A Clinical Review on Nutritional Requirements and Assessment for Type 2 Diabetes Mellitus with Chronic Renal Disease

BACKGROUND

A significant correlation exists between type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD), where up to 40% of diabetic patients suffer from CKD as a direct result of diabetic complications. The management of diabetes in CKD patients can be challenging due to their need for disease-specific diets, as well as increased risks of complications due to malnutrition, which is why their dietary needs and nutritional requirements require attention to detail, and have to be assessed and tailored according to the patient's needs.

OBJECTIVES

This systematic review aimed to assess nutritional requirements for type 2 diabetes mellitus patients with chronic renal failure.

METHODS

In this review, 85 articles were screened, and 22 articles were then analyzed and selected as per the study criteria. PRISMA guidelines were used to select and screen the articles. Data search included a PubMed search using MeSH terms, and a literature review through the Cochrane library and the British Medical Journal.

RESULTS

The study highlighted the important nutrients and minerals needed to be maintained within a specified range in accordance with the patient's needs and conditions. In addition, dietary restrictions must be set to prevent disease progression and deterioration. Dietary intake in hemodialysis patients must be carefully calculated based on their needs, with tight monitoring of their blood glucose. Protein intake in hemodialysis patients should be determined based on risk-to-benefit ratios.

CONCLUSION

Dietary requirements should be individualized based on the patient's disease severity and progression. Assessment of the patient's previous and current diet, as well as matching it with their dietary requirements and preferences is crucial.

Dietary intake in type 1 diabetes at different stages of diabetic kidney disease

AIM

Diet plays an important role in the kidney health of individuals with type 1 diabetes. However, not much is known about dietary practices at different stages of diabetic nephropathy. We aimed at investigating food intake, dietary patterns, and nutrient intakes in individuals with type 1 diabetes differing in renal status.

METHODS

Data were available from 1874 individuals with type 1 diabetes (45% men, age 48 ± 13 years). Diet was assessed at the levels of food items and diet patterns (diet questionnaire), and energy and nutrient intakes (food record). Six groups were formed based on the eGFR or dialysis and transplantation status.

RESULTS

Reductions in liquid-milk product and salt consumption, and increase in special diet adherence were observed at the early stages of eGFR decline. Reduced coffee consumption was observed after eGFR was <30 ml/min/1.73 m². With advancing kidney failure, rye bread consumption decreased, but that of wheat bread increased. Compared to those with intact kidney function (the index group), the Fish and vegetable diet pattern scores were higher in individuals with mildly-to-severely decreased eGFR. Instead, the Sweet pattern scores were lower than in the index group in all other groups. Energy intake was lower in all groups compared to those with intact kidney function. Advancing kidney failure was associated with reductions in protein intake per body weight, and in the intakes of sodium, potassium, calcium, and phosphorus.

CONCLUSIONS

Differences in the dietary intake are seen already at the early stages of kidney function decline.

The combined diabetes and renal control trial (C-DIRECT) - a feasibility randomised controlled trial to evaluate outcomes in multi-morbid patients with diabetes and on dialysis using a mixed methods approach

BACKGROUND

This cluster randomised controlled trial set out to investigate the feasibility and acceptability of the "Combined Diabetes and Renal Control Trial" (C-DIRECT) intervention, a nurse-led intervention based on motivational interviewing and self-management in patients with coexisting end stage renal diseases and diabetes mellitus (DM ESRD). Its efficacy to improve glycaemic control, as well as psychosocial and self-care outcomes were also evaluated as secondary outcomes.

METHODS

An assessor-blinded, clustered randomised-controlled trial was conducted with 44 haemodialysis patients with DM ESRD and ≥ 8% glycated haemoglobin (HbA1c), in dialysis centres across Singapore. Patients were randomised according to dialysis shifts. 20 patients were assigned to intervention and 24 were in usual care. The C-DIRECT intervention consisted of three weekly chair-side sessions delivered by diabetes specialist nurses. Data on recruitment, randomisation, and retention, and secondary outcomes such as clinical endpoints, emotional distress, adherence, and self-management skills measures were obtained at baseline and at 12 weeks follow-up. A qualitative evaluation using interviews was conducted at the end of the trial.

