Background: Protein restriction may retard the need for renal replacement therapy; compliance is considered a barrier, especially in elderly patients. Methods: A feasibility study was conducted in a newly organized unit for advanced kidney disease; three diet options were offered: normalization of protein intake (0.8 g/kg/day of protein); moderate protein restriction (0.6 g/kg/day of protein) with a “traditional” mixed protein diet or with a “plant-based” diet supplemented with ketoacids. Patients with protein energy wasting (PEW), short life expectancy or who refused were excluded. Compliance was estimated by Maroni-Mitch formula and food diary. Results: In November 2017–July 2018, 131 patients started the program: median age 74 years (min–max 24-101), Charlson Index (CCI): 8 (min-max: 2–14); eGFR 24 mL/min (4–68); 50.4% were diabetic, BMI was ≥ 30 kg/m² in 40.4%. Normalization was the first step in 75 patients (57%, age 78 (24–101), CCI 8 (2–12), eGFR 24 mL/min (8–68)); moderately protein-restricted traditional diets were chosen by 24 (18%, age 74 (44–91), CCI 8 (4–14), eGFR 22 mL/min (5–40)), plant-based diets by 22 (17%, age 70 (34–89), CCI 6.5 (2–12), eGFR 15 mL/min (5–46)) (p < 0.001). Protein restriction was not undertaken in 10 patients with short life expectancy. In patients with ≥ 3 months of follow-up, median reduction of protein intake was from 1.2 to 0.8 g/kg/day (p < 0.001); nutritional parameters remained stable; albumin increased from 3.5 to 3.6 g/dL (p = 0.037); good compliance was found in 74%, regardless of diets. Over 1067 patient-months of follow-up, 9 patients died (CCI 10 (6–12)), 7 started dialysis (5 incremental). Conclusion: Protein restriction is feasible by an individualized, stepwise approach in an overall elderly, high-comorbidity population with a baseline high-protein diet and is compatible with stable nutritional status.

Background: Chronic kidney disease (CKD) is a global public health problem and is linked to adverse outcomes during pregnancy; the high prevalence of CKD (3–6%) in women of childbearing age is of particular relevance in emerging countries where CKD prevalence is higher and resources are limited. Although CKD is a public health problem in Mexico, there is scant information on outcomes in pregnant CKD women in this country. We report maternal–fetal outcomes in a prospective cohort of poor, CKD pregnant women, and compare results with those of pregnant women without CKD. Methods: A prospective study of pregnant CKD women referred to a public obstetrics/nephrology clinic from July 2013 to December 2017; sociodemographic and clinical data, including complications and perinatal outcomes, were recorded. CKD was defined at referral as per KDIGO guidelines; preeclampsia and superimposed preeclampsia were defined as appearance or worsening of hypertension and proteinuria. Findings were compared to official data for ­Mexico and to a historic control of pregnant women without CKD who delivered at our hospital. Results: Sixty-two pregnancies in CKD patients, age 23.4 ± 5.8 years were observed; 46.8% of patients were primiparous. At referral, serum creatinine was 1.8 (1.1–3.0) mg/dL with an estimate glomerular filtration rate (eGFR) of 38.1 (21.9–68.0) mL/min/1.73 m². In half of the cases, CKD was diagnosed during pregnancy. Forty-eight pregnant women without CKD, age 27 (22–34) years, who delivered during the study period were selected as controls: 33% were primiparous, serum creatinine was 0.50 (0.4–0.6) mg/dL, and estimate glomerular filtration rate was 135 (112–174) mL/min/1.73 m². Twenty patients needed dialysis (HD-CKD): 2 were already on dialysis, and 18 began treatment during pregnancy; 42 CKD patients did not require dialysis (non-HD CKD). After delivery, 15 patients remained dialysis dependent while 5 did not. Preeclampsia was more frequent in CKD patients in comparison to controls. In total, 93% of CKD patients and 98% of controls delivered a live baby. Prematurity was more frequent in CKD patients than controls and was higher in HD-CKD than in non-HD CKD. Birth weight was lower in CKD when compared to controls. Logistic regression showed a higher risk of preeclampsia in CKD pregnancies than in controls, but it was not affected by age, parity, CKD stage, or need for dialysis during pregnancy. Conclusions: Underserved CKD Mexican women have a high rate of adverse maternal-fetal outcomes during pregnancy. The risk may be higher in patients needing dialysis during pregnancy, many of whom remained dialysis dependent after delivery.

