Journal of Renal Nutrition RSS feed: Current Issue. The Journal of Renal Nutrition is devoted exclusively to renal nutrition science and renal dietetics. Its content is appropriate for nutritionists, physicians and researchers working in nephrology. Each issue contains a state-of-the-art review, original research, articles on the clinical management and education of patients, a current literature review, and nutritional analysis of food products that have clinical relevance.http://www.jrnjournal.org/?rss=yesElsevier Inc.en © 2010 National Kidney Foundation, Inc. Published by Elsevier Inc All rights reserved. Journal of Renal Nutrition1051-2276205September 2010 © 2010 National Kidney Foundation, Inc. Published by Elsevier Inc All rights reserved. healthpermissions@elsevier.comhttp://www.jrnjournal.org/article/PIIS1051227610000816/abstract?rss=yesObjective: The primary objective of this systematic review was to determine the relationship between body mass index (BMI) and all-cause and cardiovascular mortality.Design: Systematic review of primarily observational studies.Patients: Adult patients from all gender, race, or ethnic groups on maintenance hemodialysis.Methods: Medline, Science Citation Index, Academic Search Premier, Cochrane Library, and Embase electronic databases covering the period 1966 to December 2008 were searched with the help of a qualified librarian. Reference lists of included papers and collections also were searched. Each study was reviewed by 2 independent reviewers who also performed the data extraction from full papers. Differences between reviewers were resolved by consensus or by a third reviewer in the case of disagreements. The quality of studies selected for inclusion in the systematic review was also assessed by 2 independent reviewers.Main Outcomes: BMI and mortality.Results: Eighteen studies (60%) reported a significant inverse relationship between all-cause mortality and BMI. This inverse relationship was more prevalent in older patients, larger retrospective studies, and studies that did not adjust for inflammation. On the other hand, 57% of the 7 studies reporting on cardiovascular mortality found no significant relationship with BMI.Conclusions: This systematic review shows evidence of an inverse relationship between BMI and all-cause mortality in adult patients on maintenance HD, especially in older patients, but the relationship with cardiovascular mortality is less clear.Relationship Between Body Mass Index and Mortality in Adults on Maintenance Hemodialysis: A Systematic ReviewMarietjie Herselman, Nazeema Esau, Jean-Marie Kruger, Demetre Labadarios, Mohammed Rafique Moosa10.1053/j.jrn.2010.03.010Journal of Renal Nutrition 20, 5 (2010)2010-06-28Journal of Renal Nutrition2010-06-28205S1051-2276(10)X0005-XReview281292.e7http://www.jrnjournal.org/article/PIIS1051227610000063/abstract?rss=yesObjective: We sought to assess whether the use of folic acid vitamin supplements reduced cardiac and stroke mortality in hemodialysis patients. Further, we examined whether the consumption of folic acid from vitamin supplements >1000 μg compared with the standard 1000 μg, and 1000 μg compared with either a lower dose or no consumption, were associated with reduced cardiac and stroke mortality risk.Design: We performed a secondary analysis of data from the Hemodialysis Study, a randomized clinical trial examining dialysis treatment regimens over a 3-year follow-up.Participants: Participants included 1846 hemodialysis patients previously participating in the Hemodialysis Study.Interventions: There were no interventions.Main Outcome Measure: Cardiac and stroke mortality were our main outcome measures.Results: Based on time-dependent Cox proportional hazard regression models, folic acid consumption from vitamin supplements, above or below the standard 1000-μg dose, was not associated with a decrease or increase in cardiac mortality (P = .53, above vs. standard dose; P = .46, below vs. standard dose). There was also no association between folic acid consumption and mortality from stroke (P = .27, above vs. standard dose; P = .64, below vs. standard dose).Conclusion: The consumption of higher than the standard 1000-μg prescribed dose of folic acid was not beneficial in reducing cardiac or stroke mortality in hemodialysis patients. Similarly, the