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Extension of Healthy Life Span of Dialysis Patients in the Era of a 100-Year Life

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A special issue of Nutrients (ISSN 2072-6643).

Deadline for manuscript submissions: closed (28 February 2021) | Viewed by 67463

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Special Issue Editors

Dr. Masaaki Inaba

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Guest Editor

Kidney Center, Ohno Memorial Hospital, 1-26-10, Minami-Horie, Nishi-ku, Osaka 550-0015, Japan
Interests: sarcopenia/frailty in CKD patients; clinical significance; nutritional support for patients

Prof. Dr. Katsuhiko Mori

E-Mail Website
Guest Editor

Department of Nephrology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
Interests: insulin resistance; insulin signaling; atherosclerosis; vascular calcification; diabetic nephropathy; renal failure

Special Issue Information

Dear Colleagues,

Malnutrition has become a greater health problem with an increasing number of elderly CKD patients on dialysis. Malnutrition is a frequent complication in the CKD population, which is now increasingly recognized as a significant risk factor for adverse outcomes such as higher mortality, higher rates of hospitalization, and poorer quality of life in such patients. We previously found that malnutrition develops preferentially in dialysis patients complicated with diabetes, inflammation, sarcopenia/frailty, and CVD, each of which is a definite and independent risk factor associated with higher mortality, although it is possible that malnutrition could increase mortality by exacerbating such factors. The positive impact of nutritional support to dialysis patients has been well established from the standpoint of mortality and quality of life. Although the restriction of protein intake has been recommended to protect progressive decline in eGFR in CKD patients, it is widely recognized that such protein restriction might accelerate the loss of skeletal muscle in CKD patients who have already suffered from uremic sarcopenia. Increased protein and calorie intake or oral protein-based nutritional supplements, particularly from animal sources, to malnourished dialysis patients is important in increasing serum albumin, muscle mass, and adipose mass to prevent against the development of sarcopenia/frailty. However, although increased protein and calorie intake might increase serum phosphate, a biological toxin, leading to the development of vascular calcification and subsequent poorer prognosis, it is shown that an improved nutritional state rather than hyperphosphatemia might be preferred based on survival rate. The simultaneous introduction of exercise therapy, particularly by isotonic exercise, is needed to increase muscle mass together with the increase of food and nutrient intake. Furthermore, the frequent deficiency of micronutrients, and thus the importance of their sufficient intake, is also recognized, as well as the homeostasis of electrolytes. Finally, new techniques such as MRI are also expected to quantitate malnutrition in dialysis patients to justify early intervention.

This Special Issue will update knowledge on the frequent occurrence of malnourished dialysis patients, and its prevention and treatment to improve quality of life and extend healthy life expectancy. To prevent the onset and development of malnutrition in dialysis patients, it should be emphasized that comprehensive care by a wide variety of medical staff is essential.

The issue will comprise manuscripts of papers presented in the symposium sessions related to nutrition at the 2020 65th Annual Meeting of the Japanese Society for Dialysis Therapy: Extension of Healthy Life Span of Dialysis Patients in the Era of 100-Year Life (https://site.convention.co.jp/65jsdt/).

Dr. Masaaki Inaba
Prof. Dr. Katsuhiko Mori
Guest Editors

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Nutrients is an international peer-reviewed open access semimonthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2900 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

Malnutrition
CKD
diabetes, dialysis
sarcopenia
frailty
skeletal muscle
adipose tissue
phosphate
trace elements
potassium
zinc

Published Papers (13 papers)

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Editorial

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2 pages, 168 KiB

Open AccessEditorial

Extension of Healthy Life Span of Dialysis Patients in the Era of a 100-Year Life

by Masaaki Inaba and Katsuhito Mori

Nutrients 2021, 13(8), 2693; https://0-doi-org.brum.beds.ac.uk/10.3390/nu13082693 - 04 Aug 2021

Cited by 2 | Viewed by 1789

Abstract

With both the elongation of hemodialysis (HD) duration resulting from the sophistication of HD technology and the increasing age at the time of HD initiation due to the aging society of Japan, the mean age of prevalent HD patients is increasing at an [...] Read more.

