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Evenepoel P, Jørgensen HS, Bover J, Davenport A, Bacchetta J, Haarhaus M, Hansen D, Gracia-Iguacel C, Ketteler M, McAlister L, White E, Mazzaferro S, Vervloet M, Shroff R. Recommended calcium intake in adults and children with chronic kidney disease-a European consensus statement. Nephrol Dial Transplant 2024; 39:341-366. [PMID: 37697718 DOI: 10.1093/ndt/gfad185] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Indexed: 09/13/2023] Open
Abstract
Mineral and bone disorders (MBD) are common in patients with chronic kidney disease (CKD), contributing to significant morbidity and mortality. For several decades, the first-line approach to controlling hyperparathyroidism in CKD was by exogenous calcium loading. Since the turn of the millennium, however, a growing awareness of vascular calcification risk has led to a paradigm shift in management and a move away from calcium-based phosphate binders. As a consequence, contemporary CKD patients may be at risk of a negative calcium balance, which, in turn, may compromise bone health, contributing to renal bone disease and increased fracture risk. A calcium intake below a certain threshold may be as problematic as a high intake, worsening the MBD syndrome of CKD, but is not addressed in current clinical practice guidelines. The CKD-MBD and European Renal Nutrition working groups of the European Renal Association (ERA), together with the CKD-MBD and Dialysis working groups of the European Society for Pediatric Nephrology (ESPN), developed key evidence points and clinical practice points on calcium management in children and adults with CKD across stages of disease. These were reviewed by a Delphi panel consisting of ERA and ESPN working groups members. The main clinical practice points include a suggested total calcium intake from diet and medications of 800-1000 mg/day and not exceeding 1500 mg/day to maintain a neutral calcium balance in adults with CKD. In children with CKD, total calcium intake should be kept within the age-appropriate normal range. These statements provide information and may assist in decision-making, but in the absence of high-level evidence must be carefully considered and adapted to individual patient needs.
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Affiliation(s)
- Pieter Evenepoel
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium
- Department of Medicine, Division of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Hanne Skou Jørgensen
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium
- Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Nephrology, Aalborg University Hospital, Aalborg, Denmark
| | - Jordi Bover
- Department of Nephrology, University Hospital Germans Trias i Pujol, Barcelona, Catalonia, Spain
- REMAR-IGTP Group, Germans Trias i Pujol Research Institute, Can Ruti Campus, Barcelona, Catalonia, Spain
| | - Andrew Davenport
- Department of Renal Medicine, Royal Free Hospital, University College London, London, UK
| | - Justine Bacchetta
- Pediatric Nephrology Rheumatology and Dermatology Unit, Reference Center for Rare Renal Diseases, ORKID and ERK-Net networks, Lyon University Hospital, Bron, France
- Lyon Est Medical School, INSERM1033 Research Unit, Claude Bernard Lyon 1 University, Lyon, France
| | - Mathias Haarhaus
- Division of Renal Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Diaverum Sweden, Malmö, Sweden
| | - Ditte Hansen
- Department of Nephrology, Copenhagen University Hospital-Herlev, Copenhagen
- Institute of Clinical Medicine, University of Copenhagen, Denmark
| | - Carolina Gracia-Iguacel
- Department of Renal Medicine, IIS-Fundación Jiménez Díaz UAM University Hospital, Madrid, Spain
| | - Markus Ketteler
- Department of General Internal Medicine and Nephrology, Robert-Bosch Hospital, Stuttgart, Germany
| | - Louise McAlister
- Dietetic Team, UCL Great Ormond Street Hospital for Children and University College London, London, UK
| | - Emily White
- Dietetic Team, Royal Free Hospital, University College London, London, UK
| | - Sandro Mazzaferro
- Department of Translation and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Marc Vervloet
- Amsterdam Cardiovascular Sciences, Amsterdam UMC, The Netherlands
- Department of Nephrology, Amsterdam UMC, The Netherlands
| | - Rukshana Shroff
- Renal Unit, UCL Great Ormond Street Hospital for Children, London, UK
- Institute of Child Health, University College London, London, UK
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Sullivan VK, Rebholz CM. Nutritional Epidemiology and Dietary Assessment for Patients With Kidney Disease: A Primer. Am J Kidney Dis 2023; 81:717-727. [PMID: 36610612 PMCID: PMC10200755 DOI: 10.1053/j.ajkd.2022.11.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 11/19/2022] [Indexed: 01/06/2023]
Abstract
Nutritional epidemiology seeks to understand nutritional determinants of disease in human populations using experimental and observational study designs. Though randomized controlled trials provide the strongest evidence of causality, the expense and difficulty of sustaining adherence to dietary interventions are substantial barriers to investigating dietary determinants of kidney disease. Therefore, nutritional epidemiology commonly employs observational study designs, particularly prospective cohort studies, to investigate long-term associations between dietary exposures and kidney disease. Due to the covarying nature and synergistic effects of dietary components, holistic characterizations of dietary exposures that simultaneously consider patterns of foods and nutrients regularly consumed are generally more relevant to disease etiology than single nutrients or foods. Dietary intakes have traditionally been self-reported and are subject to bias. Statistical methods including energy adjustment and regression calibration can reduce random and systematic measurement errors associated with self-reported diet. Novel approaches that assess diet more objectively are gaining popularity but have not yet fully replaced self-report and require refinement and validation in populations with chronic kidney disease. More accurate and frequent diet assessment in existing and future studies will yield evidence to better personalize dietary recommendations for the prevention and treatment of kidney disease.
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Affiliation(s)
- Valerie K Sullivan
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Maryland
| | - Casey M Rebholz
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Maryland; Division of Nephrology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland.
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Muniz GAS, Ramos CI, Claudino G, Cuppari L. Development and Validation of a Food Frequency Questionnaire to Assess Potassium Intake of Patients on Hemodialysis. J Ren Nutr 2023; 33:386-392. [PMID: 36270482 DOI: 10.1053/j.jrn.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 09/02/2022] [Accepted: 10/09/2022] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To develop and to validate a food frequency questionnaire (FFQ) to assess potassium intake of patients on hemodialysis. METHODS This is a cross-sectional study that included 41 patients in the FFQ development step and 53 patients in the FFQ validation step. In the FFQ development step, the patients completed a 3-day food record (used as a reference method). Total potassium intake and potassium from each food item were calculated. Food items that contributed up to 90% of the total potassium intake were considered to be included in the FFQ food list. Then the FFQ was applied in person through the google-forms platform. The result of potassium intake obtained by the FFQ was compared with that obtained by the 3-day food record. RESULTS A total of 94 patients were included: 53.2% women; age 55.7 ± 15.0 years; 47.9% had diabetes; body mass index 25.0 ± 4.5 kg/m2; and dialysis vintage 34.5 (17.0-68.2) months. Demographic, clinical, and laboratory parameters did not differ between the development and validation groups. From the 255 registered food items, 85 comprised the FFQ. The standardized Cronbach's alpha obtained was 0.71. No difference was found between the potassium intake obtained by the FFQ and by the 3-day food record (1,438.5 ± 659.4 mg/d vs. 1,464.8 ± 529.4 mg/d; P = .753, respectively) with an intraclass correlation coefficient of 0.66 (P = .001). No systematic bias or proportionality bias between the methods was observed in the Bland-Altman graphical analysis. CONCLUSION The quantitative FFQ presented strong relative validity and may constitute a practical tool in the analysis of potassium intake of patients on hemodialysis.
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Affiliation(s)
| | | | | | - Lilian Cuppari
- Division of Nephrology, Universidade Federal de São Paulo, Brazil; Nutrition Program, Universidade Federal de São Paulo, Brazil.
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Wendling AL, Crispim SP, Ribeiro SAV, Balbino KP, Hermsdorff HHM. Relative validity and reproducibility of food frequency questionnaire for individuals on hemodialysis (NUGE-HD study). Hemodial Int 2021; 26:386-396. [PMID: 34970823 DOI: 10.1111/hdi.12995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 12/08/2021] [Accepted: 12/09/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Adequate assessment of food intake is essential to establish the magnitude and direction of the relationship of food, nutrients, and bioactive compounds with clinical outcomes of individuals in hemodialysis. We evaluated the relative validity and reproducibility of a specific food frequency questionnaire for individuals on hemodialysis (FFQ-HD). METHODS Eighty-two participants (57.3% male, 57.5 ± 14.4 years) from the open cohort Nutrition and Genetics in Hemodialysis Outcomes participated in this study. The relative validity of the FFQ-HD was assessed using the mean of two 24-h food recall (24hR) adjusted for within-subject variability as a reference method. We also performed Pearson correlations, and agreement between tertile, kappa statistics, and Bland-Altman scatter plots were validated. Reproducibility was assessed after 1 year using intraclass correlation coefficient (ICC). FINDINGS Daily energy intake was not different between FFQ-HD and 24hR (mean difference of 50.1 kcal). Intake of protein, linolenic acid, fiber, phosphorus, potassium, sodium, calcium, and sugar showed a moderate correlation (r between 0.4 and 0.5) among instruments, while mean correlation coefficient was r = 0.38 to food group intake. Bland-Altman plots showed good agreement for micronutrients, phosphorus, sodium, and potassium and for the groups "flour, bread, and pasta" and "processed, canned meat, salts, and seasonings". The reproducibility of FFQ-HD for nutrients and food groups was satisfactory, reaching a maximum ICC of 0.72 and 0.59, respectively. DISCUSSION The FFQ-HD showed moderate validity and reproducibility for calories, nutrients, and food groups of clinical and nutritional interest for HD subjects so that it can be a useful tool in epidemiological studies in this population.
