Journal of Renal Nutrition - Articles in Press

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.

Vitamin C Affects the Expression of Hepcidin and Erythropoietin Receptor in HepG2 Cells - Corrected Proof

Ping-Fang Chiu, Shun-Yao Ko, Chia-Chu Chang — 2012-01-09

Backgrounds: Hepcidin modulates the de novo absorption of iron from the duodenum and the recycling of iron released from the reticuloendothelial system. In patients with chronic renal failure, administration of higher doses of erythropoietin (EPO) or vitamin C (Vit C) can correct the functional iron deficiency. While EPO-regulated hepcidin expression within hepatocytes has been recently identified, the relation between vitamin C with hepcidin expression is still uncertain.Methods: Hepcidin-producing HepG2 cells (a human liver carcinoma cell line) were cultured with 50- to 100-μg/mL vitamin C or 0.25- to 1.0-U/mL EPO for 6 hours. Reverse transcription polymerase chain reaction was performed for quantitative measurements of hepcidin, EPO, and EPO receptor (EPOR) expression.Results: EPO and vitamin C inhibited hepcidin expression within HepG2 cells; the EPO effect was dose dependent. EPO downregulated EPOR and vitamin C and upregulated EPOR. However, vitamin C had little effect on the expression of EPO.Conclusions: EPO is capable of downregulating EPOR when it acts early. Vitamin C directly inhibits hepcidin expression within HepG2 cells. Moreover, by enhancing EPOR production, vitamin C may correct the downregulating EPOR from EPO, which has additional effect with EPO in treating anemia.

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.

Cognitive Dysfunction and Depression in Adult Kidney Transplant Recipients: Baseline Findings from the FAVORIT Ancillary Cognitive Trial (FACT) - Corrected Proof

2011-12-08

Objective: Hyperhomocysteinemia and B-vitamin deficiency may be treatable risk factors for cognitive impairment and decline. Hyperhomocysteinemia, cognitive impairment, and depression are all common in individuals with kidney disease, including kidney transplant recipients. Accordingly, we assessed the prevalence of cognitive impairment and depressive symptoms in transplant recipients and their association with kidney function, plasma total homocysteine, and B-vitamin concentrations.Setting: Cross-sectional analysis of baseline data from the Folic Acid for Vascular Outcome Reduction In Transplantation (FAVORIT) Ancillary Cognitive Trial (FACT), which included 183 participants in FAVORIT who underwent detailed neuropsychological assessment before the study intervention.Results: The mean age was 54.0 ± 9.5 years (range: 7 to 386 months). Men comprised 55.2% of the cohort, and the mean time between the current transplant and cognitive testing was 7.0 ± 5.8 years. Twenty-four percent of participants reported neurological or psychiatric complaints, and 30% exhibited symptoms of mild to severe depression. Testing revealed evidence of significant and selective deficits in this population: 33% performed more than 1 standard deviation (SD) below normed means on a memory test, 58% fell lower than 1 SD below the norms on a test of attention and mental processing speed, and 33% to 42% fell lower than 1 SD below the norms on several tests of executive function. Lower estimated glomerular filtration rate and lower folate were associated with poorer performance on tests of memory and executive function.Conclusions: These observations confirm previous reports of mood and cognitive impairments in adult kidney transplant recipients. Further research is needed to determine the benefit of B-vitamin supplementation and other interventions in this patient population.

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.

Non–High-Density Lipoprotein Cholesterol and Its Correlation With Anthropometric Markers of Cardiovascular Risk in Hemodialysis - Corrected Proof

2011-11-28

Introduction: Non–high-density lipoprotein cholesterol (non–HDL-c) may be a better indicator of atherogenicity in the hemodialysis population.Purpose: To investigate the correlation of non–HDL-c with anthropometric measurements associated to cardiovascular risk, such as body mass index, waist circumference, waist-to-height ratio, waist-to-height2 ratio, and waist-to-hip circumference ratio.Methods: We evaluated anthropometric markers and lipids in 86 hemodialysis patients, and the correlation between them was investigated.Results: Non–HDL-c had a positive correlation with body mass index (r = 0.273; P = .01), waist circumference (r = 0.375; P = .000), waist-to-height ratio (r = 0.333; P = .002), waist-to-height2 ratio (r = 0.270; P = .012), and waist-to-hip circumference ratio (r = 0.356; P = .001).Conclusions: This study detected a positive and significant correlation between non–HDL-c, but not low-density lipoprotein cholesterol, and the anthropometric cardiovascular risk indexes. We could suggest that non–HDL-c can be used as a cardiovascular risk factor indicator among dialysis patients.

