Effects of Renal-specific Oral Supplementation in Malnourished Hemodialysis Patients

Effect of a personalized nutritional intervention program on nutritional status, quality of life and mortality in hemodialysis patients

Introduction

Objective: dietary advice provided through a nutritional intervention program (NIP) is recommended by renal clinic guidelines to prevent or treat malnutrition, that could improve quality of life (QoL) and survival in hemodialysis (HD) patients. This study set out to evaluate the effect of a personalized NIP on the nutritional status and its impact on QoL and mortality in dialyzed patients. Material and methods: this was a 12-month intervention study with regular follow-up in which nutritional parameters were measured at baseline and after 6 and 12 months. QoL was assessed by the Kidney Disease Quality of Life version 1.2 (KDQOL-SF) at baseline and at the end of the study. All dialyzed patients received individualized consultations with a trained dietitian. The content of the nutritional education program included a personalized meal plan and educational materials addressing nutrition to manage fluids, electrolytes, and vitamin D. Results: a total of 75 patients were included. After the NIP, visceral proteins, phosphorous, potassium and vitamin D levels had improved significantly (p < 0.001). The percentage of well-nourished patients increased by 30 % (p < 0.001). At the end of the study, the well-nourished patients had significantly improved scores on the general summary areas of the KDQOL-SF, reduced worry concerning fluid and dietary restrictions (p < 0.001), and the survival rate was 12 months longer (p < 0.01). Conclusion: the results of this study suggest that personalized NIP contributed to improved nutritional status, QoL and survival in HD 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.

Nutritional status improvement in elderly CKD patients: a systematic review

PURPOSE

Almost all CKD patients have a poor nutritional status, while elderly CKD patients are specifically frail and malnourished. Our aim is to conduct a systematic review of the up to date primary studies that look at methods of improving nutritional status in CKD patients in the elderly demographic.

METHODS

A focussed and sensitive search strategy was applied to the PUBMED database to identify relevant English language articles. Once articles were identified a detailed quality and bias assessment was performed. Two independent researchers (MZ and SM) then subsequently carried out detailed data extraction and analysis and this was subsequently verified by a third researcher (IN).

RESULTS

A total of 19 studies were included in our systematic review which included 7 non-randomised control trials and 15 randomised controlled trials. The outcomes that we considered to be most relevant for our subject title were: mortality data, SGA, albumin, total protein, isoleucine, leucine, prealbumin, transferrin, leptin, valine, TAG, HDL, LDL and total amino acids. Detailed bias analysis of the different studies was also conducted.

CONCLUSION

This is the first systematic review of the literature, so far, on the subject, involving elderly CKD patients. The quality of trials is low, very heterogenic in patients, methods and outcomes. However, we found a positive effect of dietary interventions on the nutritional status of most patients studied, highlighted by improvement in serum albumin and SGA, the most measured outcomes.

The effect of protein-enriched snacks on serum albumin concentration in non-selected haemodialysis patients

OBJECTIVE

Serum albumin level is not only one of the protein-energy wasting criteria but also a powerful marker of mortality in patients on haemodialysis (HD) treatment. The study aimed to assess the effect of a protein-enriched snack given during HD treatment on serum albumin level.

DESIGN AND METHODS

This prospective, single-centre, observational, non-randomized 16-month study was sub-divided into four 4-month periods. Patients on hemodialysis for more than three months and receiving a regular standard snack (8.8 g of protein) during the HD session were included and assigned during four four-month periods to receive either the standard snack or a protein-enriched snack (28.7 g). Patients were not selected based on nutritional criteria.

RESULTS

Sixty-six patients completed the study. Serum albumin levels significantly increased, from 3.43 ± 0.28 g/dl in the first period (standard snack) to 3.62 ± 0.32 g/dl (p < 0.0001) in the second period (enriched snack). In the third period (standard snack), albumin levels remained stable (3.61 ± 0.35 g/dl). After the fourth period (enriched snack), serum albumin levels further increased significantly (3.69 ± 0.30 g/dl; p = 0.05 and p = 0.007, respectively). Weight and normalized protein nitrogen appearance remained stable during the 16-month study period.

