Validity of cachexia diagnosis using AWGC criteria in outpatients with chronic kidney disease undergoing hemodialysis

Validity of cachexia diagnosis using AWGC criteria in outpatients with chronic kidney disease undergoing hemodialysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Validity of cachexia diagnosis using AWGC criteria in outpatients with chronic kidney disease undergoing hemodialysis Takuma Yagi, Tatsuro Inoue, Masato Ogawa, Masatsugu Okamura, Kengo Shirado, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6634728/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: Cachexia worsens the long-term prognosis of patients with chronic kidney disease (CKD) receiving hemodialysis. The Asian Working Group for Cachexia (AWGC) has proposed diagnostic criteria tailored to Asian populations. In this study, we aimed to validate the AWGC criteria for diagnosing cachexia in patients with CKD receiving hemodialysis by focusing on prevalence, diagnostic accuracy, health-related quality of life (HRQoL), and instrumental activities of daily living (IADL). Methods: This cross-sectional study included 93 outpatients with CKD undergoing hemodialysis. Cachexia was diagnosed using the AWGC and Evans criteria. HRQoL was assessed using the European quality of life 5 dimensions 5-level (EQ-5D-5L), and IADL was evaluated using the Lawton IADL scale. Statistical analyses included sensitivity, specificity, and multiple regression to examine the associations between cachexia definitions, HRQoL, and IADL. Results: Cachexia prevalence was 30.1% according to the AWGC criteria and 24.7% by Evans criteria. All patients identified by the Evans criteria were also identified by the AWGC criteria. The AWGC criteria demonstrated superior diagnostic accuracy (κ = 0.865), with a sensitivity of 1.000 and specificity of 0.929. Associations of cachexia (as defined by each criterion) with HRQoL and IADL were similar. Conclusion: In contrast to the Evans criteria, the AWGC criteria demonstrated high validity and superior applicability for diagnosing cachexia in outpatients with CKD receiving hemodialysis. These findings highlight the practicality of the AWGC criteria. Their use may facilitate early detection and help prevent cachexia progression, thereby improving patient outcomes. hemodialysis cachexia Asian Working Group for Cachexia diagnostic accuracy chronic kidney disease Figures Figure 1 Figure 2 Figure 3 Figure 4 Key summary points Aim: To validate the diagnostic accuracy and clinical applicability of the Asian Working Group for Cachexia (AWGC) criteria in diagnosing cachexia among outpatients with chronic kidney disease receiving hemodialysis. Findings: The AWGC criteria identified more cases of cachexia than the Evans criteria, with significant diagnostic agreement (κ = 0.865), sensitivity (1.000), and specificity (0.929). Associations with health-related quality of life and instrumental activities of daily living were consistent across both criteria. Message: The AWGC criteria are valid, practical, and potentially more effective for early detection of cachexia in patients receiving hemodialysis. 1. Introduction Chronic kidney disease (CKD) is recognized as a public health issue associated with increased mortality, decreased quality of life (QoL), and rising healthcare costs [ 1 ]. As CKD progresses toward end-stage renal disease, renal replacement therapy becomes inevitable [ 2 ]. In 2010, individuals undergoing renal replacement therapy were reportedly 262 million globally, which is expected to rise to 543.9 million by 2030 [ 3 ]. Although renal replacement therapy improves survival, the 5-year survival rate for patients on hemodialysis or peritoneal dialysis is only 42.3%, demonstrating an exceptionally high mortality rate compared to the general population [ 4 ]. Cachexia is a complex metabolic syndrome associated with underlying diseases, such as CKD, and is characterized by muscle loss, with or without fat loss [ 5 ]. The international diagnostic criteria proposed by Evans et al. are commonly used for cachexia diagnosis [ 5 ]. Cachexia, as defined by the Evans criteria, affects 16% of patients with CKD on hemodialysis and negatively impacts their long-term prognosis [ 6 ]. However, Konishi et al. suggested that existing international criteria emphasizing body composition and muscle loss might underestimate cachexia in Asians owing to differences in body physique compared to the Western populations [ 7 ]. In 2023, the Asian Working Group for Cachexia (AWGC) released a consensus statement regarding the diagnostic criteria for cachexia in Asian populations [ 8 ]. However, the utility of AWGC criteria for diagnosing cachexia in patients with CKD undergoing hemodialysis remains invalidated. In the AWGC consensus statement, QoL and instrumental activities of daily living (IADL) were highlighted as critical clinical outcomes of cachexia [ 8 ]. Patient-reported outcomes, particularly QoL indicators, are increasingly recognized as essential and meaningful endpoints in the context of severe and treatment-resistant conditions such as cachexia [ 8 ]. Patients with CKD undergoing hemodialysis may experience decreased health-related QoL (HRQoL) owing to fatigue and malnutrition [ 9 ] and often experience a heavy burden of physical and psychological symptoms, often linked to lower HRQoL [ 10 ]. Additionally, IADL is used to assess advanced functional abilities in daily life beyond basic activities, requiring both cognitive and physical capabilities [ 11 ]. A cross-sectional study revealed that approximately 80% of patients with CKD undergoing hemodialysis had IADL dependence, with a higher degree of IADL dependence associated with lower HRQoL [ 12 ]. IADL and QoL are closely related, and a decline in IADL can directly lead to difficulties in independent living and a deterioration in QoL [ 12 ]. It is essential to investigate the relationship between cachexia, HRQoL, and IADL as key clinical outcomes for validating the diagnostic utility of the cachexia criteria. This study assessed cachexia using both the AWGC and Evans definitions, compared the diagnostic accuracy and prevalence of the AWGC criteria, and examined their associations with HRQoL and IADL, thereby evaluating the validity of diagnosing cachexia based on the AWGC criteria. 2. Methods 2.1 Participants This study was a single-center cross-sectional study conducted at Hattori Hospital in Hyogo, Japan. The survey was conducted from May to June 2022 and included outpatients with CKD undergoing hemodialysis three times per week at the hospital. According to data from the Japanese Society for Dialysis Therapy, this frequency of outpatient hemodialysis is the most common in Japan [ 13 ]. Inclusion criterion was consent to participate, while exclusion criteria included missing data and cognitive decline that hindered the ability to respond to the questionnaire. Written informed consent was obtained from all participants or their legal guardians. The study was approved by the ethics committee of Hattori Hospital (Hyogo, Japan) (Approval No. : 2022–02) and conducted in accordance with the principles of the 1964 Declaration of Helsinki and its later amendments. 2.2 Data collection We collected data on the following parameters: age, sex, height, weight (dry weight), body mass index (BMI), comorbidities (Charlson comorbidity index: CCI) [ 14 ], history of falls, blood biochemical data (albumin [Alb], C-reactive protein [CRP], hemoglobin [Hb], blood urea nitrogen [BUN], and creatinine [Cre]), and hemodialysis data (dialysis duration, dialysis time, and standardized dialysis dose [Kt/V]). Blood biochemical data were collected before dialysis. Fall history was evaluated using a questionnaire. Malnutrition risk was assessed using the geriatric nutritional risk index (GNRI) [ 15 ]. Falls were defined according to the Prevention of Falls Network Europe consensus criteria as a situation in which a person's body part other than the sole touched the floor or ground [ 16 ]. Physical function was assessed using the short physical performance battery (SPPB), which comprises three sub-items: standing balance test, walking test, and chair stand test. Each item is scored from 0 to 4 points, with a total of 0 to 12 points [ 17 ]. The standing test measures the holding times in closed-leg standing, semi-tandem standing, and tandem standing. The walking test measures the time required to walk 4 m at a normal walking speed. The chair stand test measures the time required to stand five times with maximum effort [ 17 ]. 