Dietary Protein and Physical Activity Interventions to Support Muscle Maintenance in End-Stage Renal Disease Patients on Hemodialysis

The Association of Short Physical Performance Battery With Mortality and Hospitalization in Patients Receiving Hemodialysis

OBJECTIVE

The Short Physical Performance Battery (SPPB) is recommended for evaluating physical performance in patients on hemodialysis (HD). However, the association between SPPB score and long-term health outcomes in these patients remains unclear. We examined the association of SPPB score with all-cause mortality, all-cause hospitalization, and cardiovascular hospitalization in patients on HD.

DESIGN AND METHODS

This retrospective cohort study included 326 patients (median age, 68 years; 62% men) who received outpatient HD therapy. These patients were divided into 2 SPPB groups: low (SPPB ≤9) and high (SPPB >9). We investigated the association of SPPB score and their change over time with health outcomes using Cox regression analysis.

RESULTS

Low SPPB score was associated with a higher risk for all-cause mortality (hazard ratio [HR]: 3.19, 95% confidence interval [95% CI]: 1.89-5.38), all-cause hospitalization (HR: 2.01, 95% CI: 1.44-2.82), and cardiovascular hospitalization (HR: 2.20, 95% CI: 1.45-3.35). Additionally, change in SPPB score over 1 year was associated with health outcomes.

CONCLUSIONS

Lower SPPB score was significantly associated with a higher risk for all-cause mortality, all-cause hospitalization, and cardiovascular hospitalization. The SPPB may be a valuable indicator for risk stratification in patients on HD. Additionally, preventive treatments may be an effective management strategy in limiting the high mortality and hospitalization rates in patients with decreased SPPB score.

Physical Activity, Sedentary Behavior, Fruit and Vegetable Consumption, and Sarcopenia in Older Chinese Adults: A Cross-Sectional Study

PURPOSE

The purpose of this study was to investigate the association between moderate to vigorous physical activity (MVPA), sedentary behavior, fruit and vegetable intake, and the risk of sarcopenia among older Chinese adults.

METHODS

This cross-sectional study enrolled 5418 older Chinese adults who participated in the Study on Global Aging and Adult Health (SAGE). Participants reported information about their physical activity, sedentary behavior, and dietary habits (fruit and vegetable intake). Sarcopenia was defined as the presence of low skeletal muscle mass and either a slow gait speed or weak handgrip strength. A multiple logistic regression model was employed to determine the relationship between MVPA, sedentary behavior, fruit and vegetable intake, and the risk of sarcopenia.

RESULTS

Only 32.63% of participants met all three recommendations (for MVPA, sedentary behavior, and fruit and vegetable intake). Compared with meeting none of the recommendations, meeting all three recommendations was associated with a lower risk of sarcopenia (OR = 0.63, 95% CI = 0.41-0.98). Moreover, meeting the recommendation for sufficient fruit and vegetable intake (OR = 0.69, 95% CI = 0.58-0.83), MVPA and fruit/vegetable intake (OR = 0.67, 95% CI = 0.52-0.86), and sedentary behavior and fruit/vegetable intake (OR = 0.69, 95% CI = 0.48-0.98) was associated with a lower risk of sarcopenia.

CONCLUSION

Our findings indicate that in this large representative sample of older Chinese adults, meeting lifestyle recommendations for MVPA, sedentary behavior, and fruit and vegetable intake protected against sarcopenia.

Clinical features and molecular mechanism of muscle wasting in end stage renal disease

Muscle wasting in end-stage renal disease (ESRD) is an escalating issue due to the increasing global prevalence of ESRD and its significant clinical impact, including a close association with elevated mortality risk. The phenomenon of muscle wasting in ESRD, which exceeds the rate of muscle loss observed in the normal aging process, arises from multifactorial processes. This review paper aims to provide a comprehensive understanding of muscle wasting in ESRD, covering its epidemiology, underlying molecular mechanisms, and current and emerging therapeutic interventions. It delves into the assessment techniques for muscle mass and function, before exploring the intricate metabolic and molecular pathways that lead to muscle atrophy in ESRD patients. We further discuss various strategies to mitigate muscle wasting, including nutritional, pharmacological, exercise, and physical modalities intervention. This review seeks to provide a solid foundation for future research in this area, fostering a deeper understanding of muscle wasting in ESRD, and paving the way for the development of novel strategies to improve patient outcomes. [BMB Reports 2023; 56(8): 426-438].

