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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2019  |  Volume : 30  |  Issue : 4  |  Page : 891-897
Correlation between central arterial stiffness and handgrip strength in chronic hemodialysis patients

Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia and Dr. Cipto Mangunkusumo General National Hospital, Jakarta, Indonesia

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Date of Submission27-Nov-2018
Date of Decision19-Jun-2018
Date of Acceptance30-Dec-2018
Date of Web Publication27-Aug-2019


This study aimed to find the correlation between central arterial stiffness and handgrip strength (HGS). We conducted a cross-sectional study at the Dialysis Unit of Dr. Cipto Mangunkusumo General National Hospital, Jakarta, Indonesia, from April to May 2018. The recruited participants were aged between 18 and 60 years and underwent dialysis twice a week for over three months. Examination of central arterial stiffness and HGS was done by SphygmoCor® and Jamar® dynamometer, respectively. The obtained data were analyzed with bivariate correlation and partial correlation to confounding factors. The participants of this study comprised 45 men and 40 women. We found that there was a tendency to have increased central arterial stiffness in participants who had low HGS, although it was statistically insignificant. There was no correlation between central pulse wave velocity (cPWV) and HGS in men (r = -0.046, P = 0.763) and women (r = -0.285, P = 0.113). Stratified analysis in women with height over 150 cm showed a moderate negative correlation between cPWV and HGS (r = -0.466; r2 = 0.217; P = 0.016). cPWV accounted for 21.7% of HGS, whereas 78.3% suggested to be influenced by the confounding factors. The group with low HGS had an increased cPWV in all age categories. Central arterial stiffness was not associated with HGS in chronic HD patients.

How to cite this article:
Yunita Sari CM, Suhardjono, Nainggolan G, H. Marbun MB, Abdullah M. Correlation between central arterial stiffness and handgrip strength in chronic hemodialysis patients. Saudi J Kidney Dis Transpl 2019;30:891-7

How to cite this URL:
Yunita Sari CM, Suhardjono, Nainggolan G, H. Marbun MB, Abdullah M. Correlation between central arterial stiffness and handgrip strength in chronic hemodialysis patients. Saudi J Kidney Dis Transpl [serial online] 2019 [cited 2020 Dec 2];30:891-7. Available from: https://www.sjkdt.org/text.asp?2019/30/4/891/265465

   Introduction Top

Decline in muscle strength and physical capa- ity in chronic kidney disease (CKD) patients is relatively common.[1],[2] Muscle mass and isometric strength determine functional capacity more than reduced oxygen delivery.[3],[4] Exercise capacity can be predicted by assessing muscle strength with handgrip capacity.[5],[6] It correlates closely with the measurement of muscle strength from other muscle groups.[7]

Arterial stiffness assessed by central pulse wave velocity (cPWV) contributes to the decreased exercise capacity.[3],[8] Arterial calcification in CKD is high, leading to arterial stiffness.[9] Nitric oxide plays an important role in maintaining skeletal muscle contraction.[10] Stiff vessels will impair the endothelial nitric oxide synthase stimulation.[11]

In Indonesia, many patients receive twice-a- week hemodialysis (HD) sessions. Therefore, the correlation between central arterial stiffness and muscle strength needs to be investigated.

   Patients and Methods Top

This was a cross-sectional study, conducted at the Dialysis Unit of Dr. Cipto Mangunkusumo General National Hospital, Jakarta, between April and May 2018. The recruited individuals were consented patients aged between 18 and 60 years, had ≥8 g/dL of hemoglobin (Hb), and had been on maintenance dialysis twice a week for over three months. Exclusion criteria included traveling patients, patients with a history of cardiovascular diseases and inpatient hospitalization for any indication within the past three months, had conditions that inhibit cPWV measurement and assessment of handgrip strength (HGS), had hemodynamic disturbances, had fluid overload, depressed patients, pregnant patients, patients using immuno-suppressive drugs, those having cancer, and those who refuse to participate in this study.

The individuals were selected consecutively with a minimum sample size of 38, with coefficient correlation formula. Examination of central arterial stiffness and HGS was made by SphygmoCor® and Jamar® dynamometer, respectively. The HGS measurement was repeated thrice on the nonfistula arm with intervals of at least 30 s. We used the maximum value of HGS. Both examinations were performed after HD (minimum 30 min post- HD).

At the beginning of the study, we obtained baseline characteristics of the participants consisting of age, dialysis vintage, comor-bidity, medication use, laboratory parameters, anthropometric measurements [weight, height, body index mass (BMI), mid upper-arm circumference, mid-arm muscle circumference (MAMC)], and physical activity level using the International Physical Activity Questionnaire (IPAQ) score.