Effect of Hemodialysis and Diet on the Exhaled Breath Methanol Concentration in Patients with ESRD - Corrected Proof

Hyun Ji (Julie) Lee, Madeleine V. Pahl, Nosratola D. Vaziri, Donald R. Blake — 2011-11-21

Objectives: End-stage renal disease (ESRD) causes accumulation of nitrogenous waste products and acid-base, mineral, fluid, and electrolyte disorders, which are partially corrected by hemodialysis (HD). While the effects of ESRD and dialysis on body fluid composition are well known, the effects on composition of expired breath are uncertain. Methanol is produced from unabsorbable complex carbohydrates by the colonic microbiome. Dietary restrictions of fruits and vegetables aimed at limiting potassium intake lower the intake of dietary fibers; the reduced fiber intake can in turn reduce production of methanol and its appearance in the exhaled breath. In this study, we investigated the inter- and intradialytic changes in the breath methanol levels.Design and Method: Ten ESRD patients were studied during HD procedures at 3- and 2-day interdialytic intervals. On each occasion, 20 exhaled breath and room air samples were collected using evacuated canisters. Ten age-matched normal subjects served as controls. The samples were analyzed on a unique 6-column/detector gas chromatography system.Results: Seven ESRD patients consuming renal diet had lower methanol concentration (90 ± 29 ppbv) than the 3 patients consuming high-fiber diet (340 ± 48 ppbv, P ≤ .0006) and the 10 controls consuming unrestricted diets (202 ± 80 ppbv, P ≤ .001). HD significantly lowered breath methanol (60% ± 12%), paralleling the fall in serum urea concentration (70% ± 6%). The predialysis methanol concentration was slightly higher at 3-day than the 2-day interdialytic intervals.Conclusion: Dietary restriction of fruits and vegetables lowers methanol production by the gut microbial flora in ESRD patients. Perhaps, methanol is a reliable breath biomarker to monitor individuals’ daily fiber intake. Breath methanol is dramatically reduced by HD, reflecting its efficient removal.

Gastrointestinal Symptoms and Nutritional Status in Women and Men on Maintenance Hemodialysis - Corrected Proof

2011-11-10

Objective: The main objective was to investigate whether the prevalences of nausea, vomiting, diarrhea, and reduced appetite varied by gender in maintenance hemodialysis (MHD) patients. We also evaluated whether these symptoms explain female–male difference in nutritional status.Design: Cross section of baseline data of the Prospective Study of the Prognosis in Chronic Hemodialysis Patients.Setting: Dialysis units in the city of Salvador, Brazil.Patients: Three hundred ninety-seven men and 287 women with more than three months on MHD.Predictor Variable: Gender.Outcome Measures: The patient’s self-reported nausea, vomiting, diarrhea, and reduced appetite. The malnutrition–inflammation score (MIS) was used to assess nutritional status.Results: The prevalence of symptoms was 24.3% for reduced appetite, 19.7% for nausea, 12.3% for vomiting, and 3.5% for diarrhea. In a logistic regression model with adjustments for age, diabetes, congestive heart failure, hemoglobin, albumin, Kt/V, and years on dialysis, women were found to have significantly higher odds of reduced appetite (odds ratio [OR] = 1.97), nausea (OR = 1.90), and vomiting (OR = 2.21). MIS was 5.41 ± 3.18 for women and 4.66 ± 3.28 for men (P = .002) corresponding to a percentage difference of 13.86%. The female-male difference reduced by more than half after excluding the gastrointestinal symptoms component and by approximately 65% after excluding both the gastrointestinal symptoms and the dietary intake components from the MIS.Conclusions: The results suggest that the prevalences of nausea, vomiting, and reduced appetite are higher in women than in men on MHD. These gastrointestinal symptoms and perhaps their detrimental effects on dietary intake may partially explain a poorer nutritional status in MHD women.

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.

Phosphate Content of Beverages in Addition to Food Phosphate Additives: Real and Insidious Danger for Renal Patients - Corrected Proof

Lorenzo A. Calò, Vincenzo Savica, Paul A. Davis — 2011-11-10

The association of high plasma phosphate levels with cardiovascular morbidity and mortality is increasingly recognized. This association has been most clearly demonstrated particularly in patients with renal disease, both in patients under chronic dialysis and in those under conservative treatment in which elevated serum phosphorus level has been shown to relate with disease progression. This association has also been extended to include healthy individuals in whom blood phosphate levels in the high normal range were shown to be associated with an increased coronary artery calcium content, this latter being strongly associated with atherosclerosis and cardiovascular disease risk. Given the relationship between dietary phosphate intake and plasma phosphate, and considering the importance of reduced phosphate intake—particularly to control the phosphate levels in dialysis patients—phosphate intake, sources, and means of reducing plasma phosphate are of primary importance and the subject of considerable research.

