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Morimoto N, Shioji S, Akagi Y, Fujiki T, Mandai S, Ando F, Mori T, Susa K, Naito S, Sohara E, Anzai T, Takahashi K, Akita W, Ohta A, Uchida S, Iimori S. Associations Between Dietary Potassium Intake From Different Food Sources and Hyperkalemia in Patients With Chronic Kidney Disease. J Ren Nutr 2024:S1051-2276(24)00058-X. [PMID: 38621432 DOI: 10.1053/j.jrn.2024.03.008] [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: 01/30/2024] [Revised: 03/15/2024] [Accepted: 03/23/2024] [Indexed: 04/17/2024] Open
Abstract
OBJECTIVE Previous studies reported mixed results on associations between dietary potassium intake and hyperkalemia in patients with chronic kidney disease (CKD). This study investigated the association between potassium intake from different food sources and hyperkalemia in patients with non-dialysis-dependent CKD. METHODS A total of 285 patients were recruited at a university hospital and 2 city hospitals in Tokyo. Dietary potassium intake was estimated by a validated diet history questionnaire. Associations of potassium intake from all foods and individual food groups with serum potassium were examined by multivariable linear regression among potassium binder nonusers. An association between tertile groups of potassium intake and hyperkalemia, defined as serum potassium ≥5.0 mEq/L, was evaluated by multivariable logistic regression. RESULTS Among 245 potassium binder nonusers, total potassium intake was weakly associated with serum potassium (regression coefficient = 0.147, 95% confidence interval (CI): 0.018-0.277), while an association with hyperkalemia was not observed (first vs third tertile: adjusted odds ratio = 0.98, 95% CI: 0.29-3.26). As for food groups, potassium intakes from potatoes, pulses, and green/yellow vegetables were positively associated with serum potassium. Patients in the highest tertile of potassium intake from potatoes had higher odds of hyperkalemia as compared to those in the lowest tertile (adjusted odds ratio = 4.12, 95% CI: 1.19-14.34). CONCLUSION Total potassium intake was weakly associated with serum potassium, but not with hyperkalemia. Potassium intake from potatoes was associated with hyperkalemia. These findings highlight the importance of considering food sources of potassium in the management of hyperkalemia in CKD.
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Affiliation(s)
- Nobuhisa Morimoto
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shingo Shioji
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yuichiro Akagi
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tamami Fujiki
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shintaro Mandai
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Fumiaki Ando
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takayasu Mori
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Koichiro Susa
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shotaro Naito
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Eisei Sohara
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tatsuhiko Anzai
- Department of Biostatistics, M&D Data Science Center, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kunihiko Takahashi
- Department of Biostatistics, M&D Data Science Center, Tokyo Medical and Dental University, Tokyo, Japan
| | - Wataru Akita
- Department of Nephrology, Doai Memorial Hospital, Tokyo, Japan
| | - Akihito Ohta
- Department of Nephrology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Shinichi Uchida
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Soichiro Iimori
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan.
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Kato K, Nakashima A, Morishita M, Ohkido I, Yokoo T. Calcium-based phosphate binders and bone mineral density in patients undergoing hemodialysis: a retrospective cohort study. Clin Exp Nephrol 2024:10.1007/s10157-024-02493-8. [PMID: 38594468 DOI: 10.1007/s10157-024-02493-8] [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: 02/08/2024] [Accepted: 03/19/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Calcium supplements are commonly prescribed to prevent fractures in patients with osteoporosis. Nonetheless, they are generally eschewed in hemodialysis patients because they increase vascular calcification and induce cardiovascular disease. This retrospective cohort study aimed to investigate the effect of calcium-based phosphate binders (CBPB) on bone mineral density (BMD) in hemodialysis patients. METHODS Outpatients on dialysis who underwent BMD measurement from January to December 2017, whose data on BMD trends and CBPB administration were recorded over the next 4 years, were enrolled. Patients receiving anti-osteoporotic medications were excluded. The association between the presence and duration of CBPB administration and changes in BMD was evaluated. RESULTS The femoral neck's BMD decreased from 0.836 g/cm2 (0.702-0.952) to 0.764 g/cm2 (0.636-0.896) (P < 0.001) in the non-CBPB group (patients who never received CBPB over 4 years, n = 32). The CBPB group (n = 56) exhibited only a minute decrease from 0.833 g/cm2 (0.736-0.965) to 0.824 g/cm2 (0.706-0.939) (P = 0.004). Multivariate linear regression analysis revealed better BMD maintenance in the CBPB group [β-coefficient (95% CI): 0.033 (0.001-0.065); P = 0.046] than in the non-CBPB group. Additionally, the prolonged-CBPB administration group showed superior BMD preservation [β-coefficient (95% CI): 0.038 (0.001-0.076); P = 0.042]. CONCLUSION CBPB administration may be associated with BMD maintenance.
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Affiliation(s)
- Kazuhiko Kato
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi Minato-Ku, Tokyo, 105-8461, Japan
- Division of Molecular Epidemiology, The Jikei University School of Medicine, Tokyo, Japan
- Department of Nephrology, Morishita Memorial Hospital, Kanagawa, Japan
| | - Akio Nakashima
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi Minato-Ku, Tokyo, 105-8461, Japan.
| | | | - Ichiro Ohkido
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi Minato-Ku, Tokyo, 105-8461, Japan
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi Minato-Ku, Tokyo, 105-8461, Japan
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Evenepoel P, Jørgensen HS, Bover J, Davenport A, Bacchetta J, Haarhaus M, Hansen D, Gracia-Iguacel C, Ketteler M, McAlister L, White E, Mazzaferro S, Vervloet M, Shroff R. Recommended calcium intake in adults and children with chronic kidney disease-a European consensus statement. Nephrol Dial Transplant 2024; 39:341-366. [PMID: 37697718 DOI: 10.1093/ndt/gfad185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Indexed: 09/13/2023] Open
Abstract
Mineral and bone disorders (MBD) are common in patients with chronic kidney disease (CKD), contributing to significant morbidity and mortality. For several decades, the first-line approach to controlling hyperparathyroidism in CKD was by exogenous calcium loading. Since the turn of the millennium, however, a growing awareness of vascular calcification risk has led to a paradigm shift in management and a move away from calcium-based phosphate binders. As a consequence, contemporary CKD patients may be at risk of a negative calcium balance, which, in turn, may compromise bone health, contributing to renal bone disease and increased fracture risk. A calcium intake below a certain threshold may be as problematic as a high intake, worsening the MBD syndrome of CKD, but is not addressed in current clinical practice guidelines. The CKD-MBD and European Renal Nutrition working groups of the European Renal Association (ERA), together with the CKD-MBD and Dialysis working groups of the European Society for Pediatric Nephrology (ESPN), developed key evidence points and clinical practice points on calcium management in children and adults with CKD across stages of disease. These were reviewed by a Delphi panel consisting of ERA and ESPN working groups members. The main clinical practice points include a suggested total calcium intake from diet and medications of 800-1000 mg/day and not exceeding 1500 mg/day to maintain a neutral calcium balance in adults with CKD. In children with CKD, total calcium intake should be kept within the age-appropriate normal range. These statements provide information and may assist in decision-making, but in the absence of high-level evidence must be carefully considered and adapted to individual patient needs.
