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Meade A, Dawson J, Mullan A. Revisiting Intradialytic Parenteral Nutrition: How Can We Apply the Evidence in Clinical Practice? ADVANCES IN KIDNEY DISEASE AND HEALTH 2023; 30:502-507. [PMID: 38453266 DOI: 10.1053/j.akdh.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 07/17/2023] [Accepted: 07/24/2023] [Indexed: 03/09/2024]
Abstract
Intradialytic parenteral nutrition (IDPN) remains a controversial nutrition support practice in hemodialysis. Multiple reviews and evidence-based clinical practice guidelines have been published in the past 20 years. Despite essentially looking at the same evidence, conclusions and recommendations vary significantly, leading to widespread uncertainty among clinicians on the value of and indications for IDPN. This paper aims to bring a clinical perspective to the current state of evidence and clinical practice, recognizing the strengths and weaknesses of current evidence and the clinical questions that remain unanswered, as well as providing guidance for using IDPN in clinical practice. IDPN should be considered a strategy to complement spontaneous oral intake in clinically stable patients receiving maintenance hemodialysis or who have or are at risk of malnutrition and who have substantial but not adequate protein and/or energy intake. There is a clear need for robust randomized controlled trials evaluating the impact of IDPN in appropriately selected patients. Additionally, future trials should include patient-centered outcome measures such as appetite, spontaneous oral intake, quality of life, and reliable measures of nutritional status.
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Affiliation(s)
- Anthony Meade
- Central Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, SA, Australia.
| | - Jessica Dawson
- Department of Nutrition and Dietetics, St George Hospital, NSW, Australia; NHMRC Clinical Trials Centre, The University of Sydney, NSW, Australia
| | - Adam Mullan
- Northland Renal Service, Whangarei Hospital, Whangarei, New Zealand
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Singh BKS, Khor BH, Sahathevan S, Gafor AHA, Fiaccadori E, Chinna K, Ng SH, Karupaiah T. Barriers and Facilitators to Intradialytic Parenteral Nutrition Implementation Targeting Protein Energy Wasting in Malaysian Hemodialysis Patients. Healthcare (Basel) 2022; 10:healthcare10102090. [PMID: 36292538 PMCID: PMC9602673 DOI: 10.3390/healthcare10102090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 10/04/2022] [Accepted: 10/13/2022] [Indexed: 11/22/2022] Open
Abstract
The capacity to deliver intradialytic parenteral nutrition (IDPN) for patients on hemodialysis (HD) diagnosed with protein energy wasting (PEW) in low resource settings is unknown. This study aimed to examine the extent of IDPN practice in HD units in Malaysia, and its implementation to treat PEW. We surveyed pharmacists (n = 56), who are central to parenteral nutrition delivery in Malaysia including IDPN. Seventeen healthcare stakeholders engaging with the Promoting Action on Research Implementation in Health Services (PARIHS) framework used the Likert scale to rate survey outcomes on IDPN implementation to treat PEW, according to the Evidence, Context, and Facilitation elements. IDPN for HD patients was available in 28 of 56 hospitals providing parenteral nutrition services, with only 13 hospitals (23.2%) providing IDPN to outpatients. Outpatient treatment was concentrated to urban locations (12/13) and significantly associated (p < 0.001) with resident nephrologists. The Evidence domain was rated poorly (2.18 ± 0.15) pertaining to IDPN indication when the oral spontaneous intake was ≤20 kcal/kg/day. The Context domain indicated good adherence to international best practice relating to IDPN administration (4.59 ± 0.15) and infusion time (4.59 ± 0.12). Poor adherence was observed in the Facilitation domain on ’Access to pharmacist and dietitian at HD units’ (2.65 ± 0.21) and ’Access to continuous medical education on managing PEW patients on HD’ (2.53 ± 0.15). The IDPN outpatient service was concentrated to urban hospitals with greater manpower resources. The PARIHS evaluation on IDPN implementation to treat PEW revealed facilitators in good practice adherence for prescribing and administration of IDPN but highlighted major barriers relating to IDPN indication and nutrient calculation.
