Protein-energy wasting and nutritional supplementation in patients with end-stage renal disease on hemodialysis

© 2016 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism Background & aims Protein-Energy Wasting (PEW) is the depletion of protein/energy stores observed in the most advanced stages of Chronic Kidney Disease (CKD). PEW is highly prevalent among patients on chronic dialysis, and is associated with adverse clinical outcomes, high morbidity/mortality rates and increased healthcare costs. This narrative review was aimed at exploring the pathophysiology of PEW in end-stage renal disease (ESRD) on hemodialysis. The main aspects of nutritional status evaluation, intervention and monitoring in this clinical setting were described, as well as the current approaches for the prevention and treatment of ESRD-related PEW. Methods An exhaustive literature search was performed, in order to identify the relevant studies describing the epidemiology, pathogenesis, nutritional intervention and outcome of PEW in ESRD on hemodialysis. Results and conclusion The pathogenesis of PEW is multifactorial. Loss of appetite, reduced intake of nutrients and altered lean body mass anabolism/catabolism play a key role. Nutritional approach to PEW should be based on a careful and periodic assessment of nutritional status and on timely dietary counseling. When protein and energy intakes are reduced, nutritional supplementation by means of specific oral formulations administered during the hemodialysis session may be the first-step intervention, and represents a valid nutritional approach to PEW prevention and treatment since it is easy, effective and safe. Omega-3 fatty acids and fibers, now included in commercially available preparations for renal patients, could lend relevant added value to macronutrient supplementation. When oral supplementation fails, intradialytic parenteral nutrition can be implemented in selected patients

Development and evaluation of continuing education course in renal nutrition

BACKGROUND/OBJECTIVE: Competent renal dietitians are crucial for better patient compliance and clinical outcomes, specifically in critical settings. The aim of this study was to develop and evaluate an evidence-based course in renal dietetics for dietitians working in health care systems where dietetic specialization is absent. SUBJECTS/METHODS: Fifteen licensed dietitians working with hemodialysis patients in Lebanon were randomly recruited to participate in the course. The latter was developed by the study's primary investigator, according to evidence-based practice guidelines, and focused on all aspects of renal nutrition. Total course duration was 28 hours spread over a 2 month period. Dietitians' knowledge in renal nutrition was tested pre- and post-training through a 23-item questionnaire; the total score was expressed in percentage (<60% score indicated insufficient knowledge). Paired-samples t test was used for statistical analysis. RESULTS: Overall knowledge of the dietitians significantly improved post-training and reached satisfactory levels (pre: 38.75 +/- 17.20%, post: 62.08 +/- 21.85%). Sub-analysis of the change in the knowledge showed significant and satisfactory improvement only in 3 topics: 1) correct body weight use in calculations, 2) energy estimation method and 3) phosphorus management. Knowledge in the fluid management significantly improved but did not achieve a satisfactory level. CONCLUSION: The course significantly improved dietitians' knowledge in renal nutrition. If adopted as part of the continuing education of dietitians in countries that lack dietetic specializations, it may serve the first step towards improving health care practice

The association between gut peptides and markers of obesity and insulin resistance in lean and obese individuals in the United Arab Emirates

Objective: To compare fasting gut peptides levels between obese and non-obese emirati adults and investigate possible associations of these hormones with markers of obesity and insulin resistance. Methods: This cross-sectional study included 43 obese (body mass index (BMI): 43.12±6.83; mean age, 29.95±9.13 years) and 31 age- and sex-matched lean subjects (BMI: 22.49±1.93; mean age 29.67±10.73 years). BMI, waist circumference (WC), waist-to-height ratio (WHtR), percentage body fat (PBF), fasting blood levels of GLP-1, GLP-2, insulin, leptin, ghrelin, CCK, PYY), blood sugar (FBS), and Homeostatic model assessment-insulin resistance (HOMA-IR) were assessed. Associations between gut peptides and indices of obesity and IR were tested using Independents-samples t-test, Mann-Whitney-U, partial correlation, and logistic regression. Results: FBS, insulin, HOMA-IR, GLP-1, GLP2, and Leptin were significantly higher in the obese group (p&lt;0.05), whereas ghrelin and CCK were significantly higher in lean participants (p&lt;0.05). No between-group significant differences were noted regarding PYY. Controlling for BMI, GLP-1 was correlated with WHtR (r=0.312, p=0.039), and WC among females only (r=0.447, p&lt;0.001). Insulin was positively correlated with WHtR (r=0.275, p=0.019), while, ghrelin was inversely correlated with WHtR (r=-0.302, p=0.019). GLP-1 and GLP-2 were correlated with insulin (r=0.612, p&lt;0.001; r=0.236, p=0.046, respectively). GLP-1 was moderately correlated with HOMA-IR (r=0.667, p&lt;0.001). None of the gut peptides was correlated with FBS. PYY was not correlated with any marker. In the regression, GLP-1 was positively associated with obesity, WC, WHtR, and HOMA-IR (ExpB:1.367, 95%CI: 1.117-1.672; ExpB: 1.196, 95%CI: 1.001-1.430; ExpB: 1.591, 95%CI: 1.072-2.363; ExpB: 1.221, 95%CI: 1.079-1.382; respectively), and negatively associated with PBF (ExpB: 0.717, 95%CI: 0.542-0.949). Leptin was also positively associated with obesity (ExpB: 1.239, 95%CI: 1.018-1.508). Conclusions: Obese and lean adults displayed significant differences in plasma gut peptides levels. GLP-1 levels was independently associated with markers of obesity and IR. Restoring the disordered gut hormone balance in obesity may represent a major potential therapeutic target.THIS DATASET IS ARCHIVED AT DANS/EASY, BUT NOT ACCESSIBLE HERE. TO VIEW A LIST OF FILES AND ACCESS THE FILES IN THIS DATASET CLICK ON THE DOI-LINK ABOV