2.3 Definition of cachexia Cachexia was diagnosed based on Evan's criteria, following the consensus guidelines for cachexia [ 5 ]. Evans diagnostic criteria for cachexia include the presence of chronic disease and either > 5% body weight loss within 12 months or BMI 0.5 mg/dL, Hb < 12.0 g/dL, Alb < 3.2 g/dL) [ 5 ]. Muscle strength was measured using a Smedley hand dynamometer (TKK5401, TAKEI, Niigata). Measurements were taken twice on each side for 3 seconds at maximum effort in a standing or sitting position, with the upper limb relaxed along the body, and the highest value was recorded. Based on the Asian Working Group for Sarcopenia (AWGS) 2019 definition, the cutoff values for decreased muscle strength were < 28 kg for men and < 18 kg for women, with values below these thresholds considered indicative of muscle weakness [ 18 ]. Fatigue was assessed using the revised Japanese Cardiovascular Health Study (J-CHF) criteria for frailty diagnosis, where individuals who experienced "feeling tired for no reason in the past two weeks" were classified as experiencing fatigue [ 19 ]. Anorexia was assessed using the simplified nutrition assessment questionnaire (SNAQ) [ 20 ], which comprises four appetite-related questions, each scored on a five-point scale (maximum 20 points in total). A cutoff score of ≤ 14 indicated anorexia [ 20 ]. Skeletal muscle mass was measured using dual-energy X-ray absorptiometry (DEXA) and calculated as appendicular skeletal muscle mass index (ASMI, kg/m²). The cutoff values were < 7.25 kg/m² for men and < 5.45 kg/m² for women, and values below these thresholds were defined as low muscle mass index [ 5 ]. The AWGC developed cachexia diagnostic criteria to establish a consensus on cachexia in the Asian population and its clinical outcomes [ 8 ]. Based on these criteria, cachexia was defined as the presence of chronic disease and either ≥ 2% weight loss over 3–6 months or BMI < 21 kg/m², with at least one of the following: anorexia, reduced grip strength (< 28 kg for men, 0.5 mg/dL. Anorexia was assessed using SNAQ. 2.4 Health-related quality of life (HR-QoL) HRQoL was assessed using the European Quality of Life 5 (EuroQoL 5) dimensions 5-level (EQ-5D-5L) [ 21 ], a standardized measure developed by the EuroQoL Group for clinical and economic evaluations and population health surveys [ 22 ]. The EQ-5D-5L comprises five dimensions: "mobility," "self-care," "usual activities," "pain/discomfort," and "anxiety/depression," with five levels each and with scores ranging from 0 (death) to 1 (perfect health). Scores were converted into an EQ-5D-5L index using the EQ-5D-5L index calculator downloaded from the EuroQoL website [ 23 ]. The index score ranges from 0.111 to 1, with higher values indicating better health status. The Japanese version of EQ-5D-5L has been validated and is reliable [ 24 ]. 2.5 IADL IADL was assessed using the Lawton IADL Scale [ 11 ], the most widely used measure for evaluating IADL in older adult populations. Lawton-IADL comprises eight items: "telephone use," "shopping," "meal preparation," "housekeeping," "laundry," "transportation use," "medication management," and "financial management" [ 11 ]. Each item was scored as 0 (unable or partially able to perform) or 1 (fully able to perform), with a total score ranging from 0 (low function, dependence) to 8 (high function, independence) [ 25 ]. 2.6 Statistical analysis Data are presented as mean standard deviation (SD) for parametric data and median (25–75% percentile) for non-parametric data. Comparisons between groups with and without cachexia were performed using t-tests, Mann–Whitney U tests, and χ² tests. Comparisons of EQ-5D scores based on the presence or absence of each cachexia criterion were conducted using t-tests and Mann–Whitney U tests. To assess the agreement between the AWGC and Evans criteria for cachexia diagnosis, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and Cohen’s kappa (κ) coefficient were calculated. Multiple regression analysis was performed with EQ-5D-5L and IADL as dependent variables and cachexia (AWGC and Evans) as explanatory variables. From a clinical perspective, age, sex, BMI, CCI, history of falls, Kt/V, and dialysis duration, were included as confounding factors in the regression model. Statistical significance was set at p < 0.05. All analyses were performed using EZR Ver.1.38 (Saitama Medical Center, Jichi Medical University, Saitama, Japan) [ 26 ], a graphical user interface for R (The R Foundation for Statistical Computing, Vienna, Austria). 3. Results A total of 119 outpatients with CKD were undergoing hemodialysis during the study period. Of these, 100 were included after excluding those who refused to participate (n = 19). Patients with missing data (n = 4) and cognitive impairment (n = 3) were excluded from the analysis. Finally, 93 patients were enrolled in the study (Fig. 1). The mean age of the participants was 69.4 ±11.0 years, and 46 patients (49.5%) were female. The median duration of outpatients with CKD undergoing hemodialysis was 6.3 years (interquartile range (IQR): 2.8–12.5), and the mean time per hemodialysis session was 3.9 ±0.4 h. Regarding nutritional status, the mean BMI was 23.0 ±4.5 kg/m², and 68.8% of patients were identified as being at risk of malnutrition based on GNRI (Table 1). [INSERT TABLE 1 HERE] The prevalence of cachexia was 28 patients (30.1%) according to the AWGC criteria and 23 patients (24.7%) according to the Evans criteria. All patients diagnosed with cachexia by the Evans criteria were also classified under the AWGC criteria (Fig. 2). Fig. 3 and 4 show the diagnostic criteria for AWGC and Evans criteria by individual components. Among the AWGC criteria, the mandatory requirement of BMI < 21 kg/m² was met by 31 patients (33.3%). In addition, the diagnostic criteria components included abnormal biochemistry in 3 patients (3.2%), decreased muscle strength in 24 patients (25.8%), and fatigue in 13 patients (14.0%). Among the Evans criteria, the mandatory requirement of BMI < 20 kg/m² was met by 24 patients (25.8%). The diagnostic criteria components included abnormal biochemistry in 21 patients (22.6%), anorexia in 11.8% (11 patients), decreased muscle strength in 21 patients (22.6%), low fat-free mass index in 18 patients (19.4%), and fatigue in 13 patients (14.0%). The diagnostic accuracy parameters of the AWGC criteria compared to the Evans criteria were as follows: sensitivity 1.00 (95% confidence interval [CI]: 0.79–1.00), specificity 0.93 (95% CI: 0.84–0.98), PPV 0.82 (95% CI: 0.63–0.94), and NPV 1.00 (95% CI: 0.92–1.00). In addition, the kappa coefficient (κ) was 0.87 (95% CI: 0.75–0.98) (Table 2). [INSERT TABLE 2 HERE] Table 3 presents a comparison of participants with and without cachexia diagnosed by the AWGC and Evans criteria. Participants diagnosed with cachexia by both criteria were significantly older ( p < 0.001) and had significantly lower BMI ( p < 0.001), creatinine ( p = 0.004 vs. 0.002), ASM ( p = 0.004 vs. 0.019), and ASMI ( p < 0.001 vs. 0.004). Moreover, malnutrition risk was higher in participants with cachexia than in those without ( p < 0.001 vs. 0.028). Handgrip strength ( p < 0.001), walking speed ( p = 0.002 vs. < 0.001), and SPPB ( p < 0.001) were significantly lower in the cachexia group than in the non-cachexia group. [INSERT TABLE 3 HERE] Table 4 presents the comparison of EQ-5D-5L and IADL scores between patients with and without cachexia according to the AWGC and Evans criteria. In the AWGC criteria, EQ-5D ( p < 0.001) and IADL ( p = 0.006) were significantly lower in the cachexia group than in the non-cachexia group. Similarly, in the Evans criteria, EQ-5D ( p < 0.001) and IADL ( p = 0.001) were significantly lower in the cachexia group than in the non-cachexia group. [INSERT TABLE 4 HERE] Table S1 presents comparisons between patients with cachexia diagnosed by the AWGC criteria alone and those diagnosed by both the AWGC and Evans criteria. No significant differences existed between the groups in EQ-5D-5L (0.83 vs. 0.72, p = 0.126) or IADL (8.0 vs. 7.0, p = 0.198). Table 5 presents the results of multiple regression analysis for EQ-5D-5L. In the AWGC criteria, cachexia (β = -0.099, p = 0.005) and age (β = -0.003, p = 0.023) were independently associated with EQ-5D-5L (R² = 0.26). Similarly, in the Evans criteria, cachexia (β = -0.112, p = 0.003) and age (β = -0.003, p = 0.024) were independently associated with EQ-5D-5L (R² = 0.27). These results were consistent between the AWGC and Evans criteria. [INSERT TABLE 5 HERE] Table 6 presents the results of multiple regression analysis for IADL. According to the AWGC criteria, cachexia (β = -0.894, p = 0.019), age (β = -0.047, p = 0.004), and Kt/V (β = 2.211, p = 0.008) were independently associated with IADL (R² = 