Benefits of fish oil supplementation for hemodialysis patients

Acellular fish skin grafts in the treatment of diabetic wounds: Advantages and clinical translation

Diabetic wounds cannot undergo normal wound healing due to changes in the concentration of hyperglycemia in the body and soon evolve into chronic wounds causing amputation or even death of patients. Diabetic wounds directly affect the quality of patients and social medical management; thus researchers started to focus on skin transplantation technology. The acellular fish skin grafts (AFSGs) are derived from wild fish, which avoids the influence of human immune function and the spread of the virus through low-cost decellularization. AFSGs contain a large amount of collagen and omega-3 polyunsaturated fatty acids and they have an amazing effect on wound regeneration. However, after our search in major databases, we found that there were few research trials in this field, and only one was clinically approved. Therefore, we summarized the advantages of AFSGs and listed the problems faced in clinical use. The purpose of this paper is to enable researchers to better carry out original experiments at various stages.

Pruritus-reducing effects of omega-3 fatty acids in hemodialysis patients: A cross-over randomized clinical trial

INTRODUCTION

Chronic kidney disease-associated pruritus is a common complication in patients with end-stage renal disease. In this study, we have explored the outcome of omega-3 supplementary intake for the treatment of this symptom.

METHODS

This double-blinded, randomized, crossover study was conducted in two dialysis centers in which 40 hemodialysis patients suffering from pruritus were randomly assigned into two groups (Group A and Group B). Patients in Group A consumed omega-3 capsules for 4 weeks and after a washout period (6 weeks), they took placebo for another 4 weeks. The same was performed in Group B but in the reverse order. Pruritus score was determined at the baseline, Week 4, 10, and 14. Serum levels of prostaglandin E2 were also recorded at the baseline and Week 4.

RESULTS

There was a statistically significant reduction of pruritus score in patients who took the omega-3 fatty acid supplement. The mean pruritus score decreased significantly in both first (-3.41 ± 2.62, p < 0.001) and second (-1.00 ± 1.84, p = 0.04) treatment period after omega-3 treatment; but no significant mean pruritus score difference in placebo group after both intervention periods was observed. The decrease in prostaglandin E2 amount was not statistically significant in the intervention (omega-3) group compared to the placebo group (p = 0.204).

DISCUSSION

Our observations indicate that omega-3 fatty acids (3 grams per day) have decreasing effects on pruritus. Also, reduction in prostaglandin E2 levels in the omega-3 group did not differ from the changes in the placebo group.

Omega-3 fatty acids for uremic pruritus: A meta-analysis of randomized controlled trials

Uremic pruritus (UP) is common in the late stages of chronic kidney disease. Currently, there is a lack of effective treatment for UP. Limited evidence exists on the therapeutic effect of omega-3 fatty acid (O3FA). The aim of this study was to evaluate the efficacy of O3FA supplements in UP patients. We evaluated the efficacy of O3FA supplements in patients with UP through a systematic review and a meta-analysis of randomized control trials retrieved from PubMed, Embase, Cochrane Library, CINAHL, and ClinicalTrials.gov databases. The included studies were summarized and assessed for the risk of bias, and pruritus assessment results were analyzed. To compared with a controlled group, five articles including 164 participants published between 2012 and 2019 using different pruritus scales reported that patients taking O3FA supplement exhibited no significant decrease in the pruritus score (standardized mean difference [SMD] =1.34, 95% confidence interval [CI] = -2.70-0.01, P = 0.05), but three articles using same pruritus scale significant decrease Duo pruritus score (SMD = -0.85, 95% CI = -1.39 to -0.30, P < 0.05). O3FA supplement could be an appealing complementary therapy for UP patients. More rigorously designed studies are needed before recommending the O3FA supplement.

