Does intradialytic oral nutrition impact hemodialysis patients' quality of life, appetite, and safety? a pilot study of a crossover clinical trial / ¿La nutrición oral intradialítica impacta en la calidad de vida, el apetito y la seguridadde los pacientes en hemodiálisis? Estudio piloto de un ensayo clínico cruzado

Introduction: due to the catabolic characteristics of hemodialysis (HD), patients should consume foods or supplements during this treatment to meet their energy requirements and maintain a neutral nitrogen balance; however, there are some outcomes in which the effect of intradialytic oral nutrition (ION) is scarcely known. Objectives: this study aims to evaluate the effect of two types of ION (liquid and solid) on Quality of Life (QoL), appetite, and safety in HD patients. Methods: a pilot randomized, crossover clinical trial was performed in 18 patients on chronic HD. One group received ION for 18 HD sessions, after the crossover continued for 18 more sessions in the control group, and vice versa. We recorded QoL, appetite, systolic blood pressure (SBP), and intradialytic hypotension (IH) events. Results: clinical improvement was observed for most QoL components. Regardless of the consistency of supplementation, SBP increased to 4.10 mmHg. Both study groups reported a “very good-to-good” appetite. Conclusion: favorable clinical changes were observed in QoL scores during the study. Five of six IH events were reported for patients in the ION group, and SBP increased within the safe range (≤ 10 mmHg); appetite remained stable in both groups. Therefore, we concluded that this strategy, regardless of implementation consistency, is safe to be used in stable patients.(AU)

Introducción: debido a las características catabólicas de la hemodiálisis (HD), los pacientes deben consumir alimentos o suplementos durante este tratamiento para cubrir sus requerimientos energéticos y mantener un balance nitrogenado neutro; sin embargo, existen algunos desenlaces en los que el efecto de la nutrición oral intradialítica (NOID) es poco conocido.Objetivo: este estudio tiene como objetivo evaluar el efecto de dos tipos de NOID (líquido y sólido) sobre la calidad de vida, el apetito y la seguridad en pacientes en HD. Métodos: se realizó un estudio piloto en forma de ensayo clínico aleatorizado y cruzado con 18 pacientes en HD crónica. Un grupo recibió NOID durante 18 sesiones de HD, después del cruzamiento continuaron durante 18 sesiones más en el grupo de control, y viceversa. Se registraron la calidad de vida, el apetito, la presión arterial sistólica (PAS) y la hipotensión intradialítica (HI).Resultados: se observó mejoría clínica en la mayoría de los componentes de la calidad de vida. Independientemente de la consistencia de la suplementación, la PAS aumentó hasta 4,10 mmHg. Ambos grupos de estudio informaron de un apetito "muy bueno-bueno". Conclusiones: se observaron cambios clínicos favorables en las puntuaciones de calidad de vida durante el estudio. Cinco de seis eventos de HI se reportaron en pacientes del grupo de NOID y la PAS aumentó dentro del rango seguro (≤ 10 mmHg); el apetito se mantuvo estable en ambos grupos. Por lo tanto, se puede concluir que esta estrategia, independientemente de la consistencia implementada, es segura para ser utilizada en pacientes estables.(AU)

Does intradialytic oral nutrition impact hemodialysis patients' quality of life, appetite, and safety? A pilot study of a crossover clinical trial.

Introduction: Introduction: due to the catabolic characteristics of hemodialysis (HD), patients should consume foods or supplements during this treatment to meet their energy requirements and maintain a neutral nitrogen balance; however, there are some outcomes in which the effect of intradialytic oral nutrition (ION) is scarcely known. Objectives: this study aims to evaluate the effect of two types of ION (liquid and solid) on Quality of Life (QoL), appetite, and safety in HD patients. Methods: a pilot randomized, crossover clinical trial was performed in 18 patients on chronic HD. One group received ION for 18 HD sessions, after the crossover continued for 18 more sessions in the control group, and vice versa. We recorded QoL, appetite, systolic blood pressure (SBP), and intradialytic hypotension (IH) events. Results: clinical improvement was observed for most QoL components. Regardless of the consistency of supplementation, SBP increased to 4.10 mmHg. Both study groups reported a "very good-to-good" appetite. Conclusion: favorable clinical changes were observed in QoL scores during the study. Five of six IH events were reported for patients in the ION group, and SBP increased within the safe range (≤ 10 mmHg); appetite remained stable in both groups. Therefore, we concluded that this strategy, regardless of implementation consistency, is safe to be used in stable patients.

