Malnutrition in hemodialysis patients

Low Dose Megestrol Increases Serum Albumin in Malnourished Dialysis Patients

To evaluate the efficacy of low dose megestrol on malnourished dialysis patients we treated 16 dialysis patients with persistent hypoalbuminemia (<3.5 gm/dl for 2 consecutive months) and adequate dialysis at a dose of 20 mg orally twice daily. Twelve patients on peritoneal dialysis and 4 on hemodialysis were followed for 4.3 ± 0.6 m (2-11 m). Within one month serum albumin rose from 2.7 ± 0.1 to 3.0 ± 0.2 gm/dl (p<0.05) and remained elevated at the end of follow-up (3.1 ± 0.2, p<0.05 vs. pre-treatment levels). In the 12 responders (increase of albumin >0.3 gm/dl), all of whom reported improved appetite, the maximal increase of serum albumin in 2 months was 0.8 ± 0.1 gm/dl (range: 0.3–1.2). Four patients did not respond (change of albumin: -0.05±0.18, range: -0.6-0.2) because of encephalopathy, amyloidosis, depression or noncompliance. One patient stopped megestrol because of vaginal bleeding from uterine leiomyoma. Three patients died from causes unrelated to the megestrol. Our preliminary study suggestes that low dose megestrol (40 mg per day) increases serum albumin levels in 75% of dialysis patients with malnutrition. It is well tolerated but may cause vaginal bleeding from uterine tumors.

Prediction of Malnutrition Using Modified Subjective Global Assessment-dialysis Malnutrition Score in Patients on Hemodialysis

Malnutrition is widely prevalent among patients on hemodialysis. Malnutrition can be estimated using a fully quantitative scoring system Subjective Global Assessment-Dialysis Malnutrition Score which is simple, reliable and dynamic. The primary objective of the study was to assess the severity of malnutrition in patients with end stage renal disease and undergoing hemodialysis in a tertiary care teaching hospital in Chennai, using Subjective Global Asses sment-Dialysis Malnutrition Score and correlate it with standard indicators of malnutrition like anthropometric and biochemical parameters of the study population by Pearson's correlation. Anthropometric assessment included height, body weight, triceps skin fold thickness, mid arm circumference, mid arm muscle circumference % and biochemical parameters included serum albumin, transferrin, ferritin, total protein, total cholesterol, blood urea nitrogen and creatinine. Based on the scores, of the 66 patients, 91% were moderately malnourished. There was a significant negative correlation between modified Subjective Global Assessment-Dialysis Malnutrition Score and anthropometric measures such as triceps skin fold thickness, mid arm circumference, mid arm muscle circumference; biochemical markers such as albumin, transferrin and ferritin. The data obtained from this study confirm that a high degree of malnutrition was prevalent in patients on hemodialysis, as shown by anthropometric assessment, biochemical markers of malnutrition and Subjective Global Assessment-Dialysis Malnutrition Score. Nutritional status as determined by Subjective Global Assessment-Dialysis Malnutrition Score is a useful and reliable index for identifying patients at risk for malnutrition and it correlates well with anthropometric and biochemical assessment. may be integrated in regular assessment of malnutrition in patients on maintenance hemodialysis.

Family history of chronic renal failure is associated with malnutrition in Korean hemodialysis patients

The present study was to investigate the nutritional status and factors related to malnutrition in end-stage renal disease (ESRD) patients requiring hemodialysis (HD) in South Korea. Subjects were ESRD outpatients from general hospitals or HD centers in Seoul referred to the dialysis clinic for maintenance HD care. A total of 110 patients (46 men and 64 women; mean ages 58.6 ± 1.0 y) were eligible for this study. The family history of chronic renal failure (CRF) was considered positive if a patient reported having either a first-degree or second-degree relative with CRF. Malnutrition was defined as a triceps skinfold thickness or mid-arm muscle circumference below the fifth percentile for age and sex and forty-seven of the 110 patients were malnourished. Almost all (94%) patients had anemia (hemoglobin: <13 g/dL for men and <12 g/dL for women). Energy intake was below the recommended intake levels of energy [30-35 kcal/kg ideal body weight (IBW)] and protein (1.2 g/kg IBW) in 60% of patients. The duration of HD was longer in malnourished HD patients (P=0.0095). Malnutrition was more prevalent in women (P=0.0014), those who never smoked (P=0.0007), nondiabetic patients (P=0.0113), and patients with bone diseases (P=0.0427), adequate HD (spKt/V≥1.2) (P=0.0178), and those with a family history of CRF (P=0.0255). Multiple logistic regression was used to examine the relationship between malnutrition and potential risk factors. After adjusting for age, sex, and other putative risk factors for malnutrition, the OR for malnutrition was greater in HD patients with a family history of CRF (OR, 3.290; 95% CI, 1.003-10.793). Active nutrition monitoring is needed to improve the nutritional status of HD patients. A family history of CRF may be an independent risk factor for malnutrition in Korean HD patients. A follow-up study is needed to investigate whether there is a causal relationship between a family history of CRF and malnutrition in Korean ESRD patients.

Effects of unsaturated fat dietary supplements on blood lipids, and on markers of malnutrition and inflammation in hemodialysis patients

OBJECTIVE

We examined the effects of commercially available unsaturated fat dietary supplements on blood lipids, and on markers of malnutrition and inflammation, in an adult population of hemodialysis (HD) patients.

DESIGN

This was a restricted, randomized (equal blocks), investigator-blinded 2x6 week crossover trial, without a washout interval.

SETTING

This study was conducted at the Department of Nephrology, Copenhagen University Hospital Herlev, Herlev, Denmark, in spring 2007.

PATIENTS

Participants included 40 (30 males and 10 females) stable, adult patients undergoing regular HD, with a mean age of 64.6 years and a mean body mass index of 23.3kg/m(2).

INTERVENTION

In addition to patients' habitual diets, oral unsaturated fat supplements (90mL of Calogen [SHS International, Ltd., Liverpool, UK] and 4 capsules of Pikasol [Dansk Droge, Ishoej, Denmark]) were given in one period, whereas no supplements were given in the other. Dietary supplements contributed 1.8 MJ (430kcal), 47g fat, 26.5g monounsaturated fatty acids, and 3g marine n-3 polyunsaturated fatty acids per day. Blood sampling and nutritional assessments were performed at baseline, after 6 weeks, and after 12 weeks.

MAIN OUTCOME MEASURES

Dietary intakes, blood lipids, dry body weight, serum albumin, and serum C-reactive protein comprised our main outcome measures.

