Multifaceted Nutritional Intervention In Hemodialysis Patients

Mortality rate in patients undergoing chronic hemodialysis (HD) in the United States remain unacceptably high despite improvement in dialysis technology. Cardiovascular disease (CVD) account for more than 50% of the premature death in this population. Evidences indicate that the accelerated CVD are attributed to by malnutrition, inflammation, dyslipidemia and oxidative stress. Dietary intervention using nutrients with antioxidant, anti-inflammatory, and potential lipid altering properties to correct the aforementioned problems remain inconclusive. Furthermore, such nutritional intervention trial is often hampered by poor compliance related to medical and socioeconomic barriers. Therefore, a series of randomized, double-blind, placebo-controlled, parallel trials were undertaken to document the technical feasibility of `directly observed treatment\u27 and the global impact of several nutrients namely omega-3 and vitamin E tocotrienols on nutritional and oxidative indicators, inflammatory markers and lipid profiles in a cohort of chronic HD patients. The objective of the first study was to evaluate the impact of omega-3 plus liquid protein supplement on serum albumin, plasma lipids and other indicator of nutrition and inflammation. markers. The study recruited 63 subjects and they were randomized into placebo+protein (n=32) and omega-3+protein (n=31) groups. The two intervention groups received 30mL of a liquid protein plus 2.4g omega-3 or placebo, three times per week after their routine dialysis session for 6 months. Directly observed nutritional supplement resulted in significant improvement in the LDLC/HDLC ratio in the omega-3 group as compared to the placebo group (P=0.043). In the omega-3 group, serum albumin was also marginally higher after 6 months as compared to the baseline (P=0.07). The observed increase in CRP levels in the placebo group over 6 months was not apparent in the omega-3 group, although there was no significant difference between groups. NFκB, MIS, nPNA, BMI and hemoglobin were unaffected by the intervention. Therefore, it is conclude that `directly observed treatment\u27 with an omega-3 based supplement (as opposed to a pure protein supplement) showed beneficial effects on lipid profile, and CRP levels. Further studies using a combination of outpatient and inpatient `directly observed treatment\u27 is warranted. Given a proven feasibility of directly observed treatment in the first study, we conducted a second study using tocotrienol rich fractions (TRF) by incorporating the same design to maximize compliance but with additional take home supplements. Vitamin E tocotrienols have been reported to confer anti-inflammatory, antioxidant and a potential of lipid altering benefits in vitro, in vivo and in some other clinical population. However, the impact of this nutrient in HD population is unknown. Subjects were provided daily with capsules containing either vitamin E tocotrienol-rich fraction (TRF) (180 mg tocotrienols, 40 mg tocopherols) or placebo (0.48 mg tocotrienols, 0.88 mg tocopherols). For the results, TRF supplementation did not impact any nutritional, inflammatory, or oxidative status biomarkers over time when compared with the baseline within the group (one-way repeated measures analysis of variance) or when compared with the placebo group at a particular time point (independent t-test). However, the TRF supplemented group showed improvement in lipid profiles after 12 and 16 weeks of intervention when compared with placebo at the respective time points. Normalized plasma triacylglycerols (cf baseline) in the TRF group was reduced by 33 mg/dL (P=0.032) and 36 mg/dL (P=0.072) after 12 and 16 weeks of intervention but no significant improvement was seen in the placebo group. Similarly, normalized plasma high-density lipoprotein cholesterol was higher (P\u3c0,05) in the TRF group as compared with placebo at both week 12 and week 16. The changes in the TRF group at week 12 and week 16 were associated with higher plasma apolipoprotein A1 concentration (P\u3c0.02) and lower cholesteryl-ester transfer protein activity (P\u3c0.001). As a conclusion, TRF supplementation improved lipid profiles in the study of maintenance HD patients. A multi-centered trial is warranted to confirm these observations. Finally, following a positive impact of TRF supplementation on lipid profiles, we undertook a metabolomics approach to investigate whether the TRF supplementation lead to overall changes in patients\u27 metabolomics profile and whether the observed changes in plasma lipids correlates with their metabolomics profile. Based on the principal component analysis (PCA), there was a separation pattern between the TRF and placebo groups at week-12. After applying partial least square-discriminant analysis (PLS-DA), there was a clear separation between the two groups indicating different metabolomics profiles. In addition, metabolomics profile in both TRF and placebo group was correlated with inflammatory markers and lipid profiles suggesting that some plasma metabolite could predict/ responsible for the changes in lipid profiles and inflammatory markers

