Dietary energy requirements in relatively healthy maintenance hemodialysis patients estimated from long-term metabolic studies

Deconstructing Disease-Related Malnutrition: A New Assessment Framework for Clinical Practice

Protein-energy wasting (PEW) is a key cause of functional impairment and poor health outcomes in people with chronic kidney disease. While PEW can be mitigated with nutrition therapy, it is a complex myriad of disorders with numerous interacting etiologies and corresponding presentations, which make it difficult to diagnose and manage in practice. A variety of scoring rubrics have been developed to facilitate malnutrition assessment. Although these tools have greatly benefited the recognition and treatment of PEW, the typical format of grading specified PEW indicators has the potential to overlook or overstate highly relevant individual-specific factors. This review presents a simple framework for malnutrition assessment that can be used to complement and evaluate conventional assessment tools. Unlike standard tools, which are designed to identify and rate malnutrition risk and severity, the malnutrition framework is conceptual model that organizes PEW assessment into three distinct, but interacting facets of PEW risk: nutrient balance, nutrition status, and malnutrition risk. The new framework encourages critical thinking about PEW risk that may help clinicians plan and interpret assessments to efficiently and effectively manage this condition.

Bioelectrical Impedance Analysis Derived-Phase Angle as a Pragmatic Tool to Detect Protein Energy Wasting among Multi-Ethnic Hemodialysis Patients

Protein-energy wasting (PEW) is a devastating metabolic derangement that leads to increased morbidity and mortality in hemodialysis (HD) patients. This study aimed to determine the diagnostic test accuracy of bioelectrical impedance analysis derived-phase angle (PhA) in detecting PEW among HD patients. This was a multi-centre, cross-sectional study conducted amongst 152 multi-ethnic HD patients in Klang Valley, Malaysia. PEW was assessed using the International Society of Renal Nutrition and Metabolism criteria as the reference method. PhA was measured using a multi-frequency bioelectrical impedance spectroscopy at 50 kHz. Multiple and logistic regressions were used to determine factors associated with PhA and PEW diagnosis, respectively. A receiver operating characteristics curve analysis was used to establish the gender-specific PhA cut-offs to detect PEW. PEW existed in 21.1% of the HD patients. PhA was found as an independent predictor of PEW (adjOR = 0.308, p = 0.001), with acceptable to excellent discriminative performance (adjAUC_male = 0.809; adjAUC_female = 0.719). Male patients had higher PhA cut-off compared to female patients (4.26° vs. 3.30°). We concluded that PhA is a valid and pragmatic biomarker to detect PEW in multi-ethnic Malaysian HD patients and a gender-specific cut-off is necessary, attributed to the gender differences in body composition.

Chronic Kidney Disease and Nutrition Support

Individuals with chronic kidney disease (CKD), particularly those undergoing maintenance dialysis, are prone to protein-energy wasting (PEW), the latter of which can be ameliorated with different methods of nutrition support. Dietary counseling guided by dietitians is the key for preventing and managing PEW in CKD. If dietary counseling per se fails to meet the recommended energy and protein requirements, the addition of oral nutrition supplements (ONSs) would be necessary. When these initial measures cannot attain the recommended energy and protein requirements, nutrition support, including enteral tube feeding or parenteral nutrition (PN), should be considered as a viable option to improve nutrition status. Partial PN, comprising intraperitoneal PN (IPPN) and intradialytic PN (IDPN) therapies, may be attempted as supplemental nutrition support in patients with PEW requiring peritoneal dialysis and hemodialysis, respectively. Despite the debatable effectiveness of IPPN for patients undergoing peritoneal dialysis, it remains a feasible means in these patients. The indications for IPPN in patients undergoing peritoneal dialysis include inadequate dietary intake of energy and protein, and barriers of oral intake and other forms of enteral supplementation such as issues with suitability, tolerance, and compliance. Nonetheless, in the case of spontaneous dietary consumption of energy and protein meeting the difference between the IDPN provision and the nutrition targets, the use of IDPN is rational. In patients with PEW and malfunctioning gastrointestinal tract, as well as those whose enteral intake (with or without partial PN) is below the recommended nutrient requirements, total PN becomes a relevant nutrition intervention.