0.30). Similarly, using the Evans criteria, cachexia (β = -1.102, p = 0.005), age (β = -0.045, p = 0.006), and Kt/V (β = 2.182, p = 0.008) showed similar associations (R² = 0.31). The consistency of these findings across both criteria reinforces the robustness of the observed relationships. [INSERT TABLE 6 HERE] 4. Discussion This study evaluated two definitions of cachexia based on the AWGC criteria and Evans criteria, in outpatients with CKD undergoing hemodialysis. We compared the diagnostic accuracy of the AWGC criteria, the prevalence of cachexia, and its association with HRQoL and IADL. The AWGC criteria had higher diagnostic accuracy than the Evans criteria, and its associations with HRQoL and IADL were nearly identical. These findings indicate the potential of the AWGC criteria and suggest that its ease of clinical application may facilitate early detection and prevention of cachexia progression in outpatients with CKD undergoing hemodialysis. Among outpatients with CKD undergoing hemodialysis, those diagnosed with cachexia according to the Evans criteria were invariably identified by the AWGC criteria. The AWGC criteria demonstrated a high level of agreement with the Evans criteria, showing a well-balanced sensitivity and specificity. These findings suggest that the AWGC criteria may serve as a reliable indicator for diagnosing cachexia. These results suggest that the AWGC criteria exhibit high concordance with the Evans criteria, highlighting their use in cachexia diagnosis. Moreover, the AWGC criteria demonstrated high sensitivity in detecting cachexia while maintaining high accuracy in identifying non-cachectic cases. The relatively high PPV and extremely high NPV further support the reliability of the AWGC criteria as a diagnostic tool closely aligned with the Evans criteria. As the AWGC criteria comprise anorexia, decreased handgrip strength, and abnormal CRP they enable a simple and convenient assessment of cachexia. Considering their ease of clinical implementation, the AWGC criteria may facilitate convenient detection and timely intervention for cachexia in outpatients with CKD undergoing hemodialysis. Cachexia prevalence among outpatients with CKD undergoing hemodialysis was 30.1% using the AWGC criteria and 24.7% using the Evans criteria. In a previous study on Japanese outpatients with CKD undergoing hemodialysis, the prevalence of cachexia was reported as 21.3% using the Evans criteria and 35.2% using the AWGC criteria [ 17 ]. Our findings are comparable to those of the previous study, suggesting consistency across different definitions. Prevalence of cachexia determined by the AWGC criteria was higher than that determined by the Evans criteria. This discrepancy may be attributed to the BMI threshold difference, where the Evans criteria use BMI < 20 kg/m², while the AWGC criteria use BMI < 21 kg/m². Moreover, the AWGC criteria do not include muscle mass assessment or fatigue evaluation. These factors may have contributed to the higher prevalence of cachexia when using the AWGC criteria. The discrepancies between our study and previous studies may be attributed to differences in muscle mass assessment methods. While the previous study used the modified creatinine index to assess muscle mass, our study employed DEXA to calculate the skeletal muscle mass index. Given that cachexia is characterized by muscle mass loss [ 5 ], variations in assessment methods may yield different results despite applying the same cachexia definitions. Consequently, this factor should be carefully considered in future studies. The clinical significance of this study is that the AWGC criteria provide a simple and highly sensitive diagnostic tool for cachexia, enabling convenient diagnosis, risk stratification, and timely intervention in patients with CKD undergoing hemodialysis. The AWGC criteria utilize standardized and easily assessable indicators, such as CRP and handgrip strength [ 8 ], facilitating practical application in clinical settings. In this study, the AWGC criteria included all patients diagnosed with cachexia by the Evans criteria and additionally identified those with mild cachexia. Cachexia involves multiple factors and significantly worsens patient prognosis [ 6 ]. Appropriate assessment of patients with CKD and early intervention are essential in clinical practice for improving patient outcomes [ 6 ]. The AWGC criteria allow for the identification of mild cachexia cases not detected by the Evans criteria, thereby enabling early intervention. Additionally, HRQoL and IADL are critical clinical outcomes of cachexia [ 8 ], and in this study, cachexia diagnosed by the AWGC criteria was significantly associated with decreased HRQoL and IADL. In a previous study, patients undergoing hemodialysis had lower health-related QoL than pre-hemodialysis and kidney transplant patients [ 9 ]. Moreover, hemodialysis has been reported to affect HRQoL physically, psychologically, and socially [ 27 ]. Furthermore, patients with CKD undergoing hemodialysis are associated with a decline in IADL and ADL [ 28 ]. It has been reported that up to 50% of older patients with CKD undergoing hemodialysis experience impairments in ADL and IADL [ 29 ]. These findings underscore the prognostic value of the AWGC criteria. Further studies are warranted to examine the long-term impact of cachexia diagnosis using the AWGC criteria on patient outcomes. This study has some limitations. First, as an observational study conducted at a single center, the generalizability of the results may be limited. Therefore, multicenter collaborative studies should determine whether similar findings can be obtained in different clinical settings. Second, the relatively small sample size resulted in low coefficients of determination, leading to a lower goodness-of-fit in multiple regression analyses. Future studies with larger sample sizes should explore additional confounding factors. Third, this study was cross-sectional, which does not allow for causal inferences. Therefore, more detailed longitudinal studies are warranted. 5. Conclusion Our findings showed that the AWGC criteria demonstrated higher diagnostic accuracy than the Evans criteria, with nearly identical associations with HRQoL and IADL. These findings suggest the usefulness of the AWGC criteria, and considering their ease of clinical application, they may facilitate the convenient detection of cachexia and help prevent its progression in outpatients with CKD undergoing hemodialysis. Declarations Acknowledgments We would like to express our gratitude to the members of the Rehabilitation Nutrition Laboratory for their cooperation in this study. Funding Statement This study received no specific grants from public, commercial, or non-profit funding agencies. Conflict of Interest The authors declare no conflicts of interest related to the content of this article. Author Contributions T.Y., S.K., T.K., Y.I., Y.H., N.T., R.O., and S.N. conceived the idea of the study. T.Y. and T.I. developed the statistical analysis plan and conducted statistical analyses. T.Y., T.I., M.O., M.O., K.S., N.S., and S.I. contributed to the interpretation of the results. T.Y., T.I., M.O., M.O., and S.I. drafted the original manuscript. S.N. supervised the conduct of this study. All authors reviewed the manuscript draft and revised it critically on intellectual content. All authors approved the final version of the manuscript to be published. Declaration of Generative AI and AI-Assisted technologies in the writing process Ethical Guidelines Statement Informed consent was obtained from all participants or their legal guardians. This study was approved by the Ethics Committee of Hattori Hospital (Hyogo, Japan) (Approval No: 2022 –02). The study was conducted in accordance with the principles of the Declaration of Helsinki. 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Tables Tables 1 to 6 are available in the Supplementary Files section Supplementary Files SupportingInformation.docx QRBFM22Table1.docx QRBFM22Table2.docx QRBFM22Table3.docx QRBFM22Table4.docx QRBFM22Table5.docx QRBFM22Table6.