Renal Diet Research Articles

Feline CKD: Current therapies - what is achievable?

Treatment of feline chronic kidney disease (CKD) tends to focus on minimising the adverse effects of reduced renal function, rather than addressing an underlying cause. Despite this, and the progressive nature of CKD, treatment can improve quality of life and enable many cats to have long survival times. Strong evidence supports the provision of renal diets, which are protein and phosphorus restricted; compliance is improved by gradual dietary transition. Additional phosphorus restriction is achieved by the use of phosphate binding agents, although it is unknown if these yield similar survival benefits to those provided by renal diets. Interventions to control hypokalaemia and hypertension in affected cats are important to prevent serious complications. Administration of benazepril to cats with proteinuric kidney disease has been shown to significantly improve their appetite but not their survival. As CKD progresses, many cats will benefit from treatment to control clinical signs of uraemic gastroenteritis and anaemia.

Renal Dieticians Symposium

Renal Dieticians Symposium

Healthcare Reform: Implications for Renal Dietitians

Over the last 40 years, the financing and programmatic changes in the Medicare end-stage renal disease (ESRD) program have affected the renal dietitian's practice and the care of the patients we serve. The Affordable Care Act (ACA) will affect the ESRD program and funding for primary and specialty care (including medical nutrition therapy) for our patients before with chronic kidney disease Stage 1 to 4. One of the underpinnings of the ACA is the Institute for Healthcare Improvement Triple Aim Initiative http://www.ihi.org/offerings/Initiatives/TripleAim/Pages/MeasuresResults.aspx, which aims to •Improve the health of the population served, •Improve the experience of the individual, and •Provide affordability as measured by the total cost of care.

1416 ARE WE EVALUATING PROPERLY THE RENAL FUNCTION WITH THE MODIFICATION OF DIET IN RENAL DISEASE (MDRD) IN PATIENTS WITH ORTHOTOPIC ILEAL NEOBLADDER?

You have accessJournal of UrologyUrinary Diversion: Bladder Reconstruction, Augmentation, Substitution, Diversion (II)1 Apr 20131416 ARE WE EVALUATING PROPERLY THE RENAL FUNCTION WITH THE MODIFICATION OF DIET IN RENAL DISEASE (MDRD) IN PATIENTS WITH ORTHOTOPIC ILEAL NEOBLADDER? Mathieu Rouanne, Yann Neuzillet, Dominique Eladari, Thierry Lebret, and Henry Botto Mathieu RouanneMathieu Rouanne Suresnes, France More articles by this author , Yann NeuzilletYann Neuzillet Suresnes, France More articles by this author , Dominique EladariDominique Eladari Paris, France More articles by this author , Thierry LebretThierry Lebret Suresnes, France More articles by this author , and Henry BottoHenry Botto Suresnes, France More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.2770AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Few studies assessing prospectively the renal function changes after orthotopic ileal bladder substitution are available.The aim was to evaluate the accuracy of Modification of Diet in Renal Disease (MDRD) formulae as a substitute for the gold standard measure of glomerular filtration rate (GFR) using chromium 51 EDTA. METHODS Seventeen consecutive patients underwent radical cystectomy (RC) from July 2011 to December 2011 for muscle-invasive bladder cancer were included in this prospective protocol. Exclusion criteria were chronic kidney disease (CKD) and neoadjuvant chemotherapy. Bias and precision of estimated GFR (eGFR) were compared with isotopic GFR (iGFR). Chromium-51 ethylenediamine tetra-acetic acid (51 Cr-EDTA) was used to measure the glomerular filtration rate of both kidneys. 51Cr-EDTA GFR was performed preoperatively and 6 mo postoperatively. In addition, technetiumTc99m-diethylenetriaminepentaaceticacid (Tc99m-DTPA) renal scintigraphy was used to determine the glomerular filtration rate (GFR) of each kidney individually. RESULTS Mean preoperative GFR values were 84 ml/min per 1.73 m2 (range to 61-116) and 75 ml/min per 1.73 m2 (range to 60-117) using eGFR and 51 Cr-EDTA GFR respectively. At 6 mo, the mean GFR values were 77 ml/min per 1.73 m2 (range to 60-117) and 68 ml/min per 1.73 m2 (range to 60-102) using eGFR and iGFR respectively. At 6 mo, the difference between 51 Cr-EDTA GFR and eGFR was statistically different (p = 0.035). In addition, 51 Cr-EDTA GFR values were statistically different between preoperative time and at 6 mo ((p=0.025) whereas no statistical significant difference was found using eGFR (p > 0.05). CONCLUSIONS There is poor correlation between eGFR and 51Cr-EDTA GFR in patients with ileal neobladder reconstruction. eGFR should be used with caution as a surrogate marker for isotope GFR in these patients. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsCited byRouanne M, Lebret T and Courbebaisse M (2018) Re: Long-Term Renal Function Outcomes after Radical CystectomyJournal of Urology, VOL. 193, NO. 3, (1066-1067), Online publication date: 1-Mar-2015. Volume 189Issue 4SApril 2013Page: e580 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mathieu Rouanne Suresnes, France More articles by this author Yann Neuzillet Suresnes, France More articles by this author Dominique Eladari Paris, France More articles by this author Thierry Lebret Suresnes, France More articles by this author Henry Botto Suresnes, France More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

