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

Dietary counseling, meal patterns, and diet quality in patients with type 2 diabetes mellitus with/without chronic kidney disease

BACKGROUND

Aim to this study is to investigate the association of Dietary Counseling, Meal Patterns, and Diet Quality (DietQ) in Patients with Type 2 Diabetes Mellitus (T2DM) with/without chronic kidney disease (CKD) in primary healthcare.

METHODS

Cross-sectional study acquired data on dietary counseling and meal patterns by direct interview with a food-frequency questionnaire and one 24-h food-recall. The Healthy Eating Index (HEI) was used to classify DietQ ["good" DietQ (GDietQ, score ≥ 80) and "poor" DietQ (PDietQ, score < 80)].

PARTICIPANTS/SETTING

This study included 705 patients with T2DM: 306 with normal kidney function; 236 with early nephropathy, and 163 with overt nephropathy (ON).

STATISTICAL ANALYSES PERFORMED

Multivariate linear-regression models for predicting HEI and χ2 tests for qualitative variables and one-way ANOVA for quantitative variables were employed. Mann-Whitney U and independent Student t were performed for comparisons between GDietQ and PDietQ.

RESULTS

Only 18 % of the population was classified as GDietQ. Patients with ON and PDietQ vs. with GDietQ received significantly less dietary counseling from any health professional in general (45 % vs 72 %, respectively), or from any nutrition professional (36 % vs. 61 %, respectively). A better HEI was significantly predicted (F = 42.01; p = 0.0001) by lower HbA1C (β -0.53, p = 0.0007) and better diet diversity (β 8.09, p = 0.0001).

CONCLUSIONS

Patients with more advanced stages of CKD had less nutritional counseling and worse dietary patterns, as well as more frequent PDietQ. Our findings reinforce the need for dietitians and nutritionists in primary healthcare to provide timely nutritional counseling.

Seeing the Whole Picture: Evaluating the Contribution of Whole Grains to Phosphorus Exposure in People With Kidney Failure Undergoing Dialysis Treatment

Excessive dietary phosphorus is a concern among patients with kidney failure undergoing dialysis treatment because it may contribute to hyperparathyroidism and hyperphosphatemia. A long-standing but untested component of the low-phosphorus diet is the promotion of refined grains over whole grains. This paper reviews the scientific premise for restricting whole grains in the dialysis population and estimates phosphorus exposure from grain products based on three grain intake patterns modeled from reported intakes in the general US population, adjusting for the presence of phosphorus additives and phosphorus bioavailability: (1) standard grain intake, (2) 100% refined grain intake, and (3) mixed (50/50 whole and refined grain) intake. Although estimated phosphorus exposure from grains was higher with the mixed grain pattern (231 mg/day) compared to the 100% refined grain pattern (127 mg/day), the amount of additional phosphorus from grains was relatively low. Given the lack of strong evidence for restricting whole grains in people with CKD, as well as the potential health benefits of whole grains, clinical trials are warranted to address the efficacy and health impact of this practice.

Feeling gutted in chronic kidney disease (CKD): Gastrointestinal disorders and therapies to improve gastrointestinal health in individuals CKD, including those undergoing dialysis

Chronic kidney disease (CKD) affects 9.1% of the population worldwide. CKD may lead to structural and functional gastrointestinal alterations, including impairment in the intestinal barrier, digestion and absorption of nutrients, motility, and changes to the gut microbiome. These changes can lead to increased gastrointestinal symptoms in people with CKD, even in early grades of kidney dysfunction. Gastrointestinal symptoms have been associated with lower quality of life and reduced nutritional status. Therefore, there has been considerable interest in improving gastrointestinal health in this clinical population. Gastrointestinal health can be influenced by lifestyle and medications, particularly in advanced grades of kidney dysfunction. Therapies focused on gastrointestinal health have been studied, including the use of probiotics, prebiotics, and synbiotics, yielding limited and conflicting results. This review summarizes the alterations in the gastrointestinal tract structure and function and provides an overview of potential nutritional interventions that kidney disease professionals can provide to improve gastrointestinal health in individuals with CKD.

Dieta de la Milpa: A Culturally-Concordant Plant-Based Dietary Pattern for Hispanic/Latine People with Chronic Kidney Disease

Chronic kidney disease (CKD) disproportionately affects minorities in the United States, including the Hispanic/Latine population, and is a public health concern in Latin American countries. An emphasis on healthy dietary patterns, including the Mediterranean and the Dietary Approaches to Stop Hypertension (DASH) diets, has been suggested as they are associated with a lower incidence of CKD, slower CKD progression, and lower mortality in kidney failure. However, their applicability may be limited in people from Latin America. The Dieta de la Milpa (Diet of the Cornfield) was recently described as the dietary pattern of choice for people from Mesoamerica (Central Mexico and Central America). This dietary pattern highlights the intake of four plant-based staple foods from this geographical region, corn/maize, common beans, pumpkins/squashes, and chilies, complemented with seasonal and local intake of plant-based foods and a lower intake of animal-based foods, collectively classified into ten food groups. Limited preclinical and clinical studies suggest several health benefits, including cardiometabolic health, but there is currently no data concerning CKD. In this narrative review, we describe and highlight the potential benefits of the Dieta de la Milpa in CKD, including acid-base balance, protein source, potassium and phosphorus management, impact on the gut microbiota, inflammation, and cultural appropriateness. Despite these potential benefits, this dietary pattern has not been tested in people with CKD. Therefore, we suggest key research questions targeting measurement of adherence, feasibility, and effectiveness of the Dieta de la Milpa in people with CKD.

Adaptive Nutrition Intervention Stabilizes Serum Phosphorus Levels in Hemodialysis Patients: A Multicenter Decentralized Clinical Trial Using Real-World Data

OBJECTIVE

This study aims to evaluate the effect of an adaptive nutritional and educational intervention for patients on hemodialysis (HD) in a routine care setting, using real-world data from electronic health records.

METHODS

Decentralized clinical trial of seven HD facilities recruited patients who have been on HD for over 3 months (N = 153) for an 8-week adaptive intervention protocol. Patients were divided into four groups: (1) control (2) education intervention (3) meal intervention (4) education and meal interventions. Educational contents were digitally delivered via mobile phones and premade meals tailored on laboratory findings were home-delivered. Changes in serum electrolytes and malnutrition inflammation score (MIS) were analyzed.

