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Nutrition Management for Small, Anuric Pediatric Patients on Hemodialysis: A Single Center Experience
1. NUTRITIONAL STATUS DIETARY INTAKE AND QUALITY AMONG CHRONIC HEMODIALYSIS PATIENTS: Ragda Barakat1, Yossef Haviv2, Danit R Shahar1. 1Ben-Gurion University of the Negev, Beer Shevaa, Israel; 2 Soroka University Medical Center, Beer Shevaa, Israel End Stage Renal Disease (ESRD) patients are at risk for impaired nutritional status; the current study evaluated dietary intake and quality, nutritional status and indicators of ESRD among hemodialysis [HD] patients. A cross sectional study of n=74 HD patients. 24h dietary recalls were collected at 3 days [before, in and after dialysis day]. The protein catabolic rate (PCR) and the Subjective Global Assessment (SGA) were obtained. The mean caloric intake was 1683.9 ± 546.9 Kcal/ day deviating almost 20% from guideline recommendations for HD patients. The major difference among macronutrients was seen in carbohydrates. Subjects consumed 25% less carbohydrates than the recommended intake for HD patients. Patients’ mean energy intake was the highest on a dialysis day (1766 ± 745.4 Kcal/day), and the lowest on the day after dialysis treatment (1651.5 ± 624.6 Kcal/day). The PCR correlated with Urea values (P= 0.004), the Urea Reduction Ratio (URR) (P= 0.019) and the Kt/v (P=0.023) but not with diet and nutritional status. The SGA calculations showed that 71% of patients were well nourished, 23.4% were borderline nourished and only 1.4% undernourished. We showed differences in the dietary intake of HD patients between the days of the week that warrant further studies. Based on our findings, future intervention studies may focus on the day after dialysis.
3. THE EFFECT OF INCREASED RENAL DIETITIAN (RD) HOURS ON BONE MINERAL METABOLISM (BMM) PARAMETERS OVER 18 MONTHS: Shirley Brown, Fresenius Kidney Care, Methuen, MA, USA Renal dietitians cite lack of time as a barrier in managing BMM. The purpose of this study is to examine the effect of a 10 hr./wk. increase from 30 to a full time (FT) RD hours over 18 months. With a FT RD, process improvement and team building initiatives were implemented. The process improvement initiative centered on a BMM algorithm with more frequent lab monitoring, earlier use of calcimimetics, and initial dose of vitamin D derivative based on PTH level (versus a standard 0.25 mcg dose). This new algorithm was supported by two clinic team building initiatives: educating / engaging patient care technicians in increasing patient’s understanding of labs, increasing physician’s receptiveness to binder titration. A retrospective study was conducted using data from quality status reports in a clinic between April 2015 and September 2016. Labs monitored included the % of patients whose 3 month average met the target for the current month. Parameters monitored included: serum phosphorus (PHOS) 3.0-5.5 mg/dL, PTH 150-600 mcg, Total Calcium (TC) <10.0 mg/L, and composite BMM. The average census was 112 with 99% of pts having labs drawn over the 18 months. All parameters improved with the FT RD. To simplify reporting, changes are reported in terms of the 1st 9 months with the FT RD and the 2nd 9 months with the FT RD. The greatest improvement was in the PTH with a range of 62.5% - 68% in the first 9 months and 68.2% 79.8% in 2nd 9 months. The second notable change was in composite BMM improving with a range of 44%-50% in the 1st 9 months and 47.3%-57% in the second 9 months. Findings suggest improvements are attributed primarily to the implementation of the BMM algorithm. An increase in RD hours has a positive effect on bone mineral parameters. Further research is needed on the impact of these parameters on patient outcomes.
