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Nutrition in Dialysis and IDPN

Kam Kalantar-Zadeh, MD, MPH, PhDTwitter/Facebook/LinkedIn: @KamKalantar

Professor of Medicine, Pediatrics, Public Health, and Nursing SciencesChief, Division of Nephrology, Hypertension and Kidney Transplanation

University of California Irvine (UCI) School of MedicineHarold Simmons Center for Kidney Disease Research & Epidemiology, Orange, CA

Tibor Rubin Veteran Administrations’ Long Beach Healthcare System, Long Beach, CAProfessor of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA

World Kidney Day (WKD) Steering Committeewww.WorldKidneyDay.org

Past PresidentInternational Society of Renal Nutrition & Metabolism (ISRNM)

Board of Directors

The National Forum of the ESRD NetworksEditor-in-Chief

Journal of Renal Nutrition (JREN)www.JRNjournal.org

Dr. K. Kalantar‐Zadeh has received honoraria and/or support in different forms from Abbott, Abbvie, Alexion, Amgen, ASN (American Society of Nephrology), Astra‐Zeneca, Aveo, Chugai, DaVita, Fresenius, Genentech, Haymarket Media, Hofstra 

Medical School, IFKF (International Federation of Kidney Foundations), ISH (International Society of Hemodialysis), International Society of Renal Nutrition & Metabolism (ISRNM), JSDT (Japanese Society of Dialysis Therapy), Hospira, Kabi, 

Keryx, Novartis, NIH (National Institutes of Health), NKF (National Kidney Foundations), Pfizer, Relypsa, Resverlogix, Sandoz, Sanofi, Shire, Vifor, UpToDate, 

ZS‐Pharma.

Kamyar Kalantar-Zadeh, MD, MPH, PhD

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Objectives

1. To examine pathophysiology and clinical implications of protein‐energy wasting, sarcopenia, cachexia and malnutrition in CKD with focus on dialysis patients (ESRD).

2. To discuss role of serum albumin as a potential maker in PEW

3. To review data on high protein intake and IDPN in CKD patients on dialysis.

Nutritional and Dietary Management of Kidney Disease: A Patient Care Approach 

• We are what we eat: Learn how to enforce kidney health through nutrition and diet

• Saturday, Feb. 29, 2020 – 7:30 am ‐ 4:45 pm• University of California Irvine (UCI) Medical Center, Bldg. 53, Auditorium 101 

• The City Drive South, Orange, California 92868, USA

• UCI Nephrology has teamed up with the nation’s leading experts to leverage their interests and expertise to provide insights on real‐world clinical management and hands‐on workshops for dietary  approaches.

• This is a full‐day CME course for physicians (nephrologists, internists, urologists and family practitioners) and other healthcare providers and allied health professionals (dietitians, nurses,  nutritionists and researchers) who will learn the pathophysiology and mechanisms related to the role of nutrition in kidney disease and kidney health.

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Sources of this Presentation

• Two Textbooks and a Review Article:

• Kopple, Massry & Kalantar-Zadeh, Nutritional Management of Renal Disease. 3rd Edition, 2013• Rhee, Kalantar-Zadeh, Brent , Endocrine Disorders in Kidney Disease,2019• Kalantar-Zadeh & Foque, Nutritional Management of CKD. NEJM Nov 2, 2017

Part 1

Does Transition to Dialysis Affect the Nutritional Status and

Survival?

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Does DIALYSIS therapy “CAUSE” Protein‐Energy Wasting (PEW) Cachexia and Sarcopenia and Frailty and MORTALITY Risk?

Probably YES

• Low nutrient intake• Amino acid (AA) losses in 

dialysate• Hypoalbuminemia

Cytokine activation

↑Muscle protein catabolism

Impaired AA availability for protein synthesis

AA release from the muscleAA release from the muscle

↑Acute phase protein synthesis↑Acute phase protein synthesis

Dialysis

PEW

Undernutrition

Catabolism+

Carrero JJ, et al. J Ren Nutr. 2013;23:77‐90

ISRNM Consensus Paper

Protein-Energy Wasting (PEW)

Is higher weight good or bad in dialysis patients?

