The effect of dietary supplements on the nPCR in stable hemodialysis patients

Muscle Status Response to Oral Nutritional Supplementation in Hemodialysis Patients With Protein Energy Wasting: A Multi-Center Randomized, Open Label-Controlled Trial

Background: Muscle wasting, observed in patients with end-stage kidney disease and protein energy wasting (PEW), is associated with increased mortality for those on hemodialysis (HD). Oral nutritional supplementation (ONS) and nutrition counseling (NC) are treatment options for PEW but research targeting muscle status, as an outcome metric, is limited.

Aim: We compared the effects of combined treatment (ONS + NC) vs. NC alone on muscle status and nutritional parameters in HD patients with PEW.

Methods: This multi-center randomized, open label-controlled trial, registered under ClinicalTrials.gov (Identifier no. NCT04789031), recruited 56 HD patients identified with PEW using the International Society of Renal Nutrition and Metabolism criteria. Patients were randomly allocated to intervention (ONS + NC, n = 29) and control (NC, n = 27) groups. The ONS + NC received commercial renal-specific ONS providing 475 kcal and 21.7 g of protein daily for 6 months. Both groups also received standard NC during the study period. Differences in quadriceps muscle status assessed using ultrasound (US) imaging, arm muscle area and circumference, bio-impedance spectroscopy (BIS), and handgrip strength (HGS) methods were analyzed using the generalized linear model for repeated measures.

Results: Muscle indices as per US metrics indicated significance (p < 0.001) for group × time interaction only in the ONS + NC group, with increases by 8.3 and 7.7% for quadriceps muscle thickness and 4.5% for cross-sectional area (all p < 0.05). This effect was not observed for arm muscle area and circumference, BIS metrics and HGS in both the groups. ONS + NC compared to NC demonstrated increased dry weight (p = 0.039), mid-thigh girth (p = 0.004), serum prealbumin (p = 0.005), normalized protein catabolic rate (p = 0.025), and dietary intakes (p < 0.001), along with lower malnutrition–inflammation score (MIS) (p = 0.041). At the end of the study, lesser patients in the ONS + NC group were diagnosed with PEW (24.1%, p = 0.008) as they had achieved dietary adequacy with ONS provision.

Conclusion: Combination of ONS with NC was effective in treating PEW and contributed to a gain in the muscle status as assessed by the US, suggesting that the treatment for PEW requires nutritional optimization via ONS.

Evaluating haemodialysis patient's nutritional status: Body mass index or body cell mass index?

OBJECTIVE

Evaluate which of two combinations of parameters based on International Society of Renal Nutrition and Metabolism recommendations could better identify patients with protein-energy wasting (PEW) and to compare the relationship of these two combinations with other clinical and body composition parameters.

METHODS

This was a multicentre longitudinal study with 24 months of follow-up. The PEW patients were characterized by: Group A (G_A ) - normalized protein catabolic rate (nPCR) < 1.0 g/kg per day, albumin <3.8 g/dL and body cell mass index (BCMI) < 6.4 kg/m² (n = 203); Group B (G_B ) - nPCR <1.0 g/kg per day, albumin <3.8 g/dL and body mass index (BMI) <23 kg/m² (n = 109). All the patients who did not meet these requirements were considered "well-nourished" (G_A : n = 1818; G_B : n = 3292).

RESULTS

When compared to the well-nourished patients, PEW patients in the G_A presented higher age, Kt/V, C-reactive protein, relative overhydration, fat tissue index (FTI); lower creatinine, albumin, nPCR, PTH, haemoglobin, phosphorus, calcium X phosphorus product, potassium, dry weight, BMI, BCMI, lean tissue index, %IDWG . In the G_B , well-nourished patients FTI was significantly higher. In Cox analysis, the combination with BCMI was a strong independent predictor of mortality in these patients (hazard ratio: 1.48; confidence interval: 1.00-2.19; P = 0.048), even after adjustment. Although G_B combination seemed to be also a predictor of death (hazard ratio: 2.67; confidence interval: 1.92-3.71; P < 0.001), when adjusted, the association remained no longer significant.

CONCLUSION

A new combination of parameters including protein intake, albumin and BCMI demonstrated significant associations with other nutrition and inflammation parameters as well as with mortality.

