Sarcopenic Obesity Definitions by Body Composition and Mortality in the Hemodialysis Patients

doi:10.1053/j.jrn.2016.09.010

Journal of Renal Nutrition

Volume 27, Issue 2, March 2017, Pages 84-90

https://doi.org/10.1053/j.jrn.2016.09.010 Get rights and content

Objective

Sarcopenic obesity (SO), a combination of low muscle mass and high fat mass, is considered as risk factor for mortality in general population. It is unclear if SO affects mortality in maintenance hemodialysis (MHD) patients. In this study, we aimed to determine whether body composition as assessed by currently available SO definitions is related to all-cause mortality in MHD subjects. We also examined the impact of applying different definitions on the prevalence of SO in our MHD database.

Design

Retrospective analysis.

Subjects

Adult patients on MHD for at least 3 months with no acute illness studied in the clinical research center between 2003 and 2011.

Intervention

Assessment of body composition was performed using dual energy x-ray absorptiometry. SO (appendicular skeletal mass: arm lean mass + leg lean mass and fat mass) was defined according to Baumgartner definition, Janssen criteria 1, and Janssen criteria 2.

Main Outcome Measure

All-cause mortality and prevalence of SO. Patient deaths were ascertained from medical records and United States social security death index.

Results

Of 122 participants, 62% were male; mean age was 46 years (interquartile range: 40, 54) in men and 50 years (44, 61) in women. Prevalence of SO ranged from 12% to 62% in men and 2% to 74% in female according to different definitions. SO prevalence was lowest using the Baumgartner criteria (all: 8%, men 12%, women: 2%) and highest according to the Janssen criteria 2 (all: 57%, men 46%, women 74%). There were 45 deaths during a median follow-up period of 44 (20, 76) months. SO by any definition was not statistically significantly associated with mortality during follow-up.

Conclusions

The current SO definitions are not applicable to predict increased risk of death in MHD patients. We found high degree of variation in the rates of SO when using different definitions. Future studies should focus on establishing MHD population-specific thresholds of muscle mass and adiposity for accurate prognostication.

Introduction

Low muscle mass, also termed as sarcopenia, is common in maintenance hemodialysis (MHD) patients and contributes to increased morbidity and mortality.1, 2, 3 In addition, sarcopenic MHD patients exhibit reduced physical functioning and are at an increased risk of hospitalization.4, 5, 6 Over the past decade, with increasing prevalence of obesity, researchers have started to focus on potential interplay of muscle and fat mass (FM) and its association with mortality.7, 8, 9, 10, 11, 12, 13, 14 In fact, the term “sarcopenic obesity” (SO) has been coined to describe the concurrence presence of lower muscle mass and higher FM in an individual. Several SO definitions developed in healthy young or elderly populations have been studied extensively, especially regarding their association with clinical outcomes.15, 16 However, the applicability of these current definitions to predict mortality in MHD subjects has yet to be fully investigated.17, 18 While obesity is known to be an independent risk factor for cardiovascular disease and mortality in the general population,19, 20 this may not be true in MHD patients where the presence of excessive FM seems to be protective and obese MHD patients have more favorable clinical prognosis.21, 22

In this study, we hypothesized that the currently proposed SO definitions based on low muscle and high FM can predict increased all-cause mortality in MHD subjects. We also determined the impact of using different SO definitions on prevalence estimates.

Section snippets

Methods

This is a retrospective study conducted at large, tertiary care university hospital. The Institutional Review Board committee at the Vanderbilt University Medical Center (VUMC) approved each study that the data were collected from. Written informed consent was obtained from each participant.

Study Cohort Characteristics

Clinical, demographic, and body composition characteristics at baseline are summarized in Table 2 and Table 3. Of 122 participants, 62% were male and 38% female. The median (interquartile range) age was 46 years (40, 54) in men and 50 years (44, 61) in women. The study subjects were predominantly African-American (76%), and 34% (n = 42) were diabetic. The median duration of dialysis was 31 (10, 68) months.

The mean arm lean mass (7.1 vs. 4.6 kg), leg lean mass (18.1 vs. 14.6 kg), and ASM/Ht²

Discussion

In this study, we found that current SO criteria are of limited utility in predicting all-cause mortality in prevalent MHD patients. In fact, the contrary was true, and the patients who did not meet the criteria for SO phenotype had worse survival. We also found large differences in SO prevalence rates when using different definitions. These findings indicate the need to develop appropriate cutoff values of muscle and FM for predicting mortality in MHD patients.