Obesity ParadoxReverse Epidemiology

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Kalantar-Zadeh et al. Kidney Int. 2003;63:793-808.

BMI ↑ Deathin the General Population

BMI Associated Death Risk: General Population

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

BMI, kg/m2

Rel

ativ

e R

isk

of

Dea

th*

General Population

Kalantar-Zadeh et al. Kidney Int. 2003;63:793-808.

BMI Associated Death Risk: General Population versus Hemodialysis Patients

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

BMI, kg/m2

Rel

ativ

e R

isk

of

Dea

th*

General Population

Hemodialysis **

<20

20-2325-30

>30

23-25

BMI ↑ Deathin the General Population

Reverse Epidemiologyin Dialysis Patients

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What is “Dry Weight” loss? Fat or Muscle?

Higher weight is good in dialysis patients?

Does higher mean higher “fat” or higher “muscle”?

Association of Higher Body Fat and Better Survival in Dialysis Patients.

0.8

80.

90

0.9

20.

94

0.9

60.

98

1.0

0

prop

ort

ion

surv

ivin

g

0 100 200 300 400 500 6 00 70 0 8 00 90 0 10 00 11 00coh ort da ys

<12%

12-24%

24-36%

>36%

Kalantar-Zadeh et al, Am J Clin Nutr 2006

Lowest Body Fat Worse Survival

2.5 year survival follow-up in 535 MHD Patients

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Aparicio et al. Nephro Dial Transplant 1999

BMI < 20 kg/m2 24 %

Muscle mass < 90 % th. 62 %

Serum Albumin < 35 g/l 20 %

Serum transthyretin < 300 mg/l 36 %

nPNA < 1 g/kg/j 35 %

• French multicenter study, n=7,123

Protein-energy wasting: How about MUSCLE?

Courtesy Prof. N. Cano

-.5

0.5

1

DE

AT

H (

Log

haza

rd r

atio

)

0 20 40 60 80 100MAMC percentile

Mid-Arm Muscle Circumference and 5-Year Mortality (2001-06) in 792 hemodialysis patients

Noori … Kalantar-Zadeh CJASN 2010

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Appetite and Dialysis OutcomesHazard Ratio of Death for Reduced Appetite : 4.74 (95% CI: 1.85-12.16)

Cox p-value: 0.001; Kaplan-Meier p-value: 0.002

Death Censored

0 2 4 6 8 10 12

Time (months)

0.80

0.84

0.88

0.92

0.96

1.00

Cum

ulat

ive

Pro

port

ion

Sur

vivi

ng

Appetite status(dichatomized)

Normal Anorexia

Kalantar-Zadeh et al, Am J Clin Nutr 2004

Low appetite ↑ mortality

Good appetite better survival

Kalantar-Zadeh … Kopple. Am J Clin Nutr. 2004;80:299-307

Part 2

Nutritional Assessment Tools and Markers in CKD and Dialysis Patients

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Fouque, Kalantar-Zadeh, Kopple … Wanner Kidney International 2008

ISRNM suggested3 out of 4 criteria PEW

Serum Chemistry

Body Mass

Muscle Mass

Dietary Intake

Protein-Energy Wasting (PEW) Diagnosis

Serum ALBUMINLow Albumin Death

High Albumin Survival

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Question

Which of the following is the strongest predictor of BETTER SURVIVAL in dialysis patients?

• A. Higher blood hemoglobin

• B. Lower serum phosphorus

• C. Higher serum albumin

• D. Lower serum Calcium

1 1.211.49

1.87

8.22

5.16

3.74

2.75

0

1

2

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≥4.2 4.0-4.2 3.8-4.0 3.6-3.8 3.4-3.6 3.2-3.4 3.0-3.2 <3.0Serum Albumin (g/dL)

Haz

ard R

atio

(H

R) of D

eath

Unadjusted HR

Case-mix adjusted HR

0.21

0.24

0.42

0.88

0.99

1.42

3.06

N= 56,920 hemodialysis patients (7/2001-6/2003)

Kalantar-Zadeh, Cano, … Ikizler. Nature Reviews Nephrology 2011

Serum Albumin in Hemodialysis Patients: STRONG, ROBUST & LINEAR Predictor of Survival

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Does it matter to be twice‐a week or thrice a week HD?

