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Narasaki Y, Siu MK, Nguyen M, Kalantar-Zadeh K, Rhee CM. Personalized nutritional management in the transition from non-dialysis dependent chronic kidney disease to dialysis. Kidney Res Clin Pract 2024; 43:575-585. [PMID: 38738275 PMCID: PMC11467355 DOI: 10.23876/j.krcp.23.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 08/14/2023] [Accepted: 11/10/2023] [Indexed: 05/14/2024] Open
Abstract
Dialysis has been the dominant treatment regimen in end-stage kidney disease as a means to remove uremic waste products and to maintain electrolyte, acid base, and fluid balance. However, given that dialysis may not always provide a survival benefit nor improved quality of life in certain subpopulations, there is growing recognition of the need for conservative and preservative management as an alternative treatment strategy for advanced chronic kidney disease (CKD). Personalized nutritional management tailored to patient's sociodemographics, social needs, psychological status, health literacy level, and preferences is a key component of conservative and preservative care, as well as in the management of patients transitioning from non-dialysis dependent CKD to dialysis. In this review, we discuss the nutritional and metabolic alterations that ensue in CKD; the rationale for low-protein diets in the conservative and preservative management of advanced CKD; the role of plant-based diets in kidney health; emerging data on dietary potassium and sodium intake on CKD outcomes; and the practical implementation of dietary interventions in advanced kidney disease.
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Affiliation(s)
- Yoko Narasaki
- Division of Nephrology, Hypertension, and Kidney Transplantation, Department of Medicine, University of California Irvine, Orange, CA, USA
- Tibor Rubin Veterans Affairs Long Beach Healthcare System, Long Beach, CA, USA
| | - Man Kit Siu
- Division of Nephrology, Hypertension, and Kidney Transplantation, Department of Medicine, University of California Irvine, Orange, CA, USA
- Tibor Rubin Veterans Affairs Long Beach Healthcare System, Long Beach, CA, USA
| | - Matthew Nguyen
- Division of Nephrology, Hypertension, and Kidney Transplantation, Department of Medicine, University of California Irvine, Orange, CA, USA
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology, Hypertension, and Kidney Transplantation, Department of Medicine, University of California Irvine, Orange, CA, USA
- Tibor Rubin Veterans Affairs Long Beach Healthcare System, Long Beach, CA, USA
- The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Connie M. Rhee
- Division of Nephrology, Hypertension, and Kidney Transplantation, Department of Medicine, University of California Irvine, Orange, CA, USA
- Tibor Rubin Veterans Affairs Long Beach Healthcare System, Long Beach, CA, USA
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Wang AYM, Mallamaci F, Zoccali C. What is central to renal nutrition: protein or sodium intake? Clin Kidney J 2023; 16:1824-1833. [PMID: 37915942 PMCID: PMC10616450 DOI: 10.1093/ckj/sfad151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Indexed: 11/03/2023] Open
Abstract
Historically, nutrition intervention has been primarily focused on limiting kidney injury, reducing generation of uraemic metabolites, as well as maintaining nutrition status and preventing protein-energy wasting in patients with chronic kidney disease (CKD). This forms an important rationale for prescribing restricted protein diet and restricted salt diet in patients with CKD. However, evidence supporting a specific protein intake threshold or salt intake threshold remains far from compelling. Some international or national guidelines organizations have provided strong or 'level 1' recommendations for restricted protein diet and restricted salt diet in CKD. However, it is uncertain whether salt or protein restriction plays a more central role in renal nutrition management. A key challenge in successful implementation or wide acceptance of a restricted protein diet and a restricted salt diet is patients' long-term dietary adherence. These challenges also explain the practical difficulties in conducting randomized trials that evaluate the impact of dietary therapy on patients' outcomes. It is increasingly recognized that successful implementation of a restricted dietary prescription or nutrition intervention requires a highly personalized, holistic care approach with support and input from a dedicated multidisciplinary team that provides regular support, counselling and close monitoring of patients. With the advent of novel drug therapies for CKD management such as sodium-glucose cotransporter-2 inhibitors or non-steroidal mineralocorticoid receptor antagonist, it is uncertain whether restricted protein diet and restricted salt diet may still be necessary and have incremental benefits. Powered randomized controlled trials with novel design are clearly indicated to inform clinical practice on recommended dietary protein and salt intake threshold for CKD in this new era.
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Affiliation(s)
- Angela Yee-Moon Wang
- University Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, SAR, China
| | - Francesca Mallamaci
- Nefrologia and CNR Unit, Grande Ospedale Metropolitano, Reggio Calabria, Italy
| | - Carmine Zoccali
- Renal Research Institute, New York, USA
- Institute of Molecular Biology and Genetics (Biogem), Ariano Irpino, Italy
- Associazione Ipertensione Nefrologia Trapianto Renal (IPNET), Nefrologia, Grande Ospedale Metropolitano, Reggio Calabria, Italy
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Costa MSD, Pontes KSDS, Guedes MR, Barreto Silva MI, Klein MRST. Association of habitual coffee consumption with obesity, sarcopenia, bone mineral density and cardiovascular risk factors: A two-year follow-up study in kidney transplant recipients. Clin Nutr 2023; 42:1889-1900. [PMID: 37625318 DOI: 10.1016/j.clnu.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 07/06/2023] [Accepted: 08/06/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND & AIMS Recent evidence suggests that moderate coffee intake is associated with multiple health benefits, including lower risk of obesity, sarcopenia and cardiovascular disease (CVD) in the general population. However, to date, no study has evaluated these associations in kidney transplant recipients (KTR). The aim of the present study was to evaluate the association of habitual coffee consumption with obesity, sarcopenia, bone mineral density and CVD risk factors in KTR. METHODS This prospective 2 years-follow-up study included 170 KTR (59% men) aged 49.5 (42.0-57.0) years. At baseline participants were submitted to the following evaluations: clinical, laboratorial, dietary intake (including coffee), muscle strength, anthropometric and body composition by bioelectrical impedance analysis (BIA) and dual-energy X-ray absorptiometry (DXA). After two years 163 KTR were re-evaluated by anthropometry, BIA and muscle strength. Sarcopenia was defined according to EWGSOP2. Risk factors for CVD were hypertension, diabetes mellitus, dyslipidemia, metabolic syndrome and hyperhomcysteinemia. Participants were stratified according to coffee intake: 0 or 1 time/day (Gr0-1) and 2 or 3 times/day (Gr2-3). RESULTS The median coffee consumption was 200 (150-250)mL/day and 112 (71-155)mL/1000 kcal/day. At baseline, Gr2-3 vs. Gr0-1 exhibited significantly higher values of waist circumference, waist-to-height ratio (WHtR) and presented a higher odds ratio for central obesity according to WHtR (2.68; 95%CI:1.19-6.02; p = 0.02) after adjustment for confounders. Coffee consumption (mL/1000 kcal/day) showed, even after adjustment for confounders, (1) a positive association with all parameters of body adiposity (anthropometry, BIA and DXA) and (2) a negative association with muscle quality index. After two years, coffee intake (mL/1000 kcal/day) at baseline presented a positive correlation with changes in fat mass (kg) by BIA (r = 0.22, p = 0.01) after adjustment for confounders. CONCLUSION This study suggests that in KTR, higher coffee consumption is associated with increased adiposity, specially, central adiposity and lower muscle quality, but is not related with the other evaluated parameters.
