Oral Nutritional Supplement Prescription and Patient-Reported Symptom Burden Among Patients With Late-Stage Non-Dialysis Chronic Kidney Disease

Background

Malnutrition and protein-energy wasting (PEW) are nutritional complications of advanced chronic kidney disease (CKD) that contribute to morbidity, mortality, and decreased quality of life. No previous studies have assessed the effect of oral nutritional supplements (ONSs) on patient-reported symptom burden among patients with non-dialysis CKD (CKD-ND) who have or are at risk of malnutrition/PEW.

Objective

The objective of this study was (1) to quantify the associations between baseline nutritional parameters and patient-reported symptom scores for wellbeing, tiredness, nausea, and appetite and (2) to compare the change in symptom scores among patients prescribed ONS with patients who did not receive ONS in a propensity-score-matched analysis.

Design

This study conducted observational cohort analysis using provincial registry data.

Setting

This study was done in multidisciplinary CKD clinics in British Columbia.

Patients

Adult patients >18 years of age with CKD-ND entering multidisciplinary CKD clinics between January 1, 2010-July 31, 2019 who had at least 2 Edmonton Symptom Assessment System Revised: Renal (ESASr:Renal) assessments.

Measurements

The measurements include nutrition-related parameters such as body mass index (BMI), serum albumin, serum phosphate, serum bicarbonate, neutrophil-to-lymphocyte ratio (NLR), and ESASr:Renal scores (overall and subscores for wellbeing, tiredness, nausea, and appetite).

Methods

Multivariable linear regression was applied to assess associations between nutritional parameters and ESASr:Renal scores. Propensity-score matching using the greedy method was used to match patients prescribed ONS with those not prescribed ONS using multiple demographic, comorbidity, health care utilization, and temporal factors. Linear regression was used to assess the association between first ONS prescription and change in ESASr:Renal overall score and subscores for wellbeing, tiredness, nausea, and appetite.

Results

Of total, 2076 patients were included. Higher baseline serum albumin was associated with lower overall ESASr:Renal score (-0.20, 95% confidence interval [CI] = -0.40 to -0.01 per 1 g/L increase in albumin), lower subscores for tiredness (-0.04, 95% CI = -0.07 to -0.01), nausea (-0.03, 95% CI = -0.04 to -0.01), and appetite (-0.03, 95% CI = -0.06 to -0.01). Higher BMI was associated with higher overall ESASr:Renal score (0.32, 95% CI = 0.16 to 0.48 per 1 kg/m2 increase in BMI), higher symptom subscores for wellbeing (0.02, 95% CI = 0.00 to 0.04) and tiredness (0.05, 95% CI = 0.02 to 0.07). Higher baseline NLR was associated with higher overall score (0.21, 95% CI = 0.03 to 0.39 per 1 unit increase in NLR), higher symptom subscores for wellbeing (0.03, 95% CI = 0.01 to 0.05) and nausea (0.03, 95% CI = 0.02 to 0.05). In the propensity-score-matched analysis, there were no statistically significant associations between ONS prescription and change in overall ESASr:Renal (beta coefficient for change in ESASr:Renal = 0.17, 95% CI = -2.64 to 2.99) or for subscores for appetite, tiredness, nausea, and wellbeing.

Limitations

Possible residual confounding. The ESASr:Renal assessments were obtained routinely only in patients with G5 CKD-ND and/or experiencing significant CKD-related symptoms.

Conclusions

This exploratory observational analysis of patients with advanced non-dialysis CKD demonstrated BMI, serum albumin, and NLR were modestly associated with patient-reported symptoms, but we did not observe an association between ONS use and change in ESASr:Renal scores.

The Impact of Combined Nutrition and Exercise Interventions in Patients with Chronic Kidney Disease

Combined nutrition and exercise interventions potentially improve protein-energy wasting/malnutrition-related outcomes in patients with chronic kidney disease (CKD). The aim was to systematically review the effect of combined interventions on nutritional status, muscle strength, physical performance and QoL. MEDLINE, Cochrane, Embase, Web of Science and Google Scholar were searched for studies up to the date of July 2023. Methodological quality was appraised with the Cochrane risk-of-bias tool. Ten randomized controlled trials (nine publications) were included (334 patients). No differences were observed in body mass index, lean body mass or leg strength. An improvement was found in the six-minute walk test (6-MWT) (n = 3, MD 27.2, 95%CI [7 to 48], p = 0.008), but not in the timed up-and-go test. No effect was found on QoL. A positive impact on 6-MWT was observed, but no improvements were detected in nutritional status, muscle strength or QoL. Concerns about reliability and generalizability arise due to limited statistical power and study heterogeneity of the studies included.

Effects of nutritional supplementation stabilizing muscle mass loss in older patients on hemodiafiltration

BACKGROUND & AIMS

Malnutrition is common in older individuals with end-stage renal disease on maintenance dialysis. Whether nutritional supplementation may improve skeletal muscle mass (SMM) and survival rate in this population is uncertain. We aimed to analyze the effect of a year of nutritional supplementation on muscle mass and survival rate in older patients on hemodiafiltration.

METHODS

In this observational study, older patients (≥65 years old) on maintenance hemodiafiltration were selected to receive nutritional counselling + nutritional supplementation (N = 85, Supp+) or nutritional counselling alone (N = 47, Supp-) and followed for 1 year. The outcomes were a change in SMM and sarcopenia diagnosis. The secondary outcome was 1-year mortality rate. Nutritional parameters included calf circumference, body mass index, anthropometric measurements, subjective global assessment, and handgrip strength (HGS). Data were evaluated using GLM for repeated measures with adjustment for covariates (age and diabetes).

RESULTS

Malnutrition was found in 50.8% of patients. At baseline, patients from the Supp+ group were older and had worse nutritional parameters including hand grip strength, calf circumference, anthropometric findings and sarcopenia (all p values < 0.05). During the follow-up, there was no significant change in sarcopenia (from 50.8% to 58.3%, p = 0.108), and there was a more pronounced decrease in the SMM index in the Supp-group (p = 0.049), with a significant intervention interaction (p = 0.030). Twenty deaths occurred, 7 (35%) in the Supp- and 13 (65%) in the Supp+ group (p = 0.540). SMM index (relative risk 0.90, p = 0.030) and age (relative risk 1.07, p = 0.046) were independently associated with higher mortality rates.

CONCLUSION

Nutritional supplementation in older and malnourished individuals undergoing hemodiafiltration mitigates the loss of the SMM index and benefits survival rate.

Effects of oral nutritional supplements on the nutritional status and inflammatory markers in patients on maintenance dialysis: a systematic review and meta-analysis of randomized clinical trials

Background and aims

Patients on hemodialysis (HD) or peritoneal dialysis (PD) often have insufficient energy and protein intake, resulting in poor nutritional status and adverse outcomes. Oral nutritional supplements (ONSs) are the most commonly used to increase such patients' energy and protein intakes.

Methods

In this systematic review and meta-analysis, we analyzed studies on nutritional status, inflammatory markers, and electrolyte levels in patients on dialysis receiving ONSs. We searched four electronic databases from inception until 31 December 2022, for randomized controlled trials comparing ONS treatment versus placebo or routine care.

