Download Effect of personalized nutritional counseling in maintenance

Hemodialysis International 2015; ••:••–••
Effect of personalized nutritional
counseling in maintenance
hemodialysis patients
Cristina Antunes GARAGARZA, Ana Tentúgal VALENTE, Telma Sobral OLIVEIRA,
Cristina Guerreiro CAETANO
Nephrocare Dialysis Units, Lisbon, Portugal
Abstract
Monitoring nutritional parameters is an integral part of hemodialysis (HD) patient treatment
program. The purpose of this study was to evaluate the impact of the personalized nutritional
counseling (PNC) on calcium–phosphorus metabolism, potassium, albumin, protein intake, interdialytic weight gain (IDWG), body composition parameters and fluid overload in HD patients. This
was a multicenter longitudinal intervention study with 6 months of follow-up and 731 patients on
maintenance HD from 34 dialysis units in Portugal were enrolled. Biochemical and body composition parameters were measured at baseline, 1, 3 and 6 months after the PNC. Patient’s mean age
was 64.9 (95% confidence interval [CI]: 63.8–66.0) years and mean HD time was 59.8 (95% CI:
55.3–64.3) months. Regarding data comparison collected before PNC vs. 6 months after, we
obtained, respectively, the following results: patients with normalized protein catabolic rate
(nPCR) ≥ 1 g/kg/day = 66.5% vs. 73.5% (P = 0.002); potassium > 5.5 mEq/L = 52% vs. 35.8%
(P < 0.001); phosphorus between 3.5 and 5.5 mg/dL = 43.2% vs. 52.5% (P < 0.001); calcium/
phosphorus (Ca/P) ratio ≤ 50 mg/dL = 73.2 % vs. 81.4% (P < 0.001); albumin ≥ 4.0 g/dL = 54.8%
vs. 55% (P = 0.808); presence of relative overhydration = 22.4% vs. 25% (P = 0.283);
IDWG > 4.5% = 22.3% vs. 18.2% (P = 0.068). PNC resulted in a significant decrease in the prevalence
of hyperkalemia, hypophosphatemia and also showed amelioration in Ca/P ratio, nPCR and an
increase in P of hyphosphatemic patients. Our study suggests that dietetic intervention contributes
to the improvement of important nutritional parameters in patients receiving hemodialysis
treatment.
Key words: Nutrition, patient education, outcomes research
INTRODUCTION
Correspondence to: C. Garagarza, MSc, Nephrocare
Dialysis Units, Rua Prof. Salazar de Sousa, Lote 12, Lisboa
1750-233, Portugal. E-mail: [email protected]
Disclosure: This manuscript has been seen and approved by
all authors and is not under consideration for publication in
a similar form, in any language.
There was no funding source for this study.
Patients in maintenance hemodialysis (HD) require
proper, intensive and sufficient instruction, as well as
repeated reinforcement to deal with the complex renal
diet. The main goals of nutritional counseling should be
helping patients manage their own diet in the correct way
and help them feel in control.1 Because of the increased
© 2015 International Society for Hemodialysis
DOI:10.1111/hdi.12260
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Garagarza et al.
nutrient requirements and dietetic restrictions, management of anthropometric and biochemical parameters,
such as phosphorus, calcium, potassium, albumin and
normalized protein catabolic rate (nPCR), in HD
patients must be taken into account, therefore patients
should follow a diet to improve or maintain nutritional
status.2
With the decline of the renal function, the intake of
phosphorus, potassium, protein and fluids must be controlled. A high potassium intake is related with an
increased death risk in these patients because it can lead to
cardiac arrest.2,3 Similarly, hyperphosphatemia is associated with mineral bone disorder and increases cardiovascular mortality risk in HD patients.4,5 Furthermore, the
presence of hypophosphatemia has been linked to muscle
weakness, ventilatory failure, myocardial dysfunction and
other complications.6 Moreover, recurrent fluid overload
leads to increased cardiac strain causing left ventricular
hypertrophy and ultimately dilatation, which leads to
higher cardiac mortality in these patients.7
HD patients are characterized by catabolic processes
that modify their body composition, such as inflammation, muscle wasting and declined visceral protein
stores.8–10 It is well recognized that a low protein intake
can predispose these patients to protein energy wasting,
and losses of amino acids during HD might also contribute. Bioimpedance spectroscopy (BIS) seems to be a valid
method for assessing and monitoring hydration and nutritional status in HD patients, and has been shown to be as
precise as the gold standard reference methods and considered as being of high reproducibility and specificity.11–13
Apart from determining the individual fluid status—total
body water, intra and extracellular water (ECW) independently, it analyzes body composition (body cell mass,
lean mass and fat mass) simply, objectively and
noninvasively.14–16 ECW is the compartment that predominantly reflects overhydration (OH).16,17
Nutritionists and dietitians are considered important
parts of the dialysis team, providing nutritional counseling
and following the effects of dietetic recommendations on
nutritional status and medical conditions of dialysis
patients.18–20 Dietary advice in HD patients is recommended by the European Best Practice Guidelines on
Nutrition as well as by the Kidney Disease Outcomes
Quality Iniciative, through a nutritional care plan and
individualized dietary counseling,2,21 which promotes an
accurate selection of food options.
