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Recommendations Summary

CKD: Nutrition Assessment: Other Anthropometric Assessment Methods (2020)

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.

  • Recommendation(s)

    CKD: Skinfold Thickness

    In adults with CKD 1-5D (1B) or posttransplantation (OPINION), in the absence of edema, we suggest using skinfold thickness measurements to assess body fat.

    Rating: Strong

    CKD: Waist Circumference

    In adults with CKD 5D, we suggest that waist circumference may be used to assess abdominal obesity, but its reliability in assessing changes over time is low (2C).

    Rating: Weak

    CKD: Conicity Index

    In adults with CKD 5D on MHD,  we suggest that the conicity index may be used to assess nutritional status (OPINION) and as a predictor of mortality (2C).

    Rating: Weak

    CKD: Creatinine Kinetics

    In adults with CKD 5D, we suggest that creatinine kinetics may be used to estimate muscle mass, though very high or very low dietary intake of meat and/or creatine supplements will influence accuracy of this measurement (2C).

    Rating: Weak

    • Risks/Harms of Implementing This Recommendation

      There are no obvious risks or harms associated with these recommendations. 

    • Conditions of Application

      Special Discussions
      The recommendation for skinfold measurements requires specialized equipment.  Good quality calipers are needed to obtain an accurate measurement of skinfold thickness.  However, the measurer must be trained in order to obtain accurate results.  To obtain waist circumference, only a measuring tape is required.  Once again, the measurer must be trained on how to obtain this measure.  

      Implementation Considerations

      Skinfold Measurements

      • The guideline for skinfold measurements apply to all adult CKD patients, including post-transplant.  However, for the measurements to be useful to the practitioner, longitudinal assessments must be done to provide meaningful information about changes in percent body fat for that patient.
      • There are no potential risks or harms associated with the application of the guideline for skinfold measurements in all adult CKD patients. 
      • Skinfold measurements may not be accurate for obese patients, since calipers may have upper limits that do not accommodate high levels of adiposity.

      Creatinine Kinetics

      • The guideline for using creatinine kinetics to measure muscle mass applies to all adult CKD patients.  However, the procedure requires the patient to collect his/her urine for a 24-hour period and, preferably, to keep the collection on ice, which may make the procedure inconvenient for some patients.  Furthermore, intake of meat or protein supplements containing creatine may contribute to urine creatinine excretion and this must be considered when calculating creatinine kinetics.  In MHD patients, creatinine kinetics is more useful for patients who are anuric.
      • There are no potential risks or harms associated with the application of the guideline for creatinine kinetics in adult CKD patients. 

      Monitoring and Evaluation

      • Anthropometric measurements for assessment of body composition should be done routinely in CKD patients; these include skinfold measurements, waist circumference and creatinine kinetics.

    • Potential Costs Associated with Application

      The recommendations for skinfold measurements and waist circumference require specialized equipment.  Good quality calipers are needed to obtain an accurate measurement of skinfold thickness. 

    • Recommendation Narrative

      Methods of assessing body composition, including anthropometric measurements, are components of the nutrition assessment in CKD.  Anthropometric measurements are practical, inexpensive and non-invasive techniques that describe body mass, size, shape, and levels of fatness and leanness; they are the most basic and indirect methods of assessing body composition. These include height, weight, skinfolds, circumferences, bioelectrical impedance analysis (BIA) and creatinine kinetics. 

      Regardless of the method selected to assess body composition, none are perfect, and the errors surrounding them should not be ignored.  Errors may have clinical relevance, especially if the individual is treated and observed over time (Chumlea et al 2008). Moreover, the results of the measures are only as useful as the availability of suitable reference data from a group of persons of at least the same age, race, gender and disease status.

      Skinfold Measurements
      Ten studies reported on the use of skinfold measurements to assess body composition, including four agreement/validity/reliability studies (Avesani et al 2004, Bross et al 2010, Kamimura et al 2003, Woodrow et al 1996),  one prediction study (Araujo et al 2006) and six correlation studies Aatif et al 2013, Kalantar-Zadeh et al, Kamimura et al 2003b, Oe et al, Stall et al 1996).

      Maintenance Hemodialysis Patients 
      Bross et al used DEXA as the reference test and showed that, triceps skinfold thickness (TSF), BIA (Kushner), and near-infrared interactance were most accurate of the index tests in estimating total BF%, although the BIA (Segal) and BIA (Lukaski) equations overestimated total BF%. These results were not affected by skin color. In Bross, et al, there were significant correlations (all p<0.001) between DEXA measurements and triceps skinfold measures of body fat in MHD participants. Kamimura et al compared skinfold thickness with DEXA and BIA and found that body fat estimates using skinfold thickness (SKF) and BIA were not significantly different from those obtained by DEXA in the total group. There were significant intra-class correlations between DEXA with SKF (r=0.94) and BIA (r=0.91). DEXA showed relatively good agreement with both SKF [0.47 ±2.8 (-5.0 to 6.0) kg] and BIA [0.39 ±3.3 (-6.9 to 6.1) kg] in the total group, but BIA showed greater mean prediction error for both men and women. This study indicated that SKF was preferable over BIA, which showed gender-specific variability in the assessment of body fat.