Introducción: Introducción: debido a las características catabólicas de la hemodiálisis (HD), los pacientes deben consumir alimentos o suplementos durante este tratamiento para cubrir sus requerimientos energéticos y mantener un balance nitrogenado neutro; sin embargo, existen algunos desenlaces en los que el efecto de la nutrición oral intradialítica (NOID) es poco conocido. Objetivo: este estudio tiene como objetivo evaluar el efecto de dos tipos de NOID (líquido y sólido) sobre la calidad de vida, el apetito y la seguridad en pacientes en HD. Métodos: se realizó un estudio piloto en forma de ensayo clínico aleatorizado y cruzado con 18 pacientes en HD crónica. Un grupo recibió NOID durante 18 sesiones de HD, después del cruzamiento continuaron durante 18 sesiones más en el grupo de control, y viceversa. Se registraron la calidad de vida, el apetito, la presión arterial sistólica (PAS) y la hipotensión intradialítica (HI). Resultados: se observó mejoría clínica en la mayoría de los componentes de la calidad de vida. Independientemente de la consistencia de la suplementación, la PAS aumentó hasta 4,10 mmHg. Ambos grupos de estudio informaron de un apetito "muy bueno-bueno". Conclusiones: se observaron cambios clínicos favorables en las puntuaciones de calidad de vida durante el estudio. Cinco de seis eventos de HI se reportaron en pacientes del grupo de NOID y la PAS aumentó dentro del rango seguro (≤ 10 mmHg); el apetito se mantuvo estable en ambos grupos. Por lo tanto, se puede concluir que esta estrategia, independientemente de la consistencia implementada, es segura para ser utilizada en pacientes estables.

Evaluation of the introduction of novel potassium binders in routine care; the Stockholm CREAtinine measurements (SCREAM) project.

BACKGROUND: The pharmacological management of hyperkalemia traditionally considered calcium or sodium polystyrene sulfonate and, since recently, the novel binders patiromer and sodium zirconium cyclosilicate. We evaluated their patterns of use, duration of treatment and relative effectiveness/safety in Swedish routine care. METHODS: Observational study of adults initiating therapy with sodium polystyrene sulfonate or a novel binder (sodium zirconium cyclosilicate or patiromer) in Stockholm 2019-2021. We quantified treatment duration by repeated dispensations, compared mean achieved potassium concentration within 60 days, and potential adverse events between treatments. RESULTS: A total of 1879 adults started treatment with sodium polystyrene sulfonate, and 147 with novel binders (n = 41 patiromer and n = 106 sodium zirconium cyclosilicate). Potassium at baseline for all treatments was 5.7 mmol/L. Sodium polystyrene sulfonate patients stayed on treatment a mean of 61 days (14% filled ≥3 consecutive prescriptions) compared to 109 days on treatment (49% filled ≥3 prescriptions) for novel binders. After 15 days of treatment, potassium similarly decreased to 4.6 (SD 0.6) and 4.8 (SD 0.6) mmol/L in the sodium polystyrene sulfonate and novel binder groups, respectively, and was maintained over the 60 days post-treatment. In multivariable regression, the odds ratio for novel binders (vs sodium polystyrene sulfonate) in reaching potassium ≤ 5.0 mmol/L after 15 days was 0.65 (95% CI 0.38-1.10) and after 60 days 0.89 (95% CI 0.45-1.76). Hypocalcemia, hypokalemia, and initiation of anti-diarrheal/constipation medications were the most-commonly detected adverse events. In multivariable analyses, the OR for these events did not differ between groups. CONCLUSION: We observed similar short-term effectiveness and safety for all potassium binders. However, treatment duration was longer for novel binders than for sodium polystyrene sulfonate.

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.

Pharmacological strategies to manage hyperkalaemia: out with the old, in with the new? Not so fast .

Since the 1950s, sodium polystyrene sulphonate (SPS) has been the dominant cation exchange agent prescribed for hyperkalaemia. Clinicians have had plenty of time to learn of SPS's advantages and limitations. The demands of drug regulatory agencies regarding the incorporation of medications into the market were not so stringent then as they are today, and the efficacy and safety of SPS have been questioned. In recent years, two novel cation exchangers, patiromer and sodium zirconium cyclosilicate, have received (or are in the process of receiving) regulatory approval in multiple jurisdictions globally, after scrutiny of carefully conducted trials regarding their short-term and mid-term efficacy. In this debate, we defend the view that all three agents are likely to have similar efficacy. Harms are much better understood for SPS than for newer agents, but currently there are no data to suggest that novel agents are safer than SPS. Drug choices need to consider costs, access and numbers-needed-to-treat to prevent clinically important events; for potassium exchangers, we need trials directly examining clinically important events.

Impact of SARS-CoV-2 Pandemic on food Security in Patients With chronic Kidney Disease.

OBJECTIVE: The present study aims to determine the degree of Food Insecurity (FI) in adult patients with CKD during the COVID-19 pandemic, as well as the association between FI and food consumption. METHODS: A cross-sectional study was conducted on patients with chronic kidney disease (CKD), with and without substitutive treatment, and older than 18 years of age. Food security was measured using the Mexican Food Security Scale (MFSS). Sociodemographic data and a food frequency questionnaire were obtained. Multinomial logistic regression was performed using the 4 categories of food security (food security as reference); principal component analysis was also performed to assess the relationship between food consumption patterns and sociodemographic characteristics. RESULTS: The prevalence of FI in patients with CKD was 71.6%, the most prevalent degree of FI was moderate. As FI increased, a greater amount of beans, eggs, sweets/desserts, soft drinks, and artificial juices (P < .001) was consumed. The risk factors of FI were diabetes, hypertension, unpaid occupation, living in the country's capital, having children at home, or a decrease in income due to the pandemic. Four main components were identified that were associated with the different degrees of FI. CONCLUSION: The present study allowed us to conclude that more than 70% of CKD patients in the study cohort had some type of FI, which makes it difficult to adhere to treatment and may increase the risk of advanced CKD. A less healthy food pattern is associated with greater FI.

