Journal of Renal Nutrition - Articles in Press

Malnutrition-Inflammation Score and Endothelial Dysfunction in Hemodialysis Patients - Corrected Proof

Murat Demir, Adem Kucuk, Mehmet Tugrul Sezer, Atila Altuntas, Selcuk Kaya — 2010-07-22

Objective: The aim of this study was to find out the relationship between Malnutrition-Inflammation score (MIS) and the endothelial function parameters, including measurements of flow-mediated vasodilatation (FMD) in the brachial artery and serum vascular cell adhesion molecule-1 (VCAM-1). Furthermore, predictors of FMD were also assessed.Materials and Methods: A total of 70 anuric hemodialysis patients were enrolled in this cross-sectional study. Measurements of FMD, serum VCAM-1, oxidized low density lipoprotein cholesterol (oxLDL) were done before the mid-week dialysis session from all participants at the time of MIS calculation. Patients were divided into 3 groups according to MIS (the MIS was ≤4 in group I, 4< and ≤7 in group II, and >7 in group III) and compared for above parameters.Results: Patients with higher MIS had higher serum high sensitive C-reactive protein, oxLDL and VCAM-1 levels whereas these patients had lower serum albumin, hemoglobin levels, and FMD rates. MIS was positively correlated with high sensitive C-reactive protein, oxLDL and VCAM-1 levels. However, there was a negative correlation between MIS and FMD. MIS and oxLDL were found as an independent significant predictors of FMD (P = .014 and P = .018, respectively) in a multivariate analysis.Conclusions: MIS is a useful tool in prediction of the severity of endothelial dysfunction. Furthermore, decrease in MIS by the modifiable parameters and also treatment of oxLDL could be expected to improve endothelial dysfunction in hemodialysis patients.

Self-Management and Biomedical Outcomes of a Cooking, and Exercise Program for Patients with Chronic Kidney Disease - Corrected Proof

2010-07-22

Background: Limited research has been done on integrating cooking and exercise classes into the routine care of chronic kidney disease (CKD) patients. The main purpose of the research was to determine whether the addition of these services would slow the progression of certain CKD parameters.Methods: The study evaluated 5 endpoints, at baseline, 6 months, and 12 months: urinary protein, blood pressure, urinary sodium, glomerular filtration rate, and total cholesterol between 2 groups (control group receiving CKD standard care and experimental group receiving standard care plus cooking and exercise classes). Eighty percent of the experimental group was hypothesized to improve in 4 out of the 5 endpoints versus ≤50% in the control group with a P-value of 0.05. An overall difference of 30% was anticipated between the 2 groups. The research also compared self-efficacy and health status outcomes using a self-management questionnaire.Results: Forty randomly assigned patients participated in the study (17 controls and 23 experimental). In the control group, 2 of 17 people improved in at least 4 of the 5 endpoints. In the experimental group, 14 of 23 people improved in at least 4 of the 5 endpoints.Conclusions: Sixty-one percent of experimental subjects showed improvements in 4 of 5 endpoints, showing a significant difference overall when compared with the control group (12% improved in 4 out of 5 endpoints). In looking at the trend in qualitative measures from the comparison of the self-management questionnaire, the overall trend showed more improved answers with the experimental group versus the control group.

The Effect of Nocturnal and Conventional Hemodialysis on Markers of Nutritional Status: Results From a Randomized Trial - Corrected Proof

2010-07-22

Objective: More frequent dialysis may improve nutrition and remove dietary restrictions in hemodialysis (HD) patients. We present results from a trial comparing nutritional parameters between nocturnal hemodialysis (NHD) and conventional HD patients.Methods: Patients were randomized to conventional thrice weekly HD or NHD for a 6-month study period. Dietary intake was recorded by patients using a 3-day food record at baseline and study exit.Results: Of 51 patients, 23 completed baseline and exit food records and were included in the analysis. Although dietary intake of calcium, potassium, and lipids increased in the NHD group, serum levels of calcium and potassium remained within target limits. The majority of NHD subjects were able to reduce or discontinue their phosphate binders and maintain serum phosphate levels within target limits. Serum albumin improved among the NHD group (0.7 g/L) and declined for the conventional group (−1.6 g/L). None of the between group differences achieved statistical significance.Conclusions: As compared with conventional dialysis, NHD was associated with a nonstatistically significant increase in dietary intake for some nutrients, with maintenance of serum levels for potassium, calcium, and phosphorus. Whether increased dietary intake translates into improvement in morbidity and mortality remains to be determined.

