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Hevilla F, Padial M, Blanca M, Barril G, Jiménez-Salcedo T, Ramirez-Ortiz M, Nogueira Á, Gentile A, García-Escobar E, Romero-Zerbo SY, Olveira G. Effect on nutritional status and biomarkers of inflammation and oxidation of an oral nutritional supplement (with or without probiotics) in malnourished hemodialysis patients. A multicenter randomized clinical trial "Renacare Trial". Front Nutr 2023; 10:1107869. [PMID: 36819685 PMCID: PMC9936863 DOI: 10.3389/fnut.2023.1107869] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 01/03/2023] [Indexed: 02/05/2023] Open
Abstract
Background Malnutrition in patients undergoing hemodialysis is frequent and associated with a reduction in muscular mass and strength, with an increment in biomarkers of inflammation and oxidation. Materials and methods Randomized, multicenter, parallel-group trial in malnourished hemodialysis patients with three groups [(1) control (C) individualized diet, (2) oral nutritional supplement-ONS- + placebo-SU- PL-, and (3) ONS + probiotics-SU-PR]; the trial was open regarding the intake of ONS or individualized diet recommendations, but double-blind for the intake of probiotics. We obtained, at baseline and after 3 and 6 months, anthropometric measurements, handgrip strength, bioelectrical impedance analysis (BIA), dietary records, and routine biochemical parameters. Inflammation and oxidation were determined using ELISA techniques (Versamax and ProcartaPlex multiplex Immunoassay). Results were analyzed by intention to treat. Results A total of 31 patients (11 corresponding to group C, 10 to SU-PL, and 10 to SU-PR) completed the 6-months trial. The two groups that took supplements significantly increased their protein calorie, fat (total and n-3), and fiber intake. Weight and fat-free mass (FFM) also increased significantly in the groups on supplements, both at 3 and 6 months, and dynamometry did so in the SU-PL group. At month 3, prealbumin and vitamin D were significantly increased in the SU-TOT (SU-PL + SU-PR) group. No changes were observed regarding levels of phosphorus and potassium in any of the groups. Urea increased significantly at 6 months in the SU-PL group. There were significant changes in some inflammation biomarkers in the groups on supplements during the intervention (brain-derived neurotrophic factor, bone morphogenetic protein-2, MCP-1, IL-1-beta, IL-10, IL-4, and IL-8). The total antioxidant capacity (TAC) increased significantly in the supplemented patients, with no significant changes observed in isoprostanes. Conclusion The specific ONS improved protein-calorie intake, nutritional status (mainly FFM), and some biomarkers of inflammation/oxidation. The addition of probiotics could have a synergistic effect with ONS in such biomarkers. Clinical trail registration https://clinicaltrials.gov/ct2/show/, identifier NCT03924089.
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Affiliation(s)
- Francisco Hevilla
- Servicio de Endocrinología y Nutrición, Instituto de Investigación Biomédica de Málaga–Plataforma BIONAND, Hospital Regional Universitario de Málaga, Málaga, Spain
- Departamento de Medicina y Dermatología, Universidad de Málaga, Málaga, Spain
| | - Marina Padial
- Servicio de Endocrinología y Nutrición, Instituto de Investigación Biomédica de Málaga–Plataforma BIONAND, Hospital Regional Universitario de Málaga, Málaga, Spain
- Departamento de Medicina y Dermatología, Universidad de Málaga, Málaga, Spain
| | - María Blanca
- Servicio de Endocrinología y Nutrición, Hospital Universitario Rey Juan Carlos, Madrid, Spain
| | | | | | - Mercedes Ramirez-Ortiz
- Servicio de Endocrinología y Nutrición, Hospital Universitario Rey Juan Carlos, Madrid, Spain
| | - Ángel Nogueira
- Servicio de Nefrología, Hospital de la Princesa, Madrid, Spain
| | - Adriana Gentile
- Servicio de Endocrinología y Nutrición, Instituto de Investigación Biomédica de Málaga–Plataforma BIONAND, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Eva García-Escobar
- Servicio de Endocrinología y Nutrición, Instituto de Investigación Biomédica de Málaga–Plataforma BIONAND, Hospital Regional Universitario de Málaga, Málaga, Spain
- CIBER de Diabetes y Enfermedades Metabólicas Asociadas, Instituto de Salud Carlos III, Málaga, Spain
| | - Silvana Y. Romero-Zerbo
- Servicio de Endocrinología y Nutrición, Instituto de Investigación Biomédica de Málaga–Plataforma BIONAND, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Gabriel Olveira
- Servicio de Endocrinología y Nutrición, Instituto de Investigación Biomédica de Málaga–Plataforma BIONAND, Hospital Regional Universitario de Málaga, Málaga, Spain
- Departamento de Medicina y Dermatología, Universidad de Málaga, Málaga, Spain
- CIBER de Diabetes y Enfermedades Metabólicas Asociadas, Instituto de Salud Carlos III, Málaga, Spain
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Abstract
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.