CONCLUSIONS

This study suggests that the intake of a protein-enriched snack during HD treatment, independently from baseline serum albumin level, could significantly increase their serum albumin levels. Serum albumin level is a powerful predictor of mortality; therefore, this simple and effective action could be of real interest to improve patients' outcomes.

Effect of the omega-3 fatty acid plus vitamin E supplementation on subjective global assessment score, glucose metabolism, and lipid concentrations in chronic hemodialysis patients

SCOPE

This study was conducted to determine the effects of omega-3 fatty acid plus vitamin E supplementation on subjective global assessment (SGA) score and metabolic profiles in chronic hemodialysis (HD) patients.

METHODS AND RESULTS

This randomized double-blind placebo-controlled clinical trial was conducted among 120 chronic HD patients. Participants were randomly divided into four groups to receive: (i) 1250 mg/day omega-3 fatty acid containing 600 mg eicosapentaenoic acid and 300 mg docosahexaenoic acid + vitamin E placebo (n = 30), (ii) 400 IU/day vitamin E + omega-3 fatty acids placebo (n = 30), (iii) 1250 mg omega-3 fatty acids/day + 400 IU/day vitamin E (n = 30), and (iv) omega-3 fatty acids placebo + vitamin E placebo (n = 30) for 12 wk. Fasting blood samples were taken at baseline and after 12-wk intervention to measure metabolic profiles. Patients who received combined omega-3 fatty acids and vitamin E supplements compared with vitamin E, omega-3 fatty acids, and placebo had significantly decreased SGA score (p < 0.001), fasting plasma glucose (p = 0.01), serum insulin levels (p = 0.001), homeostasis model of assessment insulin resistance (p = 0.002), and improved quantitative insulin sensitivity check index (p = 0.006).

CONCLUSION

Omega-3 fatty acids plus vitamin E supplementation for 12 wk among HD patients had beneficial effects on SGA score and metabolic profiles.

Muscle performance, size, and safety responses after eight weeks of resistance training and protein supplementation: a randomized, double-blinded, placebo-controlled clinical trial

The purpose of this study was to examine the effects of 2 different types of protein supplementation on thigh muscle cross-sectional area (CSA), blood markers, muscular strength, endurance, and body composition after 8 weeks of low- or moderate-volume resistance training in healthy, recreationally trained, college-aged men. One hundred and six men were randomized into 5 groups: low-volume resistance training with bioenhanced whey protein (BWPLV; n = 22), moderate-volume resistance training with BWP (BWPMV; n = 20), moderate-volume resistance training with standard whey protein (SWPMV; n = 22), moderate-volume resistance training with a placebo (PLA; n = 21), or moderate-volume resistance training with no supplementation (CON; n = 21). Except for CON, all groups consumed 1 shake before and after each exercise session and one each on the nontraining day. The BWPLV, BWPMV, and SWPMV groups received approximately 20 g of whey protein per shake, whereas the BWP groups received 5 g of additional polyethylene glycosylated (PEG) leucine. Resistance training sessions were performed 3 times per week for 8 weeks. There were no interactions (p > 0.05) for muscle strength and endurance variables, body composition, muscle CSA, and safety blood markers, but the main effects for training were observed (p ≤ 0.05). However, the Albumin:Globulin ratio for SWPMV was lower (p = 0.037) than BWPLV and BWPMV. Relative protein intake (PROREL) indicated a significant interaction (p < 0.001) with no differences across groups at pre; however, BWPLV, BWPMV, and SWPMV had a greater intake than did PLA or CON at post (p < 0.001). This study indicated that 8 weeks of resistance training improved muscle performance and size similarly among groups regardless of supplementation.

