Investigating Physical and Nutritional Changes During Prolonged Intermittent Fasting in Hemodialysis Patients: A Prospective Cohort Study

OBJECTIVE

Studies investigating the health effects of prolonged intermittent fasting during Ramadan among Muslim patients on hemodialysis (HD) are limited and reported heterogeneous findings. This study aimed to evaluate the effects of intermittent fasting during Ramadan on nutritional and functional status of patients on maintenance HD.

DESIGN AND METHODS

This was a 12-week, multicenter, prospective observational study. The study setting included three HD centers. Adult Muslim patients, who were undergoing HD session thrice weekly and planned to fast during Ramadan, were screened for eligibility and recruited. Nutritional and functional status assessments were carried out 2 weeks before (V₀), at the fourth week of Ramadan (V₁), and 4 weeks after Ramadan (V₂). Nutritional status parameters included anthropometry (body mass index, interdialytic weight gain, waist circumference), body composition (mid-arm circumference, triceps skinfold, body fat percentage), blood biochemistry (albumin, renal profile, lipid profile, and inflammatory markers), blood pressure, dietary intake, and handgrip strength. Changes in nutritional and functional status parameters across study timepoints were analyzed using repeated-measures analysis of variance.

RESULTS

A total of 87 patients completed the study, with 68 patients (78.2%) reporting fasting ≥20 days. Ramadan fasting led to significant reductions (all P < .05) in body mass index, interdialytic weight gain, waist circumference, mid-arm circumference, fat tissue mass, and body fat percentage, but these were not accompanied by any significant change in lean tissue mass (P > .05). Significant improvement was observed in serum phosphate levels, but serum albumin, urea, and creatinine were also reduced significantly during Ramadan (P < .05). There were no significant changes in lipid profile and inflammatory markers. Interestingly, energy and protein intakes remain unchanged during Ramadan. Handgrip strength improved significantly during Ramadan and further improved after Ramadan.

CONCLUSION

Intermittent Ramadan fasting leads to temporary changes in nutritional status parameters and poses nondetrimental nutritional risk for patients on maintenance HD.

Oral nutritional supplements and 30-day readmission rate in hypoalbuminemic maintenance hemodialysis patients

INTRODUCTION

Hemodialysis (HD) patients are hospitalized nearly twice yearly, and 35% of these patients are rehospitalized within 30-days postdischarge. We hypothesized that monitored oral nutritional supplementation (ONS) during HD treatment may decrease readmissions.

METHODS

A cohort of maintenance HD patients, treated at a large dialysis organization, who were hospitalized with a postdischarge albumin of ≤3.5 g/dL, without documented ONS use 90 days prior to the index hospitalization were identified. Individuals who received monitored intradialytic ONS postdischarge were compared to those without receipt of ONS. The outcome of interest was 30-day hospital readmissions. Logistic regression was used to assess the association between ONS receipt and 30-day readmission events, with adjustment for case-mix and laboratory variables.

FINDINGS

Of 5479 eligible patients, ONS was prescribed to 1420 individuals. Mean age was 64.6 ± 14.1 (SD) years; median dialysis vintage was 3.9 years. There were 274 (19%) readmissions among ONS recipients vs. 1571 (38.7%) among controls during the 30-day follow-up period. Individuals who did not receive ONS had increased odds of readmission [OR 2.26 (95% CI 1.02, 2.53)] in 30 days, as compared to those who did receive ONS postdischarge. In sensitivity analyses using a propensity score matched cohort, the odds ratio of readmissions within 30 days postdischarge was 1.71 (95% CI: 1.42, 2.07) for individuals who did not receive ONS as compared to those who received ONS.

DISCUSSION

Consumption of ONS during HD sessions is associated with reduced hospital readmission rates among in-center maintenance HD with severe hypoalbuminemia at 30 days post-hospital discharge.