(This article belongs to the Special Issue Extension of Healthy Life Span of Dialysis Patients in the Era of a 100-Year Life)

Review

Jump to: Editorial

11 pages, 1244 KiB

Open AccessReview

Importance of Considering Malnutrition and Sarcopenia in Order to Improve the QOL of Elderly Hemodialysis Patients in Japan in the Era of 100-Year Life

by Masaaki Inaba, Senji Okuno and Yoshiteru Ohno

Nutrients 2021, 13(7), 2377; https://0-doi-org.brum.beds.ac.uk/10.3390/nu13072377 - 12 Jul 2021

Cited by 18 | Viewed by 4005

Abstract

In the current aging society of Japan, malnutrition and resultant sarcopenia have been widely identified as important symptomatic indicators of ill health and can cause impairments of longevity and quality of life in older individuals. Elderly individuals are recommended to have sufficient calorie and protein intake so as to enjoy a satisfactory quality of life, including maintaining activities of daily living in order to avoid emaciation and sarcopenia. The prevalence of emaciation and sarcopenia in elderly hemodialysis (HD) patients in Japan is higher than in non-HD elderly subjects due to the presence of malnutrition and sarcopenia associated with chronic kidney disease (CKD). Furthermore, comorbidities, such as diabetes and osteoporosis, induce malnutrition and sarcopenia in HD patients. This review presents findings regarding the mechanisms of the development of these early symptomatic conditions and their significance for impaired QOL and increased mortality in elderly HD patients. Full article

(This article belongs to the Special Issue Extension of Healthy Life Span of Dialysis Patients in the Era of a 100-Year Life)

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13 pages, 1056 KiB

Open AccessReview

Application of Magnetic Resonance Imaging in the Evaluation of Nutritional Status: A Literature Review with Focus on Dialysis Patients

by Tsutomu Inoue, Eito Kozawa, Masahiro Ishikawa and Hirokazu Okada

Nutrients 2021, 13(6), 2037; https://0-doi-org.brum.beds.ac.uk/10.3390/nu13062037 - 14 Jun 2021

Cited by 6 | Viewed by 3229

Abstract

Magnetic resonance imaging (MRI) is indispensable in clinical medicine for the morphological and tomographic evaluation of many parenchymal organs. With varied imaging methods, diverse biological information, such as the perfusion volume and measurements of metabolic products, can be obtained. In addition to conventional MRI for morphological assessment, diffusion-weighted MRI/diffusion tensor imaging is used to evaluate white matter structures in the brain; arterial spin labeling is used for cerebral blood flow evaluation; magnetic resonance elastography for fatty liver and cirrhosis evaluation; magnetic resonance spectroscopy for evaluation of metabolites in specific regions of the brain; and blood oxygenation level-dependent imaging for neurological exploration of eating behavior, obesity, and food perception. This range of applications will continue to expand in the future. Nutritional science is a multidisciplinary and all-inclusive field of research; therefore, there are many different applications of MRI. We present a literature review of MRI techniques that can be used to evaluate the nutritional status, particularly in patients on dialysis. We used MEDLINE as the information source, conducted a keyword search in PubMed, and found that, as a nutritional evaluation method, MRI has been used frequently to comprehensively and quantitatively evaluate muscle mass for the determination of body composition. Full article

(This article belongs to the Special Issue Extension of Healthy Life Span of Dialysis Patients in the Era of a 100-Year Life)

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18 pages, 327 KiB

Open AccessReview

Significance of Adipose Tissue Maintenance in Patients Undergoing Hemodialysis

by Senji Okuno

Nutrients 2021, 13(6), 1895; https://0-doi-org.brum.beds.ac.uk/10.3390/nu13061895 - 31 May 2021