RESULTS

Of the 44 recruited at baseline, 42 patients were evaluated at follow-up. One patient died, and one discontinued the study due to deteriorating health. Recruitment, retention, and acceptability rates of C-DIRECT were generally satisfactory HbA1c levels decreased in both groups, but C-DIRECT had more participants with HbA1c < 8% at follow up compared to usual care. Significant improvements in role limitations due to physical health were noted for C-DIRECT whereas levels remained stable in usual care. No statistically significant differences between groups were observed for other clinical markers and other patient-reported outcomes. There were no adverse effects.

CONCLUSIONS

The trial demonstrated satisfactory feasibility. A brief intervention delivered on bedside as part of routine dialysis care showed some benefits in glycaemic control and on QOL domain compared with usual care, although no effect was observed in other secondary outcomes. Further research is needed to design and assess interventions to promote diabetes self-management in socially vulnerable patients.

TRIAL REGISTRATION NUMBER

Trial registered with the International Standard Randomised Controlled Trial (ISRCTN10546597). Registered 12 September 2016 (Retrospectively registered).

Malnutrition and Metabolic Changes in Patients with Type 2 Diabetes

Background/Aim: In patients with type 2 diabetes (T2D), malnutrition has been recognized as a serious health problem mainly in hospitalized conditions, but there is little data regarding malnutrition outside hospital settings. The aim of this study was to evaluate the risk of malnutrition and associated metabolic changes in ambulatory patients with T2D.

Material and methods: This analysis used data collected from 161 patients with T2D enrolled in a larger cross-sectional study. Several anthropometric and metabolic parameters were obtained. Nutritional status was evaluated using the Controlling Nutritional Status (CONUT) score. Correlations between nutritional status and metabolic and anthropometric parameters of interest were examined.

Results: Of all T2D patients, 29.8% had mild malnutrition (CONUT score 2–4). These patients presented lower triglyceride (124.8 ± 42.3 mg/dL vs. 165.7 ± 84.3 mg/dL, p <0.01) and LDL cholesterol concentrations (62.7 ± 20.0 mg/dL vs. 104.9 ± 30.6 mg/dL, p <0.0001), higher leptin levels (10.2 [1.6–44.9] ng/mL vs. 7.3 [0.9–49.8] ng/mL, p <0.05) and free leptin index (0.65 [0.04–2.88] vs. 0.36 [0.01–3.98], p <0.05) compared with patients with normal nutritional status. They also had higher total body adiposity. In patients with obesity, triglycerides levels were lower in those with mild malnutrition vs. those without malnutrition (mean difference: 27.26 mg/dL, p <0.05). Serum C peptide/leptin ratio was higher in T2D patients with normal nutritional status without obesity, the differences being significant vs. the two groups with obesity (with or without malnutrition, 0.71 ± 0.53, 0.42 ± 0.33, and 0.49 ± 0.68, respectively). HOMA-IR was lower in patients with normal nutritional status without obesity vs. those with obesity (mean difference: −0.7126, p <0.05), while in patients with mild malnutrition, HOMA-IR values were higher, but no differences were noted between the groups with or without obesity.

Conclusion: In patients with T2D, malnutrition associated with lower triglycerides concentrations, even in the presence of obesity. Malnutrition and/or obesity associated with higher HOMA-IR, serum leptin levels and lower C peptide/leptin ratio.