Association Between Adherence to Folic Acid Supplements and Serum Folate, and Plasma Homocysteine Among Hemodialysis Patients - Corrected Proof

2010-07-22

Objective: To examine the relationship between adherence to prescribed folic acid supplements and folic acid intake, serum folate and plasma homocysteine in hemodialysis patients. The effects of change in adherence patterns from enrollment to 1 year later on changes in these same measures were also assessed.Design: Secondary data analysis.Participants: Eighty-six hemodialysis patients who participated in the Hemodialysis (HEMO) Study's Homocysteine ancillary study.Main Outcome Measures: Folic acid supplement intake, serum folate, and plasma homocysteine.Results: Eighty-eight percent of patients at enrollment and 91% 1 year later were adherent to prescribed folic acid supplements. Nonadherers had lower intakes of folic acid at both enrollment and 1 year later and lower serum folate levels at enrollment. Percent change was significantly different between the 3 adherence change groups for folic acid intake (P = .001) and plasma homocysteine (P < .001) from enrollment to 1 year later. The nonadherent group at enrollment had the lowest intakes and serum folate levels, and the highest plasma homocysteine levels. When they became adherent 1 year later, they had the greatest change in folic acid intake (5,461%; P = .03), coupled with a 69% increase in serum folate (P = .04) and a 29% decrease in plasma homocysteine (P = .03).Conclusions: Hemodialysis patients who were nonadherent to folic acid supplement prescriptions had low folic acid intakes, low serum folates, and high homocysteine levels. When their adherence improved, folic acid intakes rose, serum folates increased, and plasma homocysteine levels decreased, although mild hyperhomocysteinemia persisted.

Targeting Parathyroid Hormone Level in Diabetic Patients With Stage 3 to 5 Chronic Kidney Disease: Does Metabolic Syndrome Matter? - Corrected Proof

Rengin Elsurer, Baris Afsar, Ertugrul Guner, Idris Yildiz — 2010-07-22

Objectives: Patients with type 2 diabetes have lower intact parathyroid hormone (iPTH) levels when compared with non-diabetics. Patients with metabolic syndrome (MetSyn) have increased iPTH levels than normal subjects. We hypothesized that patients with type 2 diabetes and MetSyn might have higher iPTH levels as compared with those without MetSyn.Methods: The study had an observational design. A total of 84 patients with type 2 diabetes and stage 3 to stage 5 chronic kidney disease (CKD) were recruited (male/female, 40/44).Results: A total of 59 (70.2%) patients had MetSyn. Progress from stage 3 to stage 5 CKD lead to a significant increase in iPTH levels (P-trend = .018). Patients with diabetes and MetSyn had lower high-density lipoprotein cholesterol (P = .018) and higher waist circumference (P = .019), systolic blood pressure (P = .036), fasting plasma glucose (P = .005), HbA1c levels (P = .012), triglyceride (P < .0001), and iPTH (P = .009) as compared with patients without MetSyn. Serum iPTH was negatively correlated with estimated glomerular filtration rate, as measured by Modification of Diet in Renal Disease formula (r = −0.339, P = .002), serum calcium (r = −0.232, P = .037), glucose (r = −0.240, P = .03), and HbA1c (r = −0.301, P = .04) and was positively correlated with urinary albumin excretion rate (r = +0.225, P = .044). After adjusting for potential confounders, logPTH was higher in patients with MetSyn as compared with those without among type 2 diabetic patients with CKD (P = .039).Conclusions: MetSyn might influence iPTH levels in type 2 diabetic patients with stage 3 to 5 CKD. However, it is still debatable whether MetSyn should be taken into account in determining target iPTH levels in type 2 diabetic patients with CKD.

