Dietary intake in hemodialysis patients does not reflect a heart healthy diet

Effect of banana intake on serum potassium level in patients undergoing maintenance hemodialysis: A randomized controlled trial

Objective

This study aimed to assess the effect of banana intake during hemodialysis on serum potassium levels in maintenance hemodialysis (MHD) patients.

Methods

This study was a single-center, randomized controlled clinical trial conducted from September 15 to December 15, 2021, at a tertiary hospital in southern China. A total of 126 MHD patients were randomly assigned to either the intervention group (n = 64) or the control group (n = 62). Patients in the intervention group consumed approximately 250 g of bananas during hemodialysis, while those in the control group did not consume any food during hemodialysis. Demographic information and hemodialysis-related parameters were collected through case information collection before hemodialysis. Laboratory indicators (such as complete blood count, biochemical indicators, inflammation markers, liver function, kidney function, etc.) were evaluated by collecting pre-hemodialysis blood samples from patients. Serum potassium and blood glucose levels were measured at 2 h and 4 h of hemodialysis, as well as before the next hemodialysis session, and hemodialysis-related complications were recorded. The blood potassium and blood glucose indicators during hemodialysis were compared using repeated measures analysis.

Results

A total of 122 MHD patients completed the study (61 in each group). The results showed that there was no significant interaction between group and time on serum potassium levels. However, serum potassium levels in the intervention group were higher than those in the control group at 2 h (3.9 ± 0.5 mmol/L vs. 3.6 ± 0.3 mmol/L, P < 0.01) and 4 h (3.5 ± 0.4 mmol/L vs. 3.3 ± 0.3 mmol/L, P < 0.01) of hemodialysis. There was no interaction between group and time on blood glucose levels. The incidence of arrhythmias (8.2% vs. 29.5%, P = 0.003) and hypokalemia (52.5% vs. 80.3%, P = 0.002) during hemodialysis was significantly lower in the intervention group compared to the control group.

Conclusion

Consuming approximately 250 g of bananas at the start of hemodialysis does not lead to hyperkalemia. It can effectively reduce the incidence of hypokalemia and arrhythmias, and prevent a rapid decline in serum potassium levels during hemodialysis.

Examining the Relationship between Dietary Intake, Socioeconomic Status, and Systolic Blood Pressure of Adults on Hemodialysis in Quito, Ecuador

Background

In Ecuador, the number of adults on hemodialysis (HD) continues to rise. Currently, the effect dietary habits and socioeconomic status (SES) have on blood pressure is not known for those on HD.

Objectives

The objectives of this study focused on adults on HD in Quito, Ecuador to 1) assess the relationship between dietary intake and SES; 2) compare dietary intake to the Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines; and 3) explore the relationship between dietary intake and systolic blood pressure.

Methods

This cross-sectional study was conducted at the dialysis center within Eugenio Espejo Specialties Hospital in Quito, Ecuador between May and June 2022 among 50 adults on HD. Three 24-h recalls were used to determine average dietary intake and the 25-item Instituto Nacional de Estadística y Censos-Stratification of SES was used to determine SES. Electrolytes and 2 blood pressure readings were collected. Qualitative narrative data analysis was performed to identify themes using NVivo v12. T-tests of independence, simple, and multiple linear regressions using age and sex as confounders were conducted using R and a P < 0.05 was deemed as statistically significant.

Results

On an average, 76% of participants consumed <25 kcal/kg body weight energy and 64% consumed <1 g protein/kg body weight. Participants consumed less energy and protein compared with the KDOQI guidelines (P < 0.05). Positive relationships were observed with potassium and blood pressure (β = 0.020, P < 0.05) and SES with energy, protein, and phosphorus (P < 0.05). Themes that were identified as contributing to dietary intake were limited knowledge, lack of consistency with dietary information, and limited appetite.

Conclusions

Findings from this study indicate that the focus should be on improving energy and protein intake for this population.

Managing Phosphate Burden in Patients Receiving Dialysis: Beyond Phosphate Binders and Diet

Most patients receiving dialysis rely on dietary restriction and phosphate binders to minimize the risk of hyperphosphatemia, which is associated with increased mortality. However, dietary restriction is difficult because of hidden phosphate additives in processed foods and medications. Restriction of dietary phosphate sources such as protein may increase the risk of malnutrition. Phosphate binders, the only pharmacologic option for phosphate management since aluminum salts were introduced several decades ago, are often insufficient for binding the 1400-2500 mg of phosphate potentially consumed daily. Over the last decade, serum phosphate levels in the United States have risen, and >69% of patients receiving dialysis exhibited a most recent phosphate level >4.5 mg/dl (above the normal range), indicating an urgent need for new, more effective therapies to manage phosphate burden. Novel, nonbinder therapies such as transcellular and paracellular phosphate absorption inhibitors may be used for phosphate management, and future studies should examine whether they allow fewer dietary restrictions for patients receiving dialysis, potentially improving patient quality of life and nutritional status. It is imperative that we collaborate to move beyond the restrictive approaches available today and provide patients and clinicians with an array of strategies so that they may choose the most appropriate patient-centered therapy.

Managing Hyperkalemia in the Modern Era: A Case-Based Approach

The last decade has seen tremendous advances in the prevention and treatment of recurrent hyperkalemia. In this narrative review, we aim to highlight contemporary data on key areas in the epidemiology and management of hyperkalemia. Focusing on drug-induced hyperkalemia (the implications of renin-angiotensin-aldosterone system inhibitors [RAASi] discontinuation and the role of mineralocorticoid receptor antagonists), newer concurrent therapies that modify potassium handling (sodium-glucose transporter 2 inhibitors [SGLT2i]), the introduction of new treatment agents (oral potassium binding agents), and the controversial role of dietary potassium restriction, we apply recent research findings and review the evidence in a case-based format.

Pea hull fiber supplementation does not modulate uremic metabolites in adults receiving hemodialysis: a randomized, double-blind, controlled trial

Background

Fiber is a potential therapeutic to suppress microbiota-generated uremic molecules. This study aimed to determine if fiber supplementation decreased serum levels of uremic molecules through the modulation of gut microbiota in adults undergoing hemodialysis.

