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Rachana B, Shobana S, Lalithya PV, Sudha V, Vinita S, Gayathri R, Kalpana N, Ranjit MA, Viswanathan M. Glycemic index of a nutritional supplement designed for people with chronic kidney disease. Food Sci Nutr 2023; 11:5379-5387. [PMID: 37701241 PMCID: PMC10494616 DOI: 10.1002/fsn3.3495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 05/18/2023] [Accepted: 05/24/2023] [Indexed: 09/14/2023] Open
Abstract
The study was carried out to measure the glycemic index (GI) of an oral food supplement for people with CKD as well as on patients on maintenance dialysis. The study was conducted as per international protocols for testing GI, was approved by the local institutional ethics committee, and was registered with the Clinical Trial Registry of India (CTRI). This was a crossover randomized controlled study which enrolled 15 participants between the ages of 18 and 45 years. The participants were randomly allotted to one group that consumed either the reference food (27.5 g of glucose monohydrate) or 118 g of the nutritional supplement which contained 25 g of available carbohydrates. Fasting capillary blood samples as well as blood samples at different time intervals as per the GI protocol, after consumption of either the supplement or the reference food were taken from the participants. Each testing day was separated by a 3-day washout period. GI was calculated from the incremental area under the blood glucose response elicited by the nutritional supplement as a percentage of the response after the consumption of 25 g of glucose (27.5 g of glucose monohydrate) by the same participant using a standard formula. The GI of the nutritional supplement was calculated to be 10.3 ± 2.0 which is considered to be low as per international GI testing standards. The product was created to supplement the diet of people with CKD at different stages and to help prevent the progression from CKD to ESRD as well as the risk for CVD. This product was found to have a low GI which is desirable for people with CKD as well as diabetics in general who are at risk for developing CKD.
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Affiliation(s)
- Bhoite Rachana
- Dr. Reddy's Laboratories Pvt Ltd.HyderabadTelanganaIndia
| | - Shanmugam Shobana
- Department of FoodsNutrition & Dietetics Research, Madras Diabetes Research FoundationChennaiTamil NaduIndia
| | | | - Vasudevan Sudha
- Department of FoodsNutrition & Dietetics Research, Madras Diabetes Research FoundationChennaiTamil NaduIndia
| | | | - Rajagopal Gayathri
- Department of FoodsNutrition & Dietetics Research, Madras Diabetes Research FoundationChennaiTamil NaduIndia
| | - Natarajan Kalpana
- Department of FoodsNutrition & Dietetics Research, Madras Diabetes Research FoundationChennaiTamil NaduIndia
| | - Mohan Anjana Ranjit
- Department of FoodsNutrition & Dietetics Research, Madras Diabetes Research FoundationChennaiTamil NaduIndia
- Department of DiabetologyDr. Mohan's Diabetes Specialities CentreChennaiTamil NaduIndia
| | - Mohan Viswanathan
- Department of FoodsNutrition & Dietetics Research, Madras Diabetes Research FoundationChennaiTamil NaduIndia
- Department of DiabetologyDr. Mohan's Diabetes Specialities CentreChennaiTamil NaduIndia
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Ruperto M, Barril G. Nutritional Status, Body Composition, and Inflammation Profile in Older Patients with Advanced Chronic Kidney Disease Stage 4-5: A Case-Control Study. Nutrients 2022; 14:nu14173650. [PMID: 36079906 PMCID: PMC9460397 DOI: 10.3390/nu14173650] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 08/30/2022] [Accepted: 08/31/2022] [Indexed: 12/17/2022] Open
Abstract
Nutritional status is a predictor of adverse outcomes and mortality in patients with advanced chronic kidney disease (ACKD). This study aimed to explore and evaluate risk factors related to nutritional status, body composition, and inflammatory profile in patients with ACKD compared with age- and sex-matched controls in a Mediterranean cohort of the Spanish population. Out of 200 volunteers recruited, 150 participants (64%) were included, and a case-control study was conducted on 75 ACKD patients (stages 4−5), matched individually with controls at a ratio of 1:1 for both age and sex. At enrolment, demographic, clinical, anthropometric, and laboratory parameters were measured. Bioimpedance analysis (BIA) was used to assess both body composition and hydration status. ACKD patients had lower body cell mass (BCM%), muscle mass (MM%) phase angle (PA), s-albumin, and higher C-reactive protein (s-CRP) than controls (at least, p < 0.05). PA correlated positively with BCM% (cases: r = 0.84; controls: r = 0.53, p < 0.001), MM% (cases: r = 0.65; controls: r = 0.31, p < 0.001), and inversely with s-CRP (cases: r = −0.30, p < 0.001; controls: r = −0.31, p = 0.40). By univariate and multivariate conditional regression analysis, total body water (OR: 1.186), extracellular mass (OR: 1.346), s-CRP (OR: 2.050), MM% (OR: 0.847), PA (OR: 0.058), and s-albumin (OR: 0.475) were significantly associated among cases to controls. Nutritional parameters and BIA-derived measures appear as prognostic entities in patients with stage 4−5 ACKD compared to matched controls in this Mediterranean cohort.