twice‐a week

twice‐a week

Part 4

Nutritional Scoring Systems in CKD and Dialysis Patients

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Fouque, Kalantar-Zadeh, Kopple … Wanner Kidney International 2008

suggested 3 out of 4 criteria

PEW

Serum Chemistry

Body Mass

Muscle Mass

Dietary Intake

PEW Diagnosis

Nutritional Scoring Systems

SGA Rating

Kalantar-Zadeh K, Luft FC, et al; Total iron binding capacity-estimated transferrin concentrations in dialysis patients correlate with the subjective global assessment of nutrition; Am J Kidney Dis; 31(2):263-272; February 1998.

• Score A: well-nourished

• Score B: mildly to moderately

malnourished

• Score C: severely malnourished

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Further evolution of the SGA and DMS:

Malnutrition Inflammation Score(MIS)

• Three new components:

A) Body Mass Index (BMI) B) Serum AlbuminC) Transferrin (TIBC)

• The MIS has 10 components, each with 4 levels of severity: from 0 (normal) to 3 (very severe).

• The sum of all 10 DMS components: ranges from 0 (normal) to 30 (severely malnourished).

Kalantar-Zadeh et al; AJKD 2001

Part 5

Dietary Intake of Prevalent Dialysis Patients

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Dietary Protein Intakein Dialysis Patients

nPCR*: Protein Catabolic Rate

nPNA*: Protein Nitrogen Appearance

*n: normalized (divided by body weight in kg)

Fre

qu

ency

0

2000

4000

6000

8000

10000

(time dependent cox model)

< 0.6

0.6 - 0.69

0.7 - 0.79

0.8 - 0.89

0.9 - 0.99

1.0 - 1.09

1.1 - 1.19

1.2 - 1.29

1.3 - 1.39

>= 1.4

All

Ca

us

e D

eath

Ha

zard

Ra

tio

0.6

1.5

2

3

1

nPCR (nPNA) [estimate of dietary protein intake] g/kg/day

nPCR in 53,933 hemodialysis patients

KDOQI recommended

range:1.0-1.2 g/kg/day

Over half of dialysis patients receiveless than recommendedprotein intake (nPCR<1.0 g/kg/day)

Distribution of estimated Protein Intake (nPCR, nPNA) in 53,933 Hemodialysis Patients

Shinaberger … Kalantar-Zadeh, Am J Kidney Dis 2006; 48:37-49

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Fre

qu

ency

0

2000

4000

6000

8000

10000

y(time dependent cox model)

nPNA (nPCR) (g/kg/day)

< 0.6

0.6 - 0.69

0.7 - 0.79

0.8 - 0.89

0.9 - 0.99

1.0 - 1.09

1.1 - 1.19

1.2 - 1.29

1.3 - 1.39

>= 1.4

All

Ca

use

De

ath

Ha

zard

Rat

io

0.6

1.5

2

3

1

unadjustedcase-mixcase-mix & MICS

Incident & Prevalent MHD Patients

n= 53,933

y(time dependent cox model)

nPNA (nPCR) (g/kg/day)

< 0.6

0.6 - 0.69

0.7 - 0.79

0.8 - 0.89

0.9 - 0.99

1.0 - 1.09

1.1 - 1.19

1.2 - 1.29

1.3 - 1.39

>= 1.4

All

Ca

use

De

ath

Ha

zard

Rat

io

0.6

1.5

2

3

1

unadjustedcase-mixcase-mix & MICS

y(time dependent cox model)

nPNA (nPCR) (g/kg/day)

< 0.6

0.6 - 0.69

0.7 - 0.79

0.8 - 0.89

0.9 - 0.99

1.0 - 1.09

1.1 - 1.19

1.2 - 1.29

1.3 - 1.39

>= 1.4

All

Ca

use

De

ath

Ha

zard

Rat

io

0.6

1.5

2

3

1

unadjustedcase-mixcase-mix & MICS

KDOQI Recommended

range:1.0-1.2 g/kg/day

Association of Protein Intake (nPCR, nPNA) and Mortality in Hemodialysis Patients