Methods

A randomized, double-blinded, controlled crossover study was conducted. Following a 1-week baseline, participants consumed muffins with added pea hull fiber (PHF) (15 g/d) and control muffins daily, each for 4 weeks, separated by a 4-week washout. Blood and stool samples were collected per period. Serum p-cresyl sulfate (PCS), indoxyl sulfate (IS), phenylacetylglutamine (PAG), and trimethylamine N-oxide (TMAO) were quantified by LC-MS/MS, and fecal microbiota profiled by 16S rRNA gene amplicon sequencing and specific taxa of interest by qPCR. QIIME 2 sample-classifier was used to discover unique microbiota profiles due to the consumption of PHF.

Results

Intake of PHF contributed an additional 9 g/d of dietary fiber to the subjects' diet due to compliance. No significant changes from baseline were observed in serum PCS, IS, PAG, or TMAO, or for the relative quantification of Akkermansia muciniphila, Faecalibacterium prausnitzii, Bifidobacterium, or Roseburia, taxa considered health-enhancing. Dietary protein intake and IS (r = -0.5, p = 0.05) and slow transit stool form and PCS (r = 0.7, p < 0.01) were significantly correlated at baseline. PHF and control periods were not differentiated; however, using machine learning, taxa most distinguishing the microbiota composition during the PHF periods compared to usual diet alone were enriched Gemmiger, Collinsella, and depleted Lactobacillus, Ruminococcus, Coprococcus, and Mogibacteriaceae.

Conclusion

PHF supplementation did not mitigate serum levels of targeted microbial-generated uremic molecules. Given the high cellulose content, which may be resistant to fermentation, PHF may not exert sufficient effects on microbiota composition to modulate its activity at the dose consumed.

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

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

Adherence to Caloric and Protein Recommendations in Older Hemodialysis Patients: A Multicenter Study

Hemodialysis (HD) patients are characterized by malnutrition, which adversely affects their survival. The development of malnutrition is influenced, among other factors, by improper diet and the advanced age of patients. The study aimed to assess the nutritional status and adherence to dietary recommendations among older patients. The multicenter study included 179 stable HD patients. The nutritional status was assessed by a 7-point Subjective Global Assessment (SGA). Anthropometry and body composition was analyzed. The diet was assessed based on the 3-day food diary and the Food Frequency Questionnaire with 6 answers (FFQ-6). Blood laboratory tests were performed. Based on the 7-point SGA, malnutrition was diagnosed in 38.5% of HD patients. The decreased content of the muscle tissue (LTI < 14 kg/m2) was observed in 70.4% of the examined patients and the decreased concentration of s-albumin was observed in 44.1% of patients. Older patients had significantly lower LTI. 26% of patients consumed less than 25 kcal/kg body weight and less than 0.8 g protein/kg body weight. Older patients’ diets contained significantly fewer calories. There were significant differences between nutrient intake on a weekday with dialysis, a weekday without dialysis, and a weekend day without dialysis. The lowest intake of nutrients was observed on the day of dialysis. Nutritional education and the determination of whether food is permitted during hemodialysis are necessary to improve patients’ nutrition.

The Interplay between Dietary Phosphorous, Protein Intake, and Mortality in a Prospective Hemodialysis Cohort

(1) Background: Current dietary recommendations for dialysis patients suggest that high phosphorus diets may be associated with adverse outcomes such as hyperphosphatemia and death. However, there has been concern that excess dietary phosphorus restriction may occur at the expense of adequate dietary protein intake in this population. We hypothesized that higher dietary phosphorus intake is associated with higher mortality risk among a diverse cohort of hemodialysis patients. (2) Methods: Among 415 patients from the multi-center prospective Malnutrition, Diet, and Racial Disparities in Kidney Disease Study, we examined the associations of absolute dietary phosphorus intake (mg/day), ascertained by food frequency questionnaires, with all-cause mortality using multivariable Cox models. In the secondary analyses, we also examined the relationship between dietary phosphorus scaled to 1000 kcal of energy intake (mg/kcal) and dietary phosphorus-to-protein ratio (mg/g) with survival. (3) Results: In expanded case-mix + laboratory + nutrition adjusted analyses, the lowest tertile of dietary phosphorus intake was associated with higher mortality risk (ref: highest tertile): adjusted HR (aHR) (95% CI) 3.33 (1.75–6.33). In the analyses of dietary phosphorus scaled to 1000 kcal of energy intake, the lowest tertile of intake was associated with higher mortality risk compared to the highest tertile: aHR (95% CI) 1.74 (1.08, 2.80). Similarly, in analyses examining the association between dietary phosphorus-to-protein ratio, the lowest tertile of intake was associated with higher mortality risk compared to the highest tertile: aHR (95% CI) 1.67 (1.02–2.74). (4) Conclusions: A lower intake of dietary phosphorus was associated with higher mortality risk in a prospective hemodialysis cohort. Further studies are needed to clarify the relationship between specific sources of dietary phosphorus intake and mortality in this population.

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

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

Effect of Ramadan on Clinical and Biochemical Parameters among Non-fasting Hemodialysis Patients

The holy month of Ramadan brings many changes to the lifestyle of Muslims. The effect of these changes on patients with end-stage renal disease (ESRD) is not well studied. The purpose of this study was to investigate the effect of Ramadan on the clinical and metabolic profile of non-fasting patients with ESRD who were maintained on hemodialysis (HD) in the eastern region of Saudi Arabia. A single-center prospective longitudinal study of patients with ESRD who were maintained on HD at a major community hospital in Eastern Saudi Arabia. The patients adopted the lifestyle and dietary changes typically associated with Ramadan in Eastern Saudi Arabia. Measurements included body weight, blood pressure, interdialytic weight gain, serum potassium, serum phosphorus, and serum albumin at the beginning and the end of Ramadan. The development of fluid overload and hyperkalemia was monitored. Seventy patients with ESRD who were maintained on HD were screened and 18 patients were identified to meet the inclusion criteria. There were no differences in patients' weight, interdialytic weight gain, or blood pressure at the beginning and end of Ramadan. Laboratory parameters, including serum potassium, serum phosphorus, and serum albumin, showed no significant changes either; and there were no emergency encounters for fluid overload or hyperkalemia. Lifestyle and dietary changes during the fasting month of Ramadan did not result in significant clinical or laboratory differences among non-fasting HD patients in Eastern Saudi Arabia.

Benchmarking Diet Quality to Assess Nutritional Risk in Hemodialysis Patients: Applying Adequacy and Moderation Metrics of the Hemodialysis-Healthy Eating Index

OBJECTIVES

This study modified Healthy Eating Index (HEI) based on hemodialysis (HD) specific guidelines and investigated associations between the diet quality (DQ) and nutritional risk in HD patients.

