To assess the nutritional status of a patient in everyday clinical practice, it is common to use a whole complex of somatometric and clinical laboratory parameters. These parameters are conventionally divided into mandatory (first level) and additional (second level). Mandatory parameters include data from anthropometric, clinical and laboratory studies. These parameters can and should be used by a doctor of any specialty to determine the current nutritional status. Additional parameters are necessary for a more detailed analysis of the patient’s trophological state and are usually used by specialists in artificial nutrition. These parameters make it possible to determine individual constitutional indicators, such as, for example, body fat mass, muscle mass and their ratio.

Anthropometric (somatometric) parameters, whose measurement is formally mandatory during a physical examination of a patient, include: height-weight indicators and their derivatives (body weight, height, ideal body weight and the magnitude of its deviation, body mass index), shoulder circumference and skin thickness - fat folds.

Ideal body weight calculated using the following formulas:

BMI for men = Height - 100 - (Height - 152) x 0.2.

IBMI for women = Height - 100 - (Height - 152) x 0.4.

IBMI is measured in kilograms, height - in centimeters.

The deviation of actual body weight (FBM) from ideal weight is calculated using the formula:

Reduction in weight from ideal (%) = 100 x (1 - FMT/IdBW).

In addition, to determine normal body weight, a number of indices can theoretically be used: Brock's index, Breitman's index, Bernhard's index, Davenport's index, Oder's index, Noorden's index, Taton's index. However, most often in clinical practice, for an approximate assessment of nutritional status, body mass index. This indicator was developed by Adolphe Quetelet in 1869 and is calculated using the formula:

BMI = m/h2, where m is weight in kg, h is height in meters

Nutritional status	18 – 25 years old	26 years and older
Obesity IV degree	40, 0 and above	41, 0 and above
Obesity III degree
Obesity II degree
Obesity I degree
Increased nutrition
Normal status
Reduced nutrition
Hypotrophy I degree
Hypotrophy II degree
Hypotrophy III degree

In addition to height and weight indicators, anthropometric assessment of nutritional status can be used method for determining skin fold thickness. Using this method, the thickness of the skin fold is determined at the level of the third rib (normally 1.0-1.5 cm) and in the paraumbilical area on the side of the rectus abdominis muscle (normally 1.5 - 2.0 cm). Thickness of the skin-fat fold over the triceps measured in millimeters using a caliper. Shoulder circumference measured in centimeters at the level of the middle third (midway between the tip of the acromion process of the scapula and the olecranon process of the ulna) of the non-working, relaxed arm. The assessment of malnutrition based on anthropometric parameters is carried out taking into account the values ​​​​given in the table.

Assessment of anthropometric (somatometric) indicators of malnutrition (according to A.V. Pugaev and E.E. Achkasov, 2007).

Laboratory parameters accepted for mandatory consideration when assessing nutritional status include: total blood protein, blood albumin, blood glucose, absolute lymphocyte count, total cholesterol, blood potassium, blood sodium, 24-hour urine creatinine, 24-hour urine urea. Additionally evaluated parameters are: blood transferrin, blood lactate, blood triglycerides, magnesium, calcium, phosphorus, blood iron, creatinine-height index.

Obviously, the use of any one anthropometric or laboratory indicator will not be an objective reflection of the patient's nutritional status. In addition, in practical activities, with a known time limit, the ability to quickly (bed-side, at the patient’s bedside) and preferably simple assessment of nutritional status is needed. In this regard, since the late 1980s, integrated assessment systems have been actively introduced into clinical practice, allowing the current nutritional status of the patient to be determined by a combination of several parameters. One of the easiest to use and at the same time quite objective rating scale is the one proposed in 1991 Nutritional Risk Index (Nutritional Risk Index) . NRI is calculated using the formula:

NRI= 1.519 x plasma albumin (g/l) + 0.417 x (body weight 1 (kg) / body weight 2 (kg) x 100),

where body weight 1 is body weight at the time of examination, body weight 2 is normal body weight. Based on the NRI value, the nutritional status of patients is classified as:

• without nutritional deficiency (NRI > 97.5)
• moderate nutritional deficiency (97.5 > NRI > 83.5)
• severe nutritional deficiency (NRI)< 83, 5).

The European Society of Clinical Nutrition and Metabolism (ESPEN) recommends using the Nutritional Risk Screening (NRS) system to assess the nutritional status of patients. The American Society of Parenteral and Enteral Nutrition (ASPEN) recommends using the Patient Generated Subjective Global Assessment (PGSGA) questionnaire. The SGA scale, compared to the NRS scale, includes a significantly larger number of primary assessed indicators and its use, at a minimum, takes longer. However, from the point of view of a number of authors, it is in SGA that most of the factors influencing metabolism, as well as parameters reflecting changes in metabolic processes, are assessed in detail.

The SGA (Subjective Global Assessment) technique was first introduced into clinical practice in 1987. The parameters assessed by the SGA include the patient's weight loss, dietary restrictions, signs of dyspeptic disorders, functional activity and a number of anthropometric and clinical indicators.

Subjective global assessment of malnutrition,S.G.A. (Detsky A. S. , McLaughlin J. R. , 1987)

Criterion	Norm	Malnutrition
		moderate	heavy
Weight loss in the last 6 months	a loss< 5%
Diet	>90% of required
Dyspepsia (nausea, vomiting, diarrhea)		intermittent	daily > 2 times
Functional activity			bedridden
Main disease	remission	sluggish course	acute/exacerbation
Subcutaneous fat			significantly reduced
Muscle mass			significantly reduced
Orthostatic edema			expressed
Ascites			expressed

Determination of nutritional status using the Nutritional Risk Screening (NRS) scale - Nutritional Risk Assessment - was first used in 2002 and is based on the gradual exclusion of sick patients without trophological disorders from the entire population. At the first stage (primary assessment), patients are screened using only three parameters.

NRS 2002 scale.

If during the Initial assessment all answers are negative, then the patient is stated to have no nutritional status disorders.

If during the Initial Assessment there is a positive answer “Yes” to at least one question, then you should proceed to assessment block 2.

If the patient’s age is 70 years or more, then one more point must be added to the total amount. The points received are summed up. If the total score on the NRS 2002 scale is at least 3, then the criteria for nutritional deficiency are assessed using a number of laboratory and clinical indicators: total protein, serum albumin, peripheral blood lymphocytes, body mass index (BMI). Nutritional deficiency and its degree are diagnosed if one or more of the criteria presented in the table are present.

The severity of nutritional deficiency.

In 1998, I. E. Khoroshilov developed the “Prognostic Index of Malnutrition”, calculated using the formula:

Prognostic index of malnutrition = 140 - 1.5 (A) - 1 (OP) - 0.5 (KZhST) - 20 (L),

Where A is the blood albumin content (g/l); OP—shoulder circumference (cm); CLST - thickness of the fold above the triceps (mm); L - absolute number of lymphocytes (109/l). When this index is less than 20, there are no signs of malnutrition (nutrition is not impaired). With values ​​from 20 to 30, mild malnutrition (hypotrophy) is determined, from 30 to 50 - moderate, above 50 - severe.

In 2003, the Malnutrition Advisory Group, a permanent part of the British Association of Parenteral and Enteral Nutrition (BAREN), reasonably proposed an original screening system for assessing nutritional status MUST - Malnutrition Universal Screening Tool (Fig). This system of quick and simple verification of nutritional deficiency quickly gained many fans not only in Foggy Albion, but also very far from its shores. The MUST system is based on the assessment of three parameters - body mass index, rate of weight loss and the potential or actual inability to eat due to illness (surgery). As a result of step-by-step implementation of the algorithm for assessing nutritional status, one of the solution options is formed: treatment and preventive measures in the same volume, careful monitoring of nutritional status, and nutritional support.

The natural question is: what is the best system for assessing nutritional status? Based on an assessment of the literature data, it should be answered that today the use of any assessment system, alone or in combination, both for clinical practice and for research is quite acceptable. J. White et al. , presenting the ASPEN recommendations for identifying malnutrition in adults (2012), indicate that all known international systems for assessing nutritional status (SGA, MUST, NRI, NRS-2002) should be considered valid and statistically reliable. Of course, there are some nuances to using one or another evaluation system. So C. Velasco et al. (2012) indicate that the use of SGA, while accurate, requires the participation of a physician. This system is especially effective for assessing the dynamics of the nutritional status of cancer patients undergoing specific treatment. W. Loh et al. (2011), A. Almeida et al. (2012) believe that MUST and NRS-2002 are most suitable for assessing the nutritional status of inpatients. These scoring systems are particularly sensitive and specific as predictors of postoperative complications. These authors do not consider it possible to use BMI as the only criterion for nutritional status, due to the relative inaccuracy of this indicator, especially for obese patients. A report by M. La Torre et al. , dated 2013 and dedicated to comparing the correlation of the results of assessing nutritional status according to SGA, NRI and MUST with the actual results of surgical treatment of patients with pancreatic tumors. The report showed that MUST and NRI malnutrition scores were clearly correlated with the total number of postoperative complications, with the number of infectious complications, and with length of hospitalization. At the same time, when assessing nutritional deficiency according to SGA, the author established a clear correlation that was observed only with the indicator of the number of infectious complications in the area of ​​surgical intervention.