Ascorbic acid: physiology and health effects

Ascorbic acid (vitamin C) is an essential dietary nutrient required for various biological processes in the human body. These include its vital role as antioxidant, and it acts as cofactor for the biosynthesis of collagen, catecholamines, amino acids, and various peptide hormones. Accumulating literatures suggest that vitamin C may potentially implicate in the development of various chronic diseases partly due to its role in maintaining oxidative balance, this is due to the fact that initiation and development of many chronic diseases stemmed from oxidative stress and inflammation. Given that, vitamin C has controversially been used in the prevention and treatment of specific health conditions, this article attempts to summarize recent evidences pertaining to the roles of vitamin C in health and diseases. A brief description on the physiology of vitamin C was also included to support the understanding of its role in maintaining health

Ascorbic acid: properties, determination and uses

Vitamin C is one of the most important vitamins in human nutrition. However, the complexity of food matrices and the degradation of this vitamin pose huge challenges during analysis. The chemistry (spectral and physical properties), uses, and analytic methods for the determination of vitamin C are highlighted, along with the strategies used by various researchers to prevent vitamin oxidation during sample extraction. Furthermore, the advantages and disadvantages of different analytic methods, traditional and modern, are also discussed

Dietary factors and sleep quality among hemodialysis oatients in Malaysia

Objectives: Poor sleep quality is a commonly seen problem in hemodialysis patients. This study investigated the associations between dietary factors and sleep quality among hemodialysis patients. Design and Methods:This is a cross-sectional study conducted among 184 eligible hemodialysis patients at four dialysis units in Malaysia. Three days dietary recall were used in the analysis of dietary intake and behavior. Sleep quality was assessed through Pittsburgh Sleep Quality Index. Results: More than half of the patients were poor sleepers. Among the sleep components, sleep latency affected patients the most, with the use of sleep medications was relatively low. A majority of the patients had inadequate dietary intake of energy (88%) and protein (75%). Dietary protein, potassium adjusted for body weight, and sodium intake were significantly increased in poor sleepers. Lower percentage of energy from carbohydrates; higher percentage of energy from fats; higher intakes of dietary protein, fat, phosphorus, and sodium were correlated with poorer sleep quality and its components. Skipping dinner on non-dialysis days and having supper on dialysis days were associated with poor sleep quality. Conclusion: Poor sleep is prevalent among hemodialysis patients. Sleep quality of hemodialysis patients was highly associated with certain dietary factors. Periodical assessment of sleep quality and dietary intake is necessary to identify poor sleepers with inappropriate dietary intake to allow effective clinical and nutritional interventions to improve the sleep quality and nutritional status of these patients

Serum potassium and handgrip strength as predictors of sleep qualtiy among hemodialysis patients in Malaysia

Background and Objectives:Poor sleep quality is prevalent among hemodialysis (HD) patients and leads to adverse health outcomes. This study investigated the association of nutritional parameters with sleep quality among Malaysian HD patients. Methods and Study Design:A cross-sectional study was conducted among 184 Malaysian HD patients. Anthropometric measurements and handgrip strength (HGS) were obtained using standardized protocols. Relevant biochemical indicators were retrieved from patients’ medical records. Nutritional status was assessed using the dialysis malnutrition score. The sleep quality of patients was determined using the Pittsburgh Sleep Quality Index questionnaire on both dialysis and non-dialysis days. Results: Slightly more than half of the HD patients were poor sleepers, with approximately two-third of them having a sleep duration of <7 hours per day. Sleep latency (1.5±1.2) had the highest sleep component score, whereas sleep medicine use (0.1±0.6) had the lowest score. Significantly longer sleep latency and shorter sleep duration were observed in the poor sleepers, regardless of whether it was a dialysis day or not (p<0.001). Poor sleep quality was associated with male sex, old age, small triceps skinfold, hypoproteinemia, hyperkalemia, hyperphosphatemia, and poorer nutritional status. In a multivariate analysis model, serum potassium (β=1.41,p=0.010), male sex (β=2.15, p=0.003), and HGS (β=−0.088, p=0.021) were found as independent predictors of sleep quality.Conclusions: Poor sleep quality was evident among the HD patients in Malaysia. The sleep quality of the HD patients was associated with nutritional parameters. Routine assessment of sleep quality and nutritional parameters indicated that poor sleepers have a risk of malnutrition and may benefit from appropriate interventions