METHODS

The HD-HEI tool adapted the XXX Dietary Guidelines 2010 framework according to HD-specific nutrition guidelines. This HD-HEI was applied to 3-day dietary records of 382 HD patients. Relationships between HD-HEI scores and nutritional parameters were tested by partial correlations. Binary logistic regression models adjusted with confounders were used to determine adjusted odds ratio (_adjOR) with 95% confidence interval (CI) for nutritional risk based on HD-HEI scores categorization.

RESULTS

The total HD-HEI score (51.3 ± 10.2) for this study population was affected by ethnicity (P_trend<0.001) and sex (P=0.003). No patient achieved "good" DQ (score: 81-100), while DQ of 54.5% patients were classified as "needs improvement" (score: 51-80) and remaining as "poor" (score: 0-51). Total HD-HEI scores were positively associated with dietary energy intake (DEI) and dietary protein intakes (DPI), dry weight and handgrip strength, but inversely associated with Dietary Monotony Index (DMI) (all P<0.05). Individually, scores for refined grain, total protein, and animal protein were positively associated with DEI (all P< 0.05), whilst total, animal, fish and vegetable proteins indicated positive associations with DPI (all P< 0.05). Moderating metrics for convenience meals, saturated fats, sodium, and fluid negatively correlated towards DEI with similar trends for DPI excepting convenience meals and fluids. "Poor" DQ was associated with DMI ≥ 29.2 (_adjOR: 18.83, 95% CI: 9.36-37.86, P<0.001), Malnutrition Inflammation Score (MIS) ≥ 5 (_adjOR: 1.78, 95% CI: 1.01-3.15, P=0.045), and Protein Energy Wasting (PEW) (_adjOR: 1.96, 95% CI: 1.14-3.34, P=0.031), but became nullified with covariate adjustments. "Poor" DQ was also associated with low lean tissue mass (< 32.6 kg) in men (_adjOR: 2.38, 95% CI: 1.01-5.58, P=0.046) but not women.

CONCLUSIONS

"Poor" DQ was associated with poor nutritional status in XXX HD patients, who should be targeted for nutritional counselling.

Higher dietary fibre intake is associated with lower CVD mortality risk among maintenance haemodialysis patients: a multicentre prospective cohort study

High fibre intake is associated with reduced mortality risk in both general and chronic kidney disease populations. However, in dialysis patients, such data are limited. Therefore, the association between dietary fibre intake (DFI) and the risk of all-cause and CVD mortality was examined in this study. A total of 1044 maintenance haemodialysis (MHD) patients from eight outpatient dialysis centres in China were included in this study. Data on DFI were collected using 24-h dietary recalls for 3 d in a week and were normalised to actual dry weight. The study outcomes included all-cause and CVD mortality. Over a median of 46 months of follow-up, 354 deaths were recorded, of which 210 (59 %) were due to CVD. On assessing DFI as tertiles, the CVD mortality risk was significantly lower in patients in tertiles 2-3 (≥0·13 g/kg per d; hazard ratio (HR) 0·71; 95 % CI 0·51, 0·97) compared with those in tertile 1 (<0·13 g/kg per d). A similar but non-significant trend was found for the association between DFI (tertiles 2-3 v. tertile 1; HR 0·83; 95 % CI 0·64, 1·07) and all-cause mortality. In summary, higher DFI was associated with lower CVD mortality risk among Chinese MHD patients. This study emphasises the significance of DFI in MHD patients and provides information that is critical for the improvement of dietary guidelines for dialysis patients.

Nutritional Status of Patients on Maintenance Hemodialysis at Muhimbili National Hospital in Dar es Salaam, Tanzania: A Cross-Sectional Study

Background

Patients on hemodialysis therapy are at high risk of malnutrition which is attributed to multiple factors. Protein-energy malnutrition in these patients confers poor clinical outcomes. This study investigated the nutritional status of patients on maintenance hemodialysis at Muhimbili National Hospital in Dar es Salaam, Tanzania.

Methods

A cross-sectional descriptive study was done among 160 adult patients on maintenance hemodialysis therapy. Data concerning patients' personal, medical, dietary, and hemodialysis-related information were collected. Patients' anthropometric and laboratory tests (complete blood count, albumin, total cholesterol, creatinine, and urea) were measured. The quantitative Subjective Global Assessment (SGA) dialysis malnutrition score (DMS) was used to assess their nutritional status. Data analysis was done using the SPSS software version 20.

Results

Among the 160 hemodialysis patients, 49 (30.6%) were female. Patients' mean age was 52.2 ± 13.3 years. The median duration on hemodialysis was 18 (8.25–29.75) months. Malnutrition was present in 98 (61.2%) of the patients. Severe malnutrition was found in only 3 (1.9%) patients and 16.9% were underweight. The longer duration on hemodialysis, having diabetes mellitus, and being single were associated with increased risk for malnutrition in multivariate logistic regression. Malnourished patients had significantly lower dry weight, body mass index, mid-upper arm circumference, waist circumference, albumin, total cholesterol, and creatinine levels.

Conclusion

Malnutrition is very common among hemodialysis patients at Muhimbili National Hospital, especially those on longer duration of hemodialysis, and diabetic patients. We recommend that hemodialysis patients should be regularly assessed for malnutrition and appropriately treated which if left unattended heralds worse outcomes.

[Nutritional status of elderly hemodialysis people in Tunisia]

INTRODUCTION

The nutritional status of old hemodialysis patients determines their prognosis. The aim of this study was to evaluate the spontaneous dietary intake of hemodialysis of elderly patients.

METHODS

This cross-sectional descriptive study included 40 elderly hemodialysis patients recruited at the M8 nephrology department of Charles Nicolle hospital in Tunis. All patients went through a clinical examination to specify anthropometric measurements and a dietary survey based on food registration for 3 consecutive days to obtain a nutritional assessment.

