Journal of Renal Nutrition

Systematic Review of Evidence for the Use of Intradialytic Parenteral Nutrition in Malnourished Hemodialysis Patients

Mhairi K. Sigrist, Adeera Levin, Aaron M. Tejani — 2009-09-29

Objective: Intradialytic parenteral nutrition (IDPN) is widely used to treat malnourished hemodialysis (HD) patients. However, the benefits of this treatment are unknown. Moderate protein-energy malnutrition (PEM) is thought to affect 15% to 43% of maintenance HD patients, and is independently associated with mortality in this population. This study systematically reviews the current literature, to assess whether IDPN improves survival, quality of life, or nutritional status in those receiving maintenance HD.Methods: Two investigators undertook a formal systematic review of the literature, using the following key search words: intradialytic parenteral nutrition or intradialytic total parenteral nutrition plus any combination of renal dialysis or kidney-failure or chronic kidney disease and parenteral nutrition or intravenous nutrition or intravenous feeding.Results: The search identified three suitable randomized, controlled trials, only one of which investigated hard clinical endpoints. There were insufficient data to undertake a meta-analysis.Conclusions: The evidence from clinical studies is insufficient to demonstrate either a net benefit or a net harm associated with the providing IDPN to malnourished HD patients. We recommend that any patient in whom IDPN was deemed necessary be entered into a clinical trial or registry, to record hard clinical outcomes associated with the use of this treatment.

Nutrition Practices of Renal Dietitians in Hemodialysis Centers Throughout the United States: A Descriptive Study

Joyce Marcley Vergili, Randi L. Wolf — 2009-10-01

Objective: Little is known about either the current practices of dietitians in hemodialysis (HD) centers or the practice guidelines that dietitians themselves would like to see developed or revised. This study sought to (1) describe a broad range of nutrition practices among renal dietitians working with adults receiving maintenance HD therapy throughout the United States; (2) determine the extent to which these practices are consistent with professionally accepted guidelines, references, and resources; and (3) ascertain areas in renal nutrition for which dietitians might like the clinical practice guidelines developed or revised.Design: This was a cross-sectional study conducted by postal mail.Participants: A survey was mailed to all domestic members of the Council on Renal Nutrition of the National Kidney Foundation (n=1270). All respondents who identified themselves as renal dietitians working with adult maintenance HD patients in dialysis centers were included in the study.Description: The survey queried dietitians regarding a broad range of nutrition practices, including healthy body weight, adjusted body weight, energy requirements, clinical nutrition indicators, metabolic parameters, fluid management, serum potassium, and vitamin supplementation. Dietitians were also asked which guidelines, if any, they would like developed or revised.Results: A response rate of 68.3% was obtained. The results suggest that (1) there is substantial disparity between renal dietitians' practices and Kidney Disease Outcomes Quality Initiative nutrition guidelines in several areas, e.g., the guidelines on weight and on energy requirements; (2) dietitians' reported practices are congruent with Kidney Disease Outcomes Quality Initiative guidelines regarding metabolic parameters (e.g., diabetes); and (3) there is substantial variability among dietitians in several areas of practice, including determination of interdialytic weight gain goals. The majority of dietitians agreed that new guidelines need to be developed for interdialytic weight gain (64%) and for vitamin supplementation (80%). Among those who indicated that current guidelines need to be revised (n=333), 25% specified guidelines related to weight, and 23% specified guidelines related to energy requirements.Conclusions: This study highlights many areas in need of further research, and identifies areas in which renal dietitians would like practice guidelines developed or revised. As such, it may have implications for organizations such as the Kidney Foundation and the American Dietetic Association in their efforts to promote consistent, evidence-based practices among dietitians.

Serum Retinol, Retinol-Binding Protein, and Transthyretin in Children Receiving Dialysis

