Modality-specific nutrition support in ESRD: weighing the evidence

The Effect of Intradialytic Intralipid Therapy in Pediatric Hemodialysis Patients

OBJECTIVE

Growth of children on maintenance hemodialysis is poor. Oral nutritional supplements are the preferred way to augment nutrition; however, many children have difficulties adhering to prescribed oral supplements. In our unit, we have been utilizing intralipid (IL) therapy as nutritional supplement during hemodialysis sessions. The aim of this study was to assess the safety, efficacy, and benefits of intradialytic IL therapy.

DESIGN

A retrospective chart review.

SUBJECTS

Fifteen pediatric hemodialysis patients receiving intradialytic IL therapy for at least 3 months from July 2011 through July 2014.

MAIN OUTCOME MEASURE

For each patient, anthropometric measurements and laboratory nutritional parameters were compared prior to and at the end of IL therapy. Anthropometric measurements evaluated were dry weight, height, body mass index (BMI), and BMI corrected for height age. Laboratory nutritional parameters evaluated were albumin, normalized protein catabolic rate, predialysis blood urea nitrogen, transferrin, cholesterol, and triglyceride levels. Adverse events during therapy were also noted.

RESULTS

Significant improvement was noted in albumin levels, predialysis blood urea nitrogen, and normalized protein catabolic rate during therapy (P = .02; P = .03; P = .03, respectively). Six patients (37.5%) improved their weight standard deviation score, and eight patients (50%) improved their BMI standard deviation score though not statistically significant (P = .59; P = .9, respectively). No significant side effects were noted.

CONCLUSIONS

Administration of IL alone during hemodialysis is well tolerated with beneficial effects on nutritional parameters. The provision of IL alone is relatively cheap and does not require additional resources. In conjunction with other measures of nutritional support, it can help improve nutritional status of pediatric hemodialysis patients.

Plasma gelsolin and circulating actin correlate with hemodialysis mortality

Plasma gelsolin (pGSN) binds actin and bioactive mediators to localize inflammation. Low pGSN correlates with adverse outcomes in acute injury, whereas administration of recombinant pGSN reduces mortality in experimental sepsis. We found that mean pGSN levels of 150 patients randomly selected from 10,044 starting chronic hemodialysis were 140 +/- 42 mg/L, 30 to 50% lower than levels reported for healthy individuals. In a larger sample, we performed a case-control analysis to evaluate the relationship of pGSN and circulating actin with mortality; pGSN levels were significantly lower in 114 patients who died within 1 yr of dialysis initiation than in 109 survivors (117 +/- 38 mg/L versus 147 +/- 42 mg/L, P < 0.001). pGSN levels had a graded, inverse relationship with 1-yr mortality, such that patients with pGSN < 130 mg/L experienced a > 3-fold risk for mortality compared with those with pGSN > or = 150 mg/L. The 69% of patients with detectable circulating actin had lower pGSN levels than those without (127 +/- 45 mg/L versus 141 +/- 36 mg/L, P = 0.026). Compared with patients who had elevated pGSN and no detectable actin, those with low pGSN levels and detectable actin had markedly increased mortality (odds ratio 9.8, 95% confidence interval 2.9 to 33.5). Worsening renal function correlated with pGSN decline in 53 subjects with CKD not on dialysis. In summary, low pGSN and detectable circulating actin identify chronic hemodialysis patients at highest risk for 1-yr mortality.

Predictors of hospitalization in patients on peritoneal dialysis: the Missouri experience

BACKGROUND

We analyzed a large number of demographic and biochemical variables to identify predictors of hospitalization in subjects on peritoneal dialysis (PD).

METHODS

All patients initiated on PD at our center from January 1990 through December 1999 were included. The following variables at the initiation of PD were included: demographics, clinical data, nutritional and adequacy parameters, transport characteristics, and various co-morbidities. Co-morbidities were graded for severity using a modified version of the Index of Coexistent Disease. Variables included during the course of PD consisted of weighted time average of a number of laboratory, adequacy, and nutritional parameters along with the number of peritonitis episodes per year. Stepwise linear regression was used following a univariate screening procedure to identify independent predictors of the outcome of hospitalization days per month on PD.

RESULTS

The subject population consisted of 191 subjects (105 men, 86 women; 180 Caucasians, 10 African-American, 1 Asian). The mean age was 61 +/- 13 (SD) years and mean duration of follow-up was 21 +/- 18 months. The baseline variable analysis revealed that the presence of partner to perform PD predicted increased hospitalization (p < 0.0001). Additionally, the presence and severity of peripheral vascular disease and residual renal Kt/V at baseline (negative association) predicted increased hospitalization. In the analyses of ongoing variables, stepwise linear regression solely identified weighted time average albumin as a strong negative predictor of hospitalization (p < 0.0001).