Assessment of health-related quality of life in the elderly on maintenance hemodialysis

Introduction: Health-related quality of life (HRQOL) is one of the main indicators of health and wellbeing among dialysis patients which has attracted mounting interest in recent years in the initiation of intervention measures. Thus, this study aimed to determine the correlations between socio-demographic factors and medical characteristics with HRQOL among elderly on maintenance hemodialysis (HD). Methods: A cross-sectional study was conducted in nine HD centers in Selangor. Socio-demographic data and HRQOL were assessed using structured questionnaire and Kidney Disease Quality of Life Instrument (KDQOL-36), respectively whilst medical profile and laboratory data were collected from subjects’ medical record. Results: The mean age of subjects was 67±6 years where majority (57%) of the subjects was on maintenance HD for less than 5 years. The mean physical component summary and mental component summary scores were 33.89±11.83 and 50.23±8.88, respectively. Symptoms/problems subscale, effects of kidney disease on daily life subscale and burden of kidney disease subscale scores were 73.37±17.01, 72.63±19.74 and 54.62±30.42, respectively. There was a significant correlation between serum sodium with physical component summary (r=0.237, p<0.01) and symptoms/problems subscale (r= 0.245, p<0.01). Conclusion: Subjects perceived their mental health better than physical health but felt burdened by kidney disease the most. Serum sodium was found to be positively associated with physical functioning and symptoms/problems subscales. There is a need for routine assessment on HRQOL and appropriate intervention to enhance the quality of life among elderly on HD

Lipids, lipoprotein distribution and nutritional parameters over the ramadan period in hemodialysis patients

The period of Ramadan (R) is associated with dramatic changes in eating habits involving extended periods of fasting on a daily basis. The current study assessed whether lipids and lipoproteins were impacted during R in chronic hemodialysis (HD) patients. Forty-five subjects in an outpatient dialysis clinic in Saudi Arabia were evaluated for anthropometric and lipid changes on a monthly basis before, during as well as one and two months after R. In addition to routine biochemical measures, anthropometric assessments including hand-grip strength (HGS), mid-arm muscle circumference (MAMC), plasma lipids and lipoproteins were evaluated. Dietary assessment was carried out using 24 h recalls. Over the course of the study, changes in renal-related parameters (creatinine, albumin, Kt/V) were minor, as were changes in plasma lipids. Large high-density lipoproteins (HDLs) and low-density lipoproteins (LDLs) accounted for the majority of their respective lipoproteins and their proportions did not change over the study period. Mean LDL particle diameters were higher during the R period, but the changes over the study period were small. Calorie intake during R (2139 ± 709 kcal/d) was significantly higher than the value noted two month post-R (1755 ± 424 kcal/d) and this was associated with significant increases in protein (69 ± 24 vs. 60 ± 24 g/d) and fat (97 ± 38, vs. 73 ± 35 g/d), respectively. No changes were noted with respect to HGS and MAMC. These data show that for HD patients, the period of R results in temporal or non-significant effects on plasma lipids, despite changes in nutrient intake

Blood fatty acid status and clinical outcomes in dialysis patients: a systematic review