Shinaberger … Kalantar-Zadeh, Am J Kidney Dis 2006; 48:37-49

53,933 Hemodialysis Patients

0.25

0.5

1.0

1.5

2.0

2.5

Odd

s ra

tio o

f se

rum

Alb

>=

3.8

at P

Q3

0

5

10

15

20P

erce

nt

0-0.6 -0.4 -0.2 0.2 0.4 0.6 0.8

Change in nPCRdial+renal (g/kg/day)

1000

1500

2500

500

2000

Fre

quen

cy

0

Change in nPCRdial+renal (g/kg/day)

0to

0.1

<-0.2 0.5<-0.2to

-0.1

-0.1to0

0.1to

0.2

0.2to

0.3

0.3to

0.4

0.4to

0.5

Odd

s ra

tio o

f se

rum

Alb

>=

3.8

at P

Q3

Baseline nPCR and baseline Alb adjusted

Baseline nPCR, baseline Alb and case-mix

Baseline nPCR, baseline Alb, case-mix and MICS

0.5

1.5

2.0

0.8

1.0

Eriguchi R, Obi Y, Streja E, …, and Kalantar‐Zadeh K. Clin J Am Soc Nephrol. 2017 2017 Jul 7;12(7):1109‐1117. .

An increase in protein intake  increases the likelihood of serum albumin >3.8 g/dL

increase in protein intake drop in protein intake 

A drop in protein intake  decreases the likelihood of serum albumin >3.8 g/dL

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Nutritional objectives: 1.2 g protein and 30–35 kcal/kg/d

Mean nutritional intakes in dialysis patients: 20–25 kcal/kg/d (esp. in malnourished pts)

0.6–0.9 g protein/kg/d

Required nutritional supplementation:

EXTRA sources of Protein are needed!

Nutritional objectives in dialysis patients

Kalantar-Zadeh … Ikizler. Nature Nephrology 2011

QuestionWhat are the challenges of high protein diet in dialysis patients?

1. High phosphorus intake

2. High potassium intake

3. High fluid intake

4. High likelihood of acidosis

5. All of the above

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Question:What are the challenges of high protein diet in dialysis patients?

1. High phosphorus intake

2. High potassium intake

3. High fluid intake

4. High likelihood of acidosis

5. All of the above

Rationale: As shown in the upcoming slides, high protein intake is associated with higher burden of phosphorus and potassium, higher acid generation and high fluid intake.

1 - Clin Nutr, 20002 - Am J Kidney Dis, 20003 - Nephrol Dial Transplant, 2007

ESPEN (1) NKF (2) EBPG (3)

Protein 1.2 - 1.4 1.2 1.1g/kg/day

Energy 35 < 60 y: 35 30-35kcal/kg/day > 60 y: 30

Recommended macronutrientintakes

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Phosphorus Estimation Equation Protein Intake(assuming minimal additives)

Dietary phosphorus (milligrams) = 78 + 11.8*(protein intake [grams])

phosphorus = 11.8*protein + 78 (R2=0.83)

0 20 40 60 80 100 120 140

Dietary Protein Intake (g/day)

0

200

400

600

800

1000

1200

1400

1600

1800

2000

Die

tary

Pho

spho

rus

(mg/

day)

Kalantar-Zadeh … Kopple. CJASN 2010

CKD Patients

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Nutritional Therapy / Nutritional Support Oral

– Meals during dialysis treatment– CKD-specific protein-energy supplements

Oral nutritional supplements Tube feeding

Parenteral– IDPN (intra-dialytic parenteral nutrition)– TPN

Pharmacologic– Appetite stimulators– Anti-Depressant– Anti-inflammatory– Anabolic &/or muscle enhancing

Kalantar-Zadeh … Ikizlerl, Nature Nephrology 2011

Part 6

IDPN

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IDPNIntra‐Dialytic Parenteral Nutrition

• Nutritional support therapy designed for hemodialysis patients

• Infusion of amino acids, dextrose and lipids during dialysis

• Given three times/week during dialysis treatment

• Provides 700-1200 calories and 45-75 grams of protein/treatment

Improves– Appetite– Strength– Overall well being/nutritional status

Increases dry weight by building lean muscle mass

Improves albumin level

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Intradialytic parenteral nutrition (IDPN)