CONCLUSION

A comprehensive analysis of a large number of variables revealed that serum albumin during the course of PD (negative association) and the need for partner to perform PD strongly predicted increased hospitalization in PD subjects.

Health-related quality of life among haemodialysis patients--relationship with clinical indicators, morbidity and mortality

AIM

To verify the association between quality of life and morbidity, mortality and clinical indicators in haemodialysis patients.

BACKGROUND

While a number of therapies have been reported to increase quality of life in end-stage renal disease, patients report that they remain substantially burdened by limited physical functioning and by dialysis-related symptoms. Indeed, quality of life may be the most critical outcome for those undergoing haemodialysis. Furthermore, quality of life has been associated with clinical indicators, morbidity and survival in haemodialysis patients.

DESIGN

Descriptive cohort study of patients undergoing haemodialysis at the Nephrology Hemodialysis Unit of the Hospital de Clínicas in Porto Alegre, Brazil.

METHODS

Forty haemodialysis patients were followed for 12 months and evaluated for demographics, time on dialysis, diabetes mellitus, clinical indicators (dose of dialysis--Kt/V, haematocrit and serum albumin) and comorbidities. The comorbidities were evaluated with the end-stage renal disease severity index and health-related quality of life with The Medical Outcomes Study 36 (SF-36).

RESULTS

Men present higher health-related quality of life scores in the energy and fatigue component (P = 0.04). Patients treated for over one year at the beginning of follow up and patients with less schooling had better results in General Health Perception (P < 0.05). The health-related quality of life evaluation of patients who later died showed that they already had a worse perception of physical functioning as compared to the survivors (P = 0.05). Patients with diagnosed diabetes perceived their physical functioning more negatively compared with those with other etiologies of end-stage renal disease (P = 0.045). We found a correlation between physical functioning and serum albumin (r = 0.341, P < 0.05) and between physical functioning and haematocrit (r = 0.317, P < 0.05). The end-stage renal disease severity index was more strongly related to physical functioning (r = -0.538, P < 0.001). Comparing the patients' results to the indicators above and below the established targets, we observed a trend to worse health-related quality of life in patients with Kt/V above target. However, in the case of albumin, patients with results above target tended to have better results.

CONCLUSION

A close relationship was observed between quality of life and morbidity and mortality. Among the clinical indicators, albumin and haematocrit have the greatest influence on quality of life.

RELEVANCE TO CLINICAL PRACTICE

Haemodialysis patients experience various problems that may adversely influence their quality of life. Special care must be given to those who have diabetes mellitus, high morbidity scores, low serum albumin and low haematocrits.

Predictors of death in patients on peritoneal dialysis: the Missouri Peritoneal Dialysis Study

BACKGROUND

The study was designed to identify predictors of death in subjects on peritoneal dialysis (PD).

METHODS

The population consisted of patients initiated on PD at the University of Missouri-Columbia and Dialysis Clinic Incorporated from January 1, 1990, through December 31, 1999. Baseline variables included demographics, clinical data, initial measures of nutritional status, adequacy, and transport characteristics. Co-morbidities were scored using a modified version of the Index of Coexistent Disease. Ongoing (during the course of PD) variables consisted of clinical characteristics and weighted time average of a number of laboratory, adequacy, and nutritional variables. The variables were screened using a univariate procedure, and then analyzed using stepwise logistic regression to evaluate their independent relation to death.

RESULTS

There were 105 men and 86 women--180 Caucasians, 10 African-American, 1 Asian, mean age 61 +/- 13 (SD) years, and mean duration of follow-up 21 +/- 18 months. Eighty-two patients suffered the outcome of death. Lean body mass (LBM) at the initiation of PD was negatively associated with the risk of death (p < 0.01). In addition, the need for a partner to perform PD, total morbidity count, and the summated severity score of all co-morbidities were associated with an increased risk of death. The analysis of ongoing variables revealed that serum phosphate (negative association, p = 0.02) and number of hospitalization days per month on PD (p = 0.0006) were associated with an increased risk of death.

CONCLUSION

Phosphate levels and LBM are strong negative predictors of death in PD subjects. Further, patients who need the assistance of a partner to perform PD have decreased survival.