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Affiliation(s)
- Winnie Chan
- School of Sport, Exercise and Rehabilitation Sciences, The University of Birmingham, Edgbaston, Birmingham, United Kingdom.,Department of Nephrology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Edgbaston, Birmingham, United Kingdom
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Ikizler TA, Burrowes JD, Byham-Gray LD, Campbell KL, Carrero JJ, Chan W, Fouque D, Friedman AN, Ghaddar S, Goldstein-Fuchs DJ, Kaysen GA, Kopple JD, Teta D, Yee-Moon Wang A, Cuppari L. KDOQI Clinical Practice Guideline for Nutrition in CKD: 2020 Update. Am J Kidney Dis 2020; 76:S1-S107. [PMID: 32829751 DOI: 10.1053/j.ajkd.2020.05.006] [Citation(s) in RCA: 762] [Impact Index Per Article: 190.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 05/29/2020] [Indexed: 12/14/2022]
Abstract
The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidence-based guidelines for nutrition in kidney diseases since 1999. Since the publication of the first KDOQI nutrition guideline, there has been a great accumulation of new evidence regarding the management of nutritional aspects of kidney disease and sophistication in the guidelines process. The 2020 update to the KDOQI Clinical Practice Guideline for Nutrition in CKD was developed as a joint effort with the Academy of Nutrition and Dietetics (Academy). It provides comprehensive up-to-date information on the understanding and care of patients with chronic kidney disease (CKD), especially in terms of their metabolic and nutritional milieu for the practicing clinician and allied health care workers. The guideline was expanded to include not only patients with end-stage kidney disease or advanced CKD, but also patients with stages 1-5 CKD who are not receiving dialysis and patients with a functional kidney transplant. The updated guideline statements focus on 6 primary areas: nutritional assessment, medical nutrition therapy (MNT), dietary protein and energy intake, nutritional supplementation, micronutrients, and electrolytes. The guidelines primarily cover dietary management rather than all possible nutritional interventions. The evidence data and guideline statements were evaluated using Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria. As applicable, each guideline statement is accompanied by rationale/background information, a detailed justification, monitoring and evaluation guidance, implementation considerations, special discussions, and recommendations for future research.
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Alipoor E, Yaseri M, Mehrdadi P, Mahdavi-Mazdeh M, Murphy T, Hosseinzadeh-Attar MJ. The relationship between serum adipokines and glucose homeostasis in normal-weight and obese patients on hemodialysis: a preliminary study. Int Urol Nephrol 2020; 52:2179-2187. [PMID: 32761485 DOI: 10.1007/s11255-020-02582-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 07/25/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE Insulin resistance (IR) is a prevalent disorder in advanced renal failure irrespective of diabetes. Adipokines might play a role in IR, which has not been well-documented in uremic conditions. This study investigated the relationship of Zinc-α2-glycoprotein (ZAG), adipose triglyceride lipase (ATGL), and adipolin with glucose-insulin homeostasis in normal weight (NW) and obese (OB) patients with hemodialysis. METHODS In this cross-sectional study, 59 patients (29 NW; 18.5 ≤ BMI < 25 kg/m2, and 30 OB; BMI ≥ 30 kg/m2) were studied. Anthropometries, circulating ZAG, adipolin, ATGL, free fatty acids (FFAs), fasting blood glucose (FBG), insulin, and homeostasis model assessment of IR (HOMA)-IR were assessed. RESULTS There were no significant differences in age, gender, hemodialysis duration, dialysis adequacy and diabetes between the two groups. ZAG (100.9 ± 37.1 vs. 107.5 ± 30.5 ng/mL, P = 0.03) and adipolin (12.4 ± 1.6 vs. 13.2 ± 2.8 ng/mL, P = 0.002) concentrations were significantly lower, and FFAs (228.1 ± 112.6 vs. 185 ± 119 ng/mL, P = 0.014) were significantly higher in the OB than NW group. No significant differences were observed in ATGL, FBG, insulin and HOMA-IR between the two groups. Patients with lower IR had higher ZAG (112.9 ± 31.7 vs. 94.9 ± 34.5 ng/mL; P = 0.046), lower FFAs (167.8 ± 98.4 vs. 249.9 ± 120.8 ng/mL; P = 0.004), and marginally lower ATGL (9.1 ± 5.2 vs. 12.3 ± 9.6 mIU/mL; P = 0.079) concentrations than those with higher IR. ZAG was negatively (r = - 0.323, P = 0.018 and r = - 0.266, P = 0.054) and FFAs were positively (r = 0.321, P = 0.019 and r = 0.353, P = 0.009) correlated with insulin and HOMA-IR, respectively. ATGL was directly correlated with FFAs (r = 0.314, P = 0.018). CONCLUSIONS Novel adipokines, ZAG and ATGL, might contribute to glucose-insulin homeostasis in hemodialysis. Understanding potential causative, diagnostic or therapeutic roles of adipokines in IR require further studies.