Effects of Oral Nutritional Supplements on Mortality, Missed Dialysis Treatments, and Nutritional Markers in Hemodialysis Patients

OBJECTIVE

Protein-energy wasting is common in end-stage renal disease patients undergoing dialysis and is strongly associated with mortality and adverse outcomes. Intradialytic oral nutritional supplements (ONS) reduce risk of mortality in these patients. Large studies characterizing the impact of ONS on other outcomes are lacking. We assessed the associations between administration of ONS and clinical and nutritional outcomes.

DESIGN

Retrospective evaluation of a pilot program providing ONS to patients at a large dialysis organization in the United States. The pilot program provided ONS to in-center hemodialysis patients with serum albumin ≤3.5 g/dL at 408 facilities.

SUBJECTS

ONS patients were compared to matched controls with serum albumin ≤3.5 g/dL, identified from facilities not participating in the ONS program (n = 3,374 per group).

INTERVENTION

Receipt of ONS.

MAIN OUTCOME MEASURES

Death, missed dialysis treatments, hospitalizations, serum albumin, normalized protein catabolic rate, and postdialysis body weight were abstracted from large dialysis organization electronic medical records.

RESULTS

There was a 69% reduction in deaths (hazard ratio = 0.31; 95% confidence interval = 0.25-0.39), and 33% fewer missed dialysis treatments (incidence rate ratio = 0.77; 95% confidence interval = 0.73-0.82) among ONS patients compared to controls (P < .001 for both). The effects of ONS on nutritional indices were mixed: serum albumin was lower, whereas normalized protein catabolic rate values, a surrogate for dietary protein intake, and postdialysis body weights were higher for ONS patients compared to controls during follow-up.

CONCLUSIONS

Our evaluation confirmed the beneficial effects of ONS in reducing mortality and improving some indices of nutritional status for hypoalbuminemic hemodialysis patients. We also report the novel finding that ONS can reduce the number of missed dialysis treatments. These results support the use of intradialytic ONS as an effective intervention to improve the outcomes in hemodialysis patients with low serum albumin.

Challenges of Providing Nutrition Support in the Outpatient Dialysis Setting

Malnutrition is prevalent in maintenance hemodialysis (MHD) patients and has been strongly associated with increased morbidity and mortality. There are numerous contributors to the development, occurrence, and persistence of malnutrition in the MHD patient. Intensive diet counseling and use of enteral supplements may not be effective interventions for patients exhibiting high nutrition risk. More aggressive nutrition options such as enteral and parenteral support are less often used and have associated risks. Intradialytic parenteral nutrition (IDPN) as a form of PN delivered during the dialysis procedure is a convenient and attractive convention that is underused because of its history and controversy. There is a lack of randomized controlled trials demonstrating improved morbidity and mortality with all nutrition support interventions in MHD patients. This research is particularly crucial for IDPN in order to render change in Medicare reimbursement. Qualification of patients for this therapy is difficult because of the very strict coverage criteria. For those patients who do qualify for IDPN, clinician nutrition support knowledge is essential for safe administration of solutions and effective physical, metabolic, and nutrition management of the patient. Attention to other factors that contribute to malnutrition in MHD such as treatment adequacy and comorbid conditions is important; however, the early detection of malnutrition in the MHD patient with appropriate level of nutrition intervention is critical. Future improved understanding of the malnutrition of uremia will allow for development and investigation of other strategies that are anti-catabolic or anabolic.

Effect of personalized nutritional counseling in maintenance hemodialysis patients

Monitoring nutritional parameters is an integral part of hemodialysis (HD) patient treatment program. The purpose of this study was to evaluate the impact of the personalized nutritional counseling (PNC) on calcium-phosphorus metabolism, potassium, albumin, protein intake, interdialytic weight gain (IDWG), body composition parameters and fluid overload in HD patients. This was a multicenter longitudinal intervention study with 6 months of follow-up and 731 patients on maintenance HD from 34 dialysis units in Portugal were enrolled. Biochemical and body composition parameters were measured at baseline, 1, 3 and 6 months after the PNC. Patient's mean age was 64.9 (95% confidence interval [CI]: 63.8-66.0) years and mean HD time was 59.8 (95% CI: 55.3-64.3) months. Regarding data comparison collected before PNC vs. 6 months after, we obtained, respectively, the following results: patients with normalized protein catabolic rate (nPCR) ≥ 1 g/kg/day = 66.5% vs. 73.5% (P = 0.002); potassium > 5.5 mEq/L = 52% vs. 35.8% (P < 0.001); phosphorus between 3.5 and 5.5 mg/dL = 43.2% vs. 52.5% (P < 0.001); calcium/phosphorus (Ca/P) ratio ≤ 50 mg/dL = 73.2 % vs. 81.4% (P < 0.001); albumin ≥ 4.0 g/dL = 54.8% vs. 55% (P = 0.808); presence of relative overhydration = 22.4% vs. 25% (P = 0.283); IDWG > 4.5% = 22.3% vs. 18.2% (P = 0.068). PNC resulted in a significant decrease in the prevalence of hyperkalemia, hypophosphatemia and also showed amelioration in Ca/P ratio, nPCR and an increase in P of hyphosphatemic patients. Our study suggests that dietetic intervention contributes to the improvement of important nutritional parameters in patients receiving hemodialysis treatment.