Clinical features and molecular mechanism of muscle wasting in end stage renal disease

Muscle wasting in end-stage renal disease (ESRD) is an escalating issue due to the increasing global prevalence of ESRD and its significant clinical impact, including a close association with elevated mortality risk. The phenomenon of muscle wasting in ESRD, which exceeds the rate of muscle loss observed in the normal aging process, arises from multifactorial processes. This review paper aims to provide a comprehensive understanding of muscle wasting in ESRD, covering its epidemiology, underlying molecular mechanisms, and current and emerging therapeutic interventions. It delves into the assessment techniques for muscle mass and function, before exploring the intricate metabolic and molecular pathways that lead to muscle atrophy in ESRD patients. We further discuss various strategies to mitigate muscle wasting, including nutritional, pharmacological, exercise, and physical modalities intervention. This review seeks to provide a solid foundation for future research in this area, fostering a deeper understanding of muscle wasting in ESRD, and paving the way for the development of novel strategies to improve patient outcomes. [BMB Reports 2023; 56(8): 426-438].

Intradialytic Protein Ingestion and Exercise do Not Compromise Uremic Toxin Removal Throughout Hemodialysis

OBJECTIVE

Dietary protein and physical activity interventions are increasingly implemented during hemodialysis to support muscle maintenance in patients with end-stage renal disease (ESRD). Although muscle maintenance is important, adequate removal of uremic toxins throughout hemodialysis is the primary concern for patients. It remains to be established whether intradialytic protein ingestion and/or exercise modulate uremic toxin removal during hemodialysis.

METHODS

We recruited 10 patients with ESRD (age: 65 ± 16 y, BMI: 24.2 ± 4.8 kg/m²) on chronic hemodialysis treatment to participate in this randomized cross-over trial. During hemodialysis, patients were assigned to ingest 40 g protein or a nonprotein placebo both at rest (protein [PRO] and placebo [PLA], respectively) and following 30 min of exercise (PRO + exercise [EX] and PLA + EX, respectively). Blood and spent dialysate samples were collected throughout hemodialysis to assess reduction ratios and removal of urea, creatinine, phosphate, cystatin C, and indoxyl sulfate.

RESULTS

The reduction ratios of urea and indoxyl sulfate were higher during PLA (76 ± 6% and 46 ± 9%, respectively) and PLA + EX interventions (77 ± 5% and 45 ± 10%, respectively) when compared to PRO (72 ± 4% and 40 ± 8%, respectively) and PRO + EX interventions (73 ± 4% and 43 ± 7%, respectively; protein effect: P = .001 and P = .023, respectively; exercise effect: P = .25 and P = .52, respectively). Nonetheless, protein ingestion resulted in greater urea removal (P = .046) during hemodialysis. Reduction ratios and removal of creatinine, phosphate, and cystatin C during hemodialysis did not differ following intradialytic protein ingestion or exercise (protein effect: P > .05; exercise effect: P>.05). Urea, creatinine, and phosphate removal were greater throughout the period with intradialytic exercise during PLA + EX and PRO + EX interventions when compared to the same period during PLA and PRO interventions (exercise effect: P = .034, P = .039, and P = .022, respectively).

CONCLUSION

The removal of uremic toxins is not compromised by protein feeding and/or exercise implementation during hemodialysis in patients with ESRD.

Simplified discriminant parameters for sarcopenia among patients undergoing haemodialysis

BACKGROUND

Patients with end-stage renal disease (ESRD) are at an increased risk of developing sarcopenia, which can lead to various adverse health outcomes. Although the diagnosis of sarcopenia is essential for clinical management, it is not feasible in routine clinical practice for populations undergoing haemodialysis because it is time-consuming and resources are limited. Serum creatinine levels in patients with ESRD have been gaining attention as a screening parameter for sarcopenia because serum creatinine is a routinely measured byproduct of skeletal muscle metabolism. This study aimed to evaluate the discriminative ability of the creatinine-derived index for sarcopenia in patients undergoing haemodialysis.