When trying to summarize the literature data, attention is drawn to the fact that most studies on the problem of nutritional deficiency and its correction currently freely use absolutely any of the currently known systems for assessing nutritional status - SGA, NRI, NRS, and MUST, and even in isolation BMI or serum albumin. At the same time, the authors, as a rule, do not comment on the choice of a specific assessment system. Agree that in this case we have every reason to use in everyday clinical practice the system that best suits our needs or, rather, capabilities and is accepted by the world medical community for assessing the nutritional status of the patient - “... a sword for a duel, a sword for battle - everyone chooses for themselves "

Summarizing the above, it should be noted once again that assessing the nutritional status makes it possible to identify the presence and severity of trophological disorders in the patient, which in essence is the actual indication for the start of nutritional support. At the same time, assessment of nutritional status over time allows one to assess the degree of effectiveness of the correction of nutritional status.

Catad_tema Chronic kidney disease - articles

Disturbances in nutritional status and the importance of a low-protein diet with the use of keto analogues of essential amino acids in the prevention of protein-energy malnutrition in patients with chronic kidney disease

Yu.S. Milovanov, I.I. Alexandrova, I.A. Dobrosmyslov GBOU VPO First Moscow State Medical University named after. Sechenov Ministry of Health of Russia, Moscow

Target. To determine the possibilities of traditional anthropometry and bioelectrical impedance analysis (BEA) for the early diagnosis of nutritional status disorders in patients with CKD with glomerulonephritis (GN) at predialysis stages and regular hemodialysis, to identify the most significant factors in their development and prevention.

Material and methods. The study included 180 patients with GN, among them 1BB with chronic GN and 25 with GN in systemic diseases: 13 with systemic lupus erythematosus (SLE) and 12 with various forms of systemic vasculitis. Depending on the diagnosis and stage of CVP, all patients included in the study were randomized into 2 groups. The first group consisted of 155 patients with chronic GN. Group 2 included 25 patients with systemic diseases (SLE, systemic vasculitis). The age of the patients ranged from 21 to 80 years (46.7 ± 10.8 years), there were 61 women, 119 men. The duration of CVP from the onset of renal dysfunction was 3.5-7.1 years (5.2 ± 1 ,3 years). The stages of COVP are determined according to the NKF K/Fe criteria n(2002), with GFR calculated using the formula ckd epi.

Results. Among all 180 patients with SH-UL CVP stages, nutritional status disorders were detected in 33.9% according to the traditional method and in 34.4% using VID. At the same time, the frequency of nutritional status disorders increased depending on the degree of renal failure. in patients of both groups who received a low-protein diet (LPD) in combination with keto analogues of essential amino acids (EA) for at least 12 months before the start of the study (n=39), none of them had nutritional status disorders (VID method) . Moreover, among patients who received MVL, but without the use of ketoacids, nutritional status disorders were detected in 1.2% of cases, and among patients who did not restrict protein in the diet (n = 31) - in more than 11% of cases. Among patients of the 1st and 2nd groups who received MVL in combination with ketoacids at the predialysis stage for at least 12 months before the start of dialysis treatment^ = 39), during the first year of treatment with regular GL, significantly less often than among patients (n = 61 ) to whom keto analogues of essential amino acids were not prescribed in the pre-dialysis period, disturbances in nutritional status were noted (VID method).

Conclusion. Voluntary CVP requires early diagnosis of nutritional status disorders and regular monitoring, including with the help of VID. The use of keto analogues of essential amino acids when using MVL at the pre-dialysis stage of CVP allows maintaining the nutritional status of patients with CVP.

Keywords. Epidemiology, nutritional disorders, chronic kidney disease, hemodialysis, low-protein diet, keto analogues of essential amino acids

Introduction

One of the pressing problems of nephrology remains improving the quality of life and overall “survival” of patients with chronic kidney disease (CKD), the prevalence of which is steadily increasing in the world.

Despite the fact that the introduction of renal replacement therapy (RRT) methods has contributed to an increase in life expectancy in patients with CKD, a number of new problems have emerged, including those associated with the frequency of nutritional disorders and protein-energy malnutrition (PEM), especially for patients on regular hemodialysis (GD). Violations of nutritional status have important prognostic significance, since they have a significant impact on the survival and level of rehabilitation of these groups of patients. It was noted that the mortality rate of patients during the first year of dialysis therapy was 15% among patients with a normal body mass index - an integral indicator of nutritional status assessment, and 39% among patients whose body mass index was less than 19 kg/m2.

Currently, simple and accessible non-invasive methods for assessing the degree of nutritional status disorders, including in patients with edema, are anthropometry and bioelectrical impedance analysis (BIA). However, there are no studies in which, using anthropometry and bioelectrical impedance analysis, a comparative assessment of the nutritional status of CKD patients at the pre-dialysis stages of CKD and during treatment with regular HD was carried out, as well as a study of risk factors for the development of nutritional disorders in these patients.

Many studies have shown that limiting the daily quota of protein in food to 0.3-0.6 g/kg/day prevents the accumulation of toxic products and reduces or delays the appearance of uremic dyspepsia. However, the results of several other studies, including the well-known MDRD (Modification of Diet in Renal Disease) study, do not provide such a clear conclusion. The difference in results is explained by the difficulties in organizing the MBD, its compliance, especially on a mass scale, and at the same time ensuring sufficient caloric content of food (at least 35 kcal/kg/day). How to improve control of MBD and compliance of CKD patients is the subject of ongoing research. The objectives of the study included:

1. Establish the frequency and degree of nutritional disorders using anthropometry and bioelectrical impedance analysis (BIA).

2. To evaluate the role of a low-protein diet (LPD) in combination with the use of keto analogues of essential amino acids in the prevention of nutritional status disorders in patients at the pre-dialysis stage of CKD and subsequently on dialysis.

Material and methods

The study included 180 patients with GN, among them 155 with chronic and 25 with GN in systemic diseases: 13 with systemic lupus erythematosus (SLE) and 12 with various forms of systemic vasculitis (Table 1).

Among the 180 patients included in the study, 80 were diagnosed with stage III-IV CKD (initial and moderate CKD) and among 100 patients - CKD stage UD (severe CKD - ​​dialysis stage).

Depending on the etiology and stage of CKD, all patients included in the study were randomized into two groups (Table 2). The first group consisted of 155 patients with chronic GN, among them 22 with stage III CKD (GFR -30 -

59 ml/min/1.73 m2), 40 with CKD stage IV (GFR -15-29 ml/min/1.73 m2) and 93 stage UD (GFR< 10 мл/мин/1,73 м 2). В группу 2 включены 25 больных с системными заболеваниями: 10 больных ХБП III стадии, 8 - IV и 7 - УД-стадии. Для более точной оценки роли степени почечной недостаточности в развитии нутритивных нарушений больные III стадии обеих групп были разделены на 2 подгруппы: в подгруппу IIIA включены больные с СКФ 45-59 мл/ мин/1,73 м 2 , в ШБ - больных с СКФ 30-44 мл/мин/1,73 м 2 (Table 2).

Table 2. Distribution of patients depending on the stage of CKD
Groups of patients	CKD stage III		CKD stage IV (GFR 15-29 ml/min/1.73 m2)	CKD stage VD (GFR< 10 мл/мин/1,73 м 2)
	A (GFR 45-59 ml/min/1.73 m2)	B (GFR 30-44 ml/min/1.73 m2)
Number of patients
Group 1 (CGN), n = 155
Group 2 (GN in systemic diseases), n = 25

The age of the patients ranged from 21 to 80 years (46.7 ± 10.8 years), there were 61 women, 119 men (rice. 1). The duration of CKD from the onset of renal dysfunction was 3.5-7.1 years (5.2 ± 1.3 years).

The diagnosis of GN was established based on the clinical picture; in 2/3 of the patients, the diagnosis was confirmed morphologically by intravital kidney biopsy.

In all patients included in group 1, GN was not exacerbating. In 120 patients, a decrease in GFR and an increase in creatinine levels were combined with a decrease in kidney size of varying degrees (shrinkage).

Systemic diseases were diagnosed according to the criteria adopted for each nosological form.

Patients in this group had a recurrent course of nephritis, some patients (10 - SLE, 2 - microscopic polyarteritis, 2 - Wegener's granulomatosis) had a history of exacerbations, clinically occurring as rapidly progressive nephritis, for the relief of which treatment was carried out with corticosteroids, including in large doses (pulse therapy). The criterion for inclusion of patients with systemic diseases in the study was the absence during the study period of signs of disease activity (hypocomplementemia, high titer of antibodies to double-stranded DNA, anticytoplasmic antibodies - p- and c-ANCA).

