Association between Phase Angle and Protein-Energy Wasting.

The predictive quality of the whole body phase angle makes it a vital measurement of the anthropometric assessment. Furthermore, conditions like protein-energy wasting assessment within the CKD population rely upon slight fluctuations of the patient’s body composition.

The inflammatory component of chronic kidney disease associates tightly with the lower levels of phase angle. Therefore, the phase angle measurement application can be a powerful predictive tool to prevent further complications or evaluate the disease condition.

What is protein-energy wasting?

Protein-energy wasting (PEW) is a prevalent syndrome in patients suffering from chronic kidney disease (CKD) and going through dialysis treatment. Also, PEW has a strong association with higher morbidity and mortality. 

PEW definition:

“The loss of somatic and circulation body protein and energy reserves, and is a common complication among hemodialysis patients.”

There are many factors involved with PEW:

• Decreased protein and energy intake: Patients with CKD struggle with anorexia. In turn, this can dysregulate appetite mediators or cytokines, branched amino acid intake may be low in these patients leading to a hyperserotoninergic-like syndrome. 
• Hypermetabolism: CKD comes with a component of increased energy expenditure that is cytokine-mediated. The dietary restrictions and the micronutrient depletion caused by dialysis promote the inability to produce metabolic cofactors. The insulin resistance and the increased glucocorticoid activity that accompanies CKD can cause a release of glycogen and muscle proteolysis, leading to the production of uremic toxins.
• Metabolic acidosis.
• Decreased physical activity.
• Decreased anabolism:  The implication of insulin resistance, growth hormone, and IGF-1 is involved in the loss of these patients’ muscle mass. The HPA-axis becomes involved in this situation as well. These patients have decreased testosterone concentrations that have a direct relation with the drop of thyroid hormone levels.
• Comorbidities and lifestyle:  Chronic conditions like diabetes mellitus, depression, heart failure, coronary artery disease, and peripheral vascular disease may affect the evolution of this syndrome. 
• Dialysis: Dialysis treatment may contribute in a different way to PEW’s development:

1. Tube placement infections.
2. Dialysis induced- inflammation.
3. Protein and amino acid loss during the dialysis session.
4. Loss of residual kidney function.

Phase angle assessment and Protein-energy wasting

Early detection and screening of PEW have high clinical practice importance. BIA provides a safe, quick method to evaluate hydration status, dry weight, and nutritional status management among patients treated with dialysis.

Precisely, phase angle can measure the body’s resistance and reaction in response to an external current, providing clinically relevant information about the cell membrane vitality and integrity. The phase angle is the only measurement not influenced by the hydration status assumptions, commonly affected in these patients.

Clinical setting: PEW & Phase Angle

In a clinical setting, a low phase angle measurement is indicative of disease progression and poor clinical outcome. A clinical research study by Saitoh et al. demonstrated that phase angle could be a simple screening tool that predicts PEW in patients going through hemodialysis.

Adding to these findings, a lower BMI, a hand-grip strength loss, and elevated C- reactive protein levels have a tight association with lower phase angle results.

In another study, Ruperto et al. stated that a phase angle <4 degrees was an independent predictor for PEW in HD patients. 

The phase angle’s clinical relevance allows it to transcend the anthropometric assessment and predict the development of certain diseases. BIA assessment can be accessible, affordable, and reproducible makes phase angle a crucial prognostic tool to populations, like PEW patients, that could not be assessed otherwise. Furthermore, time and future clinical applications will provide a better understanding of how phase angle predicts and its relationship with muscle loss.- Ana Paola Rodríguez Arciniega, MS.

References:

Carrero, Juan Jesús et al. “Etiology of the protein-energy wasting syndrome in chronic kidney disease: a consensus statement from the International Society of Renal Nutrition and Metabolism (ISRNM).” Journal of renal nutrition: the official journal of the Council on Renal Nutrition of the National Kidney Foundation vol. 23,2 (2013): 77-90. doi:10.1053/j.jrn.2013.01.001

Saitoh, Masakazu et al. “Bioelectrical impedance analysis-derived phase angle as a determinant of protein-energy wasting and frailty in maintenance hemodialysis patients: retrospective cohort study.” BMC nephrology vol. 21,1 438. 19 Oct. 2020, doi:10.1186/s12882-020-02102-2

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