1. The mortality associated with body size and muscle mass, fat mass and abdominal obesity in patients receiving hemodialysis Date: 2012/12/21 實習生：余萍 指導老師：蕭佩珍營養師 1

2. 2 CKD patients with HD BMI Mortality Muscle mass Fat mass Abdominal obesity ?

3. 33 K/DOQI Guideline

4. KDOQI Guideline 4

5. 5

6. The Obesity Paradox and Mortality Associated With Surrogates of Body Size and Muscle Mass in Patients Receiving Hemodialysis Mayo Clin Proc. November 2010;85(11):991-1001 6

7. Introduction Patients with chronic kidney disease (CKD) who require maintenance hemodialysis (HD) treatment for survival have a high mortality of approximately 20% in the U.S. A high values of body mass index are associated with improved survival. obesity paradox obesity is risk factor of cardiovascular disease in patients with CKD or cardiac disease 7

8. Purpose To determine whether dry weight gain accompanied by an increase in muscle mass is associated with a survival benefit in patients receiving maintenance hemodialysis (HD). 8

9. Patients and Methods 9 121,762 patients in DaVita large dialysis organization ( HD 3 times/week from 2001.7/1 2006.6/30) Unadjusted model Case-mix model Case-mix& MICS model serum creatinine BMI 5 years post-HD dry weight was measured 3 times /week serum creatinine measured 1 times /month

10. 10 Result Characteristics of 121,762 Patients Age:63+15 (y) female:46% white:41% Time on dialysis Primary insurance Marital status DM:51% Kt/V

11. Result BMI & Mortality 11 27-30 3-month–averaged dry weight adjusted for height for 5 years BMI:45

12. Dry weight change during the first 6 months & predictor of mortality 12 Figure 2. Change in dry weight during the first 6 months of the cohort as a predictor of mortality in 57,247 patients receiving hemodialysis(HD) who survived through the first 2 calendar quarters

13. Serum creatinine concentrations & mortality 13 FIGURE 3. Time-dependent associations between 3-month–averaged serum creatinine concentrations before hemodialysis

14. Change in serum creatinine concentration & mortality 14 Figure 4. Change in serum creatinine concentration (a surrogate of change in muscle mass) during the first 6 months of the cohort as a predictor of mortality in 58,201 patients receiving hemodialysis (HD) who survived through the first 2 calendar quarters

15. A combination of changes in dry weight and serum creatinine level & mortality 15 Wt & Cr Improved survival

16. Conclusion In patients with CKD who require maintenance HD treatment to survive, higher BMI or a higher serum creatinine concentration is associated with greater survival. 16 Or CKD patients with HD higher BMI higher serum creatinine greater survival

17. Conclusion A combination of muscle gain and weight loss appears higher survival benefit than does weight gain accompanied by loss of muscle mass. 17

18. Both low muscle mass and low fat are associated with higher all cause mortality in hemodialysis patients Kidney Int. 2010 April ; 77(7): 624–629. 18

19. Introduction A higher body mass index is associated with better outcomes in hemodialysis patients, however, this index does not differentiate between fat and muscle mass. 19

20. Purpose To evaluate the separate associations of fat and muscle mass with all-cause mortality in hemodialysis (HD) patients and compared their associations with BMI. 20

21. Adjusted model 907patients (there were 802 deaths during 2.5years.) Patients and Methods 21 1709 patients 18-80 years old (March 1995 - October 2000) Triceps skin-fold thickness Mid-arm muscle circumference Cox regression Evaluate the relationship between measures of body composition with all-cause mortality assess body fat assess Body muscle mass Unadjusted model 1709 patients HD 3 times/week measurements trained on standard

22. Result 22

23. Result 23 linear relationship Not linear relationship U shape relationship lowest quartile and reaching a plateau at 25 cm Lowest risk at 30 kg/m2

24. Discussion Why low muscle mass may be associated with worse survival? 1.Reflect poor nutrition status 2.Reflect a level of inflammation 3.May have a higher concentration of uremic toxin 24

25. Discussion Why low fat mass may be associated with high mortality in dialysis patients? 1.Reflect severity of underlying disease 2.Reflect decreased energy stores for catabolic stress of dialysis Confirm low BMI being associated with mortality 25

26. Conclusion Both low muscle and low peripheral fat mass are associated with higher all-cause mortality in HD patients. may have important clinical implications regarding weight loss recommendations in dialysis patients on and off the transplant list. 26 Low muscle mass Low fat mass High mortality

27. Abdominal Obesity and All-Cause and Cardiovascular Mortality in End-Stage Renal Disease J Am Coll Cardiol 2009;53:1265–72 27

28. Introduction Surrogate measures of abdominal obesity and segmental fat distribution (waist circumference and waist/hip ratio [WHR]) are stronger predictors of all-cause and CV death than body mass index (BMI) in the general population, but the issue has never been investigated in patients with ESRD. 28

29. Purpose The aim of this study was to investigate the predictive value for all-cause and cardiovascular (CV) death of anthropometric measurements of abdominal obesity in patients with end-stage renal disease (ESRD).

30. Patients and Methods 30 537 patients Waist circumferences Hip circumference Cox regression Evaluate the relationship between measures of body composition with all-cause mortality Waist / hip ratio

31. 31 Result Waist and hip circumferences were directly and significantly related to BMI

32. 32 Result

33. 33 Discussion 10-cm larger waist circumference 26% risk of death 38% risk of CV death Large waist circumference Risk of all-cause & CV mortality

34. 34 Conclusion Abdominal obesity underlies a high risk of all- cause and CV mortality in patients with ESRD. Redefinition of nutritional status by combining the metrics of abdominal obesity and BMI may refine prognosis in the ESRD population

35. 35 Low survival rate Study1Study2Study3 conclusion low BMI low serum creatinine Low muscle mass Low fat mass large waist circumference

36. 36 Weight gain Muscle mass Fat mass BETTER! GOOD! large waist circumference AVOID!

37. 37 Thanks for your listening !