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Affiliation(s)
- Mariana Silva da Costa
- Post Graduation Program in Medical Science, Rio de Janeiro State University, Rio de Janeiro, Brazil.
| | - Karine Scanci da Silva Pontes
- Post-Graduation Program in Clinical and Experimental Pathophysiology, State University of Rio de Janeiro (UERJ), Rio de Janeiro, Brazil.
| | - Marcella Rodrigues Guedes
- Post-Graduation Program in Clinical and Experimental Pathophysiology, State University of Rio de Janeiro (UERJ), Rio de Janeiro, Brazil.
| | - Maria Inês Barreto Silva
- Department of Applied Nutrition, Nutrition Institute, State University of Rio de Janeiro (UERJ), Rio de Janeiro, Brazil; Department of Applied Nutrition, Nutrition School, Federal University of the State of Rio de Janeiro (UNIRIO), Rio de Janeiro, Brazil; Human Nutrition Research Unit, Department of Agricultural, Food and Nutritional Science, Division of Human Nutrition, University of Alberta, Edmonton, Alberta, Canada.
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Mak RH, Iyengar A, Wang AYM. Nutrition Management for Chronic Kidney Disease: Differences and Special Needs for Children and Adults. Semin Nephrol 2023; 43:151441. [PMID: 37981474 DOI: 10.1016/j.semnephrol.2023.151441] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
Common goals of nutritional therapy across the spectrum of pediatric and adult chronic kidney disease (CKD) include maintaining normal body mass and composition and reducing associated morbidity and mortality. Adult nephrologists caring for children and adolescents may be challenged by the existing complexities in identifying and interpreting the nutritional status and growth in children. Pediatric nephrologists may face situations that call for a sound knowledge of assessing nutritional status and providing nutrition therapy for adolescents and young adults. One important additional nutrition goal in children is to achieve normal growth and development. Children are growing and therefore need more calories and nutrients than just maintaining their body weight and composition. Lack of weight and height gain actually is considered failure to thrive in children. Some fundamental differences in approaches to nutritional therapy in CKD are necessitated based on the etiology of CKD. A large proportion of adults with CKD are diabetics, so the approach would be a low-carbohydrate diet. Children with CKD, especially young ones, often are anorexic, so calorie supplements that could include quite a lot of carbohydrates often are prescribed. More adults with CKD have hypertension and atherosclerotic comorbidities, which result in recommendations for low-salt and low-fat diets. Children with CKD often have salt and electrolyte wasting disease states and would require normal- or even high-salt diets, and fats often are included in supplements to bolster calorie intake. Low-protein diets often are recommended in adults with predialysis CKD to slow disease progression. Children are growing and have a higher protein daily requirement. Low-protein diets have not been found to be efficacious in children with CKD, in achieving normal growth, or in slowing disease progression. Adult nephrologists caring for children and adolescents may be challenged by the existing complexities in identifying and interpreting nutritional status and growth in children. Pediatric nephrologists may face situations that call for a sound knowledge of assessing nutritional status and providing nutrition therapy for adolescents and young adults. This article discusses the differences in the assessment of nutritional status between children and adults, as well as provides a comprehensive approach to nutritional management for CKD across the age spectrum. Semin Nephrol 43:x-xx © 2023 Elsevier Inc. All rights reserved.
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Affiliation(s)
- Robert H Mak
- Division of Pediatric Nephrology, Rady Children's Hospital, University of California, San Diego, CA.
| | - Arpana Iyengar
- Department of Pediatric Nephrology, St John's Medical College Hospital, Bangalore, India
| | - Angela Yee-Moon Wang
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong Special Administrative Region, China
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Jayaraman P, Crouse A, Nadkarni G, Might M. A Primer in Precision Nephrology: Optimizing Outcomes in Kidney Health and Disease through Data-Driven Medicine. KIDNEY360 2023; 4:e544-e554. [PMID: 36951457 PMCID: PMC10278804 DOI: 10.34067/kid.0000000000000089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 01/04/2023] [Indexed: 03/24/2023]
Abstract
This year marks the 63rd anniversary of the International Society of Nephrology, which signaled nephrology's emergence as a modern medical discipline. In this article, we briefly trace the course of nephrology's history to show a clear arc in its evolution-of increasing resolution in nephrological data-an arc that is converging with computational capabilities to enable precision nephrology. In general, precision medicine refers to tailoring treatment to the individual characteristics of patients. For an operational definition, this tailoring takes the form of an optimization, in which treatments are selected to maximize a patient's expected health with respect to all available data. Because modern health data are large and high resolution, this optimization process requires computational intervention, and it must be tuned to the contours of specific medical disciplines. An advantage of this operational definition for precision medicine is that it allows us to better understand what precision medicine means in the context of a specific medical discipline. The goal of this article was to demonstrate how to instantiate this definition of precision medicine for the field of nephrology. Correspondingly, the goal of precision nephrology was to answer two related questions: ( 1 ) How do we optimize kidney health with respect to all available data? and ( 2 ) How do we optimize general health with respect to kidney data?