The stages of CKD are determined according to the NKF K/DOQI criteria (2002), with GFR calculated using the CKD EPI formula.

In addition to the general clinical examination of patients, adopted in the nephrology department, special studies were carried out to solve the assigned problems (Table 3).

To determine the degree of nutritional imbalance in patients with CKD, we used two methods (Table 3):

Table 3 Special research methods
Methods for assessing nutritional imbalances	Frequency of studies
Diagnostic methods
Traditional:
1. Subjective assessment methods (questioning, getting acquainted with the anamnesis - identifying characteristic complaints, etiological factors).	1 time/3 months
2. Anthropometric: - body mass index (BMI) - thickness of the skin-fat fold over the triceps brachii muscle - shoulder muscle circumference (UMC)	1 time/6 months
3. Laboratory: - level of albumin and transferrin in the blood - absolute number of blood lymphocytes.	1 time/3 months
II. Instrumental. Bioelectrical impedance method (BIA) - BMI: - percentage of body fat mass - percentage of lean body mass.	1 time/6 months
III. Protein intake and caloric content of food according to three daily food diaries	1 time/3 months
IV. Quality of Life Questionnaire SF-36

1. Anthropometric assessment method - anthropometric measurements.

2. Instrumental assessment method - determining the patient’s body composition using bioelectrical impedance analysis (BIA monitor, Tanita Company, USA). Anthropometric measurements obtained and results

BIA was supplemented by a subjective general assessment (questioning, familiarization with anamnesis - identification of characteristic complaints, etiological factors) and laboratory tests (albumin concentration in plasma, absolute number of lymphocytes in peripheral blood, transferrin level in the blood).

When assessing the quality of life, the SF-36 (Medical Outcomes Study Survey Short Form-36) questionnaire was used in its own modification, concerning various aspects of the physical and mental health of patients.

When calculating survival, the end point was the initiation of replacement therapy.

In all 100 patients with CKD, Vl-a^mi (eGFR< 10 мл/мин/ 1,73 м 2) использованы стандартный интермиттирующий low-flux-ГД или интермиттирующая гемодиафильтрация (ГДФ) в режиме реального времени (on line).

Statistical processing of the material was carried out using the SPSS 12.0 program. The critical level of significance of the null statistical hypothesis (about the absence of differences and influences) is assumed to be 0.05. To analyze qualitative variables, the Pearson x 2 test or the Fisher test for 2 x 2 tables was used. To determine the strength of the relationship, Spearman's two-way rank correlation analysis or Pearson's two-way correlation analysis was used. Multiple stepwise logistic regression analysis was used to identify factors associated with the development of nutritional disorders.

results

Among all 180 patients with stage III-VD CKD, nutritional status disorders (ISD) were detected in 33.9% using the traditional method and in 34.4% using the BIA monitor. At the same time, the frequency of nutritional status disorders depended on the degree of renal failure: among patients with CKD with a GFR level of 59-30 ml/min/1.73 m2, nutritional status disorders were detected both according to the traditional method and using BIA only in 3, 1%, while among patients with CKD with a GFR level of 29-15 ml/min/1.73 m2 they were already diagnosed in 14.5 and 18.7% of patients, as well as in 51 and 54% of dialysis patients, respectively (rice. 2).

Among patients of group 2 with CKD as part of systemic diseases with high proteinuria (> 1.5 g/day), a history of corticosteroid treatment (> 6 months before inclusion in the study), nutritional disorders were noted even with a moderate decrease in GFR (44-30 ml/min/1.73 m2). In group 1, they were identified only among patients with stage IV CKD according to both anthropometry and BIA data.

The screening results made it possible to identify a different number of patients with nutritional status disorders depending on the research method used: traditional - for 59 patients (9% in pre-dialysis stages and 51% in dialysis), and bioimpedance analysis (BIA) - for 64 patients (10 and 10%, respectively). 64%). When determining the reason for the discrepancy in the results, it turned out that in 5 patients (all women), in whom, using the traditional method, no disturbance in nutritional status was detected, moderate swelling of the trunk and limbs was noted, which led to an overestimation of the result of anthropometric measurements and a final increase in the number of points.

Thus, the BIA method makes it possible to obtain more accurate results of determining the lean and fat mass of patients with edema than the traditional method, which included anthropometric diagnostic parameters.

Among the patients of the 1st and 2nd groups observed by us (n = 39), who received MBD in combination with the drug of essential amino acids and their keto analogues (EAA and KA) - Ketosteril® for at least 12 months before the start of the study, none of them Nutritional status disorders were not recorded in them (BIA method). Moreover, among patients (n = 10) who received MBD, but without the use of EAC and CA, nutritional status disorders were detected in 1.2%, and among patients (n = 31) who did not restrict protein in the diet - in more than 11% of cases (p< 0,05) (Table 4).

Table 4. Frequency of nutritional status disorders among patients with CKD stages III-IV depending on
	Diets/number of patients (absolute number; %)
Groups of patients	MBD (0.6 g/kg/day protein) + keto analogues of essential amino acids	MBD (0.6 g/kg/day protein)
Group 1 (chronic GN), n = 62
Group 2 (nephritis in systemic diseases),
Total, n = 80
* The first number of the fraction is the number of patients with impaired nutritional status, the second is the number of patients in the subgroup; % of the total number of patients.

Using Pearson's pairwise correlation coefficients (Table 5) the effect on the reduction of body mass index (BMI) as an integral indicator of nutritional status disturbances, low caloric intake (< 33 ккал/сут; связь прямая, сильная) (rice. 3), severity of renal failure (GFR< 30 мл/мин/1,73 м 2) (связь прямая, сильная), выраженности анемии (Hb < 9 г/дл; связь прямая, сильная), у больных 2-й группы также высокой протеинурии (>1.5 g/day, inverse connection, strong) (Fig. 4) and duration of corticosteroid therapy (> 6 months, inverse, strong relationship). The combination of two or more of these factors statistically significantly increased the risk of developing nutritional disorders.

Table 5. Factors influencing the decrease in body mass index (BMI) in patients with CKD stages III-IV (n = 80) 1
	Doubles coefficient	Pearson correlations
	Group 1 (n = 62)	Group 2 (n = 18)	Group 1 (n=62)	Group 2 (n = 18)
Caloric intake (< 33 ккал/кг/сут)
SCF< 30 (мл/мин/1,73 м 2)
Anemia Hb< 9 (г/дл)
Proteinuria > 1.5 (g/day)
Treatment with corticosteroids (period > 6 months)

The effect of a low calorie diet on reducing body weight (by 3-5% per month) is presented in rice. 4. In the observed patients with CKD at the predialysis stage, persistent proteinuria (> 1.5 g/day) increased the risk of weight loss (rice. 4).

The violation of the nutritional status was found to correspond to the severity of anemia (the correlation is direct, strong) (rice. 6).

Among patients with CKD stages III-IV of both groups, nutritional status disorders (Table 6) were detected significantly more often among elderly patients (> 65 years), with depressed mood and intolerance to salt-free, unleavened foods. These patients often had bacterial and viral infections, aggravating the course of renal failure and nutritional disorders.

In multiple logistic regression modeling, only the presence of a low calorie diet was significantly and independently associated with the development of nutritional disorders (< 33 ккал/кг/сут) (Exp (B) = 6,2 (95 % ДИ - 2,25-16,8; р < 0,001) и СКФ < 30 (мл/мин/1,73 м 2) (Exp (B) = 1,07 (95% ДИ - 1,00-1,13; р = 0,049), у больных 2-й группы также высокой протеинурии (>1.5 g/day) (Exp (B) = 2.05 (95% CI - 1.2-2.5; p = 0.033) and treatment with corticosteroids (period > 6 months) (Exp (B) = 2, 01 (95% CI - 1.0-2.13; p = 0.035) when adjusting the model by sex and age.

Among the patients of the 1st and 2nd groups observed by us, who received MBD in combination with EAA and CA drugs at the pre-dialysis stage at least 12 months before the start of dialysis treatment^ = 39), during the first year of treatment with regular HD, nutritional disorders were noted status (BIA method) significantly less frequently than among patients (n = 61) to whom EAC and CA were not prescribed in the predialysis period (Table 7). Among patients on program HD of both groups, nutritional status disorders (BIA + laboratory methods were used) were also identified significantly more often, among patients with inadequate dialysis syndrome (Kt/V< 1,0; URR < 65 %), хронического воспаления (инфицированный сосудистый доступ, оппортунистические инфекции, вирусоносительство, гиперпродукция С-реактивного белка), а также при длительном использовании стандартного диализирующего раствора, содержащего уксусную кислоту (Table 8), and the development of secondary hyperparathyroidism (Fig. 6).

