Eating during the Hemodialysis Session: A Practice Improving Nutritional Status or a Risk Factor for Intradialytic Hypotension and Reduced Dialysis Adequacy?

Hemodialysis Procedures for Stable Incident and Prevalent Patients Optimize Hemodynamic Stability, Dialysis Dose, Electrolytes, and Fluid Balance

The demographic profile of patients transitioning from chronic kidney disease to kidney replacement therapy is changing, with a higher prevalence of aging patients with multiple comorbidities such as diabetes mellitus and heart failure. Cardiovascular disease remains the leading cause of mortality in this population, exacerbated by the cardiovascular stress imposed by the HD procedure. The first year after transitioning to hemodialysis is associated with increased risks of hospitalization and mortality, particularly within the first 90-120 days, with greater vulnerability observed among the elderly. Based on data from clinics in Fresenius Medical Care Europe, Middle East, and Africa NephroCare, this review aims to optimize hemodialysis procedures to reduce mortality risk in stable incident and prevalent patients. It addresses critical aspects such as treatment duration, frequency, choice of dialysis membrane, dialysate composition, blood and dialysate flow rates, electrolyte composition, temperature control, target weight management, dialysis adequacy, and additional protocols, with a focus on mitigating prevalent intradialytic complications, particularly intradialytic hypotension prevention.

Questionnaire survey of the frequency of dietary intake during hemodialysis and the impact of COVID-19 in Japan

BACKGROUND

There have been no coherent reports on the effects of dietary intake during hemodialysis in Japan. Furthermore, few studies have reported the impact of the COVID-19 pandemic on them. This study aimed to investigate dietary intake during hemodialysis and its impact on the spread of COVID-19.

METHODS

This consecutive cross-sectional study included a survey of all hemodialysis facilities in the Niigata Prefecture. The survey form was sent via e-mail or fax.

RESULTS

Fifty four facilities (98%) responded to the 2018 survey. Twenty-eight facilities (52%) provided meals, with 18% of all patients undergoing dialysis and 41% of patients undergoing nocturnal dialysis consuming meals during hemodialysis. In the 2020 survey, the number of facilities decreased to 17 (33%), and the number of all patients undergoing dialysis and nocturnal dialysis consuming meals decreased to 13% and 32%, respectively. In the 2022 survey, the number of facilities decreased to 14 (27%), and the number of all patients undergoing dialysis and nocturnal dialysis decreased to 9% and 19%, respectively.

CONCLUSION

The COVID-19 pandemic has caused a decrease in both facilities serving meals and patients' food consumption during hemodialysis. To prevent the loss of meal opportunities, establishing safe methods for food intake and alternatives in hemodialysis facilities is necessary.

Deleterious effects of intradialytic meals' suppression during the COVID pandemic

BACKGROUND&AIMS

Patients with end-stage renal failure on chronic hemodialysis present an important risk of malnutrition, which is associated with a significant risk of morbidity and mortality. Meals during the dialysis session are important for maintaining the nutritional status of dialysis patients but represent a risk for intradialytic hypotension. During the COVID-19 pandemic, several dialysis centers stopped providing meals during the dialysis session as a protective measure. The aim of this retrospective, multicentric cross-over study was to study the evolution of the nutritional parameters of a cohort of hemodialysis patients for 12 months before, during and after the suspension of meals during dialysis due to the COVID-19 pandemics.

METHODS

We registered the evolution of dry weight, C Reactive Protein (CRP), serum Potassium and Phosphate before the dialysis session, serum albumin and prealbumin levels as well as normalized Protein Catabolic Ratio (nPCR).

