Effect of fish oil supplement in maintenance hemodialysis patients: a systematic review and meta-analysis of published randomized controlled trials

A roadmap for implementing a successful clinical experience with intradialytic parenteral nutrition

BACKGROUND AND AIMS

Intradialytic parenteral nutrition (IDPN) is a safe and effective patient-tailored nutritional strategy for providing nutrient supplementation to malnourished or at risk of malnutrition patients on hemodialysis (HD), who did not adequately respond to intensive dietary counselling and oral nutritional supplementation. Although IDPN is recommended by current ESPEN and KDOQI guidelines for nutrition in HD patients, none of these documents informs how to successfully implement this therapy, being the lack of knowledge on practical aspects of IDPN one of the main limitations to its use. The aim of this narrative review was to provide a practical roadmap for guiding the nephrologists, dietitians, and renal nurses in their everyday clinical practice about the use of IDPN.

METHODS

A multidisciplinary group formed by specialists from the areas of Nephrology and Nutrition agreed to address different practical aspects related to IDPN in HD patients. Based on the available evidence in the literature and on the authors' clinical experience, different topics were selected to develop a detailed plan for implementing a successful experience with IDPN, proposing a practical IDPN roadmap.

RESULTS

This IDPN roadmap provides practical information on when an IDPN should be started; what type of nutrients should be part of an IDPN; how the IDPN should be administered; how the effectiveness and safety of the IDPN should be monitored; how to determine the effectiveness of IDPN; and the conditions that advise discontinuing the IDPN.

CONCLUSIONS

IDPN is a safe and effective nutritional therapy for HD patients, although the lack of staff training may limit its use. This review addresses different practical aspects of IDPN, helping interdisciplinary teams in their daily clinical practice to improve the nutritional care of HD patients, either malnourished or at risk of malnutrition.

Effectiveness of fish oil in controlling inflammation in adult patients undergoing hemodialysis: A systematic review and meta-analysis

Objective

Hemodialysis patients with chronic kidney disease often exhibit inflammation characterized by elevated levels of C-reactive protein, Interleukin 6 and tumor necrosis factor-alpha, and they are shown to be associated with cardiovascular impairment and enhanced renal failure. This study aims to assess the impact of fish oil intake on inflammation indicators in adult hemodialysis patients.

Methods

From the inception to December 2023, the datasets Cochrane Central, Google Scholar, Science Direct, Embase, and Pubmed were examined. Two authors independently searched, selected, and screened the literature. The pooled results are represented by weighted mean difference (WMD) with 95% confidence intervals. To investigate the causes of heterogeneity, subgroup analysis was done. Sensitivity analysis was then used to evaluate the validity of the combined findings.

Results

Thirteen randomized control trials studies were included. The pooled results showed that fish oil supplementation caused a significant reduction of the C-reactive protein level (WMD, -2.92 mg/L; 95% Confidence interval, -5.23, to -0.61; p = 0.01; I 2 = 99%), especially in patients with baseline C-reactive protein ⩾5 mg/L (WMD, -4.39 mg/L; 95% Confidence interval, -5.93 to 2.85; p < 0.00001; I 2 = 33%). Subgroup analyses showed that C-reactive protein baseline level (C-reactive protein <5 mg/L) was the main source of heterogeneity. Fish oil intake may not reduce the level of Interleukin 6 (WMD, -2.26; 95% Confidence interval: -19.61 to 15.09; p = 0.80; I 2 = 93%), nor will it reduce the level of tumor necrosis factor-alpha (random model: WMD, -2.51; 95% Confidence interval: 6.08 to 1.06; p = 0.17; I 2 = 98%).

Conclusion

Hemodialysis patients, especially those with C-reactive protein > 5 mg/L, responded to fish oil supplementation to reduce their C-reactive protein level; however, Interleukin 6 and tumor necrosis factor-alpha levels did not appear to be affected.