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Affiliation(s)
- Aline L Wendling
- Department of Nutrition and Health, Universidade Federal de Viçosa, Viçosa, Brazil
| | - Sandra P Crispim
- Department of Nutrition, Federal University of Paraná, Curitiba, Brazil
| | | | - Karla P Balbino
- Department of Nutrition and Health, Universidade Federal de Viçosa, Viçosa, Brazil
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Ahmed S, Rahman T, Ripon MSH, Rashid HU, Kashem T, Md Ali MS, Khor BH, Khosla P, Karupaiah T, Daud ZAM. A Food Frequency Questionnaire for Hemodialysis Patients in Bangladesh (BDHD-FFQ): Development and Validation. Nutrients 2021; 13:4521. [PMID: 34960076 PMCID: PMC8707927 DOI: 10.3390/nu13124521] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 12/12/2021] [Accepted: 12/14/2021] [Indexed: 11/17/2022] Open
Abstract
Diet is a recognized risk factor and cornerstone for chronic kidney disease (CKD) management; however, a tool to assess dietary intake among Bangladeshi dialysis patients is scarce. This study aims to validate a prototype Bangladeshi Hemodialysis Food Frequency Questionnaire (BDHD-FFQ) against 3-day dietary recall (3DDR) and corresponding serum biomarkers. Nutrients of interest were energy, macronutrients, potassium, phosphate, iron, sodium and calcium. The BDHD-FFQ, comprising 132 food items, was developed from 606 24-h recalls and had undergone face and content validation. Comprehensive facets of relative validity were ascertained using six statistical tests (correlation coefficient, percent difference, paired t-test, cross-quartiles classification, weighted kappa, and Bland-Altman analysis). Overall, the BDHD-FFQ showed acceptable to good correlations (p < 0.05) with 3DDR for the concerned nutrients in unadjusted and energy-adjusted models, but this correlation was diminished when adjusted for other covariates (age, gender, and BMI). Phosphate and potassium intake, estimated by the BDHD-FFQ, also correlated well with the corresponding serum biomarkers (p < 0.01) when compared to 3DDR (p > 0.05). Cross-quartile classification indicated that <10% of patients were incorrectly classified. Weighted kappa statistics showed agreement with all but iron. Bland-Altman analysis showed positive mean differences were observed for all nutrients when compared to 3DDR, whilst energy, carbohydrates, fat, iron, sodium, and potassium had percentage data points within the limit of agreement (mean ± 1.96 SD), above 95%. In summary, the BDHD-FFQ demonstrated an acceptable relative validity for most of the nutrients as four out of the six statistical tests fulfilled the cut-off standard in assessing dietary intake of CKD patients in Bangladesh.
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Affiliation(s)
- Shakil Ahmed
- Department of Food Technology and Nutrition Science, Noakhali Science and Technology University, Sonapur 3814, Bangladesh; (S.A.); (M.S.H.R.)
| | - Tanjina Rahman
- Institute of Nutrition and Food Science, University of Dhaka, Dhaka 1000, Bangladesh;
| | - Md Sajjadul Haque Ripon
- Department of Food Technology and Nutrition Science, Noakhali Science and Technology University, Sonapur 3814, Bangladesh; (S.A.); (M.S.H.R.)
| | - Harun-Ur Rashid
- Kidney Foundation Hospital and Research Institute, Dhaka 1216, Bangladesh; (H.-U.R.); (T.K.)
| | - Tasnuva Kashem
- Kidney Foundation Hospital and Research Institute, Dhaka 1216, Bangladesh; (H.-U.R.); (T.K.)
| | - Mohammad Syafiq Md Ali
- Department of Nutrition Sciences, Kulliyyah of Allied Health Sciences, International Islamic University Malaysia, Kuantan 25200, Pahang, Malaysia;
| | - Ban-Hock Khor
- Faculty of Food Science and Nutrition, Universiti Malaysia Sabah, Kota Kinabalu 88400, Sabah, Malaysia;
| | - Pramod Khosla
- Department of Nutrition and Food Science, Wayne State University, Detroit, MI 48202, USA;
| | - Tilakavati Karupaiah
- School of Biosciences, Taylors’ University, Subang Jaya 47500, Selangor, Malaysia;
| | - Zulfitri Azuan Mat Daud
- Department of Dietetics, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang 43400, Selangor, Malaysia
- Research Center of Excellence (RCoE) Nutrition and Non-Communicable Diseases, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang 43400, Selangor, Malaysia
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Brightwell CR, Kulkarni AS, Paredes W, Zhang K, Perkins JB, Gatlin KJ, Custodio M, Farooq H, Zaidi B, Pai R, Buttar RS, Tang Y, Melamed ML, Hostetter TH, Pessin JE, Hawkins M, Fry CS, Abramowitz MK. Muscle fibrosis and maladaptation occur progressively in CKD and are rescued by dialysis. JCI Insight 2021; 6:150112. [PMID: 34784301 PMCID: PMC8783691 DOI: 10.1172/jci.insight.150112] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 11/11/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Skeletal muscle maladaptation accompanies chronic kidney disease (CKD) and negatively impacts physical function. Emphasis in CKD has historically been placed on muscle fiber intrinsic deficits, such as altered protein metabolism and atrophy. However, targeted treatment of fiber intrinsic dysfunction has produced limited improvement, whereas alterations within the fiber extrinsic environment have scarcely been examined. METHODS We investigated alterations to the skeletal muscle interstitial environment with deep cellular phenotyping of biopsies from patients with CKD compared to age-matched control participants and performed transcriptome profiling to define the molecular underpinnings of CKD-associated muscle impairments. We further examined changes in the observed muscle maladaptation following initiation of dialysis therapy for kidney failure. RESULTS Patients with CKD exhibited a progressive fibrotic muscle phenotype, which was associated with impaired regenerative capacity and lower vascular density. The severity of these deficits was strongly associated with the degree of kidney dysfunction. Consistent with these profound deficits, CKD was associated with broad alterations to the muscle transcriptome, including altered extracellular matrix organization, downregulated angiogenesis, and altered expression of pathways related to stem cell self-renewal. Remarkably, despite the seemingly advanced nature of this fibrotic transformation, dialysis treatment rescued these deficits, restoring a healthier muscle phenotype. Furthermore, after accounting for muscle atrophy, strength and endurance improved after dialysis initiation. CONCLUSION These data identify a dialysis-responsive muscle fibrotic phenotype in CKD and suggest that the early dialysis window presents a unique opportunity of improved muscle regenerative capacity during which targeted interventions may achieve maximal impact. TRIAL REGISTRATION NCT01452412FUNDING. NIH.
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Affiliation(s)
- Camille R Brightwell
- Department of Athletic Training and Clinical Nutrition, University of Kentucky, Lexington, United States of America
| | - Ameya S Kulkarni
- Department of Medicine, Albert Einstein College of Medicine, Bronx, United States of America
| | - William Paredes
- Department of Medicine, Albert Einstein College of Medicine, Bronx, United States of America
| | - Kehao Zhang
- Department of Medicine, Albert Einstein College of Medicine, Bronx, United States of America
| | - Jaclyn B Perkins
- Department of Nutrition and Metabolism, The University of Texas Medical Branch, Galveston, United States of America
| | - Knubian J Gatlin
- Department of Nutrition and Metabolism, The University of Texas Medical Branch, Galveston, United States of America
| | - Matthew Custodio
- Department of Medicine, Albert Einstein College of Medicine, Bronx, United States of America
| | - Hina Farooq
- Department of Medicine, Albert Einstein College of Medicine, Bronx, United States of America
| | - Bushra Zaidi
- Department of Medicine, Albert Einstein College of Medicine, Bronx, United States of America
| | - Rima Pai
- Department of Medicine, Albert Einstein College of Medicine, Bronx, United States of America
| | - Rupinder S Buttar
- Department of Medicine, Albert Einstein College of Medicine, Bronx, United States of America
| | - Yan Tang
- Department of Medicine, Albert Einstein College of Medicine, Bronx, United States of America
| | - Michal L Melamed
- Department of Medicine, Albert Einstein College of Medicine, Bronx, United States of America
| | - Thomas H Hostetter
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, United States of America
| | - Jeffrey E Pessin
- Department of Medicine, Albert Einstein College of Medicine, Bronx, United States of America
| | - Meredith Hawkins
- Department of Medicine, Albert Einstein College of Medicine, Bronx, United States of America
| | | | - Matthew K Abramowitz
- Department of Medicine, Albert Einstein College of Medicine, Bronx, United States of America
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Ko GJ, Kalantar-Zadeh K. How important is dietary management in chronic kidney disease progression? A role for low protein diets. Korean J Intern Med 2021; 36:795-806. [PMID: 34153180 PMCID: PMC8273814 DOI: 10.3904/kjim.2021.197] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 06/08/2021] [Indexed: 02/07/2023] Open
Abstract
High dietary protein intake may lead to increased intraglomerular pressure and glomerular hyperfiltration, which in the long-term can lead to de novo or aggravating preexisting chronic kidney disease (CKD). Hence, a low protein diet (LPD, 0.6 to 0.8 g/kg/day) is recommended for the management of CKD. There are evidences that dietary protein restriction mitigate progression of CKD and retard the initiation of dialysis or facilitate incremental dialysis. LPD is also helpful to control metabolic derangements in CKD such as metabolic acidosis and hyperphosphatemia. Recently, a growing body of evidence has emerged on the benefits of plant-dominant low-protein diet (PLADO), which composed of > 50% plant-based sources. PLADO is considered to be helpful for relieving uremic burden and metabolic complications in CKD compared to animal protein dominant consumption. It may also lead to favorable alterations in the gut microbiome, which can modulate uremic toxin generation along with reducing cardiovascular risk. Alleviation of constipation in PLADO may minimize the risk of hyperkalemia. A balanced and individualized dietary approach for good adherence to LPD utilizing various plant-based sources as patients' preference should be elaborated for the optimal care in CKD. Periodic nutritional assessment under supervision of trained dietitians should be warranted to avoid protein-energy wasting.