Intradialytic Parenteral Nutrition Treatment and Biochemical Marker Assessment for Malnutrition in Adolescent Maintenance Hemodialysis Patients

Protein-energy malnutrition (PEM) is a significant cause of morbidity and mortality for patients receiving maintenance hemodialysis. Minimal study has evaluated therapeutic options for and biochemical marker assessment of pediatric patient PEM. In 2001, we expanded the indications for intradialytic parenteral nutrition (IDPN) treatment of PEM to all maintenance hemodialysis patients, regardless of etiology, who had a >10% weight loss and were at less than the 90th percentile of ideal body weight. Nine patients received thrice weekly IDPN from 3 to 22 months with minimal side effects. Six patients had weight and body mass index increase, 1 patient stopped losing weight, and 2 patients continued to lose weight during the initial 5 months of IDPN therapy. Cohort subanalysis showed that all patients with organic PEM responded to IDPN therapy, whereas patients with psychosocial causes of PEM did not. The normalized protein catabolic rate increased significantly for patients whose condition responded to IDPN therapy, whereas serum albumin did not change. The current study suggests that IDPN is effective treatment of organic causes of PEM in pediatric patients receiving maintenance hemodialysis and that normalized protein catabolic rate may be superior to serum albumin as a marker of nutrition status. The observation that IDPN was not sufficient to reverse PEM in patients with psychosocial PEM causes should direct caregivers to address the relevant underlying causes as well as to provide intensive nutrition therapy.

C-reactive protein and end-stage renal disease

The significance of CRP and inflammation has increased over time, especially in the end-stage renal disease (ESRD) population. From a simple marker it now appears that CRP is an active participant in pro-atherosclerotic phenomenon including local pro-inflammatory and thrombotic events. Studies in the general population indicate the usefulness of CRP in prognostication and in monitoring response to therapy. The clinical usefulness of CRP monitoring in chronic kidney disease (CKD) and especially in ESRD deserves closer study. In the meantime, the utility of CRP measurements for monitoring and treatment is on a case-by-case basis. Management of traditional cardiovascular risk factors should be considered. In the interest of optimizing therapy it is prudent to use biocompatible membranes and ultrapure water. A careful search for infectious processes in dialysis patients is recommended, with special attention to vascular access sites, periodontitis, gastritis, and other potentially chronic or covert infections. ACE-inhibitor use should be maximized in all eligible CKD patients. The data on the use of statins in ESRD have been generally positive but await further validation. Individualized use for selected patients is probably beneficial.

Malnutrition in Patients Undergoing Hemodialysis: Is Intradialytic Parenteral Nutrition the Answer?

Patients with end-stage renal disease often experience malnutrition as a result of decreased dietary intake; inadequate dialysis; loss of nutrients into the dialysate; abnormal protein, carbohydrate, and lipid metabolism; and concomitant diseases, which may contribute to an increase in morbidity and mortality. Intradialytic parenteral nutrition (IDPN) is being used to improve nutritional status, in conjunction with other methods of nutritional supplementation. The biggest advantage of IDPN is probably its convenience since it is administered during dialysis treatment and thus does not require additional clinic visits or prolonged dialysis time. Although IDPN has several disadvantages, its ability to improve nutritional status and reduce morbidity and mortality in patients with end-stage renal disease is promising. Well-designed, large-scale, prospective studies are required to confirm its beneficial effects.

The impact of nutrition intervention on a reliable morbidity and mortality indicator: the hemodialysis-prognostic nutrition index

OBJECTIVE

To determine the prevalence of risk for hospitalization in hemodialysis (HD) patients and examine the impact of oral kilocalorie and protein supplementation in two Midwestern outpatient dialysis centers.

DESIGN/SETTING

This was a prospective intervention study conducted at 2 outpatient dialysis centers in the Midwest.

PATIENTS

The inclusion criteria for patients were (1) more than 18 years of age, (2) receiving HD 3 times per week, and (3) a functioning gastrointestinal tract.

INTERVENTION

Patients who met study criteria and signed an informed consent form were screened using the hemodialysis prognostic nutrition index (HD-PNI) to determine risk for hospitalization. Patients determined to be at high risk (HD-PNI > or =0.8) were included in the treatment group, and patients at low risk did not receive the intervention. They followed their normal nutritional regimen. The intervention group received an oral supplement daily for 3 months. The team of the dietitian, patient, researcher, and physician determined the type of oral supplements based on patient needs and preferences.

MAIN OUTCOME MEASURES

Before and after HD-PNI, 24-hour recall and subjective global assessments (SGA) were conducted to assess risk for hospitalization, dietary intake, and nutritional status, respectively.

RESULTS

A total of 117 patients were screened, with a total of 26 in the treatment group (high risk) and 91 in the low-risk group. Baseline SGA distribution was 23% for patients with low nutritional risk (group A), 64% for those with moderate nutritional risk (group B), and 13% for those with severe nutritional risk (group C). When the HD-PNI scores of the treatment group were analyzed using paired t-tests, significant differences were observed between pre- and post-HD-PNI mean scores, 1.92 +/- 1.16 and 1.42 +/- 1.59, (P <.05) respectively. When comparing the responders versus the nonresponders by the dependent and independent variables (pre- and post-HD-PNI, SGA, kilocalorie intake, diabetic status, and presence of hypertension) only post-HD-PNI score was significantly different (0.96 +/- 1.69 and 2.20 +/- 1.09, respectively).