A Difference Between Day and Night: Protein Intake Improves After the Transition From Conventional to Frequent Nocturnal Home Hemodialysis - Corrected Proof

2011-11-07

Background: Malnutrition is an important cause of the excessive morbidity and mortality rate of dialysis patients. Frequent nocturnal home hemodialysis (NHHD) has many benefits compared with conventional thrice-weekly hemodialysis (CHD), due to the virtual absence of dietary restrictions and a much higher overall dialysis efficiency. In this observational study, we investigated whether these benefits of NHHD translate into an improved nutritional intake, with a special emphasis on protein intake.Methods: We prospectively assessed the effect of the transition of CHD to NHHD on nutritional intake (5-day dietary intake journal), normalized protein catabolic rate, and anthropometric parameters in 15 consecutive patients who started NHHD in our center between 2004 and 2009 and completed at least 8 months of follow-up. Data were collected before the transition from CHD to NHHD and 4 and 8 months after the transition.Results: Protein intake, as measured by both dietary intake journal and normalized protein catabolic rate, increased significantly after the transition from CHD to NHHD. Accordingly, phosphate intake increased significantly; however, serum phosphate levels did not increase, despite negligible phosphate binder use during NHHD. Body mass index and upper arm muscle circumference did not change significantly.Conclusion: The transition from CHD to NHHD has a positive effect on nutritional intake, in particular, protein intake. NHHD should be considered in malnourished patients on CHD.

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.

Comparison of Markers of Appetite and Inflammation Between Hemodialysis Patients With and Without Failed Renal Transplants - Corrected Proof

2011-11-04

Objective: The survival of patients returning to hemodialysis (HD) following kidney transplant failure is unfavorable. However, the factors responsible for this poor outcome are largely unknown; chronic inflammation due to failed allograft and malnutrition may contribute to morbidity and mortality. We aim to compare the markers of appetite and malnutrition, and their relation with inflammation in HD patients with and without previous kidney transplantation.Methods: Fifty-six patients with failed renal allografts at least 3 months on dialysis (31 men, 25 women; mean age, 46 ± 9 years) and 77 HD patients who never underwent a transplant (43 men, 34 women; mean age, 50 ± 15 years) were included in the study. The appetite and diet assessment tool (ADAT) was used to determine the self reported appetite of patients. Serum concentrations of ghrelin, leptin, insulin like growth factor 1 (IGF-1), interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), and high-sensitivity C-reactive protein (hs-CRP) were measured. Associations among these variables were analyzed.Results: There were no significant differences considering age, gender or duration of renal replacement therapy between the 2 groups. The scores from Appetite and Diet Assessment Tool were significantly higher in the failed-transplant group. Serum ghrelin levels were significantly higher and serum albumin levels were significantly lower in the failed-transplant group. Serum leptin levels were similar between 2 groups. In addition, hs-CRP, IL-6, and TNF-α levels, which were used as inflammatory parameters, were significantly higher in the failed-transplant group.Conclusions: Elevated serum ghrelin levels and inflammation may cause diminished appetite and malnutrition in patients with failed renal allografts, and higher levels of this hormone seem to be associated with inflammation caused by retained failed allografts.

Adductor Pollicis Muscle Thickness: A Promising Anthropometric Parameter for Patients With Chronic Renal Failure - Corrected Proof