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Affiliation(s)
- Pushkala Jayaraman
- The Charles Bronfman Institute for Personalized Medicine Icahn School of Medicine at Mount Sinai, New York, New York
| | - Andrew Crouse
- Hugh Kaul Precision Medicine Institute, University of Alabama at Birmingham, Birmingham, Alabama
| | - Girish Nadkarni
- The Charles Bronfman Institute for Personalized Medicine Icahn School of Medicine at Mount Sinai, New York, New York
- The Mount Sinai Clinical Intelligence Center (MSCIC), Icahn School of Medicine at Mount Sinai, New York, New York
- Division of Data Driven and Digital Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- Barbara T Murphy Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Matthew Might
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
- Department of Computer Science, University of Alabama at Birmingham, Birmingham, Alabama
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Wang AYM. Introduction: Advances in Nutrition Management in Chronic Kidney Disease. Semin Nephrol 2023; 43:151445. [PMID: 37871488 DOI: 10.1016/j.semnephrol.2023.151445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Affiliation(s)
- Angela Yee-Moon Wang
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR, China
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Developing an Evidence and Theory Based Multimodal Integrative Intervention for the Management of Renal Cachexia: A Theory of Change. Healthcare (Basel) 2022; 10:healthcare10122344. [PMID: 36553868 PMCID: PMC9777598 DOI: 10.3390/healthcare10122344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 11/04/2022] [Accepted: 11/09/2022] [Indexed: 11/23/2022] Open
Abstract
In this study, we aimed to develop a theoretical framework for a multimodal, integrative, exercise, anti-inflammatory and dietary counselling (MMIEAD) intervention for patients with renal cachexia with reference to how this addresses the underlying causal pathways for renal cachexia, the outcomes anticipated, and how these will be evaluated. We used a Theory of Change (ToC) approach to guide six steps. Step 1 included inputs from a workshop to obtain key stakeholder views on the potential development of a multimodal intervention for renal cachexia. Step 2 included the findings of a mixed-methods study with Health Care Practitioners (HCPs) caring for individuals with End Stage Kidney Disease (ESKD) and cachexia. Step 3 included the results from our systematic literature review on multimodal interventions for cachexia management. In step 4, we used the body of our research team's cachexia research and wider relevant research to gather evidence on the specific components of the multimodal intervention with reference to how this addresses the underlying causal pathways for renal cachexia. In steps 5 and 6 we developed and refined the ToC map in consultation with the core research team and key stakeholders which illustrates how the intervention components of MMIEAD interact to achieve the intended long-term outcomes and anticipated impact. The results of this study provide a theoretical framework for the forthcoming MMIEAD intervention for those with renal cachexia and in subsequent phases will be used to determine whether this intervention is effective. To the best of our knowledge no other multimodal intervention trials for cachexia management have reported a ToC. Therefore, this research may provide a useful framework and contribute to the ongoing development of interventions for cachexia management.
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Iseki K. Nutrition and quality of life in chronic kidney disease patients: a practical approach for salt restriction. Kidney Res Clin Pract 2022; 41:657-669. [PMID: 35172533 PMCID: PMC9731783 DOI: 10.23876/j.krcp.21.203] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 10/24/2021] [Accepted: 10/25/2021] [Indexed: 11/25/2023] Open
Abstract
The clinical practice guidelines (CPGs) for nutrition in chronic kidney disease (CKD) were updated after 20 years from the previous guidelines by the Kidney Disease Outcomes Quality Initiative (KDOQI). During this period, the severity of CKD was defined by eGFR and albuminuria by the organization Kidney Disease: Improving Global Outcomes (KDIGO). Main risk factors for CKD such as hypertension, hyperlipidemia, obesity, metabolic syndrome, and diabetes mellitus are closely related to lifestyle. Nutritional management is important to prevent and retard the progression of CKD. Members of the International Society of Renal Nutrition and Metabolism (ISRNM) reviewed the KDOQI CPG draft. ISRNM is an international scientific society comprising members of multiple subspecialties. ISRNM proposed the medical term protein-energy wasting (PEW), which is a keyword in renal nutrition. The prevalence of PEW among dialysis patients is high. The success of dietary therapy depends on adherence to the diet. It has to be palatable, otherwise eating habits will not change. To prevent the development and progression of CKD and PEW, regular consultation with an expert dietitian is required, especially regarding salt and protein restriction. Our cluster-randomized trial showed that intervention by a dietician was effective at retarding the progression of stage 3 CKD. In this review, I focus on salt (sodium) restriction and introduce tips for salt restriction and Japanese kidney-friendly recipes. Due to the lack of randomized controlled trials, nutritional management of CKD inevitably relies on expert opinion. In this regard, well-designed observational studies are needed. Too strict salt restriction may decrease quality of life and result in PEW.
