Which diet for which renal failure: making sense of the options

Logistic Regression Model in a Machine Learning Application to Predict Elderly Kidney Transplant Recipients with Worse Renal Function One Year after Kidney Transplant: Elderly KTbot

Background

Renal replacement therapy (RRT) is a public health problem worldwide. Kidney transplantation (KT) is the best treatment for elderly patients' longevity and quality of life.

Objectives

The primary endpoint was to compare elderly versus younger KT recipients by analyzing the risk covariables involved in worsening renal function, proteinuria, graft loss, and death one year after KT. The secondary endpoint was to create a robot based on logistic regression capable of predicting the likelihood that elderly recipients will develop worse renal function one year after KT.

Method

Unicentric retrospective analysis of a cohort was performed with individuals aged ≥60 and <60 years old. We analysed medical records of KT recipients from January to December 2017, with a follow-up time of one year after KT. We used multivariable logistic regression to estimate odds ratios for elderly vs younger recipients, controlled for demographic, clinical, laboratory, data pre- and post-KT, and death.

Results

18 elderly and 100 younger KT recipients were included. Pretransplant immune variables were similar between two groups. No significant differences (P > 0.05) between groups were observed after KT on laboratory data means and for the prevalences of diabetes mellitus, hypertension, acute rejection, cytomegalovirus, polyomavirus, and urinary infections. One year after KT, the creatinine clearance was higher (P = 0.006) in youngers (70.9 ± 25.2 mL/min/1.73 m²) versus elderlies (53.3 ± 21.1 mL/min/1.73 m²). There was no difference in death outcome comparison. Multivariable analysis among covariables predisposing chronic kidney disease epidemiology collaboration (CKD-EPI) equation <60 mL/min/1.73 m² presented a statistical significance for age ≥60 years (P = 0.01) and reduction in serum haemoglobin (P = 0.03). The model presented goodness-fit in the evaluation of artificial intelligence metrics (precision: 90%; sensitivity: 71%; and F ₁ score: 0.79).

Conclusion

Renal function in elderly KT recipients was lower than in younger KT recipients. However, patients aged ≥60 years maintained enough renal function to remain off dialysis. Moreover, a learning machine application built a robot (Elderly KTbot) to predict in the elderly populations the likelihood of worse renal function one year after KT.

Experiences of people of Acadian descent receiving hemodialysis in southwest Nova Scotia

We conducted a group interview with five hemodialysis patients of Acadian descent. Our purpose was to learn about their intakes of Acadian foods so we could tailor our advice for other Acadian patients receiving hemodialysis. This approach builds on evidence that addressing cultural aspects of food choice and aligning dietary recommendations with usual intakes create optimal conditions for diet adherence while preserving personal habits and heritage. In this study, "the Acadian diet" held multiple meanings for different participants, participants varied in their intakes of traditional Acadian foods, intakes of traditional Acadian foods were decreasing in younger generations, and the desire to preserve kidney function had priority over eating much-loved traditional foods. These findings support the practices of individualized nutritional and dialysis care and discourage generalized nutrition messages based on assumptions of homogeneity of all people within a cultural group.

The effects of boiling and leaching on the content of potassium and other minerals in potatoes

The white potato (Solanum tuberosum L.) is a valuable source of potassium in the human diet. While most consumers benefit from high levels of potassium in potato tubers, individuals with compromised kidney function must minimize their potassium intake. This study was undertaken to determine the effects of leaching and boiling on levels of potassium and other minerals in potato tubers. Leaching alone did not significantly reduce levels of potassium or other minerals in tubers. Boiling tuber cubes and shredded tubers decreased potassium levels by 50% and 75%, respectively. Reductions in mineral amounts following boiling were observed for phosphorus, magnesium, sulfur, zinc, manganese, and iron. There was no difference between the leaching and boiling treatment and the boiling treatment. In addition, mineral levels in tubers of 6 North American potato cultivars are reported. Significant differences in mineral levels were detected among cultivars, but they were too small to be nutritionally important. Individuals wishing to maximize the mineral nutrition benefits of consuming potatoes should boil them whole or bake, roast, or microwave them. Those who must reduce potassium uptake should boil small pieces before consuming them.