2. THE RELATIONSHIPS BETWEEN FAT FREE MASS ESTIMATES AND FLUID STATUS IN PATIENTS ON MAINTENANCE HEMODIALYSIS: AnDre’ Blanks1, Rebecca Brody1, Andrea Marcus1, Scott Parrott1, Emily Peters1, Rosa Hand2, Laura Byham-Gray1. 1 Rutgers University, Newark, NJ, USA; 2Case Western Reserve University, Cleveland OH, USA Body composition estimates are influenced by the relationship between fat free mass (FFM), fat mass, fluid status, and patient characteristics for individuals on maintenance hemodialysis (MHD). The purpose of this study was to examine relationships among FFM estimates using three validated equations with body mass index (BMI), interdialytic weight gain (IDWG), and fluid overload. This was a secondary analysis of the multi-site cross-sectional Development and Validation of Predictive Energy Equations in Hemodialysis study. FFM was calculated with BIA using three validated equations (Kushner, Lukaski, and Segal). Relationships between calculated FFM and the patient characteristics including IDWG and fluid overload (expected minus measured extracellular fluid, values above zero were categorized as fluid overload) were assessed using Pearson, Point Biserial, and Spearman rank correlation coefficients. A total of 133 participants were included in this sample. The mean (+SD) age was 55.4 ±12.3 years, 39.1 % (n=52) of participants were obese, and 31.8% (n=41) were fluid overloaded. The mean FFM using the equations were: Lukaski 52.6±11.3 kg; Kushner, 54.3±12 kg; and Segal 56±12.3 kg. Participants with lower FFM weight estimates were more likely to be of older age, female, and have a longer dialysis vintage Significant moderate and strong positive relationships were found between IDWG and FFM (Kushner r= 0.428, p<0.001; Lukaski, r= 0.409, p<0.001; Segal r= 0.49, p<0.001), and between fluid overload and FFM (Kushner, r= 0.483, p<0.001; Lukaski, r= 0.453, p<0.001; Segal r= 0.335, p<0.001). Participants with higher FFM weight estimates had higher IDWGs, BMIs, and were more likely to be fluid overloaded. The increases in FFM weight estimates appeared to be related to fluid increases. FFM weight estimations may vary based on how equations account for fluid.
4. NUTRITION MANAGEMENT FOR SMALL, ANURIC PEDIATRIC PATIENTS ON HEMODIALYSIS: A SINGLE CENTER EXPERIENCE: C Finotti, C Kaspar, M Lo, N Xiao, TE Bunchman, R Bholah. Children’s Hospital of Richmond at Virginia Commonwealth University, Richmond, VA, USA We present the cases of two G-tube dependent, anuric toddlers whose 5 day per week hemodialysis (HD) schedule dictated uneven nutrition provision. Case I is a 3-year-old, 15 kg child with renal dysplasia who started dialysis at age 2. Urine output declined while on peritoneal dialysis (PD) and she gradually became anuric. Peritoneal membrane failure required converting to HD 5 days per week. Case II is a 3-year-old, 14 kg child with anuria from birth secondary to cortical necrosis from polycythemia requiring PD from early infancy. Peritonitis prompted switching to HD 5 days per week. Fluid and electrolyte management in the setting of anuria was challenging with 2 fewer days of solute clearance and ultrafiltration when transitioning from 7 days of PD to 5 days of HD. The caloric needs of each child ranged from 80-100 kcal/kg/d. 60-70% of the week’s nutrition requirements were provided as formula across HD days with remaining 30-40% divided over 2 days of skipped dialysis. Table 1 summarizes allocation of formula per day (HD and non-HD). Both children demonstrated acceptable intradialytic weight gain and blood pressures, normalized electrolytes and greater than expected estimated dry weight gain. Hemodynamic stability was achieved in both children without compromising nutrition provision for adequate growth. We hence propose to correlate fluid and formula intake to the HD schedule by liberalizing fluid/nutrient provision on HD days and restricting on non-HD days.
142
Table 1. Summary of daily intake with correlating fluid weight gain Case 1 Case 2 mL/kg/d Kcal/kg/d Wt. ∆ g/d
HD day 49 91 ↑300-400
Non-HD day 15 45 ↑200-250
HD day 64 122 ↑400-500
Non-HD day 19 37 ↑350-400
Journal of Renal Nutrition, Vol 27, No 2 (March), 2017: pp 142-144
3. THE EFFECT OF INCREASED RENAL DIETITIAN (RD) HOURS ON BONE MINERAL METABOLISM (BMM) PARAMETERS OVER 18 MONTHS: Shirley Brown, Fresenius Kidney Care, Methuen, MA, USA Renal dietitians cite lack of time as a barrier in managing BMM. The purpose of this study is to examine the effect of a 10 hr./wk. increase from 30 to a full time (FT) RD hours over 18 months. With a FT RD, process improvement and team building initiatives were implemented. The process improvement initiative centered on a BMM algorithm with more frequent lab monitoring, earlier use of calcimimetics, and initial dose of vitamin D derivative based on PTH level (versus a standard 0.25 mcg dose). This new algorithm was supported by two clinic team building initiatives: educating / engaging patient care technicians in increasing patient’s understanding of labs, increasing physician’s receptiveness to binder titration. A retrospective study was conducted using data from quality status reports in a clinic between April 2015 and September 2016. Labs monitored included the % of patients whose 3 month average met the target for the current month. Parameters monitored included: serum phosphorus (PHOS) 3.0-5.5 mg/dL, PTH 150-600 mcg, Total Calcium (TC) <10.0 mg/L, and composite BMM. The average census was 112 with 99% of pts having labs drawn over the 18 months. All parameters improved with the FT RD. To simplify reporting, changes are reported in terms of the 1st 9 months with the FT RD and the 2nd 9 months with the FT RD. The greatest improvement was in the PTH with a range of 62.5% - 68% in the first 9 months and 68.2% 79.8% in 2nd 9 months. The second notable change was in composite BMM improving with a range of 44%-50% in the 1st 9 months and 47.3%-57% in the second 9 months. Findings suggest improvements are attributed primarily to the implementation of the BMM algorithm. An increase in RD hours has a positive effect on bone mineral parameters. Further research is needed on the impact of these parameters on patient outcomes.