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Affiliation(s)
- Mar Ruperto
- Department of Pharmaceutical & Health Sciences, School of Pharmacy, Universidad San Pablo-CEU, CEU Universities, Urbanización Monteprincipe, 28660 Madrid, Spain
- Correspondence: (M.R.); (G.B.)
| | - Guillermina Barril
- Nephrology Department, Hospital Universitario La Princesa, C/Diego de León 62, 28006 Madrid, Spain
- Correspondence: (M.R.); (G.B.)
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Wong MMY, Zheng Y, Renouf D, Sheriff Z, Levin A. Trajectories of Nutritional Parameters Before and After Prescribed Oral Nutritional Supplements: A Longitudinal Cohort Study of Patients With Chronic Kidney Disease Not Requiring Dialysis. Can J Kidney Health Dis 2022; 9:20543581211069008. [PMID: 35070337 PMCID: PMC8771735 DOI: 10.1177/20543581211069008] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 11/02/2021] [Indexed: 11/15/2022] Open
Abstract
Background: The association between oral nutritional supplement use and nutritional parameters among patients with nondialysis chronic kidney disease (CKD-ND) with or at high risk of undernutrition/protein-energy wasting has not been previously studied. The definition of patient subgroups most likely to benefit from oral nutritional supplementation (ONS) is also an area where more research is needed. Objective: To assess nutritional parameter trajectories among patients with CKD-ND prescribed oral nutritional supplements in British Columbia, and to compare trajectories by nutritional phenotype. Design: Longitudinal cohort study, pre-post design. Setting: Multidisciplinary CKD clinics across British Columbia. Patients: A total of 3957 adult patients with CKD-ND, who entered multidisciplinary CKD clinics during 2010 to 2019, met criteria for oral nutritional supplement prescription based on dietitian assessment, and received ≥1 oral nutritional supplement prescription. Measurements: Longitudinal nutritional parameters, including body mass index (BMI), serum albumin, serum bicarbonate, serum phosphate, and neutrophil-to-lymphocyte ratio (NLR). Methods: Using linear mixed models, slopes for nutritional and inflammation parameters were assessed in the 2-year periods before and after the first oral nutritional supplement prescription. Hierarchical cluster analysis was applied to identify nutritional phenotypes using baseline data, and slope analysis was repeated by cluster. Results: In the pre-oral-nutritional-supplement period, declines in BMI (−0.87 kg/m2/year, 95% confidence interval [CI]: −0.99 to −0.75), albumin (−1.11 g/L/year, 95% CI: −1.27 to −0.95), and bicarbonate (−0.49 mmol/L/year; 95% CI: −0.59 to −0.39), and increases in NLR (+0.79/year; 95% CI: 0.60 to 0.98) and phosphate (+0.05 mmol/L/year; 95% CI: 0.04 to 0.06) were observed. Following oral nutritional supplement prescription, there were statistically significant increases in BMI slope (+0.91 kg/m2/year, P < .0001), albumin slope (+0.82 g/L/year, P < .0001), and phosphate slope (+0.02 mmol/L/year, P = .005), as well as a decline in NLR slope of −0.55/year ( P < .0001). There was no significant change in bicarbonate slope. Cluster analysis identified 5 distinct phenotypes. The cluster with the highest mean baseline NLR and lowest mean BMI demonstrated the greatest number of improvements in nutritional parameter slopes in the post-oral-nutritional-supplement period. Limitations: Possibility of residual confounding. Data on dietary intake, muscle mass, and nutritional scoring systems were not available in the registry. Conclusions: Among patients with CKD-ND prescribed oral nutritional supplements, there were improvements in nutrition/inflammation parameters over time following the first ONS prescription. The heterogeneity in response to ONS by cluster subgroup suggests an individualized approach to nutritional management may be beneficial.
