Improved survival
The crude death rates in the ITT cohort were 30.1 percent for the ONS group and 30.4 percent for the controls, while they were 30.9 percent and 37.3 percent, respectively, in the as-treated cohort. These extremely high death rates reflect that hypoalbuminemic patients belonged to the worst risk group in the maintenance HD population because they are severely malnourished, the investigators explained in the AJKD paper.
Overall, ONS patients had 9 percent increased survival than controls in the ITT analysis and 34 percent increased survival in the as-treated analysis. The difference in outcomes between the two models is because in the ITT analyses, 40 percent of the patients in the control group did receive some ONS during the follow-up period. Additional analyses showed that the greatest effect of supplements on the death rate was among those with baseline albumin levels of 3.2 g/dL or less. In other words, the worse the malnutrition, the more effective is ONS.
The observed difference in survival represents a major finding that supports what has long been proposed: that increasing protein and caloric intake during thrice-weekly HD treatments “may facilitate achieving sufficient nutritional support and improve physiologic processes enough to reduce their high risk of mortality,” Hakim and his colleagues stated in their paper. They strongly recommended “that intradialytic oral nutrition be offered as a treatment option to eligible hypoalbuminemic maintenance-hemodialysis patients.”
In a separate presentation at the meeting, Lacson, using the same study population, showed that intradialytic ONS reduces the risk of hospitalization and the length of hospital stay compared to not receiving intradialytic ONS. The time to first hospitalization was significantly shorter in intradialytic ONS patients compared with controls. The average hospitalization rates were 2.5 and 2.7 episodes/patient-year in the two groups, respectively. In addition, the ONS and controls group had 19.2 and 20.4 hospitalization days/patient-year, respectively, and 29.4 percent and 36.6 percent mortality rates, respectively.
Also at the symposium, T. Alp Ikizler, MD, also of Vanderbilt, stressed the importance of boosting nutrition among patients with chronic kidney disease (CKD) when indicated, an approach used widely around the world but not in North America.
Although eating meals during dialysis potentially could be associated with a small risk of hypotension and some inconvenience for dialysis center staff, it can counteract HD-related protein catabolism, improve patients' nutritional status, increases their dialysis adherence, and enhance phosphate and fluid removal, Ikizler said. He discussed these points in detail in a recent review article, which also included a proposed algorithm for nutritional support in CKD patients (Nature Rev Nephrol 2011;7:369-384). He also discussed the algorithm in detail at the congress.