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Affiliation(s)
- Birinder Kaur Sadu Singh
- Department of Pharmacy, Hospital Canselor Tuanku Muhriz, Universiti Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia
| | - Ban-Hock Khor
- Faculty of Food Science and Nutrition, Universiti Malaysia Sabah, Kota Kinabalu 88400, Malaysia
| | - Sharmela Sahathevan
- Division of Nutrition and Dietetics, Faculty of Health Sciences, International Medical University, Kuala Lumpur 57000, Malaysia
| | - Abdul Halim Abdul Gafor
- Department of Medicine, Hospital Canselor Tuanku Muhriz, Universiti Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia
| | - Enrico Fiaccadori
- Nephrology Unit, Department of Medicine and Surgery, Parma University Hospital, 43121 Parma, Italy
| | - Karuthan Chinna
- Faculty of Business and Management, USCI University, Kuala Lumpur 56000, Malaysia
| | - See-Hoe Ng
- School of BioSciences, Faculty of Health and Medical Sciences, Taylor’s University Lakeside, Selangor 47500, Malaysia
| | - Tilakavati Karupaiah
- School of BioSciences, Faculty of Health and Medical Sciences, Taylor’s University Lakeside, Selangor 47500, Malaysia
- Correspondence:
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Yasukawa R, Hosojima M, Kabasawa H, Takeyama A, Ugamura D, Suzuki Y, Saito A, Narita I. Intradialytic parenteral nutrition using a standard amino acid solution not for renal failure in maintenance hemodialysis patients with malnutrition: a multicenter pilot study. RENAL REPLACEMENT THERAPY 2022. [DOI: 10.1186/s41100-022-00432-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Standard amino acid solutions have recently been removed from the contraindications for use in dialysis patients in Japan. However, the details of their safety and efficacy in these patients are still not known. In this study, we investigated the safety and efficacy of intradialytic parenteral nutrition (IDPN) using ENEFLUID® injection containing standard amino acids, glucose, electrolytes, fats, and water-soluble vitamins in maintenance hemodialysis patients with malnutrition.
Methods
This clinical trial was designed as a multicenter, prospective, non-randomized, open-label, single-arm, observational pilot study. The participants were patients on maintenance hemodialysis who were in the nutritional high-risk group according to the Nutritional Risk Index for Japanese Hemodialysis Patients. One bag of ENEFLUID® injection was administered during every hemodialysis session for 12 weeks. The primary endpoint was change in serum transthyretin levels between before and after the 12-week period. As safety endpoints, we evaluated changes in body fluid volume and blood biochemical tests, including blood urea nitrogen and electrolytes, as well as blood glucose variability using flash glucose monitoring (FGM).
Results
The mean age and body mass index of the 13 participants were 79.0 ± 10.7 years and 18.0 ± 1.7 kg/m2, respectively. No significant changes were observed in nutritional parameters, including serum transthyretin, between before and after the start of the study. After IDPN initiation, there was no obvious fluid overload or significant changes in blood biochemical tests, including electrolytes, and the treatment could be safely continued for 12 weeks. In the FGM analysis, asymptomatic hypoglycemia during hemodialysis was observed at the beginning of the study, but there was a trend toward improvement after 12 weeks (area over the curve < 70 mg/dl per dialysis session: 747.5 ± 1333.9 to 21.6 ± 54.3, P = 0.09).
Conclusions
IDPN using ENEFLUID® injection can be safely continued, although it does not significantly improve markers of nutritional status. It also showed the potential to ameliorate asymptomatic hypoglycemia during hemodialysis sessions. More detailed studies of the improvement in nutritional indicators are needed.
Trial registration: This study was registered with the University Hospital Medical Information Network-Clinical Trials Registry (UMIN-CTR) on May 9, 2021 (registration ID, UMIN000044051).
