Comparison of diet quality tools to assess nutritional adequacy for adults living with kidney disease.

There is no specific diet quality tool recommended for adults living with chronic kidney disease (CKD). Identifying how diet quality tools assess nutritional adequacy and correlate with potassium and phosphorus (nutrients of interest in CKD) is warranted. Our aim was to compare Mediterranean Diet Scores (MDS), Healthy Eating Index (HEI), and Healthy Food Diversity (HFD) to determine their correlation with nutrient intake in adults living with diabetes and CKD. Using data from a longitudinal study of 50 participants with diabetes and CKD, diet quality was assessed at baseline and 1 or more times at annual visits up to 5 years (complete diet records n = 178). Diet quality was investigated for correlation with nutrient intake. Compared with HEI and HFD, MDS was poorly correlated with nutrient intake (all r values <0.40). HFD and HEI were moderately correlated with potassium (r = 0.66, P < 0.01 and r = 0.57, P < 0.01, respectively). HEI was weakly correlated with phosphorus (r = 0.365, P < 0.01). MDS recommends moderation of dairy and meat, this may have specific benefits for CKD as these are both sources of phosphorus, as such high MDS were associated with lower phosphorus intake. This study suggests that development of a renal specific diet quality assessment tool may be useful; however, further studies are needed.

Assessing Global Kidney Nutrition Care.

BACKGROUND AND OBJECTIVES: Nutrition intervention is an essential component of kidney disease management. This study aimed to understand current global availability and capacity of kidney nutrition care services, interdisciplinary communication, and availability of oral nutrition supplements. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: The International Society of Renal Nutrition and Metabolism (ISRNM), working in partnership with the International Society of Nephrology (ISN) Global Kidney Health Atlas Committee, developed this Global Kidney Nutrition Care Atlas. An electronic survey was administered among key kidney care stakeholders through 182 ISN-affiliated countries between July and September 2018. RESULTS: Overall, 160 of 182 countries (88%) responded, of which 155 countries (97%) answered the survey items related to kidney nutrition care. Only 48% of the 155 countries have dietitians/renal dietitians to provide this specialized service. Dietary counseling, provided by a person trained in nutrition, was generally not available in 65% of low-/lower middle-income countries and "never" available in 23% of low-income countries. Forty-one percent of the countries did not provide formal assessment of nutrition status for kidney nutrition care. The availability of oral nutrition supplements varied globally and, mostly, were not freely available in low-/lower middle-income countries for both inpatient and outpatient settings. Dietitians and nephrologists only communicated "sometimes" on kidney nutrition care in ≥60% of countries globally. CONCLUSIONS: This survey reveals significant gaps in global kidney nutrition care service capacity, availability, cost coverage, and deficiencies in interdisciplinary communication on kidney nutrition care delivery, especially in lower-income countries.

Concentrations of Trace Elements in Hemodialysis Patients: A Prospective Cohort Study.

BACKGROUND: Low concentrations and excessive concentrations of trace elements have been commonly reported in hemodialysis patients, but available studies have several important limitations. STUDY DESIGN: Random sample of patients drawn from a prospective cohort. SETTING & PARTICIPANTS: 198 incident hemodialysis patients treated in 3 Canadian centers. MEASUREMENTS: We used mass spectrometry to measure plasma concentrations of the 25 elements at baseline, 6 months, 1 year, and 2 years following enrollment in the cohort. We focused on low concentrations of zinc, selenium, and manganese and excessive concentrations of lead, arsenic, and mercury; low and excessive concentrations of the other 19 trace elements were treated as exploratory analyses. Low and excessive concentrations were based on the 5th and 95th percentile plasma concentrations from healthy reference populations. RESULTS: At all 4 occasions, low zinc, selenium, and manganese concentrations were uncommon in study participants (≤5.1%, ≤1.8%, and ≤0.9% for zinc, selenium, and manganese, respectively) and a substantial proportion of participants had concentrations that exceeded the 95th percentile (≥65.2%, ≥74.2%, and ≥19.7%, respectively). Almost all participants had plasma lead concentrations above the 95th percentile at all time points. The proportion of participants with plasma arsenic concentrations exceeding the 95th percentile was relatively constant over time (9.1%-9.8%); the proportion with plasma mercury concentrations that exceeded the 95th percentile varied between 15.2% and 29.3%. Low arsenic, platinum, tungsten, and beryllium concentrations were common (>50%), as were excessive cobalt, manganese, zinc, vanadium, cadmium, selenium, barium, antimony, nickel, molybdenum, lead, and chromium concentrations. CONCLUSIONS: There was no evidence that low zinc, selenium, or manganese concentrations exist in most contemporary Canadian hemodialysis patients. Some patients have excessive plasma arsenic and mercury concentrations, and excessive lead concentrations were common. These findings require further investigation.

