Protein and energy: recommended intake and nutrient supplementation in chronic dialysis patients

Nutritional Status and Other Clinical Variables Are Associated to the Resting Energy Expenditure in Patients With Chronic Kidney Disease: A Validity Study

Background

Estimating energy requirements (ER) is crucial for nutritional attention to chronic kidney disease (CKD) patients. Current guidelines recommend measuring ER with indirect calorimetry (IC) when possible. Due to clinical settings, the use of simple formulas is preferred. Few studies have modeled equations for estimating ER for CKD. Nevertheless, variables of interest such as nutritional status and strength have not been explored in these models. This study aimed to develop and validate a model for estimating REE in patients with CKD stages 3–5, who were not receiving renal replacement therapy (RTT), using clinical variables and comparing it with indirect calorimetry as the gold standard.

Methods

In this study 80 patients with CKD participated. Indirect calorimetry (IC) was performed in all patients. The calorimeter analyzed metabolic measurements every minute for 15 min after autocalibration with barometric pressure, temperature, and humidity. Bioelectrical Impedance Analysis (BIA) was performed. Fat-free mass (FFM) was registered among other bioelectrical components. Handgrip strength (HGS) was evaluated and an average of 3 repetitions was recorded. Nutritional status was assessed with the subjective global assessment (SGA). Patients categorized as B or C were then considered as having malnutrition.

Results

We analyzed 71 patients and 3 models were generated. Model 1a included FFM; Model 2a included weight; Model 3c included handgrip strength (HGS). All other variables were stepwise, computer-selected with a p < 0.01 significance level; Malnutrition was consistently associated with ER among other clinical variables in all models (p < 0.05). The model that included BIA-FFM had R²_adjusted = 0.46, while the model that included weight (Kg) had an adjusted R²_adjusted = 0.44. The models had moderate concordance, LC = 0.60–0.65 with the gold standard, whereas other energy expenditure estimation equations had LC = 0.36 and 0.55 with indirect calorimetry. Using these previously validated equations as a reference, our models had concordance values ranging from 0.66 to 0.80 with them.

Conclusion

Models incorporating nutritional status and other clinical variables such as weight, FFM, comorbidities, gender, and age have a moderate agreement with REE. The agreement between our models and others previously validated for the CKD patient is good; however, the agreement between the latter and IC measurements is moderate. The KDOQI lowest recommendation (25 Kcals/kg body weight) considering the 22% difference with respect to the IC for total energy expenditure rather than for REE.

Methods and Nutritional Interventions to Improve the Nutritional Status of Dialysis Patients in JAPAN-A Narrative Review

Patients receiving dialysis therapy often have frailty, protein energy wasting, and sarcopenia. However, medical staff in Japan, except for registered dietitians, do not receive training in nutritional management at school or on the job. Moreover, registered dietitians work separately from patients and medical staff even inside a hospital, and there are many medical institutions that do not have registered dietitians. In such institutions, medical staff are required to manage patients' nutritional disorders without assistance from a specialist. Recent studies have shown that salt intake should not be restricted under conditions of low nutrition in frail subjects or those undergoing dialysis, and protein consumption should be targeted at 0.9 to 1.2 g/kg/day. The Japanese Society of Dialysis Therapy suggests that the Nutritional Risk Index-Japanese Hemodialysis (NRI-JH) is a useful tool to screen for older patients with malnutrition.

Malnutrition, inflamation and atherosclerosis (MIA syndrome) in patients with end stage renal disease on maintenance hemodialysis (a single centre experience)

BACKGROUND

Inflammation and malnutrition play an important role in endothelial dysfunction, atherosclerosis and excessive cardiovascular morbidity and mortality in ESRD patients AIM OF THE STUDY: The primary objective is to determine the prevalence of inflammation, malnutrition and atherosclerosis in patients on maintenance haemodialysis. Secondary objective was to determine the association for atherosclerosis with inflammation and malnutrition.

PATIENT AND METHODS

One hundred and one adult patients with end stage renal disease on maintenance haemodialysis who are met with the exclusion criteria were enrolled in this cross sectional study from haemodialysis unit of Baghdad teaching hospital over the period of July/2015 - June 2016. All patients were thoroughly examined and many variables were evaluated (age, gender, blood pressure, diabetes mellitus, serum lipid profile, smoking habits, serum albumin, CRP, calcium, Phosphate, Parathyroid hormone and haemoglobin measurements). All patients underwent a carotid Doppler ultrasound study.