Whole-body protein metabolism

p<0.05

p<0.05p<0.05

catabolism

anabolism

96%

50%

-3.0

-2.0

-1.0

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

Protein Synthesis Proteolysis Net Balance

Who

le-b

ody

prot

ein

hom

eost

asis

(mg/

kg

FF

M/ m

in)

Control IDPN

Pupim, LB, Ikizler TA, JCI, 2002

Nutritional effect of IDPN

Chertow GM et al. Am J Kidney Dis 1994

Overall population of Health care systemIDPN, n=1679 Controls, n=22517

IDPN initiation

Courtesy Prof. Noel Cano

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Fines: Patients Survival

Mean cumulative survival: 77% at 1 yr, 58% at 2 yr

Death: Control: n = 36, IDPN: n = 40

0 200 400 600 Days

Logrankp = 0.33P

atie

nt c

umul

ated

sur

viva

l

NS

J Am Soc Nephrol 2007 Courtesy Prof. Noel Cano

Dezfuli, A., et al. (2009). "Severity of hypoalbuminemia predicts response to intradialytic parenteral nutrition in hemodialysis patients." J Ren Nutr 2009.

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Dezfuli, A., et al. (2009). "Severity of hypoalbuminemia predicts response to intradialytic parenteral nutrition in hemodialysis patients." J Ren Nutr 2009.

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Plasma AA are replenished during intradialyticnutritional supplementation

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IDPN is a beneficial therapeutic option in hemodialysis patients with PEW Malnourished pts requiring therapy can be identified by standard nutr

assessments (SGA, prealbumin, etc)

IDPN should be started early (not beyond SGA-B - moderate malnutrition) in order to improve nutritional status over longer periods of time and to improve survival in HD Response to IDPN can be monitored with albumin, prealbumin, hand

grip strength, etc Patients responding to IDPN justify further repetitive treatment

episodes.

Part 8

Meals & Supplements on Dialysis

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US Fresenius Study Nationwide Study in a Large Dialysis Organization:Can oral nutritional supplement during HD treatment

improve survival?

2012

K-M survival curves comparing patients who received monitored oral supplements to controls

1:1 “as-treated” matched cohort

Lacson et al, AJKD 2012

US Fresenius Study: Monitored in-centered intradialytic oral nutritional supplements (ONS)

1.4

0.6

0.4

0.2

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ProsImpact on nutritional status and clinical outcomes> Meals during HD is practiced routinely in many industrialized nations including Europe and South East Asia> Excellent survival in most countries where meals are served during HD> No major unfavorable outcomes reported in countries offering meals during HD

Mitigates/corrects intra- and post-dialysis catabolism> HD Rx exerts catabolic effects that can be avoided by eating during HD> Muscle wasting may be mitigated> Effectively increases the frequency of daily meal intakes

Better control of dietary phosphorus, potassium, salt and fluid> In-center meals and supplements can be more optimally prepared for the specific needs of CKD patients > In-center meals may improve adherence to restricted salt and fluid intake> Intake of phosphorus binder can be monitored> Improved patient education can be achieved by simultaneous interaction with dietitian and nephrologist while eating

Increased adherence with hemodialysis treatment> Increases the likelihood of attending HD treatment>May mitigate the likelihood of HD treatment shortening by hungry patients > Enhances communication between patients and dietitians and other clinic staff

Improved patient satisfaction and quality of life> In-center meals may make patients more content with dialysis treatment life style> Improved quality of life by means of in-center meal may improve survivalRelatively low costs of meals on HD> The costs of providing in-center meals is a small fraction of expensive medications used in ESRD > Dialysis organizations can adapt this in form of efficient and economical approaches

Kalantar-Zadeh K, Ikizler TA. J Ren Nutr. 2013 May;23(3):157-63

Table 2. Pros and cons of in-center (in the dialysis clinic) monitored eating and provision of meals during hemodialysis treatments

ConsLow blood pressure and labile circulation during food ingestion> blood pressure may be lowered during and after eating due to splanchnic circulation expansion even with new dialysis treatment and techniques> Hypotensive episode may lead to shortening dialysis Rx or less efficient fluid removalRisk of aspiration and other respiratory complications

