Malnourished Hemodialysis Patients Research Articles

A Cohort Study of Subjective Global Assessment and Mortality in Taiwanese Hemodialysis Patients

Many patients with end-stage renal disease are malnourished, and cross-sectional studies have shown that markers of malnutrition may predict death. In this study, we investigated the possible association of Subjective Global Assessment and mortality in a small cohort of Taiwanese hemodialysis patients. Fifty hemodialysis patients at a hemodialysis center in eastern Taiwan were enrolled in June 2002. Height and weight were used to determine the body mass index. Bioelectrical impedance analysis of body fat mass was performed before and after a mid-week dialysis session. Biochemical indexes of the nutritional status included serum albumin, creatinine, transferrin, cholesterol, and the normalized protein catabolic rate. Mortality data during 42 months after enrollment were obtained. Twenty-six hemodialysis patients were classified as well-nourished and twenty-four as malnourished based on Subjective Global Assessment. Decreased body mass index (p = 0.006), increased body fat mass (p = 0.019 before hemodialysis; p = 0.007 after hemodialysis), decreased serum albumin (p = 0.011), and decreased serum creatinine (p = 0.006) were significantly higher in the malnourished group. Older age (p = 0.042), decreased serum albumin (p = 0.028), decreased serum transferrin (p = 0.041), and malnourishment (p = 0.004) were significantly higher in the mortality group. Multivariate forward stepwise linear regression analysis of mortality and nutrition profiles show that Subjective Global Assessment is the independent predictor of mortality (R2 = 0.20). Malnourished hemodialysis patients had a higher mortality rate than well-nourished hemodialysis patients in Taiwan. Subjective Global Assessment of the nutritional status appears to be a simple tool for assessing the nutritional status of hemodialysis patients in long-term care. This assessment tool is also beneficial for hemodialysis patients who are at a greater risk of nutritional-associated mortality.

Nutritional Status in Hemodialysis Patients: Options for On-Line Convective Treatment

Although hemodialysis (HD) has improved the life expectancy of patients with end-stage renal disease (ESRD), uremic patients continue to experience high morbidity and mortality. Two of the most important risk factors for morbidity and mortality are protein-energy malnutrition (PEM) and inflammation. The causes for PEM in ESRD are numerous. The use of materials for dialysis, especially of the dialyzer membrane, is reported as one of the recognized causes for chronic inflammation in hemodialysis. We performed a 6-month prospective study examining the influence of on-line predilution hemodiafiltration on the inflammatory and nutritional status in a population of male hemodialysis patients using ultrapure dialysis fluid and polyamide dialyzers. We evaluated serum C-reactive protein, albumin, and transferrin and some nutritional parameters such as body mass index (BMI), phase angle (phi), fatty mass (FM), and free fatty mass (FFM) using bioelectrical impedance (BIA). Results showed significant amelioration of BMI and the re-equilibrium of the acute phase protein after on-line predilution hemodiafiltration. These results support the hypothesis that on-line predilution hemodiafiltration, as convective extracorporeal treatment, may be used to treat malnourished hemodialysis patients and to prevent malnutrition in the ESRD patient at risk for malnutrition.

Standardized Protocol for Using Intradialytic Parenteral Nutrition (IDPN) as an Adjunct Therapy in Severely Malnourished Hemodialysis Patients

To develop and utilize a protocol for the initiation, monitoring, and termination of Intradialytic Parenteral Nutrition in maintenance hemodialysis patients.

Intradialytic amino acids supplementation in hemodialysis patients with malnutrition: results of a multicenter cohort study