RESULTS

According to a per-protocol analysis of 14 study completers, fat supplementation resulted in significantly increased total energy intake (+1.6 MJ/day, or 380kcal/day) and an increased dietary fat energy percentage (+9%). We observed no significant changes in blood lipids. Dry body weight (+0.49kg, P=.04) increased, and serum C-reactive protein concentration fell (-1.69mg/L, P=.01), with fat supplementation. Intention-to-treat analysis of 39 participants confirmed the absence of adverse blood-lipid changes.

CONCLUSIONS

Unsaturated fat supplementation increased total dietary energy intake to recommended levels, had no adverse impact on blood lipids, improved nutritional status as assessed according to dry body weight, and reduced systemic inflammation as assessed according to C-reactive protein serum concentrations. Adding unsaturated fat to the diet seems to be a safe and effective way to prevent and treat malnutrition in hemodialysis patients.

Nutritional status and the role of diabetes mellitus in hemodialysis patients

This study was aimed to investigate the nutritional status and the role of diabetes mellitus in hemodialysis (HD) patients. Anthropometric, biochemical, and dietary assessments for HD 110 patients (46 males and 64 females) were conducted. Mean body mass index (BMI) was 22.1 kg/m(2) and prevalence of underweight (BMI<18.5 kg/m(2)) was 12%. The hypoalbuminemia (<3.5 g/dl) was found in 15.5% of the subject, and hypocholesterolemia (<150 mg/dl) in 46.4%. About half (50.9%) patients had anemia (hemoglobin: <11.0 g/dL). High prevalence of hyperphosphatemia (66.4%) and hyperkalemia (43.5%) was also observed. More than 60 percent of subjects were below the recommended intake levels of energy (30-35 kcal/kg IBW) and protein (1.2 g/kg IBW). The proportions of subjects taking less than estimated average requirements for calcium, vitamin B(1), vitamin B(2), vitamin C, and folate were more than 50%, whereas, about 20% of the subjects were above the recommended intake of phosphorus and potassium. Diabetes mellitus was the main cause of ESRD (45.5%). The diabetic ESRD patients showed higher BMI and less HD adequacy than nondiabetic patients. Diabetic patients also showed lower HDL-cholesterol levels. Diabetic ESRD patients had less energy from fat and a greater percentage of calories from carbohydrates. In conclusion, active nutrition monitoring is needed to improve the nutritional status of HD patients. A follow-up study is needed to document a causal relation between diabetes and its impact on morbidity and mortality in ESRD patients.

Body composition of children with chronic and end-stage renal failure

AIM

Protein energy malnutrition is common in children with chronic renal failure (CRF) and may negatively impact on clinical outcome. Although the aetiology of malnutrition is multifactorial, descriptive information on body composition may guide nutritional interventions aimed at optimising nutritional status.

METHODS

This prospective cohort study in children with CRF was conducted from April 1999 to November 2000. Patients were categorised according to their glomerular filtration rate (GFR) into CRF and end-stage renal failure (ESRF). Body composition was assessed based on anthropometry, total body potassium (TBK), total body protein (TBP) and dual X-ray absorptiometry (DEXA).

RESULTS

Fifteen patients (10 male, 5 female; mean age: 13.4 +/- 4.3 years) were studied, including eight patients with CRF (mean GFR: 17.0 +/- 7.2 mL/min/1.73 m(2)) and seven patients with ESRF (mean GFR: 6.4 +/- 1.7 mL/min/1.73 m(2)). Patients in both groups (n = 15) had deficits in height and TBP (mean z-score height-for-age: -1.19 +/- 1.05, P < 0.01; mean z-score TBP: -0.71 +/- 0.71, P < 0.05). There were no significant differences in weight, height, fat-free mass, TBK and TBP between patients with CRF and ESRF.

CONCLUSIONS

Linear growth impairment and decreased TBP are common in children with chronic and ESRF. TBK and DEXA may underestimate the degree of malnutrition in these patients.

Protein and energy intake in advanced chronic kidney disease: how much is too much?

Uremic wasting is strongly associated with increased risk of death and hospitalization events in patients with advanced chronic kidney disease (CKD). Recent evidence indicates that patients with advanced chronic kidney disease are prone to uremic wasting due to several factors, which include the dialysis procedure and certain comorbid conditions, especially chronic inflammation and insulin resistance or deficiency. While the catabolic effects of dialysis can be readily avoided with intradialytic nutritional supplementation, there are no established alternative strategies to avoid the catabolic consequences of comorbid conditions other than treatment of their primary etiology. To this end, there is no indication that simply increasing dietary protein and energy intake above the required levels based on level of kidney disease is beneficial in patients with advanced chronic kidney disease. However, aside from the potential adverse effects such as uremic toxin production, dietary protein and energy intake in excess of actual needs might be beneficial in maintenance dialysis patients as it may lead to weight gain over time. Clearly, the role of obesity in advanced uremia needs to be examined in detail prior to making any clinically applicable recommendations, both in terms of ''low'' and ''high'' dietary protein and energy intake.

Nutrition and Metabolism in Kidney Disease

Nutritional and metabolic derangements are highly prevalent in patients with chronic kidney disease (CKD) and patients on renal replacement therapy. These derangements, which can be termed uremic malnutrition, significantly affect the high morbidity and mortality rates observed in this patient population. Uremic malnutrition clearly is related to multiple factors encountered during the predialysis stage and during chronic dialysis therapy. Several preliminary studies suggested that interventions to improve the nutritional status and metabolic status of uremic patients actually may improve the expected outcome in these patients, although their long-term efficacy is not well established. It therefore is important to emphasize that uremic malnutrition is a major comorbid condition in CKD and renal replacement therapy patients, and that all efforts should be made to try to understand better and treat these conditions effectively to improve not only mortality but also the quality of life of chronically uremic patients. In this article we review the current state of knowledge in the field of nutrition and metabolism in all stages of CKD and renal replacement therapy, including kidney transplant. We also address questions that face investigators in this field and suggest where future research might be headed.

Outcomes of continuous process improvement of nutritional care program among geriatric units

BACKGROUND

Up to 65% of elderly patients are protein-calorie undernourished at admission or acquire nutritional deficits while hospitalized. The aims of this project were: (a) to assess the quality of care concerning nutrition among Belgian geriatric units, (b) to include more routinely nutritional assessments and interventions in comprehensive geriatric assessment, and (c) to assess the impact of nutritional recommendations on nutritional status and on the length of hospitalization. Method. We studied 1139 patients consecutively admitted to 12 geriatric units of general hospitals prospectively for 6 months (from January through June 2001). All patients underwent a comprehensive geriatric assessment. For the first 3 months, the nutritional status of the patients on admission and at discharge were assessed without particular recommendations for nutritional intervention. A standardized nutritional intervention was proposed for the last 3 months.