Nutritional predictors of early mortality in incident hemodialysis patients

PURPOSE

Low serum albumin concentration and low dietary protein intake are associated with protein-energy wasting (PEW) and higher mortality in maintenance hemodialysis patients. The role of these nutritional markers is less clear in clinical outcomes of the first several months of dialysis therapy, where mortality is exceptionally high.

METHODS

In a cohort of 17,445 incident hemodialysis patients, we examined variation in serum albumin and the normalized protein catabolic rate (nPCR), a surrogate of dietary intake, and quarterly mortality in the first 2 years of dialysis therapy. Cox proportional hazard models were fitted to estimate the association between mortality and combined albumin/nPCR categories for eight quarters. We investigated the associations between mortality and baseline and subsequent serum albumin levels per cohort quarter as well as changes in albumin and nPCR over time.

RESULTS

Patients were 64 ± 15 years old (mean ± SD) and included 45 % women, 24 % African Americans and 58 % diabetics. Correlations between quarterly serum albumin and nPCR varied from 0.18 to 0.25. Serum albumin <3.5 g/dL was consistently associated with high mortality as was nPCR <1 g/kg/day (except for qtr1). Low serum albumin and nPCR greater than 0.2 g/dLg/dL or g/kg/day, respectively, were associated with increased risk of death. Quarterly rise in nPCR (>+0.2 g/kg/day) showed reverse effect on mortality from the 2nd to the last quarter.

CONCLUSIONS

Low serum albumin and nPCR are associated with mortality. A rapid rise in nPCR by the end of the second year may indicate pre-existing PEW.

Sarcopenia: a major challenge in elderly patients with end-stage renal disease

Sarcopenia is a condition of multifaceted etiology arising in many elderly people. In patients with chronic kidney, the loss of muscle mass is much more intensive and the first signs of sarcopenia are observed in younger patients than it is expected. It is associated with the whole-body protein-energy deficiency called protein-energy wasting (PEW). It seems to be one of the major factors limiting patient's autonomy as well as decreasing the quality of life. If it cannot be treated with the simple methods requiring some knowledge and devotion, we will fail to save patients who die due to cardiovascular disease and infection, despite proper conduction of renal replacement therapy. Many factors influencing the risk of sarcopenia development have been evaluated in number of studies. Many studies also were conducted to assess the efficacy of different therapeutic strategies (diet, physical activity, hormones). Nevertheless, there is still no consensus on treatment the patients with PEW. Therefore, in the paper we present the reasons and pathophysiology of sarcopenia as an important element of protein energy wasting (PEW) in elderly patients suffering from chronic kidney disease. We also analyze possible options for treatment according to up-to-date knowledge.

Diets and enteral supplements for improving outcomes in chronic kidney disease

Protein-energy wasting (PEW), which is manifested by low serum levels of albumin or prealbumin, sarcopenia and weight loss, is one of the strongest predictors of mortality in patients with chronic kidney disease (CKD). Although PEW might be engendered by non-nutritional conditions, such as inflammation or other comorbidities, the question of causality does not refute the effectiveness of dietary interventions and nutritional support in improving outcomes in patients with CKD. The literature indicates that PEW can be mitigated or corrected with an appropriate diet and enteral nutritional support that targets dietary protein intake. In-center meals or oral supplements provided during dialysis therapy are feasible and inexpensive interventions that might improve survival and quality of life in patients with CKD. Dietary requirements and enteral nutritional support must also be considered in patients with CKD and diabetes mellitus, in patients undergoing peritoneal dialysis, renal transplant recipients, and in children with CKD. Adjunctive pharmacological therapies, such as appetite stimulants, anabolic hormones, and antioxidative or anti-inflammatory agents, might augment dietary interventions. Intraperitoneal or intradialytic parenteral nutrition should be considered for patients with PEW whenever enteral interventions are not possible or are ineffective. Controlled trials are needed to better assess the effectiveness of in-center meals and oral supplements.