Ginger Feeding Protects Against Renal Oxidative Damage Caused by Alcohol Consumption in Rats - Corrected Proof

2010-07-05

Objective: This study investigated the nephro-protective effect of ginger against chronic alcohol-induced oxidative stress and tissue damage.Design: This is a prospective animal study in which renal antioxidant enzymes were demolished by alcohol consumption and restored with ginger feeding. We fed rats with ginger for 30 days to evaluate the nephro-protective effect against alcohol toxicity.Methods: Twenty-four Wistar strain rats were divided into 4 equal groups: normal control (Nc), ginger treated (Gt), alcohol treated (At), and alcohol plus ginger treated (At + Gt). Ginger was given to the At group for 30 days and renal antioxidant enzymes were assayed.Results: Renal antioxidant enzymes including superoxide dismutase, catalase, glutathione peroxidase, and glutathione reductase activities, and the levels of glutathione were significantly (P < .001) decreased, whereas malondialdehyde levels were elevated in At group. However, ginger extract supplementation to the At rats reversed these effects and attained the antioxidant status to normal levels. Furthermore, degenerative changes in renal cells with alcohol treatment were minimized to nearness in architecture by ginger supplementation.Conclusions: This study concludes that alcohol-induced nephro-toxicity was attenuated by ginger extract treatment, thus ginger can used as a regular nutrient to protect the renal cells.

Lanthanum Carbonate Provides Control of Phosphorus Levels in Patients New to Phosphate Binder Therapy and Patients Changed From Other Phosphate Binders - Corrected Proof

Linda Noto — 2010-07-05

Objective: This retrospective study examined whether patients in an outpatient clinical setting with chronic kidney disease (CKD) stage 5, and who were either new to phosphate binder treatment or were previously treated with other phosphate binders, received benefit from treatment with lanthanum carbonate (LC).Design: This was a retrospective analysis of patient records.Setting: Patients were treated at the Western New York Dialysis Center, LLC (Orchard Park, NY).Patients: Patients (n = 33) were identified through records as having CKD stage 5 and currently receiving or about to begin dialysis treatment. Naive patients (n = 16) had serum phosphorus levels >5.5 mg/dL and did not have previous exposure to phosphate binder treatment. “Changed” patients (n = 17) were treated with sevelamer hydrochloride or calcium-based binders before changing treatment to LC.Interventions: Patients received 500 to 1,500 mg LC thrice daily as needed, to achieve serum phosphorus levels ≤5.5 mg/dL.Results: Serum phosphorus control with LC was rapid (within 1 month) and sustained (after 6 months) in 81% of naive patients; serum albumin levels were maintained at 3.61 ± 0.28 g/dL over a period of 13.81 ± 8.4 months. Treatment with LC maintained serum phosphorus control after 10 to 12 months in 65% of patients in whom treatment was changed from other phosphate binders; serum albumin levels were maintained at 3.78 ± 0.35 g/dL after the change.Conclusions: In this clinical setting, outpatients treated with LC maintained serum phosphorus control and serum albumin levels, suggesting that LC may be effective as an alternative to other phosphate binders or as first-line therapy for controlling serum phosphorus for ≤6 months in patients with CKD stage 5 beginning dialysis.

The Effect of Resistance Exercise to Augment Long-term Benefits of Intradialytic Oral Nutritional Supplementation in Chronic Hemodialysis Patients - Corrected Proof