The aim of this study was to prospectively evaluate the
effects of personalized nutritional counseling (PNC) in
laboratory parameters and body composition of HD
patients during 6 months of follow-up.
2
MATERIALS AND METHODS
Study design
This was a multicenter longitudinal intervention study of
a cohort of maintenance HD patients with 6 months of
follow-up.
Patients
This study was performed at 34 Nephrocare dialysis units
in Portugal. Between July 2013 and May 2014, 731
patients were assigned to receive PNC depending on their
biochemical and nutritional parameters.
At baseline, an individualized consultation by a renal
dietitian was provided to all participants with the aim
of improving patient’s altered parameters: Phosphorus
>5.5 mg/dL or <3.5 mg/dL, potassium >5.5 mEq/L,
interdialytic weight gain (IDWG) >4.5%, relative
OH/ECW ≥ 15% and/or nPCR < 1 g/kg/day. The consultation consisted of a 30- to 40-minute PNC session
through motivational advice focused on the altered
parameters. A 24-hour recall was also performed and
discussed with patients in order to recommend eating
habits changes and to empower them to get involved in
their health care. A laboratory results review with the
patients was also performed. A book containing information about fluid intake, potassium, phosphorus, protein,
sodium and additives management, and 16 recipes was
given to each patient. Whenever considered necessary,
written summarized advice with specific food alternatives
was also provided at the end of the session, and verbal
counseling was reinforced. Depending on the patient
shift, patient’s caregivers were invited to be present in the
consultation, which took place before or after the HD
treatment.
Inclusion criteria included age ≥18 years and three
times weekly in-center HD for ≥3 months (with an online
hemodiafiltration technique). All patients were dialyzed
with high-flux (Helixone®, Fresenius Medical Care
Deutschland GmbH, Germany) membranes and ultrapure
water in accordance with the criteria of ISO regulation
13959:2009—water for HD and related therapies.
Data analysis
Dry weight (DW), IDWG %, body mass index (BMI), lean
tissue index (LTI), fat tissue index (FTI), potassium, phosphorus, calcium/phosphorus (Ca/P) ratio and nPCR, were
recorded at baseline, 1, 3 and 6 months after the PNC.
Serum albumin was measured both at baseline and at the
end of the study. Anthropometric and biochemical data
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Nutritional counseling in hemodialysis
were registered before the midweek dialysis session, close
to the day in which the BIS was carried out.
Analysis of body composition
In all patients, BIS was carried out using the Body Composition Monitor (Fresenius Medical Care Deutschland
GmbH, Germany), which takes measurements at 50 frequencies in a range of 5–1000 kHz. The measurement was
performed approximately 30 minutes before the midweek
HD session, with four conventional electrodes being
placed in the patient, who was lying in the supine position: two electrodes on the hand and two electrodes on the
foot contralateral to the vascular access. Regarding the
quality of measurements, all exceeded 95%. LTI (kg/m2),
FTI (kg/m2) and OH/ECW were obtained directly through
BIS. One of the limitations documented by the manufacturer of the Body Composition Monitor consists of its use
in patients with major amputations of limbs or with pacemakers, as it does not guarantee that the measurements
will be accurate in these patients. Therefore, these patients
were excluded from the study.
Statistical analysis
All statistical tests were performed using the Statistical
Package for the Social Sciences (SPSS) 14.0 software
(SPSS, Inc., Chicago, IL, USA). Categorical variables were
described as percentage of relative frequencies and quantitative variables as mean (95% confidence interval [CI] ).
