Abstract
Development of Pictorial Dietary Education Resources to Cater for People with English as a Second Language and/or Low Literacy
Background: Renal dietitians have an important role in helping people on dialysis to control their potassium level. In CMDHB some of our dialysis patients have English as their second language and/or have a low literacy level. This can make it hard to give dietary K+ information as most resources are written in English. This may lead to noncompliance issues secondary to misinterpretation/ miscommunication, which in turn may have a detrimental impact on our patients’ health. Studies have consistently shown the success and effectiveness of pictorial educational resources in the healthcare system.
Aims: To develop pictorial seasonal low K+ vegetable and fruit posters to display in peritoneal dialysis (PD) training unit, home dialysis units, and renal ward in spring and summer. To explore the impact of these visual resource on patients’ understanding about dietary K+ information in conjunction with our written resources
Methods: In 2007 a K+ education sheet was developed by the Auckland Regional Renal Dietitians Group. I used the background information collected in this project to identify commonly eaten local fruit and vegetables, collected appropriate colored photos, developed posters in A4 sizes, collected feedback from colleagues and patients. The poster content was then reviewed and final copies were made in A2/A3 size. A survey was conducted to ask patients how they rated food photos compared to written information after the posters were displayed.
Results: Two posters were displayed in the renal units and ward during spring and summer which were well received:
Loved the colors: appealing to the eyes, make it more interesting than black and white written information.
Clear, simple, easy to understand/see – “right there show you directly what to eat/avoid.”
A quick reference before shopping trips/planning meals.
Help people with limited English to know what they can/cannot have.
We also developed posters into A4 size handouts as patients’ request.
Conclusion: (1) The posters helped increase awareness and understanding about which fruit and vegetables are high or low in K+ for patients and their families. (2) From this experience, we have learned that some of our patients prefer information in a more visual, pictorial form. (3) When developing new information for patients, we need to use some visual aid to cater for people with English as a second language and/or a low literacy level.
Stability of Carnitine in Patients with Peritoneal Dialysis (PD)
Background: Carnitine supplementation is beneficial for patients (pts) undergoing hemodialysis or PD as it can offset possible renal anemia, lipid abnormality, and cardiac dysfunction resulting from dialytic loss of carnitine. At present, carnitine supplement can be given via intravenous route. However, this is inconvenient for pts with PD. In order to simplify the supplementation procedure, the aim of this study was to evaluate whether addition of carnitine into PD fluids to supply carnitine during PD course is a safe and convenient alternative.
Methods: A simple, sensitive, accurate, and robust capillary electrophoresis (CE) based on fluorometric derivation of the carboxyl group of carnitine with 4-nitro-7-piperazinobenzofurazan (NBD-PZ) was developed for determination of carnitine in hydrophilic milieus such as PD formulation and plasma.
Results: Recovery of carnitine from preparation procedure is above 90%; derivation is rapid and complete with the total time including sample derivation and analysis less than 30 min; and the lower detection limit is 6.5 nmol/L (signal-to-noise ratio of 3). This method was further validated to have satisfactory linearity, precision, and accuracy for detection of carnitine in both simple and complex PD-related samples, according to the guidelines of the International Conference on Harmonization of Technical Requirements for Registration of Pharmaceuticals for Human Use (ICH). In addition, the stability of carnitine in PD formulations was tested using this method. At either 25°C or 37°C, carnitine was demonstrated to have been fairly stable (residue >90%) in PD fluids varied in dextrose contents (e.g., 1.5%–4.25%) for at least 3 days. Furthermore, this method has been successfully applied to quantitate carnitine in pts’ plasma during or after PD course.
Conclusion: A new CE-based method suitable for rapid quantification of carnitine in aqueous milieus was developed. Addition of carnitine into PD fluids for simultaneously conducting PD course and supplying carnitine was validated to be a simple and safe means for PD pts requiring carnitine supplementation.
The Change of Anthropometry in Patients with Chronic Peritoneal Dialysis
Objective: Malnutrition is common among patients with chronic peritoneal dialysis (CPD). Anthropometry measurements are valid markers of nutrition status, particularly with regard to states of energy balance (depletion and excess). We have evaluated the change of anthropometry in patients with CPD.
Methods: The study included 29 patients ((M 10, F 19) treated by PD at National Cheng Kung University Hospital, Tainan, Taiwan. There were 39 nonuremic population in control group and matched with age and sex between study patients. We analyzed serum albumin, anthropometry parameters, muscle strength, nutrition status by Subjective Global Assessment (SGA), and diet intake during the 4-year follow-up.
Results: Mean age of study group was 42.1 ± 12.3 years and mean dialysis duration was 4.0 ± 2.4 years. The CPD patients had significantly decreased in triceps skinfold thickness (TSF) and midarm circumference (MAC); and lower energy intake /kg BW/day in fourth year than first year (p = 0.03), and significantly lower than non-CKD patients at the third and fourth year of fallowing up (p < 0.0001). In study group, midarm muscle circumference (MAMC) and midarm muscle circumference (MAMA) had a decreasing trend with follow-up times. In muscle strength, there were no significant changes in hand grip strength (HGS) and pinch strength (PS) in the 4 years, but CPD patients had lower HGS compared with non-CKD patients. Nutrition status by SGA and serum albumin had no significant difference in the study.
Conclusions: Our study showed the TSF and MAC of CPD patients were significantly lower than nonuremic population and the body fat decreased with dialysis duration increasing. Anthropometry measurements are valid markers of nutrition status, particularly with depletion of energy balance for CPD patients.
Fat Free Mass Estimated by Body Composition Monitor in Peritoneal Dialysis Patients
Background: Protein-energy malnutrition is a major negative prognostic factor in dialysis patients. In highly hydration status, simple and reliable estimation of body nutrition status presents a challenge for clinical practitioner due to poor accuracy and large variation which may be largely caused by hydration status.
Methods: This study recruited 94 regular peritoneal dialysis patients (male: 38, female: 56). Fat free mass as presented by lean tissue index (LTI) and lean tissue mass (LTM) measured by a new bioimpedance spectroscopy device (BCM, body composition monitor). Other nutrition-related indicators included handgrip strength, Subjective Global Assessment (SGA), and biochemical nutrition indices (albumin, transferrin, prealbumin), collected and compared concomitantly.