RESULTS

Atherosclerosis was present in 65.3%: 58.4% of patients had malnutrition and 43.6% had inflammation. The association for atherosclerosis and high CRP and low serum albumin is strong and independent of other atherosclerosis risk factors. There is significant inverse and independent correlation between CRP and albumin.

CONCLUSION

Inflammation (high serum CRP) and malnutrition (low serum albumin) in patients on haemodialysis are significantly associated with carotid atherosclerosis. Inflammation was more prevalent in the malnourished patients than in those with normal nutritional status.

Comparison of a Handheld Indirect Calorimetry Device and Predictive Energy Equations Among Individuals on Maintenance Hemodialysis

OBJECTIVES

Practical methods for determining resting energy expenditure (REE) among individuals on maintenance hemodialysis (MHD) are needed because of the limitations of indirect calorimetry. Two disease-specific predictive energy equations (PEEs) have been developed for this metabolically complex population. The aim of this study was to compare estimated REE (eREE) by PEEs to measured REE (mREE) with a handheld indirect calorimetry device (HICD).

METHODS

A prospective pilot study of adults on MHD (N = 40) was conducted at 2 dialysis clinics in Houston and Texas City, Texas. mREE by an HICD was compared with eREE determined by 6 PEEs using Bland-Altman analysis with a band of acceptable agreement of ±10% of the group mean mREE. Paired t-test and the intraclass correlation coefficient were also used to compare the alternate methods of measuring REE. A priori alpha was set at P < .05.

RESULTS

The mean (±standard deviation) age was 56.7 ± 12.9 years, 52.5% (n = 21) were female, and 85% (n = 34) were African American. Body mass index (BMI) ranged from 18.1 to 47.1 kg/m², 67.5% were overweight (BMI ≥25 kg/m²) and 50% were obese (BMI ≥30 kg/m²). The Maintenance Hemodialysis Equation-Creatinine version (MHCD-CR) was the most accurate PEE with 52.5% of values within the band of acceptable agreement, followed by the Mifflin-St. Jeor Equation and the Vilar et al. Equation at 45.0% and 42.5%, respectively.

CONCLUSION

When compared with mREE by the HICD, the MHDE-CR was more accurate and precise than other PEEs evaluated; however, this must be interpreted with caution as mREE was consistently lower than eREE from all PEEs. Further research is needed to validate the MHDE-CR and other practical methods for determining REE among individuals on MHD.

Dietary Approaches in the Management of Diabetic Patients with Kidney Disease

Chronic kidney disease (CKD) is one of the most prevalent complications of diabetes, and patients with diabetic kidney disease (DKD) have a substantially higher risk of cardiovascular disease and death compared to their non-diabetic CKD counterparts. In addition to pharmacologic management strategies, nutritional and dietary interventions in DKD are an essential aspect of management with the potential for ameliorating kidney function decline and preventing the development of other end-organ complications. Among DKD patients with non-dialysis dependent CKD, expert panels recommend lower dietary protein intake of 0.8 g/kg of body weight/day, while higher dietary protein intake (>1.2 g/kg of body weight/day) is advised among diabetic end-stage renal disease patients receiving maintenance dialysis to counteract protein catabolism, dialysate amino acid and protein losses, and protein-energy wasting. Carbohydrates from sugars should be limited to less than 10% of energy intake, and it is also suggested that higher polyunsaturated and monounsaturated fat consumption in lieu of saturated fatty acids, trans-fat, and cholesterol are associated with more favorable outcomes. While guidelines recommend dietary sodium restriction to less than 1.5-2.3 g/day, excessively low sodium intake may be associated with hyponatremia as well as impaired glucose metabolism and insulin sensitivity. As patients with advanced DKD progressing to end-stage renal disease may be prone to the "burnt-out diabetes" phenomenon (i.e., spontaneous resolution of hypoglycemia and frequent hypoglycemic episodes), further studies in this population are particularly needed to determine the safety and efficacy of dietary restrictions in this population.

Correlations of dietary energy and protein intakes with renal function impairment in chronic kidney disease patients with or without diabetes