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Affiliation(s)
- Gang-Jee Ko
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA
- Department of Medicine, Long Beach Veteran Affairs Health System, Long Beach, CA, USA
- Los Angeles Biomedical Research Institute at Harbor, University of California Los Angeles, Torrance, CA, USA
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Rao SN, Chandra A, Tiwari P, Mishra P. Development and Validation of a Novel Food-frequency Questionnaire for Hemodialysis Patients in Lucknow, India. Indian J Nephrol 2021; 31:276-282. [PMID: 34376943 PMCID: PMC8330646 DOI: 10.4103/ijn.ijn_134_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 10/17/2019] [Accepted: 11/17/2019] [Indexed: 11/09/2022] Open
Abstract
Introduction: Food-frequency questionnaire (FFQ) is a preferred tool for longitudinal dietary assessment and has been recently validated in patients on hemodialysis in other countries. As dietary habits vary vastly across regions, this study was planned to develop and validate a novel dialysis FFQ in northern India. Materials and Methods: Dietary recall data from patients on hemodialysis available from the previous year were used for identifying food items for inclusion in the FFQ. A nutrient database was created to estimate energy, protein, calcium, phosphorus, and potassium content of the foods included in the food list. The FFQ was validated against a 2-day dietary recall method (one predialysis, one on the dialysis day) in patients on maintenance hemodialysis in a tertiary care hospital in Lucknow, northern India. Results: Dietary recall data from 78 patients on hemodialysis were used for the generation of the FFQ. A total of 84 patients completed the validation study. All the nutrients measured by the FFQ correlated significantly with the means of the 2-day dietary record (r values 0.31–0.76) both in crude- and energy-adjusted intakes. De-attenuation further improved the correlation (0.35–0.80). Bland-Altman plots showed higher estimates by FFQ than by dietary recall. Cross-classification analysis showed correct classification in the exact or adjacent quintile (average 60%) by both methods and 2% gross misclassification. Weighted kappa showed fair agreement for energy intake and slight agreement for others. Conclusion: This novel semiquantitative FFQ is a valid tool for measuring energy and nutrient intakes in hemodialysis patients.
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Affiliation(s)
- S Namrata Rao
- Department of Nephrology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Abhilash Chandra
- Department of Nephrology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Poonam Tiwari
- Department of Dietetics, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Prabhaker Mishra
- Department of Biostatistics and Health Informatics, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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K P B, L L J, A L W, J B, N S, J R H, H H M H. Dietary inflammatory index and mortality in hemodialysis patients by path analysis approach (NUGE-HD study). Nutrition 2021; 89:111239. [PMID: 33930786 DOI: 10.1016/j.nut.2021.111239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 02/28/2021] [Accepted: 03/04/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the interrelationships between dietary, nutritional, and inflammatory factors in predicting all-cause mortality among individuals in hemodialysis (HD) treatment. METHODS Participating in this study were 137 patients undergoing HD (58.4% men, 61.7 ± 15.4 y of age) from the NUtrition and GEnetics on HemoDialysis outcomes (NUGE-HD study) cohort. Sociodemographic, anthropometric, and clinical data were collected. Dietary inflammatory index scores were calculated from a quantitative food frequency questionnaire. Plasma C-reactive protein was used as an inflammatory marker. Data were analyzed by path analysis. RESULTS During the 2-y follow-up, 27 patients (19.7%) died. Compared with survivors, non-survivors were older (P = 0.01) and had lower body mass index (P = 0.04). In relation to direct (unmediated) associations, dietary inflammatory index (P = 0.049) and C-reactive protein (P = 0.016) were positively associated, whereas body mass index was negatively associated with mortality (P = 0.012). There were no indirect (mediated) associations of the variables evaluated with mortality. CONCLUSION More proinflammatory diet and systemic inflammation have a direct association with mortality among patients undergoing HD therapy. Additionally, more proinflammatory diet is associated with unhealthy dietary pattern.
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Affiliation(s)
- Balbino K P
- Department of Nutrition and Health, Universidade Federal de Viçosa, Viçosa, Minas Gerais, Brazil
| | - Juvanhol L L
- Department of Nutrition and Health, Universidade Federal de Viçosa, Viçosa, Minas Gerais, Brazil
| | - Wendling A L
- Department of Nutrition and Health, Universidade Federal de Viçosa, Viçosa, Minas Gerais, Brazil
| | - Bressan J
- Department of Nutrition and Health, Universidade Federal de Viçosa, Viçosa, Minas Gerais, Brazil
| | - Shivappa N
- Cancer Prevention and Control Program, University of South Carolina, Columbia, South Carolina, United States; Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, United States; Department of Nutrition, Connecting Health Innovations LLC, Columbia, South Carolina, United States
| | - Hebert J R
- Cancer Prevention and Control Program, University of South Carolina, Columbia, South Carolina, United States; Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, United States; Department of Nutrition, Connecting Health Innovations LLC, Columbia, South Carolina, United States
| | - Hermsdorff H H M
- Department of Nutrition and Health, Universidade Federal de Viçosa, Viçosa, Minas Gerais, Brazil.
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Kalantar-Zadeh K, Moore LW. Renal Telenutrition for Kidney Health: Leveraging Telehealth and Telemedicine for Nutritional Assessment and Dietary Management of Patients With Kidney Disorders. J Ren Nutr 2020; 30:471-474. [DOI: 10.1053/j.jrn.2020.09.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 09/28/2020] [Indexed: 12/14/2022] Open
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Johns TS, Brown DD, Litwin AH, Goldson G, Buttar RS, Kreimerman J, Lo Y, Reidy KJ, Bauman L, Kaskel F, Melamed ML. Group-Based Care in Adults and Adolescents With Hypertension and CKD: A Feasibility Study. Kidney Med 2020; 2:317-325. [PMID: 32734251 PMCID: PMC7380347 DOI: 10.1016/j.xkme.2020.01.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Rationale & Objective Group-based care provides an opportunity to increase patient access to providers without increasing physician time and is effective in the management of chronic diseases in the general population. This model of care has not been investigated in chronic kidney disease (CKD). Study Design Randomized controlled trial in adults (n = 50); observational study in adolescents (n = 10). Setting & Participants Adults and adolescents with CKD and hypertension in the Bronx, NY. Intervention Group-based care (monthly sessions over 6 months) versus usual care in adults. All adolescents received group-based care and were analyzed separately. Outcomes Participant attendance and satisfaction with group-based care were used to evaluate intervention feasibility. The primary clinical outcome was change in mean 24-hour ambulatory blood pressure. Secondary outcomes included physical activity, medication adherence, quality of life, and sodium intake as assessed by 24-hour urinary sodium excretion and food frequency questionnaires. Results Among adults randomly assigned to group-based care, attendance was high (77% of participants attended ≥3 sessions) and most reported higher satisfaction. Mean 24-hour ambulatory systolic blood pressure decreased by −4.2 (95% CI, −13.3 to 5.8) mm Hg in group-based care patients compared with usual care at 6 months but this was not statistically significant. Similarly, we did not detect significant differences in health-related behaviors (such as medication adherence, sodium intake, and physical activity) or quality-of-life measures between the 2 groups. Among the adolescents, attendance was very poor; self-reported satisfaction, although high, did not change from baseline compared with the 6-month follow-up. Limitations Small study size, missing data. Conclusions Group-based care is feasible and acceptable among adults with hypertension and CKD. However, a larger trial is needed to determine the effect on blood pressure and health-related behaviors. Patient participation may limit the effectiveness of group-based care models in adolescents. Funding National Institutes of Health R34 DK102174. Trial registration https://clinicaltrials.gov/show/NCT02467894.