Differences between clinical data before and after PNC
were assessed by Student’s t-test for paired samples,
Cochran’s Q and Friedman’s test. A P value of <0.05 was
considered to be statistically significant.
RESULTS
This study included 731 patients of which, 53 (7.3%)
died, 9 (1.2%) were transplanted and 9 (1.2%) transferred
to other dialysis units during the study period. From the
remaining 660 patients, 43.8% were women and 34.4%
had diabetes, the mean age was 64.9 (95% CI: 63.8–66.0)
years and mean HD time was 59.8 (95% CI: 55.3–64.3)
months.
Patient’s baseline parameters are summarized in Table 1
as mean (95% CI). Of the total sample, 5.5% were underweight (BMI < 18.5 kg/m2), 44.2% had a BMI between
18.5 and 24.9 kg/m2, the prevalence of overweighed
patients was 28.6% (BMI 25.0–29.9 kg/m2) and 21.7%
were obese (BMI > 30.0 kg/m2).
The frequency of distribution of categorized parameters
over time among patients enrolled is shown in Table 2. At
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Table 1 Baseline characteristics of HD patients
participating in the study (mean [95% CI] )
Baseline n = 660
DW (kg)
nPCR (g/kg/day)
Albumin (g/dL)
K (mEq/L)
P(mg/dL)
Ca/P (mg/dL)
IDWG (%)
OH/ECW (%)
BMI (kg/m2)
FTI (kg/m2)
LTI (kg/m2)
68.83 (67.6–70.1)
1.13 (1.1–1.2)
3.93 (3.9–4.0)
5.54 (5.5–5.6)
4.51 (4.4–4.6)
40.05 (38.8–41.3)
3.50 (3.4–3.6)
8.97 (8.3–9.6)
25.86 (25.4–26.3)
13.31 (12.8–13.8)
12.6 (12.3–12.8)
BMI = body mass index; Ca/P = calcium/phosphorus ratio;
CI = confidence interval; DW = dry weight; FTI = fat tissue index;
IDWG = interdialytic weight gain; K = potassium; LTI = lean tissue
index; nPCR = normalized protein catabolic rate; OH/ECW = relative overhydration/extracellular water; P = phosphorus.
the end of the study all the parameters analyzed improved,
with the exception of hypophosphatemia and OH.
However, if we consider the effect of the PNC on the
altered parameters, on which it was focused on, a significant positive impact in all the data studied was observed
(Table 3).
DISCUSSION
Our findings suggest that PNC led to better outcomes that
support the relevance of this type of approach in avoiding
inappropriate food intake and improving nutritional
markers.
Although serum potassium levels at baseline were
above the desirable target, the nutritional intervention
demonstrated a significant and continuous decrease in the
number of patients with hyperkalemia from 52.0% to
35.8% (Table 2) while potassium mean within patients
with hyperkalemia had a reduction of 0.67 mEq/L
(P < 0.001) (Table 3). Changes in serum potassium are
frequent in HD patients and it may vary throughout the
day depending on food choices. Noori et al. state that
potassium levels in these patients are influenced by
dietary potassium intake, but they suggest that this occurs
only when the intake of potassium is too high or too low.
Moreover, these values are also affected by other factors
such as dialysis dose, schedule of HD treatments and the
degree of residual renal function. In the same study, the
authors found an association between the high intake of
potassium and the increased risk of death in patients on
HD,3 which reinforces the importance of limiting the daily
intake of potassium.
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Garagarza et al.
Table 2 Changes in different parameters at baseline and during follow-up (%)
nPCR ≥ 1 g/kg/day
Albumin ≥ 4,0 g/dL
K > 5,5 mEq/L
Phosphorus (mg/dL)
<3,5
3,5-5,5
>5,5
Ca/P ≤ 50 mg/dL
IDWG > 4,5%
OH/ECW ≥ 15%
Normal FTI (kg/m2)
Normal LTI (kg/m2)
Month 0
Month 1
Month 3
Month 6
P
66.5
54.8
52.0
71.6
—
43.8
71.7
—
39.8
73.5
55.0
35.8
0.01
0.81
<0.001
28.5
43.2
28.3
73.2
22.3
22.4
67.7
54.3
28.2
49.6
22.1
79.2
21.1
23.2
69.0
54.7
28.1
55.4
16.6
84.3
23.2
24.8
66.9
53.2
28.9
52.5
18.6
81.4
18.2
25.0
67.9
50.8
<0.001
<0.001
0.07
0.28
0.01
0.01
Ca/P = calcium/phosphorus ratio; FTI = fat tissue index; IDWG = interdialytic weight gain; K = potassium; LTI = lean tissue index;
nPCR = normalized protein catabolic rate; OH/ECW = relative overhydration/extracellular water; P = phosphorus.