Analysis of serum phosphate control and phosphate binder utilization in incident hemodialysis patients

The purpose of this study was to conduct a retrospective analysis of serum phosphate level variability in patients new to hemodialysis (HD) and to identify patient characteristics associated with this variability. The medical records of 47,742 incident HD patients attending US outpatient dialysis centers between January 1, 2006 and March 31, 2009 were analyzed. Monthly mean serum phosphate levels determined over a 6-month evaluation period (months 4–9 after HD initiation) were assigned to one of three strata: low (<1.13 mmol/L [<3.5 mg/dL]); target (1.13–1.78 mmol/L [3.5–5.5 mg/dL]); or high (>1.78 mmol/L [>5.5 mg/dL]). Patients were classified into one of six serum phosphate variability groups based on variability among monthly mean phosphate levels over the 6-month evaluation period: consistently target; consistently high; high-to-target; high-to-low; target-to-low; or consistently low. Only 15% of patients (consistently target group) maintained monthly mean serum phosphate levels within the target range throughout the 6-month evaluation period. Age, Charlson comorbidity index, serum phosphate, and intact parathyroid hormone levels prior to HD initiation were strongly associated (P<0.001) with serum phosphate levels after HD initiation. Overall patient-reported phosphate binder usage increased from 35% at baseline to 52% at end of study. The low proportion of patients achieving target phosphate levels and low rates of phosphate binder usage observed during the study suggest that alternative strategies could be developed to control serum phosphate levels. Possible strategies that might be incorporated to help improve the management of hyperphosphatemia in incident HD patients include dietary modification, dialysis optimization, and earlier and sustained use of phosphate binders.

Anabolic Effect of Exercise Training in People with End-Stage Renal Disease on Hemodialysis: A Systematic Review with Meta-analysis

PURPOSE

The primary purpose of this systematic review was to evaluate the anabolic effect of exercise intervention in adults with end-stage renal disease on hemodialysis (HD). The secondary objectives were to evaluate the influences of participant characteristics and exercise parameters on changes in muscle size.

METHODS

Electronic databases (Cochrane, CINAHL, EMBASE, PEDro, PubMed and SCOPUS) were searched from inception to November 2012. Randomized clinical trials published in English that included adults on HD undergoing an exercise intervention where muscle mass was measured as an outcome were included in this review. Two reviewers independently selected the studies, extracted data, and assessed risk of bias within the included studies. RESULTS were then combined by meta-analysis. The effect of exercises was determined using a standardized mean difference (SMD), expressed as Hedges' g, computed using a random effects model.

RESULTS

Seven SMDs extracted from five studies were included for final analysis. Strength training was used in all studies; one study used aerobic and mixed strength and aerobic training with two subgroups of participants. The overall effect of exercise on muscle mass was statistically significant (SMD: 0.272; 95% CI, 0.020-0.525).

CONCLUSIONS

Our results confirm a small but significant effect of strengthening exercise as an anabolic intervention to increase muscle mass. Exercise training should be included in routine management of people on maintenance HD. Although current results indicate that one in nine people on HD is likely to benefit from exercise intervention, parameters influencing these results require further research.

Gastrointestinal symptoms and nutritional status in women and men on maintenance hemodialysis

OBJECTIVE

The main objective was to investigate whether the prevalences of nausea, vomiting, diarrhea, and reduced appetite varied by gender in maintenance hemodialysis (MHD) patients. We also evaluated whether these symptoms explain female-male difference in nutritional status.

DESIGN

Cross section of baseline data of the Prospective Study of the Prognosis in Chronic Hemodialysis Patients.

SETTING

Dialysis units in the city of Salvador, Brazil.

PATIENTS

Three hundred ninety-seven men and 287 women with more than three months on MHD.

PREDICTOR VARIABLE

Gender.

OUTCOME MEASURES

The patient's self-reported nausea, vomiting, diarrhea, and reduced appetite. The malnutrition-inflammation score (MIS) was used to assess nutritional status.

RESULTS

The prevalence of symptoms was 24.3% for reduced appetite, 19.7% for nausea, 12.3% for vomiting, and 3.5% for diarrhea. In a logistic regression model with adjustments for age, diabetes, congestive heart failure, hemoglobin, albumin, Kt/V, and years on dialysis, women were found to have significantly higher odds of reduced appetite (odds ratio [OR] = 1.97), nausea (OR = 1.90), and vomiting (OR = 2.21). MIS was 5.41 ± 3.18 for women and 4.66 ± 3.28 for men (P = .002) corresponding to a percentage difference of 13.86%. The female-male difference reduced by more than half after excluding the gastrointestinal symptoms component and by approximately 65% after excluding both the gastrointestinal symptoms and the dietary intake components from the MIS.

CONCLUSIONS

The results suggest that the prevalences of nausea, vomiting, and reduced appetite are higher in women than in men on MHD. These gastrointestinal symptoms and perhaps their detrimental effects on dietary intake may partially explain a poorer nutritional status in MHD women.