The role of phosphorus in the pathophysiology of chronic kidney disease

To review the human and veterinary literature on the role of phosphorus in the pathophysiology of chronic kidney disease (CKD) and to explore why control of plasma phosphorus concentration is an important goal in the management of patients with this disease. Human and veterinary studies, reviews, clinical reports, textbooks, and recent research findings focused on phosphate homeostasis and CKD patient management. Recent studies using rodent models and human patients with CKD have focused on trying to elucidate the role of the phosphatonins, predominantly fibroblast growth factor-23, in phosphate homeostasis and the pathophysiology of secondary renal hyperparathyroidism (SRHP). Fibroblast growth factor-23 is now considered to be a key regulator of plasma phosphorus concentration in people but has only recently been investigated in companion animal species. Cross-sectional studies of naturally occurring CKD in dogs and cats have shown hyperphosphatemia and SRHP to be highly prevalent and associated with increased morbidity and mortality in these patients. Experimental studies of surgically induced renal impairment in the dog and cat, and cases of naturally occurring CKD have emphasized the ability of renal care diets to modify plasma phosphorus and parathyroid hormone concentrations. Evidence from these studies indicates that maintaining plasma phosphorus concentrations to within the International Renal Interest Society targets for CKD patients improves survival time and reduces clinical manifestations of hyperphosphatemia and SRHP. The maintenance of plasma phosphorus concentrations in to within the International Renal Interest Society targets is recommended in management of CKD patients. The discovery of the phosphatonins has improved understanding of the mechanisms involved in phosphorus homeostasis and SRHP and may lead to improved ability to monitor and manage these patients.

Handbook of Nutrition and the Kidney. 6th Edition

Handbook of Nutrition and the Kidney 6th Edition is as the title suggests a pocket sized review of the nutritional issues impacting upon and suffered by those with kidney disease. It is edited by two experts in nephrology, with chapter authors drawn from across the world. This helps ensure the recommendations are relevant to all rather than country specific as is usually the case. The chapters cover a broad range from the more scientific describing the impact of nutritional support and restriction in nephritic syndrome, to the practicalities of sample menus for ‘chronic kidneys disease’. The former is an interesting read, as despite all of the studies carried out over many years, there is still no consensus as to whether we should be restricting protein in patients with kidney disease. Undoubtedly the data seems to show it has a beneficial effect, especially in protein losing diseases such as nephritic syndrome. The problem is that patients who then go on to end-stage and require renal replacement therapy are often malnourished, partly due to nausea from uraemic toxins, and therefore restricting their diets in any way prior to this may simply exacerbate the problem. This book provides an excellent review of the data and with its practical advice on menus, the reader is able to make an informed choice and provide practical help. Subsequent chapters describe the nutritional requirements of haemodialysis, transplant and peritoneal dialysis patients, specific diseases such as kidney stones, and the impact of obesity on kidney disease. They are clear and well described with interesting illustrations. Overall this is an excellent book that would prove very useful for any renal nurse and specialist renal dietician. Vital CKD is a companion to the excellent Vital Nephrology from the same publishers. It follows the same format of a quick reference guide and again is written by an experienced clinical nephrologist. Vital CKD differs in that it has more of a primary care and patient focus. As an example, each chapter has a ‘Patient and carer information’ section that can be photocopied and given to those who would like to know more about their condition. The chapters are laid out in a logical manner, starting with kidney basics that highlight the various functions of the kidney. Subsequent chapters discuss the screening and diagnosis, classification and epidemiology of CKD. The latter is a very useful chapter that provides a perspective of CKD in the community, and describes the impact of ageing on the kidney, mortality in CKD and the effect of ethnicity on rates of disease. The next section on management draws in the latest guidelines from the National Institute for Clinical Excellence (NICE) and those of the Joint Royal College of General Physicians and Renal Association group. Specific kidney diseases are well described, as are the complications of and living with CKD. The final chapter is very helpful for those that relate better to real-life scenarios. The case studies in this ‘CKD clinic’ section show how to apply the guidelines in real life situations and how they can help decide the most appropriate treatment. In summary, this is a very helpful quick reference guide that provides relevant guideline information along with more in-depth detail and also helpful patient and carer information. It is useful both for renal nurses dealing with early kidney disease and those such as practice nurses who deal with it on a less frequent basis but who nevertheless need quick and accurate information. Vital CKD: Keeping Kidneys Healthy