Effects of Vitamin D3 and Marine Omega-3 Fatty Acids Supplementation on Biomarkers of Systemic Inflammation: 4-Year Findings from the VITAL Randomized Trial

Background: The VITAL study was a nationwide, randomized, double-blind, placebo-controlled, 2 × 2 factorial trial of vitamin D3 (2000 IU/day) and marine n-3 FAs (1 g/day) supplements. We recently reported that vitamin D supplementation with or without omega 3 fatty acids reduced autoimmune disease by 22% in the VITAL study. Objective: To investigate the effects of vitamin D3 and/or n-3 FAs on changes in systemic inflammatory biomarkers including pro- and anti-inflammatory cytokines over a 4-year period in the VITAL sub-cohort with in-person evaluations at the Center for Clinical Investigations (CCI) in Boston. Design: Serum levels of four inflammatory biomarkers (high-sensitivity C-reactive protein [hs-CRP], interleukin-6, interleukin-10, and tumor necrosis factor-α) were measured in a total of 2713 samples from those 1054 VITAL/CCI participants (aged 64.9 ± 6.5 years, 49% female, 84% white, and 9% black) at baseline, year 2, and year 4 follow-up visits. Results: In multiple-adjusted models, vitamin D3 supplementation decreased serum hs-CRP levels by 19% at 2-year follow-up (nominal p = 0.007; p-value after multiple comparison adjustment = 0.028), but not at 4-year follow-up (nominal and adjusted p-values > 0.05). The effects of vitamin D3 on other inflammatory markers were not statistically significant either at year 2 or year 4 (all adjusted p-values > 0.05). Marine n-3 FAs were not significantly associated with changes of all the above inflammatory markers either at years 2 and 4, after multiple comparison adjustment (all p-values > 0.05). Conclusions: Vitamin D3 supplementation with or without n-3 FAs decreased hs-CRP by 19% at year 2, but not other inflammatory biomarkers at year 2 or year 4, while n-3 FAs with or without vitamin D3 did not significantly affect these biomarkers at either time point. Our findings support a potential role of vitamin D supplementation in modulating the chronic inflammatory process, systemic inflammation, and possibly autoimmune disease progression.

Developing an Evidence and Theory Based Multimodal Integrative Intervention for the Management of Renal Cachexia: A Theory of Change

In this study, we aimed to develop a theoretical framework for a multimodal, integrative, exercise, anti-inflammatory and dietary counselling (MMIEAD) intervention for patients with renal cachexia with reference to how this addresses the underlying causal pathways for renal cachexia, the outcomes anticipated, and how these will be evaluated. We used a Theory of Change (ToC) approach to guide six steps. Step 1 included inputs from a workshop to obtain key stakeholder views on the potential development of a multimodal intervention for renal cachexia. Step 2 included the findings of a mixed-methods study with Health Care Practitioners (HCPs) caring for individuals with End Stage Kidney Disease (ESKD) and cachexia. Step 3 included the results from our systematic literature review on multimodal interventions for cachexia management. In step 4, we used the body of our research team's cachexia research and wider relevant research to gather evidence on the specific components of the multimodal intervention with reference to how this addresses the underlying causal pathways for renal cachexia. In steps 5 and 6 we developed and refined the ToC map in consultation with the core research team and key stakeholders which illustrates how the intervention components of MMIEAD interact to achieve the intended long-term outcomes and anticipated impact. The results of this study provide a theoretical framework for the forthcoming MMIEAD intervention for those with renal cachexia and in subsequent phases will be used to determine whether this intervention is effective. To the best of our knowledge no other multimodal intervention trials for cachexia management have reported a ToC. Therefore, this research may provide a useful framework and contribute to the ongoing development of interventions for cachexia management.

Efficacy of the omega-3 fatty acids supplementation on inflammatory biomarkers: An umbrella meta-analysis

BACKGROUND

Existing meta-analyses on omega-3 polyunsaturated fatty acids and their anti-inflammatory effects have reported uncertain findings. The current umbrella meta-analysis aimed to assess the findings of multiple meta-analyses on the efficacy of n-3 PUFAs on inflammatory biomarkers in adults with different health conditions.

METHODS

Using suitable keywords, articles published until December 2021 were searched in PubMed/Medline, Web of Science, Scopus, EMBASE, and Google Scholar. Meta-analyses investigating the impact of supplementation of n-3 PUFAs on inflammatory biomarkers in adults were included. We performed this meta-analysis using a random-effects model.

RESULTS

Overall, 32 meta-analyses were qualified in this umbrella meta-analysis. Our findings demonstrated that the n-3 PUFA supplementation significantly reduced serum C-reactive protein (CRP) (ES = -0.40; 95 % CI: -0.56, -0.24, p < 0.001; I² = 89.5 %, p < 0.001), Tumour necrosis factor α (TNFα) (ES = -0.23; 95 % CI: -0.37, -0.08, p = 0.002; I² = 60.1 %, p < 0.001), and interleukin 6 (IL-6) concentrations (ES = -0.22; 95 % CI: -0.39, -0.05, p = 0.010; I² = 66.2 %, p < 0.001).