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Affiliation(s)
- Pieter Evenepoel
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium
- Department of Medicine, Division of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Hanne Skou Jørgensen
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium
- Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Nephrology, Aalborg University Hospital, Aalborg, Denmark
| | - Jordi Bover
- Department of Nephrology, University Hospital Germans Trias i Pujol, Barcelona, Catalonia, Spain
- REMAR-IGTP Group, Germans Trias i Pujol Research Institute, Can Ruti Campus, Barcelona, Catalonia, Spain
| | - Andrew Davenport
- Department of Renal Medicine, Royal Free Hospital, University College London, London, UK
| | - Justine Bacchetta
- Pediatric Nephrology Rheumatology and Dermatology Unit, Reference Center for Rare Renal Diseases, ORKID and ERK-Net networks, Lyon University Hospital, Bron, France
- Lyon Est Medical School, INSERM1033 Research Unit, Claude Bernard Lyon 1 University, Lyon, France
| | - Mathias Haarhaus
- Division of Renal Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Diaverum Sweden, Malmö, Sweden
| | - Ditte Hansen
- Department of Nephrology, Copenhagen University Hospital-Herlev, Copenhagen
- Institute of Clinical Medicine, University of Copenhagen, Denmark
| | - Carolina Gracia-Iguacel
- Department of Renal Medicine, IIS-Fundación Jiménez Díaz UAM University Hospital, Madrid, Spain
| | - Markus Ketteler
- Department of General Internal Medicine and Nephrology, Robert-Bosch Hospital, Stuttgart, Germany
| | - Louise McAlister
- Dietetic Team, UCL Great Ormond Street Hospital for Children and University College London, London, UK
| | - Emily White
- Dietetic Team, Royal Free Hospital, University College London, London, UK
| | - Sandro Mazzaferro
- Department of Translation and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Marc Vervloet
- Amsterdam Cardiovascular Sciences, Amsterdam UMC, The Netherlands
- Department of Nephrology, Amsterdam UMC, The Netherlands
| | - Rukshana Shroff
- Renal Unit, UCL Great Ormond Street Hospital for Children, London, UK
- Institute of Child Health, University College London, London, UK
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Tunnicliffe DJ, Palmer SC, Cashmore BA, Saglimbene VM, Krishnasamy R, Lambert K, Johnson DW, Craig JC, Strippoli GF. HMG CoA reductase inhibitors (statins) for people with chronic kidney disease not requiring dialysis. Cochrane Database Syst Rev 2023; 11:CD007784. [PMID: 38018702 PMCID: PMC10685396 DOI: 10.1002/14651858.cd007784.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
BACKGROUND Cardiovascular disease is the most frequent cause of death in people with early stages of chronic kidney disease (CKD), and the absolute risk of cardiovascular events is similar to people with coronary artery disease. This is an update of a review first published in 2009 and updated in 2014, which included 50 studies (45,285 participants). OBJECTIVES To evaluate the benefits and harms of statins compared with placebo, no treatment, standard care or another statin in adults with CKD not requiring dialysis. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 4 October 2023. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. An updated search will be undertaken every three months. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs that compared the effects of statins with placebo, no treatment, standard care, or other statins, on death, cardiovascular events, kidney function, toxicity, and lipid levels in adults with CKD (estimated glomerular filtration rate (eGFR) 90 to 15 mL/min/1.73 m2) were included. DATA COLLECTION AND ANALYSIS Two or more authors independently extracted data and assessed the study risk of bias. Treatment effects were expressed as mean difference (MD) for continuous outcomes and risk ratios (RR) for dichotomous benefits and harms with 95% confidence intervals (CI). The risk of bias was assessed using the Cochrane risk of bias tool, and the certainty of the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS We included 63 studies (50,725 randomised participants); of these, 53 studies (42,752 participants) compared statins with placebo or no treatment. The median duration of follow-up was 12 months (range 2 to 64.8 months), the median dosage of statin was equivalent to 20 mg/day of simvastatin, and participants had a median eGFR of 55 mL/min/1.73 m2. Ten studies (7973 participants) compared two different statin regimens. We were able to meta-analyse 43 studies (41,273 participants). Most studies had limited reporting and hence exhibited unclear risk of bias in most domains. Compared with placebo or standard of care, statins prevent major cardiovascular events (14 studies, 36,156 participants: RR 0.72, 95% CI 0.66 to 0.79; I2 = 39%; high certainty evidence), death (13 studies, 34,978 participants: RR 0.83, 95% CI 0.73 to 0.96; I² = 53%; high certainty evidence), cardiovascular death (8 studies, 19,112 participants: RR 0.77, 95% CI 0.69 to 0.87; I² = 0%; high certainty evidence) and myocardial infarction (10 studies, 9475 participants: RR 0.55, 95% CI 0.42 to 0.73; I² = 0%; moderate certainty evidence). There were too few events to determine if statins made a difference in hospitalisation due to heart failure. Statins probably make little or no difference to stroke (7 studies, 9115 participants: RR 0.64, 95% CI 0.37 to 1.08; I² = 39%; moderate certainty evidence) and kidney failure (3 studies, 6704 participants: RR 0.98, 95% CI 0.91 to 1.05; I² = 0%; moderate certainty evidence) in people with CKD not requiring dialysis. Potential harms from statins were limited by a lack of systematic reporting. Statins compared to placebo may have little or no effect on elevated liver enzymes (7 studies, 7991 participants: RR 0.76, 95% CI 0.39 to 1.50; I² = 0%; low certainty evidence), withdrawal due to adverse events (13 studies, 4219 participants: RR 1.16, 95% CI 0.84 to 1.60; I² = 37%; low certainty evidence), and cancer (2 studies, 5581 participants: RR 1.03, 95% CI 0.82 to 1.30; I² = 0%; low certainty evidence). However, few studies reported rhabdomyolysis or elevated creatinine kinase; hence, we are unable to determine the effect due to very low certainty evidence. Statins reduce the risk of death, major cardiovascular events, and myocardial infarction in people with CKD who did not have cardiovascular disease at baseline (primary prevention). There was insufficient data to determine the benefits and harms of the type of statin therapy. AUTHORS' CONCLUSIONS Statins reduce death and major cardiovascular events by about 20% and probably make no difference to stroke or kidney failure in people with CKD not requiring dialysis. However, due to limited reporting, the effect of statins on elevated creatinine kinase or rhabdomyolysis is unclear. Statins have an important role in the primary prevention of cardiovascular events and death in people who have CKD and do not require dialysis. Editorial note: This is a living systematic review. We will search for new evidence every three months and update the review when we identify relevant new evidence. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.