Vitamin D3 supplementation, bone health and quality of life in adults with diabetes and chronic kidney disease: Results of an open label randomized clinical trial.

BACKGROUND: Adults with diabetes (DM) and chronic kidney disease (CKD) are at risk for vitamin D (vitD) insufficiency, suboptimal bone health and reduced quality of life (QoL) due to limited sunlight exposure, poor vitD intake and CKD. AIMS: This open-labeled, randomized clinical trial, compared the impact of daily (2000 IU/D) verses monthly (40,000 IU/month) vitD3 supplementation over six months on markers of vitD status, bone health and QoL in adults with DM and CKD (stages: 1-4). METHODS: Participants (18-80 years) were randomized to daily (n = 60) or monthly (n = 60) vitD3 for six months. Primary outcomes included: vitD status (25-hydroxyvitD [25(OH)D], 1, 25-dihydroxyvitD [1,25(OH)2D], bone health (bone mineral density [BMD] and serum concentrations of bone-specific alkaline phosphatase [BSAP], osteocalcin [OC], N-telopeptide-type 1-collagen [NTx]) and Fibroblast Growth Factor-23 (FGF-23). Secondary outcomes included QoL (Short Form-36 questionnaire). RESULTS: Adherence by dose allocation over six months was 95.0 ± 5.7% (daily) and 94.1 ± 4.1% (monthly), respectively (p = 0.44); resulting in an overall median [95% CI] increase in serum 25(OH)D of 19 (12-26) nmol/L (p < 0.001). Serum 25(OH)D increased at three (p < 0.001) and six months (p < 0.001) in the daily and monthly groups, respectively. No significant differences over six months between groups were observed in serum concentrations of 1,25(OH)2D, FGF-23, OC and NTx, BMD and QoL measures (p > 0.05). Serum 25(OH)D ≥ 75 nmol/L was associated with significant reductions in BSAP (p = 0.01) and improved physical functioning vs those with concentrations < 75 nmol/L (62.5 ± 26.8 vs 52.7 ± 26.3; p = 0.03) in the monthly and daily groups, respectively. CONCLUSIONS: Daily (2000 IU/D) and monthly (40,000 IU/month) vitD3 supplementation for six months in adults with DM and CKD was safe, and resulted in equivalent adherence and improvements in overall vitD status, but only modest changes in markers of bone health and QoL.

Vitamin D Status and Bone Mineral Density is Influenced by Vitamin D Supplementation and Vitamin K1 Intake in Adults with Diabetes and Chronic Kidney Disease.