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6634728","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":455620479,"identity":"5935ccfb-ecd0-47e0-9e35-222a17419e0c","order_by":0,"name":"Takuma Yagi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA90lEQVRIiWNgGAWjYJACCSBmnMHM2HD4TwWQyczcgFc5D0jLAZAWdubGAzxnQFoYidXCz958gLcNJEZAiz372YO3P9TckZ3ZzNhwQHJebTR/O1DLj4ptuG3hyUu2OHDsmfFsoHsOGG47njvjMGMDY8+Z23gclmMmcYDtcOI8kJbEbcdyG4BamBnb8GjhfwPU8g+q5eCcY7nzCWqRANpysO1wIshhBxsbanI3ENRy442xxdm+w8Yg7x9mOHYgdyNQy0F8fmHvzzG8UfHtsOyM88cff2aoqcudd/7wwQc/KnBrQQeHweQBotUDQR0pikfBKBgFo2CEAAByyWQT5x9qjwAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0002-7569-6095","institution":"Hattori Hospital","correspondingAuthor":true,"prefix":"","firstName":"Takuma","middleName":"","lastName":"Yagi","suffix":""},{"id":455620480,"identity":"8ac5e5be-a725-44d5-97f3-cea0c569ac9b","order_by":1,"name":"Tatsuro Inoue","email":"","orcid":"","institution":"Niigata University of Health and Welfare: Niigata Iryo Fukushi Daigaku","correspondingAuthor":false,"prefix":"","firstName":"Tatsuro","middleName":"","lastName":"Inoue","suffix":""},{"id":455620481,"identity":"92b35e3c-6edc-4f2e-97ca-a72cf44d7940","order_by":2,"name":"Masato Ogawa","email":"","orcid":"","institution":"Kobe University: Kobe Daigaku","correspondingAuthor":false,"prefix":"","firstName":"Masato","middleName":"","lastName":"Ogawa","suffix":""},{"id":455620482,"identity":"adee224b-5979-4411-8dda-1722404a7c7b","order_by":3,"name":"Masatsugu Okamura","email":"","orcid":"","institution":"Charité Universitätsmedizin Berlin: Charite Universitatsmedizin Berlin","correspondingAuthor":false,"prefix":"","firstName":"Masatsugu","middleName":"","lastName":"Okamura","suffix":""},{"id":455620483,"identity":"79ec99b3-9fd8-4095-907e-22f871c6d5ad","order_by":4,"name":"Kengo Shirado","email":"","orcid":"","institution":"Iizuka Hospital: Iizuka Byoin","correspondingAuthor":false,"prefix":"","firstName":"Kengo","middleName":"","lastName":"Shirado","suffix":""},{"id":455620484,"identity":"da42f64f-a3f5-4ff8-9822-e780be05847e","order_by":5,"name":"Nobuyuki Shirai","email":"","orcid":"","institution":"Niigata Rinko Hospital","correspondingAuthor":false,"prefix":"","firstName":"Nobuyuki","middleName":"","lastName":"Shirai","suffix":""},{"id":455620485,"identity":"d79b1ee4-fe35-4511-bfed-335ccc3bfc40","order_by":6,"name":"Shuji Konishi","email":"","orcid":"","institution":"Hattori Hospital","correspondingAuthor":false,"prefix":"","firstName":"Shuji","middleName":"","lastName":"Konishi","suffix":""},{"id":455620486,"identity":"5341106d-ed42-4295-874a-a431bcf20b78","order_by":7,"name":"Takashi Koshiba","email":"","orcid":"","institution":"Hattroi Hospital","correspondingAuthor":false,"prefix":"","firstName":"Takashi","middleName":"","lastName":"Koshiba","suffix":""},{"id":455620487,"identity":"43fa6729-f5ef-4f45-ba6a-3bfdf8e373e8","order_by":8,"name":"Yuichiro Ishigaki","email":"","orcid":"","institution":"Hattori Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yuichiro","middleName":"","lastName":"Ishigaki","suffix":""},{"id":455620488,"identity":"11ea1001-5933-4eac-b56f-a5bdc5d9233e","order_by":9,"name":"Yasunori Heguri","email":"","orcid":"","institution":"Hattori Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yasunori","middleName":"","lastName":"Heguri","suffix":""},{"id":455620489,"identity":"8baf60ef-df63-43d2-9c3b-ef4df728c5cc","order_by":10,"name":"Naoki Tanimiya","email":"","orcid":"","institution":"Hattori 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12:21:31","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6634728/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6634728/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82888436,"identity":"61b95dcb-5f54-4829-bde5-65e1e77ccb3a","added_by":"auto","created_at":"2025-05-16 12:02:24","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":29490,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart showing the patient selection criteria, inclusion, and follow-up of participants\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6634728/v1/b73a5200533ef25911f6e62e.png"},{"id":82892194,"identity":"88dc714c-d825-441e-b767-f9ed30db1ed4","added_by":"auto","created_at":"2025-05-16 12:18:24","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":35909,"visible":true,"origin":"","legend":"\u003cp\u003ePrevalence of cachexia according to AWGC and Evans criteria\u003c/p\u003e\n\u003cp\u003eAWGC: Asian Working Group for Cachexia, BMI: body mass index, CRP: C-reactive protein\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6634728/v1/bb3488958a5bde3d75ca6f32.png"},{"id":82886775,"identity":"87ef2c5d-97f9-434f-a7bf-a42993a10ff3","added_by":"auto","created_at":"2025-05-16 11:54:24","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":13802,"visible":true,"origin":"","legend":"\u003cp\u003eThe prevalence of each diagnostic criterion item for cachexia according to AWGC\u003c/p\u003e\n\u003cp\u003eBMI: body mass index, CRP: C-reactive protein\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6634728/v1/90d388f2bd27a11992abceae.png"},{"id":82886774,"identity":"52d1a5e3-0c8d-4ab9-989e-4ed026a8d3c4","added_by":"auto","created_at":"2025-05-16 11:54:24","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":14658,"visible":true,"origin":"","legend":"\u003cp\u003eThe prevalence of each diagnostic criterion item for cachexia according to Evans\u003c/p\u003e\n\u003cp\u003eBMI: body mass index\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6634728/v1/e878146d30077ef7aa5308b9.png"},{"id":93325047,"identity":"c418dbee-65bd-4fe0-b0c4-6584dcfce1b6","added_by":"auto","created_at":"2025-10-12 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11:54:24","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":18904,"visible":true,"origin":"","legend":"","description":"","filename":"QRBFM22Table1.docx","url":"https://assets-eu.researchsquare.com/files/rs-6634728/v1/8f9b134fa829f6083cbbb069.docx"},{"id":82890742,"identity":"408e7aac-f89e-4d92-acdf-976849da6c5e","added_by":"auto","created_at":"2025-05-16 12:10:24","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":15369,"visible":true,"origin":"","legend":"","description":"","filename":"QRBFM22Table2.docx","url":"https://assets-eu.researchsquare.com/files/rs-6634728/v1/7a909c93db9f51c77bed869e.docx"},{"id":82886777,"identity":"b0c5e4f1-bbaa-474b-9091-221101167f1b","added_by":"auto","created_at":"2025-05-16 11:54:24","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":22144,"visible":true,"origin":"","legend":"","description":"","filename":"QRBFM22Table3.docx","url":"https://assets-eu.researchsquare.com/files/rs-6634728/v1/1157e478522a363c39a84f43.docx"},{"id":82886782,"identity":"ea2c0e06-5d60-4607-8575-090bf17627e8","added_by":"auto","created_at":"2025-05-16 11:54:24","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":20752,"visible":true,"origin":"","legend":"","description":"","filename":"QRBFM22Table4.docx","url":"https://assets-eu.researchsquare.com/files/rs-6634728/v1/e9fcb094a4a79eb0878f41c6.docx"},{"id":82890748,"identity":"43c1b7dd-c0a4-4b76-b544-eb0f277b3fb7","added_by":"auto","created_at":"2025-05-16 12:10:24","extension":"docx","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":17619,"visible":true,"origin":"","legend":"","description":"","filename":"QRBFM22Table5.docx","url":"https://assets-eu.researchsquare.com/files/rs-6634728/v1/6ace3c892ce0c489ece5e796.docx"},{"id":82886781,"identity":"712d457b-af6f-46fd-ab6e-7cef5632303e","added_by":"auto","created_at":"2025-05-16 11:54:24","extension":"docx","order_by":7,"title":"","display":"","copyAsset":false,"role":"supplement","size":17420,"visible":true,"origin":"","legend":"","description":"","filename":"QRBFM22Table6.docx","url":"https://assets-eu.researchsquare.com/files/rs-6634728/v1/56c955d21fb991da73cbb7b7.docx"}],"financialInterests":"","formattedTitle":"Validity of cachexia diagnosis using AWGC criteria in outpatients with chronic kidney disease undergoing hemodialysis","fulltext":[{"header":"Key summary points","content":"\u003cp\u003e\u003cstrong\u003eAim:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo validate the diagnostic accuracy and clinical applicability of the Asian Working Group for Cachexia (AWGC) criteria in diagnosing cachexia among outpatients with chronic kidney disease receiving hemodialysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFindings:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe AWGC criteria identified more cases of cachexia than the Evans criteria, with significant diagnostic agreement (κ = 0.865), sensitivity (1.000), and specificity (0.929). Associations with health-related quality of life and instrumental activities of daily living were consistent across both criteria.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMessage:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe AWGC criteria are valid, practical, and potentially more effective for early detection of cachexia in patients receiving hemodialysis.