Journal of Renal Nutrition - Articles in Press

Body Mass Index, Coronary Artery Calcification, and Kidney Function Decline in Stage 3 to 5 Chronic Kidney Disease Patients - Corrected Proof

2012-04-30

Objective: To determine whether body mass index (BMI) and coronary artery calcification (CAC) are risk factors for kidney function decline in predialysis chronic kidney disease (CKD) patients.Design: Prospective cohort study of 125 stage 3 to 5 predialysis CKD patients.Subjects and Setting: CKD patients receiving care in Kingston, Ontario, Canada.Methods: BMI, CAC, and kidney function were measured at baseline. CAC was measured by multislice computed tomography scan. Kidney function was determined by the 4-variable reexpressed Modification of Diet in Renal Disease Study equation. At study end, kidney function decline among patients was compared according to baseline BMI and CAC.Main Outcome: Kidney function decline was defined as a 1-year decline in estimated glomerular filtration rate (eGFR) of ≥5%.Results: Individuals with a decline in eGFR of ≥5% at 1 year had higher baseline BMI (33.5 ± 8.3 vs. 28.4 ± 4.9 kg/m2; P = .0001) and higher baseline median CAC scores (239 vs. 25 Agatston units; P = .01) compared with subjects without such a decline. BMI (r = 0.35; P < .0001) and logarithmically transformed CAC score (r = 0.22; P = .01) correlated with an eGFR decline of ≥5%. Both crude and adjusted logistic regression analyses showed escalating CAC (with CAC reported in quintiles and CAC score = 0 Agatston unit as the reference group) was associated with an increased risk of eGFR decline of ≥5%.Conclusions: CAC and BMI were associated with kidney function decline over 1 year. The risk of kidney function decline was greater in those with increasing burden of CAC, which remained robust in the adjusted analysis accounting for the risk factors for CKD progression. Larger studies will be required for independent validation of the associations of BMI, CAC, and kidney function decline, and to investigate whether obesity and CAC treatment strategies are efficacious in attenuating kidney function decline in predialysis CKD patients.

Implementation and Practical Application of the Nutrition Care Process in the Dialysis Unit - Corrected Proof

Debra Memmer — 2012-04-23

The Nutrition Care Process (NCP) was introduced in 2003 (Lacey and Pritchett, J Am Diet Assoc. 2003;103:1061-1071). Since then, dietitians have been encouraged to incorporate the NCP into their daily practice, yet it has not been totally adopted in all dialysis units (Dent and McDuffie, J Ren Nutr. 2011;1:205-207). The renal dietitian has the benefit of being able to follow-up with the dialysis patient on a monthly basis. During these monthly visits, as information unfolds, a unique relationship culminates with the dialysis patient. The NCP allows the dietitian to make precise nutrition diagnoses, which reflect the complexity of the renal dietitian’s involvement with the dialysis patient. The purpose of this article is to provide a brief description of the NCP as it relates to dialysis, offer a framework on how to begin using the NCP in the dialysis unit, and provide an example of a monthly nutrition note.

Plant Protein Intake is Associated With Fibroblast Growth Factor 23 and Serum Bicarbonate Levels in Patients With Chronic Kidney Disease: The Chronic Renal Insufficiency Cohort Study - Corrected Proof

2012-04-06

Background: Protein from plant, as opposed to animal, sources may be preferred in chronic kidney disease (CKD) because of the lower bioavailability of phosphate and lower nonvolatile acid load.Study Design: Observational cross-sectional study.Setting and Participants: A total of 2,938 participants with CKD and information on their dietary intake at the baseline visit in the Chronic Renal Insufficiency Cohort Study.Predictors: Percentage of total protein intake from plant sources (percent plant protein) was determined by scoring individual food items using the National Cancer Institute Diet History Questionnaire (DHQ).Outcomes: Metabolic parameters, including serum phosphate, bicarbonate (HCO3), potassium, and albumin, plasma fibroblast growth factor 23 (FGF-23), and parathyroid hormone (PTH), and hemoglobin levels.Measurements: We modeled the association between percent plant protein and metabolic parameters using linear regression. Models were adjusted for age, sex, race, diabetes status, body mass index, estimated glomerular filtration rate, income, smoking status, total energy intake, total protein intake, 24-hour urinary sodium concentration, use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and use of diuretics.Results: Higher percent plant protein was associated with lower FGF-23 (P = .05) and higher HCO3 (P = .01) levels, but not with serum phosphate or parathyroid hormone concentrations (P = .9 and P = .5, respectively). Higher percent plant protein was not associated with higher serum potassium (P = .2), lower serum albumin (P = .2), or lower hemoglobin (P = .3) levels. The associations of percent plant protein with FGF-23 and HCO3 levels did not differ by diabetes status, sex, race, CKD stage (2/3 vs. 4/5), or total protein intake (≤0.8 g/kg/day vs. >0.8 g/kg/day; P-interaction >.10 for each).Limitations: This is a cross-sectional study; determination of percent plant protein using the Diet History Questionnaire has not been validated.Conclusions: Consumption of a higher percentage of protein from plant sources may lower FGF-23 and raise HCO3 levels in patients with CKD.

Bioelectrical Impedance Analysis and Skinfold Thickness Sum in Assessing Body Fat Mass of Renal Dialysis Patients - Corrected Proof

2012-04-01

Objective: In chronic renal failure patients under hemodialysis (HD) treatment, the availability of simple, safe, and effective tools to assess body composition enables evaluation of body composition accurately, in spite of changes in body fluids that occur in dialysis therapy, thus contributing to planning and monitoring of nutritional treatment. We evaluated the performance of bioelectrical impedance analysis (BIA) and the skinfold thickness sum (SKF) to assess fat mass (FM) in chronic renal failure patients before (BHD) and after (AHD) HD, using air displacement plethysmography (ADP) as the standard method.Design: This single-center cross-sectional trial involved comparing the FM of 60 HD patients estimated BHD and AHD by BIA (multifrequential; 29 women, 31 men) and by SKF with those estimated by the reference method, ADP. Body fat-free mass (FFM) was also obtained by subtracting the total body fat from the individual total weight.Results: Mean estimated FM (kg [%]) observed by ADP BHD was 17.95 ± 0.99 kg (30.11% ± 1.30%), with a 95% confidence interval (CI) of 16.00 to 19.90 (27.56 to 32.66); mean estimated FM observed AHD was 17.92 ± 1.11 kg (30.04% ± 1.40%), with a 95% CI of 15.74 to 20.10 (27.28 to 32.79). Neither study period showed a difference in FM and FFM (for both kg and %) estimates by the SKF method when compared with ADP; however, the BIA underestimated the FM and overestimated the FFM (for both kg and %) when compared with ADP.Conclusion: The SKF, but not the BIA, method showed results similar to ADP and can be considered adequate for FM evaluation in HD patients.