CONCLUSION

The current umbrella meta-analysis found that supplementation of n-3 PUFAs in adults can improve CRP, TNF-α, and IL-6 concentrations under various health conditions. n-3 PUFAs can be recommended as adjuvant anti-inflammatory agents.

Dietary Lipids and Dyslipidemia in Chronic Kidney Disease

The progression of chronic kidney disease (CKD) leads to altered lipid metabolism. CKD patients exhibit high blood triglyceride (TG) levels, reduced concentrations and functionality of high-density lipoproteins (HDL), and elevated levels of atherogenic small, dense, low-density lipoproteins (sdLDL). Disorders of lipid metabolism and other metabolic disturbances place CKD patients at high risk for cardiovascular disease (CVD). Extensive evidence supports the cardioprotective effects of unsaturated fatty acids, including their beneficial effect on serum cholesterol and TG levels. Dietary lipids might therefore be especially important in the nutritional management of CKD. We review current dietary recommendations for fat intake by CKD patients and suggest potential nutritional interventions by emphasizing dietary lipids that might improve the blood lipid profile and reduce cardiovascular risk in CKD.

The effect of fish oil on inflammation markers in adult patients undergoing hemodialysis: A meta-analysis

OBJECTIVE

This meta-analysis was to assess the effect of fish oil supplementation on inflammation markers in adult patients receiving hemodialysis.

METHODS

CENTRAL, EMBASE, MEDLINE databases were searched from inception to 10 April 2020. Two authors independently searched, selected, and screened the literature. The pooled results are represented by WMD or SMD with 95% confidence intervals. Subgroup analysis and meta-regression were used to explore sources of heterogeneity, and sensitivity analysis was used to assess the robustness of the pooled results. Funnel plots were used to assess publication bias.

RESULTS

Eleven RCT (randomized control trials) studies were included. The pooled results showed that fish oil supplementation caused a significant reduction of the CRP(C-reactive protein) level (random model: WMD, -3.36, 95%CI: -5.46 to -1.26, P = .002), especially in patients with baseline CRP ≥ 5 mg/L (random model: WMD, -4.43, 95%CI: -6.10 to -2.76, P = .00001, I²  = 41%). Meta-regression analyses showed that CRP baseline level (CRP < 5 mg/L) was the main source of heterogeneity (P = .036). Sensitive analyses revealed that the result was hardly changed. Fish oil supplementation might not reduce the level of IL-6 (random model: WMD, -2.26, 95%CI: -19.61 to 15.09, P = .80) in four studies or the level of TNF-α (random model: SMD, -2.51, 95%CI: -6.08 to 1.06, P = .17) in three studies.

CONCLUSIONS

Fish oil supplementation could reduce the level of CRP in hemodialysis patients, especially in patients with CRP ≥ 5 mg/L, but had no effects on IL-6 and TNF-α.

Lipoproteins and fatty acids in chronic kidney disease: molecular and metabolic alterations

Chronic kidney disease (CKD) induces modifications in lipid and lipoprotein metabolism and homeostasis. These modifications can promote, modulate and/or accelerate CKD and secondary cardiovascular disease (CVD). Lipid and lipoprotein abnormalities - involving triglyceride-rich lipoproteins, LDL and/or HDL - not only involve changes in concentration but also changes in molecular structure, including protein composition, incorporation of small molecules and post-translational modifications. These alterations modify the function of lipoproteins and can trigger pro-inflammatory and pro-atherogenic processes, as well as oxidative stress. Serum fatty acid levels are also often altered in patients with CKD and lead to changes in fatty acid metabolism - a key process in intracellular energy production - that induce mitochondrial dysfunction and cellular damage. These fatty acid changes might not only have a negative impact on the heart, but also contribute to the progression of kidney damage. The presence of these lipoprotein alterations within a biological environment characterized by increased inflammation and oxidative stress, as well as the competing risk of non-atherosclerotic cardiovascular death as kidney function declines, has important therapeutic implications. Additional research is needed to clarify the pathophysiological link between lipid and lipoprotein modifications, and kidney dysfunction, as well as the genesis and/or progression of CVD in patients with kidney disease.