Therapeutic Effects of Omega-3 Fatty Acids on Chronic Kidney Disease-Associated Pruritus: a Literature Review

Uremic pruritus remains one of the most tormenting, frequent and potentially disabling problem in chronic kidney disease (CKD) patients. However, an area of substantial etiological interest with relation to uremic pruritus is the essential fatty acids deficiency. So we performed a literature review to elucidate the efficacy of omega-3 fatty acids on uremic pruritus. This review evaluated all of the studies published in English language, focusing on the clinical effects of omega-3 fatty acids on uremic pruritus. The literature review was conducted in December 2015 and carried out by searching Scopus, Medline, Cochrane central register of controlled trials, and Cochrane database of systematic reviews. The search terms were "kidney injury", "kidney failure", "chronic kidney disease", "end-stage renal disease", "dialysis", "hemodialysis", "peritoneal dialysis", "pruritus", "itch", "skin problems", "fish oil", "omega 3", "n-3 fatty acids", "polyunsaturated fatty acids", "docosahexaenoic acid", and "eicosapentaenoic acid". Four small studies investigating potential benefits of omega-3 fatty acids on symptoms of uremic pruritus were found. Among them, three small randomized controlled trials have shown a significant improvement in pruritus symptoms (evaluated by a standard questionnaire) in CKD patients who took omega-3 supplement compared to omega-6, omega-9, and placebo supplementation. Despite numerous limitations of the studies, it is worth noting that even minor reduction in itching symptoms may be clinically significant for CKD patients. Therefore, and considering multiple health benefits of omega-3 fatty acids in advanced CKD and negligible risk profile, omega-3 intake can wisely be applied to CKD patients with uremic pruritus.

Natural history of bleeding risk in colonic diverticulosis patients: a long-term colonoscopy-based cohort study

BACKGROUND

The natural history of bleeding risk from colonic diverticulosis remains unclear.

AIM

To identify the incidence of bleeding in colonic diverticulosis patients and associated risk factors.

METHODS

A cohort of 1514 patients with colonoscopy-confirmed asymptomatic diverticulosis was selected between 2001 and 2013. Age, sex and location of colonic diverticulosis (right or left side, or bilateral) were assessed. The endpoint was a bleeding event, and data were censored at the time of last colonoscopy. The cumulative and overall incidences of bleeding were estimated using the Kaplan-Meier and person-years methods. The Cox proportional hazards model was used to estimate age- and sex-adjusted hazard ratios (aHRs).

RESULTS

The median follow-up period was 46 months. Bleeding events occurred in 35 patients, and the median time-to-event interval was 50 months. Kaplan-Meier analysis showed that the cumulative incidence of diverticular bleeding was 0.21% at 12 months, 2.2% at 60 months and 9.5% at 120 months. By the person-years method, the overall incidence rate of bleeding was 0.46 per 1000 patient-years. On multivariate analysis, age ≥70 (aHR. 3.7) and bilateral diverticulosis (aHR, 2.4) were significant risk factors for bleeding.

CONCLUSIONS

This long-term follow-up study demonstrated that the cumulative incidence of bleeding from diverticulosis was approximately 2% at 5 years and 10% at 10 years, and the overall incidence was 0.46 per 1000 patient-years. Bilateral diverticulosis increased the risk of bleeding.

Patency in Arteriovenous Grafts in Hemodialysis Patients

Objective:

It is difficult to maintain a working access for patients on hemodialysis. Despite current Dialysis Outcome Quality Initiatives recommendations of “Fistula First,” not everyone qualifies for a fistula, and those patients undergoing the alternative treatment, a graft, can experience graft failure. This study examines factors associated with arteriovenous graft (AVG) patency.

Methods:

A retrospective analysis was completed for all the patients who had an AVG during 2005 to 2010. Data were collected from electronic medical records, including date of first and subsequent interventions, salvage technique (surgical vs percutaneous), medical comorbidities, and use of antiplatelet medications (aspirin and clopidogrel). Continuous variables were compared with 2 sample t tests, and categorical variables with chi-square/Fisher exact test. Logistic regression was used to determine the odds ratio for risk factors associated with patency. A P value of <.05 was considered significant. All analyses were done using SAS 9.2 (SAS Institute Inc, Cary, North Carolina).