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Affiliation(s)
- David J Tunnicliffe
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Brydee A Cashmore
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Valeria M Saglimbene
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | | | - Kelly Lambert
- School of Medicine, University of Wollongong, Wollongong, Australia
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
| | - Jonathan C Craig
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Giovanni Fm Strippoli
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
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Udomkarnjananun S, Phannajit J, Takkavatakarn K, Tumkosit M, Kingpetch K, Avihingsanon Y, Praditpornsilpa K, Eiam-Ong S, Susantitaphong P. Effects of Phosphate Binders on Bone Biomarkers and Bone Density in Hemodialysis Patients. Nephrology (Carlton) 2022; 27:441-449. [PMID: 35044029 DOI: 10.1111/nep.14022] [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: 11/12/2021] [Revised: 01/04/2022] [Accepted: 01/12/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUNDS The incidences of osteoporosis, fracture, and vascular calcification increase concordantly with the progression of chronic kidney disease (CKD). CKD-mineral bone disease (CKD-MBD) induced by hyperphosphatemia is a major pathophysiologic mechanism. The effects of phosphate binders on bone turnover biomarkers and bone mineral density (BMD) in hemodialysis patients are still inconclusive. Our aim is to demonstrate the effects of these phosphate binders on different aspects of CKD-MBD. METHODS We conducted a prospective cohort of 65 hemodialysis patients to investigate the effect of 12-month monotherapy of phosphate binders composing calcium-based phosphate binders (CPB) or non-calcium-based phosphate binders (NCPB), including sevelamer and lanthanum, on bone turnover biomarkers and BMD changes. The performance of bone turnover biomarkers to predict low BMD was attentively determined. RESULTS When compared with CPB, NCPB use was associated with higher levels of bone turnover biomarkers. NCPB was also associated with lower BMD at lumbar and distal radius. Total procollagen type 1 N-terminal propeptide (P1NP), bone-specific alkaline phosphatase (BALP), and tartrate-resistant acid phosphatase 5b (TRAP5b) provided the best performance for diagnosing low BMD in hemodialysis patients. CONCLUSIONS Switching from CPB to NCPB might increase bone biomarkers and prevent the development of adynamic bone disease. On the contrary, NCPB should be cautiously used in hemodialysis patients who already had low BMD. P1NP, BALP, and TRAP5b could be used to guide the appropriate management, including anti-resorptive and anabolic medications, and predict low BMD in hemodialysis patients treated with phosphate binders. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Suwasin Udomkarnjananun
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Jeerath Phannajit
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,Research Unit for Metabolic Bone Disease in CKD Patients, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kullaya Takkavatakarn
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Monravee Tumkosit
- Department of Radiology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Kanaungnit Kingpetch
- Division of Nuclear Medicine, Department of Radiology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Yingyos Avihingsanon
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Kearkiat Praditpornsilpa
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Somchai Eiam-Ong
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Paweena Susantitaphong
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,Research Unit for Metabolic Bone Disease in CKD Patients, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Hashimoto H, Shikuma S, Mandai S, Adachi S, Uchida S. Calcium-based phosphate binder use is associated with lower risk of osteoporosis in hemodialysis patients. Sci Rep 2021; 11:1648. [PMID: 33462371 PMCID: PMC7814124 DOI: 10.1038/s41598-021-81287-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 01/04/2021] [Indexed: 01/29/2023] Open
Abstract
Loss of bone mineral density (BMD) is a substantial risk of mortality in addition to fracture in hemodialysis patients. However, the factors affecting BMD are not fully determined. We conducted a single-center, cross-sectional study on 321 maintenance hemodialysis patients who underwent evaluation of femoral neck BMD using dual-energy X-ray absorptiometry from August 1, 2018, to July 31, 2019. We examined factors associated with osteoporosis defined by T-score of ≤ - 2.5, using logistic regression models. Median age of patients was 66 years, and 131 patients (41%) were diagnosed with osteoporosis. Older age, female, lower body mass index, diabetes mellitus, and higher Kt/V ratios were associated with higher osteoporosis risk. The only medication associated with lower osteoporosis risk was calcium-based phosphate binders (CBPBs) [odds ratio (OR), 0.41; 95% confidence interval (CI), 0.21-0.81]. In particular, CBPB reduced the osteoporosis risk within subgroups with dialysis vintage of ≥ 10 years, albumin level of < 3.5 mg/dL, active vitamin D analog use, and no proton pump inhibitor (PPI) use. In conclusion, CBPB use was associated with lower osteoporosis risk in hemodialysis patients. This effect might be partially attributable to calcium supplementation, given its higher impact in users of active vitamin D analogs or non-users of PPI, which modulate calcium absorption.
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Affiliation(s)
- Hiroko Hashimoto
- Department of Nephrology, Shuuwa General Hospital, 1200 Yaharashinden, Kasukabe, Saitama 344-0035 Japan
| | - Satomi Shikuma
- Department of Nephrology, Shuuwa General Hospital, 1200 Yaharashinden, Kasukabe, Saitama 344-0035 Japan
| | - Shintaro Mandai
- grid.265073.50000 0001 1014 9130Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo, Tokyo 113-8519 Japan
| | - Susumu Adachi
- Department of Cardiology, Shuuwa General Hospital, 1200 Yaharashinden, Kasukabe, Saitama 344-0035 Japan
| | - Shinichi Uchida
- grid.265073.50000 0001 1014 9130Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo, Tokyo 113-8519 Japan
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7
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Katkov A, Sinuani I, Azar A, Shapiro G, Efrati S, Beberashvili I. Age modifies the association between serum obestatin, appetite and nutritional status in maintenance hemodialysis patients. Eur J Clin Nutr 2018; 72:1007-1018. [PMID: 29362457 DOI: 10.1038/s41430-018-0087-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 12/20/2017] [Accepted: 12/27/2017] [Indexed: 01/10/2023]
Abstract
BACKGROUND/OBJECTIVES Increased age is strongly associated with anorexia and protein-energy wasting (PEW) in maintenance hemodialysis (MHD) population. We hypothesized that the association of obestatin, a recently discovered anorexigenic gut hormone, with appetite and nutritional status differs by age groups. SUBJECTS/METHODS We performed a cross-sectional study on 261MHD patients. Obestatin, acyl-ghrelin, markers of inflammation (CRP, IL-6, TNF-α) and nutrition (self-reported appetite, dietary intake, biochemical nutritional parameters, and body composition) were measured. RESULTS Obestatin was associated with appetite in multivariate analyses even after controlling for such confounders as lean body mass (LBM), IL-6 and acyl-ghrelin in patients younger than 71 years. For each ng/ml increase in obestatin levels, the odds for diminished appetite was 0.75 (95% CI: 0.59-0.96). However, these associations were not observed in patients 71 years and older. Multivariable logistic regression models (including appetite) also showed increasing odds for PEW (defined by ESPEN consensus-based criteria for the diagnosis of malnutrition) across increasing serum obestatin levels (OR: 1.51, 95% CI: 1.05-2.18) in patients 71 years and older. However, after lean body mass (LBM) was added to this model, the association between obestatin and malnutrition was abolished (OR: 1.26, 95% CI: 0.83-1.91). CONCLUSIONS The association between serum obestatin, appetite and PEW differs depending on age in MHD patients. A positive link with appetite exists in patients younger than 71 years, whereas this relationship disappears by the age of 71. In older MHD patients, obestatin is associated with PEW through mechanisms related to LBM, but not to appetite.
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Affiliation(s)
- Anna Katkov
- Nephrology Division, Assaf Harofeh Medical Center, Zerifin, Affiliated to Sackler Faculty of Medicine Tel Aviv University, Tel Aviv, Israel
| | - Inna Sinuani
- Pathology Department, Assaf Harofeh Medical Center, Zerifin, Affiliated to Sackler Faculty of Medicine Tel Aviv University, Tel Aviv, Israel
| | - Ada Azar
- Nutrition Department, Assaf Harofeh Medical Center, Zerifin, Affiliated to Sackler Faculty of Medicine Tel Aviv University, Tel Aviv, Israel
| | - Gregory Shapiro
- Nephrology Division, Assaf Harofeh Medical Center, Zerifin, Affiliated to Sackler Faculty of Medicine Tel Aviv University, Tel Aviv, Israel
| | - Shai Efrati
- Nephrology Division, Assaf Harofeh Medical Center, Zerifin, Affiliated to Sackler Faculty of Medicine Tel Aviv University, Tel Aviv, Israel
| | - Ilia Beberashvili
- Nephrology Division, Assaf Harofeh Medical Center, Zerifin, Affiliated to Sackler Faculty of Medicine Tel Aviv University, Tel Aviv, Israel.