RESULTS

Meal intervention statistically significantly stabilized serum phosphorus level (β = -0.81 mg/dL, 95% confidence interval = [-1.40, -0.22]) at week 8, with increased likelihood of being within target serum value range (odds ratio = 1.21, 95% confidence interval = [1.04, 1.40]). Meal group showed better nutritional status (MIS = 3.65) than the education group (MIS = 5.10) at week 8 (adjusted p < .05). No significant changes were observed in serum potassium level, depression, and self-efficacy.

CONCLUSION

It was demonstrated that an adaptive meal intervention in a real-world care setting may benefit serum phosphorus control and nutritional status of patients on HD, without negative effect on depression levels or self-efficacy. More work is needed to develop an effective educational intervention.

Home-Delivered Medically Tailored Meal Engagement Among Hemodialysis Patients and Providers

OBJECTIVE

Hemodialysis patients face one of the most difficult diets among clinical patient populations. Furthermore, dialysis dietary adherence is generally reported as low with providers generally lacking the time and resources to implement effective behavior change. The purpose of this study was to elucidate measures of patient and provider engagement with home-delivered medically tailored meals (MTMs).

METHODS

We surveyed patients and staff at dialysis centers within the Denver metropolitan area. Surveys focused on 1) patient dietary intake, 2) awareness, support, and utilization of meal programs, and 3) nutritional challenges and barriers (including food security).

RESULTS

We surveyed 118 patients (mean age 61.0 ± 14.2 year, 58.5% male, and dialysis vintage of 4.6 ± 4.9 years) and 26 staff across the included dialysis facilities. Patients were 20.3% White/Non-Hispanic, 35.6% Hispanic/Latin, and 31.4% Black/African American. Most patients reported eating 2 meals per day (N = 53, 44.9%) and 52.2% reported difficulty with following a kidney diet. The most cited reasons for not following the diet were behavioral or knowledge (38.5%), taste (26.3%), time/convenience (26.9%) and food autonomy (16.9%). Sixty participants (52.2%) reported living in a food desert and 26.3% reported food insecurity. Seventy-one patients (61.2%) were aware of MTMs but only 40.5% had been referred. Most (76.9%) dialysis providers were aware of MTMs but only 15 (57.7%) had actually referred patients to such a service. Black individuals were less likely to be referred for MTMs than White or Hispanics/Latin (29.7% vs 48.1% White and 45.0% Hispanic/Latin) individuals.

CONCLUSION

Medically tailored meals (MTMs) represent a potential method to alleviate or bypass some of the many barriers expressed by patients. Our findings reveal a critical need for education around MTMs for both patients and providers. Medically tailored meals (MTMs) could potentially demonstrate health kidney dietary patterns that might translate to altered dietary preferences or toward future behavior change.

Association between the dietary inflammatory index and markers of endothelial and systemic inflammation in hemodialysis patients

Objectives

The current survey aimed to investigate the link between energy-adjusted dietary inflammatory index (E-DII) and risk factors for CVD including markers of endothelial and systemic inflammation in Iranian hemodialysis patients.

Methods

Patients on hemodialysis for at least 6 months prior to enrollment were considered eligible in this cross-sectional study. The usual dietary intakes of the hemodialysis individuals were examined through 4 non-consecutive days including 2 dialysis days and 2 non-dialysis days using a 24-h recall approach to calculate E-DII. Multiple linear regression analysis was utilized to investigate the link between E-DII and selected biomarkers of inflammation and oxidative stress including high-sensitive C reactive protein (hs-CRP), serum intercellular adhesion molecule (sICAM), serum vascular cell adhesion molecule (sVCAM), malondialdehyde, and nitric oxide (NO), sE-selectin, and endothelin-1, and beta (β) and 95% confidence interval (CI) was reported. Value of p < 0.05 was considered statistically significant.

Results

Overall, 291 hemodialysis patients make up our study population. In the crude model, the E-DII score was positively associated with a higher sVCAM-1 (β = 177.39; 95% CI: 60.51, 294.26; ptrend = 0.003). Further adjustment for potential confounders attenuated the findings in a way that an increase of 128.72 in the sVCAM-1 was observed when the E-DII score increased from -2.68 to -1.14 (95% CI: 13.50, 243.94). After controlling for potential confounders, E-DII was associated with sE-selectin in hemodialysis patients in the highest category of E-DII as compared to the lowest category (β = 4.11; 95% CI: 0.22, 8.00; ptrend = 0.039).

Conclusion

The present findings suggest that adherence to a pro-inflammatory diet among hemodialysis patients is associated with a higher inflammatory status as evidenced by sVCAM-1 and sE-selectin; however, bidirectionality may exist and the role of residual confounders should be taken into account. Therefore, more longitudinal investigations are needed to elucidate the role of diet on the inflammatory status of hemodialysis patients.

The Lived Self-Care Experiences of Patients Undergoing Long-Term Haemodialysis: A Phenomenological Study

The study aims to understand the lived self-care experiences of patients who have undergone long-term haemodialysis. The study adopts a qualitative phenomenological design. Data were collected for six months, from 1 July to 31 December 2020. Out of 90 outpatients in a haemodialysis clinic at a university hospital in Seoul, Korea, 11 patients who had received haemodialysis for more than 10 years were purposefully selected, and 9 of them took part in in-depth interviews. The main research question was, 'What was the experience of surviving long-term haemodialysis?' The study revealed four main themes surrounding the topic of self-care: (A) the desire to keep living despite challenges, (B) creating one's own dietary principles, (C) moving one's body with the remaining strength, and (D) moving toward independence. In the long-term self-care of haemodialysis patients, they shared personal observations on their disease and treatment process and their struggles to try to manage their own physical and emotional self-care. By exploring the experience of long-term haemodialysis, it is possible to gain a deeper understanding of their perceptions, emotions, and motivations. With this information, healthcare professionals can develop interventions and support strategies that are tailored to the specific needs of haemodialysis patients.

