Original Research
Handgrip Strength at Baseline and Mortality Risk in a Cohort of Women and Men on Hemodialysis: A 4-Year Study

https://doi.org/10.1053/j.jrn.2013.12.005Get rights and content

Objective

The objective of this study was to investigate the association between handgrip strength (HGS) and the risk of all-cause mortality in maintenance hemodialysis (MHD) patients and its relationship with nutritional status. This study also investigated whether the association between HGS and mortality is similar in female and male patients.

Design and Methods

This was a cohort study using data from the Prospective Study of the Prognosis of Chronic Hemodialysis Patients (PROHEMO) with a median follow-up of 33.81 months. The study setting was satellite dialysis units in the city of Salvador, Brazil.The sample included 443 adult patients in MHD. The main predictor variable was baseline HGS categorized into low and high groups on the basis of sex-specific optimized cutoffs, and the main outcome measure was all-cause mortality.

Results

In Cox regression models adjusted for age and other demographic variables, the hazard of death was significantly higher for patients with lower HGS for males (hazard ratio [HR] = 3.10, 95% confidence interval [CI] = 1.68-5.74) and for females (HR = 2.72, 95% CI = 1.03-7.19). The hazard of death for male and female patients with lower HGS was more than 2 times higher in models that included numerous covariates, with the exception of nutritional status indicators. After nutritional indicators were included, the hazard of death associated with lower HGS decreased by 6% in males and 55% in females.

Conclusions

This study demonstrates that HGS predicts all-cause mortality in men and women on MHD. Differences seem to exist between women and men on MHD in the role played by nutritional status in explaining the increased risk of death associated with low HGS.

Introduction

Previous studies using various nutritional indicators have demonstrated that protein-energy wasting (PEW), a condition characterized by loss of muscle and visceral protein stores, is strongly associated with a higher mortality risk in patients on maintenance hemodialysis (MHD).1, 2, 3, 4 These data support the recommendation for frequent evaluation of PEW in all MHD patients to prevent malnutrition and to improve survival.5 One increasingly used research tool for evaluating PEW in dialysis patients is the malnutrition-inflammation score (MIS), a comprehensive measure that considers several nutritional components.4, 6, 7, 8, 9 The MIS strongly predicts health outcomes in MHD patients.4, 9 However, a systematic evaluation of the nutritional status of all patients in a hemodialysis unit using the MIS would be time-consuming and require expertise in renal nutrition to ensure accuracy.

A simple and validated nutritional tool that does not require expertise for use in clinical practice would enable more frequent evaluations of nutritional status in all patients in hemodialysis units as well as earlier detection of reduced nutritional status. We have demonstrated that handgrip strength (HGS), measured with a dynamometer, can be used as a simple nutritional tool to identify MHD patients with a higher probability of PEW as diagnosed by the MIS.10 Studies of the general population, in patients without kidney disease and in those with advanced stages of chronic kidney disease nearing the initiation of dialysis or undergoing peritoneal dialysis, identified an association between reduced HGS and a higher risk of death.11, 12, 13, 14

Additional studies are required to assess the association between HGS and mortality risk in patients on MHD. In these studies, it will be important to consider potential variations in the association between HGS and mortality risk resulting from demographic and clinical characteristics that are related to HGS, nutritional status, or body composition, such as sex, race, and prevalent comorbid conditions (e.g., diabetes). Studies of the general population and of patients with chronic kidney disease have consistently shown an association between decreased HGS and mortality risk in men,11, 15 but a consistent association between HGS and mortality risk has not been reported for women.12, 16, 17

The objective of the study presented here was to investigate the association between HGS and mortality risk in MHD patients using a sample from a prospective cohort study of MHD patients treated at dialysis clinics in Salvador, Brazil. The hypotheses were that HGS is associated with mortality risk in MHD patients and that the association could be partially or completely explained by nutritional status indicators. This study also investigated whether the association between HGS and mortality is similar in female and male patients.

Section snippets

Study Design and Subjects

The study presented here included data from a prospective cohort of 443 adult patients on MHD enrolled in the Prospective Study of the Prognosis of Chronic Hemodialysis Patients (PROHEMO). The patients were treated at 4 dialysis clinics in Salvador, Brazil. All patients aged 18 years or older treated at the dialysis clinics between February 2007 and March 2009 were invited to participate in the study. The acceptance rate was higher than 95%. The patients were followed until death,

Patient Characteristics

The distribution of the baseline characteristics in the entire cohort by HGS categories is presented in Table 1. The mean age of the patients was 46.61 ± 14.09 years. Most patients were male (62.1%) and non-White (88.9%). Approximately 22.0% were diabetic. Patients with lower HGS were generally older, less likely to be non-White, exhibited signs of worse nutritional status (higher MIS, lower serum creatinine, and lower serum albumin), and had a higher prevalence of diabetes and peripheral

Discussion

This study expands our knowledge regarding the utility of HGS in nephrology clinics by providing evidence that this simple measurement can identify MHD patients at an increased risk of death. The results indicate that HGS helps to predict the risk of death for males and females receiving MHD. According to the results, similar sex-specific cutoffs may be used to identify MHD patients at higher risk of malnutrition and death. The definition of lower and higher HGS in the study presented here was

Practical Application

The use of a hand dynamometer to measure HGS is suitable for clinical practice with MHD patients because it is an objective and easily performed measure at bedside. Lower HGS correlates with indicators of lower nutritional status. The results support the use of HGS to identify men and women on MHD who need a more detailed evaluation of the nutritional status and interventions to improve survival.

Acknowledgments

PROHEMO was supported by research grants from the Brazilian National Council for Scientific and Technological Development (CNPq), grants 484743/2006-6 and 308068/2006-8. The authors are grateful for the support of the medical directors and staff at the following dialysis units: Clínica NEPHRON of Itapuã, Clínica NEPHRON of Barris, INED, and CLINIRIM.

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    Support: The study received financial support from a governmental agency from the Brazilian Ministry of Science and Technology, the Brazilian National Council for Scientific and Technological Development (CNPq), grants 484743/2006-6 and 308068/2006-8.

    See also Acknowledgments on page 162.

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