Results:

A total of 193 unique patients had an AVG. Of the 193 patients, 64% were female, 83% were hypertensive, and 64% were diabetic. The locations of the grafts were 80% arm, 15% forearm, and 5% thigh. Configurations, including loop and straight, were 34% and 63%, respectively. Comorbidities were not associated with patency. Primary patency was not found to be different with respect to location and configuration of graft and type of intervention. Primary patency for patients taking only aspirin (n = 43) and only clopidogrel (n = 17) were significantly different from patients on a combination of aspirin and clopidogrel (n = 7), with a P = .0051 and P = .0447, respectively.

Conclusion:

Neither location nor configuration affects the primary patency of AVGs. Aspirin alone is not inferior to aspirin and clopidogrel. Further prospective studies may be warranted to establish a consensus regarding medications and patency with AVGs.

Effectiveness of Topical Chia Seed Oil on Pruritus of End-stage Renal Disease (ESRD) Patients and Healthy Volunteers

BACKGROUND

Several studies have been performed to evaluate the efficacy of dietary n-3 fatty acid for patients with renal dysfunction. While about 40% to 80% of patients with end-stage renal disease (ESRD) complain about pruritus and xerosis, there are few reports on the effects of topical n-3 fatty acid on these symptoms.

OBJECTIVE

In order to investigate the possible beneficial effects of topical n-3 fatty acid, oils extracted from chia (Salvia hispanica) seed were formulated into topical products, the effects of which were measured.

METHODS

Five healthy volunteers having xerotic pruritus symptoms and 5 patients with pruritus caused by either ESRD or diabetes were involved in this study. A topical formulation containing 4% chia seed oils were applied for an 8-week duration. Subjective itching symptoms were assessed on a 6-point scale, as were other skin functions, namely transepidermal water loss and skin capacitance.

RESULTS

After the 8 weeks of application, significant improvements in skin hydration, lichen simplex chronicus, and prurigo nodularis were observed in all patients. A similar improvement was also observed among healthy volunteers with xerotic pruritus. Improvement of epidermal permeability barrier function and skin hydration, represented by trans-epidermal water loss and skin capacitance, respectively, were also observed. No adverse effects were observed in all the tested patients and volunteers.

CONCLUSION

Chia seed oil can be used as an adjuvant moisturizing agent for pruritic skin, including that of ESRD patients.

Nutritional and anti-inflammatory interventions in chronic heart failure

Currently, there are 5 million individuals with chronic heart failure (CHF) in the United States who have poor clinical outcomes, including high death rates. Observational studies have indicated a reverse epidemiology of traditional cardiovascular risk factors in CHF; in contrast to trends seen in the general population, obesity and hypercholesterolemia are associated with improved survival. The temporal discordance between the overnutrition (long-term killer) and undernutrition (short-term killer) not only can explain some of the observed paradoxes but also may indicate that malnutrition, inflammation, and oxidative stress may play a role that results in protein-energy wasting contributing to poor survival in CHF. Diminished appetite or anorexia and nutritional deficiencies may be both a cause and a consequence of this so-called malnutrition-inflammation-cachexia (MIC) or wasting syndrome in CHF. Neurohumoral activation, insulin resistance, cytokine activation, and survival selection-resultant genetic polymorphisms also may contribute to the prominent inflammatory and oxidative characteristics of this population. In patients with CHF and wasting, nutritional strategies including amino acid supplementation may represent a promising therapeutic approach, especially if the provision of additional amino acids, protein, and energy includes nutrients with anti-inflammatory and antioxidant properties. Regardless of the etiology of anorexia, appetite-stimulating agents, especially those with anti-inflammatory properties such as megesterol acetate or pentoxyphylline, may be appropriate adjuncts to dietary supplementation. Understanding the factors that modulate MIC and body wasting and their associations with clinical outcomes in CHF may lead to the development of nutritional strategies that alter the pathophysiology of CHF and improve outcomes.