consumption of less than the standard dose was not associated with an increase in either cardiac or stroke mortality.Folic Acid Supplementation and Cardiac and Stroke Mortality among Hemodialysis PatientsJune Leung, Brett Larive, Johanna Dwyer, Patricia Hibberd, Paul Jacques, William Rand, HEMO Study Group10.1053/j.jrn.2010.01.005Journal of Renal Nutrition 20, 5 (2010)2010-03-22Journal of Renal Nutrition2010-03-22205S1051-2276(10)X0005-XOriginal Research293302http://www.jrnjournal.org/article/PIIS1051227609002830/abstract?rss=yesObjectives: The aim of this study was to investigate the serum concentration of adipokines, such as leptin, adiponectin, and resistin, and assess its relation to nutritional and inflammatory parameters in both overweight and normal weight patients on maintenance hemodialysis.Methods: A total of 36 hemodialysis patients (27 M, 9 F; mean age 55.3 ± 12 yr.) were examined and 23 additional healthy volunteers were recruited as the control group. The concentrations of leptin, leptin receptor, adiponectin, resistin, IL-6, TNFa and CRP were measured by ELISA. Assessment of nutritional status was determined by the levels of albumin, BMI, percentage of body fat (%F), lean body mass (LBM), and Subjective Global Assessment Score (SGA).Results: According to the SGA 7-points score and the albumin level, 20 patients were of good nutritional status (6-7 points), while 16 patients were mildly malnourished (4-5 points). The concentrations of CRP, resistin, adiponectin, and TNFa were statistically higher in hemodialysis patients than in the control group (p£0.05). The adiponectin level was inversely correlated with %F (R Spearman=-0.3; p £ 0.05). The level of leptin was positively correlated with %F as well as with BMI and SGA scores (R Spearman=0.4; p£0.05). Although there was no significant difference in the nutritional status between the nonoverweight (BMI 18.5-24.99) and overweight (BMI 325.0) groups of patients, in the nonoverweight group there were 12 patients (54.5%) with signs of mild malnutrition compared to 4 malnourished patients (28.5%) in the overweight group. Nonoverweight patients presented significantly lower leptin concentration (12.7 vs 27.8 ug/l) and higher adiponectin level (38.9 vs 32.5 ng/ml) when compared to overweight patients. The levels of IL-6 and TNFa were higher in the nonoverweight group of patients. Overweight patients also had shorter durations of stay in the hemodialysis program (30.5 vs. 87.6 months).Conclusion: The results of our study indicate that lean hemodialysis patients are more prone to malnutrition and inflammation. The increased levels of leptin and decreased levels of adiponectin in the overweight hemodialysis patients support the idea of a reverse epidemiology phenomenon in this group of patients.Adipokines and Nutritional Status for Patients on Maintenance HemodialysisS. Małgorzewicz, E. Aleksandrowicz-Wrona, A. Owczarzak, A. Dębska-Ślizień, B. Rutkowski, W. Łysiak-Szydłowska10.1053/j.jrn.2009.10.005Journal of Renal Nutrition 20, 5 (2010)2010-01-13Journal of Renal Nutrition2010-01-13205S1051-2276(10)X0005-XOriginal Research303308http://www.jrnjournal.org/article/PIIS1051227610000087/abstract?rss=yesObjective: The present study was designed to investigate the effect of a single purple grape juice administration on cyclosporin A (CyA) oral bioavailability in healthy volunteers.Design: The study followed a two-period crossover design, where the volunteers were randomly assigned to receive 200-mg CyA soft-gelatin capsules with 200 mL of either purple grape juice or water in the first day of the experiment.Setting and Patients: Volunteers were kept at the clinical research unit during the blood sampling period and fasted from 10 p.m. until 4 hours after dosing. A washout period of 1 week was observed before the second treatment was administered.Main Outcome Measure: Blood samples were taken before and at 0.5, 1, 1.5, 2, 2.5, 3, 4, 6, 8, 10, and 12 hours after CyA dosing. All meals received during the study day were standardized. Whole blood was assayed to determined CyA concentration using the Emit 2000 Cyclosporine specific immunoassay (Dade Behring Limited, Syva Company, Dade Behring Inc. Cupertino, CA). Pharmacokinetic parameters were determined by noncompartmental analysis from the individual