RESULTS

Median value of the Mini Nutritional Assessment test score was 18 points (range 9-29), mean admission's serum prealbumin concentration was 0.185 +/- 0.076 g/L, and C-reactive protein was 5.3 +/- 7.5 mg/100 ml. Hospitalization stay was significantly lower during the interventional period than during the observational period. A higher mean serum prealbumin concentration variation was observed during the interventional period as compared to the observational period.

CONCLUSIONS

Nutritional assessment should be part of routine clinical practice in elderly hospitalized patients. A comprehensive screening tool for assessment of nutritional status is needed that is clinically relevant and cost effective to perform. If malnutrition is suggested by such screening tests, then a supplemental conventional nutritional assessment should be performed before treatment is planned.

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

Nutritional status is an important predictor of clinical outcome in end-stage renal disease (ESRD) patients, especially in patients on chronic hemodialysis. Uremic malnutrition is strongly associated with increased risk of death and hospitalization events in this patient population, and decreased muscle mass is the most significant predictor of these outcomes. Several factors that influence protein metabolism predispose chronic hemodialysis patients to increased catabolism and loss of lean body mass. The available evidence suggests that low protein and energy intake associated with advanced uremia along with catabolic consequences of dialytic therapies can lead to the development of uremic malnutrition. Recent studies show that the hemodialysis procedure induces a net protein catabolic state at the whole-body level as well as skeletal muscle. There is evidence to suggest that these undesirable effects are due to decreased protein synthesis and increased proteolysis. Provision of nutrients, either in the form of intradialytic parenteral nutrition or oral feeding during hemodialysis, can adequately compensate for the catabolic effects of the hemodialysis procedure. While the mechanisms of these effects are not studied in detail, changes in extracellular amino acid concentrations, along with certain anabolic hormones such as insulin, are important mediators of these actions.

Effects of hemodialysis on protein metabolism

Uremic malnutrition, as evidenced by decreased muscle mass, is strongly associated with increased risk of death and hospitalization events in chronic hemodialysis (CHD) patients. Several factors that influence protein metabolism predispose CHD patients to increased catabolism and loss of lean body mass. It has been long suspected that the hemodialysis (HD) procedure is a net catabolic event. Recent studies show that the HD procedure indeed induces a net protein catabolic state at the whole-body level as well as in skeletal muscle. There is evidence to suggest that these undesirable effects are caused by decreased protein synthesis and increased proteolysis. Animal studies suggest that decreased protein synthesis is likely mediated by the significant decrease in plasma amino acid concentrations during HD. On the other hand, increased protein degradation is, at least in part, mediated by the HD-associated inflammatory response.

Protein homeostasis in chronic hemodialysis patients

PURPOSE OF REVIEW

Nutritional status is an important predictor of clinical outcome in chronic hemodialysis patients, as uremic malnutrition is strongly associated with an increased risk of death and hospitalization events. Decreased muscle mass is the most significant predictor of morbidity and mortality in these patients. Several factors that influence protein metabolism predispose chronic hemodialysis patients to increased catabolism and the loss of lean body mass. The purpose of this review is to discuss recent advances in the understanding of abnormalities in protein homeostasis in chronic hemodialysis patients.

RECENT FINDINGS

It has long been suspected that the hemodialysis procedure is a net catabolic event. Recent studies have indeed shown that the hemodialysis procedure induces a net protein catabolic state at the whole-body level as well as in skeletal muscle. There is evidence to suggest that these undesirable effects are caused by decreased protein synthesis and increased proteolysis. The provision of nutrients, either in the form of intradialytic parenteral nutrition or oral feeding during hemodialysis, can adequately compensate the catabolic effects of the hemodialysis procedure. Whereas the mechanisms of these effects have not been studied in detail, changes in extracellular amino acid concentrations and certain anabolic hormones such as insulin are important mediators of these actions.

SUMMARY

There is now indisputable evidence to suggest that the hemodialysis procedure leads to a highly catabolic state. Despite this, chronic hemodialysis patients can still achieve anabolism when given adequate protein supplementation to meet the metabolic requirements of hemodialysis, and when adequate insulin is present.

Metabolism and clinical interest of serum transthyretin (prealbumin) in dialysis patients

Chronic renal failure is responsible for an increase in serum concentrations of transthyretin. Elevated serum transthyretin during renal insufficiency is secondary to the lack of retinol-binding protein degradation in renal tubules and to the subsequent increase in the fraction of transthyretin bound to retinol-binding protein. In both hemodialysis and peritoneal dialysis patients, serum transthyretin was demonstrated to be a reliable marker of nutritional status, exhibiting significant relationships with energy and protein intakes as well as with fat stores and lean body mass. Serum transthyretin levels less than 300 mg/l were shown to be associated with an increased risk of morbidity and mortality in dialysis patients. The predictive value of transthyretin was shown to be independent of serum albumin. Regular measurements of both serum albumin and transthyretin make it possible to detect patients whose prognosis is compromised by malnutrition and in whom an active nutritional therapy must be undertaken. Simultaneous measurements of inflammatory markers such as serum C-reactive protein are required to evaluate the role of inflammation in serum albumin and transthyretin variations. These low-cost protein parameters should be incorporated in the regular assessment of dialysis patients and measured every 1 to 3 months.

Nutritional status affects quality of life in Hemodialysis (HEMO) Study patients at baseline

OBJECTIVE

To evaluate associations between frequently used indicators for assessing nutritional status and health-related quality of life in hemodialysis patients after controlling for demographics, comorbidity, and dialysis dose.

DESIGN

Survey of 1,387 hemodialysis patients enrolled at baseline in the Hemodialysis (HEMO) Study. Nutritional status indicators included dietary energy intake, equilibrated normalized protein catabolic rate (enPCR), serum creatinine (SCr), serum albumin (SAlb), body mass index (BMI), calf circumference, and appetite. Health-related quality of life was measured by the Medical Outcomes Study Short Form-36 (MOS-SF-36) summary measures: the Physical Component Scale (PCS) and Mental Component Scale (MCS).

SETTING

Fifteen clinical sites throughout the United States providing in-center hemodialysis.

RESULTS

The mean PCS score was 36.1 +/- 10 SD, lower than normative data in healthy populations. PCS scores were lower among women, whites, and those with diabetes, severe comorbidities, and poor appetites. Appetite, dietary energy intake, SAlb, and SCr were strongly associated with PCS scores even after controlling for demographics and comorbidity. The sum of the parameter estimates for the effects of nutritional status on PCS was large, 7 points or more depending on the individual's nutritional status indicators. The mean MCS score was 49.7 +/- 10.1 SD, similar to scores in healthy populations, but lower among those with severe comorbidities, poor appetites, advanced age, and more years on dialysis. Appetite, age, and years on dialysis were significantly associated with MCS after controlling for other demographics and comorbidity. Dialysis dose did not significantly alter these relationships.