The effects of omega-3 fatty acids supplementation on metabolic status in pregnant women: a systematic review and meta-analysis of randomized controlled trials

Background and objective

Data regarding the effects of omega-3 polyunsaturated fatty acids (PUFA) supplementation on metabolic status of pregnant women are limited. This systematic review and meta-analysis were done based on randomized controlled trials (RCTs) dealing with the effects of omega-3 PUFA supplementation on glycemic control, lipoproteins, inflammation and oxidative stress in pregnant women.

Methods

Following databases were searched for eligible studies published from inception to until 2019: MEDLINE, EMBASE, Web of Science, PubMed, Scopus, Cochrane Library, and Google scholar. Studies that evaluated the effect of omega-3 PUFA supplementation on parameters of glycemic control, lipoproteins, inflammation and oxidative stress in pregnant women were found by using the key MeSH. A study quality assessment was performed using the Cochrane Collaboration risk of bias tool and heterogeneity between studies was statistically computed using Cochrane's Q test and I-square (I²). Data were pooled using a random-effects model and weighted mean difference (WMD) was considered as the overall effect size.

Results

No significant effects of omega-3 PUFA supplementation on FPG, insulin, insulin resistance, total cholesterol, triglycerides, LDL-cholesterol, total cholesterol/HDL-cholesterol, interleukin 6 (IL-6), IL-8, and malondialdehyde were found. However, omega-3 PUFA significantly increased serum concentrations of HDL-cholesterol (WMD: 3.10; 95% CI: 0.18, 6.03) and reduced C-reactive protein (WMD: -1.85; 95% CI: -2.61, -1.09).

Conclusion

Based on the results of this meta-analysis omega-3 PUFA supplementation during pregnancy has a significant beneficial effect on HDL-cholesterol, and C-reactive protein.

Effects of fish oil during hemodialysis on nutritional status and quality of life: a randomized double-blinded trial

Background

Supplementation of fish oil has been shown to exert beneficial effects in patients undergoing hemodialysis. The aim of this study was to investigate the efficacy of fish oil in improving the quality of life of these patients through a randomized, double-blinded clinical trial.

Methods

Among the 103 patients enrolled in the study, a total of 74 patients were randomized to receive fish oil (intervention group) or placebo (n=37 per group). Patients received identical soft-gel capsules, with each capsule containing either 1000 mg fish oil or placebo for 4 months. Personnel responsible for data collection and analyses were blinded to the grouping.

Results

The reduction of protein-energy wasting (PEW) in the intervention group was significantly more prominent compared to the placebo group (P=0.023). The intervention group demonstrated significant increase in midarm circumference, arm muscle circumference, and triceps skinfold thickness after fish oil intake. The intervention group also exhibited significant differences from the placebo group in creatinine, uric acid, and serum calcium levels. Significant improvement was seen regarding the physical role and energy/figure in the intervention group.

Conclusions

Our study demonstrated that fish oil intake in patient undergoing hemodialysis can significantly reduce PEW, and improve physical and biochemical parameters and quality of life, which could provide guidance to clinical management of these patients.

The Effect of Omega-3 Supplementation on Serum Levels of Inflammatory Biomarkers and Albumin in Hemodialysis Patients: A Systematic Review and Meta-analysis

This systematic review and meta-analysis were performed to evaluate the effect of omega-3 supplementation on serum levels of inflammatory biomarkers (C-reactive protein [CRP], high-sensitivity CRP [hs-CRP], tumor necrosis factor-alpha, interleukin-6) and albumin in patients on hemodialysis. A literature search was performed in MEDLINE, Cochrane Central Register of Controlled Trials, PubMed, EMBASE, Web of Science, and Google Scholar. Randomized controlled trials that evaluated the effect of omega-3 supplementation versus placebo were selected. Eight randomized controlled trials comprising 371 patients on hemodialysis were included. According to our results, omega-3 supplementation significantly decreased serum levels of CRP (standardized mean difference [SMD]: -1.95 mg/Dl; 95% confidence interval [CI]: -3.09, -0.80) and hs-CRP (SMD: -2.09; 95% CI: -3.62, -0.56) but did not significantly improve albumin (SMD: 0.91; 95% CI: -0.78, 2.59), tumor necrosis factor-alpha (SMD: -1.51; 95% CI: -3.24, 0.22), and interleukin-6 (SMD: 0.72, 95% CI: -0.56, 1.99). We concluded that omega-3 supplementation leads to a significant decrease in serum levels of CRP and hs-CRP.