Adherence to Mediterranean Diet in Individuals on Renal Replacement Therapy

Patients on renal replacement therapy are typically subject to several dietary restrictions; however, this approach has been questioned in recent years, with some suggesting that the Mediterranean diet might be beneficial. Data on the adherence to this diet and factors that influence it are scarce. We conducted a web survey among individuals on renal replacement therapy (dialysis or kidney transplant, KT) using the MEDI-LITE questionnaire to assess adherence to the Mediterranean diet and dietary habits in this population. Adherence to the Mediterranean diet was generally low, and significantly lower among participants on dialysis versus KT recipients (19.4% vs. 44.7%, p < 0.001). Being on dialysis, adopting fluid restrictions, and having a basic level of education were predictors of low adherence to the Mediterranean diet. Consumption of foods typically included in the Mediterranean diet, including fruit, legumes, fish, and vegetables, was generally low, particularly among those on dialysis. There is a need for strategies to improve both the adherence to and the quality of the diet among individuals on renal replacement therapy. This should be a shared responsibility between registered dietitians, physicians, and the patient.

Nutritional and Hydration Status and Adherence to Dietary Recommendations in Dalmatian Dialysis Patients

Protein-energy wasting (PEW) is considered one of the major complications of chronic kidney disease (CKD), particularly in dialysis patients. Insufficient energy and protein intake, together with clinical complications, may contribute to the onset and severity of PEW. Therefore, the aim of the study was to analyze the differences in nutritional and hydration status and dietary intake among Dalmatian dialysis patients. Fifty-five hemodialysis (HD) and twenty peritoneal dialysis (PD) participants were included. For each study participant, data about body composition, anthropometric, laboratory, and clinical parameters were obtained. The Malnutrition Inflammation Score (MIS) and two separate 24-h dietary recalls were used to assess nutritional status and dietary intake. The Nutrient Adequacy Ratio (NAR) and Mean Adequacy Ratio (MAR) were calculated to compare actual dietary intake with recommended intake. Additionally, the estimated 10-year survival was calculated using the Charlson Comorbidity Index. The prevalence of malnutrition according to MIS was 47.3% in HD and 45% in PD participants. Significant differences in fat tissue parameters were found between HD and PD participants, whereas significant differences in hydration status and muscle mass parameters were not found. A significant difference in NAR between HD and PD participants was noticed for potassium and phosphorus intake, but not for MAR. MIS correlated negatively with anthropometric parameters, fat mass, visceral fat level and trunk fat mass, and iron and uric acid in HD participants, whereas no significant correlations were found in PD participants. The estimated 10-year survival correlated with several parameters of nutritional status in HD and PD participants, as well as nutrient intake in HD participants. These results indicate a high prevalence of malnutrition and inadequate dietary intake in the Dalmatian dialysis population which, furthermore, highlights the urgent need for individualized and structural nutritional support.

Relación entre calidad de vida, adherencia al tratamiento y nivel de conocimiento del paciente en hemodiálisis

Objetivo: Analizar la calidad de vida relacionada con la salud de los pacientes en tratamiento con hemodiálisis y su relación con su adherencia al tratamiento, comorbilidad y aspectos prácticos de autocuidado.Material y Método: Se ha llevado a cabo un estudio descriptivo, transversal, realizado en el Complexo Hospitalario de Ourense (España). Se incluyeron 51 pacientes en programa de hemodiálisis, con una edad media 64,96±13,03 años, y un tiempo en diálisis fue de 4,32±5,32 años. El 62,75% fueron hombres. Se analizó calidad de vida relacionada con la salud, comorbilidad, adherencia al tratamiento, nivel de conocimientos prácticos, además de variables sociodemográficas. Como instrumentos de medida: Índice comorbilidad de Charlson modificado, Test de Hermes, Kidney Disease Quality of Life-Short Form (KDQOL-SFTM). Se evaluaron conocimientos de autocuidado sobre cuidados generales, acceso vascular y dietéticos.Resultados: El índice de Comorbilidad medio fue de 4,42±2,83 puntos, y la adherencia al tratamiento, mediante el Test de Hermes de 2,78±0,84 puntos. En el análisis de regresión lineal, según modelo del componente físico, los valores del coeficiente Beta (β) asociado al sexo fueron β=0,304 (p=0,031) y a la comorbilidad de β=-0,436 (p=0,003). En el componente mental, coeficiente Beta (β) asociado al sexo β=0,330 (p=0,035) y la adherencia al tratamiento de β=0,311 (p=0,048) respectivamente.Conclusiones: El bajo nivel de conocimientos no se asocia a menor calidad de vida en la muestra estudiada. Los pacientes cumplidores obtienen mejores resultados en el componente mental estandarizado. A mayor comorbilidad menor calidad de vida.

A Comparison of Dietary Intake Between Individuals Undergoing Maintenance Hemodialysis in the United Kingdom and China

OBJECTIVE

Protein-energy wasting is highly prevalent in people with end-stage kidney disease receiving regular hemodialysis. Currently, it is unclear what the optimal nutritional recommendations are, which is further complicated by differences in dietary patterns between countries. The aim of the study was to understand and compare dietary intake between individuals receiving hemodialysis in Leicester, UK and Nantong, China.

METHODS

The study assessed 40 UK and 44 Chinese participants' dietary intake over a period of 14 days using 24-hour diet recall interviews. Nutritional blood parameters were obtained from medical records. Food consumed by participants in the UK and China was analyzed using the Nutritics and Nutrition calculator to quantify nutritional intake.

RESULTS

Energy and protein intake were comparable between UK and Chinese participants, but with both below the recommended daily intake. Potassium intake was higher in UK participants compared to Chinese participants (2,115 [888] versus 1,159 [861] mg/d; P < .001), as was calcium (618 [257] versus 360 [312] mg/d; P < .001) and phosphate intake (927 [485] versus 697 [434] mg/d; P = .007). Vitamin C intake was lower in UK participants compared to their Chinese counterparts (39 [51] versus 64 [42] mg/d; P = .024). Data are reported here as median (interquartile range).