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Affiliation(s)
- Kunitoshi Iseki
- Clinical Research Support Center, Nakamura Clinic, Okinawa, Japan
- Okinawa Dialysis and Transplant Association, Okinawa, Japan
- Okinawa Heart and Renal Association, Okinawa, Japan
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Kalantar-Zadeh K, Moore LW. Functional Nutrition, Naturopathic Nutrition, and Integrative and Holistic Renal Nutrition in Kidney Health and Value-Based Kidney Care Models. J Ren Nutr 2022; 32:493-497. [PMID: 35843458 DOI: 10.1053/j.jrn.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 07/11/2022] [Indexed: 11/11/2022] Open
Affiliation(s)
- Kamyar Kalantar-Zadeh
- Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine, Orange, CA, USA.
| | - Linda W Moore
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
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Effects of Concurrent Exposure to Chronic Restraint-Induced Stress and Total-Body Iron Ion Radiation on Induction of Kidney Injury in Mice. Int J Mol Sci 2022; 23:ijms23094866. [PMID: 35563256 PMCID: PMC9099542 DOI: 10.3390/ijms23094866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/20/2022] [Accepted: 04/25/2022] [Indexed: 02/04/2023] Open
Abstract
Concurrent exposure to ionizing radiation (IR) and psychological stress (PS) may affect the development of adverse health consequences in scenarios such as space missions, radiotherapy and nuclear accidents. IR can induce DNA damage and cell apoptosis in the kidneys, thus potentially leading to renal fibrosis, which is the ultimate outcome of various chronic progressive nephropathies and the morphological manifestation of a continuous coordinated response after renal injury. However, little is known regarding the effects of concurrent IR exposure and PS on renal damage, particularly renal fibrosis. In this study, using a chronic restraint-induced PS (CRIPS) model, we exposed Trp53-heterozygous mice to total body irradiation with 0.1 or 2 Gy 56Fe ions on the eighth day of 28 consecutive days of a restraint regimen. At the end of the restraint period, the kidneys were collected. The histopathological changes and the degree of kidney fibrosis were assessed with H&E and Masson staining, respectively. Fibronectin (FN) and alpha smooth muscle actin (α-SMA), biomarkers of fibrosis, were detected by immunohistochemistry. Analysis of 8-hydroxy-2 deoxyguanosine (8-OHdG), a biomarker of oxidative DNA damage, was performed with immunofluorescence, and terminal deoxynucleotidyl transferase-mediated nick end labeling assays were used to detect apoptotic cells. Histopathological observations did not indicate significant structural damage induced by IR or CRIPS + IR. Western blotting revealed that the expression of α-SMA was much higher in the CRIPS + IR groups than the CRIPS groups. However, no differences in the average optical density per area were observed for FN, α-SMA and 8-OHdG between the IR and CRIPS + IR groups. No difference in the induction of apoptosis was observed between the IR and CRIPS + IR groups. These results suggested that exposure to IR (0.1 and 2 Gy 56Fe ions), 28 consecutive days of CRIPS or both did not cause renal fibrosis. Thus, CRIPS did not alter the IR-induced effects on renal damage in Trp53-heterozygous mice in our experimental setup.
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Wong MMY, Zheng Y, Renouf D, Sheriff Z, Levin A. Trajectories of Nutritional Parameters Before and After Prescribed Oral Nutritional Supplements: A Longitudinal Cohort Study of Patients With Chronic Kidney Disease Not Requiring Dialysis. Can J Kidney Health Dis 2022; 9:20543581211069008. [PMID: 35070337 PMCID: PMC8771735 DOI: 10.1177/20543581211069008] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 11/02/2021] [Indexed: 11/15/2022] Open
Abstract
Background: The association between oral nutritional supplement use and nutritional parameters among patients with nondialysis chronic kidney disease (CKD-ND) with or at high risk of undernutrition/protein-energy wasting has not been previously studied. The definition of patient subgroups most likely to benefit from oral nutritional supplementation (ONS) is also an area where more research is needed. Objective: To assess nutritional parameter trajectories among patients with CKD-ND prescribed oral nutritional supplements in British Columbia, and to compare trajectories by nutritional phenotype. Design: Longitudinal cohort study, pre-post design. Setting: Multidisciplinary CKD clinics across British Columbia. Patients: A total of 3957 adult patients with CKD-ND, who entered multidisciplinary CKD clinics during 2010 to 2019, met criteria for oral nutritional supplement prescription based on dietitian assessment, and received ≥1 oral nutritional supplement prescription. Measurements: Longitudinal nutritional parameters, including body mass index (BMI), serum albumin, serum bicarbonate, serum phosphate, and neutrophil-to-lymphocyte ratio (NLR). Methods: Using linear mixed models, slopes for nutritional and inflammation parameters were assessed in the 2-year periods before and after the first oral nutritional supplement prescription. Hierarchical cluster analysis was applied to identify nutritional phenotypes using baseline data, and slope analysis was repeated by cluster. Results: In the pre-oral-nutritional-supplement period, declines in BMI (−0.87 kg/m2/year, 95% confidence interval [CI]: −0.99 to −0.75), albumin (−1.11 g/L/year, 95% CI: −1.27 to −0.95), and bicarbonate (−0.49 mmol/L/year; 95% CI: −0.59 to −0.39), and increases in NLR (+0.79/year; 95% CI: 0.60 to 0.98) and phosphate (+0.05 mmol/L/year; 95% CI: 0.04 to 0.06) were observed. Following oral nutritional supplement prescription, there were statistically significant increases in BMI slope (+0.91 kg/m2/year, P < .0001), albumin slope (+0.82 g/L/year, P < .0001), and phosphate slope (+0.02 mmol/L/year, P = .005), as well as a decline in NLR slope of −0.55/year ( P < .0001). There was no significant change in bicarbonate slope. Cluster analysis identified 5 distinct phenotypes. The cluster with the highest mean baseline NLR and lowest mean BMI demonstrated the greatest number of improvements in nutritional parameter slopes in the post-oral-nutritional-supplement period. Limitations: Possibility of residual confounding. Data on dietary intake, muscle mass, and nutritional scoring systems were not available in the registry. Conclusions: Among patients with CKD-ND prescribed oral nutritional supplements, there were improvements in nutrition/inflammation parameters over time following the first ONS prescription. The heterogeneity in response to ONS by cluster subgroup suggests an individualized approach to nutritional management may be beneficial.