Renal Dietitian’s Subjective Assessments Of Dietary Intakes Show Differences Compared to NKF-KDOQI Guidelines: A Pilot Study

Renal Dietitian’s Subjective Assessments Of Dietary Intakes Show Differences Compared to NKF-KDOQI Guidelines: A Pilot Study

Always Look on the Bright Side of Life

It's a dreary October morning as I sit to write my last message to you as CRN Chair. It's a time for reflection on where the renal community has been in the past 2 years and where we are going. I'm sad but hopeful because I know that the Executive Committee has steered the CRN through the tumultuous times of Conditions for Coverage, the incorporation of CRN councils into the National Kidney Foundation (NKF), and the start of bundling and Medicare QIP. I am leaving the Council in the experienced hands of Jessie Pavlinac. There are many people I need to thank along the way. To Jean Stover, I thank you for all of your expert advice, your willingness to jump into any position or project, and your amazing calmness when I was at my wits end. To Denise Dilley, you have been a wonderful friend as we have navigated the sometimes complex world of the NKF. You brought me great perspective on how the NFK has navigated these challenging times. You have often provided me a smile on Friday afternoons around 5 pm! To the Executive Committee, you are a wonderful group of strong women who have spearheaded projects, initiatives, and fun. I have always valued your opinions and insights. It has been a great honor to work with you and I hope that our paths cross again. Finally, to the CRN membership, you have been and will always be my driving force. It takes a special, and sometimes crazy, person, to take on the world of renal nutrition. This field is not for the meek. We have labs to evaluate, patients to educate, doctors to call, medication recommendations to make, regulations to follow, and goals to reach. Despite the vast changes we have just undergone, we still stay committed to the community we serve. Let's face it, telling patients to take their binders over and over gets boring, yet we do it month in and month out because we see the bigger picture. We care. This dedication goes mostly unnoticed by our community, but I've noticed and I have pushed for the empowerment of the renal dietitian. Thank you for your commitment and thank you for your support. Jessie Pavlinac steps into the CRN Chair position in February. Jessie has had a long history with the CRN and served as its Chair in 1993. I won't recant her entire history because I don't want to “age” her, but I can tell you that she started in this field when big hair and leg warmers were a fashion trend. In addition to her involvement with the NKF and CRN, Jessie is also very active with the Academy of Nutrition (AND) and the Dietetics and the Renal Practice Group, serving as AND President, Speaker in the House of AND Delegates, and on many committees. She will remain active in the organization as she takes over the position of CRN Chair, bridging the relationship between the CRN and the Renal Practice Group. Jessie is currently the Director of Clinical Nutrition, Food, and Nutrition Services at the Oregon Health and Science University in Portland, Oregon. She is also a senior instructor at the University's School of Medicine. Internationally known, Jessie has been an invited presenter and publisher on many topics, including promotion of the field of dietetics and implementation of nutrition practices, research, and health care reform. She is a strong addition to the Executive Committee, and I am confident she is ready to tackle the challenges that face our field in the upcoming future. I am grateful for her belief in what we, the CRN, have accomplished over the past few years. So, as I step down from the CRN, I wish all of you much joy, happiness, and success in our chosen field. May you always look on the bright side of life!