2011-11-04

Introduction: Protein-calorie malnutrition is a prevalent disorder in chronic renal failure (CRF) and a major risk factor for increased mortality in hemodialysis (HD) patients. Although many methods have been used to assess malnutrition in CRF, the role of adductor pollicis muscle thickness (APMt) is not established yet.Aims: This study aimed to analyze the APMt in HD patients and to investigate the correlation between APMt and conventional anthropometric, laboratory, and bioelectrical impedance markers, as well as its association with mortality/morbidity in a period of 12 months of follow-up.Subjects and Methods: The study included 143 HD patients from a single facility. After dialysis, the dry weight, height, mid-arm circumference, triceps skinfold thickness, and APMt were measured. Subsequently, the body mass index, percentage of standard body weight, the mid-arm muscle circumference, and the mid-arm muscle area were calculated. Blood counts were performed for hemoglobin, creatinine, and albumin. Patients were also submitted to a single-frequency tetrapolar bioimpedance test for measuring resistance, reactance, phase angle, and percentage of body cell mass. The correlation between APMt and anthropometric, laboratory, and bioelectrical impedance parameters was calculated using Pearson’s linear correlation. Multiple linear regression analysis was used to select independent risk factors to death and hospitalizations in 6 and 12 months of follow-up, among parameters selected by univariate analysis.Results: Patients were aged 52.2 ± 16.6 years (20 to 83 years) on average, 58% were men, and mean dialysis vintage was 5.27 ± 5.12 years. APMt was 11.85 ± 1.63 mm (men, 12.34 ± 1.53; women, 11.19 ± 1.51; P < .0001). APMt was positively correlated with body mass index (r = 0.37; P < .0001), mid-arm circumference (r = 0.437; P < .0001), mid-arm muscle circumference (r = 0.494; P < .0001), mid-arm muscle area (r = 0.449; P < .0001), percentage of standard body weight (r = 0.355; P = .000), creatinine (r = 0.230; P = .006), albumin (r = 0.207; P = .013), percentage of body cell mass (r = 0.293; P = .000), and phase angle (r = 0.402; P < .0001), and negatively correlated with resistance (r = −0.403; P < .0001). The APMt ≤10.6 mm was associated with a 3.3 times greater risk of hospitalization within 6 months of follow-up (OR = 3.3, 95% CI: 1.13 to 9.66; P = .029) compared with patients with an APMt >10.6 mm. The APMt was not associated with risk of death at 6 and 12 months or hospitalization within 12 months of follow-up.Conclusion: This is the first study testing APMt as an anthropometric marker in HD patients. The parameter is easy to measure and does not seem to be significantly affected by variations in hydration status. The parameter was significantly correlated with markers reflecting the condition of the muscle compartment, but not with parameters estimating the fat mass. The determination of an APMt cutoff point for malnutrition in patients with CRF and its correlation with morbidity and mortality will require further investigation in clinical studies.

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.

Protective and Therapeutic Effects of Licorice in Rats with Acute Tubular Necrosis - Corrected Proof

2011-11-02

Objectives: Various protective and therapeutic effects such as antioxidant, anti-inflammatory, anticancer, antihistaminic, and antibacterial effects have been depicted for licorice. However, its biological effects in the kidney are still not clear. Therefore, we aimed to investigate the efficiency of licorice in rats with gentamicin (GM)-induced acute tubular necrosis.Design and Methods: Rats were randomized into the control group (only saline for 12 days), licorice group (licorice for 12 days), GM group (GM for 12 days), GM + licorice group, and licorice-treated GM group (licorice for 12 days after taking GM for 12 days). Blood urea, creatinine, and uric acid levels were measured and histopathological analyses of the kidneys were performed. The oxidative side of oxidant-antioxidant balance was evaluated by detecting lipid peroxidation (LPO) and total peroxide levels, and antioxidative side was determined by measuring total antioxidant capacity (TAC) and reduced glutathione (GSH) levels in plasma and kidney tissues.Results: The oxidant-antioxidant balance seemed to be shifted to the oxidative side in the GM group when compared with the control and GM + licorice groups. In GM group, biochemical profiles showed a remarkable increase in blood uric acid, urea, and creatinine levels, and depletion of renal tissue and plasma TAC and GSH levels. In addition, histopathologic studies revealed severe acute tubular necrosis, congestion, and hyaline casts, verifying GM-induced nephrotoxicity. Licorice was effective in reduction of blood urea, creatinine, and uric acid levels, and also effective in decreasing the tubular necrosis score. Licorice treatment also significantly reduced LPO and total peroxide levels, and increased TAC and GSH levels in both renal tissue and blood. Moreover, these changes in rats subjected to the combined therapy (GM + licorice) were significantly less than those of GM group.Conclusions: Licorice ameliorates GM-induced nephrotoxicity and oxidative damage by scavenging oxygen free radicals, decreasing LPO, and improving antioxidant defense.

Differences among Total and In Vitro Digestible Phosphorus Content of Meat and Milk Products - Corrected Proof

Heini Karp, Päivi Ekholm, Virpi Kemi, Tero Hirvonen, Christel Lamberg-Allardt — 2011-10-07

Objective: Meat and milk products are important sources of dietary phosphorus (P) and protein. The use of P additives is common both in processed cheese and meat products. Measurement of in vitro digestible phosphorus (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 meat and milk products and to compare amounts of TP and DP and the proportion of DP to TP among different foods.Methods: TP and DP contents of 21 meat and milk products were measured by inductively coupled plasma optical emission spectrometry (ICP-OES). In DP analysis, samples were digested enzymatically, in principle, in the same way as in the alimentary canal before the analyses. The most popular national brands of meat and milk products were chosen for analysis.Results: The highest TP and DP contents were found in processed and hard cheeses; the lowest, in milk and cottage cheese. TP and DP contents in sausages and cold cuts were lower than those in cheeses. Chicken, pork, beef, and rainbow trout contained similar amounts of TP, but slightly more variation was found in their DP contents.Conclusions: Foods containing P additives have a high content of DP. Our study confirms that cottage cheese and unenhanced meats are better choices than processed or hard cheeses, sausages, and cold cuts for chronic kidney disease patients, based on their lower P-to-protein ratios and sodium contents. The results support previous findings of better P absorbability in foods of animal origin than in, for example, legumes.