2. THE RELATIONSHIPS BETWEEN FAT FREE MASS ESTIMATES AND FLUID STATUS IN PATIENTS ON MAINTENANCE HEMODIALYSIS: AnDre’ Blanks1, Rebecca Brody1, Andrea Marcus1, Scott Parrott1, Emily Peters1, Rosa Hand2, Laura Byham-Gray1. 1 Rutgers University, Newark, NJ, USA; 2Case Western Reserve University, Cleveland OH, USA Body composition estimates are influenced by the relationship between fat free mass (FFM), fat mass, fluid status, and patient characteristics for individuals on maintenance hemodialysis (MHD). The purpose of this study was to examine relationships among FFM estimates using three validated equations with body mass index (BMI), interdialytic weight gain (IDWG), and fluid overload. This was a secondary analysis of the multi-site cross-sectional Development and Validation of Predictive Energy Equations in Hemodialysis study. FFM was calculated with BIA using three validated equations (Kushner, Lukaski, and Segal). Relationships between calculated FFM and the patient characteristics including IDWG and fluid overload (expected minus measured extracellular fluid, values above zero were categorized as fluid overload) were assessed using Pearson, Point Biserial, and Spearman rank correlation coefficients. A total of 133 participants were included in this sample. The mean (+SD) age was 55.4 ±12.3 years, 39.1 % (n=52) of participants were obese, and 31.8% (n=41) were fluid overloaded. The mean FFM using the equations were: Lukaski 52.6±11.3 kg; Kushner, 54.3±12 kg; and Segal 56±12.3 kg. Participants with lower FFM weight estimates were more likely to be of older age, female, and have a longer dialysis vintage Significant moderate and strong positive relationships were found between IDWG and FFM (Kushner r= 0.428, p<0.001; Lukaski, r= 0.409, p<0.001; Segal r= 0.49, p<0.001), and between fluid overload and FFM (Kushner, r= 0.483, p<0.001; Lukaski, r= 0.453, p<0.001; Segal r= 0.335, p<0.001). Participants with higher FFM weight estimates had higher IDWGs, BMIs, and were more likely to be fluid overloaded. The increases in FFM weight estimates appeared to be related to fluid increases. FFM weight estimations may vary based on how equations account for fluid.
4. NUTRITION MANAGEMENT FOR SMALL, ANURIC PEDIATRIC PATIENTS ON HEMODIALYSIS: A SINGLE CENTER EXPERIENCE: C Finotti, C Kaspar, M Lo, N Xiao, TE Bunchman, R Bholah. Children’s Hospital of Richmond at Virginia Commonwealth University, Richmond, VA, USA We present the cases of two G-tube dependent, anuric toddlers whose 5 day per week hemodialysis (HD) schedule dictated uneven nutrition provision. Case I is a 3-year-old, 15 kg child with renal dysplasia who started dialysis at age 2. Urine output declined while on peritoneal dialysis (PD) and she gradually became anuric. Peritoneal membrane failure required converting to HD 5 days per week. Case II is a 3-year-old, 14 kg child with anuria from birth secondary to cortical necrosis from polycythemia requiring PD from early infancy. Peritonitis prompted switching to HD 5 days per week. Fluid and electrolyte management in the setting of anuria was challenging with 2 fewer days of solute clearance and ultrafiltration when transitioning from 7 days of PD to 5 days of HD. The caloric needs of each child ranged from 80-100 kcal/kg/d. 60-70% of the week’s nutrition requirements were provided as formula across HD days with remaining 30-40% divided over 2 days of skipped dialysis. Table 1 summarizes allocation of formula per day (HD and non-HD). Both children demonstrated acceptable intradialytic weight gain and blood pressures, normalized electrolytes and greater than expected estimated dry weight gain. Hemodynamic stability was achieved in both children without compromising nutrition provision for adequate growth. We hence propose to correlate fluid and formula intake to the HD schedule by liberalizing fluid/nutrient provision on HD days and restricting on non-HD days.
142
Table 1. Summary of daily intake with correlating fluid weight gain Case 1 Case 2 mL/kg/d Kcal/kg/d Wt. ∆ g/d
HD day 49 91 ↑300-400
Non-HD day 15 45 ↑200-250
HD day 64 122 ↑400-500
Non-HD day 19 37 ↑350-400
Journal of Renal Nutrition, Vol 27, No 2 (March), 2017: pp 142-144