Blood fatty acids (FAs) are derived from endogenous and dietary routes. Metabolic abnormalities from kidney dysfunction, as well as cross-cultural dietary habits, may alter the FA profile of dialysis patients (DP), leading to detrimental clinical outcomes. Therefore, we aimed to (i) summarize FA status of DP from different countries, (ii) compare blood FA composition between healthy controls and DP, and (iii) evaluate FA profile and clinical endpoints in DP. Fifty-three articles from 1980 onwards, reporting FA profile in hemodialysis and peritoneal DP, were identified from PubMed, Embase, and the Cochrane library. Studies on pediatric, predialysis chronic kidney disease, acute kidney injury, and transplant patients were excluded. Moderate to high levels of n-3 polyunsaturated fatty acids (PUFA) were reported in Japan, Korea, Denmark, and Sweden. Compared to healthy adults, DP had lower proportions of n-3 and n-6 PUFA, but higher proportion of monounsaturated fatty acids. Two studies reported inverse associations between n-3 PUFAs and risks of sudden cardiac death, while one reported eicosapentaenoic acid + docosahexaenoic acid)/arachidonic acid ratio was inversely associated with cardiovascular events. The relationship between all-cause mortality and blood FA composition in DP remained inconclusive. The current evidence highlights a critical role for essential FA in nutritional management of DP

Efficacy of nutritional interventions on inflammatory markers in haemodialysis patients: a systematic review and limited meta-analysis

Low-grade chronic inflammation is prevalent in patients undergoing haemodialysis (HD) treatment and is linked to the development of premature atherosclerosis and mortality. The non-pharmacological approach to treat inflammation in HD patients through nutritional intervention is well cited. We aimed to assess the efficacy of different nutritional interventions at improving inflammatory outcomes in HD patients, based on markers such as C-reactive protein (CRP), interleukin-6 (IL-6), and tumour necrosis factor-α (TNF-α). We searched PubMed, Cochrane Library, and Embase for randomized controlled trials (RCT) published before June 2017. Inclusion criteria included RCTs on adult patients on maintenance HD treatment with duration of nutritional interventions for a minimum 4 weeks. Risk of bias was assessed using the Jadad score. In total, 46 RCTs experimenting different nutritional interventions were included in the review and categorized into polyphenols rich foods, omega-3 fatty acids, antioxidants, vitamin D, fibres, and probiotics. Meta-analyses indicated significant reduction in CRP levels by omega-3 fatty acids (Random model effect: −0.667 mg/L, p < 0.001) and vitamin E (fixed model effect: −0.257 mg/L, p = 0.005). Evidence for other groups of nutritional interventions was inconclusive. In conclusion, our meta-analysis provided evidence that omega-3 fatty acids and vitamin E could improve inflammatory outcomes in HD patients

A Food Frequency Questionnaire for Hemodialysis Patients in Bangladesh (BDHD-FFQ): Development and Validation

Diet is a recognized risk factor and cornerstone for chronic kidney disease (CKD) management; however, a tool to assess dietary intake among Bangladeshi dialysis patients is scarce. This study aims to validate a prototype Bangladeshi Hemodialysis Food Frequency Questionnaire (BDHD-FFQ) against 3-day dietary recall (3DDR) and corresponding serum biomarkers. Nutrients of interest were energy, macronutrients, potassium, phosphate, iron, sodium and calcium. The BDHD-FFQ, comprising 132 food items, was developed from 606 24-h recalls and had undergone face and content validation. Comprehensive facets of relative validity were ascertained using six statistical tests (correlation coefficient, percent difference, paired t-test, cross-quartiles classification, weighted kappa, and Bland-Altman analysis). Overall, the BDHD-FFQ showed acceptable to good correlations (p 0.05). Cross-quartile classification indicated that <10% of patients were incorrectly classified. Weighted kappa statistics showed agreement with all but iron. Bland-Altman analysis showed positive mean differences were observed for all nutrients when compared to 3DDR, whilst energy, carbohydrates, fat, iron, sodium, and potassium had percentage data points within the limit of agreement (mean ± 1.96 SD), above 95%. In summary, the BDHD-FFQ demonstrated an acceptable relative validity for most of the nutrients as four out of the six statistical tests fulfilled the cut-off standard in assessing dietary intake of CKD patients in Bangladesh