Acidosis: progression of chronic kidney disease and quality of life.

Metabolic acidosis (MA) is relatively common in patients with chronic kidney disease (CKD) particularly in stages 4 and 5. It is assumed to play a contributory role in the development of several complications including bone disease, skeletal muscle wasting, altered protein synthesis, and degradation. Recent evidence also suggests that even mild acidosis might play a role in progressive glomerular filtration rate loss. Experimental and clinical studies suggest that correction of acidosis by alkali therapy attenuates these complications and improves quality of life. Despite several recent small and single-center studies supporting this notion, more robust evidence is required with regard to the long-term benefits of alkali therapy, type of alkali supplements, and the optimal level of serum bicarbonate.

Oncology-Led Early Identification of Nutritional Risk: A Pragmatic, Evidence-Based Protocol (PRONTO).

Nutritional issues, including malnutrition, low muscle mass, sarcopenia (i.e., low muscle mass and strength), and cachexia (i.e., weight loss characterized by a continuous decline in skeletal muscle mass, with or without fat loss), are commonly experienced by patients with cancer at all stages of disease. Cancer cachexia may be associated with poor nutritional status and can compromise a patient's ability to tolerate antineoplastic therapy, increase the likelihood of post-surgical complications, and impact long-term outcomes including survival, quality of life, and function. One of the primary nutritional problems these patients experience is malnutrition, of which muscle depletion represents a clinically relevant feature. There have been recent calls for nutritional screening, assessment, treatment, and monitoring as a consistent component of care for all patients diagnosed with cancer. To achieve this, there is a need for a standardized approach to enable oncologists to identify patients commencing and undergoing antineoplastic therapy who are or who may be at risk of malnutrition and/or muscle depletion. This approach should not replace existing tools used in the dietitian's role, but rather give the oncologist a simple nutritional protocol for optimization of the patient care pathway where this is needed. Given the considerable time constraints in day-to-day oncology practice, any such approach must be simple and quick to implement so that oncologists can flag individual patients for further evaluation and follow-up with appropriate members of the multidisciplinary care team. To enable the rapid and routine identification of patients with or at risk of malnutrition and/or muscle depletion, an expert panel of nutrition specialists and practicing oncologists developed the PROtocol for NuTritional risk in Oncology (PRONTO). The protocol enables the rapid identification of patients with or at risk of malnutrition and/or muscle depletion and provides guidance on next steps. The protocol is adaptable to multiple settings and countries, which makes implementation feasible by oncologists and may optimize patient outcomes. We advise the use of this protocol in countries/clinical scenarios where a specialized approach to nutrition assessment and care is not available.

Gastrointestinal Tolerance and Protein Absorption Markers with a New Peptide Enteral Formula Compared to a Standard Intact Protein Enteral Formula in Critically Ill Patients.

The aim of this exploratory study was to investigate gastrointestinal tolerance and protein absorption markers with a new enteral peptide formula (PF) compared to an isocaloric enteral intact protein standard formula (SF) containing the same amount of protein in ICU patients. Patients admitted to a cardio-thoracic intensive care unit expected to receive tube feeding for ≥5 days were randomized to receive either PF (1.5 kcal/mL) or SF in a double-blind manner for ≤14 days. Twenty-six patients were randomized (13 SF and 13 PF) and 23 (12 SF and 11 PF) completed at least 5 days of product administration. There were no statistically significant differences between the feeds during the first 5 days of intervention for diarrhea (SF:3 (23%); PF:5 (39%), p = 0.388), vomiting (SF:1 (8%); PF:2 (15%), p = 0.549), constipation (SF:7 (54%), PF:3 (23%), p = 0.115), and high gastric residual volume (>500 mL: SF:1 (8%); PF: 2 (15%), p = 0.535). There were no differences in plasma amino acids or urinary markers of protein absorption and metabolism. In conclusion, no major differences were found in tolerability and protein absorption markers between the standard intact protein formula and the peptide formula.

Bicarbonate supplementation slows progression of CKD and improves nutritional status.

Bicarbonate supplementation preserves renal function in experimental chronic kidney disease (CKD), but whether the same benefit occurs in humans is unknown. Here, we randomly assigned 134 adult patients with CKD (creatinine clearance [CrCl] 15 to 30 ml/min per 1.73 m(2)) and serum bicarbonate 16 to 20 mmol/L to either supplementation with oral sodium bicarbonate or standard care for 2 yr. The primary end points were rate of CrCl decline, the proportion of patients with rapid decline of CrCl (>3 ml/min per 1.73 m(2)/yr), and ESRD (CrCl <10 ml/min). Secondary end points were dietary protein intake, normalized protein nitrogen appearance, serum albumin, and mid-arm muscle circumference. Compared with the control group, decline in CrCl was slower with bicarbonate supplementation (5.93 versus 1.88 ml/min 1.73 m(2); P < 0.0001). Patients supplemented with bicarbonate were significantly less likely to experience rapid progression (9 versus 45%; relative risk 0.15; 95% confidence interval 0.06 to 0.40; P < 0.0001). Similarly, fewer patients supplemented with bicarbonate developed ESRD (6.5 versus 33%; relative risk 0.13; 95% confidence interval 0.04 to 0.40; P < 0.001). Nutritional parameters improved significantly with bicarbonate supplementation, which was well tolerated. This study demonstrates that bicarbonate supplementation slows the rate of progression of renal failure to ESRD and improves nutritional status among patients with CKD.

Association Between AND-ASPEN Malnutrition Criteria and Hospital Mortality in Critically Ill Trauma Patients: A Prospective Cohort Study.