Table 7. Frequency of nutritional disorders among patients with end-stage CKD during1 first year of treatment with regular HD, depending on the diet used at the pre-dialysis stage (n=100)1
	Diets in the predialysis period /number of patients (abs. number; %)
Groups of patients	MBD (0.6 g/kg/day protein) + keto analogues of essential amino acids	MBD (0.6 g/kg/day protein)	No daily protein quota limit
Group 1 (chronic GN), n = 93
Group 2 (nephritis in systemic diseases), n = 7
Total (n = 100)
* the first number of the fraction is the number of patients with impaired nutritional status, the second is the number of patients in the subgroup; % of total number of patients

In 12 patients we observed, dialysis using a concentrate containing acetic acid caused instability of hemodynamic parameters (intradialytic hypotension), nausea, headache, and anorexia. Replacing all 12 (ashes) of the traditional concentrate for HD with a concentrate in which hydrochloric acid is used instead of acetic acid, allowed all these patients to eliminate intradialytic hypotension and improve the tolerability of HD procedures and normalize appetite.

According to the data presented in the literature and the results of our study, an increase in the level of iPTH in the blood increases catabolism (rapid loss of body weight against the background of progression of metabolic acidosis and hyperuricemia), aggravation of renal failure. An increase in iPTH concentration with calcitriol deficiency and a decrease in the activity of cellular vitamin D receptors (VDR) in CKD induces the formation of glomerulosclerosis and tubulointerstitial fibrosis.

An inverse correlation was established (r = (-)619; p< 0,01) между ИМТ (кг/м 2) и иПТГ (пг/мл) (rice. 7).

Impaired nutritional status was also detected significantly more often in patients treated with intermittent low-flux HD (x2 = 5.945, p = 0.01), compared to patients treated with intermittent hemodiafiltration (HDF) (Table 9).

With the help of HDF, due to the high blood flow rate (300-400 ml/min) and intensive ultrafiltration with hemodilution and automatic volumetric control, it was possible to achieve easier removal of excess fluid during the procedure, improve nutritional status (normalize muscle mass And increase in albumin levels).

"In patients on program HD, using the Cox regression model, an unfavorable effect of hypoalbuminemia on the risk of mortality from any cause (cardiovascular complications - cardiovascular complications, infections, etc.), hospitalizations for cardiovascular complications, the need for correction of the dialysis regimen (for each end point separately) was established ) (Fig. 7 and 8).

Compared with patients without hypoalbuminemia, those with the most severe hypoalbuminemia (< 30 г/л) установлен более высокий риск летальности (отношение шансов - ОШ 1,3; 95% доверительный интервал - ДИ 0,9-1,9), частоты госпитализаций по поводу ССО (ОШ - 2,18; ДИ - 1,76-2,70) и необходимости коррекции режима диализной терапии (ОШ - 5,46; ДИ - 3,38-8,822), причем ОШ отражало изменяющиеся во времени показатели альбумина и Kt/V.

The association of hypoalbuminemia with the studied endpoints became stronger with increasing severity of hypoalbuminemia. Based on these results, the following conclusion can be drawn: the level of albumin reduction is a predictor of poor prognosis and complications associated with CKD.

The assessment of the quality of life in groups of patients with identified nutritional disorders was carried out using the SF-36 form modified by us. The results of the patient survey are presented in table 10.

According to our data, the prevalence of depression and anxiety, which significantly affect physical activity and social relationships, in patients at the pre-dialysis stages of CKD is 20%, and among dialysis patients increases to 50% (p< 0,01). При этом некоторые составляющие качества жизни, такие,как общее самочувствие, утомляемость, склонность к депрессии и тревожность, усугублялись с увеличением диализного стажа.

Discussion and conclusions

We assessed the possibilities of determining body composition using the traditional method (which included a subjective assessment of the patient's condition, anthropometric and clinical parameters) in comparison with the BIA method for the early diagnosis of nutritional status disorders in patients with CKD at the pre-dialysis stages and in dialysis patients.

Table 9. dynamics of nutritional status during HDF treatment (BIA method)
Index	Type of dialysis therapy
	Intermittent low-flux-HD	Intermittent HDF
BMI, kg/m2
Fat percentage
Percentage of muscle mass
Serum albumin, g/l
Serum transferrin, mg/dL

Among 180 patients, nutritional status disorders were detected in 3.1% of patients with the initial stage of renal failure (CKD stage IIIB) without differences in the frequency of disorders when compared with the traditional method of anthropometry and bioelectrical impedance analysis. The incidence of nutritional status disorders increased in direct proportion to the increase in renal failure and depended on the diagnostic method (traditional anthropometry or bioelectrical impedance analysis), amounting to 14.5 and 18.7%, respectively, for patients with CKD stage IV, and 51 and 54% for dialysis patients.

According to our data, bioelectrical impedance analysis provides more accurate information about the ratio of a patient’s lean and fat mass compared to the traditional method of determining nutritional status, especially in patients with edema. The method is convenient for screening assessment of nutritional status both in the population of patients at the pre-dialysis stage of CKD treatment and in dialysis patients. If anthropometric measurements took an average of 40 ± 10.4 minutes, then measurements using BIA took 2.5 ± 0.5 minutes.

Diagnosis of nutritional status using BIA in patients with CKD should also include questioning about the patient’s complaints, familiarization with the medical history (identification of characteristic complaints, etiological factors), determination of indicators of the synthesis of visceral proteins (the content of albumin, transferrin in the blood plasma and the number of lymphocytes in the peripheral blood).

We assessed the influence of risk factors common to CKD (type of diet, high proteinuria, duration of corticosteroid therapy, depression) and those associated with uremia (secondary hyperparathyroidism, anemia, treatment with program hemodialysis) on the occurrence or progression of nutritional disorders. It was established that their frequency and severity of uremia factors increased and their role increased as CKD progressed to Vr-n^rni.

The study showed that more frequent PEM in dialysis patients compared to the predialysis period is caused by greater severity of depression, anorexia, an additional increase in catabolism during regular HD, as well as the influence of an ineffective dialysis regimen (underdialysis syndrome).

The use of MBD with the use of keto analogues of essential amino acids at the pre-dialysis stage of CKD allows for a rational balanced diet for patients, preventing the development of nutritional disorders before dialysis, and has a beneficial effect subsequently on dialysis.

In patients with CKD stages III-VD, hypoalbuminemia is closely associated with an increase in concomitant diseases (infections), hospitalizations and the risk of mortality. Using pairwise Pearson correlation coefficients, an inverse correlation was revealed between serum levels of acute phase C-reactive protein and albumin.

Chronic inflammation syndrome, diagnosed in 18.8% of patients with PEM, was caused by the influence of infected dialysis vascular access and opportunistic infections (pneumonia, urinary infection, etc.). Concomitant cardiovascular diseases (CHD, CMP), hypervolemic overhydration, acetate intolerance syndrome, and severe anemia also played an important role in the induction of chronic inflammation and the development of nutritional disorders.

The results of our study allow us to expand our understanding of the epidemiology of nutritional disorders in patients with CKD stages III-VD, and to identify specific factors contributing to the development and progression of CKD and PEM in this population. Among patients with CKD as part of systemic diseases, nutritional disorders were observed already with a moderate decrease in GFR (44-30 ml/min/1.73 m2), while among patients with chronic GN they were detected with a more pronounced drop in GFR (< 29 мл/мин/1,75 м 2). У всех больных ХБП в период включения в исследование отсутствовали признаки активности заболевания. Однако у подавляющего числа больных системными заболеваниями (СКВ, системные васкулиты), несмотря на развитие ХБП, сохранялась высокая протеинурия (>1.5 g/day) and all of them had a history of exacerbations of the disease, during which the patients received corticosteroids for a long time (> 6 months), including in ultra-high doses. In patients with CKD, as part of systemic diseases, a relationship was found between rapid weight loss and high proteinuria (inverse relationship, strong) and the duration of treatment with corticosteroids (direct relationship, strong). However, it appears that the role of proteinuria in the development of nutritional disorders was not limited to protein loss in the urine. Evidence has been obtained that proteinuria exceeding 1 g/l, inducing the production of proinflammatory cytokines (TNF-a, IL-8) and growth factors (transforming growth factor-β), chemokines (monocyte chemoattractant protein-1, RANTES) by the tubular epithelium and oxygen free radicals, leads to apoptosis of the tubular epithelium with accelerated formation of tubulointerstitial fibrosis and progression of renal failure with a high risk of developing or worsening nutritional disorders. However, assessing the role of proteinuria as a leading factor in the progression of CKD (proteinuric remodeling of the tubulointerstitium) was not the scope of our study.

The results of our study and analysis of literature data allowed us to determine the principles of early diagnosis of nutritional status disorders in observed patients with CKD stages III-VD (rice. 9).

All patients with CKD who are receiving a low-protein diet (0.6 g protein/kg/day) with insufficient energy value of food, high proteinuria (> 1.5 g/day), prolonged (> 6 months) treatment with corticosteroids.