Objective Prospective evaluation of the effect of 6-month-long intradialytic amino acids (AA) supplementation on selected nutritional variables in malnourished hemodialysis (HD) patients. Design Multicenter, prospective, (nonrandomized, noncontrolled) observational study. Setting Thirty-one HD units affiliated with academic centers and tertiary-care hospitals. Patients Adult patients treated by HD for at least 6 months. Inclusion criteria were: serum albumin concentration ≤39 g/L and at least 4% loss of body weight during the last 6 months in otherwise stable HD patients. From a cohort of 133 patients who were enrolled, 97 (54 men and 43 women) were eligible for the analysis. Intervention Intradialytic AA supplementation with 500 mL 10% solution per HD session for a period of 6 months. Main outcome measures Serum albumin concentration, modified Subjective Global Assessment (SGA) score, body mass index (BMI), mid-arm circumference (MAC), and total lymphocyte count. Measurements were recorded at baseline and after 3 and 6 months of AA supplementation. Results Serum albumin concentration increased significantly from the mean 32.5 ± 4.6g/L at baseline to 36.4 ± 4.8 g/L at 3 months ( P < .001) and 37.1 ± 4.8g/L at final observation ( P < .001 versus baseline). Significant correlation was observed between frequency of AA supplementation and serum albumin increase ( r = 0.41; P < .0001). Rate of improvement negatively correlated significantly with baseline concentration of serum albumin ( r = − 0.42; P < .0001). SGA score significantly improved from median of 16 points at baseline to 12 points at 3 months ( P < .01) and 11 points at 6 months ( P < .01 versus baseline), and this improvement also correlated with the frequency of AA supplementation. Small yet significant increase of MAC was observed at 6 months (from baseline 24.1 ± 4.3 to 24.8 ± 4.8 cm; P < .01), whereas BMI remained unchanged. Conclusion Intradialytic AA supplementation improves selected nutritional parameters of HD patients with malnutrition. The improvement depends on the intensity of supplementation.

Is serum albumin a marker of nutritional status in hemodialysis patients without evidence of inflammation?

Hypoalbuminemia, a strong predictor of morbidity and mortality in hemodialysis patients, can be a consequence of a combination of malnutrition and inflammatory reactions. The purpose of this study was to analyze serum albumin as a marker of nutritional status in maintenance hemodialysis patients with no signs of inflammation. In a cross-sectional study, we selected 40 stable hemodialysis patients with normal levels of C-reactive protein (<0.8 mg/dL). The patients were classified as well nourished (65%) or malnourished (35%) according to the subjective global assessment. No significant differences were observed in serum albumin concentrations (immunoturbidimetric method) between well-nourished (4.3 +/- 0.3 g/dL) and malnourished (4.0 +/- 0.5 g/dL) patients, and the mean values were within the normal range in both groups. Albumin was inversely correlated with age (n=40; r=-0.32; P=0.02) and directly with energy intake (n=28; r=0.43; P=0.04). In this study, serum albumin did not discriminate well-nourished and malnourished hemodialysis patients without evidence of inflammation.

One-Year Growth Hormone Therapy Improves Granulocyte Function without Major Effects on Nutritional and Anthropometric Parameters in Malnourished Hemodialysis Patients

Background/Aims: Growth hormone (GH) resistance leads to enhanced protein catabolism and contributes to the malnutrition of patients with chronic renal failure (CRF). In short-term trials anabolic effects of rhGH therapy have been demonstrated in patients on chronic hemodialysis. Methods: This study was initiated to determine the effects of 12 months of rhGH therapy on polymorphonuclear leukocyte (PMNL) function as well as on nutritional and anthropometric parameters. 0.125 IU/kg rhGH was given 3 times a week during the first 4 weeks and 0.25 IU/kg thereafter to 19 malnourished hemodialysis patients with a mean age of 59.3 ± 13.4 years. Results: Insulin-like growth factor I (IGF-I) concentrations rose significantly from 169.2 ± 95.6 to 262.9 ± 144.4 ng/ml (p < 0.01) in the first 3 months, but declined thereafter. Phagocytic activity of PMNLs also increased significantly in response to rhGH therapy and this activation remained stable over the whole 12-month period. Other parameters of PMNL function were not influenced by rhGH therapy. In addition, nutritional parameters such as albumin, prealbumin, transferrin, cholesterol, HDL-cholesterol, cholinesterase, predialytic creatinine and blood urea nitrogen were not affected by rhGH therapy. A decline of total body fat (TBF) was observed after 3 and 9 months of rhGH therapy (17.5 ± 10 vs. 16.7 ± 10% after 3 months, p < 0.017 and 16.8 ± 8.7% after 9 months, p < 0.049), whereas lean body mass remained stable. Conclusions: Twelve months of rhGH therapy caused a significant increase in IGF-I levels, stimulated phagocytic activity of PMNLs and induced a decline of TBF. Other anthropometric and nutritional parameters were not affected, which might be related to the persistence of GH resistance.

