Nutritional status in the HEMO Study cohort at baseline. Hemodialysis

Is intradialytic oral nutritional supplementation safe and effective on clinical outcomes? A systematic review with conventional meta-analysis and network meta-analysis

AIM

determine the effect of intradialytic oral nutrition (ION) on clinical and safety outcomes.

DESIGN

Systematic Review with conventional Meta-analysis, and a Network Meta-analysis (NMA) as sensitivity analysis. We searched on MEDLINE, LILACS, CENTRAL, and EMBASE in June 2020, and the last update was until August 2022. We selected observational and randomized controlled trials with ION for at least four weeks. Primary outcomes were all-cause mortality and quality of life (QoL); adverse events, physical performance, and appetite were secondary outcomes.

RESULTS

Seven clinical trials and three observational studies were selected. Even when we did not obtain significant differences in physical performance and gastrointestinal symptoms, we identified a clinical improvement in the QoL's physical role, bodily pain, and physical performance domains. After pooling the data on mortality, a protection rate trend was observed in the ION group without statistical significance. The home-prepared ION was the best nutritional supplementation when assessing the appetite outcome through NMA.

CONCLUSIONS

ION seems to have a protective trend in mortality risk; the current evidence is insufficient to establish a relationship with adverse events or other clinical outcomes. The lack of homogeneity in the trials makes it difficult to generalize these results.

PROSPERO REGISTRATION

CRD42020186311.

Effects of oral nutritional supplements on the nutritional status and inflammatory markers in patients on maintenance dialysis: a systematic review and meta-analysis of randomized clinical trials

Background and aims

Patients on hemodialysis (HD) or peritoneal dialysis (PD) often have insufficient energy and protein intake, resulting in poor nutritional status and adverse outcomes. Oral nutritional supplements (ONSs) are the most commonly used to increase such patients' energy and protein intakes.

Methods

In this systematic review and meta-analysis, we analyzed studies on nutritional status, inflammatory markers, and electrolyte levels in patients on dialysis receiving ONSs. We searched four electronic databases from inception until 31 December 2022, for randomized controlled trials comparing ONS treatment versus placebo or routine care.

Results

22 studies with 1185 patients on dialysis were included in our meta-analysis. Compared with the control group, the ONS group exhibited significantly increased serum albumin levels [1.26 g/l (95%CI, 0.50-2.02, P < 0.0001; I2 = 80.4%)], body mass indexes (BMIs) [0.30 kg/m2 (95%CI, 0.09-0.52, P = 0.005; I2 = 41.4%)], and handgrip strength (HGS) [0.96 kg (95%CI, 0.07-1.84, P = 0.034; I2 = 41.4%)] from baseline to the end of intervention. No significant differences were observed between the groups in lean body mass, phase angle, C-reactive protein, and serum phosphorus and potassium levels. In terms of improving albumin, the subgroup analyses show that ONS use seems to be more inclined to three variations: HD patients, short-term use, and non-intradialytic supplementation.

Conclusion

In conclusion, ONS use can improve the nutritional status of patients on dialysis in terms of their serum albumin, BMI, and HGS without significant effects on serum phosphorus, potassium, and C-reactive protein levels. However, it remains uncertain whether these results translate to improvement in clinically relevant outcomes. Large-scale high-quality studies are still required in this population.

Impact of pretransplantation malnutrition risk on the clinical outcome and graft survival of kidney transplant patients

BACKGROUND

The prevalence of malnourished patients before transplantation and the influence of malnutrition on graft and patient outcomes remain underestimated, despite being associated with higher postoperative morbidity and mortality. This study aimed to develop an easy nutritional screening tool and evaluate the impact of nutritional status on clinical outcome, graft survival (GS) and mortality risk in kidney transplant patients (KTP).

METHODS

In this retrospective cohort study including 451 KTP, we developed a score by using anthropometric, clinical, and laboratory measures performed in the pretransplant evaluation. The patients were stratified into 3 groups according to the final score: G1 (0 or 1 point)=low risk, G2 (2 to 4 points)=moderate risk, and G3 (>5 points)=high risk of malnutrition. The patients were monitored after transplantation at least 1 to 10 years.

RESULTS

Stratifying the 451 patients based on the pretransplant risk score, G1, G2, and G3 were composed of 90, 292, and 69 patients, respectively. Patients from G1 maintained the lowest serum creatinine levels at hospital discharge when compared with others (p = 0.012). The incidence of infection in the patients from G3 was higher than patients from G1 and G2 (p = 0.030). G3 recipients showed worse GS than G1 patients (p = 0.044). G3 patients showed almost threefold higher risk for graft loss (HR 2.94, 95% CI 1.084-7.996).

CONCLUSIONS

KTP with higher malnutrition risk score were associated with worse outcomes and GS. The nutritional screening tool is easy to be used in clinical practice to evaluate the patient in preparation for kidney transplant.

Neutrophil reactive oxygen formation, bacterial infections and mortality in malnourished hemodialysis patients: Evaluation of clinical outcomes

INTRODUCTION

Patients with end stage kidney disease undergoing maintenance hemodialysis (MHD) are prone to malnutrition and infections.

OBJECTIVE

The objective of this study was to evaluate the effect of polymorphonuclear (PMN) cell dysfunction on clinical outcomes of MHD patients, in association with nutritional status.

METHODS

This prospective study investigated 39 MHD patients by evaluating the oxidative activity of their PMN cells using Phorbol 12-Myristate-13-Acetate (PMA) stimulation. Blood samples were taken from each participant at dialysis initiation. Demographics, laboratory data, and clinical outcomes during a 24-month follow-up period were obtained from electronic medical records.

RESULTS

Phagocytic activity was described in percentiles of mean fluorescence intensity (MFI) of PMA levels. There were no differences in comorbidities between patients with low or high MFI-PMA percentiles. Patients in the lowest (25th) MFI-PMA percentile (N = 10) had poorer nutritional status and more frequent severe infections compared to the other 29 patients (4.3 ± 3.4 events versus 2 ± 2.2 events, p = 0.017). Furthermore, they had more frequent hospitalizations (>3) due to infections (70% versus 41%, p = 0.073) and their mortality rate was higher (80% versus 31%, p = 0.007). The odds ratio for all-cause mortality was 8.85. In multivariate analysis, the MFI-PMA percentile and ischemic heart disease were the strongest predictors of all-cause mortality (p = 0.02 and p = 0.005, respectively).

CONCLUSIONS

Low MFI-PMA levels were associated with poor nutritional status and adverse clinical outcomes and might serve as a prognostic biomarker, predicting severe infections and mortality among malnourished MHD patients.

The change in Geriatric Nutritional Risk Index is associated with mortality in patients who start hemodialysis: Korean Renal Data Registry, 2016-2018

Malnutrition is common in patients undergoing hemodialysis (HD) and is associated with mortality. This study aimed to investigate the association between changes in nutrition status measured by the Geriatric Nutritional Risk Index (GNRI) and all-cause mortality in patients who started HD. A nationwide retrospective cohort study was conducted based on the Korean Renal Data System database. Patients who started HD from January 2016 to December 2018, and were eligible for GNRI and GNRI trend were included. GNRI trend was a longitudinal change of GNRI, assessed by random slope in a mixed-effect model. Positive and negative random slopes in each patient were assigned to positive and negative GNRI trends. A total of 2313 patients were included and median follow-up period was 3.1 (2.6-3.7) years. GNRI values decreased over time (estimate - 1.212, 95% confidence interval (CI) - 1.116-0.692) and positive GNRI trend was associated with survival benefit (hazard ratio 0.55, 95% CI 0.36-0.84) after multivariate adjustment. These findings show that serial GNRI assessment, besides GNRI, is a useful prognostic factor for mortality in patients who start HD.

Screening of malnutrition with malnutrition inflammation score and geriatric nutritional risk index in hemodialysis patients

BACKGROUND AND AIMS

Screening malnutrition, which is the most common complication in hemodialysis patients, is extremely important for these patients. Malnutrition inflammation score (MIS) and geriatric nutritional risk index (GNRI) are malnutrition screening tests used in hemodialysis patients in recent years. The purposes of this study are to evaluate the nutritional status of hemodialysis patients with different screening tests and to determine the cutoff values for this disease-specific MIS and GNRI.

METHODS

The study was conducted with 194 adult patients including 98 males and 96 females whose mean age was 53.1 ± 10.96. Subjective global assessment (SGA) and MIS tests were applied, and the GNRI value was calculated for screening malnutrition. MIS and GNRI cutoff values were obtained by adopting the SGA scores as a standard and drawing a receiver operating characteristic curve. The tatistical Package for the Social Sciences-22.0 package program was used in the analysis.

RESULTS

According to SGA, 70.7% of the patients were nourished, 21.1% were mildly-moderately malnourished, and 8.2% were found to be severely malnourished. The optimal cutoff value predicted for malnutrition was 6.5 points (94.7% sensitivity and 98.5% specificity) for MIS and 86.0 points (64.9% sensitivity and 62.8% specificity) for GNRI. Based on these cutoff values, 28.9% of the patients were determined to be malnourished according to MIS and 45.4% according to GNRI.