CONCLUSION

This study succeeded in showing that 22% of the hemodialysis patients in 2 Midwestern centers were at an increased risk for hospitalization. Furthermore, dietitian intervention with oral kilocalorie and protein supplements decreased the patients' hemodialysis prognostic nutrition index scores and thereby decreased the patients' risks for hospitalization.

Practical aspects of intradialytic nutritional support

A critical review of recent international literature related to the use of intradialytic parenteral nutrition is given. The role of intradialytic parenteral nutrition as a therapy in malnourished hemodialysis patients is established and the need for systematic monitoring of this population at high risk of malnutrition is emphasized.

Treatment of protein-energy malnutrition in chronic nonmalignant disorders

Protein-energy malnutrition (PEM) is common in connection with chronic disease and is associated with increased morbidity and mortality. Because the risk of PEM is related to the degree of illness, the causal connections between malnutrition and a poorer prognosis are complex. It cannot automatically be inferred that nutritional support will improve the clinical course of patients with wasting disorders. We reviewed studies of the treatment of PEM in cases of chronic obstructive pulmonary disease, chronic heart failure, stroke, dementia, rehabilitation after hip fracture, chronic renal failure, rheumatoid arthritis, and multiple disorders in the elderly. Several methodologic problems are associated with nutrition treatment studies in chronically ill patients. These problems include no generally accepted definition of PEM, uncertain patient compliance with supplementation, and a wide range of outcome variables. Avail-able treatment studies indicate that dietary supplements, either alone or in combination with hormonal treatment, may have positive effects when given to patients with manifest PEM or to patients at risk of developing PEM. In chronic obstructive pulmonary disease, nutritional treatment may improve respiratory function. Nutritional therapy of elderly women after hip fractures may speed up the rehabilitation process. When administered to elderly patients with multiple disorders, diet therapy may improve functional capacity. The data regarding nutritional treatment of the conditions mentioned above is still inconclusive. There is still a great need for randomized controlled long-term studies of the effects of defined nutritional intervention programs in chronically ill and frail elderly with a focus on determining clinically relevant outcomes.

Can a nutrition intervention improve albumin levels among hemodialysis patients? A pilot study

OBJECTIVE

To determine the effect of a tailored intervention on albumin levels among hemodialysis patients.

DESIGN

Randomized controlled trial.

SETTING

Eight freestanding chronic hemodialysis units in northeast Ohio.

SUBJECTS

Eighty-three randomly selected adult patients who had been on dialysis for at least 6 months and had a mean albumin <3.7 g/dL (bromcresol green method) or <3.4 g/dL (bromcresol purple method) for the last 3 months. To better elucidate the feasibility and outcomes of the intervention, we selected more intervention than control patients.

INTERVENTION

Dietitians of the 52 intervention patients determined whether any of the following potential barriers to adequate protein nutrition were present for each patient: (1) poor knowledge of protein-containing foods, (2) poor appetite, (3) needing help shopping or cooking, (4) low fluid intake, and (5) inadequate dialysis. Depending on the specific barriers present, the dietitians (1) educated patients on protein-containing foods, (2) recommended snacks for which patients had preserved appetite, (3) helped set up social supports, (4) provided recommendations on fluid intake, and/or (5) arranged for improved dialysis. Dietitians of the 31 control patients continued to provide usual care.

MAIN OUTCOME MEASURES

Change in albumin after 6 months, stratified as minimal change (less than.25 g/dL increase or decrease), moderate improvement (.25 to.49 g/dL increase), and large improvement (increase of .50 g/dL or more). To examine the role of inflammatory states, we also determined serum C-reactive protein levels at the beginning and end of the trial.

RESULTS

Among intervention patients, 29% had a minimal change in albumin, 44% had a moderate improvement, and 27% had a large improvement. Among control patients, 74% had a minimal change in albumin, 19% had a moderate improvement, and 6% had a large improvement (P <.001 for comparison of intervention and control subjects). About 60% of subjects had high baseline C-reactive protein levels (> 10 mg/L). However, there was little relationship between change in albumin and either baseline C-reactive protein levels or changes in C-reactive protein levels (P = .83).

CONCLUSION

A nutrition intervention tailored to patient-specific barriers resulted in improved albumin levels even among patients with high C-reactive protein levels. Further work is needed to refine and test this intervention on a larger sample.