Management of adults with diabetes on the haemodialysis unit: summary of guidance from the Joint British Diabetes Societies and the Renal Association

Diabetic nephropathy remains the principal cause of end-stage renal failure in the UK and its prevalence is set to increase. People with diabetes and end-stage renal failure on maintenance haemodialysis are highly vulnerable, with complex comorbidities, and are at high risk of adverse cardiovascular outcomes, the leading cause of mortality in this population. The management of people with diabetes receiving maintenance haemodialysis is shared between diabetes and renal specialist teams and the primary care team, with input from additional healthcare professionals providing foot care, dietary support and other aspects of multidisciplinary care. In this setting, one specialty may assume that key aspects of care are being provided elsewhere, which can lead to important components of care being overlooked. People with diabetes and end-stage renal failure require improved delivery of care to overcome organizational difficulties and barriers to communication between healthcare teams. No comprehensive guidance on the management of this population has previously been produced. These national guidelines, the first in this area, bring together in one document the disparate needs of people with diabetes on maintenance haemodialysis. The guidelines are based on the best available evidence, or on expert opinion where there is no clear evidence to inform practice. We aim to provide clear advice to clinicians caring for this vulnerable population and to encourage and improve education for clinicians and people with diabetes to promote empowerment and self-management.

Low-protein diet supplemented with ketoacids delays the progression of diabetic nephropathy by inhibiting oxidative stress in the KKAy mice model

Diabetic nephropathy (DN) is a major cause of chronic kidney disease. We aimed to investigate the effect of the low-protein diets (LPD) supplemented with ketoacids (LPD+KA) in KKAy mice, an early type 2 DN model. KKAy mice were treated with normal protein diet (NPD), LPD or LPD+KA from 12 to 24 weeks of age. A period of 12-week treatment with LPD significantly reduced albuminuria as compared with that observed after NPD treatment. Treatment with LPD+KA further reduced albuminuria as compared with that observed with LPD treatment alone. Moreover, LPD treatment reduced mesangial expansion, thickness of glomerular basement membrane and the severity of the podocyte foot process effacement in KKAy mice; these effects were more pronounced in KKAy mice treated with LPD+KA. Both LPD and LPD+KA treatments slightly reduced total body weight, but had no significant effect on kidney weight and blood glucose concentrations when compared with NPD-treated KKAy mice. LPD treatment slightly attenuated oxidative stress in kidneys as compared with that observed in NPD-treated KKAy mice; however, LPD+KA treatment remarkably ameliorated oxidative stress in diabetic kidneys as shown by decreased malondialdehyde concentrations, protein carbonylation, nitrotyrosine expression and increased superoxide dismutase expression. Nutritional therapy using LPD+KA confers additional renal benefits as compared with those of LPD treatment alone in early type 2 DN through inhibition of oxidative stress.

Prevalence and determinants of anxiety and depression in end stage renal disease (ESRD). A comparison between ESRD patients with and without coexisting diabetes mellitus

OBJECTIVE

To compare anxiety and/or depressive symptoms between patients with end-stage renal disease with and without comorbid diabetes and identify factors associated with symptoms of distress in this population.

METHODS

Data from two studies (conducted between 2010 and 2014) were pooled. A total of 526 patients on hemodialysis (68.8% with diabetes) completed the Hospital Anxiety and Depression Scale (HADS). Elevated symptoms were defined as HADS-Anxiety or HADS-Depression≥8. Univariate and multivariate logistic regressions were used to estimate associations between diabetic status, and other socio-demographic and clinical factors with baseline clinical anxiety and depression.

RESULTS

A total of 233 (45.4%) reported elevated anxiety symptoms and 256 (49.9%) reported elevated depressive symptoms sufficient for caseness. Rates were not different between patients with and without diabetes. Risk for clinical depression was higher in patients who were single/unpartnered (OR=1.828), Chinese vs. Malay (OR=2.05), or had lower albumin levels (OR=0.932). None of the parameters were associated with anxiety caseness.

CONCLUSION

Sociocultural factors rather than comorbid burden may help identify patients at risk for depression. The high rates of anxiety and depression underlie the importance for monitoring and intervention in dialysis care.