Efficacy of intradialytic parenteral nutrition in malnourished hemodialysis patients.

The efficacy of intradialytic parenteral nutrition (IDPN) in malnourished hemodialysis patients was studied. All patients at a large tertiary care institution who received IDPN for one month or longer between June 1997 and December 2000 were included in the study. The IDPN formulation contained 10% amino acids 250 or 500 mL, 50% dextrose 250 mL, and 20% fat emulsion 250 mL. IDPN was administered during each thrice-weekly hemodialysis session. Patient data were collected 6 and 3 months before IDPN therapy began, at baseline, and 3, 6, 9, and 12 months after the therapy began. Therapeutic efficacy was assessed by the percent change from baseline in dry body weight and serum albumin concentration. Twenty-six courses of IDPN in 24 patients met the study's inclusion criteria. The mean duration of treatment was 4.3 months. Dry body weights were significantly lower 6 and 3 months before the start of IDPN therapy than at baseline and significantly higher 6, 9, and 12 months after the start of therapy. Serum albumin levels were also significantly higher at 3 and 9 months than at baseline. The percentage of treatment courses in which patients had a serum albumin concentration of > or = 34 g/L was 12% at baseline, 39% at 6 months, and 47% at 9 months. Adverse effects consisted primarily of excess fluid gain and hyperglycemia. IDPN therapy significantly increased body weight and serum albumin levels in malnourished hemodialysis patients.

Practical aspects of intradialytic nutritional support.

A critical review of recent international literature related to the use of intradialytic parenteral nutrition is given. The role of intradialytic parenteral nutrition as a therapy in malnourished hemodialysis patients is established and the need for systematic monitoring of this population at high risk of malnutrition is emphasized.

Differential effects of growth hormone therapy in malnourished hemodialysis patients

Malnutrition is common in chronic hemodialysis patients and is associated with increased morbidity and mortality. Several factors such as metabolic acidosis, hyperparathyroidism, and insulin as well as growth hormone (GH) resistance may lead to enhanced protein catabolism. Recombinant human growth hormone (rhGH) has been proposed as treatment of malnutrition because of its anabolic effects. In the present placebo-controlled, double blind study, the effects of three months of rhGH therapy on nutritional and anthropometric parameters, on bone metabolism and bone mineral density (BMD), as well as on polymorphonuclear leukocyte (PMNL) function and quality of life (QoL) were evaluated in 19 malnourished hemodialysis patients (10 females and 9 males) with a mean age of 59.3 +/- 13.4 years. RhGH (0.125 IU/kg) was given three times a week during the first four weeks and 0.25 IU/kg thereafter three times a week after each dialysis session. Insulin-like growth factor I (IGF-I) concentration rose significantly from 169.2 +/- 95.6 ng/mL to 262.9 +/- 144.4 ng/mL (p< 0.01) in the group receiving rhGH. Albumin, prealbumin, transferrin, cholesterol, high-density lipoprotein (HDL) cholesterol, cholinesterase, predialytic creatinine, and blood urea nitrogen showed no significant changes during the three months in both groups. Total body fat (%TBF) was slightly reduced after three months (P = NS) in the patients receiving GH, whereas lean body mass (LBM) remained stable during therapy. Procollagen I carboxy terminal peptide (PICP), a marker of bone formation, increased significantly after three months from 250.1 +/- 112.6 to 478.5 +/- 235.2 microg/L (P < 0.01) in the GH-treated patients, whereas parameters of bone resorption like telopeptide ICTP showed only a slight increase (50.3 +/- 18.5 vs. 70.0 +/- 39.5 microg/L, P = NS). BMD at the lumbar spine decreased significantly after three months in the treatment group (0.8 +/- 0.17 vs. 0.77 +/- 0.16 g/cm2, P < 0.01), whereas BMD at the femoral neck remained stable in both groups. Phagocytic activity of PMNLs increased significantly after three months of therapy with rhGH, whereas other parameters of PMNL function were not affected by GH. QoL was slightly improved in the GH treated group, but decreased markedly in the placebo group. Three months of treatment with rhGH in malnourished patients on chronic hemodialysis causes a significant increase in IGF-I levels without significant changes in nutritional and anthropometric parameters. In contrast, bone turnover was enhanced with an initial decrease in BMD at the lumbar spine, and phagocytic activity of PMNLs was increased.