whole blood concentration-time curves after each treatment using Excel 2003 software. Statistical analysis was performed using paired Student t-test (a 5 .05) with the aid of SAS software.Results: Twelve healthy male volunteers were enrolled in the study, with a mean age of 20.6 years (range 19 -23 years). Purple grape juice significantly decreased cyclosporine AUC by 30% and Cmax by 28%. The time to peak blood level and elimination half-life of the drug, however, were not affected. The clearance determined increased around 50%, with purple grape juice. CyA half-life was not affected, indicating that the change observed in clearance (CL/F) was probably due to a change in the absorption (bioavailability) rather than in the elimination process after administration with purple grape juice.Conclusion: Purple grape juice decreased AUC and Cmax, whereas half-life was not changed, suggesting that juice affects the absorption and not drug elimination. The above findings are similar to previous data on the effects on CyA pharmacokinetics caused by the ingestion of red wine. Our findings are potentially relevant in the clinic. The intake of CyA with purple grape juice should be discouraged, as drug bioavailability can be decrease by 30%, leading to blood levels below the drug therapeutic window. A free interval of at least 2 hours between CyA intake and purple juice drinking is recommended.Influence of Purple Grape Juice in Cyclosporine BioavailabilityVera L. Oliveira-Freitas, Teresa Dalla Costa, Roberto C. Manfro, Luciane B. Cruz, Gilberto Schwartsmann10.1053/j.jrn.2010.01.007Journal of Renal Nutrition 20, 5 (2010)2010-03-22Journal of Renal Nutrition2010-03-22205S1051-2276(10)X0005-XOriginal Research309313http://www.jrnjournal.org/article/PIIS1051227610000099/abstract?rss=yesObjective: Bioelectrical impedance analysis (BIA) is a fast, noninvasive method for assessing body composition, and its role in the evaluation of nutritional status in haemodialysis (HD) has been studied. This study aimed to compare BIA parameters to clinical, biochemical, and anthropometric markers of nutrition in HD patients, such as subjective global assessment modified for renal disease (SGA-1), serum albumin, body mass index (BMI), percent of standard body weight (%SBW), deviation of triceps skinfold thickness (TSF), mid-arm circumference (MAC), mid-arm muscle circumference (MAMC) from the standard value (50th percentile), anthropometry-derived fat (FM-A), and fat-free mass (FFM-A).Methods: BIA was performed 30 minutes after a HD session and the reactance (Xc), resistance (R), phase angle (PA), body cell mass (BCM), fat mass (FM-BIA), and fat-free mass (FFM-BIA) values were recorded. The prevalence of malnutrition was estimated according to PA and percent of BCM. The correlation between methods was assessed through Pearson's correlation coefficient and Bland and Altman analysis.Results: A total of 58 patients were studied (30 women and 28 men; mean age of 49.2 ± 14.8 years). The mean PA was 6.19 ± 1.33 degrees and the mean percent of BCM was 33.75 ± 5.91%. The prevalence of malnutrition was 17.5% and 43.9% according to the PA and percent of BCM, respectively. PA had a negative correlation with age and SGA-1 score and a positive correlation with percent SBW, MAC, MAMC, FFM-A, and albumin. Percent of BCM had a negative correlation with age, MAC, MAMC and FM-A and a positive correlation with FFM-A and albumin. A significant correlation between FFM-A and FFM-BIA was observed, as well as between FM-A and FM-BIA.Conclusions: BIA indexes reflected nutritional state. PA and BCM seem to be less influenced by changes in volume and can be used for nutritional assessments of dialysis patients.The Phase Angle and Mass Body Cell as Markers of Nutritional Status in Hemodialysis PatientsClaudia M.C. Oliveira, Marcos Kubrusly, Rosa S. Mota, Carlos A.B. Silva, Gabriel Choukroun, Valzimeire N. Oliveira10.1053/j.jrn.2010.01.008Journal of Renal Nutrition 20, 5 (2010)2010-03-22Journal of Renal Nutrition2010-03-22205S1051-2276(10)X0005-XOriginal Research314320http://www.jrnjournal.org/article/PIIS1051227610000038/abstract?rss=yesObjective: We sought to evaluate the effects of omega-3 polyunsaturated fatty-acid (PUFA) supplementation on dyslipidemia, lipid and protein peroxidation, and antioxidant defense