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.

Energy Requirement of Patients Undergoing Hemodialysis: A Cross-Sectional Study in Multiple Centers

BACKGROUND

Energy requirements must be estimated before nutritional care can be provided for patients undergoing hemodialysis (HD). However, the recommended caloric intake for patients has not been conclusively determined because of insufficiently large sample sizes.

METHOD

This cross-sectional observational study recruited patients undergoing long-term HD from multiple centers as well as people in the general population without chronic kidney disease. People from both groups were matched by sex and age. Resting energy expenditure (REE) was estimated using an indirect calorimeter. Two commonly used equations for estimating REE and daily energy requirement recommended by the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (K/DOQI) were chosen.

RESULTS

This study had 154 HD patients and 33 matched HD-control group pairs. Age (r = -0.36, p < 0.01) and dry body weight after dialysis (r = -0.36, p < 0.01) and dry body weight after dialysis (.

CONCLUSIONS

Age and dry body weight are the main factors affecting the energy expenditure of HD patients. Furthermore, predicting the energy expenditure of HD patients by measuring the energy expenditure of their sedentary counterparts in the general population with the same sex, age range, and weight may yield better results than using traditional equations for predicting TEE. In East Asian populations, the TEE values were 32 and 30 kcal/kg dry weight for those aged <65 and ≥65 years, respectively. Future prospective cohort studies with larger sample sizes are needed.

The Demographic Diversity of Food Intake and Prevalence of Kidney Stone Diseases in the Indian Continent

Food intake plays a pivotal role in human growth, constituting 45% of the global economy and wellbeing in general. The consumption of a balanced diet is essential for overall good health, and a lack of equilibrium can lead to malnutrition, prenatal death, obesity, osteoporosis and bone fractures, coronary heart diseases (CHD), idiopathic hypercalciuria, diabetes, and many other conditions. CHD, osteoporosis, malnutrition, and obesity are extensively discussed in the literature, although there are fragmented findings in the realm of kidney stone diseases (KSD) and their correlation with food intake. KSD associated with hematuria and renal failure poses an increasing threat to healthcare infrastructures and the global economy, and its emergence in the Indian population is being linked to multi-factorial urological disorder resulting from several factors. In this realm, epidemiological, biochemical, and macroeconomic situations have been the focus of research, even though food intake is also of paramount importance. Hence, in this article, we review the corollary associations with the consumption of diverse foods and the role that these play in KSD in an Indian context.

High rates of central obesity and sarcopenia in CKD irrespective of renal replacement therapy - an observational cross-sectional study

Background

Poor nutritional status of patients with renal disease has been associated with worsening of renal function and poor health outcomes. Simply measuring weight and height for calculation of the body mass index does however not capture the true picture of nutritional status in these patients. Therefore, we measured nutritional status by BMI, body composition, waist circumference, dietary intake and nutritional screening in three groups of renal patients.

Methods

Patients with chronic kidney disease not on renal replacement therapy (CKD stages 3–5, n = 112), after renal transplantation (n = 72) and patients treated with hemodialysis (n = 24) were recruited in a tertiary hospital in Bergen, Norway in a cross-sectional observational study. Dietary intake was assessed by a single 24 h recall. All patients underwent nutritional screening, anthropometric measurements, body composition measurement andfunctional measurements (hand grip strength). The prevalence of overweight and obesity, central obesity, sarcopenia, sarcopenic obesity and nutritional risk was calculated.

Results

Central obesity and sarcopenia were present in 49% and 35% of patients, respectively. 49% of patients with central obesity were normal weight or overweight according to their BMI. Factors associated with central obesity were a diagnosis of diabetes and increased fat mass, while factors associated with sarcopenia were age, female gender, number of medications. An increase in the BMI was associated with lower risk for sarcopenia.

Conclusion

Central obesity and sarcopenia were present in renal patients at all disease stages. More attention to these unfavorable nutritional states is warranted in these patients.

Inadequate dietary energy intake associates with higher prevalence of metabolic syndrome in different groups of hemodialysis patients: a clinical observational study in multiple dialysis centers

BACKGROUND

Metabolic syndrome (MetS) has been established as a risk for cardiovascular diseases and mortality in hemodialysis patients. Energy intake (EI) is an important nutritional therapy for preventing MetS. We examined the association of self-reported dietary EI with metabolic abnormalities and MetS among hemodialysis patients.