Comparison of the effects of two early intervention strategies on the health outcomes of malnourished hemodialysis patients

Objective: To determine the efficacy and cost-effectiveness of providing oral supplementation early in the course of malnutrition for hemodialysis (HD) patients. Design: The study design consisted of 3 groups: an experimental group, a control group of patients with mild hypoalbuminemia (HA) (serum albumin [SA] = 3.5 to 3.7 g/dL), and a comparison group of patients with moderate to severe HA (SA = 2.5 to 3.4 g/dL). Setting: Ten outpatient hemodialysis centers in southeast lower Michigan. Patients: Treatment and control groups consisted of 32 HD patients with mild HA. Fourteen HD patients with moderate to severe HA comprised the comparison group. Intervention: The experimental group received diet counseling and oral supplementation, and the control group received diet counseling only. The comparison group received physician-prescribed oral supplements and dietary counseling to permit comparison of the experimental treatment with current supplementation practices. Main Outcome Measures: Differences between groups in the number of patients reaching nutritional repletion, change in SA levels at the end of the study, and follow-up periods, were tested using chi-square analysis. Analysis of variance was used to compare group differences in treatment duration to repletion and number of hospitalization days. Results: During the study period, significantly more patients reached nutritional repletion in the experimental group and control group (50% and 57%, respectively) than in the comparison group (7%). Overall, repletion occured more quickly in the experimental group (3.2 ± 1.7 months) than in the control group (3.5 ± 1.2 months), with a larger number of patients in the experimental group repleted by month 2 of the study phase. During follow-up, patients in the experimental group were far more likely to maintain nutritional repletion or continue to improve (61%) than patients in the control group (14%). Although too few patients were hospitalized to show statistical significance, there was a trend toward greater numbers of hospital days in more malnourished patients (208 days for the comparison group), followed by those with mild HA who did not receive oral supplements (107 days), and the experimental group (71 days). Conclusion: Although the sample size for this study was too small for the results to be conclusive, it appears that use of nutritional supplements early in the course of malnutrition may provide benefits such as, attaining nutritional repletion more quickly, which results in less product usage. It is also more likely that good nutritional status will be maintained after supplementation is discontinued. © 2001 by the National Kidney Foundation, Inc.

Oral and Parenteral Essential Amino Acid Therapy in Malnourished Hemodialysis Patients

Background/Aims: Malnutrition has been encountered more frequently than expected and is associated with increased morbidity and mortality in hemodialysis (HD) patients. Until the last few years, only oral and enteral nutritional supplies have been used in the treatment of malnutrition in HD patients. However, intradialytic parenteral essential amino acid (EAA) nutrition has recently been introduced to treat these patients. The present study was conducted to compare both methods of EAA nutrition, oral and parenteral, in malnourished HD patients. Methods: Half of the 20 malnourished HD patients in this study received 0.9 g/kg/week of oral EAA (oral group), while the other half of the patients were treated with the same dose of parenteral EAA (parenteral group) for 4 months. However, at the very beginning of the study, 4 patients from the oral group were transferred to the parenteral group because of complaints such as nausea and vomiting. Therefore, this study was completed with 6 patients in the oral group and 14 patients in the parenteral group. Some biochemical parameters, including blood lymphocyte counts and anthropometric measurements as indicators of the nutritional status, were obtained from both of the groups in the pre- and posttreatment periods. Results: Following the treatment, there were no statistically significant differences between the groups with respect to anthropometric measurements. However, statistically significant increases were observed in serum albumin (p = 0.048) and creatinine (p = 0.006) levels and blood lymphocyte counts (p = 0.006) in the parenteral group, while there were statistically significant increases only in serum calcium (p = 0.028) levels and blood lymphocyte counts (p = 0.038) in the oral group following the treatment when compared to pretreatment values. Conclusion: These results show that parenteral EAA therapy is more comfortable and effective than oral EAA therapy in the treatment of malnourished HD patients.

