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Supplementation With over-The-Counter Cholecalciferol Increases Serum 25 Hydroxy Vitamin D Levels in Hemodialysis Subjects
MEETING ABSTRACTS
1
3
BENEFIT OF USING VISUAL TEACHING TOOLS FOR PHOSPHORUS CONTROL IN HEMODIALYSIS UNIT
EFFECTS OF A 6-MONTH INTAKE OF 3 GRAMS OMEGA 3 FATTY ACIDS ON INFLAMMATORY MARKERS IN MAINTENANCE HEMODIALYSIS PATIENTS
Carol Allen, Da Vita Inc., Selma, CA, USA Renal dialysis patients need continuous educatio related to their clinical care and well being. It is important to present the same educational topics in different formats with different tools to keep the patients’ motivated. Patients at a Californian hemodialysis unit, with a high non-literate rate (30%) and high percentage of Spanish speaking only population (30%), were experiencing high serum phosphrous levels. The center’s registered dietitian developed a new visual teaching tool/game call "Phosphorus Island" with the goal of improving the patients’ phosphorus levels. Baseline values (reported in December, 2007) showed that 40% of the 83 hemodialysis patients had serum P . 5.5 and 10% of those had serum P . 8.0. In January 2008, Phosphorus Island was constructed on the unit’s lobby wall. Pictorial elements were used to represent phosphorus levels , 5.5 and . 5.5. Then related items showed the "Consequences of Poor Phosphorus control" including causes of SHPT and "Low P food substitutes for high P foods" in Spanish. After 9 months of education using Phosphorus Island, 75% of patients had serum P , 5.5 and only 6% had P . 8. Visually reminding patients if they were ‘‘safe" (P #5.5) or "drowning" (P . 5.5) has greatly improved serum phosphorus levels in our hemodialysis unit despite lack of language skills or literacy. Improving serum phosphorus levels in new, fun, visual way has decreased the risk of calcification in this hemodialysis population and decreased the patients’ risk of mortality.
2 SUPPLEMENTATION WITH OVER-THE-COUNTER CHOLECALCIFEROL INCREASES SERUM 25 HYDROXY VITAMIN D LEVELS IN HEMODIALYSIS SUBJECTS
Clement Louise, Bollman Lacey, Jackson Traci, Shen Chwan-Li, Spallholz Julian, and Boylan Mallory, South Plains Kidney Disease Center; Texas Tech University and TTU Health Sciences Center, Lubbock, TX Vitamin D deficiency is very prevalent in hemodialysis (HD) subjects, and ergocalciferol in a once a month dose has been demonstrated to improve vitamin D status in HD subjects. In nondialysis subjects, cholecalciferol (vitamin D 3) has been reported to be more effective than ergocalciferol (vitamin D 2) in raising serum 25 hydroxy vitamin D levels. The purpose of this study was to evaluate the effect of a once daily oral dose of over-the-counter (OTC) cholecalciferol on serum 25 hydroxy vitamin D levels in HD subjects. Subjects (n 5 84) on HD had serum 25 hydroxy vitamin D levels measured and 68 subjects (81%) were found to have levels below 30 ng/mL. The subjects with serum 25 hydroxy vitamin D levels below 30 ng/ml were instructed to take a once daily dose of 1000 IU cholecalciferol per day for 20 weeks. Serum 25 hydroxycholecalciferol, calcium, and phosphorus values were obtained by chart review before and after supplementation. Subjects (n553) whose pill count values exceeded 40% and serum 25 hydroxy vitamin D levels were above 30 ng/ mL at the 20 week time point were assigned to the compliant group for comparison of pre and post-supplementation values. Paired sample t tests were used to determine significant differences in pre- and postsupplementation mean values. In the compliant group, mean serum 25 hydroxy vitamin D levels rose significantly (p , 0.0001) from 16.2 6 6.5 to 51.4 6 14.4 ng/mL. Serum corrected calcium levels were slightly but significantly lower (p , 0.007) after supplementation (9.3 6 0.5; 9.160.6) and mean serum phosphorus levels were not significantly different (p , 0.365). Daily oral supplementation with OTC cholecalciferol is effective in improving serum 25 hydroxy vitamin D levels in HD subjects, without raising serum calcium or phosphorus levels. Although preliminary, this is the first published study reporting the use of cholecalciferol, rather than ergocalciferol, for the treatment of vitamin D insufficiency and deficiency, in the HD population.
