An individualized supplemented diet in hemodialysis patients with malnutrition

ORIGINAL

RESEARCH

An Individualized Supplemented Diet in Hemodialysis Patients With Malnutrition Vladimir Teplan, MD, PhD,* and Olga Mengevovc$ RDf

Objective: To develop and test an individualized dietary program for long-term hemodialysis patients with of malnutrition. Design: Metabolic study started with a 2-week dietary questionnaire to determine eating habits of patients and to estimate intake of protein and energy. Setting: One clinical site. Patients: Forty-two patients with signs of malnutrition receiving regular hemodialysis treatment were monitored for a period of 2 months. Intervention: A long-term dietary regimen was developed by a DIETA computer program with a database containing the compositions of all used dishes of Czech cuisine. When a patient was unable to receive the recommended dose of a nutrient, the diet was supplemented with oral nutrition solutions. Main outcome measures: Monitor patient for malnutrition and levels of S-albumin, S-transferrin, body mass index, and Whitehead quotient. Results: Significant improvement (P < .Ol) was seen in values of S-albumin, S-transferrin, body mass index, and Whitehead quotient during the 2-month follow-up period. Mild improvement in protein catabolic rate (P < .05) was noted, and value of KW (urea) was >l and not significant. Compliance was in excess of 70%. Conclusions: Individualized diet combined with adequate dialysis treatment significantly helps control the metabolic status of patients with malnutrition who are on regular dialysis. o 1997by the National Kidney Foundation, Inc.

P

ROTEIN AND ENERGY malnutrition is frequently present in patients on long-term dialysis. Several recent studies have suggested that malnutrition is an important risk factor for morbidity and mortality in hemodialysis patients. i,a Malnutrition may be the consequence of multiple factors associated with chronic renal failure including disturbances in protein and energy metabolism, hormonal derangement, infections, other superimposed illnesses, and inadequate food intake.3 The metabolic and nutritional problems can be improved or even normalized by an

fRenal Dietitian, Department oj Nephrology. Institute and Experimental Medidne, Prague, Czech Republic.

for

Clinical

Address reprint requesfs to Madimir Teplan, MD, PhD. Depnrtrnent of Nephlogy, Institute fbr Clinical and Experinwntnl Medicine, V~deiiskd 800 l? O.B. 10, f4O 00 Prague 4, Czech Republic 0 2997 by the Natioml Kidttey Foundation. IHC. lO5l-2276/97/0702-0005$03.00/O

Jumal

ofRerral

Nutrition,

Vol

7, No

2 (April),

1997:

pp 73-76

adequate dialysis technique.4,5 On the other hand, renal replacement therapy such as hemodialysis may induce catabolism which, together with the non-negligible loss of amino acids during hemodialysis, increases protein and energy requirements above those in non-dialysis patients.“x6 The issue of biocompatibility of the membranes used in the hemodialysis procedure should also be taken into account as a potential factor of muscle protein catabolism and impaired appetite.6z7 Very frequent are other metabolic disorders of these patients such as hyperkalemia, hyperphosphatemia, diabetes mellitus, hyperlipidemia, metabolic acidosis and, very often, a combination of all the above factors. Under these conditions, nutritional therapy plays a very important role and its efficacy has an impact on long-term survival.8~9 Over the years, we have gained considerable experience with a balanced frozen low-protein diet.‘O Based on our previous experience, it is clear 73

74

TEXAN

AND

that the key role in long-term dietary intervention (long-term adherence to the dietary regimen) is played by compliance. High compliance exceeding 70% (measured using urea and phosphate excretion) was attained by individualizing the dietary protocol, mainly taking into account the individual eating habits of each patient. In a number of other cases, the diet was regularly enriched with energy (mainly taking the form of malto-dextrose added to meals), or low-phosphate high-energy protein pharmacologically defined nutritional products (Sonana ren-o-prot [Nephro-Medica, Linden, Germany], Renilon [Nutria, Zoetermeer, The Netherlands] = Nefro, Re/Neph HP/HC US). The individualized dietary protocol developed for patients with signs of malnutrition was first analyzed using a 2-week dietary questionnaire, noting the eating habits of individual patients, and estimating their intake of nutritional components. At the same time, dialysis treatment that used a dialysis solution with bicarbonate was standardized. Next, modified individualized hypernutritional food was given to the patients to reverse the malnutrition for a total period of 6 weeks.