Effects of Growth Hormone on Leptin Metabolism and Energy Expenditure in Hemodialysis Patients with Protein-Calorie Malnutrition

The relationships among growth hormone (GH), leptin, and resting energy expenditure (REE) are not understood. It has been reported that in malnourished hemodialysis patients, GH increases muscle protein synthesis, a process that requires energy. The present study evaluated the arterial levels and the forearm exchange of leptin, as well as the REE of the same patients during their participation in the same study, in four sequential 6-wk periods: I, baseline; II, GH treatment; III, washout; and IV, GH + intradialytic parenteral nutrition. During periods II and IV, patients received GH (5 mg three times per week). REE rose by 5% in period II, declined during period III, and rose by 7% during period IV. Basal leptin levels were low (2.0 +/- 0.19 ng/L). Insulin and leptin levels, as well as leptin release from the forearm, were unchanged during periods I through III but rose (+ 36%; P: < 0.05) during period IV. Changes in arterial leptin were directly related to changes in forearm leptin release (P: < 0.002), indicating a role of leptin production by peripheral tissues on leptinemia. Changes in leptin release were directly related to insulin (P: < 0.001) and, less consistently, to insulin-like growth factor-binding protein-1 levels (P: < 0.02). Similarly, variations in leptin levels were directly related to insulin (P: < 0.01). Variations in REE were not related to variations in leptin or insulin levels but to changes in muscle protein synthesis (P: < 0.025). The data show that in malnourished hemodialysis patients, treatment with GH is not invariably associated with an increase in leptin production. An increase in leptin release by peripheral tissues and leptin levels occurs only in the setting of hyperinsulinemia. The increase in REE that is induced by treatment with GH is not dependent on changes in leptin but is largely accounted for by the energy cost of the stimulation of muscle protein synthesis.

High Protein/Energy vs. Standard Protein/Energy Nutritional Regimen in the Treatment of Malnourished Hemodialysis Patients

Although malnutrition is frequently encountered in maintenance hemodialysis (MHD) patients, a clear method of treating this complication is still lacking. Failure of nutritional support regimens may be due to inadequate support of dietary needs. Therefore, a high vs. standard or low protein/energy dietary regimen was studied in malnourished MHD patients. A total of 18 malnourished MHD patients selected according to subjective global assessment (SGA)-scores and biochemical indicators of malnutrition (serum albumin <40 g/l, cholesterol <200 mg/dl, prealbumin <30 mg/dl; two out of three) were assigned to three treatment groups: (A: 45 kcal/kg/d and 1.5 g protein/kg/d; B: 35 kcal/kg/d and 1.2 g protein/kg/d; C: spontaneous intake supplemented with 10% of mean protein and energy intake). A and B received food supplements at appropriate dosing to reach the targeted nutritional intake. During 3-month follow-up nutrient intake was assessed by repeated 4-day dietary diaries. Compliance and tolerance was good in each group. Weight gain (1.2±0.4 kg) was observed in group A, but not in B and C. Serum albumin levels increased by 1.0±0.5 g/l in group A, but not in B and C. Prealbumin and cholesterol levels were unaffected. Weight change correlated with mean dietary energy intake, but not with mean dietary protein intake. We conclude that prescription of 45 kcal/kg/d and 1.5 g protein/kg/d may be necessary to achieve weight gain and improvement of nutritional indices in malnourished MHD pts. Oral food supplements can be used safely and effectively to increase nutrient intake to high levels in these patients.

Proposed clinical trials in the evaluation of intradialytic parenteral nutrition.