Renal Dietitians Lack Time and Resources to Follow the NKF KDOQI Guidelines for Frequency and Method of Diet Assessment: Results of a Survey

This study was conducted to determine how often renal dietitians assess patients' diets and what methods they use to collect and analyze the data. Data were collected through an anonymous online survey. The survey was distributed to renal dietitians during the winter of2012. Currently practicing renal dietitian members of the International Society for Renal Nutrition and Metabolism, the National Kidney Foundation Council on Renal Nutrition, the Academy of Nutrition and Dietetics Renal Practice Group, and the RenalRD listserve were invited to participate. Of 599 usable responses received, 91% worked in the United States. The main outcome measure was dietitian compliance with Kidney Disease Outcomes Quality Initiative (KDOQI) nutrition assessment guidelines. Most dietitians collect dietary intake data when certain laboratory results are abnormal (70%) whereas 6.5% biannually collect dietary intake data (recommended by KDOQI). The most common reasons for not collecting dietary intake data more frequently were lack of time (42%) and software (25%). Most dietitians determine the frequency of dietary intake assessment on their own (60%) whereas 10% follow the KDOQI guidelines. The most common method of dietary intake data collection was a typical day recall (50%), although 8% reported using a 3-day food record as recommended by KDOQI. The most common method for analyzing dietary intake data was "estimate in my head" (62%) followed by calculate by hand (24.5%). Renal dietitians do not follow the KDOQI guidelines for diet assessment because of time constraints. Research must explore which nutrition assessment tools may improve patient outcomes and can also be completed within the time allotted for nutritioncare.

Adherence to Phosphate Binder Therapy Is the Primary Determinant of Hyperphosphatemia Incidence in Patients Receiving Peritoneal Dialysis

We investigated the major determinant of hyperphosphatemia incidence among patients receiving peritoneal dialysis. Seventy-six patients aged 25-55 years who had received peritoneal dialysis for more than 3 months were recruited. The patients were divided into three groups according to their serum phosphorus levels (Group 1, ≥ 6 mg/dL; Group 2, 5.9-4.8 mg/dL; and Group 3, <4.8 mg/dL). Renal dietitians interviewed the patients to determine their phosphate intake and adherence to phosphate binder therapy. No statistical differences in demographics or phosphate intake were identified among the groups. However, adherence to phosphate binders was greater in Group 3 than in Groups 1 and 2 (96.3% vs. 21.4% and 52.4%, respectively; P < 0.001). Multivariate analysis showed that adherence to phosphate binder therapy was the only significant contributor to serum phosphorus levels (P= 0.0001). Adherence to diet was better than adherence to phosphate binder therapy among patients receiving peritoneal dialysis, and the latter determined the incidence of hyperphosphatemia.

Renal patient's diet: Can fish be included?

Medical and nutritional treatment for renal disease, now a major public health issue, is highly complicated. Nutritional therapy must seek to retard renal dysfunction, maintain an optimal nutritional status and prevent the development of underlying pathologies. To analyze ten fish species to identify those that, because of their low phosphorus content, high biological value protein and elevated n-3 fatty acids EPA and DHA, could be included in renal patient's diet. The following fish species (Litte tunny, Red drum, Spotted eagleray, Escolar, Swordfish, Big-scale pomfret, Cortez flounder, Largemouth blackbass, Periche mojarra, Florida Pompano) were analyzed according to the AOAC and Keller techniques to determine their protein, phosphorus, sodium, potassium, cholesterol, vitamins D(3) and E, and n-3 EPA+DHA content. These results were used to calculate relations between nutrients. The protein in the analyzed species ranged from 16.5 g/100 g of fillet (Largemouth black bass) to 27.2 g/100 g (Red drum); the lowest phosphorus value was 28.6 mg/100 g (Periche mojarra) and the highest 216.3 mg/100 g (Spotted eagle ray). 80% of the fish presented > 100 mg EPA + DHA in 100 g of fillet. By its Phosphorus/gProtein ratio, Escolar and Swordfish could not be included in the renal diet; Little tunny, Escolar, Big-scale pomfret, Largemouth black-bass, Periche mojarra and Florida Pompano presented a lower Phosphorus/EPA + DHA ratio. Florida pompano is the most recommended specie for renal patients, due to its optimal nutrient relations. However, all analyzed species, except Escolar and Swordfish, could be included in renal diets.