Our findings are in contrast with

Practical Application

The present study indicates that SO defined by current definitions do not seem to predict mortality in MHD patients. Prevalence of SO varies widely with different SO diagnostic criteria. Future confirmatory studies are warranted to validate our results.

Acknowledgments

This work was supported by grants from Department of Veterans Affairs (merit award #I01 CX000414), grant K24 DK 62849 from the National Institute of Diabetes and Digestive and Kidney Diseases, the Clinical Translational Science Award UL1TR000445 from the National Center for Research Resources, and funds from the Vanderbilt Center for Kidney Disease. S.M.D. is also supported by American Heart Association. Dr. Malhotra had full access to all of the data in the study and takes responsibility for

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Cited by (32)

Sarcopenic obesity and its relation with muscle quality and mortality in patients on chronic hemodialysis
2023, Clinical Nutrition
Sarcopenia is prevalent in patients with end-stage kidney disease (ESKD) on hemodialysis (HD), and is associated with poor outcomes, while obesity may be protective. Sarcopenic obesity is associated with increased frailty, morbidity and mortality in the general population. Myosteatosis, i.e., muscle fat infiltration, has major effects on muscle strength and physical performance, but is poorly investigated in the nephrology setting. In the present study we aimed to assess the association between sarcopenic obesity, as diagnosed by abdominal CT, and mortality. Moreover, the relationship between myosteatosis, sarcopenic obesity and mortality was also investigated.
This is a retrospective study in which ESKD patients on HD submitted to unenhanced abdominal CT for clinical reasons at least 6 months after dialysis initiation were evaluated for sarcopenic obesity and myosteatosis, defined as intermuscular fat area and low attenuation muscle area. Sarcopenic obesity was diagnosed in cases of low abdominal skeletal muscle area and high total fat area. Receiver-operating characteristics (ROC) analysis with Youden index was used to determine the cut-off for high total fat area. Intermuscular fat area and low attenuation muscle area were evaluated by applying the Hounsfield unit of interest (−190; −30, and −29; +29 respectively). Cox regression analysis was used to evaluate the association between predictors and mortality risk.
We enrolled 212 patients, aged 68.8 (±14.7) years, 65.5% (139/212) male. Median follow-up was 19.7 (interquartile range [IQR] 2.7–35) months. Sarcopenic obesity was diagnosed in 19.8% of patients and was associated with increased mortality (HR: 3.29 (1.72; 6.27), P < 0.001), and with the presence of myosteatosis. Both intermuscular fat area and low attenuation muscle area were associated with increased mortality in adjusted analyses.
Patients with sarcopenic obesity have increased myosteatosis. Sarcopenic obesity and myosteatosis are associated with increased mortality in patients on HD.
Sarcopenic Obesity Versus Nonobese Sarcopenia in Hemodialysis Patients: Differences in Nutritional Status, Quality of Life, and Clinical Outcomes
2023, Journal of Renal Nutrition
Citation Excerpt :
The main findings of our study are that MHD patients with SO compared with nonobese sarcopenia patients have a better long-term prognosis, better nutritional status, and possibly a better quality-of-life, which is mainly expressed in better physical health. Of note, all previous studies that we found have compared MHD patients with sarcopenia and/or SO to the MHD patients without sarcopenia.1-4,8-11,17,19 To the best of our knowledge, this is the first report that demonstrates the differences in clinical characteristics and prognosis of MHD patients with SO compared with patients with nonobese sarcopenia.
Sarcopenia and sarcopenic obesity (SO) are linked to unfavorable prognosis in maintenance hemodialysis (MHD) populations. We tested whether nonobese sarcopenia and SO, as different stages of extreme protein-energy wasting, have different prognoses.
In this prospective observational study, 261 MHD patients were recruited from October 2010 to April 2012 and followed until October 2020. Two definitions were used to diagnose sarcopenia: the European Working Group on Sarcopenia in Older People consensus and the Foundation for the National Institutes of Health (FNIH) Biomarkers Consortium criteria. Obesity was determined as the percentage of total body fat, ≥27% for men and ≥38% for women. Data for all-cause and cardiovascular morbidity and mortality, baseline nutrition markers, inflammation and oxidative stress, adipokines, body composition parameters, handgrip strength, and quality of life (QoL) scores were measured.
According to European Working Group on Sarcopenia in Older People, 115 (44.1%) patients were sarcopenic and 120 (46.0%) according to FNIH definitions. Of them, 28.4% and 34.5% were SO, respectively. Higher levels of albumin, creatinine, uric acid, leptin, phase angle, better nutritional scores, and lower adiponectin levels characterized SO patients compared with nonobese sarcopenic patients regardless of indexing method. Better QoL scores were noted in SO compared with nonobese sarcopenic patients using the FNIH sarcopenia criteria. The hazard of all-cause death, cardiovascular death, and first cardiovascular event for patients with SO was lower compared with the nonobese patients after multivariate adjustments. Statistical significance of these associations disappeared after including fat mass in multivariate models.
MHD patients with SO have better nutritional status and prognosis for cardiovascular events, all-cause and cardiovascular disease mortality, and possibly better QoL compared with nonobese sarcopenic MHD patients. The better prognosis appears to be entirely due to the excess fat, which is protective in sarcopenic MHD patients similar to that described in the entire MHD population.