Results: Based on Spearman or Pearson analysis, both LTI and LTM significantly (p < 0.05) correlated with handgrip strength and SGA score. Mean levels of handgrip strength and SGA were positively associated with low (33 percentile), mid (66 percentile), and high (66 percentile) levels of LTI (p < 0.05). Only the handgrip strength measure was associated with low, mid, and high LTM (p < 0.05). In contrast, visceral protein indicators including albumin, transferrin, and prealbumin did not show significant association with various levels of LTI and LTM. Based on multivariable regression analysis adjusted for age, gender, and dialysis duration year, LTI remained significantly (p < 0.05) associated with SGA scores and handgrip strength (p < 0.05), and LTM was related to handgrip strength only.
Conclusion: The BCM can measure the fat free mass indicators, LTI and LTM, accurately and sensitively in peritoneal dialysis patients, and may be better for long-term follow-up.
Leptin Concentration and Body Fat Mass in the Patient with End-Stage Renal Disease Starting Peritoneal Dialysis
Background: Plasma leptin is strongly correlated with body fat mass. Peritoneal dialysis (PD) is characterized by gain of fat mass, hyperleptinemia, and hyperadiponectinemia. We investigated the association and serial change of body fat mass with serum leptin and adiponectin concentration in patients starting PD.
Methods: We prospectively collected data for patients [n = 26; 13 men; mean age: 54.38 ± 12.20 years; 16 (61.5%) with diabetes] who started and maintained continuous ambulatory and automated PD for at least 6 months at our institution. We measured baseline body composition using bioimpedance analysis (BIA) and abdominal computed tomography (CT) imaging, including fat amount and visceral/subcutaneous fat ratio (VSR). To investigate serial changes in fat mass, abdominal fat CT was repeated at 6 months after PD start. At the same time, serum leptin, adiponectin, lipid profile, and albumin were also evaluated.
Results: At baseline, mean visceral fat mass was 75.2 ± 53.8 cm2, and subcutaneous fat mass was 91.3 ± 53.7 cm2. Visceral and subcutaneous fat mass were not different according to sex, diabetes, or old age. Serum triglycerides (TG) was 101.7 ± 47.0 mg/dL. Visceral fat mass was positively correlated with TG (r = 0.405, p = 0.040) and subcutaneous fat mass (r = 0.502, p = 0.009). Subcutaneous fat mass showed positive correlations with serum albumin (r = 0.493, p = 0.011) and serum leptin (r = 0.682, p = 0.000).
After 6 months, visceral and subcutaneous fat increased to 17.0 ± 19.8 cm2 and 24.5 ± 46.2 cm2 respectively. Although not statistically significant, adiponectin decreased to 59.9 ± 165.3 μg/mL (p = 0.155), leptin increased 25.2 ± 145.5 μg/mL (p = 0.485), and TG increased to 24.8 ± 56.8 mg/dL (p = 0.091). The change in subcutaneous fat mass (ΔS) was correlated with change in serum albumin (r = 0.482, p = 0.043), and the change in TG negatively correlated with change in serum leptin (r = –0.578, p = 0.019).
Conclusions: Patients starting PD showed a gain of visceral and subcutaneous fat mass after 6 months of treatment. Baseline leptin was initially associated with high subcutaneous fat mass. Although not statistically significant, leptin showed a tendency to increase 6 months later. The increase in leptin level was not associated with change in body fat mass.
Effects of 1.1% Amino Acid-Based Peritoneal Dialysis (PD) Solution Use on Nutritional Markers Are Associated with Changes of Body Fluid Compositions
CAPD patients (pts) are frequently associated with protein-calorie malnutrition due to continuous protein loss during dialysis procedure and is an important prognostic factors of pt outcome. Amino acid-based PD solution (AAD) has been used for better nitrogen balance and improving nutritional markers of CAPD pts but its effect on body fluid composition and various nutritional markers, such as serum albumin (sAlb) level is contradictory. Nutritional markers are influenced by various clinical parameters such as pt's extracellular fluid (ECF) volume status. AAD may cause different ultrafiltration profile from conventional glucose-based solution (GD) and causes change in pts’ volume status. We evaluated effects of AAD on nutritional markers including sAlb and various body composition using multifrequency bioimpedance analyzer. 35 CAPD pts (>6 month on CAPD) were prospectively randomized 17 to AAD group (Nutrineal®, 1 time use/day) and 18 to GD group (kept their glucose-based PD solution). After 3 months’ treatment follow-up, AAD group showed favored several markers including sAlb level (3.54 ± 0.11 vs 3.74 ± 0.11, p = 0.02), BUN (53.96 ± 3.89 vs 75.71 ± 3.88, p = 0.00), and nPCR (1.59 ± 0.07 vs 1.98 ± 0.08, p = 0.00). AAD group showed marginally increased drainage volume (8.77 ± 0.76 vs 9.12 ± 0.83 L, p = 0.09) and was associated with decreased ECF volume (12.45 ± 0.54 vs 12.10 ± 0.57 L, p = 0.06). Body composition analysis also showed marginally increased body weight (63.44 ± 2.5 vs 64.24 ± 2.6 kg, p = 0.09) and fat mass (14.19 ± 1.39 vs 15.13 ± 1.56 kg, p = 0.06) but intracellular fluid volume was not changed (22.2 ± 0.9 vs 22.3 ± 0.9 L, p > 0.05) in AAD treatment group. Although sAlb level was increased, total plasma Alb amount, correction with ECF volume (Alb level × ECF volume) made no difference (43.45 ± 2.13 vs 44.80 ± 2.28, p = 0.14). Furthermore, Alb vs ECF showed negative correlation pattern (r = –0.46, p = 0.07), which means sAlb change was influenced by ECF volume change.
In conclusion, AAD treatment improved markers of better nutrition status including sAlb, fat mass, body weight, BUN, and nPCR. However, the change in sAlb level was influenced by pt's ECF volume status, which can partially explain contradictory effect of amino acid-based PD solution on sAlb level.
Nutrition Status in Continuous Ambulatory Peritoneal Dialysis (CAPD) Patients Covered by “PD First” Policy Project in Thailand
Background: In 2002, the Thai government launched a healthcare scheme in Thailand to include 48 million people who are not government related and not private employee. This scheme is called “universal coverage (UC)” healthcare. Thai government has officially announced a “peritoneal dialysis first” (PD-first) policy for ESRD people in October 2007 and set it effective since 1 January 2008. At present over 3000 new PD patients have received the treatment. Data from 23 CAPD hospitals in Thailand, which had experience with PD before the policy, were studied.