Screening for protein-energy malnutrition should be carried out at the pre-dialysis stage in all persons with CKD with complaints that suggest the presence of disturbances in nutritional status:

Progressive weight loss;
depression;
worsening arterial hypertension, unexplained other causes;
development of severe anemia not corresponding to the degree of renal failure (a decrease in erythropoiesis may be due to a decrease in protein synthesis).

Nutritional status should be monitored regularly. A comprehensive assessment of nutritional status in patients with CKD can be rapidly performed using BIA. In this case, it is necessary to analyze BMI, the dynamics of “dry weight”, the volume of lean and lean body mass, gastrointestinal symptoms, dialysis time, laboratory data (albumin and blood transferrin), the frequency of hospitalizations and the risk of mortality on HD.

The use of keto analogues of essential amino acids when using MBD at the pre-dialysis stage of CKD allows maintaining the nutritional status of patients with CKD.

Literature

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2. Nikolaev A.Yu., Milovanov Yu.S. Treatment of kidney failure. 2nd edition. M. 2011. Publisher: MIA. 58855 p.
3. KDIGO Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. 2013; (1):3.
4. K/DOQI Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification. Am. J. Kidney Dis. 2002;39 (suppl 1).
5. Chauveue P., Aparicio A. Benefits in nutritional interventions in patients with CKD stage 3-4. J Renal Nutrition. 2001;21(1):20-22.
6. Milovanov Yu.S. Chronic renal failure. In the book "Rational Pharmacotherapy" / ed. ON THE. Mukhina, L.V. Kozlovskaya, E.M. Shilova. M.: Litterra. 2006; 13: 586-601.
7. Mukhin N.A., Tareeva I.E., Shilov E.M. Diagnosis and treatment of kidney diseases. M.: GEOTAR-MED. 2002; 381 p.
8. Shutov E.V. Nutritional status in patients with chronic renal failure (literature review). Nephrol. dial 2008; 3-4(10):199-207.
9. Milovanov Yu.S., Nikolaev A.Yu., Lifshits N.L. Diagnosis and principles of treatment of chronic renal failure. Russian honey. magazine. 1997;23: 7-11.
10. Smirnov A.V., Beresneva O.N., Parastaeva M.M. and others. The effectiveness of low-protein diets using Ketosteril and soy isolate on the course of experimental renal failure. Nephrol. dial 2006; 4(8): 344-349.
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18. Fouque D. et al. Nutrition and chronic kidney disease. Kidney International 2011;80:348-357.

Quantitative assessment of a patient's nutritional status is an important clinical parameter and should be performed for every patient.

The cost of inpatient treatment for a patient with normal nutritional status is 1.5-5 times less than for a patient with malnutrition. In this regard, the most important task of the clinician is to recognize states of malnutrition and adequate control over their correction. Numerous studies have proven that the state of protein-energy malnutrition significantly affects morbidity and mortality rates among patients.

Obesity and severe malnutrition can be recognized by history and clinical examination, but subtle signs of malnutrition are often overlooked, especially in the presence of edema.

Quantitative assessment of nutritional status allows early detection of life-threatening disorders and assessment of positive changes as recovery begins. Objective measures of nutritional status correlate with morbidity and mortality. However, none of the indicators of quantitative assessment of nutritional status has a clear prognostic significance for a particular patient without taking into account the dynamics of changes in this indicator.

• Nutritional (nutritional, trophological) status of the patient and indications for its assessment

  In the domestic literature there is no generally accepted term for assessing a patient’s nutrition. Different authors use the concepts of nutritional status, nutritional status, trophological status, protein-energy status, nutritional status. When assessing nutritional status, it is most correct to use the term “nutrition status of the patient,” since it reflects both the nutritional and metabolic components of the patient’s condition. The ability to timely diagnose nutritional disorders is necessary in the practice of doctors of all specialties, especially when working with geriatric, gastroenterological, nephrological, endocrine and surgical patients.

  Nutritional status should be determined in the following situations:

  • When diagnosing protein-energy malnutrition.
  • When monitoring the treatment of protein-energy deficiency.
  • When predicting the course of the disease and assessing the risk of surgical and unsafe treatment methods (chemotherapy, radiation therapy, etc.).

• Methods for assessing nutritional status
  • Physical examination

    A physical examination allows the doctor to diagnose both obesity and protein-energy malnutrition, as well as determine specific nutrient deficiencies. If a patient is suspected of having a nutrient deficiency after examination, it is necessary to confirm the assumption with laboratory tests.

    WHO experts describe the following clinical signs of protein-energy malnutrition: protrusion of skeletal bones; loss of skin elasticity; thin, sparse, easily pulled out hair; depigmentation of skin and hair; swelling; muscle weakness; decreased mental and physical performance.

    • Nutrients	Deficiency Disorders and Symptoms	Laboratory results
      Water	Thirst, decreased skin turgor, dry mucous membranes, vascular collapse, mental disorders	Increased concentration of electrolytes in the blood serum, serum osmolarity; decrease in the total amount of water in the body
      Calories (energy)	Weakness and lack of physical activity, loss of subcutaneous fat, muscle wasting, bradycardia	Decrease in body weight, GIFT, OMP, SOOV
      Protein	Psychomotor changes, graying, thinning and hair loss, scaly dermatitis, edema, muscle wasting, hepatomegaly, growth retardation	Reducing OMP, serum concentrations of albumin, transferrin associated with retinol protein; anemia; decrease in creatinine/height, the ratio of urea and creatinine in urine; increasing the ratio of essential and essential amino acids in the blood serum
      Linoleic acid	Xerosis, desquamation, thickening of the stratum corneum, baldness, fatty liver disease, delayed wound healing	Increased ratio of trienoic and tetraenoic fatty acids in blood serum
      Vitamin A	Xerosis of the eyes and skin, xerophthalmia, formation of Bitot's plaques, follicular hyperkeratosis, hypogeusia, hyposmia	Decreased concentration of vitamin A in blood plasma; increasing the duration of dark adaptation
      Vitamin D	Rickets and growth disorders in children, osteomalacia in adults	Increased serum concentrations of alkaline phosphatase; decrease in the concentration of 25-hydroxycholecalciferol in the blood serum
      Vitamin E	Anemia	Decrease in plasma tocopherol concentration, hemolysis of erythrocytes
      Vitamin K	Hemorrhagic diathesis	Increased prothrombin time
      Vitamin C (ascorbic acid)	Scurvy, petechiae, ecchymosis, perifollicular hemorrhage, loosening and bleeding gums (or tooth loss)	Decrease in the concentration of ascorbic acid in the blood plasma, platelet count, whole blood mass and leukocyte count; decrease in the concentration of ascorbic acid in urine
      Thiamine (vitamin B1)	Beriberi, muscle soreness and weakness, hyporeflexia, hypersthesia, tachycardia, cardiomegaly, congestive heart failure, encephalopathy	Reducing the activity of thiamine pyrophosphate and transketolase contained in erythrocytes and enhancing the in vitro effect of thiamine pyrophosphate on it; decrease in thiamine content in urine; increase in blood levels of pyruvate and ketoglutarate
      Riboflavin (vitamin B2)	Zaeda (or angular scars), cheilosis, Gunter's glossitis, atrophy of the tongue papillae, corneal vascularization, angular blepharitis, seborrhea, scrotal (vulvar) dermatitis	Reduced EGR activity and increased effect of flavin adenine dinucleotide on EGR activity in vitro; decreased activity of pyridoxal phosphate oxidase and increased effect of riboflavin on it in vitro; decreased concentration of riboflavin in urine
      Niacin	Pellagra, a bright red and ragged tongue; atrophy of the tongue papillae, fissures of the tongue, pellagrossic dermatitis, diarrhea, dementia	Decrease in the content of 1-methyl-nicotinamide and the ratio of 1-methyl-nicotinamide and 2-pyridone in urine

      
      Note: MRV – basal metabolic rate; BUN – blood urea nitrogen; creatinine/height – the ratio of the concentration of creatinine in daily urine to height; ECG – electrocardiogram; EGSHUT – erythrocyte glutamic oxaloacetic transaminase; EGR – erythrocyte glutathione reductase; OMP – shoulder muscle circumference; SFST – skin-fat fold above the triceps; RAI – radioactive iodine; T – triiodothyronine; T – thyroxine; TSH is the thyroid-stimulating hormone of the pituitary gland.
  • Anthropometric measurements and body composition analysis

    Anthropometric measurements are of particular importance in the physical examination. Anthropometric measurements are a simple and accessible method that allows, using calculation formulas, to assess the composition of the patient’s body and the dynamics of its changes. However, when analyzing the data obtained, it must be remembered that tabular data is not always suitable for a particular person. The existing standards were initially designed for healthy people and cannot always be accepted for the patient. It is correct to compare the identified indicators with the data of the same patient in his favorable period.

    • Body mass

      Determination of body weight (BW) is a basic indicator in assessing nutritional status.

      Body weight is usually compared with the ideal (recommended) body weight. The recommended weight can be taken as the body weight calculated according to one of the numerous formulas and normograms or the body weight that was most “comfortable” in the past for a given patient.