What is the Impact of Nutritional Status on Health-Related Quality of Life in Hemodialysis Patients? - Corrected Proof

2011-09-26

Objectives: To develop a nutrition-specific quality of life (NSQOL) questionnaire that combines the Appetite and Diet Assessment Tool and the Food Enjoyment in Dialysis tool, and to measure the association between nutritional status and both the NSQOL and the generic health-related quality of life (HRQOL) in hemodialysis patients.Methods: Cross-sectional study of 89 hemodialysis patients. Nutritional status was measured by subjective global assessment and biochemical indices, including serum albumin concentration. Adequacy of dialysis was also measured. To determine the correlation between quality of life and nutritional status, both the NSQOL and the HRQOL instruments were used.Results: The mean NSQOL score for the entire cohort was 8.9 ± 4.5. The NSQOL was positively correlated with the mental component score (r = 0.52, P < .001) and the physical component score (PCS) (r = 0.29, P < .05) of the HRQOL questionnaire. There was no difference in the NSQOL score between the moderately malnourished and the mildly malnourished to well-nourished patients. The mean PCS was significantly lower in the moderately malnourished group as compared with the mildly malnourished and well-nourished groups (33.4 ± 10.7 vs. 38.9 ± 10.2, P < .05); however, there was no difference in the mean mental component score between the groups. Nutritional status, as assessed by subjective global assessment, was positively correlated with the PCS (r = 0.33, P < .05) and serum albumin concentration (r = 0.35, P = .01).Conclusion: We developed an NSQOL questionnaire by combining the Appetite and Diet Assessment Tool and the Food Enjoyment in Dialysis tool. The NSQOL questionnaire is a rapid self-administered tool that can be used to assess appetite-related quality of life in patients receiving maintenance hemodialysis. This instrument correlated well with HRQOL indices in this cohort of hemodialysis patients.

Effects of Alpha-Lipoic Acid Supplementation on Inflammation, Oxidative Stress, and Serum Lipid Profile Levels in Patients with End-Stage Renal Disease on Hemodialysis - Corrected Proof

Tannaz Khabbazi, Reza Mahdavi, Javid Safa, Parvin Pour-Abdollahi — 2011-09-12

Objective: We examined the effects of alpha-lipoic acid (ALA) supplementation on inflammation, oxidative stress, and serum lipid profile levels in hemodialysis (HD) patients.Design: This was a double-blinded, randomized, placebo-controlled clinical trial.Setting: The present study involved HD centers in Tabriz, Iran.Patients: Participants included 63 patients with end-stage renal disease (43 men and 20 women; age range: 22-79 years) undergoing maintenance HD.Intervention: HD patients were randomly assigned into the supplemented group (n = 31), receiving a daily dose of ALA (600 mg), or a control group (n = 32), receiving placebo for 8 weeks.Main Outcome Measures: High sensitivity C-reactive protein (hsCRP), malondialdehyde, total antioxidant status, total cholesterol, triglyceride, high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C) were measured at baseline and after 8 weeks of supplementation.Results: At the end of intervention, 11 patients were excluded from the study. HsCRP levels decreased by 18.7% in the supplemented group after 8 weeks of supplementation, and the reduction was significant in comparison with the placebo group (P < .05); this finding was also significant after adjusting for baseline values of hsCRP. The mean malondialdehyde and total antioxidant status levels did not change significantly in the 2 groups during the study. The mean high-density lipoprotein cholesterol concentrations increased significantly in the supplemented group at the end of the study (P < .05); however, this improvement was not statistically significant as compared with the placebo group. No significant alterations were observed in the other lipid profile parameters within each group during the study.Conclusion: ALA supplementation significantly reduced hsCRP levels, which is a risk factor for cardiovascular disease in HD patients.