CONCLUSION

Both UK and Chinese hemodialysis participants have insufficient protein and energy in their diet. New strategies are required to increase protein and energy intakes. All participants had inadequate daily intake of vitamins C and D; there may well be a role in the oral supplementation of these vitamins, and further studies are urgently needed.

Mediterranean Diet Adherence and Nutritional Status in Dalmatian Diabetic Hypertensive Patients Regarding Presence of Chronic Kidney Disease—Is There Any Difference?

In recent years, the Mediterranean diet has emerged as one of the dietary patterns that could have positive effects on overall health as well in the treatment of non-communicable chronic diseases. The aim of this cross-sectional study was to determine differences in adherence to the Mediterranean diet (MeDi) and nutritional status in patients with type 2 diabetes mellitus (T2DM) and arterial hypertension (AH) regarding the presence of chronic kidney disease (CKD). Two hundred and forty-eight Dalmatian diabetic hypertensive patients (DDHP) were included, and 164 (66.1%) of them had CKD. Data about anthropometric parameters, clinical and laboratory parameters, as well as lifestyle questionnaire and Mediterranean Diet Serving Score (MDSS) were collected for each study participant. Furthermore, body composition was assessed using MC-780 Multi Frequency Segmental Body Mass Analyzer (Tanita). Body mass index (BMI) as well as waist-to-hip ratio (WHR) and waist-to-height ratio (WHtR) were calculated. Results showed that only 8.9% of DDHP were adherent to the MeDi without significant differences regarding the presence of CKD. Therefore, only 9.1% of participants with CKD were adherent to the MeDi. Dietary recommendations were received by 52.8% of DDHP and 49.4% with CKD, while only 12.8% of those with CKD were adherent to the given recommendations. The results showed that 88.3% of DDHP and 87.8% of the DDHP with CKD were overweight or obese. Statically significant lower frequency of nut intake suggested by the MeDi was found in those participants with CKD (p = 0.02). Therefore, the significant associations between adherence to each MeDi component as well as MDSS score with the development of CKD among all study subjects were not found. In conclusion, the results showed a low level of nutritional care in our region and low adherence to MeDi among DDHP. According to the results, there is an urgent need to improve nutritional care in our region, with a special focus on the MeDi for this especially vulnerable population of patients.

OUP accepted manuscript

Patients on chronic hemodialysis are counseled to reduce dietary sodium intake to limit their thirst and consequent interdialytic weight gain (IDWG), chronic volume overload and hypertension. Low-sodium dietary trials in hemodialysis are sparse and mostly indicate that dietary education and behavioral counseling are ineffective in reducing sodium intake and IDWG. Additional nutritional restrictions and numerous barriers further complicate dietary adherence. A low-sodium diet may also reduce tissue sodium, which is positively associated with hypertension and left ventricular hypertrophy. A potential alternative or complementary approach to dietary counseling is home delivery of low-sodium meals. Low-sodium meal delivery has demonstrated benefits in patients with hypertension and congestive heart failure but has not been explored or implemented in patients undergoing hemodialysis. The objective of this review is to summarize current strategies to improve volume overload and provide a rationale for low-sodium meal delivery as a novel method to reduce volume-dependent hypertension and tissue sodium accumulation while improving quality of life and other clinical outcomes in patients undergoing hemodialysis.

Perspective: Plant-based Whole-Grain Foods for Chronic Kidney Disease: The Phytate-Phosphorus Conundrum

Restriction of dietary phosphorus intake is an important component of good clinical practice in kidney failure patients, particularly after dialysis initiation. Greater consumption of predominantly plant-based diets, including phytate-rich foods, is increasingly recommended for health maintenance/disease prevention in this population, with the implicit assumption that phytate-phosphorus in whole-grain cereals, legumes, pulses, and nuts is poorly absorbed. Review of human interventions with diets high in phytate-phosphorus indeed suggests an absorption of at least 50%, still less than animal protein-bound phosphorus, but higher than the generally believed 10-30%. Factors largely ignored up to now, but of potential influence on phytate-phosphorus bioavailability, include effect of food processing in releasing phosphorus, action of colonic bacteria that are able to release inorganic phosphorus, and capacity of the colon to absorb phosphorus. These issues may become increasingly important as new plant-based alternatives to meats, all containing phytate, are being rapidly introduced in the market.

Dietary Lipids and Dyslipidemia in Chronic Kidney Disease

The progression of chronic kidney disease (CKD) leads to altered lipid metabolism. CKD patients exhibit high blood triglyceride (TG) levels, reduced concentrations and functionality of high-density lipoproteins (HDL), and elevated levels of atherogenic small, dense, low-density lipoproteins (sdLDL). Disorders of lipid metabolism and other metabolic disturbances place CKD patients at high risk for cardiovascular disease (CVD). Extensive evidence supports the cardioprotective effects of unsaturated fatty acids, including their beneficial effect on serum cholesterol and TG levels. Dietary lipids might therefore be especially important in the nutritional management of CKD. We review current dietary recommendations for fat intake by CKD patients and suggest potential nutritional interventions by emphasizing dietary lipids that might improve the blood lipid profile and reduce cardiovascular risk in CKD.

Effect of Dietary Inulin Supplementation on the Gut Microbiota Composition and Derived Metabolites of Individuals Undergoing Hemodialysis: A Pilot Study

OBJECTIVE

The prebiotic fiber inulin has been studied in individuals undergoing hemodialysis (HD) due to its ability to reduce gut microbiota-derived uremic toxins. However, studies examining the effects of inulin on the gut microbiota and derived metabolites are limited in these patients. We aimed to assess the impact of a 4-week supplementation of inulin on the gut microbiota composition and microbial metabolites of patients on HD.

DESIGN AND METHODS

In a randomized, double-blind, placebo-controlled, crossover study, twelve HD patients (55 ± 10 y, 50% male, 58% Black American, BMI 31.6 ± 8.9 kg/m2, 33% diabetes mellitus) were randomized to consume inulin [10 g/d for females; 15 g/d for males] or maltodextrin [6 g/d for females; 9 g/d for males] for 4 weeks, with a 4-week washout period. We assessed the fecal microbiota composition, fecal metabolites (short-chain fatty acids (SCFA), phenols, and indoles), and plasma indoxyl sulfate and p-cresyl sulfate.