Medical nutrition therapy in chronic kidney failure: Integrating clinical practice guidelines

This review updates earlier published recommendations and integrates current clinical practice guidelines for nutritional care in chronic kidney disease as recommended by the National Kidney Foundation Kidney Dialysis Outcome Quality Initiative (K/DOQI). The scope covers chronic kidney disease in adults prior to kidney failure (Stages 1-4), chronic kidney failure with hemodialysis or peritoneal dialysis replacement therapy (Stage 5), and management after kidney transplantation. Multiple diet parameters are necessary to provide optimal nutritional health, including monitoring of calories, protein, sodium, fluid, potassium, calcium, and phosphorus, as well as other individualized nutrients. Emphasis is placed on continuity of care within changing kidney function and treatment modality status. The rising incidence of chronic kidney disease will increase the probability of the non-renal specialist dietetics professional delivering care to this patient population.

A new approach to classifying malnutrition in the hemodialysis patient

BACKGROUND

Novel classification nomenclature defining the type of malnutrition by the root cause of the hypoalbuminenia has been developing in the literature since 1999. As the classification of malnutrition became more definite in the literature, the need to assess the type of malnutrition, thereby the root cause(s) and initiate appropriate intervention(s), has become apparent.

METHODS

In September 1999, San Diego Dialysis began a continuous quality improvement (CQI) project to assess the root causes of hypoalbuminemia for patients with serum albumin level <3.5 g/dL. An extensive review of the literature was conducted on the subject of malnutrition, inflammation, and the acute-phase reaction.

FINDINGS

Two major groups of patients emerged: those consuming adequate protein and calories, yet presenting with hypoalbuminemia, and those suffering from a protein calorie deficit. Observation of the second group showed that although the monthly percentage of patients with hypoalbuminemia remained fairly constant, the names on the list changed from month to month.

CONCLUSIONS

The CQI team developed a protocol and a unique nomenclature to classify the types of malnutrition, type I, type IIa, type IIb, or mixed, by adapting the definitions in the literature through clinical practice. Interventions were developed to address each classification of malnutrition.

Secondary prevention with antioxidants of cardiovascular disease in endstage renal disease (SPACE): randomised placebo-controlled trial

BACKGROUND

Excess cardiovascular mortality has been documented in chronic haemodialysis patients. Oxidative stress is greater in haemodialysis patients with prevalent cardiovascular disease than in those without, suggesting a role for oxidative stress in excess cardiovascular disease in haemodialysis. We investigated the effect of high-dose vitamin E supplementation on cardiovascular disease outcomes in haemodialysis patients with pre-existing cardiovascular disease.

METHODS

Haemodialysis patients with pre-existing cardiovascular disease (n=196) aged 40-75 years at baseline from six dialysis centres were enrolled and randomised to receive 800 IU/day vitamin E or matching placebo. Patients were followed for a median 519 days. The primary endpoint was a composite variable consisting of: myocardial infarction (fatal and non-fatal), ischaemic stroke, peripheral vascular disease (excluding the arteriovenous fistula), and unstable angina. Secondary outcomes included each of the component outcomes, total mortality, and cardiovascular-disease mortality.

FINDINGS

A total of 15 (16%) of the 97 patients assigned to vitamin E and 33 (33%) of the 99 patients assigned to placebo had a primary endpoint (relative risk 0.46 [95% CI 0.27-0.78], p=0.014). Five (5.1%) patients assigned to vitamin E and 17 (17.2%) patients assigned to placebo had myocardial infarction (0.3 [0.11-0.78], p=0.016). No significant differences in other secondary endpoints, cardiovascular disease, or total mortality were detected.

INTERPRETATION

In haemodialysis patients with prevalent cardiovascular disease, supplementation with 800 IU/day vitamin E reduces composite cardiovascular disease endpoints and myocardial infarction.

Can low-fat/cholesterol nutrition counseling improve food intake habits and hyperlipidemia of renal transplant patients?

OBJECTIVE

To assess the impact of low-fat/cholesterol nutrition counseling on food intake habits and blood lipid levels of renal transplant patients.

DESIGN

Prospective practice-based outcome study.

SETTING

Acute care hospital post-renal transplant outpatient clinic.