CONCLUSION

Easy-to-use indicators for assessing nutritional status (appetite, energy intake, SAlb, and SCr) together are strongly associated with health-related quality of life, even after controlling for comorbidities and dose of dialysis in hemodialysis patients, providing an additional reason for maximizing patients' nutritional status and health.

Serum prealbumin is higher in peritoneal dialysis than in hemodialysis: a meta-analysis

BACKGROUND

Although not widely appreciated, the reported concentration of serum prealbumin, like that of serum cholesterol, tends to be higher in patients on peritoneal dialysis (PD) than on hemodialysis (HD), despite the substantial loss of protein during PD.

METHODS

The mean difference in serum prealbumin was quantified by meta-analysis of the mean differences found in six cohorts with both PD and HD patients (set 1; N = 639) using a fixed-effects model, and meta-analysis of the mean prealbumin values reported in 23 cohorts of unselected dialysis patients on a single modality (set 2; 9 PD cohorts, 14 HD cohorts; N = 12,256) using a mixed model. For comparison, the mean difference in serum albumin concentration between PD and HD also was estimated in sets 1 and 2 using the same methods.

RESULTS

In set 1, the mean prealbumin difference (PD-HD) in the individual cohorts ranged from 3.6 to 14.7 mg/dL (P < 0.05 in five cohorts), and the weighted mean difference was 5.4 mg/dL (95% CI, 3.8 to 7.0 mg/dL). In set 2, weighted mean prealbumin was 8.1 mg/dL (95% CI, 5.2 to 10.9 mg/dL) higher in PD than in HD in the entire data set, and 6.9 mg/dL (95% CI, 5.2 to 8.6 mg/dL) higher in a sensitivity analysis that excluded two outlying HD studies. By contrast, weighted mean serum albumin concentration was significantly lower in PD than in HD in both sets 1 and 2; the mean difference was 0.25 g/dL (95% CI, 0.14 to 0.36 g/dL) in set 1 and 0.28 g/dL (95% CI, 0.14 to 0.42 g/dL) in set 2.

CONCLUSIONS

Serum prealbumin level is approximately 6 mg/dL higher in PD than HD, perhaps due to the stimulation of hepatic synthesis by PD albumin loss, while serum albumin is approximately 0.3 g/dL lower in PD. Different reference ranges and clinical targets (such as, K/DOQI guidelines) are needed for PD and for HD.

Inflammation, Malnutrition, and Cardiac Disease as Predictors of Mortality in Hemodialysis Patients

ABSTRACT. Various studies suggest a strong association between nutrition and clinical outcome in hemodialysis (HD) patients. Several morbidity factors that per se increase the risk of a poor outcome, such as cardiovascular disease (CVD) and inflammation, may also cause malnutrition. Among laboratory parameters used to assess nutritional status, serum albumin appears to be a particularly strong predictor of morbidity and mortality. This study assessed the importance of nutritional status and inflammation and other comorbidity factors as predictors of mortality in HD patients. Nutritional status was evaluated in 128 HD patients by subjective global nutritional assessment (SGNA) and by measuring several anthropometric markers (actual body weight, percentage of actual body weight to desirable body weight, midarm muscle circumferences, triceps skinfold thickness), and serum albumin, plasma insulin such as insulin growth factor-1 and as a marker of inflammation, serum C-reactive protein (s-CRP) levels. The mortality during the next 36 mo was analyzed in relation to age, gender, CVD, SGNA, serum albumin, CRP, and several other factors by Kaplan-Meier analysis multivariate. Cox proportional hazard analysis was used to identify independent predictors of mortality. After 36 mo, 58 patients were still on HD treatment, 57 patients (45%) had died while receiving treatment, and 13 had received a kidney transplant. The main cause of death was CVD (58%), followed by infection (18%); malnutrition/cachexia was a rare direct cause of death (5%). Kaplan-Meier analysis showed that age, female gender, CVD, diabetes, SGNA, all anthropometric parameters, serum albumin, plasma insulinlike growth factor-1, and s-CRP were significant predictors of mortality. Analysis by the Cox model showed that age, gender, CVD, nutritional status (SGNA), and CRP were independent predictors of mortality at 36 mo. A low albumin level was not an independent predictor, although it was strongly associated with a reduced survival rate in the Kaplan-Meier analysis. Inflammation, malnutrition, and CVD appeared to contribute to increased mortality in a stepwise manner. The mortality at 36 mo was 0% when none of these complications was present, whereas the mortality was 75% in those patients with all three risk factors present at baseline. It is concluded that in addition to malnutrition and comorbidities (CVD, diabetes mellitus), inflammation (elevated s-CRP) is a significant independent risk factor for mortality in HD patients. Inflammation, malnutrition, and CVD appear to be interrelated, each additionally contributing to the high mortality in these patients.

Abnormalities of bioimpedance measures in overweight and obese hemodialyzed patients

BACKGROUND

The body composition in overweight and obese hemodialyzed patients (HD) remains ill-defined. This study evaluates in HD patients the influence of body size, as indicated by body mass index (BMI, kg/m(2)), on body composition by measuring bioimpedance analysis (BIA)-derived variables (phase angle (PA), fat-free mass (FFM) and body cell mass (BCM).

METHODS

We studied 50 Caucasian patients (mean age 62.8+/-9.2 y) on standard bicarbonate hemodialysis for at least 12 months who regularly achieved dry weight in post-HD, received similar dialysis doses and were free from inflammation/infection. Thirty-eight gender- and age-matched healthy subjects were included as controls (CON). Both HD and CON were divided into three groups on the basis of their BMI(kg/m2) 18.5-24.9, normal-weight (NW); 25-29.9, overweight (OW); and > or =30, obese (OB). In HD patients, BIA was performed 30 min after the end of dialysis.

RESULTS

Seven patients were obese (12%) while 16 were overweight (32%); in CON, 12 were obese (31%) and 12 overweight (31%). BIA-measured extracellular water was comparable in all groups. PA, which was similar in normal-weight HD and CON (6.2+/-0.9 degrees and 6.3+/-0.8 degrees ), decreased in OW- and OB-HD patients (5.3+/-1.0 degrees and 5.2+/-0.6 degrees, respectively; P<0.05 vs NW-HD) while it was unchanged in OW- and OB-CON (6.1+/-0.8 degrees and 5.9+/-0.5 degrees, P<0.05 vs respective HD groups). In OW and OB patients, the lower PA values were coupled with a major reduction of BIA-derived percentage BCM and FFM (P<0.05 vs NW-HD, and vs OW- and OB-CON). In patients, PA and BCM correlated with anthropometry-measured FFM. Of note, serum albumin and protein catabolic rate were significantly reduced in OB patients.