Objectives: To study nutrition status of CAPD patients covered by PD-first policy project in Thailand and to study factors that affect nutrition status in these patients.
Methods: A descriptive study with analytical part was performed. The data were collected including baseline patient characteristics, serum albumin levels, and dietary interview. The data were analyzed by percentage, chi-square test, and Pearson product moment correlation.
Results: 91 patients were included. We found that 59 patients (66%) had poor nutrition status (mean serum albumin <3.5 g/dL.). The following factors were significant (p < 0.05) positive correlation with poor nutrition status: DM, longer duration of CAPD therapy, old age, inadequate dialysis, and peritonitis (r = 0.214, 0.379, 0.515, 0.523, and 0.724, respectively). Low protein and calorie intake was significantly (p < 0.05) correlated with poor nutrition status (r = –0.338).
Conclusions: The CAPD patients covered by PD-first policy project in the study showed poor nutrition status. The factors that affect nutrition status were DM, longer duration of the treatment, old age, inadequate dialysis, peritonitis, and low protein-calorie intake. Implementation to correct the factors is needed to avoid malnutrition.
The Influence of Peritoneal Dialysis (PD) Dose on Leptin Clearance and Nutrition Status in Patients on Peritoneal Dialysis
Objective: To investigate the effect of PD dose on leptin clearance and nutrition status in patients treated by PD.
Methods: 49 patients treated by continuous ambulatory PD for at least 1 year in our hospital were enrolled. Patients were divided into 3 groups according to the doses of dialysis: group L; low-dose group (LDG), ≤4 L/d, n = 14; group M: medium-dose group (MDG), 6 L/d, n = 16; and group S: standard-dose group (SDG), 8 L/d, n = 19. Serum and dialysate leptin were measured by a sensitive enzyme-linked immunosorbent assay (ELISA). Renal function, serum albumin (ALB), transferrin (TF), blood lipids, and Subjective Global Assessment (SGA) were also tested. Furthermore, we calculated Kt/V and body mass index (BMI) and analyzed the relationship between leptin and nutritional indices.
Results: Both serum leptin and dialysate leptin were higher (p < 0.05) in LDG (54.7 ± 9.9 and 18.6 ± 7.7) compared with MDG (46.8 ± 11.4 and 12.8 ± 9.8) and SDG (47.2 ± 12.7 and 11.1 ± 8.5). There was no significant difference between MDG and SDG in leptin level. Incidences of malnutrition in MDG and SDG were 63.1% (12/19) and 62.5% (10/16) respectively, which were lower than in LDG (78.6%) (χ2 = 7.230, p < 0.05). There was a positive correlation between nutrition status grade and serum/dialysate leptin (r = 0.451, p < 0.05; r = 0.322, p < 0.05), while serum leptin was positively correlated with dialysate leptin (r = 0.908, p < 0.01). But serum leptin seemed to be correlated negatively with eGFR (r = –0.711, p < 0.05), TSFT (r = –0.323, p < 0.05), RBW (r = –0.253, p < 0.05), AC (r = –0.257, p < 0.05), and ALB (r = –0.323; p < 0.05).
Conclusion: Leptin may play an important role in nutrition status of patients treated by PD. PD had little effect on leptin clearance. Mediumdose and standard-dose of PD solution may achieve a better nutrition status.
Comparison of Oxidative Stress and Nutrition Status in End-Stage Renal Disease Patients Undergoing Dialysis
Objective: The increased oxidative stress status due to impairment of antioxidant defense and overproduction of oxidative stress is a well-documented factor influencing the development of critical complication in end-stage renal disease (ESRD) patients. This study focuses on the comparison of oxidative stress and nutrition status in hemodialysis (HD) patients before and after treatment and in peritoneal dialysis (PD) patients.
Methods: Serum MDA, SOD, CAT, creatinine, BUN, Hb, cholesterol, triglyceride, albumin were measured in 42 HD, 29 PD, 16 nondialyzed ESRD patients and 23 normal controls.
Results: MDA was significantly higher than controls before dialysis, and was aggravated by HD but not by PD. Compared with controls, SOD and CAT were significantly decreased in HD and PD patients but no significant difference among patients. The result was not affected by HD. Hb was lower in all patients but had improvement in HD and PD patients. Cholesterol and triglyceride were in normal clinical range in all patients but PD patients had lowest reading.
Conclusion: The oxidative status of HD patients is worse than that of PD patients. Enhanced lipid nutrient supplements may be needed in PD patients.
Sleep Quality and Malnutrition in Chinese Continuous Ambulatory Peritoneal Dialysis (CAPD) Patients
Objective: Patients (pts) on PD have more sleep complaints such as insomnia and daytime sleepiness than the general population. Poor nutrition status could affect morbidity and mortality rates. However, the contribution to sleep symptoms of nutrition status remains unclear. This study attempts to assess the prevalence of sleep quality (SQ) in Chinese CAPD pts and investigate the relationship between malnutrition and SQ.
Methods: This was a cross-sectional study. All pts on PD more than 3 months in our center from January to April 2009 were enrolled into the study. Clinical and sociodemographic data were obtained and laboratory findings were collected from pts’ monthly records. The Pittsburgh Sleep Quality Index (PSQI) and the Subjective Global Assessment (SGA) were used to assess SQ and nutrition status respectively. The main outcome measures were analyzed by univariate and multivariate analyses for relationships of SQ with SGA, and laboratory findings.
Result: 192 PD pts [103 males, 89 females; mean age 49.9 ± 15.84 years; mean PD duration 23.3 ± 21.2 (3-139) months] were entered into this study. The average global PSQI score was 9.4 ± 5.1. The prevalence of pts with PSQI scores of ≥5 (“poor SQ “) was 80.7%. Compared with good sleepers, poor sleepers had significantly lower serum albumin (sAlb) level (36.8 ± 4.1 vs 42.2 ± 4.3, p < 0.05). All patients (41 patients) with serum albumin level <35 g/dL had poor SQ. The global PSQI score or poor SQ was negatively correlated with SGA score (r = –0.278, p = 0.000) and sAlb level (r = –0.212, p = 0.003), and positively correlated with age (r = 0.342, p = 0.000), C-reactive protein (r = 0.195, p = 0.008), and level of calcium–phosphorus products (r = 0.189, p = 0.008). No significant association between global PSQI score and gender, marital status, education level, economic level, insurance, cigarette smoking, body mass index, hemoglobin, iPTH, Kt/V, or eGFR was observed. In multiple linear regression with stepwise selection analysis, SGA score (β = –0.172, p = 0.000) and sAlb level (β = –0.242, p = 0.002) were independent predictors for the global PSQI score. In addition, among the poor sleepers, only 14.8% of pts had ever received hypnotics for improving the SQ.