CONCLUSION

In conclusion, screening tests are very important in the early identification of malnutrition in hemodialysis patients. This study was conducted to evaluate the malnutrition of hemodialysis patients with different screening tests. At the end of the study, the availability of MIS was found to be high in detecting malnutrition in hemodialysis patients because of its high accuracy and sensitivity of MIS. The cutoff points we identified for both MIS and GNRI are thought to facilitate the determination of malnutrition.

The Impact of Chronic Kidney Disease on Nutritional Status and Its Possible Relation with Oral Diseases

Several studies have demonstrated a strong relation between periodontal diseases and chronic kidney disease (CKD). The main mechanisms at the base of this link are malnutrition, vitamin dysregulation, especially of B-group vitamins and of C and D vitamins, oxidative stress, metabolic acidosis and low-grade inflammation. In particular, in hemodialysis (HD) adult patients, an impairment of nutritional status has been observed, induced not only by the HD procedures themselves, but also due to numerous CKD-related comorbidities. The alteration of nutritional assessment induces systemic manifestations that have repercussions on oral health, like oral microbiota dysbiosis, slow healing of wounds related to hypovitaminosis C, and an alteration of the supporting bone structures of the oral cavity related to metabolic acidosis and vitamin D deficiency. Low-grade inflammation has been observed to characterize periodontal diseases locally and, in a systemic manner, CKD contributes to the amplification of the pathological process, bidirectionally. Therefore, CKD and oral disease patients should be managed by a multidisciplinary professional team that can evaluate the possible co-presence of these two pathological conditions, that negatively influence each other, and set up therapeutic strategies to treat them. Once these patients have been identified, they should be included in a follow-up program, characterized by periodic checks in order to manage these pathological conditions.

Predialysis Urea Nitrogen Is a Nutritional Marker of Hemodialysis Patients

End-stage renal disease (ESRD) patients on hemodialysis have poor nutritional status and associated problems such as inflammation and sarcopenia. Blood urea nitrogen (BUN) is an important measure of uremic toxins, and urea reduction is a marker of hemodialysis efficacy. However, a low protein diet for lower BUN could aggravate malnutrition in patients, and optimal pre-dialysis BUN is not defined. We investigated the association of pre-dialysis BUN with patients' comorbidities and the relationship between pre-dialysis BUN and serum albumin as a nutrient marker. Among the 67 patients, the average pre- and post-dialysis BUN were 59.2 and 15.0 mg/dL, respectively, serum creatinine was 10.1 mg/dL, and the average serum albumin was 4.0 g/dL. Patients' age was negatively correlated with serum creatinine (r=-0.277, p<0.05) and albumin (r=-0.453, p<0.001). Predialysis BUN showed a significant positive correlation with serum albumin (r=0.287, p<0.05) and creatinine (r=0.454, p<0.001). However, the predialysis BUN was not significantly related to diabetes, coronary artery disease, congestive heart failure, or cerebrovascular disease. Hemodialysis patients with high pre-dialysis BUN and high serum creatinine could be regarded as having good nutritional status. The significance of this study lies in the potential utility of pre-dialysis blood urea nitrogen as an indicator of the nutritional status of patients. Liberal protein intake might be recommended to adequately dialyzed patients.

The beneficial effects of intradialytic parenteral nutrition in hemodialysis patients with protein energy wasting: a prospective randomized controlled trial

In hemodialysis (HD) patients, protein-energy wasting (PEW) is highly prevalent and firstly treated with oral nutritional supplements (ONS). The extent to which intradialytic parenteral nutrition (IDPN) contributes to improve PEW status in HD patients intolerable to ONS remains unclear. Maintenance PEW HD patients being unable to tolerate ONS adverse effects, and having spontaneous energy and protein intake of ≥ 20 kcal/kg/day and ≥ 0.8 g/kg/day, respectively were randomly assigned 1:1 into IDPN and control groups. In IDPN group, most concentrated 3-in-1, fish-oil based parenteral nutrition was infused during HD for 3 months. The control group received intensive dietary counselling once weekly for 3 months. Both groups were then followed for additional 3 months after intervention. A total of 38 patients were randomized (mean age 67.6 years). After 3 months, serum albumin was significantly higher in the IDPN (n = 18) compared with control group (from 3.5 ± 0.3 to 3.8 ± 0.2 vs from 3.6 ± 0.3 to 3.5 ± 0.3 g/dL, respectively, p = 0.01). Spontaneous dietary intake (p = 0.04), body weight (p = 0.01), and malnutrition inflammation score (MIS, p = 0.01) were improved in the IDPN, but not in the control group. Muscle mass, strength, serum prealbumin, interleukin-6, high sensitivity-c reactive protein, and acylated ghrelin were not significantly different but leptin levels increased in the control group after 3 months (p = 0.03). At 6 months, serum albumin in the IDPN group was persistently higher than baseline (p = 0.04). Neither volume overload nor uncontrolled hyperglycemia was found throughout the study. In conclusion, a 3-month IDPN supplementation demonstrated a significant increase in serum albumin, body weight, spontaneous oral intake, and MIS; and appeared to be superior to continuing intensive dietary counselling among HD patients intolerable to ONS. The impacts of IDPN therapy on clinical outcomes may require larger scale with longer period of study.

Comparison of intradialytic neuromuscular electrical stimulation and oral nutritional supplements in hemodialysis patients: study protocol for a multicenter, parallel-group, randomized controlled trial in Korea

Background

The prevalence of sarcopenia increases as renal function decreases, and a considerable number of hemodialysis (HD) patients have sarcopenia. Exercise and nutritional support are established interventions to prevent and treat sarcopenia. Recently, many studies evaluating intradialytic neuromuscular electrical stimulation (NMES) showed improvement of muscular strength and mass, functional capacity, and quality of life (QOL). However, there has been no research about the effect of simultaneous nutritional support and NMES in HD patients.

Methods

This is a 12-week, randomized controlled, parallel-group, multicenter trial of intradialytic NMES and protein supplementation for HD patients. Seventy-two patients receiving HD will be randomly assigned in a 1:1:1:1 ratio to control, intradialytic NMES only, protein supplementation only, and intradialytic NMES combined with protein supplementation groups. NMES will be delivered to a total of four areas of the bilateral vastus medialis and vastus lateralis using a 4-channel NMES instrument. A total of 25 g of protein supplements will be provided at the beginning of every dialysis session or after the NMES. The primary endpoint is the difference of hand grip and leg muscle strength at 12 weeks among 4 treatment groups. Secondary endpoints include muscle mass, physical performances, and questionnaires about QOL and physical activity.

Discussion

In this study, we will evaluate the differential effectiveness of nutritional support and NMES during HD on muscle strength, muscle mass, physical function, and QOL. We expect that this study can provide guidelines for a new therapeutic option for HD patients who are unable or hesitant to exercise. Furthermore, this option can offer an opportunity to improve the physical function, QOL, and prognosis of HD patients.

Trial registration

Clinical Research Information Service (CRIS), Korea, KCT0005573. Retrospectively registered on 03 November 2020

Nutritional predictors associated with malnutrition in continuous ambulatory peritoneal dialysis patients

BACKGROUND

Currently in China, out of the total dialysis population, approximately 20% represents continuous ambulatory peritoneal dialysis (CAPD) and almost half of CAPD patients was affected by malnutrition. This study aimed to investigate the association between nutritional predictors and malnutrition with 5.1 years of dialysis according to the subjective global assessment (SGA) in continuous ambulatory peritoneal dialysis (CAPD) patients.

METHODS

A cross-sectional study was conducted from April 2013 to May 2018 and included 70 CAPD patients. The relationship between anthropometric and biochemical parameters with malnutrition was assessed by multiple logistic regression analysis.

RESULTS

The prevalence of malnutrition in CAPD patients was 52.9%. Our result revealed a 7.05-fold increased odds of malnutrition for patients with protein equivalent of total nitrogen appearance normalized to body weight (nPNA) < 1.0 g/kg per day (d) versus patients with normal nPNA (confidence interval (CI) 1.33-37.34; p < 0.05). Patients whose normalized protein catabolic rate (nPCR) was <1.2 g/(kg/d) had a significant positive association with malnutrition versus patients with normal nPCR (adjusted odds ratio (OR) 7.99; p < 0.05). Patients with dietary protein intake (DPI) < 1.0 g/(kg/d) had a higher likelihood of malnutrition than those with normal DPI (OR 12.73; p < 0.05). CAPD patients with upper arm circumference (UAC) < 23.2 cm had a high risk of malnutrition versus patients with normal UAC (OR 12.99; p < 0.05).

CONCLUSIONS

Our study suggested a close association between nPNA, DPI, nPCR, and UAC and malnutrition in CAPD patients. Further studies can be warranted the use of these variables as predictors and a malnutrition consequence among Chinese CAPD patients.