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Affiliation(s)
- Michelle M. Y. Wong
- Department of Medicine, The University of British Columbia, Vancouver, Canada
- BC Renal, Vancouver, BC, Canada
| | | | - Dani Renouf
- St. Paul’s Hospital, Providence Health Care, Vancouver, BC, Canada
| | - Zainab Sheriff
- Division of Nephrology, The University of British Columbia, Vancouver, Canada
| | - Adeera Levin
- BC Renal, Vancouver, BC, Canada
- St. Paul’s Hospital, Providence Health Care, Vancouver, BC, Canada
- Division of Nephrology, The University of British Columbia, Vancouver, Canada
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Mah JY, Choy SW, Roberts MA, Desai AM, Corken M, Gwini SM, McMahon LP. Oral protein-based supplements versus placebo or no treatment for people with chronic kidney disease requiring dialysis. Cochrane Database Syst Rev 2020; 5:CD012616. [PMID: 32390133 PMCID: PMC7212094 DOI: 10.1002/14651858.cd012616.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Malnutrition is common in patients with chronic kidney disease (CKD) on dialysis. Oral protein-based nutritional supplements are often provided to patients whose oral intake is otherwise insufficient to meet their energy and protein needs. Evidence for the effectiveness of oral protein-based nutritional supplements in this population is limited. OBJECTIVES The aims of this review were to determine the benefits and harms of using oral protein-based nutritional supplements to improve the nutritional state of patients with CKD requiring dialysis. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 12 December 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials (RCTs) of patients with CKD requiring dialysis that compared oral protein-based nutritional supplements to no oral protein-based nutritional supplements or placebo. DATA COLLECTION AND ANALYSIS Two authors independently assessed studies for eligibility, risk of bias, and extracted data from individual studies. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference and 95% CI for continuous outcomes. MAIN RESULTS Twenty-two studies (1278 participants) were included in this review. All participants were adults on maintenance dialysis of whom 79% were on haemodialysis (HD) and 21% peritoneal dialysis. The follow-up period ranged from one to 12 months. The majority of studies were at unclear risk of selection, performance, and reporting bias. The detection bias was high for self-reported outcomes. Oral protein-based nutritional supplements probably lead to a higher mean change in serum albumin compared to the control group (16 studies, 790 participants: MD 0.19 g/dL, 95% CI 0.05 to 0.33; moderate certainty evidence), although there was considerable heterogeneity in the combined analysis (I2 = 84%). The increase was more evident in HD participants (10 studies, 526 participants: MD 0.28 g/dL, 95% CI 0.11 to 0.46; P = 0.001 for overall effect) and malnourished participants (8 studies, 405 participants: MD 0.31 g/dL, 95% CI 0.10 to 0.52, P = 0.003 for overall effect). Oral protein-based nutritional supplements also probably leads to a higher mean serum albumin at the end of the intervention (14 studies, 715 participants: MD 0.14 g/dL, 95% CI 0 to 0.27; moderate certainty evidence), however heterogeneity was again high (I2 = 80%). Again the increase was more evident in HD participants (9 studies, 498 participants: MD 0.21 g/dL, 95% CI 0.03 to 0.38; P = 0.02 for overall effect) and malnourished participants (7 studies, 377 participants: MD 0.25 g/dL, 95% CI 0.02 to 0.47; P = 0.03 for overall effect). Compared to placebo or no supplement, low certainty evidence showed oral protein-based nutritional supplements may result in a higher serum prealbumin (4 studies, 225 participants: MD 2.81 mg/dL, 95% CI 2.19 to 3.43), and mid-arm muscle circumference (4 studies, 216 participants: MD 1.33 cm, 95% CI 0.24 to 2.43) at the end of the intervention. Compared to placebo or no supplement, oral protein-based nutritional supplements may make little or no difference to weight (8 studies, 365 participants: MD 2.83 kg, 95% CI -0.43 to 6.09; low certainty evidence), body mass index (9 studies, 368 participants: MD -0.04 kg/m2, 95% CI -0.74 to 0.66; moderate certainty evidence) and lean mass (5 studies, 189 participants: MD 1.27 kg, 95% CI -1.61 to 4.51; low certainty evidence). Due to very low quality of evidence, it is uncertain whether oral protein-based nutritional supplements affect triceps skinfold thickness, mid-arm circumference, C-reactive protein, Interleukin 6, serum potassium, or serum phosphate. There may be little or no difference in the risk of developing gastrointestinal intolerance between participants who received oral protein-based nutritional supplements compared with placebo or no supplement (6 studies, 426 participants: RR 2.81, 95% CI 0.58 to 13.65, low certainty evidence). It was not possible to draw conclusions about cost or quality of life, and deaths were not reported as a study outcome in any of the included studies. AUTHORS' CONCLUSIONS Overall, it is likely that oral protein-based nutritional supplements increase both mean change in serum albumin and serum albumin at end of intervention and may improve serum prealbumin and mid-arm muscle circumference. The improvement in serum albumin was more evident in haemodialysis and malnourished participants. However, it remains uncertain whether these results translate to improvement in nutritional status and clinically relevant outcomes such as death. Large well-designed RCTs in this population are required.