Animal Protein Intake and Possible Cardiovascular Risk in People With Chronic Kidney Disease: Mechanisms and Evidence.

Individuals with chronic kidney disease (CKD) have an increased risk of cardiovascular disease (CVD), and the kidney function is a critical determinant of this risk. CKD is also a major cause of complications and disease progression in patients with CVD. Practice guidelines suggest that CVD risk in CKD patients can be managed through healthy lifestyle and dietary behaviors. Assessing the impact of diet on heart and kidney health is complex because numerous bioactive compounds from diet may contribute to or prevent CVD or CKD via a myriad of pathways and mechanisms. The objective of this review was to provide a discussion of the mechanisms and evidence linking protein-rich foods and CVD risk in people with CKD. This review highlights the current evidence-based strategies for primary CKD prevention that incorporate a healthy dietary pattern, while tertiary prevention strategies focus on avoiding excess protein and reducing dietary acid load. The effect of protein restriction for improving CVD and CKD outcomes is conflicting; however, these approaches show no negative effects on kidney health. Low-protein and very low-protein diets are promising interventions for reducing the progression of CKD and CVD. Animal-sourced protein may be more detrimental to kidney health than plant-sourced protein due to specific acid load, amino acid composition, generation of uremic toxins, accompanying saturated fat content, low fiber composition, and higher generation of advanced glycation end-products. There are no one-size fits all nutrition prescriptions. Personalized nutrition interventions that target the unique risk factors for CVD associated with reduced kidney function are required to improve the health of people living with CKD.

Agreement between vector analysis and body composition measurements by four types of bioelectrical impedance technology in hemodialysis patients.

Introduction: Background: the differences in bioelectrical impedance vector analysis (BIVA) results from different analyzers that use different bioelectrical impedance analysis (BIA) measurement technologies are not known. This study aimed to identify the degree of agreement between the BIVA results of four different BIA measurement techniques and to evaluate the degree of agreement between their estimates of fat-free mass (FFM) and fat mass (FM) and those determined by the gold-standard method of dual-energy X-ray absorptiometry (DEXA) in a subgroup of patients without overhydration. Methods: a cross-sectional study was conducted with hemodialysis (HD) patients with end-stage renal disease (ESRD) aged 18 to 65 years. BIA was measured with four different techniques: spectroscopic (BIA-BIS), multifrequency (BIA-MF), single-frequency (BIA-SF), and segmental multifrequency (BIA-MS) techniques. The differences and concordance between the components of the BIA (resistance, reactance, and phase angle) of the four devices were analyzed. Patients with a normal hydration status were identified, and concordance between FM and FFM measurements with each impedance device and DEXA was observed only in these patients. Results: thirty patients were included. The concordance between the components of BIA ranged from good to excellent (phase angle: intraclass correlation coefficient (ICC) = 0.82, 95 % confidence interval (CI): 0.77-0.93; resistance: ICC = 0.98, 95 % CI: 0.92-0.99). The overall concordance for BIVA diagnosis between the analyzers was substantial for hydration (k = 0.71, 95 % CI: 0.71-0.72) and for body tissues (k = 0.68, 95 % CI: 0.67-0.68). Bland-Altman plots showed the lowest bias between BIA-BIS and DEXA for both FM and FFM. Conclusions: the agreement among the four devices was good for diagnosis by BIVA. The BIA-BIS analyzer and DEXA had the lowest bias for both FFM and FM, although with higher limits of agreement. The lowest limits of agreement were found with the BIA-MS analyzer.

Introducción: Antecedentes: se desconoce si existen diferencias en el diagnóstico dado por el análisis de vectores de impedancia bioeléctrica (BIVA por sus siglas en inglés) entre los analizadores que utilizan distintas tecnologías de medición de impedancia bioeléctrica (IBE). Este estudio tuvo como objetivo identificar el grado de concordancia entre el diagnóstico por BIVA de cuatro técnicas diferentes de medición de IBE, así como evaluar el grado de concordancia entre sus estimaciones de masa magra (MM) y masa grasa (MG) en comparación con el método de absorciometría de rayos X de energía dual (DEXA) en un subgrupo de pacientes sin sobrecarga de volumen. Métodos: se realizó un estudio transversal en pacientes con enfermedad renal crónica avanzada (ERCA) en hemodiálisis (HD) con edades entre los 18 a 65 años. La IBE se midió con cuatro diferentes tecnologías: espectroscópica (IBE-BIS), multifrecuencia (IBE-MF), una sola frecuencia (IBE-SF) y multifrecuencia segmental (IBE-MS). Se analizaron las diferencias y concordancias entre los componentes de la IBE (resistencia, reactancia y ángulo de fase) de los cuatro analizadores. Se identificaron pacientes con estado de hidratación normal, y solo en ellos se evaluó la concordancia de FFM y FM entre cada analizador de impedancia y DEXA. Resultados: se incluyeron 30 pacientes. La concordancia entre los componentes del IBE varió de buena a excelente (ángulo de fase: coeficiente de correlación intraclase (ICC) = 0,82, IC del 95 %: 0,77-0,93; resistencia: ICC = 0,98, IC del 95 %: 0,92-0,99). La concordancia general en el diagnóstico de BIVA entre los analizadores fue substancial para la hidratación (k = 0,71, IC del 95 %: 0,71-0,72) y los tejidos corporales (k = 0,68, IC del 95 %: 0,67-0,68). Los gráficos de Bland-Altman mostraron un sesgo más bajo entre BIA-BIS y DEXA tanto para FM como para FFM. Conclusiones: la concordancia entre el diagnóstico por BIVA, entre los cuatro dispositivos, fue sunstancial. El analizador BIA-BIS y DEXA mostraron los sesgos más bajos, tanto para FFM como para FM, aunque con límites de concordancia más altos. Los límites más bajos de concordancia se encontraron con el analizador BIA-MS.