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Affiliation(s)
- Elham Alipoor
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran.,Department of Nutrition, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Mehdi Yaseri
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Parvaneh Mehrdadi
- Department of Nutrition, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Mitra Mahdavi-Mazdeh
- Iranian Tissue Bank and Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Tim Murphy
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, Australia
| | - Mohammad Javad Hosseinzadeh-Attar
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran. .,Department of Clinical Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, No#44, Hojjatdoust St., Naderi St., Keshavarz Blvd., Tehran, Iran.
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Li J, Hou G, Sun X, Chen A, Chai Y. A Low-Cost, Intradialytic, Protein-Rich Meal Improves the Nutritional Status in Chinese Hemodialysis Patients. J Ren Nutr 2020; 30:e27-e34. [DOI: 10.1053/j.jrn.2019.03.084] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 02/20/2019] [Accepted: 03/30/2019] [Indexed: 12/12/2022] Open
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Liu PJ, Ma F, Wang QY, He SL. The effects of oral nutritional supplements in patients with maintenance dialysis therapy: A systematic review and meta-analysis of randomized clinical trials. PLoS One 2018; 13:e0203706. [PMID: 30212514 PMCID: PMC6136747 DOI: 10.1371/journal.pone.0203706] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 08/25/2018] [Indexed: 12/22/2022] Open
Abstract
Background/objective This systematic review aims to determine the potential effects of oral nutritional supplements (ONS) in patients receiving maintenance dialysis therapy (MDT). Methods Electronic databases were searched without language limits through to July 2018. Randomized controlled trials (RCTs) that involved comparisons of ONS versus placebo or routine care are included in this meta-analysis. RevMan 5.3 statistical software was used for meta-analysis. Results 15 articles with 589 subjects were included in our study. There are insufficient comparable data of randomized trials to allow meta-analysis of mortality. Albumin levels may be improved by the macronutrient blends or protein/amino acid supplements in MDT patients. Compared with the control group, serum albumin levels and BMI in the ONS group were increased by 1.58 g/L (95% CI, 0.52–2.63, P = 0.003; I2 = 85%) and 0.40 kg/m2 (95% CI, 0.10–0.71, P = 0.01; I2 = 49%), respectively. In the subgroup analysis of patients receiving hemodialysis, albumin levels in ONS group were increased by 2.17 g/L (95% CI, 0.89–3.45, P<0.001; I2 = 90%). ONS may not influence serum phosphorus and potassium levels. Conclusions Very low-quality evidence suggests that Short-term oral energy or protein/amino acid supplements may improve nutritional status by increasing serum albumin levels and BMI in MDT patients, without influence on serum potassium levels. High-quality and large RCTs, particularly regarding the effects of ONS on mortality and quality of life, are needed to further validate our findings.