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St-Jules DE, Fouque D. A Novel Approach for Managing Protein-Energy Wasting in People With Kidney Failure Undergoing Maintenance Hemodialysis: Rationale and Call for Trials. Am J Kidney Dis 2022; 80:277-284. [PMID: 34974032 DOI: 10.1053/j.ajkd.2021.10.012] [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: 08/08/2021] [Accepted: 10/28/2021] [Indexed: 01/27/2023]
Abstract
Protein-energy wasting (PEW) is a unique presentation of protein-energy malnutrition in people with kidney disease that is characterized by body protein catabolism exceeding anabolism. PEW is especially common in patients undergoing maintenance hemodialysis (HD) treatment. Dietary guidelines for managing PEW in HD patients primarily focus on protein adequacy and typically promote the intake of animal-based protein foods. Although intake of protein and essential amino acids is important for protein synthesis, the emphasis on protein adequacy largely fails to address-and may actually exacerbate-many of the root causes of PEW. This perspective examines the dietary determinants of PEW in people undergoing HD treatment, with an emphasis on upstream disease-related factors that reduce dietary protein utilization and impair dietary intakes. From this, we present a theoretical diet model for managing PEW that includes etiology-based dietary strategies to address barriers to intake and treat disease-related factors, as well as supportive dietary strategies to promote adequate energy and protein intakes. Given the complexity of diet-disease interactions in the pathogenesis of PEW, and its ongoing burden in HD patients, interventional trials are urgently needed to evaluate alternative diet therapy approaches for PEW in this population.
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Affiliation(s)
| | - Denis Fouque
- CarMeN Laboratory, INSERM U1060, Université Claude Bernard Lyon 1, Villeurbanne, and Department of Nephrology, Nutrition, and Dialysis, Centre Hopitalier Lyon Sud, Pierre-Benite, France.
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Carrero JJ, Severs D, Aguilera D, Fiaccadori E, Gonzalez MG, Haufe CC, Teta D, Molina P, Visser W. Intradialytic parenteral nutrition for patients on hemodialysis: when, how and to whom? Clin Kidney J 2022; 16:5-18. [PMID: 36726442 PMCID: PMC9871859 DOI: 10.1093/ckj/sfac171] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Indexed: 02/04/2023] Open
Abstract
Hemodialysis is associated with high morbidity and mortality rates as well as low quality of life. Altered nutritional status and protein-energy wasting are important indicators of these risks. Maintaining optimal nutritional status in patients with hemodialysis is a critical but sometimes overlooked aspect of care. Nutritional support strategies usually begin with dietary counseling and oral nutritional supplements. Patients may not comply with this advice or oral nutritional supplements, however , or compliance may be affected by other complications of progressive chronic kidney disease. Intradialytic parenteral nutrition (IDPN) may be a possibility in these cases, but lack of knowledge on practical aspects of IDPN delivery are seldom discussed and may represent a barrier. In this review, we, as a consensus panel of clinicians experienced with IDPN, survey existing literature and summarize our views on when to use IDPN, which patients may be best suited for IDPN, and how to effectively deliver and monitor this strategy for nutritional support.
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Affiliation(s)
| | - David Severs
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | | | | | | | | | - Pablo Molina
- Department of Nephrology, FISABIO, Hospital Universitari Doctor Peset, Universitat de València, Valencia, Spain
| | - Wesley Visser
- Department of Internal Medicine, Division of Dietetics, Erasmus Medical Center, Rotterdam, The Netherlands
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González-Ortiz A, Ramos-Acevedo S, Santiago-Ayala V, Gaytan G, Valencia-Flores M, Correa-Rotter R, Carrero JJ, Xu H, Espinosa-Cuevas Á. Sleep Quality After Intradialytic Oral Nutrition: A New Benefit of This Anabolic Strategy? A Pilot Study. Front Nutr 2022; 9:882367. [PMID: 35938133 PMCID: PMC9355791 DOI: 10.3389/fnut.2022.882367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 06/20/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundSince disturbances of appetite and sleep are closely related and both affect metabolic disorders, it would be expected that a renal specific oral nutritional supplement (RS-ONS) that covers the energy the patient does not consume on the HD day, could contribute to improve the nutritional status and body composition, as well as sleep quality. There is still scarce information related to this topic.AimTo evaluate the effect of the use of intra-dialytic RS-ONS vs. RS-ONS at home on sleep quality, nutritional status, and body composition in patients on HD.MethodsAdult patients < 65 years, with ≥3 months on HD were invited to participate in an open randomized pilot study (ISRCTN 33897). Patients were randomized to a dialysis-specific high-protein supplement provided during the HD session (Intradialytic oral nutrition [ION]) or at home (control), during non-HD days (thrice weekly, for both) 12 weeks. The primary outcome was sleep quality defined by the Pittsburgh Sleep Quality Index (PSQI) score. Nutritional assessment included Malnutrition Inflammation Score (MIS), bioelectrical impedance analysis, anthropometry, 3-day food records, and routine blood chemistries.ResultsA total of 23 patients completed the study. Age was median 35 (range 24–48 years), 42% were women. At baseline, the PSQI score was median 4 (range 2–7), and MIS showed a median of 6 (range 5–8); there were no baseline differences between groups. After intervention, both groups improved their MIS scores and similarly when we analyzed the whole cohort (pre- vs. post-intervention P < 0.01). Patients in the ION group improved the overall PSQI score to median 3 (2–5), and assessment of sleep duration and sleep disturbances (pre- vs. post-intervention P < 0.05), with a trend toward an effect difference compared to patients consuming the supplement at home (P for treatment-effect across arms 0.07 for PSQI score and 0.05 for sleep latency).ConclusionOral supplementation improved nutritional status in the whole cohort, but only ION improved the PSQI score. More studies are needed to explore the nutritional strategies that influence the relationship between sleep and nutritional status in HD patients.