Phytochemicals That Interfere With Drug Metabolism and Transport, Modifying Plasma Concentration in Humans and Animals.

Phytochemicals (Pch) present in fruits, vegetables and other foods, are known to inhibit or induce drug metabolism and transport. An exhaustive search was performed in five databases covering from 2000 to 2021. Twenty-one compounds from plants were found to modulate CYP3A and/or P-gp activities and modified the pharmacokinetics and the therapeutic effect of 27 different drugs. Flavonols, flavanones, flavones, stilbenes, diferuloylmethanes, tannins, protoalkaloids, flavans, hyperforin and terpenes, reduce plasma concentration of cyclosporine, simvastatin, celiprolol, midazolam, saquinavir, buspirone, everolimus, nadolol, tamoxifen, alprazolam, verapamil, quazepam, digoxin, fexofenadine, theophylline, indinavir, clopidogrel. Anthocyanins, flavonols, flavones, flavanones, flavonoid glycosides, stilbenes, diferuloylmethanes, catechin, hyperforin, alkaloids, terpenes, tannins and protoalkaloids increase of plasma concentration of buspirone, losartan, diltiazem, felodipine, midazolam, cyclosporine, triazolam, verapamil, carbamazepine, diltiazem, aripiprazole, tamoxifen, doxorubicin, paclitaxel, nicardipine. Interactions between Pchs and drugs affect the gene expression and enzymatic activity of CYP3A and P-gp transporter, which has an impact on their bioavailability; such that co-administration of drugs with food, beverages and food supplements can cause a subtherapeutic effect or overdose. Therefore, it is important for the clinician to consider these interactions to obtain a better therapeutic effect.

Agreement between vector analysis and body composition measurements by four types of bioelectrical impedance technology in hemodialysis patients / Concordancia del análisis vectorial y medidas de composición corporal de cuatro tipos de tecnología de impedancia bioeléctrica en pacientes en hemodiálisis

Background: the differences in bioelectrical impedance vector analysis (BIVA) results from different analyzers that use different bioelectrical impedance analysis (BIA) measurement technologies are not known. This study aimed to identify the degree of agreement between the BIVA results of four different BIA measurement techniques and to evaluate the degree of agreement between their estimates of fat-free mass (FFM) and fat mass (FM) and those determined by the gold-standard method of dual-energy X-ray absorptiometry (DEXA) in a subgroup of patients without overhydration. Methods: a cross-sectional study was conducted with hemodialysis (HD) patients with end-stage renal disease (ESRD) aged 18 to 65 years. BIA was measured with four different techniques: spectroscopic (BIA-BIS), multifrequency (BIA-MF), single-frequency (BIA-SF), and segmental multifrequency (BIA-MS) techniques. The differences and concordance between the components of the BIA (resistance, reactance, and phase angle) of the four devices were analyzed. Patients with a normal hydration status were identified, and concordance between FM and FFM measurements with each impedance device and DEXA was observed only in these patients. Results: thirty patients were included. The concordance between the components of BIA ranged from good to excellent (phase angle: intraclass correlation coefficient (ICC) = 0.82, 95 % confidence interval (CI): 0.77-0.93; resistance: ICC = 0.98, 95 % CI: 0.92-0.99). The overall concordance for BIVA diagnosis between the analyzers was substantial for hydration (k = 0.71, 95 % CI: 0.71-0.72) and for body tissues (k = 0.68, 95 % CI: 0.67-0.68). Bland–Altman plots showed the lowest bias between BIA-BIS and DEXA for both FM and FFM. (AU)

