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Providing in-between meals during dialysis treatment contributes to an adequate protein and energy intake in hemodialysis patients

Nutritional status in nocturnal hemodialysis patients

BACKGROUND: Hemodialysis patients experience an elevated risk of malnutrition associated with increased morbidity and mortality. Nocturnal hemodialysis (NHD) results in more effective removal of waste products and fluids. Therefore, diet and fluid restrictions are less restricted in NHD patients. However, it is ambiguous whether transition from conventional hemodialysis (CHD) to NHD leads to improved intake and nutritional status. We studied the effect of NHD on protein intake, laboratory indices of nutritional status, and body composition.STUDY DESIGN: Systematic review with meta-analysis.POPULATION: NHD patients.SEARCH STRATEGY: Systematic literature search from databases, Medline, Cinahl, EMBASE and The Cochrane Library, to identify studies reporting on nutritional status post-transition from CHD to NHD.INTERVENTION: Transition from CHD to NHD.OUTCOMES: Albumin, normalized protein catabolic rate (nPCR), dry body weight (DBW), body mass index (BMI), phase angle, protein intake, and energy intake.RESULTS: Systematic literature search revealed 13 studies comprising 282 patients that made the transition from CHD to NHD. Meta-analysis included nine studies in 229 patients. In control group controlled studies (n = 4), serum albumin increased significantly from baseline to 4-6 months in NHD patients compared with patients that remained on CHD (mean difference 1.3 g/l, 95% CI 0.02; 2.58, p = 0.05). In baseline controlled studies, from baseline to 4-6 months of NHD treatment, significant increases were ascertained in serum albumin (mean difference (MD) 1.63 g/l, 95% CI 0.73-2.53, p<0.001); nPCR (MD 0.16 g/kg/day; 95% CI 0.04-0.29, p = 0.01); protein intake (MD 18.9 g, 95% CI 9.7-28.2, p<0.001); and energy intake (MD 183.2 kcal, 95% CI 16.8-349.7, p = 0.03). Homogeneity was rejected only for nPCR (baseline versus 4-6 months). DBW, BMI, and phase angle did not significantly change. Similar results were obtained for comparison between baseline and 8-12 months of NHD treatment.LIMITATIONS: Most studies had moderate sample sizes; some had incomplete dietary records and relatively brief follow-up period. Studies markedly differed with regard to study design.CONCLUSIONS: NHD is associated with significantly higher protein and energy intake as well as increases in serum albumin and nPCR. However, the data on body composition are inconclusive.

The prevalence of intradialytic hypotension in patients on conventional hemodialysis

Intradialytic hypotension (IDH) is considered to be a frequent complication of hemodialysis (HD) and is associated with symptom burden, increased incidence of access failure, cardiovascular events, and higher mortality. This systematic literature review aims to analyse studies that investigated the prevalence of IDH. A complicating factor herein is that many different definitions of IDH are used in literature.Methods: A systematic literature search from databases, Medline, Cinahl, EMBASE, and the Cochrane library to identify studies reporting on the actual prevalence of IDH was conducted. Studies were categorized by the type of definition used for the prevalence of IDH. A meta-analysis of the prevalence of IDH was performed.Results: In a meta-analysis comprising 4 studies including 1,694 patients and 4 studies including 13,189 patients, the prevalence of HD sessions complicated by IDH was 10.1 and 11.6% for the European Best Practice Guideline (EBPG) definition and the Nadir <90 definition, respectively. The proportion of patients with frequent IDH could not reliably be established because of the wide range in cutoff values that were used to identify patients with frequent IDH. There was a large variety in the prevalence of symptoms and interventions. Major risk factors associated with IDH across studies were diabetes, a higher interdialytic weight gain, female gender, and lower body weight.Conclusion: Our meta-analysis suggests that the prevalence of IDH is lower than 12% for both the EBPG and the Nadir <90 definition which is much lower than stated in most reviews.

Are we overfeeding hemodialysis patients with protein?