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Affiliation(s)
| | - Samuel Ramos-Acevedo
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Victoria Santiago-Ayala
- Neurology Department, Sleep Disorders Clinic, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
- School of Psychology, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Gabriela Gaytan
- Neurology Department, Sleep Disorders Clinic, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Matilde Valencia-Flores
- Neurology Department, Sleep Disorders Clinic, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
- School of Psychology, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Ricardo Correa-Rotter
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Juan Jesus Carrero
- Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Hong Xu
- Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Ángeles Espinosa-Cuevas
- Translational Research Center, Instituto Nacional de Pediatría, Mexico City, Mexico
- Health Care Department, Universidad Autónoma Metropolitana-Xochimilco, Mexico City, Mexico
- *Correspondence: Ángeles Espinosa-Cuevas
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Fujiwara M, Ando I, Shishido Y, Imai Y, Terawaki H. Amino acid availability enhanced through glucose coadministration of amino acid supplementation during hemodiafiltration: two case reports. RENAL REPLACEMENT THERAPY 2022. [DOI: 10.1186/s41100-022-00417-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Intravenous administration of amino acid (AA) formulation (IVAA) as intradialytic parenteral nutrition is widely used for malnourished patients with end-stage kidney disease (ESKD) treated with hemodialysis (HD) or hemodiafiltration (HDF). Although various therapy recipes such as AA compositions or simultaneous administration of glucose and/or lipids have been attempted, the specific effects of each recipe on AA behaviors and metabolic consequences have not been well investigated. To clarify the effect of simultaneous glucose administration with IVAA, we investigated the behavior of AAs, insulin as a metabolic hormone, and energy-related metabolites during an HDF session in two patients.
Case presentation
We aimed to determine the effect of IVAA with or without simultaneous glucose administration. The plasma levels of AAs, branched-chain AAs (leucine, isoleucine, and valine), major nonessential AAs (alanine and glutamine with glutamate), insulin, glucose, and ketone bodies were measured before HDF and at the second hour (prior to the meal in the HDF session). Lost AAs in the spent dialysate were also measured for the first two hours during the HDF session.
Conclusion
In the absence of glucose administration, plasma AA levels and the loss of AAs in the dialysate increased owing to IVAA, with the increase in plasma levels in ketone bodies occurring because of scarce secretion of plasma insulin. In the presence of glucose administration, plasma levels and the loss of AA decreased even when the same amount of AAs was injected, possibly because of the profound secretion of insulin with a decrease in ketone bodies. The present findings suggest that the metabolic effects of simultaneous glucose administration on IVAAs enhanced AA uptake into the body during HDF sessions, which might increase the effectiveness of IVAAs.