METHODS

We diagnosed sarcopenia according to the Asian Working Group for Sarcopenia (AWGS) 2 criteria in 356 clinically stable outpatients with ESRD enrolled from three dialysis facilities. We adopted the modified creatinine index as a simplified discriminant parameter for sarcopenia in addition to the calf circumference, SARC-F score, and combination of both (i.e. SARC-CalF score), which are recommended by the AWGS. Receiver operating characteristic analysis and logistic regression analysis were conducted to evaluate the discriminative ability of the modified creatinine index for sarcopenia.

RESULTS

Of the study participants, 142 (39.9%) were diagnosed with sarcopenia. The areas under the curve of the modified creatinine index against sarcopenia in the male and female participants were 0.77 (95% confidence interval [CI]: 0.71 to 0.83) and 0.77 (95% CI: 0.69 to 0.85), respectively. All simplified discriminant parameters were significantly associated with sarcopenia, even after adjusting for patient characteristics and centre. In the comparison of the odds ratios for sarcopenia for 1-standard deviation change in the simplified discriminant parameters, the odds ratio of the modified creatinine index was 1.92 (95% CI: 1.15 to 3.19), which was lower than that of the calf circumference (odds ratio: 6.58, 95% CI: 3.32 to 13.0) and similar to that of the SARC-F (odds ratio: 1.57, 95% CI: 1.14 to 2.16) and SARC-CalF scores (odds ratio: 2.36, 95% CI: 1.60 to 3.47).

CONCLUSIONS

This study revealed a strong association between the creatinine-derived index and sarcopenia in patients undergoing haemodialysis. The modified creatinine index was equal or superior to those of SARC-F and SARC-CalF score in discriminability for sarcopenia. However, the ability of the calf circumference to discriminate sarcopenia is extremely high, and further study is needed to determine whether it can be used to detect deterioration of muscle mass and function over time.

Impact of personalized nutritional intervention on nutritional status and quality of life of maintenance hemodialysis patients with protein energy wasting

BACKGROUND: Protein energy wasting (PEW) is a common multifactorial problem affecting maintenance hemodialysis (MHD) patients. OBJECTIVES: We aimed to explore the impact of personalized nutritional intervention on nutritional status and quality of life (QOL) in MHD patients. METHODS: Interventional study included 18 MHD patients suffering from PEW. They were subjected to personalized nutritional intervention for 6 months according to Kidney Disease Outcomes Quality Initiative (KDOQI) Clinical Practice Guidelines (2000). QOL was evaluated by using the Kidney Disease Quality of Life (36 KDQOL-36). Nutritional status and QOL of those patients were re-assessed after 6 months and compared to those at the baseline. RESULTS: Fourteen patients completed six months of the study. Following such intervention, half of these patients became no longer suffering from PEW (responder group). Most of the nutritional and QOL data improved in the responder in contrary to the non-responder group of patients. The baseline level of parathyroid hormone (PTH) was significantly higher but physical health was significantly lower in non-responder than responder groups. CONCLUSIONS: Implementation of an internationally acknowledged nutritional program could improve the nutritional status and QOL of MHD patients with PEW. Moreover, PTH level, and physical health of the studied patients could contribute to the positive response to nutritional intervention.

A Comparative Study of the Efficacy of an Intervention with a Nutritional Supplement for Patients with Chronic Kidney Disease: A Randomized Trial

Chronic kidney disease (CKD) involves heterogeneous diseases that affect the renal structure and function. Malnutrition plays a crucial role during patients with CKD on hemodialysis (HD) treatment and is associated with an increased rate and duration of hospitalizations. The aim of this randomized, parallel, intervention-controlled trial was to assess whether the use of daily supplementation with a new nutritional product developed by the Grand Fontaine Laboratories improves the nutritional status and anthropometric parameters of stage 5 CKD patients, compared with standard renal dietary advice, after three months of follow-up. Dietary intake, anthropometric measurements, physical activity, and blood samples were collected at baseline and after three months of intervention. Significant improvements were observed within the intervention group in body weight (1.5 kg [95% CI: 0.9 to 2.12 kg]) and BMI (0.54 kg/m² [95% CI: 0.31 to 0.77]; p-value between groups, 0.002 and 0.006, respectively). In the control group, significant decreases were observed in transferrin saturation (-5.04% [95% CI: -8.88 to -1.21]) and alpha-tocopherol levels (-3.31 umol/L [95% CI: -6.30 to -0.32]). We concluded that daily dietary intake of a specific renal nutritional complement in CKD patients with or at risk of malnutrition may prevent deterioration in nutritional parameters.