\u003c/p\u003e"},{"header":"1. Introduction","content":"\u003cp\u003eChronic kidney disease (CKD) is recognized as a public health issue associated with increased mortality, decreased quality of life (QoL), and rising healthcare costs [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. As CKD progresses toward end-stage renal disease, renal replacement therapy becomes inevitable [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In 2010, individuals undergoing renal replacement therapy were reportedly 262\u0026nbsp;million globally, which is expected to rise to 543.9\u0026nbsp;million by 2030 [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Although renal replacement therapy improves survival, the 5-year survival rate for patients on hemodialysis or peritoneal dialysis is only 42.3%, demonstrating an exceptionally high mortality rate compared to the general population [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCachexia is a complex metabolic syndrome associated with underlying diseases, such as CKD, and is characterized by muscle loss, with or without fat loss [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The international diagnostic criteria proposed by Evans et al. are commonly used for cachexia diagnosis [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Cachexia, as defined by the Evans criteria, affects 16% of patients with CKD on hemodialysis and negatively impacts their long-term prognosis [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, Konishi et al. suggested that existing international criteria emphasizing body composition and muscle loss might underestimate cachexia in Asians owing to differences in body physique compared to the Western populations [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In 2023, the Asian Working Group for Cachexia (AWGC) released a consensus statement regarding the diagnostic criteria for cachexia in Asian populations [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. However, the utility of AWGC criteria for diagnosing cachexia in patients with CKD undergoing hemodialysis remains invalidated.\u003c/p\u003e \u003cp\u003eIn the AWGC consensus statement, QoL and instrumental activities of daily living (IADL) were highlighted as critical clinical outcomes of cachexia [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Patient-reported outcomes, particularly QoL indicators, are increasingly recognized as essential and meaningful endpoints in the context of severe and treatment-resistant conditions such as cachexia [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Patients with CKD undergoing hemodialysis may experience decreased health-related QoL (HRQoL) owing to fatigue and malnutrition [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] and often experience a heavy burden of physical and psychological symptoms, often linked to lower HRQoL [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Additionally, IADL is used to assess advanced functional abilities in daily life beyond basic activities, requiring both cognitive and physical capabilities [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. A cross-sectional study revealed that approximately 80% of patients with CKD undergoing hemodialysis had IADL dependence, with a higher degree of IADL dependence associated with lower HRQoL [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. IADL and QoL are closely related, and a decline in IADL can directly lead to difficulties in independent living and a deterioration in QoL [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. It is essential to investigate the relationship between cachexia, HRQoL, and IADL as key clinical outcomes for validating the diagnostic utility of the cachexia criteria.\u003c/p\u003e \u003cp\u003eThis study assessed cachexia using both the AWGC and Evans definitions, compared the diagnostic accuracy and prevalence of the AWGC criteria, and examined their associations with HRQoL and IADL, thereby evaluating the validity of diagnosing cachexia based on the AWGC criteria.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Participants\u003c/h2\u003e \u003cp\u003eThis study was a single-center cross-sectional study conducted at Hattori Hospital in Hyogo, Japan. The survey was conducted from May to June 2022 and included outpatients with CKD undergoing hemodialysis three times per week at the hospital. According to data from the Japanese Society for Dialysis Therapy, this frequency of outpatient hemodialysis is the most common in Japan [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Inclusion criterion was consent to participate, while exclusion criteria included missing data and cognitive decline that hindered the ability to respond to the questionnaire. Written informed consent was obtained from all participants or their legal guardians. The study was approved by the ethics committee of Hattori Hospital (Hyogo, Japan) (Approval No. : 2022\u0026ndash;02) and conducted in accordance with the principles of the 1964 Declaration of Helsinki and its later amendments.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Data collection\u003c/h2\u003e \u003cp\u003eWe collected data on the following parameters: age, sex, height, weight (dry weight), body mass index (BMI), comorbidities (Charlson comorbidity index: CCI) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], history of falls, blood biochemical data (albumin [Alb], C-reactive protein [CRP], hemoglobin [Hb], blood urea nitrogen [BUN], and creatinine [Cre]), and hemodialysis data (dialysis duration, dialysis time, and standardized dialysis dose [Kt/V]). Blood biochemical data were collected before dialysis. Fall history was evaluated using a questionnaire. Malnutrition risk was assessed using the geriatric nutritional risk index (GNRI) [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Falls were defined according to the Prevention of Falls Network Europe consensus criteria as a situation in which a person's body part other than the sole touched the floor or ground [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Physical function was assessed using the short physical performance battery (SPPB), which comprises three sub-items: standing balance test, walking test, and chair stand test. Each item is scored from 0 to 4 points, with a total of 0 to 12 points [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The standing test measures the holding times in closed-leg standing, semi-tandem standing, and tandem standing. The walking test measures the time required to walk 4 m at a normal walking speed. The chair stand test measures the time required to stand five times with maximum effort [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Definition of cachexia\u003c/h2\u003e \u003cp\u003eCachexia was diagnosed based on Evan's criteria, following the consensus guidelines for cachexia [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Evans diagnostic criteria for cachexia include the presence of chronic disease and either \u0026gt;\u0026thinsp;5% body weight loss within 12 months or BMI\u0026thinsp;\u0026lt;\u0026thinsp;20 kg/m\u0026sup2;, plus at least three of the following five criteria: (1) decreased muscle strength, (2) fatigue, (3) anorexia, (4) low fat-free mass, or (5) abnormal biochemical markers (CRP\u0026thinsp;\u0026gt;\u0026thinsp;0.5 mg/dL, Hb\u0026thinsp;\u0026lt;\u0026thinsp;12.0 g/dL, Alb\u0026thinsp;\u0026lt;\u0026thinsp;3.2 g/dL) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Muscle strength was measured using a Smedley hand dynamometer (TKK5401, TAKEI, Niigata). Measurements were taken twice on each side for 3 seconds at maximum effort in a standing or sitting position, with the upper limb relaxed along the body, and the highest value was recorded. Based on the Asian Working Group for Sarcopenia (AWGS) 2019 definition, the cutoff values for decreased muscle strength were \u0026lt;\u0026thinsp;28 kg for men and \u0026lt;\u0026thinsp;18 kg for women, with values below these thresholds considered indicative of muscle weakness [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Fatigue was assessed using the revised Japanese Cardiovascular Health Study (J-CHF) criteria for frailty diagnosis, where individuals who experienced \"feeling tired for no reason in the past two weeks\" were classified as experiencing fatigue [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Anorexia was assessed using the simplified nutrition assessment questionnaire (SNAQ) [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], which comprises four appetite-related questions, each scored on a five-point scale (maximum 20 points in total). A cutoff score of \u0026le;\u0026thinsp;14 indicated anorexia [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Skeletal muscle mass was measured using dual-energy X-ray absorptiometry (DEXA) and calculated as appendicular skeletal muscle mass index (ASMI, kg/m\u0026sup2;). The cutoff values were \u0026lt;\u0026thinsp;7.25 kg/m\u0026sup2; for men and \u0026lt;\u0026thinsp;5.45 kg/m\u0026sup2; for women, and values below these thresholds were defined as low muscle mass index [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe AWGC developed cachexia diagnostic criteria to establish a consensus on cachexia in the Asian population and its clinical outcomes [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Based on these criteria, cachexia was defined as the presence of chronic disease and either \u0026ge;\u0026thinsp;2% weight loss over 3\u0026ndash;6 months or BMI\u0026thinsp;\u0026lt;\u0026thinsp;21 kg/m\u0026sup2;, with at least one of the following: anorexia, reduced grip strength (\u0026lt;\u0026thinsp;28 kg for men, \u0026lt; 18 kg for women), or CRP\u0026thinsp;\u0026gt;\u0026thinsp;0.5 mg/dL. Anorexia was assessed using SNAQ.