Results

22 studies with 1185 patients on dialysis were included in our meta-analysis. Compared with the control group, the ONS group exhibited significantly increased serum albumin levels [1.26 g/l (95%CI, 0.50-2.02, P < 0.0001; I2 = 80.4%)], body mass indexes (BMIs) [0.30 kg/m2 (95%CI, 0.09-0.52, P = 0.005; I2 = 41.4%)], and handgrip strength (HGS) [0.96 kg (95%CI, 0.07-1.84, P = 0.034; I2 = 41.4%)] from baseline to the end of intervention. No significant differences were observed between the groups in lean body mass, phase angle, C-reactive protein, and serum phosphorus and potassium levels. In terms of improving albumin, the subgroup analyses show that ONS use seems to be more inclined to three variations: HD patients, short-term use, and non-intradialytic supplementation.

Conclusion

In conclusion, ONS use can improve the nutritional status of patients on dialysis in terms of their serum albumin, BMI, and HGS without significant effects on serum phosphorus, potassium, and C-reactive protein levels. However, it remains uncertain whether these results translate to improvement in clinically relevant outcomes. Large-scale high-quality studies are still required in this population.

Glycemic index of a nutritional supplement designed for people with chronic kidney disease

The study was carried out to measure the glycemic index (GI) of an oral food supplement for people with CKD as well as on patients on maintenance dialysis. The study was conducted as per international protocols for testing GI, was approved by the local institutional ethics committee, and was registered with the Clinical Trial Registry of India (CTRI). This was a crossover randomized controlled study which enrolled 15 participants between the ages of 18 and 45 years. The participants were randomly allotted to one group that consumed either the reference food (27.5 g of glucose monohydrate) or 118 g of the nutritional supplement which contained 25 g of available carbohydrates. Fasting capillary blood samples as well as blood samples at different time intervals as per the GI protocol, after consumption of either the supplement or the reference food were taken from the participants. Each testing day was separated by a 3-day washout period. GI was calculated from the incremental area under the blood glucose response elicited by the nutritional supplement as a percentage of the response after the consumption of 25 g of glucose (27.5 g of glucose monohydrate) by the same participant using a standard formula. The GI of the nutritional supplement was calculated to be 10.3 ± 2.0 which is considered to be low as per international GI testing standards. The product was created to supplement the diet of people with CKD at different stages and to help prevent the progression from CKD to ESRD as well as the risk for CVD. This product was found to have a low GI which is desirable for people with CKD as well as diabetics in general who are at risk for developing CKD.

Effect of intradialytic oral nutritional supplementation on nutritional markers in malnourished chronic hemodialysis patients: prospective randomized trial

BACKGROUND AND OBJECTIVES

Malnutrition is prevalent in chronic hemodialysis (HD) patients. It increases mortality and negatively affects quality of life. This study aimed to assess the effect of intradialytic oral nutritional supplement (ONS) on nutritional markers in chronic HD patients with protein energy wasting (PEW).

METHODS

This 3-month prospective, open-label, randomized controlled trial included 60 chronic HD patients with PEW. The intervention group (30 patients) received intradialytic ONS and dietary counseling, whereas the control group (30 patients) received only dietary counseling. Nutritional markers were measured at the beginning and end of the study.

RESULTS

The mean age of the patients was 54 ± 12.7 years, and that of the HD vintage was 64 ± 49.3 months. Compared to the control group, the intervention group showed a significant increase in serum albumin (p < 0.001), prealbumin (p < 0.001), cholesterol (p = 0.016), body mass index (BMI) (p = 0.019), serum creatinine/body surface area (BSA) (p = 0.016), and composite French PEW score (p = 0.002), as well as a significant decrease in high-sensitivity C-reactive protein (hs-CRP) (p = 0.001). The total iron binding capacity, normalized protein nitrogen appearance, and hemoglobin levels increased significantly in both groups.

CONCLUSION

Intradialytic ONS and dietary counseling for three months were more effective than dietary counseling alone in terms of improving nutritional status and inflammation in chronic HD patients, as evidenced by increases in serum albumin, prealbumin, BMI, serum creatinine/BSA, composite French PEW score, and a decrease in hs-CRP.

Effect of oral nutritional supplementation combined with impedance vectors for dry weight adjustment on the nutritional status, hydration status and quality of life in patients on chronic hemodialysis: A pilot study

BACKGROUND & AIMS

Protein energy wasting frequently affect hemodialysis patients and contribute to the development of overhydration. The objective of this study was to assess the effect of oral nutritional supplementation (ONS) combined with bioelectrical vector analysis (BIVA) on the nutritional and hydration status and the quality of life (QoL) in hemodialysis (HD) patients.

METHODS

Thirty-two chronic HD patients were included in a 6-month randomized pilot study. Patients in SUPL group received a simultaneous intervention consisting of a personalized diet, 245 mL/d ONS and dry weight adjustment through BIVA. Patients in CON group received a personalized diet and dry weight adjustment by BIVA. Anthropometrical, biochemical, dietary, QoL, handgrip strength (HGS) and bioimpedance measurements were performed. Malnutrition Inflammation Score (MIS) was applied.

RESULTS

At the end of the intervention, moderate undernutrition decreased by 43.8% in SUPL group while in CON group, severe undernutrition increased by 13% (p < 0.04 between groups). In the adjusted covariance analysis, SUPL compared to CON group, increased HGS (Δ 2.8 Kg vs Δ -1.8 Kg, p = 0.003), serum albumin (Δ 0.29 g/dL vs Δ -0.03 g/dL, p = 0.04) and serum transferrin (Δ 4.7 mg/dL vs Δ -0.7 mg/dL, p = 0.0007). The increase in QoL was significantly higher in SUPL group. Dry weight was achieved in 100% of patients in SUPL and 95% in CON group.

CONCLUSIONS

ONS combined with BIVA for dry weight adjustment, improved nutritional status, QoL and achieved dry weight in HD patients.

Effect on nutritional status and biomarkers of inflammation and oxidation of an oral nutritional supplement (with or without probiotics) in malnourished hemodialysis patients. A multicenter randomized clinical trial "Renacare Trial"

Background

Malnutrition in patients undergoing hemodialysis is frequent and associated with a reduction in muscular mass and strength, with an increment in biomarkers of inflammation and oxidation.

Materials and methods

Randomized, multicenter, parallel-group trial in malnourished hemodialysis patients with three groups [(1) control (C) individualized diet, (2) oral nutritional supplement-ONS- + placebo-SU- PL-, and (3) ONS + probiotics-SU-PR]; the trial was open regarding the intake of ONS or individualized diet recommendations, but double-blind for the intake of probiotics. We obtained, at baseline and after 3 and 6 months, anthropometric measurements, handgrip strength, bioelectrical impedance analysis (BIA), dietary records, and routine biochemical parameters. Inflammation and oxidation were determined using ELISA techniques (Versamax and ProcartaPlex multiplex Immunoassay). Results were analyzed by intention to treat.

Results

A total of 31 patients (11 corresponding to group C, 10 to SU-PL, and 10 to SU-PR) completed the 6-months trial. The two groups that took supplements significantly increased their protein calorie, fat (total and n-3), and fiber intake. Weight and fat-free mass (FFM) also increased significantly in the groups on supplements, both at 3 and 6 months, and dynamometry did so in the SU-PL group. At month 3, prealbumin and vitamin D were significantly increased in the SU-TOT (SU-PL + SU-PR) group. No changes were observed regarding levels of phosphorus and potassium in any of the groups. Urea increased significantly at 6 months in the SU-PL group. There were significant changes in some inflammation biomarkers in the groups on supplements during the intervention (brain-derived neurotrophic factor, bone morphogenetic protein-2, MCP-1, IL-1-beta, IL-10, IL-4, and IL-8). The total antioxidant capacity (TAC) increased significantly in the supplemented patients, with no significant changes observed in isoprostanes.