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Affiliation(s)
- Tanya S Johns
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
| | - Denver D Brown
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
| | - Alain H Litwin
- University of South Carolina School of Medicine-Greenville, Greenville, SC.,Greenville Health System, Greenville, SC
| | | | - Rupinder S Buttar
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
| | | | - Yungtai Lo
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
| | - Kimberly J Reidy
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
| | - Laurie Bauman
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
| | - Frederick Kaskel
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
| | - Michal L Melamed
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
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12
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Balbino KP, Juvanhol LL, Wendling AL, Marota LD, Costa JBS, Bressan J, Hermsdorff HHM. Dietary intake, clinical-nutritional status, and homocysteine in hemodialysis subjects: the mediating role of inflammation (NUGE-HD study). Appl Physiol Nutr Metab 2020; 45:845-850. [PMID: 32680432 DOI: 10.1139/apnm-2019-0800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The aim of the present study was to test the hypothesis that inflammation mediates the associations among food intake, clinical-nutritional status, and plasma homocysteine (Hcys) in hemodialysis (HD) subjects. This was a cross-sectional analysis of data on 129 subjects undergoing HD (58.9% male, 61.8 ± 15.5 years of age) from the cohort Nutrition and Genetics on HD outcomes (NUGE-HD study). Sociodemographic, anthropometric, and metabolic data were collected, and food intake was assessed using a quantitative food frequency questionnaire. Plasma C-reactive protein (CRP) was used as an inflammatory marker. Data were analyzed by structural equation modeling. Regarding the direct effects, complex B vitamin intake was negatively associated with body mass index, and diabetes mellitus was positively associated with CRP. Plasma CRP also showed a negative association with Hcys, and the ratio of saturated and polyunsaturated fatty acids intake showed a positive association with Hcys. Regarding indirect effects, the results showed that the relationship between the presence of diabetes mellitus and Hcys is mediated by plasma CRP. In conclusion, the ratio of saturated and polyunsaturated fatty acids had a direct effect on plasma Hcys, whereas inflammation had a direct and mediating effect on the relationship between Hcys and diabetes mellitus in HD subjects. Novelty In end-stage renal disease, CRP influences plasma Hcys directly and also indirectly through its mediating effect. The quantity and quality of dietary fatty acids influence plasma Hcys concentrations in HD subjects.
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Affiliation(s)
- Karla Pereira Balbino
- Department of Nutrition and Health, Universidade Federal de Viçosa, Viçosa, MG 36570-900, Brazil
| | - Leidjaira Lopes Juvanhol
- Department of Nutrition and Health, Universidade Federal de Viçosa, Viçosa, MG 36570-900, Brazil
| | - Aline Lage Wendling
- Department of Nutrition and Health, Universidade Federal de Viçosa, Viçosa, MG 36570-900, Brazil
| | | | | | - Josefina Bressan
- Department of Nutrition and Health, Universidade Federal de Viçosa, Viçosa, MG 36570-900, Brazil
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13
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Kalantar-Zadeh K, Joshi S, Schlueter R, Cooke J, Brown-Tortorici A, Donnelly M, Schulman S, Lau WL, Rhee CM, Streja E, Tantisattamo E, Ferrey AJ, Hanna R, Chen JL, Malik S, Nguyen DV, Crowley ST, Kovesdy CP. Plant-Dominant Low-Protein Diet for Conservative Management of Chronic Kidney Disease. Nutrients 2020; 12:E1931. [PMID: 32610641 PMCID: PMC7400005 DOI: 10.3390/nu12071931] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 06/22/2020] [Accepted: 06/22/2020] [Indexed: 02/07/2023] Open
Abstract
Chronic kidney disease (CKD) affects >10% of the adult population. Each year, approximately 120,000 Americans develop end-stage kidney disease and initiate dialysis, which is costly and associated with functional impairments, worse health-related quality of life, and high early-mortality rates, exceeding 20% in the first year. Recent declarations by the World Kidney Day and the U.S. Government Executive Order seek to implement strategies that reduce the burden of kidney failure by slowing CKD progression and controlling uremia without dialysis. Pragmatic dietary interventions may have a role in improving CKD outcomes and preventing or delaying dialysis initiation. Evidence suggests that a patient-centered plant-dominant low-protein diet (PLADO) of 0.6–0.8 g/kg/day composed of >50% plant-based sources, administered by dietitians trained in non-dialysis CKD care, is promising and consistent with the precision nutrition. The scientific premise of the PLADO stems from the observations that high protein diets with high meat intake not only result in higher cardiovascular disease risk but also higher CKD incidence and faster CKD progression due to increased intraglomerular pressure and glomerular hyperfiltration. Meat intake increases production of nitrogenous end-products, worsens uremia, and may increase the risk of constipation with resulting hyperkalemia from the typical low fiber intake. A plant-dominant, fiber-rich, low-protein diet may lead to favorable alterations in the gut microbiome, which can modulate uremic toxin generation and slow CKD progression, along with reducing cardiovascular risk. PLADO is a heart-healthy, safe, flexible, and feasible diet that could be the centerpiece of a conservative and preservative CKD-management strategy that challenges the prevailing dialysis-centered paradigm.
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Affiliation(s)
- Kamyar Kalantar-Zadeh
- Department of Medicine, Division of Nephrology Hypertension and Kidney Transplantation, University of California Irvine (UCI), Orange, CA 90286, USA; (A.B.-T.); (W.-L.L.); (C.M.R.); (E.S.); (E.T.); (A.J.F.); (R.H.); (D.V.N.)
- Tibor Rubin VA Long Beach Healthcare System, Long Beach, CA 90822, USA;
| | - Shivam Joshi
- Department of Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA;
| | | | - Joanne Cooke
- Kansas City VA Medical Center, Kansas City, MO 64128, USA;
| | - Amanda Brown-Tortorici
- Department of Medicine, Division of Nephrology Hypertension and Kidney Transplantation, University of California Irvine (UCI), Orange, CA 90286, USA; (A.B.-T.); (W.-L.L.); (C.M.R.); (E.S.); (E.T.); (A.J.F.); (R.H.); (D.V.N.)
| | | | - Sherry Schulman
- UCI Health Susan Samueli Center Integrative Health Institute, Irvine, CA 92626, USA; (S.S.); (S.M.)
| | - Wei-Ling Lau
- Department of Medicine, Division of Nephrology Hypertension and Kidney Transplantation, University of California Irvine (UCI), Orange, CA 90286, USA; (A.B.-T.); (W.-L.L.); (C.M.R.); (E.S.); (E.T.); (A.J.F.); (R.H.); (D.V.N.)
| | - Connie M. Rhee
- Department of Medicine, Division of Nephrology Hypertension and Kidney Transplantation, University of California Irvine (UCI), Orange, CA 90286, USA; (A.B.-T.); (W.-L.L.); (C.M.R.); (E.S.); (E.T.); (A.J.F.); (R.H.); (D.V.N.)
| | - Elani Streja
- Department of Medicine, Division of Nephrology Hypertension and Kidney Transplantation, University of California Irvine (UCI), Orange, CA 90286, USA; (A.B.-T.); (W.-L.L.); (C.M.R.); (E.S.); (E.T.); (A.J.F.); (R.H.); (D.V.N.)
- Tibor Rubin VA Long Beach Healthcare System, Long Beach, CA 90822, USA;
| | - Ekamol Tantisattamo
- Department of Medicine, Division of Nephrology Hypertension and Kidney Transplantation, University of California Irvine (UCI), Orange, CA 90286, USA; (A.B.-T.); (W.-L.L.); (C.M.R.); (E.S.); (E.T.); (A.J.F.); (R.H.); (D.V.N.)
| | - Antoney J. Ferrey
- Department of Medicine, Division of Nephrology Hypertension and Kidney Transplantation, University of California Irvine (UCI), Orange, CA 90286, USA; (A.B.-T.); (W.-L.L.); (C.M.R.); (E.S.); (E.T.); (A.J.F.); (R.H.); (D.V.N.)
| | - Ramy Hanna
- Department of Medicine, Division of Nephrology Hypertension and Kidney Transplantation, University of California Irvine (UCI), Orange, CA 90286, USA; (A.B.-T.); (W.-L.L.); (C.M.R.); (E.S.); (E.T.); (A.J.F.); (R.H.); (D.V.N.)
| | - Joline L.T. Chen
- Tibor Rubin VA Long Beach Healthcare System, Long Beach, CA 90822, USA;
| | - Shaista Malik
- UCI Health Susan Samueli Center Integrative Health Institute, Irvine, CA 92626, USA; (S.S.); (S.M.)
| | - Danh V. Nguyen
- Department of Medicine, Division of Nephrology Hypertension and Kidney Transplantation, University of California Irvine (UCI), Orange, CA 90286, USA; (A.B.-T.); (W.-L.L.); (C.M.R.); (E.S.); (E.T.); (A.J.F.); (R.H.); (D.V.N.)
| | - Susan T. Crowley
- VA Connecticut Healthcare System, West Haven, CT 06516, USA;
- Division of Nephrology, Yale University School of Medicine, New Haven, CT 06516, USA
| | - Csaba P. Kovesdy
- Division of Nephrology, University of Tennessee Health Sciences Center, Memphis, TN 38163, USA;
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14
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HD-FFQ to Detect Nutrient Deficiencies and Toxicities for a Multiethnic Asian Dialysis Population. Nutrients 2020. [PMCID: PMC7352606 DOI: 10.3390/nu12061585] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
A rapid and reliable tool appropriate to quantifying macronutrient and micronutrient intakes in diets consumed by Malaysian hemodialysis (HD) patients is lacking. We aimed to develop and validate a novel HD-food frequency questionnaire (HD-FFQ) to assess habitual nutritional intakes of HD patients with diverse ethnic backgrounds. This study was conducted in three phases. In Phase I, a HD-FFQ comprising 118 food items was developed using 3-day diet recalls (3DDR) from 388 HD patients. Phase II was the face and content validation using the Scale-Content Validity Index (S-CVI). After successfully developing the FFQ, Phase III tested relative validation against a reference method, the 3DDR. Results from Phase III showed that the mean difference for absolute intakes of nutrients assessed by HD-FFQ and 3DDR were significant (p < 0.05). However, there was a significant correlation between the HD-FFQ and reference method ranging from 0.35–0.47 (p < 0.05). Cross-quartile classification showed that <10% of patients were grossly misclassified. In conclusion, the HD-FFQ has an acceptable relative validity in assessing and ranking the dietary intake of the HD patients in Malaysia.