Cited by 9 | Viewed by 3372

Abstract

In the general population, obesity is known to be associated with adverse outcomes, including mortality. In contrast, high body mass index (BMI) may provide a survival advantage for hemodialysis patients, which is known as the obesity paradox. Although BMI is the most commonly used measure for the assessment of obesity, it does not distinguish between fat and lean mass. Fat mass is considered to serve as an energy reserve against a catabolic condition, while the capacity to survive starvation is also thought to be dependent on its amount. Thus, fat mass is used as a nutritional marker. For example, improvement of nutritional status by nutritional intervention or initiation of hemodialysis is associated with an increase in fat mass. Several studies have shown that higher levels of fat mass were associated with better survival in hemodialysis patients. Based on body distribution, fat mass is classified into subcutaneous and visceral fat. Visceral fat is metabolically more active and associated with metabolic abnormalities and inflammation, and it is thus considered to be a risk factor for cardiovascular disease and mortality. On the other hand, subcutaneous fat has not been consistently linked to adverse phenomena and may reflect nutritional status as a type of energy storage. Visceral and subcutaneous adipose tissues have different metabolic and inflammatory characteristics and may have opposing influences on various outcomes, including mortality. Results showing an association between increased subcutaneous fat and better survival, along with other conditions, such as cancer or cirrhosis, in hemodialysis patients have been reported. This evidence suggests that fat mass distribution (i.e., visceral fat and subcutaneous fat) plays a more important role for these beneficial effects in hemodialysis patients. Full article

(This article belongs to the Special Issue Extension of Healthy Life Span of Dialysis Patients in the Era of a 100-Year Life)

19 pages, 1346 KiB

Open AccessReview

Potassium Metabolism and Management in Patients with CKD

by Shinsuke Yamada and Masaaki Inaba

Nutrients 2021, 13(6), 1751; https://0-doi-org.brum.beds.ac.uk/10.3390/nu13061751 - 21 May 2021

Cited by 36 | Viewed by 8775

Abstract

Potassium (K), the main cation inside cells, plays roles in maintaining cellular osmolarity and acid–base equilibrium, as well as nerve stimulation transmission, and regulation of cardiac and muscle functions. It has also recently been shown that K has an antihypertensive effect by promoting sodium excretion, while it is also attracting attention as an important component that can suppress hypertension associated with excessive sodium intake. Since most ingested K is excreted through the kidneys, decreased renal function is a major factor in increased serum levels, and target values for its intake according to the degree of renal dysfunction have been established. In older individuals with impaired renal function, not only hyperkalemia but also hypokalemia due to anorexia, K loss by dialysis, and effects of various drugs are likely to develop. Thus, it is necessary to pay attention to K management tailored to individual conditions. Since abnormalities in K metabolism can also cause lethal arrhythmia or sudden cardiac death, it is extremely important to monitor patients with a high risk of hyper- or hypokalemia and attempt to provide early and appropriate intervention. Full article

(This article belongs to the Special Issue Extension of Healthy Life Span of Dialysis Patients in the Era of a 100-Year Life)

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21 pages, 607 KiB

Open AccessReview

Association of Zinc Deficiency with Development of CVD Events in Patients with CKD

by Shinya Nakatani, Katsuhito Mori, Tetsuo Shoji and Masanori Emoto

Nutrients 2021, 13(5), 1680; https://0-doi-org.brum.beds.ac.uk/10.3390/nu13051680 - 15 May 2021

Cited by 29 | Viewed by 4766

Abstract

Deficiency of the micronutrient zinc is common in patients with chronic kidney disease (CKD). The aim of this review is to summarize evidence presented in literature for consolidation of current knowledge regarding zinc status in CKD patients, including those undergoing hemodialysis. Zinc deficiency is known to be associated with various risk factors for cardiovascular disease (CVD), such as increased blood pressure, dyslipidemia, type 2 diabetes mellitus, inflammation, and oxidative stress. Zinc may protect against phosphate-induced arterial calcification by suppressing activation of nuclear factor kappa light chain enhancer of activated B. Serum zinc levels have been shown to be positively correlated with T₅₀ (shorter T₅₀ indicates higher calcification propensity) in patients with type 2 diabetes mellitus as well as those with CKD. Additionally, higher intake of dietary zinc was associated with a lower risk of severe abdominal aortic calcification. In hemodialysis patients, the beneficial effects of zinc supplementation in relation to serum zinc and oxidative stress levels was demonstrated in a meta-analysis of 15 randomized controlled trials. Thus, evidence presented supports important roles of zinc regarding antioxidative stress and suppression of calcification and indicates that zinc intake/supplementation may help to ameliorate CVD risk factors in CKD patients. Full article

