Diagnosis of protein caloric malnutrition in diabetic patients on hemodialysis and peritoneal dialysis. Nephron 33:127-132, 1988 20. Ishimura E, Nishizawa Y, Inaba M, Matsumoto N, Emoto M, Kawagishi T, Shoji S, Okuno S, Kim M, Miki T, Morii H: Serum levels of 1,25-dihydroxyvitamin D, 24,25dihydroxyvitamin D, and 25-hydroxyvitamin D in nondialyzed patients with chronic renal failure. Kidney Int 55:10191027, 1999