ESPEN Congress Leipzig Prognostic impact of body composition. Phase angle: the best predictor for outcome? K. Norman (DE)

Transcription

1 ESPEN Congress Leipzig 2013 Prognostic impact of body composition Phase angle: the best predictor for outcome? K. Norman (DE)

2 Phase angle the best predictor of outcome? Kristina Norman, PhD CHARITÉ Universitätsmedizin Berlin Research Group on Geriatrics

3 Background Bioelectrical Impedance Analysis Clinical use of BIA in subjects at extremes of BMI ranges or with abnormal hydration cannot be recommended for routine assessment of patients until further validation has proven for BIA algorithm to be accurate in such conditions. ESPEN GUIDELINES Bioelectrical impedance analysis part I: review of principles and methods Clinical Nutrition (2004) 23 Requirements for algorithms with tetrapolar BIA: BMI range kg/m² undisturbed hydration

4 Increasing use of raw impedance parameters in clinical research and practise

5 I m p e d a n c e (Z) = Z 2 = R 2 + Xc 2 R e s i s t a n c e (R) = pure opposition of a biological conductor to alternating electric current R e a c t a n c e (Xc) = capacitive effect produced by the tissue interfaces and cell membranes P h a s e A n g l e (α) Reactance 180 x Resistance π

6 Phase angle as indicator of nutritional and functional parameters Norman et al Nutrition 2007; 23 BMI: 25 BMI: 25 BMI: 25 Age: 65 Age: 67 Age: 64 Toso et al. Nutrition 2000;16 Norman et al. Am J Clin Nutr 2010;92 5

7 Low phase angle values: highly predictive of outcome (eg disease progression) and mortality - Cancer (pancreatic, lung, colorectal, breast, mixed) - HIV/AIDS - Liver disease - Neurologic disease (ALS) - Rheumatic disease (systemic sclerosis) - Kidney disease (haemodialysis and peritoneal dialysis) - Cardiac disease - Geriatrics - Surgery (cardiac and gastrointestinal) Norman et al Clin Nutr. 2012;31 [Review article] 6

8 Impact of phase angle on mortality in HIV n= 257 (234 on HAART) 39.7 y old; 85% male 1.5 y prospective study Schwenk et al. Am J Clin Nutr 2000;72 7

9 Impact of phase angle on mortality in colon cancer n=52 Patients with colon cancer stage IV [57% male] 3 y retrospective review 5.57 (median) as the cutoff < 5.57 > 5.57 Gupta et al Am J Clin Nutr 2004;80 8

10 Impact of phase angle on mortality in congestive heart disease n= 41 patients with CHD Prospective study on 5 y mortality AUC Phase angle 0.86 indexed EAT 0.82 ICW 0.83 MM 0.82 LV-EF 0.68 FFM for PA sensitivity 75% specificity 65% 22 g/m² for EAT sensitivity 88% specificity 67% Dösch et al. Obesity 2010;10 EAT epicardial adipose tissue; ICW intracellular water; MM muscle mass; LV-EF left ventricular ejection fraction; FFM fat free mass 9

11 Cut off values for clinical use? Norman et al Clin Nutr. 2012;31 [Review article] 10

12 Determinants and influencing factors: In health: In disease: BMI Sex Age Phase angle Weight loss Inflammation Bosy-Westphal et al. JPEN 2006;30 Barbosa- Silva et al. Am J Clin Nutr 2005;82 Stobäus et al. Br J Nutr 2012;107 Johansen et al. Am J Clin Nutr 2003;77

13 Interpretation in clinical practice:? Phase angle? yrs.. Age yrs 26.3 kg/m 2..BMI kg/m 2

14 Interpretation of phase angle in clinical practise Sex, age and BMI - stratified reference values Bosy-Westphal et al. JPEN 2006;30 Barbosa- Silva et al. Am J Clin Nutr 2005;82 Standardization of raw values Z-score standardized phase angle = (observed phase angle - mean* phase angle) SD* of the phase angle *mean and SD are from sex-, age-, and BMI-stratified reference values. 13

15 Sex, age and BMI - stratified reference values 14

16 Clinical case: Phase angle: 5.0 male 71 yrs old BMI 26.3 kg/m above the 10 th reference percentile Bosy-Westphal et al. JPEN 2006; 30

17 Clinical case: Phase angle: 5.0 female 23 yrs old BMI 22.6 kg/m below the 5 th and 10 th reference percentile Bosy-Westphal et al. JPEN 2006; 30

18 5 th reference percentile of phase angle in cancer: Prognostic impact on 6-mo mortality (n=208) (n=191) n= 399 (m/f (208/191) Age 63.0 ± 11.8 y Malnourished (SGA B+C) 58.1% GI tract tumour: 38% Advanced disease stage: 60.8 (%) OR: 4.0; [95% CI: 2.4, 6.8] P< Norman et al. Am J Clin Nutr 2010;92

19 Phase angle: Functional parameters and quality of life in elderly cancer patients 433 patients < 60 y mean age 70 Phase angle < 5th reference percentile > 5th reference percentile EORTC function scales and symptoms Significant impact of phase (General Linear Model, selected excerpt of the models): ESPEN 2013 Poster PP-136-SUN 18

20 Standardization of raw values Z-score standardized phase angle = (observed phase angle - mean* phase angle) SD* of the phase angle *mean and SD are from sex-, age-, and BMI-stratified reference values. 19

21 Absolute vs. standardized phase angle Phase angle absolute values [ ] Norman et al. Am J Clin Nutr 2010;92 20

22 Standardized phase angle in cancer: Prognostic impact on 6-mo mortality (weight loss) 1 = 399. Age, sex, standardized phase angle, Subjective Global Assessment (SGA), BMI, handgrip strength, tumor type, disease severity, and type of treatment were introduced into the generalized linear model regression model. Norman et al. Am J Clin Nutr 2010;92

23 Standardized phase angle in cancer: Prognostic impact on 6-mo mortality AUC Standardized phase angle Subjective Global Assessment UICC Norman et al. Am J Clin Nutr 2010;92 22

24 Standardized phase angle in chemotherapy: prognostic impact on 3 y mortality 195 patients before 1. chemotherapy cycle 3 y prospective study Cut off for standardized phase angle SD Multivariate Cox regression analysis RR 2.35 CI: ; p=0.001 Paiva et al. Support Care Cancer 2011; 19 23

25 C o n c l u s i o n s Phase angle is a good predictor of clinical outcome, particularly for short term mortality Phase angle is influenced by sex and age, hydration and nutritional status as well as disease severity Interpretation in clinical use is facilitated by reference values 24