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8
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Sabatino A, Regolisti G, Gandolfini I, Delsante M, Fani F, Gregorini MC, Fiaccadori E. Diet and enteral nutrition in patients with chronic kidney disease not on dialysis: a review focusing on fat, fiber and protein intake. J Nephrol 2017; 30:743-754. [PMID: 28884267 DOI: 10.1007/s40620-017-0435-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 08/24/2017] [Indexed: 02/07/2023]
Abstract
The clinical data available on dietary requirements of patients with chronic kidney disease (CKD) not on dialysis are limited and largely inconclusive in terms of the renal, cardiovascular and nutritional outcomes achievable through dietary modifications. Restriction of protein intake during the early stages of CKD may in fact slow its progression, but at the same time this approach may also lead to protein-energy wasting, if energy intake is not adequate and properly monitored. Unfortunately, compliance to dietary recommendations is traditionally low in this patient population. A switch from saturated to mono- and polyunsaturated fats is generally recognized as advantageous for cardiac health; however, the benefits in term of renal function are largely unknown. Similarly, the association between dietary fiber intake and kidney disease is largely unknown. In fact, while there is evidence on the positive health effects of dietary fibers in the general population, nutritional guidelines for CKD lack formal recommendations concerning fiber intake. This paper reviews data and evidence from clinical trials and meta-analyses on renal and cardiovascular outcomes related to modifications in protein, fat and fiber intake. Suggestions for maintaining nutritional status through patient-oriented dietary patterns and enteral supplementation in CKD patients on conservative therapy are also presented.
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Affiliation(s)
- Alice Sabatino
- Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43100, Parma, Italy
| | - Giuseppe Regolisti
- Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43100, Parma, Italy
| | - Ilaria Gandolfini
- Postgraduate School of Nephrology, University of Parma, Parma, Italy
| | - Marco Delsante
- Postgraduate School of Nephrology, University of Parma, Parma, Italy
| | - Filippo Fani
- Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43100, Parma, Italy
| | | | - Enrico Fiaccadori
- Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43100, Parma, Italy. .,Postgraduate School of Nephrology, University of Parma, Parma, Italy.
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9
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Metzger M, Yuan WL, Haymann JP, Flamant M, Houillier P, Thervet E, Boffa JJ, Vrtovsnik F, Froissart M, Bankir L, Fouque D, Stengel B. Association of a Low-Protein Diet With Slower Progression of CKD. Kidney Int Rep 2017; 3:105-114. [PMID: 29340320 PMCID: PMC5762958 DOI: 10.1016/j.ekir.2017.08.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 06/21/2017] [Accepted: 08/07/2017] [Indexed: 01/17/2023] Open
Abstract
Introduction Reducing protein intake is recommended for slowing chronic kidney disease (CKD) progression, but assessment of its true effectiveness is sparse. Methods Using the Maroni formula, we assessed dietary protein intake (DPI) from 24-hour urinary urea excretion in 1594 patients (67% men and 33% women) with CKD, 784 of whom also had 7-day food records. Cause-specific hazard ratios (HRs) and 95% confidence intervals for the competing risks of DPI-associated end-stage renal disease (ESRD) or death were estimated in 1412 patients with baseline glomerular filtration rate ≥15 ml/min per 1.73 m2, measured by 51Cr-EDTA renal clearance (mGFR). Results Overall, mean DPI estimated from urea excretion was 1.09 ± 0.30 g/kg of body weight per day (range = 0.34-2.76); 20% of patients had values > 1.3 g/kg per day, and 1.9% had values < 0.6 g/kg per day. Urea excretion and food records produced similar estimates of mean DPI. The lower the mGFR, the lower the mean DPI. Over a median follow-up of 5.6 years, there were 319 ESRD events and 189 pre-ESRD deaths. After adjusting for relevant covariates, each 0.1 g/kg daily higher baseline urea excretion-based DPI or food record-based DPI was associated with an HR for ESRD of 1.05 (95% confidence interval 1.01-1.10) or 1.09 (95% confidence interval 1.04-1.14), respectively. HRs were stronger in patients with baseline mGFR < 30 ml/min per 1.73 m2. There was no association with mortality. The mean age of the patients was 59 ± 15 years, and mean body mass index was 26.6 ± 5.2 kg/m2. Conclusion In this prospective observational study, the lower the baseline DPI, the slower the progression toward ESRD. Most importantly, the absence of threshold for the relation between DPI and ESRD risk indicates that there is no optimal DPI in the range observed in this cohort.
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Affiliation(s)
- Marie Metzger
- Centre de recherches en Epidémiologie et Santé des Populations, Inserm, University of Paris-Sud, University of Versailles Saint-Quentin, University of Paris-Saclay, Villejuif, France
| | - Wen Lun Yuan
- Centre des Sciences du Goût et de l’Alimentation, Centre National de la Recherche Scientifique, Institut National de la Recherche Agronomique, University of Bourgogne Franche-Comté, Dijon, France
- Centre de Recherche Épidémiologie et Statistique Sorbonne, Inserm, University of Paris-Descartes, Villejuif, France
| | - Jean-Philippe Haymann
- Assistance Publique-Hôpitaux de Paris, Hôpital Tenon, Paris, France
- Inserm Unité mixte de recherche scientifique, 1155, University Pierre et Marie-Curie, Paris, France
| | - Martin Flamant
- Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris, France
- Centre de Recherche sur l’Inflammation, Inserm, Université Paris-Diderot, Paris, France
| | - Pascal Houillier
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France
- Inserm Unité mixte de recherche scientifique, 1138, Centre de Recherche des Cordeliers, Paris, 75006, France
- University Paris Descartes, Paris, France
| | - Eric Thervet
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France
- Paris Centre de Recherche Cardiovasculaire, Inserm, University of Paris-Descartes, Paris, France
| | - Jean-Jacques Boffa
- Assistance Publique-Hôpitaux de Paris, Hôpital Tenon, Paris, France
- Inserm Unité mixte de recherche scientifique, 1155, University Pierre et Marie-Curie, Paris, France
| | - François Vrtovsnik
- Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris, France
- Centre de Recherche sur l’Inflammation, Inserm, Université Paris-Diderot, Paris, France
| | - Marc Froissart
- Centre de recherches en Epidémiologie et Santé des Populations, Inserm, University of Paris-Sud, University of Versailles Saint-Quentin, University of Paris-Saclay, Villejuif, France
- Centre hospitalier universitaire vaudois/University of Lausanne, Centre de Recherche Clinique, Lausanne, Switzerland
| | - Lise Bankir
- Inserm Unité mixte de recherche scientifique, 1138, Centre de Recherche des Cordeliers, Paris, 75006, France
| | - Denis Fouque
- Centre Hospitalier Lyon Sud, Pierre-Bénite, France
- Laboratoire Cardiovasculaire, Métabolisme, Diabétologie et Nutrition, Unité mixte de recherche scientifique, 1060, Inserm, University Lyon-Sud, Oullins, France
| | - Bénédicte Stengel
- Centre de recherches en Epidémiologie et Santé des Populations, Inserm, University of Paris-Sud, University of Versailles Saint-Quentin, University of Paris-Saclay, Villejuif, France
- Correspondence: Bénédicte Stengel, Inserm U1018, CESP, Team 5, 16, avenue P. Vaillant Couturier, F-94807, Villejuif, France.Inserm U1018CESPTeam 5, 16, avenue P. Vaillant Couturier, F-94807VillejuifFrance
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10
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Abstract
PURPOSE OF REVIEW The kidneys play a critical role in the balance between the internal milieu and external environment. Kidney failure is known to disrupt a number of homeostatic mechanisms that control serum calcium and normal bone metabolism. However, our understanding of calcium balance throughout the stages of chronic kidney disease is limited and the concept of balance itself, especially with a cation as complex as calcium, is often misunderstood. Both negative and positive calcium balance have important implications in patients with chronic kidney disease, where negative balance may increase risk of osteoporosis and fracture and positive balance may increase risk of vascular calcification and cardiovascular events. Here, we examine the state of current knowledge about calcium balance in adults throughout the stages of chronic kidney disease and discuss recommendations for clinical strategies to maintain balance as well as future research needs in this area. RECENT FINDINGS Recent calcium balance studies in adult patients with chronic kidney disease show that neutral calcium balance is achieved with calcium intake near the recommended daily allowance. Increases in calcium through diet or supplements cause high positive calcium balance, which may put patients at risk for vascular calcification. However, heterogeneity in calcium balance exists among these patients. Given the available calcium balance data in this population, it appears clinically prudent to aim for recommended calcium intakes around 1000 mg/day to achieve neutral calcium balance and avoid adverse effects of either negative or positive calcium balance. Assessment of patients' dietary calcium intake could further equip clinicians to make individualized recommendations for meeting recommended intakes.