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Health-related quality of life (HR-QoL)\u003c/h2\u003e \u003cp\u003eHRQoL was assessed using the European Quality of Life 5 (EuroQoL 5) dimensions 5-level (EQ-5D-5L) [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], a standardized measure developed by the EuroQoL Group for clinical and economic evaluations and population health surveys [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The EQ-5D-5L comprises five dimensions: \"mobility,\" \"self-care,\" \"usual activities,\" \"pain/discomfort,\" and \"anxiety/depression,\" with five levels each and with scores ranging from 0 (death) to 1 (perfect health). Scores were converted into an EQ-5D-5L index using the EQ-5D-5L index calculator downloaded from the EuroQoL website [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The index score ranges from 0.111 to 1, with higher values indicating better health status. The Japanese version of EQ-5D-5L has been validated and is reliable [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 IADL\u003c/h2\u003e \u003cp\u003eIADL was assessed using the Lawton IADL Scale [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], the most widely used measure for evaluating IADL in older adult populations. Lawton-IADL comprises eight items: \"telephone use,\" \"shopping,\" \"meal preparation,\" \"housekeeping,\" \"laundry,\" \"transportation use,\" \"medication management,\" and \"financial management\" [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Each item was scored as 0 (unable or partially able to perform) or 1 (fully able to perform), with a total score ranging from 0 (low function, dependence) to 8 (high function, independence) [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Statistical analysis\u003c/h2\u003e \u003cp\u003eData are presented as mean standard deviation (SD) for parametric data and median (25\u0026ndash;75% percentile) for non-parametric data. Comparisons between groups with and without cachexia were performed using t-tests, Mann\u0026ndash;Whitney U tests, and χ\u0026sup2; tests. Comparisons of EQ-5D scores based on the presence or absence of each cachexia criterion were conducted using t-tests and Mann\u0026ndash;Whitney U tests.\u003c/p\u003e \u003cp\u003eTo assess the agreement between the AWGC and Evans criteria for cachexia diagnosis, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and Cohen\u0026rsquo;s kappa (κ) coefficient were calculated.\u003c/p\u003e \u003cp\u003eMultiple regression analysis was performed with EQ-5D-5L and IADL as dependent variables and cachexia (AWGC and Evans) as explanatory variables. From a clinical perspective, age, sex, BMI, CCI, history of falls, Kt/V, and dialysis duration, were included as confounding factors in the regression model. Statistical significance was set at \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003cp\u003eAll analyses were performed using EZR Ver.1.38 (Saitama Medical Center, Jichi Medical University, Saitama, Japan) [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], a graphical user interface for R (The R Foundation for Statistical Computing, Vienna, Austria).\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eA total of 119 outpatients with CKD were undergoing hemodialysis during the study period. Of these, 100 were included after excluding those who refused to participate (n = 19). Patients with missing data (n = 4) and cognitive impairment (n = 3) were excluded from the analysis. Finally, 93 patients were enrolled in the study (Fig. 1).\u003c/p\u003e\n\u003cp\u003eThe mean age of the participants was 69.4\u0026nbsp;±11.0 years, and 46 patients (49.5%) were female. The median duration of outpatients with CKD undergoing hemodialysis was 6.3 years (interquartile range (IQR): 2.8–12.5), and the mean time per hemodialysis session was 3.9\u0026nbsp;±0.4 h. Regarding nutritional status, the mean BMI was 23.0\u0026nbsp;±4.5 kg/m², and 68.8% of patients were identified as being at risk of malnutrition based on GNRI (Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e[INSERT TABLE 1 HERE]\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe prevalence of cachexia was 28 patients (30.1%) according to the AWGC criteria and 23 patients (24.7%) according to the Evans criteria. All patients diagnosed with cachexia by the Evans criteria were also classified under the AWGC criteria (Fig. 2).\u003c/p\u003e\n\u003cp\u003eFig. 3 and 4 show the diagnostic criteria for AWGC and Evans criteria by individual components. Among the AWGC criteria, the mandatory requirement of BMI \u0026lt; 21 kg/m² was met by 31 patients (33.3%). In addition, the diagnostic criteria components included abnormal biochemistry in 3 patients (3.2%), decreased muscle strength in 24 patients (25.8%), and fatigue in 13 patients (14.0%). Among the Evans criteria, the mandatory requirement of BMI \u0026lt; 20 kg/m² was met by 24 patients (25.8%). The diagnostic criteria components included abnormal biochemistry in 21 patients (22.6%), anorexia in 11.8% (11 patients), decreased muscle strength in 21 patients (22.6%), low fat-free mass index in 18 patients (19.4%), and fatigue in 13 patients (14.0%).\u003c/p\u003e\n\u003cp\u003eThe diagnostic accuracy parameters of the AWGC criteria compared to the Evans criteria were as follows: sensitivity 1.00 (95% confidence interval [CI]: 0.79–1.00), specificity 0.93 (95% CI: 0.84–0.98), PPV 0.82 (95% CI: 0.63–0.94), and NPV 1.00 (95% CI: 0.92–1.00). In addition, the kappa coefficient (κ) was 0.87 (95% CI: 0.75–0.98) (Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e[INSERT TABLE 2 HERE]\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 3 presents a comparison of participants with and without cachexia diagnosed by the AWGC and Evans criteria. Participants diagnosed with cachexia by both criteria were significantly older (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001) and had significantly lower BMI (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001), creatinine (\u003cem\u003ep\u003c/em\u003e = 0.004 vs. 0.002), ASM (\u003cem\u003ep\u003c/em\u003e = 0.004 vs. 0.019), and ASMI (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001 vs. 0.004). Moreover, malnutrition risk was higher in participants with cachexia than in those without (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001 vs. 0.028). Handgrip strength (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001), walking speed (\u003cem\u003ep\u003c/em\u003e = 0.002 vs. \u0026lt; 0.001), and SPPB (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001) were significantly lower in the cachexia group than in the non-cachexia group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e[INSERT TABLE 3 HERE]\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 4 presents the comparison of EQ-5D-5L and IADL scores between patients with and without cachexia according to the AWGC and Evans criteria. In the AWGC criteria, EQ-5D (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001) and IADL (\u003cem\u003ep\u003c/em\u003e = 0.006) were significantly lower in the cachexia group than in the non-cachexia group. Similarly, in the Evans criteria, EQ-5D (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001) and IADL (\u003cem\u003ep\u003c/em\u003e = 0.001) were significantly lower in the cachexia group than in the non-cachexia group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e[INSERT TABLE 4 HERE]\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable S1 presents comparisons between patients with cachexia diagnosed by the AWGC criteria alone and those diagnosed by both the AWGC and Evans criteria. No significant differences existed between the groups in EQ-5D-5L (0.83 vs. 0.72, \u003cem\u003ep\u003c/em\u003e = 0.126) or IADL (8.0 vs. 7.0, \u003cem\u003ep\u003c/em\u003e = 0.198).