(This article belongs to the Special Issue Extension of Healthy Life Span of Dialysis Patients in the Era of a 100-Year Life)

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22 pages, 7018 KiB

Open AccessReview

The Importance of Phosphate Control in Chronic Kidney Disease

by Ken Tsuchiya and Taro Akihisa

Nutrients 2021, 13(5), 1670; https://0-doi-org.brum.beds.ac.uk/10.3390/nu13051670 - 14 May 2021

Cited by 21 | Viewed by 5073

Abstract

A series of problems including osteopathy, abnormal serum data, and vascular calcification associated with chronic kidney disease (CKD) are now collectively called CKD-mineral bone disease (CKD-MBD). The pathophysiology of CKD-MBD is becoming clear with the emerging of αKlotho, originally identified as a progeria-causing protein, and bone-derived phosphaturic fibroblast growth factor 23 (FGF23) as associated factors. Meanwhile, compared with calcium and parathyroid hormone, which have long been linked with CKD-MBD, phosphate is now attracting more attention because of its association with complications and outcomes. Incidentally, as the pivotal roles of FGF23 and αKlotho in phosphate metabolism have been unveiled, how phosphate metabolism and hyperphosphatemia are involved in CKD-MBD and how they can be clinically treated have become of great interest. Thus, the aim of this review is reconsider CKD-MBD from the viewpoint of phosphorus, its involvement in the pathophysiology, causing complications, therapeutic approach based on the clinical evidence, and clarifying the importance of phosphorus management. Full article

(This article belongs to the Special Issue Extension of Healthy Life Span of Dialysis Patients in the Era of a 100-Year Life)

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22 pages, 1821 KiB

Open AccessReview

Maintenance of Skeletal Muscle to Counteract Sarcopenia in Patients with Advanced Chronic Kidney Disease and Especially Those Undergoing Hemodialysis

by Katsuhito Mori

Nutrients 2021, 13(5), 1538; https://0-doi-org.brum.beds.ac.uk/10.3390/nu13051538 - 02 May 2021

Cited by 26 | Viewed by 7075

Abstract

Life extension in modern society has introduced new concepts regarding such disorders as frailty and sarcopenia, which has been recognized in various studies. At the same time, cutting-edge technology methods, e.g., renal replacement therapy for conditions such as hemodialysis (HD), have made it possible to protect patients from advanced lethal chronic kidney disease (CKD). Loss of muscle and fat mass, termed protein energy wasting (PEW), has been recognized as prognostic factor and, along with the increasing rate of HD introduction in elderly individuals in Japan, appropriate countermeasures are necessary. Although their origins differ, frailty, sarcopenia, and PEW share common components, among which skeletal muscle plays a central role in their etiologies. The nearest concept may be sarcopenia, for which diagnosis techniques have recently been reported. The focus of this review is on maintenance of skeletal muscle against aging and CKD/HD, based on muscle physiology and pathology. Clinically relevant and topical factors related to muscle wasting including sarcopenia, such as vitamin D, myostatin, insulin (related to diabetes), insulin-like growth factor I, mitochondria, and physical inactivity, are discussed. Findings presented thus far indicate that in addition to modulation of the aforementioned factors, exercise combined with nutritional supplementation may be a useful approach to overcome muscle wasting and sarcopenia in elderly patients undergoing HD treatments. Full article

(This article belongs to the Special Issue Extension of Healthy Life Span of Dialysis Patients in the Era of a 100-Year Life)

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15 pages, 3095 KiB

Open AccessReview

Renal Rehabilitation: Exercise Intervention and Nutritional Support in Dialysis Patients

by Junichi Hoshino

Nutrients 2021, 13(5), 1444; https://0-doi-org.brum.beds.ac.uk/10.3390/nu13051444 - 24 Apr 2021