Nancy Fassinger, Abubakr Imam, David M. Klurfeld — 2009-07-21

Objective: We investigated the relationships of retinol (ROH), retinol-binding protein (RBP), and transthyretin (TTR) in children with end-stage renal disease (ESRD). Our hypothesis was that levels of ROH and RBP would be elevated in children with ESRD.Methods and Patients: We measured ROH, RBP, and TTR serum concentrations in a group of pediatric ESRD patients biannually. Children were grouped according to age and method of dialysis, i.e., hemodialysis (HD) or peritoneal dialysis (PD): HD1, aged <12 years (n = 8); PD1, aged <12 years (n = 19); HD2, aged ≥12 years (n =19); and PD2, aged ≥12 years (n = 29).Results: No differences in ROH, RBP, TTR, or their ratios were found as a function of type of dialysis in groups PD2 and HD2. The ROH and TTR were significantly higher in PD1 than HD1 (P = .01 and P = .003, respectively). No correlations were evident between ROH and RBP or TTR with length of time on dialysis, serum calcium, or serum creatinine, except for group PD2, in which ROH was positively correlated with RBP (P = .025). There were no significant differences among any of the ratios in terms of age or method of dialysis.Conclusions: The data indicate that children with ESRD exhibit elevated levels of serum ROH, RBP, and TTR, in proportions similar to those reported in the adult ESRD literature. Further study is needed to clarify the consequences of increased ROH in uremic children.

Dietary Intakes and Biochemical Status of B Vitamins in a Group of Children Receiving Dialysis

Tania Don, Stella Friedlander, William Wong — 2009-07-13

Objective: We investigated the dietary intake and biochemical status of B vitamins (thiamin, riboflavin, vitamin B6, and vitamin B12) in a group of mainly unsupplemented children with endstage renal disease receiving dialysis, to determine if B vitamin supplementation is indicated.Design: This was a cross-sectional, observational clinical trial.Setting: Children with endstage renal disease were receiving dialysis, under the care of Renal Services, at Starship Children's Health (Grafton, Auckland, New Zealand).Patients: We studied 12 children (including 7 girls, and 8 children receiving peritoneal dialysis) mean age 7.8 ± 5.3 years (SD).Intervention: Three-day diet records were collected and analyzed with FoodWorks software. Blood was collected for vitamin assay testing.Main Outcome Measure: Dietary intake of B vitamins was measured as a percentage of recommended dietary intake (RDI) or adequate intakes (AIs) for age. Biochemical status was measured as the concentration of each B vitamin compared with reference ranges.Results: Mean intakes from diet alone comprised <100% of the RDI or AI for each B vitamin. Mean intakes, with nutritional support, reached >100% of the RDI or AI for each B vitamin. All children achieved >100% RDI or AI for thiamin, riboflavin, and vitamin B12. Two children who were not receiving nutritional support received <100% of the RDI for vitamin B6. Blood levels of B vitamins were normal to high, compared with reference ranges, for each B vitamin in all children, indicating adequate status.Conclusions: Intakes were adequate in the majority of children. Status was adequate in all children. In this group of children undergoing dialysis, B-vitamin supplementation was not indicated.

Geriatric Nutritional Risk Index as a Screening Tool for Malnutrition in Patients on Chronic Peritoneal Dialysis

2009-07-13

Background: Malnutrition is common among peritoneal dialysis (PD) patients. Recently, the Geriatric Nutrition Risk Index (GNRI) was found to be a reliable tool for screening malnutrition in hemodialysis patients. However, the GNRI has not been validated in PD patients.Methods: We studied 314 unselected, adult PD patients from a single dialysis unit. We compared their GNRI scores with their comprehensive Malnutrition-Inflammation Scores (MIS) and 7-point Subjective Global Assessment (SGA) scores. We randomly selected 106 patients for a repeated assessment, and the changes in their three indices were compared.Results: Baseline GNRI was significantly correlated with MIS (r = −0.487, P < .0001) and SGA (r = 0.234, P < .0001). When MIS ≥6 was defined as malnutrition, the sensitivity and specificity of GNRI ≤93 in predicting malnutrition were 68.0% and 67.7%, respectively. When SGA ≤5 was used to define malnutrition, the sensitivity and specificity were 54.5% and 71.1%, respectively. The change in GNRI was correlated with the change in MIS (r = −0.244, P = .012) and overall SGA score (r = 0.266, P = .006), respectively. When an increase in MIS was defined as a worsening of nutrition, the sensitivity and specificity of GNRI were 45.7% and 81.7%, respectively. When a decrease in SGA was used to define a worsening of nutrition, the sensitivity and specificity were 42.3% and 87.0%, respectively.Conclusions: Although GNRI is significantly correlated with other nutritional indices, it is not sensitive for screening malnutrition in PD patients. Serial measurements of GNRI are also not sensitive in detecting a change in nutritional status. Further study is needed to identify a simple and reliable tool for the assessment and monitoring of nutritional status in PD patients.