[Efficacy of oral supplementation during dialysis in patients with chronic renal failure]

Protein-calorie malnutrition is common in hemodialysis patients and is a powerful predictor of morbidity and mortality. Nutritional supplementation, administered orally or parenterally, especially during dialysis, may compensate for the relatively inadequate protein and energy intake and improves net protein anabolism in chronic hemodialysis patients. Intradialytic oral nutrition seems preferable to intradialytic parenteral nutrition (IDPN) due to its lower cost and persistence of its anabolic effects after infusion is stopped, and because IDPN induces a higher increase in serum glucose and insulin levels and a greater reduction in serum ghrelin concentrations. Further larger scale randomized, controlled trials of nutritional interventions should be performed in maintenance dialysis patients to assess their efficacy regarding quality of life, morbidity, and mortality.

Wasting in chronic kidney disease

Wasting/cachexia is prevalent among patients with chronic kidney disease (CKD). It is to be distinguished from malnutrition, which is defined as the consequence of insufficient food intake or an improper diet. Malnutrition is characterized by hunger, which is an adaptive response, whereas anorexia is prevalent in patients with wasting/cachexia. Energy expenditure decreases as a protective mechanism in malnutrition whereas it remains inappropriately high in cachexia/wasting. In malnutrition, fat mass is preferentially lost and lean body mass and muscle mass is preserved. In cachexia/wasting, muscle is wasted and fat is relatively underutilized. Restoring adequate food intake or altering the composition of the diet reverses malnutrition. Nutrition supplementation does not totally reverse cachexia/wasting. The diagnostic criteria of cachexia/protein-energy wasting in CKD are considered. The association of wasting surrogates, such as serum albumin and prealbumin, with mortality is strong making them robust outcome predictors. At the patient level, longevity has consistently been observed in patients with CKD who have more muscle and/or fat, who report better appetite and who eat more. Although inadequate nutritional intake may contribute to wasting or cachexia, recent evidence indicates that other factors, including systemic inflammation, perturbations of appetite-controlling hormones from reduced renal clearance, aberrant neuropeptide signaling, insulin and insulin-like growth factor resistance, and metabolic acidosis, may be important in the pathogenesis of CKD-associated wasting. A number of novel therapeutic approaches, such as ghrelin agonists and melanocortin receptor antagonists are currently at the experimental level and await confirmation by randomized controlled clinical trials in patients with CKD-associated cachexia/wasting syndrome.

Challenges of nutrition intervention for malnourished dialysis patients

Malnutrition, or protein energy wasting (PEW), is prevalent in patients with chronic kidney disease stage 5 dialysis (CKD-5). One criterion of PEW strongly associated with morbidity and mortality in CKD-5 dialysis patients is the serum albumin level. Serum albumin levels have not improved over the past 10 years. Typical intervention strategies need to be reevaluated. Intradialytic parenteral nutrition (IDPN) is a form of parenteral nutrition delivered during dialysis that is a convenient and assured route of nutrition alimentation for high-nutrition-risk PEW patients who cannot improve nutrition status by oral and enteral routes. Recent qualification criteria for IDPN changes in Medicare part D have made this therapy an available option for many more of these high-nutrition-risk PEW patients. Nutrition support knowledge in clinicians is essential to administer IDPN effectively and to optimize clinical response. An improved understanding of the milieu of uremia and PEW of CKD-5, as well as the study of nutrition interventions inclusive of IDPN, will allow for effective strategies toward improved outcomes in the future.

Protein supplementation with sports protein bars in renal patients

BACKGROUND

Malnutrition prevalence in patients on dialysis is well established. The protein requirements for both hemodialysis and peritoneal dialysis have been documented elsewhere, including the Kidney Disease Outcomes Quality Initiative Clinical Practice Guidelines for Nutrition in Chronic Renal Failure. The clinical challenge is to assist patients in meeting these targets, especially in those with anorexia. Traditional supplements have included fluid, which is an issue for patients who are fluid restricted.

OBJECTIVES

The study objectives were to (1) investigate the range of sports protein supplements that may be suitable for patients on hemodialysis to use and (2) trial nonfluid protein supplements in patients on hemodialysis.