Antecedentes: se desconoce si existen diferencias en el diagnóstico dado por el análisis de vectores de impedancia bioeléctrica (BIVA por sus siglas en inglés) entre los analizadores que utilizan distintas tecnologías de medición de impedancia bioeléctrica (IBE). Este estudio tuvo como objetivo identificar el grado de concordancia entre el diagnóstico por BIVA de cuatro técnicas diferentes de medición de IBE, así como evaluar el grado de concordancia entre sus estimaciones de masa magra (MM) y masa grasa (MG) en comparación con el método de absorciometría de rayos X de energía dual (DEXA) en un subgrupo de pacientes sin sobrecarga de volumen. Métodos: se realizó un estudio transversal en pacientes con enfermedad renal crónica avanzada (ERCA) en hemodiálisis (HD) con edades entre los 18 a 65 años. La IBE se midió con cuatro diferentes tecnologías: espectroscópica (IBE-BIS), multifrecuencia (IBE-MF), una sola frecuencia (IBE-SF) y multifrecuencia segmental (IBE-MS). Se analizaron las diferencias y concordancias entre los componentes de la IBE (resistencia, reactancia y ángulo de fase) de los cuatro analizadores. Se identificaron pacientes con estado de hidratación normal, y solo en ellos se evaluó la concordancia de FFM y FM entre cada analizador de impedancia y DEXA. Resultados: se incluyeron 30 pacientes. La concordancia entre los componentes del IBE varió de buena a excelente (ángulo de fase: coeficiente de correlación intraclase (ICC) = 0,82, IC del 95 %: 0,77-0,93; resistencia: ICC = 0,98, IC del 95 %: 0,92-0,99). La concordancia general en el diagnóstico de BIVA entre los analizadores fue substancial para la hidratación (k = 0,71, IC del 95 %: 0,71-0,72) y los tejidos corporales (k = 0,68, IC del 95 %: 0,67-0,68). Los gráficos de Bland-Altman mostraron un sesgo más bajo entre BIA-BIS y DEXA tanto para FM como para FFM. (AU)

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.

Is there a relationship between oral hygiene and nutritional status in peritoneal dialysis patients?

Introduction: Brackground: in the early stages of kidney disease, oral manifestations (gingivitis and periodontitis) may cause premature tooth loss and limit food intake. There is scarce evidence of the relationship of oral hygiene and nutritional status in patients on Peritoneal Dialysis (PD). Objective: we aimed to assess the relationship of oral hygiene with nutritional, clinical, and physical performance parameters in PD patients. Methods: this cross-sectional study included outpatients aged 34-69 years. Oral health questionnaire, nutritional, functional, and clinical assessment tools such as Malnutrition Inflammation Score (MIS), Subjective Global Assessment (SGA), handgrip strength, and Gastrointestinal Symptoms Questionnaire (GSQ) were applied. Patients were divided according to debris, calculus, and Simplified Oral Hygiene Index (OHI-S) in two groups: "clean-slightly dirty" and "dirty-very dirty". Results: in total, 41 patients were included, those in the "dirty-very dirty" group had a worse nutritional status with higher scores on the MIS tool and worse nutritional diagnosis with SGA as compared to the "clean-slightly dirty" group. The handgrip strength was higher in patients in the best category of oral hygiene, and those with the worst hygiene presented greater severity of gastrointestinal symptoms. The risks of malnutrition in the three indices of oral hygiene with the worst category were statistically significant. Conclusion: poor oral hygiene was associated with poorer nutritional status, lower handgrip, and worse GSQ. Poor oral hygiene might be related to persistent inflammation status and catabolism that favored protein-energy wasting.

Introducción: Introducción: en las primeras etapas de la enfermedad renal, las manifestaciones orales (gingivitis y periodontitis) pueden causar la pérdida de dientes prematura y limitar la ingestión de los alimentos. Existe poca evidencia de la relación entre la higiene bucal y el estado de nutrición en los pacientes con Diálisis Peritoneal (PD). Objetivos: evaluar la relación de la higiene bucal con los parámetros nutricionales, clínicos y de funcionalidad física en pacientes con DP. Métodos: este es un estudio transversal que incluyó a pacientes ambulatorios de 34 a 69 años. Se aplicó un cuestionario de salud bucal, herramientas de evaluación nutricional, pruebas de funcionalidad y un cuestionario de síntomas gastrointestinales, con las herramientas MIS (Malnutrition Inflammation Score), SGA (Subjective Global Assessment); fuerza de prensión de mano y el cuestionario de síntomas gastrointestinales GSQ (Gastrointestinal Score Questionnaire). Los pacientes fueron agrupados de acuerdo con los índices de placa, cálculo y OHI-S (Simplified Oral Hygiene Index) en dos grupos: "limpio-ligeramente sucio" y "sucio-muy sucio". Resultados: se incluyeron 41 pacientes en total, aquellos en el grupo "sucio-muy sucio" presentaron un peor estado nutricional con mayores puntajes de la herramienta MIS y peor diagnóstico nutricional con la SGA comparado con el grupo "limpio-ligeramente sucio". La fuerza de prensión de mano fue mayor en los pacientes con la mejor categoría de higiene bucal, y aquellos con peor higiene presentaron mayor gravedad de síntomas gastrointestinales. El riesgo de desnutrición en los tres índices de higiene bucal con la peor categoría fueron estadísticamente significativos. Conclusiones: la mala higiene bucal se asoció con un peor estado nutricional, menor fuerza de prensión de la mano y peor GSQ. Una higiene bucal deficiente podría estar relacionada con un estado de inflamación y catabolismo persistentes favoreciendo el desgaste proteínico energético en pacientes en diálisis peritoneal.

Frequency of Intradialytic Hypotension Events Do Not Increase with Oral Nutritional Supplementation during Hemodialysis Treatment: A Randomized Controlled Trial.