Conclusion: Our results demonstrated that the prevalence of poor SQ is high in Chinese CAPD pts and malnutrition plays an important role in sleep disorder. Further studies are necessary to explore methods to improve SQ in CAPD populations.
Metabolic Syndrome in Nondiabetic Patients on Peritoneal Dialysis
Objective: To investigate the metabolic syndrome in nondiabetic patients during continuous ambulatory peritoneal dialysis (CAPD).
Methods: 52 nondiabetic patients were involved in the study who were on stable CAPD over 6 months using glucose-based dialysate. Blood pressure and body weight were recorded and blood glucose, lipids, and C-reactive protein (CRP) were measured. Metabolic syndrome was defined according to the Adult Treatment Panel III (ATP III) criteria.
Results: Patients were on CAPD without peritonitis and followed up for a mean of 31.1 (13.5–38.0) months. 35 (67.3%) of them developed metabolic syndrome during follow-up compared with that of 19.2% (n = 10) at the beginning of peritoneal dialysis (p < 0.05). Metabolic syndrome occurred at a median of 11.5 (6.5–26.0) months after CAPD. Abnormal body mass index (BMI), blood lipid levels, and metabolic syndrome components number were correlated with peritoneal glucose exposure and CAPD duration. Old age, high BMI, elevated serum triglyceride levels, CRP, and glucose exposure were all independently associated with metabolic syndrome during CAPD treatment.
Conclusions: Increased prevalence of metabolic syndrome is found in end-stage renal disease patients on CAPD. The possible risk factors of metabolic syndrome in this particular situation include high glucose exposure and long PD duration, old age, high BMI, elevated serum levels of triglyceride and CRP.
Improved Plasma Amino Acids Pattern following Twelve Months of Supplemented Low-Protein Diet in Peritoneal Dialysis (PD) Patients: A Prospective Randomized Trial
Objective: Decreased plasma essential amino acids (EAA), increased nonessential amino acids (NEAA), and a low EAA-to-NEAA ratio (E/NEAA) are common in PD patients (pts) and may be associated with a poor outcome. Previous studies in predialysis pts indicate that supplemented low protein diet can normalize plasma AA patterns but this diet is not recommended for PD pts due to a fear of peritoneal cavity protein loss. We conducted a randomized trial to test whether supplemented low protein diet would be nutritionally safe in PD pts and if it would be associated with normalization of plasma AA patterns.
Methods: We conducted a nitrogen balance study in 34 PD pts randomized to receive in-center diets containing 1.2, 0.9, or 0.6 g of protein/kg ideal body weight (IBW)/d for 10 days. As these pts were able to maintain N balance, we next studied 39 prevalent PD pts (51.3% males, age 53.6 ± 12.8 years) randomized to receive either low (LP: 0.6–0.8 g/kg IBW/d, n = 13), keto acids-supplemented low (sLP: 0.6–0.8 g/kg IBW/d + 0.12 g/kg IBW/d keto acids, n = 12), or high (HP: 1.0–1.2 g/kg IBW/d, n=14) protein diets during 1 year, with serial measurements of plasma AA patterns, nutrition status (Subjective Global Assessment, plasma albumin, body mass index), and clinical parameters.
Results: A neutral or positive N balance was achieved in all 3 groups. After 1 year, the E/NEAA had increased significantly in group sLP (0.58 ± 0.16 to 0.83 ± 0.20, p < 0.05), while there was no difference in groups LP (0.62 ± 0.20 to 0.72 ± 0.13, p = NS) and HP (0.66 ± 0.14 to 0.74 ± 0.12, p = NS). The change in E/NEAA in group sLP was due to a significant decrease in NEAA concomitantly with maintained EAA levels. In the other groups, neither EAA nor NEAA changed significantly. There was no statistical change from baseline in any of the nutritional variables.
Conclusion: A diet containing 0.6–0.8 g of protein/kg IBW/d is nutritionally safe and, when combined with keto acids, associated with an improved plasma AA pattern in maintenance PD pts.
Supplemented Low Protein Diet Shows Benefits on Quality of Life in Peritoneal Dialysis Patients
Objective: K/DOQI on nutrition recommends peritoneal dialysis (PD) patients to achieve a dietary protein intake (DPI) of 1.2 to 1.3 g/kg ideal body weight (IBW)/day. However, high DPI may be associated with uremic waste accumulation and increase dialysis burden. We recently reported that a supplemented low protein diet was associated with maintenance of residual renal function without altering nutrition status in a randomized controlled trial of PD patients. Whether this dietary intervention would affect the quality of life (QoL) in PD patients is unknown.
Methods: A total of 32 PD patients (53.1% males, age 53.7 ± 12.0 years) were randomized to receive either low (LP: 0.6–0.8 g/kg IBW/d, n = 13), keto acids-supplemented low (sLP: 0.6–0.8 g/kg IBW/d + 0.12 g/kg IBW/d of keto acids, n = 12), or high (HP: 1.0–1.2 g/kg IBW/d, n = 14) protein diets during 1 year. At baseline and 12 month, we assessed QoL using the Medical Outcomes Study Short Form 36 (SF-36®), which included 8 different dimensions regarding both physical and emotional health.
Results: Demographic and clinical characteristics were similar among the 3 groups at baseline. Baseline overall SF-36® scores (group LP: 58 ± 15; group sLP: 62 ± 16; group HP: 54 ± 12; p > 0.05) and the 8 dimensions of the 3 groups also showed no difference. At 12 month, compared with both group LP and HP, group sLP showed higher scores in dimension of general health problems (group sLP: 50 ± 23; group LP: 28 ± 18; group HP: 30 ± 17; p < 0.05) and health transitions (group sLP: 77 ± 21; group LP: 53 ± 30; group HP: 43 ± 30; p < 0.05). The rest dimensions and overall scores of SF-36® at 12-month showed no differences among the 3 groups.
