A High Prevalence of Abnormal Nutrition Parameters Found in Predialysis End-Stage Kidney Disease: Is It a Result of Uremia or Poor Eating Habits?

Vitamin Supplement Use in Patients With CKD: Worth the Pill Burden?

All vitamins play essential roles in various aspects of body function and systems. Patients with chronic kidney disease (CKD), including those receiving dialysis, may be at increased risk of developing vitamin deficiencies due to anorexia, poor dietary intake, protein energy wasting, restricted diet, dialysis loss, or inadequate sun exposure for vitamin D. However, clinical manifestations of most vitamin deficiencies are usually subtle or undetected in this population. Testing for circulating levels is not undertaken for most vitamins except folate, B12, and 25-hydroxyvitamin D because assays may not be available or may be costly to perform and do not always correlate with body stores. The last systematic review through 2016 was performed for the Kidney Disease Outcome Quality Initiative (KDOQI) 2020 Nutrition Guideline update, so this article summarizes the more recent evidence. We review the use of vitamins supplementation in the CKD population. To date there have been no randomized trials to support the benefits of any vitamin supplementation for kidney, cardiovascular, or patient-centered outcomes. The decision to supplement water-soluble vitamins should be individualized, taking account the patient's dietary intake, nutritional status, risk of vitamins deficiency/insufficiency, CKD stage, comorbid status, and dialysis loss. Nutritional vitamin D deficiency should be corrected, but the supplementation dose and formulation need to be personalized, taking into consideration the degree of 25-hydroxyvitamin D deficiency, parathyroid hormone levels, CKD stage, and local formulation. Routine supplementation of vitamins A and E is not supported due to potential toxicity. Although more trial data are required to elucidate the roles of vitamin supplementation, all patients with CKD should undergo periodic assessment of dietary intake and aim to receive various vitamins through natural food sources and a healthy eating pattern that includes vitamin-dense foods.

Nutritional status, symptom burden, and predictive validity of the Pt-Global web tool/PG-SGA in CKD patients: A hospital based cross sectional study

BACKGROUND

Despite not being frequently recognized, malnutrition, a consequence of chronic kidney disease, negatively affects morbidity, mortality, functional activity, and patient's quality of life. Management of this condition is made more difficult by the dearth of knowledge regarding the symptom burden brought on by inadequate nutritional status. Additionally, there are multiple tools to evaluate nutritional status in CKD; but, Pt-Global web tool/PG-SGA used in oncology, has not been investigated in chronic kidney disease patients. This study aimed to explore the nutritional status, symptom burden and also investigate the predictive validity of Pt-Global web tool/PG-SGA among pre-dialysis diabetic and non-diabetic chronic kidney disease patients.

METHODOLOGY

This cross-sectional study was carried out at a renal clinic of a tertiary care public teaching hospital. Nutritional status and symptom burden was evaluated by employing a 'Pt-Global web tool/PG-SGA' which is considered as a preeminent interdisciplinary tool in oncology and other chronic catabolic conditions. The predictive validity of the Pt-Global web tool/PG-SGA, referred as overall score for malnutrition was ascertained using Receiver Operating Curves (ROC). The conclusions were drawn using descriptive statistics, correlation, and regression analysis.

RESULTS

In a sample of 450 pre-dialysis CKD patients, the malnutrition was present in 292(64.9%) patients. Diabetic CKD patients exhibit higher proportion of malnutrition 159(35.3%). The prevalence of malnutrition was exacerbated by eGFR reduction. The overall Pt-Global web tool/PGA-SGA score was significantly influenced by the symptoms of fatigue (81.5%), appetite loss (54.8%), physical pain (45.3%), constipation (31.78%), dry mouth (26.2%), and feeling full quickly (25.8%). The ROC analysis showed that the AUC for the total PG-SGA score was 0.988 (95% CI: 0.976-1.000), indicating that it is a reliable indicator of malnutrition. The sensitivity (84.2%) for identifying malnutrition was low when using the conventional tool cut off score of ≥9. Instead, it was discovered that a score of ≥3 had a greater sensitivity (99.3%) and specificity (44.3%) and was therefore recommended.