Effects of omega-3 fatty acid supplementation on vascular access thrombosis in polytetrafluorethylene grafts

OBJECTIVE

The purpose of this study was to investigate the effects of orally administered over-the-counter omega-3 (n-3) fatty acid supplements on primary patency of polytetrafluoroethylene (PTFE) grafts.

DESIGN

This study was conducted with a triple-blind, permuted-block, randomized, placebo-controlled experimental design.

SETTING

Dialysis clinics with patients who, in accordance with physician diagnosis, needed a new PTFE graft.

PATIENTS AND OTHER PARTICIPANTS

Patients on long-term hemodialysis with newly placed PTFE grafts who were unable to receive a native arteriovenous fistula.

INTERVENTION

Patients were followed prospectively for 8 months after they had been placed into an n-3 fatty acid or control group and were monitored for primary patency.

MAIN OUTCOME VARIABLE

Primary patency of the PTFE graft.

RESULTS

The n-3 fatty acid group had a mean PTFE graft primary patency rate of 254.2 days (SEM = 51.8), and the control group had a mean PTFE graft primary patency rate of 254.1 days (SEM = 34.6), revealing no significant difference in survival time between groups.

CONCLUSIONS

No significant differences in primary patency rates were noted in the experimental and control groups.

The kidney disease wasting: Inflammation, oxidative stress, and diet-gene interaction

The 350,000 maintenance hemodialysis (MHD) patients in the United States have an unacceptably high mortality rate of >20%/year. Almost half of all deaths are assumed to be cardiovascular. Markers of kidney disease wasting (KDW) such as hypoalbuminemia, anorexia, body weight and fat loss, rather than traditional cardiovascular risk factors, appear to be the strongest predictors of early death in these patients. The KDW is closely related to oxidative stress (SOX). Such SOX markers as serum myeloperoxidase are associated with pro-inflammatory cytokines and poor survival in MHD patients. Identifying the conditions that modulate the KDW/SOX-axis may be the key to improving outcomes in MHD patients. Dysfunctional lipoproteins such as a higher ratio of the high-density lipoprotein inflammatory index (HII) may engender or aggravate the KDW, whereas functionally intact or larger lipoprotein pools, as in hypercholesterolemia and obesity, may mitigate the KDW in MHD patients. Hence, a reverse epidemiology or "bad-gone-good" phenomenon may be observed. Diet and gene and their complex interaction may lead to higher proportions of pro-inflammatory or oxidative lipoproteins such as HII, resulting in the aggravation of the SOX and inflammatory processes, endothelial dysfunction, and subsequent atherosclerotic cardiovascular disease and death in MHD patients. Understanding the factors that modulate the KDW/SOX complex and their associations with genetic polymorphism, nutrition, and outcomes in MHD patients may lead to developing more effective strategies to improve outcomes in this and the 20 to 30 million Americans with chronic disease states such as individuals with chronic heart failure, advanced age, malignancies, AIDS, or cachexia.

Kidney insufficiency and nutrient-based modulation of inflammation

PURPOSE OF REVIEW

Patients with chronic kidney disease have a high cardiovascular mortality rate. Despite recent advances in dialysis techniques, over 20% of US dialysis patients die every year. Protein-energy malnutrition and inflammation are common and usually concurrent in chronic kidney disease patients, and have been implicated as the main cause of high mortality. We reviewed the pathophysiology of the malnutrition-inflammation complex syndrome and its potential modulation by dietary and other nutritional interventions in chronic kidney disease patients.

RECENT FINDINGS

The malnutrition-inflammation complex syndrome is a main cause of the atherosclerotic cardiovascular disease epidemic in chronic kidney disease. This may be by virtue of the syndrome's inflammatory components. Malnutrition and inflammation lead to weight loss over time, i.e. cachexia in slow motion, and result in decreased serum cholesterol and homocysteine levels. A 'reverse epidemiology' of cardiovascular risk factors is observed in chronic kidney disease, in that obesity, hypercholesterolemia and hyperhomocysteinemia are paradoxically associated with better survival. Among the possible etiologies of the malnutrition-inflammation complex syndrome, anorexia, low nutrient intake and oxidative stress are theoretically amenable to dietary modulation; however, the bulk of findings are epidemiological.