Conclusion

The specific ONS improved protein-calorie intake, nutritional status (mainly FFM), and some biomarkers of inflammation/oxidation. The addition of probiotics could have a synergistic effect with ONS in such biomarkers.

Clinical trail registration

https://clinicaltrials.gov/ct2/show/, identifier NCT03924089.

Association of malnutrition with SARS-CoV-2 vaccine response in patients undergoing hemodialysis

BACKGROUND & AIMS

Patients undergoing dialysis are less likely to develop immune responses to SARS-CoV-2 vaccine. Malnutrition is common in the dialysis population. However, whether malnutrition contributes to the impaired immunogenicity remains unknown. The aim of this study was to assess the association between nutritional status and SARS-CoV-2 vaccine response in patients receiving maintenance hemodialysis.

METHODS

A total of 206 hemodialysis patients (mean age, 67 ± 13 years) without prior SARS-CoV-2 infection were examined for the primary outcome of seroconversion, defined as the detection of IgG antibodies (≥50 AU/mL) to the receptor-binding domain of the S1 spike protein of SARS-CoV-2 one month after a priming dose of ChAdOx1 nCoV-19, an adenovirus-vectored vaccine. Nutritional status was assessed by using the Controlling Nutritional Status (CONUT) score, an objective indicator of nutrition incorporating serum albumin, total cholesterol, and total lymphocyte count, as well as the subjective global assessment (SGA).

RESULTS

Overall, 16.5% of patients were classified as malnourished, and 64.1% of patients were at risk for malnutrition based on the CONUT score. Anti-SARS-CoV-2 IgG were the highest in patients with normal nutrition. In multivariate logistic regression analyses adjusted for age, sex, comorbidities, and use of immunosuppressants, patients with malnutrition remained less likely to develop an antibody response than those with normal nutrition (odds ratio 0.23, 95% CI, 0.07-0.76). SGA was a significant predictor of anti-SARS-CoV-2 IgG seroconversion in univariate but not multivariate analyses.

CONCLUSIONS

Malnutrition according to CONUT score is associated with impaired humoral responses to SARS-CoV-2 vaccination in patients undergoing hemodialysis. Our results highlight the importance of incorporating nutritional assessment into routine dialysis care to identify patients at risk for suboptimal immune responses after SARS-CoV-2 vaccination. Further research is needed to determine whether nutritional intervention can improve immune responses in these vulnerable patients.

Effects of oral non-protein calorie supplements on nutritional status among maintenance hemodialysis patients with protein-energy wasting: a multi-center randomized controlled trial

Protein-energy wasting (PEW) is prevalent in maintenance hemodialysis (MHD) patients, and is one of the major risk factors for poor outcomes and death. This study aimed to investigate the effects of non-protein calorie supplements on the nutritional status of MHD patients with PEW. MHD patients with PEW were enrolled in this multi-center, open-label, randomized controlled trial. Then, they were randomly assigned to the intervention group to receive the non-protein calorie supplements containing 280 kcal of energy every day for 6 months or the control group to complete all aspects of the study without receiving supplements. Patients in both groups received dietary counselling from dietitians. Data on nutritional assessments, anthropometric measurements, blood analysis and dietary recall were collected at the baseline and at six months from both groups. Statistical analyses were performed using analysis of covariance (ANCOVA) adjusted for sex and baseline values. Ninety-two MHD patients completed the study. A significant increase in the subjective global assessment (SGA) score was found in the intervention group compared with the control group (4.88 ± 1.41 vs. 4.40 ± 1.16, p = 0.044). The ratio of PEW patients (diagnosed with SGA ≤5) in the intervention group (61.2%) was also significantly lower than that in the control group (83.7%) (p < 0.001). Moreover, significant improvements in body mass index (20.81 ± 2.46 kg m^-2vs. 19.51 ± 2.60 kg m^-2, p < 0.001), nutrition risk screening 2002 (2.45 ± 1.40 vs. 3.12 ± 1.37, p = 0.038), mid-upper arm circumference (23.30 ± 2.78 cm vs. 21.75 ± 2.87 cm, p = 0.001), and mid-arm muscle circumference (20.51 ± 2.32 cm vs. 19.06 ± 2.92 cm, p = 0.005) were observed in the intervention group compared with the control group. Patients in the intervention group took in more dietary energy than the control group (26.96 ± 4.75 kcal per kg body weight per day vs. 24.33 ± 2.68 kcal per kg body weight per day, p < 0.001). In conclusion, non-protein calorie supplements may improve the nutritional status of MHD patients with PEW.

A Comparative Study of the Efficacy of an Intervention with a Nutritional Supplement for Patients with Chronic Kidney Disease: A Randomized Trial

Chronic kidney disease (CKD) involves heterogeneous diseases that affect the renal structure and function. Malnutrition plays a crucial role during patients with CKD on hemodialysis (HD) treatment and is associated with an increased rate and duration of hospitalizations. The aim of this randomized, parallel, intervention-controlled trial was to assess whether the use of daily supplementation with a new nutritional product developed by the Grand Fontaine Laboratories improves the nutritional status and anthropometric parameters of stage 5 CKD patients, compared with standard renal dietary advice, after three months of follow-up. Dietary intake, anthropometric measurements, physical activity, and blood samples were collected at baseline and after three months of intervention. Significant improvements were observed within the intervention group in body weight (1.5 kg [95% CI: 0.9 to 2.12 kg]) and BMI (0.54 kg/m² [95% CI: 0.31 to 0.77]; p-value between groups, 0.002 and 0.006, respectively). In the control group, significant decreases were observed in transferrin saturation (-5.04% [95% CI: -8.88 to -1.21]) and alpha-tocopherol levels (-3.31 umol/L [95% CI: -6.30 to -0.32]). We concluded that daily dietary intake of a specific renal nutritional complement in CKD patients with or at risk of malnutrition may prevent deterioration in nutritional parameters.

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.

Comparison of intradialytic neuromuscular electrical stimulation and oral nutritional supplements in hemodialysis patients: study protocol for a multicenter, parallel-group, randomized controlled trial in Korea

Background

The prevalence of sarcopenia increases as renal function decreases, and a considerable number of hemodialysis (HD) patients have sarcopenia. Exercise and nutritional support are established interventions to prevent and treat sarcopenia. Recently, many studies evaluating intradialytic neuromuscular electrical stimulation (NMES) showed improvement of muscular strength and mass, functional capacity, and quality of life (QOL). However, there has been no research about the effect of simultaneous nutritional support and NMES in HD patients.

Methods

This is a 12-week, randomized controlled, parallel-group, multicenter trial of intradialytic NMES and protein supplementation for HD patients. Seventy-two patients receiving HD will be randomly assigned in a 1:1:1:1 ratio to control, intradialytic NMES only, protein supplementation only, and intradialytic NMES combined with protein supplementation groups. NMES will be delivered to a total of four areas of the bilateral vastus medialis and vastus lateralis using a 4-channel NMES instrument. A total of 25 g of protein supplements will be provided at the beginning of every dialysis session or after the NMES. The primary endpoint is the difference of hand grip and leg muscle strength at 12 weeks among 4 treatment groups. Secondary endpoints include muscle mass, physical performances, and questionnaires about QOL and physical activity.