The role of diabetes mellitus in the effectiveness of intradialytic exercise intervention on patients' muscle function

INTRODUCTION

The purpose of this study is to identify the role of diabetes mellitus in the effectiveness of intradialytic exercise intervention among haemodialysis patients.

METHODS

In this multicentre study 90 dialysed patients were allocated to the experimental (EXG, n=57) or control group (CNG, n=33). In EXG, we included 20 diabetic and 37 non-diabetic patients. In CNG, we enrolled 8 diabetic and 25 non-diabetic patients. EXG underwent a 12-week supervised, progressive, intradialytic resistance training programme, while CNG stayed inactive during dialysis. Baseline, post-interventional and post-follow-up assessments of maximal force during hip extension (HE), hip flexion (HF) and knee extension (KE) contractions were completed in both groups of patients.

RESULTS

HE increased in diabetic and non-diabetic EXG patients (diabetic EXG, change: +14.5N; 95% CI=-5.5 to +34.5; non-diabetic EXG, +18.6N; 95% CI=+3.4 to +33.8) and diabetic CNG patients (change: +17.9N; 95% CI=-9.2 to +44.9). Only non-diabetic CNG patients experienced a decrease in HE (change: -22.8N; 95% CI=-36.9 to -8.7, P<.05).

CONCLUSIONS

Resistance training improved muscle function among dialysis patients regardless of the presence of diabetes mellitus. We found that non-diabetic patients lose their muscle function extensively during inactivity, while diabetic patients retain their muscle function.

Renal rehabilitation as a management strategy for physical frailty in CKD

An aging population and the increasing prevalence of lifestyle-related diseases have led to a worldwide increase in the rate of chronic kidney disease requiring renal replacement therapy. The mean age of individuals requiring dialysis therapy has been increasing, and Japanese patients are aging more rapidly than those in the USA and Europe. Patients undergoing renal replacement therapy are at increased risk of sarcopenia/frailty compared with people with normal kidney function due to comorbid burden, long-standing malnutrition, chronic inflammation, metabolic acidosis, anabolic resistance, hormonal changes, physical inactivity and amino acid loss via dialysis treatment in addition to aging. Sarcopenia and frailty are serious global health problems that can decrease access to kidney transplantation and lead to various adverse health outcomes, including functional dependence, hospitalizations and deaths in patients on dialysis treatment. However, sarcopenia/frailty fortunately is potentially modifiable by early identification of poor physical functioning, sustainment and enhancement of daily physical activity, and participation in exercise treatments. The Japanese Society of Renal Rehabilitation was established in 2011 and published a clinical practice guideline for “Renal Rehabilitation” targeting nondialysis-dependent and dialysis-dependent patients and renal transplant recipients, in 2019. The guideline emphasized the importance of physical management for patients with kidney diseases in addition to nutritional supports and anemia management. Kidney health professionals should manage sarcopenia and physical frailty as a part of routine clinical care for patients undergoing hemodialysis to improve poor physical functioning, functional dependence, decreased quality of life and poor prognosis.

Amino acid removal during hemodialysis can be compensated for by protein ingestion and is not compromised by intradialytic exercise: a randomized controlled crossover trial

BACKGROUND

Patients with end-stage renal disease (ESRD) undergoing hemodialysis experience a rapid decline in skeletal muscle mass and strength. Hemodialysis removes amino acids (AAs) from the circulation, thereby lowering plasma AA concentrations and stimulating proteolysis.

OBJECTIVES

In the present study, we evaluate the impact of intradialytic protein ingestion at rest and following exercise on AA removal and plasma AA availability in patients with ESRD.