PURPOSE: Patients with diabetes (DM) and chronic kidney disease (CKD) are at increased risk for suboptimal bone health. The study objective was to investigate the relationships between vitamin D (vitD), vitamin K1 (vitK1), and calcium intake with bone mineral density (BMD) and vitamin D status in an ambulatory population with DM and CKD. METHODS: Adults (age 18-80 years; n = 62) with DM and CKD (stages 1-4) were recruited from the Northern Alberta Renal Program. Primary outcome variables included vitD, vitK1, and calcium intake; serum 25(OH)D, 1,25(OH)2D; and BMD as measured by dual X-ray absorptiometry. Statistical significance was determined at P < 0.05. RESULTS: Participants met the estimated average requirement or adequate intake for vitD, vitK1, and calcium intake in 73% (n = 45), 66% (n = 39), and 52% (n = 31), respectively, with a combined intake of micronutrient supplementation and diet. Participants had serum 25(OH)D concentrations ≥75 nmol/L (n = 41), normal BMDs (n = 48), and 66% (n = 41/62) were taking vitD supplements (>1000 IU/D). BMD was positively influenced by serum 25(OH)D. However, serum 25(OH) ≥100 nmol/L was associated with lower BMD (absolute and T-scores) for whole-body and spine (P ≤ 0.05). VitK1 intake (≥200 µg/day) was associated with higher whole-body and femoral-neck BMDs (absoluteand T-scores; P ≤ 0.05). CONCLUSION: VitD status and BMD in adults with DM and CKD was influenced by vitD supplementation and vitK1 intake.

Ferric pyrophosphate citrate (Triferic™) administration via the dialysate maintains hemoglobin and iron balance in chronic hemodialysis patients.

BACKGROUND: Administration of ferric pyrophosphate citrate (FPC, Triferic™) via hemodialysate may allow replacement of ongoing uremic and hemodialysis-related iron losses. FPC donates iron directly to transferrin, bypassing the reticuloendothelial system and avoiding iron sequestration. METHODS: Two identical Phase 3, randomized, placebo-controlled trials (CRUISE 1 and 2) were conducted in 599 iron-replete chronic hemodialysis patients. Patients were dialyzed with dialysate containing 2 µM FPC-iron or standard dialysate (placebo) for up to 48 weeks. Oral or intravenous iron supplementation was prohibited, and doses of erythropoiesis-stimulating agents were held constant. The primary efficacy end point was the change in hemoglobin (Hgb) concentration from baseline to end of treatment (EoT). Secondary end points included reticulocyte hemoglobin content (CHr) and serum ferritin. RESULTS: In both trials, Hgb concentration was maintained from baseline to EoT in the FPC group but decreased by 0.4 g/dL in the placebo group (P < 0.001, combined results; 95% confidence interval [CI] 0.2-0.6). Placebo treatment resulted in significantly larger mean decreases from baseline in CHr (-0.9 pg versus -0.4 pg, P < 0.001) and serum ferritin (-133.1 µg/L versus -69.7 µg/L, P < 0.001) than FPC treatment. The proportions of patients with adverse and serious adverse events were similar in both treatment groups. CONCLUSIONS: FPC delivered via dialysate during hemodialysis replaces iron losses, maintains Hgb concentrations, does not increase iron stores and exhibits a safety profile similar to placebo. FPC administered by hemodialysis via dialysate represents a paradigm shift in delivering maintenance iron therapy to hemodialysis patients.

"Vitamin D supplementation and bone health in adults with diabetic nephropathy: the protocol for a randomized controlled trial".

BACKGROUND: Suboptimal vitamin D status is highly prevalent in Northern communities, particularly in those patients with chronic diseases such as diabetes and chronic renal disease. Emerging literature suggests that adherence to daily vitamin D supplementation may be an important factor influencing vitamin D status and overall bone health, but compliance with therapies for bone health is a major challenge. It is unknown what level of vitamin D supplementation will ameliorate or improve suboptimal vitamin D status in patients with diabetic nephropathy or contribute to improved bone health, particularly for those living in northern climates. METHODS/DESIGN: The study purpose was to examine two different strategies of vitamin D3 supplementation; daily dosing of 2000 IU per day verses monthly dosing of 40,000 IU per month on markers of vitamin D status, bone health and to examine whether adherence, quality of life and patient satisfaction with the supplementation strategy differs between the two vitamin D strategies in adults diagnosed with diabetic nephropathy. DISCUSSION: The need for RCTs assessing higher doses of vitamin D3 supplementation at varying frequencies of administration and its impact on bone health in adults with diabetes and chronic kidney disease are needed. TRIAL REGISTRATION: ClinicalTrials.gov NCT01476501.