Impact of Cholecalciferol Treatment on Biomarkers of Inflammation and Myocardial Structure in Hemodialysis Patients without Hyperparathyroidism - Corrected Proof

2011-09-12

Introduction: Vitamin D (25-hydroxyvitamin D, 25(OH)D) deficiency, hypovitaminosis D, is highly prevalent in chronic kidney disease patients and is potentially involved with complications in the hemodialysis (HD) population. The aim of this study was to evaluate the impact of cholecalciferol supplementation on biomarkers of mineral metabolism, inflammation, and cardiac function in a group of HD patients presenting with hypovitaminosis D and low intact parathyroid hormone (iPTH) levels.Material and Methods: HD patients with iPTH levels of <300 pg/mL, not receiving vitamin D therapy, and presenting with 25(OH)D levels of <30 ng/mL were enrolled in this prospective study. Oral cholecalciferol was prescribed once a week in the first 12 weeks (50,000 IU) and in the last 12 weeks (20,000 IU) of the study. High-sensitivity C-reactive protein, interleukin-6, and serum albumin were used as inflammatory markers. Echocardiograms were performed on a midweek interdialytic day at baseline and after 6 months of cholecalciferol supplementation.Results: In all, 30 patients were included in the final analysis. We observed a significant increase in serum 25(OH)D levels after 3 months (46.2 ± 14.4 ng/mL vs. 18.1 ± 6.6 ng/mL; P < .001) and after 6 months (40.4 ± 10.4 ng/mL vs. 18.1 ± 6.6 ng/mL; P < .001) of cholecalciferol supplementation. There were no significant changes in alkaline phosphatase, iPTH, phosphorus, and serum albumin levels, but there was a slight but significant increase in calcium levels after 6 months of cholecalciferol supplementation (9.4 ± 0.6 mg/dL vs. 9.0 ± 0.6 mg/dL; P = .02). Additionally, we observed a significant reduction in high-sensitivity C-reactive protein levels after 3 months (median: 0.62 [0.05 to 29.6] mg/L vs. 0.32 [0.02 to 3.13] mg/L; P = .02) and after 6 months (median: 0.62 [0.05 to 29.6] mg/L vs. 0.50 [0.02 to 5.66] mg/L; P = .04) of cholecalciferol supplementation, as well as a significant reduction in interleukin-6 levels (median: 6.44 pg/mL vs. 3.83 pg/mL; P = .018) after 6 months of supplementation. Left ventricular mass index was significantly reduced at the end of supplementation (159 ± 55 g/m2 vs. 175 ± 63 g/m2; P = .03).Conclusions: Cholecalciferol supplementation in HD patients was found to be safe and efficient to correct hypovitaminosis D and established little impact on mineral metabolism markers. Additionally, we observed a reduction in important surrogate markers of cardiovascular risk, namely systemic inflammation and left ventricular hypertrophy, suggesting an anti-inflammatory action and possibly an improvement of cardiac dysfunction.

Examining Associations of Circulating Endotoxin With Nutritional Status, Inflammation, and Mortality in Hemodialysis Patients - Corrected Proof

2011-09-01

Objective: Lipopolysaccharide or endotoxin constitutes most part of the outer portion of the cell wall in the gram-negative bacteria. Subclinical endotoxemia could contribute to increased inflammation and mortality in hemodialysis (HD) patients. Endotoxin level and clinical effect are determined by its soluble receptor sCD14 and high-density lipoprotein. We examine the hypothesis that endotoxin level correlates with mortality.Methods: In this cohort study, endotoxin levels were measured in 306 long-term HD patients who were then followed up for a maximum of 42 months. Soluble CD14 and cytokines levels were also measured.Results: The mean (±SD) endotoxin level was 2.31 ± 3.10 EU/mL (minimum: 0.26 EU/mL, maximum: 22.94 EU/mL, interquartile range: 1.33 EU/mL, median: 1.27 EU/mL). Endotoxin correlated with C-reactive protein (r = 0.11, P < .04). On multivariate logistic regression analysis, high body mass index and low high-density lipoprotein (HDL) cholesterol levels were associated with higher endotoxemia (endotoxin below or above of median). In multivariate Cox regression analysis adjusted for case-mix and nutritional/inflammatory confounders, endotoxin levels in the third quartile versus first quartile were associated with a trend toward increased hazard ratio for death (hazard ratio: 1.83, 95% confidence interval: 0.93 to 3.6, P = .08).Conclusions: In this HD cohort, we found associations between endotoxemia and C-reactive protein, body composition, and HDL. Moderately high endotoxin levels tended to correlate with increased mortality than the highest circulating endotoxin level. Additional studies are required to assess the effect of endotoxemia on mortality in dialysis population.

