Body composition and survival in dialysis patients: results from an international cohort study.

BACKGROUND AND OBJECTIVES High body mass index appears protective in hemodialysis patients, but uncertainty prevails regarding which components of body composition, fat or lean body mass, are primarily associated with survival. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Data between April 2006 and December 2012 were extracted from the Fresenius Medical Care Europe subset of the international MONitoring Dialysis Outcomes initiative. Fresenius Medical Care Europe archives a unique repository of predialysis body composition measurements determined by multifrequency bioimpedance (BCM Body Composition Monitor). The BCM Body Composition Monitor reports lean tissue indices (LTIs) and fat tissue indices (FTIs), which are the respective tissue masses normalized to height squared, relative to an age- and sex-matched healthy population. The relationship between LTI and FTI and all-cause mortality was studied by Kaplan-Meier analysis, multivariate Cox regression, and smoothing spline ANOVA logistic regression. RESULTS In 37,345 hemodialysis patients, median (25th-75th percentile) LTI and FTI were 12.2 (10.3-14.5) and 9.8 (6.6-12.4) kg/m(2), respectively. Median (25th-75th percentile) follow-up time was 266 (132-379) days; 3458 (9.2%) patients died during follow-up. Mortality was lowest with both LTI and FTI in the 10th-90th percentile (reference group) and significantly higher at the lower LTI and FTI extreme (hazard ratio [HR], 3.37; 95% confidence interval [95% CI], 2.94 to 3.87; P<0.001). Survival was best with LTI between 15 and 20 kg/m(2) and FTI between 4 and 15 kg/m(2) (probability of death during follow-up: <5%). When taking the relation between both compartments into account, the interaction was significant (P=0.01). Higher FTI appeared protective in patients with low LTI (HR, 3.37; 95% CI, 2.94 to 3.87; P<0.001 at low LTI-low FTI, decreasing to HR, 1.79; 95% CI, 1.47 to 2.17; P<0.001 at low LTI-high FTI). CONCLUSIONS This large international study indicates best survival in patients with both LTI and FTI in the 10th-90th percentiles of a healthy population. In analyses of body composition, both lean tissue and fat tissue compartments and also their relationship should be considered.

[1]  A. Bosy-Westphal,et al.  A whole-body model to distinguish excess fluid from the hydration of major body tissues. , 2007, The American journal of clinical nutrition.

[2]  J. Carrero,et al.  Muscle atrophy, inflammation and clinical outcome in incident and prevalent dialysis patients. , 2008, Clinical nutrition.

[3]  Yuedong Wang,et al.  The MONitoring Dialysis Outcomes (MONDO) Initiative , 2013, Blood Purification.

[4]  V. Hughes,et al.  Sarcopenia: current concepts. , 2000, The journals of gerontology. Series A, Biological sciences and medical sciences.

[5]  K. Kalantar-Zadeh,et al.  Survival advantages of obesity in dialysis patients. , 2005, The American journal of clinical nutrition.

[6]  H Steil,et al.  EuCliD (European Clinical Database): a database comparing different realities. , 2001, Journal of nephrology.

[7]  E. Lonn,et al.  Malnutrition-inflammation complex syndrome in dialysis patients: causes and consequences. , 2003, American journal of kidney diseases : the official journal of the National Kidney Foundation.

[8]  C. Bouchard.  BMI, fat mass, abdominal adiposity and visceral fat: where is the ‘beef’? , 2007, International Journal of Obesity.

[9]  Yuedong Wang,et al.  Smoothing Splines: Methods and Applications , 2011 .

[10]  D. Gaita,et al.  Benefits of Exercise Training during Hemodialysis Sessions: A Prospective Cohort Study , 2013, Nephron Clinical Practice.

[11]  W. Mitch,et al.  Chronic kidney disease causes defects in signaling through the insulin receptor substrate/phosphatidylinositol 3-kinase/Akt pathway: implications for muscle atrophy. , 2006, Journal of the American Society of Nephrology : JASN.

[12]  K. Leunissen,et al.  Body composition in dialysis patients: a functional assessment of bioimpedance using different prediction models. , 2015, Journal of renal nutrition : the official journal of the Council on Renal Nutrition of the National Kidney Foundation.

[13]  J. Baeyens,et al.  European working group on sarcopenia in older people. Sarcopenia: European consensus on definition and diagnosis: report of the European working group on sarcopenia in older people , 2010 .