RESULTS

We studied 168 hemodialysis patients (113M, 55F, mean age at inclusion:68.45 ± 0.45 years). The results ares shown as mean values (±SEM). The supression of the intradialytic meals led to significant reduction of the patients' dry weight (in Kg) from 78.66 ± 0.72 to 76.50 ± 0.49, p = 0.013, serum albumin (in g/l) (from 40.72 ± 0.16 to 39.25 ± 0.12, p < 0.001) and prealbumin levels (in g/l) (from 33.82 ± 0.31 to 32.73 ± 0.22, p = 0.004) as well as the nPCR values (from 1.08 ± 0.08 to 1.05 ± 0.11, p = 0.021). Serum CRP as well as predialytic Potassium and Phosphate levels did not change significantly. The reinstitution of the intradialytic meals led to a complete correction of the studied nutritional parameters with Body weight values evolving from 76.50 ± 0.49 to 78.28 ± 1.01, p = 0.025, serum albumin from 39.25 ± 0.12 to 40.53 ± 1.04, p < 0.001, serum prealbumin levels from 32.73 ± 0.22 to 33.95 ± 0.64, p = 0.001 an nPCR from 1.05 ± 0.11 to 1.08 ± 0.08, p = 0.021.

CONCLUSION

In conclusion, the suppression of intradialytic meals during the COVID-19 pandemic had deleterious effects on the nutritional parameters of patients on chronic hemodialysis.

The effect of food intake during hemodialysis on blood pressure: A nonrandomized experimental trial

BACKGROUND

Intradialytic hypotension (IDH) is one of the most important intradialytic complications and is thought to be associated with intradialytic food intake. Allowing intradialytic feeding is still unclear. This study aimed to determine the relationship between IDH and intradialytic food intake.

METHODS

A nonrandomized experimental study was conducted to determine the effect of intradialytic food intake on blood pressure (BP) in hemodialysis patients. Each patient was assessed twice using an ambulatory BP monitor with and without intradialytic food intake.

RESULTS

The study was completed with 54 patients. Intradialytic hypotension developed in 40 patients (74.1%) during the food intake session, while intradialytic hypotension developed in 22 participants (40%) in the no-food session. Repeated BP readings showed that eating 2 h or more after the start of hemodialysis significantly reduced BP.

CONCLUSIONS

Intradialytic food intake affects the development of IDH. Patients who ate during hemodialysis had a trend of higher of IDH than those who ate nothing during hemodialysis. Eating during dialysis is not recommended.

Survey of food offered to United Kingdom haemodialysis patients attending for dialysis sessions in main dialysis centres and satellite units and international comparison

Background

Haemodialysis (HD) patients are at increased risk of frailty, sarcopenia and protein energy wasting, all associated with increased mortality. Most of the dialysis day is taken up with travelling to and from dialysis centres and dialysis treatment. The International Society of Nutrition and Metabolism (ISNM) recommend that meals or supplements should be part of standard clinical practice when patients attending for dialysis.

Results

We surveyed adult UK centres to determine the provision of food to dialysis patients in the United Kingdom (UK). A hot meal was provided by six (8.7%) of the 69 UK adult units, although 16 (23.2%) main centres would potentially provide meals to a restricted number of malnourished patients. Forty-seven (68.1%) centres provided sandwiches, although this was restricted in eight main centres, and 26.2% of units did not provide sandwiches to patients in their satellite dialysis centres. Biscuits were the only nutrition routinely offered in 15 (21.7%) of the main dialysis units, 41.3% of satellite units. Meals were more likely to be offered in Northern Ireland and Scotland compared to England, and 38% of the main dialysis units in England, and 58% of their satellite centres did not routinely offer patients a sandwich compared to none or one centre in Wales, Scotland and Northern Ireland.

Conclusions

Despite an increasing older, more frail dialysis population in the UK, food provision for dialysis patients has reduced, particularly in England, with < 10% of centres routinely offering hot food, and > 50% of dialysis units now only offering biscuits to their satellite dialysis patients.