Championing the Renal Dietitian

Championing the Renal Dietitian

Compliance With a Structured Weight Loss Program Is Associated With Reduced Systolic Blood Pressure in Obese Patients With Chronic Kidney Disease

The effectiveness of lifestyle-based weight loss programs in obese patients with chronic disease has not been widely studied. This study examined the effectiveness of a weight management program (WMP), and sought to determine factors associated with successful weight loss in obese patients with chronic kidney disease (CKD). In this prospective cohort study, all patients with a body mass index (BMI) of >30 kg/m(2) referred to our clinic from January 2005 to December 2008 and who commenced a structured WMP of an energy-reduced renal diet, exercise, and pharmacotherapy were included in the analyses. Changes in body weight and associated variables up to 24 months were assessed with intention-to-treat mixed linear models and predictors of weight loss were identified with multiple linear regression. One hundred and thirty-five patients (56% male), of mean age 52.2 years and BMI 36.4 kg/m(2) commenced the WMP. Significant weight loss was achieved for all patients at 6, 12, 18, and 24 months. Weight loss at 12 months was predicted by compliance and age, but not by baseline BMI, blood pressure (BP), stage of CKD or pharmacotherapy use. Greater compliance was associated with decreased systolic BP, with no change in mean antihypertensive medication dose. Significant weight loss was achieved, demonstrating the effectiveness of the WMP, and compliance with a structured program improved weight loss and systolic BP.

Knowledge In Renal Nutrition Of Medical Doctors And Nursing Staff

Diet prescription for hospitalized renal patients should be individualized and based on their nutritional status and biochemical profiles. However the practice of ordering a ‘renal diet’ which consists of low protein, low salt, low potassium and low phosphate for all renal patients is common in the acute hospital setting. A total of 49 medical doctors were interviewed on their diet prescription practices for renal patients. In addition, a questionnaire was distributed to 488 nurses to assess their knowledge in renal nutrition. 68% of house officers (first year residents) reported that a ‘renal diet’ should be low in protein, salt, potassium, phosphate but only 38% of medical officers reported the same. While 100% of medical doctors stated that renal patients are at risk of compromised nutrition, only 45% of them would refer all renal patients to a dietitian. 47% of nurses believed that ‘renal diet’ low in potassium, salt, phosphate and protein should be prescribed to all patients with chronic renal failure. Only 38% of nurses were aware of the need for higher protein diet for patients on dialysis. In conclusion, there is a need to improve the knowledge of medical doctors and nursing staff in renal nutrition.

Renal Dietitians Lack Time And Resources To Collect And Analyze Dietary Intake Data

Previous research indicated that renal dietitians lack the time and computer software to implement the KDOQI nutrition guidelines for assessing dietary intake. This study used an online survey to determine the frequency and method of collecting and analyzing dietary intake data among renal dietitians in the USA and overseas. The link to the survey was emailed to the members of the RenalRD listserve (n=2077), the International Society of Renal Nutrition and Metabolism (n=93), the Academy of Nutrition and Dietetics Renal Practice Group (n=2362), and the National Kidney Foundation Council on Renal Nutrition (n=1491). Only currently practicing renal dietitians were asked to respond; 599 usable responses were received. A response rate cannot be calculated due to membership overlap between the 4 organizations, although individuals were asked to answer only once. Respondents were 99% female, 91% worked in the USA, 45% had a M.S. degree or higher, and 21% were Board Certified Specialists in Renal Nutrition. Dietitians worked mostly in dialysis (hospital based facility 30%, Fresenius 18%, DaVita 17%) and 5% worked in a pre-dialysis CKD clinic. Median patient load was 120/Full Time Equivalent (inner quartile range 100-150). Dietitians reported that they collected dietary intake data most frequently when labs were abnormal (70%), yearly (41%), and at the first visit only (35%). They did not collect intake data more frequently due to lack of time (42%) and not having analysis software (24.9%). Only 10% of renal dietitians reported that the frequency of diet analysis was determined by following the KDOQI guidelines, while 58.5% reported deciding on their own when to collect data. The most common methods of data collection were the “typical day” recall (50%) and the 24-hour recall (37%). Only 8% reported using a 3-day food record (as recommended by KDOQI). Methods of diet analysis were “estimation in my head” (62%), “calculate by hand” (25%), computer software (6%) and internet analysis sites (7%). These data show that most dietitians are not following the KDOQI nutrition guidelines for frequency or method of diet analysis, and new, inexpensive, and rapid methods of diet assessment must be explored.