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15
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Kim SM, Kang BC, Kim HJ, Kyung MS, Oh HJ, Kim JH, Kwon O, Ryu DR. Comparison of hemodialysis and peritoneal dialysis patients' dietary behaviors. BMC Nephrol 2020; 21:91. [PMID: 32156264 PMCID: PMC7063748 DOI: 10.1186/s12882-020-01744-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 02/27/2020] [Indexed: 01/12/2023] Open
Abstract
Background Nutritional factors are associated with high mortality and morbidity in dialysis patients, and protein-energy wasting is regarded as an important one. The modality of dialysis may affect patients’ dietary behavior and nutritional status, but no study has compared the dietary behavior, nutrient intake, and nutritional adequacy of hemodialysis (HD) and peritoneal dialysis (PD) patients. Methods From December 2016 to May 2017, a dietary behavior survey and Semi-quantitative Food Frequency Questionnaire (Semi-FFQ) were conducted on 30 HD patients and 30 PD patients in Ewha Womans University Mokdong Hospital, and laboratory parameters were obtained. The results of prevalent HD and PD patients were then compared. Results The mean age of HD patients was higher than that of PD patients; HD: 58.5 ± 9.1 years, PD: 49.3 ± 9.7 years (p = 0.001). In the dietary behavior survey, HD patients showed more appropriate dietary behavior patterns overall than PD patients. In the dietary intake analysis with the Semi-FFQ, energy intake was significantly lower in the PD group than in the HD group due to the lower intake of carbohydrates, fat, and protein. A comparison of nutrient intake-to-recommended allowance ratio between the HD and PD groups revealed that the HD group showed higher nutrient intake than the PD group. Serum albumin and potassium levels were significantly higher in HD than in PD patients. Conclusion According to this study, the dietary behavior and nutritional intake of prevalent PD patients were worse than those of HD patients.
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Affiliation(s)
- Seon-Mi Kim
- Department of Internal Medicine, Graduate School, Ewha Womans University, Seoul, Korea
| | - Byung Chin Kang
- Department of Nutrition, Ewha Womans University, Seoul Hospital, Seoul, Korea.,Graduate School of Converging Clinical and Public Health, Ewha Womans University, Seoul, Korea
| | - Hyun-Jung Kim
- College of Nursing, Ewha Womans University, Seoul, Korea
| | | | - Hyung Jung Oh
- Ewha Institute of Convergence Medicine, Ewha Womans University, Mokdong Hospital, Seoul, Korea.,Research Institute for Human Health Information, Ewha Womans University, Mokdong Hospital, Seoul, Korea
| | - Jung-Hyun Kim
- Department of Home Economics Education, Pai Chai University, Daejeon, Korea
| | - Oran Kwon
- Department of Nutritional Science and Food Management, Ewha Womans University, Seoul, Korea
| | - Dong-Ryeol Ryu
- Research Institute for Human Health Information, Ewha Womans University, Mokdong Hospital, Seoul, Korea. .,Department of Internal Medicine, School of Medicine, Ewha Womans University, 260, Gonghang-daero, Seoul, Gangseo-gu, Korea.
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16
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Improved Understanding of Interactions between Risk Factors for Child Obesity May Lead to Better Designed Prevention Policies and Programs in Indonesia. Nutrients 2020; 12:nu12010175. [PMID: 31936306 PMCID: PMC7019618 DOI: 10.3390/nu12010175] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 12/23/2019] [Accepted: 01/07/2020] [Indexed: 12/14/2022] Open
Abstract
The nutrition transition in low-middle income countries is marked by rising intakes of highly caloric, low nutrient-dense (junk) foods, decreasing intakes of fruits and vegetables, and sedentary behavior. The objective of this study was to explore interactions among fruit-and-vegetable intake, junk food energy intake, sedentary behavior, and obesity in Indonesian children. We conducted this school-based, case-control study in 2013 in Yogyakarta Special Province, Indonesia. The cases were 244 obese children aged 7–12 years having a BMI ≥95th percentile of an age- and sex-specific distribution from the Centers for Disease Control and Prevention. The controls (n = 244) were classroom-matched children with a BMI <85th percentile. Using conditional logistic regression, the relative odds (95% confidence intervals; OR: 95% CI) of obesity given reported frequent fruit-and-vegetable intake (≥3 servings/day), low junk food energy (≤1050 kcal/day) intake and low sedentary behavior (<5 h/day) was 0.46 (0.30–0.69), 0.61 (0.37–0.98), and 0.18 (0.12–0.28), respectively. Effect sizes were dose-responsive and appeared additive. For example, children with low sedentary behavior and frequent fruit-and-vegetable intake were 92% less likely (OR = 0.08; 0.04–0.15) to be obese than children not exceeding either of these thresholds. Similarly, children frequently eating fruits and vegetables and reporting a low junk food energy intake were 70% less likely (OR = 0.30; 0.15–0.59) to be obese. The findings were unchanged after adjusting for child, maternal, and household covariates. Preventive interventions for child obesity need multiple components to improve diets and raise levels of physical activity rather than just addressing one of the three types of assessed behaviors.
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17
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Balbino KP, Juvanhol LL, Epifânio ADPS, Marota LD, Bressan J, Hermsdorff HHM. Dietary intake as a predictor for all-cause mortality in hemodialysis subjects (NUGE-HD study). PLoS One 2019; 14:e0226568. [PMID: 31846484 PMCID: PMC6917285 DOI: 10.1371/journal.pone.0226568] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 11/29/2019] [Indexed: 11/25/2022] Open
Abstract
This study aimed to identify the factors capable of mortality prediction in patients on hemodialysis, using a prospective cohort with three years of follow-up. We hypothesized that lack of clinical-metabolic control, impairment of nutritional status, and inadequate food consumption are risk factors for mortality in this population. This is a longitudinal study on a non-probabilistic sample of 85 adults and elderly patients undergoing hemodialysis, aged ≥ 18 years (66.0% male, 61.6±13.7 years). Data on anthropometric, biomarkers, body composition and food intake were obtained. Predictors of mortality were evaluated using Cox regression analysis. During the three years follow-up, 16 patients (18.8%) died. We observed that age (HR = 1.319, CI 95% = 1.131-1.538), calcium-phosphorus product (HR = 1.114, CI 95% = 1.031-1.205), ferritin (HR = 1.001, CI 95% = 1.001-1.002), nitric oxide (HR = 1.082, CI 95% = 1.006-1.164), and vitamin C intake (HR = 1.005, CI 95% = 1.001-1.009) were positively associated with mortality. Serum iron (HR = 0.717, CI 95% = 0.567-0.907), triceps skinfold thickness (HR = 0.704, CI 95% = 0.519-0.954), lean mass (HR = 0.863, CI 95% = 0.787-0.945), and the ratio of dietary monounsaturated/polyunsaturated fat (HR = 0.022, CI 95% = 0.001-0.549) were independent negative predictors of mortality. Our results suggest that dietary intake is also a predictor of mortality in patients on hemodialysis, besides nutritional status, body composition, oxidative stress, inflammation, and bone metabolism, indicating the importance of evaluation of these factors altogether for better prognosis.
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Affiliation(s)
- Karla Pereira Balbino
- Department of Nutrition and Health. Universidade Federal de Viçosa, Viçosa, Minas Gerais, Brazil
| | - Leidjaira Lopes Juvanhol
- Department of Nutrition and Health. Universidade Federal de Viçosa, Viçosa, Minas Gerais, Brazil
| | | | | | - Josefina Bressan
- Department of Nutrition and Health. Universidade Federal de Viçosa, Viçosa, Minas Gerais, Brazil
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18
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Araújo MJS, Silva LF, Martins MTS, Matos CM, Lopes MB, Santos RFS, Santos L, Kraychete AC, Martins MTS, Silva FA, Lopes AA. A 3-day diary of dietary protein and calorie intake by serum phosphate concentration and binder use in hemodialysis patients. Int J Artif Organs 2017; 41:0. [PMID: 29148025 DOI: 10.5301/ijao.5000654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2017] [Indexed: 11/20/2022]
Abstract
INTRODUCTION The use of phosphate binders to control hyperphosphatemia may allow diets less restricted in protein and calories for maintenance hemodialysis (MHD) patients. The study compared intakes of protein, calorie and phosphate among MHD patients with different serum phosphate concentrations, taking into account binder use. The hypothesis was that low serum phosphate would be associated with low intakes of protein and calories only in patients not on binders. METHODS A cross-sectional study of 443 patients enrolled in the Prospective Study of the Prognosis of Chronic Hemodialysis Patients (PROHEMO) in Salvador, Brazil, with stratified sampling on serum phosphate: ≤3.0 (n = 41), 3.5-5.5 (n = 328) and ≥7.0 mg/dL (n = 74). A 3-day diet diary was used to determine dietary intakes. RESULTS Approximately 49.0% confirmed binder use. Covariate-adjusted linear regression showed that associations between dietary intakes and serum phosphate were modified by the binder use. In patients not on binders, protein intake was >20% lower for serum phosphate ≤3.0 mg/dL compared to higher concentrations. Also in those not on binders, calorie intake was >30% lower for serum phosphate ≤3.0 mg/dL compared to ≥7.0 mg/dL. Differences in dietary intakes by serum phosphate were virtually absent in patients on binders. CONCLUSIONS The results are consistent with the hypothesis that low serum phosphate is associated with low protein and calorie intake only among MHD patients not on binders. This study supports recommendations to prevent hyperphosphatemia in MHD patients by adequate combination of binder use and selection of foods restricted in phosphors but not severely restricted in protein and calories.