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Affiliation(s)
- Jia Yee Mah
- Integrated Renal Service, Eastern Health, Box Hill, Australia
| | - Suet Wan Choy
- Integrated Renal Service, Eastern Health, Box Hill, Australia
| | - Matthew A Roberts
- Integrated Renal Service, Eastern Health, Box Hill, Australia
- Eastern Health Clinical School, Monash University, Box Hill, Australia
| | - Anne Marie Desai
- Department of Dietetics/Renal, Eastern Health, Box Hill, Australia
| | - Melissa Corken
- Department of Dietetics/Renal, Eastern Health, Box Hill, Australia
| | - Stella M Gwini
- Department of Epidemiology and Preventive Medicine, Monash University, Clayton, Australia
| | - Lawrence P McMahon
- Integrated Renal Service, Eastern Health, Box Hill, Australia
- Eastern Health Clinical School, Monash University, Box Hill, Australia
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van de Luijtgaarden MWM, Caskey FJ, Wanner C, Chesnaye NC, Postorino M, Janmaat CJ, Rao A, Torino C, Klinger M, Drechsler C, Heimburger O, Szymczak M, Evans M, Dekker FW, Jager KJ. Uraemic symptom burden and clinical condition in women and men of ≥65 years of age with advanced chronic kidney disease: results from the EQUAL study. Nephrol Dial Transplant 2020; 34:1189-1196. [PMID: 29905848 DOI: 10.1093/ndt/gfy155] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The epidemiology and prognosis of chronic kidney disease (CKD) differ by sex. We aimed to compare symptom prevalence and the clinical state in women and men of ≥65 years of age with advanced CKD receiving routine nephrology care. METHODS The European QUALity study on treatment in advanced chronic kidney disease (EQUAL) study follows patients from six European countries of ≥65 years of age years whose estimated glomerular filtration rate (eGFR) dropped to ≤20 mL/min/1.73 m2 for the first time during the last 6 months. The Dialysis Symptom Index was used to assess the prevalence and severity of 33 uraemic symptoms. Data on the clinical state at baseline were collected from medical records. Prevalence was standardized using the age distribution of women as the reference. RESULTS The results in women (n = 512) and men (n = 967) did not differ with age (77.0 versus 75.7 years) or eGFR (19.0 versus 18.5). The median number of symptoms was 14 [interquartile range (IQR) 9-19] in women, and 11 (IQR 7-16) in men. Women most frequently reported fatigue {39% [95% confidence interval (CI) 34-45]} and bone/joint pain [37% (95% CI 32-42)] as severe symptoms, whereas more men reported difficulty in becoming sexually aroused [32% (95% CI 28-35)] and a decreased interest in sex [31% (95% CI 28-35)]. Anaemia [73% (95% CI 69-77) versus 85% (95% CI 82-87)] was less common in women than in men, as were smoking history and cardiovascular comorbidity. However, a diagnosis of liver disease other than cirrhosis, psychiatric disease and mild malnutrition were more common among women. CONCLUSIONS Women in secondary care with an incident eGFR ≤20 mL/min/1.73 m2 reported a higher symptom burden, while their clinical state was considered similar or even more favourable as compared with men.