> Risk of choking is likely higher in patients with a history of neurologic disorders, swallowing problems or other disabilities

> Even in sitting position aspiration may happen in patient who cannot feed themselves at home

Infectious control and hygiene issues> Fecal–oral transmission of infection including hepatitis A possible> Food crumbs may lead to infestation> Risk if ingestion of rotten food and food poisoning is possible> Meal tray delivery and storage may pose additional hygiene challengesBurden on dialysis staff and logistics constraints> Overworked dialysis staff face with additional responsibilities

> Providing nutrition may not be regarded as an a justifiable part of patient care in dialysis clinics

Only a fraction of required meals are provided> Thrice-weekly meals account for 15% of all meals

> The evidence that catabolic effect of HD can be mitigated or reversed by intradialytic nutrition is not convincing

Added expenses to dialysis treatment> The costs of meals during dialysis may be small but still not negligible> If costs of meals are factored in by the insurance company or in the bundling equation, this may be at the cost of other more critical treatment components and medications

ISRNM Consensus Paper JREN 2017

Whereas larger multicenter randomized trials are needed, meals and supplements during hemodialysis should be considered as a part of the standard-of-care practice for patients without contraindications.

Kistler… Kalantar-Zadeh. J Ren Nutr. 2017

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Essen waehrend Hemodialyse(meals during hemodialysis)

Essen waehrend Hemodialyse(meals during hemodialysis)

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Essen waehrend Hemodialyse(meals during hemodialysis)

Essen waehrend Hemodialyse(meals during hemodialysis)

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Essen waehrend Hemodialyse(meals during hemodialysis)

Essen waehrend Hemodialyse(meals during hemodialysis)

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Essen waehrend Hemodialyse(meals during hemodialysis)

Essen waehrend Hemodialyse(meals during hemodialysis)

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Essen waehrend HemodialyseEating During Dialysis, Wurzburg, Germany

Connie M. Rhee, Amy S. You, Tara Koontz Parsons, Amanda R. Tortorici, Rachelle Bross, David E. St‐Jules, Jennie Jing, Martin L. Lee, Debbie Benner, 

Csaba P. Kovesdy, Rajnish Mehrotra, Joel D. Kopple and Kamyar Kalantar‐Zadeh.

Nephrol Dial Transplant (2017)62

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Post-Study visit

8-week Study Period

55 Treatmentn=51

55 Controln=55

Dietary counseling↑pro intake with ↓phos:protein ratio

High protein meals

Meal tray: 50 g+ 850 Cal

Phosphorus Binder

Fosrenol

Routine dietary counseling

Low protein meals<1 g of protein, 25

Cal

Phosphorus BinderMaintain previous

binder

(1) ClinicalTrials.gov # NCT0111694 (2) Koontz … Kalantar-Zadeh. FrEDI study. Kidney Res Clin Pract 31[2], June 2012; and Oral presentation, ISRNM Congress, Honolulu, HI, June 2012. (3) Kalantar-Zadeh K, Bross R, Koonz T, Lee ML, Shah A, Molnar MZ, Luna C, Jing J, Benner D, Unruh M, Mehrotra R, Kovesdy CP, Kopple JD. High protein meals during hemodialysis traetment to increase serum albumin while controlling phosphorus. Preliminary results from the fredi study. Am J Kidney Dis. 2013 [NKF abstract];Suppl SCM 2013 Apr. (4) AJKD Blog, NKF SCM13: eAJKD interview with Dr. Kamyar Kalantar-Zadeh, April 2013, Orlando, FL, https://www.youtube.com/watch?v=PuRvb0I4zts

FREDI Study110 hypoalbuminemic HD patients

(serum albumin < 4.0 g/dL)

Randomized

Rhee…Kalantar-Zadeh, NDT 2017

Eating During Dialysis Study, Los Angeles, California: Randomized Control Trial (FREDI Study)

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NephMadness visual abstract

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ProsImpact on nutritional status and clinical outcomes> Meals during HD is practiced routinely in many industrialized nations including Europe and South East Asia> Excellent survival in most countries where meals are served during HD> No major unfavorable outcomes reported in countries offering meals during HD

