#3246 THE ASSOCIATION OF THE CO-OCCURRENCE OF MALNUTRITION AND SARCOPENIA WITH MORTALITY IN HEMODIALYSIS PATIENTS: A MULTICENTER PROSPECTIVE COHORT STUDY
Authors: Matsuzawa Ryota , Imai Hiroto , Wada Kosuke , Okada Takuya , Deguchi Keitaro , Horinouchi Aoi , Tsujimoto Naoyuki , Kakita Daisuke , Shimokado Kiyoshi , Matsunaga Atsuhiko , Tamaki Akira 
Published: June 2023

Abstract

Background and Aims
Frailty is widely acknowledged as an age-related fragile state characterized by physiological vulnerability to stress, and it is prevalent among patients undergoing maintenance hemodialysis therapy. Various factors are interconnected and can be theoretically consolidated into a cycle of frailty, with malnutrition and sarcopenia at the core. These can result in numerous negative health outcomes in patients on hemodialysis and prompt identification and treatment are necessary. However, limited research has investigated the impact of the overlap between malnutrition and sarcopenia on mortality in this patient population. In this study, we examined the association of the overlap between malnutrition and sarcopenia with all-cause mortality in patients undergoing maintenance hemodialysis.

Method
The present prospective cohort study recruited outpatients on hemodialysis from three facilities in Japan. At the study baseline, data on patients' characteristics including age, gender, body mass index, duration of dialysis, primary kidney diseases, 11 comorbid conditions, and laboratory parameters (including serum albumin level) were collected from medical records. In addition, muscle mass (skeletal muscle index [SMI]), muscle strength (handgrip strength), and physical performance (short physical performance battery [SPPB]) were measured by physical therapists. A comorbidity index was used to quantify the severity of comorbid illnesses, which was calculated based on primary kidney diseases and the 11 comorbidities. Malnutrition was identified based on geriatric nutritional risk index &lt;98, which was calculated using the serum albumin level and body weight. Sarcopenia was diagnosed when patients had low muscle mass (SMI &lt;7.0 kg/m2 for males and &lt;5.7 kg/m2 for females) and low muscle strength (handgrip strength &lt;28.0kg for males and &lt;18 kg for females) or low physical performance (SPPB ≤9), in accordance with the Asian Working Group for Sarcopenia 2019 criteria. After classifying the study participants into four groups based on the absence or presence of malnutrition and sarcopenia, the mortality risk was evaluated using the Kaplan-Meier method and Cox proportional hazard analysis. This study was approved by the Research Ethics Committee and conducted in accordance with the principles of the Declaration of Helsinki.

Results
A total of 379 patients on hemodialysis were included in the analysis. The mean age of the patients was 69.5±12.6 years, and 40.2% of the cohort being female. The mean duration of dialysis was 7.9±4.5 years. The most prevalent underlying kidney disease was diabetes mellitus. At baseline, the prevalence rates of malnutrition and sarcopenia were 32.7% and 28.2%, respectively. Over a mean follow-up period of 4.3 years, 23 patients died. The Kaplan-Meier analysis demonstrated a lower cumulative survival rate in patients with malnutrition and/or sarcopenia. After adjustment for the effect of age, gender, duration of dialysis, and comorbidity index, the hazard ratio in patients with both malnutrition and sarcopenia was significantly higher than in patients without both (hazard ratio [HR] 5.78, 95% confidence interval [CI] 1.86-17.94). However, the hazard ratios in patients suffering from either malnutrition or sarcopenia alone were not significantly different (Table 1).

Conclusion
The present study has demonstrated the strong association of a state of co-occurrence between malnutrition and sarcopenia, which implies starvation and muscle wasting, with a poor prognosis in patients undergoing hemodialysis. The findings of this study have accentuated the significance of addressing both malnutrition and sarcopenia in routine clinical practice for patients undergoing maintenance hemodialysis.