CONCLUSIONS

This study not only presents empirical evidence of poor nutritional status in CKD patients but also reveals that it is worse in patients with diabetes, hypoalbuminemia, and poorer kidney function (well recognized risk factors for cardiovascular disease). Early diagnosis and management of symptoms contributing malnutrition will reduce mortality and CKD progression. The Pt-Global web tool/PG-SGA total score of 3 or more appears to be the ideal cut off score for identifying malnutrition, which can be utilized by dietician for improving malnutrition.

Dietary habits in Australian, New Zealand and Malaysian patients with end stage kidney failure: A pre-specified cross-sectional study of the FAVOURED trial participants

BACKGROUND

Dietary management plays an important role in patients with kidney failure. Current dietary habits of Australians and New Zealanders (ANZ) and Malaysians with chronic kidney disease (CKD Stage 4-5) have not been adequately investigated. We report the dietary habits of people with advanced CKD and their adherence to country-specific dietary guidelines.

METHODS

Participants with CKD Stage 4-5, enrolled in the Omega-3 Fatty Acids (Fish oils) and Aspirin in Vascular access Outcomes in Renal Disease (FAVOURED) trial, completed a lifestyle questionnaire at baseline on their dietary intake.

RESULTS

Of 567 participants, 538 (ANZ, n = 386; Malaysian, n = 152; mean ± SD age 54.8 ± 14.3 years, 64% male) completed the questionnaire. Dietary fruit and vegetable intakes were higher in ANZ participants; 49% (n = 189) consumed ≥2 serves day^-1 of fruit and 61% (n = 235) ate ≥2 serves day^-1 of vegetables compared to 24% (n = 36) and 34% (n = 52) of Malaysians, respectively (p < 0.0001). Only 4% (n = 15) of ANZ participants met Australian Dietary recommendations of two fruit and five vegetable serves day^-1 . Fish consumption was higher in Malaysians with 83% (n = 126) consuming ≥2 serves week^-1 compared to 21% (n = 81) of ANZ participants (p < 0.001). Red meat intake was higher in ANZ participants; however, chicken consumption was similar; 48% (n = 185) consumed >2 chicken serves week^-1 and 65% (n = 251) ate >2 serves week^-1 of red meat compared to 43% (n = 65) and 15% (n = 23) of Malaysians, respectively.

CONCLUSIONS

Significant regional variation in dietary intake for fruit, vegetables and animal protein is described that likely reflects cultural and economic differences. Barriers to meeting recommended dietary intakes require further investigation.

Smart Management of Malnutrition Using Local Foods: A Sustainable Initiative for Developing Countries

Malnutrition is one of the major challenges the developing world is currently facing, whether it is caused by climate change, terrorism and conflict, or demographic shifts. Poverty is the main cause of malnutrition in this part of the world, and no progress is possible without the alleviation of poverty to reduce malnutrition. Reducing household vulnerability and increasing household resilience is the pathway to sustainable malnutrition management. Malnutrition has been a major threat to the health and development of children in developing countries, presenting as high levels of micronutrient deficiencies, stunting, and global acute malnutrition. The rates of malnutrition of all forms are above the thresholds accepted by the WHO in some regions. To this end, the resilience program on achieving nutrition in a developing country through at-home learning activities for nutritional rehabilitation and dietary promotion (known as FARN) reported, in this case, successful results from both statements from beneficiaries and non-beneficiaries on the reduction and management of malnutrition in their health centers. FARN activity encourages the consumption of locally available foods not only to eradicate malnutrition but also to protect the ecosystem and sustainable nutrition security. This is much like the saying, “Give a man a fish and you feed him for a day. Teach a man to fish and you feed him for a lifetime” to the vulnerable people; parents' knowledge of their child's nutritional status and the use of local-based foods diets showed improvement, which is proof of the impact of the resilience program. It can be concluded that the resilience program through its activities at the level of the selected community significantly affected the factors and degree of persistence of malnutrition and the level of resilience of the populations. Thus, the FARN program showed resounding success in its ability to promote sustainable malnutrition management.