New revised policies relating to intradialytic parenteral nutrition (IDPN) reimbursement by Medicare have made it difficult, if not impossible, to qualify malnourished hemodialysis patients for this potentially useful therapy. These policies were adopted by Medicare because of a lack of studies that provide clear documentation of the medical benefits of IDPN or their cost-effectiveness. We propose a limited study of the role of IDPN with and without anabolic growth factors to improve predefined nutritional parameters and document its cost-effectiveness by monitoring hospitalization and mortality. The proposed study will be multicenter, prospective, limited to severely malnourished patients, and will include a control group that would receive standard of care.

Renal Dietitian's perspective: Identification, prevalence, and intervention for malnutrition in dialysis patients in texas

Objective: Determine the prevalence of malnutrition per facility standards; examine interventions used to treat malnutrition; and share experiences, concerns, and solutions to problems in the management of malnutrition in dialysis patients in Texas. Design: Structured survey questionnaires. Setting: 196 outpatient hemodialysis (HD) and 86 peritoneal dialysis (PD) programs in End-Stage Renal Disease (ESRD) Network of Texas, Inc. Participants: Renal dietitians who worked in Texas dialysis facilities that treated chronic, outpatient adult, and pediatric ESRD patients on HD or PD. Measures: Criteria used to identify malnourished patients, prevalence of malnutrition in dialysis recipients, prevalence and types of interventions used to manage malnourished patients, and participation in quality management activities among renal dietitians. Results: For facilities that treated both HD and PD patients in 1996: (1) a significantly greater proportion of PD patients were identified as malnourished than HD patients: (2) facilities that had a high percentage of malnourished HD patients also had a high percentage of malnourished PD patients; (3) a significantly greater proportion of PD patients received commercial nutrition supplements than HD patients; and (4) use of tube feedings, intradialytic parenteral nutrition, intraperitoneal parenteral nutrition, and total parenteral nutrition among HD and PD patients decreased significantly from the past to the current survey year. Renal dietitians shared their experiences, concerns and solutions to problems in the management of malnutrition in this population. Conclusion: Results indicate a need to improve the nutritional status of malnourished dialysis patients, to increase consideration of tube feedings as viable nutrient delivery routes, and to maximize involvement of renal dietitians in the quality management process. With the cooperative effort of staff, care givers, patients, and family, early identification and appropriate interventions may improve the nutritional status and quality of life of dialysis patients.

Effect of megestrol acetate on the nutritional status of malnourished hemodialysis patients

Effect of megestrol acetate on the nutritional status of malnourished hemodialysis patients

Effects of recombinant human growth hormone on muscle protein turnover in malnourished hemodialysis patients.

To assess the effect of recombinant human growth hormone (rhGH) on muscle protein metabolism in uremic patients with malnutrition, forearm [3H]phenylalanine kinetics were evaluated in six chronically wasted (body weight 79% of ideal weight) hemodialysis (HD) patients in a self-controlled, crossover study. Forearm protein dynamics were evaluated before, after a 6-wk course of rhGH (5 mg thrice weekly) and after a 6-wk washout period. After rhGH: (a) forearm phenylalanine net balance--the difference between phenylalanine incorporation into and phenylalanine release from muscle proteins--decreased by 46% (-8+/-2 vs. -15+/-2 nmol/min x 100 ml at the baseline and -11+/-2 after washout, P < 0.02); (b) phenylalanine rate of disposal, an index of protein synthesis, increased by 25% (25+/-5 vs. 20+/-5 at the baseline and 20+/-4 after washout, P < 0.03); (c) phenylalanine rate of appearance, an index of protein degradation, was unchanged (33+/-5 vs. 35+/-5 at the baseline and 31+/-4 after washout); (d) forearm potassium release declined (0.24+/-0.13 vs. 0.60+/-0.15 microeq/min at the baseline, and 0.42+/-0.20 microeq/min after washout P < 0.03); (e) changes in the insulin-like growth factor binding protein (IGFBP)-1 levels and insulin-like growth factor-I (IGF-I)/IGFBP-3 ratios accounted for 15.1% and 47.1% of the percent variations in forearm net phenylalanine balance, respectively. Together, these two factors accounted for 62.2% of variations in forearm net phenylalanine balance during and after rhGH administration. These data indicate: (a) that rhGH administration in malnourished hemodialysis patients is followed by an increase in muscle protein synthesis and by a decrease in the negative muscle protein balance observed in the postabsorptive state; and (b) that the reduction in net protein catabolism obtained with rhGH can be accounted for by the associated changes in circulating free, but not total, IGF-I levels.