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11
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Alipoor E, Hosseinzadeh-Attar MJ, Mahdavi-Mazdeh M, Yaseri M, Zahed NS. Comparison of malnutrition inflammation score, anthropometry and biochemical parameters in assessing the difference in protein-energy wasting between normal weight and obese patients undergoing haemodialysis. Nutr Diet 2017; 74:283-290. [PMID: 28731598 DOI: 10.1111/1747-0080.12343] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 11/05/2016] [Accepted: 01/05/2017] [Indexed: 12/23/2022]
Abstract
AIM Protein-energy wasting (PEW) is prevalent in haemodialysis. Obesity is an independent risk factor of kidney insufficiency, but it is proposed to have beneficial roles in better outcomes in the final stage of disease. Better nutritional status and body reserves are among probable mechanisms, but direct examinations are limited. The present study aimed to investigate whether obese patients have preferable nutritional status compared to normal weight patients based on malnutrition inflammation score (MIS) and other PEW parameters in haemodialysis. METHODS This case-control study investigated 52 normal weight (18.5 < body mass index (BMI) < 25 kg/m2 ) and 48 obese (BMI≥30 kg/m2 ) patients on regular haemodialysis. PEW was assessed based on anthropometric and biochemical factors, recent weight changes, appetite, anorexia, dietary intake and MIS. RESULTS Obese patients had better MIS compared with the normal weight group (P < 0.001), although varying degrees of wasting were prevalent among this group too (75% mild and 25% moderate wasting). The obese group had less significant weight loss (4.2 vs 8%) and anorexia and better appetite. However, a considerable percentage of patients in both groups showed muscle (94.6% of normal weight and 19.5% of obese) and peripheral fat tissue (89.2% of normal weight and 31.7% of obese) losses compared to the 50th percentile. Biochemical parameters were not significantly different between groups except for triglyceride (P = 0.001), transferrin and total iron-binding capacity (P = 0.028). CONCLUSIONS MIS was significantly better in obese patients; however, both groups showed degrees of wasting based on MIS and other PEW parameters. Nutritional status of obese haemodialysis patients should be monitored regularly because of high risk of PEW like other BMI categories.
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Affiliation(s)
- Elham Alipoor
- Department of Clinical Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Mitra Mahdavi-Mazdeh
- Iranian Tissue Bank & Research Centre, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehdi Yaseri
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Narges S Zahed
- Department of Nephrology, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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12
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Perez Vogt B, Costa Teixeira Caramori J. Are Nutritional Composed Scoring Systems and Protein-Energy Wasting Score Associated With Mortality in Maintenance Hemodialysis Patients? J Ren Nutr 2016; 26:183-9. [DOI: 10.1053/j.jrn.2015.11.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 09/20/2015] [Accepted: 11/05/2015] [Indexed: 12/20/2022] Open
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13
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Luis D, Zlatkis K, Comenge B, García Z, Navarro JF, Lorenzo V, Carrero JJ. Dietary Quality and Adherence to Dietary Recommendations in Patients Undergoing Hemodialysis. J Ren Nutr 2016; 26:190-5. [PMID: 26827131 DOI: 10.1053/j.jrn.2015.11.004] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 11/01/2015] [Accepted: 11/03/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The multiple dietary restrictions recommended to hemodialysis patients may be difficult to achieve and, at the same time, may result in nutritional deficiencies rendering a poor dietary quality. We here assess the dietary quality and adherence to renal-specific guideline recommendations among hemodialysis patients from a single center in Canary Islands, Spain. METHODS Cross-sectional study, including 91 patients undergoing maintenance hemodialysis. Clinical data and 3-day dietary records were collected. We compared patient's reported nutrients intake with guideline recommendations. We also evaluated their alignment with current American Heart Association dietary guidelines for cardiovascular prevention. RESULTS Seventy-seven percent and 50% of patients consumed less than the recommended daily energy and protein, respectively. Although half of the patients met the recommendations for dietary fat intake, this was accounted by an excess of saturated fat in 92% of them. Only 22% consumed sufficient fiber. A very small proportion of patients (less than 50%) met the requirements for vitamins and other micronutrients. Insufficient dietary intake was observed in most patients for all vitamins except for cobalamin. Similarly, inadequate dietary intake was observed for many minerals, by both excess (phosphorus, calcium, sodium, and potassium) and defect (magnesium). Most patients met the recommendations for iron and zinc in their diets. CONCLUSIONS A large proportion of hemodialysis patients at our center did not meet current renal-specific dietary recommendations. The quality of the diet was considered poor and proatherogenic according to American Heart Association guidelines.
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Affiliation(s)
- Desiree Luis
- Division of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Nephrology Service and Research Unit, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain.
