Is intradialytic oral nutritional supplementation safe and effective on clinical outcomes? A systematic review with conventional meta-analysis and network meta-analysis.

AIM: determine the effect of intradialytic oral nutrition (ION) on clinical and safety outcomes. DESIGN: Systematic Review with conventional Meta-analysis, and a Network Meta-analysis (NMA) as sensitivity analysis. We searched on MEDLINE, LILACS, CENTRAL, and EMBASE in June 2020, and the last update was until August 2022. We selected observational and randomized controlled trials with ION for at least four weeks. Primary outcomes were all-cause mortality and quality of life (QoL); adverse events, physical performance, and appetite were secondary outcomes. RESULTS: Seven clinical trials and three observational studies were selected. Even when we did not obtain significant differences in physical performance and gastrointestinal symptoms, we identified a clinical improvement in the QoL's physical role, bodily pain, and physical performance domains. After pooling the data on mortality, a protection rate trend was observed in the ION group without statistical significance. The home-prepared ION was the best nutritional supplementation when assessing the appetite outcome through NMA. CONCLUSIONS: ION seems to have a protective trend in mortality risk; the current evidence is insufficient to establish a relationship with adverse events or other clinical outcomes. The lack of homogeneity in the trials makes it difficult to generalize these results. PROSPERO REGISTRATION: CRD42020186311.

Sleep Quality After Intradialytic Oral Nutrition: A New Benefit of This Anabolic Strategy? A Pilot Study.

Background: Since disturbances of appetite and sleep are closely related and both affect metabolic disorders, it would be expected that a renal specific oral nutritional supplement (RS-ONS) that covers the energy the patient does not consume on the HD day, could contribute to improve the nutritional status and body composition, as well as sleep quality. There is still scarce information related to this topic. Aim: To evaluate the effect of the use of intra-dialytic RS-ONS vs. RS-ONS at home on sleep quality, nutritional status, and body composition in patients on HD. Methods: Adult patients < 65 years, with ≥3 months on HD were invited to participate in an open randomized pilot study (ISRCTN 33897). Patients were randomized to a dialysis-specific high-protein supplement provided during the HD session (Intradialytic oral nutrition [ION]) or at home (control), during non-HD days (thrice weekly, for both) 12 weeks. The primary outcome was sleep quality defined by the Pittsburgh Sleep Quality Index (PSQI) score. Nutritional assessment included Malnutrition Inflammation Score (MIS), bioelectrical impedance analysis, anthropometry, 3-day food records, and routine blood chemistries. Results: A total of 23 patients completed the study. Age was median 35 (range 24-48 years), 42% were women. At baseline, the PSQI score was median 4 (range 2-7), and MIS showed a median of 6 (range 5-8); there were no baseline differences between groups. After intervention, both groups improved their MIS scores and similarly when we analyzed the whole cohort (pre- vs. post-intervention P < 0.01). Patients in the ION group improved the overall PSQI score to median 3 (2-5), and assessment of sleep duration and sleep disturbances (pre- vs. post-intervention P < 0.05), with a trend toward an effect difference compared to patients consuming the supplement at home (P for treatment-effect across arms 0.07 for PSQI score and 0.05 for sleep latency). Conclusion: Oral supplementation improved nutritional status in the whole cohort, but only ION improved the PSQI score. More studies are needed to explore the nutritional strategies that influence the relationship between sleep and nutritional status in HD patients.

Nutritional Status and Other Clinical Variables Are Associated to the Resting Energy Expenditure in Patients With Chronic Kidney Disease: A Validity Study.