Metabolic Disorders Following Kidney Transplantation - Corrected Proof

Stacey Phillips, Rochelle Heuberger — 2012-03-26

Kidney transplantation in patients suffering from end-stage renal disease, although beneficial, may result in potential complications increasing cardiovascular risk of mortality. Common metabolic problems after surgery are weight gain, hypertension, hyperlipidemia, and insulin resistance. Immunosuppressant therapy can enhance comorbidity progression. Early identification and treatment of these abnormalities can promote transplant function. Lifestyle modifications have shown to be promising in the reduction of the metabolic syndrome symptoms, but there remain limited trials focusing on this area. This article reflects a comprehensive review of the available research of each of the potential metabolic complications within the renal transplant population. Immunosuppressant medication effects, biochemical values, and medical nutrition therapy intervention are also included with regard to their influence with these metabolic disorders. Methods for review completion included a MEDLINE search for peer-reviewed research, using the following keywords: transplant, chronic kidney disease, nutrition, metabolic syndrome, and diet after transplantation.

Vitamin B6 and the Immunity in Kidney Transplant Recipients - Corrected Proof

2012-03-23

Objective: The study aimed to determine vitamin B6 status in elderly (age ≥60 years) and younger (age <60 years) recipients of allogeneic kidney graft and to investigate associations between vitamin B6 status and immunity markers.Design: A retrospective observational study.Setting: The study was conducted at the Medical University of Gdańsk, Poland.Subjects: We recruited 34 kidney allograft recipients (17 males and 17 females) and allocated them into 2 groups: patients aged ≥60 years (18 patients) and those aged <60 years (16 patients). Exclusion criteria included patients receiving vitamin B6 supplementation or drugs known to influence vitamin B6 metabolism.Main Outcome Measure: Plasma levels of pyridoxal 5’-phosphate (PLP), pyridoxal, pyridoxine, pyridoxamine, pyridoxamine 5’-phosphate, and 4 pyridoxic acid were determined by high-performance liquid chromatography. Measured immunity markers were serum cytokines (interleukin-6, interleukin-10, and transforming growth factor-β), levels of T-lymphocyte subsets, and the proliferative ability of peripheral blood mononuclear cells.Results: Concentrations of all vitamin B6 vitamers in plasma (PLP, pyridoxal, pyridoxamine 5’-phosphate, pyridoxamine, pyridoxine, 4 pyridoxic acid) were comparable in the 2 studied groups. There were no cases of PLP deficiency in the study population, but 29% of patients had PLP concentrations more than the upper reference limit. Vitamin B6 vitamer concentrations were not influenced by gender, estimated glomerular filtration rate, and circulating phosphate concentration. There was no difference in immunity markers according to age. However, the plasma concentrations of vitamin B6 vitamers were inversely associated with levels of CD28+ lymphocyte subsets, as well as with the proliferative response of peripheral blood mononuclear cells in both groups.Conclusions: No cases of vitamin B6 deficiency were found among kidney allograft recipients, and we report inverse links between vitamin B6 vitamer concentrations and markers of cellular immunity, suggesting that bioactive vitamin B6 concentration in kidney allograft recipients merits further investigation.

Malnutrition (Subjective Global Assessment) Scores and Serum Albumin Levels, but not Body Mass Index Values, at Initiation of Dialysis are Independent Predictors of Mortality: A 10-Year Clinical Cohort Study - Corrected Proof

Maria Chan, John Kelly, Marijka Batterham, Linda Tapsell — 2012-03-12

Objective: To examine the associations between demographic, clinical, lifestyle, and nutritional parameters at the start of dialysis and mortality, including the combined effects on nutritional parameters, which were seldom investigated in the literature.Design: Ten-year retrospective clinical cohort study.Setting: Dialysis unit of a metropolitan tertiary teaching hospital in Sydney, Australia.Subjects: Incident dialysis patients (n = 167; hemodialysis, 57.5%; male, 61.7%; age, 65.3 ± 13.6 years; diabetic, 24.5%) who commenced on a planned dialysis program.Methods: Associations were examined between all-cause mortality and baseline demographics, including age and gender; clinical and lifestyle characteristics, including glomerular filtration rate, smoking habits, presence of comorbidities (e.g., coronary artery disease, diabetes mellitus, and peripheral vascular disease); and nutritional parameters, including body mass index (BMI), serum albumin (s-albumin) levels, and subjective global assessment score (SGA). Associations with combination values for malnutrition, s-albumin (<3.3 vs. ≥3.3 g/dL), and BMI (<26 vs. ≥26 kg/m2) were also examined.Results: Median survival was 54.2 months (interquartile range, 23 to 83), and 52.1% of patients were malnourished (SGA score B and C) at the start of dialysis. Advanced age (classified as >65 years, P < .0001), presence of peripheral vascular disease (P < .0001), reduced s-albumin levels (P = .01), and malnutrition scores (P = .02) independently predicted mortality. Being overweight and obese (BMI: ≥26 kg/m2) did not show any advantage on survival (P = .73). Being malnourished and overweight (or obese) was associated with a 3-fold increase in mortality risk (adjusted hazard ratio [HR], 2.96; 95% confidence interval [CI], 1.12 to 7.33; P = .02) compared with being well nourished with a BMI <26 kg/m2 (referent). Compared with being well nourished (SGA = A), being malnourished with normal or low s-albumin was associated with higher risk (HR, 2.06; 95% CI, 1.06 to 4.00; P = .03 and HR, 2.86; 95% CI, 1.65 to 4.94; P < .0001, respectively). There was no statistical difference between mortality risks through any combination of s-albumin and BMI values (P = .54).Conclusion: Malnutrition and reduced s-albumin levels were found to be independent predictors of mortality, whereas being overweight and obese did not show protective effects.

Sevelamer Hydrochloride Binds Phosphate Released from Phytate in Chicks Fed 1α-Hydroxy Cholecalciferol - Corrected Proof

2012-03-12

Objective: Hyperphosphatemia in animal models of human renal disease has been linked to increased risk of death. Phosphate binders (e.g., sevelamer hydrochloride) and plant-based, low phosphate diets are used to reduce dietary phosphate load; however, animal models show that treatment with active forms of vitamin D3 (e.g., calcitriol, a renal disease therapy) renders plant phytate phosphate available for absorption. Using an established chick model, the effectiveness of sevelamer in preventing the apparent absorption of liberated phytate phosphate during active vitamin D use was investigated in two separate experiments.Design: One-day-old chicks were fed ad libitum a basal diet containing deficient levels of inorganic phosphate (0.13%), but adequate in total phosphate (0.40%, 0.23% as phytate phosphate), with or without the inclusion of sevelamer hydrochloride (a phosphate binder), available inorganic phosphate, or active vitamin D as 1α-(OH) D3.Main outcome measures: Plasma phosphate (mg/dL), total bone ash (%), and weight gain (g).Results: Adding inorganic phosphate (0.36%) or 1α-(OH) D3 increased plasma phosphate 49% and 48%, respectively (P < .0001), and bone ash 23% and 19%, respectively (P < .001). The addition of 1% sevelamer to the basal diet with added inorganic phosphate or 1α-(OH) D3 significantly decreased plasma phosphate by 28% and 20%, respectively (P < .01).Conclusion: Active vitamin D increased the availability of phytate phosphate for intestinal absorption in an animal model; however, sevelamer effectively reduced the availability of phosphate liberated from phytate. These data imply that sevelamer has phytate phosphate binding efficacy.