METHODS

Ten patients (age: 65 ± 16 y, male/female: 8/2, BMI: 24.2 ± 4.8 kg/m2, serum albumin: 3.4 ± 0.3 g/dL) with ESRD undergoing hemodialysis participated in this randomized controlled crossover trial. During 4 hemodialysis sessions, patients were assigned to ingest 40 g protein or a placebo 60 min after initiation, both at rest (PRO and PLA, respectively) and following exercise (PRO + EX and PLA + EX, respectively). Spent dialysate and blood samples were collected every 30 min throughout hemodialysis to assess AA removal and plasma AA availability.

RESULTS

Plasma AA concentrations declined by 26.1 ± 4.5% within 30 min after hemodialysis initiation during all interventions (P < 0.001, η2p > 0.79). Protein ingestion, but not intradialytic exercise, increased AA removal throughout hemodialysis (9.8 ± 2.0, 10.2 ± 1.6, 16.7 ± 2.2, and 17.3 ± 2.3 g during PLA, PLA + EX, PRO, and PRO + EX interventions, respectively; protein effect P < 0.001, η2p = 0.97; exercise effect P = 0.32, η2p = 0.11). Protein ingestion increased plasma AA concentrations until the end of hemodialysis, whereas placebo ingestion resulted in decreased plasma AA concentrations (time effect P < 0.001, η2p > 0.84). Plasma AA availability (incremental AUC) was greater during PRO and PRO + EX interventions (49 ± 87 and 70 ± 34 mmol/L/240 min, respectively) compared with PLA and PLA + EX interventions (-227 ± 54 and -208 ± 68 mmol/L/240 min, respectively; protein effect P < 0.001, η2p = 0.98; exercise effect P = 0.21, η2p = 0.16).

CONCLUSIONS

Protein ingestion during hemodialysis compensates for AA removal and increases plasma AA availability both at rest and during recovery from intradialytic exercise. Intradialytic exercise does not compromise AA removal or reduce plasma AA availability during hemodialysis in a postabsorptive or postprandial state.

Dietary Intake, Body Composition, and Clinical Parameters: Associations Between the Level and Type of Physical Activity in Hemodialysis Patients

BACKGROUND

Physical inactivity and muscle wasting potentiate each other and are highly prevalent among hemodialysis (HD) patients. The authors evaluated the association between physical activity (PA), clinical, nutritional, and body composition parameters in HD patients.

METHODS

Multicenter cross-sectional study with 581 HD patients. Clinical, body composition, dietary intake, and PA data were recorded. For the analysis, patients were divided into active (follow World Health Organization recommendations) and inactive groups.

RESULTS

A total of 20% of the patients followed World Health Organization recommendations on PA. Differences between physically active and physically inactive patients were observed in age, biochemical parameters and total body water, intracellular water, lean tissue index (LTI), body cell mass, energy, and protein intake. PA was a predictor of higher LTI, body cell mass, and energy intake independently of age, gender, presence of diabetes, dialysis adequacy, and dialysis vintage. Controlling for the effect of age, walking and vigorous PA were positively correlated with energy and protein intake. Vigorous PA was also positively correlated with LTI.

CONCLUSION

The PA is a predictor of higher LTI, body cell mass, and energy intake. Vigorous PA is associated with an improved body composition and dietary pattern, whereas walking seems to be also associated with a favorable nutritional status.

The effects of amino acid/protein supplementation in patients undergoing hemodialysis: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND & AIMS

We evaluated the efficacy of the intervention consisting of amino acid/protein supplementation on muscle mass, muscle strength and physical function in patients on hemodialysis.

METHODS

This systematic review and meta-analysis identified potential studies through a systematic search of 4 electronic databases and references from eligible studies from database inception to August 2020. We included only randomized controlled trials reporting the efficacy of amino acid/protein supplementation on muscle mass, muscle strength and physical function in patients on hemodialysis.

RESULTS

Of 6529 unique citation records, 4 studies including 243 participants were selected for inclusion in the meta-analysis. Although there were no significant differences in muscle mass and muscle strength between the intervention and control groups, amino acid/protein supplementation was shown to significantly improve physical function (shuttle walk, MD 32.7, 95% CI 21.7 to 43.7, P < 0.001; gait speed, MD 0.07, 95% CI 0.01 to 0.13, P = 0.02; timed up and go, MD -0.42, 95% CI -0.68 to -0.15, P = 0.002) in patients on hemodialysis.

