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Wong MMY, Zheng Y, Zhu B, Er L, Atiquzzaman M, Romann A, Renouf D, Sheriff Z, Levin A. Oral Nutritional Supplement Prescription and Patient-Reported Symptom Burden Among Patients With Late-Stage Non-Dialysis Chronic Kidney Disease. Can J Kidney Health Dis 2024; 11:20543581241228731. [PMID: 38328391 PMCID: PMC10848794 DOI: 10.1177/20543581241228731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 12/04/2023] [Indexed: 02/09/2024] Open
Abstract
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.
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Affiliation(s)
- Michelle M. Y. Wong
- Division of Nephrology, Department of Medicine, The University of British Columbia, Vancouver, BC, Canada
- BC Renal, Vancouver, BC, Canada
| | | | | | - Lee Er
- BC Renal, Vancouver, BC, Canada
| | | | | | - Dani Renouf
- St. Paul’s Hospital, Providence Health Care, Vancouver, BC, Canada
| | - Zainab Sheriff
- Division of Nephrology, Department of Medicine, The University of British Columbia, Vancouver, BC, Canada
- BC Renal, Vancouver, BC, Canada
| | - Adeera Levin
- Division of Nephrology, Department of Medicine, The University of British Columbia, Vancouver, BC, Canada
- BC Renal, Vancouver, BC, Canada
- St. Paul’s Hospital, Providence Health Care, Vancouver, BC, Canada
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Torreggiani M, Wang AYM, Fois A, Piccoli GB. Personalized Low-Protein Diet Prescription in CKD Population: Merging Evidence From Randomized Trials With Observational Data. Semin Nephrol 2023; 43:151402. [PMID: 37536057 DOI: 10.1016/j.semnephrol.2023.151402] [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] [Indexed: 08/05/2023]
Abstract
Nutritional therapy is a cornerstone of the clinical management of chronic kidney disease (CKD). Nevertheless, randomized controlled trials often have failed to show a relevant benefit of low-protein diets in nonselected CKD populations in terms of slowing the progression of kidney disease and need for dialysis. The more the target population is selected, the less the results can be generalizable to implement in clinical practice. On the contrary, observational studies, especially if performed with patient-centered, flexible approaches, point toward an extensive implementation of dietary protein restriction in different and unselected CKD populations. The observational evidence cannot be disregarded anymore. The most recent guidelines advise implementing low-protein diets or even very-low-protein diets in all CKD patients as early as stage 3. However, the lack of data from large randomized controlled trials on unselected CKD populations as well as on specific subpopulations, such as diabetic or obese patients, which nowadays comprise the majority of CKD subjects, reduces the generalizability of the recommendations. For some patient populations, such as those encompassing very old, nephrotic, or pregnant patients, the literature is even more limited because of the lower prevalence of these conditions and diffused prejudices against reducing protein intake. This pragmatic review discusses the need for integrating information derived from randomized trials with evidence derived from observational studies to guide feasible strategies for more successful implementation of low-protein diets in the treatment of all segments of the CKD population.
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Affiliation(s)
| | - Angela Yee-Moon Wang
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR, China
| | - Antioco Fois
- Néphrologie et Dialyse, Centre Hospitalier Le Mans, Le Mans, France
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Dawson J, McLean C. Nutrition in Conservative Kidney Management: From Evidence to Practice. Semin Nephrol 2023; 43:151399. [PMID: 37506469 DOI: 10.1016/j.semnephrol.2023.151399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2023]
Abstract
Conservative kidney management (CKM) is a treatment option for kidney failure, particularly for the elderly and those with co-morbidities. Dietitians can play an important role in the provision of CKM by enhancing patients' quality of life through the management of nutrition impact symptoms (symptoms that result in decreased eating, including anorexia, nausea, dry mouth, and taste changes), as well as symptoms that result from malnutrition, including fatigue, weakness, activity intolerance, slow wound healing, and low mood. There are many gaps in the literature regarding optimal nutritional recommendations for patients on CKM. More research is needed on symptom management and interventions to delay or slow the progression of malnutrition and frailty. This article provides an overview of important nutritional considerations, a synthesis of the current literature, and recommendations for application of evidence into the practice of CKM.