Cost analysis of in-centre nocturnal compared with conventional hemodialysis.

BACKGROUND: Provision of in-centre nocturnal hemodialysis (ICNHD; 6-8 hours thrice weekly) is associated with health benefits, but the economic implications of providing this treatment are unclear. OBJECTIVE: We conducted a health care costing study comparing ICNHD to in-centre thrice-weekly conventional hemodialysis (CvHD). DESIGN: Micro-costing of both ICNHD and CvHD as practiced at our centre. SETTING: Hemodialysis unit at a tertiary-care hospital in Edmonton. PARTICIPANTS: An informal survey of 2 other Canadian ICNHD programs was conducted to inform practices that may deviate from ours to guide sensitivity analysis. MEASUREMENTS: Resources consumed for each strategy were determined, and the cost of each unit (CAN $2012) was used to calculate incremental costs of ICNHD and CvHD. METHODS: We focused on resources that differ between strategies (staffing, dialysis materials, and utilities). The reference case considered 1:3 staff to patient ratio; alternate scenarios explored nursing pay grade and ratio, full care vs. self-care dialysis (including training costs), and medication costs. RESULTS: In the reference case, ICNHD was $61 more costly per dialysis treatment compared with CvHD ($9,538 per patient per year). Incremental annual costs for staffing, dialysis materials, and utilities were $8,201, $1,193, and $144, respectively. If ICNHD reduces medication use (anti-hypertensives, bone mineral metabolism medications), the incremental cost of ICNHD decreases to $8,620 per patient per year. In a scenario of self-care ICNHD utilizing a staff-to-patient ratio of 1:10, ICNHD is more costly in year 1 ($15,196), but results in cost savings of $2,625 in subsequent years compared with CvHD. LIMITATIONS: The findings of this cost analysis may not be generalizable to other health care systems, including other parts of Canada. CONCLUSIONS: Compared to CvHD, provision of ICNHD is more expensive, largely driven by increased staffing costs as patients dialyze longer. Alternate staffing models, including self-care ICNHD with minimal staff, may lead to net cost savings. The incremental cost of treatment should be considered in the context of impact on patient health outcomes, staffing model, and pragmatic factors, such as current capacity for daytime CvHD and the capital costs of new dialysis stations.

