Dietary Protein Intake and Survival in 100,088 Maintenance Hemodialysis Patients: The Role of Race and Albumin

Decreased dietary protein intake may be associated with increased mortality risk in individuals undergoing maintenance hemodialysis (MHD). We examined 8−year all-cause mortality in 100,088 MHD patients from DaVita dialysis clinics in the US (2001–2009) and hypothesized that survival is better across higher levels of nPNA, (nPCR, a dietary protein intake surrogate) with consistent trends across race and in hypoalbuminemic patients. Time-averaged Cox models were used to estimate death hazard ratios for quarterly averaged nPNA categories controlled for case-mix, comorbidity, dialysis dose, and available markers of malnutrition-inflammation-complex syndrome (MICS). In all patients, both low (<0.6g/kg/day, HR 1.53, [1.47–1.59]) and high nPNA (≥1.4g/kg/day, HR 1.26, [1.19-1.34]) were associated with higher all-cause mortality when compared with the reference (1.0–<1.1g/kg/day). This reverse–J–shape association was also found in sub-analyses performed among racial groups and in hypoalbuminemic patients (Figure). Hence, hypoalbuminemic patients of all races may benefit from higher protein intake, which needs controlled trial to verify

Structures, processes and outcomes of specialist critical care nurse education: An integrative review

Objectives: The objective of this study was to review and synthesise international literature to reveal the contemporary structures, processes, and outcomes of critical care nurse (CCN) education. Method: An integrative review on specialist critical care education was guided by Whittemore and Knafl's integrative review steps: problem identification; literature search; and data evaluation, analysis, and presentation. Donabedian's Quality Framework (Structure-Process-Outcome) provided a useful analytical lens and structure for the reporting of findings. Results: (1) Structures for CCN education incorporated transition-to-practice and ongoing education programs typically offered by hospitals and health services and university-level graduate certificate, diploma, and masters programs. Structural expectations included a standard core curriculum, clinically credible academic staff, and courses compliant with a higher education framework. Published workforce standards and policies were important structures for the practice learning environment. (2) Processes included incremental exposure to increasing patient acuity; consistent and appropriately supported and competent hospital-based preceptors/assessors; courses delivered with a flexible, modular approach; curricula that support nontechnical skills and patient- and family-centred care; stakeholder engagement between the education provider and the clinical setting to guide course planning, evaluation and revalidation; and evidence-based measurement of clinical capabilities/competence. (3) Outcomes included articulation of the scope and levels of graduate attributes and professional activities associated with each level. The role of higher degree research programs for knowledge creation and critical care academic leadership was noted. Conclusions: Provision of high-quality critical care education is multifaceted and complex. These findings provide information for healthcare organisations and education providers. This may enable best practice structures and processes for critical care specialist training that meets the needs of industry and safely supports developing CCN expertise. There is an acknowledged tension between the expectations of governing bodies for policies, standards, and position statements to enhance quality and reduce care variance and the availability of high-quality evidence to underpin these across international contexts

Finishing the euchromatic sequence of the human genome

The sequence of the human genome encodes the genetic instructions for human physiology, as well as rich information about human evolution. In 2001, the International Human Genome Sequencing Consortium reported a draft sequence of the euchromatic portion of the human genome. Since then, the international collaboration has worked to convert this draft into a genome sequence with high accuracy and nearly complete coverage. Here, we report the result of this finishing process. The current genome sequence (Build 35) contains 2.85 billion nucleotides interrupted by only 341 gaps. It covers ∼99% of the euchromatic genome and is accurate to an error rate of ∼1 event per 100,000 bases. Many of the remaining euchromatic gaps are associated with segmental duplications and will require focused work with new methods. The near-complete sequence, the first for a vertebrate, greatly improves the precision of biological analyses of the human genome including studies of gene number, birth and death. Notably, the human enome seems to encode only 20,000-25,000 protein-coding genes. The genome sequence reported here should serve as a firm foundation for biomedical research in the decades ahead

Novice to expert

Many DCPs are now looking to achieve personal professional fulfilment through addressing the challenges that their work in the dental sector presents to them, says Debbie Reed

Association of dietary phosphorus intake and phosphorus to protein ratio with mortality in hemodialysis patients.

Background and objectivesEpidemiologic studies show an association between higher predialysis serum phosphorus and increased death risk in maintenance hemodialysis (MHD) patients. The hypothesis that higher dietary phosphorus intake and higher phosphorus content per gram of dietary protein intake are each associated with increased mortality in MHD patients was examined.Design, setting, participants, &amp; measurementsFood frequency questionnaires were used to conduct a cohort study to examine the survival predictability of dietary phosphorus and the ratio of phosphorus to protein intake. At the start of the cohort, Cox proportional hazard regression was used in 224 MHD patients, who were followed for up to 5 years (2001 to 2006).ResultsBoth higher dietary phosphorus intake and a higher dietary phosphorus to protein ratio were associated with significantly increased death hazard ratios (HR) in the unadjusted models and after incremental adjustments for case-mix, diet, serum phosphorus, malnutrition-inflammation complex syndrome, and inflammatory markers. The HR of the highest (compared with lowest) dietary phosphorus intake tertile in the fully adjusted model was 2.37. Across categories of dietary phosphorus to protein ratios of &lt;12, 12 to &lt;14, 14 to &lt;16, and &gt; or =16 mg/g, death HRs were 1.13, 1.00 (reference value), 1.80, and 1.99, respectively. Cubic spline models of the survival analyses showed similar incremental associations.ConclusionsHigher dietary phosphorus intake and higher dietary phosphorus to protein ratios are each associated with increased death risk in MHD patients, even after adjustments for serum phosphorus, phosphate binders and their types, and dietary protein, energy, and potassium intakes

Kidney insufficiency and nutrient-based modulation of inflammation.