Conclusion: In 1-year follow-up, low protein diet of 0.6–0.8 g/kg IBW/d but supplemented with keto acids shows benefits on QoL in PD patients.
Effect of Non-Dietary Factors on the Nutrition Status of Peritoneal Dialysis Patients
Objective: Malnutrition is a risk factor for morbidity and mortality in peritoneal dialysis (PD) patients. Many studies have shown that its prevalence in PD patients is up to 40%–50%. So far, studies of the influence of non-dietary factors on nutrition status are rare. In this study, we want to determine the influence of non-dietary factors on the nutrition status of Chinese PD patients.
Methods: We examined the nutrition status in 78 PD patients including Subjective Global Assessment (SGA), hemoglobin, serum albumin, and serum total protein. The non-dietary factors including daily dialysate dosage, the glucose concentration of PD fluid, peritonitis rates, cultural level, and the status of work were investigated.
Results: There were no differences in the nutrition status comparison between 4–6 L/d and 8 L/d dialysate dosage (p > 0.05). The patients with high peritonitis rates had worse nutrition status (p < 0.01). The patients without work had worse nutrition status (p < 0.05). The well-educated patients had better nutrition status (p < 0.05).
Conclusion: Non-dietary factors, such as daily dialysate dosage, the glucose concentration of PD fluid, peritonitis rates, education, and the status of work are related to the nutrition status of PD patients.
Impact of Residual Renal Function on Peritoneal Dialysis Patients’ Nutrition Status
Objective: To investigate the impact of residual renal function (RRF) on peritoneal dialysis (PD) patients’ nutrition status.
Method: 54 PD patients were enrolled in this study. All the patients were divided into 2 groups according to eGFR: group A (eGFR >15 mL/min) and group B (eGFR >15 mL/min). The patients were evaluated predialysis and 6 months after the PD being initiated, respectively. The nutrition status was evaluated by Subjective Global Assessment (SGA) and index of biochemistry was examined. RRF was calculated by clearance rate of creatinine and blood urea nitrogen (BUN).
Results: Malnutrition was common in these patients (n = 35, 64.8%). In predialysis patients, the level of albumin in A and B groups was 33.60 ± 0.56 g/L and 31.60 ± 0.78 g/L respectively. After 6 months, the level of albumin in A and B groups was 31.03 ± 0.35 g/L and 26.16 ± 0.25 g/L respectively (p < 0.01). In the B group, the level of albumin, prealbumin, and transferrin was significantly decreased after PD was employed (p < 0.01). The incidence of malnutrition in A and B groups was 50% and 76.7% respectively (p < 0.05). In malnutrition patients, the eGFR of predialysis and after 6 months of dialysis was 6.31 ± 0.51 mL/min and 3.31 ± 0.63 mL/min (p < 0.05).
Conclusion: RRF is one of the key factors that might impact the nutrition status of PD patients.
Causes of Deteriorated Nutrition Status in Continuous Ambulatory Peritoneal Dialysis Patients
Objective: Malnutrition is common in continuous ambulatory peritoneal dialysis (CAPD) patients although we have dramatically decreased the incidence of malnutrition in this patient population recently. In the present study, we investigated the possible causes of malnutrition in CAPD patients.
Methods: Patients in our CAPD program during June 2007 to May 2009 were enrolled in the present study. The nutrition status was evaluated once every 3 months for all the patients using Subjective Global Assessment (SGA). In the present analysis, patients’ SGA changed from A to B or to C were included. A comorbidity checklist was also used when the SGA was assessed. The causes of nutritional changes were analyzed.
Results: During the 2-year period, 52 patients (27 males, 25 females; age 68.7 ± 17.67 years) experienced deterioration in their nutrition status: 51 patients changed from A to B and 1 patient from B to C. The causes of deteriorated nutrition status included infections in 19 patients (3 with peritonitis, 7 with upper respiratory tract infection, 2 with pneumonia, 4 with exit-site infection, 2 with gastritis, 1 with diabetic foot), severe volume overload leading to congestive heart failure in 12 patients, inadequate dialysis due to poor economy (3 cases) or loss of residual renal function (4 cases) in 7 patients, resistant hypotension in 5 patients, acute trauma in 3 patients, malignancy in 2 patients, stoke in 1 patients, and unknown in 3 patients.
Conclusion: Malnutrition during peritoneal dialysis usually occurred after acute comorbidities. Aggressively treatment of comorbidities may thus help to reduce incidence of malnutrition in CAPD patients.
The Evolution of Body Composition in the First Two Years in Patients on Continuous Ambulatory Peritoneal Dialysis (CAPD)
Objective: CAPD is an established therapy to treat uremic patients (pts); however, the evolution of body composition since the initiation of dialysis in CAPD pts was not clear.
Methods: All incident CAPD pts who initiated dialysis treatment in 2006 in a single center were enrolled but only those who survived longer than 2 years were considered eligible for this follow-up study. After baseline measurement, the changes in body weight, systolic/diastolic blood pressure (SBP/DBP), body composition, urine output, and ultrafiltration were evaluated every 6 months. Body composition, including extracellular water (ECW; used as volume marker), intracellular water (ICW; used as nutritional marker), total body water (TBW), and ECW/TBW ratio (E/T; also used as volume status) were measured by bioimpedance analysis.
Results: There were 124 incident CAPD pts in 2006 in this center; 78 survived longer than 2 years (mean age 64 years; 31 males, 47 females). After 2 years on dialysis, urine output decreased significantly, from 742 ± 519 at baseline to 395 ± 428 mL/d at 24 months (p < 0.05). Ultrafiltration increased from 400 ± 342 at baseline to 457 ± 284 mL/d at 24 months, but this change was not statistically significant. Body weight increased by 2 kg at each follow-up time point compared with baseline value (p < 0.05). Both SBP and DBP showed slight decrease in the follow-up period but these changes did not reach statistical significance. ECW did not show significant changes in the 2-year follow-up (ECW: 15.3 ± 3.8 L, 15.4 ± 3.9 L, 14.9 ± 3.6 L, 14.9 ± 3.6 L, and 15.3 ± 4.4 L at 0, 6, 12, 18, and 24 months, respectively). ICW showed a slight decrease in the first year but significant increase afterwards (ICW: 14.4 ± 4.0 L, 13.8 ± 4.6 L, 13.6 ± 5.7 L, 15.3 ± 4.2 L, and 15.5 ± 3.9 L at 0, 6, 12, 18, and 24 months, respectively). TBW showed no significant change. E/T ratio increased significantly in the first year and decreased significantly afterwards (p < 0.05).