CONCLUSION

In overweight and obese HD patients, BIA-derived FFM, BCM and PA are significantly lower with respect to normal-weight patients and BMI-matched controls. These abnormalities of body composition are coupled with reduction of anthropometric measures of lean mass and a decrease of protein intake that, however, becomes significant only in the obese. We therefore suggest that overweight and obese HD patients are at risk of protein malnutrition in spite of excessive energy intake. BIA may be considered as a useful diagnostic tool to detect such a condition early.

Malnutrition in long-term haemodialysis survivors

BACKGROUND

Long survival is now common in patients with end-stage renal disease owing to improvement in dialysis techniques and kidney transplantation. As malnutrition is commonly reported in dialysis patients, we evaluated the nutritional status of patients treated with haemodialysis (HD) for more than 20 years.

METHODS

Ten patients (59.5 years old; 4F/6M; HD treatment for 304 months; group A) underwent an extensive nutritional examination and were compared to a control group of 10 patients treated with HD for an average of 51 months and strictly matched for age (58.6 years old), gender, and height (group B). The patients were treated on a similar basis (long-duration HD, cellulosic membranes, Daugirdas index >2).

RESULTS

The body weight (BW) in group A had decreased gradually from the 11th year of HD treatment, whereas it had increased by an average of 1.9+/-4.4% since the beginning of the HD treatment in group B. The body mass index (BMI) was lower in group A (19.3 +/- 2.3 vs 21.4 +/- 2.8 kg/m(2); P = 0.05). The arm-muscle circumference (AMC), the arm-muscle area (AMA), and triceps skinfold (TSF) were lower in group A than in group B. The fat mass assessed with anthropometry (10.8 +/- 4.0 vs 14.8 +/- 4.2 kg) was significantly lower in group A. The deviation of actual BW from ideal BW (IBW) was significantly lower in group A than in group B (80.6 +/- 10.7% vs 89.6 +/- 9.0%; P = 0.028); The deviations of actual BW, TSF, and AMA from standard values of the NHANES II study were more marked in group A than in group B. On the other hand, daily energy and protein intakes (DEI and DPI) were identical in both groups and met the recommendations for dialysis patients when normalized to the actual BW. When normalized to the IBW, the DEI appeared low. Energy expenditure was not different between groups, and not different from the resting metabolism calculated from the Harris and Benedict formula. Average albumin, prealbumin, and IgF-1 were normal and not different between groups. Branched-chain amino acids (BCAA), and especially leucine, were correlated with BMI in group A but not in group B. Serum total and free carnitine were low in both groups. Three patients had ascorbic acid deficiency in group A but none in group B.

CONCLUSIONS

Hence, despite adequate dialysis dose and protein intake, patients treated with HD for a long period of time became malnourished, whereas the classical nutritional markers remained in normal ranges. Among the potential causes leading to malnutrition, inadequate energy intake and micronutrient deficiencies were found in these patients.

Nutritional aspects in hemodialysis

The results of cross sectional studies throughout the world indicate that maintenance hemodialysis patients are at risk of malnutrition. Longitudinal studies show that malnutrition is associated with a reduced life expectancy mainly because of cardiovascular and infectious complications. Several factors are responsible for malnutrition of hemodialysis patients. Protein-energy intake is often reduced because of inappropriate dietary restrictions, anorexia, and taste alterations, promoting malnutrition in most patients entering dialysis. Intercurrent illnesses and frequent hospitalizations add to meal disturbances. A state of persistent catabolism may result from acidosis, resistance to anabolic factors such as growth hormone, insulin, and insulin-like growth factor-1, as well as a chronic inflammatory state caused by dialysis membrane and fluid bioincompatibility. In addition, losses of nutrients, including glucose, amino acids, proteins, and vitamins, occur during the dialysis treatment. Careful monitoring of dietary intakes is mandatory even in predialysis patients. In hemodialysis patients, the dose of dialysis should be adapted to correct acidosis and to relieve anorexia caused by accumulation of uremic toxins and hyperleptinemia. When malnutrition is established, active therapeutic interventions should take place, including intradialytic parenteral nutrition if oral supplementation has failed to improve nutritional status. Anabolism has been observed during the administration of recombinant growth hormone and insulin-like growth factor-1. Emerging therapeutic strategies against malnutrition may also involve a short period of daily dialysis.

Body composition, treatment time, and outcome in hemodialysis patients

OBJECTIVE

To review the nutritional status, hemodialysis (HD) treatment times, and outcome in stable HD patients.

DESIGN

A cross-sectional study with follow-up 12 months later.

SETTING

Five HD units in the Southwest of England, United Kingdom.

PATIENTS

A random selection of 180 stable HD patients who had been receiving dialysis treatment for at least 6 months.

MEASURES

Anthropometric measurements of triceps and biceps skinfold thickness, and mid arm circumference, to calculate indices of nutritional status and body composition.

RESULTS

(1) Male HD patients had severe reductions in muscle mass compared with the normal population (P < 0.01), with 50% below the 10th percentile of normal; (2) nondiabetic female patients had significant reductions in body fat stores compared with the normal (P < 0.001); (3) reduced HD treatment times (less than 12 hours per week) were associated with significantly reduced values of muscle mass (P < 0.02) in males and significantly reduced body fat stores (P < 0.001) and muscle mass (P < 0.05) in females; (4) reduced treatment times were also associated with the lowest serum albumin (P < 0.001) and creatinine (P < 0.001) levels; and (5) a serum albumin level below 36 g/L was associated with a 2.4-fold higher mortality rate.

CONCLUSION

Despite the apparent well-being of the patients, a substantial proportion are malnourished, with reduced body fat in females and reduced muscle mass in males. Those patients who receive shorter treatment times are at the greatest risk of malnutrition and of having a low serum albumin level, which is related to a higher mortality rate.

Association of morbidity with markers of nutrition and inflammation in chronic hemodialysis patients: a prospective study

BACKGROUND

Numerous studies suggest a strong association between nutrition and clinical outcome in chronic hemodialysis (CHD) patients. Nevertheless, the pathophysiological link between malnutrition and morbidity remains to be clarified. In addition, recent evidence suggests that nutritional indices may reflect an inflammatory response, as well as protein-calorie malnutrition. In this study, we prospectively assessed the relative importance of markers of nutritional status and inflammatory response as determinants of hospitalization in CHD patients.