PATIENTS

Forty-three renal transplant patients not on lipid-lowering medications referred to the renal dietitian for low-fat/cholesterol nutrition counseling between September 1994 and September 1997.

INTERVENTION

Individual assessment and counseling using the Healthy Heart Nutrition Guidelines Step 1 diet (<30% of total calories from fat, <300 mg cholesterol, and <10% of total calories from saturated fatty acids).

MAIN OUTCOME MEASURES

Three-day food records precounseling and 3-day food records (n = 13) or descriptive intake changes (n = 30) postcounseling (time interval: 2 to 8 months). Fasting/random serum total cholesterol, high-density lipoprotein-cholesterol (HDL-C), and low-density lipoprotein-cholesterol (LDL-C), as available.

RESULTS

Total cholesterol (n = 43) and LDL-C (n = 22) decreased significantly (0. 54 mmol/L P <.000 and 0.53 mmol/L P <.000, respectively). There were no significant changes in HDL-C and triglycerides. Twenty percent of patients (n = 43) reached target levels of total cholesterol <5.2 mmol/L, and 35% of patients (n = 22) reached target levels of LDL-C <3.4 mmol/L. Percentage of total calories from fat decreased significantly (7.58% P <.03). Descriptive intake changes of lower fat choices were reported in the no post-food records group.

CONCLUSION

Patients can make changes in food intake habits after nutrition counseling. Serum lipid levels can improve after nutrition counseling, but many patients may still require lipid lowering medications to reach target levels. Nutrition counseling should be considered for the initial treatment of hyperlipidemia in renal transplant patients.

The interdisciplinary team's approach to lupus nephritis

The interdisciplinary team approach in assessment and treatment of patients with chronic disease in general and lupus nephritis in particular provides a global format for identifying the multiple problem areas that retard or prevent optimal patient functioning. These areas include the physical, emotional, economic, psychosocial, and functional. Benefits to the individual patient include a thorough multifaceted assessment by professionals who have the benefit of peer collaboration and validation. This increases the likelihood that the whole patient is considered, not just the problem of nephritis. For example, how does the patient and her or his family cope with the impact of such a disease and how, in turn, do the coping abilities of the patient and family affect the disease. The interdisciplinary team also assesses how the treatment strategies for each problem area influence each other. Finally, the interdisciplinary team serves as a positive role model for effective collaboration among health professionals and for students in their respective disciplines.

Energy supplementation in chronic hemodialysis patients with moderate and severe malnutrition

OBJECTIVE

Prospectively evaluate the effect on the nutritional status of a glucose polymer as energy supplementation alone in chronic hemodialysis patients with moderate and severe malnutrition.

MATERIAL AND METHODS

The nutritional status of 55 hemodialysis patients was assessed by using a score that included Iron binding capacity, albumin, cholesterol, body mass index, mid brachial circumference, arm muscle area, triceps skinfold, and clinical impression. Twenty-two of 27 patients (14 men and 8 women, mean age 43 +/- 15 years, time on dialysis 65 +/- 49 months) were classified as moderately or severely malnourished and were supplemented for 6 months with 100 g of glucose polymers per day (equivalent to 380 kcal or 1590 kJ) added to the usual food intake. The patients were reevaluated at 3 and 6 months.

RESULTS

Only body weight, body mass index, triceps skinfold, and brachial circumference and clinical impression increased significantly at the end of the third month (P < .05) in the 22 patients. These results were confirmed at 6 months in 18 patients that completed the study. Mean body weight increase was 2.4 kg (range, .2 to 6.3 kg). The nutritional status, evaluated through the score, improved in only 4 patients at the end of the study. Few gastrointestinal side effects were observed. Triglycerides increased from 136 +/- 40 mg/dL to 235 +/- 120 mg/dL. Follow-up of the patients showed that fat mass (assessed by anthropometry) was maintained for 6 months after supplementation was discontinued.

CONCLUSION

Energy supplementation alone in patients with moderate and severe malnutrition on chronic hemodialysis resulted in an increase in body weight, owing to an increase in body fat, but the nutritional status did not improve.

Renal disease and diet therapy in the elderly

Renal disease is a disease closely associated with aging. Although kidney disease can occur at any age, the prevalence and severity of renal disease is far more prominent in the elderly. As the geriatric population continues to grow, nurses can anticipate treating significant numbers of elderly people with renal disease. Research suggests that with early dietary intervention the progression of renal disease can be altered. Therefore, knowledge of the characteristics and goals of diet therapy are necessary to provide effective client education and promote compliance.