SUMMARY

There is no consensus as to how to correct the malnutrition-inflammation complex syndrome in chronic kidney disease patients. Because the malnutrition-inflammation complex syndrome is multifactorial, its correction probably requires a battery of simultaneous interventions, rather than one single modality. Clinical trials focusing on the syndrome are currently non-existent and are therefore urgently required to improve poor clinical outcome in chronic kidney disease patients.

Use of alternative medicine by patients with stage 5 chronic kidney disease

The use of complementary and alternative medicine (CAM) in the United States is growing at a remarkable speed. Herbal products and dietary supplements are CAM therapies that have grown faster than any other CAM treatments. Little information is available about herbs and dietary supplement use in the stage 5 chronic kidney disease population. These products contain a myriad of pharmacologically active compounds that, when used by people with kidney disease, may be hazardous. Members of the renal dietitian listserv were queried about herbs and dietary supplements reportedly used by dialysis patients. Up-to-date information on the use, safety, efficacy, adverse effects, and recommended dosages in the nondialysis population are presented for 24 products. In the dialysis population, Noni juice should be avoided because of its high potassium content. In addition, bulk-forming laxatives such as flaxseed should be used with caution because of the need for increased fluid intake. Dialysis practitioners should include specific questions about herbs and dietary supplement use in medical and nutrition histories, and they should increase their knowledge about these products to advise patients appropriately. A list of reliable sources of information for the health care provider on herbs and dietary supplements is also presented.

Vascular access for hemodialysis: 2004 and beyond

PURPOSE OF REVIEW

Developments in vascular access are accruing rapidly. The last systematic Kidney Disease Outcomes Quality Initiative guidelines review took place in 2000. The purpose of this review is to update several major areas in which clear progress has been made. A major 'Fistula First Initiative' in the USA is an attempt to increase markedly the fraction of patients receiving an autologous arteriovenous fistula as opposed to a graft. Preoperative mapping to evaluate veins and artery may permit construction of arteriovenous fistula in up to 70% of all patients, thereby reducing access thrombosis, infection, and perhaps increasing survival of patients.

RECENT FINDINGS

Although a number of different synthetic materials have been tried, none seems to have any definite advantage over plain expanded polytetrafluoroethylene for constructing synthetic bridge grafts. Two developments may influence practice: use of composite self-sealing grafts that can be used within hours may eliminate the need for temporary catheters; and use of nitinol surgical clips may reduce endothelial trauma and improve patency. Large-bore catheters can deliver blood flows of over 400 ml/min initially, but they are prone to progressive occlusion. Optimal means of using a fibrinolytic to preserve flow must be evaluated. Surveillance techniques are undergoing rapid re-evaluation. Finally, a variety of antibiotic lock techniques are being evaluated for their ability to prevent catheter-related infections.

SUMMARY

Greater efforts must be made to establish pre-end-stage renal disease programs to educate and prepare patients for hemodialysis and improve arteriovenous fistula placement rates, and to encourage clinicians to re-examine their current clinical practices and dedicate themselves to improving vascular access outcomes.

Medical nutrition therapy in chronic kidney failure: Integrating clinical practice guidelines

This review updates earlier published recommendations and integrates current clinical practice guidelines for nutritional care in chronic kidney disease as recommended by the National Kidney Foundation Kidney Dialysis Outcome Quality Initiative (K/DOQI). The scope covers chronic kidney disease in adults prior to kidney failure (Stages 1-4), chronic kidney failure with hemodialysis or peritoneal dialysis replacement therapy (Stage 5), and management after kidney transplantation. Multiple diet parameters are necessary to provide optimal nutritional health, including monitoring of calories, protein, sodium, fluid, potassium, calcium, and phosphorus, as well as other individualized nutrients. Emphasis is placed on continuity of care within changing kidney function and treatment modality status. The rising incidence of chronic kidney disease will increase the probability of the non-renal specialist dietetics professional delivering care to this patient population.