Assessment of Body Composition Using Dry Mass Index and Ratio of Total Body Water to Estimated Volume Based on Bioelectrical Impedance Analysis in Chronic Kidney Disease Patients - Corrected Proof

2012-03-12

Objective: Body mass index (BMI) is commonly used for assessment of nutritional status. However, changes in BMI in chronic kidney disease (CKD) patients are affected not only by muscle and fat but also by fluid volume. The ratio of extracellular water (ECWBIA) to total body water (TBWBIA) in multifrequency bioelectrical impedance analysis is commonly used for assessing abnormal fluid status. This study reexamines ECWBIA/TBWBIA and evaluates the reliability of TBWBIA/TBWwatson and dry mass index (DMI) in the assessment of fluid and nutritional status.Design, Setting, and Subjects: TBWBIA, intracellular water (ICWBIA), and ECWBIA were measured in 45 randomly selected CKD patients. Participants were surveyed for age, gender, BMI, blood pressure, serum albumin, estimated glomerular filtration rate, and proteinuria. DMI was calculated by the formula ([weight − TBWBIA]/height2) and TBWBIA/TBWwatson using an anthropometric formula (Watson). Fluid and nutritional status were assessed using ECWBIA/TBWBIA, TBWBIA/TBWwatson, and DMI.Results: TBWBIA/TBWwatson positively correlated with weight, BMI, and diastolic blood pressure and negatively correlated with age and serum albumin level. In contrast, ECWBIA/TBWBIA correlated with ICW deficit, aging, and body weight loss. On the basis of DMI and TBWBIA/TBWwatson, participants were categorized as follows: 1 obese patient with hypovolemia and 2 with euvolemia; 17 overweight patients with hypovolemia (n = 6), euvolemia (n = 8), or hypervolemia (n = 3); 24 patients of optimal weight with hypovolemia (n = 10), euvolemia (n = 9), or hypervolemia (n = 5); and 1 underweight patient with euvolemia.Conclusions: A combination of DMI, BMI, and TBWBIA/TBWwatson makes it possible to include assessment of fluid volume to the physique index. In addition, ECWBIA/TBWBIA is not a reliable marker of edematous state in CKD patients.

Differential Effect of Baseline Adiponectin on All-Cause Mortality in Hemodialysis Patients Depending on Initial Body Mass Index. Long-Term Follow-Up Data of 4.5 Years - Corrected Proof

2012-03-12

Objectives: We sought to investigate the interaction of adiponectin levels and body mass index (BMI) for predicting all-cause mortality in a cohort of hemodialysis (HD) patients.Design: Longitudinal, observational cohort study.Setting: HD unit.Subjects: Sixty patients (mean age: 64 ± 13 years, 39 men) with end-stage renal disease on maintenance HD followed up for 4.5 years represented the prospective study cohort.Intervention: Associations between baseline plasma adiponectin levels and initial BMI with all-cause mortality were assessed taking into account the assumption of nonlinear correlations. The association between adiponectin, BMI, and serum levels of interleukin-10 (IL-10) and interleukin-6 (IL-6) with survival was determined cross-sectionally.Main outcome measure: All-cause mortality.Results: Nonlinear survival modeling showed that there was a U-shaped association of BMI with all-cause mortality, whereas there was an inverse U-shaped association for plasma adiponectin levels. Using a BMI of 24 kg/m2 as a cutoff, an interaction effect of BMI on the association between adiponectin and mortality was observed (P = .045). In participants with BMI ≥ 24 kg/m2, each 15 μg/mL increase in plasma adiponectin levels was associated with a decreased hazard of death (hazard ratio: 0.57, 95% CI: 0.32 to 0.99) in unadjusted analysis. In HD patients with BMI < 24 kg/m2, no significant association was observed between adiponectin and mortality (P = .989). Cross-sectional analysis showed that in the subgroup of patients in whom the protective effect of adiponectin was observed (BMI ≥ 24 kg/m2), a positive linear association existed between adiponectin and IL-10 levels (r = 0.345, P = .027) as well as a negative association with IL-6 levels (r = −0.322, P = .040). No association was observed in patients with BMI < 24 kg/m2, neither with IL-10 nor with IL-6.Conclusions: Obesity possibly modifies the effect of adiponectin on all-cause mortality in HD patients, thus explaining the published conflicting results in recent literature regarding the association of plasma adiponectin levels and mortality in chronic kidney disease patients.

Associations of Dietary Phosphorus Intake, Urinary Phosphate Excretion, and Fibroblast Growth Factor 23 With Vascular Stiffness in Chronic Kidney Disease - Corrected Proof

2012-03-12

Objective: Elevated serum phosphate concentrations are established risk factors for cardiovascular disease and mortality in chronic kidney disease (CKD). Independent associations of other indices of phosphorus metabolism, such as phosphorus intake, urinary phosphate excretion, or hormones that regulate these systems, like fibroblast growth factor 23 (FGF23), with markers of cardiovascular disease in CKD, have been studied in less detail.Design: Cross-sectional study.Participants: Seventy-four adult CKD patients with mean creatinine clearance of 51 ± 19 mL/minute.Outcome: Augmentation index (AI)—a surrogate marker of arterial stiffness.Results: Although serum phosphate varied little across quartiles of creatinine clearance, average daily phosphorus intake and 24-hour urinary phosphate excretion decreased from highest to lowest quartile (by 31% and 60%, respectively, P for trend .05 for both). Older age, higher systolic blood pressure, female gender, and black race were independently associated with increased AI. In contrast, there were no associations of serum phosphate, dietary phosphorus intake, urinary phosphate excretion, or FGF23 with AI in multivariate-adjusted models.Conclusions: In this sample of patients with CKD, established risk factors for arterial stiffness, but not mediators of phosphorus metabolism, were associated with increased AI. In addition, there were no significant associations between FGF23 and dietary phosphorus or urinary phosphate excretion. Future studies are needed to determine the main factors associated with elevations in FGF23 in CKD and to further assess the association of disordered phosphorus metabolism with subclinical markers of vascular disease.

Novel Differential Measurement of Natural and Added Phosphorus in Cooked Ham With or Without Preservatives - Corrected Proof

2012-03-12

Objective: Assessment of the quantity and chemical type of phosphorus (P) content in cooked ham products with or without preservatives using a novel biochemical procedure.Methods: We examined the quantity and types of P in 40 samples of cooked ham, including 20 without and 20 with P-containing preservatives, which were purchased randomly from a grocery store in Italy. Food samples were analyzed for dry matter, nitrogen, fat, and P content. Novel spectrophotometric methods were used to measure total P and 3 different P subtypes, that is, water-soluble (inorganic) P including added preservatives and natural P derived from phospholipids and phosphoproteins, separately.Results: Compared with hams without preservatives, hams with P-containing preservatives had significantly lower dry matter and protein and fat contents. There was 66% more inorganic P (IP) in ham with preservatives than in samples without preservatives (169 ± 36 vs. 102 ± 16 mg/100 g, P < .001, respectively). There were no significant differences in P contents derived from proteins or lipids. The P-to-protein ratio was higher in ham samples with preservatives than in those without preservatives (16.1 ± 4.0 and 9.8 ± 0.8 mg/g, P < .001). The sum of measured IP and P from phospholipids and phosphoproteins was 91% ± 4% of measured total P (207.1 ± 50.7 vs. 227.2 ± 54.4 mg/100 g), indicating a small portion of unspecified P and/or under measurement.Conclusions: Novel differential dietary P measurement detects added P-containing preservatives. Cooked ham with preservatives has 66% more measurable IP and 64% higher P-to-protein ratio than ham without preservatives. The contribution of food added with P-containing preservatives to global dietary P burden can negatively influence chronic kidney disease outcome and counteract the efficacy of P-binder medications: this is an important topic that warrants additional investigations.