Conclusion: The body composition of CAPD pts in the first 2 years showed varied changes: no significant change in ECW; first year decrease and afterwards increase in ICW; and first year increase and afterwards decrease in E/T, which suggested that CAPD could maintain stable volume status and improve nutrition status in the first 2 years of treatment.
Seasonal Variation in Albumin in Chronic Peritoneal Dialysis Patients
Background: Seasonal variations in blood pressure, serum sodium and potassium, ultrafiltration volume, and body weight have been reported in patients on dialysis. Seasonal variation of plasma albumin level was demonstrated here, and possible reasons were explored.
Method: 41 patients (16 male and 25 female) on peritoneal dialysis (PD), whose residual renal function were steady from September 2006 to August 2007, were enrolled in this study. Mean age was 59.69 ± 14.23 (range 27–80) years and mean dialysis vintage was 39.64 ± 19.27 (range 6–104) months. Serum albumin and other laboratory variables, dialysis adequacy, dietary intake, and climate variables were recorded and compared among seasons using repeated measure design. Every patient had at least 1 measurement of the above variables in each of spring (March, April, and May), summer (June, July, and August), autumn (September, October, and November), and winter (December, January, and February), and averaged by season. Dietary protein intake (DPI) and daily protein losses (DPL) in both urine and dialysate were comparable among seasons. Seasons were classified according to monthly temperatures.
Results: Patients on PD exhibited seasonal variation in serum albumin. The mean peak (37.21 ± 2.43) and nadir (35.46 ± 2.50) values of albumin occurred in winter and summer respectively (p < 0.001). The percent of patients with albumin level <35 g/L was 19.51% in winter and 34.15% in summer. They had no significant differences in DPI and DPL during the year.
Conclusion: The albumin of PD patients in Beijing present seasonal variations. Because the DPI and protein loss were comparable among seasons, it was postulated that seasonal variation of protein and energy expenditure be the main reason of seasonal variation of albumin. Modification of DPI prescription according to season might be needed to gain stable serum albumin level.
Safety and Efficacy of Atorvastatin in Chinese Dyslipidemic Patients Undergoing Peritoneal Dialysis: A Randomized Controlled Study
Objective: Patients with hyperlipidemia account for more than 70% of chronic peritoneal dialysis (PD) in our center. However, the safety and efficacy of lipid-lowering agents remain unclear in Chinese dyslipidemic PD patients. The relationship between statin and multiple beneficial effects is to be proven by further studies in PD patients. We performed a prospective study to evaluate the efficacy and safety of atorvastatin in dyslipidemic PD patients.
Methods: 52 patients with hyperlipidemia and receiving PD were included in our study, and had been randomly treated with atorvastatin (n = 29) or not (n = 23). All patients were instructed to have a lipid-lowering diet. In the treatment group, patients received atorvastatin daily. Fasting lipid profile was monitored on monthly basis. They had undergone assessments of comorbid diseases, high-sensitivity C-reactive protein (hs-CRP), adequacy of dialysis, nutrition status, and peritoneal transport characteristics timely.
Results: Compared with controls, patients in the atorvastatin group had decreased levels of low-density lipoprotein cholesterol (difference between groups, 41.5%; p < 0.001) and triglyceride (difference between groups, 26.0%; p < 0.001) after 12 weeks. HDL-cholesterol was increased significantly (1.58 ± 0.44 vs 0.76 ± 0.38, p = 0.02) after lipid-lowering therapy in patients with dyslipidemia. There were no significant differences in hs-CRP (2.26 ± 4.24 vs 3.05 ± 5.83, p > 0.05) and adverse effects between 2 groups. No serious adverse events were found.
Conclusions: Our study demonstrates that atorvastatin administration is useful and safe for controlling dyslipidemia and improving the metabolic control in Chinese PD patients. The long-term effects of atorvastatin on PD patients are under observation.
Feasibility of Treatment with Low Protein Intake and Low Dialysate Volume
Objective: To study the feasibility of a treatment that controls the dietary protein intake (DPI) and gives a low dialysate volume at the same time for a certain group of patients (pts) with economic difficulty.
Methods: End-stage renal disease (ESRD) pts with economic difficulty were selected as the study subjects. Given a certain recipe of daily diet, the pts had a DPI of 0.7 g/kg/d and a dietary energy intake (DEI) of 35 kcal/kg/d. According to the dietary intake of protein and the body weight of the patients, we applied urea kinetic modeling to calculate the minimal adequate dialysate volume based on nitrogen balance. By regulating the dwell time and the glucose concentration of the dialysate and controlling the dietary intake of salt, we kept the water balance in the group of low-dose peritoneal dialysis. We compared the adequacy indices and nutrition status between the CAPD pts of low dialysate volume and the CAPD pts of 8 L/d in 1 year.
Results: 41 pts (16 in low dialysate volume, 25 in 8 L/d) participated in the study. In the low dialysate volume group, DPI and DEI were 0.68 ± 0.15 g/kg/d and 32 ± 5.23 kcal/kg/d respectively. In 8 L/d group, DPI and DEI were 1.03 ± 0.11 g/kg/d and 26 ± 2.34 kcal/kg/d respectively. Significant differences between the 2 groups were found. After using 75 ± 5 bags of the dialysate per month in the low dialysate volume group and 120 bags in the 8 L/d group, we found no significant differences between the 2 groups in hypertension, anemia, hyperphosphatemia, acidosis, and nutrition.
Conclusion: Low-protein diet combined with low-dose dialysate volume can be used as the early treatment of ESRD pts. With adequate calorie, low-protein diet can still meet the ESRD pts’ need of nutrition. Above all, the cost of such a treatment will be reduced and ESRD pts can benefit.
Expression of Leptin in Adipose Tissue of Uremic Patients
Objective: To investigate expression of leptin (Lep) in adipose tissue and its relationship with insulin resistance in uremic patients (pts).