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Affiliation(s)
- Michelle M. Y. Wong
- Department of Medicine, The University of British Columbia, Vancouver, Canada
- BC Renal, Vancouver, BC, Canada
| | | | - Dani Renouf
- St. Paul’s Hospital, Providence Health Care, Vancouver, BC, Canada
| | - Zainab Sheriff
- Division of Nephrology, The University of British Columbia, Vancouver, Canada
| | - Adeera Levin
- BC Renal, Vancouver, BC, Canada
- St. Paul’s Hospital, Providence Health Care, Vancouver, BC, Canada
- Division of Nephrology, The University of British Columbia, Vancouver, Canada
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Wang AYM, Okpechi IG, Ye F, Kovesdy CP, Brunori G, Burrowes JD, Campbell K, Damster S, Fouque D, Friedman AN, Garibotto G, Guebre-Egziabher F, Harris D, Iseki K, Jha V, Jindal K, Kalantar-Zadeh K, Kistler B, Kopple JD, Kuhlmann M, Lunney M, Mafra D, Malik C, Moore LW, Price SR, Steiber A, Wanner C, ter Wee P, Levin A, Johnson DW, Bello AK. Assessing Global Kidney Nutrition Care. Clin J Am Soc Nephrol 2022; 17:38-52. [PMID: 34980675 PMCID: PMC8763143 DOI: 10.2215/cjn.07800621] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 11/15/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND OBJECTIVES Nutrition intervention is an essential component of kidney disease management. This study aimed to understand current global availability and capacity of kidney nutrition care services, interdisciplinary communication, and availability of oral nutrition supplements. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The International Society of Renal Nutrition and Metabolism (ISRNM), working in partnership with the International Society of Nephrology (ISN) Global Kidney Health Atlas Committee, developed this Global Kidney Nutrition Care Atlas. An electronic survey was administered among key kidney care stakeholders through 182 ISN-affiliated countries between July and September 2018. RESULTS Overall, 160 of 182 countries (88%) responded, of which 155 countries (97%) answered the survey items related to kidney nutrition care. Only 48% of the 155 countries have dietitians/renal dietitians to provide this specialized service. Dietary counseling, provided by a person trained in nutrition, was generally not available in 65% of low-/lower middle-income countries and "never" available in 23% of low-income countries. Forty-one percent of the countries did not provide formal assessment of nutrition status for kidney nutrition care. The availability of oral nutrition supplements varied globally and, mostly, were not freely available in low-/lower middle-income countries for both inpatient and outpatient settings. Dietitians and nephrologists only communicated "sometimes" on kidney nutrition care in ≥60% of countries globally. CONCLUSIONS This survey reveals significant gaps in global kidney nutrition care service capacity, availability, cost coverage, and deficiencies in interdisciplinary communication on kidney nutrition care delivery, especially in lower-income countries.
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Affiliation(s)
- Angela Yee-Moon Wang
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Ikechi G. Okpechi
- Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa,Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa
| | - Feng Ye
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Csaba P. Kovesdy
- University of Tennessee Health Science Center and Memphis Veterans Affairs Medical Center, Memphis, Tennessee
| | - Giuliano Brunori
- Division of Nephrology and Dialysis, Santa Chiara Hospital, Trento, Italy
| | - Jerrilynn D. Burrowes
- Department of Biomedical, Health and Nutritional Sciences, Long Island University Post, Greenvale, New York
| | - Katrina Campbell
- Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
| | | | - Denis Fouque
- University Claude Bernard Lyon1, Hospital Lyon Sud - Lyon-France, South Lyon, France
| | - Allon N. Friedman
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Giacomo Garibotto
- Division of Nephrology, Dialysis and Transplantation Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Fitsum Guebre-Egziabher
- Department of Nephrology, Dialysis and Hypertension, Hospices Civils de Lyon, Hospital Edouard Herriot, Lyon, France,CarMeN Laboratory, Institut National de la Santé et de la Recherche Médicale (INSERM) UMR 1060, Lyon East Faculty of Medicine, University Claude Bernard Lyon 1, Lyon, France
| | - David Harris
- Centre for Transplantation and Renal Research, Westmead Institute for Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - Kunitoshi Iseki
- Clinical Research Support Center, Nakamura Clinic, Okinawa, Japan
| | - Vivekanand Jha
- George Institute for Global Health India, University of New South Wales, New Delhi, India,School of Public Health, Imperial College, London, United Kingdom,Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
| | - Kailash Jindal
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine Medical Center, Orange, California
| | - Brandon Kistler
- Department of Nutrition and Health Science, Ball State University, Muncie, Indiana
| | - Joel D. Kopple
- Division of Nephrology and Medicine and the Lundquist Research Institute at Harbor–University of California Los Angeles (UCLA) Medical Center, David Geffen School of Medicine at UCLA and UCLA Fielding School of Public Health, Los Angeles, California
| | | | - Meaghan Lunney
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Denise Mafra
- Federal University Fluminense, Rio de Janeiro, Brazil
| | - Charu Malik
- International Society of Nephrology, Brussels, Belgium
| | - Linda W. Moore
- Houston Methodist Hospital, Department of Surgery, Houston, Texas
| | - S. Russ Price
- Departments of Internal Medicine and Biochemistry-Molecular Biology, Brody School of Medicine at East Carolina University, Greenville, North Carolina
| | - Alison Steiber
- Research, International, and Scientific Affairs, Academy of Nutrition and Dietetics, Chicago, Illinois
| | - Christoph Wanner
- Department of Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Pieter ter Wee
- Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Adeera Levin
- Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - David W. Johnson
- Centre for Kidney Disease Research, University of Queensland, Brisbane, Australia,Translational Research Institute, Brisbane, Australia,Metro South and Integrated Nephrology and Transplant Services (MINTS), Princess Alexandra Hospital, Brisbane, Australia
| | - Aminu K. Bello
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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13
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Bielopolski D, Wenziger C, Steinmetz T, Rozen Zvi B, Kalantar-Zadeh K, Streja E. Novel Protein to Phosphorous Ratio Score Predicts Mortality in Hemodialysis Patients. J Ren Nutr 2021; 32:450-457. [PMID: 34740537 DOI: 10.1053/j.jrn.2021.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 07/19/2021] [Accepted: 08/10/2021] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE Lowering serum phosphorus in people on hemodialysis may improve their survival. However, prior studies have shown that restricting dietary protein intake, a major source of phosphorus, is associated with higher mortality. We hypothesized that a novel metric that incorporates both these values commensurately can improve survival prediction. METHODS We used serum phosphorous and normalized protein catabolic rate (nPCR), a surrogate of dietary protein intake, to form a new metric R that was used to examine the associations with mortality in 63,016 people on hemodialysis (HD) of one year after treatment initiation. Survival models were adjusted for case-mix, malnutrition-inflammation cachexia syndrome (MICS), and residual kidney function (RKF). RESULTS Individuals treated with hemodialysis were divided into five groups in accordance with R value. Group 1 included sick individuals with high phosphorous and low nPCR. Group 5 included individuals with low phosphorous and high nPCR. After 1-year follow-up, survival difference between the groups reflected R value, where an increase in R was associated with improved survival. The association of R with mortality was strengthened by adjustment in demographic variables and attenuated after adjustment to MICS. Mortality associations in accordance with R were not influenced by residual kidney function (RKF). CONCLUSION The novel protein to phosphorus ratio score R predicts mortality in people on dialysis, probably reflecting both nutrition and inflammation state independent of RKF. The metric enables better phosphorus monitoring, although adequate dietary protein intake is ensured and may improve the prediction of outcomes in the clinical setting.