Outcomes associated with intradialytic oral nutritional supplements in patients undergoing maintenance hemodialysis: a quality improvement report

BACKGROUND

Insufficient clinical data exist to determine whether provision of oral nutritional supplements during dialysis can improve survival in hypoalbuminemic maintenance hemodialysis patients.

STUDY DESIGN

Retrospective matched-cohort study.

SETTING & PARTICIPANTS

All oral nutritional supplement program-eligible in-center maintenance hemodialysis patients with albumin level ≤3.5 g/dL in quarter 4 of 2009 without oral nutritional supplements in the prior 90 days at Fresenius Medical Care, North America facilities.

QUALITY IMPROVEMENT PLAN

Monitored intradialytic oral nutritional supplements were provided to eligible maintenance hemodialysis patients upon physician order, to continue for a year or until serum albumin level was ≥4.0 g/dL.

OUTCOME

Mortality (including deaths and withdrawals), followed up until December 31, 2010.

MEASUREMENTS

Both an intention-to-treat (ITT) and an as-treated analysis was performed using a 1:1 geographic region and propensity score-matched study population (using case-mix, laboratory test, access type, 30-day prior hospitalization, and incident patient status) comparing patients treated with intradialytic oral nutritional supplements with usual-care patients. Cox models were constructed, unadjusted and adjusted for facility standardized mortality ratio and case-mix and laboratory variables.

RESULTS

The ITT and as-treated analyses both showed lower mortality in the oral nutritional supplement group. The conservative ITT models with 5,227 matched pairs had 40% of controls subsequently receiving oral nutritional supplements after January 1, 2010 (because many physicians delayed participation), with comparative death rates of 30.1% versus 30.4%. The corresponding as-treated (excluding crossovers) death rates for 4,289 matched pairs were 30.9% versus 37.3%. The unadjusted ITT mortality HR for oral nutritional supplement use was 0.95 (95% CI, 0.88-1.01), and the adjusted HR was 0.91 (95% CI, 0.85-0.98); the corresponding as-treated HRs were 0.71 (95% CI, 0.66-0.76) and 0.66 (95% CI, 0.61-0.71) before and after adjustment, respectively.

LIMITATIONS

Limited capture of oral nutritional supplement intake outside the facility and potential residual confounding from unmeasured variables, such as dietary intake.

CONCLUSIONS

Maintenance hemodialysis patients with albumin levels ≤3.5 g/dL who received monitored intradialytic oral nutritional supplements showed survival significantly better than similar matched patient controls, with the as-treated analysis highlighting the potentially large effect of this strategy in clinical practice.

Intensity of care and better outcomes among hemodialysis patients: a role for the Medical Director

The Medical Director is responsible for all levels of quality patient care in the facility as mandated by the 2008 revision of the Medicare Conditions for Coverage of dialysis facilities. He/she is the leader and primary individual tasked with ensuring that facility processes are in place to meet or exceed key quality goals or adopt new ones and prioritize them appropriately-all to drive improved facility performance, particularly the ultimate outcomes of morbidity and mortality rates. Management of vascular access, dialysis dose, mineral metabolism, acid-base balance, sodium and fluid management, anemia, among other aspects of care, have representative intermediate clinical outcomes that are often called "surrogate" or "process" measures-because they may reflect the quality of care delivery while impacting "primary" outcomes such as death and hospitalization. The proportion of dialysis patients within a dialysis facility meeting a selected group among these goals has become the standard "care process" metric since the 1990s. Evidence supports its use, in that graded improvements in the facility patients' primary outcomes have been documented as more patients in a facility achieved a greater number of these "process" goals. A caveat: these process measures do not represent overall quality by themselves because nonclinical processes also influence primary outcomes. Nevertheless, process improvement in meeting facility goals should be led by the Medical Director, particularly those with the strongest links to primary outcomes such as reduction of hemodialysis catheter exposure, forming the cornerstone of quality improvement efforts. Specific recommendations on how to effectively lead a care team to achieve these goals are discussed.