Interpersonal Psychosocial Factors Associated With Underreported Dietary Energy Intake in Hemodialysis Patients - Corrected Proof

2012-03-12

Objective: To examine the association between degree of underreporting energy intake and psychosocial (including interpersonal and personal) factors among hemodialysis patients in Japan.Design: We conducted a cross-sectional study. Predictors of difference were identified using multiple linear regression analysis.Setting: Study was conducted at a public hospital and a dialysis clinic in a single district in northeast Honshu, Japan.Subjects: Participants were hemodialysis outpatients. Patients aged more than 20 years and undergoing treatment for end-stage renal disease for at least 6 months were included. Exclusion criteria were diagnosis of depression, a mental disease, or dementia.Main Outcome: The outcome measure was the difference in reported energy intake defined by the differences between a brief administered dietary history questionnaire and diet record stratified by standardized weight.Results: Seventy patients undergoing hemodialysis participated (44 men [62.9%] and 26 women [37.1%]). Of these, 54.3% underreported energy intake (by >10%). Sex (male) and employment status (employed) were statistically associated with energy intake underreporting. A lower score of dialysis staff encouragement was associated with greater energy intake underreporting (β coefficient = 3.89 kcal/standardized weight, 95% confidence interval: 0.89 to 6.90; P = .012).Conclusion: Degree of underreporting energy intake is significantly associated with interpersonal psychosocial factors among hemodialysis patients in Japan. The interpersonal relationship with encouragement by the dialysis staff is important in improving the accuracy of reporting energy intake among dialysis patients.

Pica: An Important and Unrecognized Problem in Pediatric Dialysis Patients - Corrected Proof

2012-02-10

Objective: Pica is the compulsive consumption of non-nutritive substances, and this disorder may occur more frequently in dialysis patients. The purpose of our study was to determine the prevalence of pica and the associated demographic and metabolic characteristics.Design: Retrospective, cross-sectional analysis.Setting: Hospital-based, outpatient, pediatric hemodialysis unit.Subjects: Eighty-seven pediatric patients on chronic dialysis therapy were interviewed. Sixty-seven patients were receiving hemodialysis, whereas the remaining 20 were maintained on peritoneal dialysis. The predominantly nonwhite (93%) patient population had a mean age of 17.2 ± 7.2 years. Dialysis efficiency, estimated by urea clearance per patient volume (Kt/V), averaged 1.5 ± 0.5.Intervention: Standard patient interview and documentation of laboratory and dialytic parameters.Main outcome measure: Prevalence of pica and associated comorbid conditions.Results: The survey indicated that 46% of patients experienced pica, further divided into simple “ice” pica (34.5%) versus “hard” pica (12.6%). Hard pica included the consumption of chalk, starch, sugar, soap, sand, clay, Ajax cleanser, sponge, wood, and potting soil. Patients on hemodialysis were 8.3 times more likely to have hard pica compared with those on peritoneal dialysis. Greater than 5 years on dialysis was associated with a 3.2 odds ratio of having pica (P = .02). Anemia was the most significant morbid association, occurring at an odds ratio of 4.4 (P = .001) for all pica and 10.6 (P = .004) for hard pica.Conclusion: Pica, therefore, is prevalent and potentially harmful, requiring further attention in the nutritional management of pediatric dialysis patients.

Nutritional Knowledge in Hemodialysis Patients and Nurses: Focus on Phosphorus - Corrected Proof

2012-02-10

Objective: To assess the knowledge of adult hemodialysis patients and nurses working in dialysis units, specifically with regard to knowledge of phosphorus and other nutrients related to dietary management of end-stage renal disease.Design: Cross-sectional cohort study.Setting: Hemodialysis unit.Subjects: One hundred ninety-one hemodialysis patients and 105 dialysis nurses, as well as 86 control hospital employees who are not health professionals.Intervention: Nutritional knowledge was assessed by a 25-item chronic kidney disease knowledge assessment tool for nutrition, which includes 15 questions on phosphorus and 10 questions on protein, sodium, and potassium knowledge.Results: The scores obtained by patients were much lower than those of nurses (11.6 ± 3.9 vs. 16.0 ± 2.2, P < .001) but slightly higher than those of controls (10.6 ± 3.2, P < .05). Patients with phosphorus serum level >5.5 mg/dL showed chronic kidney disease knowledge assessment tool for nutrition scores similar to those of patients with a serum phosphorus level <5.5 mg/dL. The prevalence of right answers to questions regarding knowledge of phosphorus was lower than that regarding knowledge of the other nutrients, both for patients (38.4% ± 17.8% vs. 57.3% ± 19.9%, P < .001) and nurses (55.6% ± 11.1% vs. 74.8% ± 11.7%, P < .001) as well as for controls (30.7% ± 14.5% vs. 60.1% ± 17.4%, P < .001).Conclusions: Our study suggests that nutritional knowledge of hemodialysis patients, although higher than the general population, is lower for phosphorus with respect to the other nutrients, such as protein, sodium, and potassium. This occurs even in patients with hyperphosphatemia or those taking phosphate binder medications. Nurses showed the best scores; however, improvement is necessary, especially with regard to knowledge of phosphorus. Training programs on nutrition for nurses and on information for patients should be implemented. They can contribute to achievement of a more effective control of phosphate balance, reduction of costs, and improvement of the quality of care for hemodialysis patients.

The Effects of Fish Oil Supplementation on Markers of Inflammation in Chronic Kidney Disease Patients - Corrected Proof

2012-01-30

Objective: One prevalent characteristic of all stages of chronic kidney disease (CKD) is excessive production of proinflammatory cytokines. Fish oil (FO) supplementation has been reported to lower levels of proinflammatory cytokines. The benefits of FO for an extensive range of populations and a variety of health concerns are apparent, yet the anti-inflammatory benefits for nondialysis CKD patients are not as well documented. Therefore, the purpose of this study was to investigate the effects of the daily consumption of FO (1,400 mg eicosapentaenoic acid + 1,000 mg docosahexaenoic acid) on interleukin 1β (IL-1β), interleukin 6 (IL-6), and tumor necrosis factor α (TNF-α) for 8 weeks in nondialysis CKD patients.Design, Setting, and Subjects: In this double-blind, randomized, placebo-controlled intervention, the effect of 8 weeks of FO administration on IL-1β, IL-6, and TNF-α levels in nondialysis CKD patients were evaluated.Intervention: Thirty-one nondialysis CKD patients (17 = FO; 14 = placebo) randomly received either FO dietary supplementation 2.4 g/day (1,400 mg eicosapentaenoic acid + 1,000 mg docosahexaenoic acid) or placebo (safflower oil) for 8 weeks.Main Outcome Measures: IL-1β, IL-6, and TNF-α were all measured as markers of inflammation.Results: One-way analysis of variance revealed no significant differences in IL-6 (P = .06), IL-1β (P = .18), and TNF-α (P = .20) between groups in pretest values. Additionally, no pretest differences existed between groups for age (P = .549), weight (P = .324), waist circumference (P = .086), gender (P = .591), and ethnicity (P = .875). Covariance was calculated using compliance, age, gender, ethnicity, body weight, and waist circumference as covariates. No significant differences were discovered between groups after FO supplementation for IL-6 (P = .453) and TNF-α (P = .242). A significant difference was discovered for IL-1β (P = .050) with lower levels in the FO group.Conclusions: The results of this study are in agreement with some previous studies that suggest that FO supplementation has no effect on plasma proinflammatory cytokines TNF-α or IL-6, but does have an effect on IL-1β in nondialysis CKD patients.