Adherence to Caloric and Protein Recommendations in Older Hemodialysis Patients: A Multicenter Study

Hemodialysis (HD) patients are characterized by malnutrition, which adversely affects their survival. The development of malnutrition is influenced, among other factors, by improper diet and the advanced age of patients. The study aimed to assess the nutritional status and adherence to dietary recommendations among older patients. The multicenter study included 179 stable HD patients. The nutritional status was assessed by a 7-point Subjective Global Assessment (SGA). Anthropometry and body composition was analyzed. The diet was assessed based on the 3-day food diary and the Food Frequency Questionnaire with 6 answers (FFQ-6). Blood laboratory tests were performed. Based on the 7-point SGA, malnutrition was diagnosed in 38.5% of HD patients. The decreased content of the muscle tissue (LTI < 14 kg/m2) was observed in 70.4% of the examined patients and the decreased concentration of s-albumin was observed in 44.1% of patients. Older patients had significantly lower LTI. 26% of patients consumed less than 25 kcal/kg body weight and less than 0.8 g protein/kg body weight. Older patients’ diets contained significantly fewer calories. There were significant differences between nutrient intake on a weekday with dialysis, a weekday without dialysis, and a weekend day without dialysis. The lowest intake of nutrients was observed on the day of dialysis. Nutritional education and the determination of whether food is permitted during hemodialysis are necessary to improve patients’ nutrition.

Correlation of NO and ET-1 Levels with Blood Pressure Changes in Hemodialysis Patients after Arteriovenous Fistula Surgery

Hemodialysis (HD) is the most common renal replacement therapy for patients with end-stage renal disease (ESRD) and can significantly reduce mortality and improve the quality of life of patients. The occurrence of intradialytic hypotension and intradialytic hypertension are important risk factors for death and disability during dialysis in patients with ESRD, yet their etiology remains unclear, and some studies suggest that nitric oxide (NO) and endothelin-1 (ET-1) may play an important role in these hemodynamic alterations. For this purpose we examined the changes in NO and ET-1 levels during hemodialysis in 30 patients on maintenance hemodialysis (MHD) after arteriovenous fistula surgery. Thirty dialysis patients were divided into group I (stable blood pressure during dialysis), group II (Intradialytic hypotension) and group III (Intradialytic hypertension) according to the change of blood pressure (BP) during hemodialysis, with 10 cases in each group. BP of MHD patients were measured Pre-dialysis (Pre-D), at 1 h of dialysis (1h-D), at 2 h of dialysis (Mid-D, 2h-D), at 3 h of dialysis (3h-D), and at the end of dialysis (Post-D); and blood samples were taken from the arterial end at Pre-D, Mid-D, and Post-D to measure NO and ET-1 levels. The results of the analysis showed that as dialysis proceeded and ended, the NO levels in the three groups gradually decreased, with significant differences compared with those before dialysis (p < 0.05); the ET-1 levels in group III gradually increased, with significant differences compared with those before dialysis (p < 0.05), while the increasing trend of ET-1 levels in group I and group II was not significant. The increasing trend of MAP in group I was not significant (p > 0.05); MAP in group II showed a gradual decrease and MAP in group III showed an increasing trend, and the difference between MAP after dialysis and before dialysis was significant (p < 0.05). Correlation analysis showed a significant positive correlation between ET-1 levels and MAP in Group III at Mid-D (r = 0.847, p = 0.002). This shows that serum ET-1 and NO levels are significantly higher than normal in MHD patients after arteriovenous endovascular fistula surgery, and both ET-1 and NO levels are changing during dialysis, and there may be a link between their changes and blood pressure changes. It is suggested that the blood pressure fluctuations that occur during dialysis in MHD patients may be related to endothelial cell dysfunction.

Feeding during Dialysis Increases Intradialytic Blood Pressure Variability and Reduces Dialysis Adequacy