Are we overfeeding hemodialysis patients with protein? Exploring an alternative method to estimate protein needs

BACKGROUND & AIMS

Sufficient protein intake is of great importance in hemodialysis (HD) patients, especially for maintaining muscle mass. Daily protein needs are generally estimated using bodyweight (BW), in which individual differences in body composition are not accounted for. As body protein mass is best represented by fat free mass (FFM), there is a rationale to apply FFM instead of BW. The agreement between both estimations is unclear. Therefore, the aim of this study is to compare protein needs based on either FFM or BW in HD patients.

METHODS

Protein needs were estimated in 115 HD patients by three different equations; FFM, BW and BW adjusted for low or high BMI. FFM was measured by multi-frequency bioelectrical impedance spectroscopy and considered the reference method. Estimations of FFM x 1.5 g/kg and FFM x 1.9 g/kg were compared with (adjusted)BW x 1.2 and x 1.5, respectively. Differences were assessed with repeated measures ANOVA and Bland-Altman plots.

RESULTS

Mean protein needs estimated by (adjusted)BW were higher compared to those based on FFM, across all BMI categories (P < 0.01) and most explicitly in obese patients. In females with BMI >30, protein needs were 69 ± 17.4 g/day higher based on BW and 45 ± 9.3 g/day higher based on BMI adjusted BW, compared to FFM. In males with BMI >30, protein needs were 51 ± 20.4 g/day and 23 ± 20.9 g/day higher compared to FFM, respectively.

CONCLUSIONS

Our data show large differences and possible overestimations of protein needs when comparing BW to FFM. We emphasize the importance of more research and discussion on this topic.

Comprehensive lifestyle modification as complementary therapy to prevent and manage post-transplant diabetes mellitus*

Post-transplant diabetes mellitus (PTDM) is one from the most common metabolic complications after kidney transplantation. PTDM develops in the early period after transplantation. The risk factors of PTDM are carbohydrate imbalances occurring in the patient prior to transplantation, surgery and the inclusion of immunosuppressive treatment. Kidney transplant patients tend to gain weight, which is associated with an increased risk of post-transplant diabetes, cardiovascular diseases and abnormal transplanted kidney function. Patients after kidney transplantation should be advised to adopt a lifestyle based on a proper diet, exercise, weight control and smoking cessation. The strategy to reduce the risk factors for PTDM development should start before transplantation and continue after kidney transplantation. A targeted, non-pharmacological approach to patients already during the dialysis period may have a significant impact on reducing post-transplantation diabetes. Lifestyle interventions can effectively reduce the risk of development and inhibit the progression of post-transplantation diabetes. The article describes elements of comprehensive non-pharmacological management based on available knowledge of rehabilitation, dietetics and psychology.

The effect of protein-enriched snacks on serum albumin concentration in non-selected haemodialysis patients

OBJECTIVE

Serum albumin level is not only one of the protein-energy wasting criteria but also a powerful marker of mortality in patients on haemodialysis (HD) treatment. The study aimed to assess the effect of a protein-enriched snack given during HD treatment on serum albumin level.

DESIGN AND METHODS

This prospective, single-centre, observational, non-randomized 16-month study was sub-divided into four 4-month periods. Patients on hemodialysis for more than three months and receiving a regular standard snack (8.8 g of protein) during the HD session were included and assigned during four four-month periods to receive either the standard snack or a protein-enriched snack (28.7 g). Patients were not selected based on nutritional criteria.

RESULTS

Sixty-six patients completed the study. Serum albumin levels significantly increased, from 3.43 ± 0.28 g/dl in the first period (standard snack) to 3.62 ± 0.32 g/dl (p < 0.0001) in the second period (enriched snack). In the third period (standard snack), albumin levels remained stable (3.61 ± 0.35 g/dl). After the fourth period (enriched snack), serum albumin levels further increased significantly (3.69 ± 0.30 g/dl; p = 0.05 and p = 0.007, respectively). Weight and normalized protein nitrogen appearance remained stable during the 16-month study period.

CONCLUSIONS

This study suggests that the intake of a protein-enriched snack during HD treatment, independently from baseline serum albumin level, could significantly increase their serum albumin levels. Serum albumin level is a powerful predictor of mortality; therefore, this simple and effective action could be of real interest to improve patients' outcomes.

Understanding Development of Malnutrition in Hemodialysis Patients: A Narrative Review

Hemodialysis (HD) majorly represents the global treatment option for patients with chronic kidney disease stage 5, and, despite advances in dialysis technology, these patients face a high risk of morbidity and mortality from malnutrition. We aimed to provide a novel view that malnutrition susceptibility in the global HD community is either or both of iatrogenic and of non-iatrogenic origins. This categorization of malnutrition origin clearly describes the role of each factor in contributing to malnutrition. Low dialysis adequacy resulting in uremia and metabolic acidosis and dialysis membranes and techniques, which incur greater amino-acid losses, are identified modifiable iatrogenic factors of malnutrition. Dietary inadequacy as per suboptimal energy and protein intakes due to poor appetite status, low diet quality, high diet monotony index, and/or psychosocial and financial barriers are modifiable non-iatrogenic factors implicated in malnutrition in these patients. These factors should be included in a comprehensive nutritional assessment for malnutrition risk. Leveraging the point of origin of malnutrition in dialysis patients is crucial for healthcare practitioners to enable personalized patient care, as well as determine country-specific malnutrition treatment strategies.

KDOQI Clinical Practice Guideline for Nutrition in CKD: 2020 Update

The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidence-based guidelines for nutrition in kidney diseases since 1999. Since the publication of the first KDOQI nutrition guideline, there has been a great accumulation of new evidence regarding the management of nutritional aspects of kidney disease and sophistication in the guidelines process. The 2020 update to the KDOQI Clinical Practice Guideline for Nutrition in CKD was developed as a joint effort with the Academy of Nutrition and Dietetics (Academy). It provides comprehensive up-to-date information on the understanding and care of patients with chronic kidney disease (CKD), especially in terms of their metabolic and nutritional milieu for the practicing clinician and allied health care workers. The guideline was expanded to include not only patients with end-stage kidney disease or advanced CKD, but also patients with stages 1-5 CKD who are not receiving dialysis and patients with a functional kidney transplant. The updated guideline statements focus on 6 primary areas: nutritional assessment, medical nutrition therapy (MNT), dietary protein and energy intake, nutritional supplementation, micronutrients, and electrolytes. The guidelines primarily cover dietary management rather than all possible nutritional interventions. The evidence data and guideline statements were evaluated using Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria. As applicable, each guideline statement is accompanied by rationale/background information, a detailed justification, monitoring and evaluation guidance, implementation considerations, special discussions, and recommendations for future research.

Effect of high bicarbonate hemodialysis solution on biochemical parameters and anthropometric indices

INTRODUCTION

Protein energy wasting is an adverse consequence of renal failure, which is correlated with increased mortality and morbidity. Metabolic acidosis has a major role in the development of protein energy wasting in hemodialysis patients. Every effort that could ameliorate this catabolic state would be beneficial to stabilize body composition. The aim of this study was to investigate the possible beneficial effects of high bicarbonate dialysis on anthropometric indices and biochemical parameters of nutrition.

METHODS

Fifty-six hemodialysis patients were randomly enrolled in two groups: an intervention group that underwent hemodialysis for 6 months with high bicarbonate dialysate concentration (36 mmol/L, N = 26) and a control group that underwent hemodialysis using a bicarbonate dialysate concentration of 30 mmol/L (N = 30). Biochemical parameters of nutrition and weight, body mass index (BMI), total body water, percent body fat, and other anthropometric indices were measured at the beginning and the end of the trial.

FINDINGS

At the end of the 6 month evaluation period, plasma levels of albumin, phosphorus, K, calcium, and bicarbonate showed no significant changes. Body weight and BMI increased significantly in high bicarbonate arm but did not change significantly in the control group. Percent body fat in the arms and legs did not change in intervention arm, but decreased significantly in the controls.

DISCUSSION

The results suggest that higher bicarbonate dialysis can have beneficial effects on nutritional status and might protect against loss of fat mass.

Geriatric Nutritional Risk Index (GNRI) and Creatinine Index Equally Predict the Risk of Mortality in Hemodialysis Patients: J-DOPPS

The geriatric nutritional risk index (GNRI) and creatinine (Cr) index are indexes often used as nutritional surrogates in patients receiving hemodialysis. However, few studies have directly compared the clinical characteristics of these two indexes. We investigated 3,536 hemodialysis patients enrolled in the Japan DOPPS phases 4 and 5. The primary outcome was all-cause mortality and the main exposures were the GNRI and Cr index. We confirmed and compared the association between these indexes and mortality risk as estimated by a multivariable-adjusted Cox proportional hazards model. During the median 2.2-year follow-up period, 414 patients died of any cause. In the multivariable-adjusted model, lower GNRI and Cr index were both associated with increased risk of all-cause mortality, and these associations were further confirmed by restricted cubic spline curves. The predictability of all-cause mortality, as represented by the c-statistic, was comparable between the two indexes. Furthermore, baseline nutritional surrogates that corresponded with lower GNRI or Cr index values were comparable between the two indexes. Given that calculating the GNRI is simpler than calculating the Cr index, our data suggest that the GNRI may be preferable to the Cr index for predicting clinical outcomes in patients undergoing maintenance hemodialysis.