      A prediction study by Araujo et al 2006 showed that TSF <90% was not associated with higher odds of mortality.  Oe et al in MHD patients found a significant correlation in LBM (r=0.69, p<0.025) between four skinfold anthropometry and BIA. BF-FSA was positively correlated with BF-BIA (r=0.65, p<0.005). Both techniques are comparable for LBM and BF measurements; however, four site skinfold anthropometry (FSA) is less affected by change in fluid status. Malnutrition score was significantly correlated with bicep skinfolds (r= -0.32) in MHD patients in a study by Kalantar-Zadeh et al.  Aatif et al showed that fat tissue index and triceps skinfold thickness had a positive significant correlation (r=0.61, p<0.001). Kamimura et al found a strong correlation between BIA and skinfold thickness (r=0.87) and near-infrared interactance and skinfold thickness (r=0.78). This study confirmed that the most simple, long-established, and inexpensive method of SFT is very useful for assessing body fat in patients on long-term MHD therapy.

      Peritoneal Dialysis Patients:
      Stall et al examined five different tools to assess BF%. BF% measurements were different between all methods (p<0.001), although there were differences according to sex. For men, all techniques were significantly different from each other (p<0.05) except BIA and DEXA, as well as the Steinkamp method (skinfold thickness) and total body potassium. For women, all techniques were significantly different from each other (p<0.05) except DEXA and the two methods for measuring skinfold thickness (Durnin & Womersley and Steinkamp). Despite the differences between modalities, all techniques were found to correlate significantly with each other (p<0.01 or better for men and p<0.001 or better for women).

      Hemodialysis and Peritoneal Dialysis Patients 
      Woodrow et al compared skinfold thickness with DEXA and BIA. Bland & Altman analysis demonstrated no observed differences in 95% levels of agreement for percent total body fat (TBF) and FFM from SF-BIA or skinfold anthropometry (SFA) compared with DEXA (%TBF BIA-DEXA -13.7 to +8.3; %TBF SFA-DEXA -13.0 to +9.4%; FFM BIA-DEXA -5.1 to +9.6 kg; FFM SFA-DEXA -5.6 to +9.1 kg). There were considerable variations in agreement between the measures.

      Pre-Dialysis Patients 
      Avesani et al used a Bland-Altman plot analysis for body fat% and showed that the best agreement was between skinfold thickness and DEXA compared to other measures. Skinfold thickness also had significant intraclass correlations with body fat% and it significantly correlated with FFM as measured by DEXA (r=0.74, r=0.85) indicating moderate and good reproducibility, respectively. This study indicated that skinfold thickness may be a good method to determine body fat% in pre-dialysis, and mild to advanced CKD patients.

      Serum Creatinine/Creatinine Kinetics
      Seven studies examined the relationship between serum creatinine or creatinine kinetics and comparative measures of muscle mass in MHD, PD and pre-dialysis patients. 

      Maintenance Hemodialysis Patients
      One study in MHD patients showed that creatinine kinetics correlated with creatinine levels, and other traditional measures of muscle mass (e.g. CT scan, anthropometric measurements) (Kaizu et al 2002). Three studies in MHD patients showed that pre-dialysis, inter-dialytic change, and weekly creatinine clearance levels predicted mortality (Kaizu et al 2002, Walther et al 2011, de Roij van Zuijdewijn et al 2015).

      Peritoneal Dialysis Patients 
      In PD patients, creatinine kinetics was correlated with other body composition measurements in one study (Borovnicar et al 1996); however, significant differences existed between creatinine and anthropometric measures for LBM/FFM in another (Szeto et al 2000). A study in PD examined creatinine clearance and relative risk of mortality (Churchill et al 1996). Evidence was limited in pre-dialysis patients to one study (Avesani et al 2004). CK was significantly correlated with BF% and FFM from DEXA (r=0.47 and r=0.57, respectively, indicating moderate reproducibility, though there were significant differences in adjusted means of BF% and FFM between CK and DEXA (p<0.05) (Avesani et al 2004).

      Waist Circumference
      Two studies reported on the use of waist circumference to assess nutritional status in dialysis patients.

      Maintenance Hemodialysis Patients 
      Cordeiro, et al. examined risk of PEW, inflammation and mortality according to waist circumference tertile in MHD patients. As waist circumference increased, indicating increased abdominal fat, patients had increased odds of PEW (assessed by SGA) and inflammation (assessed by IL-6). In the fully adjusted model, there was no increased risk of mortality according to waist circumference tertile.

      Peritoneal Dialysis Patients
      Bazanelli et al found a strong correlation between waist circumference and trunk fat (r=0.81, p<0.001) for both men and women, and a significant association with BMI (r=0.86, p<0.001). There was a moderate agreement between WC and trunk fat (kappa=0.59) and area under the curve was 0.90.  In a prospective evaluation of the same study, changes in waist circumference was also correlated with changes in trunk fat (r=0.49, p<0.001) and kappa of 0.48 indicated a moderate agreement between the tools. The authors concluded that waist circumference is a reliable marker of abdominal adiposity in PD patients.

      Conicity Index
      In one positive-quality study with HD patients, as Conicity Index tertile increased, indicating increased abdominal fat, patients had increased risk of PEW (assessed by SGA), increased fat BMI, waist circumference and inflammatory marker levels of CRP and IL-6 and had lower serum creatinine levels and handgrip strength (p<0.01 for each measure). In the model adjusted for age, sex, comorbidities and dialysis vintage, the highest tertile of conicity index was associated with mortality [HR (95% CI) 1.93 (1.06–3.49)], but the results were not significant after adjustment for IL-6 and PEW (Cordeiro, et al. 2010). Based on one study, Conicity Index may be a useful measure of nutritional status, inflammation and mortality in HD patients, but evidence was limited.

    • Recommendation Strength Rationale

      The evidence supporting the recommendations are based on GradesII and III/ Grade B, C and D evidence. 

    • Minority Opinions

      Consensus reached.