Whether hemodialysis patients should be allowed or even encouraged to eat during dialysis remains a controversial topic. This cross-over study aimed to evaluate the impact of feeding during dialysis on intradialytic blood pressure (BP) profile and dialysis adequacy in 26 patients receiving thrice-weekly, in-center hemodialysis. Over three consecutive mid-week dialysis sessions, intradialytic BP was monitored using the Mobil-O-Graph device (IEM, Stolberg, Germany). Blood samples were also obtained for the determination of the urea reduction ratio (URR). At baseline, patients underwent dialysis without the provision of a meal. In phases A and B, a meal with either high-protein (1.5 gr/kg of body weight) or low-protein (0.7 gr/kg of body weight) content was administered 1 h after the initiation of dialysis. The sequence of meals (high-protein and low-protein or vice versa) was randomized. Average intradialytic systolic BP (SBP) was similar on all three occasions. However, compared with baseline, the standard deviation (SD) (11.7 ± 4.1 vs. 15.6 ± 7.6 mmHg, p < 0.01), coefficient of variation (CV) (9.5 ± 3.7% vs. 12.4 ± 6.0%, p < 0.01) and average real variability (ARV) (9.4 ± 3.9 vs. 12.1 ± 5.2 mmHg, p < 0.01) of intradialytic SBP were higher in phase A. Similarly, compared with the baseline evaluation, all three indices of intradialytic SBP variability were higher in phase B (SD: 11.7 ± 4.1 vs. 14.1 ± 4.5 mmHg, p < 0.05; CV: 9.5 ± 3.7% vs. 11.1 ± 3.8%, p < 0.05; ARV: 9.4 ± 3.9 vs. 10.9 ± 3.9 mmHg, p < 0.05). Compared with dialysis without a meal, the consumption of a high-protein or low-protein meal resulted in a lower URR (73.4 ± 4.3% vs. 65.7 ± 10.7%, p < 0.001 in phase A and 73.4 ± 4.3% vs. 67.6 ± 4.3%, p < 0.001 in phase B, respectively). In conclusion, in the present study, feeding during dialysis was associated with higher intradialytic SBP variability and reduced adequacy of the delivered dialysis.

Reconsidering the Trendelenburg position during intradialytic hypotension

ABSTRACT

Intradialytic hypotension (IDH) is the most common complication that patients experience during hemodialysis. This article discusses IDH and its emergency management, focusing on Trendelenburg position, which may create more risks than benefits.

The effects of the transtheoretical model combined with nutritional intervention in hemodialysis patients

OBJECTIVE

To investigate the effects of the transtheoretical model combined with nutritional intervention (TTMNI) in hemodialysis (HD) patients.

METHODS

The clinical data of 100 HD patients recorded from October 2018 to October 2020 were retrospectively collected and divided into two groups according to the intervention method each patient underwent. Group A (n=49) underwent routine nursing intervention and group B (n=51) underwent TTMNI combined with routine nursing intervention. The two groups were compared before and after intervention in terms of their nutritional indices, Renal Adherence Attitudes Questionnaire (RAAQ) scores, their Renal Adherence Behavior Questionnaire (RABQ) scores, their Subjective Global Assessment (SGA) statuses, their anthropometric indicators such as their serum creatinine (SCr), blood urea nitrogen (BUN), mid-arm muscle circumference (MAMC), triceps skinfold (TSF), body mass index (BMI), urea clearance index (KT/V), and urea reduction ratios (URR%).

RESULTS

Compared with group A, group B showed higher transferrin (TRF), prealbumin (PA), and albumin (ALB) levels, higher RAAQ and RABQ scores, higher MAMC, TSF, and BMI levels and lower SGA scores, and lower SCr, and BUN levels (P<0.05). After the intervention, the attainment rate of target KT/V was 94.12% in group B, higher than the 63.27% in group A, and the patients with target URR% accounted for 96.07% in group B, higher than the 61.22% in group A (P<0.05).

CONCLUSION

TTMNI for HD patients is helps improve patients' nutritional statuses and their dietary compliance as well as their liver function, and it increases their dialysis attainment rate.