Methods: 28 uremic pts who received the operation of catheter insertion in our hospital were employed as the experimental group (ExpG) and 12 pts who received abdominal surgery and with normal renal function as the control group (CG). Body mass index (BMI) of pts in ExpG was <25, CO2CP > 22 mmol/L, and these pts had no serious heart disease, liver dysfunction, infection, or malignancy. BMI of the pts in CG was also <25 and these pts had no hypertension, diabetes, hyperlipidemia, cancer, serious infections, cerebrovascular accidents, heart failure, or liver or kidney insufficiency. The adipose tissues were taken from the pts’ subcutis in both groups. The expression of Lep protein in adipose cells was detected by SABC immunohistochemistry. The Lep-positive cells were counted and the pathological studies were carried on by light microscopy. Serum Lep and fasting insulin (FINS) were determined by competitive immunoradiometric assay method. Oxidase method was used for detecting fasting blood glucose (FBG). The insulin sensitivity index (ISI) and the natural logarithm of ISI were calculated by statistical analysis. Serum creatinine (Scr) and BUN were determined by conventional methods in our hospital. Gender, age, and BMI were analyzed at the same time.
Results: There was no statistical significance in gender, age, and BMI between the 2 groups (p > 0.05). The levels of BUN and Scr in ExpG were significantly higher than in CG (p < 0.001). Serum Lep, FINS, and FBG in ExpG were higher than that in CG (p < 0.001, < 0.05, < 0.01, respectively). The ISI in ExpG was significantly lower than that in CG (p < 0.001), which showed the existence of insulin resistance in uremic pts. Serum Lep concentration was negatively correlated with the ISI in ExpG (r = –0.42, p < 0.05) and the number of Lep(+) cells in adipose tissue of pts in ExpG was significantly higher than in pts of CG (12.89 ± 1.20 vs 5.83 ± 1.69, t = 3.31, p < 0.01). Also there was a negative relationship between the number of Lep(+) cells in adipose tissue and the ISI in ExpG (r = –0.38, p < 0.05).
Conclusions: The results demonstrated that the insulin sensitivity decreased along with the increase of the leptin. Insulin resistance is probably correlated with the high leptin level.
Energy Requirement is Lower in Chinese Peritoneal Dialysis (PD) Patients Compared with Their Western Counterparts
Objective: Inadequate energy intake is one of the important causes of protein–calorie malnutrition in PD patients (pts). A few studies have shown that energy intake failed to meet the requirement of energy expenditure in PD pts. However, energy balance status in Chinese PD pts has not been adequately investigated. The aim of this study was to compare total energy intake with total energy expenditure in Chinese PD pts.
Methods: A cross-sectional study was performed in 53 PD pts who were well-nourished and clinically stable. Total energy intake equals dietary energy intake plus energy provided by glucose absorbed from the dialysate. A 3-day food diary was used to assess dietary energy intake and a 24-hour dialysate collection was used to assess energy provided by glucose absorbed from the dialysate. Total energy expenditure equals resting energy expenditure (REE) plus thermal effect of food (TEF) and energy cost of physical activity. REE was measured using indirect calorimeter along with other clinical, nutritional, and dialysis parameters after 12-hour fasting. TEF was substituted by 10% of dietary energy intake. A 3-day activity diary (the same days as food diary) was used to assess energy cost of physical activity.
Results: Mean total energy expenditure (REE + TEF and activity) was 28.7 kcal/kg/d. Mean energy intake was 29.1 kcal/kg/d. There was no significant difference between mean total energy expenditure and mean energy intake. Energy intake of PD pts was positively correlated with energy expenditure (r = 0.413, p < 0.01).
Conclusion: Despite they took less energy than the international recommendation, our PD pts maintained their nutrition status well and good physical activity with lower energy consumption, indicating that our Chinese PD pts may require less energy than their Western counterparts.
High Level of Insulin Resistance is Associated with Dysmetabolism and High Cardiovascular (CV) Mortality in Nondiabetic Continuous Ambulatory Peritoneal Dialysis (CAPD) Patients: A Prospective Cohort Study in One Center in China
Objective: We hypothesized that high level of insulin resistance (IR) is associated with dysmetabolism development and CV modality and mortality in nondiabetic CAPD patients (pts).
Methods: A cohort of 62 nondiabetic prevalent CAPD pts was prospectively enrolled. At baseline, the HOMA-IR [fasting serum insulin (μU/mL) × fasting serum glucose (mmol/L/22.5)] formula was used to determine IR. The cutoff point for IR was established by the median. According to it, pts were divided into 2 groups: high-IR if HOMA was ≥ the median and low-IR if < this level. The differences of dysmetabolism parameters (BMI, cholesterol, triglyceride, HDL, LDL, CRP, total adiponectin, leptin, resistin) and development of diabetes mellitus, CV modality and mortality were investigated between the 2 groups over a 16.51 ± 9.4 month follow-up period.
Results: At the beginning of the study, average age was 62.5 ± 15.5 years, 57.4% were female, and median time on PD was 15.6 (3.23–26.43) months. The cutoff point of IR was 2.85. Average age, PD duration, and 24 hour peritoneal dialysate glucose absorption did not differ between the 2 groups. The level of BMI (24.20 ± 2.76 vs 22.34 ± 4.58 kg/m2, p = 0.03), median triglyceride [2.68 (0.81–18.08) vs 1.61 (0.63–10.56) mmol/L,p = 0.006], average LDL (2.83 ± 0.82 vs 2.42 ± 0.61 mmol/L, p = 0.004), median CRP [11.7 (0.56–117) vs 3.07 (0.36–12.10) mg/L,p = 0.00], average leptin (2.84 ± 1.71 vs 1.62 ± 1.14 ng/mL, p = 0.004) were higher in high-IR than in low-IR. However, median HDL [0.9 (0.53–1.42) vs 1.05 (0.6–4.34) mmol/L,p = 0.04] and median adiponectin [3.03 (0.72–22.) vs 4.51 (0.51–25.36),p = 0.04] were lower in high-IR than in low-IR. In the 16.51 ± 9.4 months follow-up period, there were 8 patients in high-IR but no patient in low-IR developed to diabetes mellitus (p = 0.002). Five CV events (including pulmonary infarction 1, cerebral infarction 1, phlebothrombosis in lower limb 1, and angina pectoris 2) occurred in high-IR but no event occurred in low-IR (p = 0.029). Seven pts died (CV events 3, serious pneumonia 1, cancer 1, peritonitis 1, unknown reason 1) in high-IR but only 2 pts died (serious pneumonia 1, peritonitis 1) in low-IR (p = 0.154).