| | - Karyn Zlatkis
- Patient Association "Enfermos Renales de Tenerife (ERTE)", Santa Cruz de Tenerife, Spain
| | - Beatriz Comenge
- Patient Association "Enfermos Renales de Tenerife (ERTE)", Santa Cruz de Tenerife, Spain
| | - Zoraida García
- Nephrology Service, Hospiten Tamaragua, Puerto de la Cruz, Santa Cruz de Tenerife, Spain
| | - Juan F Navarro
- Nephrology Service and Research Unit, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Victor Lorenzo
- Nephrology Service, Hospital Universitario de Canarias and Hospiten Tamaragua, Puerto de la Cruz, Spain
| | - Juan Jesús Carrero
- Division of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
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14
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Shapiro BB, Bross R, Morrison G, Kalantar-Zadeh K, Kopple JD. Self-Reported Interview-Assisted Diet Records Underreport Energy Intake in Maintenance Hemodialysis Patients. J Ren Nutr 2015; 25:357-63. [PMID: 25682334 PMCID: PMC4469525 DOI: 10.1053/j.jrn.2014.12.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2014] [Revised: 12/11/2014] [Accepted: 12/18/2014] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVES Studies suggest that maintenance hemodialysis (MHD) patients report dietary energy intakes (EIs) that are lower than what is actually ingested. Data supporting this conclusion have several important limitations. The present study introduces a novel approach of assessing underreporting of EI in MHD patients. DESIGN Comparisons of EI of free-living MHD patients determined from food records to their measured energy needs. SETTING Metabolic research ward. SUBJECTS Thirteen clinically stable MHD patients with unchanging weights whose EI was assessed by dietitian interview-assisted 3-day food records. INTERVENTION EI was compared with (1) patients' resting energy expenditure (REE), measured by indirect calorimetry, and estimated total energy expenditure (TEE) and (2) patients' dietary energy requirements (DER) measured while patients underwent nitrogen balance studies and consumed a constant energy diet in a research ward for a mean duration of 89.5 days. DER was calculated as the actual EI during the research study corrected for changes in body fat and lean body mass measured by Dual X-Ray Absorptiometry. MAIN OUTCOME MEASURE Underreporting of EI was determined by an EI:REE ratio <1.27 and an EI:TEE ratio or EI:DEE ratio <1.0. RESULTS Seven of the 13 MHD patients studied were male. Patient's ages were 47.7 ± standard deviation 9.7 years; body mass index averaged 25.4 ± 2.8 kg/m2, and dialysis vintage was 53.3 ± 37.1 months. The EI:REE ratio (1.03 ± 0.23) was significantly less than the cutoff value for underreporting of 1.27 (P = .001); 12 of 13 patients had EI:REE ratios <1.27. The mean EI:TEE ratio was significantly less than the cutoff value of 1.0 (0.73 ± 0.17, P < .0001), and 12 MHD patients had EI:TEE ratios <1.0. The EI:DER ratio was also <1.0 (0.83 ± 0.25, P = .012), and 10 MHD had EI:DER ratios <1.0. CONCLUSIONS Dietitian interview-assisted diet records by MHD patients substantially underestimate the patient's dietary EI.
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Affiliation(s)
- Bryan B Shapiro
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California; Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California
| | - Rachelle Bross
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California; UCLA Clinical and Translational Science Institute, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California
| | - Gillian Morrison
- UCLA Clinical and Translational Science Institute, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California; UCLA Fielding School of Public Health, Los Angeles, California; Division of Nephrology and Hypertension, University of California at Irvine, Orange, California
| | - Joel D Kopple
- Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California; UCLA Fielding School of Public Health, Los Angeles, California; David Geffen School of Medicine at UCLA, Los Angeles, California.
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15
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Archer E, Blair SN. Implausible data, false memories, and the status quo in dietary assessment. Adv Nutr 2015; 6:229-30. [PMID: 25770263 PMCID: PMC4352183 DOI: 10.3945/an.114.007799] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Edward Archer
- From the Office of Energetics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL (EA, e-mail: ); and the Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC (SNB)
| | - Steven N Blair
- From the Office of Energetics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL (EA, e-mail: ); and the Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC (SNB)
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16
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Abstract
Objective:To evaluate the intake of energy and nutrients by individuals on hemodialysis, following especific recommendations for this population and according to Food Guide for the Brazilian Population.Methods: A cross-sectional study, 118 adult patients, considered stable from, ten dialysis centers in Goiânia, Goiás. Dietary intake was estimated by six 24-hour recalls, and classified as adequate or inadequate, according to specific recommendations for individuals undergoing dialysis and that recommended for a healthy diet. A descriptive analysis was performed.Results: Average dietary intake of 2022.40 ± 283.70 kcal/day; 31.18 kcal/kg/day; 55.03 ± 4.20% carbohydrate; 30.23 ± 3.71% lipid, 1.18 ± 0.23 g protein/kg/day. Important prevalences of inadequacy were observed for the intake of calories (39.0%), protein (39.0%) and other nutrients such as retinol (94.9%), saturated fat (87.3%), cholesterol (61,9%), iron (61.0%), potassium (60.2%) and zinc (45.0%). Patients had a low intake of fruit food group (1.22 ± 0.89 servings) and vegetables (1.76 ± 1.01 servings), dairy products (0.57 ± 0.43 servings) and high intake of food group of oils and fats (3.45 ± 0.95 servings), sugars and sweets (1.55 ± 0.77 servings).Conclusion: Observed food consumption imbalance, characterized by excess of oils and fats, especially saturated oils and cholesterol, sugars and sweets, parallel to low intake of fruits and vegetables and dairy products. A considerable percentage of patients did not intake the minimum recommended of calories, protein, retinol, iron, zinc and potassium.
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Chan M, Kelly J, Batterham M, Tapsell L. A High Prevalence of Abnormal Nutrition Parameters Found in Predialysis End-Stage Kidney Disease: Is It a Result of Uremia or Poor Eating Habits? J Ren Nutr 2014; 24:292-302. [DOI: 10.1053/j.jrn.2014.03.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2013] [Revised: 03/20/2014] [Accepted: 03/27/2014] [Indexed: 01/04/2023] Open
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18
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Palmer SC, Navaneethan SD, Craig JC, Johnson DW, Perkovic V, Hegbrant J, Strippoli GFM. HMG CoA reductase inhibitors (statins) for people with chronic kidney disease not requiring dialysis. Cochrane Database Syst Rev 2014:CD007784. [PMID: 24880031 DOI: 10.1002/14651858.cd007784.pub2] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Cardiovascular disease (CVD) is the most frequent cause of death in people with early stages of chronic kidney disease (CKD), for whom the absolute risk of cardiovascular events is similar to people who have existing coronary artery disease. This is an update of a review published in 2009, and includes evidence from 27 new studies (25,068 participants) in addition to the 26 studies (20,324 participants) assessed previously; and excludes three previously included studies (107 participants). This updated review includes 50 studies (45,285 participants); of these 38 (37,274 participants) were meta-analysed. OBJECTIVES To evaluate the benefits (such as reductions in all-cause and cardiovascular mortality, major cardiovascular events, MI and stroke; and slow progression of CKD to end-stage kidney disease (ESKD)) and harms (muscle and liver dysfunction, withdrawal, and cancer) of statins compared with placebo, no treatment, standard care or another statin in adults with CKD who were not on dialysis. SEARCH METHODS We searched the Cochrane Renal Group's Specialised Register to 5 June 2012 through contact with the Trials' Search Co-ordinator using search terms relevant to this review. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs that compared the effects of statins with placebo, no treatment, standard care, or other statins, on mortality, cardiovascular events, kidney function, toxicity, and lipid levels in adults with CKD not on dialysis were the focus of our literature searches. DATA COLLECTION AND ANALYSIS Two or more authors independently extracted data and assessed study risk of bias. Treatment effects were expressed as mean difference (MD) for continuous outcomes (lipids, creatinine clearance and proteinuria) and risk ratio (RR) for dichotomous outcomes (major cardiovascular events, all-cause mortality, cardiovascular mortality, fatal or non-fatal myocardial infarction (MI), fatal or non-fatal stroke, ESKD, elevated liver enzymes, rhabdomyolysis, cancer and withdrawal rates) with 95% confidence intervals (CI). MAIN RESULTS We included 50 studies (45,285 participants): 47 studies (39,820 participants) compared statins with placebo or no treatment and three studies (5547 participants) compared two different statin regimens in adults with CKD who were not yet on dialysis. We were able to meta-analyse 38 studies (37,274 participants).The risk of bias in the included studies was high. Seven studies comparing statins with placebo or no treatment had lower risk of bias overall; and were conducted according to published protocols, outcomes were adjudicated by a committee, specified outcomes were reported, and analyses were conducted using intention-to-treat methods. In placebo or no treatment controlled studies, adverse events were reported in 32 studies (68%) and systematically evaluated in 16 studies (34%).Compared with placebo, statin therapy consistently prevented major cardiovascular events (13 studies, 36,033 participants; RR 0.72, 95% CI 0.66 to 0.79), all-cause mortality (10 studies, 28,276 participants; RR 0.79, 95% CI 0.69 to 0.91), cardiovascular death (7 studies, 19,059 participants; RR 0.77, 95% CI 0.69 to 0.87) and MI (8 studies, 9018 participants; RR 0.55, 95% CI 0.42 to 0.72). Statins had uncertain effects on stroke (5 studies, 8658 participants; RR 0.62, 95% CI 0.35 to 1.12).Potential harms from statin therapy were limited by lack of systematic reporting and were uncertain in analyses that had few events: elevated creatine kinase (7 studies, 4514 participants; RR 0.84, 95% CI 0.20 to 3.48), liver function abnormalities (7 studies, RR 0.76, 95% CI 0.39 to 1.50), withdrawal due to adverse events (13 studies, 4219 participants; RR 1.16, 95% CI 0.84 to 1.60), and cancer (2 studies, 5581 participants; RR 1.03, 95% CI 0.82 to 130).Statins had uncertain effects on progression of CKD. Data for relative effects of intensive cholesterol lowering in people with early stages of kidney disease were sparse. Statins clearly reduced risks of death, major cardiovascular events, and MI in people with CKD who did not have CVD at baseline (primary prevention). AUTHORS' CONCLUSIONS Statins consistently lower death and major cardiovascular events by 20% in people with CKD not requiring dialysis. Statin-related effects on stroke and kidney function were found to be uncertain and adverse effects of treatment are incompletely understood. Statins have an important role in primary prevention of cardiovascular events and mortality in people who have CKD.