Adequacy of Hemodialysis and Its Associated Factors among Patients Undergoing Chronic Hemodialysis in Dar es Salaam, Tanzania

The worldwide prevalence of maintenance hemodialysis continues to rise. An adequate delivery of hemodialysis dose as measured by Kt/V or urea reduction ratio is a crucial determinant of clinical outcome for chronic hemodialysis patients. The aim of this study was to assess the adequacy of hemodialysis and its associated factors among patients undergoing chronic hemodialysis in Dar es Salaam. This was a cross-sectional study done on patients undergoing chronic hemodialysis in four dialysis centers in Dar es Salaam. Sociodemographic information and treatment characteristics were collected. Urea reduction rate and single-pool Kt/V were calculated to determine the adequacy of hemodialysis. The data were analyzed and any associated factors for inadequate hemodialysis were determined using a chi-square test and a logistic regression analysis. A total of 143 patients participated in the study. Males represented 65.7% of the study population. The mean age (±SD) was 51.7 ± 1.2 years. Only 34.3% (based on urea reduction ratio (URR)) and 40.6% (based on Kt/V) of patients received adequate hemodialysis. The univariate analysis showed that males were more likely to have inadequate dialysis (65.6% versus 48.0%, p=0.048 based on Kt/V). Patients using hemodialyzers with dialyzer surface area less than 1.4 m² received significantly less hemodialysis dose than those with more than 1.4 m² (69.0% versus 41.2%, p=0.02, by URR) (62.7% versus 35.3%, p=0.03, by Kt/V criteria). Patients who had hemoglobin <10 g/dl received significantly inadequate hemodialysis dose as compared to patients with hemoglobin ≥10 g/dl by Kt/V criteria (69.8% versus 51.3%, p=0.03). None of the factors acquired significance in the multivariate analysis. The proportion of patients receiving an adequate hemodialysis dose is low (34.3% based on URR and 40.6% based on Kt/V). Male gender, dialyzer surface area of <1.4 m², and hemoglobin level of <10 g/dl were associated with an inadequate delivered dose of hemodialysis in the univariate analysis but not in the multivariate analysis. This study can increase awareness about the importance of measuring hemodialysis adequacy and giving the correct hemodialysis dose to achieve the intended benefit.

Modified creatinine index and risk for long-term infection-related mortality in hemodialysis patients: ten-year outcomes of the Q-Cohort Study

Modified creatinine (Cr) index, calculated by age, sex, pre-dialysis serum Cr concentration, and Kt/V for urea, is an indicator of skeletal muscle mass in hemodialysis (HD) patients. It remains unknown whether the modified Cr index predicts infection-related mortality in this population. We investigated the association between the modified Cr index and infection-related mortality. A total of 3046 patients registered in the Q-Cohort Study, a multicenter, observational study of HD patients, were analyzed. Associations between sex-specific quartiles (Q1–Q4) of the modified Cr index and the risk for infection-related mortality were analyzed by Cox proportional hazard model. During a median follow-up of 8.8 years, 387 patients died of infection. The estimated risk for infection-related mortality was significantly higher in the lower quartiles (Q1, Q2, and Q3) than in the highest quartile (Q4) as the reference group (hazard ratios and 95% confidence intervals [CI]: Q1, 2.89 [1.70–5.06], Q2, 2.76 [1.72–4.62], and Q3, 1.79 [1.12–2.99]). The hazard ratio (95% CI) for a 1 mg/kg/day decrease in the modified Cr index was 1.18 (1.09–1.27, P < 0.01) for infection-related mortality. In conclusion, a lower modified Cr index is associated with an increased risk for long-term infection-related mortality in the HD population.

The association between dietary energy intake and the risk of mortality in maintenance haemodialysis patients: a multi-centre prospective cohort study

Maintenance haemodialysis (MHD) is the use of a machine to filter wastes, salts and fluid from blood for at least 3 months to prolong the life of patients with advanced kidney failure. Although low dietary energy intake (DEI) has been observed in MHD patients, few studies have related DEI to the risk of mortality. To explore this relationship, a study included 1039 MHD patients from eight centres was conducted. DEI was assessed by three 24-h diet recalls and was normalised to ideal body weight (IBW). All-cause mortality and CVD mortality were the primary and secondary outcomes, respectively. During a median follow-up of 28 months, a U-shaped relationship was observed between DEI and all-cause or CVD mortality. The risk of all-cause mortality decreased significantly with the increase of DEI in participants with DEI <167·4 kJ/kg IBW per d (hazard ratio (HR) 0·98; 95 % CI 0·96, 1·00) and increased significantly with the increase of DEI in those with DEI ≥167·4 kJ/kg IBW per d (HR 1·12; 95 % CI 1·04, 1·20). Similarly, the risk of CVD mortality decreased with the increase of DEI in participants with DEI <152·7 kJ/kg IBW per d (HR 0·96; 95 % CI 0·93, 0·99) and increased with the increase of DEI in participants with DEI ≥152·7 kJ/kg IBW per d (HR 1·11; 95 % CI 1·04, 1·18). In summary, there was a U-shaped association between DEI and all-cause or CVD mortality, with a turning point at about 167·4 and 152·7 kJ/kg IBW per d, respectively, in MHD patients.

Cachexia/Protein energy wasting syndrome in CKD: Causation and treatment

Cachexia is a multifactorial syndrome defined by significant body weight loss, fat and muscle mass reduction, and increased protein catabolism. Protein energy wasting (PEW) is characterized as a syndrome of adverse changes in nutrition and body composition being highly prevalent in patients with CKD, especially in those undergoing dialysis, and it is associated with high morbidity and mortality in this population. Multiple mechanisms are involved in the genesis of these adverse nutritional changes in CKD patients. There is no obvious distinction between PEW and cachexia from a pathophysiologic standpoint and should be considered as part of the spectrum of the same nutritional disorder in CKD with similar management approaches for prevention and treatment based on current understanding. A plethora of factors can affect the nutritional status of CKD patients requiring a combination of therapeutic approaches to prevent or reverse protein and energy depletion. At present, there is no effective pharmacologic intervention that prevents or attenuates muscle atrophy in catabolic conditions like CKD. Prevention and treatment of uremic muscle wasting involve optimal nutritional support, correction of acidosis, and physical exercise. There has been emerging consistent evidence that active treatment, perhaps by combining nutritional interventions and resistance exercise, may be able to improve but not totally reverse or prevent the supervening muscle wasting and weakness. Active research into more direct pharmacological treatment based on basic mechanistic research is much needed for this unmet medical need in patients with CKD.

The effects of oral nutritional supplements in patients with maintenance dialysis therapy: A systematic review and meta-analysis of randomized clinical trials

Background/objective

This systematic review aims to determine the potential effects of oral nutritional supplements (ONS) in patients receiving maintenance dialysis therapy (MDT).

Methods

Electronic databases were searched without language limits through to July 2018. Randomized controlled trials (RCTs) that involved comparisons of ONS versus placebo or routine care are included in this meta-analysis. RevMan 5.3 statistical software was used for meta-analysis.

Results

15 articles with 589 subjects were included in our study. There are insufficient comparable data of randomized trials to allow meta-analysis of mortality. Albumin levels may be improved by the macronutrient blends or protein/amino acid supplements in MDT patients. Compared with the control group, serum albumin levels and BMI in the ONS group were increased by 1.58 g/L (95% CI, 0.52–2.63, P = 0.003; I² = 85%) and 0.40 kg/m² (95% CI, 0.10–0.71, P = 0.01; I² = 49%), respectively. In the subgroup analysis of patients receiving hemodialysis, albumin levels in ONS group were increased by 2.17 g/L (95% CI, 0.89–3.45, P<0.001; I² = 90%). ONS may not influence serum phosphorus and potassium levels.

Conclusions

Very low-quality evidence suggests that Short-term oral energy or protein/amino acid supplements may improve nutritional status by increasing serum albumin levels and BMI in MDT patients, without influence on serum potassium levels. High-quality and large RCTs, particularly regarding the effects of ONS on mortality and quality of life, are needed to further validate our findings.

Modified creatinine index and risk for cardiovascular events and all-cause mortality in patients undergoing hemodialysis: The Q-Cohort study

BACKGROUND AND AIMS

The modified creatinine (Cr) index, calculated by age, sex, pre-dialysis serum Cr levels, and Kt/V for urea, reflects skeletal muscle mass in patients on hemodialysis. Whether the modified Cr index is associated with cardiovascular events and all-cause mortality remains unknown.