Data analyses were performed by Statistical Package for Social Sciences (SPSS) version 25.0 (IBM Corp., Armonk, NY, USA). P <0.05 was considered statistically significant. Numerical data with normal distribution were presented as mean (standard deviation). Numerical data with abnormal distribution were presented as median (maximum–minimum). Bivariate analysis was performed with Pearson’s or Spearman’s correlation test. In addition, partial correlation to confounding factors (height, age, dialysis duration, physical activity level, and Hb level) was performed.

This study was approved by the Ethical Committee of Research Faculty of Medicine, University of Indonesia and Dr. Cipto Mangunkusumo General National Hospital, Jakarta, Indonesia. All participants gave consent after receiving verbal and written explanation regarding the study.

   Results Top

There were 99 individuals who met the inclusion criteria, of whom 14 refused to join this study. Thus, a total of 85 individuals were included in this study. The study participants’ characteristics are summarized in [Table 1].
Table 1: Baseline characteristics of the study participants.

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Comparison of cPVW and HGS values based on age categories in both sexes is summarized in [Table 2].
Table 2: Comparison of cPVW and HGS values based on age categories in men and women.

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Weak negative correlations were found between cPWV and HGS in men and women (r = -0.046, P = 0.763, and r = -0.285, P = 0.113). Furthermore, partial correlation for confounding variables was seen as mentioned in [Table 3].
Table 3: Correlation of cPWV and HGS to confounding variables.

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Partial and weak negative correlation to height was seen in females (r = -0.310, P = 0.055). Stratification analysis of height categories based on median height (150 cm) showed a moderate negative correlation between cPWV and HGS in women [Table 4].
Table 4: Stratification analysis in groups of women based on height.

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There was a tendency for cPWV to be higher in groups with low HGS [Figure 1].
Figure 1: Comparative diagram of cPWV and HGS values based on age.
cPWV: Central pulse wave velocity, HGS: Handgrip strength.

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   Discussion Top

The crude cPWV values in this study did not correlate with HGS both in men (r = -0.046, P = 0.763) and women (r = -0.285, P = 0.113). Partial weak negative correlation of height with confounding variables was seen in women; r = -0.310. In accordance with the results of the coefficient of determination (r2) in women with height over 150 cm, 21.7% of the CAS explained the HGS value. Meanwhile, another 78.3% was influenced by other factors such as age, dialysis duration, Hb levels, and level of physical activity.

This study excluded individuals with age over 60 years, and the present study did not assess the level of inflammation and hence, the cPWV value was lower than the study of Porazko et al[12] [9.75 (18) m/sec]. They studied HD individuals with an average age of 58.0 (12.84) years and had the hsCRP value of 7.76 (4.81) (P <0.001). The cPWV value in the study of Yang et al[13] was lower [8.3 (2.0) m/sec] than this study. They studied 56 HD patients in the age range of 51 (13) years. Their HD session was performed for 4 h, thrice a week, and excluded diabetic patients. HGS was stratified based on age and gender categories for the Southeast Asian population.[7]

For each category in this study, there was lower HGS in HD patients for both men and women. As shown in [Table 2], the HGS value in the younger age group (<30 years) was lower than that in the age group of 30–39 years. Alkahtani[14] found that muscle strength reached its maximum level at the age of 30 years and lasted until the age of 50 years. Decreased muscle strength occurred after the age of 50 years.

The cPWV values were found to be higher in individuals with low HGS in all age groups. This finding had a very important clinical significance even though it was not statistically significant. The difference in cPWV values between normal and low HGS groups was most clearly seen in the age group of 30–39 years. It showed that the individuals with low and normal HGS had cPWV values of 9.5 m/s and 7.9 m/s, respectively. In normal HGS individuals, there was only a slight increase in cPWV values according to age. The individuals in the 30–39 years’ age group with normal HGS had longer dialysis duration (105 months) compared to 40-49 years’ age group (55.5 months’ dialysis duration). While in the age group of 40–49 years, patients with low HGS had better muscle mass compared to those in 30–39 years’ age group.

In the age group of 50–59 years, two individuals had normal HGS and increased cPWV value (10.4 m/s). Both of them had a good physical activity, muscle mass, and dialysis duration of 24 and 36 months. The age group <30 years had lower cPWV values compared to the other groups. It showed that age was one of the traditional risk factors for CAS.