Impact of Metabolic Syndrome and Malnutrition on Mortality in Chronic Hemodialysis Patients

2009-05-25

Objective: Metabolic abnormalities contribute to increases in the mortality rate of patients on hemodialysis. Here, we estimate the importance and influence of metabolic syndrome and malnutrition on mortality rate.Design: This was a follow-up study.Methods: We examined the demographic characteristics of time on dialysis, body mass index, indications for hospitalization, treatment outcomes, and biochemical parameters over a 4-year period.Results: Whereas 31.7% of patients had metabolic syndrome, 26.7% showed evidence of malnutrition. More than two thirds of the malnourished patients died. Many patients (46%) with malnutrition were hospitalized because of problems with vascular access, whereas hospitalization of half of the examined patients with metabolic syndrome was attributable to cardiovascular disorders. Differences between groups in the parameters of anemia, total proteins, albumin, and low-density lipoprotein cholesterol also occurred, with the lowest values in malnourished patients. Glycemia, total cholesterol, and fibrinogen were significantly higher in patients with metabolic syndrome, whereas those with malnutrition had a markedly higher concentration of C-reactive protein. The mean survival was 24 months with metabolic syndrome and 17.5 months with malnutrition, which was significantly shorter.Conclusions: More than half of the examined patients had metabolic abnormalities. Patients with malnutrition had a lower rate of survival compared with those who had metabolic syndrome. Two thirds of our malnourished patients died, and the total rate of mortality in the examined sample was 38%.

Assessment of Prealbumin in Hemodialysis and Renal-Transplant Patients

2009-09-04

Objective: This study assessed prealbumin in hemodialysis (HD) and renal-transplant (RT) patients, and compared it with other biochemical and anthropometric markers, clinical conditions, and treatment variables.Design: We used a research design.Patients: Serum prealbumin was measured in 84 HD patients with a mean age of 60.47 ± 17.81 years and a mean body mass index (BMI) of 24.38 ± 4.87 kg/m2, and in 154 RT patients with a mean age of 44.08 ± 13.59 years and a mean BMI of 24.97 ± 3.87 kg/m2. Renal-transplant patients were divided into three groups, based on year of renal transplantation (first year, first to second year, and third to tenth year). Serum albumin, creatinine, cholesterol, glucose, triglycerides, white blood cells, BMI, midarm circumference, and triceps and biceps skinfolds were measured.Results: Prealbumin levels were significantly higher in HD patients compared with RT patients. Both groups had prealbumin levels <30 mg/dL, but almost all RT patients in our study had prealbumin levels <20 mg/dL. Gender, age, and presence of anemia, hypertension, and diabetes did not significantly affect prealbumin levels in the two groups. Prealbumin levels were significantly positively correlated with duration of dialysis in the HD group and with albumin in the RT group.Conclusions: Hemodialysis patients have higher levels of prealbumin compared with RT patients. Prealbumin levels are below normal range in both groups of patients. Prealbumin reflects nutritional status in RT patients, but is also affected by other factors.

Report of a Pilot, Double-Blind, Placebo-Controlled Study of Megestrol Acetate in Elderly Dialysis Patients With Cachexia

2009-10-12

Objective: We examined the effects of megestrol acetate versus placebo and progressive resistance physical exercise on weight, lean muscle mass, quality of life, ability to exercise, proinflammatory cytokines, and anti-inflammatory cytokines, and their correlations with one another.Design: We organized a prospective 20-week, randomized, double-blind, placebo-controlled pilot trial of hemodialysis patients.Setting: This study took place at the Outpatient Unit of the Northport Veteran Affairs Medical Center.Subjects: We studied nine male hemodialysis patients who had two or more of the following: albumin level <4.0 g/dL, total cholesterol <150 mg/dL, protein catabolic rate <0.8 g/kg/day, and predialysis serum urea nitrogen <60 mg/dL. Their ages were 50 to 83 years. Two were diabetic, and seven were nondiabetic.Interventions: Interventions included megestrol acetate (MA) or placebo 800 mg oral daily for 20 weeks, along with weight resistance physical therapy with weights twice a week before dialysis. Patients were followed prospectively for an additional 4 weeks.Main Outcome Measurements: Weight, body composition, activities of daily living, ability to exercise, and plasma cytokine levels were measured.Results: At 24 weeks, the MA group had a statistically significant weight gain (11.1-pound increase vs. 1.5-pound decrease for the placebo group, P = .018), body fat gain (6.2-pound increase vs. a 0.4-pound decrease for the placebo group, P = .044) and fat-free mass gain (5-pound increase vs. a 1.2-pound decrease in the placebo group). The MA group also had a greater tendency toward increased appetite and sense of well-being. The MA group showed a greater improvement in ability to exercise (mean change in rate of perceived exertion (RPE), 4.7) vs. the placebo group (mean change in RPE vs. 0.5, P = .02). Elevated cytokine levels were evident at baseline in both groups. In all patients, increases in weight, fat-free mass, sense of well-being, appetite, and ability to exercise were negatively correlated with tumor necrosis factor receptor subunit p75 (P < .05). There was a trend toward all of these parameters to be negatively correlated with tumor necrosis factor receptor subunit p55, although only sense of well-being was statistically significant (P < .05).Conclusion: In a pilot trial in dialysis patients, MA showed significant benefits in improving weight and ability to exercise. Cytokine changes were correlated with weight gains and increases in fat-free mass.

