Sarcopenia, Relative Sarcopenia and Excess Adiposity in Chronic Kidney Disease

susan ziolkowski, Jin Long, Joshua F Baker, Julia F Simard, Glenn M Chertow, Mary B Leonhard


Background: Conventional definitions of sarcopenia based on lean mass fail to capture low lean mass relative to fat mass, i.e., relative sarcopenia. Unlike percent body fat (%BF) and Quételet’s (body mass) index (BMI, kg/m2), definitions of obesity based on fat mass index (FMI, kg/m2) are not confounded by lean mass.  The objective is to determine the prevalence of sarcopenia, relative sarcopenia, and obesity in CKD, and determine if CKD is associated with relative sarcopenia and obesity, independent of demographics and comorbidities. 

Methods:  DXA-derived appendicular lean mass index (ALMI, kg/m2) and FMI were assessed in 13,980 NHANES participants. ALMI, FMI, and ALMI relative to FMI (ALMI FMI) were expressed as sex- and race/ethnicity-specific standard deviation scores compared with young adults (T-scores) and by age (Z-scores). Sarcopenia was defined as ALMI T-score < -2, relative sarcopenia as ALMI FMI T-score < -2, and low lean mass relative to fat mass for age as ALMI FMI Z-score < -1.  Obesity was defined using conventional BMI and %BF cutpoints and as sex- and race/ethnicity-specific FMI cutpoints. Glomerular filtration rate (GFR) was estimated using creatinine- (eGFR Cr) and cystatin C- (eGFR Cys).

Results: The prevalence of relative sarcopenia was higher than the prevalence of sarcopenia, especially in CKD stages 3b and 4 using eGFR Cr; these CKD stages were associated with the highest FMI. CKD stage was independently associated with low ALMI FMI for age using eGFR Cys. BMI underestimated and %BF overestimated the prevalence of obesity compared with FMI. CKD was not independently associated with obesity by FMI.

Conclusions: In CKD, conventional definitions of sarcopenia underestimate muscle deficits and %BF overestimates the prevalence of obesity. CKD is independently associated with relative sarcopenia, but not excess adiposity.

Full Text:




X.H. Wang, W.E. Mitch, Mechanisms of muscle wasting in chronic kidney disease, Nature reviews. Nephrology 10(9) (2014) 504-16.

N. Noori, J.D. Kopple, C.P. Kovesdy, U. Feroze, J.J. Sim, S.B. Murali, et al., Mid-arm muscle circumference and quality of life and survival in maintenance hemodialysis patients, Clinical journal of the American Society of Nephrology : CJASN 5(12) (2010) 2258-68.

Y. Bao, L. Dalrymple, G.M. Chertow, G.A. Kaysen, K.L. Johansen, Frailty, dialysis initiation, and mortality in end-stage renal disease, Archives of internal medicine 172(14) (2012) 1071-7.

K.L. Johansen, G.A. Kaysen, L.S. Dalrymple, B.A. Grimes, D.V. Glidden, S. Anand, et al., Association of physical activity with survival among ambulatory patients on dialysis: the Comprehensive Dialysis Study, Clinical journal of the American Society of Nephrology : CJASN 8(2) (2013) 248-53.

D. Weber, J. Long, M.B. Leonard, B. Zemel, J.F. Baker, Development of Novel Methods to Define Deficits in Appendicular Lean Mass Relative to Fat Mass, PLoS One 11(10) (2016) e0164385.

J.F. Baker, J.T. Giles, D. Weber, M.B. Leonard, B.S. Zemel, J. Long, et al., Assessment of muscle mass relative to fat mass and associations with physical functioning in rheumatoid arthritis, Rheumatology (Oxford, England) (2017).

J.F. Baker, J. Long, M.B. Leonard, T. Harris, M.J. Delmonico, A. Santanasto, et al., Estimation of Skeletal Muscle Mass Relative to Adiposity Improves Prediction of Physical Performance and Incident Disability, The journals of gerontology. Series A, Biological sciences and medical sciences (2017).

A.S. Levey, L.A. Stevens, C.H. Schmid, Y. Zhang, A.F. Castro, H.I. Feldman, et al., A New Equation to Estimate Glomerular Filtration Rate, Annals of internal medicine 150(9) (2009) 604-612.

National Health and Nutrition Examination Survey. Available from:

B.E. Ainsworth, W.L. Haskell, M.C. Whitt, M.L. Irwin, A.M. Swartz, S.J. Strath, et al., Compendium of physical activities: an update of activity codes and MET intensities, Medicine and science in sports and exercise 32(9 Suppl) (2000) S498-504.

L.A. Stevens, J. Coresh, C.H. Schmid, H.I. Feldman, M. Froissart, J. Kusek, et al., Estimating GFR using serum cystatin C alone and in combination with serum creatinine: a pooled analysis of 3,418 individuals with CKD, Am J Kidney Dis 51(3) (2008) 395-406.

I.H. de Boer, B.C. Astor, H. Kramer, W. Palmas, K. Rudser, S.L. Seliger, et al., Mild elevations of urine albumin excretion are associated with atherogenic lipoprotein abnormalities in the Multi-Ethnic Study of Atherosclerosis (MESA), Atherosclerosis 197(1) (2008) 407-14.

J. LaForgia, J. Dollman, M.J. Dale, R.T. Withers, A.M. Hill, Validation of DXA body composition estimates in obese men and women, Obesity (Silver Spring, Md.) 17(4) (2009) 821-6.