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Affiliation(s)
- Jessica Dawson
- Department of Nutrition and Dietetics, St George Hospital, Sydney, New South Wales, Australia; NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia.
| | - Cameron McLean
- Department of Nutrition and Dietetics, St George Hospital, Sydney, New South Wales, Australia; School of Medical, Indigenous and Health Sciences, University of Wollongong, Wollongong, New South Wales, Australia
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Wang AYM, Okpechi IG, Ye F, Kovesdy CP, Brunori G, Burrowes JD, Campbell K, Damster S, Fouque D, Friedman AN, Garibotto G, Guebre-Egziabher F, Harris D, Iseki K, Jha V, Jindal K, Kalantar-Zadeh K, Kistler B, Kopple JD, Kuhlmann M, Lunney M, Mafra D, Malik C, Moore LW, Price SR, Steiber A, Wanner C, ter Wee P, Levin A, Johnson DW, Bello AK. Assessing Global Kidney Nutrition Care. Clin J Am Soc Nephrol 2022; 17:38-52. [PMID: 34980675 PMCID: PMC8763143 DOI: 10.2215/cjn.07800621] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 11/15/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND OBJECTIVES Nutrition intervention is an essential component of kidney disease management. This study aimed to understand current global availability and capacity of kidney nutrition care services, interdisciplinary communication, and availability of oral nutrition supplements. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The International Society of Renal Nutrition and Metabolism (ISRNM), working in partnership with the International Society of Nephrology (ISN) Global Kidney Health Atlas Committee, developed this Global Kidney Nutrition Care Atlas. An electronic survey was administered among key kidney care stakeholders through 182 ISN-affiliated countries between July and September 2018. RESULTS Overall, 160 of 182 countries (88%) responded, of which 155 countries (97%) answered the survey items related to kidney nutrition care. Only 48% of the 155 countries have dietitians/renal dietitians to provide this specialized service. Dietary counseling, provided by a person trained in nutrition, was generally not available in 65% of low-/lower middle-income countries and "never" available in 23% of low-income countries. Forty-one percent of the countries did not provide formal assessment of nutrition status for kidney nutrition care. The availability of oral nutrition supplements varied globally and, mostly, were not freely available in low-/lower middle-income countries for both inpatient and outpatient settings. Dietitians and nephrologists only communicated "sometimes" on kidney nutrition care in ≥60% of countries globally. CONCLUSIONS This survey reveals significant gaps in global kidney nutrition care service capacity, availability, cost coverage, and deficiencies in interdisciplinary communication on kidney nutrition care delivery, especially in lower-income countries.
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Affiliation(s)
- Angela Yee-Moon Wang
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Ikechi G. Okpechi
- Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa,Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa
| | - Feng Ye
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Csaba P. Kovesdy
- University of Tennessee Health Science Center and Memphis Veterans Affairs Medical Center, Memphis, Tennessee
| | - Giuliano Brunori
- Division of Nephrology and Dialysis, Santa Chiara Hospital, Trento, Italy
| | - Jerrilynn D. Burrowes
- Department of Biomedical, Health and Nutritional Sciences, Long Island University Post, Greenvale, New York
| | - Katrina Campbell
- Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
| | | | - Denis Fouque
- University Claude Bernard Lyon1, Hospital Lyon Sud - Lyon-France, South Lyon, France
| | - Allon N. Friedman
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Giacomo Garibotto
- Division of Nephrology, Dialysis and Transplantation Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Fitsum Guebre-Egziabher
- Department of Nephrology, Dialysis and Hypertension, Hospices Civils de Lyon, Hospital Edouard Herriot, Lyon, France,CarMeN Laboratory, Institut National de la Santé et de la Recherche Médicale (INSERM) UMR 1060, Lyon East Faculty of Medicine, University Claude Bernard Lyon 1, Lyon, France
| | - David Harris
- Centre for Transplantation and Renal Research, Westmead Institute for Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - Kunitoshi Iseki
- Clinical Research Support Center, Nakamura Clinic, Okinawa, Japan
| | - Vivekanand Jha