Significant Association of Diabetes With Mortality of Chronic Hemodialysis Patients, Independent of the Presence of Obesity, Sarcopenia, and Sarcopenic Obesity
2022, Journal of Renal Nutrition
Citation Excerpt :
Sarcopenic obesity is the result of coexistence of sarcopenia and obesity, and affected older individuals are considered to have higher risks of mobility disability, morbidity, and cardiometabolic disease, as well as increased mortality.1,24,25 However, the prevalence of sarcopenic obesity differs substantially, because of several different definitions.2,13,26 This seems to be due, at least in part, to the fact that the definition of obesity varies among several studies that utilized body mass index, waist circumference, fat mass measured by a bioimpedance method, or fat mass measured by DXA.26
This retrospective cohort study investigated the association of diabetes with mortality in hemodialysis patients with regard to obesity, sarcopenia, and sarcopenic obesity, along with examining the prevalence of each group and diabetes.
Muscle strength, muscle mass, and fat mass were evaluated using a hand dynamometer and dual-energy X-ray absorptiometry, respectively, in 308 chronic hemodialysis patients (age 58.0 ± 11.9 years, hemodialysis duration 6.5 ± 6.0 years, males 60.1%, diabetes 32.8%). Sarcopenia was defined according to the new criteria established by the Asian Working Group on Sarcopenia 2019. Obesity was defined by percent body fat mass (males ≥25%, females ≥35%).
The enrolled patients were divided into the normal (38.7%), obesity (18.8%), sarcopenia (26.9%), and sarcopenic obesity (15.6%) groups. The prevalence of diabetes was significantly skewed among the 4 groups (χ² test, P = .0057), being higher in the sarcopenic obesity group (54.2%) compared to the others (25.9-33.7%). Multivariate regression analysis revealed that diabetes was significantly and independently associated with sarcopenic obesity (odds ratio 3.495, 95% confidence interval 1.683-7.255, P = .0008) after adjustments for several cofounders, but not significantly associated with sarcopenia. During the follow-up period of 76 ± 35 months, 100 patients died. Those in the sarcopenia and sarcopenic obesity groups had significantly higher rates of all-cause mortality compared to patients in the normal and obesity groups (P = .0004, log-rank test). Furthermore, multivariate Cox proportional hazards analysis revealed that presence of diabetes was significantly associated with higher all-cause mortality in all 308 patients, after adjustments for several factors, including the presence of each group in 4 models.
Sarcopenic obesity is highly prevalent in chronic hemodialysis patients. Diabetes was found to be a significant and independent contributor to the presence of sarcopenic obesity. Diabetes was shown to be a significant predictor of all-cause mortality, independent of the present normal, obesity, sarcopenia, and sarcopenic obesity groups.
Improving Muscle Strength and Preventing Sarcopenia and Cachexia in Chronic Kidney Disease and Transplanted Patients by Physical Activity and Exercise
2019, Journal of Renal Nutrition
How to Prevent Renal Cachexia? A Clinical Randomized Pilot Study Testing Oral Supplemental Nutrition in Hemodialysis Patients With and Without Human Immunodeficiency Virus Infection
2018, Journal of Renal Nutrition
Citation Excerpt :
Blood samples were obtained before hemodialysis after the long (72 hours) hemodialysis-free interval. Surrogates of nutritional status included body mass index (BMI; weight/height2), Subjective Global Assessment (SGA) score,15 and multi-frequency body impedance analysis (BIA; M2000 apparatus; Darmstadt, Germany) to determine phase angle alpha and estimated body cell mass (BCM). Mid-arm circumference of the nondominant arm, or, if applicable, of the contralateral side of the hemodialysis-access arm was taken.
End-stage renal disease associates with catabolism and sarcopenia. Hypothetically, peroral supplemental nutrition over 6 months prevents catabolism in hemodialysis patients.
Prospective randomized pilot study (ClinicalTrials.gov Identifier: NCT00687050).
Twenty-three hemodialysis patients (15 males and 7 females) with or without human immunodeficiency virus (HIV) infection of 2 ambulatory hemodialysis centers.
HIV-positive hemodialysis patients (n = 7, Group 1) were started on supplemental nutrition drinks (250 kcal/day), HIV-negative hemodialysis patients (n = 16, Group 2) were randomized to supplemental nutrition drinks (250 kcal/day) or received none.
Body impedance analysis, anthropometric measures, magnetic resonance imaging results for mid-iliopsoas muscle cross-sectional area and laboratory parameters including albumin, cytokines at baseline, and at 6 months follow-up.
Seven patients in Group 1 (mean age: 50.6 ± 9.6 years) and 16 patients in Group 2 (mean age: 54.0 ± 13.3 years) were recruited. Serum creatinine (Group 1: 6.4 ± 3.0 mg/dL; Group 2: 10.7 ± 2.5 mg/dL; P < .01), Body impedance analysis–derived phase angle alpha (Group 1: 5.1 ± 1.2; Group 2: 6.9 ± 1.6; P < .01), mid-arm circumference (Group 1: 26.1 ± 1.3 cm; Group 2: 29.6 ± 2.4 cm; P < .01) were less in Group 1 versus Group 2 patients at baseline suggesting that HIV-positive hemodialysis patients had a poorer nutritional status at baseline. At 6-month follow-up, mortality was higher in Group 1 patients (29%) than in Group 2 patients (6%). There was no significant treatment effect on nutritional status in survivors of Group 1 or in the supplemental nutrition arm of Group 2 when compared with baseline or to untreated controls.
A new oral supplemental nutrition over 6 months had no treatment effect in surviving HIV-positive hemodialysis patients or in maintenance hemodialysis patients without HIV infection. The limitations of this study were small study size and unexpected high mortality among HIV-positive hemodialysis patients.
Association between sarcopenic obesity and mortality in patients on peritoneal dialysis: a prospective cohort study
2024, Frontiers in Medicine