Diet as a system: an observational study investigating a multi-choice system of moderately restricted low-protein diets

BACKGROUND

There is no single, gold-standard, low-protein diet (LPD) for CKD patients; the best compliance is probably obtained by personalization. This study tests the hypothesis that a multiple choice diet network allows patients to attain a good compliance level, and that, in an open-choice system, overall results are not dependent upon the specific diet, but upon the clinical characteristics of the patients.

METHODS

Observational study: Three LPD options were offered to all patients with severe or rapidly progressive CKD: vegan diets supplemented with alpha-ketoacids and essential aminoacids; protein-free food in substitution of normal bread and pasta; other (traditional, vegan non supplemented and tailored). Dialysis-free follow-up and survival were analyzed by Kaplan Meier curves according to diet, comorbidity and age. Compliance and metabolic control were estimated in 147 subjects on diet at March 2015, with recent complete data, prescribed protein intake 0.6 g/Kg/day. Protein intake was assessed by Maroni Mitch formula.

RESULTS

Four hundreds and forty nine patients followed a LPD in December, 2007- March, 2015 (90% moderately restricted LPDs, 0.6 g/Kg/day of protein, 10% at lower targets); age (median 70 (19-97)) and comorbidity (Charlson index: 7) characterized our population as being in line with the usual CKD European population. Median e-GFR at start of the diet was 20 mL/min, 33.2% of the patients were diabetics. Baseline data differ significantly across diets: protein-free schemas are preferred by older, high-comorbidity patients (median age 76 years, Charlson index 8, GFR 20.5 mL/min, Proteinuria: 0.3 g/day), supplemented vegan diets by younger patients with lower GFR and higher proteinuria (median age 65 years, Charlson index 6, GFR 18.9 mL/min; Proteinuria: 1.2 g/day); other diets are chosen by an intermediate population (median age 71 years, Charlson index 6; GFR 22.5 mL/min; Proteinuria: 0.9 g/day); (p <0.001 for age, Charlson index, proteinuria, GFR). Adherence was good, only 1.1% of the patients were lost to follow-up and protein intake was at target in most of the cases with no differences among LPDs (protein intake: 0.47 (0.26-0.86) g/Kg/day). After adjustment for confounders, and/or selection of similar populations, no difference in mortality or dialysis start was observed on the different LPDs. Below the threshold of e-GFR 15 mL/min, 50% of the patients remain dialysis free for at least two years.

CONCLUSION

A multiple choice LPD system may allow reaching good adherence, without competition among diets, and with promising results in terms of dialysis-free follow-up. The advantages with respect to a non-customized approach deserve confirmation in further comparative studies or RCTs.

Low-Protein Diets in Diabetic Chronic Kidney Disease (CKD) Patients: Are They Feasible and Worth the Effort?

Low-protein diets (LPDs) are often considered as contraindicated in diabetic patients, and are seldom studied. The aim of this observational study was to provide new data on this issue. It involved 149 diabetic and 300 non-diabetic patients who followed a LPD, with a personalized approach aimed at moderate protein restriction (0.6 g/day). Survival analysis was performed according to Kaplan-Meier, and multivariate analysis with Cox model. Diabetic versus non-diabetic patients were of similar age (median 70 years) and creatinine levels at the start of the diet (2.78 mg/dL vs. 2.80 mg/dL). There was higher prevalence of nephrotic proteinuria in diabetic patients (27.52% vs. 13.67%, p = 0.002) as well as comorbidity (median Charlson index 8 vs. 6 p = 0.002). Patient survival was lower in diabetic patients, but differences levelled off considering only cases with Charlson index > 7, the only relevant covariate in Cox analysis. Dialysis-free survival was superimposable in the setting of good compliance (Mitch formula: 0.47 g/kg/day in both groups): about 50% of the cases remained dialysis-free 2 years after the first finding of e-GFR (estimated glomerular filtration rate) < 15 mL/min, and 1 year after reaching e-GFR < 10 mL/min. In patients with type 2 diabetes, higher proteinuria was associated with mortality and initiation of dialysis. In conclusion, moderately restricted LPDs allow similar results in diabetic and non non-diabetic patients with similar comorbidity.