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Affiliation(s)
- Moniek W M van de Luijtgaarden
- ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Christoph Wanner
- Department of Medicine, Division of Nephrology, University Hospital of Würzburg, Würzburg, Germany
| | - Nicholas C Chesnaye
- ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, The Netherlands
| | - Maurizio Postorino
- Clinical Epidemiology and Pathophysiology of Renal Diseases and Hypertension, CNR-IFC, Reggio Calabria, Italy
| | - Cynthia J Janmaat
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Anirudh Rao
- Department of Nephrology and Transplantation, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Claudia Torino
- Clinical Epidemiology and Pathophysiology of Renal Diseases and Hypertension, CNR-IFC, Reggio Calabria, Italy
| | - Marian Klinger
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Christiane Drechsler
- Department of Medicine, Division of Nephrology, University Hospital of Würzburg, Würzburg, Germany
| | - Olof Heimburger
- Department of Clinical Sciences Intervention and Technology, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - Maciej Szymczak
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Marie Evans
- Department of Clinical Sciences Intervention and Technology, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Kitty J Jager
- ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, The Netherlands
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Wang AYM, Kalantar-Zadeh K, Fouque D, Wee PT, Kovesdy CP, Price SR, Kopple JD. Precision Medicine for Nutritional Management in End-Stage Kidney Disease and Transition to Dialysis. Semin Nephrol 2019; 38:383-396. [PMID: 30082058 DOI: 10.1016/j.semnephrol.2018.05.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Chronic kidney disease (CKD) is a global public health burden. Dialysis is not only costly but may not be readily available in developing countries. Even in highly developed nations, many patients may prefer to defer or avoid dialysis. Thus, alternative options to dialysis therapy or to complement dialysis are needed urgently and are important objectives in CKD management that could have huge clinical and economic implications globally. The role of nutritional therapy as a strategy to slow CKD progression and uremia was discussed as early as the late 19th and early 20th century, but was only seriously explored in the 1970s. There is a revival of interest recently owing to encouraging data as well as the increase of precision medicine with an emphasis on a personalized approach to CKD management. Although part of the explanation for the inconclusive data may relate to variations in study design and dietary prescription, diversity in genetic make-up, variations in the non-nutritional management of CKD, intra-individual variations in responses to dietary and nondietary treatment, psychosocial factors, and dietary compliance issues, these all may contribute to the heterogeneous data and responses. This brings in the evolving concept of precision medicine, in which disease management should be tailored and individualized according not only to clinical manifestations but also to the genetic make-up and biologic responses to therapy, which may vary depending on genetic composition. Precision nutrition management also should take into account patient demographics, social, psychological, education, and compliance factors, which all may influence the therapeutic needs and responses to the nutritional therapy prescribed. In this review, we provide a novel concept of precision medicine in nutritional management in end-stage kidney disease with a transition to dialysis and propose how this may be the way forward for nutritional therapy in the CKD population.
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Affiliation(s)
- Angela Yee-Moon Wang
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China.
| | | | - Denis Fouque
- Department of Nephrology, Centre Hospitalier Lyon Sud, Université de Lyon, Pierre Bénite, Lyon, France
| | - Pieter T Wee
- Department of Nephrology, VU University Medical Center and Institute for Cardiovascular Research of the Vrije Universiteit, Amsterdam, The Netherlands
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN
| | - S Russ Price
- Department of Internal Medicine, Department of Biochemistry and Molecular Biology, Brody School of Medicine at East Carolina University, Greenville, NC
| | - Joel D Kopple
- Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA and the UCLA Fielding School of Public Health, Los Angeles, CA
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Carrero JJ, Thomas F, Nagy K, Arogundade F, Avesani CM, Chan M, Chmielewski M, Cordeiro AC, Espinosa-Cuevas A, Fiaccadori E, Guebre-Egziabher F, Hand RK, Hung AM, Ikizler TA, Johansson LR, Kalantar-Zadeh K, Karupaiah T, Lindholm B, Marckmann P, Mafra D, Parekh RS, Park J, Russo S, Saxena A, Sezer S, Teta D, Ter Wee PM, Verseput C, Wang AY, Xu H, Lu Y, Molnar MZ, Kovesdy CP. Global Prevalence of Protein-Energy Wasting in Kidney Disease: A Meta-analysis of Contemporary Observational Studies From the International Society of Renal Nutrition and Metabolism. J Ren Nutr 2018; 28:380-392. [DOI: 10.1053/j.jrn.2018.08.006] [Citation(s) in RCA: 135] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 08/14/2018] [Accepted: 08/14/2018] [Indexed: 01/09/2023] Open