RESULTS

At baseline, factors that explained the gut microbiota variability included BMI category and type of phosphate binder prescribed. Inulin increased the relative abundance of the phylum Verrucomicrobia and its genus Akkermansia (P interaction = 0.045). Inulin and maltodextrin resulted in an increased relative abundance of the phylum Bacteroidetes and its genus Bacteroides (P time = 0.04 and 0.03, respectively). Both treatments increased the fecal acetate and propionate (P time = 0.032 and 0.027, respectively), and there was a trend toward increased fecal butyrate (P time = 0.06). Inulin did not reduce fecal p-cresol or indoles, or plasma concentrations of p-cresyl sulfate or indoxyl sulfate.

CONCLUSIONS

A 4-week supplementation of inulin did not lead to major shifts in the fecal microbiota and gut microbiota-derived metabolites. This may be due to high variability among participants and an unexpected increase in fecal excretion of SCFA with maltodextrin. Larger studies are needed to determine the effects of prebiotic fibers on the gut microbiota and clinical outcomes to justify their use in patients on HD.

[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.

The International Society of Renal Nutrition and Metabolism Commentary on the National Kidney Foundation and Academy of Nutrition and Dietetics KDOQI Clinical Practice Guideline for Nutrition in Chronic Kidney Disease

The Academy of Nutrition and Dietetics and the National Kidney Foundation collaborated to provide an update to the Clinical Practice Guidelines (CPG) for nutrition in chronic kidney disease (CKD). These guidelines provide a valuable update to many aspects of the nutrition care process. They include changes in the recommendations for nutrition screening and assessment, macronutrients, and targets for electrolytes and minerals. The International Society of Renal Nutrition and Metabolism assembled a special review panel of experts and evaluated these recommendations prior to public review. As one of the highlights of the CPG, the recommended dietary protein intake range for patients with diabetic kidney disease is 0.6-0.8 g/kg/day, whereas for CKD patients without diabetes it is 0.55-0.6 g/kg/day. The International Society of Renal Nutrition and Metabolism endorses the CPG with the suggestion that clinicians may consider a more streamlined target of 0.6-0.8 g/kg/day, regardless of CKD etiology, while striving to achieve intakes closer to 0.6 g/kg/day. For implementation of these guidelines, it will be important that all stakeholders work to detect kidney disease early to ensure effective primary and secondary prevention. Once identified, patients should be referred to registered dietitians or the region-specific equivalent, for individualized medical nutrition therapy to slow the progression of CKD. As we turn our attention to the new CPG, we as the renal nutrition community should come together to strengthen the evidence base by standardizing outcomes, increasing collaboration, and funding well-designed observational studies and randomized controlled trials with nutritional and dietary interventions in patients with CKD.

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.

Evaluation of the effect of nutrition-related visual education on the comfort of patients receiving hemodialysis therapy

RESUMO Objetivo O objetivo deste estudo foi avaliar o efeito da educação visual no conforto dos pacientes que recebem terapia de hemodiálise. Métodos Foi utilizado um projeto de estudo aleatório em um ambiente controlado. Este estudo foi realizado com 90 pacientes hemodialisados crônicos em dois centros de diálise, sendo que 45 pacientes pertenciam ao grupo de intervenção e os outros 45 pacientes perterciam ao grupo de controle. Formulário de dados do paciente, escala de conforto de hemodiálise - Versão II, escala de controle de fluidos do paciente de hemodiálise, escala de conhecimento dietético e escala de comportamentos dietéticos foram os documentos usados. No grupo de intervenção, foram conduzidas três entrevistas. Na primeira entrevista, a educação visual foi aplicada e reaplicada após 15 dias. No grupo de controle, duas entrevistas foram realizadas e nenhuma intervenção foi feita. Resultados Descobriu-se que o programa de treinamento tem um amplo efeito sobre o conforto e relaxamento físico do paciente, assim como relaxamento psicoespiritual, transcendência psicoespiritual, transcendência ambiental e relaxamento sociocultural. Além disso, foi notado um efeito moderado sobre o alívio físico no grupo de intervenção no terceiro mês. Dessa maneira, foi determinado que o programa de educação visual aplicado teve um amplo efeito no controle de fluidos, conhecimento de dieta e comportamento do grupo de intervenção. Conclusão Verificou-se que a educação visual tem um efeito positivo no estado de conforto, no conhecimento dietético e no comportamento dietético dos pacientes submetidos à terapia de hemodiálise

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.

Pilot study to reduce interdialytic weight gain by provision of low-sodium, home-delivered meals in hemodialysis patients

INTRODUCTION

Patients with kidney failure undergoing maintenance hemodialysis (HD) therapy are routinely counseled to reduce dietary sodium intake to ameliorate sodium retention, volume overload, and hypertension. However, low-sodium diet trials in HD are sparse and indicate that dietary education and behavioral counseling are ineffective in reducing sodium intake. This study aimed to determine whether 4 weeks of low-sodium, home-delivered meals in HD patients reduces interdialytic weight gain (IDWG). Secondary outcomes included changes in dietary sodium intake, thirst, xerostomia, blood pressure, volume overload, and muscle sodium concentration.

METHODS

Twenty HD patients (55 ± 12 years, body mass index [BMI] 40.7 ± 16.6 kg/m² ) were enrolled in this study. Participants followed a usual (control) diet for the first 4 weeks followed by 4 weeks of three low-sodium, home-delivered meals per day. We measured IDWG, hydration status (bioimpedance), standardized blood pressure (BP), food intake (3-day dietary recall), and muscle sodium (magnetic resonance imaging) at baseline (0 M), after the 4-week period of usual diet (1 M), and after the meal intervention (2 M).

FINDINGS

The low-sodium meal intervention significantly reduced IDWG when compared to the control period (-0.82 ± 0.14 kg; 95% confidence interval, -0.55 to -1.08 kg; P < 0.001). There were also 1 month (1 M) to 2 month (2 M) reductions in dietary sodium intake (-1687 ± 297 mg; P < 0.001); thirst score (-4.4 ± 1.3; P = 0.003), xerostomia score (-6.7 ± 1.9; P = 0.002), SBP (-18.0 ± 3.6 mmHg; P < 0.001), DBP (-5.9 ± 2.0 mmHg; P = 0.008), and plasma phosphorus -1.55 ± 0.21 mg/dL; P = 0.005), as well as a 0 M to 2 M reduction in absolute volume overload (-1.08 ± 0.33 L; P = 0.025). However, there were no significant changes in serum or tissue sodium (all P > 0.05).