      The reliability of body weight assessment may be affected by edema syndrome. In the absence of edema, body weight calculated as a percentage of ideal body weight is a useful indicator of adipose tissue plus lean body mass. Ideal body weight can be calculated using a standard height/weight chart.

      With a disproportionate loss of various components of the body, the absence of significant changes in the patient’s body weight may mask a protein deficiency while maintaining a normal or slightly excess fat component (for example, the body weight of an emaciated patient who was initially obese may be equal to or exceed the recommended one).

      A decrease in the measured body weight/ideal body weight ratio to 80% or less usually signals insufficient protein-energy nutrition.

      • Body weight limits (kg)
        Height, cm	Low	Average	High
        MEN
        157,5	58,11-60,84	59,47-64,01	62,65-68,10
        160,0	59,02-61,74	60,38-64,92	63,56-69,46
        162,6	59,93-62,65	61,29-65,83	64,47-70,82
        165,1	60,84-63,56	62,20-67,19	65,38-72,64
        167,6	61,74-64,47	63,11-68,55	66,28-74,46
        170,2	62,65-65,83	64,47-69,92	67,65-71,73
        172,7	63,56-67,19	65,83-71,28	69,01-78,09
        175,3	64,47-68,55	67,19-72,64	70,37-79,90
        177,8	65,38-69,92	68,55-74,00	71,73-81,72
        180,3	66,28-71,28	69,92-75,36	73,09-83,54
        182,9	67,65-72,64	71,28-77,18	74,46-85,35
        185,4	69,01-74,46	72,64-79,00	76,27-87,17
        188,0	70,37-76,27	74,46-80,81	78,09-89,44
        190,5	71,73-78,09	75,82-82,63	79,90-91,71
        193,04	73,55-79,90	77,63-84,90	82,17-93,98
        WOMEN
        147,3	46,31-50,39	49,49-54,93	53,57-59,47
        149,9	46,76-51,30	50,39-55,84	54,48-60,84
        152,4	47,22-52,21	51,30-57,20	55,39-62,20
        154,9	48,12-53,57	52,21-58,57	56,75-63,56
        157,5	49,03-54,93	53,57-59,93	58,11-64,92
        160,0	50,39-56,30	54,93-61,29	59,47-66,74
        162,6	51,76-57,66	56,30-62,65	60,84-68,55
        165,1	53,12-59,02	57,66-64,01	62,20-70,37
        167,6	54,48-60,38	59,02-65,38	63,56-72,19
        170,18	55,84-61,74	60,38-66,74	64,92-74,00
        172,72	57,20-63,11	61,74-68,10	66,28-75,82
        175,26	58,57-64,47	63,11-69,46	67,65-77,18
        177,8	59,93-65,83	64,47-70,82	69,01-78,54
        180,34	61,29-67,19	65,83-72,19	70,37-79,90
        182,88	62,65-68,55	67,19-73,55	71,73-81,27

    • Body composition

      Body composition assessment is based on the concept of distinguishing between extracellular and intracellular body mass.

      The cellular mass consists mainly of visceral organs and skeletal muscles. The assessment of cell mass is based on the determination of potassium content in the body by various, mainly radioisotope, methods. The extracellular mass, which primarily performs a transport function, anatomically includes blood plasma, interstitial fluid, adipose tissue and is assessed by determining metabolic sodium. Thus, the intracellular mass reflects predominantly the protein component, and the extracellular mass the fat component of the body.

      The ratio of plastic and energy resources can be described through two main components: the so-called lean or lean body mass (TMB), which includes muscle, bone and other components and is primarily an indicator of protein metabolism, and adipose tissue, which indirectly reflects energy metabolism .

      MT = TMT + fat component.

      Thus, to assess body composition, it is enough to calculate one of these values. A normal body fat content is considered to be 15–25% for men and 18–30% of total body weight for women, although these figures may vary. Skeletal muscle on average makes up 30% of the TMT, the mass of visceral organs is 20%, bone tissue is 7%.

      A decrease in fat reserves in the body is a sign of a significant deficiency in the energy component of nutrition.

      • Methods for determining body composition

        To assess body fat content, the method of assessing the average skin fold (anthropometric data) is usually used. There are also various methods for calculating the content of adipose tissue, which are based on determining the density of the human body. Based on the difference in density of various tissues, the fat component is estimated.

        To assess lean body mass, creatinine excretion is studied or bioimpedance measurements are performed.

        • The main method for determining body fat content is based on assessing the middle skin-fat fold (MSF) with a caliper using several SFAs (most often over the triceps, over the biceps, subscapular and supraileal).

          A caliper is a device that allows you to measure FLC and has a standard degree of fold compression of 10 mg/cm 3 . Caliper production is available on an individual basis.

          
          
          

          Rules for measuring skin-fat folds with a caliper.

          • Anthropometric measurements are taken on the non-working (non-dominant) arm and the corresponding half of the torso.
          • The direction of the folds created during measurement should coincide with their natural direction.
          • Measurements are carried out three times, the values ​​are recorded 2 seconds after releasing the device lever.
          • The skin-fat fold is grasped by the examiner with 2 fingers and pulled back approximately 1 cm.
          • Shoulder measurements are taken with the arm hanging freely along the body.
          • Mid-shoulder: the middle of the distance between the articulation of the shoulder with the acromion process of the scapula and the olecranon process of the ulna (the shoulder circumference is also determined at this level).
          • The FLC above the triceps is determined at the level of the middle of the shoulder, above the triceps (in the middle of the back surface of the arm), and is located parallel to the longitudinal axis of the limb.
          • The LCS above the biceps is determined at the level of the middle of the shoulder, above the triceps (on the front surface of the arm), and is located parallel to the longitudinal axis of the limb.
          • The subscapular (subscapular) CL is determined 2 cm below the angle of the scapula, usually located at an angle of 45° to the horizontal.
          • LCS above the iliac crest (supraileal): determined directly above the iliac crest along the midaxillary line, usually located horizontally or at a slight angle.
          • Anthropometric indicators are determined in the middle third of the shoulder of the non-working arm. Their proportions make it possible to judge the relationship of tissues throughout the body.
          • Typically, measurements are taken of the triceps skin fold (TSF) and upper arm circumference, from which the upper arm muscle circumference (AMC) is calculated.

          The calculated values ​​characterizing the masses of the shoulder muscles and subcutaneous adipose tissue correlate with fairly high accuracy, respectively, with lean (LMP) and fat (LFT) body masses, and, accordingly, with the total peripheral reserves of proteins and the fat reserves of the body.

          On average, anthropometric indicators corresponding to 90–100% of the generally accepted values ​​are characterized as normal, 80–90% as mild malnutrition, 70–80% as moderate, and below 70% as severe.

          Basic anthropometric indicators of nutritional status (according to Heymsfield S.B. et al., 1982)

          
          

          Index	Norms
          	men	women
          Skinfold over the triceps (SFST), mm	12,5	16,5
          Shoulder circumference (UA), cm	26	25
          Shoulder muscle circumference (UMC), cm = OP – π×KZhST	25,3	23,2
          Area of ​​subcutaneous adipose tissue, cm 2 = KZhST×ΟΜΠ/2 – π×KZhST2/4	17	21
          Shoulder muscle area, cm 2 = (ΟΠ – π × KZhST)2/4p	51	43

          
          

          Note: Average values ​​shown. Somatometric indicators vary depending on the age group.

          Immunological indicators for assessing nutritional status.

        • Comprehensive methods for assessing nutritional status

          A large number of complex indices and methods have been developed that make it possible to assess the nutritional status of a patient with varying degrees of reliability. All of them include a combination of anthropometric, biochemical and immunological indicators.

          1. Reduction of body weight by more than 10%.
          2. Decrease in total blood protein below 65 g/l.
          3. A decrease in blood albumin below 35 g/l.
          4. Decrease in the absolute number of lymphocytes less than 1800 per μl.

          Subjective global assessment according to A. S. Detsky et al. (1987) includes clinical assessment of 5 parameters:

          1. Loss of body weight over the past 6 months.
          2. Dietary changes (diet assessment).
          3. Gastrointestinal symptoms (anorexia, nausea, vomiting, diarrhea) lasting more than 2 weeks.
          4. Functional capacity (bed rest or normal physical activity).
          5. Disease activity (degree of metabolic stress).

          In parallel with the listed studies, a subjective and physical examination is carried out: loss of subcutaneous fat, muscle wasting, presence of edema.

          According to the above indicators, patients are divided into three categories:

          • With normal nutritional status.
          • With moderate exhaustion.
          • With severe exhaustion.

          The most common is a score of 8 diverse markers of nutritional status. Among these indicators, different authors include clinical assessment, anthropometric and biochemical indicators, results of a skin test with an antigen, etc.