RESULTS

The evaluation of patients' energy intake showed an average daily intake of 25.3±12.3kcal/kg of ideal weight/day. The average total energy intake of patients on dialysis and non-dialysis days was 29.7±17.7kcal/kg and 20.9±6.9kcal/kg, respectively, with a statistically significant difference (P=0.001). The average daily protein intake was 0.99±0.57g/kg on the day of no dialysis. It decreased statistically significantly (P=0.005) on the day of no dialysis at 0.73±0.28g/kg. Phosphorus consumption was excessive on dialysis and non-dialysis days respectively in 20% and 3% of cases. Deficiency of calcium intake affected the entire population studied on the day of non-dialysis. Only 6% of patients had a calcium intake satisfactory on the day of dialysis.

CONCLUSION

A lot of dietary errors were noticed in our study. The assessment of nutritional intake in elderly people with hemodialysis should be part of their management systematically.

Dietary intake in adults on hemodialysis compared with guideline recommendations

Background

Clinical practice guidelines of dietary management are designed to promote a balanced diet and maintain health in patients undergoing haemodialysis but they may not reflect patients’ preferences. We aimed to investigate the consistency between the dietary intake of patients on maintenance haemodialysis and guideline recommendations.

Methods

Cross-sectional analysis of the DIET-HD study, which included 6,906 adults undergoing haemodialysis in 10 European countries. Dietary intake was determined using the Global Allergy and Asthma European Network (GA²LEN) Food Frequency Questionnaire (FFQ), and compared with the European Best Practice Guidelines. Consistency with guidelines was defined as achieving the minimum daily recommended intake for energy (≥ 30 kcal/kg) and protein (≥ 1.1 g/kg), and not exceeding the maximum recommended daily intake for phosphate (≤ 1000 mg), potassium (≤ 2730 mg), sodium (≤ 2300 mg) and calcium (≤ 800 mg).

Results

Overall, patients’ dietary intakes of phosphate and potassium were infrequently consistent with guidelines (consistent in 25% and 25% of patients, respectively). Almost half of the patients reported that energy (45%) and calcium intake (53%) was consistent with the guidelines, while the recommended intake of sodium and protein was consistent in 85% and 67% of patients, respectively. Results were similar across all participating countries. Intake was consistent with all six guideline recommendations in only 1% of patients.

Conclusion

Patients on maintenance haemodialysis usually have a dietary intake which is inconsistent with current recommendations, especially for phosphate and potassium.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40620-020-00962-3.

Nutrition-Based Management of Inflammaging in CKD and Renal Replacement Therapies

Access to renal transplantation guarantees a substantial improvement in the clinical condition and quality of life (QoL) for end-stage renal disease (ESRD) patients. In recent years, a greater number of older patients starting renal replacement therapies (RRT) have shown the long-term impact of conservative therapies for advanced CKD and the consequences of the uremic milieu, with a frail clinical condition that impacts not only their survival but also limits their access to transplantation. This process, referred to as “inflammaging,” might be reversible with a tailored approach, such as RRT accompanied by specific nutritional support. In this review, we summarize the evidence demonstrating the presence of several proinflammatory substances in the Western diet (WD) and the positive effect of unprocessed food consumption and increased fruit and vegetable intake, suggesting a new approach to reduce inflammaging with the improvement of ESRD clinical status. We conclude that the Mediterranean diet (MD), because of its modulative effects on microbiota and its anti-inflammaging properties, may be a cornerstone in a more precise nutritional support for patients on the waiting list for kidney transplantation.

Benefits of resistant starch type 2 for patients with end-stage renal disease under maintenance hemodialysis: a systematic review and meta-analysis

Background: Resistant starch type 2 (RS2) has been documented to regulate gut microbiota and to improve the clinical outcomes of several diseases. However, whether RS2 may benefit patients with end-stage renal disease under maintenance hemodialysis (MHD) remains unknown. Methods: We conducted a systemic review and meta-analysis of randomized controlled trials (RCTs). Adult patients receiving MHD were treated with RS2 (CRD42020160332). The primary outcomes were changes of uremic toxins, and the secondary outcomes were changes of inflammatory indicators, albumin and phosphorus. Results: After screening 65 records, five RCTs (n = 179) were included. A significant decrease of blood urea nitrogen (weighted mean difference (WMD) = -6.91, 95% CI: -11.87 to -1.95, I² = 0%, P = 0.006), serum creatinine (WMD = -1.11, 95% CI: -2.18 to -0.05, I² = 44%, P = 0.04) and interleukin (IL)-6 in blood (standard mean difference (SMD) = -1.08, 95% CI: -1.64 to -0.53, I² = 35%, P = 0.0001) was revealed in the RS2 group. Analyses of blood levels of uric acid, p-cresyl sulfate, indoxyl sulfate, high sensitive C-reaction protein, albumin and phosphorus yielded no significant difference. Conclusions: Our results suggest that RS2 may improve the residual renal function of patients under MHD and mitigate a proinflammatory response.

Chronic Kidney Disease, Gut Dysbiosis, and Constipation: A Burdensome Triplet

Gut dysbiosis has been implicated in the progression of chronic kidney disease (CKD). Alterations in the gut environment induced by uremic toxins, the dietary restriction of fiber-rich foods, and multiple drugs may be involved in CKD-related gut dysbiosis. CKD-related gut dysbiosis is considered to be characterized by the expansion of bacterial species producing precursors of harmful uremic toxins, such as indoxyl sulfate and p-cresyl sulfate, and the contraction of species generating beneficial short-chain fatty acids, such as butyrate. Gut-derived uremic toxins cause oxidative stress and pro-inflammatory responses, whereas butyrate exerts anti-inflammatory effects and contributes to gut epithelial integrity. Gut dysbiosis is associated with the disruption of the gut epithelial barrier, which leads to the translocation of endotoxins. Research on CKD-related gut dysbiosis has mainly focused on chronic inflammation and consequent cardiovascular and renal damage. The pathogenic relationship between CKD-related gut dysbiosis and constipation has not yet been investigated in detail. Constipation is highly prevalent in CKD and affects the quality of life of these patients. Under the pathophysiological state of gut dysbiosis, altered bacterial fermentation products may play a prominent role in intestinal dysmotility. In this review, we outline the factors contributing to constipation, such as the gut microbiota and bacterial fermentation; introduce recent findings on the pathogenic link between CKD-related gut dysbiosis and constipation; and discuss potential interventions. This pathogenic link needs to be elucidated in more detail and may contribute to the development of novel treatment options not only for constipation, but also cardiovascular disease in CKD.