Effectiveness of Oral Energy-Protein Supplementation in Severely Malnourished Hemodialvsis Patients

■ Objective: To evaluate the effect of an oral energy-protein supplementation on the nutritional status of severely malnourished uremic hemodialysis patients. ■ Design: A cohort study of malnourished patients orally supplemented for 4 months. ■ Setting: A satellite hemodialysis unit at the Escola Paulista de Medicina, Såo Paulo, Brazil. ■ Patients: In a population-based sample, 14 of 123 chronic severe malnourished patients selected by clinical and anthropometric criteria initiated the study. Ten patients completed the trial. ■ Interventions: In addition to the instructed diet, each patient received a flavored oral powder supplement containing egg albumin, corn and coconut oils, hydrogenated fat, and malto-dextrin, providing 800 kcal and 19.6 g protein/d. ■ Main outcome measures: The following parameters were obtained: 3-day dietary diaries, protein catabolic rate (PCR), body weight (BW), triceps skinfold thickness (TSF), midarm circumference (MAC), body mass index, body fat (BF), percentage of body fat (PF), lean body mass (LBM), midarm muscle area (MAMA), and hematological and biochemical indices. ■ Results: At the end of the study, significant increases in total energy (27 ± 6 to 43 ± 6 kcal/kg/d) and protein consumption (1.07 ± 0.4 to 1.57 ± 0.4 g/kg/d) were observed. Significant increases were also observed in BW (48.9 ± 8.4 to 50.4 ± 8.9 kg), MAC (23 ± 2.6 to 23.8 ± 2.5 cm), TSF (6.5 ± 3.1 to 7.9 ± 3.6 mm), and BF (7.2 ± 2.8 to 8.6 ± 3.3 kg). There were no modifications in LBM and MAMA. Changes in BW correlated significantly with changes in PF (<i>r</i> = 0.47; <i>P</i> < .01). PCR also increased significantly, from 1.06 ± 0.2 to 1.22 ± 0.3 g/kg/d, and correlated with protein intake (<i>r</i> = 0.63; <i>P</i> < .01). Biochemical and hematological indices remained constant. ■ Conclusion: The oral supplement was well tolerated and was effective in improving the nutritional status of malnourished hemodialysis patients.

Serum lipoprotein changes after prolonged intralipid infusion in malnourished haemodialysis patients

Fat emulsions have been shown to be on efficient source of energy support in malnourished haemodialysis patients. This work was conducted in order to study the effect of prolonged intralipid infusion, during dialysis, on lipid metabolism. The following fasting serum parameters were measured before and after a 1 month infusion of 20% Intralipid (67 kJ/kg body wt/dialysis) in 10 malnourished patients undergoing dialysis: total cholesterol, triglycerides, phospholipids, HDL-cholesterol, LDL-cholesterol, HDL2-cholesterol, HDL3-cholesterol, apolipoproteins A-I, A-II, A-IV, C-II, C-III, and lipoproteins A-I, A-I A-II, EB and (a). After prolonged lipid infusion, the apoprotein B (p < 0.05) and C-II (p < 0.005) increased suggesting a triglyceride transport activation. Apolipoprotein A-I (p < 0.05) and lipoprotein A-I (p < 0.05) decreased without a change in total cholesterol. Lipoprotein (a) decreased in each case (p < 0.005), suggesting a reduction of its related risk of atherogenesis.