METHODS

A cross-sectional study design was carried out from September 2013 to April 2017 in seven hemodialysis centers. Data were collected from 228 hemodialysis patients with acceptable EI report, 20 years old and above, underwent three hemodialysis sessions a week for at least past 3 months. Dietary EI was evaluated by a three-day dietary record, and confirmed by 24-h dietary recall. Body compositions were measured by bioelectrical impedance analysis. Biochemical data were analyzed using standard laboratory tests. The cut-off values of daily EI were 30 kcal/kg, and 35 kcal/kg for age ≥ 60 years and < 60 years, respectively. MetS was defined by the American Association of Clinical Endocrinologists (AACE-MetS), and Harmonizing Metabolic Syndrome (HMetS). Logistic regression models were utilized for examining the association between EI and MetS. Age, gender, physical activity, hemodialysis vintage, Charlson comorbidity index, high sensitive C-reactive protein, and interdialytic weight gains were adjusted in the multivariate analysis.

RESULTS

The prevalence of inadequate EI, AACE-MetS, and HMetS were 60.5%, 63.2%, and 53.9%, respectively. Inadequate EI was related to higher proportion of metabolic abnormalities and MetS (p <  0.05). Results of the multivariate analysis shows that inadequate EI was significantly linked with higher prevalence of impaired fasting glucose (OR = 2.42, p <  0.01), overweight/obese (OR = 6.70, p <  0.001), elevated waist circumference (OR = 8.17, p <  0.001), AACE-MetS (OR = 2.26, p <  0.01), and HMetS (OR = 3.52, p <  0.01). In subgroup anslysis, inadequate EI strongly associated with AACE-MetS in groups of non-hypertension (OR = 4.09, p = 0.004), and non-cardiovascular diseases (OR = 2.59, p = 0.012), and with HMetS in all sub-groups of hypertension (OR = 2.59~ 5.33, p <  0.05), diabetic group (OR = 8.33, p = 0.003), and non-cardiovascular diseases (OR = 3.79, p <  0.001).

CONCLUSIONS

Inadequate EI and MetS prevalence was high. Energy intake strongly determined MetS in different groups of hemodialysis patients.

Patients receiving dialysis do not have increased energy needs compared with healthy adults

BACKGROUND

Patients receiving dialysis are thought to have increased energy needs due to stress from the dialysis process or uraemic toxins. However, certain conditions may induce hypometabolic states potentially leading to unwanted weight gains when increased calorie intake is recommended.

OBJECTIVES

Since there is conflicting research, this study aims to assess total energy expenditure (TEE) of patients receiving dialysis through analysis of resting energy expenditure (REE) and physical activity levels.

DESIGN

Comprehensive review of the current literature on REE and physical activity levels.

METHODS

Two electronic databases (PubMed and CINAHL) were searched using keywords to find papers published within the last 10 years for physical activity studies and within the last five years for REE.

INCLUSION CRITERIA

Adults undergoing long-term dialysis treatments who do not have comorbidities that influence energy expenditure such as inflammation, hyperthyroidism or cancers. Participants were also required to ambulate without assistance.

RESULTS

Only seven of the 325 studies found were included in this review. Most studies were controlled trials with one being a prospective study. Patients receiving dialysis had rest energy expenditures comparable to healthy adults. There was not a consensus between studies as to which predictive energy equation produced accurate energy recommendations. Overall, patients receiving dialysis were significantly less active compared with healthy adults and this related to muscle mass.

CONCLUSION

Patients receiving dialysis tend to be sedentary or lightly active and do not have increased energy expenditure compared with healthy adults. Therefore, stable patients should not be prescribed increased calorie intake.