Food as medicine: targeting the uraemic phenotype in chronic kidney disease

The observation that unhealthy diets (those that are low in whole grains, fruits and vegetables, and high in sugar, salt, saturated fat and ultra-processed foods) are a major risk factor for poor health outcomes has boosted interest in the concept of 'food as medicine'. This concept is especially relevant to metabolic diseases, such as chronic kidney disease (CKD), in which dietary approaches are already used to ameliorate metabolic and nutritional complications. Increased awareness that toxic uraemic metabolites originate not only from intermediary metabolism but also from gut microbial metabolism, which is directly influenced by diet, has fuelled interest in the potential of 'food as medicine' approaches in CKD beyond the current strategies of protein, sodium and phosphate restriction. Bioactive nutrients can alter the composition and metabolism of the microbiota, act as modulators of transcription factors involved in inflammation and oxidative stress, mitigate mitochondrial dysfunction, act as senolytics and impact the epigenome by altering one-carbon metabolism. As gut dysbiosis, inflammation, oxidative stress, mitochondrial dysfunction, premature ageing and epigenetic changes are common features of CKD, these findings suggest that tailored, healthy diets that include bioactive nutrients as part of the foodome could potentially be used to prevent and treat CKD and its complications.

Healthy Eating Index of Living Donor Renal Transplantation Recipients During the First Year Posttransplant

BACKGROUND

The aim of this study was to examine the relationship between diet quality and weight gain in kidney transplant recipients from pretransplant baseline through posttransplant at 3 months and 1 year.

METHODS

Data from a prospective, observational cohort study of kidney transplant patients (n = 26) were analyzed. Participants were adult (aged 18-65 years), living donor kidney transplant recipients who were participating in a prospective body composition study. Body weight, body mass index, dietary intake, and Healthy Eating Index scores were used to assess changes in weight, nutrient intake, and diet quality.

FINDINGS

At the time of kidney transplantation, 42% (n = 11) were obese and 27% (n = 7) were overweight. Weight significantly increased from transplantation to 12 months (mean [SD]: 83 [18] kg and 90 [18] kg, respectively; mean change 8.4%, P = .002). At 12 months posttransplant, dietary fat intake significantly increased (P = .033). Body weight was strongly correlated with total dietary fat intake (r = 0.56, P = .003). The Healthy Eating Index total scores at baseline and 1-year posttransplant were not significantly different (45.75 [14.99] and 42.59 [12.70]). Likewise, component scores did not change from pretransplant to posttransplant.

DISCUSSION

Diet quality of transplant recipients was poor both before and after transplantation. Using the Healthy Eating Index confirmed that improvements in food intake are needed. Further research is warranted to identify dietary recommendations for the prevention of excessive weight gain and the potential adverse health complications following kidney transplantation.

Impact of Dietary Potassium Restrictions in CKD on Clinical Outcomes: Benefits of a Plant-Based Diet

In patients with advanced-stage chronic kidney disease (CKD), progressive kidney function decline leads to increased risk for hyperkalemia (serum potassium > 5.0 or >5.5 mEq/L). Medications such as renin-angiotensin-aldosterone system inhibitors pose an additional hyperkalemia risk, especially in patients with CKD. When hyperkalemia develops, clinicians often recommend a diet that is lower in potassium content. This review discusses the barriers to adherence to a low-potassium diet and the impact of dietary restrictions on adverse clinical outcomes. Accumulating evidence indicates that a diet that incorporates potassium-rich foods has multiple health benefits, which may also be attributable to the other vitamin, mineral, and fiber content of potassium-rich foods. These benefits include blood pressure reductions and reduced risks for cardiovascular disease and stroke. High-potassium foods may also prevent CKD progression and reduce mortality risk in patients with CKD. Adjunctive treatment with the newer potassium-binding agents, patiromer and sodium zirconium cyclosilicate, may allow for optimal renin-angiotensin-aldosterone system inhibitor therapy in patients with CKD and hyperkalemia, potentially making it possible for patients with CKD and hyperkalemia to liberalize their diet. This may allow them the health benefits of a high-potassium diet without the increased risk for hyperkalemia, although further studies are needed.

Effect of a Nutritional Intervention, Based on Transtheoretical Model, on Metabolic Markers and Food Consumption of Individuals Undergoing Hemodialysis

OBJECTIVE

This study aimed to evaluate the effect of a nutritional intervention, based on the transtheoretical model, on the metabolic markers and dietary intake of individuals undergoing hemodialysis (HD).

METHODS

Intervention study at a nephrology clinic includes 83 individuals undergoing HD, over a period of 4 months. The nutritional intervention based on the transtheoretical model was composed of two group meetings and three individual ones, with delivery of personalized food plans and nutritional education activities. Anthropometry, dietary intake, metabolic markers, and stage of behavior change were evaluated before and after nutritional intervention.

RESULTS

There was a significant change from the stage of contemplation to the stage of action, after the intervention (P < .001). There was a significant reduction in serum concentrations of creatinine and predialysis and postdialysis urea (P < .001). Hyperphosphataemia and hyperkalemia in the group were also significantly reduced as were markers related to bone metabolism (P < .001). The markers of iron metabolism (P < .001), protein (P = .042), and globulin (P < .001) showed a significant increase. Regarding food consumption, the caloric intakes (P = .034), cholesterol (P = .034), protein, and lipid as well as intake of iron, phosphorus, potassium, copper, and vitamin C (P < .001) were significantly higher after intervention.

CONCLUSIONS

The nutritional intervention based on the transtheoretical model promoted a change in the behavior of individuals undergoing HD, with an important improvement in their metabolic control. This can be explained by the significant change in the intake of calories, macronutrients, and micronutrients, as well as adequate use of phosphorus binders, indicating the crucial role of nutrition in this group.

