Using the hemodialysis prognostic nutrition index and urea reduction ratio to predict morbidity and mortality: a pilot study of the 1995 council on renal nutrition national research question

Frailty as a novel predictor of mortality and hospitalization in individuals of all ages undergoing hemodialysis

OBJECTIVES

To quantify the prevalence of frailty in adults of all ages undergoing chronic hemodialysis, its relationship to comorbidity and disability, and its association with adverse outcomes of mortality and hospitalization.

DESIGN

Prospective cohort study.

SETTING

Single hemodialysis center in Baltimore, Maryland.

PARTICIPANTS

One hundred forty-six individuals undergoing hemodialysis enrolled between January 2009 and March 2010 and followed through August 2012.

MEASUREMENTS

Frailty, comorbidity, and disability on enrollment in the study and subsequent mortality and hospitalizations.

RESULTS

At enrollment, 50.0% of older (≥ 65) and 35.4% of younger (<65) individuals undergoing hemodialysis were frail; 35.9% and 29.3%, respectively, were intermediately frail. Three-year mortality was 16.2% for nonfrail, 34.4% for intermediately frail, and 40.2% for frail participants. Intermediate frailty and frailty were associated with a 2.7 times (95% confidence interval (CI) = 1.02-7.07, P = .046) and 2.6 times (95% CI = 1.04-6.49, P = .04) greater risk of death independent of age, sex, comorbidity, and disability. In the year after enrollment, median number of hospitalizations was 1 (interquartile range 0-3). The proportion with two or more hospitalizations was 28.2% for nonfrail, 25.5% for intermediately frail, and 42.6% for frail participants. Although intermediate frailty was not associated with number of hospitalizations (relative risk = 0.76, 95% CI = 0.49-1.16, P = .21), frailty was associated with 1.4 times (95% CI = 1.00-2.03, P = .049) more hospitalizations independent of age, sex, comorbidity, and disability. The association between frailty and mortality (interaction P = .64) and hospitalizations (P = .14) did not differ between older and younger participants.

CONCLUSIONS

Adults of all ages undergoing hemodialysis have a high prevalence of frailty, more than five times as high as community-dwelling older adults. In this population, regardless of age, frailty is a strong, independent predictor of mortality and number of hospitalizations.

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.

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.

History of the professional councils of the National Kidney Foundation

As the Councils move toward the new millennium, efforts to improve outcomes for patients with renal disease will be at the forefront. Each council has established a commitment to improving the quality of life for these individuals. Toward this goal, the CNNT, the CRN, and the CNSW will each propose programs to the NKF for improving the knowledge and skills of the professionals within these councils, promoting research within the respective scope of these professions, and working together to bring a better understanding of the issues confronted by the patients and the professionals as well. As an example of the combined effort of the Councils, the first joint project of the century will be to bring the communications packages of each council under a common framework by joining the newsletters of each council. It is an exciting time to be part of the NKF. As a professional in the renal community, being a part of the CNNT, the CRN, or the CNSW offers a professional enrichment and opportunities to participate in making lives better for those with renal disease.

Hemodialysis prognostic nutrition index as a predictor for morbidity and mortality in hemodialysis patients and its correlation to adequacy of dialysis. Council on Renal Nutrition National Research Question Collaborative Study Group

OBJECTIVE

Prospectively examine the use of a hemodialysis prognostic nutrition index (HD-PNI) as a predictor for morbidity and mortality in hemodialysis patients and its correlation to adequacy of dialysis.

DESIGN

Prospective randomized collaborative study group.

SETTING

There were 211 chronic hemodialysis centers; 202 from 43 United States, 9 from Canada.

PATIENTS

There were 1527 hemodialysis patients undergoing treatment a minimum of 3 months and at least 18 years of age. Sample mirrored United States Renal Data System data for age, sex, race, and etiology of renal failure.

INTERVENTIONS

None; routinely collected demographic, biochemical, and clinical data for 8-month baseline and 3-month predictive phases.

METHODS

HD-PNI calculated from baseline data as linear mathematical equation using level of serum albumin, level of serum creatinine, and number of days and times hospitalized; HD-PNI risk defined as >/=0.8. Adequacy of dialysis calculated as urea reduction ratio (URR) from baseline data; adequacy risk defined as URR of </=65%.

MAIN OUTCOME MEASURES

Number of times and days hospitalized, mortality.

RESULTS

For this research, 1167 patients completed the study (76%) with 360 (24%) dropped due to death, incomplete data, transfer, or change in modality. Patients completing study with HD-PNI risk (n = 208, 18%) compared with patients who had no HD-PNI risk (n = 959, 82%) were hospitalized more often (57.2% v 28.5%, P <. 01), hospitalized with infection more often (14.6% v 4.6%, P <.01), and had greater mortality (7.7% v 2.5%, P <.01). Stratification of HD-PNI risk by URR of >/=65% did not significantly improve prediction.

CONCLUSIONS

Use of HD-PNI is an effective screening tool to identify hemodialysis patients at risk for morbidity and mortality. No correlation was found between URR and HD-PNI.