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Affiliation(s)
- Meiry J S Araújo
- NEPHRON Clinic, Salvador, BA - Brazil
- Post-Graduate Program in Medicine and Health, Federal University of Bahia, Salvador, BA - Brazil
| | - Luciana F Silva
- Post-Graduate Program in Medicine and Health, Federal University of Bahia, Salvador, BA - Brazil
- Department of Life Sciences, University of the State of Bahia, Salvador, BA - Brazil
- Nephrology and Dialysis Institute (INED), Salvador, BA - Brazil
| | - Maria T S Martins
- NEPHRON Clinic, Salvador, BA - Brazil
- Post-Graduate Program in Medicine and Health, Federal University of Bahia, Salvador, BA - Brazil
| | - Cacia M Matos
- Post-Graduate Program in Medicine and Health, Federal University of Bahia, Salvador, BA - Brazil
- Nephrology and Dialysis Institute (INED), Salvador, BA - Brazil
| | - Marcelo B Lopes
- Post-Graduate Program in Medicine and Health, Federal University of Bahia, Salvador, BA - Brazil
| | - Rilma F S Santos
- NEPHRON Clinic, Salvador, BA - Brazil
- Post-Graduate Program in Health Sciences, Federal University of Bahia, Salvador, BA - Brazil
| | - LarissaS Santos
- NEPHRON Clinic, Salvador, BA - Brazil
- Kidney and Hyptertension Clinic (CLINIRIM), Salvador, BA - Brazil
| | - Angiolina C Kraychete
- Post-Graduate Program in Medicine and Health, Federal University of Bahia, Salvador, BA - Brazil
- Nephrology and Dialysis Institute (INED), Salvador, BA - Brazil
| | - Márcia T S Martins
- Post-Graduate Program in Medicine and Health, Federal University of Bahia, Salvador, BA - Brazil
- Kidney and Hyptertension Clinic (CLINIRIM), Salvador, BA - Brazil
| | - Fernanda A Silva
- NEPHRON Clinic, Salvador, BA - Brazil
- Post-Graduate Program in Medicine and Health, Federal University of Bahia, Salvador, BA - Brazil
| | - Antonio A Lopes
- Department of Internal Medicine and Diagnostic Support, Federal University of Bahia, Salvador, BA - Brazil
- Center for Clinical Epidemiology and Evidence-Based Medicine, Professor Edgard Santos University Hospital, Federal University of Bahia, Salvador, BA - Brazil
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Ko GJ, Kalantar-Zadeh K, Goldstein-Fuchs J, Rhee CM. Dietary Approaches in the Management of Diabetic Patients with Kidney Disease. Nutrients 2017; 9:E824. [PMID: 28758978 PMCID: PMC5579617 DOI: 10.3390/nu9080824] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 07/22/2017] [Accepted: 07/25/2017] [Indexed: 12/13/2022] Open
Abstract
Chronic kidney disease (CKD) is one of the most prevalent complications of diabetes, and patients with diabetic kidney disease (DKD) have a substantially higher risk of cardiovascular disease and death compared to their non-diabetic CKD counterparts. In addition to pharmacologic management strategies, nutritional and dietary interventions in DKD are an essential aspect of management with the potential for ameliorating kidney function decline and preventing the development of other end-organ complications. Among DKD patients with non-dialysis dependent CKD, expert panels recommend lower dietary protein intake of 0.8 g/kg of body weight/day, while higher dietary protein intake (>1.2 g/kg of body weight/day) is advised among diabetic end-stage renal disease patients receiving maintenance dialysis to counteract protein catabolism, dialysate amino acid and protein losses, and protein-energy wasting. Carbohydrates from sugars should be limited to less than 10% of energy intake, and it is also suggested that higher polyunsaturated and monounsaturated fat consumption in lieu of saturated fatty acids, trans-fat, and cholesterol are associated with more favorable outcomes. While guidelines recommend dietary sodium restriction to less than 1.5-2.3 g/day, excessively low sodium intake may be associated with hyponatremia as well as impaired glucose metabolism and insulin sensitivity. As patients with advanced DKD progressing to end-stage renal disease may be prone to the "burnt-out diabetes" phenomenon (i.e., spontaneous resolution of hypoglycemia and frequent hypoglycemic episodes), further studies in this population are particularly needed to determine the safety and efficacy of dietary restrictions in this population.
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Affiliation(s)
- Gang Jee Ko
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA 92868, USA.
- Department of Internal Medicine, Korea University, School of Medicine, Seoul 08308, Korea.
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA 92868, USA.
- Department of Medicine, Tibor Rubin Veteran Affairs Health System, Long Beach, CA 90822, USA.
- Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA 90502, USA.
| | - Jordi Goldstein-Fuchs
- Sierra Nevada Nephrology Consultants, Reno, NV 89511, USA.
- Department of Internal Medicine, University of Nevada Reno, School of Medicine, Reno, NV 89557, USA.
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA 92868, USA.
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20
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Abstract
PURPOSE OF REVIEW The kidneys play a critical role in the balance between the internal milieu and external environment. Kidney failure is known to disrupt a number of homeostatic mechanisms that control serum calcium and normal bone metabolism. However, our understanding of calcium balance throughout the stages of chronic kidney disease is limited and the concept of balance itself, especially with a cation as complex as calcium, is often misunderstood. Both negative and positive calcium balance have important implications in patients with chronic kidney disease, where negative balance may increase risk of osteoporosis and fracture and positive balance may increase risk of vascular calcification and cardiovascular events. Here, we examine the state of current knowledge about calcium balance in adults throughout the stages of chronic kidney disease and discuss recommendations for clinical strategies to maintain balance as well as future research needs in this area. RECENT FINDINGS Recent calcium balance studies in adult patients with chronic kidney disease show that neutral calcium balance is achieved with calcium intake near the recommended daily allowance. Increases in calcium through diet or supplements cause high positive calcium balance, which may put patients at risk for vascular calcification. However, heterogeneity in calcium balance exists among these patients. Given the available calcium balance data in this population, it appears clinically prudent to aim for recommended calcium intakes around 1000 mg/day to achieve neutral calcium balance and avoid adverse effects of either negative or positive calcium balance. Assessment of patients' dietary calcium intake could further equip clinicians to make individualized recommendations for meeting recommended intakes.
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Abstract
PURPOSE OF REVIEW High-protein intake may lead to increased intraglomerular pressure and glomerular hyperfiltration. This can cause damage to glomerular structure leading to or aggravating chronic kidney disease (CKD). Hence, a low-protein diet (LPD) of 0.6-0.8 g/kg/day is often recommended for the management of CKD. We reviewed the effect of protein intake on incidence and progression of CKD and the role of LPD in the CKD management. RECENT FINDINGS Actual dietary protein consumption in CKD patients remains substantially higher than the recommendations for LPD. Notwithstanding the inconclusive results of the 'Modification of Diet in Renal Disease' (MDRD) study, the largest randomized controlled trial to examine protein restriction in CKD, several prior and subsequent studies and meta-analyses appear to support the role of LPD on retarding progression of CKD and delaying initiation of maintenance dialysis therapy. LPD can also be used to control metabolic derangements in CKD. Supplemented LPD with essential amino acids or their ketoanalogs may be used for incremental transition to dialysis especially on nondialysis days. The LPD management in lieu of dialysis therapy can reduce costs, enhance psychological adaptation, and preserve residual renal function upon transition to dialysis. Adherence and adequate protein and energy intake should be ensured to avoid protein-energy wasting. SUMMARY A balanced and individualized dietary approach based on LPD should be elaborated with periodic dietitian counseling and surveillance to optimize management of CKD, to assure adequate protein and energy intake, and to avoid or correct protein-energy wasting.