CONCLUSIONS

We confirmed the positive effect of amino acid/protein supplementation on physical function in people undergoing hemodialysis. However, there is still insufficient evidence, and more rigorously designed randomized controlled trials with high quality are needed.

One-year intradialytic leg exercises with resistance bands and fat mass increase in elderly hemodialysis patients: a retrospective study

Background

Intradialytic exercises are recommended to be available as a treatment for enhancing physical functioning. However, there have been few reports which evaluated the results of long-term mild intradialytic exercises in elderly patients. The purpose of this study is to investigate the changes in body weight, body composition, and laboratory data in elderly hemodialysis patients after 1-year intradialytic leg exercises with resistance bands.

Methods

A retrospective study. Twenty-one outpatients, aged 65 or older (mean ± SD, 75.2 ± 5.1 years), received intradialytic leg exercises with resistance bands for a year were analyzed. The values of dry weight, body composition, and laboratory data were collected from the year-ago period, at baseline and 1 year after baseline. Fat and muscle mass were evaluated by using a multi-frequency bioimpedance device.

Results

Physical performance changed and body weight increased after 1-year resistance band exercises. However, the participants gained fat mass, not muscle mass. Although the changes in biochemical data related to protein intake were equivocal, triglyceride levels increased significantly after 1-year exercises. An elevation in serum creatinine levels was observed, even if solute clearance increased significantly.

Conclusions

One-year intradialytic leg exercises with resistance bands may have a potential clinical benefit for body mass index even in elderly hemodialysis patients. However, optimal dietary modification is needed to achieve a balanced increase of muscle and fat mass. An increase of serum creatinine levels does not always mean muscle mass hypertrophy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41100-021-00341-z.

The role of diabetes mellitus in the effectiveness of intradialytic exercise intervention on patients' muscle function

INTRODUCTION

The purpose of this study is to identify the role of diabetes mellitus in the effectiveness of intradialytic exercise intervention among haemodialysis patients.

METHODS

In this multicentre study 90 dialysed patients were allocated to the experimental (EXG, n=57) or control group (CNG, n=33). In EXG, we included 20 diabetic and 37 non-diabetic patients. In CNG, we enrolled 8 diabetic and 25 non-diabetic patients. EXG underwent a 12-week supervised, progressive, intradialytic resistance training programme, while CNG stayed inactive during dialysis. Baseline, post-interventional and post-follow-up assessments of maximal force during hip extension (HE), hip flexion (HF) and knee extension (KE) contractions were completed in both groups of patients.

RESULTS

HE increased in diabetic and non-diabetic EXG patients (diabetic EXG, change: +14.5N; 95% CI=-5.5 to +34.5; non-diabetic EXG, +18.6N; 95% CI=+3.4 to +33.8) and diabetic CNG patients (change: +17.9N; 95% CI=-9.2 to +44.9). Only non-diabetic CNG patients experienced a decrease in HE (change: -22.8N; 95% CI=-36.9 to -8.7, P<.05).

CONCLUSIONS

Resistance training improved muscle function among dialysis patients regardless of the presence of diabetes mellitus. We found that non-diabetic patients lose their muscle function extensively during inactivity, while diabetic patients retain their muscle function.

Therapeutic effects of exercise interventions for patients with chronic kidney disease: protocol for an overview of systematic reviews and meta-analyses of clinical trials

INTRODUCTION

An increasing number of systematic reviews and meta-analyses of clinical trials have begun to investigate the effects of exercise interventions in patients with chronic kidney disease (CKD). To systematically appraise and synthesise these results, we will conduct an overview of systematic reviews and meta-analyses.

METHODS AND ANALYSIS

This is a protocol for an overview of systematic reviews and meta-analyses. We will search four databases: PubMed, Embase, Web of Science Core Collection and Cochrane Central Registry of Controlled Trials. Systematic reviews and meta-analyses of clinical trials evaluating the effect of exercise interventions on patients with CKD will be included. Two independent authors will screen titles and abstracts retrieved in the literature search and select studies meeting the eligibility criteria for full-text review. The methodological quality of the included reviews will be assessed using A Measurement Tool to Assess Systematic Reviews-2. We estimate the summary effects for each meta-analyses based on the standardised mean difference and its 95% CI. Additionally, the heterogeneity will be assessed by I2 evidence of small-study effect and the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation system.