METHODS AND DESIGN

Known manufacturers of sports protein bars and other sports supplements available in Australia were contacted for the nutrient breakdown of high-protein products, specifically potassium, protein, and phosphorus contents. As a result, selected high-protein sports bars (Protein FX, Aussie Bodies, Port Melbourne, Victoria, Australia) were used as an alternative to the more commonly used renal-specific fluid supplements (Nepro, Abbott Laboratories, Abbott Park, IL; Novasource Renal, Novartis Nutrition Corporation, Fremont, MI; and Renilon, Nutricia, Wiltshire, UK) in patients with poor nutritional status requiring supplementation. Patient satisfaction and clinical nutrition markers were investigated.

SETTING

The study took place at inpatient, in-center, and satellite hemodialysis settings in Adelaide, South Australia.

PARTICIPANTS

A total of 32 patients (16 females and 16 males) with an average age of 62.9 years (range 32-86 years) undergoing hemodialysis (acute and maintenance) were included. Subjects were selected by the author as part of routine clinical nutrition care.

INTERVENTION

Patients trialed sports protein bars as a protein supplement alone or in conjunction with other supplementary products.

RESULTS

All patients were in favor of the trial, with 22 of 32 patients continuing with the protein bars as the preferred supplement. The major reasons for not continuing were taste and chewability, especially in older patients with dentures. Serum potassium and phosphate levels were not increased with supplementation. Measured serum albumin and protein catabolic rate were considered unreliable indicators because not all patients were medically stable.

CONCLUSIONS

Sports protein bars are an acceptable protein and energy supplement for patients on hemodialysis. Sports protein bars are well accepted by patients except when dentures limit chewability. Sports protein bars have advantages over fluid-based supplements in patients with fluid restrictions.

Should food or supplements be used in the community for the treatment of disease-related malnutrition?

Strategies are needed for community-based treatment of disease-related malnutrition (DRM), which is a common debilitating condition that in the UK is estimated to cost >£7×109annually. Whilst dietary fortification and counselling are often used as a first-line treatment for malnutrition, the numbers of dietitians available to undertake and oversee such practices are currently insufficient to address the extent of DRM in primary care. Although dietary fortification and counselling can improve nutritional (primarily energy) intake, the evidence base for this practice is weak and it needs addressing with well-designed trials that assess clinically-relevant outcome measures and costs. Liquid oral nutritional supplements (ONS) are increasingly used in the community, often in combination with dietary counselling. The larger evidence base of trials that have assessed ONS suggests that nutritional intake and some functional outcomes can be improved in some patient groups in the community. Although meta-analysis indicates significant reductions in mortality (odds ratio 0.59 (95% CI 0.48, 0.72),n3258) and complication rates (odds ratio 0.41 (95% CI 0.31, 0.53),n1710) with ONSv. routine care, few of these studies are community based. Thus, the impact of ONS on clinical outcome, healthcare use and costs requires further assessment. Similarly, the clinical and cost efficacy of other strategies (e.g. sensory enhancement, music, behavioural therapy), alone or in combination with other treatments, requires greater investigation in order to meet the challenge of treating DRM more effectively and cheaply in the future.

Multinutrient Oral Supplements and Tube Feeding in Maintenance Dialysis: A Systematic Review and Meta-Analysis

BACKGROUND

This systematic review aims to determine the potential benefits of enteral multinutrient support (oral or tube) in patients with chronic kidney disease (CKD) receiving maintenance dialysis.

METHODS

Studies of multinutrient oral supplements and enteral tube feeding that involved comparisons of nutritional support versus routine care (ie, usual diet), disease-specific formulae (with adapted macronutrient and micronutrient composition for use in maintenance dialysis patients) versus standard formulae, and enteral tube feeding versus parenteral nutrition are included in this review. The outcome measures sought were clinical (quality of life, complications, and mortality), biochemical (albumin and electrolyte levels), and nutritional (dietary intake and anthropometry). Meta-analyses were performed when possible.

RESULTS

This review of 18 studies (5 randomized controlled trials [RCTs], 13 non-RCTs) suggests that enteral nutritional support increased total (energy and protein) intake and increased serum albumin concentration by 0.23 g/dL (2.3 g/L; 95% confidence interval, 0.037 to 0.418 g/dL [0.37 to 4.18 g/L]; 1 RCT, 2 non-RCTs), with little effect on electrolyte status (serum phosphate and potassium). Few studies reported clinical outcome, and there was insufficient information to compare disease-specific versus standard formulae or enteral versus parenteral nutrition.