Discussion

In this study, we will evaluate the differential effectiveness of nutritional support and NMES during HD on muscle strength, muscle mass, physical function, and QOL. We expect that this study can provide guidelines for a new therapeutic option for HD patients who are unable or hesitant to exercise. Furthermore, this option can offer an opportunity to improve the physical function, QOL, and prognosis of HD patients.

Trial registration

Clinical Research Information Service (CRIS), Korea, KCT0005573. Retrospectively registered on 03 November 2020

The Effects of Oral Energy-Dense Supplements on Nutritional Status in Nondiabetic Maintenance Hemodialysis Patients: A Randomized Controlled Trial

BACKGROUND AND OBJECTIVES

Fat-based energy-dense nutritional supplements may offer benefits over protein- or carbohydrate-dense supplements for patients receiving dialysis because of the adverse metabolic consequences of the latter. We conducted a randomized controlled trial to assess the effects of the short-term use of a fat-based nutritional supplement on various measures of nutritional status in patients receiving maintenance hemodialysis who have low dietary energy intake.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We enrolled nondiabetic patients receiving hemodialysis for >3 months who had inadequate dietary energy intake (<30 kcal/kg per day). The participants were randomly assigned in a 1:1 ratio to receive an oral fat-based energy-dense supplement (300 kcal daily) or routine care for 12 weeks (n=120 per group). The primary outcome was the change in phase angle measured by bioelectrical impedance analysis, a marker of cell integrity and body cell mass, from the baseline to week 12. The secondary outcomes were changes in quality of life. Other outcomes included laboratory nutritional indicators and physical examinations.

RESULTS

The average age of the total population was 47 (SD: 12) years, and 55% were men. The median of dialysis vintage was 43.4 (22.5-76.3) months; 240 participants were randomly assigned to the intervention (n=120) or control group (n=120). In total, 228 (95%) participants completed the trial. The change in phase angle did not differ significantly between the intervention and control groups (estimate, 0.0; 95% confidence interval, -0.1 to 0.1 versus estimate, 0.0; 95% confidence interval, -0.1 to 0.1; estimated difference, 0.0; 95% confidence interval -0.2 to 0.2; P=0.99). None of the 19 domains of quality of life differed between the groups. Adverse events were reported in 23 (19%) participants in the control group and 40 (33%) participants in the intervention group.

CONCLUSIONS

In nondiabetic patients on maintenance hemodialysis, short-term administration of fat-based energy-dense nutritional supplement has no clinically significant effect on nutritional status as measured by phase angle.

PODCAST

This article contains a podcast at https://https://www.asn-online.org/media/podcast/CJASN/2021_08_03_CJN16821020.mp3.

Significance of Adipose Tissue Maintenance in Patients Undergoing Hemodialysis

In the general population, obesity is known to be associated with adverse outcomes, including mortality. In contrast, high body mass index (BMI) may provide a survival advantage for hemodialysis patients, which is known as the obesity paradox. Although BMI is the most commonly used measure for the assessment of obesity, it does not distinguish between fat and lean mass. Fat mass is considered to serve as an energy reserve against a catabolic condition, while the capacity to survive starvation is also thought to be dependent on its amount. Thus, fat mass is used as a nutritional marker. For example, improvement of nutritional status by nutritional intervention or initiation of hemodialysis is associated with an increase in fat mass. Several studies have shown that higher levels of fat mass were associated with better survival in hemodialysis patients. Based on body distribution, fat mass is classified into subcutaneous and visceral fat. Visceral fat is metabolically more active and associated with metabolic abnormalities and inflammation, and it is thus considered to be a risk factor for cardiovascular disease and mortality. On the other hand, subcutaneous fat has not been consistently linked to adverse phenomena and may reflect nutritional status as a type of energy storage. Visceral and subcutaneous adipose tissues have different metabolic and inflammatory characteristics and may have opposing influences on various outcomes, including mortality. Results showing an association between increased subcutaneous fat and better survival, along with other conditions, such as cancer or cirrhosis, in hemodialysis patients have been reported. This evidence suggests that fat mass distribution (i.e., visceral fat and subcutaneous fat) plays a more important role for these beneficial effects in hemodialysis patients.

Dietary Factors and Sleep Quality Among Hemodialysis Patients in Malaysia

OBJECTIVES

Poor sleep quality is a commonly seen problem in hemodialysis patients. This study investigated the associations between dietary factors and sleep quality among hemodialysis patients.

DESIGN AND METHODS

This is a cross-sectional study conducted among 184 eligible hemodialysis patients at four dialysis units in Malaysia. Three days dietary recall were used in the analysis of dietary intake and behavior. Sleep quality was assessed through Pittsburgh Sleep Quality Index.

RESULTS

More than half of the patients were poor sleepers. Among the sleep components, sleep latency affected patients the most, with the use of sleep medications was relatively low. A majority of the patients had inadequate dietary intake of energy (88%) and protein (75%). Dietary protein, potassium adjusted for body weight, and sodium intake were significantly increased in poor sleepers. Lower percentage of energy from carbohydrates; higher percentage of energy from fats; higher intakes of dietary protein, fat, phosphorus, and sodium were correlated with poorer sleep quality and its components. Skipping dinner on non-dialysis days and having supper on dialysis days were associated with poor sleep quality.

CONCLUSION

Poor sleep is prevalent among hemodialysis patients. Sleep quality of hemodialysis patients was highly associated with certain dietary factors. Periodical assessment of sleep quality and dietary intake is necessary to identify poor sleepers with inappropriate dietary intake to allow effective clinical and nutritional interventions to improve the sleep quality and nutritional status of these patients.

Chronic Kidney Disease and Nutrition Support

Individuals with chronic kidney disease (CKD), particularly those undergoing maintenance dialysis, are prone to protein-energy wasting (PEW), the latter of which can be ameliorated with different methods of nutrition support. Dietary counseling guided by dietitians is the key for preventing and managing PEW in CKD. If dietary counseling per se fails to meet the recommended energy and protein requirements, the addition of oral nutrition supplements (ONSs) would be necessary. When these initial measures cannot attain the recommended energy and protein requirements, nutrition support, including enteral tube feeding or parenteral nutrition (PN), should be considered as a viable option to improve nutrition status. Partial PN, comprising intraperitoneal PN (IPPN) and intradialytic PN (IDPN) therapies, may be attempted as supplemental nutrition support in patients with PEW requiring peritoneal dialysis and hemodialysis, respectively. Despite the debatable effectiveness of IPPN for patients undergoing peritoneal dialysis, it remains a feasible means in these patients. The indications for IPPN in patients undergoing peritoneal dialysis include inadequate dietary intake of energy and protein, and barriers of oral intake and other forms of enteral supplementation such as issues with suitability, tolerance, and compliance. Nonetheless, in the case of spontaneous dietary consumption of energy and protein meeting the difference between the IDPN provision and the nutrition targets, the use of IDPN is rational. In patients with PEW and malfunctioning gastrointestinal tract, as well as those whose enteral intake (with or without partial PN) is below the recommended nutrient requirements, total PN becomes a relevant nutrition intervention.

Effectiveness of renal-specific oral nutritional supplements compared with diet counseling in malnourished hemodialysis patients

BACKGROUND

Malnutrition is highly prevalent and a consequence of inflammation and related comorbidities among patients on maintenance hemodialysis. Oral nutritional supplementation (ONS) is recommended for malnourished patients with kidney failure. The study aimed to evaluate renal-specific oral nutrition (ONCE dialyze) supplement on nutritional status in patients on hemodialysis.