Intake of Antioxidants and their Status in Chronic Kidney Disease Patients - Corrected Proof

N. Sahni, K.L. Gupta, S.V. Rana, R. Prasad, A.K. Bhalla — 2012-01-09

Objective: To evaluate the intake and status of antioxidants in chronic kidney disease (CKD) patients.Design: Randomized control trial.Setting: Hospital outpatient department.Subjects: One hundred eighty-five subjects (145 predialysis CKD patients and 40 apparently healthy controls) were enrolled for this study. The patients were divided into moderate and severe renal failure groups based on their creatinine and glomerular filtration rates.Intervention: All patients completed a food frequency questionnaire, 24-hour dietary recall form, and anthropometric measurements and underwent biochemical and antioxidant lab tests.Main Outcome Measures: Dietary intake, anthropometry, biochemical measures of blood and antioxidant enzymes as well as oxidative stress.Results: Overall, the diet was significantly lower in antioxidant-rich food intake in all the CKD patients as compared with controls. The oxidative stress measured in blood was found to be in consonance with the intake from diet.Conclusion: Micronutrients play a major role in the antioxidant status of the patients and must be monitored, as deficiency of these might elevate the oxidative stress of the body, especially in the chronic diseases.

Development and Validation of an Expedited 10 g Protein Counter (EP-10) for Dietary Protein Intake Quantification - Corrected Proof

Su-Lin Lim, Jamie Lye, Liang Shen, Michelle Miller, Yap-Seng Chong — 2012-01-09

Objective: Precise protein quantification is essential in clinical dietetics, particularly in the management of renal, burn, and malnourished patients. The expedited 10 g protein counter (EP-10) was developed to expedite the estimation of dietary protein for nutritional assessment and recommendation. The main objective of this study was to compare the validity and efficacy of the EP-10 with the American Dietetic Association’s “Exchange List for Meal Planning” (ADA-7 g) in quantifying dietary protein intake, against computerized nutrient analysis (CNA).Design: Protein intake of 197 food records kept by healthy adult subjects in Singapore was determined thrice using 3 different methods: (1) EP-10, (2) ADA-7 g, and (3) CNA using SERVE program (Version 4.0). Assessments using the EP-10 and ADA-7 g were performed by 2 assessors in a blind crossover manner while a third assessor performed the CNA. All assessors were blind to each other’s results. Time taken to assess a subsample (n = 165) using the EP-10 and ADA-7 g was also recorded.Results: Mean difference in protein intake quantification when compared with the CNA was statistically nonsignificant for the EP-10 (1.4 ± 16.3 g, P = .239) and statistically significant for the ADA-7 g (−2.2 ± 15.6 g, P = .046). Both the EP-10 and ADA-7 g had clinically acceptable agreement with the CNA, as determined via Bland–Altman plots, although it was found that EP-10 had a tendency to overestimate with protein intakes above 150 g. The EP-10 required significantly less time for protein intake quantification than the ADA-7 g (mean time of 65 ± 36 seconds vs. 111 ± 40 seconds, P < .001).Conclusion: The EP-10 and ADA-7 g are valid clinical tools for protein intake quantification in an Asian context, with EP-10 being more time efficient. However, a dietician’s discretion is needed when the EP-10 is used on protein intakes above 150 g.

Association of 1,25-Dihydroxyvitamin D Levels With Physical Performance and Thigh Muscle Cross-sectional Area in Chronic Kidney Disease Stage 3 and 4 - Corrected Proof

Patricia L. Gordon, Julie W. Doyle, Kirsten L. Johansen — 2012-01-09

Background: Declines in 1,25-dihydroxyvitamin D (1,25(OH)2D) levels and physical functioning follow the course of chronic kidney disease (CKD). Although the molecular actions of vitamin D in skeletal muscle are well known, and muscle weakness and atrophy are observed in vitamin D–deficient states, there is little information regarding vitamin D and muscle function and size in CKD.Objective: To examine associations of vitamin D with physical performance (PF) and muscle size.Design: Cross-sectional.Setting: CKD clinic.Subjects: Twenty-six patients (61 ± 13 years, 92% men) with CKD stage 3 or 4.Main Outcome Measures: Gait speed, 6-minute walk, sit-to-stand time, 1-legged balance, and thigh muscle cross-sectional area (MCSA), measured by magnetic resonance imaging (MRI).Results: Overall, 73% were 25-hydroxyvitamin D (25(OH)D) deficient (n = 10) or insufficient (n = 9) (Kidney Disease Outcomes Quality Initiative guidelines). 25(OH)D level was associated with normal gait speed only (r = 0.41, P = .04). Normal and fast gait speed, the distance walked in 6 minutes, and sit-to-stand time were best explained by 1,25(OH)2D and body mass index (P < .05 for all) and 1-legged stand by 1,25(OH)2D (r = 0.40, P < .05) only. There were no associations of age, estimated glomerular filtration rate (eGFR), intact parathyroid hormone (iPTH), or albumin with any PF measures. MCSA was associated with eGFR (r = 0.54, P < .01) only. Variance in MCSA was best explained by a model containing 1,25(OH)2D, plasma Ca2+, and daily physical activity (by accelerometry) (P < .05 for all). Once these variables were in the model, there was no contribution of eGFR.Conclusion: These results suggest that 1,25(OH)2D is a determinant of PF and muscle size in patients with stage 3 and 4 CKD.

Therapy of Hyperhomocysteinemia in Hemodialysis Patients: Effects of Folates and N-Acetylcysteine - Corrected Proof

2012-01-09

Objective: Uremia represents a state where hyperhomocysteinemia is resistant to folate therapy, thus undermining intervention trials’ efficacy. N-acetylcysteine (NAC), an antioxidant, in addition to folates (5-methyltetrahydrofolate, MTHF), was tested in a population of hemodialysis patients.Design: The study is an open, parallel, intervention study.Setting: Ambulatory chronic hemodialysis patients.Subjects: Clinically stable chronic hemodialysis patients, on hemodialysis since more than 3 months, undergoing a folate washout. Control group on standard therapy (n = 50).Intervention: One group was treated with intravenous MTHF (MTHF group, n = 48). A second group was represented by patients treated with MTHF, and, during the course of 10 hemodialysis sessions, NAC was administered intravenous (MTHF + NAC group, n = 47).Main Outcome Measure: Plasma homocysteine measured before and after dialysis at the first and the last treatment.Results: At the end of the study, there was a significant decrease in predialysis plasma homocysteine levels in the MTHF group and MTHF + NAC group, compared with the control group, but no significant difference between the MTHF group and MTHF + NAC group. A significant decrease in postdialysis plasma homocysteine levels in MTHF + NAC group (10.27 ± 0.94 μmol/L, 95% confidence interval: 8.37-12.17) compared with the MTHF group (16.23 ± 0.83, 95% confidence interval: 14.55-17.90) was present. In the MTHF + NAC group, 64% of patients reached a postdialysis homocysteine level <12 μmol/L, compared with 19% in the MTHF group and 16% in the control group.Conclusions: NAC therapy induces a significant additional decrease in homocysteine removal during dialysis. The advantage is limited to the time of administration.