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8
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Windahl K, Faxén Irving G, Almquist T, Lidén MK, van de Luijtgaarden M, Chesnaye NC, Voskamp P, Stenvinkel P, Klinger M, Szymczak M, Torino C, Postorini M, Drechsler C, Caskey FJ, Wanner C, Dekker FW, Jager KJ, Evans M. Prevalence and Risk of Protein-Energy Wasting Assessed by Subjective Global Assessment in Older Adults With Advanced Chronic Kidney Disease: Results From the EQUAL Study. J Ren Nutr 2018; 28:165-174. [PMID: 29459026 DOI: 10.1053/j.jrn.2017.11.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 11/15/2017] [Accepted: 11/18/2017] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Prevalence and risk factors for protein-energy wasting (PEW) are poorly studied in the nondialysis, older population with advanced chronic kidney disease (CKD). Our aim was to evaluate the prevalence of PEW in advanced stage CKD patients aged greater than 65 years. Furthermore, we aimed to describe risk factors for PEW in the overall study population and among obese individuals. DESIGN Prospective observational cohort study. METHODS The EQUAL study, a European Quality Study on treatment in advanced chronic kidney disease, is a multicenter prospective observational cohort study in six European countries. We included patients aged ≥65 years with incident glomerular filtration rate <20mL/min/1.73m2 not on dialysis attending nephrology care. PEW was assessed by 7-point Subjective Global Assessment (7-p SGA). RESULTS In general, the study cohort (n = 1,334) was overweight (mean body mass index [BMI] 28.4 kg/m2). The majority of the patients had a normal nutritional status (SGA 6-7), 26% had moderate PEW (SGA 3-5), and less than 1% had severe PEW (SGA 1-2). Muscle wasting and loss of fat tissue were the most frequent alterations according to the SGA subscales, especially in those aged >80 years. The prevalence of PEW was higher among women, increased with age, and was higher in those with depression/dementia. PEW was the most common in those with underweight (BMI <22 kg/m2), 55% or normal weight (BMI 22-25 kg/m2), 40%. In obese individuals (BMI >30 kg/m2), 25% were diagnosed with protein wasting. Risk factors for SGA ≤5 in obese people were similar to those for the overall study population. CONCLUSION This European multicenter study shows that the prevalence of PEW is high in patients with advanced CKD aged >65 years. The risk of PEW increases substantially with age and is commonly characterized by muscle wasting. Our study suggests that focus on nutrition should start early in the follow-up of older adults with CKD.
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Affiliation(s)
- Karin Windahl
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Division of Clinical Nutrition and Dietetics, Department of Orthopaedics, Danderyds Hospital, Stockholm, Sweden
| | - Gerd Faxén Irving
- Division of Clinical Geriatrics, Department of NVS, Karolinska Institutet, Stockholm, Sweden; Division of Clinical Nutrition, Karolinska University Hospital, Stockholm, Sweden
| | - Tora Almquist
- Division of Nephrology, Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden
| | - Maarit Korkeila Lidén
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Moniek van de Luijtgaarden
- ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, The Netherlands
| | - Nicholas C Chesnaye
- ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, The Netherlands
| | - Pauline Voskamp
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leidenthe, The Netherlands
| | - Peter Stenvinkel
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Marian Klinger
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Poland
| | - Maciej Szymczak
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Poland
| | - Claudia Torino
- Nephrology, Dialysis and Transplantation Unit and CNR-IFC Research Unit of Reggio Calabria, Reggio Calabria, Italy
| | - Maurizio Postorini
- Nephrology, Dialysis and Transplantation Unit and CNR-IFC Research Unit of Reggio Calabria, Reggio Calabria, Italy
| | - Christiane Drechsler
- Department of Internal Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Fergus J Caskey
- United Kingdom Renal Registry (UKRR), Southmead Hospital, Bristol, United Kingdom; Division of Population Health Sciences, Department of Medical School, University of Bristol, Bristol, United Kingdom
| | - Christoph Wanner
- Department of Internal Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leidenthe, The Netherlands
| | - Kitty J Jager
- ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, The Netherlands
| | - Marie Evans
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.