BACKGROUND & AIMS: Sufficient protein intake is of great importance in hemodialysis (HD) patients, especially for maintaining muscle mass. Daily protein needs are generally estimated using bodyweight (BW), in which individual differences in body composition are not accounted for. As body protein mass is best represented by fat free mass (FFM), there is a rationale to apply FFM instead of BW. The agreement between both estimations is unclear. Therefore, the aim of this study is to compare protein needs based on either FFM or BW in HD patients.METHODS: Protein needs were estimated in 115 HD patients by three different equations; FFM, BW and BW adjusted for low or high BMI. FFM was measured by multi-frequency bioelectrical impedance spectroscopy and considered the reference method. Estimations of FFM x 1.5 g/kg and FFM x 1.9 g/kg were compared with (adjusted)BW x 1.2 and x 1.5, respectively. Differences were assessed with repeated measures ANOVA and Bland-Altman plots.RESULTS: Mean protein needs estimated by (adjusted)BW were higher compared to those based on FFM, across all BMI categories (P < 0.01) and most explicitly in obese patients. In females with BMI >30, protein needs were 69 ± 17.4 g/day higher based on BW and 45 ± 9.3 g/day higher based on BMI adjusted BW, compared to FFM. In males with BMI >30, protein needs were 51 ± 20.4 g/day and 23 ± 20.9 g/day higher compared to FFM, respectively.CONCLUSIONS: Our data show large differences and possible overestimations of protein needs when comparing BW to FFM. We emphasize the importance of more research and discussion on this topic.

Influence of frequent nocturnal home hemodialysis on food preference

Objective: Dialysis patients frequently report a change of taste that is reversible after renal transplantation, suggesting that uremic toxins may negatively influence taste. Currently, frequent nocturnal home hemodialysis (NHHD) is the most effective method of hemodialysis, and is associated with the lowest levels of uremic toxins. We studied preferences for various foods as an indicator of taste perception. We questioned whether food preference differs between NHHD patients and those on conventional hemodialysis. Design and Patients: In this transverse, cross-sectional pilot study, we assessed food preference by means of a questionnaire for patients on NHHD (n = 6; 8 hours of dialysis per night, for 5 or 6 nights a week) and 3 age-matched and sex-matched control groups: chronic home hemodialysis patients (HHD; n = 9; 4 to 5 hours of dialysis per day, 3 days a week), chronic in-center hemodialysis patients (CHD; n = 18; 4 to 5 hours of dialysis per day, 3 days a week), and healthy control subjects (HC; n = 23). Results: Mean scores for food preference did not differ between groups (P = .32). Similarly, the preference for product groups did not differ between groups. On an individual product level, we found only minor differences. The NHHD patients had a preference for savory snacks, as did the HC and CHD groups, whereas the HHD group had a preference for sweet snacks (P < .05). Hemodialysis patients reported dry mouth more often than did the HC patients (P < .05). Conclusions: Frequent NHHD has no major impact on food preference. The change in taste reported by NHHD patients is not related to their particular food preferences. © 2010 National Kidney Foundation, Inc.

Nocturnal Hemodialysis Leads to Improvement in Physical Performance in Comparison with Conventional Hemodialysis

End-stage kidney disease patients treated with conventional hemodialysis (CHD) are known to have impaired physical performance and protein-energy wasting (PEW). Nocturnal hemodialysis (NHD) was shown to improve clinical outcomes, but the evidence is limited on physical performance and PEW. We investigate whether NHD improves physical performance and PEW. This prospective, multicenter, non-randomized cohort study compared patients who changed from CHD (2-4 times/week 3-5 h) to NHD (2-3 times/week 7-8 h), with patients who continued CHD. The primary outcome was physical performance at 3, 6 and 12 months, assessed with the short physical performance battery (SPPB). Secondary outcomes were a 6-minute walk test (6MWT), physical activity monitor, handgrip muscle strength, KDQOL-SF physical component score (PCS) and LAPAQ physical activity questionnaire. PEW was assessed with a dietary record, dual-energy X-ray absorptiometry, bioelectrical impedance spectroscopy and subjective global assessment (SGA). Linear mixed models were used to analyze the differences between groups. This study included 33 patients on CHD and 32 who converted to NHD (mean age 55 ± 15.3). No significant difference was found in the SPPB after 1-year of NHD compared to CHD (+0.24, [95% confidence interval -0.51 to 0.99], p = 0.53). Scores of 6MWT, PCS and SGA improved (+54.3 [95%CI 7.78 to 100.8], p = 0.02; +5.61 [-0.51 to 10.7], p = 0.03; +0.71 [0.36 to 1.05], p < 0.001; resp.) in NHD patients, no changes were found in other parameters. We conclude that NHD patients did not experience an improved SPPB score compared to CHD patients; they did obtain an improved walking distance and self-reported PCS as well as SGA after 1-year of NHD, which might be related to the younger age of these patients.