Underreporting of Energy Intake in Maintenance Hemodialysis Patients: A Cross-sectional Study - Corrected Proof

2012-01-09

Objective: To analyze the reported energy intake (EIrep) in hemodialysis (HD) patients by total energy expenditure (TEE) measured by a dedicated device.Design: Cross-sectional study.Setting: RenalCor and RenalVida Clinics (Rio de Janeiro, Brazil).Patients and Others Participants: Forty-eight HD patients (51.4 ± 12.2 years, 62% men, body mass index [BMI], 23.8 ± 4.5 kg/m2) were studied.Main Outcome Measure: EIrep was evaluated using a 3-day food record. TEE was measured over a 2-day period by SWA (SenseWear Pro2 Armband, BodyMedia Inc., Pittsburgh, PA). Subjects were identified as underreporters (URs), acceptable reporters (ARs), or overreporters (ORs) from their EIrep/TEE ratio. ARs were defined as having the EIrep/TEE ratio in the range of 0.76 to 1.24, URs as EIrep/TEE <0.76, ORs as EIrep/TEE >1.24 according to Goldberg index.Results: The mean TEE and EIrep were 34.7 ± 9.4 kcal/kg/day and 22.8 ± 10.6 kcal/kg/day, respectively, and 37.5% of patients presented overweight or obesity. Thirty-one patients (65%) were identified as URs, and the mean of Goldberg index was 0.54 ± 0.12 (0.23 to 0.75), versus 0.95 ± 0.12 (0.79 to 1.2) for ARs. There were no ORs among the patients studied. There were negative correlations between Goldberg index and BMI (r = −0.35, P < .01) and % body fat (r = −0.4, P < .01) and between EIrep and BMI (r = −0.58, P < .001).Conclusion: These results confirm a high prevalence of underreporting of EI in HD patients, particularly in patients with high BMI.

Assessing the Validity and Reliability of the MUST and MST Nutrition Screening Tools in Renal Inpatients - Corrected Proof

2012-01-05

Objective: The aim of this study was to determine the validity and reliability of the Malnutrition Universal Screening Tool (MUST) and the Malnutrition Screening Tool (MST) in hospital inpatients with renal disease.Design: A cross-sectional and longitudinal study.Setting: The study took place on 3 renal inpatient wards in a tertiary hospital in south London.Patients: A total of 276 participants were recruited.Intervention: Not applicable.Main Outcome Measure: Concurrent validity was assessed by comparing the MUST and MST tools completed by nursing staff with the subjective global assessment tool completed by dietetic staff. Predictive validity was evaluated by assessing the association between malnutrition and length of hospital stay. Mid-upper arm circumference and bioelectrical impedance spectroscopy were used to assess construct validity. In the reliability study, the MUST and MST tools were repeated on the same day by nursing staff.Objective: MUST had a sensitivity of 53.8% (95% confidence interval [CI], 46.6% to 60.0%) and a specificity of 78.3% (95% CI, 70.1% to 85.2%), and MST had a sensitivity of 48.7% (95% CI, 41.7% to 54.0%) and a specificity of 85.5% (95% CI, 77.9 to 91.3) when compared with subjective global assessment. Risk of malnutrition as identified by MUST but not the MST tools had a significantly longer length of hospital stay (P = .038 and .061). Both MUST and MST tools identified patients at risk of malnutrition had a significantly lower mid-upper arm circumference (P = .005 and P = .029, respectively) and percent fat mass (P = .023 and P = .052, respectively). Reliability assessed by kappa was 0.58 for MUST (95% CI, 0.20 to 0.80) and 0.33 for MST (95% CI, −0.03 to 0.54).Conclusions: The MUST and MST nutrition tools are not sensitive enough to identify all of the malnourished renal inpatients, despite being fairly reliable and related to other nutrition status markers.

Associations of Socioeconomic Status and Processed Food Intake With Serum Phosphorus Concentration in Community-Living Adults: The Multi-Ethnic Study of Atherosclerosis (MESA) - Corrected Proof

2012-01-05

Objective: Higher serum phosphorus concentrations are associated with cardiovascular disease events and mortality. Low socioeconomic status is linked with higher serum phosphorus concentration, but the reasons are unclear. Poor individuals disproportionately consume inexpensive processed foods commonly enriched with phosphorus-based food preservatives. Accordingly, we hypothesized that excess intake of these foods accounts for a relationship between lower socioeconomic status and higher serum phosphorus concentration.Design: Cross-sectional analysis.Setting and Participants: We examined a random cohort of 2,664 participants with available phosphorus measurements in the Multi-Ethnic Study of Atherosclerosis, a community-based sample of individuals free of clinically apparent cardiovascular disease from across the United States.Predictor Variables: Socioeconomic status, the intake of foods commonly enriched with phosphorus-based food additives (processed meats, sodas), and frequency of fast-food consumption.Outcomes: Fasting morning serum phosphorus concentrations.Results: In unadjusted analyses, lower income and lower educational achievement categories were associated with modestly higher serum phosphorus concentration (by 0.02 to 0.10 mg/dL, P < .05 for all). These associations were attenuated in models adjusted for demographic and clinical factors, almost entirely due to adjustment for female gender. In multivariable-adjusted analyses, there were no statistically significant associations of processed meat intake or frequency of fast-food consumption with serum phosphorus. In contrast, each serving per day higher soda intake was associated with 0.02 mg/dL lower serum phosphorus concentration (95% confidence interval, −0.04, −0.01).Conclusions: Greater intake of foods commonly enriched with phosphorus additives was not associated with higher serum phosphorus concentration in a community-living sample with largely preserved kidney function. These results suggest that excess intake of processed and fast foods may not impact fasting serum phosphorus concentrations among individuals without kidney disease.

Effect of Brazil Nut Supplementation on Plasma Levels of Selenium in Hemodialysis Patients: 12 Months of Follow-up - Corrected Proof

2012-01-05

Background: Large amounts of reactive oxygen species are produced in hemodialysis (HD) patients, and, at higher concentrations, reactive oxygen species are thought to be involved in the pathogenesis of cardiovascular disease. It has been proposed that selenium (Se) may exert an antiatherogenic influence by reducing oxidative stress. The richest known food source of Se is the Brazil nut (Bertholletia excelsa, family Lecythidaceae), found in the Amazon region.Objective: The objective of this work was to determine if Se plasma levels in HD patients submitted to a program of supplementation during 3 months with 1 Brazil nut by day could be sustained after 12 months.Methods: A total of 21 HD patients (54.2 ± 15.2 years old; average time on dialysis, 82.3 ± 51.6 months; body mass index, 24.4 ± 3.8 kg/m2) from the RenalCor Clinic in Rio de Janeiro, Brazil, were followed up 12 months after the supplementation study ended. The Se plasma levels were determined by atomic absorption spectrophotometry with hydride generation.Results: The Se Plasma levels (17.3 ± 19.9 μg/L) were below the normal range (60 to 120 μg/L) before nut supplementation, and after 3 months of supplementation, the levels increased to 106.8 ± 50.3 μg/L (P < .0001). Twelve months after supplementation, the plasma Se levels decreased to 31.9 ± 14.8 μg/L (P < .0001).Conclusions: The data showed that these patients were Se deficient and that the consumption of Brazil nut was effective to increase the Se parameters of nutritional status. Se levels 12 months after the supplementation period were not as low as presupplementation levels but yet significantly lower, and we needed to motivate patients to adopt different dietary intake patterns.