          Each of the indicators is scored: 3 points - if it is within the normal range, 2 points - if it corresponds to a mild degree of protein-energy malnutrition, 1 point - to a moderate degree, 0 points - to a severe degree. A score of 1–8 points allows a diagnosis of mild protein-energy malnutrition, 9–16 points – moderate, and 17–24 points – severe. A total score of 0 points indicates the absence of nutritional disorders.

          According to the order of the Ministry of Health of the Russian Federation No. 330 dated August 5, 2003, the nutritional status is assessed according to indicators, the totality of which characterizes the nutritional status of the patient and his need for nutrients:

          • Anthropometric data: height; body mass; body mass index (BMI); shoulder circumference; measurement of the triceps skin-fat fold (TSF).
          • Biochemical indicators: total protein; albumen; transferrin.
          • Immunological indicators: total number of lymphocytes.

1

Malnutrition is a striking and frequent manifestation of chronic obstructive pulmonary disease (COPD), which affects the frequency of exacerbations, respiratory parameters and the quality of life of patients. The purpose of the study is to assess the nutritional status of COPD patients using anthropometry and bioimpedance measurements in a comparative aspect. 60 patients with stages I, II and III COPD were examined. According to the results of the study, a decrease in body mass index (BMI) was established in stages II and III of COPD compared to the control group. Loss of the muscle component or lean body mass (LBM) occurs already at stage I of COPD, the most significant decrease in LBM was found at stage III of the disease. When comparing two diagnostic methods, no significant differences were found in BMI and TMT in the general group of COPD patients and at different stages of the disease. When dividing the examined people into groups with normal, reduced and increased body mass index, significant differences in BMI indicators were established in the group of patients with BMI >25 kg/m2. In this group, the bioimpedansometry method had lower TMT indicators compared to the anthropometry method. Accordingly, the bioelectrical impedance method can be recommended for a more accurate assessment and early diagnosis of protein-energy malnutrition in COPD patients with BMI>25 kg/m2.

chronic obstructive pulmonary disease

nutritional deficiency

anthropometry method

bioimpedansometry method

1. Avdeev S. N. Chronic obstructive pulmonary disease as a systemic disease // Pulmonology. - 2007. - No. 2.

2. Nevzorova V. A., Barkhatova D. A. Features of the course of exacerbation of COPD depending on the nature of the pathogen and the activity of systemic inflammation // Bulletin of Physiology and Pathology of Respiration. - 2006. - No. S 23. - pp. 25-30.

3. Nevzorova V. A. Systemic inflammation and the state of skeletal muscles of patients with COPD / V. A. Nevzorova, D. A. Barkhatova // Therapist. arch. - 2008. - T. 80.

4. Nevzorova V. A. Content of adipokines (leptin and adiponekin) in blood serum at different nutritional status of COPD patients / V. A. Nevzorova, D. A. Barkhatova // Collection of proceedings of the XVIII National Congress on Respiratory Diseases. - Ekaterinburg, 2008.

5. Rudmen D. Assessment of nutritional status // Internal diseases. - M.: Medicine, 1993. T. 2.

6. Bernard S., LeBlanc P. et al. Peripheral muscle weakness in patients with chronic obstructive pulmonary desease // Am.J.Respir.Crit.Care. Med. -1998.

7. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for diagnosis, management, and prevention of chronic obstructive pulmonary disease. NHLBI/WHO workshop report. Last updated 2008. www.goldcopd.org/.

8. Body composition by bioelectrica-impedance analysis compared with deuterium dilution and skinfold and thropometry in patients with chronic obstructive pulmonary disease / A.M.W.J.Schols, E.F.M.Wouters, P.B.Soeters et al // Am.J.Clin.Nutr. - 1991.- Vol. 53.- P. 421-424.

9. Prevalence and characteristics of nutritional depletion in patients with stable COPD eligible for pulmonary rehabition / A.M.W.J.Schols, P.B.Soeters, M.C.Dingemans et al // Am.Rev.Respir.Dis. -1993. - Vol. 147. - P. 1151-1156.

Introduction

Nutritional status reflects the state of the body's plastic and energy resources and is closely related to the processes of systemic inflammation, oxidative stress, and hormonal imbalance. Malnutrition is a striking and frequent manifestation of chronic obstructive pulmonary disease (COPD), which affects the frequency of exacerbations, respiratory parameters and quality of life. It has been established that the appearance of protein-energy deficiency aggravates the course of the underlying disease and worsens its prognosis.

Anthropometric measurements are a simple and accessible method that allows, using calculation formulas, to assess the composition of the patient’s body and the dynamics of its changes. The ratio of plastic and energy resources can be described through two main components: lean body mass (LBM), which includes muscle, bone and other components and is an indicator of protein metabolism, as well as adipose tissue, which indirectly reflects energy metabolism. With nutritional deficiency in patients with COPD, a disproportionate loss of various components of the body occurs, in which the absence of significant changes in the patient’s body weight can mask protein deficiency while maintaining a normal or slightly excess fat component.

The method of anthropometric measurements is not recommended for use in elderly patients, as well as in cases of edema syndrome, due to the disproportionate distribution of adipose tissue and its predominant localization in the abdominal cavity. An alternative or more accurate measurement of composite body structure is the bioelectrical impedance method, which is based on the estimation of water volume distribution and evaluates the electrical conductivity of tissues. When conducting impedance measurements, the determination of body composition is based on the greater conductivity of TMT compared to body fat mass, which is associated with different fluid contents in these tissues.

Comparison of the information content of widely used methods for assessing nutritional deficiency in COPD determines the relevance of the study.

Purpose of the study:

To assess the nutritional status of COPD patients using anthropometry and bioimpedance measurements in a comparative aspect.

Materials and methods:

We examined 60 patients with phenotypic manifestations of the European race, living in the Primorsky Territory for more than 15 years at the age of 63 ± 12.1 years, who were treated in the pulmonology department of City Clinical Hospital No. 1 and the allergy-respiratory center of Vladivostok during 2009-2010. with a diagnosis of COPD (general group of patients). All patients were informed about the study in full and filled out informed consent. The control group consisted of 10 healthy non-smoking volunteers, 8 men and 2 women aged 59 ± 10.7 years, who were not relatives of the main group. To diagnose the stage of COPD, the recommendations of the international classification GOLD 2008 were used. All examined patients were divided into 3 groups based on the indicators of the post-bronchodilation test FEV1: group I - 20 patients with COPD stage I (FEV1=85±1.3), group II - 20 people with COPD stage II (FEV1=65±1.8), group III - 20 people with COPD stage III (FEV1=40±1.5). The exclusion criteria from the study were the presence of bronchial asthma, myocardial infarction, stroke and other serious diseases, alcohol and drug abuse, elderly people who are unable to understand the goals and objectives of the study, and patients’ refusal to participate in the study. To assess nutritional deficiency, methods of anthropometric measurements and calculations of BMI, BMI, as well as bioimpedance measurements and determination of BMI, BFM (fat-free mass, expressed in %) were used. When calculating anthropometric indicators of TMT, the Durnin-Womersley method (1972) was used, which is based on assessing the average skin-fat fold (ASF) with a caliper, followed by calculating TMT using a formula depending on the patient’s gender, age and BMI. Determination of BMI, which allows for the primary diagnosis of the degree of malnutrition, was determined according to the formula of A. Ketele: BMI = MT (kg) / height (m 2).

Bioimpedansometry was carried out using a rheoanalyzer "Diamant" St. Petersburg. The results obtained were processed on an IBM PC personal computer running Windows-XP using the Statistica 6.0 program with the calculation of the arithmetic mean (M), its error (± m), and relative error (± m%). Statistical processing when comparing two independent groups was carried out using the nonparametric Mann-Whitney test and determining significant differences between groups according to this criterion. Differences between comparative values ​​were considered statistically significant at the p significance level<0,05. Анализ взаимосвязей проводился непараметрическим методом корреляционного анализа Спирмена для ненормального распределения с вычислением ошибки коэффициента корреляции.

Research results

The following anthropometric data were established in the main group of patients: average height 172 ± 5.3 cm, average weight 76.5 ± 5.5 kg. The smoking person's index (SCI) averaged 33 ± 2.3, smoking experience was 30 ± 3.3 years, which indicates a high degree of nicotine-associated risk. We analyzed the ratio of BMI (body mass index) and BMI%, as well as BWMI using anthropometry and bioimpedansometry methods in COPD patients depending on the stage of the disease (Table 1).

Table 1. Correlation of BMI, BMI and BMI in patients with COPD

Groups examined	Anthropometry method		Bioimpedansometry method
	Indicators		Indicators
Control group
General group	25.2±0.4 *	72.2±1.3 *	25.0±0.6 *	71.7±0.7 *
COPD stage I		75.5±1.1 *		75.5±0.4 *
COPD IIstages	24.3±0.9 * #	72.0±1.6 * #	23.8±0.8* #	71.65±0.6 #
COPD stage III	19.9±0.7 * #&	64.6±1.7 *#&	19.4±0.5 *#&	64.2±0.5 *#&

Note. Significance of differences (p<0,05): * - между группой контроля, общей группой и стадиями ХОБЛ, # - significance of differences between stages I and II of COPD, stages I and III of COPD , & - between stages II and III of COPD.