2010-06-28

Background: Resistance exercise combined with intradialytic oral nutrition (IDON) supplementation improves net protein balance in the acute setting in chronic hemodialysis patients. We hypothesized that combination of long-term resistance exercise and IDON would improve markers of muscle mass and strength further compared with IDON alone.Methods: Thirty-two participants (21 male; mean age, 43 ± 13 years) on chronic hemodialysis were randomly assigned to IDON plus resistance exercise (NS + EX), or IDON (NS) alone for 6 months. IDON consisted of a lactose-free formula consisting of protein, carbohydrate, and fat. Three sets of 12 repetitions of leg-press were completed before each dialysis session in the NS + EX arm. Primary outcome measurement was lean body mass. Muscle strength and other nutritional parameters were measured as secondary outcomes.Results: Of 32 participants, 22 completed the 6-month intervention. There were no statistically significant differences between the study interventions with respect to changes in lean body mass and body weight, when comparing NS + EX to NS. There were also no statistically significant differences in any of the secondary outcomes measured in the study. Body weight (80.3 ± 16.6 kg, 81.1 ± 17.5 kg, and 80.9 ± 18.2 kg at baseline, month 3, and month 6, respectively; P = .02) and 1-repetition maximum (468 ± 148 lb, 535 ± 144 lb, and 552 ± 142 lb, respectively; P = .001) increased statistically significantly during the study for all patients combined.Conclusion: This study did not show further benefits of additional resistance exercise on long-term somatic protein accretion above and beyond nutritional supplementation alone. When both treatments groups were combined, body weight and muscle strength improved during the study.

Impact of Poverty on Serum Phosphate Concentrations in the Third National Health and Nutrition Examination Survey - Corrected Proof

Orlando M. Gutiérrez, Tamara Isakova, Gwen Enfield, Myles Wolf — 2010-05-31

Objective: Increased serum phosphate is associated with adverse health outcomes. High intake of inexpensive processed and fast foods is common in impoverished communities, and is linked with excessive dietary phosphorus intake and elevated serum phosphate concentrations in chronic kidney disease patients. We examined the impact of socioeconomic status on dietary phosphorus intake and serum phosphate concentrations in the general population.Design: Cross-sectional study.Participants: A total of 14,261 adult participants in the Third National Health and Nutrition Examination Survey.Predictors and Outcomes: Poverty to income ratio (PIR; family income indexed to the federal poverty level) was the primary index of socioeconomic status. Serum phosphate was the primary outcome variable.Results: Although estimated phosphorus intake decreased with decreasing quartiles of PIR (P < .001), serum phosphate was inversely associated with PIR (P = .003). The relationship between lower PIR and higher serum phosphate remained significant after adjustment for demographic, laboratory, and dietary intake characteristics (P = .02). Compared with participants in the highest PIR quartile (income >300% of the federal poverty level), participants in the lowest quartile (income < the federal poverty level) had more than twice the odds of hyperphosphatemia (≥4.4 mg/dL) in unadjusted and multivariable-adjusted logistic regression analyses (OR, 2.2; 95% CI, 1.5 to 3.2).Conclusions: Although lower income was associated with decreased estimated phosphorus intake, increasing poverty was independently linked with increased serum phosphate and higher likelihood of hyperphosphatemia. These findings may indicate that conventional dietary instruments underestimate phosphorus intake, especially among impoverished individuals. Further studies are needed to explore these possibilities.

Vitamin D Deficiency in Dialysis Patients: Effect of Dialysis Modality and Implications on Outcome - Corrected Proof

2010-05-31

Objective: Vitamin D deficiency has been linked to cardiovascular disease and mortality in hemodialysis (HD) patients. The purpose of the present cross-sectional study was to analyze the Vitamin D status of dialysis patients from a single center, study determinants of Vitamin D deficiency, and assess its implications on outcome.Methods: A prospective observational study of 115 prevalent dialysis patients was carried out, in which clinical and dialysis-related characteristics including routine biochemistry were studied in relation to levels of 25-hydroxyvitamin-D (25[OH]D, chemiluminescence). Survival was assessed after a median follow-up period of 413 days.Results: 25(OH)D deficiency and insufficiency was present in 51% and 42% of the patients, respectively. Only 7% of the patients showed normal 25(OH)D levels. Peritoneal dialysis patients presented the lowest 25(OH)D levels. Also, a significant difference was found between on-line hemodiafiltration (OL-HDF) and conventional HD (11 [6 to 16] versus 19 [13 to 27] ng/mL; P < 0.001; 25th to 75th percentiles, conventional HD versus OL-HDF respectively). In multinomial logistic regression analysis, patients on conventional HD had 8.35 greater odds (95% CI [2.04 to 34.20]) of 25(OH)D deficiency than OL-HDF even after adjustment for sex, parathyroid hormone, pH, and Charlson comorbidity index. During the follow-up period, 18 patients died. Both crude and adjusted (hazard ratio, 6.96; 95% CI [1.44 to 33.64]) Cox analysis identified 25(OH)D deficiency as a mortality risk factor.Conclusion: This observational study underlines the high prevalence of hypovitaminosis D in dialysis patients and its strong implications on outcome. Furthermore, our results suggest that OL-HDF was associated with a better preservation of the vitamin D status as compared with conventional HD.