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Affiliation(s)
- Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, 2 Riccarton Ave, PO Box 4345, Christchurch, New Zealand, 8140
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Fassett RG, Geraghty DP, Coombes JS. The impact of pre-intervention rate of kidney function change on the assessment of CKD progression. J Nephrol 2014; 27:515-9. [PMID: 24504906 DOI: 10.1007/s40620-014-0058-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 11/25/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND Without a run-in phase, chronic kidney disease (CKD) patients enrolled in clinical trials may not be identified as having progressive disease. The aim of this analysis was to quantify the effects of a run-in phase on kidney function outcome in CKD patients enrolled in the Lipid Lowering and Onset of Renal Disease (LORD) trial. METHODS The LORD trial assessed the effects of atorvastatin on the rate of change in the estimated glomerular filtration rate (eGFR) and included patients with serum creatinine 120 μmol/l. In this post hoc analysis, we assessed eGFR change during the 12-month period prior to enrolment, the 3-month run-in phase and the first 12-month period of the trial. Eighty of the original 132 patients (where retrospective data were available) were included. The rate of eGFR change during each period was compared. RESULTS Overall kidney function decreased during the 12 months prior to enrolment by (mean, SD) 0.39 ± 0.98 ml/min/1.73 m(2)/month, improved during the 3-month run-in phase by 0.48 ± 2.90 ml/min/1.73 m(2)/month and decreased during the first 12 months of the trial by 0.15 ± 0.57 ml/min/1.73 m(2)/month. However, only 39 % of patients had declining eGFR during the 12 months prior, 19 % in the 3-month run-in and 42 % during the first 12-month study phase. CONCLUSION Most patients (>60 %) entering this clinical trial had stable or improving kidney function. Enrolment was associated with further improved kidney function, which may have been due to 'regression to the mean' or to the Hawthorne effect. Investigators should include a run-in period to establish the presence of eGFR decline to use as an inclusion criterion in clinical trials assessing this measure of CKD progression.
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Moore LW, Byham-Gray LD, Scott Parrott J, Rigassio-Radler D, Mandayam S, Jones SL, Mitch WE, Osama Gaber A. The mean dietary protein intake at different stages of chronic kidney disease is higher than current guidelines. Kidney Int 2013; 83:724-32. [PMID: 23302719 DOI: 10.1038/ki.2012.420] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The actual dietary protein intake of adults without and with different stages of chronic kidney disease is not known. To evaluate this we performed cross-sectional analyses of 16,872 adults (20 years of age and older) participating in the National Health and Nutrition Examination Survey 2001-2008 who completed a dietary interview by stage of kidney disease. Dietary protein intake was assessed from 24-h recall systematically collected using the Automated Multiple Pass Method. Complex survey analyses were used to derive population estimates of dietary protein intake at each stage of chronic kidney disease. Using dietary protein intake of adults without chronic kidney disease as the comparator, and after adjusting for age, the mean dietary protein intake was 1.30 g/kg ideal body weight/day (g/kgIBW/d) and was not different from stage 1 or stage 2 (1.28 and 1.25 g/kgIBW/d, respectively), but was significantly different in stage 3 and stage 4 (1.22 and 1.13 g/kgIBW/d, respectively). These mean values appear to be above the Institute of Medicine requirements for healthy adults and the NKF-KDOQI guidelines for stages 3 and 4 chronic kidney disease. Thus, the mean dietary protein intake is higher than current guidelines, even after adjusting for age.
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Affiliation(s)
- Linda W Moore
- Department of Surgery, The Methodist Hospital, Houston, Texas, USA.
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21
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Bovio G, Montagna G, Brazzo S, Piazza V, Segagni S, Cena H. Energy balance in haemodialysis and peritoneal dialysis patients assessed by a 7-day weighed food diary and a portable armband device. J Hum Nutr Diet 2012. [DOI: 10.1111/j.1365-277x.2012.01291.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- G. Bovio
- Metabolic-Nutritional Unit and Palliative Care Unit; Salvatore Maugeri Foundation, IRCCS Rehabilitation Institute of Pavia; Pavia; Italy
| | - G. Montagna
- Division of Nephrology and Hemodialysis; Salvatore Maugeri Foundation; IRCCS Rehabilitation Institute of Pavia; Pavia; Italy
| | - S. Brazzo
- Ambulatory of Clinical Nutrition and Dietetics; Division of General Medicine; Salvatore Maugeri Foundation; IRCCS Rehabilitation Institute of Pavia; Pavia; Italy
| | - V. Piazza
- Division of Nephrology and Hemodialysis; Salvatore Maugeri Foundation; IRCCS Rehabilitation Institute of Pavia; Pavia; Italy
| | - S. Segagni
- Division of Nephrology and Hemodialysis; Salvatore Maugeri Foundation; IRCCS Rehabilitation Institute of Pavia; Pavia; Italy
| | - H. Cena
- Department of Applied Health Sciences; Section of Human Nutrition and Dietetics; Faculty of Medicine; University of Pavia; Pavia; Italy
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Mafra D, Moraes C, Leal VO, Farage NE, Stockler-Pinto MB, Fouque D. Underreporting of energy intake in maintenance hemodialysis patients: a cross-sectional study. J Ren Nutr 2012; 22:578-83. [PMID: 22227181 DOI: 10.1053/j.jrn.2011.10.037] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Revised: 09/29/2011] [Accepted: 10/09/2011] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE To analyze the reported energy intake (EI(rep)) in hemodialysis (HD) patients by total energy expenditure (TEE) measured by a dedicated device. DESIGN Cross-sectional study. SETTING RenalCor and RenalVida Clinics (Rio de Janeiro, Brazil). PATIENTS AND OTHERS PARTICIPANTS Forty-eight HD patients (51.4 ± 12.2 years, 62% men, body mass index [BMI], 23.8 ± 4.5 kg/m(2)) were studied. MAIN OUTCOME MEASURE EI(rep) was evaluated using a 3-day food record. TEE was measured over a 2-day period by SWA (SenseWear Pro2 Armband, BodyMedia Inc., Pittsburgh, PA). Subjects were identified as underreporters (URs), acceptable reporters (ARs), or overreporters (ORs) from their EI(rep)/TEE ratio. ARs were defined as having the EI(rep)/TEE ratio in the range of 0.76 to 1.24, URs as EI(rep)/TEE <0.76, ORs as EI(rep)/TEE >1.24 according to Goldberg index. RESULTS The mean TEE and EI(rep) were 34.7 ± 9.4 kcal/kg/day and 22.8 ± 10.6 kcal/kg/day, respectively, and 37.5% of patients presented overweight or obesity. Thirty-one patients (65%) were identified as URs, and the mean of Goldberg index was 0.54 ± 0.12 (0.23 to 0.75), versus 0.95 ± 0.12 (0.79 to 1.2) for ARs. There were no ORs among the patients studied. There were negative correlations between Goldberg index and BMI (r = -0.35, P < .01) and % body fat (r = -0.4, P < .01) and between EI(rep) and BMI (r = -0.58, P < .001). CONCLUSION These results confirm a high prevalence of underreporting of EI in HD patients, particularly in patients with high BMI.