A Preliminary Report on the Functioning and Data Collection Capabilities of a Web-based Nutrition Algorithm for Patients with Chronic Kidney Disease - Corrected Proof

Rosa K. Hand, Janeen León, Lillian Cuppari, Alison Leah Steiber — 2011-08-12

Objective: The purpose of this study was to test the functional and data collection capabilities of an online nutrition algorithm for patients with chronic kidney disease by comparing dietitian-selected nutrition diagnoses, etiologies, and interventions in hemodialysis (HD) patients with and without diabetes mellitus (DM).Design: Data were collected using an online nutrition screening tool and algorithm for HD patients based on the American Dietetic Association’s Nutrition Care Process.Setting: Data were collected by dietitians in the United States, New Zealand, Australia, and Brazil.Patients: Patients undergoing HD under the care of a participating dietitian and who were deemed at nutrition risk at visit 1 were eligible to participate. Other inclusion criteria included age >19 years, able to speak and write English, and not receiving hospice care or the international equivalent. Data were available on 26 patients (50% males, 39% with DM). Mean baseline values were as follows: age, 56.3 years; body mass index, 28.2 kg/m2; and serum albumin (bromocresol green), 36.8 g/L (3.68 g/dL). There were no statistically significant differences between DM and non-DM patients except in mean hemoglobin A1C.Main Outcome Measure: Differences in the frequency of selection of diagnoses, etiology, and intervention categories were compared.Results: The algorithm is under continuous development using input from participating dietitians, but its use was generally considered feasible. The initial data analysis showed that the algorithm is an effective method for collecting data on HD patients. In this small cohort, patients with and without DM had similar dietitian-selected nutrition diagnoses and etiologies, but had statistically significant differences in the dietitian-selected nutrition interventions that were selected most frequently. Health Care Team Referral was selected more often in DM patients (P < .003) and Recommendation of Specific Foods was selected more often in non-DM patients (P < .0170).Conclusion: This preliminary analysis shows that the algorithm can be used as both a clinical and a data collection tool. The test analysis, although small in sample size, showed interesting differences in the care of DM and non-DM HD patients.

Plasma Fatty Acids in Chronic Kidney Disease: Nervonic Acid Predicts Mortality - Corrected Proof

2011-07-21

Although the value of red blood cell fatty acids (FAs) in estimating risk for acute coronary syndrome in the general population is evident, the value of FAs in chronic kidney disease (CKD) is unknown. Here, we provide an initial pilot FA assessment in a spectrum of CKD patients. Plasma samples were obtained from 20 patients on incident dialysis (stage 5 CKD), matched with samples from 10 patients with stage 3-4 CKD, and 10 control subjects. Whole plasma FAs were measured using gas chromatography. Although neither linoleic acid nor arachidonate (AA) was altered in CKD, metabolic intermediates of AA synthesis (γ-linolenate and dihomo γ-linolenate) were reduced in CKD. Deming (orthogonal) correlation of FA abundance with estimated glomerular filtration rate identified several saturated and unsaturated FAs in addition to the intermediates; again, neither linoleate nor AA was related. Follow-up data within the stage 5 CKD patients revealed that nervonic acid, a component of membrane sphingolipids and phosphatidylethanolamines, was a significant predictor of all-cause mortality; the age-adjusted relative risk for a 0.15% change is 2.1 (95% CI: 1.4, 3.7; P = .0008). These findings support the exploration of FAs in larger studies for validation of their role in cardiovascular risk and mortality in CKD patients.

Association Between Fish Consumption and Nephropathy in American Indians—The Strong Heart Study - Corrected Proof

2011-07-11

Objective: The present study examined the association between fish consumption and nephropathy in American Indians.Methods: In the family cohort of the Strong Heart Study, we investigated 2,261 participants with baseline examination between 2001 and 2003 and follow-up examination between 2006 and 2008. The average follow-up period was 5.4 years. We defined fish consumption as the sum of dietary intake of tuna, fried fish, and nonfried fish obtained from a validated food frequency questionnaire. Nephropathy was defined as microalbuminuria (urinary albumin–creatinine ratio [ACR]: 30 to 299 mg/g), macroalbuminuria (urinary ACR: ≥300 mg/g), or an estimated glomerular filtration rate of <60 mL/min/1.73 m2. Using regression models, we examined the association between fish consumption measured at baseline and 2 outcomes in nephropathy present at follow-up, albuminuria, or renal impairment, and change in urinary ACR or estimated glomerular filtration rate between baseline and follow-up examinations.Results: The prevalence of microalbuminuria, macroalbuminuria, and renal impairment was 13%, 3%, and 4%, respectively. The fish items consumed by the participants were predominantly deep-fried. We found no associations between fish consumption and any measure of nephropathy after adjusting for demographic, clinical, lifestyle, and dietary factors.Conclusions: Dietary intake of predominantly fried fish was not associated with a lower risk of nephropathy in American Indians.

