Case Study: The Weighty Issue of Treatment Options for Obese Dialysis Patients.

Obesity is a complex chronic disease and common comorbidity in kidney failure and is the leading causes of death and disability in this population. Guidelines do not specifically address the preferred weight management option(s) for obesity while on dialysis. Large body size is a limiting factor for consideration of a kidney transplantation. We report on a successful bariatric surgery with a young adult after 5.5 years on dialysis with hope for a future transplant. Success was demonstrated with progressive weight loss without adverse changes in renal clinical markers accompanied by improvements in exercise tolerance and health status thereby improving her suitability for a kidney transplant. Further studies and guidelines are needed to address weight loss options for those with obesity on dialysis and want to lose weight.

Medical Nutrition Therapy Provided by Dietitians is Effective and Saves Healthcare Costs in the Management of Adults with Dyslipidemia.

PURPOSE OF REVIEW: Referral to nutrition care providers in the USA such as registered dietitian nutritionists (RDNs) for medical nutrition therapy (MNT) remains low. We summarize research on the effectiveness of MNT provided by dietitians versus usual care in the management of adults with dyslipidemia. Improvements in lipids/lipoproteins were examined. If reported, blood pressure (BP), fasting blood glucose (FBG) glycated hemoglobin (A1c), body mass index (BMI), and cost outcomes were also examined. RECENT FINDINGS: The synthesis of three systematic reviews included thirty randomized controlled trials. Multiple MNT visits (3-6) provided by dietitians, compared with usual care, resulted in significant improvements in total cholesterol (mean range: - 4.64 to - 20.84 mg/dl), low-density lipoprotein cholesterol (mean range: - 1.55 to - 11.56 mg/dl), triglycerides (mean range: - 15.9 to - 32.55 mg/dl), SBP (mean range: - 4.7 to - 8.76 mm Hg), BMI (mean: - 0.4 kg/m2), and A1c (- 0.38%). Cost savings from MNT were attributed to a decrease in medication costs and improved quality of life years (QALY). Multiple MNT visits provided by dietitians compared with usual care improved lipids/lipoproteins, BP, A1c, weight status, and QALY with significant cost savings in adults with dyslipidemia and justify a universal nutrition policy for equitable access to MNT.

Effectiveness of medical nutrition therapy in the management of adult dyslipidemia: A systematic review and meta-analysis.

Cardiovascular disease (CVD) is a leading cause of mortality in the United States. Many primary risk factors, such as dyslipidemia and blood pressure, are modifiable with diet and lifestyle interventions. Therefore, the objective of this systematic review and meta-analysis was to evaluate the effectiveness of medical nutrition therapy (MNT) interventions provided by registered dietitian nutritionists (RDN) or international equivalents, compared to usual care or no MNT, on lipid profile and blood pressure (secondary outcome) in adults with dyslipidemia. The databases MEDLINE, CINAHL, Cochrane CENTRAL, and Cochrane Database of Systematic Reviews were searched for randomized controlled trials (RCTs) published between January 2005 and July 2021. Meta-analyses were performed using a random-effects model for lipid outcomes (seven RCTs, n=838), systolic blood pressure (SBP) (three RCTs, n=308), and diastolic blood pressure (DBP) (two RCTs, n=109). Compared to usual care or no intervention, MNT provided by RDNs improved total cholesterol (total-C) [mean difference (95% CI): -20.84 mg/dL (-40.60, -1.07), P=0.04]; low-density lipoprotein cholesterol (LDL-C) [-11.56 mg/dL (-21.10, -2.03), P=0.02]; triglycerides (TG) [-32.55 mg/dL (-57.78, -7.32), P=0.01];; and SBP [ -8.76 mm Hg (-14.06 lower to -3.45) P<0.01].High-density lipoprotein cholesterol (HDL-C) [1.75 mg/dl (-1.43, 4.92), P=0.28] and DBP [-2.9 mm Hg (-7.89 to 2.09), P=0.25] were unchanged. Certainty of evidence was moderate for total-C, LDL-C, and TG, and low for HDL-C, SBP, and DBP. In conclusion, in adults with dyslipidemia, MNT interventions provided by RDNs are effective for improving serum lipids/lipoproteins and SBP levels.

Association of Urine Findings with Metabolic Syndrome Traits in a Population of Patients with Nephrolithiasis.