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Affiliation(s)
- Denise Mafra
- Medical Sciences Post-Graduate Program, Federal University Fluminense, Niterói, Brazil.
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Abstract
The kidneys are famously responsible for maintaining external balance of prevalent minerals, such as sodium, chloride, and potassium. The kidney's role in handling trace minerals is more obscure to most nephrologists. Similarly, the impact of kidney failure on trace mineral metabolism is difficult to anticipate. The associated dietary modifications and dialysis create the potential for trace mineral deficiencies and intoxications. Indeed, there are numerous reports of dialysis-associated mishaps causing mineral intoxication, notable for the challenge of assigning causation. Equally challenging has been the recognition of mineral deficiency syndromes, amid what is often a cacophony of multiple comorbidities that vie for the attention of clinicians who care for patients with chronic kidney disease. In this paper, I review a variety of minerals, some of which are required for maintenance of normal human physiology (the U.S. Food and Drug Administration's list of essential minerals), and some that have attracted attention in the care of dialysis patients. For each mineral, I will discuss its role in normal physiology and will review reported deficiency and toxicity states. I will point out the interesting inter-relationships between several of the elements. Finally, I will address the special concerns of aluminum and magnesium as they pertain to the dialysis population.
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Affiliation(s)
- Richard K Kasama
- Division of Nephrology, UMDNJ-Robert Wood Johnson Medical School, Cooper University Hospital, Camden, New Jersey 08103 , USA.
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Cuppari L, Ikizler TA. Energy balance in advanced chronic kidney disease and end-stage renal disease. Semin Dial 2010; 23:373-7. [PMID: 20701716 DOI: 10.1111/j.1525-139x.2010.00744.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Energy intake, resting energy expenditure, and energy expended for physical activity (EEPA) are components of energy balance that may be disrupted by a number of disorders and clinical conditions commonly present in advanced chronic kidney disease (CKD) and end-stage renal disease (ESRD). Energy intake of patients with CKD has been consistently lower than the recommended intake in multiple reports. On the other hand, while reduced energy intake due to anorexia may be applicable for ESRD patients with overt protein-energy wasting, it is potentially unrealistic for overweight or obese subjects who are able to maintain their body weight. Studies on resting energy expenditure have provided mixed results, most likely as a consequence of differences in the population characteristics, clinical conditions, and stage of the disease. Finally, although there is lack of specific studies on EEPA, there is evidence that ESRD patients, particularly those undergoing hemodialysis are in general less active than sedentary healthy individuals. These observations may raise questions regarding the accuracy of dietary reports and the uncertainties related to the energy requirements, optimal dietary energy intake, and recommendations for physical activity in these patients.
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Affiliation(s)
- Lillian Cuppari
- Division of Nephrology, Federal University of São Paulo, Sao Paulo, SP, Brazil.
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Bazanelli AP, Kamimura MA, Vasselai P, Draibe SA, Cuppari L. Underreporting of Energy Intake in Peritoneal Dialysis Patients. J Ren Nutr 2010; 20:263-9. [DOI: 10.1053/j.jrn.2009.08.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2009] [Indexed: 11/11/2022] Open
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Noori N, Kovesdy CP, Murali S, Benner D, Bross R, Block G, Kopple JD, Kalantar-Zadeh K. Dietary assessment of individuals with chronic kidney disease. Semin Dial 2010; 23:359-64. [PMID: 20673254 PMCID: PMC3175367 DOI: 10.1111/j.1525-139x.2010.00743.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Examining the quality and quantity of food intake by appropriate methods is critical in the management of patients with chronic kidney disease (CKD). The four commonly used dietary assessment methods in CKD patients include short-term dietary recalls, several days of food records with or without dietary interviews, urea kinetic based estimates such as protein nitrogen appearance calculation, and food histories including food screeners and food frequency questionnaires (FFQ). There are a number of strengths and limitations of these dietary assessment methods. Accordingly, none of the four methods is suitable in and of itself to give sufficiently accurate dietary information for all purposes. Food frequency questionnaires, which is the preferred method for epidemiological studies, should be used for dietary comparisons of patients within a given population rather than individual assessment. Food histories including FFQ and dietary recalls may underestimate important nutrients, especially in CKD patients. Given the large and increasing number of dialysis patients and work responsibilities of renal dietitians, routine analysis of dietary records and recalls is becoming less feasible. Ongoing and future studies will ascertain additional strengths and limitations of dietary assessment methods in CKD populations including the assessment of food intake during an actual hemodialysis treatment.
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Affiliation(s)
- Nazanin Noori
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California
| | - Csaba P Kovesdy
- Division of Nephrology, Salem Veterans Affairs Medical Center, Salem Virginia
- Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Sameer Murali
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California
| | | | - Rachelle Bross
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California
| | - Gladys Block
- NutritionQuest, Berkeley, California
- Department of Public Health Nutrition, University of California, Berkeley, California
| | - Joel D Kopple
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California
- David Geffen School of Medicine at UCLA, Los Angeles, California
- Departments of Epidemiology or Community Health Sciences , UCLA School of Public Health, Los Angeles, California
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27
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Zabel R, Ash S, King N, Bauer J. The relationship between subjective appetite sensations, markers of inflammation and appetite in dialysis patients. J Hum Nutr Diet 2009; 22:343-50. [DOI: 10.1111/j.1365-277x.2009.00968.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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28
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FASSETT ROBERTG, ROBERTSON IAINK, GERAGHTY DOMINICP, BALL MADELEINEJ, BURTON NICOLAW, COOMBES JEFFS. Physical Activity Levels in Patients with Chronic Kidney Disease Entering the LORD Trial. Med Sci Sports Exerc 2009; 41:985-91. [DOI: 10.1249/mss.0b013e3181940aef] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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