OBJECTIVE: This study aimed to compare the effect of the use of a renal-specific oral nutritional supplement (RS-ONS) during hemodialysis sessions and the use of RS-ONS at home on the incidence of intradialytic hypotension. METHODS: A single-center, 12-week, open-label, randomized controlled clinical trial was conducted. The intervention was a RN-ONS divided into two portions: 100 and 137 mL. The first portion was given after 1 hour of hemodialysis (HD) treatment, while the second portion was given 45 minutes before the end of HD. The research staff registered the baseline and final nutritional parameters and systolic arterial pressure (SAP) from the screen of the HD device during 36 HD sessions. Hypotension symptoms were also recorded every hour during each HD session. The nutritional and functional status was also assessed. RESULTS: We registered a total of 16 hypotensive events during 1082 HD sessions: 9 were in patients supplemented at home (551 HD sessions) and 7 occurred in patients supplemented during HD P = .668. Incidence of intradialytic hypotension (IH) during 1082 HD sessions was 1.4%. The total malnutrition inflammation score (MIS) decreased in both groups (P < .01), and the percentage of cachexia improved in the supplemented-during-HD group (P < .05). CONCLUSIONS: In this randomized controlled trial, intradialytic hypotension events did not increase with the RS-ONS during HD treatment. This strategy appears to be a safe anabolic nutritional strategy for the prevention of PEW, selecting stable patients and administering a fractioned volume of the supplement after the first hour of HD treatment. More studies with larger samples size are required to confirm these findings.

Modifiable Lifestyle Factors for Primary Prevention of CKD: A Systematic Review and Meta-Analysis.

BACKGROUND: Despite increasing incidence of CKD, no evidence-based lifestyle recommendations for CKD primary prevention apparently exist. METHODS: To evaluate the consistency of evidence associating modifiable lifestyle factors and CKD incidence, we searched MEDLINE, Embase, CINAHL, and references from eligible studies from database inception through June 2019. We included cohort studies of adults without CKD at baseline that reported lifestyle exposures (diet, physical activity, alcohol consumption, and tobacco smoking). The primary outcome was incident CKD (eGFR<60 ml/min per 1.73 m2). Secondary outcomes included other CKD surrogate measures (RRT, GFR decline, and albuminuria). RESULTS: We identified 104 studies of 2,755,719 participants with generally a low risk of bias. Higher dietary potassium intake associated with significantly decreased odds of CKD (odds ratio [OR], 0.78; 95% confidence interval [95% CI], 0.65 to 0.94), as did higher vegetable intake (OR, 0.79; 95% CI, 0.70 to 0.90); higher salt intake associated with significantly increased odds of CKD (OR, 1.21; 95% CI, 1.06 to 1.38). Being physically active versus sedentary associated with lower odds of CKD (OR, 0.82; 95% CI, 0.69 to 0.98). Current and former smokers had significantly increased odds of CKD compared with never smokers (OR, 1.18; 95% CI, 1.10 to 1.27). Compared with no consumption, moderate consumption of alcohol associated with reduced risk of CKD (relative risk, 0.86; 95% CI, 0.79 to 0.93). These associations were consistent, but evidence was predominantly of low to very low certainty. Results for secondary outcomes were consistent with the primary finding. CONCLUSIONS: These findings identify modifiable lifestyle factors that consistently predict the incidence of CKD in the community and may inform both public health recommendations and clinical practice.

Nutritional status, hyperkalaemia and attainment of energy/protein intake targets in haemodialysis patients following plant-based diets: a longitudinal cohort study.

BACKGROUND: Patients undergoing haemodialysis (HD) are often discouraged from eating fruits and vegetables because of fears of hyperkalaemia and undernutrition, yet evidence to support these claims is scarce. We here explore the association between adherence to a healthy plant-based diet with serum potassium, surrogates of nutritional status and attainment of energy/protein intake targets in HD patients. METHODS: We performed an observational single-centre study of stable patients undergoing HD with repeated dietary assessment every 3 months. Patients were provided with personalized nutritional counselling according to current guidelines. The diet was evaluated by 3-day food records and characterized by a healthy plant-based diet score (HPDS), which scores positively the intake of plant foods and negatively animal foods and sugar. The malnutrition inflammation score (MIS) and serum potassium were also assessed at each visit. We used mixed-effects models to evaluate the association of the HPDS with markers of nutritional status, serum potassium levels and attainment of energy/protein intake targets. RESULTS: After applying inclusion and exclusion criteria, a total of 150 patients contributing to 470 trimestral observations were included. Their mean age was 42 years [standard deviation (SD) 18] and 59% were women. In multivariable models, a higher HPDS was not associated with serum potassium levels or odds of hyperkalaemia {potassium >5.5 mEq/L; odds ratio [OR] 1.00 [95% confidence interval (CI) 0.94-1.07] per HPDS unit higher}. Patients with a higher HPDS did not differ in terms of energy intake [OR for consuming <30 kcal/kg day 1.05 (95% CI 0.97-1.13)] but were at risk of low protein intake [OR for consuming <1.1 g of protein/kg/day 1.11 (95% CI 1.04-1.19)]. A higher HPDS was associated with a lower MIS, indicating better nutritional status. CONCLUSIONS: In patients undergoing HD, adherence to a healthy plant-based diet was not associated with serum potassium, hyperkalaemia or differences in energy intake. Although these patients were less likely to reach daily protein intake targets, they appeared to associate with better nutritional status over time.