METHODS

Patients were randomized into 3 groups; treatment groups received 370 kcal/day of ONCE Dialyze (N = 26) or 370 kcal/day of NEPRO (N = 30) for 30 days. The control group (N = 24) received no intervention. All patients were counseled by the same registered dietitian during the study. The nutritional status was evaluated using malnutrition inflammation score (MIS) assessment, body compositions, serum albumin and pre-albumin levels at baseline and 30 days.

RESULTS

Eighty patients were analyzed with mean age of 57.2 ± 15.9 years. The intervention group exhibited significant improvements in energy, protein, fat, fiber and magnesium intake by dietary interview compared with the control group. Percentage of changes in MIS was - 29.0% (95% CI - 40.5 to - 17.4), - 23.9% (95% CI - 37.2 to - 10.6) and 12.1% (95% CI - 19.2 to 43.4) for the ONCE dialyze, NEPRO and control groups, respectively (overall P = 0.006). Percentage of changes in serum albumin was 5.3% (95% CI 1.9-8.7), 3.3% (95% CI - 0.1 to 6.7) and - 0.8% (95% CI - 4.3 to 2.7) for the ONCE dialyze, NEPRO, and control groups, respectively (overall P = 0.039; P = 0.043 for ONCE dialyze vs. control). No serious adverse effects were reported in any group.

CONCLUSION

Dietary advice combined with ONS especially ONCE dialyze was associated with improved MIS, serum albumin, dietary energy and macronutrient intake among patients with kidney failure on maintenance hemodialysis.

CLINICAL TRIAL REGISTRATION

TCTR20200801001.

KDOQI Clinical Practice Guideline for Nutrition in CKD: 2020 Update

The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidence-based guidelines for nutrition in kidney diseases since 1999. Since the publication of the first KDOQI nutrition guideline, there has been a great accumulation of new evidence regarding the management of nutritional aspects of kidney disease and sophistication in the guidelines process. The 2020 update to the KDOQI Clinical Practice Guideline for Nutrition in CKD was developed as a joint effort with the Academy of Nutrition and Dietetics (Academy). It provides comprehensive up-to-date information on the understanding and care of patients with chronic kidney disease (CKD), especially in terms of their metabolic and nutritional milieu for the practicing clinician and allied health care workers. The guideline was expanded to include not only patients with end-stage kidney disease or advanced CKD, but also patients with stages 1-5 CKD who are not receiving dialysis and patients with a functional kidney transplant. The updated guideline statements focus on 6 primary areas: nutritional assessment, medical nutrition therapy (MNT), dietary protein and energy intake, nutritional supplementation, micronutrients, and electrolytes. The guidelines primarily cover dietary management rather than all possible nutritional interventions. The evidence data and guideline statements were evaluated using Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria. As applicable, each guideline statement is accompanied by rationale/background information, a detailed justification, monitoring and evaluation guidance, implementation considerations, special discussions, and recommendations for future research.

Development of muffins as dialysis snacks for patients undergoing hemodialysis: results of chemical composition and sensory analysis

Objective

This study aimed to develop two non-industrial food products as financially accessible options to prevent and treat malnutrition in hemodialysis (HD) patients. These food products were developed and intended for use as dialysis snacks.

Methods

This is a cross-sectional and multi-step study. First, 183 adult HD patients (55 ± 14 years; 50.8% males), replied to a questionnaire with their food preferences regarding taste (salty, sweet, bitter, sour) and consistency (liquid, solid, pasty) for a dialysis snack. Most patients preferred a food product with a solid consistency (90%) and a salty flavor (81.4%). Second, three muffin formulations of fine herbs were developed; one enriched with whey protein concentrate (WPC), a second with textured soy protein (TSP) and a third standard formulation without protein for comparison with the protein-enriched muffins, for which the chemical and nutritional compositions were analyzed. In the third step, 60 patients on HD (61 ± 15 years; 53% males) were enrolled in a sensory analysis by applying a 9-point structured hedonic scale, ranging from “extremely liked” (score 9) to “extremely disliked” (score 1).

Results

When compared with the standard formulation, the formulations enriched with WPC and TSP protein had a significantly higher amount of protein/serving (Standard: 5.9 ± 0.3 g vs WPC: 14.5 ± 0.9 g and TSP 10.8 ± 0.7 g; P < 0.05) but a lower amount of carbohydrate (Standard: 13.1 ± 2.2 g vs WPC: 5.6 ± 0.8 g and TSP 6.0 ± 1.2 g vs; P < 0.05). The mineral content/serving of the protein-enriched muffins was low in phosphorus (50 mg) and sodium (180 mg). The potassium content/serving was moderate for the WPC muffin (225.2 mg) and low for the TSP muffin (107.9 mg). The acceptability index (AI) for the enriched protein muffins was higher than 70% and similar to the standard formulation.

Conclusion

The muffins with fine herbs and enriched with protein were well-accepted by all patients and appropriate to serve as dialysis snacks for HD patients.

Oral protein-based supplements versus placebo or no treatment for people with chronic kidney disease requiring dialysis

BACKGROUND

Malnutrition is common in patients with chronic kidney disease (CKD) on dialysis. Oral protein-based nutritional supplements are often provided to patients whose oral intake is otherwise insufficient to meet their energy and protein needs. Evidence for the effectiveness of oral protein-based nutritional supplements in this population is limited.

OBJECTIVES

The aims of this review were to determine the benefits and harms of using oral protein-based nutritional supplements to improve the nutritional state of patients with CKD requiring dialysis.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 12 December 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of patients with CKD requiring dialysis that compared oral protein-based nutritional supplements to no oral protein-based nutritional supplements or placebo.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for eligibility, risk of bias, and extracted data from individual studies. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference and 95% CI for continuous outcomes.

MAIN RESULTS

Twenty-two studies (1278 participants) were included in this review. All participants were adults on maintenance dialysis of whom 79% were on haemodialysis (HD) and 21% peritoneal dialysis. The follow-up period ranged from one to 12 months. The majority of studies were at unclear risk of selection, performance, and reporting bias. The detection bias was high for self-reported outcomes. Oral protein-based nutritional supplements probably lead to a higher mean change in serum albumin compared to the control group (16 studies, 790 participants: MD 0.19 g/dL, 95% CI 0.05 to 0.33; moderate certainty evidence), although there was considerable heterogeneity in the combined analysis (I² = 84%). The increase was more evident in HD participants (10 studies, 526 participants: MD 0.28 g/dL, 95% CI 0.11 to 0.46; P = 0.001 for overall effect) and malnourished participants (8 studies, 405 participants: MD 0.31 g/dL, 95% CI 0.10 to 0.52, P = 0.003 for overall effect). Oral protein-based nutritional supplements also probably leads to a higher mean serum albumin at the end of the intervention (14 studies, 715 participants: MD 0.14 g/dL, 95% CI 0 to 0.27; moderate certainty evidence), however heterogeneity was again high (I² = 80%). Again the increase was more evident in HD participants (9 studies, 498 participants: MD 0.21 g/dL, 95% CI 0.03 to 0.38; P = 0.02 for overall effect) and malnourished participants (7 studies, 377 participants: MD 0.25 g/dL, 95% CI 0.02 to 0.47; P = 0.03 for overall effect). Compared to placebo or no supplement, low certainty evidence showed oral protein-based nutritional supplements may result in a higher serum prealbumin (4 studies, 225 participants: MD 2.81 mg/dL, 95% CI 2.19 to 3.43), and mid-arm muscle circumference (4 studies, 216 participants: MD 1.33 cm, 95% CI 0.24 to 2.43) at the end of the intervention. Compared to placebo or no supplement, oral protein-based nutritional supplements may make little or no difference to weight (8 studies, 365 participants: MD 2.83 kg, 95% CI -0.43 to 6.09; low certainty evidence), body mass index (9 studies, 368 participants: MD -0.04 kg/m², 95% CI -0.74 to 0.66; moderate certainty evidence) and lean mass (5 studies, 189 participants: MD 1.27 kg, 95% CI -1.61 to 4.51; low certainty evidence). Due to very low quality of evidence, it is uncertain whether oral protein-based nutritional supplements affect triceps skinfold thickness, mid-arm circumference, C-reactive protein, Interleukin 6, serum potassium, or serum phosphate. There may be little or no difference in the risk of developing gastrointestinal intolerance between participants who received oral protein-based nutritional supplements compared with placebo or no supplement (6 studies, 426 participants: RR 2.81, 95% CI 0.58 to 13.65, low certainty evidence). It was not possible to draw conclusions about cost or quality of life, and deaths were not reported as a study outcome in any of the included studies.