According to the presented results, BMI indicators in COPD patients in the general group are lower than in the control group, both when studied by anthropometry and bioimpedansometry. Analysis of BMI values ​​depending on the stage of COPD showed that at stage I of the disease, BMI does not change compared to the control. Its significant decrease occurs only in stages II and III COPD (p<0,05). Несмотря на снижение показателей ИМТ по сравнению с контрольной группой, при всех стадиях ХОБЛ ИМТ находится в пределах референсных значений для нормальных показателей или превышает 20 кг/м 2 . Различий в значениях ИМТ, определенных как методом антропометрии, так и импедансометрии не установлено. Выяснено, что показатели ИМТ при II и III стадиях ХОБЛ достоверно ниже, чем при I стадии ХОБЛ (p<0,05), более того установлено наибольшее снижение показателей ИМТ при III стадии заболевания (p< 0,05).

Data characterizing TMT in the general group of COPD patients, obtained by anthropometry and bioimpedancemetry, were significantly reduced compared to the control group (p<0,05).

The results of the analysis of TMT values ​​depending on the stage of COPD demonstrated that, in contrast to BMI, loss of TMT occurs already at stage I of COPD. Thus, in stage I COPD, TMT indicators are lower compared to controls (p<0,05). При II и III стадиях ХОБЛ значения ТМТ становятся еще меньше (p<0,05), достигая минимальных результатов при III стадии ХОБЛ (p=0,004). В последнем случае показатели ТМТ достоверно ниже результатов, полученных при исследовании пациентов с I и II стадий ХОБЛ (p<0,05). Во всех группах различий в данных, относящихся к ТМТ, в результате использования методов антропометрии и биоимпедансометрии не установлено.

In contrast to BMI, which is within the reference interval, for healthy people (BMI 18.5-25 kg/m2) at all stages of COPD, BMI indicators at stage III of the disease decrease below the recommended values ​​and become below 70%.

Based on the main goal of our study and relying on the results of the authors, indicating the greater sensitivity of the bioimpedansometry method in assessing indicators of the nutritional status of patients with signs of obesity and uneven distribution of fat and muscle tissue, we compared BMI and TMI indicators in groups of patients depending on the mass index bodies.

For this purpose, COPD patients were divided into three groups: group I - BMI from 20-25 kg/m2, group II - BMI< 20 кг/м 2 и III группа ИМТ >25 kg/m2. The results of the study are presented in Table 2.

Table 2. Indicators of MI, BMI, BMI in patients with COPD depending on BMI values

Index	IgruppAn=20	IIgroupn=20	IIIgroupn=20
	BMI20- 25	BMI< 2 0	BMI>25
TMT (%), anthropometry method
BZHM(%), bioimpedansometry method

Note: Significance of differences(p<0,05): *- между ТМТ метода антропометрии и БЖМТ биоимпедансометрии у пациентов ХОБЛ.

As follows from the presented results, significant differences were obtained between the values ​​of BWM as a result of using the anthropometry method and BWM values ​​using bioimpedance measurements in COPD patients with BMI>25 kg/m2. In this group of patients, the indicators of TMT turned out to be significantly higher than BWMT and amounted to 78.5 ± 1.25 and 64.5 ± 1.08 p<0,05 соответственно. Очевидно, что использование метода биоимпедансометрии в группе пациентов ХОБЛ с ИМТ>25kg/m2 has clear advantages for diagnosing LBW loss compared to standard anthropometric measurements.

Discussion of the results obtained

COPD is characterized by weight loss associated with protein-energy imbalance. In clinical practice, when determining the nutritional status of patients, they are often limited to calculating only BMI. As a result, it was found that BMI indicators in COPD patients in the general group are lower than in the control group, both when studied by anthropometry and bioimpedansometry. Analysis of BMI values ​​depending on the stage of COPD showed that at stage I of the disease, BMI does not change compared to the control. Its significant decrease occurs only in stages II and III of COPD. Moreover, regardless of the stage of COPD, BMI indicators are within the reference values ​​for healthy people or exceed 20 kg/m2. Accordingly, determining BMI is not sufficient to assess nutritional status in COPD. To assess body composition, it is necessary to differentiate body fat mass from muscle mass, since COPD, with normal or increased BMI, is characterized by a decrease in muscle mass.

According to our study, TMT values ​​in the general group of COPD patients, assessed by anthropometry and bioimpedansometry, were significantly reduced compared to the control group (p<0,05). Анализ результатов измерения ТМТ в зависимости от стадии ХОБЛ показал, что в отличие от показателей ИМТ при I стадии заболевания ТМТ достоверно ниже по сравнению с контролем (p<0,05).

In stages II and III of COPD, an even more pronounced loss of the protein component of patients’ body weight occurs. This is evidenced by a significant decrease in data characterizing TMT in stages II and III of COPD compared to stage I of the disease. The lowest TMT values ​​were found in stage III COPD. Noteworthy is the fact that the reduction in TMT is lower than the recommended values ​​in stage III COPD. In other words, our study established an accelerated loss of TMT in patients with COPD compared to BMI. A distinctive feature of our sample is that for all COPD patients, regardless of stage, BMI remained within the recommended values ​​for a healthy population. Despite this, we recorded the fact of a true decrease in TMT in stage III COPD using both research methods used. Considering the most pronounced changes in the values ​​of BMI and TMT in stage III COPD, it seemed interesting to us to conduct a correlation analysis between the indicators of BMI, TMT and FEV1.

The correlation analysis showed the absence of significant relationships between FEV1, a diagnostic indicator of the stage of COPD and BMI, in anthropometry and bioimpedance measurements. At the same time, a direct relationship of average strength was established between the values ​​of TMT as a result of the study of the anthropometry method and FEV1 (R=0.40+/-0.9; p<0,001) и прямая связь средней силы между данными БЖМТ в результате измерений методом биоимпедансометрии и ОФВ1 (R=0,55+/-0,9; p<0,0005).

Obviously, in COPD, such an indicator of the composite body structure as TMT or BWMT suffers most significantly. Regardless of the presence or absence of signs of hypoxemia, the loss of TMT is directly related to the progression of COPD and a decrease in respiratory function.

Based on the purpose of the study, the indicators of BMI and BMI, diagnosed using anthropometry and bioimpedansometry methods, do not differ significantly, however, these methods were used with BMI in patients who were not divided into groups with normal, reduced and increased body mass index, which must be taken into account. We analyzed the comparative characteristics of TMT and BWMT as a result of the methods used for various BMI indicators. Significant differences were revealed between BMI obtained by anthropometry and BMI, as a result of measurement using the bioimpedansometry method, with BMI>25 kg/m 2 in patients with COPD (p<0,05). Однако при ИМТ (20-25 кг/м 2), находящегося в пределах референсного значения для здоровых людей и при ИМТ<20кг/м 2 , достоверных различий не выявлено.

Obviously, the method of anthropometric measurements is not recommended for use in patients with a BMI>25 kg/m2, due to the predominant concentration of adipose tissue in the abdominal cavity, which leads to an underestimation of total fat mass.

The bioelectric impedance method makes it possible to more accurately determine protein-energy deficiency with a predominant decrease in muscle mass in COPD patients with a BMI>25 kg/m2.

conclusions

1. COPD is characterized by the development of nutritional deficiency, the phenotypic manifestations of which are loss of lean body mass, recorded even with a normal body mass index. There is a loss of lean body mass, the muscular component of the body, already at stage I of COPD, the most significant decrease in BMT was found at stage III of the disease (p<0,05).
2. Unlike body mass index, loss of lean body mass has a direct relationship with the stage of COPD, as evidenced by the correlation analysis.
3. In the general group of patients without taking into account body weight indicators, when comparing the methods of anthropometry and bioimpedanceometry, the indicators of BMI and TMI do not differ significantly. The bioelectric impedance method makes it possible to more accurately determine protein-energy deficiency with a predominant decrease in muscle mass in COPD patients with a BMI>25 kg/m2.

Reviewers:

• Duizen I.V., Doctor of Medical Sciences, Professor of the Department of General and Clinical Pharmacology of VSMU, Vladivostok.
• Brodskaya T. A., Doctor of Medical Sciences, Dean of the Faculty of Advanced Studies of VSMU, Vladivostok.

Bibliographic link

Burtseva E.V. STUDY OF THE NUTRITIONAL STATUS OF COPD PATIENTS USING ANTHROPOMETRY AND BIOIMPEDANOMETRY METHODS // Modern problems of science and education. – 2012. – No. 2.;
URL: http://science-education.ru/ru/article/view?id=5912 (access date: 02/01/2020). We bring to your attention magazines published by the publishing house "Academy of Natural Sciences"