Coming Together

Karen Wiesen — 2010-01-01

The Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Registered Dietitians in Nephrology Care were released in September 2009, and published in the Journal of the American Dietetic Association and in the online version of the Journal of Renal Nutrition. This marked the completion of a 3-year joint project between the National Kidney Foundation Council on Renal Nutrition (NKF-CRN) and the American Dietetic Association Renal Practice Group (ADA-RPG). The SOP and SOPP provide a framework to help us evaluate our individual practices, and guide us in deciding our next steps in professional development and ongoing education, whether we are new renal dietitians or experienced professionals. The two standards are also a tool for demonstrating individual competence in delivering nutrition services. The SOP and SOPP answer the question, “What skills, competencies, and knowledge must renal dietitians possess to provide safe and effective care in nephrology nutrition?”

Meeting Announcements

2010-01-01

Continuous Renal Replacement Therapies (CRRT) 2010 Conference, February 24–27, 2010, Hotel del Coronado, San Diego, California. Visit www.crrtonline.com/conference/ or call 858-272-1018.

Water, Water Everywhere, But What to Drink? An Update on Hidden Phosphorus in Popular Beverages

Lisa Gutekunst — 2010-01-01

PRACTITIONERS in the field of chronic kidney disease (CKD) are more aware of the dangers of hidden phosphorus. Articles published in the Journal of Renal Nutrition and other peer-reviewed journals have helped healthcare professionals identify foods containing hidden phosphorus, and provide information on the most common phosphate additives and their uses. Awareness of this new and growing danger has stimulated further research into the phosphate-additive content of foods. In 2002, the Journal of Renal Nutrition published “Hidden Phosphorus in Popular Beverages,” which focused on the dangers of hidden phosphorus in beverages that were once considered “safe” for CKD patients. Since then, more “new and improved” beverages have entered the market, further complicating renal diets and limiting choices for the CKD population. Keeping up with the appropriateness of these beverages for the CKD population is difficult because of the number of new products and the lack of phosphate contents on nutrition labels. This update describes the phosphorus content of popular beverages, and provides information on other popular beverages that contain phosphate additives.

Masthead

2010-01-01

Editorial Board

2010-01-01

Guidelines for Contributing Authors

2010-01-01

Journal of Renal Nutrition

Systematic Review of Evidence for the Use of Intradialytic Parenteral Nutrition in Malnourished Hemodialysis Patients

Nutrition Practices of Renal Dietitians in Hemodialysis Centers Throughout the United States: A Descriptive Study

Serum Retinol, Retinol-Binding Protein, and Transthyretin in Children Receiving Dialysis

Dietary Intakes and Biochemical Status of B Vitamins in a Group of Children Receiving Dialysis

Geriatric Nutritional Risk Index as a Screening Tool for Malnutrition in Patients on Chronic Peritoneal Dialysis

Impact of Metabolic Syndrome and Malnutrition on Mortality in Chronic Hemodialysis Patients

Assessment of Prealbumin in Hemodialysis and Renal-Transplant Patients

Report of a Pilot, Double-Blind, Placebo-Controlled Study of Megestrol Acetate in Elderly Dialysis Patients With Cachexia

Coming Together

Meeting Announcements

Water, Water Everywhere, But What to Drink? An Update on Hidden Phosphorus in Popular Beverages

Masthead

Editorial Board

Table of Contents

Guidelines for Contributing Authors