The Effect of Intradialytic Parenteral Nutrition on Hospitalization Rate and Mortality in Malnourished Hemodialysis Patients

■ Objective: To determine if intradialytic parenteral nutrition (IDPN) therapy of malnourished hemodialysis patients results in a decrease in hospitalization rate and mortality. ■ Data sources: Outpatient hemodialysis records, patient interviews, registered dietitian evaluations, and hospitalization discharge summaries. ■ Study selection: All hemodialysis patients treated with IDPN from July 1, 1989, until March 15, 1991, death, or cessation of IDPN. All patients had to meet criteria defining malnutrition and to have failed 2 weeks of intensive dietary counseling with (64%) or without (36%) dietary supplements. ■ Data extraction: Data base abstracted by two registered nurses skilled in data collection and familiar with hemodialysis. Data were collected, and patients were evaluated on a monthly basis. ■ Data synthesis: Responders (Rs) were those with a greater than 5-g/L (0.5-g/dL) increase in albumin or total protein or a greater than 10% nonfluid weight gain. Rs differed from nonresponders (NRs) in baseline values for albumin (22 ± 7 g/L [2.2 ± 0.7 g/dL]; 30 ± 9 g/L [3.0 ± 0.9 g/dL]; P < .0001) and total protein (53 ± 10 g/L [5.3 ± 1.0 g/dL]; 62 ± 13 g/L [6.2 ± 1.3 g/dL]; P < .01). There was a significant increase in body weight in Rs versus NRs (3.5 ± 5.4 kg, -0.5 ± 0.3 kg; P < .0001). There was no difference in International Classification of Diseases-9-CM (ninth revision, Clinical Modification) diagnoses or demographics. Mortality was different for Rs versus NRs (9/52 v 11 /20; P = .0001) as was the hospitalization rate before (0.36 ± 0.23 v 0.25 ± 0.20 episodes/patient month; P < .0001) and during (0.12 ± 0.20 v 0.25 ± 0.26 episodes/patient month; P < .0001) IDPN treatment. Of the living Rs, 26 (50%) were able to discontinue IDPN by increasing oral intake to more than 90% of the prescribed diet. ■ Conclusion: IDPN may be related to increased serum albumin and total protein concentrations in subsets of malnourished hemodialysis patients. There may also be a link between decreased hospitalizations and mortality in patients who respond to IDPN. Differences in Rs and NRs could not be found to explain these findings. ■ Objective: To determine if intradialytic parenteral nutrition (IDPN) therapy of malnourished hemodialysis patients results in a decrease in hospitalization rate and mortality. ■ Data sources: Outpatient hemodialysis records, patient interviews, registered dietitian evaluations, and hospitalization discharge summaries. ■ Study selection: All hemodialysis patients treated with IDPN from July 1, 1989, until March 15, 1991, death, or cessation of IDPN. All patients had to meet criteria defining malnutrition and to have failed 2 weeks of intensive dietary counseling with (64%) or without (36%) dietary supplements. ■ Data extraction: Data base abstracted by two registered nurses skilled in data collection and familiar with hemodialysis. Data were collected, and patients were evaluated on a monthly basis. ■ Data synthesis: Responders (Rs) were those with a greater than 5-g/L (0.5-g/dL) increase in albumin or total protein or a greater than 10% nonfluid weight gain. Rs differed from nonresponders (NRs) in baseline values for albumin (22 ± 7 g/L [2.2 ± 0.7 g/dL]; 30 ± 9 g/L [3.0 ± 0.9 g/dL]; P < .0001) and total protein (53 ± 10 g/L [5.3 ± 1.0 g/dL]; 62 ± 13 g/L [6.2 ± 1.3 g/dL]; P < .01). There was a significant increase in body weight in Rs versus NRs (3.5 ± 5.4 kg, -0.5 ± 0.3 kg; P < .0001). There was no difference in International Classification of Diseases-9-CM (ninth revision, Clinical Modification) diagnoses or demographics. Mortality was different for Rs versus NRs (9/52 v 11 /20; P = .0001) as was the hospitalization rate before (0.36 ± 0.23 v 0.25 ± 0.20 episodes/patient month; P < .0001) and during (0.12 ± 0.20 v 0.25 ± 0.26 episodes/patient month; P < .0001) IDPN treatment. Of the living Rs, 26 (50%) were able to discontinue IDPN by increasing oral intake to more than 90% of the prescribed diet. ■ Conclusion: IDPN may be related to increased serum albumin and total protein concentrations in subsets of malnourished hemodialysis patients. There may also be a link between decreased hospitalizations and mortality in patients who respond to IDPN. Differences in Rs and NRs could not be found to explain these findings.