The incremental treatment of ESRD: a low-protein diet combined with weekly hemodialysis may be beneficial for selected patients

Abstract

BackgroundInfrequent dialysis, namely once-a-week session combined with very low-protein, low-phosphorus diet supplemented with ketoacids was reported as a useful treatment schedule for ESRD patients with markedly reduced residual renal function but preserved urine output. This study reports our findings from the application of a weekly dialysis schedule plus less severe protein restriction (standard low-protein low-phosphorus diet) in stage 5 CKD patients with consistent dietary discipline.MethodsThis is a multicenter, prospective controlled study, including 68 incident CKD patients followed in a pre-dialysis clinic with Glomerular Filtration Rate 5 to 10 ml/min/1.73/ m2 who became unstable on the only medical treatment. They were offered to begin a Combined Diet Dialysis Program (CDDP) or a standard thrice-a-week hemodialysis (THD): 38 patients joined the CDDP, whereas 30 patients chose THD. Patients were studied at baseline, 6 and 12 months; hospitalization and survival rate were followed-up for 24 months.ResultsVolume output and residual renal function were maintained in the CDDP Group while those features dropped quickly in THD Group. Throughout the study, CDDP patients had a lower erythropoietin resistance index, lower β2 microglobulin levels and lower need for cinacalcet of phosphate binders than THD, and stable parameters of nutritional status. At 24 month follow-up, 39.4% of patients were still on CDDP; survival rates were 94.7% and 86.8% for CDDP and THD patients, respectively, but hospitalization rate was much higher in THD than in CDDP patients. The cost per patient per year resulted significantly lower in CDDP than in THD Group.ConclusionsThis study shows that a CDDP served to protect the residual renal function, to maintain urine volume output and to preserve a good nutritional status. CDDP also blunted the rapid β2 microglobulin increase and resulted in better control of anemia and calcium-phosphate abnormalities. CDDP was also associated with a lower hospitalization rate and reduced need of erythropoietin, as well as of drugs used for treatment of calcium-phosphate abnormalities, thus leading to a significant cost-saving. We concluded that in selected ESRD patients with preserved urine output attitude to protein restriction, CDDP may be a beneficial choice for an incremental hemodialysis program.

Nutritional Status Disorders in Chronic Kidney Disease: Practical Aspects (Systematic Review)

“…Meanwhile, the results of epidemiological studies conducted for recent years have convincingly demonstrated that nutritional status disorders appear to be revealed much earlier, before dialysis treatment starting, from stages 3B-4 CKD, and impact on prognosis of patients on dialysis [1,2,12,13,15]. The incidence of PEW depends on the stage of CKD ( Table 1): among CKD patients with a glomerular filtration rate (GFR) of 44-30 ml/min/1.73m 2 , PEW is detected in 4.2% of cases in average, whereas in CKD patients with GFR of 29-15 ml/min/1.73m 2 in 21.3%, and almost all patients with end-stage of CKD have PEW [1,2,7,13,15,16].…”

“…Based on the available literature data, the correction of NSD, especially early, even at the predialysis stage not only improves the quality of life of patients but also contributes to slowing the progression of CKD and CVE, to prevent PEW at the stage of regular HD [12]. Thus, the correction of NSD becomes an important and obligatory part in the treatment of patients with CKD [1,14] …”

“…It was found that the mortality rate of dialysis patients is inversely related to the amount of protein intake (protein quota), body mass index, and serum albumin [1,12].…”

Gradual initiation of dialysis as a means to reduce cost while providing quality health care

“…For example, once weekly dialysis sessions could facilitate the smooth initi ation of dialysis for certain individuals without negatively affecting their social activities, working hours and, theoretically through preservation of RKF 6 and cardiovascular condition (reported to be the main cause of mortality in the first year of dialysis initiation 5,7,8 ). Such an incremental approach to dialysis initi ation also allows additional time to plan for fistula creation and maturation, preserves RKF and decreases health-care costs 9 . Cost reductions would not only result from the reduced number of haemodialysis sessions, but would also ensue due to vascular access preservation owing to the lower frequencies of punctures, reduced hospitalization from myocardial ischaemic events (as preserved RKF 6 and RUV enables a lower ultrafiltration rate, which is associated with a low risk of myocardial stunning) 9 and reduced absence from work.…”

“…Such an incremental approach to dialysis initi ation also allows additional time to plan for fistula creation and maturation, preserves RKF and decreases health-care costs 9 . Cost reductions would not only result from the reduced number of haemodialysis sessions, but would also ensue due to vascular access preservation owing to the lower frequencies of punctures, reduced hospitalization from myocardial ischaemic events (as preserved RKF 6 and RUV enables a lower ultrafiltration rate, which is associated with a low risk of myocardial stunning) 9 and reduced absence from work.…”