AUTHORS' CONCLUSIONS

Overall, it is likely that oral protein-based nutritional supplements increase both mean change in serum albumin and serum albumin at end of intervention and may improve serum prealbumin and mid-arm muscle circumference. The improvement in serum albumin was more evident in haemodialysis and malnourished participants. However, it remains uncertain whether these results translate to improvement in nutritional status and clinically relevant outcomes such as death. Large well-designed RCTs in this population are required.

Ready-Made Oral Nutritional Supplements Improve Nutritional Outcomes and Reduce Health Care Use-A Randomised Trial in Older Malnourished People in Primary Care

Large trials assessing oral nutritional supplements (ONS) and dietary advice (DA) in primary care are lacking. This study examined effects of ONS + DA versus DA on intake, weight, QoL, healthcare use and satisfaction in malnourished free-living older people. Three hundred and eight people (71.5 ± 10.7y) were randomised to receive ONS + DA (n154) or DA (n154) for 12 weeks. At baseline, 4, 8, 12 weeks, intake, weight, QoL, healthcare use and satisfaction were measured. ONS + DA group (mean daily intake ONS 480 kcal; 21 g protein; 80% compliance) had significantly greater total energy and protein intakes (+401 kcal/d, p < 0.001; +15 g/d, p < 0.001) and weight gain (+0.8 kg; p < 0.001) compared to DA. QoL improved in both groups over time with a significant improvement in index with ONS + DA (p = 0.009). Significantly more participants found ONS + DA made a difference for them (p = 0.011), but no differences were found between groups using Euroqol. Compared to DA, healthcare use reduced with ONS + DA, (HCP visits by 34%, emergency admissions 50%, LOS 62%). Acceptability of both interventions was high (ONS 96%, DA 95%), with significantly more participants satisfied with ONS (89%) than DA (73%) (p = 0.009). This trial in primary care indicates that ONS are acceptable, make a difference to patients, significantly improve intake and weight, and reduce health care use with potential savings.

Hypoproteinemia as a factor in assessing malnutrition and predicting survival on hemodialysis

Series of studies have described malnutrition as one of the main non-traditional risk factors associated with poor prognosis and treatment outcome in patients on hemodialysis (HD). The aims of this study were to evaluate the link between HD treatment quality and the nutritional status and to additionally investigate the association of malnutrition and overall survival. A total of 134 adult out-patients (56.4% male, mean age 60.8 ± 16.15 years) were enrolled in the study. Clinical and laboratory data were obtained from the medical records. Anthropometric measurements were performed prior to HD. Malnutrition-Inflammation Score (MIS) was used as a scoring system representing the severity of protein-energy wasting (PEW). Malnourished patients were significantly older when compared to non-malnourished patients. They had significantly longer dialysis vintage and lower residual diuresis, BMI, serum proteins, and albumins and lean tissue index (LTI). Malnourished patients survived significantly shorter than non-malnourished patients. Hypoproteinemic patients had significantly lower values of serum albumins and LTI and survived shorter than normoproteinemic patients. Only malnourishment and age were associated with higher overall mortality in all groups of patients. By focusing on MIS and serum protein status rather than dialysis-related factors and different treatment techniques, we could accomplish better nutrition status and improved overall outcomes. While anticipating new and more effective measures for preventing malnutrition, our results clearly demonstrate that striving for the highest possible nutrition status should be one of the key strategies in improving the outcomes in this specific group of patients.

The effects of oral nutritional supplements in patients with maintenance dialysis therapy: A systematic review and meta-analysis of randomized clinical trials

Background/objective

This systematic review aims to determine the potential effects of oral nutritional supplements (ONS) in patients receiving maintenance dialysis therapy (MDT).

Methods

Electronic databases were searched without language limits through to July 2018. Randomized controlled trials (RCTs) that involved comparisons of ONS versus placebo or routine care are included in this meta-analysis. RevMan 5.3 statistical software was used for meta-analysis.

Results

15 articles with 589 subjects were included in our study. There are insufficient comparable data of randomized trials to allow meta-analysis of mortality. Albumin levels may be improved by the macronutrient blends or protein/amino acid supplements in MDT patients. Compared with the control group, serum albumin levels and BMI in the ONS group were increased by 1.58 g/L (95% CI, 0.52–2.63, P = 0.003; I² = 85%) and 0.40 kg/m² (95% CI, 0.10–0.71, P = 0.01; I² = 49%), respectively. In the subgroup analysis of patients receiving hemodialysis, albumin levels in ONS group were increased by 2.17 g/L (95% CI, 0.89–3.45, P<0.001; I² = 90%). ONS may not influence serum phosphorus and potassium levels.

Conclusions

Very low-quality evidence suggests that Short-term oral energy or protein/amino acid supplements may improve nutritional status by increasing serum albumin levels and BMI in MDT patients, without influence on serum potassium levels. High-quality and large RCTs, particularly regarding the effects of ONS on mortality and quality of life, are needed to further validate our findings.

Factors Associated with Frailty and Its Trajectory among Patients on Hemodialysis

BACKGROUND AND OBJECTIVES

Frailty is common among patients on hemodialysis and associated with adverse outcomes. However, little is known about changes in frailty over time and the factors associated with those changes.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

To address these questions, we examined 762 participants in the A Cohort to Investigate the Value of Exercise/Analyses Designed to Investigate the Paradox of Obesity and Survival in ESRD cohort study, among whom frailty was assessed at baseline and 12 and 24 months. We used ordinal generalized estimating equations analyses and modeled frailty (on a scale from zero to five possible components) and death during follow-up.