METHODS

The study consisted of serial measurements of concentrations of serum albumin, creatinine, transferrin, prealbumin, C-reactive protein (CRP), and reactance values by bio-electrical impedance analysis (BIA) as an indirect measure of lean body mass every 3 months over a period of 15 months in 73 CHD patients. Outcome was determined by hospitalizations over the subsequent three months following each collection of data.

RESULTS

Patients who required hospitalization in the three months following each of the measurement sets had significantly different values for all parameters than patients who were not hospitalized. Thus, serum albumin (3.93 +/- 0.39 vs. 3.74 +/- 0.39 g/dl), serum creatinine (11.0 +/- 3.7 vs. 9.1 +/- 3.5 mg/dl), serum transferrin (181 +/- 35 vs. 170 +/- 34 mg/dl), serum prealbumin (33.6 +/- 9.2 vs. 30.0 +/- 10.1 mg/dl), and reactance (50.4 +/- 15.6 vs. 43.0 +/- 13.0 ohms) were higher for patients not hospitalized, whereas CRP (0.78 +/- 0.89 vs. 2.25 +/- 2.72 mg/dl) was lower in patients who were not hospitalized. All differences were statistically significant (P < 0.05 for all parameters). When multivariate analysis was performed, serum CRP and reactance values were the only statistically significant predictors of hospitalization (P < 0.05 for both). When a serum CRP concentration of 0.12 mg/dl was considered as a reference range (relative risk 1.0), the relative risk for hospitalization was 7% higher (relative risk = 1.07) for a CRP concentration of 0.92 mg/dl and was 30% (relative risk = 1.30) higher for a CRP concentration of 3.4 mg/dl. When a reactance value of 70 ohms was considered as a reference range with a relative risk of 1.0, the relative risk of hospitalization increased to 1.09 for a reactance value of 43 ohms and further increased to 1.14 for a reactance value of 31 ohms.

CONCLUSIONS

The results of this study strongly indicate that both nutritional status and inflammatory response are independent predictors of hospitalization in CHD patients. CRP and reactance values by BIA are reliable indicators of hospitalization. Visceral proteins such as serum albumin, prealbumin, and transferrin are influenced by inflammation when predicting hospitalization. When short-term clinical outcomes such as hospitalizations are considered, markers of both inflammation and nutrition should be evaluated.

Validation of serum transthyretin (prealbumin) as a nutritional parameter in hemodialysis patients

OBJECTIVE

To evaluate the use of serum transthyretin (TTR) as a valid indicator of nutritional status in the hemodialysis patient and to validate the correlation of low-serum (TTR) levels with established nutrition assessment parameters.

DESIGN

Prospective, cohort, correlation analysis.

SETTING

Free-standing outpatient dialysis center.

PATIENTS

Fifty-one stable, chronic hemodialysis patients meeting the following selection criteria: (1) received thrice weekly hemodialysis treatments for greater than 3 months, (2) absence of impaired hepatic function, (3) absence of chronic infection, inflammatory syndromes, or infections in the 3 months before the study, (4) not taking corticosteroids, and (5) willing to participate in the study as evidenced by signing of an informed consent.

INTERVENTION

Serum TTR, albumin, blood urea nitrogen, creatinine, cholesterol, postdialysis weight and body mass index were measured monthly for 6 consecutive months. Normalized protein catabolic rate and KT/V were measured monthly for 3 consecutive months.

MAIN OUTCOME MEASURES

Nutrition and biochemical indices.

RESULTS

The overall mean TTR level was 32 mg/dL +/- 7 for the 6-month study period. Thirty-six percent of patients had mean TTR levels less than 30 mg/dL. TTR levels less than 30 mg/dL correlated significantly with urine outputs greater than 240 mL/24 hours, predialysis blood urea nitrogen < 18 mmol/L (<50 mg/dL), and normalized protein catabolic rate less than 0.8 g/kg/d (P < .05). A significant correlation was found between TTR and creatinine, albumin and loss of dry body weight (P < .05). Mean TTR levels less than 30 mg/dL were found in 33% of subjects with mean albumin levels greater than 35 g/L (>3.5 g/dL) and in 19% with mean albumin levels greater than 40 g/L (>4.0 g/dL). TTR levels were consistently lower in diabetics for all 6 months (statistically significant in 2 out of 6 months).

CONCLUSION

Measuring serial serum TTR levels in hemodialysis patients is a reliable method for identifying patients in need of nutrition intervention.

Factors predicting malnutrition in hemodialysis patients: a cross-sectional study

Signs of protein-energy malnutrition are common in maintenance hemodialysis (HD) patients and are associated with increased morbidity and mortality. To evaluate the nutritional status and relationship between various parameters used for assessing malnutrition, we performed a cross-sectional study in 128 unselected patients treated with hemodialysis (HD) thrice weekly for at least two weeks. Global nutritional status was evaluated by the subjective global nutritional assessment (SGNA). Body weight, skinfold thicknesses converted into % body fat mass (BFM), mid-arm muscle circumference, hand-grip strength and several laboratory values, including serum albumin (SA1b), plasma insulin-like growth factor I (p-IGF-I), serum C-reactive protein (SCRP) and plasma free amino acids, were recorded. Dose of dialysis and protein equivalence of nitrogen appearance (nPNA) were evaluated by urea kinetic modeling. The patients were subdivided into three groups based on SGNA: group I, normal nutritional status (36%); group II, mild malnutrition (51%); and group III, moderate or (in 2 cases) severe malnutrition (13%). Clinical factors associated with malnutrition were: high age, presence of cardiovascular disease and diabetes mellitus. nPNA and Kt/V(urea) were similar in the three groups. However, when normalized to desirable body wt, both were lower in groups II and III than in group I. Anthropometric factors associated with malnutrition were low body wt, skinfold thickness, mid-arm muscle circumference (MAMC), and handgrip strength. Biochemical factors associated with malnutrition were low serum levels of albumin and creatinine and low plasma levels of insulin-like growth factor 1 (IGF-1) and branched-chain amino acids (isoleucine, leucine and valine). The serum albumin (SAlb) level was not only a predictor of nutritional status, but was independently influenced by age, sex and SCRP. Plasma IGF-1 levels also reflected the presence and severity of malnutrition and appeared to be more closely associated than SAlb with anthropometric and biochemical indices of somatic protein mass. Elevated SCRP (> 20 mg/liter), which mainly reflected the presence of infection/inflammation and was associated with hypoalbuminemia, was more common in malnourished patients than in patients with normal nutritional status, and also more common in elderly than in younger patients. Plasma amino acid levels, with the possible exception of the branched-chain amino acids (isoleucine, leucine, valine), seem to be poor predictors of nutritional status in hemodialysis patients.