DISCUSSION

Low-sodium, home-meal delivery appears to be an effective method for improving volume control and blood pressure in HD patients. Future studies with larger sample sizes are needed to examine the long-term effects of home-delivered meals on these outcomes and to assess cost-effectiveness.

Understanding How Nutrition Literacy Links to Dietary Adherence in Patients Undergoing Maintenance Hemodialysis: A Theoretical Exploration Using Partial Least Squares Structural Equation Modeling

Dietary non-adherence is pervasive in the hemodialysis (HD) population. Health literacy is a plausible predictor of dietary adherence in HD patients, but its putative mechanism is scarcely studied. Thus, this study aimed to establish the causal model linking nutrition literacy to dietary adherence in the HD population. This was a multi-centre, cross-sectional study, involving 218 randomly selected multi-ethnic HD patients from nine dialysis centres in Klang Valley, Malaysia. Dietary adherence and self-management skills were assessed using validated End-Stage Renal Disease Adherence Questionnaire and Perceived Kidney/Dialysis Self-Management Scale, respectively. Validated self-developed scales were used to gauge nutrition literacy, dietary knowledge and Health Belief Model constructs. Relationships between variables were examined by multiple linear regressions and partial least squares structural equation modeling. Limited nutrition literacy was evident in 46.3% of the HD patients, associated with older age, lower education level, and shorter dialysis vintage. Dietary adherence rate was at 34.9%. Nutrition literacy (β = 0.390, p < 0.001) was an independent predictor of dietary adherence, mediated by self-efficacy (SIE = 0.186, BC 95% CI 0.110-0.280) and self-management skills (SIE = 0.192, BC 95% CI 0.103-0.304). Thus, nutrition literacy-enhancing strategies targeting self-efficacy and self-management skills should be considered to enhance dietary adherence in the HD population.

Perceptions on Adherence to Dietary Prescriptions for Adults with Chronic Kidney Disease on Hemodialysis: A Qualitative Study

Diet is one of the modifiable lifestyle factors in management of kidney disease. We explored perceptions on adherence to dietary prescriptions for adults with chronic kidney disease on hemodialysis. This was a qualitative descriptive study. Participants were purposively selected at renal clinics/dialysis units at national referral hospitals in Kenya. Data were collected using in-depth interviews, note-taking and voice-recording. The data were managed and analyzed thematically in NVIV0-12 computer software. Study participants were 52 patients and 40 family caregivers (42 males and 50 females) aged 20 to 69 years. Six sub-themes emerged in this study: “perceived health benefits”; “ease in implementing prescribed diets”; “cost of prescribed renal diets”; “nutrition information and messages”; “transition to new diets” and “fear of complications/severity of disease”. Both patients and caregivers acknowledged the health benefits of adherence to diet prescriptions. However, there are mixed messages to the patients and caregivers who have challenges with management and acceptability of the prescriptions. Most of them make un-informed dietary decisions that lead to consumption of unhealthy foods with negative outcomes such as metabolic waste accumulation in the patients’ bodies negating the effects of dialysis and undermining the efforts of healthcare system in management of patients with chronic kidney disease.

Translation of Nutrient Level Recommendations to Control Serum Phosphate Into Food-Based Advice

The control of hyperphosphatemia is key to the management of chronic kidney disease mineral and bone disorder. Dietary restriction of phosphorus is essential to control hyperphosphatemia. Guidelines for chronic kidney disease and end-stage kidney disease generally provide high-level guidance on whether a nutrient should be restricted e.g, restrict dietary phosphorus. Dietitians translate such guidance into nutrient-based strategies and finally into food-based practical dietary advice for patients to follow. The practical aspects of dietary advice are not well described in the literature, neither are the challenges of concurrently altering 1 nutrient e.g., phosphorus while continuing to restrict others e.g., potassium, while maintaining overall nutritional adequacy and quality of life. In this article, we describe how we translated updated nutrient level recommendations into practical dietary advice to be delivered at the bedside.

Pilot feasibility study examining the effects of a comprehensive volume reduction protocol on hydration status and blood pressure in hemodialysis patients

INTRODUCTION

Chronic volume overload is a persistent problem in hemodialysis (HD) patients. The purpose of this study was to investigate the impacts of comprehensive volume reduction protocol on HD patient's hydration status and blood pressure (BP).

METHODS

Twenty-three HD patients (age = 55.7 ± 13.3 years) completed a 6-month comprehensive volume control protocol consisting of: reducing postdialysis weight; reducing BP medication prescriptions; and weekly intradialytic counseling to reduce dietary sodium intake and interdialytic weight gain (IDWG). The primary outcome was volume overload (VO) measured by bioelectrical impedance spectroscopy. Secondary outcomes included: IDWG, postdialysis weight, estimated dry weight (EDW), dietary sodium intake, BP and BP medication prescriptions.

FINDINGS

From baseline (0M) to 6 months (6M), significant improvements were noted in: VO (0M 3.9 ± 3.9 L vs. 6M 2.6 ± 3.4 L, P = 0.003), postdialysis weight (0M 89.4 ± 23.1 kg vs. 6M 87.6 ± 22.2 kg; P = 0.012), and EDW (0M 89.0 ± 23.2 vs. 6M 86.7 ± 22.5 kg., P = 0.009). There was also a trend for a reduction in monthly averaged IDWG (P = 0.053), and sodium intake (0M 2.9 ± 1.6 vs. 6M 2.3 ± 1.1 g/d, P = 0.125). Neither systolic BP (0M 162 ± 27 vs. 6M 157 ± 23 mmHg, P = 0.405) nor diastolic BP (0M 82 ± 21 vs. 6M 82 ± 19 mmHg, P = 0.960) changed, though there was a significant reduction in the total number of BP medications prescribed (0M 3.0 ± 1.0 vs. 6M 1.5 ± 1.0 BP meds; P = 0.004).