Does dietary potassium intake associate with hyperkalemia in patients with chronic kidney disease?

BACKGROUND: Dietary potassium restriction is a strategy to control hyperkalemia in chronic kidney disease (CKD). However, hyperkalemia may result from a combination of clinical conditions. This study aimed to investigate whether dietary potassium or the intake of certain food groups associate with serum potassium in the face of other risk factors. METHODS: We performed a cross-sectional analysis including a nondialysis-dependent CKD (NDD-CKD) cohort and a hemodialysis (HD) cohort. Dietary potassium intake was assessed by 3-day food records. Underreporters with energy intake lower than resting energy expenditure were excluded. Hyperkalemia was defined as serum potassium >5.0 mEq/L. RESULTS: The NDD-CKD cohort included 95 patients {median age 67 [interquartile range (IQR) 55-73] years, 32% with diabetes mellitus (DM), median estimated glomerular filtration rate 23 [IQR 18-29] mL/min/1.73 m2} and the HD cohort included 117 patients [median age 39 (IQR 18-67) years, 50% with DM]. In NDD-CKD, patients with hyperkalemia (36.8%) exhibited lower serum bicarbonate and a tendency for higher serum creatinine, a higher proportion of DM and the use of renin-angiotensin-aldosterone system blockers, but lower use of sodium bicarbonate supplements. No association was found between serum and dietary potassium (r = 0.01; P = 0.98) or selected food groups. Conditions associated with hyperkalemia in multivariable analysis were DM {odds ratio [OR] 3.55 [95% confidence interval (CI) 1.07-11.72]} and metabolic acidosis [OR 4.35 (95% CI 1.37-13.78)]. In HD, patients with hyperkalemia (50.5%) exhibited higher serum creatinine and blood urea nitrogen and lower malnutrition inflammation score and a tendency for higher dialysis vintage and body mass index. No association was found between serum and potassium intake (r = -0.06, P = 0.46) or food groups. DM [OR 4.22 (95% CI 1.31-13.6)] and serum creatinine [OR 1.50 (95% CI 1.24-1.81)] were predictors of hyperkalemia in multivariable analyses. CONCLUSIONS: Dietary potassium was not associated with serum potassium or hyperkalemia in either NDD-CKD or HD patients. Before restricting dietary potassium, the patient's intake of potassium should be carefully evaluated and other potential clinical factors related to serum potassium balance should be considered in the management of hyperkalemia in CKD.

Partial sleep deprivation on dietary energy intake in healthy population: a systematic review and meta-analysis / Efectos de la privación parcial de sueño sobre la ingesta energética en una población sana: revisión sistemática y metaanálisis

INTRODUCTION: the restriction of nocturnal sleep has immediate effects, including the presence of excessive daytime sleepiness, general fatigue, or impaired concentration. In the long term, it increases the risk of death from cardiac, respiratory, and metabolic disorders, and the prevalence of obesity in healthy populations. However, despite the existence of a large number of studies on this topic, results have been controversial. OBJECTIVE: to discuss and analyze the evidence on the effects of nocturnal sleep restriction versus habitual sleep on dietary energy intake, including specific meals, as well as the relationship between ghrelin and leptin levels in a healthy population. METHODS: a systematic search of the literature was conducted in October 2016 and February 2019 using the PubMed, Scopus, Lilacs, and Embase databases. Terms used were "sleep," "feeding behavior," "dietary energy intake," "energy intake," "meal," "ghrelin," and "leptin." RESULTS: the bibliographic search identified 384 potential articles. Of a total of eight articles accepted in the review, six contain information available for the analysis of total energy intake. The overall result shows a significant difference in energy intake between study groups (149.86 (95 % CI: 10.09-289.63); p = 0.04), and a higher intake of all macronutrients. CONCLUSIONS: the present systematic review and meta-analysis demonstrated that partial sleep deprivation increases total energy intake, as well as all macronutrients, when compared to habitual sleep

INTRODUCCIÓN: la restricción del sueño nocturno tiene efectos inmediatos, como la presencia de somnolencia diurna excesiva, fatiga general o alteraciones en la concentración; a largo plazo, aumenta el riesgo de muerte por trastornos cardíacos, respiratorios y metabólicos, y aumenta la prevalencia de la obesidad en las poblaciones sanas. Sin embargo, a pesar de la existencia de una gran cantidad de estudios, los resultados siguen siendo controvertidos. OBJETIVO: discutir y analizar la evidencia sobre la restricción parcial del sueño frente al sueño habitual y su efecto en la ingesta dietética de energía, incluyendo comidas específicas, así como en las concentraciones de ghrelina y leptina en una población sana. MÉTODOS: se realizó una búsqueda electrónica de la literatura entre octubre de 2016 y febrero de 2019 en PubMed, Scopus, Lilacs y Embase. Los términos utilizados fueron "sleep", "feeding behavior", "dietary energy intake", "energy intake", "meal", "ghrelin" y "leptin". RESULTADOS: la búsqueda bibliográfica identificó 384 artículos potenciales. De un total de 8 artículos aceptados en la revisión, 6 tenían información disponible para el análisis de la ingesta total de energía. El resultado general mostró una diferencia significativa en la ingesta de energía (149,86 (IC 95 %: 10,09-289,63); p = 0,04) y una mayor ingesta de todos los macronutrientes. CONCLUSIONES: la presente revisión sistemática y meta-análisis indicó que la restricción del sueño aumenta la ingesta total de energía, así como la de todos los macronutrientes, en comparación con el sueño habitual

Partial sleep deprivation on dietary energy intake in healthy population: a systematic review and meta-analysis.