METHODS

A total of 3027 patients registered in the Q-Cohort Study, a multicenter, prospective study of patients on hemodialysis in Japan, were analyzed. The main outcomes were cardiovascular events and all-cause mortality. Associations between sex-specific quartiles of the modified Cr index and outcomes were analyzed by the Cox proportional hazard models and the Fine-Gray proportional subdistribution hazards model.

RESULTS

The modified Cr index was correlated with known nutritional and inflammatory markers. During a 4-year follow-up, 499 patients died of any cause, 372 experienced heart disease, and 194 developed stroke. The risk for all-cause mortality was significantly higher in the lower quartiles (Q1 and Q2) than in the highest quartile (Q4) as the reference group (hazard ratios and 95% confidence intervals: Q1, 2.65 [1.69-4.25], Q2, 1.92 [1.27-2.94], and Q3, 1.31 [0.87-2.02]). The risk of heart disease was significantly higher in Q1 than in Q4 (hazard ratios and 95% confidence intervals: Q1, 1.64 [1.04-2.61], Q2, 1.34 [0.91-2.00], and Q3, 1.04 [0.71-1.52]). The risk of stroke was not associated with the modified Cr index.

CONCLUSIONS

A lower modified Cr index is associated with an increased risk for heart disease and all-cause mortality, but not with the risk for stroke in patients on hemodialysis.

Hydration and nutritional status in patients on home-dialysis-A single centre study

BACKGROUND

Over-hydration (OH) and malnutrition are prevalent among patients on dialysis therapy. The prevalence of OH and malnutrition as well as the risk factors associated with OH and malnutrition in our patients on home peritoneal dialysis (PD) and home haemodialysis (HD) are examined.

DESIGN AND METHODS

This was a cross-sectional study. The hydration and nutritional status of the study groups were assessed by a Body Composition Monitor. Patients who were stable on home dialysis therapy for over one year were invited to participate. Univariate and multivariate analyses were performed to identify associated factors and determine the predictors of OH and malnutrition, respectively.

RESULTS

Eighty-eight patients (41 PD and 47 home HD) were recruited. A 32.95% of our patients on home dialysis therapy were in OH status. There was a significance difference in the prevalence of hydration status between patients on PD and home HD (p = 0.014), as overhydration was more common in patients on PD than home HD (46.34 vs. 21.28%). Dehydration was more common in patients on home HD than PD (29.79 vs. 9.76%). Male gender, decreasing haemoglobin level and presence of diabetes mellitus (DM) were risk factors of OH on multivariable analysis. There was no significance difference in the prevalence of malnutrition between patients on PD and home HD (p = 0.27). Increasing Fat Tissue Index (FTI), height and patients on PD therapy were at higher risk of malnutrition.

CONCLUSION

OH and malnutrition were prevalent patients on home dialysis therapy.

An integrative review of the methodology and findings regarding dietary adherence in end stage kidney disease

BACKGROUND

Dietary modification is an important component of the management of end stage kidney disease (ESKD). The diet for ESKD involves modifying energy and protein intake, and altering sodium, phosphate, potassium and fluid intake. There have been no comprehensive reviews to date on this topic. The aims of this integrative review were to (i) describe the methods used to measure dietary adherence (ii) determine the rate of dietary adherence and (iii) describe factors associated with dietary adherence in ESKD.

METHODS

The Web of Science and Scopus databases were searched using the search terms 'adherence' and 'end stage kidney disease'. Of the 787 potentially eligible papers retrieved, 60 papers of 24,743 patients were included in this review. Of these papers, 44 reported the rate of dietary adherence and 44 papers described factors associated with adherence.

RESULTS

Most of the evidence regarding dietary adherence is derived from studies of hemodialysis patients (72% of patients). The most common method of measuring dietary adherence in ESKD was subjective techniques (e.g. food diaries or adherence questionnaires). This was followed by indirect methods (e.g. serum potassium, phosphate or interdialytic weight gain). The weighted mean adherence rate to ESKD dietary recommendations was 31.5% and 68.5% for fluid recommendations. Adherence to protein, sodium, phosphate, and potassium recommendations were highly variable due to differences in measurement methods used, and were often derived from a limited evidence base. Socioeconomic status, age, social support and self-efficacy were associated with dietary adherence. However, factors such as taste, the impact of the diet on social eating occasions; and dietetic staffing also appear to play a role in dietary adherence.

CONCLUSION

Dietary adherence rates in people with ESKD are suboptimal. Further research is required on dietary adherence in patients with ESKD from different social, educational, economic and ethnic groups. This research may identify other factors which may impact upon adherence, and could be used to inform the design of future strategies to improve dietary adherence. Future research that reports not just the rate of adherence to individual components of the nutrient prescription but also the overall quality of the diet would be useful.

Does Whey Protein Supplementation Improve the Nutritional Status in Hypoalbuminemic Peritoneal Dialysis Patients?

Limited data are available regarding the effects of whey protein on the nutritional status of the peritoneal dialysis population. This study evaluated the effects of whey protein supplementation for 12 weeks on the nutritional status in hypoalbuminemic peritoneal dialysis patients. Thirty-six stable adult patients on maintenance peritoneal dialysis with serum albumin levels <3.5 g/dL were enrolled in the study and were divided into two groups similar in their serum albumin and normalized protein equivalent of total nitrogen appearance (nPNA). Nineteen patients were instructed to receive 1.2 g/kg per day of protein diet and additional whey protein supplement at a dose of 25% of the instructed daily protein diet (whey protein group), and 17 patients were instructed to receive 1.2 g/kg per day protein diet without additional whey protein supplementation (control group). Nutritional status was assessed using two measures: nPNA and lean tissue mass index (LTI) obtained by whole-body bioimpedance spectroscopy technique. In the whey protein group serum albumin and nPNA significantly increased from baseline to week 6 (P < 0.001, P = 0.034; respectively) and from week 6 to week 12 (P < 0.001, P = 0.001; respectively); LTI significantly increased from week 6 to week 12 (P = 0.022). Compared to the control group at week 12, serum albumin, nPNA and LTI values were significantly higher in the whey protein group (P < 0.001, P = 0.002, P = 0.001; respectively). This study demonstrated for the first time that oral supplementation with whey protein improves nutritional status and is well tolerated in hypoalbuminemic PD patients.

Nutritional status among peritoneal dialysis patients after oral supplement with ONCE dialyze formula

BACKGROUND

Malnutrition is an important problem in patients treated with long-term dialysis, and most dialysis patients have lower dietary energy and protein intake. This study was undertaken to examine whether orally administered Otsuka Nutrition Pharmaceutical (ONCE) dialyze formula (ODF) supplement would improve energy intake without mineral and electrolyte disturbances in patients with continuous ambulatory peritoneal dialysis (CAPD).

METHODS

The effects of ODF supplementation on nutrition markers including serum albumin and prealbumin concentrations and inflammatory stress in patients with chronic CAPD were evaluated. All patients received daily oral ODF supplements for 15 days. During follow-up, all patients were evaluated clinically and biochemically, and nutritional status was assessed.

RESULTS

Thirty patients with mean age 61.9±12.3 years and weekly Kt/V 2.2±0.4 were studied. The mean values for nutritional parameters included a body weight of 53.7±9.5 kg, a serum albumin level of 3.3±0.4 g/dL, a serum prealbumin level of 33.8±11.1 mg/dL, a dietary energy intake of 21.9±7.1 kcal/kg/day, and a dietary protein intake of 0.9±0.3 g/kg/day. After 15-day ODF treatment, these patients had significant dietary energy and protein, carbohydrate, fat, fiber, potassium, calcium, and magnesium intake from baseline (P<0.05). Furthermore, significant improvements were found in nutritional markers including body weight, blood urea nitrogen, and prealbumin levels, but no changes were observed in serum albumin and high-sensitivity C-reactive protein levels. At the end of follow-up, the frequency of patients with moderate malnutrition decreased from 24.2% to 18.2%, and no increased incidence was observed of hyperkalemia, hyperphosphatemia, and metabolic acidosis.

CONCLUSION

ODF supplementation ameliorates low dietary energy and nutrient intake as well as improves serum prealbumin and body weight in patients with long-term CAPD.

Symptom Management of the Patient with CKD: The Role of Dialysis

As kidney disease progresses, patients often experience a variety of symptoms. A challenge for the nephrologist is to help determine if these symptoms are related to advancing CKD or the effect of various comorbidities and/or medications prescribed. The clinician also must decide the timing of dialysis initiation. The initiation of dialysis can have a variable effect on quality of life measures and the alleviation of uremic signs and symptoms, such as anorexia, fatigue, cognitive impairment, depressive symptoms, pruritus, and sleep disturbances. Thus, the initiation of dialysis should be a shared decision-making process among the patient, the family and the nephrology team; information should be provided, in an ongoing dialogue, to patients and their families concerning the benefits, risks, and effect of dialysis therapies on their lives.

