Nutrition has always been, and always will be, a paramount concern for dialysis patients and those professionals who care for them. However, making sure patients are staying up with their dietary needs is a daunting task, especially for renal dietitians. They need to make sure patients remain compliant, as well as keep up with the latest trends and science in renal nutrition. One of those trends is the use of using supplements to aid dialysis patients in their quest for better nutrition. However, there is still trepidation on how to best use supplements and what their effects may be. To help shed some light on this issue, as well as how to best educate patients, RBT asked the following experts to weigh in on the questions below.
- Debbie Benner, MA, RD, CSR, Vice President of Clinical Support, DaVita Inc.
- Barbara Zebrowski, MS, RD, CSR, LDN, Corporate Dietitian, Fresenius Medical Care North America (FMCNA)
- Karen Wiesen, MS, RD, LD, Chair, National Kidney Foundation-Council on Renal Nutrition (NKF-CRN)
- Ray Chow, PhD, President and Founder, Nephrian Inc.
How is the renal community performing overall in nutrition, and are there areas that can be improved? If so, what are they?
Chow: Undoubtedly, there have been improvements, but the report card would still read, “Could do better.” The number of patients with low albumin levels, due to malnutrition (based on body composition) or chronic inflammation remains high, for reasons that remain unclear. However, credibility of nutritional supplement use and even a fundamental understanding of their mechanistic action may be contributing factors. An obvious factor discouraging broader use is that a vast majority of supplements are not covered under Medicare or health plans. Many patients end up paying out of their own pocket.
But, clinical research and education remain key areas necessary for continual improvement. Recent research on the benefits with nutritional vitamin D use has been encouraging but there is evidence with other nutritional products that merit further research. However, any clinical benefits resulting from validated research must be followed up with a solid education program, otherwise it will be a badly missed opportunity. Even today, a substantial body of evidence exists, which requires collation into educational programs for both providers and patients. Integration of nutritional programs into clinical practice with feedback mechanisms on parameters such as functional status and clinical outcomes, are essential if nutritional supplement use is to be optimized.
Wiesen: The etiology of malnutrition in the dialysis patient is complicated and can be a result of a combination of inadequate nutrient intake, inflammation, dialysate losses, metabolic acidosis, oxidative stress, and inflammation-induced cachexia. Protein energy malnutrition is a type of PEW caused by inadequate intake alone. In 2008, the International Society of Renal Nutrition and Metabolism (Fouque, et al, Kidney International 2008) proposed a singular name for this syndrome to help with diagnosis: protein energy wasting (PEW). PEW is estimated to occur in 18 percent to 75 percent of hemodialysis and peritoneal dialysis patients depending on the modality. So PEW remains a big concern in the dialysis population and can significantly affect mortality and morbidity.
I am not sure there is one easy answer as to how we can improve these numbers. Certainly earlier diagnosis and intervention for inflammatory processes and malnutrition may help but we also need better coverage and reimbursement for nutritional supplements and intradialytic nutrition.
Benner: Adequate nutrition is a complex challenge for patients with chronic kidney disease and especially challenging for dialysis patients. This chronic disease state raises the risk for malnutrition. In addition, many patients suffer with varying levels of inflammation which add to the complexity. Registered dietitians work collaboratively with the team to address both the nutrition and non-nutritional factors that affect nutritional status. Over the years our knowledge related to malnutrition and inflammation has increased and with that knowledge the value and contributions of the registered dietitian have grown.
Zebrowski: Malnutrition stemming from physical and economic conditions remains an ever-present concern in the renal community. According to the 2009 USDA survey on food insecurity, the number of Americans found in the “food insecure” category in 2008 rose to 49 million individuals (17.1 million households). Life on dialysis brings challenges that can make some patients vulnerable to “food insecurity,” described as a “limited or uncertain availability of nutritionally adequate and safe foods.” Concerns expressed by Fresenius Medical Care North America (FMCNA) dietitians have led us to seek solutions for patients who may not be able to afford the foods that supply high-quality protein and adequate calories required for a person following the renal diet.
As part of the renal community, we are working to find ways to improve the nutrition status of dialysis patients. Fresenius Medical Care Nutrition Network, the quarterly nutrition-related newsletter for dietitians from the FMCNA Nutrition Services Advisory Board, has addressed this concern. The board first identified community assistance programs and links to websites developed by the renal community and the government. The dietitians also developed education materials to guide patients on how to stretch their food dollars at home and on the go.
Malnutrition will be a concern in the renal community for the foreseeable future. Dialysis clinicians and patients will need to make use of the tools and information provided in order for our patients to overcome the physical and economic barriers to nutritional well-being.
Do nutritional supplements have a role in dialysis nutrition? Are there any pros and cons?
Wiesen: Yes, they have an important role. It has been shown that the relative risk of death for dialysis patients is two-times that of the reference group when albumin is between 3.5-4.0 g/dL. That increases to five times when the albumin falls to between 3.0-3.5 g/dL. Numerous studies have shown that nutritional supplementation can improve albumin levels. Albumin is an acute phase reactant and will fall in response to inflammation unrelated to nutrient intake. However recent studies in the past three to four years have demonstrated that albumin levels can be improved even when inflammation is present, which is promising. Kalantar-Zadeh (2006), in a study examining albumin and mortality predictability, showed a rise in serum albumin over time was associated with better survival independent of the baseline albumin. One of the biggest problems remains availability and affordability of nutritional supplements. These are usually not covered by private insurance or Medicare or Medicaid.