BACKGROUND: Malnutrition is prevalent in trauma victims because of intense muscle wasting triggered by traumatic events and is a mortality risk. The Academy of Nutrition and Dietetics-American Society for Parenteral and Enteral Nutrition (AND-ASPEN) tool has the potential to diagnose malnutrition in this population. This study aims to evaluate this criterion as a malnutrition diagnostic tool and as a hospital mortality predictor in critically ill trauma patients. METHODS: We performed an observational prospective cohort study from April 2015 to February 2017 in a Brazilian hospital. Patients were >18 years old, remained in the intensive care unit (ICU) >48 hours, and had completed data regarding the recommended clinical characteristics (RCCs) for malnutrition. The main exposure of interest was malnutrition assessed by a specialist dietitian using AND-ASPEN. The primary outcome was all causes of mortality during hospital stay. Secondary outcome was the RCCs assessment, to predict malnutrition and hospital mortality. RESULTS: Included were 414 trauma patients. Malnutrition prevalence was 26.8% at ICU admission. The main analysis showed that malnutrition increases mortality chances 1.96 times (95% CI, 1.13-3.30; P = .015). Secondary analysis showed that all 5 RCCs were significantly associated with malnutrition. The only RCC associated with mortality was energy intake (odds ratio 1.5; 95% CI, 1.1-2.0; P = .008). CONCLUSIONS: AND-ASPEN criterion is a feasible and accurate method to recognize malnutrition and predict hospital mortality when applied by trained dietitians for the critical care trauma population. Further studies are needed considering patient subgroups such as obese and elderly.

Diarrhea in Critically Ill Patients: The Role of Enteral Feeding.

This tutorial presents a systematic approach to the management of diarrhea in the critical care setting. Diarrhea is a common and prevalent problem in critically ill patients. Despite the high prevalence, its management is far from simple. Professionals are confronted with a myriad of definitions based on frequency, consistency, and volume. The causes are complex and multifactorial, yet enteral tube feeding formula is believed to be the perpetrator. Potential causes for diarrhea are discussed, and 3 case reports provide context to examine the treatment from a nutrition perspective. Each scenario is comprehensively addressed discussing potential causes and providing specific clinical strategies contributing to improved bowel function in this patient group. The approach used for diarrhea management is based on a complete understanding of enteral tube formula, their composition, and their impact in the presence of gut dysfunction. Choosing the right feeding formula may positively influence bowel function and contribute to improved nutrition.

Protected time for nutrition support teams: What are the benefits?

BACKGROUND & AIMS: Nutrition support teams (NSTs) are important and unique entities in acute care hospitals. Despite their utility, NSTs are lacking in the majority of hospitals worldwide and where they exist, most members only spend a fraction of their time working within that role. We aim to evaluate the effect of protected time on NST performance by assessing the influence of structure and process in NST activities. METHODS: All large public hospitals (>250 beds) in the Brazilian Federal District were evaluated with a structured questionnaire designed to assess NST performance. The questionnaire was adapted to include the Donabedian quality processes comprising 54 questions split amongst 6 domains; mainly structure and processes. The percentage of questionnaire compliance (NST outcome) was utilized to assess differences regarding structure and process. Hospitals with protected time to NST activities (Group I) were compared to hospitals without NSTs protected times (Group II). RESULTS: Seven hospitals were assessed. Group I, n = 3, showed a significantly higher performance outcome than Group II, n = 4 (77.9 × 60.3; P = 0.004), and only Group I's score achieved the benchmark for quality standards (75% compliance). Significant differences between groups were also found in structure (P = 0.017) and process (P = 0.014). CONCLUSIONS: This study indicates that protected time for NST activities is paramount to increase NST performance and could positively influence Donabedian quality indicators. Our results highlight the importance of NSTs in large hospitals and is an advocate for public policies requiring dedicated time for NST work. Only a larger study can confirm our findings.

The role of salt intake and salt sensitivity in the management of hypertension in South Asian people with chronic kidney disease: a randomised controlled trial.

BACKGROUND: The effectiveness of salt restriction to lower blood pressure (BP) in Bangladeshi patients with chronic kidney disease (CKD) is uncertain. OBJECTIVE: To test the hypothesis that a tailored intervention intended to reduce salt intake in addition to standard care will achieve a greater reduction in BP in UK Bangladeshi patients with CKD than standard care alone. DESIGN: A randomised parallel-group controlled trial conducted over a 6 month period. SETTING: A tertiary renal unit based in acute care hospital in East London. PARTICIPANTS: 56 adult participants of Bangladeshi origin with CKD and BP >130/80 mm Hg or on antihypertensive medication. INTERVENTION: Participants were randomly allocated to receive a tailored low-salt diet or the standard low-salt advice. BP medication, physical activity and weight were monitored. MAIN OUTCOME MEASURES: The primary outcome was change in ambulatory BP. Adherence to dietary advice was assessed by measurement of 24 h urinary salt excretion. RESULTS: Of 56 participants randomised, six withdrew at the start of the study. During the study, one intervention group participant died, one control group participant moved to Bangladesh. Data were available for the primary endpoint on 48 participants. Compared with control group the intervention urinary sodium excretion fell from 260 mmol/d to 103 mmol/d (-131 to -76, p<0.001) at 6 months and resulted in mean (95% CI) falls in 24 h systolic/diastolic BP of -8 mm Hg (-11 to -5)/2 (-4 to -2) both p<0.001. CONCLUSIONS: A tailored intervention can achieve moderate salt restriction in patients with CKD, resulting in clinically meaningful falls in BP independent of hypertensive medication. TRIAL REGISTRATION: ClinicalTrials.gov NCT00702312.