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8
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The beneficial effects of intradialytic parenteral nutrition in hemodialysis patients with protein energy wasting: a prospective randomized controlled trial. Sci Rep 2022; 12:4529. [PMID: 35296793 PMCID: PMC8927103 DOI: 10.1038/s41598-022-08726-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 03/07/2022] [Indexed: 11/29/2022] Open
Abstract
In hemodialysis (HD) patients, protein-energy wasting (PEW) is highly prevalent and firstly treated with oral nutritional supplements (ONS). The extent to which intradialytic parenteral nutrition (IDPN) contributes to improve PEW status in HD patients intolerable to ONS remains unclear. Maintenance PEW HD patients being unable to tolerate ONS adverse effects, and having spontaneous energy and protein intake of ≥ 20 kcal/kg/day and ≥ 0.8 g/kg/day, respectively were randomly assigned 1:1 into IDPN and control groups. In IDPN group, most concentrated 3-in-1, fish-oil based parenteral nutrition was infused during HD for 3 months. The control group received intensive dietary counselling once weekly for 3 months. Both groups were then followed for additional 3 months after intervention. A total of 38 patients were randomized (mean age 67.6 years). After 3 months, serum albumin was significantly higher in the IDPN (n = 18) compared with control group (from 3.5 ± 0.3 to 3.8 ± 0.2 vs from 3.6 ± 0.3 to 3.5 ± 0.3 g/dL, respectively, p = 0.01). Spontaneous dietary intake (p = 0.04), body weight (p = 0.01), and malnutrition inflammation score (MIS, p = 0.01) were improved in the IDPN, but not in the control group. Muscle mass, strength, serum prealbumin, interleukin-6, high sensitivity-c reactive protein, and acylated ghrelin were not significantly different but leptin levels increased in the control group after 3 months (p = 0.03). At 6 months, serum albumin in the IDPN group was persistently higher than baseline (p = 0.04). Neither volume overload nor uncontrolled hyperglycemia was found throughout the study. In conclusion, a 3-month IDPN supplementation demonstrated a significant increase in serum albumin, body weight, spontaneous oral intake, and MIS; and appeared to be superior to continuing intensive dietary counselling among HD patients intolerable to ONS. The impacts of IDPN therapy on clinical outcomes may require larger scale with longer period of study.
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Continuous intradialytic amino acid infusion from the start of dialysis is better to avoid catabolism under the high-volume pre-dilution on-line HDF. J Artif Organs 2022; 25:377-381. [DOI: 10.1007/s10047-022-01319-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 02/03/2022] [Indexed: 10/19/2022]
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10
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Behrad Nasab M, Akbari ME, Rastgoo S, Gholami S, Hajipour A, Majidi N, Gholamalizadeh M, Mirzaei Dahka S, Doaei S, Goodarzi MO. Comparison of Biochemical and Pathological Parameters and Parenteral Nutrition of ICU Patients Under Supervision of Dietitians and Surgeons. Front Nutr 2021; 8:729510. [PMID: 34692745 PMCID: PMC8528958 DOI: 10.3389/fnut.2021.729510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 09/13/2021] [Indexed: 11/18/2022] Open
Abstract
Background: Nutrient imbalance can frequently occur in patients with indications for parenteral nutrition (PN) after gastrointestinal surgery. This study aimed to compare the recommendations of a surgeon to those of a dietitian in the field of parenteral nutrition. Methods: This study was performed on 256 patients undergoing gastrointestinal surgery who received PN, which included 120 patients who received PN based on recommendations of the surgeons and 136 patients who were referred to receive PN under the supervision of a dietitian in Razi Hospital in Rasht, Iran. Data on PN and clinical outcomes of the patients were collected. Results: Patients under the supervision of dietitians received higher vitamin B complex and lipids and lower vitamin A and vitamin E than the surgeon-supervised patients (all P < 0.001). In the group receiving PN under the supervision of a surgeon, the level of blood glucose (207 vs. 182, P < 0.01), sodium (138 vs. 136, P = 0.01), potassium (3.97 vs. 3.53, P < 0.01), and white blood cell count (9.83 vs. 9.28, P < 0.01) increased significantly at the end of the PN compared to baseline. In the group receiving PN under the supervision of a dietician, the level of serum Cr (1.23 vs. 1.32, P = 0.04), Mg (2.07 vs. 1.84, P < 0.01), and pH (7.45 vs. 7.5, P = 0.03) significantly improved after receiving parenteral nutrition compared to baseline. Conclusion: The amounts of nutrients recommended for PN by the surgeon and dietitian were different. Implementation of dietitian recommendations in critically ill patients under PN can improve patients' clinical parameters.