Purpose of reviewPatients with chronic kidney disease have a high cardiovascular mortality rate. Despite recent advances in dialysis techniques, over 20% of US dialysis patients die every year. Protein-energy malnutrition and inflammation are common and usually concurrent in chronic kidney disease patients, and have been implicated as the main cause of high mortality. We reviewed the pathophysiology of the malnutrition-inflammation complex syndrome and its potential modulation by dietary and other nutritional interventions in chronic kidney disease patients.Recent findingsThe malnutrition-inflammation complex syndrome is a main cause of the atherosclerotic cardiovascular disease epidemic in chronic kidney disease. This may be by virtue of the syndrome's inflammatory components. Malnutrition and inflammation lead to weight loss over time, i.e. cachexia in slow motion, and result in decreased serum cholesterol and homocysteine levels. A 'reverse epidemiology' of cardiovascular risk factors is observed in chronic kidney disease, in that obesity, hypercholesterolemia and hyperhomocysteinemia are paradoxically associated with better survival. Among the possible etiologies of the malnutrition-inflammation complex syndrome, anorexia, low nutrient intake and oxidative stress are theoretically amenable to dietary modulation; however, the bulk of findings are epidemiological.SummaryThere is no consensus as to how to correct the malnutrition-inflammation complex syndrome in chronic kidney disease patients. Because the malnutrition-inflammation complex syndrome is multifactorial, its correction probably requires a battery of simultaneous interventions, rather than one single modality. Clinical trials focusing on the syndrome are currently non-existent and are therefore urgently required to improve poor clinical outcome in chronic kidney disease patients

Dietary egg whites for phosphorus control in maintenance haemodialysis patients: a pilot study.

BackgroundHigh dietary protein intake is associated with greater survival in maintenance haemodialysis (MHD) patients. High-protein foods may increase dietary phosphorus burden, which is associated with increased mortality in these patients. Hypothesis is: an egg white based diet with low phosphorus to protein ratio (&lt;1.4 mg/g) will lower serum phosphorus without deteriorating the nutritional status in MHD patients.ObjectiveWe assessed serum phosphorus and albumin levels in MHD patients who agreed to ingest one meal per day with pasteurised liquid egg whites without phosphorus additives, as principal protein source.MethodsThirteen otherwise stable MHD patients with serum phosphorus &gt;4.0 mg/dl agreed to consume eight ounces (225 g) of pasteurised liquid egg whites one meal per day for six weeks. Recipes were suggested to improve diet variety.ResultsThirteen participating patients included seven women, three African Americans and five diabetics. Twelve patients exhibited drop in serum phosphorus. Mean population fall in serum phosphorus was 0.94 mg/dl, i.e. from 5.58 ± 1.34 (mean ± SD) to 4.63 ± 1.18 (p = 0.003). Serum albumin showed an increase by 0.19 g/dl, i.e. from 4.02 ± 0.29 to 4.21 ± 0.36 g/dl (p = 0.014). Changes in phosphorus pill count were not statistically significant (p = 0.88). The egg white diet was well tolerated, and recipe variety appreciated.ConclusionPasteurised liquid egg whites may be an effective diet component lowering serum phosphorus without risking malnutrition. Controlled trials are indicated to examine egg white based dietary interventions in MHD patients at home or during haemodialysis treatment

Dietary assessment of individuals with chronic kidney disease.

Examining the quality and quantity of food intake by appropriate methods is critical in the management of patients with chronic kidney disease (CKD). The four commonly used dietary assessment methods in CKD patients include short-term dietary recalls, several days of food records with or without dietary interviews, urea kinetic based estimates such as protein nitrogen appearance calculation, and food histories including food screeners and food frequency questionnaires (FFQ). There are a number of strengths and limitations of these dietary assessment methods. Accordingly, none of the four methods is suitable in and of itself to give sufficiently accurate dietary information for all purposes. Food frequency questionnaires, which is the preferred method for epidemiological studies, should be used for dietary comparisons of patients within a given population rather than individual assessment. Food histories including FFQ and dietary recalls may underestimate important nutrients, especially in CKD patients. Given the large and increasing number of dialysis patients and work responsibilities of renal dietitians, routine analysis of dietary records and recalls is becoming less feasible. Ongoing and future studies will ascertain additional strengths and limitations of dietary assessment methods in CKD populations including the assessment of food intake during an actual hemodialysis treatment

Dietary assessment of individuals with chronic kidney disease.

Examining the quality and quantity of food intake by appropriate methods is critical in the management of patients with chronic kidney disease (CKD). The four commonly used dietary assessment methods in CKD patients include short-term dietary recalls, several days of food records with or without dietary interviews, urea kinetic based estimates such as protein nitrogen appearance calculation, and food histories including food screeners and food frequency questionnaires (FFQ). There are a number of strengths and limitations of these dietary assessment methods. Accordingly, none of the four methods is suitable in and of itself to give sufficiently accurate dietary information for all purposes. Food frequency questionnaires, which is the preferred method for epidemiological studies, should be used for dietary comparisons of patients within a given population rather than individual assessment. Food histories including FFQ and dietary recalls may underestimate important nutrients, especially in CKD patients. Given the large and increasing number of dialysis patients and work responsibilities of renal dietitians, routine analysis of dietary records and recalls is becoming less feasible. Ongoing and future studies will ascertain additional strengths and limitations of dietary assessment methods in CKD populations including the assessment of food intake during an actual hemodialysis treatment