Cited by 30 | Viewed by 9260

Abstract

With the growing number of dialysis patients with frailty, the concept of renal rehabilitation, including exercise intervention and nutrition programs for patients with chronic kidney disease (CKD), has become popular recently. Renal rehabilitation is a comprehensive multidisciplinary program for CKD patients that is led by doctors, rehabilitation therapists, diet nutritionists, nursing specialists, social workers, pharmacists, and therapists. Many observational studies have observed better outcomes in CKD patients with more physical activity. Furthermore, recent systematic reviews have shown the beneficial effects of exercise intervention on exercise tolerance, physical ability, and quality of life in dialysis patients, though the beneficial effect on overall mortality remains unclear. Nutritional support is also fundamental to renal rehabilitation. There are various causes of skeletal muscle loss in CKD patients. To prevent muscle protein catabolism, in addition to exercise, a sufficient supply of energy, including carbohydrates, protein, iron, and vitamins, is needed. Because of decreased digestive function and energy loss due to dialysis treatment, dialysis patients are recommended to ingest 1.2-fold more protein than the regular population. Motivating patients to join in activities is also an important part of renal rehabilitation. It is essential for us to recognize the importance of renal rehabilitation to maximize patient satisfaction. Full article

(This article belongs to the Special Issue Extension of Healthy Life Span of Dialysis Patients in the Era of a 100-Year Life)

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8 pages, 492 KiB

Open AccessReview

Methods and Nutritional Interventions to Improve the Nutritional Status of Dialysis Patients in JAPAN—A Narrative Review

by Yoshihiko Kanno, Eiichiro Kanda and Akihiko Kato

Nutrients 2021, 13(5), 1390; https://0-doi-org.brum.beds.ac.uk/10.3390/nu13051390 - 21 Apr 2021

Cited by 10 | Viewed by 3650

Abstract

Patients receiving dialysis therapy often have frailty, protein energy wasting, and sarcopenia. However, medical staff in Japan, except for registered dietitians, do not receive training in nutritional management at school or on the job. Moreover, registered dietitians work separately from patients and medical staff even inside a hospital, and there are many medical institutions that do not have registered dietitians. In such institutions, medical staff are required to manage patients’ nutritional disorders without assistance from a specialist. Recent studies have shown that salt intake should not be restricted under conditions of low nutrition in frail subjects or those undergoing dialysis, and protein consumption should be targeted at 0.9 to 1.2 g/kg/day. The Japanese Society of Dialysis Therapy suggests that the Nutritional Risk Index-Japanese Hemodialysis (NRI-JH) is a useful tool to screen for older patients with malnutrition. Full article

(This article belongs to the Special Issue Extension of Healthy Life Span of Dialysis Patients in the Era of a 100-Year Life)

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23 pages, 6050 KiB

Open AccessFeature PaperReview

Significance of Levocarnitine Treatment in Dialysis Patients

by Hiroyuki Takashima, Takashi Maruyama and Masanori Abe

Nutrients 2021, 13(4), 1219; https://0-doi-org.brum.beds.ac.uk/10.3390/nu13041219 - 07 Apr 2021

Cited by 15 | Viewed by 4581

Abstract

Carnitine is a naturally occurring amino acid derivative that is involved in the transport of long-chain fatty acids to the mitochondrial matrix. There, these substrates undergo β-oxidation, producing energy. The major sources of carnitine are dietary intake, although carnitine is also endogenously synthesized in the liver and kidney. However, in patients on dialysis, serum carnitine levels progressively fall due to restricted dietary intake and deprivation of endogenous synthesis in the kidney. Furthermore, serum-free carnitine is removed by hemodialysis treatment because the molecular weight of carnitine is small (161 Da) and its protein binding rates are very low. Therefore, the dialysis procedure is a major cause of carnitine deficiency in patients undergoing hemodialysis. This deficiency may contribute to several clinical disorders in such patients. Symptoms of dialysis-related carnitine deficiency include erythropoiesis-stimulating agent-resistant anemia, myopathy, muscle weakness, and intradialytic muscle cramps and hypotension. However, levocarnitine administration might replenish the free carnitine and help to increase carnitine levels in muscle. This article reviews the previous research into levocarnitine therapy in patients on maintenance dialysis for the treatment of renal anemia, cardiac dysfunction, dyslipidemia, and muscle and dialytic symptoms, and it examines the efficacy of the therapeutic approach and related issues. Full article

