The renal dietitian's role in managing hyperphosphatemia and secondary hyperparathyroidism in dialysis patients: a national survey

Dietary egg whites for phosphorus control in maintenance haemodialysis patients: a pilot study

BACKGROUND

High dietary protein intake is associated with greater survival in maintenance haemodialysis (MHD) patients. High-protein foods may increase dietary phosphorus burden, which is associated with increased mortality in these patients. Hypothesis is: an egg white based diet with low phosphorus to protein ratio (<1.4 mg/g) will lower serum phosphorus without deteriorating the nutritional status in MHD patients.

OBJECTIVE

We assessed serum phosphorus and albumin levels in MHD patients who agreed to ingest one meal per day with pasteurised liquid egg whites without phosphorus additives, as principal protein source.

METHODS

Thirteen otherwise stable MHD patients with serum phosphorus >4.0 mg/dl agreed to consume eight ounces (225 g) of pasteurised liquid egg whites one meal per day for six weeks. Recipes were suggested to improve diet variety.

RESULTS

Thirteen participating patients included seven women, three African Americans and five diabetics. Twelve patients exhibited drop in serum phosphorus. Mean population fall in serum phosphorus was 0.94 mg/dl, i.e. from 5.58 ± 1.34 (mean ± SD) to 4.63 ± 1.18 (p = 0.003). Serum albumin showed an increase by 0.19 g/dl, i.e. from 4.02 ± 0.29 to 4.21 ± 0.36 g/dl (p = 0.014). Changes in phosphorus pill count were not statistically significant (p = 0.88). The egg white diet was well tolerated, and recipe variety appreciated.

CONCLUSION

Pasteurised liquid egg whites may be an effective diet component lowering serum phosphorus without risking malnutrition. Controlled trials are indicated to examine egg white based dietary interventions in MHD patients at home or during haemodialysis treatment.

Adequacy of dialysis clinic staffing and quality of care: a review of evidence and areas of needed research

Improving the quality of care delivered to patients receiving in-center dialysis treatment remains a perpetual concern with stakeholders. Quality indicators traditionally have focused on such items as adequacy of dialysis, anemia management, patient survival, and, most recently, the percentage using arteriovenous fistulas. Largely overlooked in the quest for improvement has been adequate consideration of dialysis clinic staffing levels. Staffing is important because it has been identified as a structural measure of quality. With 326,671 (93.1%) of all dialysis patients receiving in-center treatments, this is a potentially critical issue. This article reviews evidence related to inadequacies in clinic staffing and how they may be contributing to suboptimal care and outcomes. Focusing on nephrologists, nurses, patient care technicians, dietitians, and social workers, this article suggests areas of needed research.

Is controlling phosphorus by decreasing dietary protein intake beneficial or harmful in persons with chronic kidney disease?

BACKGROUND

Dietary restrictions to control serum phosphorus, which are routinely recommended to persons with chronic kidney disease, are usually associated with a reduction in protein intake. This may lead to protein-energy wasting and poor survival.

OBJECTIVE

We aimed to ascertain whether a decline in serum phosphorus and a concomitant decline in protein intake are associated with an increase in the risk of death.

DESIGN

In a 3-y study (7/2001-6/2004) of 30 075 prevalent maintenance hemodialysis (MHD) patients, we examined changes in serum phosphorus and in normalized protein nitrogen appearance (nPNA), a surrogate of dietary protein intake, during the first 6 mo and the subsequent mortality. Four groups of MHD patients were defined on the basis of the direction of the changes in serum phosphorus and nPNA.

RESULTS

Baseline phosphorus had a J-shaped association with mortality, whereas higher baseline nPNA was linearly associated with greater survival. Compared with MHD patients whose serum phosphorus and nPNA both rose over 6 mo, those whose serum phosphorus decreased but whose nPNA increased had greater survival, with a case mix-adjusted death risk ratio of 0.90 (95% confidence limits: 0.86, 0.95; P < 0.001), whereas those whose phosphorus increased but whose nPNA decreased or those whose phosphorus and nPNA both decreased had worse mortality with a risk ratio of 1.11 (1.05,1.17; P < 0.001) and 1.06 (1.01,1.12; P = 0.02), respectively.

CONCLUSIONS

The risk of controlling serum phosphorus by restricting dietary protein intake may outweigh the benefit of controlled phosphorus and may lead to greater mortality. Additional studies including randomized controlled trials should examine whether nondietary control of phosphorus or restriction of nonprotein sources of phosphorus is safer and more effective.