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Chao CT, Tang CH, Cheng RWY, Wang MYH, Hung KY. Protein-energy wasting significantly increases healthcare utilization and costs among patients with chronic kidney disease: a propensity-score matched cohort study. Curr Med Res Opin 2017; 33:1705-1713. [PMID: 28699849 DOI: 10.1080/03007995.2017.1354823] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Disease-related malnutrition is highly prevalent, and has prognostic implications for patients with chronic kidney disease (CKD); however, few studies have investigated the impact of malnutrition, or protein-energy wasting (PEW), on healthcare utilization and medical expenditure among CKD patients. METHODS Using claim data from the National Health Insurance in Taiwan, this study identified patients with CKD between 2009-2013 and categorized them into those with mild, moderate, or severe CKD. Cases with PEW after CKD was diagnosed were propensity-score matched with controls in a 1:4 ratio. Healthcare resource utilization metrics were compared, including outpatient and emergency department visits, frequency and duration of hospitalization, and the cumulative costs associated with different CKD severity. RESULTS From among 347,501 CKD patients, eligible cohorts of 66,872 with mild CKD (49.2%), 27,122 with moderate CKD (19.9%), and 42,013 with severe CKD (30.9%) were selected. Malnourished CKD patients had significantly higher rates of hospitalization (p < .001 for all severities) and re-admission (p = .015 for mild CKD, p = .002 for severe CKD) than non-malnourished controls. Cumulative medical costs for outpatient and emergency visits, and hospitalization, were significantly higher among all malnourished CKD patients than non-malnourished ones (p < .001); total medical costs were also higher among malnourished patients with mild (62.9%), moderate (59.6%), or severe (43.6%) CKD compared to non-malnourished patients (p < .001). CONCLUSIONS In a nationally-representative cohort, CKD patients with PEW had significantly more healthcare resource utilization and higher aggregate medical costs than those without, across the spectrum of CKD: preventing PEW in CKD patients should receive high priority if we would like to reduce medical costs.
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Affiliation(s)
- Chia-Ter Chao
- a Department of Medicine , National Taiwan University Hospital Jin-Shan branch , Wuhu Village, Jinshan Dist. , New Taipei City , Taiwan
- b Department of Internal Medicine , National Taiwan University Hospital , Taipei , Taiwan
| | - Chao-Hsiun Tang
- c School of Health Care Administration, College of Management , Taipei Medical University , Taipei , Taiwan
| | | | | | - Kuan-Yu Hung
- b Department of Internal Medicine , National Taiwan University Hospital , Taipei , Taiwan
- e Department of Internal Medicine , National Taiwan University Hospital Hsin-Chu branch , Hsinchu City , Taiwan
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10
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Pérez-Torres A, González Garcia ME, San José-Valiente B, Bajo Rubio MA, Celadilla Diez O, López-Sobaler AM, Selgas R. Protein-energy wasting syndrome in advanced chronic kidney disease: prevalence and specific clinical characteristics. Nefrologia 2017; 38:141-151. [PMID: 28755901 DOI: 10.1016/j.nefro.2017.06.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Revised: 05/19/2017] [Accepted: 06/06/2017] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Protein-energy wasting (PEW) is associated with increased mortality and differs depending on the chronic kidney disease (CKD) stage and the dialysis technique. The prevalence in non-dialysis patients is understudied and ranges from 0 to 40.8%. OBJECTIVE To evaluate the nutritional status of a group of Spanish advanced CKD patients by PEW criteria and subjective global assessment (SGA). PATIENTS AND METHODS Cross-sectional study of 186 patients (101 men) with a mean age of 66.1±16 years. The nutritional assessment consisted of: SGA, PEW criteria, 3-day dietary records, anthropometric parameters and bioelectrical impedance vector analysis. RESULTS The prevalence of PEW was 30.1%, with significant differences between men and women (22.8 vs. 33.8%, p < 0.005), while 27.9% of SGA values were within the range of malnutrition. No differences were found between the 2methods. Men had higher proteinuria, percentage of muscle mass and nutrient intake. Women had higher levels of total cholesterol, HDL and a higher body fat percentage. The characteristics of patients with PEW were low albumin levels and a low total lymphocyte count, high proteinuria, low fat and muscle mass and a high Na/K ratio. The multivariate analysis found PEW to be associated with: proteinuria (OR: 1.257; 95% CI: 1.084-1.457, p=0.002), percentage of fat intake (OR: 0.903; 95% CI: 0.893-0.983, p=0.008), total lymphocyte count (OR: 0.999; 95% CI: 0.998-0.999, p=0.001) and cell mass index (OR: 0.995; 95% CI: 0.992-0.998). CONCLUSION Malnutrition was identified in Spanish advanced CKD patients measured by different tools. We consider it appropriate to adapt new diagnostic elements to PEW criteria.