Challenges of Providing Nutrition Support in the Outpatient Dialysis Setting

Malnutrition is prevalent in maintenance hemodialysis (MHD) patients and has been strongly associated with increased morbidity and mortality. There are numerous contributors to the development, occurrence, and persistence of malnutrition in the MHD patient. Intensive diet counseling and use of enteral supplements may not be effective interventions for patients exhibiting high nutrition risk. More aggressive nutrition options such as enteral and parenteral support are less often used and have associated risks. Intradialytic parenteral nutrition (IDPN) as a form of PN delivered during the dialysis procedure is a convenient and attractive convention that is underused because of its history and controversy. There is a lack of randomized controlled trials demonstrating improved morbidity and mortality with all nutrition support interventions in MHD patients. This research is particularly crucial for IDPN in order to render change in Medicare reimbursement. Qualification of patients for this therapy is difficult because of the very strict coverage criteria. For those patients who do qualify for IDPN, clinician nutrition support knowledge is essential for safe administration of solutions and effective physical, metabolic, and nutrition management of the patient. Attention to other factors that contribute to malnutrition in MHD such as treatment adequacy and comorbid conditions is important; however, the early detection of malnutrition in the MHD patient with appropriate level of nutrition intervention is critical. Future improved understanding of the malnutrition of uremia will allow for development and investigation of other strategies that are anti-catabolic or anabolic.

Protein and Energy Depletion in Chronic Hemodialysis Patients: Clinical Applicability of Diagnostic Tools

Protein and energy depletion states are common and associated with increased morbidity and mortality in chronic hemodialysis (CHD) patients. Therefore, proper use of diagnostic tools to assess depleted states in CHD patients is critical. Assessment of protein and energy status can be done by an array of methodologies that include simple estimates of the visceral and somatic pools of protein to more refined techniques to measure protein and energy balance. The nutritional and metabolic derangements in the CHD population are highly complex and can be confounded by multiple comorbidities and fluid shifts between body compartments. Therefore, assessment of protein and energy status in CHD patients requires a wide range of methodologies that not only identify depleted states but also monitor nutrition therapy and predict clinical outcome. Most important, these methods require cautious and individualized interpretation in order to minimize the interference of comorbid conditions frequently observed in the CHD population. Currently, there is not a single method that can be considered the gold standard for assessment of protein and energy status in CHD patients. Therefore, a combination of methods is recommended. In this review, we describe available methods to assess protein and energy status, with special considerations pertaining to CHD patients.

A Simpler Creatinine Index Can Predict Long-Term Survival in Chinese Hemodialysis Patients

Background

Low lean body mass (LBM) is an indicator of malnutrition inflammation syndrome, which is common in hemodialysis (HD) patients. The creatinine index (CI) has been validated as a reliable method to estimate LBM and evaluate the protein-energy status of HD patients. However, the traditional creatinine index formula was complex. We sought to investigate the impact of CI derived from a new simple formula on Chinese HD patient outcomes.

Methods

In this retrospective cohort study, we enrolled 1269 patients who initiated HD between February 1981 and February 2012 and followed them until the end of February 2013. CI was calculated using the simple creatinine kinetic model (CKM) formula. Multiple linear regression analysis and Cox regression proportional hazard analysis were used to define independent variables and compare survival between groups.

Results

The 1269 HD patients were categorized into 3 groups according to the tertiles of calculated CI between men and women. Each group consisted of 423 patients (50.6% men, 49.4% women). Patients in the highest sex-specific tertile of CI had longer overall survival (HR, 0.46; P 0.002). BMI did not significantly associate with survival after adjustment (HR,0.99; P 0.613).

Conclusions

CI derived from the simple CKM formula serves as a good parameter than BMI to predict the survival of HD patients. The formula could extend its convenient use in clinical practice for HD patients.

The effects of resistance exercise and oral nutritional supplementation during hemodialysis on indicators of nutritional status and quality of life

BACKGROUND

Protein-energy wasting (PEW) is common in patients undergoing hemodialysis (HD). Studies have assessed the positive effect of oral nutritional supplementation (ONS) or resistance exercise (RE) on nutritional status (NS) markers in patients undergoing HD.

METHODS

The aim of this study was to assess the effect of ONS and RE on NS and the quality of life (QOL) of 36 patients undergoing HD. In a randomized clinical trial, patients were divided into the following two groups: a control group (ONS) that received a can of ONS during their HD sessions and an intervention group (ONS + RE) that received a can of ONS and underwent a 40-min session of RE during their HD sessions. Both interventions lasted 12 weeks. The patients' anthropometric, biochemical, dietetic and bioelectrical impedance measurements as well as their QOL, evaluated using the Kidney Disease Quality of Life Short Form, were recorded.

RESULTS

At baseline, 55.5% of patients presented with PEW according to International Society of Renal Nutrition and Metabolism criteria (20 patients). We found statistically significant changes from baseline in both groups, such as increases in body weight, body mass index, midarm circumference, midarm muscle circumference, triceps skinfold thickness, fat mass percentage, handgrip strength, phase angle and serum albumin. A decrease in the prevalence of PEW was observed in both groups at the end of the intervention. A delta comparison between groups showed no statistically significant differences in the anthropometric and biochemical parameters. No significant improvement was observed in QOL and body composition measured by bioimpedance vector analysis. Dietary energy and protein intake increased significantly during the study period for all patients.

CONCLUSION

Oral nutritional supplementation during HD improves NS. The addition of RE during HD does not seem to augment the acute anabolic effects of intradialytic ONS on NS.

Inadequate Macronutrient and Micronutrient Intakes in Hemodialysis and Peritoneal Dialysis Patients: Data from a Seven-Day Weighed Dietary Record

BACKGROUND/AIMS

It is very important to assess the nutritional intake in patients on dialysis given the high prevalence of poor nutritional status of those in this population. The aim of this study was to assess nutrient intakes in hemodialysis (HD) and peritoneal dialysis (PD) patients.

METHODS

A clinical cross-sectional study was conducted over 7 days on 14 dialysis patients (98 days) who were trained to keep a weighed food record and a 7-day food diary. Nutrient intake adequacy was compared with specific guidelines for Italians and dialysis patients.

RESULTS

The mean daily protein intake (0.92 ± 0.36 g/kg) and energy intake (EI; 25.3 ± 7.4 kcal/kg) were inadequate according to the European best practice guidelines (EBPG). The ratio of EI to resting energy expenditure was 1.22. Inadequate intakes, compared to the EBPG, were found for calcium (525 ± 162 mg/day) and iron (8.7 ± 2.1 mg/day). Dietary fiber (14.7 ± 8.7 g/day), niacin (14.4 ± 5.2 mg/day), thiamine (0.8 ± 0.3 mg/day) and riboflavin (1.1 ± 0.4 mg/day) were also inadequate according to the Italian recommended dietary allowances (LARN). HD patients did not display different nutrient intakes between the dialysis days and the interdialytic period. Overall, the percentage of days during which nutrient recommendations were not satisfied ranged from 16 to 100% depending on the nutrient.

CONCLUSION

Macronutrient and micronutrient intakes in HD and PD patients are largely inadequate compared to the EBPG. The weighed dietary record appears to be a useful and accurate tool for individual assessment of food intake in motivated patients. No nutrient intake differences were found between dialytic and interdialytic days in patients on HD.

Antidepressants for treating depression in adults with end-stage kidney disease treated with dialysis

BACKGROUND

Depression affects approximately one-quarter of people treated with dialysis and is considered an important research uncertainty by patients and health professionals. Treatment for depression in dialysis patients may have different benefits and harms compared to the general population due to different clearances of antidepressant medication and the severity of somatic symptoms associated with end-stage kidney disease (ESKD). Guidelines suggest treatment of depression in dialysis patients with pharmacological therapy, preferably a selective serotonin reuptake inhibitor. This is an update of a review first published in 2005.

OBJECTIVES

To evaluate the benefit and harms of antidepressants for treating depression in adults with ESKD treated with dialysis.

SEARCH METHODS

We searched Cochrane Kidney and Transplant's Specialised Register to 20 January 2016 through contact with the Information Specialist using search terms relevant to this review.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing antidepressant treatment with placebo or no treatment, or compared to another antidepressant medication or psychological intervention in adults with ESKD (estimated glomerular filtration rate < 15 mL/min/1.73 m(2)).

DATA COLLECTION AND ANALYSIS

Data were abstracted by two authors independently onto a standard form and subsequently entered into Review Manager. Risk ratios (RR) for dichotomous data and mean differences (MD) for continuous data were calculated with 95% confidence intervals (95% CI).