ETHICS AND DISSEMINATION

Ethics approval are not required as no private information from individuals is collected. The results will be published in a peer-reviewed journal or disseminated in relevant conferences.

PROSPERO REGISTRATION NUMBER

CRD42020223591.

Dietary protein interventions to improve nutritional status in end-stage renal disease patients undergoing hemodialysis

PURPOSE OF REVIEW

Poor nutritional status is prevalent among end-stage renal disease patients undergoing hemodialysis. Chronic hemodialysis patients show an accelerated decline in skeletal muscle mass and strength, which is associated with higher mortality rates and a reduced quality of life. The current review aims to summarize recent advances regarding underlying causes of muscle loss and interventions that support muscle mass maintenance in patients with chronic hemodialysis.

RECENT FINDINGS

Muscle maintenance in chronic hemodialysis patients is compromised by low dietary protein intake levels, anabolic resistance of skeletal muscle tissue, sedentary behavior, and amino acid removal during hemodialysis. Studies assessing the effect of increased protein intake on nutritional status generally show beneficial results, especially in hypoalbuminemic chronic hemodialysis patients. The muscle protein synthetic response following protein ingestion in chronic hemodialysis patients may be enhanced through incorporation of structured physical activity and/or concurrent ketoacid ingestion.

SUMMARY

A coordinated program that combines nutritional and physical activity interventions is likely required to attenuate the decline in muscle mass and strength of chronic hemodialysis patients. Nephrologists, dieticians, and exercise specialists should collaborate closely to establish guidelines regarding the appropriate quantity and timing of protein ingestion. In addition, they should provide tailored nutritional and physical activity interventions for chronic hemodialysis patients (see video, Supplemental Digital Content 1, Video abstract, http://links.lww.com/COCN/A14).

The effects of amino acid/protein supplementation in hemodialysis patients: study protocol for a systematic review and meta-analysis

Background

Multiple factors including older age, comorbidities, inflammation, metabolic acidosis, dialysis-related hypercatabolism and anabolic resistance of skeletal muscle, extraction of circulating amino acids through hemodialysis and inadequate dietary protein intake due to anorexia, and strictly limited dietary phosphorus intake are likely to contribute to the high prevalence of malnutrition and metabolic abnormalities, more aptly called protein-energy wasting, in patients on hemodialysis. The consensus from the International Society of Renal Nutritional and Metabolism states that nutritional supplementation is effective for replenishing protein and energy stores. Although we hypothesize that amino acid/protein supplementation can overcome the anabolic resistance of skeletal muscle tissue and attenuate or even prevent the accelerated loss of skeletal muscle mass and strength through nutritional status improvement in patients on hemodialysis, whether amino acid and/or protein administration is associated with improvements in these outcomes is unknown. The main objective of this study is to systematically review the impact of amino acid/protein supplementation on skeletal muscle mass, muscle strength, physical function, and quality of life in end-stage renal disease patients requiring hemodialysis.

Methods

Published randomized controlled trials (RCTs) assessing the effectiveness of amino acid/protein supplementation in hemodialysis patients with respect to body composition, muscle mass, muscle strength, physical function, and quality of life will be included. The bibliographic databases include MEDLINE, the Web of Science, the Cochrane Central Register of Controlled Trials, and Embase. The risk of bias of the included RCTs will be assessed using the Cochrane Collaboration’s tool by two independent reviewers. The primary outcome will be skeletal muscle mass, muscle strength, and physical function, and the secondary outcome will be quality of life. This review protocol is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol (PRISMA-P) 2015 checklist.

Ethics and dissemination

Ethical approval is not required because this study does not include confidential personal data or involve patient interventions. This review is expected to inform readers on the effect of amino acid/protein supplementation in patients undergoing hemodialysis. The findings will be presented at conferences and submitted to a peer-reviewed journal for publication.

Trial registration

The trial registration number is (CRD42020181087), and the trial was registered on 5 July 2020.