Patient-Reported Outcome and Experience Measures Administered by Dietitians in the Outpatient Setting: Systematic Review

Understanding how patients perceive their health and the experience with the dietitian is fundamental to providing patient-centred care. The types of patient reported measures (PRMs) used by outpatient dietitians is unclear. Guidance about use of PRMs for dietitians is also lacking. The aim of this systematic review was to synthesise evidence regarding the use of PRMs by dietitians in the outpatient setting and evaluate the methodological quality of studies evaluating the psychometric properties of PRMs. Eight databases were searched systematically for studies of dietitians working in the outpatient setting and administering a PRM. Forty-four studies were evaluated and described 58 different PRMs. These included direct nutrition related (n = 12 studies), clinical (n = 21 studies), and health-related quality of life PRMs (n = 24 studies); 1 study documented use of a patient-reported experience measure. A large range of PRMs are used by outpatient dietitians. Of the most common PRMs, the majority are administered in similar populations to the original validation study. Dietitians should use a combination of 3 PRMs: a generic health-related quality of life tool, an experience measure, and at least 1 clinical or direct nutrition-related measure. This will enable dietitians to fully capture the impact of their care on patients.

Gastrointestinal symptom burden and dietary intake in patients with chronic kidney disease

BACKGROUND

Gastrointestinal (GI) symptoms can present a significant burden to patients with chronic kidney disease (CKD) but the reported prevalence is inconsistent.

OBJECTIVE

To examine the GI burden and dietary intake in patients with CKD with or without dialysis.

METHODS

This was a cross-sectional study of 216 adults, recruited from outpatient and dialysis clinics, with CKD stage 4 or 5 not receiving dialysis (CKD-ND), or receiving haemodialysis (HD) or peritoneal dialysis (PD). Three questionnaires were administered: the Bristol Stool Form Scale (BSFS); a modified Gastrointestinal Symptom Rating Scale and a short Food Frequency Questionnaire. Outcomes were stool frequency and consistency, GI symptoms and dietary intake.

RESULTS

Data were collected from 216 patients (mean age, 63 years [95% CI: 61, 65]; 63% males; CKD-ND: n = 134; HD: n = 67; PD: n = 15). Mean stool frequency for all groups was one bowel action per day (p = .45) and consistency was normal (BSFS type 4, p = .95). Overall GI symptom burden was low but several symptoms occurred at least "most of the time" including "tiredness/lethargy" (54% of participants), "reduced appetite" (29%), "early satiety" (25%) and "change in taste" (15%). Low intakes of fresh fruit, vegetables, whole-grains and legumes were found. No associations were observed between diet and GI symptoms.

CONCLUSION

The overall GI symptom burden was low, but >15% of participants reported several symptoms as occurring most to all of the time. Low intakes of fresh fruit, vegetables, whole-grains and legumes were observed in all CKD patients.

Obesity and Other Nutrition Related Abnormalities in Pre-Dialysis Chronic Kidney Disease (CKD) Participants

Chronic kidney disease (CKD) is increasing in sub-Saharan Africa. Undernutrition has been prevalent amongst end stage CKD patients, with limited data on the prevalence of obesity. The aim of this study was to assess the nutritional status of CKD patients using various methods sensitive to over and under-nutrition. Stage 3 to 5 CKD patients (glomerular filtration rate (GFR) < 60 mL/min/1.73 m²) attending a pre-dialysis clinic in Cape Town, were enrolled. Exclusion criteria included infectious and autoimmune conditions. Sociodemographic, clinical and biochemical data were collected, and anthropometric measurements were performed. Dietary intake was measured with a quantified food frequency questionnaire (FFQ). Statistical Package for the Social Sciences (SPSS) version 26 was used for statistical analysis. Seventy participants, with mean age of 41.8 ± 11.8 years, 52.9% females and 47.1% males were enrolled. Participants enrolled mainly had stage 5 kidney failure. Thirty percent were overweight (21) and 25 (36%) were obese, 22 (60%) of females were overweight and obese, while 13 (39.4%) of males were predominantly normal weight. Abdominal obesity was found in 42 (60%) of participants, mainly in females. Undernutrition prevalence was low at 3%. Dietary assessment showed a high sugar and protein intake. There was a high prevalence of overweight, obesity and abdominal obesity in CKD stage 35 patients, with unhealthy dietary intake and other nutritional abnormalities.