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Affiliation(s)
- Mojgan Behrad Nasab
- Department of Physical Education and Sport Sciences, Faculty of Sport Science, Central Tehran Branch, Islamic Azad University, Tehran, Iran
| | | | - Samira Rastgoo
- Department of Clinical Nutrition and Dietetics, Research Institute Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Somayeh Gholami
- Razi Hospital, Guilan University of Medical Sciences, Rasht, Iran
| | - Azadeh Hajipour
- Department of Health Sciences in Nutrition, School of Health, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Nazanin Majidi
- Department of Nutrition, Science and Research Branch, Islamic Azad University, Tehran, Iran
| | - Maryam Gholamalizadeh
- Student Research Committee, Cancer Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Saied Doaei
- Reproductive Health Research Center, School of Health, Guilan University of Medical Sciences, Rasht, Iran
| | - Mark O Goodarzi
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States
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Garibotto G, Saio M, Aimasso F, Russo E, Picciotto D, Viazzi F, Verzola D, Laudon A, Esposito P, Brunori G. How to Overcome Anabolic Resistance in Dialysis-Treated Patients? Front Nutr 2021; 8:701386. [PMID: 34458305 PMCID: PMC8387577 DOI: 10.3389/fnut.2021.701386] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 07/12/2021] [Indexed: 02/05/2023] Open
Abstract
A current hypothesis is that dialysis-treated patients are "anabolic resistant" i. e., their muscle protein synthesis (MPS) response to anabolic stimuli is blunted, an effect which leads to muscle wasting and poor physical performance in aging and in several chronic diseases. The importance of maintaining muscle mass and MPS is often neglected in dialysis-treated patients; better than to describe mechanisms leading to energy-protein wasting, the aim of this narrative review is to suggest possible strategies to overcome anabolic resistance in this patient's category. Food intake, in particular dietary protein, and physical activity, are the two major anabolic stimuli. Unfortunately, dialysis patients are often aged and have a sedentary behavior, all conditions which per se may induce a state of "anabolic resistance." In addition, patients on dialysis are exposed to amino acid or protein deprivation during the dialysis sessions. Unfortunately, the optimal amount and formula of protein/amino acid composition in supplements to maximixe MPS is still unknown in dialysis patients. In young healthy subjects, 20 g whey protein maximally stimulate MPS. However, recent observations suggest that dialysis patients need greater amounts of proteins than healthy subjects to maximally stimulate MPS. Since unneccesary amounts of amino acids could stimulate ureagenesis, toxins and acid production, it is urgent to obtain information on the optimal dose of proteins or amino acids/ketoacids to maximize MPS in this patients' population. In the meantime, the issue of maintaining muscle mass and function in dialysis-treated CKD patients needs not to be overlooked by the kidney community.
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Affiliation(s)
- Giacomo Garibotto
- Department of Internal Medicine, University of Genoa, Genova, Italy
- *Correspondence: Giacomo Garibotto
| | - Michela Saio
- Department of Internal Medicine, University of Genoa, Genova, Italy
| | - Francesca Aimasso
- Clinical Nutrition Unit, Istituto di Ricerca a Carattere Scientifico Ospedale Policlinico San Martino, Genova, Italy
| | - Elisa Russo
- Department of Internal Medicine, University of Genoa, Genova, Italy
- Clinica Nefrologica, Dialisi e Trapianto, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Daniela Picciotto
- Department of Internal Medicine, University of Genoa, Genova, Italy
- Clinica Nefrologica, Dialisi e Trapianto, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Francesca Viazzi
- Department of Internal Medicine, University of Genoa, Genova, Italy
- Clinica Nefrologica, Dialisi e Trapianto, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Daniela Verzola
- Department of Internal Medicine, University of Genoa, Genova, Italy
| | - Alessandro Laudon
- Division of Nephrology and Dialysis, Ospedale Santa Chiara, Trento, Italy
| | - Pasquale Esposito
- Department of Internal Medicine, University of Genoa, Genova, Italy
- Clinica Nefrologica, Dialisi e Trapianto, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Giuliano Brunori