Have Renal Dietitians Successfully Implemented Evidence-Based Guidelines Into Practice? A Survey of Dietitians Across Australia and New Zealand - Corrected Proof

Emma J. Hall-McMahon, Katrina L. Campbell — 2012-01-05

Objective: Successful implementation of evidence-based practice (EBP) guidelines has been shown to improve the nutrition status of dialysis patients. This study aimed to establish use of EBP guidelines and implementation of key recommendations for nutrition assessment of dialysis patients, as well as to identify barriers and enablers associated with EBP guideline adherence.Design: A survey of nutrition assessment practices and barriers to implementation of EBP guidelines was developed and piloted. The survey measured implementation of guidelines regarding frequency of nutrition assessment and use of the subjective global assessment (SGA) to diagnose malnutrition. Barriers to guideline implementation were measured using agreement with statements rated on a Likert scale. Data were summarized as counts and percentages and analyzed using chi-squared tests of association, with P < .05 indicating statistical significance.Setting: The survey targeted specialist renal dietitians across Australian and New Zealand.Participants: Sixty-five renal dietitians from Australia and New Zealand responded to the survey. Most were females (89%, n = 58 of 65), aged <35 years (72%, n = 47 of 65), with one-third (n = 22 of 65) working in renal dietetics for longer than 4 years.Results: Nearly all participants (n = 62 of 65) reported routinely using EBP guidelines; however, only 55% and 66% indicated they had successfully implemented the guidelines regarding minimum 6-monthly nutrition assessment of dialysis patients (n = 36 of 65) and use of the SGA (n = 43 of 65), respectively. Barriers related to time, skills/self-efficacy, and an inefficient referral system were related to lower rates of guideline implementation.Conclusion: These findings indicate an evidence–practice gap in the nutritional management of dialysis patients. A standardized approach to EBP guideline implementation including structured 6-monthly nutrition assessment of dialysis patients and group training for use of the SGA tool may assist in closing this evidence–practice gap.

Body Fat Percentage as a Risk Factor for Atherosclerosis but not for Inflammation for Hemodialysis Patients: Differences Between Genders - Corrected Proof

Siren Sezer, Şebnem Karakan, Gülşah Şaşak, Emre Tutal, F. Nurhan Özdemir Acar — 2011-12-08

Introduction: Atherosclerosis (AS) and malnutrition are 2 major causes of morbidity and mortality in hemodialysis (HD) patients. A high body fat percentage (BFP) may be paradoxically associated with improved survival in chronic HD patients. We aimed to establish BFP profile of the HD patients by using bioimpedance analysis, body mass index (BMI), and waist/hip ratio (WHR) to find out their association with inflammation and AS.Methods: In total, 125 HD patients (64 male, 51% mean age of 49.7 ± 12.3 years) were included in the study. Malnutrition–inflammation score (MIS) has been used and supported with biochemical parameters: C-reactive protein, serum iron, total iron binding capacity, ferritin, complete blood count, serum albumin, total cholesterol, low- and high-density lipoproteins, and triglyceride. The patients were divided into 3 groups according to their BFP that were defined by bioimpedance analysis. We also compared these groups according to BMI percentiles. Independent variables affecting BMI and MIS were identified by logistic regression analysis.Results: AS was correlated with high BFP for our female HD patients, but not for the males. BFP, BMI, and WHR were significantly higher for females. Older age (P = .02), BMI (P < .01), WHR (P < .01), total leukocyte count (P = .02), serum iron (P < .01), and total iron-binding capacity (P = .02) were found significantly correlated with higher BFP for female HD patients, whereas only BMI (P < .01) and serum creatinine levels (P = .04) were significant for male patients. In logistic regression analysis, independent factors affecting cardiovascular disease (CVD) were gender, BFP, MIS, and lymphocyte/leukocyte ratio. Independent factors affecting MIS were gender, BFP, CVD, serum albumin level, and serum C-reactive protein.Conclusion: BFP and male gender may be contributing factors for CVD; however, female HD patients with high BFP had higher risk of CVD than male counterparts. Further studies are needed to evaluate the pathophysiology of this discrepancy between genders.

Predictors of Vitamin D Status in Predialysis Chronic Kidney Disease Patients: A Cross-sectional Analysis in a High Ultraviolet Climate - Corrected Proof

William G. Petchey, David W. Johnson, Carmel M. Hawley, Nicole M. Isbel — 2011-11-10

Objective: To determine vitamin D status in a subtropical climate among an unselected, referred predialysis chronic kidney disease (CKD) population; assess risks and correlates; and review whether higher 25-hydroxyvitamin D (25-OHD) concentration can mitigate the decrement in circulating 1,25-dihydroxyvitamin D (1,25-OHD) normally encountered with advancing CKD.Design: Prospective cross-sectional cohort study.Setting: Renal unit in Brisbane, Australia (27°28’ S).Subjects: Five hundred ninety-three consecutive CKD patients (stage 1 to 5).Main Outcome Measure: 25-OHD insufficiency (concentrations: 15 to 30 ng/mL) and deficiency (<15 ng/mL), bone-mineral parameters, including 1,25-OHD, calcium, and phosphate.Results: Despite potentially higher environmental ultraviolet (UV) exposure, only 48% of patients with CKD were 25-OHD sufficient. Traditional risks for hypovitaminosis D were maintained, and sufficiency was independently predicted by testing in the summer/autumn period (odds ratio [OR]: 2.77, 95% confidence interval [CI]: 1.88 to 4.08, P < .001), male gender (OR: 2.18, 95%CI: 1.46 to 3.24, P < .001), Caucasian race (OR: 2.28, 95%CI: 1.37 to 3.78, P = .001), hypoalbuminemia (OR: 0.47, 95%CI: 0.25 to 0.85, P = .01), macroalbuminuria (OR: 0.60, 95%CI: 0.39 to 0.92, P = .02), and normal body mass index (OR: 1.94, 95%CI: 1.22 to 3.07, P = .005). Vitamin D sufficiency was also associated with higher corrected calcium (0.4 mg/dL increments; OR: 1.29, 95%CI: 1.08 to 1.55, P = .005). Although circulating 25-OHD concentrations were relatively maintained across the range of renal function observed, 1,25-OHD concentrations decreased with advancing CKD.Conclusion: 25-OHD insufficiency is mitigated but still highly prevalent in patients with CKD in a high ambient UV environment. Despite the maintenance of relatively higher 25-OHD concentrations with advancing CKD, substrate availability does not appear to be a major determinant of circulating 1,25-OHD.