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Affiliation(s)
- Dana Bielopolski
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, School of Medicine, Irvine, CA; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Nephrology Institute, Rabin Medical Center, Petah Tiqva, Israel.
| | - Cachet Wenziger
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, School of Medicine, Irvine, CA
| | - Tali Steinmetz
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Nephrology Institute, Rabin Medical Center, Petah Tiqva, Israel
| | - Benaya Rozen Zvi
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Nephrology Institute, Rabin Medical Center, Petah Tiqva, Israel
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, School of Medicine, Irvine, CA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, School of Medicine, Irvine, CA
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14
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Kalantar-Zadeh K, Wang AYM, Moore LW, Lui SF. The World Kidney Recipes: Teaming up to Empower Patients, Care-Partners, Dietitians, and Chefs With Culinary Creativity and Multicultural Diversity in Renal Nutrition and Dietetics. J Ren Nutr 2021; 31:545-549. [PMID: 34503901 DOI: 10.1053/j.jrn.2021.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 08/26/2021] [Indexed: 01/02/2023] Open
Affiliation(s)
- Kamyar Kalantar-Zadeh
- Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine, Orange, California.
| | - Angela Yee-Moon Wang
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR, China
| | | | - Siu-Fai Lui
- Hong Kong Kidney Foundation, Hong Kong Special Administrative Region, China
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15
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Ikizler TA. Better Nutrition Care for Patients on Hemodialysis: One Step at a Time. Clin J Am Soc Nephrol 2021; 16:1143-1145. [PMID: 34348931 PMCID: PMC8455048 DOI: 10.2215/cjn.06800521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 06/16/2021] [Accepted: 06/18/2021] [Indexed: 02/04/2023]
Affiliation(s)
- T. Alp Ikizler
- Division of Nephrology and Hypertension and Vanderbilt Center for Kidney Disease, Vanderbilt University Medical Center, Nashville, Tennessee
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16
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Molina P, Gavela E, Vizcaíno B, Huarte E, Carrero JJ. Optimizing Diet to Slow CKD Progression. Front Med (Lausanne) 2021; 8:654250. [PMID: 34249961 PMCID: PMC8267004 DOI: 10.3389/fmed.2021.654250] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 05/31/2021] [Indexed: 12/15/2022] Open
Abstract
Due to the unique role of the kidney in the metabolism of nutrients, patients with chronic kidney disease (CKD) lose the ability to excrete solutes and maintain homeostasis. Nutrient intake modifications and monitoring of nutritional status in this population becomes critical, since it can affect important health outcomes, including progression to kidney failure, quality of life, morbidity, and mortality. Although there are multiple hemodynamic and metabolic factors involved in the progression and prognosis of CKD, nutritional interventions are a central component of the care of patients with non-dialysis CKD (ND-CKD) and of the prevention of overweight and possible protein energy-wasting. Here, we review the reno-protective effects of diet in adults with ND-CKD stages 3-5, including transplant patients.
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Affiliation(s)
- Pablo Molina
- Department of Nephrology, Hospital Universitari Dr. Peset, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (FISABIO), Valencia, Spain
- Department of Medicine, Universitat de València, Valencia, Spain
| | - Eva Gavela
- Department of Nephrology, Hospital Universitari Dr. Peset, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (FISABIO), Valencia, Spain
| | - Belén Vizcaíno
- Department of Nephrology, Hospital Universitari Dr. Peset, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (FISABIO), Valencia, Spain
| | - Emma Huarte
- Department of Nephrology, Hospital San Pedro, Logroño, Spain
| | - Juan Jesús Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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17
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Xu X, Yang Z, Ma T, Li Z, Chen Y, Zheng Y, Dong J. Novel equation for estimating resting energy expenditure in patients with chronic kidney disease. Am J Clin Nutr 2021; 113:1647-1656. [PMID: 33693520 DOI: 10.1093/ajcn/nqaa431] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 12/16/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND In chronic kidney disease (CKD), determining energy expenditure is the precondition for recommending energy intake in nutrition management. OBJECTIVES We aimed to develop and validate a resting energy expenditure (REE) equation for patients with CKD. METHODS This cross-sectional study enrolled 300 patients with CKD (stages 3-5) according to inclusion and exclusion criteria. Stepwise linear regression analysis was used to derive a new REE equation (eREE-CKD) according to actual REE (aREE) measured using indirect calorimetry in the development dataset. The eREE-CKD value was then validated with aREE in the validation dataset and compared with values from existing equations obtained in general populations, namely, the Harris-Benedict, Mifflin, WHO, and Schofield equations in terms of bias, precision, and accuracy. RESULTS The eREE-CKD equation: eREE-CKD (kcal) = (1 if male; 0 if female) × 106.0 - [1 if diabetes mellitus (DM); 0 if non-DM] × 51.6 - 4.7 × age (y) + 13.1 × weight (kg) + 645.5 (R2 = 0.779).The bias, precision, and accuracy (percentage of estimates that differed >20% from the measured REE) of the eREE-CKD equation were -0.4 (IQR: -29.8, 23.8) kcal, 98.4 (IQR: 79.5, 116.6) kcal, and 5.4%, respectively with indirect calorimetry as the reference method. Both bias and precision of the eREE-CKD were significantly better than the Harris-Benedict, WHO, and Schofield equations (P < 0.001) and similar to the Mifflin equation (P = 0.125 for bias and 0.268 for precision). Accuracy of the eREE-CKD was significantly better than the Harris-Benedict, WHO, Mifflin, and Schofield equations (P < 0.001). Bias, precision, and accuracy of the eREE-CKD equation were consistent when applied to subgroups categorized according to high-sensitivity C-reactive protein concentrations and CKD stages, respectively. CONCLUSIONS The eREE-CKD equation using age, sex, weight, and DM data could serve as a reliable tool for estimating REE in patients with CKD. This trial was registered at clinicaltrials.gov as NCT03377413.
