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Nutrition in acute and chronic diseases

Quadriceps muscle thickness assessed by ultrasound is independently associated with mortality in hemodialysis patients



Estimation of muscle mass is an integral part of nutritional assessment in End-Stage Kidney Disease (ESKD) patients on chronic hemodialysis (HD). In this respect, muscle ultrasound (US) is a valid and reliable tool but has not been previously related to outcomes in this population. Aims of this study were to assess the relationship between quadriceps muscle thickness as assessed by US and outcomes in ESKD patients on HD; we also compared US with anthropometry and malnutrition inflammation score (MIS).


In this prospective study, 181 prevalent patients on HD were included. Thickness of the quadriceps rectus femoris and vastus intermedius (VIT) were assessed separately using ultrasonography, and were indexed for height squared. Mid-arm muscle circumference (MAMC) and area (MAMA) were assessed by anthropometry. MIS was evaluated. In the absence of predetermined cut-offs, values below the median of the distribution of VIT index were considered low. Instead, cut-off for anthropometric values such as MAMC and MAMA were set at ≥90% of agreement with the 50th percentile of the sex- and age-specific normal distribution. Cox-regression analysis was used to assess the association of US, MIS, and anthropometric parameters with mortality.


Patients were followed for a median of 35 months. During this period 36% of patients died. Multivariable Cox-regression analysis (adjusted for demographic, biochemical and clinical variables), demonstrated that higher VIT distal index values were independently associated with lower mortality risk (HR: 0.76 (0.59–0.99); P = 0.040), whilst higher MIS values were independently associated with higher (HR 1.22 (1.10–1.35); P < 0.001) mortality risk. When assessing muscle parameters as categorical variables, both low VIT distal index (HR: 1.71 (1.01–2.89); 0.045) and MAMC (HR: 1.74 (1.02–2.96); 0.042) were independently associated with increased risk of death.


Indexed distal VIT was independently associated with mortality both as continuous and as a categorical variable. Muscle US is a simple practical tool that adds prognostic information to the bedside nutritional assessment in ESKD patients on maintenance HD.

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Fig. 1: Kaplan–Meier survival curves of patients with end-stage kidney disease on hemodialysis (n = 181) with low muscle status.

Data availability

The data analyzed during this study are available from the corresponding author on reasonable request.


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Author contributions

AS was responsible for designing the protocol, data collection, and analysis, as well as writing the manuscript. JPK, mentorship and contribution to writing the manuscript. TDM, CC, MG, and SB, contributed by collecting data and revising the manuscript. GR was responsible for analyzing the data and writing the manuscript. EF, mentorship and revision of the manuscript.


This study was partially funded by the young investigator research fellowship by the Italian Society of Parenteral and Enteral Nutrition (SINPE, Società Italiana di Nutrizione Parenterale ed Enterale) for the project: “Valutazione nutrizionale nell’insufficienza renale mediante ecografia del muscolo quadricipite femorale” (“Nutritional assessment of patients with chronic kidney disease and acute kidney injury through ultrasound of the quadriceps femoris muscle”) received by Alice Sabatino.

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Correspondence to Alice Sabatino.

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The authors declare no competing interests.

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The study was approved by the local Institutional Review Board (AVEN ref. no 45737, December 12th, 2015).

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Sabatino, A., Kooman, J.P., Di Motta, T. et al. Quadriceps muscle thickness assessed by ultrasound is independently associated with mortality in hemodialysis patients. Eur J Clin Nutr (2022).

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