CONCLUSION

This systematic review suggests that enteral multinutrient support significantly increases serum albumin concentrations and improves total dietary intake. This may improve clinical outcome, especially in malnourished patients, but insufficient published data exist to examine this. Additional research is required to investigate clinical, economic, and nutritional consequences of using oral supplements and tube feeding (using standard or disease-specific feeds) in patients with CKD receiving maintenance dialysis.

The effect of dialysis dose and membrane flux on nutritional parameters in hemodialysis patients: Results of the HEMO Study

BACKGROUND

The effect of standard or high dialysis dose and low or high dialysis flux on nutritional status was ascertained in 1846 maintenance hemodialysis patients enrolled in the HEMO Study.

METHODS

Serum albumin levels, equilibrated protein catabolic rate, and postdialysis weight were obtained monthly, while adjusted protein and energy intake, self-reported appetite assessment, upper arm circumference, and calf circumference were obtained yearly. To account for patient attrition due to death or transfer, three statistical models were used to test the effects of the study interventions on longitudinal changes in nutritional parameters.

RESULTS

During the first 3 years of follow-up, neither mean serum albumin levels, which declined by 0.21 g/dL, nor mean postdialysis weight, which declined by 2.7 kg, were significantly affected by either study intervention. Mean levels of all anthropometric measures declined during follow-up. For years 1, 2, and 3, the mean +/- SE declines in upper arm and calf circumferences were 0.35 +/- 0.16 cm (P= 0.031) and 0.31 +/- 0.13 (P= 0.015) cm less, respectively, in the high flux compared to the low flux group. Appetite scores and mean equilibrated protein catabolic rate also declined in all randomized groups; however, the average decline in equilibrated protein catabolic rate during years 1, 2, and 3 was 0.019 +/- 0.007 g/kg/day less in the high dose than the standard dose group (P= 0.007). There was no significant change in either mean energy or protein intake from diet records over time, and neither parameter was affected by the study interventions.

CONCLUSION

Although the dose and flux interventions may subtly influence certain nutritional parameters, neither intervention prevented deterioration in nutritional status over time.

The impact of nutrition intervention on a reliable morbidity and mortality indicator: the hemodialysis-prognostic nutrition index

OBJECTIVE

To determine the prevalence of risk for hospitalization in hemodialysis (HD) patients and examine the impact of oral kilocalorie and protein supplementation in two Midwestern outpatient dialysis centers.

DESIGN/SETTING

This was a prospective intervention study conducted at 2 outpatient dialysis centers in the Midwest.

PATIENTS

The inclusion criteria for patients were (1) more than 18 years of age, (2) receiving HD 3 times per week, and (3) a functioning gastrointestinal tract.

INTERVENTION

Patients who met study criteria and signed an informed consent form were screened using the hemodialysis prognostic nutrition index (HD-PNI) to determine risk for hospitalization. Patients determined to be at high risk (HD-PNI > or =0.8) were included in the treatment group, and patients at low risk did not receive the intervention. They followed their normal nutritional regimen. The intervention group received an oral supplement daily for 3 months. The team of the dietitian, patient, researcher, and physician determined the type of oral supplements based on patient needs and preferences.

MAIN OUTCOME MEASURES

Before and after HD-PNI, 24-hour recall and subjective global assessments (SGA) were conducted to assess risk for hospitalization, dietary intake, and nutritional status, respectively.

RESULTS

A total of 117 patients were screened, with a total of 26 in the treatment group (high risk) and 91 in the low-risk group. Baseline SGA distribution was 23% for patients with low nutritional risk (group A), 64% for those with moderate nutritional risk (group B), and 13% for those with severe nutritional risk (group C). When the HD-PNI scores of the treatment group were analyzed using paired t-tests, significant differences were observed between pre- and post-HD-PNI mean scores, 1.92 +/- 1.16 and 1.42 +/- 1.59, (P <.05) respectively. When comparing the responders versus the nonresponders by the dependent and independent variables (pre- and post-HD-PNI, SGA, kilocalorie intake, diabetic status, and presence of hypertension) only post-HD-PNI score was significantly different (0.96 +/- 1.69 and 2.20 +/- 1.09, respectively).

CONCLUSION

This study succeeded in showing that 22% of the hemodialysis patients in 2 Midwestern centers were at an increased risk for hospitalization. Furthermore, dietitian intervention with oral kilocalorie and protein supplements decreased the patients' hemodialysis prognostic nutrition index scores and thereby decreased the patients' risks for hospitalization.