Patient-Reported Measures and Lifestyle Are Associated With Deterioration in Nutritional Status in CKD Stage 4-5: The EQUAL Cohort Study

Abstract

The aim of this study was to explore the changes in nutritional status before dialysis initiation and to identify modifiable risk factors of nutritional status decline in older adults with advanced renal disease.Design and Methods: The European Quality Study on treatment in advanced chronic kidney disease (EQUAL) is a prospective, observational cohort study involving six European countries. We included 1,103 adults .65 years with incident estimated glomerular filtration rate ,20 mL/min/1.73 m 2 not on dialysis, attending nephrology care. Nutritional status was assessed with the 7-point Subjective Global Assessment tool (7-p SGA), patient-reported outcomes with RAND-36 and the Dialysis Symptom Index. Logistic regression was used to estimate the associations between potential risk factors and SGA decline.Results: The majority of the patients had a normal nutritional status at baseline, 28% were moderately malnourished (SGA #5). Overall, mean SGA decreased by 20.18 points/year, (95% confidence interval 20.21; 20.14). More than one-third of the study participants (34.9%) deteriorated in nutritional status (1 point decline in SGA) and 10.9% had a severe decline in SGA ($2 points). The proportion of patients with low SGA (#5) increased every 6 months. Those who dropped in SGA also declined in estimated glomerular filtration rate and mental health score. Every 10 points decrease in physical function score increased the odds of decline in SGA by 23%. Lower physical function score at baseline, gastrointestinal symptoms, and smoking were risk factors for impaired nutritional status. There was an interaction between diabetes and physical function on SGA decline.

Prevalence and Severity of Lower Gastrointestinal Symptoms amongst Non-Dialysis Chronic Kidney Disease Patients: A Systematic Review and Meta-Analysis

“…Basic characteristics of the included studies are summarized in Table 1 . All except seven studies had a cross-sectional design: five were prospective cohorts [ 23 , 24 , 25 , 26 , 27 ], one a retrospective cohort [ 28 ], and one was a case-control study [ 29 ]. There were studies from each of the WHO regions: 12 from the Western Pacific Region (Australia, Brunei, China, Japan, Malaysia, and South Korea), 11 from the European Region (Belgium, Denmark, Germany, Italy, the Netherlands, Poland, Spain, Sweden, Turkey, and the United Kingdom), 6 from the Region of the Americas (Brazil, Mexico, United States), 4 from the South-East Asian Region (all from Sri Lanka), 2 from the African Region (both from Nigeria), and 2 from the Eastern Mediterranean Region (Iraq, Saudi Arabia).…”

“… a only clinical/lab/HRQoL associations with the outcome were extracted, not the prevalence or severity. b The median age and percentage of males in the EQUAL study were extracted from the article written by Windahl et al [ 23 ], whereas the number of analyzed participants was larger (data from the authors). Abbreviations: ADPKD, autosomal dominant polycystic kidney disease; AP, self-reported abdominal pain; B, self-reported bloating; BM, frequency of bowel movements; BMI, body mass index; BSFS, stool consistency according to the Bristol stool form scale; C, self-reported constipation; D, self-reported diarrhea; FC, functional constipation; FI, self-reported fecal incontinence; NR, not reported; RP, rectal pain; -s, severity of the symptom.…”

“…Data on self-reported constipation prevalence in CKD were provided in 24 studies, of which 22 were included in the meta-analyses below ( Figure 2 ). They were conducted primarily in the WHO Western Pacific (9 studies [ 24 , 26 , 35 , 37 , 42 , 55 , 56 , 58 , 64 ]) and European (8 studies [ 23 , 28 , 30 , 31 , 38 , 44 , 53 , 62 , 65 ]) Regions. Data were collected using authors’ questionnaires/during anamnesis in the case of 8 studies, and using validated questionnaires: renal version of the Patient Outcome Scale—symptom module (POS-S Renal; 5 studies [ 24 , 27 , 31 , 35 , 64 ]); Integrated Palliative Care Outcome Scale (IPOS)-Renal (3 studies [ 26 , 37 , 39 ]); Dialysis Symptom Index (DSI) (3 studies [ 23 , 53 , 57 , 58 ]); Memorial Symptom Assessment Scale–Short Form (MSAS-SF; 2 studies [ 44 , 62 ]).…”

“…Analyses of symptom clusters led to different results: Lee SJ et al found that constipation and diarrhea clustered together with the “difficulty sleeping” item into the “neurological and bowel problem” symptom cluster [ 35 ], whereas both Gutiérrez Sánchez et al and Almutary et al failed to cluster constipation together with other symptoms [ 31 , 69 ]. Interestingly, Dawson et al found an association between taste disturbances and constipation prevalence [ 37 ], while the EQUAL study showed that constipation was an independent predictor of a decline in nutritional status [ 23 ]. Finally, Murtagh et al showed that the prevalence of constipation within a month before death was 1.87 times higher than in the whole baseline CKD group [ 62 , 63 ]; nonetheless, the increase in the prevalence of constipation in CKD patients was evidenced also over the 1-year follow-up period in the EQUAL study [ 52 ].…”

Global Kidney Nutrition Care and Health Literacy: Overcoming the Disparities in Renal Nutrition Service Capacity and Education

“…The articles represent data from more than 4,000 patients in whom the prevalence of sarcopenia ranged from 6% to 62% and identify a 43% increased risk of mortality associated with sarcopenia. Windahl et al 26 report on the EQUAL study and patient-reported outcomes. Their work identified that patients who reported lower physical function, more gastrointestinal symptoms, and those who were smokers had higher risk of developing malnutrition during the year of follow-up.…”