Constipation in chronic kidney disease: it is time to reconsider

Constipation is highly prevalent in patients with chronic kidney disease (CKD) and is primarily characterized by decreased intestinal motility. This chronic disorder affects the quality of life of patients. However, nephrologist and dialysis clinicians have long had a disproportionately limited understanding of constipation. Accumulating evidence has revealed a relationship between constipation and cardiovascular disease and CKD. The pathogenesis of constipation in CKD patients is multifactorial: decreased physical activity, comorbidities affecting bowel movement, such as diabetes mellitus, cerebrovascular disease, and hyperparathyroidism, a restricted dietary intake of plant-based fiber-rich foods, and multiple medications, including phosphate binders and potassium-binding resins, have all been implicated. CKD is associated with alterations in the composition and function of the gut microbiota, so-called gut dysbiosis. Recent studies showed that CKD-related gut dysbiosis decreased intestinal motility via intestinal inflammation or the increased generation of gut-derived uremic toxins, such as indoxyl sulfate and p-cresyl sulfate. Furthermore, the gastrointestinal secretion of mucin was found to be decreased in CKD animal models, which may delay colonic transit by diminished lubrication in the alimentary tract. Thus, CKD-related gut dysbiosis may play a role in constipation, but limited information is currently available. Since constipation is often intractable, particularly in CKD patients, every available means needs to be employed in its treatment. The effects of probiotics, prebiotics, and synbiotics on the composition of the gut microbiota and gut-derived uremic toxins have been increasingly reported. However, their effects on stool consistency or frequency in CKD patients remain unclear. Some laxatives may be beneficial for improving not only bowel habits but also gut dysbiosis. Further studies are required to elucidate the CKD-specific pathogenesis of constipation and develop novel effective treatment options.

Registered dietitian nutritionists and perceptions of liberalizing the hemodialysis diet

BACKGROUND/OBJECTIVES

The objective of this study was to assess the level of awareness, comfort, and likelihood of liberalizing the hemodialysis diet in practicing renal registered dietitian nutritionists (RDN).

SUBJECTS/METHODS

An original, cross-sectional survey was sent to the Academy of Nutrition and Dietetics' Renal Practice Group in May 2017, consisting primarily of renal dietitians.

RESULTS

A total of 187 renal dietitians responded to the survey designed to assess their current practices regarding the renal diet for hemodialysis patients and how comfortable they would be liberalizing the current restrictions. On average, 16.3% of dietitians are extremely likely to liberalize the restrictions on various food groups including fruits and vegetables, beans and legumes, and whole grains.

CONCLUSIONS

RDN feel confident in their ability to interpret and apply evidence-based literature into practice, and they are moderately comfortable liberalizing the renal diet. The participants were generally more comfortable liberalizing the phosphorus restriction than the potassium restriction, and the sodium restriction remains important to control interdialytic weight gain and hypertension. Future research is needed to establish efficacy of a liberalized diet as well as interventions to help RDN feel more comfortable implementing a liberalization of the renal diet.

Dietary fatty acid intake in hemodialysis patients and associations with circulating fatty acid profiles: A cross-sectional study

OBJECTIVES

The aims of this study were threefold: first, to assess the dietary fatty acid (FA) intake and blood FA status in Malaysian patients on hemodialysis (HD); second, to examine the association between dietary FA intakes and blood FA profiles in patients on HD; and third, to determine whether blood FAs could serve as a biomarker of dietary fat intake quality in these patients.

METHODS

Using 3 d of dietary records, FA intakes of 333 recruited patients were calculated using a food database built from laboratory analyses of commonly consumed Malaysian foods. Plasma triacylglycerol (TG) and erythrocyte FAs were determined by gas chromatography.

RESULTS

High dietary saturated fatty acid (SFA) and monounsaturated fatty acid (MUFA) consumption trends were observed. Patients on HD also reported low dietary ω-3 and ω-6 polyunsaturated fatty acid (PUFA) consumptions and low levels of TG and erythrocyte FAs. TG and dietary FAs were significantly associated respective to total PUFA, total ω-6 PUFA, 18:2 ω-6, total ω-3 PUFA, 18:3 ω-3, 22:6 ω-3, and trans 18:2 isomers (P < 0.05). Contrarily, only dietary total ω-3 PUFA and 22:6 ω-3 were significantly associated with erythrocyte FAs (P < 0.01). The highest tertile of fish and shellfish consumption reflected a significantly higher proportion of TG 22:6 ω-3. Dietary SFAs were directly associated with TG and erythrocyte MUFA, whereas dietary PUFAs were not.

CONCLUSION

TG and erythrocyte FAs serve as biomarkers of dietary PUFA intake in patients on HD. Elevation of circulating MUFA may be attributed to inadequate intake of PUFAs.

Low-Fiber Intake Is Associated With High Production of Intraperitoneal Inflammation Biomarkers

OBJECTIVE

Fiber intake influences disturbances in the gastrointestinal tract and is associated with systemic inflammation in the general population. Systemic and intraperitoneal inflammation play an important role in defining outcomes in peritoneal dialysis (PD), but the relationship between dietary fiber intake and inflammatory biomarkers has not yet been reported in the population on PD. The objective of the present study is to analyze whether or not fiber intake in patients on PD is associated with serum and intraperitoneal levels of inflammatory biomarkers.

DESIGN AND METHODS

Adult and clinically stable PD patients were included in this observational and cross-sectional study. Fiber intake was assessed by means of a dietary survey and calculated using the DietPro program 5.6i. The population was divided into two groups according to the median fiber intake. We investigated interleukin (IL)-1β, IL-6, tumor necrosis factor-α, monocyte chemoattractant protein-1 (MCP-1), B-cell-activating factor, and plasminogen-activator inhibitor-1 in both serum and peritoneal fluid. The latter was determined after a dwell time of 4 hours.

RESULTS

Fifty-two patients (42% men; aged 53 ± 14 years, 36% diabetics) were evaluated. Low intake of dietary fiber was found in 90% of patients, with a median of 12.2 g per day (3.4-33.3). The group with the highest fiber intake presented lower intraperitoneal levels of IL-6, IL-8, and MCP-1. In contrast, only MCP-1 was lower in the serum of those who consumed more fiber. All the associations remained significant after adjustment for confounders with plasminogen-activator inhibitor-1 included.

CONCLUSIONS

Patients on PD frequently present inadequate dietary fiber intake, which appears to have an association with the inflammatory response, particularly in the intraperitoneal component. Further prospective studies, evaluating whether or not a dietetic intervention with a focus on fiber intake affects these biomarkers and clinical outcomes, are essential to determine causality and clinical relevance.