MAIN RESULTS

Four studies in 170 participants compared antidepressant therapy (fluoxetine, sertraline, citalopram or escitalopram) versus placebo or psychological training for 8 to 12 weeks. In generally very low or ungradeable evidence, compared to placebo, antidepressant therapy had no evidence of benefit on quality of life, had uncertain effects on increasing the risk of hypotension (3 studies, 144 participants: RR 1.72, 95% CI 0.75 to 3.92), headache (2 studies 56 participants: RR 2.91, 95% CI 0.73 to 11.57), and sexual dysfunction (2 studies, 101 participants: RR 3.83, 95% CI 0.63 to 23.34), and increased nausea (3 studies, 114 participants: RR 2.67, 95% CI 1.26 to 5.68). There were few or no data for hospitalisation, suicide or all-cause mortality resulting in inconclusive evidence. Antidepressant therapy may reduce depression scores during treatment compared to placebo (1 study, 43 participants: MD -7.50, 95% CI -11.94 to -3.06). Antidepressant therapy was not statistically different from group psychological therapy for effects on depression scores or withdrawal from treatment and a range of other outcomes were not measured.

AUTHORS' CONCLUSIONS

Despite the high prevalence of depression in dialysis patients and the relative priority that patients place on effective treatments, evidence for antidepressant medication in the dialysis setting is sparse and data are generally inconclusive. The relative benefits and harms of antidepressant therapy in dialysis patients are poorly known and large randomised studies of antidepressants versus placebo are required.

Lean Body Mass and Survival in Hemodialysis Patients and the Roles of Race and Ethnicity

BACKGROUND

Lean body mass (LBM) represents the "fat-free" muscle mass in hemodialysis (HD) patients and is an important nutritional measure. Previous studies have found that both higher LBM and body mass index (BMI) were related to greater survival in HD patients. Additional studies have shown differences in survival across racial-ethnic groups of HD patients. However, the association of LBM and mortality across racial-ethnic subgroups has not been examined.

OBJECTIVE

We hypothesize that racial differences in LBM affect the mortality in HD patients.

SETTING AND SUBJECTS

Chronic HD patients from a large dialysis organization in the United States.

PREDICTORS

Estimated LBM (eLBM), self-identified racial subgroups.

MAIN OUTCOME MEASURE

5-year survival.

STUDY DESIGN

We examined the association between baseline eLBM and survival using Cox proportional hazard models adjusted for demographics, comorbidities, and laboratory measures. Associations were examined across subgroups of race-ethnicity (non-Hispanic white, African American, and Hispanic) and BMI.

RESULTS

The final cohort included 117,683 HD patients, who were 62 ± 15 (mean ± standard deviation) years old, 43% women and 59% with diabetes mellitus. Higher eLBM was linearly associated with lower mortality. Compared with the reference group (48.4-<50.5 kg), patients with the lowest eLBM (<41.3 kg) had a 1.4-fold higher risk of mortality (hazard ratio: 1.37; 95% confidence interval: 1.30-1.44) in the fully adjusted model. A similar linear association was seen among patients with BMI < 35 kg/m(2) and in non-Hispanic whites and African American subgroups. However, higher eLBM was not associated with improved survival in Hispanic patients or patients with BMI ≥ 35 kg/m(2).

LIMITATION

Potential residual confounding.

CONCLUSIONS

Higher eLBM is associated with a lower mortality risk in HD patients, especially among non-Hispanic white and African American groups. Hispanic patients do not demonstrate a similar inverse relationship. The association between LBM and mortality among different racial groups of HD patients deserves additional study.

Relationships Between Malnutrition, Inflammation, Sleep Quality, and Restless Legs Syndrome in Hemodialysis Patients

Restless legs syndrome (RLS) is a common neurologic sensorimotor disorder. It is also seen in hemodialysis patients in whom the mechanism is not thoroughly understood. The aim of this study was to evaluate the association between malnutrition-inflammation score (MIS), sleep quality, and RLS in chronic hemodialysis patients. This cross-sectional study included 232 adult stable chronic hemodialysis patients (mean age 60.9 ± 14.1 years, 56.5% male). RLS frequency, MIS, Pittsburgh Sleep Quality Index (PSQI), laboratory data of patients as well as severity of RLS were evaluated. Thirty-seven patients (15.9%) were diagnosed with RLS. Mean MIS of patients with or without RLS were similar. PSQI of patients with RLS was significantly higher than patients without RLS (P = 0.002). There was a significant positive correlation between RLS severity and PSQI (r = 0.445, P = 0.006). A significant positive correlation was also found between PSQI and MIS in patients with RLS (r = 0.419, P = 0.010). RLS severity was positively correlated with some inflammatory parameters such as white blood cell count and C-reactive protein (r = 0.427, P = 0.008 and r = 0.418 P = 0.010). PSQI was found as an independent significant predictor of RLS (odds ratio [OR] = 1.15 (1.06-1.25), P = 0.001) in multivariate logistic regression analysis. Our study revealed that there was no significant relationship between RLS and MIS in chronic hemodialysis patients. However, RLS severity is correlated with inflammatory parameters. Also, sleep quality in chronic hemodialysis patients with RLS is negatively associated with MIS.

Comparison of Nutrition Profile and Diet Record Between Veteran and Nonveteran End-Stage Renal Disease Patients Receiving Hemodialysis in Veterans Affairs and Community Clinics in Metropolitan South-Central Texas

BACKGROUND

U.S. military veterans have high rates of chronic disease and social disadvantage, which are risk factors for protein-energy wasting (PEW). It is not known whether this translates into high prevalence of PEW in veterans with end-stage renal disease.

METHODS

We compared the clinical, socioeconomic, and nutrition status and the diet of 33 veteran and 38 nonveteran clinically stable patients receiving maintenance hemodialysis (MHD) in south-central Texas.

RESULTS

The whole cohort included 82% Mexican Americans (MAs), 72% type 2 diabetics, and 73% males. The body mass index was 28.9 ± 6.2, while energy intake was 21.5 ± 8.2 kcal/kg/d and protein intake was 1.0 ± 0.4 g/kg/d. Serum albumin (bromocresol purple) was 3.5 ± 0.4 g/dL, transferrin was 171.9 ± 27.8 mg/d, C-reactive protein was 2.9 (1.4-6.5) mg/L, interleukin-6 (IL-6) was 8.3 (4.2-17.9) pg/mL, neutrophil gelatinase-associated lipocalin was 729 (552-1256) ng/mL, and the malnutrition-inflammation score was 8.8 ± 3.0. In group comparison that adjusted for sex and ethnicity, the veterans had better household income, less MAs (60% vs 100%), more males (94% vs 55%), more use of a renin-angiotensin-aldosterone system blockade (66% vs 33%), and lower IL-6 levels (4.4 [3.1-5.8] vs 15.4 [8.3-20.5] pg/mL; P = .01) than nonveterans. In regression analysis, the lower serum IL-6 level in veterans was independently explained by dialysis clinic, sex, and, possibly, household income (intermediate significance).

CONCLUSION

In a relatively small cohort of clinically stable MHD patients, the veterans showed equivalent nutrition status and dietary intake and less inflammation than the nonveterans, thus not supporting the possibility that veteran MHD patients may have worse nutrition than the nonveteran counterpart.

Nutrition and dietary intake and their association with mortality and hospitalisation in adults with chronic kidney disease treated with haemodialysis: protocol for DIET-HD, a prospective multinational cohort study

INTRODUCTION

Adults with end-stage kidney disease (ESKD) treated with haemodialysis experience mortality of between 15% and 20% each year. Effective interventions that improve health outcomes for long-term dialysis patients remain unproven. Novel and testable determinants of health in dialysis are needed. Nutrition and dietary patterns are potential factors influencing health in other health settings that warrant exploration in multinational studies in men and women treated with dialysis. We report the protocol of the "DIETary intake, death and hospitalisation in adults with end-stage kidney disease treated with HaemoDialysis (DIET-HD) study," a multinational prospective cohort study. DIET-HD will describe associations of nutrition and dietary patterns with major health outcomes for adults treated with dialysis in several countries.

METHODS AND ANALYSIS

DIET-HD will recruit approximately 10,000 adults who have ESKD treated by clinics administered by a single dialysis provider in Argentina, France, Germany, Hungary, Italy, Poland, Portugal, Romania, Spain, Sweden and Turkey. Recruitment will take place between March 2014 and June 2015. The study has currently recruited 8000 participants who have completed baseline data. Nutritional intake and dietary patterns will be measured using the Global Allergy and Asthma European Network (GA(2)LEN) food frequency questionnaire. The primary dietary exposures will be n-3 and n-6 polyunsaturated fatty acid consumption. The primary outcome will be cardiovascular mortality and secondary outcomes will be all-cause mortality, infection-related mortality and hospitalisation.

ETHICS AND DISSEMINATION

The study is approved by the relevant Ethics Committees in participating countries. All participants will provide written informed consent and be free to withdraw their data at any time. The findings of the study will be disseminated through peer-reviewed journals, conference presentations and to participants via regular newsletters. We expect that the DIET-HD study will inform large pragmatic trials of nutrition or dietary interventions in the setting of advanced kidney disease.