- Division of Nephrology and Dialysis, Ospedale Santa Chiara, Trento, Italy
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12
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Hendriks FK, Kooman JP, van Loon LJ. Dietary protein interventions to improve nutritional status in end-stage renal disease patients undergoing hemodialysis. Curr Opin Clin Nutr Metab Care 2021; 24:79-87. [PMID: 33060457 PMCID: PMC7752218 DOI: 10.1097/mco.0000000000000703] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Poor nutritional status is prevalent among end-stage renal disease patients undergoing hemodialysis. Chronic hemodialysis patients show an accelerated decline in skeletal muscle mass and strength, which is associated with higher mortality rates and a reduced quality of life. The current review aims to summarize recent advances regarding underlying causes of muscle loss and interventions that support muscle mass maintenance in patients with chronic hemodialysis. RECENT FINDINGS Muscle maintenance in chronic hemodialysis patients is compromised by low dietary protein intake levels, anabolic resistance of skeletal muscle tissue, sedentary behavior, and amino acid removal during hemodialysis. Studies assessing the effect of increased protein intake on nutritional status generally show beneficial results, especially in hypoalbuminemic chronic hemodialysis patients. The muscle protein synthetic response following protein ingestion in chronic hemodialysis patients may be enhanced through incorporation of structured physical activity and/or concurrent ketoacid ingestion. SUMMARY A coordinated program that combines nutritional and physical activity interventions is likely required to attenuate the decline in muscle mass and strength of chronic hemodialysis patients. Nephrologists, dieticians, and exercise specialists should collaborate closely to establish guidelines regarding the appropriate quantity and timing of protein ingestion. In addition, they should provide tailored nutritional and physical activity interventions for chronic hemodialysis patients (see video, Supplemental Digital Content 1, Video abstract, http://links.lww.com/COCN/A14).
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Affiliation(s)
- Floris K. Hendriks
- Department of Human Biology
- Department of Internal Medicine, NUTRIM School of Nutrition and Translational Research in Metabolism
| | - Jeroen P. Kooman
- Department of Internal Medicine, NUTRIM School of Nutrition and Translational Research in Metabolism
- Division of Nephrology, Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
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13
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Moore LW, Kalantar-Zadeh K. Implementing the "Advancing American Kidney Health Initiative" by Leveraging Nutritional and Dietary Management of Kidney Patients. J Ren Nutr 2020; 29:357-360. [PMID: 31472903 DOI: 10.1053/j.jrn.2019.07.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 07/31/2019] [Indexed: 02/08/2023] Open
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Bolasco P. Hemodialysis-Nutritional Flaws in Diagnosis and Prescriptions. Could Amino Acid Losses be the Sharpest "Sword of Damocles"? Nutrients 2020; 12:nu12061773. [PMID: 32545868 PMCID: PMC7353226 DOI: 10.3390/nu12061773] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 06/01/2020] [Accepted: 06/10/2020] [Indexed: 02/06/2023] Open
Abstract
This review aims to highlight the strengths and weaknesses emerging from diagnostic evaluations and prescriptions in an intent to prevent progression over time of malnutrition and/or protein-energy wasting (PEW) in hemodialysis (HD) patients. In particular, indications of the most effective pathway to follow in diagnosing a state of malnutrition are provided based on a range of appropriate chemical-clinical, anthropometric and instrumental analyses and monitoring of the nutritional status of HD patients. Finally, based on the findings of recent studies, therapeutic options to be adopted for the purpose of preventing or slowing down malnutrition have been reviewed, with particular focus on protein-calorie intake, the role of oral and/or intravenous supplements and efficacy of some classes of amino acids. A new determining factor that may lead inexorably to PEW in hemodialysis patients is represented by severe amino acid loss during hemodialysis sessions, for which mandatory compensation should be introduced.