Associations of dietary macronutrients and micronutrients with the traditional and nontraditional risk factors for cardiovascular disease among hemodialysis patients: A clinical cross-sectional study

The current study was to examine the association of adequate intake of macronutrients and micronutrients with traditional and nontraditional cardiovascular risk factors in hemodialysis patients.A clinical cross-sectional study was conducted between September 2013 and April 2017 on 492 hemodialysis patients aged 20 years and above, received thrice-weekly hemodialysis treatment for at least 3 months, adequate dialysis quality (equilibrated Kt/V ≥ 1.2 g/kg/d) from 7 hospital-based hemodialysis centers in Taiwan. The dietary intake was evaluated by the 3-day dietary record, and a 24-hour dietary recall. Biochemical parameters were archived from laboratory tests. The cardiovascular disease (CVD) risk factors were defined by the Kidney Disease Outcomes Quality Initiative (K/DOQI) Clinical Practice Guidelines. The adequate dietary intake of macronutrients and micronutrients was recommended by the European Best Practice Guidelines, K/DOQI, and Institute of Medicine guidelines. Logistic regression analysis was used.All hemodialysis patients had CVD risks, the lowest proportion of patients with adequate intake of macronutrients and micronutrients were 8.7% and 1.8%, respectively. The adequate dietary intake associated with lower likelihood of having CVD risks in hemodialysis patient by 47% to 84%, including 39% to 58% lower hypertension, 37% to 50% lower dyslipidemia, 42% to 63% diabetes mellitus, 44% to 84% lower obesity, 58% lower low calcium, 38% lower hyperparathyroidism, 47% to 64% lower hyperhomocysteinemia, and 41% to 67% lower inflammation, 63% to 74% lower hypoalbumin, 73% lower inadequate normalized protein nitrogen appearance.Adequate dietary nutrients intake may reduce the cardiovascular risks factors, in turn, to prevent the cardiovascular morbidity and mortality.

Malnutrition, Inflammation, Atherosclerosis Syndrome (MIA) and Diet Recommendations among End-Stage Renal Disease Patients Treated with Maintenance Hemodialysis

Malnutrition-inflammation-atherosclerosis syndrome is one of the causes of increased mortality in chronic kidney disease (CKD). The aim of the study was to assess the inflammation and nutritional status of patients in end-stage kidney disease treated with maintenance hemodialysis. The study included a group of 98 hemodialyzed patients with stage 5 CKD (38 women and 60 men). Albumin, prealbumin (PRE), and C-reactive protein (CRP) were measured in serum samples collected before mid-week dialysis. Fruit and vegetables frequency intakes were assessed with a questionnaire. CRP was above the reference limit of 5 mg/L in 53% of patients. Moreover, the Glasgow Prognostic Score (GPS) indicated the co-occurrence of inflammation and protein calorie malnutrition in 11% of patients, and the presence of either inflammation or malnutrition in 25%. The questionnaire revealed that hemodialyzed patients frequently exclude fruit and vegetables from their diets. Nearly 43% of the interviewed patients declared frequently eating vegetables, and 35% declared frequently eating fruit, a few times per week or less. The most frequently selected fruit and vegetables had a low antioxidant capacity. The strict dietary restrictions in CKD are difficult to fulfill, and if strictly followed, may lead to protein-calorie malnutrition.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Diet quality in patients with end-stage kidney disease undergoing dialysis

BACKGROUND

People on haemodialysis (HD) are at risk of consuming a poor quality diet. This includes inadequate intake of omega-3 long chain polyunsaturated fatty acids (n-3 LCPUFA).

OBJECTIVE

This study aims to investigate diet quality, with a particular focus on n-3 LCPUFA intake, in a population of incentre HD patients.

DESIGN

Dietary intake was measured using three 24 hour recalls; the Polyunsaturated food frequency questionnaire (PUFA FFQ) and the Total Diet Score (TDS). Dietary intake was also compared to evidence based practice guidelines (EBPG). Nutritional status was assessed using the Patient Generated Subjective Global Assessment (PG SGA).

SUBJECTS

A total of 32 dialysis patients were recruited, from two regional HD centres in New South Wales, Australia.

MAIN OUTCOME MEASURE

Diet quality was the main outcome measure.

RESULTS

Diet quality of study participants was poor, with the majority not meeting the EBPG for energy, protein and potassium. All participants exceeded the recommended amount of saturated fat. The mean TDS of the dialysis cohort was 10.2, which was significantly higher than the TDS of 9.3 of a healthy disease free cohort (p < 0.05). Positive correlations were found between TDS and LC omega-3 intake (r = 0.392) and TDS and total omega-6 intake (r = 0.363). Only 22% of participants met the suggested dietary target for n-3 LCPUFA intake.

CONCLUSION

Dialysis patients in this study had suboptimal diet quality. Improvements are required for better adherence to the EBPG. Increased consumption of n-3 LCPUFA fatty acids may also be of benefit.

The Diet and Haemodialysis Dyad: Three Eras, Four Open Questions and Four Paradoxes. A Narrative Review, Towards a Personalized, Patient-Centered Approach

The history of dialysis and diet can be viewed as a series of battles waged against potential threats to patients' lives. In the early years of dialysis, potassium was identified as "the killer", and the lists patients were given of forbidden foods included most plant-derived nourishment. As soon as dialysis became more efficient and survival increased, hyperphosphatemia, was identified as the enemy, generating an even longer list of banned aliments. Conversely, the "third era" finds us combating protein-energy wasting. This review discusses four questions and four paradoxes, regarding the diet-dialysis dyad: are the "magic numbers" of nutritional requirements (calories: 30-35 kcal/kg; proteins > 1.2 g/kg) still valid? Are the guidelines based on the metabolic needs of patients on "conventional" thrice-weekly bicarbonate dialysis applicable to different dialysis schedules, including daily dialysis or haemodiafiltration? The quantity of phosphate and potassium contained in processed and preserved foods may be significantly different from those in untreated foods: what are we eating? Is malnutrition one condition or a combination of conditions? The paradoxes: obesity is associated with higher survival in dialysis, losing weight is associated with mortality, but high BMI is a contraindication for kidney transplantation; it is difficult to limit phosphate intake when a patient is on a high-protein diet, such as the ones usually prescribed on dialysis; low serum albumin is associated with low dialysis efficiency and reduced survival, but on haemodiafiltration, high efficiency is coupled with albumin losses; banning plant derived food may limit consumption of "vascular healthy" food in a vulnerable population. Tailored approaches and agreed practices are needed so that we can identify attainable goals and pursue them in our fragile haemodialysis populations.

Stirring the Pot: Can Dietary Modification Alleviate the Burden of CKD?

