Diets and enteral supplements for improving outcomes in chronic kidney disease

Abstract

Protein-energy wasting (PEW), which is manifested by low serum levels of albumin or prealbumin, sarcopenia and weight loss, is one of the strongest predictors of mortality in patients with chronic kidney disease (CKD). Although PEW might be engendered by non-nutritional conditions, such as inflammation or other comorbidities, the question of causality does not refute the effectiveness of dietary interventions and nutritional support in improving outcomes in patients with CKD. The literature indicates that PEW can be mitigated or corrected with an appropriate diet and enteral nutritional support that targets dietary protein intake. In-center meals or oral supplements provided during dialysis therapy are feasible and inexpensive interventions that might improve survival and quality of life in patients with CKD. Dietary requirements and enteral nutritional support must also be considered in patients with CKD and diabetes mellitus, in patients undergoing peritoneal dialysis, renal transplant recipients, and in children with CKD. Adjunctive pharmacological therapies, such as appetite stimulants, anabolic hormones, and antioxidative or anti-inflammatory agents, might augment dietary interventions. Intraperitoneal or intradialytic parenteral nutrition should be considered for patients with PEW whenever enteral interventions are not possible or are ineffective. Controlled trials are needed to better assess the effectiveness of in-center meals and oral supplements.

Influence of Body Mass Index on the Association of Weight Changes with Mortality in Hemodialysis Patients

“…Expanding on previous reports (14,15), these results suggest that shortterm body weight losses may give relevant clinical insight into a patient's risk profile and should represent a call for appropriate corrective measures. Nevertheless, although nutritional support may effectively increase body weight and improve other nutritional biomarkers in dialysis patients (19), clinical trials have not yet shown that targeting body weight improves the survival of HD patients. Given the bulk of evidence accumulated since the first description of the obesity paradox (2), the need for these clinical trials is well justified.…”

“…Such is the case of the "obesity paradox," whereby a high body mass index (BMI) has been associated with longer survival in many (4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15) but not all (16)(17)(18)) studies of dialysis patients. Although there are various hypotheses for this paradoxical disconnect, the most likely explanation is that dialysis patients are at such high risk of PEW that excess weight provides a measure of protection (15,19). Likewise, body weight losses have been associated with increased mortality, whereas weight gains have been associated with longer survival (14,15,20).…”

Dialysis at a Crossroads—Part II

“…Adjunctive pharmacological therapies, such as appetite stimulants, anabolic hormones, and antioxidative or antiinflammatory agents, might augment dietary interventions. In-center meals and/or oral supplements provided during the dialysis therapy are feasible and inexpensive interventions (53). Observational data on more than 4000 dialysis patients note the positive effects of oral nutritional supplements, with a 26% reduction in mortality and decreased hospitalization rate (54).…”

Effect of high-protein meals during hemodialysis combined with lanthanum carbonate in hypoalbuminemic dialysis patients: findings from the FrEDI randomized controlled trial

“…Second, thrice-weekly dialysis sessions may coincide with core meal times, leading to inadequate food intake on dialysis treatment days [14]. This issue may be compounded by the fact that many outpatient dialysis units in the USA refrain from administering meals and prohibit outside food or beverage consumption during dialysis, given concerns about postprandial hypotension, aspiration, infection risk, staff burden and financial constraints [13,15]. Third, the importance of nutritional status, as well as the benefits of nutritional supportive measures, may remain under-recognized and underprioritized in the hemodialysis population.…”