Dietary energy and protein intake can affect progression of chronic kidney disease (CKD). CKD complicated with diabetes is often associated with a decline in renal function. We investigated the relative importance of dietary energy intake (DEI) and dietary protein intake (DPI) to renal function indicators in nondiabetic and diabetic CKD patients. A total of 539 Stage 3-5 CKD patients [estimated glomerular filtration rate (eGFR)<60 mL/min/1.73 m² using the Modification of Diet in Renal Disease equation] with or without diabetes were recruited from outpatient clinics of Nephrology and Nutrition in a medical center in Taiwan. Appropriateness of DEI and DPI was used to subcategorize CKD patients into four groups:(1) kidney diet (KD) A (KD-A), the most appropriate diet, was characterized by low DPI and adequate DEI; (2) KD-B, low DPI and inadequate DEI; (3) KD-C, excess DPI and adequate DEI; and (4) KD-D, the least appropriate diet, excess DPI and inadequate DEI. Inadequate DEI was defined as a ratio of actual intake/recommended intake less than 90% and adequate DEI as over 90%. Low DPI was defined as less than 110% of recommended intake and excessive when over 110%. Outcome measured was eGFR. In both groups of CKD patients, DEI was significantly lower (p<0.001) and DPI higher (p=0.002) than recommended levels. However, only in the nondiabetic CKD patients were KD-C and KD-D significantly correlated with reduced eGFR compared with KD-A at increments of -5.63 mL/min/1.73 m² (p = 0.029) and -7.72 mL/min/1.73 m² (p=0.015). In conclusion, inadequate energy and excessive protein intakes appear to correlate with poorer renal function in nondiabetic CKD patients. Patients with advanced CKD are in need of counseling by dietitians to improve adherence to diets.

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.

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.

Dialysis adequacy and nutritional status of hemodialysis patients

To characterize the nutritional status of renal failure patients and its relationship with hemodialysis adequacy measured by Kt/V, a study was carried out with a population of 44 adult patients with renal failure and mean age 51+/-15 years. Anthropometric data, such as dry weight, height, arm circumference, triceps skinfold thickness, mid-arm muscle circumference, and body mass index were assessed, and biochemical tests were conducted for urea, potassium, creatinine, serum albumin, and phosphorus levels, in addition to hemogram and quarterly urea reduction rate average (Kt/V). In order to evaluate calorie intake, a dietary questionnaire on habitual daily food ingestion was administered, taking into consideration the hemodialysis date. The patients were divided into 2 separate groups for the statistical analysis, with 50% of the patients in each group: A (Kt/V<1.2) and B (Kt/V>1.2). The data were tabulated as mean and standard deviation, with differences tested by Student's t test. The correlations between variables were established by the coefficient p of Pearson. Most of the patients (43%) were considered eutrophic, based on the BMI, and presented inadequate calorie intake, corresponding to 88.5+/-24% (30.8 kcal/kg actual weight) of the total energy required and adequate protein intake, reaching 109.9+/-40% of the recommended daily allowance (1.24 g/kg of actual weight). There was a correlation of Kt/V with anthropometric parameters such as body mass index, arm circumference, and mid-arm muscle circumference. The biochemical parameters related to dialysis adequacy were albumin, ferritin, and urea (predialysis). Well-dialyzed patients presented better levels of serum albumin. There was an influence of gender and age on correlations of the analyzed variables. Female and younger patients presented better dialysis adequacy. The dialysis adequacy was related to the nutritional status and influenced by the protein intake and body composition. Gender and age had an important influence in the dialysis adequacy, as men presented lower dialysis adequacy and younger adults presented better dialysis adequacy. Further research is necessary to understand better how to facilitate effective and efficient techniques for the nutritional status assessment of hemodialysis patients.

Assessing the prevalence of malnutrition in chronic kidney disease patients in jordan

OBJECTIVE

The study objective was to validate the use of subjective global assessment (SGA) in assessing the prevalence of malnutrition among patients on hemodialysis in Jordan by comparing SGA grades with anthropometric and biochemical measurements.

DESIGN

This was a cross-sectional survey.

SETTING

The study was performed at hospital hemodialysis units.

PATIENTS

End-stage renal-failure outpatients (n = 178; 94 women and 84 men; mean age +/- SD, 43.9 +/- 14.6 years) who underwent hemodialysis were recruited from five large Jordanian hospitals. The obtained data were compared with tabulated measurements of the reference population in term of age and sex.

MAIN OUTCOME MEASURES

Subjective global assessment, anthropometric (dry weight, body mass index, fat percentage, fat mass, triceps skinfold thickness, mid-arm circumference, mid-arm muscle circumference, and arm muscle area), and biochemical (albumin, total protein, hemoglobin, creatinine, urea, cholesterol, phosphorus, calcium, and potassium) measurements were assessed in all patients.

RESULTS

In this study, 56.2% of patients on hemodialysis were moderately malnourished, and 5.6% were severely malnourished. Age was inversely associated with patients' nutritional status as well as SGA grades. The findings also suggest a significant (P < .001) decrease in some anthropometric parameters (dry weight, body mass index, fat percentage, fat mass, triceps skinfold thickness, mid-arm circumference, mid-arm muscle circumference, and arm muscle area) with advanced malnutrition.