190
Sana Ghaddar, San Francisco, California - Nada Hasbini, Beirut, Lebanon - Hafez Elzein, Beirut, Lebanon This pilot study (n560) examined the effect of a 3-gram omega 3 fatty acid supplementation for 6 months on inflammation, lipid panel, change in anemia management, medication dose and malnutrition status in stable maintenance hemodialysis (MHD) patients in Lebanon. Patients were randomly assigned into 2 groups: intervention and control after an initial matching process for diabetes, gender, age and number of years on dialysis. The intervention group received 3-gram omega 3 fatty acid pills daily for 6 months and none by the controls. Markers for inflammation were C-Reactive protein (CRP) and ferritin and markers for anemia were Hgb, IV Iron dose and Erythropoeitin Stimulating Agent dose. Finally, markers for malnutrition included medication dose, lipid panel and a subjective global assessment questionnaire (SGA) score. As a safety precaution, prothrombin time, blood pressure and urea reduction ratio (URR) were monitored. To control the effect of dietary omega 3, food frequency questionnaire specific to omega 3 was conducted pre and post study. Tolerance and compliance to pill intake was also evaluated. Independent t test was used to test for statistical significance for all continuous data and Factorial ANOVA with 2 factors (time and intervention) repeated on one was used for pre and post intervention lab parameters. Changes in inflammatory markers at month-6 relative to baseline were a slight increase in CRP levels (1.25 to 2.75 mg/dl) and slight decrease in mean ferritin level from 907 ng/dl to 814 ng/dl; with both changes being statistically not significant. Within and between groups analysis did not show any significant changes in the anemia management (IV iron dose, Hgb and ESA dose) and lipid profile (LDLC, HDL-C, TC, TC/HDL-C) levels at 6 months relative to baseline. Most reported adverse event were nausea and vomiting, but were not severe to cause any interruption in the medication intake. Compliance was high ranging between 84% and 93% of the prescribed dose. Our results showed that a 6-month intake of high doses (3g) of omega 3 is well tolerated, but has no impact on inflammation markers.
4 NUTRITIONAL INTERVENTION FOR MANAGEMENT OF OSTEODYSTROPHY IN HEMODIALYSIS PATIENTS: A DEVELOPING COUNTRY MODEL (LEBANON)
Mirey Karavetian, Beirut, Lebanon - Sana Ghaddar, San Francisco, California - Hafez Elzein, Beirut, Lebanon This study examined the use of self-management focused counseling (SMFC) to improve compliance to medical nutritional management (MNT) of renal osteodystrophy in a sample of hemodialysis (HD) patients in Lebanon. The study was a randomized controlled study that included 122 stable HD adult patients randomly assigned to three study groups: full intervention (A) (n541), partial intervention (B) (n541) and control (C) (n540), according to their dialysis shifts. The full intervention included individualized 40-minute osteodystrophy related nutritional SMFC provided in 2-weekly sessions for 8 weeks. For group A, these sessions included an educational topic followed by a relevant educational game with interactive discussion and once a month assessment of related laboratory results. Group B was given the educational games without explanation once a week for 8 weeks. Group C did not receive any intervention. All patients continued to receive their routine nutrition education from the hospital dietitian. Osteodystrophy related blood parameters: Phosphorus (P) mg/dl, Calcium (Ca) mg/dl, Ca*P product and knowledge questionnaire on kidney disease and nutrition therapy for HD patients were used to assess the intervention. Paired sample ttest was used to examine the between groups difference. Results of the study showed a significant improvement in P only in group A with values changing from a baseline of 6.54 6 2.05 to 5.39 6 1.97 (p , .001) at three months. Both groups A and B showed a significant improvement in serum Ca*P product, values changing from 57.62 6 17.19 to 49.46 6 11.63 (p5.006) and from 51.95 6 14.30 to 44.75 6 15.5 (p5.011) respectively. The level of knowledge, expressed in percentage, significantly improved only for scores in group A, from 50% 6 0.17 to 69% 6 0.25 (p # 0.05). Our results showed that structured nutritional education by trained dietitians in the HD setting, improved awareness and compliance to MNT among HD patients in Lebanon in. It suggests that such model is valuable for implementation in developing countries.