Relationship Between Beliefs Regarding a Low Salt Diet in Chronic Renal Failure Patients on Dialysis - Corrected Proof

2010-05-31

Objective: The aim of this study was to investigate the relationship between beliefs regarding a low salt diet and the nutritional behavior of sodium consumption as well their relation with sociodemographic and clinical variables among chronic renal failure (CRF) patients on dialysis.Design and Methods: This cross-sectional study enrolled a sample of 117 patients who answered the Brazilian version of the Beliefs about Dietary Compliance Scale (BDCS), the sodium frequency food questionnaire, and the use of discretionary salt/day.Results: The average of total salt consumption was 10.6 g/day (± 6.3) and it was positively correlated with the interdialytic weight gain (r = 0.20 P = .032) and negatively correlated with the education level (r = −0.19 P = .044). The Benefits beliefs were discriminatory of the higher and lower salt consumers, and proportionally related to monthly income (r = 0.22 P = .017). The Barriers beliefs were positively correlated only to time on dialysis (r = 0.25 P = .008). Subjects with lower schooling and those of older age tended to consume more discretionary salt (r = −0.27, P = .005; r = 0.23, P = .016, respectively); however, they reported a lower consumption of foods with high salt content (r = 0.25 P = .006; r = −0.27 P = .004).Conclusions: Educational interventions aimed at reducing salt consumption for this group must include interventions targeted at different behaviors related to overall salt consumption, the specificities of age, and level of schooling of the patients.

One-Year Serum Albumin is an Independent Predictor of Outcomes in Kidney Transplant Recipients - Corrected Proof

2010-05-31

Objective: This research study was conducted to investigate whether serum albumin levels predict allograft/patient outcomes in the new era of transplant medicine and immunology.Methods: The association of 1-year post-transplant serum albumin, and patient and graft outcomes was retrospectively analyzed in 500 kidney transplant recipients between 1998 and 2005. Albumin was used as a categorical and a continuous variable in univariate and multivariate Cox regression and Kaplan–Meier survival analyses.Results: The average (±SE) age at transplant was 47 ± 12 years. Patients were followed up for 63.4 ± 28 months after transplant. There were 56 graft losses and 38 patient deaths. In univariate analysis, the following variables were associated with the composite endpoint of patient death or allograft loss: 1-year serum albumin (hazard ratio [HR] = 0.52, P = .0009), 1-year serum albumin <4.0 g/dL (HR = 1.81, P = .02), 1-year serum creatinine (HR = 3.55, P < .00001), angiotensin converting enzyme inhibitors or angiotensin receptor blockers use (HR = 1.61, P = .03), a history of previous transplant (HR = 1.54, P = .04), months of dialysis before transplant (HR = 1.01, P = .00003), type of transplant (deceased donor HR = 1.64, P = .02), and acute rejection (HR = 1.52, P = .0000003). Of these, multivariable Cox regression analyses retained 1-year serum albumin (HR = 1.4, P < .0001), serum creatinine (HR = 2.7, P < .0001), and acute rejection (HR = 1.7, P = .02) as significant predictors of patient/graft loss.Conclusion: One-year serum albumin is an independent predictor of poor outcomes in the contemporary era of transplant medicine and immunosuppression. Further studies are needed to separate the role of this biomarker in inflammation and nutrition in kidney transplant recipients.

