Nutritional knowledge in hemodialysis patients and nurses: focus on phosphorus.

OBJECTIVE: To assess the knowledge of adult hemodialysis patients and nurses working in dialysis units, specifically with regard to knowledge of phosphorus and other nutrients related to dietary management of end-stage renal disease. DESIGN: Cross-sectional cohort study. SETTING: Hemodialysis unit. SUBJECTS: One hundred ninety-one hemodialysis patients and 105 dialysis nurses, as well as 86 control hospital employees who are not health professionals. INTERVENTION: Nutritional knowledge was assessed by a 25-item chronic kidney disease knowledge assessment tool for nutrition, which includes 15 questions on phosphorus and 10 questions on protein, sodium, and potassium knowledge. RESULTS: The scores obtained by patients were much lower than those of nurses (11.6 ± 3.9 vs. 16.0 ± 2.2, P < .001) but slightly higher than those of controls (10.6 ± 3.2, P < .05). Patients with phosphorus serum level >5.5 mg/dL showed chronic kidney disease knowledge assessment tool for nutrition scores similar to those of patients with a serum phosphorus level <5.5 mg/dL. The prevalence of right answers to questions regarding knowledge of phosphorus was lower than that regarding knowledge of the other nutrients, both for patients (38.4% ± 17.8% vs. 57.3% ± 19.9%, P < .001) and nurses (55.6% ± 11.1% vs. 74.8% ± 11.7%, P < .001) as well as for controls (30.7% ± 14.5% vs. 60.1% ± 17.4%, P < .001). CONCLUSIONS: Our study suggests that nutritional knowledge of hemodialysis patients, although higher than the general population, is lower for phosphorus with respect to the other nutrients, such as protein, sodium, and potassium. This occurs even in patients with hyperphosphatemia or those taking phosphate binder medications. Nurses showed the best scores; however, improvement is necessary, especially with regard to knowledge of phosphorus. Training programs on nutrition for nurses and on information for patients should be implemented. They can contribute to achievement of a more effective control of phosphate balance, reduction of costs, and improvement of the quality of care for hemodialysis patients.

Anaemia and resistance to erythropoiesis-stimulating agents as prognostic factors in haemodialysis patients: results from the RISCAVID study.

BACKGROUND: Resistance to erythropoiesis-stimulating agents (ESAs) is often associated with chronic inflammation. Here, we investigated how anaemia, ESA resistance and the plasma levels of biological markers of inflammation could influence all-cause and cardiovascular disease morbidity and mortality. METHODS: Seven hundred and fifty-three haemodialysis (HD) patients (mean age 66 ± 14.2 years, mean dialytic age 70 ± 77 months and diabetes 18.8%) were enrolled and followed-up for 36 months. Demographic, clinical and laboratory data, co-morbidity conditions, administered drugs, all-cause mortality and fatal/non-fatal cardiovascular (CV) events were recorded. We measured ESA resistance index, C-reactive protein (CRP) and interleukin-6 (IL-6). RESULTS: Six hundred and fifty-one patients (86.4%) received ESAs. Patients with haemoglobin level <11 g/dL (n = 225) showed increased risk of CV [relative risk (RR) 1.415, 95% confidence interval (CI) 1.046-1.914] and overall mortality (RR 1.897, 95% CI 1.423-2.530) versus patients with haemoglobin levels >11 g/dL. ESA resistance values categorized into quartiles (Quartile I <5.6, Quartile II 5.7-9.6, Quartile III 9.7-15.4 and Quartile IV >15.4) correlated with all-cause mortality and fatal/non-fatal CV events (RR 1.97, 95% CI 1.392-2.786; RR 1.619, 95% CI 1.123-2.332, respectively). Furthermore, albumin was significantly reduced versus reference patients and correlated with all-cause mortality and CV events; CRP levels were higher in hyporesponders (Quartile IV) (P < 0.001) and predicted all-cause mortality and CV events. IL-6 but not CRP was a strong predictor of ESA resistance. CONCLUSIONS: ESA responsiveness can be considered a strong prognostic factor in HD patients and seems to be tightly related to protein-energy wasting and inflammation.

Effects of hemodialysis and vitamin E supplementation on low-density lipoprotein oxidizability in end-stage renal failure.

BACKGROUND: Cardiovascular diseases represent the major cause of mortality in hemodialysis (HD) patients. HD increases oxidative stress and oxidation of low-density lipoprotein (LDL) is a crucial step in the development of atherosclerosis. Vitamin E has been shown to reduce LDL oxidation. Our aim was to test the effect of a single HD session and chronic vitamin E supplementation on LDL oxidizability in HD patients. METHODS: LDL susceptibility to copper-induced oxidation (lag-phase, LP) was measured in 19 HD patients, both immediately before and after hemodialysis; 18 age-matched healthy subjects served as controls. Both pre-HD and post-HD measurements were repeated after 12 weeks of vitamin E supplementation (800 IU/day) in a placebo-controlled, randomized design. RESULTS: At baseline, HD patients showed hypertriglyceridemia, a significant triglyceride enrichment in LDL and HDL and an enhanced LDL resistance to oxidation (186 ± 6 vs. 163 ± 4 min, p<0.003). A single HD session decreased (to 172 ± 6 min, or -8%, p<0.002), and chronic vitamin E administration increased, LDL resistance to oxidation (+19%, p = 0.002 vs. placebo) without changing the serum lipid profile or lipoprotein lipid composition. CONCLUSIONS: We conclude that in patients on chronic hemodialysis, hypertriglyceridemia and triglyceride enrichment of LDL and HDL particles are associated with increased resistance of LDL to in vitro oxidation despite the fact that each dialysis session acutely increases LDL oxidizability. Vitamin E supplementation improves LDL resistance to oxidation without modifying circulating lipid levels and partitioning.