DISCUSSION

Our volume reduction protocol significantly improved HD patient's hydration status. While BP did not change, the reduction in prescribed BP medication number suggests improved BP control. Despite these overall positive findings, the magnitude of change in most variables was modest. Comprehensive changes in HD clinics may be necessary to realize more clinically significant results.

Dietary Patterns and Health Outcomes among African American Maintenance Hemodialysis Patients

The association between dietary patterns and health outcomes, such as quality of life (QOL), in maintenance hemodialysis (MHD) patients with certain racial backgrounds has not been studied in detail. QOL is a powerful outcome measure in which dietary patterns could be a modifying factor. This study is a secondary analysis examining the association between dietary patterns and health outcomes in 101 African American (AA) maintenance hemodialysis (MHD) patients participating in the Palm Tocotrienols in Chronic Hemodialysis (PATCH) study. Quality of life (QOL) was assessed using the Kidney Disease Quality of Life 36-item survey (KDQOL-36™). Blood samples were analyzed for lipids, lipoprotein subfractions, and inflammatory markers. Food intake was measured using six non-consecutive 24-h dietary recalls over 15 months. Implausible energy intake reports were screened out by comparing reported energy intake (rEI) with predicted total energy expenditure (pTEE). Cluster analysis, using the k-means algorithm, identified two distinct dietary patterns in the study population: a high "sugar sweetened beverage" pattern (hiSSB) and a low "sugar sweetened beverage pattern" (loSSB). In the hiSSB group, consumption of SSB accounted for ~28% of energy intake, while SSB represented only 9% of energy intake in the loSSB group. The hiSSB group was characterized by a higher intake of total calories, sugar and percentage of kilocalories from carbohydrates, whereas the percentage of kilocalories from protein and fat was lower. While additional micronutrient intakes differed between groups (vitamin C, zinc, chromium), these were significantly lower than recommended values in the entire cohort. Patients in the hiSSB group presented with lower high-density lipoprotein cholesterol (HDL-C), lower large HDL particles and smaller low density lipoprotein (LDL) particle diameters. Antidepressant usage was significantly higher in the hiSSB group. Patients in the hiSSB group scored lower across all five KDQOL domains and scored significantly lower in the mental composite domain. MHD patients following a hiSSB dietary pattern had smaller dense LDL particles, lower HDL-C, and a lower QOL. Suboptimal intakes of fruits, vegetables, and grains as well as key micronutrients were evident in both patterns.

Thirst in patients on chronic hemodialysis: What do we know so far?

Thirst has been defined as "the sensation that leads animal's and human's actions toward the goal of finding and drinking water" or as "any drive that can motivate water intake, regardless of cause". Thirst, together with xerostomia, is the main cause of poor adherence to fluid restriction and of excessive intake of fluids in patients on chronic hemodialysis, and consequently of high interdialytic weight gain. Interdialytic weight gain (IDWG) should be lower than 4.0-4.5% of dry weight. Unfortunately, many patients have an IDWG greater than this value and some have IDWG of 10-20%. High IDWG is associated with a higher risk of all-cause and cardiovascular death and increased morbidity, such as ventricular hypertrophy and major adverse cardiac and cerebrovascular events. In addition, high IDWG leads to supplementary weekly dialysis sessions with consequent deterioration of quality of life and increased costs. Thus, the knowledge of thirst in patients on chronic hemodialysis is essential to prompt its adequate management to limit IDWG in the routine clinical practice. The present review aims to describe the physiology of thirst in patients on chronic hemodialysis, as well as the prevalence, its measures, the associated variables, the consequences, and the strategies for its reduction.

Processed and ultra-processed food consumption are related to metabolic markers in hemodialysis subjects

ABSTRACT Objective To investigate the consumption of processed and ultra-processed foods and evaluate its relationship with the nutritional and metabolic status of hemodialysis patients in a single center in Brazil. Methods This cross-sectional study enrolled 73 individuals in hemodialysis (50 men and 23 women, 21-87 years-old). Clinical and lifestyle variables were assessed by a semi-structured questionnaire and dietary data by food frequency questionnaire. Anthropometric and metabolic data are collected from medical records. Results Processed and ultra-processed foods represented 11.0% of daily caloric intake, 53.0% of trans fatty acid, and 12.5% of salt consumed in the study sample. Individuals who had high intake of this food group (≥128.4g/day, median intake) had higher serum phosphorus and pre-dialysis urea values (p=0.038; p=0.013, respectively). Also, individual with higher consumption of processed meat, sausages and ready prepared food had higher pre-dialysis serum urea (p=0.021), while serum potassium was higher among the subjects who consumed more sauces and salt-based seasonings (p=0.002). Conclusion Higher consumption of processed and ultra-processed foods was associated with important biomarkers of metabolic control for hemodialysis subjects, probably due to non-health dietary composition. Nutritional guidelines and intervention strategies must be promoted to reduce consumption of these food-group in thisspecific population.

Exploring the Benefit of 2-Methylbutyric Acid in Patients Undergoing Hemodialysis Using a Cardiovascular Proteomics Approach

Short-chain fatty acids (SCFAs) can reduce pro-inflammatory parameters and oxidative stress, providing potential cardiovascular (CV) benefits. Although some evidence links SCFAs with host metabolic health via several biological mechanisms, the role of SCFA on CV disease in patients with kidney disease remains unclear. Herein, we investigate the association between a SCFA, 2-methylbutyric acid, and target CV proteomics to explore the potential pathophysiology of SCFA-related CV benefit in patients with kidney disease. Circulating 2-methylbutyric acid was quantified by high-performance liquid chromatography and 181 CV proteins by a proximity extension assay in 163 patients undergoing hemodialysis (HD). The associations between 2-methylbutyric acid and CV proteins were evaluated using linear regression analysis with age and gender, and multiple testing adjustment. The selected CV protein in the discovery phase was further confirmed in multivariable-adjusted models and evaluated by continuous scale association. The mean value of circulating 2-methylbutyric acid was 0.22 ± 0.02 µM, which was negatively associated with bone morphogenetic protein 6 (BMP-6) according to the false discovery rate (FDR) multiple testing adjustment method. The 2-methylbutyric acid level remained negatively associated with BMP-6 (β coefficient -1.00, 95% confidence interval -1.45 to -0.55, p < 0.001) after controlling for other CV risk factors in multivariable models. The cubic spline curve demonstrated a linear relationship. In conclusion, circulating 2-methylbutyric acid level was negatively associated with BMP-6, suggesting that this pathway maybe involved in vascular health in patients undergoing HD. However, further in vitro work is still needed to validate the translation of the mechanistic pathways.