RESULTS

The mean frailty score at baseline was 1.9, and the distribution of frailty scores was similar at each evaluation. However, most participants' scores changed, with patients improving almost as often as worsening (overall change, 0.2 points per year; 95% confidence interval, 0.1 to 0.3). Hispanic ethnicity (0.6 points per year; 95% confidence interval, 0.0 to 1.1) and diabetes (0.7 points per year; 95% confidence interval, 0.3 to 1.0) were associated with higher frailty scores and higher serum albumin concentration with lower frailty scores (-1.1 points per g/dl; 95% confidence interval, -1.5 to -0.7). In addition, patients whose serum albumin increased over time were less likely to become frail, with each 1-g/dl increase in albumin associated with a 0.4-point reduction in frailty score (95% confidence interval, -0.80 to -0.05). To examine the underpinnings of the association between serum albumin and frailty, we included serum IL-6, normalized protein catabolic rate, and patient self-report of hospitalization within the last year in a second model. Higher IL-6 and hospitalization were statistically significantly associated with worse frailty at any point and worsening frailty over time, whereas normalized protein catabolic rate was not independently associated with frailty.

CONCLUSIONS

There was substantial year to year variability in frailty scores, with approximately equal numbers of patients improving and worsening. Markers of inflammation and hospitalization were independently associated with worsening frailty. Studies should examine whether interventions to address inflammation or posthospitalization rehabilitation can improve the trajectory of frailty.

The effects of resistance exercise and oral nutritional supplementation during hemodialysis on indicators of nutritional status and quality of life

BACKGROUND

Protein-energy wasting (PEW) is common in patients undergoing hemodialysis (HD). Studies have assessed the positive effect of oral nutritional supplementation (ONS) or resistance exercise (RE) on nutritional status (NS) markers in patients undergoing HD.

METHODS

The aim of this study was to assess the effect of ONS and RE on NS and the quality of life (QOL) of 36 patients undergoing HD. In a randomized clinical trial, patients were divided into the following two groups: a control group (ONS) that received a can of ONS during their HD sessions and an intervention group (ONS + RE) that received a can of ONS and underwent a 40-min session of RE during their HD sessions. Both interventions lasted 12 weeks. The patients' anthropometric, biochemical, dietetic and bioelectrical impedance measurements as well as their QOL, evaluated using the Kidney Disease Quality of Life Short Form, were recorded.

RESULTS

At baseline, 55.5% of patients presented with PEW according to International Society of Renal Nutrition and Metabolism criteria (20 patients). We found statistically significant changes from baseline in both groups, such as increases in body weight, body mass index, midarm circumference, midarm muscle circumference, triceps skinfold thickness, fat mass percentage, handgrip strength, phase angle and serum albumin. A decrease in the prevalence of PEW was observed in both groups at the end of the intervention. A delta comparison between groups showed no statistically significant differences in the anthropometric and biochemical parameters. No significant improvement was observed in QOL and body composition measured by bioimpedance vector analysis. Dietary energy and protein intake increased significantly during the study period for all patients.

CONCLUSION

Oral nutritional supplementation during HD improves NS. The addition of RE during HD does not seem to augment the acute anabolic effects of intradialytic ONS on NS.

Protein-energy malnutrition: a risk factor for various ailments

The wheel of industrialization that spun throughout the last century resulted in urbanization coupled with modifications in lifestyles and dietary habits. However, the communities living in developing economies are facing many problems related to their diet and health. Amongst, the prevalence of nutritional problems especially protein-energy malnutrition (PEM) and micronutrients deficiencies are the rising issues. Moreover, the immunity or susceptibility to infect-parasitic diseases is also directly linked with the nutritional status of the host. Likewise, disease-related malnutrition that includes an inflammatory component is commonly observed in clinical practice thus affecting the quality of life. The PEM is treatable but early detection is a key for its appropriate management. However, controlling the menace of PEM requires an aggressive partnership between the physician and the dietitian. This review mainly attempts to describe the pathophysiology, prevalence and consequences of PEM and aims to highlight the importance of this clinical syndrome and the recent growth in our understanding of the processes behind its development. Some management strategies/remedies to overcome PEM are also the limelight of the article. In the nutshell, early recognition, prompt management, and robust follow up are critical for best outcomes in preventing and treating PEM.

Malnutrition in Dialysis Patients--The Need for Intervention Despite Uncertain Benefits

We are in the midst of an epidemic of overnutrition which has resulted in a widespread increase in obesity rates in modern societies. Yet for patients suffering from serious chronic illnesses such as end stage renal disease (ESRD), malnutrition (encompassing both inadequate quantity and quality of nutrient intake) represents a far more significant danger. Protein-energy wasting has been identified as one of the strongest risk factor for adverse outcomes in ESRD patients, and modeling studies have suggested that improving nutrition could result in substantial lowering of mortality rates and other benefits. To date there is ample evidence that various interventions can have a positive impact on the nutritional status of ESRD patients, yet we still lack randomized controlled clinical trials showing that the same interventions could indeed lead to better survival or other clinical benefits. This knowledge gap, which is all too common for clinical problems encountered in nephrology, should not act as a deterrent, but it should rather incentivize us to continue exploring novel interventions aimed at improving malnutrition in ESRD.

Supervised oral protein supplementation during dialysis in patients with elevated C-reactive protein levels: a two phase, longitudinal, single center, open labeled study

BACKGROUND

Inflammation is considered one of the major causes of protein-energy wasting in maintenance hemodialysis (MHD) patients. It is unclear whether dietary interventions can impact nutritional status and quality of life in MHD patients with elevated C-reactive protein (CRP) levels. Therefore, we examined the hypothesis that supervised intra-dialysis protein supplementation in MHD patients with elevated plasma CRP will improve protein stores and quality of life.

METHODS

A 24 week, two phase, longitudinal, single center, open labeled study of 50 MHD patients with plasma CRP > 3 mg/L was conducted. During the 12-week observation phase dietary advice was provided to increase protein intake to 1.2 g/kg/day. In the 12-week treatment phase 45 g of liquid protein supplement was provided at each dialysis treatment. Protein nitrogen appearance (PNA), mid-arm muscle circumference (MAMC), serum albumin, body mass index (BMI) and quality of life (assessed by Short Form-12 questionnaire) were measured at baseline, 12 and 24 weeks.

RESULTS

Median plasma CRP at baseline was 16.0 (IQR 7.7 to 25.1) mg/L. The mean MAMC was 26.5 ± 3.9 cm, BMI 29.2 ± 6.9 kg/m(2) and plasma albumin 3.8 ± 0.3 g/dl. During the intervention period, mean PNA increased by 0.13 g/kg/d (p = 0.01) under a mixed effects model. However, there were no clinically or statistically significant effects on MAMC (p = 0.87), plasma albumin (p = 0.70), BMI (p = 0.09), physical (p = 0.32) or mental (p = 0.96) composite scores.

CONCLUSIONS

In MHD patients with elevated plasma CRP but otherwise mostly normal nutritional parameters, intra-dialytic oral protein supplement was effective in increasing protein intake but did not provide a detectable impact on nutritional status or quality of life.

NOURISH, Nutritional OUtcomes from a Randomised Investigation of Intradialytic oral nutritional Supplements in patients receiving Haemodialysis: a pilot randomised controlled trial

Background

The study was done to assess the feasibility of conducting a trial evaluating the use of an intradialytic oral nutritional supplement (ONS) on nutritional status.

Methods

The study design is a single centre, parallel group, external pilot randomised controlled trial (RCT). The setting was at a haemodialysis unit in Sheffield, UK. The aim was to recruit 30 trial participants to allow at least 12 evaluable patients per arm, but the actual study sample consisted of 10 adults with a body mass index (BMI) ≤22 kg/m², receiving thrice weekly haemodialysis. All participants received nutritional advice from a renal dietitian as per usual practice. The intervention included the provision of an intradialytic ONS. Feasibility outcomes included recruitment to time and retention of participants along with palatability of ONS. Secondary outcomes were clinical parameters to obtain variance and estimates of effect size to inform the sample size calculation for a definitive trial.