in patients with chronic renal failure (CRF).Design: Eighty patients with CRF were diagnosed in the hospital of Oran between January 2008 and April 2008. Forty patients (male/female, 22/18; aged 61 ± 14 years, S.D.) were available for the study. They presented with dyslipidemia and hypertriglyceridemia (triacylglycerols, >1.7 mmol/L) and/or hypercholesterolemia (total cholesterol, >5 mmol/L).Intervention: All patients received nutritional counsel adapted to CRF, i.e., energy intake of .12 megajoule · kg−1 · body weight · day−1, protein intake of .8 g · kg−1 · body weight · day−1, and lipid intake of 35% of total energy intake with 28% PUFAs, 37% monounsaturated fatty acids, and 35% saturated fatty acids. Patients were randomized into two groups: 20 received supplementation with omega-3 fish oil (2.1 g · day−1) for 90 days, and 20 were used as controls. To control the counsel monitoring, a nutritional survey was performed at baseline and at 12 weeks. Blood samples were drawn at the beginning (T0), at 30 days (T1), at 60 days (T2), and at 90 days (T3) after initiating treatment.Results: In the omega-3 group, a reduction in triacylglycerol levels was evident at T1 (−43%), T2, and T3 (−48%). Thiobarbituric acid-reactive substances were at lower levels at T1 and T3. There was no significant difference in carbonyl values, whereas serum superoxide dismutase and glutathione peroxidase activities were increased at T1, T2, and T3. High catalase activity was evident at T2 and T3.Conclusion: Omega-3 supplementation improves hypertriglyceridemia and oxidative stress in patients with CRF, and may lead to decreased rates of cardiovascular complications.Effects of Omega-3 Polyunsaturated Fatty-Acid Supplementation on Redox Status in Chronic Renal Failure Patients With DyslipidemiaNassima Bouzidi, Khedidja Mekki, Ali Boukaddoum, Nawel Dida, Abbou Kaddous, Malika Bouchenak10.1053/j.jrn.2010.01.002Journal of Renal Nutrition 20, 5 (2010)2010-03-22Journal of Renal Nutrition2010-03-22205S1051-2276(10)X0005-XResearch Briefs321328http://www.jrnjournal.org/article/PIIS105122761000004X/abstract?rss=yesObjective: With growing recognition of the role of inflammation in the development of chronic and acute disease, fish oil is increasingly used as a therapeutic agent, but the nature of the intervention may pose barriers to adherence in clinical populations. Our objective was to investigate the feasibility of using a fish oil supplement in hemodialysis patients.Design: This was a nonrandomized intervention study.Setting: Eligible patients were recruited at the Hemodialysis Unit of Wesley Hospital, Brisbane, Queensland, Australia.Patients: The sample included 28 maintenance hemodialysis patients out of 43 eligible patients in the unit. Exclusion criteria included patients regularly taking a fish oil supplement at baseline, receiving hemodialysis for less than 3 months, or being unable to give informed consent.Intervention: Eicosapentaenoic acid (EPA) was administered at 2000 mg/day (4 capsules) for 12 weeks. Adherence was measured at baseline and weekly throughout the study according to changes in plasma EPA, and was further measured subjectively by self-report.Results: Twenty patients (74%) adhered to the prescription based on changes in plasma EPA, whereas an additional two patients self-reported good adherence. There was a positive relationship between fish oil intake and change in plasma EPA. Most patients did not report problems with taking the fish oil. Using the baseline data, it was not possible to characterize adherent patients.Conclusions: Despite potential barriers, including the need to take a large number of prescribed medications already, 74% of hemodialysis patients adhered to the intervention. This study demonstrated the feasibility of using fish oil in a clinical population.Adherence to Fish Oil Intervention in Patients With Chronic Kidney DiseaseRachel Zabel, Susan Ash, Neil King, Judith Bauer10.1053/j.jrn.2010.01.003Journal of Renal Nutrition 20, 5 (2010)2010-03-22Journal of Renal Nutrition2010-03-22205S1051-2276(10)X0005-XResearch Briefs329333http://www.jrnjournal.org/article/PIIS1051227609002416/abstract?rss=yesObjective: We sought to describe the perspectives and experiences of chronic hemodialysis (CHD) patients regarding self-care and adherence to fluid