Omega-3 fatty acids for dialysis vascular access outcomes in patients with chronic kidney disease

BACKGROUND

Maintaining long-term vascular access patency is necessary for high quality haemodialysis (HD) treatment of patients with the terminal and most serious stage of chronic kidney disease (CKD) - end-stage kidney disease (ESKD). Oral supplementation with omega-3 fatty acids (ω-3FA) may help to prevent blockage of the vascular access by reducing the risk of thrombosis and stenosis.

OBJECTIVES

To evaluate the efficacy and safety of ω-3FA supplementation versus placebo or no treatment for maintaining vascular access patency in ESKD patients undergoing HD.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 23 July 2018 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of omega-3 fatty acids versus placebo that assessed the patency of arteriovenous fistula (AVF) or arteriovenous graft (AVG) types of vascular access in ESKD patients.

DATA COLLECTION AND ANALYSIS

We assessed the risk of bias of each eligible study using the Cochrane Risk of Bias tool and made separate overall risk of bias judgments for the efficacy and safety outcomes. The certainty of evidence was assessed using the GRADE approach. The primary efficacy outcome was loss of vascular patency and the primary safety outcomes were occurrences of serious adverse events (e.g. death, hospitalisation, cardiovascular events, major bleeding). Secondary outcomes were the occurrence of non-serious adverse events (e.g. minor bleeding, gastrointestinal events and other adverse events). Efficacy effects were reported as risk ratios (RR) and safety effects as risk differences (RD) with 95% confidence intervals (CI). Studies were pooled separately by type of vascular access using a random-effects model.

MAIN RESULTS

Five studies (833 participants) were included; one was a very small pilot study of 7 participants. All studies compared oral ω-3FA supplements against placebo. Four studies enrolled participants with arteriovenous grafts (AVGs), and the other had participants with arteriovenous fistulas (AVFs). The risk of bias for both efficacy and safety outcomes was unclear for all studies, due mainly to incomplete reporting for allocation concealment and incompleteness of study follow-up.In AVF patients, ω-3FA supplementation probably makes little or no difference to the 12-month risk of patency loss (1 study, 536 participants: RR 1.01, 95% CI 0.84 to 1.21; moderate certainty evidence), risk of death (1 study, 567 participants: RD 0.00, 95% CI -0.03 to 0.02; moderate certainty evidence) and risk of hospitalisation (1 study, 567 participants: RD 0.00, 95% CI -0.08 to 0.08; low certainty evidence). There was no information on cardiovascular events and major bleeding.In AVG patients, it is very uncertain whether ω-3FA supplementation reduces the risk of patency loss within 6 months (2 studies, 41 participants: RR 0.91, 95% CI 0.36 to 2.28; very low certainty evidence) or 12 months (2 studies, 220 participants: RR 0.59, 95% CI 0.27 to 1.31; very low certainty evidence). ω-3FA supplementation may make little or no difference to the risk of death within 6 to 12 months in AVG patients (4 studies, 261 participants: RD 0.01, 95% CI -0.05 to 0.07; low certainty evidence). It is very uncertain if ω-3FA supplementation increases the risk of hospitalisation (3 studies, 65 participants: RD 0.08, 95% CI -0.11 to 0.28; very low certainty evidence), changes the risk of cardiovascular events (4 studies, 261 participants: RD -0.02, 95% CI -0.11 to 0.07; very low certainty evidence), or increases the risk of major bleeding (3 studies, 65 participants: RD 0.08, 95% CI -0.11 to 0.28; very low certainty evidence) within 6 to 12 months in AVG patients. There may be an increase in the risk of mild gastrointestinal adverse reactions (3 studies, 65 participants: RD 0.25, 95% CI 0.07 to 0.43; low certainty evidence) such as a sensation of bloatedness, gas or a fishy aftertaste.

AUTHORS' CONCLUSIONS

In CKD patients with an AVF, there is moderate certainty that ω-3FA supplementation makes little or no difference to preventing patency loss; and in patients with an AVG, it is very uncertain that ω-3FA supplementation prevents patency loss within 12 months.