Material

and Methods

Patients Malnutrition in dialysis patients was investigated in a group of 42 patients on dialysis treatment who attended the Dialysis Center at the Clinic of Nephrology in Prague (Table 1). Patients were excluded from this study for the following reasons: younger than 18 years; older than 70 years; had malignant disease; received steroid treatment; and/or had liver, heart, and lung failure. Patients had to have been receiving regular hemodialysis treatment for longer than or Table 1. Patients on Dialysis Treatment Dialysis Center Patient

at the

Characteristics

Total no. of patients Male Female Age (years) Range Mean RDT (months) Range Mean Previous renal transplantation

42 28 14 21-68 59 12-76 36 3

MENGEROVA

Table 2. Underlying Renal Failure Underlying

Renal Disease Leading Renal

Disease

Glomerulonephritis Interstitial nephritis (including pyelonephritis) Diabetic nephropathy (IDDM/NIDDM) Polycystic kidney disease Other

to n

%

15 12 10 4 1

35.7 28.6 23.8 9.5 9.4

NOTE. Of the 42 patients with malnutrition, predialysis hyperphosphatemia was diagnosed in 8 patients, hyperkalemia in 28, and hyperlipidemia in 12.

equal to 1 year. The underlying renal disease leading to renal failure is summarized in Table 2.

Dialysis and Nutritional Status Evaluation The hemodialysis treatment schedule consisted of 3 weekly sessions lasting 3.5 to 4.5 hours. Blood samples were collected after 12-hour fast in all patients before dialysis and under the same conditions after 2 months. S-albumin, S-urea, S-transferrin, and Whitehead quotient were determined in the laboratory using a Beckmann Microsome (Mannheim, Germany), SEVAC kits (Lachema Bm., Czech Republic), and chromatography. Whitehead quotient expresses the ratio between major nonessential and essential amino acids (gly + glu + ser + tau: leu + ileu + val + met). Body mass index was calculated using the formula: body weight/body height” Protein catabolic rate (PCR) was determined as a ratio of urea generation rate and urea distribution volume. Kt/V (urea) was calculated from K (dialyzer urea clearance), t (treatment time), and V (body urea distribution volume).

Signs of Malnutrition The definition of malnutrition for this study included an S-albumin level of <35 g/L, S-transferrin level of <2 g/L, Whitehead quotient of B2.02, body mass index of <22%, and PCR of <0.75 g/kg body weight/d.

Dietary Schedule Individual dietary protocols with respect to eating habits (intake of energy and nutrients) and to the other previously mentioned metabolic disorders (also, hyperphosphatemia, hyperkalemia, metabolic acidosis, hyperlipidemia, and diabetes mellitus in addition to malnutrition) were developed for each patient for a period of 6

INDIVIDUALIZED

DIET

Table 3. Individualized Diet for a Malnourished Diabetes Mellitus and Hyperlipidemia Total Energy Protein

(kJ) (g)

Pa (9) Lipid (g) Ls (9) LP (9) Chol (mg) CH (g) pas (cl) DiS (g) Fiber(g) Na Ow) K (mg) Ca O-f@ P h-4) Mg (mg) Cu (ms) Fe b-cd Vitamins C 03) A (cls) BI 0-w) BP (mg) Water (mL)

IN HEMODIALYSIS

75

PATIENTS

Dialysis Patient With Noninsulin-Dependent

Breakfast

Snack

Lunch

Tea

Supper

sum.

1856.00 15.36 10.75 14.28 4.71 9.57 25.02 63.02 40.96 22.06 7.46 331.65 598.97 104.77 197.53 60.67 .31 2.07

464.00 3.84 2.69 3.57 1.18 2.39 6.26 20.27 13.18 7.09 1.87 82.91 149.74 26.19 49.38 15.17 .08 .52

19.62 138.20 .27 .30 182.46

4.91 34.55 .07 .07 45.61

9280.00 78.80 53.76 71.38 23.56 47.83 125.11 299.83 194.89 104.94 93.28 1658.23 2994.85 523.84 987.65 303.33 1.54 10.35