Is It Possible to Include Potato in the Diet of Chronic Kidney Disease Patients? New Culinary Alternatives for Limiting Potassium Content

OBJECTIVE(S)

Despite the nutritional benefits of potato tuber, patients with chronic kidney disease (CKD) should limit the consumption because of its high potassium content. Some culinary treatments have previously been suggested to reduce the final content of this mineral; however, these are either not effective enough or involve very long procedures that affect the final flavor of the food. The aim of this work was to analyze the effect of culinary treatments on the reduction in potassium content in potatoes, offering new alternatives for minimizing the final content of this mineral to allow the increase of potato intake by patients with CKD.

DESIGN AND METHODS

Fresh potatoes, canned potatoes, and frozen french fried potatoes were submitted to three different culinary treatments: soaking, normal cooking, and frying. Two types of cut were studied: strips and dice. Initial and final potassium content and % humidity in each cooking treatment applied on the three types of potatoes were analyzed. Potassium content was analyzed using flame photometry.

RESULTS

Results show that potato soaking was ineffective for fresh raw potato, while normal cooking achieved insufficient reduction of potassium. However, when a soaking procedure was applied after normal cooking, it was found to be possible to leach up to 70% of the potassium, to final values of under 130 mg/100 g edible portion in both cut types studied. Subsequent frying did not leach potassium but rather increased potassium content; however, without reaching the 150 mg/100 g edible portion threshold. Similar results were observed for canned potatoes and frozen french fries.

CONCLUSIONS

With this new proposed culinary method, the potassium content of potatoes is reduced to an acceptable limit. Additionally, the technique maintains a low-potassium content even after frying potatoes, thus allowing potatoes to be incorporated into the CKD dietary pattern.

Adaptation and Validation of Alternative Healthy Eating Index in Hemodialysis Patients (AHEI-HD) and Its Association with all-Cause Mortality: A Multi-Center Follow-Up Study

A valid diet quality assessment scale has not been investigated in hemodialysis patients. We aimed to adapt and validate the alternative healthy eating index in hemodialysis patients (AHEI-HD), and investigate its associations with all-cause mortality. A prospective study was conducted on 370 hemodialysis patients from seven hospital-based dialysis centers. Dietary data (using three independent 24-hour dietary records), clinical and laboratory parameters were collected. The construct and criterion validity of original AHEI-2010 with 11 items and the AHEI-HD with 16 items were examined. Both scales showed reasonable item-scale correlations and satisfactory discriminant validity. The AHEI-HD demonstrated a weaker correlation with energy intake compared with AHEI-2010. Principle component analysis yielded the plateau scree plot line in AHEI-HD but not in AHEI-2010. In comparison with patients in lowest diet quality (tertile 1), those in highest diet quality (tertile 3) had significantly lower risk for death, with a hazard ratio (HR) and 95% confidence intervals (95%CI) of HR: 0.40; 95%CI: 0.18 – 0.90; p = 0.028, as measured by AHEI-2010, and HR: 0.37; 95%CI: 0.17–0.82; p = 0.014 as measured by AHEI-HD, respectively. In conclusion, AHEI-HD was shown to have greater advantages than AHEI-2010. AHEI-HD was suggested for assessments of diet quality in hemodialysis patients.

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.

Contributory Role of Gut Microbiota and Their Metabolites Toward Cardiovascular Complications in Chronic Kidney Disease

The gut microbiome recently has emerged as a novel risk factor that impacts health and disease. Our gut microbiota can function as an endocrine organ through its unique ability to metabolize various dietary precursors, and can fuel the systemic inflammation observed in chronic disease. This is especially important in the setting of chronic kidney disease, in which microbial metabolism can contribute directly to accumulation of circulating toxins that then can alter and shift the balance of microbiota composition and downstream functions. To study this process, advances in -omics technologies are providing opportunities to understand not only the taxonomy, but also the functional diversity of our microbiome. We also reliably can quantify en masse a wide range of uremic byproducts of microbial metabolism. Herein, we examine the bidirectional relationship between the gut microbiome and the failing kidneys. We describe potential approaches targeting gut microbiota for cardiovascular risk reduction in chronic kidney disease using an illustrative example of a novel gut-generated metabolite, trimethylamine N-oxide.

Egg Intake in Chronic Kidney Disease

Patients with chronic kidney disease (CKD) are often instructed to adhere to a renal-specific diet depending on the severity and stage of their kidney disease. The prescribed diet may limit certain nutrients, such as phosphorus and potassium, or encourage the consumption of others, such as high biological value (HBV) proteins. Eggs are an inexpensive, easily available and high-quality source of protein, as well as a rich source of leucine, an essential amino acid that plays a role in muscle protein synthesis. However, egg yolk is a concentrated source of both phosphorus and the trimethylamine N-oxide precursor, choline, both of which may have potentially harmful effects in CKD. The yolk is also an abundant source of cholesterol which has been extensively studied for its effects on lipoprotein cholesterol and the risk of cardiovascular disease. Efforts to reduce dietary cholesterol to manage dyslipidemia in dialysis patients (already following a renal diet) have not been shown to offer additional benefit. There is a paucity of data regarding the impact of egg consumption on lipid profiles of CKD patients. Additionally, egg consumption has not been associated with the risk of developing CKD based on epidemiological studies. The egg yolk also contains bioactive compounds, including lutein, zeaxanthin, and vitamin D, which may confer health benefits in CKD patients. Here we review research on egg intake and CKD, discuss both potential contraindications and favorable effects of egg consumption, and describe the need for further research examining egg intake and outcomes in the CKD and end-stage renal disease population.

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.