In other studies, different laboratory values such as
phosphorus, calcium, Ca/P ratio and also knowledge
about dietary phosphorus management in patients with
serum phosphorus level >6.0 mg/dL, were measured
before and after intervention. Significant improvements
were found after 6 months of intervention.1,22 These
results are in line with those shown in our study as we
found a significant decrease in the prevalence of hyperphosphatemia as well as in the number of patients with
Ca/P > 50 mg/dL with a reduction of 1.32 mg/dL
(P < 0.001) and 11.07 mg/dL (P < 0.001), respectively
(Table 3).
Regarding hypophosphatemia in all the participants,
improvement was achieved during the first 3 months, but
after that period the number of cases rose (Table 2).
Despite this situation, after the intervention a slight
enhancement from 2.5 to 3.11 mg/dL (P < 0.001) was
observed in serum phosphorus of the hypophosphatemic
patients, showing a positive effect of the PNC. However,
the positive results achieved regarding the percentage of
patients with phosphorus within the target values (3.5–
5.5 mg/dL), might have been due to the correction of
hyperphosphatemia (Table 2).
It is important to highlight the high prevalence of hypophosphatemia seen among our study population, actually
higher than hyperphosphatemia. A low phosphorus value
is a simple marker of protein-energy wasting and is a risk
factor for the presence of comorbidities, including inflammation,23 although special attention must be paid in these
cases and specific dietetic recommendations must be
given in order to improve nutritional status.
Our data show that PNC was also effective in gradually
reducing the number of patients with low protein intake
(nPCR < 1 g/kg/day; P = 0.002) by improving mean nPCR
value after the first month of the intervention, which
remained similar until the end of the follow-up period
Table 3 Evolution of different measures during the study period in patients with altered parameters before the personalized
nutritional counseling (mean [95% CI] )
Albumin <4.0 g/dL
P < 3.5 mg/dL
P > 5.5 mg/dL
K > 5.5 mEq/L
Ca/P > 50 mg/dL
IDWG > 4.5 %
OH/ECW > 15%
nPCR < 1 g/kg/day
n
Month 0
Month 1
Month 3
Month 6
P
301
188
187
343
177
149
134
208
3.61 (3.5–3.6)
2.50 (2.4–2.6)
6.70 (6.6–6.8)
6.28 (6.2–6.3)
61.18 (59.9–62.5)
5.90 (5.7–6.2)
20.05 (19.2–20.9)
0.84 (0.8–0.9)
—
3.09 (2.9–3.2)
5.77 (5.6–6.0)
5.86 (5.8–5.9)
52.15 (5.02–54.2)
5.30 (5.0–5.6)
17.85 (16.8–18.9)
0.96 (0.9–1.0)
—
3.15 (3.0–3.3)
5.38 (5.2–5.6)
5.70 (5.6–5.8)
49.02 (47.1–51.0)
5.0 (4.8–5.4)
15.80 (14.3–17.3)
0.95 (0.9–1.0)
3.75 (3.7–3.8)
3.11 (3.0–3.3)
5.38 (5.2–5.6)
5.61 (5.5–5.7)
50.11 (48.1–52.2)
4.70 (4.4–5.0)
15.11 (13.7–16.6)
0.97 (0.9–1.0)
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
Abbreviations: Ca/P = calcium/phosphorus ratio; CI = confidence interval; IDWG = interdialytic weight gain; K = potassium; nPCR = normalized protein catabolic rate; OH/ECW = relative overhydration/extracelular water; P = phosphorus.