M.I. Goran, M.J. Toth, E.T. Poehlman, Assessment of research-based body composition techniques in healthy elderly men and women using the 4-compartment model as a criterion method, International journal of obesity and related metabolic disorders : journal of the International Association for the Study of Obesity 22(2) (1998) 135-42.

N. Schenker, L.G. Borrud, V.L. Burt, L.R. Curtin, K.M. Flegal, J. Hughes, et al., Multiple imputation of missing dual-energy X-ray absorptiometry data in the National Health and Nutrition Examination Survey, Statistics in medicine 30(3) (2011) 260-76.

D.A. Schoeller, F.A. Tylavsky, D.J. Baer, W.C. Chumlea, C.P. Earthman, T. Fuerst, et al., QDR 4500A dual-energy X-ray absorptiometer underestimates fat mass in comparison with criterion methods in adults, The American journal of clinical nutrition 81(5) (2005) 1018-25.

T.L. Kelly, K.E. Wilson, S.B. Heymsfield, Dual energy X-Ray absorptiometry body composition reference values from NHANES, PLoS One 4(9) (2009) e7038.

K.M. Flegal, T.J. Cole, Construction of LMS parameters for the Centers for Disease Control and Prevention 2000 growth charts, National health statistics reports (63) (2013) 1-3.

T.J. Cole, The LMS method for constructing normalized growth standards, European journal of clinical nutrition 44(1) (1990) 45-60.

C.L. Cheung, K.S. Lam, B.M. Cheung, Evaluation of Cutpoints for Low Lean Mass and Slow Gait Speed in Predicting Death in the National Health and Nutrition Examination Survey 1999-2004, The journals of gerontology. Series A, Biological sciences and medical sciences (2015).

R.R. McLean, D.P. Kiel, Developing consensus criteria for sarcopenia: an update, Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research 30(4) (2015) 588-92.

D. Sharma, M. Hawkins, M.K. Abramowitz, Association of sarcopenia with eGFR and misclassification of obesity in adults with CKD in the United States, Clinical journal of the American Society of Nephrology : CJASN 9(12) (2014) 2079-88.

R.N. Baumgartner, S.J. Wayne, D.L. Waters, I. Janssen, D. Gallagher, J.E. Morley, Sarcopenic obesity predicts instrumental activities of daily living disability in the elderly, Obesity research 12(12) (2004) 1995-2004.

C.Y. Hsu, C.E. McCulloch, C. Iribarren, J. Darbinian, A.S. Go, Body mass index and risk for end-stage renal disease, Ann Intern Med 144(1) (2006) 21-8.

A. Vivante, E. Golan, D. Tzur, A. Leiba, A. Tirosh, K. Skorecki, et al., Body mass index in 1.2 million adolescents and risk for end-stage renal disease, Archives of internal medicine 172(21) (2012) 1644-50.

M. Madero, R. Katz, R. Murphy, A. Newman, K. Patel, J. Ix, et al., Comparison between Different Measures of Body Fat with Kidney Function Decline and Incident CKD, Clinical journal of the American Society of Nephrology : CJASN 12(6) (2017) 893-903.

A.M. Silva, W. Shen, M. Heo, D. Gallagher, Z. Wang, L.B. Sardinha, et al., Ethnicity-Related Skeletal Muscle Differences Across the Lifespan, American journal of human biology : the official journal of the Human Biology Council 22(1) (2010) 76-82.

B. USRDS: Renal Data System (USRDS) Annual Data Report, MD, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 2008.

C.A. Peralta, R. Katz, I. DeBoer, J. Ix, M. Sarnak, H. Kramer, et al., Racial and Ethnic Differences in Kidney Function Decline among Persons without Chronic Kidney Disease, Journal of the American Society of Nephrology : JASN 22(7) (2011) 1327-1334.

A.B. Newman, V. Kupelian, M. Visser, E. Simonsick, B. Goodpaster, M. Nevitt, et al., Sarcopenia: alternative definitions and associations with lower extremity function, Journal of the American Geriatrics Society 51(11) (2003) 1602-9.

R.N. Foley, C. Wang, A. Ishani, A.J. Collins, A.M. Murray, Kidney function and sarcopenia in the United States general population: NHANES III, American journal of nephrology 27(3) (2007) 279-86.

S.J. Moon, T.H. Kim, S.Y. Yoon, J.H. Chung, H.-J. Hwang, Relationship between Stage of Chronic Kidney Disease and Sarcopenia in Korean Aged 40 Years and Older Using the Korea National Health and Nutrition Examination Surveys (KNHANES IV-2, 3, and V-1, 2), 2008–2011, PLoS ONE 10(6) (2015) e0130740.

J.P. Loenneke, P.D. Loprinzi, T. Abe, The prevalence of sarcopenia before and after correction for DXA-derived fat-free adipose tissue, European journal of clinical nutrition 70(12) (2016) 1458-1460.

J.S. Chew-Harris, C.M. Florkowski, P.M. George, J.L. Elmslie, Z.H. Endre, The relative effects of fat versus muscle mass on cystatin C and estimates of renal function in healthy young men, Annals of clinical biochemistry 50(Pt 1) (2013) 39-46.

M. Ketteler, G.A. Block, P. Evenepoel, M. Fukagawa, C.A. Herzog, L. McCann, et al., Executive summary of the 2017 KDIGO Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD) Guideline Update: what's changed and why it matters, Kidney international 92(1) (2017) 26-36.



  • There are currently no refbacks.