Conclusions: Dysmetabolism was more serious in higher-IR CAPD pts. Because higher rates of diabetes development, CV modality and mortality in higher-IR CAPD pts, it was accepted that being able to correct the IR could be a novel therapeutic approach in this cohort.
Li Y., Mo Y., Tang L., Tian J., Gu Y., Lin S.Y.,
Twelve Weeks of Pioglitazone Therapy Significantly Attenuates Dysmetabolism and Reduces Inflammation in Prevalent Peritoneal Dialysis (PD) Patients: A Randomized Crossover Trial
Objective: We hypothesized that oral pioglitazone treatment could positively affect the previously described hyperlipidemia, insulin resistance, inflammation, and adipokine dysmetabolism of PD patients (pts).
Methods: We randomly assigned 36 prevalent PD pts with serum triglyceride (TG) levels >1.8 mmol/L to receive pioglitazone (Actos®, Takeda®, 15 mg per day) or no medication for 12 weeks. After the first 4 weeks, pts continued with the alternative therapy (pioglitazone or no medication). Anthropometrics and fasting blood TG, LDL- & HDL-cholesterol, glucose, insulin (for calculation of HOMA-IR), CRP, ALT/AST, leptin, total adiponectin, and resistin were measured every 6 weeks using standard methods.
Results: All 36 pts (10 diabetics, 26 nondiabetics) completed the study. At baseline, average age was 63.7 ± 10.8 years, 66.7% were female, BMI 24.1 ± 3.7 kg/m2, and median time on PD was 21 (1-112) months. Analyzing the change in measured parameters before and after the 2 interventions, average serum TG was not different between pioglitazone group (3.48 ± 1.45 to 3.51 ± 1.98 mmol/L, p = 0.13) and therapy group. However, with treatment of pioglitazone, HDL (0.94 ± 0.20 to 1.00 ± 0.21 mmol/L, p = 0.02) and adiponectin (13.38 ± 8.86 to 49.87 ± 33.34 μg/mL, p = 0.004) increased, while HOMA-IR [6.23 (1.39–29.03) to 5.28 (0.97–14.95),p = 0.01], CRP level [11.30 (0.18–53) to 3.36 (0.17–26.30) mg/L,p = 0.003], and resistin (33.09 ± 16.81 to 28.89 ± 10.76 ng/mL, p = 0.002) decreased. No change occurred in other measured variables in treatment group. Only 1 case occurred in pts with edema.
Conclusion: 12 weeks of pioglitazone (15 mg/day) did not alter blood TG in prevalent PD pts, but decreased inflammation and attenuated adipokine imbalance. Pioglitazone may be a beneficial therapy for this pt group.
Li Y., Xie Q.H., You H.Z., Tian J., Gu Y., Lin S.Y.,
Prospective Study of Metabolic Disorder in Incident Peritoneal Dialysis (PD) Patients
Objective: To investigate the changes in fat mass, insulin resistance (IR), plasma lipid levels, and adipocytokines and the risk factors for metabolic disorder in 1 year follow-up of incident PD pts.
Methods: 50 incident PD pts (DM 16, non-DM 34) were enrolled. At the time before and 1, 3, 6, and 12 months after they began PD, parameters including BMI, triceps skinfold thickness (TSF), abdominal circumference (AC), HOMA-IR, plasma lipid profile, CRP, and ferritin were assessed. Adipocytokines including leptin (Lep), adiponectin (Ad), and resistin were also analyzed by ABC-ELISA in the same situation. Peritoneal glucose absorption, Kt/V, and creatinine clearance (Ccr) of PD and residual renal function were estimated in these PD pts.
Results: After 12 months follow-up, there was a significant increase in BMI (p < 0.01), TSF (p < 0.05), AC (p < 0.05), serum TG (p < 0.01), serum Lep (p < 0.01), and a significant decrease in serum Ad (p < 0.01) in all incident PD pts. However, IR was only remarkably elevated in non-DM pts. Although no remarkable changes were found in serum CHO, HDL-C, and LDL-C levels, the proportion of pts taking statin was significantly increased (p < 0.01). Among these incident PD pts, BMI was highly positively correlated with TSF (r = 0.717, p < 0.01) and AC (r = 0.855, p < 0.01). IR was positively associated with abdominal glucose absorption [p < 0.01, OD value 2.917,95%CI (1.349,6.306)], Lep [p < 0.01, OD 2.694,95%CI (1.604,4.524)], ferritin [p < 0.05, OD 1.720,95%CI (1.038,2.852)], TG [p < 0.01, OD 2.9493,95%CI (1.491,4.169)], and Ad [p < 0.01, OD 0.441,95%CI (0.264,0.738)]. Multiple logistic regression analysis showed that changes in abdominal glucose absorption, ferritin, and serum Lep were most significant predictive factors for the change in HOMA-IR. Serum TG level was positively related to ferritin (r = 0.157, p < 0.05) and Lep (r = 0.216, p < 0.01) while negatively related to serum Ad level. Factors affecting serum TG including IR [p < 0.01, OD 2.493,95%CI (1.491,4.169)] and Ad [p < 0.01, OD 0.409,95%CI (0.244,0.686)]. CRP was positively correlated with serum Lep and resistin (r = 0.127, p < 0.05; r = 0.218, p < 0.01). Ferritin was positively related to serum resistin and abdominal glucose absorption (r = 0.133, p < 0.05; r = 0.222, p < 0.05) while negatively related to serum Ad (r = –0.139, p < 0.05). Multiple logistic regression analysis showed that changes in TSF and IR were significant predictive factors for the change in serum Lep [p < 0.01, OD 3.480,95%CI (2.049,5.911); p < 0.01, OD 2.694,95%CI (1.604,4.524)]. Serum Ad level decreased as IR and TG increased [p < 0.01, OD 0.441,95%CI (0.264,0.738); p < 0.01, OD 0.409,95%CI (0.244,0.686)].
Conclusions: Body fat mass of PD pts increased significantly during the first year of PD therapy. Metabolic disturbance including IR and dyslipidemia gradually aggravated, which was associated with multiple factors including overweight, glucose absorption, Ad, Lep, inflammation, etc.