Background: The odds of nephrolithiasis increase with more metabolic syndrome (MetS) traits. We evaluated associations of metabolic and dietary factors from urine studies and stone composition with MetS traits in a large cohort of stone-forming patients. Methods: Patients >18 years old who were evaluated for stones with 24-hour urine collections between July 2009 and December 2018 had their records reviewed retrospectively. Patient factors, laboratory values, and diagnoses were identified within 6 months of urine collection and stone composition within 1 year. Four groups with none, one, two, and three or four MetS traits (hypertension, obesity, dyslipidemia, and diabetes) were evaluated. Trends across groups were tested using linear contrasts in analysis of variance and analysis of covariance. Results: A total of 1473 patients met the inclusion criteria (835 with stone composition). MetS groups were 684 with no traits, 425 with one trait, 211 with two traits, and 153 with three or four traits. There were no differences among groups for urine volume, calcium, or ammonium excretion. There was a significant trend (P<0.001) for more MetS traits being associated with decreasing urine pH, increasing age, calculated dietary protein, urine uric acid (UA), oxalate, citrate, titratable acid phosphate, net acid excretion, and UA supersaturation. The ratio of ammonium to net acid excretion did not differ among the groups. After adjustment for protein intake, the fall in urine pH remained strong, while the upward trend in acid excretion was lost. Calcium oxalate stones were most common, but there was a trend for more UA (P<0.001) and fewer calcium phosphate (P=0.09) and calcium oxalate stones (P=0.01) with more MetS traits. Conclusions: Stone-forming patients with MetS have a defined pattern of metabolic and dietary risk factors that contribute to an increased risk of stone formation, including higher acid excretion, largely the result of greater protein intake, and lower urine pH.

Do the high-protein recommendations for athletes set some on a path to kidney injury and dialysis?

Athletes and fitness enthusiasts are often encouraged to follow high-protein diets to optimize muscle protein synthesis, modify body composition, and enhance performance, yet the safety of these higher protein intakes has been debated. Many people with kidney dysfunction are unaware of their condition, and the potential harm of excess protein intake on the kidneys may not be adequately reported in the sports nutrition literature. Studies suggesting that high-protein intake may be associated with incident kidney disease have led the nephrology community to make conservative recommendations. In contrast, the fitness community suggests that high dietary protein intake is safe and poses no risk of kidney injury. These claims often fail to acknowledge limitations in the internal validity and generalizability of the study results, despite many studies not being adequately powered to support such claims. It is essential to make dietary recommendations that consider the totality of the data and follow the ethical norm of "do no harm." Studies that evaluate the use of high-protein diets among athletes must consider the balance of efficacy with safety. While an intervention may be safe in one population, it does not mean that safety can be assumed for all groups.

Hemodialysis using a low bicarbonate dialysis bath: Implications for acid-base homeostasis.

The low bath bicarbonate concentration ([ HCO3- ]) used by a nephrology group in Japan (25.5 mEq/L), coupled with a bath [acetate] of 8 mEq/L, provided an opportunity to study the acid-base events occurring during hemodialysis when HCO3- flux is from the patient to the bath. We used an analytic tool that allows calculation of HCO3- delivery during hemodialysis and the physiological response to it in 17 Japanese outpatients with an average pre-dialysis blood [ HCO3- ] of 25 mEq/L. Our analysis demonstrates that HCO3- addition is markedly reduced and that all of it comes from acetate metabolism. The HCO3- added to the extracellular fluid during treatment (19.5 mEq) was completely consumed by H+ mobilization from body buffers. In contrast to patients dialyzing with higher bath [ HCO3- ] values in the US and Europe, organic acid production was suppressed rather than stimulated. Dietary analysis indicates that these patients are in acid balance due to the alkaline nature of their diet. In a larger group of patients using the same bath solution, pre-dialysis blood [ HCO3- ] was lower, 22.2 mEq/L, but still in an acceptable range. Our studies indicate that a low bath [ HCO3- ] is well tolerated and can prevent stimulation of organic acid production.

Medical Nutrition Therapy for Chronic Kidney Disease Improves Biomarkers and Slows Time to Dialysis.

OBJECTIVE: To investigate whether medical nutrition therapy (MNT) provided by a registered dietitian experienced in chronic kidney disease (CKD) slows the progression of disease and improves nutrition-related biomarkers. DESIGN: Retrospective cohort study. SUBJECTS: The cohort included 265 participants from a regional nephrology center in a rural state; 147 of who received MNT were compared to a group that did not receive MNT and had started dialysis over a 10-year period. INTERVENTION: MNT by a registered dietitian with expertise in CKD. MAIN OUTCOME MEASURE: Average time to dialysis, based on stage of CKD at baseline, was compared between groups. In addition, the effect of MNT on the change in biochemical measures for estimated glomerular filtration rate, blood urea nitrogen, albumin, CKD Mineral and Bone Disorder (MBD) markers (phosphorous, calcium, and intact parathyroid hormone) at baseline and at follow-up (dialysis initiation or most recent laboratories if dialysis was not started) was assessed. RESULTS: MNT group had less of a decline in estimated glomerular filtration rate than the non-MNT group (0.3 vs. 9.9 mL/minute/1.73 m(2), respectively) a mean difference of 9.6 (P < 0.001). When adjusted for stage using linear regression, the mean difference was greater (11.4, P < .001). Using survival analysis and Cox proportional hazards regression, the non-MNT group was 3.15 more likely to initiate dialysis. Stratified by Stages 3 and 4 that hazard ratio increased (3.47 and 3.45, respectively). Albumin and markers of CKD-MBD were more likely to be within normal limits in the MNT group. The results indicate that better outcomes occur when MNT is given at CKD Stage 3 or 4 rather than CKD Stage 5. CONCLUSIONS: Results suggest that people with CKD who received MNT were less likely to start dialysis and had improved nutritional biomarkers than participants who did not receive MNT.