Leptin, Insulin Resistance, and Metabolic Changes 5 Years After Renal Transplantation - Corrected Proof

2011-11-07

Objective: To evaluate leptin, insulin resistance (IR), and changes in body composition and lipid profile within 5 years after renal transplantation.Design: Longitudinal study.Setting: Hospital de Clínicas de Porto Alegre/RS, Brazil.Subjects: Thirty-two renal transplant recipients were followed up for 5 years after transplantation.Methods: Data were collected at transplantation time (T1) and after 3 months (T2), 1 year (T3), and 5 years (T4). Leptin serum levels, IR assessed by homeostasis model assessment (HOMA) index, lipid profile, and anthropometric measurements were analyzed. Data were compared with a control group at baseline.Results: At T1, pretransplant patients had leptin levels (ng/mL) (11.9 [9.2 to 25.2]) higher than the control group (7.7 [5.2 to 9.9]; P < .0001). After transplantation, levels decreased at T2 and T3, but increased at T4 to values similar to those seen at T1 (T4: 9.2 [5.7 to 21]; P = 1). HOMA also decreased at T2, but increased at T4 to identical levels (T1: 2.1 [1.63 to 2.23], T4: 2.1 [1.6 to 2.85]; P = 1). No significant changes in body fat percentage (BF%) were observed; however, the arm muscle circumference increased significantly at T4 (P < .0001). At T2, total cholesterol, triglycerides, and low-density lipoprotein cholesterol increased, whereas at T4, lipid profile moved toward T1 levels. By linear regression analysis, gender, BF%, and HOMA were independent predictors of leptin levels. A trend toward higher body mass index was observed in woman who also presented higher leptin and lower HOMA levels.Conclusion: Leptin levels and HOMA decrease in the immediate posttransplant period and remain reduced for at least 1 year. Five years post transplantation, leptin, IR, BF%, and lipids have a profile similar to those in the pretransplant period. This metabolic profile is possibly associated with the elevated incidence of cardiovascular diseases observed in the late posttransplant period.

Is Nutritional Status Associated with Self-reported Sleep Quality in the HEMO Study Cohort? - Corrected Proof

Jerrilynn D. Burrowes, Gregory B. Russell, Mark Unruh, Michael V. Rocco — 2011-11-04

Objectives: To explore the relationship between sleep quality and common measures of nutritional status in the Hemodialysis (HEMO) Study cohort. To investigate sleep quality scores based on longitudinal changes in measures of nutritional status, adjusting for case mix, lifestyle, and comorbidity factors.Design: Secondary analysis of the HEMO Study data.Setting: A 7-year, prospective, multicenter, randomized clinical trial in maintenance hemodialysis patients.Patients: Eighteen hundred forty-six patients aged between 18 and 80 years were randomized; 1,803 (97.7%) completed the Kidney Disease Quality of Life Long Form (KDQOL-LF) at baseline. Mean age was 58 years, 44% were male, 64% were Black, 37% had diabetes, and 32% had hypertension; mean duration of dialysis was 3.8 years.Main Outcome Measures: The univariate and multivariate relationships of measures of nutritional status (i.e., serum albumin, serum creatinine, postdialysis weight, body mass index, dietary protein and energy intake, and assessment of appetite) and sleep quality assessed using the sleep subscale from the KDQOL-LF.Results: In univariate analysis, sleep quality score decreased significantly in a linear fashion as appetite rating decreased from very good to very poor on both dialysis days (63.6 ± 21.8 to 43.6 ± 22.9, P < .0001) and nondialysis days (63.2 ± 21.6 to 40.7 ± 25.7, P < .0001), with higher scores reflecting better sleep quality. In multivariable analysis, serum creatinine was the only laboratory variable that was significantly associated with sleep quality score (β = 0.49, P = .0004). Poorer appetite on both dialysis days (β = −1.5, P < .0001) and nondialysis days (β = −1.7, P < .0001) was associated with poor sleep quality.Conclusions: Self-reported sleep quality was associated with appetite and serum creatinine. A simple questionnaire to assess sleep disorders in dialysis patients should be administered routinely to detect those patients at risk of sleep complaints. However, further studies are needed to determine whether improving sleep quality, directly or indirectly, would improve morbidity and mortality.

Results of a Pilot Program to Improve Phosphorus Outcomes in Hemodialysis Patients - Corrected Proof

2011-11-04

Objective: End-stage renal disease causes dysregulation of bone and mineral metabolism, including increased serum phosphorus levels. Kidney Foundation Kidney Disease Outcome Quality Initiative 2003 guidelines recommend maintaining phosphorus levels between 3.5 and 5.5 mg/dL in dialysis patients. We examined the effects of a focused phosphorus management pilot program designed to improve the percentage of hemodialysis patients achieving phosphorus levels <5.5 mg/dL.Design, Setting, Subjects, and Intervention: We conducted a prospective, multicenter, single-arm study at 8 geographically diverse at-risk facilities (n = 702 hemodialysis patients) in a large U.S. dialysis organization. The focused phosphorus management program provided in-service training to staff members, and provided patients with diet and phosphorus management through in-center, 1:1 education and support, direct-to-patient adherence communications, benefit management assistance, and adherence support specific to lanthanum carbonate over a 6-month period.Main Outcome Measure: Facility-level markers of bone and mineral metabolism (phosphorus, parathyroid hormone, corrected calcium) and nutritional status (serum albumin, normalized protein catabolic rate) were assessed before and after program implementation.Results: There was a significant increase in the percentage of patients per facility achieving phosphorus levels <5.5 mg/dL (mean ± SD at baseline = 61.6% ± 5.2%; month 6 = 71.3% ± 9.0%; P < .01) and parathyroid hormone (150 to 300 pg/mL; mean ± SD at baseline = 39.1% ± 2.4%; month 6 = 44.5% ± 7.0%; P = .04). During the course of the evaluation, mean calcium, albumin, and normalized protein catabolic rate levels did not change significantly.Conclusions: These results show proof-of-concept that a focused phosphorus management program targeting both staff members and patients can significantly improve patient outcomes without compromising nutritional status.

Differences Among Total and In Vitro Digestible Phosphorus Content of Plant Foods and Beverages - Corrected Proof

2011-07-11

Objective: Among plant foods, grain products, legumes, and seeds are important sources of phosphorus (P). Current data on P content and absorbability of P from these foods are lacking. Measurement of in vitro digestible P (DP) content of foods may reflect absorbability of P. The objective of this study was to measure both total phosphorus (TP) and DP contents of selected foods and to compare the amounts of TP and DP and the proportion of DP to TP among different foods.Methods: TP and DP content of 21 foods and drinks of plant origin were measured by inductively coupled plasma optical emission spectrometry. In DP analysis, samples were digested enzymatically in principle in the same way as in the alimentary canal before P analyses. The most popular national brands were chosen for analysis.Results: The highest amount of TP (667 mg/100 g) was found in sesame seeds with hull, which also had the lowest percentage of DP (6%) to TP. Instead, in cola drinks and beer, the percentage of DP to TP was 87 to 100% (13 to 22 mg/100 g). In cereal products, the highest TP content (216 mg/100 g) and DP proportion (100%) were present in industrial muffins, which contain sodium phosphate as a leavening agent. Legumes contained an average DP content of 83 mg/100 g (38% of TP).Conclusion: Absorbability of P may differ substantially among different plant foods. Despite high TP content, legumes may be a relatively poor P source. In foods containing phosphate additives, the proportion of DP is high, which supports previous conclusions of the effective absorbability of P from P additives.