\u003c/p\u003e\n\u003cp\u003eTable 5 presents the results of multiple regression analysis for EQ-5D-5L. In the AWGC criteria, cachexia (β = -0.099, \u003cem\u003ep\u003c/em\u003e = 0.005) and age (β = -0.003, \u003cem\u003ep\u003c/em\u003e = 0.023) were independently associated with EQ-5D-5L (R² = 0.26). Similarly, in the Evans criteria, cachexia (β = -0.112, \u003cem\u003ep\u003c/em\u003e = 0.003) and age (β = -0.003, \u003cem\u003ep\u003c/em\u003e = 0.024) were independently associated with EQ-5D-5L (R² = 0.27). These results were consistent between the AWGC and Evans criteria.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e[INSERT TABLE 5 HERE]\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 6 presents the results of multiple regression analysis for IADL. According to the AWGC criteria, cachexia (β = -0.894, \u003cem\u003ep\u003c/em\u003e = 0.019), age (β = -0.047, \u003cem\u003ep\u003c/em\u003e = 0.004), and Kt/V (β = 2.211, \u003cem\u003ep\u003c/em\u003e = 0.008) were independently associated with IADL (R² = 0.30). Similarly, using the Evans criteria, cachexia (β = -1.102, \u003cem\u003ep\u003c/em\u003e = 0.005), age (β = -0.045, \u003cem\u003ep\u003c/em\u003e = 0.006), and Kt/V (β = 2.182, \u003cem\u003ep\u003c/em\u003e = 0.008) showed similar associations (R² = 0.31).\u0026nbsp; The consistency of these findings across both criteria reinforces the robustness of the observed relationships.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e[INSERT TABLE 6 HERE]\u003c/strong\u003e\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study evaluated two definitions of cachexia based on the AWGC criteria and Evans criteria, in outpatients with CKD undergoing hemodialysis. We compared the diagnostic accuracy of the AWGC criteria, the prevalence of cachexia, and its association with HRQoL and IADL. The AWGC criteria had higher diagnostic accuracy than the Evans criteria, and its associations with HRQoL and IADL were nearly identical. These findings indicate the potential of the AWGC criteria and suggest that its ease of clinical application may facilitate early detection and prevention of cachexia progression in outpatients with CKD undergoing hemodialysis.\u003c/p\u003e \u003cp\u003eAmong outpatients with CKD undergoing hemodialysis, those diagnosed with cachexia according to the Evans criteria were invariably identified by the AWGC criteria. The AWGC criteria demonstrated a high level of agreement with the Evans criteria, showing a well-balanced sensitivity and specificity. These findings suggest that the AWGC criteria may serve as a reliable indicator for diagnosing cachexia. These results suggest that the AWGC criteria exhibit high concordance with the Evans criteria, highlighting their use in cachexia diagnosis. Moreover, the AWGC criteria demonstrated high sensitivity in detecting cachexia while maintaining high accuracy in identifying non-cachectic cases. The relatively high PPV and extremely high NPV further support the reliability of the AWGC criteria as a diagnostic tool closely aligned with the Evans criteria. As the AWGC criteria comprise anorexia, decreased handgrip strength, and abnormal CRP they enable a simple and convenient assessment of cachexia. Considering their ease of clinical implementation, the AWGC criteria may facilitate convenient detection and timely intervention for cachexia in outpatients with CKD undergoing hemodialysis.\u003c/p\u003e \u003cp\u003eCachexia prevalence among outpatients with CKD undergoing hemodialysis was 30.1% using the AWGC criteria and 24.7% using the Evans criteria. In a previous study on Japanese outpatients with CKD undergoing hemodialysis, the prevalence of cachexia was reported as 21.3% using the Evans criteria and 35.2% using the AWGC criteria [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Our findings are comparable to those of the previous study, suggesting consistency across different definitions. Prevalence of cachexia determined by the AWGC criteria was higher than that determined by the Evans criteria. This discrepancy may be attributed to the BMI threshold difference, where the Evans criteria use BMI\u0026thinsp;\u0026lt;\u0026thinsp;20 kg/m\u0026sup2;, while the AWGC criteria use BMI\u0026thinsp;\u0026lt;\u0026thinsp;21 kg/m\u0026sup2;. Moreover, the AWGC criteria do not include muscle mass assessment or fatigue evaluation. These factors may have contributed to the higher prevalence of cachexia when using the AWGC criteria. The discrepancies between our study and previous studies may be attributed to differences in muscle mass assessment methods. While the previous study used the modified creatinine index to assess muscle mass, our study employed DEXA to calculate the skeletal muscle mass index. Given that cachexia is characterized by muscle mass loss [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], variations in assessment methods may yield different results despite applying the same cachexia definitions. Consequently, this factor should be carefully considered in future studies.\u003c/p\u003e \u003cp\u003eThe clinical significance of this study is that the AWGC criteria provide a simple and highly sensitive diagnostic tool for cachexia, enabling convenient diagnosis, risk stratification, and timely intervention in patients with CKD undergoing hemodialysis. The AWGC criteria utilize standardized and easily assessable indicators, such as CRP and handgrip strength [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], facilitating practical application in clinical settings. In this study, the AWGC criteria included all patients diagnosed with cachexia by the Evans criteria and additionally identified those with mild cachexia. Cachexia involves multiple factors and significantly worsens patient prognosis [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Appropriate assessment of patients with CKD and early intervention are essential in clinical practice for improving patient outcomes [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The AWGC criteria allow for the identification of mild cachexia cases not detected by the Evans criteria, thereby enabling early intervention. Additionally, HRQoL and IADL are critical clinical outcomes of cachexia [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], and in this study, cachexia diagnosed by the AWGC criteria was significantly associated with decreased HRQoL and IADL. In a previous study, patients undergoing hemodialysis had lower health-related QoL than pre-hemodialysis and kidney transplant patients [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Moreover, hemodialysis has been reported to affect HRQoL physically, psychologically, and socially [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Furthermore, patients with CKD undergoing hemodialysis are associated with a decline in IADL and ADL [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. It has been reported that up to 50% of older patients with CKD undergoing hemodialysis experience impairments in ADL and IADL [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. These findings underscore the prognostic value of the AWGC criteria. Further studies are warranted to examine the long-term impact of cachexia diagnosis using the AWGC criteria on patient outcomes.\u003c/p\u003e \u003cp\u003eThis study has some limitations. First, as an observational study conducted at a single center, the generalizability of the results may be limited. Therefore, multicenter collaborative studies should determine whether similar findings can be obtained in different clinical settings. Second, the relatively small sample size resulted in low coefficients of determination, leading to a lower goodness-of-fit in multiple regression analyses. Future studies with larger sample sizes should explore additional confounding factors. Third, this study was cross-sectional, which does not allow for causal inferences. Therefore, more detailed longitudinal studies are warranted.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eOur findings showed that the AWGC criteria demonstrated higher diagnostic accuracy than the Evans criteria, with nearly identical associations with HRQoL and IADL. These findings suggest the usefulness of the AWGC criteria, and considering their ease of clinical application, they may facilitate the convenient detection of cachexia and help prevent its progression in outpatients with CKD undergoing hemodialysis.