Background: Estimating energy requirements (ER) is crucial for nutritional attention to chronic kidney disease (CKD) patients. Current guidelines recommend measuring ER with indirect calorimetry (IC) when possible. Due to clinical settings, the use of simple formulas is preferred. Few studies have modeled equations for estimating ER for CKD. Nevertheless, variables of interest such as nutritional status and strength have not been explored in these models. This study aimed to develop and validate a model for estimating REE in patients with CKD stages 3-5, who were not receiving renal replacement therapy (RTT), using clinical variables and comparing it with indirect calorimetry as the gold standard. Methods: In this study 80 patients with CKD participated. Indirect calorimetry (IC) was performed in all patients. The calorimeter analyzed metabolic measurements every minute for 15 min after autocalibration with barometric pressure, temperature, and humidity. Bioelectrical Impedance Analysis (BIA) was performed. Fat-free mass (FFM) was registered among other bioelectrical components. Handgrip strength (HGS) was evaluated and an average of 3 repetitions was recorded. Nutritional status was assessed with the subjective global assessment (SGA). Patients categorized as B or C were then considered as having malnutrition. Results: We analyzed 71 patients and 3 models were generated. Model 1a included FFM; Model 2a included weight; Model 3c included handgrip strength (HGS). All other variables were stepwise, computer-selected with a p < 0.01 significance level; Malnutrition was consistently associated with ER among other clinical variables in all models (p < 0.05). The model that included BIA-FFM had R 2 adjusted = 0.46, while the model that included weight (Kg) had an adjusted R 2 adjusted = 0.44. The models had moderate concordance, LC = 0.60-0.65 with the gold standard, whereas other energy expenditure estimation equations had LC = 0.36 and 0.55 with indirect calorimetry. Using these previously validated equations as a reference, our models had concordance values ranging from 0.66 to 0.80 with them. Conclusion: Models incorporating nutritional status and other clinical variables such as weight, FFM, comorbidities, gender, and age have a moderate agreement with REE. The agreement between our models and others previously validated for the CKD patient is good; however, the agreement between the latter and IC measurements is moderate. The KDOQI lowest recommendation (25 Kcals/kg body weight) considering the 22% difference with respect to the IC for total energy expenditure rather than for REE.

SURVEY ON THE PERCEPTION OF HEALTH PROFESSIONALS ON THE USE OF INTRADIALYTIC ORAL NUTRITION IN PATIENTS UNDER HEMODIALYSIS.

BACKGROUND: Intradialytic oral nutrition (ION) has been shown to improve many clinical outcomes, including lowering mortality, in hemodialysis (HD) patients. Despite the benefits, ION is underused in many countries. OBJECTIVE: The objective of our study was to determine the perception of health-care professionals (HCP) in our environment of the use of ION in patients undergoing HD. METHODS: Survey applied to HCP in Mexico who worked or had worked in an HD unit in their locality. RESULTS: From 272 HCP who answered the survey, 74.3% believed that the use of ION has at least one beneficial effect; of these, the most frequently mentioned were an improvement in quality of life (QoL) (54.7%) followed by an improvement in serum albumin (37.9%) and muscle anabolism (31.6%). However, 49% consider that its use involves some risks. Of the respondents, 22% reported that their HD units allowed patients to consume food or supplements during HD sessions; the main reason given to forbid the introduction of food or supplements was the clinic's policy (41%). CONCLUSIONS: The personnel surveyed heterogeneous opinions regarding ION, but most believe that it may improve the QoL or the nutritional status of the patients. Nevertheless, the use of ION is uncommon in our country as it is against the internal regulations of most HD units.

Survey on the perception of health professionals on the use of intradialytic oral nutrition in patients under hemodialysis

Abstract Background Intradialytic oral nutrition (ION) has been shown to improve many clinical outcomes, including lowering mortality, in hemodialysis (HD) patients. Despite the benefits, ION is underused in many countries. Objective The objective of our study was to determine the perception of health-care professionals (HCP) in our environment of the use of ION in patients undergoing HD. Methods Survey applied to HCP in Mexico who worked or had worked in an HD unit in their locality. Results From 272 HCP who answered the survey, 74.3% believed that the use of ION has at least one beneficial effect; of these, the most frequently mentioned were an improvement in quality of life (QoL) (54.7%) followed by an improvement in serum albumin (37.9%) and muscle anabolism (31.6%). However, 49% consider that its use involves some risks. Of the respondents, 22% reported that their HD units allowed patients to consume food or supplements during HD sessions; the main reason given to forbid the introduction of food or supplements was the clinic’s policy (41%). Conclusions The personnel surveyed heterogeneous opinions regarding ION, but most believe that it may improve the QoL or the nutritional status of the patients. Nevertheless, the use of ION is uncommon in our country as it is against the internal regulations of most HD units.