(This article belongs to the Special Issue Extension of Healthy Life Span of Dialysis Patients in the Era of a 100-Year Life)

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9 pages, 560 KiB

Open AccessReview

Optimal Protein Intake in Pre-Dialysis Chronic Kidney Disease Patients with Sarcopenia: An Overview

by Yoshitaka Isaka

Nutrients 2021, 13(4), 1205; https://0-doi-org.brum.beds.ac.uk/10.3390/nu13041205 - 06 Apr 2021

Cited by 14 | Viewed by 6605

Abstract

Multi-factors, such as anorexia, activation of renin-angiotensin system, inflammation, and metabolic acidosis, contribute to malnutrition in chronic kidney disease (CKD) patients. Most of these factors, contributing to the progression of malnutrition, worsen as CKD progresses. Protein restriction, used as a treatment for CKD, can reduce the risk of CKD progression, but may worsen the sarcopenia, a syndrome characterized by a progressive and systemic loss of muscle mass and strength. The concomitant rate of sarcopenia is higher in CKD patients than in the general population. Sarcopenia is also associated with mortality risk in CKD patients. Thus, it is important to determine whether protein restriction should be continued or loosened in CKD patients with sarcopenia. We may prioritize protein restriction in CKD patients with a high risk of end-stage kidney disease (ESKD), classified to stage G4 to G5, but may loosen protein restriction in ESKD-low risk CKD stage G3 patients with proteinuria <0.5 g/day, and rate of eGFR decline <3.0 mL/min/1.73 m²/year. However, the effect of increasing protein intake alone without exercise therapy may be limited in CKD patients with sarcopenia. The combination of exercise therapy and increased protein intake is effective in improving muscle mass and strength in CKD patients with sarcopenia. In the case of loosening protein restriction, it is safe to avoid protein intake of more than 1.5 g/kgBW/day. In CKD patients with high risk in ESKD, 0.8 g/kgBW/day may be a critical point of protein intake. Full article

(This article belongs to the Special Issue Extension of Healthy Life Span of Dialysis Patients in the Era of a 100-Year Life)

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17 pages, 1740 KiB

Open AccessReview

Positive and Negative Aspects of Sodium Intake in Dialysis and Non-Dialysis CKD Patients

by Yasuyuki Nagasawa

Nutrients 2021, 13(3), 951; https://0-doi-org.brum.beds.ac.uk/10.3390/nu13030951 - 16 Mar 2021

Cited by 8 | Viewed by 3727

Abstract

Sodium intake theoretically has dual effects on both non-dialysis chronic kidney disease (CKD) patients and dialysis patients. One negatively affects mortality by increasing proteinuria and blood pressure. The other positively affects mortality by ameliorating nutritional status through appetite induced by salt intake and the amount of food itself, which is proportional to the amount of salt under the same salty taste. Sodium restriction with enough water intake easily causes hyponatremia in CKD and dialysis patients. Moreover, the balance of these dual effects in dialysis patients is likely different from their balance in non-dialysis CKD patients because dialysis patients lose kidney function. Sodium intake is strongly related to water intake via the thirst center. Therefore, sodium intake is strongly related to extracellular fluid volume, blood pressure, appetite, nutritional status, and mortality. To decrease mortality in both non-dialysis and dialysis CKD patients, sodium restriction is an essential and important factor that can be changed by the patients themselves. However, under sodium restriction, it is important to maintain the balance of negative and positive effects from sodium intake not only in dialysis and non-dialysis CKD patients but also in the general population. Full article

(This article belongs to the Special Issue Extension of Healthy Life Span of Dialysis Patients in the Era of a 100-Year Life)

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