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Affiliation(s)
| | | | | | | | - Olga Celadilla Diez
- Servicio de Nefrología, Hospital Universitario La Paz. IdiPAZ, Madrid, España
| | - Ana M López-Sobaler
- Departamento de Nutrición y Bromatología I, Facultad de Farmacia, Universidad Complutense de Madrid, Madrid, España
| | - Rafael Selgas
- Servicio de Nefrología, Hospital Universitario La Paz. IdiPAZ, Madrid, España
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11
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Pérez-Torres A, González Garcia E, Garcia-Llana H, Del Peso G, López-Sobaler AM, Selgas R. Improvement in Nutritional Status in Patients With Chronic Kidney Disease-4 by a Nutrition Education Program With No Impact on Renal Function and Determined by Male Sex. J Ren Nutr 2017; 27:303-310. [PMID: 28434761 DOI: 10.1053/j.jrn.2017.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Revised: 02/02/2017] [Accepted: 02/04/2017] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE Protein-energy wasting (PEW) is associated with increased morbidity and mortality and a rapid deterioration of kidney function in patients with chronic kidney disease (CKD). However, there is little information regarding the effect of nutrition intervention. The aims of this study were to evaluate the efficacy and safety of a nutrition education program (NEP) in patients with nondialysis dependent CKD (NDD-CKD), based on the diagnostic criteria for PEW proposed by the International Society of Renal Nutrition and Metabolism. The design of the study was a 6-month longitudinal, prospective, and interventional study. The study was conducted from March 2008 to September 2011 in the Nephrology Department of La Paz University Hospital in Madrid, Spain. SUBJECTS A total of 160 patients with NDD-CKD started the NEP, and 128 finished it. INTERVENTION The 6-month NEP consisted of designing an individualized diet plan based on the patient's initial nutritional status, and 4 nutrition education sessions. MAIN OUTCOME MEASURES Changes in nutritional status (PEW) and biochemical, anthropometric and body composition parameters. RESULTS After 6 months of intervention, potassium and inflammation levels decreased, and an improved lipid profile was found. Body mass index lowered, with increased muscle mass and a stable fat mass. Men showed increased levels of albumin and prealbumin, and women showed decreased proteinuria levels. The prevalence of PEW decreased globally (27.3%-10.9%; P = .000), but differently in men (29.5%-6.5%; P = .000) and in women (25.4%-14.9%; P = .070), 3 of the women having worsened. Kidney function was preserved, despite increased protein intake. CONCLUSION The NEP in NDD-CKD generally improved nutritional status as measured by PEW parameters, but individual poorer results indicated the need to pay special attention to female sex and low body mass index at the start of the program.
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Affiliation(s)
| | | | | | - Gloria Del Peso
- Nephrology Department, La Paz University Hospital, Madrid, Spain
| | | | - Rafael Selgas
- Nephrology Department, La Paz University Hospital, Madrid, Spain
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12
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Mah JY, Choy SW, Roberts MA, Desai AM, Corken M, Gwini SM, McMahon LP. Oral protein-based supplements for people with chronic kidney disease requiring dialysis. Hippokratia 2017. [DOI: 10.1002/14651858.cd012616] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Jia Yee Mah
- Eastern Health; Integrated Renal Service; 8 Arnold Street Box Hill VIC Australia 3128
| | - Suet Wan Choy
- Eastern Health; Integrated Renal Service; 8 Arnold Street Box Hill VIC Australia 3128
| | - Matthew A Roberts
- Monash University; Eastern Health Clinical School; Box Hill VIC Australia 3128
| | - Anne Marie Desai
- Eastern Health; Department Dietetics/Renal; 8 Arnold Street Box Hill VIC Australia 3128
| | - Melissa Corken
- Eastern Health; Department of Dietetics; 8 Arnold Street Box Hill VIC Australia 3128
| | - Stella M Gwini
- Monash University; Department Epidemiology and Preventive Medicine; The Alfred Centre, 99 Commercial Road Melbourne VIC Australia 3004
| | - Lawrence P McMahon
- Eastern Health; Integrated Renal Service; 8 Arnold Street Box Hill VIC Australia 3128
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13
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Chan M. Protein-controlled versus restricted protein versus low protein diets in managing patients with non-dialysis chronic kidney disease: a single centre experience in Australia. BMC Nephrol 2016; 17:129. [PMID: 27624699 PMCID: PMC5022230 DOI: 10.1186/s12882-016-0341-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 08/29/2016] [Indexed: 01/04/2023] Open
Abstract
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.
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Affiliation(s)
- Maria Chan
- Department of Nutrition and Dietetics, The St. George Hospital, Gray Street, Kogarah, NSW, 2217, Australia. .,Department of Renal Medicine The St. George Hospital, Kogarah, NSW, 2217, Australia. .,Department of Nutrition and Dietetics, School of Medicine and Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, NSW, 2522, Australia. .,St. George Clinical School, School of Medicine, The University of New South Wales, Sydney, NSW, 2217, Australia.
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