[14]  Chong Gu.  Smoothing Spline Anova Models , 2002 .

[15]  I. Jaussent,et al.  Creatinine index and lean body mass are excellent predictors of long-term survival in haemodiafiltration patients. , 2004, Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association.

[16]  J. Passauer,et al.  Evaluation of clinical dry weight assessment in haemodialysis patients using bioimpedance spectroscopy: a cross-sectional study. , 2010, Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association.

[17]  M. Samore,et al.  Effects of body size and body composition on survival in hemodialysis patients. , 2003, Journal of the American Society of Nephrology : JASN.

[18]  Lorien S. Dalrymple,et al.  Association between body composition and frailty among prevalent hemodialysis patients: a US Renal Data System special study. , 2014, Journal of the American Society of Nephrology : JASN.

[19]  D. Marcelli,et al.  Is there any survival advantage of obesity in Southern European haemodialysis patients? , 2009, Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association.

[20]  K. Leunissen,et al.  Out of control: accelerated aging in uremia. , 2013, Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association.

[21]  F. Dabis,et al.  Weight Loss and Body Mass Index as Predictors of HIV Disease Progression to AIDS in Adults. Aquitaine Cohort, France, 1985–1997 , 2001, Journal of the American College of Nutrition.

[22]  S. Solomon,et al.  Body Mass Index and Prognosis in Patients With Chronic Heart Failure: Insights From the Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity (CHARM) Program , 2007, Circulation.

[23]  T. Parker,et al.  Quality of life and stimulation of weight gain after treatment with megestrol acetate: correlation between cytokine levels and nutritional status, appetite in geriatric patients with wasting syndrome. , 2000, The journal of nutrition, health & aging.

[24]  E. Lowrie,et al.  Obesity and mortality in ESRD: is it good to be fat? , 1999, Kidney international.

[25]  I. Bosaeus,et al.  Validation of a 3C model for determination of body fat mass , 2007 .

[26]  P. Stenvinkel,et al.  Resolved: being fat is good for dialysis patients: the Godzilla effect: con. , 2008, Journal of the American Society of Nephrology : JASN.

[27]  T. Ikizler,et al.  Oxidative stress and inflammation are associated with adiposity in moderate to severe CKD. , 2008, Journal of the American Society of Nephrology : JASN.

[28]  C. Mcnulty,et al.  A prospective study of central venous hemodialysis catheter colonization and peripheral bacteremia. , 1999, Clinical nephrology.

[29]  P. Stenvinkel,et al.  Obese sarcopenia in patients with end-stage renal disease is associated with inflammation and increased mortality. , 2007, The American journal of clinical nutrition.

[30]  T. Ikizler,et al.  Resolved: being fat is good for dialysis patients: the Godzilla effect: pro. , 2008, Journal of the American Society of Nephrology : JASN.

[31]  K. Jhaveri,et al.  Reversible Fanconi syndrome due to lenalidomide , 2008, NDT plus.

[32]  R. Jofré,et al.  Inflammatory syndrome in patients on hemodialysis. , 2006, Journal of the American Society of Nephrology : JASN.

[33]  L. Ellegård,et al.  Body fluid volume determination via body composition spectroscopy in health and disease , 2006, Physiological measurement.

[34]  S. Arver,et al.  Prevalence and clinical implications of testosterone deficiency in men with end-stage renal disease. , 2011, Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association.

[35]  N. Levin,et al.  Size Matters: Body Composition and Outcomes in Maintenance Hemodialysis Patients , 2006, Blood Purification.

[36]  D. Fouque,et al.  Serum creatinine improves body mass index survival prediction in hemodialysis patients: a 1-year prospective cohort analysis from the ARNOS study. , 2011, Journal of renal nutrition : the official journal of the Council on Renal Nutrition of the National Kidney Foundation.

[37]  B. Lindholm,et al.  Factors predicting malnutrition in hemodialysis patients: a cross-sectional study. , 1998, Kidney international.

[38]  K. Farrington,et al.  Energy metabolism, body composition, and urea generation rate in hemodialysis patients , 2013, Hemodialysis international. International Symposium on Home Hemodialysis.

[39]  B. Efron,et al.  The possible prognostic usefulness of assessing serum proteins and cholesterol in malignancy , 1975, Cancer.