Influence of parental education levels on eating habits of pupils in Nigerian primary schools

This study investigated the eating habits of pupils in Nigerian primary schools based on the respective education levels of their parents.Data were obtained using the Child Eating Behavior Questionnaire (CEBQ). Participants included a total of 144 pupils who were purposively selected from 6 primary schools. Based on responses, a cross-sectional analytic study design was implemented to investigate how parental education levels (PELs) influenced the eating habits of their children. Data assessment was performed using a one-way between-group analysis of variance at the .05 probability level.PELs significantly affected the eating habits of participants, respectively. Specifically, low PEL was associated with more satiety responsiveness to food (F [2, 141] = 14.251, P < .001), higher responsiveness to food (F [2, 141] = 36.943, P = <.001) greater food enjoyment (F [2, 141] = 93.322, P < .001), greater drinking desires (F [2, 141] = 23.677, P < .001), and the tendency for emotional over-eating (F [2, 141] = 13.428, P < .001), while high PEL was associated with slower eating (F [2, 141] = 11.665, P < .001), fussier responses to food (F [2, 141] = 14.865, P < .001), and a higher tendency for emotional under-eating (F [2, 141] = 5.137, P < .01).This study examined PELs in relation to the respective eating habits of their children, who were attending Nigerian primary schools. Data showed that children with parents who had high, middle, and low education levels tended to exhibit progressively worse eating habits, in descending order.

Dietary Phosphate Consumption in Australians With Stages 3b and 4 Chronic Kidney Disease

OBJECTIVE

Dietary phosphate modification is a common therapy to treat hyperphosphatemia in individuals with chronic kidney disease (CKD). However, current dietary intake and common food sources of phosphate typically consumed by individuals with CKD are not well characterized. This study examined a cohort of CKD patients to determine total dietary intake and common food sources of phosphate, including phosphate additives.

DESIGN AND METHODS

Participants with CKD stages 3b and 4 recruited to a substudy of the "IMPROVE-CKD (IMpact of Phosphate Reduction On Vascular End-points in Chronic Kidney Disease) Study" completed a 7-day self-administered diet record at baseline. Diet histories were analyzed and daily phosphate intakes determined using FoodWorks V.9 (Xyris). The proportion of phosphate contributed by each food group was determined using the AUSNUT 2011-2013 Food Classification System. Ingredient lists of packaged food items consumed were reviewed to determine frequency of phosphate-based additives.

RESULTS

Ninety participants (mean eGFR 26.5 mL/min/1.73 m²) completed this substudy. Mean phosphate intake of participants was 1544 ± 347 mg/day, with 96% of individuals exceeding the recommended daily intake of phosphate (1000 mg/day). The highest sources of dietary phosphate were milk-based products (25%) and meat and poultry products/dishes (25%). Phosphate-based food additives were identified in 39% (n = 331/845) of packaged foods consumed by participants.

CONCLUSION

Dietary phosphate intakes of Australians with CKD are high and come from a variety of sources. Managing dietary phosphate intake requires a patient-centered, tailored approach with an emphasis on maintaining nutritional adequacy and awareness of phosphate additives.

Detecting Lifestyle Risk Factors for Chronic Kidney Disease With Comorbidities: Association Rule Mining Analysis of Web-Based Survey Data

Background

The rise in the number of patients with chronic kidney disease (CKD) and consequent end-stage renal disease necessitating renal replacement therapy has placed a significant strain on health care. The rate of progression of CKD is influenced by both modifiable and unmodifiable risk factors. Identification of modifiable risk factors, such as lifestyle choices, is vital in informing strategies toward renoprotection. Modification of unhealthy lifestyle choices lessens the risk of CKD progression and associated comorbidities, although the lifestyle risk factors and modification strategies may vary with different comorbidities (eg, diabetes, hypertension). However, there are limited studies on suitable lifestyle interventions for CKD patients with comorbidities.