Deleting Death and Dialysis: Conservative Care of Cardio-Vascular Risk and Kidney Function Loss in Chronic Kidney Disease (CKD)

The uremic syndrome, which is the clinical expression of chronic kidney disease (CKD), is a complex amalgam of accelerated aging and organ dysfunctions, whereby cardio-vascular disease plays a capital role. In this narrative review, we offer a summary of the current conservative (medical) treatment options for cardio-vascular and overall morbidity and mortality risk in CKD. Since the progression of CKD is also associated with a higher cardio-vascular risk, we summarize the interventions that may prevent the progression of CKD as well. We pay attention to established therapies, as well as to novel promising options. Approaches that have been considered are not limited to pharmacological approaches but take into account lifestyle measures and diet as well. We took as many randomized controlled hard endpoint outcome trials as possible into account, although observational studies and post hoc analyses were included where appropriate. We also considered health economic aspects. Based on this information, we constructed comprehensive tables summarizing the available therapeutic options and the number and kind of studies (controlled or not, contradictory outcomes or not) with regard to each approach. Our review underscores the scarcity of well-designed large controlled trials in CKD. Nevertheless, based on the controlled and observational data, a therapeutic algorithm can be developed for this complex and multifactorial condition. It is likely that interventions should be aimed at targeting several modifiable factors simultaneously.

Efficacy of Nutritional Interventions on Inflammatory Markers in Haemodialysis Patients: A Systematic Review and Limited Meta-Analysis

Low-grade chronic inflammation is prevalent in patients undergoing haemodialysis (HD) treatment and is linked to the development of premature atherosclerosis and mortality. The non-pharmacological approach to treat inflammation in HD patients through nutritional intervention is well cited. We aimed to assess the efficacy of different nutritional interventions at improving inflammatory outcomes in HD patients, based on markers such as C-reactive protein (CRP), interleukin-6 (IL-6), and tumour necrosis factor-α (TNF-α). We searched PubMed, Cochrane Library, and Embase for randomized controlled trials (RCT) published before June 2017. Inclusion criteria included RCTs on adult patients on maintenance HD treatment with duration of nutritional interventions for a minimum 4 weeks. Risk of bias was assessed using the Jadad score. In total, 46 RCTs experimenting different nutritional interventions were included in the review and categorized into polyphenols rich foods, omega-3 fatty acids, antioxidants, vitamin D, fibres, and probiotics. Meta-analyses indicated significant reduction in CRP levels by omega-3 fatty acids (Random model effect: -0.667 mg/L, p < 0.001) and vitamin E (fixed model effect: -0.257 mg/L, p = 0.005). Evidence for other groups of nutritional interventions was inconclusive. In conclusion, our meta-analysis provided evidence that omega-3 fatty acids and vitamin E could improve inflammatory outcomes in HD patients.

Stirring the Pot: Can Dietary Modification Alleviate the Burden of CKD?

Diet is one of the largest modifiable risk factors for chronic kidney disease (CKD)-related death and disability. CKD is largely a progressive disease; however, it is increasingly appreciated that hallmarks of chronic kidney disease such as albuminuria can regress over time. The factors driving albuminuria resolution remain elusive. Since albuminuria is a strong risk factor for GFR loss, modifiable lifestyle factors that lead to an improvement in albuminuria would likely reduce the burden of CKD in high-risk individuals, such as patients with diabetes. Dietary therapy such as protein and sodium restriction has historically been used in the management of CKD. Evidence is emerging to indicate that other nutrients may influence kidney health, either through metabolic or haemodynamic pathways or via the modification of gut homeostasis. This review focuses on the role of diet in the pathogenesis and progression of CKD and discusses the latest findings related to the mechanisms of diet-induced kidney disease. It is possible that optimizing diet quality or restricting dietary intake could be harnessed as an adjunct therapy for CKD prevention or progression in susceptible individuals, thereby reducing the burden of CKD.

[Chronic kidney disease and dyslipidaemia]

Chronic kidney disease (CKD) has to be considered as a high, or even very high risk cardiovascular risk condition, since it leads to an increase in cardiovascular mortality that continues to increase as the disease progresses. An early diagnosis of CKD is required, together with an adequate identification of the risk factors, in order to slow down its progression to more severe states, prevent complications, and to delay, whenever possible, the need for renal replacement therapy. Dyslipidaemia is a factor of the progression of CKD that increases the risk in developing atherosclerosis and its complications. Its proper control contributes to reducing the elevated cardiovascular morbidity and mortality presented by these patients. In this review, an assessment is made of the lipid-lowering therapeutic measures required to achieve to recommended objectives, by adjusting the treatment to the progression of the disease and to the characteristics of the patient. In CKD, it seems that an early and intensive intervention of the dyslipidaemia is a priority before there is a significant decrease in kidney function. Treatment with statins has been shown to be safe and effective in decreasing LDL-Cholesterol, and in the reduction of cardiovascular events in individuals with CKD, or after renal transplant, although there is less evidence in the case of dialysed patients.

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.