Journal of Renal Nutrition, Vol 19, No 2 (March), 2009: pp 190–192
1
3
BENEFIT OF USING VISUAL TEACHING TOOLS FOR PHOSPHORUS CONTROL IN HEMODIALYSIS UNIT
EFFECTS OF A 6-MONTH INTAKE OF 3 GRAMS OMEGA 3 FATTY ACIDS ON INFLAMMATORY MARKERS IN MAINTENANCE HEMODIALYSIS PATIENTS
Carol Allen, Da Vita Inc., Selma, CA, USA Renal dialysis patients need continuous educatio related to their clinical care and well being. It is important to present the same educational topics in different formats with different tools to keep the patients’ motivated. Patients at a Californian hemodialysis unit, with a high non-literate rate (30%) and high percentage of Spanish speaking only population (30%), were experiencing high serum phosphrous levels. The center’s registered dietitian developed a new visual teaching tool/game call "Phosphorus Island" with the goal of improving the patients’ phosphorus levels. Baseline values (reported in December, 2007) showed that 40% of the 83 hemodialysis patients had serum P . 5.5 and 10% of those had serum P . 8.0. In January 2008, Phosphorus Island was constructed on the unit’s lobby wall. Pictorial elements were used to represent phosphorus levels , 5.5 and . 5.5. Then related items showed the "Consequences of Poor Phosphorus control" including causes of SHPT and "Low P food substitutes for high P foods" in Spanish. After 9 months of education using Phosphorus Island, 75% of patients had serum P , 5.5 and only 6% had P . 8. Visually reminding patients if they were ‘‘safe" (P #5.5) or "drowning" (P . 5.5) has greatly improved serum phosphorus levels in our hemodialysis unit despite lack of language skills or literacy. Improving serum phosphorus levels in new, fun, visual way has decreased the risk of calcification in this hemodialysis population and decreased the patients’ risk of mortality.
2 SUPPLEMENTATION WITH OVER-THE-COUNTER CHOLECALCIFEROL INCREASES SERUM 25 HYDROXY VITAMIN D LEVELS IN HEMODIALYSIS SUBJECTS
Clement Louise, Bollman Lacey, Jackson Traci, Shen Chwan-Li, Spallholz Julian, and Boylan Mallory, South Plains Kidney Disease Center; Texas Tech University and TTU Health Sciences Center, Lubbock, TX Vitamin D deficiency is very prevalent in hemodialysis (HD) subjects, and ergocalciferol in a once a month dose has been demonstrated to improve vitamin D status in HD subjects. In nondialysis subjects, cholecalciferol (vitamin D 3) has been reported to be more effective than ergocalciferol (vitamin D 2) in raising serum 25 hydroxy vitamin D levels. The purpose of this study was to evaluate the effect of a once daily oral dose of over-the-counter (OTC) cholecalciferol on serum 25 hydroxy vitamin D levels in HD subjects. Subjects (n 5 84) on HD had serum 25 hydroxy vitamin D levels measured and 68 subjects (81%) were found to have levels below 30 ng/mL. The subjects with serum 25 hydroxy vitamin D levels below 30 ng/ml were instructed to take a once daily dose of 1000 IU cholecalciferol per day for 20 weeks. Serum 25 hydroxycholecalciferol, calcium, and phosphorus values were obtained by chart review before and after supplementation. Subjects (n553) whose pill count values exceeded 40% and serum 25 hydroxy vitamin D levels were above 30 ng/ mL at the 20 week time point were assigned to the compliant group for comparison of pre and post-supplementation values. Paired sample t tests were used to determine significant differences in pre- and postsupplementation mean values. In the compliant group, mean serum 25 hydroxy vitamin D levels rose significantly (p , 0.0001) from 16.2 6 6.5 to 51.4 6 14.4 ng/mL. Serum corrected calcium levels were slightly but significantly lower (p , 0.007) after supplementation (9.3 6 0.5; 9.160.6) and mean serum phosphorus levels were not significantly different (p , 0.365). Daily oral supplementation with OTC cholecalciferol is effective in improving serum 25 hydroxy vitamin D levels in HD subjects, without raising serum calcium or phosphorus levels. Although preliminary, this is the first published study reporting the use of cholecalciferol, rather than ergocalciferol, for the treatment of vitamin D insufficiency and deficiency, in the HD population.