Objective

The objectives of our study are to (1) identify the lifestyle risk factors for CKD with common comorbid chronic conditions using a US nationwide survey in combination with literature mining, and (2) demonstrate the potential effectiveness of association rule mining (ARM) analysis for the aforementioned task, which can be generalized for similar tasks associated with noncommunicable diseases (NCDs).

Methods

We applied ARM to identify lifestyle risk factors for CKD progression with comorbidities (cardiovascular disease, chronic pulmonary disease, rheumatoid arthritis, diabetes, and cancer) using questionnaire data for 450,000 participants collected from the Behavioral Risk Factor Surveillance System (BRFSS) 2017. The BRFSS is a Web-based resource, which includes demographic information, chronic health conditions, fruit and vegetable consumption, and sugar- or salt-related behavior. To enrich the BRFSS questionnaire, the Semantic MEDLINE Database was also mined to identify lifestyle risk factors.

Results

The results suggest that lifestyle modification for CKD varies among different comorbidities. For example, the lifestyle modification of CKD with cardiovascular disease needs to focus on increasing aerobic capacity by improving muscle strength or functional ability. For CKD patients with chronic pulmonary disease or rheumatoid arthritis, lifestyle modification should be high dietary fiber intake and participation in moderate-intensity exercise. Meanwhile, the management of CKD patients with diabetes focuses on exercise and weight loss predominantly.

Conclusions

We have demonstrated the use of ARM to identify lifestyle risk factors for CKD with common comorbid chronic conditions using data from BRFSS 2017. Our methods can be generalized to advance chronic disease management with more focused and optimized lifestyle modification of NCDs.

Pro: The rationale for dietary therapy for patients with advanced chronic kidney disease

Dietary treatment offers many benefits to patients with advanced chronic kidney disease (CKD) who are approaching the need for renal replacement therapy. A large number of these benefits are independent of whether diets slow the rate of progression of CKD. These diets are low in protein and many minerals, and provide adequate energy for the CKD patient. The diets can reduce accumulation of potentially toxic metabolic products derived from protein and amino acid degradation, maintain a healthier balance of body water, sodium, potassium, phosphorus, calcium and other minerals, and prevent or improve protein-energy wasting. Such diets may enable patients to safely delay the onset of chronic dialysis therapy or kidney transplantation. Dietary therapy may also augment the effectiveness of infrequent or incremental dialysis by maintaining healthier metabolic and clinical status and may enable some end-stage renal disease patients to avoid the need for temporary placement of hemodialysis catheters while their arterial venous fistulae or grafts mature. The anxiety that many advanced CKD patients commonly experience with regard to starting dialysis may incentivize them to accept and adhere to dietary therapy.

Prognostic factors in patients undergoing early-start peritoneal dialysis within 24 h after catheter insertion

This study aimed to investigate the clinical characteristics, prognosis, and factors for survival of patients who underwent early-start peritoneal dialysis (PD) within 24 h after catheter insertion three years after PD. This study was conducted from January 1, 2013 to December 31, 2017. All adult patients who were diagnosed with end-stage renal disease (ESRD) and underwent PD for the first time within 24 h after catheter insertion in our hospital were included. All patients with PD were followed-up until they withdrew from PD, switching to hemodialysis, were transferred to other medical centers, underwent renal transplantation, died or were lost to follow-up, or continued to undergo dialysis until the end of the study period. The follow-up observation lasted three years. The number of eligible patients was 110, and switching to hemodialysis and death were the main reasons for patients to withdraw from PD. The 1-, 2-, and 3-year technical survival rates of patients were 89.1, 79.1, and 79.1% respectively, while the 1-, 2- and 3-year survival rates were 90, 81.8, and 81.8%, respectively. The Charlson comorbidity index, age, hemoglobin, serum albumin, diabetic nephropathy, chronic glomerulonephritis, and hypertensive renal damage were independent risk factors that affected the prognosis of PD patients. Under the condition of ensuring the quality of the PD catheter insertion, early-start PD within 24 h after catheter insertion is a safe treatment approach for ESRD patients.