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: Support: See Acknowledgments on page 90.

: Financial Disclosure: See Acknowledgments on page 90.

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Published by Elsevier Inc. on behalf of the National Kidney Foundation, Inc.

Original ResearchSarcopenic Obesity Definitions by Body Composition and Mortality in the Hemodialysis Patients

Objective

Design

Subjects

Intervention

Main Outcome Measure

Results

Conclusions

Introduction

Section snippets

Methods

Study Cohort Characteristics

Discussion

Practical Application

Acknowledgments

Clin Nutr

J Nutr Health Aging

Am J Clin Nutr

J Am Coll Cardiol

Prog Cardiovasc Dis

Comparative associations of muscle mass and muscle strength with mortality in dialysis patients

Clin J Am Soc Nephrol

Body mass index and mortality risk in Asian peritoneal dialysis patients in Hong Kong—impact of diabetes and cardiovascular disease status

Peritoneal Dial Int

Relationship between lower extremity muscle strength and all-cause mortality in Japanese patients undergoing dialysis

Phys Ther

Uraemic sarcopenia: aetiology and implications

Nephrol Dial Transplant

Frailty and protein-energy wasting in elderly patients with end stage kidney disease

J Am Soc Nephrol

Daily physical activity and physical function in adult maintenance hemodialysis patients

J Cachexia Sarcopenia Muscle

Evaluation of the usefulness of consensus definitions of sarcopenia in older men: results from the observational osteoporotic fractures in men cohort study

J Am Geriatr Soc

Original Research
Sarcopenic Obesity Definitions by Body Composition and Mortality in the Hemodialysis Patients