The Diet and Haemodialysis Dyad: Three Eras, Four Open Questions and Four Paradoxes. A Narrative Review, Towards a Personalized, Patient-Centered Approach

The history of dialysis and diet can be viewed as a series of battles waged against potential threats to patients' lives. In the early years of dialysis, potassium was identified as "the killer", and the lists patients were given of forbidden foods included most plant-derived nourishment. As soon as dialysis became more efficient and survival increased, hyperphosphatemia, was identified as the enemy, generating an even longer list of banned aliments. Conversely, the "third era" finds us combating protein-energy wasting. This review discusses four questions and four paradoxes, regarding the diet-dialysis dyad: are the "magic numbers" of nutritional requirements (calories: 30-35 kcal/kg; proteins > 1.2 g/kg) still valid? Are the guidelines based on the metabolic needs of patients on "conventional" thrice-weekly bicarbonate dialysis applicable to different dialysis schedules, including daily dialysis or haemodiafiltration? The quantity of phosphate and potassium contained in processed and preserved foods may be significantly different from those in untreated foods: what are we eating? Is malnutrition one condition or a combination of conditions? The paradoxes: obesity is associated with higher survival in dialysis, losing weight is associated with mortality, but high BMI is a contraindication for kidney transplantation; it is difficult to limit phosphate intake when a patient is on a high-protein diet, such as the ones usually prescribed on dialysis; low serum albumin is associated with low dialysis efficiency and reduced survival, but on haemodiafiltration, high efficiency is coupled with albumin losses; banning plant derived food may limit consumption of "vascular healthy" food in a vulnerable population. Tailored approaches and agreed practices are needed so that we can identify attainable goals and pursue them in our fragile haemodialysis populations.

Application of Holistic Nursing in Uremic Patients with Hematodialysis Related Malnutrition

BACKGROUND

We aimed to observe the effect of holistic nursing on patients undergoing hematodialysis for uremia who simultaneously were suffering from moderate to severe malnutrition.

METHODS

Eighty patients with uremia on maintenance hematodialysis with malnutrition between June 2014 and June 2015 from Yantaishan Hospital, Yantai, Shandong, China were included and equally and randomly were divided into the control group (n=43) and observation group (n=43). Routine nursing was used in the control group while holistic nursing was used in observation group (before, during and after dialysis) and the clinical effects in the two groups were compared after 3 months.

RESULTS

At follow-up visits, serum creatinine and urea nitrogen levels of the patients in the two groups were decreased, whereas hemoglobin and albumin levels were increased. In addition, these improvements were greater in the observation group and the differences were statistically significant (P<0.05). Furthermore, during follow-up visits, MQSGA and MIS scores of the two groups were lower and the scores of the observation group were lower than those in the control group were, and the differences were statistically significant (P<0.05).

CONCLUSION

Holistic nursing is able to improve significantly malnutrition in patients with uremia on hematodialysis.

Protein-energy wasting and nutritional supplementation in patients with end-stage renal disease on hemodialysis

BACKGROUND & AIMS

Protein-Energy Wasting (PEW) is the depletion of protein/energy stores observed in the most advanced stages of Chronic Kidney Disease (CKD). PEW is highly prevalent among patients on chronic dialysis, and is associated with adverse clinical outcomes, high morbidity/mortality rates and increased healthcare costs. This narrative review was aimed at exploring the pathophysiology of PEW in end-stage renal disease (ESRD) on hemodialysis. The main aspects of nutritional status evaluation, intervention and monitoring in this clinical setting were described, as well as the current approaches for the prevention and treatment of ESRD-related PEW.

METHODS

An exhaustive literature search was performed, in order to identify the relevant studies describing the epidemiology, pathogenesis, nutritional intervention and outcome of PEW in ESRD on hemodialysis.

RESULTS AND CONCLUSION

The pathogenesis of PEW is multifactorial. Loss of appetite, reduced intake of nutrients and altered lean body mass anabolism/catabolism play a key role. Nutritional approach to PEW should be based on a careful and periodic assessment of nutritional status and on timely dietary counseling. When protein and energy intakes are reduced, nutritional supplementation by means of specific oral formulations administered during the hemodialysis session may be the first-step intervention, and represents a valid nutritional approach to PEW prevention and treatment since it is easy, effective and safe. Omega-3 fatty acids and fibers, now included in commercially available preparations for renal patients, could lend relevant added value to macronutrient supplementation. When oral supplementation fails, intradialytic parenteral nutrition can be implemented in selected patients.