Results

Recruitment was undertaken for a fixed period of 6 weeks. Rates were lower than expected mainly due to ineligibility with only 7% of screened patients (19/265) being eligible and 4% (10/265) of these being recruited. Due to the small proportion of patients eligible for the trial, all haemodialysis patients at the specified unit were assessed for eligibility. Data completion rates were low for session questionnaires (23%). Sample sizes derived from variance in secondary outcome measure of handgrip strength and adjusted for a dropout rate of 20% indicate that 189 patients would be required for a definitive RCT, requiring 19 UK haemodialysis units to participate.

Conclusions

A definitive RCT is feasible with some adaptation to exclusion criteria and methodology. The exclusion criteria could be adapted to include an increase in upper limit for BMI. The use of questionnaires at each dialysis session may not be feasible but the inclusion of appetite and supplement consumption data collection at the main assessments would provide similar outcome data. Quality of life assessment using SF-12 would be acceptable.

Trial registration

ISRCTN37431579.

Protein energy wasting and transplantation

In patients with advanced renal failure or those undergoing dialysis, protein energy wasting (PEW) is a frequently occurring complication that is associated with increased cardiovascular morbidity and mortality. Fewer data are available for patients after transplantation. In this article, the available data on nutritional status after kidney transplantation is reviewed. It was also found that signs of PEW and microinflammation in patients undergoing kidney transplantation are associated with both impaired transplantation outcomes and decreased patient survival. Data are lacking on nutritional support and outcomes after transplantation. Only 1 study revealed a possible relationship between healthier eating habits and better outcomes in patients who have undergone transplantation. More data support the notion that sufficient physical exercise improves graft survival and patient outcome after kidney transplantation. Future studies on nutritional support in patients with signs of PEW and microinflammation immediately after transplantation could reveal whether such a strategy improves renal and patient outcomes.

Nutrition: Intradialytic oral nutrition--the ultimate conviction

Protein-energy wasting occurs frequently during maintenance dialysis. Known aetiologies include a loss of nutrients during the haemodialysis procedure and anorexia. Providing energy and protein during dialysis improves metabolism; however, the benefits of long-term support are debated. Weiner and colleagues report convincing data with an intradialytic oral nutritional intervention using protein supplements.

Nutritional outcomes from a randomised investigation of intradialytic oral nutritional supplements in patients receiving haemodialysis, (NOURISH): a protocol for a pilot randomised controlled trial

Abstract

Haemodialysis is a form of renal replacement therapy but is a catabolic process that not only filters toxins but is also known to lead to amino acid losses. Patients with chronic kidney disease often have a poor appetite and this in combination with limited dietary intake and the detrimental effects of haemodialysis can lead to the development of malnutrition. Between 20% and 50% of haemodialysis patients are thought to be malnourished. Malnutrition can worsen clinical outcomes and increase the risk of hospitalisation. We hypothesise that a nutritional supplement taken during haemodialysis may help to improve nutritional status.

The aim of this study is to conduct a pilot randomised controlled trial to assess the use of an intradialytic nutritional supplement on nutritional status. The objectives are to assess the feasibility of the trial including: recruitment and retention of participants; preference of nutritional supplements; compliance with the intervention; ease of completion of the questionnaires and appropriateness of the tools used. Secondary outcomes include clinical outcomes to obtain variance in the patient population and estimates of effect size to inform the sample size for a future definitive trial.

The trial is a single centre, randomised, parallel-group, two armed external pilot with an intervention and control group. The intervention group will take a nutritional supplement each dialysis session from a choice of prescribable drink or pudding style supplements. The control group will receive standard care.

Recruitment and feasibility elements are the primary outcomes. Recruitment will be to time (t = 6 weeks). In order to collect sufficient data to inform a future sample size calculation, we will aim to recruit 30 participants to obtain 12 evaluable per arm anticipating some drop out. Secondary outcome measures include clinical variables; hand grip strength, quality of life, weight and biochemistry completed at baseline, 1 and 2 months.

Descriptive statistics will be used to analyse the baseline characteristics of the recruited participants. Means, confidence intervals and standard deviations will be reported for the outcome measures of handgrip strength, dietary intake, quality of life and weight.

Trial registration

ISRCTN37431579.

Phosphate control in dialysis

Prevention and correction of hyperphosphatemia is a major goal of chronic kidney disease–mineral and bone disorder (CKD–MBD) management, achievable through avoidance of a positive phosphate balance. To this aim, optimal dialysis removal, careful use of phosphate binders, and dietary phosphate control are needed to optimize the control of phosphate balance in well-nourished patients on a standard three-times-a-week hemodialysis schedule. Using a mixed diffusive–convective hemodialysis tecniques, and increasing the number and/or the duration of dialysis tecniques are all measures able to enhance phosphorus (P) mass removal through dialysis. However, dialytic removal does not equal the high P intake linked to the high dietary protein requirement of dialysis patients; hence, the use of intestinal P binders is mandatory to reduce P net intestinal absorption. Unfortunately, even a large dose of P binders is able to bind approximately 200–300 mg of P on a daily basis, so it is evident that their efficacy is limited in the case of an uncontrolled dietary P load. Hence, limitation of dietary P intake is needed to reach the goal of neutral phosphate balance in dialysis, coupled to an adequate protein intake. To this aim, patients should be informed and educated to avoid foods that are naturally rich in phosphate and also processed food with P-containing preservatives. In addition, patients should preferentially choose food with a low P-to-protein ratio. For example, patients could choose egg white or protein from a vegetable source. Finally, boiling should be the preferred cooking procedure, because it induces food demineralization, including phosphate loss. The integrated approach outlined in this article should be actively adapted as a therapeutic alliance by clinicians, dieticians, and patients for an effective control of phosphate balance in dialysis patients.

Prevention and treatment of protein energy wasting in chronic kidney disease patients: a consensus statement by the International Society of Renal Nutrition and Metabolism

Protein energy wasting (PEW) is common in patients with chronic kidney disease (CKD) and is associated with adverse clinical outcomes, especially in individuals receiving maintenance dialysis therapy. A multitude of factors can affect the nutritional and metabolic status of CKD patients requiring a combination of therapeutic maneuvers to prevent or reverse protein and energy depletion. These include optimizing dietary nutrient intake, appropriate treatment of metabolic disturbances such as metabolic acidosis, systemic inflammation, and hormonal deficiencies, and prescribing optimized dialytic regimens. In patients where oral dietary intake from regular meals cannot maintain adequate nutritional status, nutritional supplementation, administered orally, enterally, or parenterally, is shown to be effective in replenishing protein and energy stores. In clinical practice, the advantages of oral nutritional supplements include proven efficacy, safety, and compliance. Anabolic strategies such as anabolic steroids, growth hormone, and exercise, in combination with nutritional supplementation or alone, have been shown to improve protein stores and represent potential additional approaches for the treatment of PEW. Appetite stimulants, anti-inflammatory interventions, and newer anabolic agents are emerging as novel therapies. While numerous epidemiological data suggest that an improvement in biomarkers of nutritional status is associated with improved survival, there are no large randomized clinical trials that have tested the effectiveness of nutritional interventions on mortality and morbidity.