Mitigates/corrects intra- and post-dialysis catabolism> HD Rx exerts catabolic effects that can be avoided by eating during HD> Muscle wasting may be mitigated> Effectively increases the frequency of daily meal intakes

Better control of dietary phosphorus, potassium, salt and fluid> In-center meals and supplements can be more optimally prepared for the specific needs of CKD patients > In-center meals may improve adherence to restricted salt and fluid intake> Intake of phosphorus binder can be monitored> Improved patient education can be achieved by simultaneous interaction with dietitian and nephrologist while eating

Increased adherence with hemodialysis treatment> Increases the likelihood of attending HD treatment>May mitigate the likelihood of HD treatment shortening by hungry patients > Enhances communication between patients and dietitians and other clinic staff

Improved patient satisfaction and quality of life> In-center meals may make patients more content with dialysis treatment life style> Improved quality of life by means of in-center meal may improve survivalRelatively low costs of meals on HD> The costs of providing in-center meals is a small fraction of expensive medications used in ESRD > Dialysis organizations can adapt this in form of efficient and economical approaches

Kalantar-Zadeh K, Ikizler TA. J Ren Nutr. 2013 May;23(3):157-63

Table 2. Pros and cons of in-center (in the dialysis clinic) monitored eating and provision of meals during hemodialysis treatments

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Kalantar-Zadeh K, Ikizler TA. J Ren Nutr. 2013 May;23(3):157-63

Table 2. Pros and cons of in-center (in the dialysis clinic) monitored eating and provision of meals during hemodialysis treatments

ConsLow blood pressure and labile circulation during food ingestion> blood pressure may be lowered during and after eating due to splanchnic circulation expansion even with new dialysis treatment and techniques> Hypotensive episode may lead to shortening dialysis Rx or less efficient fluid removalRisk of aspiration and other respiratory complications

> Risk of choking is likely higher in patients with a history of neurologic disorders, swallowing problems or other disabilities

> Even in sitting position aspiration may happen in patient who cannot feed themselves at home

Infectious control and hygiene issues> Fecal–oral transmission of infection including hepatitis A possible > Food crumbs may lead to infestation> Risk if ingestion of rotten food and food poisoning is possible > Meal tray delivery and storage may pose additional hygiene challengesBurden on dialysis staff and logistics constraints> Overworked dialysis staff face with additional responsibilities

> Providing nutrition may not be regarded as an a justifiable part of patient care in dialysis clinics

Only a fraction of required meals are provided> Thrice-weekly meals account for 15% of all meals

> The evidence that catabolic effect of HD can be mitigated or reversed by intradialytic nutrition is not convincing

Added expenses to dialysis treatment> The costs of meals during dialysis may be small but still not negligible> If costs of meals are factored in by the insurance company or in the bundling equation, this may be at the cost of other more critical treatment components and medications

Part 9

Conclusions

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Summary and conclusions

• Nutritional management of CKD should be revived in 2020 and beyond to add to the armamentarium of the MANAGEMENT of CKD

• Different dietary approaches are needed for different stages and different formats of CKD.

• IDPN is safe and recommended when serum albumin is <3.5 mg/dL along with other nutritional risks.

• Meals on dialysis are safe and practiced frequently in other countries.

• FREDI Study shows that safety and efficacy of meals during dialysis in US dialysis units.

Acknowledgement

Investigators and Staff• Elani Streja, MPH, PhD• Connie M. Rhee, MD, MSc• Hamid Moradi, MD• Wei Ling Lau, MD• Joline Chen, MD, MPH• Foad Ahamdi, MD• Paungpaga Lertdumrongluk, MD• Yoshitsugu Obi, MD• Melissa Soohoo, MPH• Bryan Shapiro, MPH• Amanda Brown, RD• Tracy Nakata

Collaborators:• Csaba P. Kovesdy, MD• Rajnish Mehrotra, MD• Joel D Kopple, MD• Matthew Budoff, MD• Steven S. Jacobsen, MD, PhD• Rajiv Saran, MD, MSc.• Miklos Z. Molnar, MD, PhD• Jongha Park, MD• Daniel Gillen, PhD• Danh Nguyen, PhD• Allen Nissenson, MD, • Steven Brunelli, MD, MS

The Harold Simmons Center for Kidney Disease Research & Epidemiology

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