Using A Web-Based Nutrition Algorithm In Hemodialysis (Hd) Patients

Nutrition care is complex and encompasses evaluation and correction of protein-energy wasting plus many nutrition abnormalities such as hyperphosphatemia, abdominal obesity, and risk factors of cardiovascular disease. The purpose of this study was to test a nutritionally comprehensive algorithm for feasibility and functionality in a diverse group of HD patients. This was a prospective, observational study designed to test a nutrition algorithm for 1) clinical feasibility; 2) logical progression; 3) ability to collect data; and 4) effectiveness in improving outcomes. Patients included in this study were enrolled by renal dietitians (RD) working in HD units based in five different countries. To select study subjects, RD were asked to screen and consent patients in their facilities until 4 patients were identified as at nutrition risk per the algorithm’s screening tool. All data were collected via the algorithm including screening, assessment, nutrition related diagnosis, etiology of the nutrition diagnosis, nutrition related barriers, nutrition focused interventions, and outcome parameters. Statistics were performed using SPSS vs 20.0 and significance set at p <0.05. One hundred patients, enrolled by 29 RD, were included in this analysis. The screening parameters that triggered an “at risk flag” for more than 50% of the patients were: PTH, serum cholesterol and unintentional weight loss. Of the patients with an albumin of <3.8 mg/dl (37% of sample), 73% were given a nutritional diagnosis of insufficient protein intake. Overall, patients with insufficient intake had significantly lower serum albumin concentrations at baseline than those who did not have this (3.7±0.4 vs. 4.0±0.4, p <0.05). Patients with a diagnosis of “high phosphorus” had decreases in serum PTH (349.5±184.5 to 201.7±113.6, p =0.06) and phosphorus (from 6.5±1.0–5.3±1.9 mg/dl, p =0.04) at the three month data collection. This study is the first of its kind to show that a web-based, HD specific, nutrition algorithm is feasible and effective.

A full color visual educating tool to improve renal diet compliance

The objective is to simplify Renal diet education of a newly diagnosed, illiterate/non-English speaking CKD patient by using a 5 step concept that is explained by a fully illustrated color manual. The 5 steps to be followed are as follows: Step 1. What foods are eaten daily? The renal dietitian is faced with many challenges when taking a diet history & educating a newly diagnosed CKD patient. It is of utmost importance to tailor education to specific patient’s needs & to adapt the diet prescription to the patient’s literacy level, culture, socio-economic circumstances & eating habits. Step 2. How kidneys work. The damaged kidney is portrayed as a sieve with very fine mesh that does not allow normal kidney functions. Once the patient understands that his uremic symptoms are related to diet & damaged kidneys, he is willing to change his old eating habits. RRT is explained visually. Step 3. What to eat. The calculated, technical diet prescription is explained in an understandable way by a visual tool called “The renal plate” that was specifically developed. The Renal plate is based on adjusting the Basic 3 Food Groups by making use of the South African Renal exchange lists. Step 4. What not to eat. Foods to avoid due to high sodium, phosphate & potassium are presented by illustrations. Step 5. How much to eat. Portion sizes are addressed through visuals since “The renal plate” only focuses on types of foods in a specific food group, not on quantity of each food group to be eaten. Compliance to a renal diet is an integral part of patient care. If understandable renal diet education is linked to uremic symptoms & starts as soon as the patient is diagnosed, there is far better future diet compliance & disease outcome.

Adequacy of Dietary Intake of Vitamin D in Stable HD Patients: Are they meeting their needs