CONCLUSION

A comparison of SGA grades with biochemical and anthropometric variables indicated that SGA could be used to assess nutritional status in patients on hemodialysis. Overall, about 38.2% of patients were well-nourished. Age and duration of hemodialysis appeared to be associated with nutritional status.

Inadequate energy and excess protein intakes may be associated with worsening renal function in chronic kidney disease

OBJECTIVES

Dietary energy and protein play important roles in chronic kidney disease (CKD). This study investigates the relationship between energy/protein intake status and renal function in CKD.

DESIGN AND STUDY POPULATION

This cross-sectional study included 599 adult patients diagnosed with stage 3 to 5 CKD in nephrology and nutrition outpatient clinics in Taiwan.

MAIN OUTCOME MEASURE

Energy and protein intakes were assessed using 24-h dietary recall. We recorded recommended calorie/protein amounts and renal function indices, glomerular filtration rate (GFR), creatinine, and blood urea nitrogen (BUN). Patients were categorized into three intake calorie/protein groups by a ratio of actual intake vs. recommended intake. High intake was defined as a ratio of actual intake/recommended intake > or = 110%, moderate intake as > or = 90% to <110%, and low intake as <90%. Data were analyzed by paired t test, one-way analysis of variance, least significant differences, and multiple linear regression.

RESULTS

The energy and protein intakes in CKD patients were significantly higher and lower than recommended levels (P < .001). Low energy intake was significantly related to worsening GFR at increments of -4.41 mL/min/1.73 m(2), compared with moderate and high energy intake (P = .008); high protein intake was also associated with worsening GFR at increments of -3.50 mL/min/1.73m(2), compared with moderate and low protein intake (P < .001). Low energy intake and high protein intake were significantly positively correlated with elevations in creatinine and BUN.

CONCLUSION

Lower energy and higher protein intakes than recommended may be associated with deteriorating renal function.

Skeletal muscle dysfunction in chronic renal failure: effects of exercise

A number of chronic illnesses such as renal failure (CRF), obstructive pulmonary disease, and congestive heart failure result in a significant decrease in exercise tolerance. There is an increasing awareness that prescribed exercise, designed to restore some level of physical performance and quality of life, can be beneficial in these conditions. In CRF patients, muscle function can be affected by a number of direct and indirect mechanisms caused by renal disease as well as various treatment modalities. The aims of this review are twofold: first, to briefly discuss the mechanisms by which CRF negatively impacts skeletal muscle and, therefore, exercise capacity, and, second, to discuss the available data on the effects of programmed exercise on muscle function, exercise capacity, and various other parameters in CRF.

Nutritional Parameters and Mortality in Incident Hemodialysis Patients

OBJECTIVE

To evaluate the impact of nutritional parameters at the time of initiation of hemodialysis (HD) on mortality.

DESIGN

Retrospective study.

SETTING

Dialysis Unit of the Federal University of Sao Paulo, Oswaldo Ramos Foundation.

PATIENTS

Three hundred forty-four incident HD patients (60.5% male, 26% diabetic) with the first nutritional evaluation performed before completing 3 months of onset of HD were included.

METHODS

The study consisted of baseline measurements of several nutritional parameters (triceps skinfold thickness [TSF], midarm muscle circumference [MAMC], body mass index [BMI], serum albumin, serum creatinine, and protein and energy intake assessed by 3-day food diary) and records of outcome (death) over a period of 10 years.

RESULTS

Muscle and/or fat depletion was observed in 51% of the studied patients, according to the percent standard of MAMC and TSF, respectively. Presence of diabetes, age over 60 years, serum albumin < 3.5 g/dL, MAMC adequacy < 90%, protein intake < 1.0 g/kg/d, and energy intake < 25 kcal/kg/d were associated with worse survival. When patients were analyzed according to tertiles of dialysis vintage, BMI > or = 25 (calculated as kg/m2) had a negative impact on survival only in the highest tertile (> 2.45 years). Patients with BMI < 25 and MAMC adequacy > or = 90% showed the best survival over the study period, and those with BMI > or = 25 but MAMC adequacy < 90% had the worst survival (P = .004). In the multivariate survival analysis adjusting for diabetes, advanced age, and hypoalbuminemia, the reduced MAMC (P = .008) and the low energy intake (P = .03) were independent predictors of death in incident HD patients.

CONCLUSIONS

Reduced MAMC and low energy intake at the beginning of chronic dialysis are risk factors for mortality. A negative effect of high BMI on survival was associated with reduced MAMC and longer dialysis vintage.