Current Uses of Dietary Therapy for Patients with Far-Advanced CKD

For several decades, inquiry concerning dietary therapy for nondialyzed patients with CKD has focused mainly on its capability to retard progression of CKD. However, several studies published in recent years indicate that, independent of whether diet can delay progression of CKD, well designed low-protein diets may provide a number of benefits for people with advanced CKD who are close to requiring or actually in need of RRT. Dietary therapy may both maintain good nutritional status and safely delay the need for chronic dialysis in such patients, offering the possibility of improving quality of life and reducing health care costs. With the growing interest in incremental dialysis, dietary therapy may enable lower doses of dialysis to be safely and effectively used, even as GFR continues to decrease. Such combinations of dietary and incremental dialysis therapy might slow the rate of loss of residual GFR, possibly reduce mortality in patients with advanced CKD, improve quality of life, and also, reduce health care costs. The amount of evidence that supports these possibilities is limited, and more well designed, randomized clinical trials are clearly indicated.

Protein-controlled versus restricted protein versus low protein diets in managing patients with non-dialysis chronic kidney disease: a single centre experience in Australia

Nutrition has been an important part of medical management in patients with chronic kidney disease for more than a century. Since the 1970s, due to technological advances in renal replacement therapy (RRT) such as dialysis and transplantation, the importance of nutrition intervention in non-dialysis stages has diminished. In addition, it appears that there is a lack of high-level evidence to support the use of diet therapy, in particular the use of low protein diets to slow down disease progression. However, nutrition abnormalities are known to emerge well before dialysis is required and are associated with poor outcomes post-commencing dialysis. To improve clinical outcomes it is prudent to incorporate practice research and quality audits into routine care, as part of the continuous clinical practice improvement process. This article summarises the experience of and current practices in a metropolitan tertiary teaching hospital in Sydney, Australia.

Medical Nutrition Therapy for Chronic Kidney Disease Improves Biomarkers and Slows Time to Dialysis

OBJECTIVE

To investigate whether medical nutrition therapy (MNT) provided by a registered dietitian experienced in chronic kidney disease (CKD) slows the progression of disease and improves nutrition-related biomarkers.

DESIGN

Retrospective cohort study.

SUBJECTS

The cohort included 265 participants from a regional nephrology center in a rural state; 147 of who received MNT were compared to a group that did not receive MNT and had started dialysis over a 10-year period.

INTERVENTION

MNT by a registered dietitian with expertise in CKD.

MAIN OUTCOME MEASURE

Average time to dialysis, based on stage of CKD at baseline, was compared between groups. In addition, the effect of MNT on the change in biochemical measures for estimated glomerular filtration rate, blood urea nitrogen, albumin, CKD Mineral and Bone Disorder (MBD) markers (phosphorous, calcium, and intact parathyroid hormone) at baseline and at follow-up (dialysis initiation or most recent laboratories if dialysis was not started) was assessed.

RESULTS

MNT group had less of a decline in estimated glomerular filtration rate than the non-MNT group (0.3 vs. 9.9 mL/minute/1.73 m(2), respectively) a mean difference of 9.6 (P < 0.001). When adjusted for stage using linear regression, the mean difference was greater (11.4, P < .001). Using survival analysis and Cox proportional hazards regression, the non-MNT group was 3.15 more likely to initiate dialysis. Stratified by Stages 3 and 4 that hazard ratio increased (3.47 and 3.45, respectively). Albumin and markers of CKD-MBD were more likely to be within normal limits in the MNT group. The results indicate that better outcomes occur when MNT is given at CKD Stage 3 or 4 rather than CKD Stage 5.

CONCLUSIONS

Results suggest that people with CKD who received MNT were less likely to start dialysis and had improved nutritional biomarkers than participants who did not receive MNT.