Outcomes research in nutrition and chronic kidney disease: perspectives, issues in practice, and processes for improvement

Moving the issue of renal dietitian staffing forward

The day-to-day pragmatic work realities of dietitians who cover dialysis clinics are rarely the focus of discussion. This article highlights the points of convergence between these realities and the research literature. Focusing on the National Kidney Foundation Kidney Disease Outcomes Quality Initiative clinical practice guidelines for nutrition and the difficulties encountered with their full implementation, a seemingly pervasive problem of limited time is revealed. Given the evidence that renal dietitians can positively impact morbidity and mortality risks, when protein-energy malnutrition is primarily the byproduct of insufficient nutrient intake, it suggests that progress with enhancing the nutritional status of patients may be fundamentally contingent on increasing the time they have available, through improved staffing.

What is the meaning of homocysteine in patients on dialysis?

OBJECTIVE

To evaluate the determinants of total plasma homocysteine levels and their relations with nutritional parameters, inflammatory status, and traditional risk factors for cardiovascular disease in renal failure patients on dialysis treatment.

DESIGN

The study was conducted on 70 clinically stable patients, 50 of them on hemodialysis (70% men; 55.3 ± 14.5 years) and 20 on peritoneal dialysis (50% men; 62 ± 13.7 years). Patients were analyzed in terms of biochemical parameters (serum lipids, creatinine, homocysteine [Hcy], creatine-kinase [Ck], folic acid, and vitamin B(12)), anthropometric data, markers of inflammatory status (tumor necrosis factor-alpha, C-reactive protein, interleukin-6), and adapted subjective global assessment.

RESULTS

The total prevalence of hyperhomocysteinemia (>15 μmol/L) was 85.7%. Plasma folic acid and plasma vitamin B(12) were within the normal range. Multiple regression analysis (r(2) = 0.20) revealed that the determinants of total Hcy were type of dialysis, creatinine, Ck, folic acid, and total cholesterol. Hcy was positively correlated with albumin and creatinine and negatively correlated with total cholesterol, high density lipoprotein cholesterol, folic acid, and vitamin B(12).

CONCLUSIONS

The determinants of total Hcy in the study sample were type of dialysis, creatinine, Ck, folic acid, and total cholesterol. Evidently, the small sample size might have had an effect on the statistical analyses and further studies are needed. However, Hcy in patients on dialysis treatment may not have the same effect as observed in the general population. In this respect, the association between malnutrition and inflammation may be a confounding factor in the determination of the true relationship between Hcy, nutritional status, and cardiovascular risk factors in this group.

Prognostic factors of spontaneous intracerebral haemorrhage in haemodialysis patients and predictors of 30-day mortality

BACKGROUND

The prognostic factors of intracerebral haemorrhage (ICH) in haemodialysis (HD) patients are not fully clear and there is no standard clinical grading scale to predict 30-day mortality. Our aim was to develop such a scale.

METHODS

Records of all HD patients with spontaneous ICH presenting to Chang Gung Memorial Hospital in Taiwan during 1994-2004 were reviewed. The study design was a retrospective analysis of data collected from one hospital. Prognostic factors were identified by Student's t-test and chi(2)-test. Independent predictors of 30-day mortality were determined by the logistic regression method. An outcome score based on a combination of these predictors was developed with weighting of independent predictors based on strength of association.

RESULTS

The overall 30-day mortality rate was 67.3%. Prognostic factors independently associated with mortality were the Glasgow Coma Scale score (P < 0.001), age >/=70 years (P = 0.032), systolic blood pressure <130 mmHg or >/=200 mmHg (P = 0.016), ICH volume >/=30 mL (P = 0.012), presence of intraventricular haemorrhage (P = 0.004) and serum glucose >/=8.8 mmol/L (P = 0.023). The score was the sum of individual points assigned as follows: Glasgow Coma Scale score 12-15 (0 points), 9-11 (1), 3-8 (4); age <70 years, yes (0), no (2); and systolic blood pressure 130-199 mmHg, yes (0), no (1). The 30-day mortality rate increased steadily with score (P < 0.001).

CONCLUSION

The outcome score is a simple clinical grading scale that allows risk stratification of HD patients presenting with ICH. This scale could be used to design treatment protocols and clinical research studies of ICH in HD patients.