- George Institute for Global Health India, University of New South Wales, New Delhi, India,School of Public Health, Imperial College, London, United Kingdom,Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
| | - Kailash Jindal
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine Medical Center, Orange, California
| | - Brandon Kistler
- Department of Nutrition and Health Science, Ball State University, Muncie, Indiana
| | - Joel D. Kopple
- Division of Nephrology and Medicine and the Lundquist Research Institute at Harbor–University of California Los Angeles (UCLA) Medical Center, David Geffen School of Medicine at UCLA and UCLA Fielding School of Public Health, Los Angeles, California
| | | | - Meaghan Lunney
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Denise Mafra
- Federal University Fluminense, Rio de Janeiro, Brazil
| | - Charu Malik
- International Society of Nephrology, Brussels, Belgium
| | - Linda W. Moore
- Houston Methodist Hospital, Department of Surgery, Houston, Texas
| | - S. Russ Price
- Departments of Internal Medicine and Biochemistry-Molecular Biology, Brody School of Medicine at East Carolina University, Greenville, North Carolina
| | - Alison Steiber
- Research, International, and Scientific Affairs, Academy of Nutrition and Dietetics, Chicago, Illinois
| | - Christoph Wanner
- Department of Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Pieter ter Wee
- Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Adeera Levin
- Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - David W. Johnson
- Centre for Kidney Disease Research, University of Queensland, Brisbane, Australia,Translational Research Institute, Brisbane, Australia,Metro South and Integrated Nephrology and Transplant Services (MINTS), Princess Alexandra Hospital, Brisbane, Australia
| | - Aminu K. Bello
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Lambert K, Bahceci S, Harrison H, Chan M. Implications for Australasian dietitians regarding the 2020 Academy of Nutrition and Dietetics and Kidney Disease Outcomes Quality Initiative Clinical Practice Guidelines for Nutrition in Chronic Kidney Disease. Nutr Diet 2021; 78:374-379. [PMID: 33786973 DOI: 10.1111/1747-0080.12668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/01/2021] [Accepted: 03/03/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Kelly Lambert
- Discipline of Nutrition and Dietetics, School of Medicine, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Su Bahceci
- Renal Dietitian, Dietetics Department, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Harriet Harrison
- Renal Dietitian, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Maria Chan
- Department of Renal Medicine, The St. George Hospital, Kogarah, New South Wales, Australia.,Department of Nutrition and Dietetics, The St. George Hospital, Kogarah, New South Wales, Australia
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Hoffmann U. [Treatment of geriatric patients with end-stage renal failure : Dialysis or conservative procedure?]. Z Gerontol Geriatr 2021; 54:223-228. [PMID: 33496833 DOI: 10.1007/s00391-021-01840-8] [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: 11/30/2020] [Accepted: 12/30/2020] [Indexed: 11/27/2022]
Abstract
Compared to younger patients, an acceptable state of health in older patients with various comorbidities is rarely achieved by the initiation of dialysis. Despite dialysis treatment, further functional and cognitive impairments often rapidly occur in geriatric patients. Thus, newer studies are concerned with the quality of life of this patient group after initiation of dialysis as well as with palliative treatment strategies as alternatives. A structured clarification for the patients on all possibilities with mediation of all necessary information is a prerequisite for a shared decision-making. To assess life expectancy after dialysis initiation, various scores have been developed but the sensitivity could not fulfil the expectations. In the case of renal replacement, chronic intermittent hemodialysis is the treatment form most frequently performed in geriatric patients. The main concern of conservative palliative treatment is the quality of life and the management of uremic symptoms, which have to be addressed by a multidisciplinary team.
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Affiliation(s)
- Ute Hoffmann
- Klinik für Allgemeine Innere Medizin und Geriatrie/Angiologie, Diabetologie, Endokrinologie, Nephrologie, Krankenhaus Barmherzige Brüder, Prüfeninger Str. 86, 93049, Regensburg, Deutschland.