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to express our gratitude to the members of the Rehabilitation Nutrition Laboratory for their cooperation in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received no specific grants from public, commercial, or non-profit funding agencies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest related to the content of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eT.Y., S.K., T.K., Y.I., Y.H., N.T., R.O., and S.N. conceived the idea of the study. T.Y. and T.I. developed the statistical analysis plan and conducted statistical analyses. T.Y., T.I., M.O., M.O., K.S., N.S., and S.I. contributed to the interpretation of the results. T.Y., T.I., M.O., M.O., and S.I. drafted the original manuscript. S.N. supervised the conduct of this study. All authors reviewed the manuscript draft and revised it critically on intellectual content. All authors approved the final version of the manuscript to be published.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Generative AI and AI-Assisted technologies in the writing process\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Guidelines Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all participants or their legal guardians. This study was approved by the Ethics Committee of Hattori Hospital (Hyogo, Japan) (Approval No: 2022\u0026nbsp;–02). The study was conducted in accordance with the principles of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all individual patients included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from all individual participants included in the study for publication of this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all participants or their legal guardians.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePatel N, Golzy M, Nainani N, Nader ND, Carter RL, Lohr JW, et al. Prevalence of various comorbidities among veterans with chronic kidney disease and its comparison with other datasets. 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Geriatric Nutritional Risk Index: A new index for evaluating at-risk elderly medical patients. Am J Clin Nutr. 2005;82:777\u0026ndash;83. https://doi.org/10.1093/ajcn/82.4.777.\u003c/li\u003e\n\u003cli\u003eLamb SE, J\u0026oslash;rstad-Stein EC, Hauer K, Becker C, Prevention of Falls Network Europe and Outcomes Consensus Group. Development of a common outcome data set for fall injury prevention trials: The Prevention of Falls Network Europe consensus. J Am Geriatr Soc. 2005;53:1618\u0026ndash;22. https://doi.org/10.1111/j.1532-5415.2005.53455.x.\u003c/li\u003e\n\u003cli\u003eGuralnik JM, Simonsick EM, Ferrucci L, Glynn RJ, Berkman LF, Blazer DG, et al. A short physical performance battery assessing lower extremity function: Association with self-reported disability and prediction of mortality and nursing home admission. J Gerontol. 1994;49:M85\u0026ndash;94. https://doi.org/10.1093/geronj/49.2.m85.\u003c/li\u003e\n\u003cli\u003eChen LK, Woo J, Assantachai P, Auyeung TW, Chou MY, Iijima K, et al. Asian Working Group for Sarcopenia: 2019 Consensus update on sarcopenia diagnosis and treatment. J Am Med Dir Assoc. 2020;21:300\u0026ndash;307.e2. https://doi.org/10.1016/j.jamda.2019.12.012.\u003c/li\u003e\n\u003cli\u003eSatake S, Arai H. The revised Japanese version of the Cardiovascular Health Study criteria (revised J-CHS criteria). Geriatr Gerontol Int. rev. Japanese version. 2020;20:992\u0026ndash;3. https://doi.org/10.1111/ggi.14005.\u003c/li\u003e\n\u003cli\u003eNakatsu N, Sawa R, Misu S, Ueda Y, Ono R. Reliability and validity of the Japanese version of the simplified nutritional appetite questionnaire in community-dwelling older adults. Geriatr Gerontol Int. 2015;15:1264\u0026ndash;9. https://doi.org/10.1111/ggi.12426.\u003c/li\u003e\n\u003cli\u003eShiroiwa T, Noto S, Fukuda T. Japanese Population Norms of EQ-5D-5L and Health Utilities Index Mark 3: Disutility catalog by disease and symptom in community settings. Value Health. 2021;24:1193\u0026ndash;202. https://doi.org/10.1016/j.jval.2021.03.010.\u003c/li\u003e\n\u003cli\u003eBrooks R, Boye KS, Slaap B. EQ-5D: A plea for accurate nomenclature. J Patient Rep Outcomes. 2020;4:52. https://doi.org/10.1186/s41687-020-00222-9.\u003c/li\u003e\n\u003cli\u003eEQ5D5L crosswalk index value calculator, https://euroqol.org/eq-5d-instruments/eq-5d-5l-about/.\u003c/li\u003e\n\u003cli\u003eShiroiwa T, Ikeda S, Noto S, Igarashi A, Fukuda T, Saito S, et al. Comparison of value set based on DCE and/or TTO data: Scoring for EQ-5D-5L health states in Japan. Value Health. 2016;19:648\u0026ndash;54. https://doi.org/10.1016/j.jval.2016.03.1834.\u003c/li\u003e\n\u003cli\u003eIsik EI, Yilmaz S, Uysal I, Basar S. Adaptation of the Lawton Instrumental Activities of Daily Living scale to Turkish: Validity and reliability study. Ann Geriatr Med Res. 2020;24:35\u0026ndash;40. https://doi.org/10.4235/agmr.19.0051.\u003c/li\u003e\n\u003cli\u003eKanda Y. Investigation of the freely available easy-to-use software\u0026rsquo;EZR\u0026rsquo;for medical statistics. Bone Marrow Transplant. 2013;48:452\u0026ndash;8. https://doi.org/10.1038/bmt.2012.244.\u003c/li\u003e\n\u003cli\u003eJesus NM, Souza GFD, Mendes RC, Almeida OPD, Rodrigues DDM, Cunha CM. Quality of life of individuals with chronic kidney disease on dialysis. Braz J Nephrol. 2019;41:364\u0026ndash;74.\u003c/li\u003e\n\u003cli\u003eBowling CB, Sawyer P, Campbell RC, Ahmed A, Allman RM. Impact of chronic kidney disease on activities of daily living in community-dwelling older adults. J Gerontol A Biol Sci Med Sci. 2011;66:689\u0026ndash;94. https://doi.org/10.1093/gerona/glr043.\u003c/li\u003e\n\u003cli\u003eKutner NG, Zhang R, Allman RM, Bowling CB. Correlates of ADL difficulty in a large hemodialysis cohort. Hemodial Int. 2014;18:70\u0026ndash;7. https://doi.org/10.1111/hdi.12098.\u003cbr\u003e \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 6 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"hemodialysis, cachexia, Asian Working Group for Cachexia, diagnostic accuracy, chronic kidney disease","lastPublishedDoi":"10.21203/rs.3.rs-6634728/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6634728/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose: \u003c/strong\u003eCachexia worsens the long-term prognosis of patients with chronic kidney disease (CKD) receiving hemodialysis. The Asian Working Group for Cachexia (AWGC) has proposed diagnostic criteria tailored to Asian populations. In this study, we aimed to validate the AWGC criteria for diagnosing cachexia in patients with CKD receiving hemodialysis by focusing on prevalence, diagnostic accuracy, health-related quality of life (HRQoL), and instrumental activities of daily living (IADL).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThis cross-sectional study included 93 outpatients with CKD undergoing hemodialysis. Cachexia was diagnosed using the AWGC and Evans criteria. HRQoL was assessed using the European quality of life 5 dimensions 5-level (EQ-5D-5L), and IADL was evaluated using the Lawton IADL scale. Statistical analyses included sensitivity, specificity, and multiple regression to examine the associations between cachexia definitions, HRQoL, and IADL.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eCachexia prevalence was 30.1% according to the\u003cstrong\u003e \u003c/strong\u003eAWGC criteria and 24.7% by Evans criteria. All patients identified by the Evans criteria were also identified by the AWGC criteria. The AWGC criteria demonstrated superior diagnostic accuracy (κ = 0.865), with a sensitivity of 1.000 and specificity of 0.929. \u0026nbsp;Associations of cachexia (as defined by each criterion) with HRQoL and IADL were similar.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eIn contrast to the Evans criteria, the AWGC criteria demonstrated high validity and superior applicability for diagnosing cachexia in outpatients with CKD receiving hemodialysis. These findings highlight the practicality of the AWGC criteria. Their use may facilitate early detection and help prevent cachexia progression, thereby improving patient outcomes.\u003c/p\u003e","manuscriptTitle":"Validity of cachexia diagnosis using AWGC criteria in outpatients with chronic kidney disease undergoing hemodialysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-16 11:54:19","doi":"10.21203/rs.3.rs-6634728/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"92f39975-90b5-47fe-91aa-a106eaa862e9","owner":[],"postedDate":"May 16th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-12T08:18:57+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-16 11:54:19","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6634728","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6634728","identity":"rs-6634728","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}