190
Sana Ghaddar, San Francisco, California - Nada Hasbini, Beirut, Lebanon - Hafez Elzein, Beirut, Lebanon This pilot study (n560) examined the effect of a 3-gram omega 3 fatty acid supplementation for 6 months on inflammation, lipid panel, change in anemia management, medication dose and malnutrition status in stable maintenance hemodialysis (MHD) patients in Lebanon. Patients were randomly assigned into 2 groups: intervention and control after an initial matching process for diabetes, gender, age and number of years on dialysis. The intervention group received 3-gram omega 3 fatty acid pills daily for 6 months and none by the controls. Markers for inflammation were C-Reactive protein (CRP) and ferritin and markers for anemia were Hgb, IV Iron dose and Erythropoeitin Stimulating Agent dose. Finally, markers for malnutrition included medication dose, lipid panel and a subjective global assessment questionnaire (SGA) score. As a safety precaution, prothrombin time, blood pressure and urea reduction ratio (URR) were monitored. To control the effect of dietary omega 3, food frequency questionnaire specific to omega 3 was conducted pre and post study. Tolerance and compliance to pill intake was also evaluated. Independent t test was used to test for statistical significance for all continuous data and Factorial ANOVA with 2 factors (time and intervention) repeated on one was used for pre and post intervention lab parameters. Changes in inflammatory markers at month-6 relative to baseline were a slight increase in CRP levels (1.25 to 2.75 mg/dl) and slight decrease in mean ferritin level from 907 ng/dl to 814 ng/dl; with both changes being statistically not significant. Within and between groups analysis did not show any significant changes in the anemia management (IV iron dose, Hgb and ESA dose) and lipid profile (LDLC, HDL-C, TC, TC/HDL-C) levels at 6 months relative to baseline. Most reported adverse event were nausea and vomiting, but were not severe to cause any interruption in the medication intake. Compliance was high ranging between 84% and 93% of the prescribed dose. Our results showed that a 6-month intake of high doses (3g) of omega 3 is well tolerated, but has no impact on inflammation markers.
4 NUTRITIONAL INTERVENTION FOR MANAGEMENT OF OSTEODYSTROPHY IN HEMODIALYSIS PATIENTS: A DEVELOPING COUNTRY MODEL (LEBANON)
Mirey Karavetian, Beirut, Lebanon - Sana Ghaddar, San Francisco, California - Hafez Elzein, Beirut, Lebanon This study examined the use of self-management focused counseling (SMFC) to improve compliance to medical nutritional management (MNT) of renal osteodystrophy in a sample of hemodialysis (HD) patients in Lebanon. The study was a randomized controlled study that included 122 stable HD adult patients randomly assigned to three study groups: full intervention (A) (n541), partial intervention (B) (n541) and control (C) (n540), according to their dialysis shifts. The full intervention included individualized 40-minute osteodystrophy related nutritional SMFC provided in 2-weekly sessions for 8 weeks. For group A, these sessions included an educational topic followed by a relevant educational game with interactive discussion and once a month assessment of related laboratory results. Group B was given the educational games without explanation once a week for 8 weeks. Group C did not receive any intervention. All patients continued to receive their routine nutrition education from the hospital dietitian. Osteodystrophy related blood parameters: Phosphorus (P) mg/dl, Calcium (Ca) mg/dl, Ca*P product and knowledge questionnaire on kidney disease and nutrition therapy for HD patients were used to assess the intervention. Paired sample ttest was used to examine the between groups difference. Results of the study showed a significant improvement in P only in group A with values changing from a baseline of 6.54 6 2.05 to 5.39 6 1.97 (p , .001) at three months. Both groups A and B showed a significant improvement in serum Ca*P product, values changing from 57.62 6 17.19 to 49.46 6 11.63 (p5.006) and from 51.95 6 14.30 to 44.75 6 15.5 (p5.011) respectively. The level of knowledge, expressed in percentage, significantly improved only for scores in group A, from 50% 6 0.17 to 69% 6 0.25 (p # 0.05). Our results showed that structured nutritional education by trained dietitians in the HD setting, improved awareness and compliance to MNT among HD patients in Lebanon in. It suggests that such model is valuable for implementation in developing countries.
Journal of Renal Nutrition, Vol 19, No 2 (March), 2009: pp 190–192