2320.00 19.20 13.44 17.85 5.89 11.96 31.28 50.01 32.51 17.50 65.29 414.56 748.71 130.96 246.91 75.83 .39 2.59

742.40 6.14 4.30 5.71 1.88 3.83 10.01 45.98 29.89 16.09 2.98 132.66 239.59 41.91 79.01 24.27 .12 .83

2784.00 23.04 16.13 21.42 7.07 14.35 37.53 71.23 46.30 24.93 11.19 497.47 898.45 157.15 296.29 91 .oo .46 3.10

1113.60 9.22 6.45 8.57 2.83 5.74 15.01 49.32 32.06 17.26 4.48 198.99 359.38 62.86 118.52 36.40 .18 1.24

98.11 690.98 1.35 1.49 912.28

24.53 172.75 .34 .37 228.07

7.85 55.28 .ll .12 72.98

29.43 207.29 .41 .45 273.68

11.77 82.92 .16 .18 109.47

NOTE. Patient’s body weight was 64 kg. Abbreviations: Pa, animal proteins; Ls, saturated PoS, polysaccharides; DiS, disaccharides.

lipid; Lp, unsaturated

lipids;

Chol, total cholesterol;

II

CH, carbohydrates;

weeks. In case of inadequate compliance (measured by urea and phosphate kinetics), the diet was supplemented with oral nutritional solutions (factory-made or dietitian-patient made) containing proteins, energy, vitamins, and trace elements.

paired and unpaired data. A P value of .05 was considered significant. Each patient served as a control to himself/herself

Statistics

The compliance in the studied group was very good, exceeding 70%. A very important role in this compliance was played by the fact The patients were motivated to long-term adherence

Statistical analysis of results obtained at the beginning (Day 0) and after 2 months of nutritional care wasperformed using Student’s t test for

0 before

0 sd

Albumin

(911) Tran~ferrin

29.8 + 3.7 35.2 f 4.8

(g/l)

1.92 * 0.08 2.24 f 0.16

Dafter

Results and Discussion

0 before

2 months

WQ

ml, (X,

2.22 * 0.22 1.02 + 0.12

I9.6 * 2.3 24.6 * 3.1

Figure 1. Change in laboratory parameters over 2 months (albumin, transferrin, BQ, body mass index).

Kt,V (ures)

Figure 2. Change in laboratory months (KtN, PCR).

Dafter

2 montl

PCR (g/kg/dv’)

parameters

over 2

76

TEXAN

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to the dietary regimen by doctors, dietitians, family members, and by their social background. The DIETA program (IKEM, Prague, Czech Republic) makes it possible to prepare many variations of menus. The composition of meals of every individual is shown daily in summary tables. In addition to the amount of all dietary components, energy intake is included. The variables that are altered include both the amount of nutrients and nutrient components (animal and vegetable proteins, unsaturated and saturated fats, polysaccharides, disaccharides, and fiber). At the same time, the composition of individual meals and menus is used to adjust the amount of consumed minerals, especially potassium, phosphorus, calcium, sodium, and magnesium. Using this approach, it is possible to develop a remarkable number of variations of the dietary schedule, which is extremely important for patients with multiple metabolic disorders. Table 3 shows the menu of a malnourished patient with non-insulin-dependent diabetes mellitus and hyperlipidemia. In 20 patients (47.6%), the diet was complemented with nutritional supplements because the patients were unable to take the recommended diet. The most often used products were whey low-phosphate protein energy mixtures (Sonanaren-o-prot and Renilon = Nefro, Re/Neph HP/HC US). Energy supplementation with a malto-dextrose mixture added to the meals was also often used. Dialysis treatment was optimized to attain a Kt/V value of >l (optimized, 1.2). During the study period, administration of the supplemented diet was associated with statistically significant (P < 0.01) increases in albumin levels, transfer&

MENGERO

Vi

levels, and body mass index. A decrease was also found in Whitehead quotient, a result that suggests increases in the serum levels of essential amino acids (Figure 1). There was no significant decrease in the value of Kt/V, which remained greater than 1. A mild increase was found in PCR (P < 0.05) (Figure 2). Based on these results, we believe that an individualized supplemented diet, combined with adequate dialysis treatment, may significantly help in controlling the metabolic status of patients with malnutrition receiving regular dialysis treatment.

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