Creatinine index as a surrogate of lean body mass derived from urea Kt/V, pre-dialysis serum levels and anthropometric characteristics of haemodialysis patients

Background and Objectives

Protein-energy wasting is common in long-term haemodialysis (HD) patients with chronic kidney disease and is associated with increased morbidity and mortality. The creatinine index (CI) is a simple and useful nutritional parameter reflecting the dietary skeletal muscle protein intake and skeletal muscle mass of the patient. Because of the complexity of creatinine kinetic modeling (CKM) to derive CI, we developed a more simplified formula to estimate CI in HD patients.

Design, Setting, Participants & Measurements

A large database of 549 HD patients followed over more than 20 years including monthly CKM-derived CI values was used to develop a simple equation based on patient demographics, predialysis serum creatinine values and dialysis dose (_spKt/V) using mixed regression models.

Results

The equation to estimate CI was developed based on age, gender, pre-dialysis serum creatinine concentrations and _spKt/V urea. The equation-derived CI correlated strongly with the measured CI using CKM (correlation coefficient  = 0.79, p-value <0.001). The mean error of CI prediction using the equation was 13.47%. Preliminary examples of few typical HD patients have been used to illustrate the clinical relevance and potential usefulness of CI.

Conclusions

The elementary equation used to derive CI using demographic parameters, pre-dialysis serum creatinine concentrations and dialysis dose is a simple and accurate surrogate measure for muscle mass estimation. However, the predictive value of the simplified CI assessment method on mortality deserves further evaluation in large cohorts of HD patients.

Validation of Mini Nutritional Assessment Scale in peritoneal dialysis patients

INTRODUCTION

Malnutrition is a negative predictive factor for survival in end stage renal disease (ESRD) patients. Coincidence of malnutrition, inflammation and atherosclerosis (MIA syndrome) in the dialysis population is an exceptionally poor outcome event. Due to flexibility, ease of performance and reproducibility, clinical scales are of particular value in assessment of nutritional status in ESRD patients. The aim of the present study was to evaluate the clinical value of Mini Nutritional Assessment (MNA) in peritoneal dialysis (PD) patients.

MATERIAL AND METHODS

Nutritional status was assessed in 41 peritoneal dialysis patients by means of the MNA scale and malnutrition inflammation score (MIS). Some other clinical and laboratory parameters associated with nutritional status were analyzed. Patients were followed up for 30 months.

RESULTS

In the analyzed group of patients a good nutritional state was diagnosed in 22 patients (54%), risk of malnutrition in 17 (41%) and malnutrition in 2 patients (5%) based on the MNA scale. A strong correlation between MNA based nutritional status and MIS was found (r = -0.85, p < 0.01, ANOVA, p < 0.01). Differences in time on dialysis, body mass index, concentration of albumin, cholesterol and triglycerides were noted between at risk/malnourished and well-nourished (according to MNA) patients. Statistically significant factors determining survival of patients by Cox proportional hazard analysis were age (HR 1.07), being at risk/malnourished according to MNA (HR 5.7), MIS (HR 1.2), and albumin (HR 0.13).

CONCLUSIONS

The MNA scale is a valuable, clinically suitable tool for assessment of nutritional status in peritoneal dialysis patients. Risk of malnutrition and malnutrition diagnosed by MNA identifies patients at high mortality risk.

A patient with CKD and poor nutritional status

Protein energy wasting is common in patients with CKD and ESRD and is associated with adverse clinical outcomes, such as increased rates of hospitalization and death, in these patients. A multitude of factors can affect the nutritional and metabolic status of patients with CKD, including decreased dietary nutrient intake, catabolic effects of renal replacement therapy, systemic inflammation, metabolic and hormonal derangements, and comorbid conditions (such as diabetes and depression). Unique aspects of CKD also confound reliable assessment of nutritional status, further complicating management of this comorbid condition. In patients in whom preventive measures and oral dietary intake from regular meals cannot help them maintain adequate nutritional status, nutritional supplementation, administered orally, enterally, or parenterally, is effective in replenishing protein and energy stores. The advantages of oral nutritional supplements include proven efficacy, safety, and compliance. Anabolic steroids and exercise, with nutritional supplementation or alone, improve protein stores and represent potential additional approaches for the treatment of PEW. There are several emerging novel therapies, such as appetite stimulants, anti-inflammatory interventions, and anabolic agents.

Prevention and treatment of protein energy wasting in chronic kidney disease patients: a consensus statement by the International Society of Renal Nutrition and Metabolism

Protein energy wasting (PEW) is common in patients with chronic kidney disease (CKD) and is associated with adverse clinical outcomes, especially in individuals receiving maintenance dialysis therapy. A multitude of factors can affect the nutritional and metabolic status of CKD patients requiring a combination of therapeutic maneuvers to prevent or reverse protein and energy depletion. These include optimizing dietary nutrient intake, appropriate treatment of metabolic disturbances such as metabolic acidosis, systemic inflammation, and hormonal deficiencies, and prescribing optimized dialytic regimens. In patients where oral dietary intake from regular meals cannot maintain adequate nutritional status, nutritional supplementation, administered orally, enterally, or parenterally, is shown to be effective in replenishing protein and energy stores. In clinical practice, the advantages of oral nutritional supplements include proven efficacy, safety, and compliance. Anabolic strategies such as anabolic steroids, growth hormone, and exercise, in combination with nutritional supplementation or alone, have been shown to improve protein stores and represent potential additional approaches for the treatment of PEW. Appetite stimulants, anti-inflammatory interventions, and newer anabolic agents are emerging as novel therapies. While numerous epidemiological data suggest that an improvement in biomarkers of nutritional status is associated with improved survival, there are no large randomized clinical trials that have tested the effectiveness of nutritional interventions on mortality and morbidity.

Inflammatory status in chronic renal failure: The role of homocysteinemia and pro-inflammatory cytokines

AIM: To evaluate determinants of inflammatory markers in chronic renal failure patients according to the level of glomerular filtration rate.

METHODS: One hundred fifty four patients (Age: 44 ± 06 years; male/female: 66/88) with chronic renal failure (CRF) were divided into 6 groups according to the National Kidney Foundation (NKF) classification. They included 28 primary stage renal failure patients (CRF 1), 28 moderate stage renal failure patients (CRF 2), 28 severe stage renal failure patients (CRF 3), 18 end-stage renal failure patients (CRF 4), 40 hemodialysis (HD) patients, and 12 peritoneal dialysis (PD) patients. Tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β), interleukin-6 (IL-6) and C-reactive protein (CRP) were analyzed by immunosorbent assay kit (ELISA) (Cayman Chemical’s ACETM EIA kit). Immunoassay methods were used for total homocysteine (tHcy) (fluorescence polarization immunoanalysis HPLC, PerkinEmer 200 series), transferrin (MININEPHTM human transferin kit: ZK070.R), ferritin (ADVIA Centaur) and fibrinogen analysis (ACL 200). Differences between groups were performed using SPSS 20.0 and data are expressed as the mean ± SD.

RESULTS: Results showed that in comparison with CRF 1 group and other groups, TNF-α and IL-6 levels were respectively more elevated in HD (16.38 ± 5.52 pg/mL vs 0.39 ± 0.03 pg/mL, 11.05 ± 3.59 pg/mL vs 8.20 ± 0.22 pg/mL, P < 0.001) and PD (14.04 ± 3.40 pg/mL vs 0.39 ± 0.03 pg/mL, 10.15 ± 1.66 pg/mL vs 8.20 ± 0.22 pg/mL, P < 0.001). IL-1β levels were increased in HD (9.63 ± 3.50 pg/mL vs 3.24 ± 0.10 pg/mL, P < 0.001) and CRF 4 (7.76 ± 0.66 pg/mL vs 3.24 ± 0.10 pg/mL, P < 0.001) patients than in CRF 1 and in the other groups. Plasma tHcy levels were higher in HD (32.27 ± 12.08 μmol/L) and PD (28.37 ± 4.98 μmol/L) patients compared to the other groups of CRF (P < 0.001). The serum CRP level was significantly increased in HD (18.17 ± 6.38 mg/L) and PD (17.97 ± 4.85 mg/L) patients compared to the other groups of CRF patients (P < 0.001). The plasma fibrinogen level was more elevated in HD (6.86 ± 1.06 g/L) and CRF 4 (6.05 ± 0.57 g/L) than in the other groups (P < 0.001). Furthermore; the ferritin level was higher in HD (169.90 ± 62.16 ng/mL) and PD (90.08 ± 22.09 ng/mL) patients compared to the other groups of CRF (P < 0.001). The serum transferrin value was significantly decreased especially in PD (1.78 ± 0.21 g/L) compared to the other groups (P < 0.001). We found a negative correlation between glomerular filtration rate (GFR), TNF-α levels (r = -0.75, P < 0.001), and tHcy levels (r = -0.68, P < 0.001). We observed a positive correlation between GFR and transferrin levels (r = 0.60, P < 0.001).

CONCLUSION: CRF was associated with elevated inflammatory markers. The inflammation was observed at the severe stage of CRF and increases with progression of renal failure.