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Affiliation(s)
- Peng Ju Liu
- Department of Clinical Nutrition, Peking Union Medical College Hospital, China Academic Medical Science and Peking Union Medical College, Beijing, PR China
- * E-mail:
| | - Fang Ma
- Department of Clinical Nutrition, Peking Union Medical College Hospital, China Academic Medical Science and Peking Union Medical College, Beijing, PR China
| | - Qi Yan Wang
- Department of Clinical Nutrition, Peking Union Medical College Hospital, China Academic Medical Science and Peking Union Medical College, Beijing, PR China
| | - Shu Li He
- Department of Clinical Nutrition, Peking Union Medical College Hospital, China Academic Medical Science and Peking Union Medical College, Beijing, PR China
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Kang SH, Lee HS, Lee S, Cho JH, Kim JC. Comparison of Muscle Mass Indices Using Computed Tomography or Dual X-Ray Absorptiometry for Predicting Physical Performance in Hemodialysis Patients. Kidney Blood Press Res 2017; 42:1119-1127. [PMID: 29224021 DOI: 10.1159/000485779] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 11/28/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Our study aims to evaluate the association between thigh muscle cross-sectional area (TMA) using computed tomography (CT), or appendicular skeletal muscle mass (ASM) using dual energy X-ray absorptiometry (DEXA), and physical performance levels in hemodialysis (HD) patients. METHODS Patients were included if they were on HD for ≥6 months (n = 84). ASM and TMA were adjusted to body weight (BW, kg) or height2 (Ht2, m2). Each participant performed a short physical performance battery test (SPPB), a sit-to-stand for 30 second test (STS30), a 6-minute walk test (6-MWT), a timed up and go test (TUG), and hand grip strength (HGS) test. RESULTS Correlation coefficients for SPPB, GS, 5STS, STS30, 6-MWT, and TUG were highest in TMA/BW. Results from partial correlation or linear regression analyses displayed similar trends to those derived from Pearson's correlation analyses. An increase in TMA/BW or TMA/Ht2 was associated with a decreased odds ratio of low SPPB, GS, or HGS in multivariate analyses. Indices using DEXA were associated with a decreased odds ratio of a low HGS only in multivariate analysis. CONCLUSION TMA indices using CT may be more valuable in predicting physical performance or strength in HD patients.
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Affiliation(s)
- Seok Hui Kang
- Division of Nephrology, Department of Internal Medicine, Yeungnam University Hospital, Daegu, Republic of Korea
| | - Hyun Seok Lee
- Department of Radiology, CHA Gumi Medical Center, CHA University, Gumi-si, Republic of Korea
| | - Sukyung Lee
- Division of Nephrology, Department of Internal Medicine, Semyung Christianity Hospital, Pohang-si, Republic of Korea
| | - Ji-Hyung Cho
- Division of Nephrology, Department of Internal Medicine, CHA Gumi Medical Center, CHA University, Gumi-si, Republic of Korea
| | - Jun Chul Kim
- Division of Nephrology, Department of Internal Medicine, CHA Gumi Medical Center, CHA University, Gumi-si, Republic of Korea
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Cawood AL, Elia M, Stratton RJ. Systematic review and meta-analysis of the effects of high protein oral nutritional supplements. Ageing Res Rev 2012; 11:278-96. [PMID: 22212388 DOI: 10.1016/j.arr.2011.12.008] [Citation(s) in RCA: 252] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2011] [Revised: 12/04/2011] [Accepted: 12/14/2011] [Indexed: 12/16/2022]
Abstract
Disease-related malnutrition is common, detrimentally affecting the patient and healthcare economy. Although use of high protein oral nutritional supplements (ONS) has been recommended to counteract the catabolic effects of disease and to facilitate recovery from illness, there is a lack of systematically obtained evidence to support these recommendations. This systematic review involving 36 randomised controlled trials (RCT) (n=3790) (mean age 74 years; 83% of trials in patients >65 years) and a series of meta-analyses of high protein ONS (>20% energy from protein) demonstrated a range of effects across settings and patient groups in favour of the high protein ONS group. These included reduced complications (odds ratio (OR) 0.68 (95%CI 0.55-0.83), p<0.001, 10 RCT, n=1830); reduced readmissions to hospital (OR 0.59 (95%CI 0.41-0.84), p=0.004, 2 RCT, n=546); improved grip strength (1.76 kg (95%CI 0.36-3.17), p<0.014, 4 RCT, n=219); increased intake of protein (p<0.001) and energy (p<0.001) with little reduction in normal food intake and improvements in weight (p<0.001). There was inadequate information to compare standard ONS (<20% energy from protein) with high protein ONS (>20% energy from protein). The systematic review and meta-analysis provides evidence that high protein supplements produce clinical benefits, with economic implications.
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Affiliation(s)
- A L Cawood
- Institute of Human Nutrition, University of Southampton, UK.
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