The rs7204609 Polymorphism in the Fat Mass and Obesity-Associated Gene is Positively Associated With Central Obesity and Microalbuminuria in Patients With Type 2 Diabetes From Southern Brazil - Corrected Proof

2011-07-11

Objective: Single nucleotide polymorphisms (SNPs) in the fat mass and obesity-associated (FTO) gene, especially the common rs9939609 (A/T) SNP, are associated with body mass index (BMI), diabetes, and metabolic syndrome (MetS). MetS is highly prevalent in patients with type 2 diabetes and has been associated with chronic diabetic complications. Therefore, the aim of this study was to evaluate possible associations of the scarcely investigated rs7204609 (C/T) polymorphism, as well as the rs9939609 (A/T) polymorphism, with MetS and chronic diabetic complications in type 2 diabetic patients from Southern Brazil.Design: This was a cross-sectional study.Patients and Methods: A total of 236 patients with type 2 diabetes (age: 60.0 ± 10.3 years; diabetes duration: 12.7 ± 8.2 years; 53.4% women) were genotyped for the FTO rs7204609 and rs9939609 polymorphisms (ABI PRISM 7000 Real-Time PCR System). Patients underwent clinical, laboratory, and nutritional evaluation. MetS was defined according to the 2009-Joint Interim Statement.Results: Carriers of C allele of the rs7204609 polymorphism (CT/CC genotypes, n = 35) were at increased risk for the presence of MetS (odds ratio [OR] = 4.56; 95% CI: 1.04 to 19.9), elevated waist circumference (OR = 8.66; 95% CI: 1.12 to 66.7), BMI: ≥30 kg/m2 (OR = 3.71; 95% CI: 1.71 to 8.02), and microalbuminuria (OR = 2.30; 95% CI: 1.08 to 4.88), adjusted for gender and diabetes duration (P < .05 for all models). The rs9939609 polymorphism was not associated with MetS, elevated waist circumference or BMI, or diabetic complications. Daily energy and nutrient intakes did not differ according to the presence of the polymorphisms.Conclusions: The C allele of the rs7204609 polymorphism in the FTO gene increased the chance for the presence of MetS, especially central obesity, and microalbuminuria, independently of energy and nutrient intakes in this sample of type 2 diabetic patients from Southern Brazil.

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.

Association Between Circulating Electronegative Low-Density Lipoproteins and Serum Ferritin in Hemodialysis Patients: A Pilot Study - Corrected Proof

2011-07-11

Background: Iron supplementation is a common recommendation to chronic kidney disease patients undergoing hemodialysis (HD). However, iron excess is closely associated with lipid peroxidation and, it is well known that electronegative low-density lipoproteins (LDL[−]) are present at higher plasma concentrations in diseases with high cardiovascular risk such as chronic kidney disease. Thus, the aim of this study was to investigate whether ferritin levels are associated with LDL(−) levels in HD patients.Design: This was a cross-sectional study.Setting: This study was conducted from a private clinic in Rio de Janeiro, Brazil.Patients: The study included 27 HD patients and 15 healthy subjects.Methods and Procedures: Twenty-seven HD patients (14 men, 58.6 ± 10 years, 62.2 ± 51.4 months on dialysis, and body mass index: 24.4 ± 4.2 kg/m2) were studied and compared with 15 healthy individuals (6 men, 53.8 ± 15.4 years, body mass index: 24.5 ± 4.3 kg/m2). Serum LDL(−) levels were measured using the enzyme-linked immunosorbent assay method; ferritin levels by commercially available kits, and tumor necrosis factor-α, interleukin-6, monocyte chemoattractant protein-1, and plasminogen activator inhibitor-1 were determined with a multiplex assay kit manufactured by R&D Systems.Results: The HD patients presented higher LDL(−) and tumor necrosis factor-α levels (0.15 ± 0.13 U/L and 5.9 ± 2.3 pg/mL, respectively) than healthy subjects (0.07 ± 0.05 U/L and 2.3 ± 1.3 pg/mL, respectively) (P = .0001). The mean ferritin level in HD patients was 1,117.5 ± 610.4 ng/mL, and 90% of patients showed ferritin levels exceeding 500 ng/mL. We found a positive correlation between LDL(−) and ferritin in the patients (r = 0.48; P = .01), and ferritin was a significant contributor to LDL(−) concentrations independent of inflammation.Conclusions: Excess body iron stores for HD patients was associated with signs of increased oxidative stress, as reflected by increased LDL(−) levels in HD patients.