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Affiliation(s)
- Piergiorgio Bolasco
- Nephrology Consultant, Sardinian Regional Public Health Institution, 09047 Selargius, Italy; ; Tel.: +39-333-2914-844; Fax: +39-070-609-3240
- Chronic Kidney Disease Treatment Group of the Italian Society of Nephrology, University Street, 11, 00185 Rome, Italy
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15
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Brook MS, Wilkinson DJ, Atherton PJ. An update on nutrient modulation in the management of disease-induced muscle wasting: evidence from human studies. Curr Opin Clin Nutr Metab Care 2020; 23:174-180. [PMID: 32175954 DOI: 10.1097/mco.0000000000000652] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW Skeletal muscle has many essential roles in maintaining human health, not only being crucial for locomotion, but further as a metabolically important organ. Muscle wasting in disease (cachexia) is highly prevalent, associated with poor clinical outcomes and is not fully reversible with nutritional interventions. Understanding proteostasis in diseased states is of great importance to design novel, effective nutritional/nutraceutical strategies aimed at alleviating muscle wasting. In this review, we will provide an update on muscle kinetics in disease and the effects of nutritional interventions. RECENT FINDINGS Whole body and skeletal muscle kinetics are commonly shown to be imbalanced in disease, promoting overall catabolism that underlies the development of cachexia. However, recent advancements in defining the effectiveness of nutritional interventions on muscle anabolism are clouded by heterogenous patient populations and a lack of direct incorporation stable isotope techniques. Current recommendations are focused on combating malnutrition, with increased protein intake (high in EAA) demonstrating promise. SUMMARY Recent progress in understanding catabolic states in cachexia across disease is minimal. Further, studies investigating muscle-specific protein turnover along with nutritional interventions are scarce. As such, there is a significant requirement for strong RCT's investigating both acute and chronic nutritional interventions and their impact on skeletal muscle in individual disease states.
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Affiliation(s)
- Matthew S Brook
- MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research, Clinical, Metabolic and Molecular Physiology, National Institute for Health Research Nottingham Biomedical Research Centre, University of Nottingham, Royal Derby Hospital Centre, Derby
- Queens Medical Centre, Nottingham, UK
| | - Daniel J Wilkinson
- MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research, Clinical, Metabolic and Molecular Physiology, National Institute for Health Research Nottingham Biomedical Research Centre, University of Nottingham, Royal Derby Hospital Centre, Derby
| | - Philip J Atherton
- MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research, Clinical, Metabolic and Molecular Physiology, National Institute for Health Research Nottingham Biomedical Research Centre, University of Nottingham, Royal Derby Hospital Centre, Derby
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16
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Intradialytic Nutrition and Hemodialysis Prescriptions: A Personalized Stepwise Approach. Nutrients 2020; 12:nu12030785. [PMID: 32188148 PMCID: PMC7146606 DOI: 10.3390/nu12030785] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 03/11/2020] [Accepted: 03/13/2020] [Indexed: 12/11/2022] Open
Abstract
Dialysis and nutrition are two sides of the same coin—dialysis depurates metabolic waste that is typically produced by food intake. Hence, dietetic restrictions are commonly imposed in order to limit potassium and phosphate and avoid fluid overload. Conversely, malnutrition is a major challenge and, albeit to differing degrees, all nutritional markers are associated with survival. Dialysis-related malnutrition has a multifactorial origin related to uremic syndrome and comorbidities but also to dialysis treatment. Both an insufficient dialysis dose and excessive removal are contributing factors. It is thus not surprising that dialysis alone, without proper nutritional management, often fails to be effective in combatting malnutrition. While composite indexes can be used to identify patients with poor prognosis, none is fully satisfactory, and the definitions of malnutrition and protein energy wasting are still controversial. Furthermore, most nutritional markers and interventions were assessed in hemodialysis patients, while hemodiafiltration and peritoneal dialysis have been less extensively studied. The significant loss of albumin in these two dialysis modalities makes it extremely difficult to interpret common markers and scores. Despite these problems, hemodialysis sessions represent a valuable opportunity to monitor nutritional status and prescribe nutritional interventions, and several approaches have been tried. In this concept paper, we review the current evidence on intradialytic nutrition and propose an algorithm for adapting nutritional interventions to individual patients.
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Lambert K, Conley MM. Practice Patterns Relating to the Use of Intradialytic Parenteral Nutrition in Australian Renal Units: Results From a Survey of Renal Dietitians. J Ren Nutr 2020; 30:163-167. [DOI: 10.1053/j.jrn.2019.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 05/20/2019] [Accepted: 05/27/2019] [Indexed: 11/11/2022] Open
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