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.
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.
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).
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).
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).
Risks/Harms of Implementing This Recommendation
There are no obvious risks or harms associated with these recommendations.
Conditions of Application
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.
- 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.
- 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.
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.
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.
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).
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.
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.
- Risks/Harms of Implementing This Recommendation
The recommendations were created from the evidence analysis on the following questions. To see detail of the evidence analysis, click the blue hyperlinks below (recommendations rated consensus will not have supporting evidence linked).
Is there evidence to support the use of creatinine/kinetics for assessing body composition in adults with CKD 1-5D and post-transplant?
Is there evidence to support the use of skinfold measurements for assessing body composition in adults with CKD 1-5D and post-transplant?
Is there evidence to support the use of waist circumference for assessing body composition in adults with CKD 1-5D and post-transplant?
Is there evidence to support the use of conicity index for assessing nutritional status in adults with CKD 1-5D and post-transplant?
Avesani C, Draibe S, Kamimura M, Cendoroglo M, Pedrosa A, Castro M, Cuppari L. Assessment of body composition by dual energy X-ray absorptiometry, skinfold thickness and creatinine kinetics in chronic kidney disease patients. Nephrology, Dialysis, Transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association 2004; 19:2289-95
Borovnicar D, Wong K, Kerr P, Stroud D, Xiong D, Strauss B, Atkins R. Total body protein status assessed by different estimates of fat-free mass in adult peritoneal dialysis patients. European Journal of Clinical Nutrition 1996; 50:607-16
David N. Churchill. Adequacy of Dialysis and Nutrition in Continuous Peritoneal Dialysis: Association with Clinical Outcomes. J. Am. Soc. Nephrol 1996; 7:198-207
de Roij van Zuijdewijn C, ter Wee P, Chapdelaine I, Bots M, Blankestijn P, van den Dorpel M, Nubé M, Grooteman M. A Comparison of 8 Nutrition-Related Tests to Predict Mortality in Hemodialysis Patients. Journal of Renal Nutrition : the official journal of the Council on Renal Nutrition of the National Kidney Foundation 2015; 25:412-9
Kaizu Y, Ohkawa S, Kumagai H. Muscle mass index in haemodialysis patients: a comparison of indices obtained by routine clinical examinations. Nephrology, Dialysis, Transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association 2002; 17:442-8
Szeto C, Kong J, Wu A, Wong T, Wang A, Li P. The role of lean body mass as a nutritional index in Chinese peritoneal dialysis patients--comparison of creatinine kinetics method and anthropometric method. Journal of the International Society for Peritoneal Dialysis 2000; 20:708-14
Walther C, Carter C, Low C, Williams P, Rifkin D, Steiner R, Ix J. Interdialytic creatinine change versus predialysis creatinine as indicators of nutritional status in maintenance hemodialysis. Nephrology, Dialysis, Transplantation : official publication of the European Dialysis and Transplant Association 2012; 27:771-6
Aatif T, Hassani K, Alayoud A, Maoujoud O, Ahid S, Benyahia M, Oualim Z. Parameters to assess nutritional status in a Moroccan hemodialysis cohort. Arab Journal of Nephrology and Transplantation 2013; 6:89-97
Araújo I, Kamimura M, Draibe S, Canziani M, Manfredi S, Avesani C, Sesso R, Cuppari L. Nutritional parameters and mortality in incident hemodialysis patients.. Journal of Renal Nutrition : the official journal of the Council on Renal Nutrition of the National Kidney Foundation 2006; 16:27-35
Bross R, Chandramohan G, Kovesdy C, Oreopoulos A, Noori N, Golden S, Benner D, Kopple J, Kalantar-Zadeh K. Comparing body composition assessment tests in long-term hemodialysis patients. American Journal of Kidney Diseases : the official journal of the National Kidney Foundation 2010; 55:885-96
Kalantar-Zadeh K, Kleiner M, Dunne E, Lee G, Luft F. A modified quantitative subjective global assessment of nutrition for dialysis patients. Nephrology, Dialysis, Transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association 1999; 14:1732-8
Kamimura M, Avesani C, Cendoroglo M, Canziani M, Draibe S, Cuppari L. Comparison of skinfold thicknesses and bioelectrical impedance analysis with dual-energy X-ray absorptiometry for the assessment of body fat in patients on long-term haemodialysis therapy. Nephrology, Dialysis, Transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association 2003; 18:101-5
Kamimura M,J osé Dos Santos N, Avesani C, Fernandes Canziani M, Draibe S, Cuppari L. Comparison of three methods for the determination of body fat in patients on long-term hemodialysis therapy. Journal of the American Dietetic Association 2003; 103:195-9
Oe B, de Fijter C, Oe P, Stevens P, de Vries P. Four-site skinfold anthropometry (FSA) versus body impedance analysis (BIA) in assessing nutritional status of patients on maintenance hemodialysis: which method is to be preferred in routine patient care?. Clinical Nephrology 1998; 49:180-5
Stall S, Ginsberg N, DeVita M, Zabetakis P, Lynn R, Gleim G, Wang J, Pierson R, Michelis M. Comparison of five body-composition methods in peritoneal dialysis patients. The American Journal of Clinical Nutrition 1996; 64:125-30
Woodrow G, Oldroyd B, Smith M, Turney J. Measurement of body composition in chronic renal failure: comparison of skinfold anthropometry and bioelectrical impedance with dual energy X-ray absorptiometry. European Journal of Clinical Nutrition 1996; 50:295-301
Bazanelli A, Kamimura M, Manfredi S, Draibe S, Cuppari L. Usefulness of waist circumference as a marker of abdominal adiposity in peritoneal dialysis: a cross-sectional and prospective analysis. Nephrology, Dialysis, Transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association 2012; 27:790-5
Cordeiro A, Qureshi A, Stenvinkel P, Heimbürger O, Axelsson J, Bárány P, Lindholm B, Carrero J. Abdominal fat deposition is associated with increased inflammation, protein-energy wasting and worse outcome in patients undergoing haemodialysis. Nephrology, Dialysis, Transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association 2010; 25:562-8
References not graded in Academy of Nutrition and Dietetics Evidence Analysis Process
Chumlea WC CD, Dwyer JT, Han H, Kelly MP. Nutritional assessment in chronic kidney disease. In: Byham-Gray LD BJ, Chertow GM, ed. Nutrition in kidney disease. Totowa, NJ: Humana Press; 2008:49–118.