Chronic kidney disease (CKD) is linked to an elevated risk of malnutrition and sarcopenia, contributing to the intricate network of CKD-related metabolic disorders. Adipokines and myokines are markers and effectors of sarcopenia and nutritional status. The aim of this study was to assess whether the adipokine–myokine signature in patients on kidney replacement therapy could help identify malnutrition and sarcopenia. The study involved three groups: 84 hemodialysis (HD) patients, 44 peritoneal dialysis (PD) patients, and 52 kidney transplant recipients (KTR). Mean age was 56.1 ± 16.3 years. Malnutrition was defined using the 7-Point Subjective Global Assessment (SGA) and the Malnutrition-Inflammation Score (MIS). Sarcopenia was diagnosed based on reduced handgrip strength (HGS) and diminished muscle mass. Concentrations of adipokines and myokines were determined using the enzyme-linked immunosorbent assay (ELISA). 32.8% of all study participants were identified as malnourished and 20.6% had sarcopenia. For malnutrition, assessed using the 7-Point SGA, in ROC analysis albumin (area under the curve (AUC) 0.67 was the best single biomarker identified. In dialysis patients, myostatin (AUC 0.79) and IL-6 (AUC 0.67) had a high discrimination value for sarcopenia, and we were able to develop a prediction model for sarcopenia, including age, albumin, adiponectin, and myostatin levels, with an AUC of 0.806 (95% CI: 0.721–0.891). Adipokines and myokines appear to be useful laboratory markers for assessing malnutrition and sarcopenia. The formula we propose could contribute to a better understanding of sarcopenia and potentially lead to more effective interventions and management strategies for dialysis patients.

Background Preeclampsia (PE) and chronic kidney disease (CKD) are linked by an only partially known cause-effect relationship. Knowledge on prevalence of CKD in PE patients is needed for evaluating the diagnostic yield of nephrology work-up after PE. Methods The study was undertaken in the Centre Hospitalier Le Mans (CHM), setting of tertiary level obstetric service (about 3500 deliveries/year). PE was identified on hospital’s discharge codes; after review, the study included 99 patients, 36 of which were also evaluated in Nephrology. A descriptive analysis was performed as appropriate. Logistic multiple regression tested the outcome “CKD diagnosis”; covariates that emerged as significant were selected; only singletons were included. Analysis was performed in SPSS. The ethics committee of the CHM approved the study. Results Prevalence of CKD was 14%; CKD was in stage 1 in 8/14 (57%); 5 patients were in stage 2 (36%), 1 in stage 3 (7%). CKD was known or acknowledged in 1 case only. Diagnoses included reflux nephropathy-other malformations (5 cases), kidney stones-chronic pyelonephritis (3), PKD (1), interstitial nephropathy (2), diabetic nephropathy (1), albuminuria in metabolic syndrome (2). At the logistic regression analysis, preterm delivery [OR 7.849 (1.667–36.968)] and a baby normal for gestational age [> 10th centile; OR 6.193 (1.400–27.394)] were significantly correlated with the diagnosis of CKD. Conclusions Within the limits of a single-center study, our data quantify CKD as common in PE women and suggest the presence of a “CKD phenotype” characterised by preterm delivery and adequate growth, implying that CKD is compatible with good placental function up to the last phase of pregnancy.