CONTEXTE: L'hémodialyse nocturne en centre (ICNHD; 6 à 8 heures, trihebdomadaire) est associée à des bienfaits pour la santé, mais nous connaissons mal les répercussions économiques de l'administration de ce traitement. OBJECTIFS: Nous avons effectué une étude des coûts de revient des soins de santé en comparant l'ICNHD à l'hémodialyse conventionnelle en centre sur une base trihebdomadaire (CvHD). TYPE D'ÉTUDE: Le calcul des coûts individuels de l'ICNHD et du CvHD tel qu'effectué dans notre centre. CONTEXTE/ÉCHANTILLON: Le service d'hémodialyse d'un hôpital de soins tertiaires d'Edmonton. PARTICIPANTS: On a effectué un sondage informel dans le cadre de deux programmes canadiens d'ICNHD afin d'indiquer les pratiques qui pourraient dévier des nôtres, permettant ainsi l'analyse de sensibilité. MESURES: Les ressources utilisées pour chacune des stratégies étaient déterminées, et le coût de chaque dialyseur (2 012 $CA) a été pris en compte dans le calcul du coût marginal de l'ICNHD et du CvHD. MÉTHODES: Nous nous sommes concentrés sur les ressources qui diffèrent selon la stratégie (dotation en personnel, matériel d'hémodialyse et équipements). L'hypothèse supposait un ratio personnel-patients de 1 :3; des scénarios alternatifs examinaient l'échelon de rémunération du personnel infirmier ainsi que les ratios, la prise en charge totale par rapport à l'auto-dialyse (incluant les coûts de formation), et le coût des médicaments. RÉSULTATS: Dans le scénario de référence, l'ICNHD s'est révélé 61 % plus coûteux par traitement de dialyse que le CvHD (9 538 $ par patient par an). Les coûts marginaux de dotation en personnel, du matériel de dialyse et des équipements étaient respectivement de 8 201 $, de 1 193 $ et de 144 $. Si l'ICNHD permet de diminuer l'utilisation de médicaments (antihypertenseurs, médicaments pour le métabolisme minéral osseux), le coût marginal de l'ICNHD diminue à 8 620 $ par patient par an. Dans le cas d'ICNHD en auto-dialyse, qui requiert un ratio personnel-patients de 1 :10, l'ICHND est plus coûteux la première année (15 196 $), mais les économies durant les années subséquentes le rendent comparables au CvHD. LIMITES DE L'ÉTUDE: Les conclusions de cette analyse de coûts peuvent se révéler peu valides pour d'autres systèmes de soins de santé, dont ceux d'autres régions du Canada. CONCLUSIONS: Comparativement au CvHD, la fourniture d'ICNHD est plus coûteuse, principalement en raison du personnel supplémentaire requis par des séances de dialyse prolongées. Des modèles de dotation alternatifs, incluant l'ICHND en auto-dialyse qui requiert un minimum de personnel, peut permettre des économies nettes. Le coût marginal du traitement devrait être considéré, en contexte, selon les répercussions possibles sur l'état de santé final des patients, les modèles de dotation, et des facteurs pragmatiques tels que la capacité actuelle du CvHD de jour et les coûts d'investissement de nouvelles stations de dialyse.

Quality of prereferral care in patients with chronic renal insufficiency.

BACKGROUND: Appropriate care in chronic renal insufficiency (CRI) includes blood pressure and diabetes control, as well as the investigation and management of anemia, acidosis, and bone disease. There is a lack of data on the control of these parameters at the time of referral to a nephrologist. Similarly, early referral has been emphasized in the literature, yet very little published has examined current referral patterns. METHODS: A single-center retrospective/prospective review of all new outpatient referrals to nephrologists in Halifax, Canada, in 1998 and 1999 was conducted to identify patients with CRI (serum creatinine > 1.6 mg/dL [141 micromol/L] for men or >1.2 mg/dL [106 micromol/L] for women). Quality of prereferral care was based on data from the initial clinic visit. RESULTS: Of 1,050 charts reviewed, 411 patients met the study criteria. Twenty-six percent of patients had diabetes mellitus, 18% were referred with a calculated glomerular filtration rate less than 15 mL/min, and blood pressure was optimally controlled (<130 mm Hg systolic and <80 mm Hg diastolic) in only 24%. Only 44% of patients were administered an angiotensin-converting enzyme inhibitor. Patients were administered an average of 1.9 antihypertensive agents. Significant anemia (hemoglobin < 10 g/dL) was present in 21%, and appropriate investigations were performed in only 35% of these patients. Calcium levels less than 8.6 mg/dL (2.15 mmol/L) were found in 19% of patients, and only 14% of these patients were started on calcium supplement therapy. Phosphate levels greater than 5.0 mg/dL (1.6 mmol/L) were seen in 20% of patients, and 14% of these patients were on phosphate-binder therapy. Parathyroid hormone levels were more than five times normal values in 18% of patients, and 25% of patients had bicarbonate levels less than 23 mmol/L. CONCLUSIONS: A significant proportion of patients referred with CRI receive inadequate prereferral care. Continuing education programs and referral guidelines must not only emphasize the importance of early referral, but also address the related consequences of CRI to delay the progression of renal disease and avoid complications.