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Affiliation(s)
- Xiao Xu
- Renal Division, Department of Medicine, Peking University First Hospital; Institute of Nephrology, Peking University; Key Laboratory of Renal Disease, Ministry of Health; Key Laboratory of Renal Disease, Ministry of Education; Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Zhikai Yang
- Renal Division, Department of Medicine, Peking University First Hospital; Institute of Nephrology, Peking University; Key Laboratory of Renal Disease, Ministry of Health; Key Laboratory of Renal Disease, Ministry of Education; Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Tiantian Ma
- Renal Division, Department of Medicine, Peking University First Hospital; Institute of Nephrology, Peking University; Key Laboratory of Renal Disease, Ministry of Health; Key Laboratory of Renal Disease, Ministry of Education; Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Ziqian Li
- Clinical Nutrition Department, Peking University First Hospital, Beijing, China
| | - Yuan Chen
- Renal Division, Department of Medicine, Peking University First Hospital; Institute of Nephrology, Peking University; Key Laboratory of Renal Disease, Ministry of Health; Key Laboratory of Renal Disease, Ministry of Education; Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Yingdong Zheng
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
| | - Jie Dong
- Renal Division, Department of Medicine, Peking University First Hospital; Institute of Nephrology, Peking University; Key Laboratory of Renal Disease, Ministry of Health; Key Laboratory of Renal Disease, Ministry of Education; Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
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18
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Adanan NIH, Adnan WAHWM, Khosla P, Karupaiah T, Daud ZAM. Exploring the experiences and perceptions of haemodialysis patients observing Ramadan fasting: a qualitative study. BMC Nephrol 2021; 22:48. [PMID: 33530941 PMCID: PMC7851908 DOI: 10.1186/s12882-021-02255-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 01/08/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND The festival of Ramadan is a month of spiritual reflection for Muslims worldwide. During Ramadan, Muslims are required to refrain from eating and drinking during daylight hours. Although exempted from fasting, many patients undergoing maintenance haemodialysis (HD) opt to participate in this religious practice. Many studies have explored the effects of Ramadan on health outcomes, however, the exploration from patients' own point of view pertaining to this religious practice is lacking. Thus, we aimed to explore the experiences and perceptions of Muslim HD patients observing Ramadan fasting from three HD centres in Klang Valley, Malaysia. METHOD An exploratory phenomenology qualitative study was conducted whereby subjects were purposively selected based on previous experience in observing Ramadan fasting. Face-to-face in-depth interviews were conducted, and study data were analyzed thematically and iteratively coded using a constant comparison method. RESULTS Four major themes emerged from the data, namely: (i) "fasting experiences", (ii) "perceived side effects of fasting", (iii) "health-seeking behavior" and, (iv) "education and awareness needs". Patients expressed the significance of Ramadan fasting as well as the perceived impact of fasting on their health. Additionally, there is lack of health-seeking behaviour observed among patients thus, raising needs for awareness and education related to Ramadan fasting. CONCLUSIONS Findings of this study shed light on patients' experiences and perceptions regarding Ramadan fasting which warrants the needs for an effective communication between patients and health care practitioners through a structured-Ramadan specific education program.
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Affiliation(s)
- Nurul Iman Hafizah Adanan
- Department of Dietetics, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, UPM, 43400, Serdang, Selangor, Malaysia
| | | | - Pramod Khosla
- Department of Nutrition and Food Science, Wayne State University, Detroit, MI, USA
| | | | - Zulfitri Azuan Mat Daud
- Department of Dietetics, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, UPM, 43400, Serdang, Selangor, Malaysia.
- Research Center of Excellent Nutrition and Non-communicable Diseases, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia.