Low protein diets in patients with chronic kidney disease: a bridge between mainstream and complementary-alternative medicines?

Dietary therapy represents an important tool in the management of chronic kidney disease (CKD), mainly through a balanced reduction of protein intake aimed at giving the remnant nephrons in damaged kidneys a "functional rest". While dialysis, transplantation, and pharmacological therapies are usually seen as "high tech" medicine, non pharmacological interventions, including diets, are frequently considered lifestyle-complementary treatments. Diet is one of the oldest CKD treatments, and it is usually considered a part of "mainstream" management. In this narrative review we discuss how the lessons of complementary alternative medicines (CAMs) can be useful for the implementation and study of low-protein diets in CKD. While high tech medicine is mainly prescriptive, prescribing a "good" life-style change is usually not enough and comprehensive counselling is required; the empathic educational approach, on which CAMs are mainly, though not exclusively based, may support a successful personalized nutritional intervention.There is no gold-standard, low-protein diet for all CKD patients: from among a relatively vast choice, the best compliance is probably obtained by personalization. This approach interferes with the traditional RCT-based analyses which are grounded upon an assumption of equal preference of treatments (ideally blinded). Whole system approaches and narrative medicine, that are widely used in the study of CAMs, may offer ways to integrate EBM and personalised medicine in the search for innovative solutions respecting individualization, but gaining sound data, such as with partially-randomised patient preference trials.

Communicative and critical health literacy, and self-management behaviors in end-stage renal disease patients with diabetes on hemodialysis

OBJECTIVE

Health literacy (HL) has been linked to disease self-management and various health outcomes, and can be separated into components of functional, communicative and critical skills. The high comorbidity between diabetes and end-stage renal disease (ESRD) poses concerns for compromised disease self-management. This study aimed to identify the relationships between HL and self-management behaviors in end-stage renal disease patients with diabetes.

METHODS

Self-report questionnaires measuring HL and self-management with the functional, communicative and critical HL scale and Summary of Diabetes Self-Care Activities, respectively, were implemented with a sample of 63 patients. Socio-demographic and clinical characteristics were obtained from medical records.

RESULTS

Self-management in diabetes was associated with communicative and critical HL, but not functional HL. Educational attainment was associated only with functional HL. No relationship between HL and glycated hemoglobin (HbA1c) was identified.

CONCLUSION

Communicative and critical HL skills are associated with self-management in ESRD patients with diabetes. Education levels are not related to self-management.

PRACTICE IMPLICATIONS

Healthcare professionals and health information aiming to improve self-management in ESRD patients with diabetes should consider their capacities of communicative and critical HL instead of solely assessing functional HL.

Managing treatment for end-stage renal disease--a qualitative study exploring cultural perspectives on facilitators and barriers to treatment adherence

Although adherence to hemodialysis (HD) regimes is important to maximise good clinical outcomes, it remains suboptimal and not well understood, particularly for those in non-Western settings and patients from Asian cultures. This qualitative study sought to explore cultural perspectives on facilitators and barriers to treatment adherence in HD patients. A descriptive exploratory design was used for the study, incorporating individual semi-structured interviews (n = 17) and three focus groups (n = 20). Each interview/focus group was audio-taped and transcribed verbatim, and coding was conducted by two coders using an iterative process. Study participants identified personal and social/contextual factors as major barriers or facilitators of treatment adherence. Barriers include time consumption, forgetfulness, concerns about safety, poor knowledge/understanding, poor communication and lack of control/social pressure. Participants also identified facilitators, both internal (self-initiated) and external (initiated by family, health care professional and peers) to ensure treatment adherence. These included support from family members and social obligation towards others, risk perception, establishment of routines and peer support. Internal and external factors can hinder or facilitate adherence to diet, fluid and medications in the context of dialysis. Several of these barriers/facilitators can be effectively addressed in the context of interventions and psycho-educational programmes.