restrictions.Design: Semistructured focus groups.Setting: Two outpatient hemodialysis centers.Participants: Nineteen patients on chronic hemodialysis.Intervention: Patients were asked a series of open-ended questions to encourage discussion about the management of fluid restriction within the broad categories of general knowledge, knowledge sources or barriers, beliefs and attitudes, self-efficacy, emotion, and self-care skills.Main outcome measure: We analyzed session transcripts using the theoretical framework of content analysis to identify themes generated by the patients.Results: Patients discussed both facilitators and barriers to fluid restriction, which we categorized into six themes: knowledge, self-assessment, psychological factors, social, physical, and environmental. Psychological factors were the most common barriers to fluid restriction adherence, predominantly involving lack of motivation. Knowledge was the most discussed facilitator with accurate self-assessment, positive psychological factors, and supportive social contacts also playing a role. Dialysis providers were most commonly described as the source of dialysis information (54%), but learning through personal experience was also frequently noted (28%).Conclusion: Interventions to improve fluid restriction adherence of chronic hemodialysis patients should target motivational issues, assess and improve patient knowledge, augment social support, and facilitate accurate self-assessment of fluid status.Patient Perspectives on Fluid Management in Chronic HemodialysisKimberly Smith, Melinda Coston, Kimberly Glock, Tom A. Elasy, Kenneth A. Wallston, T. Alp Ikizler, Kerri L. Cavanaugh10.1053/j.jrn.2009.09.001Journal of Renal Nutrition 20, 5 (2010)2009-11-16Journal of Renal Nutrition2009-11-16205S1051-2276(10)X0005-XResearch Briefs334341http://www.jrnjournal.org/article/PIIS1051227610000774/abstract?rss=yesIn studies involving dietary supplements, when use is indicated, missing data on dosage and frequency of use are common, making it more difficult to demonstrate associations between supplements and health outcomes. Furthermore, the contribution of supplements to nutrient intakes is often considerable, and so missing data distorts not only estimates of supplements but also of total nutrient intake. If individuals with missing dietary supplement dosage data are dropped, total nutrient intakes may be seriously underestimated or biased. Also, when data are missing, sample size is reduced and the efficiency of the data analyses decline. Therefore, it is imperative that missing doses be accounted for appropriately. Imputation is a valuable technique for handling missing values that, if done appropriately, reduces bias and improves the robustness and power of statistical analyses. Developing the appropriate imputation technique is an exercise involving the examination of the dataset, assessment of the missing data (whether data is missing at random or not), stating the appropriate assumptions, using the techniques properly, and retaining clinical relevance in the process. Remedies for missing data such as adopting a single default may be insufficient. More elaborate imputation strategies must be considered that employ a variety of techniques, and then the dataset with the imputed values is analyzed. Imputation is helpful, but this always involves risks and costs. This letter reviews some of the special challenges and considerations in using imputation in dietary supplement studies. This letter refers to the paper by Leung et al entitled “Folic Acid Supplementation and Cardiac and Stroke Mortality among Hemodialysis Patients” on page 293 in this issue, where various imputation methods were examined and one selected to be employed in the study.Imputation Methods for Handling Missing Dietary Supplement Dosage DataJune Leung, Johanna Dwyer, Patricia Hibberd, Paul Jacques, William Rand10.1053/j.jrn.2010.03.006Journal of Renal Nutrition 20, 5 (2010)2010-06-28Journal of Renal Nutrition2010-06-28205S1051-2276(10)X0005-XLetter to the Editor342347http://www.jrnjournal.org/article/PIIS105122761000169X/abstract?rss=yes“It is not the strongest of the species that survives, nor the most intelligent, but rather the one most responsive to change.”C. Darwin It is Fall already. Time for school and football season