Background: Chronic kidney disease (CKD) induces muscle wasting and a reduction in the maximum voluntary force (MVF). Little is known about the neuromuscular fatigability in CKD patients, defined as the reduction of muscle force capacities during exercise. Neuromuscular fatigability is a crucial physical parameter of the daily living. The quantification of explosive force has been shown to be a sensitive means to assess neuromuscular fatigability. Thus, our study used explosive force estimates to assess neuromuscular fatigability in elderly CKD patients.Methods: Inclusion criteria for CKD patients were age ≥ 60 years old and glomerular filtration rate (GFR) < 45 mL/min/1.73 m² not on dialysis, and those for controls were GFR > 60 mL/min/1.73 m², age and diabetes matched. The fatigability protocol focused on a handgrip task coupled with surface electromyography (sEMG). Scalars were extracted from the rate of force development (RFD): absolute and normalized time periods (50, 75, 100, 150 and 200 ms, RFD₅₀, RFD₇₅, RFD₁₀₀, RFD₁₅₀ and RFD₂₀₀, respectively), peak RFD (RFD_peak in absolute; NRFD_peak normalized), time‐to‐peak RFD (t‐RFD_peak) and the relative force at RFD_peak (MVF‐RFD_peak). A statistical parametric mapping approach was performed on the force, impulse and RFD–time curves. The integrated sEMG with time at 0–30, 0–50, 0–100 and 0–200 ms time intervals relative to onset of sEMG activity was extracted and groups were compared separately for each sex.Results: The cohort of 159 individuals had a median age of 69 (9_IQR) years and body mass index was 27.6 (6.2_IQR) kg/m². Propensity‐score‐matched groups balanced CKD patients and controls by gender with 66 males and 34 females. In scalar analysis, CKD patients manifested a higher decrement than controls in the early phase of contraction, regarding the NRFD_peak (P = 0.009; η²_p = 0.034) and RFD₇₅ and RFD₁₀₀ (for both P < 0.001; η²_p = 0.068 and 0.064). The one‐dimensional analysis confirmed that CKD males manifest higher and delayed neuromuscular fatigability, especially before 100 ms from onset of contraction. sEMG was lower in CKD patients than controls in the 0–100 ms (at rest: P = 0.049, Cohen's d = 0.458) and 0–200 ms (at rest: P = 0.016, Cohen's d = 0.496; during exercise: P = 0.006, Cohen's d = 0.421) time windows. Controls showed greater decrease of sEMG than CKD patients in the 0–30 ms (P = 0.020, Cohen's d = 0.533) and 0–50 ms (P = 0.010, Cohen's d = 0.640) time windows. As opposite to females, males showed almost the same differences between groups.Conclusions: Our study is the first to show that CKD patients have higher fatigability than controls, which may be associated with an impaired motor‐unit recruitment, highlighting a neural drive disturbance with CKD. Further studies are needed to confirm these findings.

Introduction: Chronic kidney disease (CKD) patients have a high degree of fatigue relating to neuromuscular symptoms. There is a lack of evidence regarding the etiology of neuromuscular fatigability in elderly CKD patients. Methods: Inclusion criteria are as follows: age ≥60 yr, glomerular filtration rate (GFR) 60 mL·min⁻¹·1.73 m⁻² in controls. The fatigability protocol consisted in a submaximal handgrip task at 40% peak force. Fatigue was assessed using the Multidimensional Fatigue Inventory–20 items (MFI-20) and the Functional Assessment of Chronic Illness Therapy–Fatigue questionnaires. Peak rate of force development (RFD_peak, normalized: NRFD_peak) and rate of EMG rise (RER) were measured during explosive contractions; peak force and mean surface EMG were measured during maximum voluntary contractions. Multilevel models tested neuromuscular parameters adjusted for clinical and Multidimensional Fatigue Inventory–20 items subscales. Neuromuscular fatigability contribution to fatigue description was tested using model comparison. Results: The study included 102 participants; 45 CKD patients and 57 controls. CKD mainly affected the mental and the reduced motivation subscales of fatigue. CKD was associated with greater neuromuscular fatigability assessed using NRFD_peak (group–time interaction, −16.7 % MVF·s⁻¹, P = 0.024), which increased with fatigue severity (P = 0.018) and with a higher rate of decrement in RER compared with controls (RER at 50 ms: β = −121.2 μV·s⁻¹, P = 0.016, and β = −48.5 μV·s⁻¹, P = 0.196, respectively). Furthermore, these patients show an association between the reduced motivation subscale and the RER (e.g., 30 ms: β = −59.8% EMG_peak·s⁻¹, P < 0.001). Only peak force fatigability contributed to fatigue variance, whereas RFD_peak did not. Conclusions: In CKD patients, the neuromuscular fatigability assessed using RFD_peak is related to an impairment in motor-unit recruitment or discharge rates, whereas only peak force fatigability was related to fatigue. This suggests that targeting exercise interventions might lessen fatigue and improve quality of life in CKD patients.