Objective: Malnutrition is very complex in patients with end-stage renal disease (ESRD) and is associated with poor prognosis. This is because hemodynamic changes, hormonal changes, persistent inflammatory reactions, and fluid overloads are more complicated as uremia is worsening. Bio-impedance spectroscopy (BIS) is a useful method to estimate fluid balance (Overhydration/ extracellular water, OH/ECW) and nutritional status (Phase angle, PhA). We aimed to evaluate the volume and nutritional status by BIS and to investigate the relationship between the appetite regulating hormones and the parameters of BIS in patients with stage 5 chronic kidney disease not undergoing dialysis (CKD5-ND).
Methods: We enrolled a total of 91 CKD5-ND patients. We measured routine serum markers including albumin and NT-proBNP and the appetite regulating hormones, leptin and ghrelin. We defined poor nutritional status as a PhA < 4.5°, and proper nutritional status as a PhA ≥ 4.5°. We also evaluated each patient's nutritional status by assessing their geriatric nutritional risk index (GNRI) and their volume status by measuring NT-proBNP.
Results: Forty-one patients (45%) had poor nutritional status. Patients with a poor nutritional status had significantly higher OH/ECW (29.6 ± 12.7% vs. 6.2 ± 10.3%, p<0.001) and lower levels of leptin (3.8 ± 3.1 vs. 7.0 ± 6.2 ng/mL, p = 0.004) than those with proper nutritional status. PhA was associated with GNRI (r = 0.597, P<0.001) and NT-proBNP was associated with OH/ECW (r = 0.384, P<0.001). Leptin was negatively correlated with OH/ECW (r = -0.288, p = 0.006). In contrast, leptin was positively correlated with PhA (r = 0.263, p = 0.012). In multivariate logistic regression, high level of leptin (OR 7.00, 95% CI 1.74-28.10) was associated with proper nutrition, while an increased OH/ECW (OR 0.65, 95% CI 0.51-0.84) was associated with poor nutrition.
Conclusions: Our study demonstrates that CKD5-ND patients with poor nutrition generally also suffer from excessive body fluid. Low leptin level suggests poor nutrition in CKD5-ND patients. PhA could be used as a nutritional index for ESRD patients.