Occupational therapy and physiotherapy interventions in palliative care: a cross-sectional study of patient-reported needs

INTRODUCTION

An interdisciplinary team approach to patients in specialised palliative care is recommended; however, the composition of the professionals tends to vary, and the roles of physiotherapists and occupational therapists may be underestimated. We aimed to investigate patient-reported unmet needs, which potentially could benefit from physiotherapy and occupational therapy interventions in a specialised palliative care team.

METHODS

Adult patients with chronic advanced diseases referred to the Specialised Palliative Care Team at Copenhagen University Hospital, Rigshospitalet were enrolled in the study. The Three-Levels-of-Needs Questionnaire was used as primary outcome to assess symptom/problem intensity, symptom/problem burden and felt needs for 12 commonly reported symptoms/problems for patients referred to a specialised palliative care team. Furthermore, participants' level of distress, fatigue and physical activity, symptoms of anxiety and depression, and barriers towards the rehabilitation programme were registered with other measures.

RESULTS

In total, 43 of 67 (64%) patients participated. The majority of participants reported severe symptoms/problems concerning fatigue (81%), impaired physical activities (77%), carrying out work and daily activities (77%), pain (72%), and worries (58%). Furthermore, need for help was expressed concerning physical activities (79%), work and daily activities (77%), fatigue (70%), pain (65%), concentration (58%) and worries (51%). On average the patients characterised 6 (out of 12) symptoms/problems as severe.

CONCLUSION

Patients referred to a specialised palliative care team reported extensive unmet needs concerning physical activities, work and daily activities, fatigue, pain, concentration and worries. Unmet needs that potentially could be alleviated by physiotherapists or occupational therapists implemented in the interdisciplinary team.

An update on nutrient modulation in the management of disease-induced muscle wasting: evidence from human studies

PURPOSE OF REVIEW

Skeletal muscle has many essential roles in maintaining human health, not only being crucial for locomotion, but further as a metabolically important organ. Muscle wasting in disease (cachexia) is highly prevalent, associated with poor clinical outcomes and is not fully reversible with nutritional interventions. Understanding proteostasis in diseased states is of great importance to design novel, effective nutritional/nutraceutical strategies aimed at alleviating muscle wasting. In this review, we will provide an update on muscle kinetics in disease and the effects of nutritional interventions.

RECENT FINDINGS

Whole body and skeletal muscle kinetics are commonly shown to be imbalanced in disease, promoting overall catabolism that underlies the development of cachexia. However, recent advancements in defining the effectiveness of nutritional interventions on muscle anabolism are clouded by heterogenous patient populations and a lack of direct incorporation stable isotope techniques. Current recommendations are focused on combating malnutrition, with increased protein intake (high in EAA) demonstrating promise.

SUMMARY

Recent progress in understanding catabolic states in cachexia across disease is minimal. Further, studies investigating muscle-specific protein turnover along with nutritional interventions are scarce. As such, there is a significant requirement for strong RCT's investigating both acute and chronic nutritional interventions and their impact on skeletal muscle in individual disease states.

Intradialytic Nutrition and Hemodialysis Prescriptions: A Personalized Stepwise Approach

Dialysis and nutrition are two sides of the same coin—dialysis depurates metabolic waste that is typically produced by food intake. Hence, dietetic restrictions are commonly imposed in order to limit potassium and phosphate and avoid fluid overload. Conversely, malnutrition is a major challenge and, albeit to differing degrees, all nutritional markers are associated with survival. Dialysis-related malnutrition has a multifactorial origin related to uremic syndrome and comorbidities but also to dialysis treatment. Both an insufficient dialysis dose and excessive removal are contributing factors. It is thus not surprising that dialysis alone, without proper nutritional management, often fails to be effective in combatting malnutrition. While composite indexes can be used to identify patients with poor prognosis, none is fully satisfactory, and the definitions of malnutrition and protein energy wasting are still controversial. Furthermore, most nutritional markers and interventions were assessed in hemodialysis patients, while hemodiafiltration and peritoneal dialysis have been less extensively studied. The significant loss of albumin in these two dialysis modalities makes it extremely difficult to interpret common markers and scores. Despite these problems, hemodialysis sessions represent a valuable opportunity to monitor nutritional status and prescribe nutritional interventions, and several approaches have been tried. In this concept paper, we review the current evidence on intradialytic nutrition and propose an algorithm for adapting nutritional interventions to individual patients.