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Affiliation(s)
- Gang Jee Ko
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA
- Department of Internal Medicine, Korea University School of Medicine, Seoul, Korea
| | - Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA
| | - Amanda R. Tortoricci
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA
- Department of Medicine, Long Beach Veteran Affairs Health System, Long Beach, CA, USA
- Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA, USA
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Therrien M, Byham-Gray L, Beto J. A Review of Dietary Intake Studies in Maintenance Dialysis Patients. J Ren Nutr 2015; 25:329-38. [DOI: 10.1053/j.jrn.2014.11.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 10/29/2014] [Accepted: 11/17/2014] [Indexed: 12/31/2022] Open
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Kalantar-Zadeh K, Brown A, Chen JLT, Kamgar M, Lau WL, Moradi H, Rhee CM, Streja E, Kovesdy CP. Dietary restrictions in dialysis patients: is there anything left to eat? Semin Dial 2015; 28:159-68. [PMID: 25649719 PMCID: PMC4385746 DOI: 10.1111/sdi.12348] [Citation(s) in RCA: 131] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
A significant number of dietary restrictions are imposed traditionally and uniformly on maintenance dialysis patients, whereas there is very little data to support their benefits. Recent studies indicate that dietary restrictions of phosphorus may lead to worse survival and poorer nutritional status. Restricting dietary potassium may deprive dialysis patients of heart-healthy diets and lead to intake of more atherogenic diets. There is little data about the survival benefits of dietary sodium restriction, and limiting fluid intake may inherently lead to lower protein and calorie consumption, when in fact dialysis patients often need higher protein intake to prevent and correct protein-energy wasting. Restricting dietary carbohydrates in diabetic dialysis patients may not be beneficial in those with burnt-out diabetes. Dietary fat including omega-3 fatty acids may be important caloric sources and should not be restricted. Data to justify other dietary restrictions related to calcium, vitamins, and trace elements are scarce and often contradictory. The restriction of eating during hemodialysis treatment is likely another incorrect practice that may worsen hemodialysis induced hypoglycemia and nutritional derangements. We suggest careful relaxation of most dietary restrictions and adoption of a more balanced and individualized approach, thereby easing some of these overzealous restrictions that have not been proven to offer major advantages to patients and their outcomes and which may in fact worsen patients' quality of life and satisfaction. This manuscript critically reviews the current paradigms and practices of recommended dietary regimens in dialysis patients including those related to dietary protein, carbohydrate, fat, phosphorus, potassium, sodium, and calcium, and discusses the feasibility and implications of adherence to ardent dietary restrictions and future research.
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Affiliation(s)
- Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California
- Long Beach Veterans Affairs Healthcare System, Long Beach, California
- Dept. Epidemiology, UCLA Fielding School of Public Health, University of California Los Angeles, Los Angeles, California
| | - Amanda Brown
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California
- Long Beach Veterans Affairs Healthcare System, Long Beach, California
| | - Joline L. T. Chen
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California
- Long Beach Veterans Affairs Healthcare System, Long Beach, California
| | | | - Wei-Ling Lau
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California
| | - Hamid Moradi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California
- Long Beach Veterans Affairs Healthcare System, Long Beach, California
| | - Connie M. Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California
- Long Beach Veterans Affairs Healthcare System, Long Beach, California
| | - Csaba P. Kovesdy
- Univ. of Tennessee Health Science Center, Memphis, Tennessee
- Memphis Veterans Affairs Healthcare System, Memphis, Tennessee
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24
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Delgado C, Ward P, Chertow GM, Storer L, Dalrymple L, Block T, Kaysen GA, Kornak J, Grimes B, Kutner NG, Johansen KL. Calibration of the brief food frequency questionnaire among patients on dialysis. J Ren Nutr 2014; 24:151-156.e1. [PMID: 24613023 PMCID: PMC4145671 DOI: 10.1053/j.jrn.2013.12.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Revised: 10/04/2013] [Accepted: 12/03/2013] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVE Estimating dietary intake is challenging in patients with chronic diseases. The aim of this study was to calibrate the Block Brief 2000 food frequency questionnaire (BFFQ) using 3-day food diary records among patients on dialysis. METHODS Data from 3-day food diary records from 146 patients new to dialysis were reviewed and entered into National Cancer Institute self-administered 24-hour dietary recall (ASA24), a web-based dietary interview system. The information was then re-entered omitting foods reported in the diaries that were not in the BFFQ to generate a "BFFQ-restricted" set of intakes. We modeled each major dietary component (i.e., energy [total calories], protein, carbohydrate, fat) separately using linear regression. The main independent variables were BFFQ-restricted food diary estimates computed as the average of the 3 days of diaries, restricted to items included in the BFFQ, with the unrestricted 3-day food diary averages as dependent variables. RESULTS The BFFQ-restricted diary energy estimate of 1,325 ± 545 kcal was 87% of the energy intake in the full food diary (1,510.3 ± 510.4, P < .0001). The BFFQ-restricted diary carbohydrate intake was 83% of the full food diary (156.7 ± 78.7 g vs. 190.4 ± 72.7, P < .0001). The BFFQ-restricted fat intake was 90% of the full-diary-reported fat intake (50.1 ± 24.1 g vs. 56.4 ± 21.6 g, P < .0001). Daily protein intake assessments were not statistically different by BFFQ-restricted diary and full diary assessment (63.1 ± 28.5 vs. 64.1 ± 21.4 g, P = .60). The associations between BFFQ-restricted diary intake and unrestricted intake were linear. Three-day diary-reported intake could be estimated from BFFQ-restricted intake with r2 ranging from 0.36 to 0.56 (P < .0001 for energy [total calories], protein, carbohydrate, and fat). Final equations did not include adjustments for age, sex, or race because the patterns of associations were not significantly different. CONCLUSION Energy and macronutrient estimates by BFFQ are lower than estimates from 3-day food diaries, but simple calibration equations can be used to approximate total intake from BFFQ responses.
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Affiliation(s)
- Cynthia Delgado
- Division of Nephrology, University of California-San Francisco, San Francisco, California; Nephrology Section, San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Patricia Ward
- Department of Rehabilitation Medicine, Emory University, Atlanta, Georgia
| | - Glenn M. Chertow
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
- United States Renal Data System Nutrition Special Studies Center, San Francisco, California
| | - Lindsey Storer
- Division of Nephrology, University of California-San Francisco, San Francisco, California; Nephrology Section, San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Lorien Dalrymple
- Division of Nephrology, University of California-Davis, Davis, California
| | | | - George A. Kaysen
- United States Renal Data System Nutrition Special Studies Center, San Francisco, California
- Division of Nephrology, University of California-Davis, Davis, California
| | - John Kornak
- United States Renal Data System Nutrition Special Studies Center, San Francisco, California
- Department of Epidemiology and Biostatistics, University of California–San Francisco, San Francisco, California
| | - Barbara Grimes
- United States Renal Data System Nutrition Special Studies Center, San Francisco, California
- Department of Epidemiology and Biostatistics, University of California–San Francisco, San Francisco, California
| | - Nancy G. Kutner
- Department of Rehabilitation Medicine, Emory University, Atlanta, Georgia
| | - Kirsten L. Johansen
- Division of Nephrology, University of California-San Francisco, San Francisco, California; Nephrology Section, San Francisco Veterans Affairs Medical Center, San Francisco, California
- United States Renal Data System Nutrition Special Studies Center, San Francisco, California
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25
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Luttrell KJ, Beto JA, Tangney CC. Selected Nutrition Practices of Women on Hemodialysis and Peritoneal Dialysis: Observations From the NKF-CRN Second National Research Question Collaborative Study. J Ren Nutr 2014; 24:81-91. [DOI: 10.1053/j.jrn.2013.12.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Revised: 12/23/2013] [Accepted: 12/27/2013] [Indexed: 11/11/2022] Open
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26
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Therrien M, Byham-Gray L, Denmark R, Beto J. Comparison of Dietary Intake Among Women on Maintenance Dialysis to a Women's Health Initiative Cohort: Results From the NKF-CRN Second National Research Question Collaborative Study. J Ren Nutr 2014; 24:72-80. [DOI: 10.1053/j.jrn.2013.09.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Revised: 09/26/2013] [Accepted: 09/27/2013] [Indexed: 12/17/2022] Open
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27
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A Pilot Study of a Subjective Dietary Analysis Tool for Use With Hemodialysis Patients. TOP CLIN NUTR 2014. [DOI: 10.1097/01.tin.0000443028.13653.5f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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28
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Luevano-Contreras C, Durkin T, Pauls M, Chapman-Novakofski K. Development, relative validity, and reliability of a food frequency questionnaire for a case-control study on dietary advanced glycation end products and diabetes complications. Int J Food Sci Nutr 2013; 64:1030-5. [PMID: 23876146 DOI: 10.3109/09637486.2013.816939] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Dietary advanced glycation end products (dAGEs) could be involved on diabetes complications, yet their quantification is not standardized. The objective of this study was to design a food frequency questionnaire (FFQ) for dAGEs, and to assess its reliability and validity. For the design, data from 30 subjects was used. The final instrument had 90 food items. To measure reliability and validity, 20 participants with type 2 diabetes filled out twice the FFQ (FFQ-T1, FFQ-T2) and 7-day food records (7-dFR). The Shrout-Fleiss coefficient was 0.98 showing good reliability. For validation, the results for the weighted kappa were 0.55 (moderate agreement) for FFQ-T1 and 0.64 (good agreement) for FFQ-T2, and 75% and 80% of subjects respectively were correctly classified into tertiles; Bland-Altman graphics showed no systematic bias. This FFQ is comparable to 7-dFR for measuring dAGEs. To our knowledge, this is the first questionnaire designed to measure specifically dAGEs.