INTRODUCTION: Background: the restriction of nocturnal sleep has immediate effects, including the presence of excessive daytime sleepiness, general fatigue, or impaired concentration. In the long term, it increases the risk of death from cardiac, respiratory, and metabolic disorders, and the prevalence of obesity in healthy populations. However, despite the existence of a large number of studies on this topic, results have been controversial. Objective: to discuss and analyze the evidence on the effects of nocturnal sleep restriction versus habitual sleep on dietary energy intake, including specific meals, as well as the relationship between ghrelin and leptin levels in a healthy population. Methods: a systematic search of the literature was conducted in October 2016 and February 2019 using the PubMed, Scopus, Lilacs, and Embase databases. Terms used were "sleep," "feeding behavior," "dietary energy intake," "energy intake," "meal," "ghrelin," and "leptin." Results: the bibliographic search identified 384 potential articles. Of a total of eight articles accepted in the review, six contain information available for the analysis of total energy intake. The overall result shows a significant difference in energy intake between study groups (149.86 (95 % CI: 10.09-289.63); p = 0.04), and a higher intake of all macronutrients. Conclusions: the present systematic review and meta-analysis demonstrated that partial sleep deprivation increases total energy intake, as well as all macronutrients, when compared to habitual sleep.

INTRODUCCIÓN: Antecedentes: la restricción del sueño nocturno tiene efectos inmediatos, como la presencia de somnolencia diurna excesiva, fatiga general o alteraciones en la concentración; a largo plazo, aumenta el riesgo de muerte por trastornos cardíacos, respiratorios y metabólicos, y aumenta la prevalencia de la obesidad en las poblaciones sanas. Sin embargo, a pesar de la existencia de una gran cantidad de estudios, los resultados siguen siendo controvertidos. Objetivo: discutir y analizar la evidencia sobre la restricción parcial del sueño frente al sueño habitual y su efecto en la ingesta dietética de energía, incluyendo comidas específicas, así como en las concentraciones de ghrelina y leptina en una población sana. Métodos: se realizó una búsqueda electrónica de la literatura entre octubre de 2016 y febrero de 2019 en PubMed, Scopus, Lilacs y Embase. Los términos utilizados fueron "sleep", "feeding behavior", "dietary energy intake", "energy intake", "meal", "ghrelin" y "leptin". Resultados: la búsqueda bibliográfica identificó 384 artículos potenciales. De un total de 8 artículos aceptados en la revisión, 6 tenían información disponible para el análisis de la ingesta total de energía. El resultado general mostró una diferencia significativa en la ingesta de energía (149,86 (IC 95 %: 10,09-289,63); p = 0,04) y una mayor ingesta de todos los macronutrientes. Conclusiones: la presente revisión sistemática y meta-análisis indicó que la restricción del sueño aumenta la ingesta total de energía, así como la de todos los macronutrientes, en comparación con el sueño habitual.

Plant-based diets, insulin sensitivity and inflammation in elderly men with chronic kidney disease.

BACKGROUND: In persons with CKD, adherence to plant-based diets is associated with lower risk of CKD progression and death, but underlying mechanisms are poorly characterized. We here explore associations between adherence to plant-based diets and measures of insulin sensitivity and inflammation in men with CKD stages 3-5. METHODS: Cross-sectional study including 418 men free from diabetes, aged 70-71 years and with cystatin-C estimated glomerular filtration rate (eGFR) <60 mL/min/1.73m2 and not receiving kidney-specific dietetic advice. Information from 7-day food records was used to evaluate the adherence to a plant-based diet index (PBDi), which scores positively the intake of plant-foods and negatively animal-foods. Insulin sensitivity and glucose disposal rate were assessed with the gold-standard hyperinsulinemic euglycemic glucose clamp technique. Inflammation was evaluated by serum concentrations of C-reactive protein (CRP) and interleukin (IL)-6. Associations were explored through linear regression and restricted cubic splines. RESULTS: The majority of men had CKD stage 3a. Hypertension and cardiovascular disease were the most common comorbidities. The median PBDi was 38 (range 14-55). Across higher quintiles of PBDi (i.e. higher adherence), participants were less often smokers, consumed less alcohol, had lower BMI and higher eGFR (P for trend <0.05 for all). Across higher PBDi quintiles, patients exhibited higher insulin sensitivity and lower inflammation (P for trend <0.05). After adjustment for eGFR, lifestyle factors, BMI, comorbidities and energy intake, a higher PBDi score remained associated with higher glucose disposal rate and insulin sensitivity as well as with lower levels of IL-6 and CRP. CONCLUSION: In elderly men with non-dialysis CKD stages 3-5, adherence to a plant-based diet was associated with higher insulin sensitivity and lower inflammation, supporting a possible role of plant-based diets in the prevention of metabolic complications of CKD.