Significance of Levocarnitine Treatment in Dialysis Patients

Carnitine is a naturally occurring amino acid derivative that is involved in the transport of long-chain fatty acids to the mitochondrial matrix. There, these substrates undergo β-oxidation, producing energy. The major sources of carnitine are dietary intake, although carnitine is also endogenously synthesized in the liver and kidney. However, in patients on dialysis, serum carnitine levels progressively fall due to restricted dietary intake and deprivation of endogenous synthesis in the kidney. Furthermore, serum-free carnitine is removed by hemodialysis treatment because the molecular weight of carnitine is small (161 Da) and its protein binding rates are very low. Therefore, the dialysis procedure is a major cause of carnitine deficiency in patients undergoing hemodialysis. This deficiency may contribute to several clinical disorders in such patients. Symptoms of dialysis-related carnitine deficiency include erythropoiesis-stimulating agent-resistant anemia, myopathy, muscle weakness, and intradialytic muscle cramps and hypotension. However, levocarnitine administration might replenish the free carnitine and help to increase carnitine levels in muscle. This article reviews the previous research into levocarnitine therapy in patients on maintenance dialysis for the treatment of renal anemia, cardiac dysfunction, dyslipidemia, and muscle and dialytic symptoms, and it examines the efficacy of the therapeutic approach and related issues.

[Prevalence and risk factors associated with intradialytic hypotension in Sub-Saharan Africa: The case of Burkina Faso]

AIM

The aim of our study was to determine the prevalence and factors associated with intradialytic hypotension in our cohort of chronic hemodialysis patients.

METHODS

This was a prospective monocentric study over a six-month period. Intradialytic hypotension was defined as a decrease in systolic blood pressure ≥ 20mmHg or a decrease in mean arterial pressure of 10mmHg associated with clinical events and the need for nursing interventions. The groups were compared using univariate analysis of variance.

RESULTS

We included 48 patients and counted 3014 hemodialysis sessions. The mean age was 44.7±15 years. The prevalence of intradialytic hypotension was 12.4%, with cramps 20 (41.7%) as the main symptom. Factors associated with frequent intradialytic hypotension compared to the groups without intradialytic hypotension and with infrequent intradialytic hypotension were age (61±13 years, p=0.018), diabetes (33.3%, p=0.019), high body mass index (27, 3±7.8kg/m2, p=0.002), interdialytic weight gain ≥ 5% of baseline weight (66.7%, p=0.033), hourly ultrafiltration (800±275ml/h, p=0.037) and perdialytic feeding (33.3%, p=0.016). Low pre-dialysis diastolic blood pressure (72±13mmHg, p=0.012) and high baseline weight (73.9±17.5kg, p=0.028) were associated with frequent versus infrequent intradialytic hypotension.

CONCLUSION

Intradialytic hypotension is common in our context. Its prevention in at-risk patients is critical to reducing morbidity and mortality and improving quality of life.

How to Overcome Anabolic Resistance in Dialysis-Treated Patients?

A current hypothesis is that dialysis-treated patients are "anabolic resistant" i. e., their muscle protein synthesis (MPS) response to anabolic stimuli is blunted, an effect which leads to muscle wasting and poor physical performance in aging and in several chronic diseases. The importance of maintaining muscle mass and MPS is often neglected in dialysis-treated patients; better than to describe mechanisms leading to energy-protein wasting, the aim of this narrative review is to suggest possible strategies to overcome anabolic resistance in this patient's category. Food intake, in particular dietary protein, and physical activity, are the two major anabolic stimuli. Unfortunately, dialysis patients are often aged and have a sedentary behavior, all conditions which per se may induce a state of "anabolic resistance." In addition, patients on dialysis are exposed to amino acid or protein deprivation during the dialysis sessions. Unfortunately, the optimal amount and formula of protein/amino acid composition in supplements to maximixe MPS is still unknown in dialysis patients. In young healthy subjects, 20 g whey protein maximally stimulate MPS. However, recent observations suggest that dialysis patients need greater amounts of proteins than healthy subjects to maximally stimulate MPS. Since unneccesary amounts of amino acids could stimulate ureagenesis, toxins and acid production, it is urgent to obtain information on the optimal dose of proteins or amino acids/ketoacids to maximize MPS in this patients' population. In the meantime, the issue of maintaining muscle mass and function in dialysis-treated CKD patients needs not to be overlooked by the kidney community.