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29
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Ravel VA, Molnar MZ, Streja E, Kim JC, Victoroff A, Jing J, Benner D, Norris KC, Kovesdy CP, Kopple JD, Kalantar-Zadeh K. Low protein nitrogen appearance as a surrogate of low dietary protein intake is associated with higher all-cause mortality in maintenance hemodialysis patients. J Nutr 2013; 143:1084-92. [PMID: 23700345 PMCID: PMC3681544 DOI: 10.3945/jn.112.169722] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
To determine the association between all-cause mortality and dietary protein intake in patients with chronic kidney disease, we performed a large-scale, 8-y prospective cohort study in 98,489 maintenance hemodialysis patients from a multicenter dialysis care provider. Compared with the reference level (60 to <70 g/d), low protein nitrogen appearance (PNA) levels [<30 g/d, HR: 1.40 (95% CI: 1.30, 1.50); 30 to <40 g/d, HR: 1.33 (95% CI: 1.28, 1.39)] was associated with higher all-cause mortality, and high PNA levels [≥110 g/d, HR: 0.92 (95% CI: 0.88, 0.97); 100 to <110 g/d, HR: 0.87 (95% CI: 0.82, 0.91)] were associated with lower all-cause mortality in all analyses. This association was also found in subanalyses performed among racial and hypoalbuminemic groups. Hence, using PNA as a surrogate for protein intake, a low daily dietary protein intake is associated with increased risk of death in all hemodialysis patients. Whether the association between dietary protein intake and survival is causal or a consequence of anorexia secondary to protein-energy-wasting/inflammation or other factors should be explored in interventional trials.
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Affiliation(s)
- Vanessa A. Ravel
- Harold Simmons Center for Chronic Disease Research & Epidemiology, University of California Irvine Medical Center, Irvine, CA,School of Public Health, University of California, Los Angeles, CA
| | - Miklos Z. Molnar
- Harold Simmons Center for Chronic Disease Research & Epidemiology, University of California Irvine Medical Center, Irvine, CA,Institute of Pathophysiology, Semmelweis University, Budapest, Hungary,Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, Canada,To whom correspondence should be addressed. E-mail: or
| | - Elani Streja
- Harold Simmons Center for Chronic Disease Research & Epidemiology, University of California Irvine Medical Center, Irvine, CA,School of Public Health, University of California, Los Angeles, CA
| | - Jun Chul Kim
- Harold Simmons Center for Chronic Disease Research & Epidemiology, University of California Irvine Medical Center, Irvine, CA
| | - Alla Victoroff
- Harold Simmons Center for Chronic Disease Research & Epidemiology, University of California Irvine Medical Center, Irvine, CA,School of Public Health, University of California, Los Angeles, CA
| | - Jennie Jing
- Harold Simmons Center for Chronic Disease Research & Epidemiology, University of California Irvine Medical Center, Irvine, CA
| | | | | | - Csaba P. Kovesdy
- Division of Nephrology, Memphis Veterans Affairs Medical Center, Memphis, TN,Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN
| | - Joel D. Kopple
- Division of Nephrology and Hypertension, Harbor-UCLA Medical Center, Torrance, CA; and
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research & Epidemiology, University of California Irvine Medical Center, Irvine, CA,Division of Nephrology & Hypertension, University of California Irvine Medical Center, Orange, CA
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30
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Kalantar-Zadeh K. Patient education for phosphorus management in chronic kidney disease. Patient Prefer Adherence 2013; 7:379-90. [PMID: 23667310 PMCID: PMC3650565 DOI: 10.2147/ppa.s43486] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES This review explores the challenges and solutions in educating patients with chronic kidney disease (CKD) to lower serum phosphorus while avoiding protein insufficiency and hypercalcemia. METHODS A literature search including terms "hyperphosphatemia," "patient education," "food fatigue," "hypercalcemia," and "phosphorus-protein ratio" was undertaken using PubMed. RESULTS Hyperphosphatemia is a strong predictor of mortality in advanced CKD and is remediated via diet, phosphorus binders, and dialysis. Dietary counseling should encourage the consumption of foods with the least amount of inorganic or absorbable phosphorus, low phosphorus-to-protein ratios, and adequate protein content, and discourage excessive calcium intake in high-risk patients. Emerging educational initiatives include food labeling using a "traffic light" scheme, motivational interviewing techniques, and the Phosphate Education Program - whereby patients no longer have to memorize the phosphorus content of each individual food component, but only a "phosphorus unit" value for a limited number of food groups. Phosphorus binders are associated with a clear survival advantage in CKD patients, overcome the limitations associated with dietary phosphorus restriction, and permit a more flexible approach to achieving normalization of phosphorus levels. CONCLUSION Patient education on phosphorus and calcium management can improve concordance and adherence and empower patients to collaborate actively for optimal control of mineral metabolism.
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Affiliation(s)
- Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine’s School of Medicine, Irvine, CA, USA
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31
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Bennett PN, Miller MD, Woodman RJ, Hill K, Murray S, Gleadle JM. Nutrition screening by nurses in dialysis. J Clin Nurs 2012; 22:723-32. [PMID: 23039313 DOI: 10.1111/j.1365-2702.2012.04286.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/03/2012] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES To determine whether a nurse-completed dialysis nutritional screening tool improves referral rates for nutritional support and compare nutrition sensitive biochemical indices, mortality rates and patient-centred quality of life outcomes between referred and non-referred dialysis patients. BACKGROUND People with chronic kidney disease requiring dialysis are nutritionally at risk. Nutrition screening has been shown to identify dialysis patients who are nutritionally at risk to refer to dietitian expertise. DESIGN Prospective cluster-randomised control trial. METHODS Monthly nurse-completed nutrition screening was completed for six consecutive months using a validated four-item instrument measuring weight change, serum phosphate, serum potassium and appetite. Participants (n = 81) were haemodialysis patients from four satellite haemodialysis centres in one Australian metropolitan health service. Primary outcome measure was rate of referral to dietetic services for nutrition support for intervention vs. control groups at six months. Secondary outcome measures were blood pressure, biochemical indices and mortality for referred vs. non-referred patients at six and nine months, and generic and dialysis-specific quality of life for referred vs. non-referred at nine months was examined. RESULTS There were three times as many dietetic referrals in the intervention group than in the control group (26·3 vs. 9·3%). Serum phosphate increased significantly more in the referred patients than the non-referred patients. There were no clinically significant changes between groups in quality of life, blood pressure, mortality rates or other biochemical indices at either six or nine months. CONCLUSION Nurse-completed nutritional screening can lead to appropriate dietetic referrals for nutritional support by nutritional expert clinicians. RELEVANCE TO CLINICAL PRACTICE This study is the first to demonstrate that monthly systematic nurse-completed nutritional screening can facilitate appropriate dietetic referrals that may lead to increased nutritional care for people in satellite dialysis centres.
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Affiliation(s)
- Paul N Bennett
- Department of Nursing, Deakin University and Southern Health Nursing Research Centre, Melbourne, Vic., Australia.
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32
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Noori N, Dukkipati R, Kovesdy CP, Sim JJ, Feroze U, Murali SB, Bross R, Benner D, Kopple JD, Kalantar-Zadeh K. Dietary omega-3 fatty acid, ratio of omega-6 to omega-3 intake, inflammation, and survival in long-term hemodialysis patients. Am J Kidney Dis 2011; 58:248-56. [PMID: 21658827 DOI: 10.1053/j.ajkd.2011.03.017] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2010] [Accepted: 03/04/2011] [Indexed: 11/11/2022]
Abstract
BACKGROUND Mortality in long-term hemodialysis patients is high, mostly attributed to cardiovascular events, and may be related to chronic inflammation. We hypothesized that the anti-inflammatory benefits of higher dietary intake of omega-3 compared with omega-6 polyunsaturated fatty acids may modulate the inflammatory processes and decrease death risk. STUDY DESIGN Prospective cohort study using linear and Cox proportional regressions. SETTING & PARTICIPANTS 145 hemodialysis patients from 8 DaVita dialysis clinics in Southern California in 2001-2007. PREDICTORS Intake of dietary omega-3 and ratio of omega-6 to omega-3 using 3-day food record supplemented by dietary interview. OUTCOMES 1-year change in serum C-reactive protein (CRP) level and 6-year survival. RESULTS Patients were aged 53 ± 14 years (mean ± SD) and included 43% women and 42% African Americans. Median dietary omega-3 intake, ratio of omega-6 to omega-3 intake, baseline serum CRP level, and change in CRP level over 1 year were 1.1 (25th-75th percentile, 0.8-1.6) g/d, 9.3 (25th-75th percentile, 7.6-11.3), 3.1 (25th-75th percentile, 0.8-6.8) mg/L, and +0.2 (25th-75th percentile, -0.4 to +0.8) mg/L, respectively. In regression models adjusted for case-mix, dietary calorie and fat intake, body mass index, and history of hypertension, each 1-unit higher ratio of omega-6 to omega-3 intake was associated with a 0.55-mg/L increase in serum CRP level (P = 0.03). In the fully adjusted model, death HRs for the first (1.7-<7.6), second (7.6-<9.3), third (9.3-<11.3), and fourth (11.3-17.4) quartiles of dietary omega-6 to omega-3 ratio were 0.39 (95% CI, 0.14-1.18), 0.30 (95% CI, 0.09-0.99), 0.67 (95% CI, 0.25-1.79), and 1.00 (reference), respectively (P for trend = 0.06). LIMITATIONS 3-day food record may underestimate actual dietary fat intake at an individual level. CONCLUSIONS Higher dietary omega-6 to omega-3 ratio appears to be associated with both worsening inflammation over time and a trend toward higher death risk in hemodialysis patients. Additional studies including interventional trials are needed to examine the association of dietary fatty acids with clinical outcomes in these patients.
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Affiliation(s)
- Nazanin Noori
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
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