Hypovitaminosis D is associated with reduced survival, increased cardiovascular events, and impaired bone-mineral balance in dialysis. The KDOQI guidelines do not have specific recommendations regarding vitamin D (VitD) intake in dialysis patients. The purpose of this study was to determine whether stable prevalent hemodialysis (HD) patients, for whom standard clinical dietary restrictions had been recommended, were able to meet their Recommended Daily Allowance (RDA) for VitD. An observational study was conducted to examine serum 25-OHD levels in relation to 3-day diet analysis, supplementation, anthropometrics and nutritional status (using Malnutrition Inflammation Score (MIS)) in 81 HD patients. Sixty-nine completed 3-day dietary intake records (1 dialysis day, 1 non-dialysis day, 1 weekend-non-dialysis day). Mean dietary VitD intake of the group was 2.5 μg/day SD±3.6, which is less than 15% of RDA of ∼17 μg/day. Only 2 out of 69 subjects (3%) met the RDA for VitD with mean intakes of 20.8±2.6 μg/day that corresponded with mean serum 25OHD of 43.5±17.6 nmol/L. Mean serum 25OHD levels for the group were 42.4 ±23.1 nmol/L, with 19 classified as deficient (28% <27.5 nmol/L), 43 insufficient (62%=27.5–75 nmol/L) and only 7 sufficient (10% >75nmol/L) in terms of 25OHD levels. 20 of the 69 (29%) took a VitD supplement and had significantly higher serum 25OHD than ones who did not take any (53.7±17.3 nmol/L vs 38.7±22.4 nmol/L, p-value=0.013). Multiple regression analysis revealed dietary calcium ( p =0.001), and dietary protein (p=0.006) were positively related and HD-vintage ( p =0.037), inversely related to dietary VitD whereas total kilocalories, dietary phosphate, MIS and dry body mass did not relate to it. Thus, inadequate intake of VitD is a common (97%) and modifiable risk factor for hypovitaminosis D in HD patietns. Factors affecting reduced intake of VitD in our patients included dietary protein and calcium but not dietary phosphorous. VitD levels were low even in the face of adequate VitD intake through supplementation and/or dietary sources, and would need monitoring if target levels are to be met by the renal dietitians and nephrologists.

VALIDATION OF THE SUBJECTIVE GLOBAL ASSESSMENT AND MALNUTRITION INFLAMMATION SCORE TRANSLATED TO PORTUGUESE FOR ELDERLY PATIENTS ON HEMODIALYSIS.

We aimed to validate the translation of the 7 point subjective global assessment (7 p-SGA) and malnutrition inflammation score (MIS) from English to Portuguese to be applied for elderly patients on hemodialysis (HD). For the translation, the back-translation method was used. First, two independent bilinguals renal dietitians (Portuguese native speakers) worked independently to translate the 7 p-SGA and MIS to Portuguese. After that, the final version was back translated to English by a bilingual English teacher (Portuguese native speaker). In order to investigate the conceptual and semantic equivalence of the translated version, a renal dietitian (English native speaker) compared each item of the original English version of the 7 p-SGA and MIS to the back translated English version by rating the similarity between both questionnaires from 1 to 100 (being 100 the highest degree of similarity). The degree of similarity was 96.8 ±7.8 for 7p-SGA and 99.6 ±1.4 for MIS, indicating that the Portuguese versions had equivalent meaning to the original English version. We then performed the validation of the Portuguese version by assessing the concurrent concordance of both nutritional composite indices with objective methods (BMI, body fat %, phase angle, handgrip strength and albumin) in 64 elderly patients on HD (male 72%; 70±3 years old). The 7p-SGA was rated as well nourished (score 7-6; n= 30); mildly to moderately malnourished (5-3; n= 34) and severely malnourished (2-1; no patient). The MIS was rated as normal nutrition (score: 0–5; n= 12); mild malnutrition (6–10; n= 38), and moderate-to-severe malnutrition (≥11; n= 14). Among the objective methods, only body fat % differed (P<0.05) between well-nourished and malnourished patients for the 7p-SGA, and for MIS, the same was observed only for body fat % and phase angle. In conclusion, these preliminary results suggest that for elderly patients on HD, the scores proposed by the 7p-SGA and MIS for screening patients with protein energy wasting should be reviewed.

Moving the Issue of Renal Dietitian Staffing Forward

The day-to-day pragmatic work realities of dietitians who cover dialysis clinics are rarely the focus of discussion. This article highlights the points of convergence between these realities and the research literature. Focusing on the National Kidney Foundation Kidney Disease Outcomes Quality Initiative clinical practice guidelines for nutrition and the difficulties encountered with their full implementation, a seemingly pervasive problem of limited time is revealed. Given the evidence that renal dietitians can positively impact morbidity and mortality risks, when protein-energy malnutrition is primarily the byproduct of insufficient nutrient intake, it suggests that progress with enhancing the nutritional status of patients may be fundamentally contingent on increasing the time they have available, through improved staffing.