Most obese individuals in the present study were female (55%), whereas most of the men had a normal BMI (42.2%). The characteristics of this study were not much different from those of Mihaescu et al’s study,[15] in which individuals had a BMI of 29.1 (5.6) kg/m2. Overall, individuals in this study had moderate activity (56.5%), and the percentage of men and women was 64.4% and 47.5% with an IPAQ score of 1386 (198–5544) and 693 (0-4398), respectively. This result was different from that of Mihaescu et al’s[16] study which reported lower activity levels because the population in this study was 47 (18–59) years old, whereas 60% of individuals in Mihaescu et al’s[16] study was 56.8 (9.5) years old. In this study, muscle mass in the low HGS group was worse than that in the normal HGS group [Table 5]. Overall, the mean value of MAMC in this study was lower than that of the report of Noori et al[17] that found 25.8 cm (4.41) of MAMC. Noori et al[17] conducted their research on individuals with a mean age of 53 years with a mean BMI value of 26.5 (6.1) kg/m2. They stated that MAMC as a marker of fat-free body mass was also an independent predictor of better quality of life and life expectancy in patients undergoing chronic HD.
Table 5: MAMC based on age and HGS.

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The mean phosphate level in this study was 6.39 (2.25) mg/dL. Johansen et al[18] found that their study participants had phosphate levels of 6.3 (1.9) mg/dL, with a dialysis duration of 2.9 (2.7) years. The high level of albumin [4.18 (0.040) g/dL] in this study indicated good nutritional condition. The calcium–phosphate product in this study was not increased (60%). It might be because that most of our study participants consumed phosphate-binding drugs (52.9%). Most patients in our study had Hb levels >10 g/dL. According to van den Ham et al,[5] the Hb level of their study participants was 7.5 ± 0.7 mmol/L (10.5 g/dL), and age was 49.0 ± 11.9 years and dialysis was 24.8 ± 18.3 months. The reason for determining the minimum Hb level of 8 g/dL was due to the difficulty in finding CKD patients who were not anemic.

Among men, the HGS variability was high and hence, no significant result was found. HGS in men strongly related to the level of physical activity. Future research is required to include the physical activity level in the calculation of sample size and HGS analysis in men. In women with height over 150 cm, a weak correlation was found. It might be related to the method of measurement of cPWV from SphygmoCor by measuring the distance of several points on the body surface. Because of the characteristic differences in women and men, future research should be able to analyze the data by stratification, mainly based on height and physical activity.

Hasheminejad et al[19] stated that gender, height, weight, and diabetes affected HGS, both in healthy individuals and HD patients. Sirajudeen et al[20] found a correlation between HGS and physical factors such as height, weight, BMI, and anthropometric measurements of hands (hand length, hand breadth, hand span, wrist circumference, and forearm girth). Garcia et al[21] conducted a study on 138 HD patients with a mean age of 55.4 (15.2) years and reported that HGS could be used as a diagnostic tool for malnutrition in HD patients with moderate and low accuracy in women and men.

Several limitations were present in this study:[1] it was a cross-sectional study, and hence we could not determine the causal relationship between CAS and HGS in patients undergoing chronic HD;[2] the measurement of body composition using anthropometric parameters so that the appendicular muscle mass cannot be assessed and not as accurate as using dual energy X-ray absorptiometry;[3] it did not assess HD adequacy, inflammatory levels, protein intake, residual renal function, insulin resistance, smoking history, calcium intake, Vitamin D levels, change in medication use, and heart function;[4] and it did not exclude the patients with diabetes and dyslipidemia.

   Conclusion Top

CAS was not associated with HGS in patients who underwent chronic HD. The cPWV value in women who had a height over 150 cm accounted for 21.7%, whereas 78.3% was influenced by other factors, such as age, dialysis duration, Hb levels, and physical activity. There was a tendency toward an increase in CAS in the group with low HGS.