to begin. It is also time for new rules in the dialysis sector. The final ruling on the Bundled Prospective Payment System for dialysis had not yet been released when this issue of JREN went to press, therefore that might be a subject for a future Chair message. However, by the time this editorial is read, that final ruling should have been released, meaning that many of us will again be looking at having to adjust to changes in the workplace. As with the 2008 Conditions of Coverage, there will be a learning curve as everyone adjusts to the changes that bundling will most likely bring to the dialysis community.The Winds of ChangeKaren Wiesen10.1053/j.jrn.2010.06.018Journal of Renal Nutrition 20, 5 (2010)2010-09-01Journal of Renal Nutrition2010-09-01205S1051-2276(10)X0005-XMessage from the Chairperson348349http://www.jrnjournal.org/article/PIIS1051227610001676/abstract?rss=yesThe 39th European Dialysis and Transplant Nurses Association/European Renal Care (EDTNA/ERCA) International Conference, September 18–21, 2010, Dublin, Ireland. Visit www.edtnaerca.org/or call +420-261-174-318.September 2010 Meeting Announcements10.1053/j.jrn.2010.06.016Journal of Renal Nutrition 20, 5 (2010)2010-09-01Journal of Renal Nutrition2010-09-01205S1051-2276(10)X0005-XAnnouncements350350http://www.jrnjournal.org/article/PIIS1051227609002799/abstract?rss=yesThe prevalence of overweight and obesity in the renal population is increasing at an exponential rate proportionate to the prevalence seen in the general U.S. population. Dialysis units and transplant centers alike are faced with an estimated majority of patients (60%) awaiting transplantation who considered overweight or obese. Obesity as reflected by a body mass index (BMI) of 30kg/m2 or over is associated with increased morbidity from hypertension, dyslipidemia, type 2 diabetes, congestive heart disease, stroke, gallbladder disease, osteoarthritis, sleep apnea and respiratory problems, and certain types of cancer. Obesity is attributable to premature death and an increase in all-cause mortality.Weight Management Tips for Patients on HemodialysisStacey Hickel10.1053/j.jrn.2009.10.001Journal of Renal Nutrition 20, 5 (2010)2010-03-04Journal of Renal Nutrition2010-03-04205S1051-2276(10)X0005-XPatient Educatione21e22http://www.jrnjournal.org/article/PIIS1051227610001688/abstract?rss=yesBreakfast is the most important meal of the day. How often have we heard this and how often have we educated our patients on the importance of breakfast? Ready-to-eat cereals are popular, quick, and easy breakfast foods for patients of all ages. It is our job to help patients choose a cereal that fits well into their renal diet while helping them wade through claims regarding fiber, whole grains, vitamins, and minerals. With respect to cereals geared toward children, there may be concerns that some of them are high sugar containing, presweetened foods. However, other cereals might provide a way to increase the uptake of fiber and vitamins as well as provide increased choices in an already limited diet. Armed with the proper information, we can help patients choose the right cereal.Cereal Choices to Start the Day RightKristin Sheridan10.1053/j.jrn.2010.06.017Journal of Renal Nutrition 20, 5 (2010)2010-09-01Journal of Renal Nutrition2010-09-01205S1051-2276(10)X0005-XProduct Updatee23e28http://www.jrnjournal.org/article/PIIS1051227610001871/abstract?rss=yesMasthead10.1053/S1051-2276(10)00187-1Journal of Renal Nutrition 20, 5 (2010)2010-09-01Journal of Renal Nutrition2010-09-01205S1051-2276(10)X0005-XFrontmatterA3A3http://www.jrnjournal.org/article/PIIS1051227610001883/abstract?rss=yesEditorial Board10.1053/S1051-2276(10)00188-3Journal of Renal Nutrition 20, 5 (2010)2010-09-01Journal of Renal Nutrition2010-09-01205S1051-2276(10)X0005-XFrontmatterA4A4http://www.jrnjournal.org/article/PIIS1051227610001901/abstract?rss=yesTable of Contents10.1053/S1051-2276(10)00190-1Journal of Renal Nutrition 20, 5 (2010)2010-09-01Journal of Renal Nutrition2010-09-01205S1051-2276(10)X0005-XFrontmatterA7A8http://www.jrnjournal.org/article/PIIS1051227610001913/abstract?rss=yesGuidelines for Contributing Authors10.1053/S1051-2276(10)00191-3Journal of Renal Nutrition 20, 5 (2010)2010-09-01Journal of Renal Nutrition2010-09-01205S1051-2276(10)X0005-XFrontmatterA11A12