Potential benefits of resistance exercise training on nutritional status in renal failure

Resistance or strength exercise training may help reverse the malnutrition common among patients in chronic renal failure and delay the progression of renal disease. Resistance training is characterized by resisting, lifting, and lowering weights. It results in muscle mass accretion, improved physical function, and slowed progression of muscle wasting. Resistance exercise training for a period of 8 to 12 weeks results in significant increases in muscle mass, muscle strength, and muscle function in frail "healthy" elderly individuals as well as in specific patient populations. States of malnutrition leading to muscle wasting directly affect lean tissue mass and functional capacity. Even at dietary protein intake below the Recommended Dietary Allowances, resistance training appears to exert an anabolic effect by improving energy intake and protein use allowing nitrogen retention. The potential benefits of resistance exercise extend beyond this direct impact on protein metabolism. They include improvements in functional capacity such as gait, balance, mobility, strength, exercise tolerance, improved glucose uptake, insulin sensitivity, and self-efficacy and self-esteem. Currently, the effects of resistance exercise in renal patients are unknown, although they are well shown in the case of other diseases. The potential benefits that resistance exercise training may have on muscle mass and function, nutritional status, hyperglycemia, disease progression, and the overall mental well-being of renal patients deserve further investigation. As an adjunct to current treatment modalities for chronic renal failure, resistance exercise may serve as a cost-effective, interdisciplinary, noninvasive approach to counteract malnutrition and improve the quality of life.

Adaptation of African-American cultural and food preferences in end-stage renal disease diets

Emphasis on culturally based and ethnically oriented food selection by nutrition health professionals is needed to effectively plan therapeutic diets. With the influx of numerous ethnic groups into the United States and the merging of cultural practices, it is important for dietitians to become familiar with specific ethnic foods and regional cooking techniques. In this review, the influence of immigration on regional cuisine is documented. Dominant patterns of typical African-American ethnic menus for holidays and special celebrations are revealed. Analysis of common foods in the African-American culture are listed for reference, along with a glossary of ethnic foods. Renal guidelines are presented for various stages of end-stage renal disease. When planning a specific renal diet, African-American ethnic preferences can be incorporated into the meal plan or appropriate substitutions can be recommended. A suggested sample menu for hemodialysis patients that incorporates African-American preferences is included for reference. Health risks also influence current eating trends of the African-American population. Hypertension and obesity are two physiological factors that need to be evaluated and considered when planning renal diets. Literacy skills and appropriate dietary instructional material is discussed. Reference materials developed for nutrition professionals are important and can be used in the planning of renal diets for African-Americans.

Regression equation predicts dietary phosphorus intake from estimate of dietary protein intake

OBJECTIVE

To develop a predictive equation for dietary phosphorus intake.

DESIGN

In this clinic-based, cross-sectional study, a dietitian-administered food frequency questionnaire provided dietary intake estimates for a population of patients with chronic renal failure. A prediction equation for dietary phosphorus intake was developed and was validated on another sample of patients with CRF from the same clinic.

SUBJECTS

Outpatients treated for chronic renal failure at the E. Wolfson Medical Center Institute of Nephrology in Holon, Israel, participated in the study (N = 104, 73 men and 31 women, mean age = 65.6 years). The validation sample consisted of 53 outpatients with chronic renal failure (38 men and 15 women, mean age = 64.2 years) from the same clinic.

MAIN OUTCOME MEASURES

Dietary variables (ie, energy, protein, carbohydrate, fat, phosphorus) were examined in terms of crude intake, as percentage of total energy intake, and per kilogram of body weight.

STATISTICAL ANALYSES PERFORMED

Stepwise linear regression analysis and Student's t tests were used to examine relationships between dietary phosphorus and other variables.

RESULTS

Dietary phosphorus (milligrams) = 128 + 14 (protein intake [grams]) was the best-fitting equation and explained 84% of the variance in dietary phosphorus intake.

APPLICATIONS

The prediction equation for dietary phosphorus intake is especially useful for renal dietitians who calculate patient diets by hand.