4
Hemodialysis International 2015; ••:••–••
Nutritional counseling in hemodialysis
(Table 3). Although nPCR levels are only valid in metabolically stable patients, some studies revealed that low
values (<1.2 g/kg body weight/day) have been associated
with increased morbidity, and a two to three times higher
death risk, showing that it is important to increase the
nPCR level in these patients, and therefore the daily
protein intake.24
Despite the rise in albumin of hypoalbuminemic
patients (P < 0.001) observed in our study, we have
noticed a modest and not statistical significant change in
patients with albumin within the desirable values
(Table 2). Albumin is well recognized as a strong predictor
of death in these patients and as it correlates with inflammation and other negative conditions, it is considered
a marker of illness rather than nutrition.25,26 In fact,
some authors propose nutritional counseling to improve
albumin19 while others do not find any changes in this
parameter after nutritional intervention, linking this situation to the multiple comorbid conditions that limit the
patient’s nutritional intake.7
The decrease in the number of patients with LTI within
desirable values (Table 2), observed at the third and sixth
months, supports the fact that HD is associated with
muscle and whole-body protein losses.27 Other studies
have also reported a decline in body composition markers
associated with nutritional status deterioration.22 Along
with this modification in the LTI, the frequency of patients
with normal FTI suffered a mild increase. The body fat
mass might be an independent risk factor of survival in
these patients, whereby a loss in fat mass is associated
with higher all-cause mortality28,29 and the fact that body
fat may reflect the severity of underlying disease and
decreased energy stores are reasons for this association.5
Thus, an adequate monitoring of nutritional status is an
important step for HD patients care and allows the identification of body composition alterations associated with
increased morbi-mortality.
The PNC focused on liquid intake showed a positive
impact on fluid status of overhydrated patients as the
mean value declined over the follow-up period. Nevertheless, the prevalence of severe OH within participants
increased during the study period (P = 0.283), suggesting
that some patients who were not severely overhydrated
(OH/ECW > 15%) at the beginning of the study, became
so after the intervention, probably because in these cases,
fluid intake was not the focus of the nutritional intervention or perhaps because of the need of adjusting patients
DW.30–32
These patients should keep close to normohydration
throughout the interdialytic interval controlling the fluid
intake between dialysis sessions. Both fluid overload and
Hemodialysis International 2015; ••:••–••
higher IDWG % are associated with higher morbidity,
poor survival and increased cardiovascular death in HD
patients.33–36 Although not significant (P > 0.005), the
prevalence of high IDWG (>4.5%) among patients
enrolled in this study decreased in the last month of the
study in comparison with baseline. Moreover, the IDWG
of patients with IDWG > 4.5% decreased significantly
during the follow-up, from 5.9% to 4.7% (P < 0.001)
(Table 3).
Clinical practice guidelines in chronic kidney disease
commonly recommends that patients in maintenance
HD must be regularly monitored and should have a
dietary interview with a renal dietitian every 3–6
months.2 Our results also emphasize this necessity as we
observed a light decline in some parameters, such as
hypophosphatemia and Ca/P ratio (Table 3) on the sixth
month after PNC and the best results for these parameters were achieved on the third month, suggesting that
it could be of interest to reinforce nutritional advisory at
this time. However, when comparing with baseline data,
all of the laboratory parameters, with the exception of
hypophosphatemia, improved significantly at the end of
the study.
It has already been demonstrated that studies integrating self-management tools into the educational material
and providing individualized counseling by a renal dietitian are those with large effect size.1,20 Dietary compliance
is critical in the treatment of HD patients and, consequently, educating patients must be one of the major
concerns of renal dietitians.1
There are some limitations to this study. First, this study
was designed as an intervention study, but there was no
control group. Finally, in the data collection, there was
little account for the effect of comorbid illness, including
markers of inflammation, on changes in dietary intake and
nutritional status.
In summary, the results obtained in the present study
show that individualized nutritional counseling is effective in improving parameters that have been associated
with nutritional status and adverse outcomes in patients
with end-stage renal disease. Nutritionists and dietitians
through nutritional counseling and with the support of
educational material, created specifically for these
patients, can increase patient’s knowledge about diet and
empower them with new skills and encouragement to
have more appropriate food choices.
Dietetic professionals can promote behavioral changes
and maintain long-term adherence to recommended
dietary regimens and optimal nutrition prescription that
can contribute to reduce cardiovascular risk factors and
prevent malnutrition.
5
Garagarza et al.
Manuscript received September 2014; revised November
2014.
15
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