Megestrol Acetate Improves Weight Gain in Pediatric Patients With Chronic Kidney Disease - Corrected Proof

2010-04-30

Objective: Megestrol acetate (MA) has been used to treat weight loss in pediatric patients with malignancies, cystic fibrosis and HIV/AIDS. We herein report our experience with MA in pediatric patients with chronic kidney disease (CKD).Design: We conducted a retrospective cohort study. Charts were evaluated for clinical, treatment, and laboratory data at six time points: approximately 6 months prior to initiation of MA, at initiation and cessation of MA, and at 2-, 4-, and 8-month follow-up. Anthropometric measurements were corrected for age and sex by conversion to z scores.Setting: Division of Pediatric Nephrology, Helen DeVos Children's Hospital, Grand Rapids, MI.Patients: Pediatric patients (n = 25) with CKD and poor weight gain.Intervention: Patients were administered MA at initial and tapered doses of 14.4 ± 8.1 mg/kg/d and 10.1 ± 6.5 mg/kg/d, respectively, for 5.4 ± 6.3 months.Results: The study population (n = 25) was 60% male, 16% African American, 72% white, and 12% Hispanic with a mean ± SD age of 8.9 ± 5.4 years. Prior to MA therapy, patients demonstrated a decrease in BMI and poor weight gain. The treatment phase was associated with significant increases in BMI (P < .0001) and weight (P < .0001), which were well sustained at 8-month follow-up (P < 0.01 and P < 0.001, respectively). Patients demonstrated continued increases in height. A single patient exhibited physical adverse side effects (cushingoid features) associated with MA; otherwise, MA was well tolerated.Conclusions: MA appears to effectively improve weight gain in pediatric CKD patients with minimal adverse side effects and may therefore serve as a safe, short-term, nutritional strategy.

Confounding Effect of Comorbidities and Malnutrition on Survival of Peritoneal Dialysis Patients - Corrected Proof

2010-03-12

Background and Objectives: Malnutrition and comorbid diseases are strong predictors of mortality in patients on continuous ambulatory peritoneal dialysis (CAPD). We undertook this study to analyze the confounding impact of comorbidities and malnutrition on the survival of CAPD patients.Methods: In this prospective, observational study, 342 CAPD patients (179 diabetics, 250 male, aged 51.5 ± 14 years) were followed for 21.62 ± 14.38 S.D. patient-months. Based on nutritional status and comorbidities, patients were categorized into four groups: (1), normal nutrition without comorbidities (n = 61, 17.8%); (2), normal nutrition with comorbidities (n = 26, 7.6%); (3), malnutrition with comorbidities (n = 160, 46.8%); and (4), malnutrition without comorbidities (n = 95, 27.8%). The risk ratios of mortality and predictors of survival were analyzed in the different groups.Results: Of 342 patients, 186 (54.4%) patients had one or more comorbidities, and 156 (45.6%) patients had no comorbidities. Of 186 patients with comorbidities, 160 (86%) patients were malnourished, and only 26 (14%) had normal nutritional status. Of 156 patients without comorbidities, 95 (61%) were malnourished, and 61 (39%) had normal nutritional status. The relative risk of developing malnutrition in patients with comorbidities was significantly high, compared with patients without comorbidities (risk ratio, 3.9; 95% confidence interval [CI], 2.3 to 6.6; P = .001). According to time-dependent multivariate Cox regression analysis, the hazard ratio of mortality was 3.6 (95% CI, 1.1 to 11.7; P = .03) in patients with normal nutrition with comorbidities; 2.9 (95% CI, 1.1 to 7.8; P = .03) in patients with malnutrition without comorbidities; and 6.6 (95% CI, 2.6 to 16.5; P = .001) in patients with both malnutrition and comorbidities. The risk ratio of mortality in patients with both malnutrition and comorbidities was 3.7 times higher than in patients with malnutrition without comorbidities.Conclusions: Patients with comorbidities are at high risk of developing malnutrition. Comorbidities and malnutrition, alone or together, constitute independent predictors of survival in these patients. Patients with both malnutrition and comorbidities demonstrate the worst survival. Malnutrition and comorbidities seem to exert a confounding effect on the survival of CAPD patients.