Protein intake and the nutritional status in patients with pre-dialysis chronic renal failure on unrestricted diet

OBJECTIVES

Malnutrition is known to be highly associated with morbidity and mortality in dialysis patients. Malnutrition may begin to develop in patients with chronic renal failure(CRF) before they need dialysis. In this study, the nutritional status of patients with moderate to severe CRF on unrestricted diet was evaluated.

METHODS

We measured dietary protein intake (DPI, g/kg/day) in 64 patients with CRF and 42 normal controls(N). Nutritional indices such as serum albumin(SA, g/dl), transferrin(TF, mg/dl), prealbumin(PA, mg/dl) and insulin-like growth factor-1(IGF-1, ng/ml) were measured to evaluate the visceral proteins, and creatinine-height index(C-H, g/d/m) to evaluate the somatic proteins.

RESULTS

Mean DPI was 0.80 +/- 0.27(S.D) in CRF and 1.07 +/- 0.30 in N(p < 0.0001). DPI was lower than 0.6 in 15 CRF patients(23%). Serum albumin, transferrin and C-H were significantly lower in CRF patients than in N(p < 0.01). In patients with CRF, nutritional indices were significantly worse with lower DPI(< 0.6 g/kg/d, n = 15) than higher DPI(> 0.6 g/kg/d, n = 49)(SA 2.9 +/- 0.7 vs. 3.6 +/- 0.8, p < 0.005; TF 147 (134-179) vs. 220(182-264), p < 0.0005; PA 24 +/- 8 vs. 32 +/- 9, p < 0.001; IGF-1 123 (66-261) vs. 226(140-344), p < 0.05; C-H 0.52 +/- 0.15 vs. 0.87 +/- 0.23, p < 0.0001). CRF patients with nephrotic range proteinuria (> 3.5 g/d, n = 19) had lower SA (2.8 +/- 0.6 vs. 3.8 +/- 0.8, p < 0.0001) and PA(27 +/- 9 vs. 32 +/- 9, p < 0.05). CRF patients with diabetes mellitus (n = 20) showed worse nutrition than non-diabetic patients(SA 2.8 +/- 0.6 g/dl vs. 3.8 +/- 0.8 g/dl, p < 0.0001; TF 176 mg/dl(148-214) vs. 220 mg/dl(175-266), p < 0.05; PA 24 +/- 10 mg/dl vs. 33 +/- 8 mg/dl, p < 0.0005; IGF-1 138 ng/ml(69-269) vs 231 ng/ml(140-364), p < 0.05; C-H 0.66 +/- 0.23 vs. 0.85 +/- 0.5, p < 0.005).

CONCLUSION

A significant protein malnutrition prevails in patients with pre-dialysis CRF on unrestricted diet, especially with low protein intake. The effort to detect and correct malnutrition should be made in patients with CRF even before initiation of maintenance dialysis.

Nutrition in end-stage renal disease

In summary, it is evident that malnutrition is highly prevalent in ESRD patients. This is clearly related to multiple factors encountered during the pre-dialysis stage, as well as during maintenance dialysis therapy. A body of evidence highlights the existence of relationship between malnutrition and outcome in this patient population. Several preliminary studies suggest that interventions to improve the poor nutritional status of the ESRD patients may actually improve the expected outcome in these patients, although their long-term efficacy is not well established. It is therefore important to emphasize that malnutrition is a major co-morbid condition in the ESRD population and that the nutritional status and the treatment parameters of these patients should be altered to improve not only the mortality outcome of ESRD patients but also their quality of life.

Effect of the membrane biocompatibility on nutritional parameters in chronic hemodialysis patients

Malnutrition is highly prevalent in chronic hemodialysis patients and is an important determinant of their morbidity and mortality. Several recent studies have suggested that the inflammatory response associated with the biocompatibility of the dialysis membranes is a potential contributing factor. In a prospective study of 159 new hemodialysis patients from two centers randomized to either a low-flux biocompatible (BCM) membrane or a low-flux bioincompatible (BICM) membrane, we measured the long-term effects of biocompatibility on several nutritional parameters, including estimated dry weight, serum albumin, insulin-like growth factor-1 (IGF-1), and prealbumin over 18 months. Our results show that the BCM group had a mean (+/- SD) increase in their dry weight of 2.96 +/- 6.88 kg at month 12 and 4.36 +/- 8.57 kg at month 18 (P < 0.05 vs. baseline for both), whereas no change in mean weight was observed in BICM group. Following initiation of hemodialysis, a significant increase was observed in serum albumin levels in both groups of patients. However, the biocompatible group had an earlier and more marked increase in serum albumin levels compared to the BICM group. The average increase in serum albumin compared to baseline was consistently greater than 0.25 g/dl after seven months in the BCM group, but did not reach this level until 12 months after initiation of dialysis in the BICM group. The difference between the groups was statistically significant at months 7, 8, and 10 (P < 0.05, higher in the BCM group). Furthermore, the overall difference in serum albumin concentration between the two groups was larger in the center where the dose of dialysis was equivalent (P < 0.001). A consistently higher value was also observed in IGF-1 levels for BCM patients compared to BICM group (P = NS). In a further analysis, changes in IGF-1 levels, but not prealbumin, predicted the subsequent changes in serum albumin. We conclude that biocompatible hemodialysis membranes favorably impact on the nutritional status of chronic hemodialysis patients, independently of the flux characteristics of the membranes, and that IGF-1 may be an early marker of nutritional status.

Interventions to treat malnutrition in dialysis patients: the role of the dose of dialysis, intradialytic parenteral nutrition, and growth hormone

Protein and calorie malnutrition often starts before initiation of dialysis, and reflects the anorexia and the catabolic state of chronic renal failure. In the face of inadequate dialysis, which perpetuates the uremic state, malnutrition often worsens. Several studies, though not all, suggest that optimal dialysis improves nutritional status of dialysis patients. Such optimal dialysis now must include the use of biocompatible membranes to deliver Kt/V > 1.4 (urea reduction ratio > 65%). Additional interventions can include the use of enteral or intravenous hyperalimentation, and recombinant growth factors such as growth hormone or insulin-like growth factor-1. Importantly, studies to document the improvement in the morbidity and mortality of patients with these interventions are still needed and require large multicenter trials.

Difficulty accepting lifestyle limitations after the abrupt onset of end-stage renal disease

Adjustment to the lifestyle changes imposed by end-stage renal disease is particularly difficult when the onset is abrupt and unheralded. A case of atheroembolism is presented in which living situation, dietary compliance, and family involvement are particularly problematic for the dialysis staff. Discussion by team members focuses on the evolution of a reasonable disposition through diligence and persistence, recognizing the need to compromise medical indications with individual lifestyle and available family support.