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19
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Sualeheen A, Khor BH, Balasubramanian GV, Sahathevan S, Ali MSM, Narayanan SS, Chinna K, Daud ZAM, Khosla P, Gafor AHA, Karupaiah T, Cheak BB, Ahmad G, Goh BL, Lim SK, Visvanathan R, Yahya R, Bavanandan S, Morad Z. Habitual Dietary Patterns of Patients on Hemodialysis Indicate Nutritional Risk. J Ren Nutr 2020; 30:322-332. [DOI: 10.1053/j.jrn.2019.09.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 09/05/2019] [Accepted: 09/15/2019] [Indexed: 02/07/2023] Open
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20
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Vitamin B 12 status in kidney transplant recipients: association with dietary intake, body adiposity and immunosuppression. Br J Nutr 2019; 122:450-458. [PMID: 31280734 DOI: 10.1017/s0007114519001417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The aim of the present study was to evaluate the prevalence of vitamin B12 (B12) deficiency in kidney transplant recipients (KTR) and its possible association with B12 dietary intake, body adiposity and immunosuppressive drugs. In this cross-sectional study, we included 225 KTR, aged 47·50 (sd 12·11) years, and 125 (56 %) were men. Serum levels of B12 were determined by chemiluminescent microparticle intrinsic factor assay and the cut-off of 200 pg/ml was used to stratify KTR into B12-sufficient or B12-deficient group. B12 dietary intake was evaluated by three 24 h dietary recalls and was considered adequate when ≥2·4 μg/d. Body adiposity was estimated after taking anthropometric measures and using the dual-energy X-ray absorptiometry (DXA) method. B12 deficiency was seen in 14 % of the individuals. B12-deficient group, compared with the B12-sufficient group, exhibited lower intake of B12 (median 2·42 (interquartile range (IQR) 1·41-3·23) v. 3·16 (IQR 1·94-4·55) μg/d, P = 0·04) and higher values of waist circumference (median 96·0 (IQR 88·0-102·5) v. 90·0 (IQR 82·0-100·0) cm, P = 0·04). When the analysis included only women, B12 deficiency was associated with higher total and central body adiposity measurements obtained with anthropometry (BMI, body adiposity index, waist and neck circumferences) and DXA (total and trunk body fat). Among individuals with adequate intake of B12, the deficiency of this vitamin was more frequently seen in those using mycophenolate mofetil (MMF) (17 %) v. azathioprine (2 %), P = 0·01. In conclusion, the prevalence of B12 deficiency in KTR was estimated as 14 % and was associated with reduced intake of B12 as well as higher adiposity, especially in women, and with the use of MMF.
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21
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Abstract
In the United States, end-stage renal disease patients receiving hemodialysis have an exceedingly high risk of sudden cardiac death (SCD), accounting for 29% of death events, likely relating to their uremic milieu, recurring exposure to fluid and electrolyte fluxes, and underlying cardiovascular pathology. Furthermore, epidemiologic studies have shown that SCD events, as well as mortality and hospitalizations, occur most frequently on the first dialysis day after the long interdialytic gap, suggesting that abrupt fluctuations in the accumulation and removal of electrolytes, fluid, and uremic toxins over the dialysis cycle may be contributory. Some population-based observational studies have suggested that lower dialysate potassium concentrations appear to be associated with a heightened risk of postdialysis cardiac arrest in hemodialysis patients, although the optimal serum-to-dialysate potassium gradient remains unclear. Some observational studies have suggested that low dialysate calcium concentrations and high serum-to-dialysate calcium gradients may predispose patients to SCD. There is ongoing controversy about an association between higher dialysate bicarbonate concentrations and higher risk of cardiac arrest, likely owing to confounding by indication. Some observational studies also have shown that large interdialytic weight gains, fluid retention, and high ultrafiltration rates are linked with higher risk of SCD and mortality. However, there remains considerable controversy regarding the pros and cons of designating a specific upper ultrafiltration limit with extended treatment times as a clinical practice measure, and further studies are needed to define the optimal tools, metrics, targets, and implementation measures for volume control in the hemodialysis population. In this review, we highlight the epidemiology and pathophysiology of how specific aspects of the hemodialysis procedure may relate to the risk of SCD, as well as preventative strategies and future research directions that can address this risk.
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22
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Piccoli GB, Cabiddu G, Breuer C, Jadeau C, Testa A, Brunori G. Dialysis Reimbursement: What Impact Do Different Models Have on Clinical Choices? J Clin Med 2019; 8:jcm8020276. [PMID: 30823518 PMCID: PMC6406585 DOI: 10.3390/jcm8020276] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 02/14/2019] [Accepted: 02/21/2019] [Indexed: 12/15/2022] Open
Abstract
Allowing patients to live for decades without the function of a vital organ is a medical miracle, but one that is not without cost both in terms of morbidity and quality of life and in economic terms. Renal replacement therapy (RRT) consumes between 2% and 5% of the overall health care expenditure in countries where dialysis is available without restrictions. While transplantation is the preferred treatment in patients without contraindications, old age and comorbidity limit its indications, and low organ availability may result in long waiting times. As a consequence, 30–70% of the patients depend on dialysis, which remains the main determinant of the cost of RRT. Costs of dialysis are differently defined, and its reimbursement follows different rules. There are three main ways of establishing dialysis reimbursement. The first involves dividing dialysis into a series of elements and reimbursing each one separately (dialysis itself, medications, drugs, transportation, hospitalisation, etc.). The second, known as the capitation system, consists of merging these elements in a per capita reimbursement, while the third, usually called the bundle system, entails identifying a core of procedures intrinsically linked to treatment (e.g., dialysis sessions, tests, intradialyitc drugs). Each one has advantages and drawbacks, and impacts differently on the organization and delivery of care: payment per session may favour fragmentation and make a global appraisal difficult; a correct capitation system needs a careful correction for comorbidity, and may exacerbate competition between public and private settings, the latter aiming at selecting the least complex cases; a bundle system, in which the main elements linked to the dialysis sessions are considered together, may be a good compromise but risks penalising complex patients, and requires a rapid adaptation to treatment changes. Retarding dialysis is a clinical and economical goal, but the incentives for predialysis care are not established and its development may be unfavourable for the provider. A closer cooperation between policymakers, economists and nephrologists is needed to ensure a high quality of dialysis care.
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Affiliation(s)
- Giorgina Barbara Piccoli
- Department of Clinical and Biological Sciences, University of Torino Italy, 10100 Torino, Italy.
- Nephrologie, Centre Hospitalier Le Mans, 72000 Le Mans, France.
| | | | - Conrad Breuer
- Direction, Centre Hospitalier Le Mans, 72000 Le Mans, France.
| | - Christelle Jadeau
- Centre de Recherche Clinique, Centre Hospitalier Le Mans, 72000 Le Mans, France.
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