Artificial Nutritional Support in Chronic Hemodialysis Patients: A Narrative Review

Effect of a personalized nutritional intervention program on nutritional status, quality of life and mortality in hemodialysis patients

Introduction

Objective: dietary advice provided through a nutritional intervention program (NIP) is recommended by renal clinic guidelines to prevent or treat malnutrition, that could improve quality of life (QoL) and survival in hemodialysis (HD) patients. This study set out to evaluate the effect of a personalized NIP on the nutritional status and its impact on QoL and mortality in dialyzed patients. Material and methods: this was a 12-month intervention study with regular follow-up in which nutritional parameters were measured at baseline and after 6 and 12 months. QoL was assessed by the Kidney Disease Quality of Life version 1.2 (KDQOL-SF) at baseline and at the end of the study. All dialyzed patients received individualized consultations with a trained dietitian. The content of the nutritional education program included a personalized meal plan and educational materials addressing nutrition to manage fluids, electrolytes, and vitamin D. Results: a total of 75 patients were included. After the NIP, visceral proteins, phosphorous, potassium and vitamin D levels had improved significantly (p < 0.001). The percentage of well-nourished patients increased by 30 % (p < 0.001). At the end of the study, the well-nourished patients had significantly improved scores on the general summary areas of the KDQOL-SF, reduced worry concerning fluid and dietary restrictions (p < 0.001), and the survival rate was 12 months longer (p < 0.01). Conclusion: the results of this study suggest that personalized NIP contributed to improved nutritional status, QoL and survival in HD patients.

Intradialytic parenteral nutrition for patients on hemodialysis: when, how and to whom?

Hemodialysis is associated with high morbidity and mortality rates as well as low quality of life. Altered nutritional status and protein-energy wasting are important indicators of these risks. Maintaining optimal nutritional status in patients with hemodialysis is a critical but sometimes overlooked aspect of care. Nutritional support strategies usually begin with dietary counseling and oral nutritional supplements. Patients may not comply with this advice or oral nutritional supplements, however , or compliance may be affected by other complications of progressive chronic kidney disease. Intradialytic parenteral nutrition (IDPN) may be a possibility in these cases, but lack of knowledge on practical aspects of IDPN delivery are seldom discussed and may represent a barrier. In this review, we, as a consensus panel of clinicians experienced with IDPN, survey existing literature and summarize our views on when to use IDPN, which patients may be best suited for IDPN, and how to effectively deliver and monitor this strategy for nutritional support.

Glycemic Response to a Renal-Specific Oral Nutritional Supplement in Patients With Diabetes Undergoing Hemodialysis: A Randomized Crossover Trial

BACKGROUND

Diabetes and malnutrition are common in patients with kidney failure. We aimed to evaluate the postprandial glucose response to oral nutritional supplement drinks (ONSs) in patients with diabetes undergoing hemodialysis treatment.

METHODS

A randomized, single-blind crossover study was conducted in patients with diabetes, and requiring chronic hemodialysis. Patients consumed either a renal-specific ONS, macronutrient-matched ONS, or standard ONS on 3 separate study days, during dialysis, following an overnight fast. Blood was collected before and 15, 30, 45, 60, 90, 120, and 180 minutes post ingestion. Mean net incremental area under the curve (iAUC) and peak incremental blood glucose concentration were compared across conditions, using analyses of variance.

RESULTS

Consumption of the renal-specific ONS resulted in the lowest mean net iAUC (87.9 ± 169.0 mmol/L per 3 hours) compared with macronutrient-matched (188.0 ± 127.5 mmol/L per 3 hours) and standard ONS (199.5 ± 169.2 mmol/L per 3 hours) (F_2,30 = 5.115, P = 0.012, partial n² = 0.254). Pairwise comparisons demonstrated a mean difference of 100.1 mmol/L per 3 hours (95% CI, -2.8 to 202.9) in mean iAUC between the renal-specific ONS and macronutrient-matched ONS (P = 0.058). Peak blood glucose concentration, corrected for baseline, was significantly lower after the renal-specific ONS (1.40 ± 1.0 mmol/L) compared with both macronutrient-matched (2.02 ± 0.71 mmol/L, P = 0.036) and standard ONS (2.3 ± 1.06 mmol/L, P = 0.017).

CONCLUSION

A renal-specific ONS elicits a lower postprandial glucose response than either macronutrient-matched ONS or standard ONS in patients with diabetes during hemodialysis.

[Nutrition in chronic kidney disease]

INTRODUCTION

Chronic kidney disease patients often also present protein-calorie malnutrition, and it is a powerful predictor of morbidity and mortality. In this article, causes and management are shown, highlighting oral and parenteral nutritional supplementation, especially during dialysis process.

Effect of Personalized Nutritional Counseling on the Nutritional Status of Hemodialysis Patients

This study set out to evaluate the impact of personalized nutritional counseling (PNC) on the nutritional status of hemodialysis (HD) patients. This was an intervention study for 10 months at 2 hospitals. Anthropometric, biochemical, dietary, and body composition parameters were measured at baseline and after 3 and 6 months of PNC. A total of 42 patients (23 men and 19 women) were included. Intake of dietary protein, serum albumin, and cholesterol levels had increased significantly from baseline to month 6 (p < 0.05). Among the bioelectrical impedance analysis (BIA) parameters, both the body cell mass (BCM) and the fat free mass (FFM) had significantly reduced at month 3 compared to baseline (p < 0.05). However, there was no difference between baseline and month 6. We assessed the nutritional status of the subjects using the malnutrition inflammation score (MIS), and divided them into an adequately nourished (AN) and a malnourished (MN) group at baseline. In the subgroup analysis, serum levels of albumin and cholesterol had increased significantly, particularly from baseline to month 6 in the MN group (p < 0.05). This study suggests that consecutive PNC contributed to the improvement of the protein intake, serum levels of albumin, cholesterol and to the delay of muscle wasting, which could also have a positive impact on the nutritional status, particularly in malnourished patients receiving HD treatment.

Renal consequences of parenteral nutrition

Parenteral nutrition (PN) can be described as the "Intravenous administration of nutrients necessary to sustain life in those who would otherwise have died or suffered serious disease". PN is indicated in children who cannot be fully fed by the oral or intestinal route, usually as a result of intestinal failure. Intradialytic parenteral nutrition (IDPN) is rarely indicated in children on dialysis and does not confer a benefit over enteral supplements in the compliant patient with adequate intestinal function. Renal and metabolic consequences of PN are potentially life-threatening and include disorders of glucose homeostasis, acid-base and fluid and electrolyte disturbances, nephrolithiasis, impaired renal function and metabolic bone disease. Many of these complications are avoidable. Adequate clinical and biochemical assessment and monitoring of children receiving PN by a multidisciplinary nutrition support team is recommended to mitigate against the risks of these complications.

[Efficacy of oral supplementation during dialysis in patients with chronic renal failure]

Protein-calorie malnutrition is common in hemodialysis patients and is a powerful predictor of morbidity and mortality. Nutritional supplementation, administered orally or parenterally, especially during dialysis, may compensate for the relatively inadequate protein and energy intake and improves net protein anabolism in chronic hemodialysis patients. Intradialytic oral nutrition seems preferable to intradialytic parenteral nutrition (IDPN) due to its lower cost and persistence of its anabolic effects after infusion is stopped, and because IDPN induces a higher increase in serum glucose and insulin levels and a greater reduction in serum ghrelin concentrations. Further larger scale randomized, controlled trials of nutritional interventions should be performed in maintenance dialysis patients to assess their efficacy regarding quality of life, morbidity, and mortality.