Diet is one of the largest modifiable risk factors for chronic kidney disease (CKD)-related death and disability. CKD is largely a progressive disease; however, it is increasingly appreciated that hallmarks of chronic kidney disease such as albuminuria can regress over time. The factors driving albuminuria resolution remain elusive. Since albuminuria is a strong risk factor for GFR loss, modifiable lifestyle factors that lead to an improvement in albuminuria would likely reduce the burden of CKD in high-risk individuals, such as patients with diabetes. Dietary therapy such as protein and sodium restriction has historically been used in the management of CKD. Evidence is emerging to indicate that other nutrients may influence kidney health, either through metabolic or haemodynamic pathways or via the modification of gut homeostasis. This review focuses on the role of diet in the pathogenesis and progression of CKD and discusses the latest findings related to the mechanisms of diet-induced kidney disease. It is possible that optimizing diet quality or restricting dietary intake could be harnessed as an adjunct therapy for CKD prevention or progression in susceptible individuals, thereby reducing the burden of CKD.

Dietary protein intake and chronic kidney disease

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.

Modified Nutritional Recommendations to Improve Dietary Patterns and Outcomes in Hemodialysis Patients

The renal diet has traditionally been regarded as one of the most complex medical nutrition therapies to teach, understand, and implement. Specifically, patients are instructed to limit fruits, vegetables, nuts, legumes, dairy, and whole grains because of both phosphorus and potassium concerns. Furthermore, hemodialysis patients are often encouraged to decrease fluid intake to control interdialytic weight gain. These restrictions can result in frustration, lack of autonomy, and the perception that there is nothing left to eat. It is possible that the traditional renal diet may be liberalized, with a focus on whole foods low in sodium and phosphorus additives, to afford patients greater choices and ultimately improved outcomes. Therefore, the objective of this review is to concisely assess the evidence in support of a renal diet focused primarily on reducing the intake of sodium and inorganic phosphorus. Finally, the limited evidence for restrictions on dietary potassium intake is summarized.

Dietary Quality and Adherence to Dietary Recommendations in Patients Undergoing Hemodialysis

BACKGROUND

The multiple dietary restrictions recommended to hemodialysis patients may be difficult to achieve and, at the same time, may result in nutritional deficiencies rendering a poor dietary quality. We here assess the dietary quality and adherence to renal-specific guideline recommendations among hemodialysis patients from a single center in Canary Islands, Spain.

METHODS

Cross-sectional study, including 91 patients undergoing maintenance hemodialysis. Clinical data and 3-day dietary records were collected. We compared patient's reported nutrients intake with guideline recommendations. We also evaluated their alignment with current American Heart Association dietary guidelines for cardiovascular prevention.

RESULTS

Seventy-seven percent and 50% of patients consumed less than the recommended daily energy and protein, respectively. Although half of the patients met the recommendations for dietary fat intake, this was accounted by an excess of saturated fat in 92% of them. Only 22% consumed sufficient fiber. A very small proportion of patients (less than 50%) met the requirements for vitamins and other micronutrients. Insufficient dietary intake was observed in most patients for all vitamins except for cobalamin. Similarly, inadequate dietary intake was observed for many minerals, by both excess (phosphorus, calcium, sodium, and potassium) and defect (magnesium). Most patients met the recommendations for iron and zinc in their diets.

CONCLUSIONS

A large proportion of hemodialysis patients at our center did not meet current renal-specific dietary recommendations. The quality of the diet was considered poor and proatherogenic according to American Heart Association guidelines.

Dietary restrictions in dialysis patients: is there anything left to eat?

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.

Food intake in patients on hemodialysis

Objective:To evaluate the intake of energy and nutrients by individuals on hemodialysis, following especific recommendations for this population and according to Food Guide for the Brazilian Population.Methods: A cross-sectional study, 118 adult patients, considered stable from, ten dialysis centers in Goiânia, Goiás. Dietary intake was estimated by six 24-hour recalls, and classified as adequate or inadequate, according to specific recommendations for individuals undergoing dialysis and that recommended for a healthy diet. A descriptive analysis was performed.Results: Average dietary intake of 2022.40 ± 283.70 kcal/day; 31.18 kcal/kg/day; 55.03 ± 4.20% carbohydrate; 30.23 ± 3.71% lipid, 1.18 ± 0.23 g protein/kg/day. Important prevalences of inadequacy were observed for the intake of calories (39.0%), protein (39.0%) and other nutrients such as retinol (94.9%), saturated fat (87.3%), cholesterol (61,9%), iron (61.0%), potassium (60.2%) and zinc (45.0%). Patients had a low intake of fruit food group (1.22 ± 0.89 servings) and vegetables (1.76 ± 1.01 servings), dairy products (0.57 ± 0.43 servings) and high intake of food group of oils and fats (3.45 ± 0.95 servings), sugars and sweets (1.55 ± 0.77 servings).Conclusion: Observed food consumption imbalance, characterized by excess of oils and fats, especially saturated oils and cholesterol, sugars and sweets, parallel to low intake of fruits and vegetables and dairy products. A considerable percentage of patients did not intake the minimum recommended of calories, protein, retinol, iron, zinc and potassium.

Dietary protein and fiber in end stage renal disease

Prior to the availability of hemodialysis, dietary protein restriction played a large part in the treatment of uremia. This therapy was based on observations that uremic symptoms increased with high protein intake. Early investigators thus presumed that "uremic toxins" were derived from the breakdown of dietary protein; its restriction improved uremic symptoms but caused malnutrition. After the availability of hemodialysis, protein restriction was no longer recommended. Studies in healthy subjects have shown that an intake of 0.6-0.8 g/kg/day is adequate to prevent protein malnutrition. Guidelines for hemodialysis patients, however, currently recommend higher protein intakes of 1.2 g/kg/day. A downside to higher intake may be increased production of protein-derived uremic solutes that caused the symptoms observed by early investigators. Some of these solutes are produced by colon microbes acting on protein which escapes digestion in the small intestine. Increasing dietary fiber may reduce the production of colon-derived solutes in hemodialysis patients without adverse effects of protein restriction. Fiber comprises carbohydrates and related substances that are resistant to digestion in the small intestine. Upon delivery to the colon, fiber is broken down to short chain fatty acids, providing energy to both the microbes and the host. With an increased energy supply, the microbes can incorporate dietary protein for growth rather than breaking them down to uremic solutes. Increasing fiber intake in hemodialysis patients has been shown to reduce the plasma levels of selected colon-derived solutes. Further studies are needed to test whether this provides clinical benefit.