Interdialytic weight gain and nutritional parameters in chronic hemodialysis patients

The extent of interdialytic weight gain (IDWG) in chronic hemodialysis patients is usually attributed to the level of compliance with fluid restriction. However, in view of the substantial water content of food (and caloric content of beverages), IDWG also may be a function of calorie and protein intake and may reflect the nutritional state of patients. To investigate this theory, the relationship between 2-day IDWG and body weight, normalized protein catabolic rate (nPCR), serum albumin, and delivered Kt/V urea was assessed in a prospective, randomized study of 860 chronic hemodialysis patients in 56 dialysis units. Compared with patients having < 2 kg IDWG (n = 378), patients with > 3 kg IDWG (n = 138) weighed more (dry weight, 76.8 v 61.7 kg), had higher nPCR (1.15 v 0.96 g/kg/d), and had higher serum albumin levels (3.96 vs 3.79 g/dL) (all P < 0.001) but did not have different levels of Kt/V (1.04 v 1.06). When IDWG was assessed as a function of dry weight, patients with IDWG > 4.5% of dry weight (n = 151) had higher nPCR (1.17 v 0.94 g/kg/d) but weighed less (60.1 v 70.0 kg) and had a higher Kt/V (1.14 v 1.01) than patients with IDWG < 3% of dry weight (n = 355) (all P < 0.001). Artifactual association between IDWG and nPCR attributable to an accentuated two-pool effect from differing ultrafiltration requirements was unlikely as assessed by the relationship between modeled Kt/V and prescribed Kt/V determined using an anthropometric urea volume.(ABSTRACT TRUNCATED AT 250 WORDS)

The association of intradialytic parenteral nutrition administration with survival in hemodialysis patients

Hemodialysis patients who had received intradialytic parenteral nutrition (IDPN) during 1991 were identified. These patients were compared with unexposed controls after adjusting for demographic variables, baseline renal diagnosis, diabetic status, serum albumin (ALB), creatinine (CRE), and urea reduction ratio. At lower levels of ALB (< or = 3.4 g/dL), treatment with IDPN was associated with a reduction in the odds of death at 1 year, an effect that became stronger at lower levels of CRE (< or = 8.0 mg/dL). In contrast, treatment with IDPN in patients with normal ALB was associated with increased mortality. Time trend analyses of ALB and CRE demonstrated progressive increases toward pretreatment levels in IDPN recipients that were not evident in control subjects. These time trend data suggest that in undernourished hemodialysis patients, IDPN can effect the serum levels of valid biochemical surrogates of visceral and somatic protein nutrition. Albeit retrospective, the improvement in survival at year's end among patients with ALB < or = 3.4 g/dL suggests that malnutrition and its attendant ill effects in hemodialysis patients may respond to aggressive therapeutic intervention, such as IDPN. These important findings should be prospectively confirmed in a randomized clinical trial.

Short-term effects of recombinant human growth hormone in CAPD patients

Protein and calorie malnutrition is common in chronic dialysis patients. Several interventions have been proposed to prevent and/or to treat malnutrition. Recombinant human growth hormone (rhGH) is a drug with anabolic properties and has been used in several catabolic conditions, such as patients with severe burns as well as in pediatric patients with chronic renal failure. In this study, we evaluated the short-term effects and safety of rhGH on urea kinetics and commonly measured biochemical parameters in 10 stable adult continuous ambulatory peritoneal dialysis (CAPD) patients. The design of the study was prospective, cross-over with the patients serving as their own controls. There were three study periods: baseline (PreGH), treatment (Tx), and follow-up (PostGH). During the seven day Tx period, patients self-administered 5 mg/day s.c. of rhGH. During this time, there was a significant decrease in blood urea nitrogen (BUN) (54 +/- 15 to 40 +/- 12 mg/dl), as well as in the combined dialysate and urine urea nitrogen excretion rate (5.69 +/- 1.86 to 4.04 +/- 1.13 g/day), and protein catabolic rate (0.82 +/- 0.13 to 0.67 +/- 0.09 g/kg/day), (all P < 0.001). Serum phosphorus (4.8 +/- 1.6 to 4.4 +/- 1.8 mg/dl) and potassium (4.0 +/- 0.4 to 3.6 +/- 0.2 mEq/liter) levels also showed a small but statistically significant decrease, in conjunction with a statistically significant increase in serum creatinine levels (12.2 +/- 5.7 to 12.9 +/- 5.7 mg/dl). Dietary protein intake, determined by dietary recall, did not change during the study (66.1 +/- 20.5 vs. 75.8 +/- 22.1 grams/day).(ABSTRACT TRUNCATED AT 250 WORDS)

Malnutrition in hemodialysis patients

Increasing attention has been paid recently to the problem of protein and energy malnutrition and its effects on mortality and morbidity in hemodialysis (HD) patients. Protein deficiency has received more attention than other nutritional problems, largely because its consequences are more easily measured and large population studies have demonstrated the adverse effects of even small decreases in serum albumin on patient's survival. This review discusses these findings and presents other indicators of early malnutrition, which range from static measurements of plasma constituents such as transferrin and insulin-like growth factor 1 (IGF-1), kinetic measurements of protein catabolic rate (PCR) derived from urea kinetic modeling, and noninvasive measurements of body composition. In addition, the predialytic and dialytic factors that influence nutritional status, including the adverse effects of uremia, inadequate dialysis, membrane bioincompatibility, and intercurrent illness requiring hospitalization, as well as socioeconomic factors, are discussed. While some of these are difficult to deal with, the review emphasizes simple interventions that are likely to benefit the patient, including the delivery of optimal dialysis, appropriate choice of medications, and dietary interventions. Once malnutrition is established, parenteral nutrition may reverse the objective evidence of malnutrition, but its effects on survival have not yet been documented. Finally, the review addresses the effects of therapeutic substances such as growth hormone (GH) and erythropoietin (EPO) in combination with nutrients that at present appear to be favorable but are still being evaluated.

Nutrition in hemodialysis patients

Malnutrition has been recognized in maintenance hemodialysis patients since the initiation of this long-term therapy. The cause of protein-caloric malnutrition in the chronic dialysis population is multifactoral, with decreased intake, increased loss, and altered metabolism as likely major categories. Despite marked improvement in the techniques and adequacy of hemodialysis and peritoneal dialysis, protein and caloric therapy has not changed in dialysis patients. Assessment of malnutrition has not been pursued as vigorously as necessary. Moreover, failure to document the diagnosis has distorted interpretation of the reported increasing mortality in this population. More intensive assessment and documentation of malnutrition states, along with alteration in the therapeutic approach, is warranted if we hope to positively affect the mortality of maintenance dialysis patients.