   References Top

Chen CT, Lin SH, Chen JS, Hsu YJ. Muscle wasting in hemodialysis patients: New therapeutic strategies for resolving an old problem. Scientific World Journal 2013;2013: 643954.  Back to cited text no. 1
Mustata S, Chan C, Lai V, Miller JA. Impact of an exercise program on arterial stiffness and insulin resistance in hemodialysis patients. J Am Soc Nephrol 2004;15:2713-8.  Back to cited text no. 2
McMahon LP. Exercise limitation in chronic kidney disease: Deep seas and new shores. Nephrol Dial Transplant 2016;31:1975-6.  Back to cited text no. 3
Leikis MJ, McKenna MJ, Petersen AC, et al. Exercise performance falls over time in patients with chronic kidney disease despite maintenance of hemoglobin concentration. Clin J Am Soc Nephrol 2006;1:488-95.  Back to cited text no. 4
van den Ham EC, Kooman JP, Schols AM, et al. Similarities in skeletal muscle strength and exercise capacity between renal transplant and hemodialysis patients. Am J Transplant 2005; 5:1957-65.  Back to cited text no. 5
Strand BH, Cooper R, Bergland A, et al. The association of grip strength from midlife onwards with all-cause and cause-specific mortality over 17 years of follow-up in the Tromsø study. J Epidemiol Community Health 2016;70:1214-21.  Back to cited text no. 6
Leong DP, Teo KK, Rangarajan S, et al. Reference ranges of handgrip strength from 125,462 healthy adults in 21 countries: A prospective urban rural epidemiologic (PURE) study. J Cachexia Sarcopenia Muscle 2016;7: 535-46.  Back to cited text no. 7
Van Craenenbroeck AH, Van Craenenbroeck EM, Van Ackeren K, et al. Impaired vascular function contributes to exercise intolerance in chronic kidney disease. Nephrol Dial Transplant 2016;31:2064-72.  Back to cited text no. 8
Toussaint ND, Lau KK, Strauss BJ, Polkinghorne KR, Kerr PG. Associations between vascular calcification, arterial stiffness and bone mineral density in chronic kidney disease. Nephrol Dial Transplant 2008; 23:586-93.  Back to cited text no. 9
Heffernan KS, Chalé A, Hau C, et al. Systemic vascular function is associated with muscular power in older adults. J Aging Res 2012; 2012:386387.  Back to cited text no. 10
Shirwany NA, Zou MH. Arterial stiffness: A brief review. Acta Pharmacol Sin 2010;31: 1267-76.  Back to cited text no. 11
Porazko T, Kuzniar J, Kusztal M, et al. Increased aortic wall stiffness associated with low circulating fetuin A and high C-reactive protein in predialysis patients. Nephron Clin Pract 2009;113:c81-7.  Back to cited text no. 12
Yang L, Lin Y, Ye C, et al. Effects of peritoneal dialysis and hemodialysis on arterial stiffness compared with predialysis patients. Clin Nephrol 2011;75:188-94.  Back to cited text no. 13
Alkahtani SA. A cross-sectional study on sarcopenia using different methods: Reference values for healthy Saudi young men. BMC Musculoskelet Disord 2017;18:119.  Back to cited text no. 14
Mihaescu A, Avram C, Bob F, Gaita D, Schiller O, Schiller A. Benefits of exercise training during hemodialysis sessions: A prospective cohort study. Nephron Clin Pract 2013;124:72-8.  Back to cited text no. 15
Mihaescu A, Olariu N, Avram C, Schiller O, Schiller A. Arterial stiffness, fitness score, muscle strength and body composition interrelations in a chronic hemodialysed population. Nephrol Dial Transplant 2013;28:i440- 59.  Back to cited text no. 16
Noori N, Kopple JD, Kovesdy CP, et al. Mid-arm muscle circumference and quality of life and survival in maintenance hemodialysis patients. Clin J Am Soc Nephrol 2010;5:2258- 68.  Back to cited text no. 17
Johansen KL, Shubert T, Doyle J, Soher B, Sakkas GK, Kent-Braun JA. Muscle atrophy in patients receiving hemodialysis: Effects on muscle strength, muscle quality, and physical function. Kidney Int 2003;63:291-7.  Back to cited text no. 18
Hasheminejad N, Namdari M, Mahmoodi MR, Bahrampour A, Azmandian J. Association of handgrip strength with malnutrition-inflammation score as an assessment of nutritional status in hemodialysis patients. Iran J Kidney Dis 2016;10:30-5.  Back to cited text no. 19
Sirajudeen MS, Shah UN, Pillai PS, Mohasin N, Shantaram M. Correlation between grip strength and physical factors in men. Int J Health Rehabil Sci 2012;1:58-63.  Back to cited text no. 20
Garcia MF, Wazlawik E, Morena YM, Führ LM, González-Chica DA. Diagnostic accuracy of handgrip strength in the assessment of malnutrition in hemodialyzed patients. Clin Nutr ESPEN 2013;8:181-6.  Back to cited text no. 21

Correspondence Address:
Cut Mela Yunita Sari
Department of Internal Medicine, Faculty of Medicine Universitas Indonesia and Dr. Cipto Mangunkusumo General National Hospital, Jakarta
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DOI: 10.4103/1319-2442.265465

PMID: 31464246

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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