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7
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Siriwardana AN, Hoffman AT, Brennan FP, Li K, Brown MA. Impact of Renal Supportive Care on Symptom Burden in Dialysis Patients: A Prospective Observational Cohort Study. J Pain Symptom Manage 2020; 60:725-736. [PMID: 32389605 DOI: 10.1016/j.jpainsymman.2020.04.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 04/20/2020] [Accepted: 04/24/2020] [Indexed: 01/28/2023]
Abstract
CONTEXT Symptom burden is a strong predictor of reduced health-related quality of life and survival in patients with end-stage kidney disease. Renal supportive care (RSC) is a comprehensive approach shown to benefit symptoms in nondialysis conservatively managed patients, although its role in dialysis patients has not been reported. OBJECTIVES This study aimed to investigate the impacts of RSC intervention on symptoms in dialysis patients. METHODS Dialysis patients who were referred to an RSC clinic for symptom control between April 2010 and December 2017 were followed prospectively. Symptoms were scored using the Integrated Palliative care Outcomes Scale-Renal Inventory. Change in symptoms was analyzed at three visits and at final RSC visit within the study period. Correlation and linear regression were used to assess for effect modifiers. RESULTS A total of 127 dialysis patients attended the RSC clinic for symptom management. Median age was 74 years, 62% males, median dialysis vintage was 2.2 years, and median-modified Charlson Comorbidity Index was 7. Mean combined physical and emotional symptom score at baseline was 17.5 (SD 9.6), the most overwhelming/severe symptoms being difficulty sleeping (35%), pain (31%), lack of energy (31%), poor mobility (24%), and itch (22%). Eighty patients had follow-up to at least three RSC visits (median 3.1 months). There was significant improvement in combined physical and emotional symptom score during three clinic visits (18.1 vs. 14.2; mean change -3.8; 95% CI -5.7 to -1.9; P < 0.001), with greatest improvement in symptom scores for the five most severe symptoms (each P < 0.001). Follow-up of these 80 patients to final RSC visit (median 13.0 months) showed sustained reduction in mean combined physical and emotional symptom score (18.1 vs. 14.4; mean change -3.7; 95% CI -5.6 to -1.7; P < 0.001). These changes occurred without change in dialysis delivery. CONCLUSION RSC intervention that focuses on symptom control and patient-centered care is associated with improved total and individual symptom burden in dialysis patients. This supports a role for RSC as a management adjunct in these patients.
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Affiliation(s)
- Amanda N Siriwardana
- Department of Renal Medicine, St George Hospital, Sydney, New South Wales, Australia; Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.
| | - Anna T Hoffman
- Department of Renal Medicine, St George Hospital, Sydney, New South Wales, Australia
| | - Frank P Brennan
- Department of Renal Medicine, St George Hospital, Sydney, New South Wales, Australia
| | - Kelly Li
- Department of Renal Medicine, St George Hospital, Sydney, New South Wales, Australia
| | - Mark A Brown
- Department of Renal Medicine, St George Hospital, Sydney, New South Wales, Australia; University of New South Wales, Sydney, New South Wales, Australia
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Ryan L, Brown E. Supporting and maintaining the frail patient on long-term renal replacement therapy. Clin Med (Lond) 2020; 20:139-141. [PMID: 32188646 DOI: 10.7861/clinmed.2019-0416] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The number of frail patients reaching end-stage kidney disease is increasing. They have a high level of comorbidity and symptom burden which need to be considered when making management plans. For those who choose renal replacement therapy, it is important to establish goals and ceilings of care and to provide holistic care focusing on optimising quality of life. Advance care planning is the process of documenting the patient's preferences for their treatment in the event they lose capacity to make decisions about their treatment.
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Affiliation(s)
- Louise Ryan
- Imperial College Renal and Transplant Centre, London, UK
| | - Edwina Brown
- Imperial College London, London, UK and consultant nephrologist, Imperial College Renal and Transplant Centre, London, UK
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