University of Groningen

Nutritional status in nocturnal hemodialysisIpema, Jacoba Regina

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Chapter 1

Introduction

10 INTRODUCTION

11

Introduction

Chronic kidney disease and renal replacement treatmentIn the Netherlands, over one million people are afflicted with chronic kidney disease, approximately 9500 patients have a functioning renal transplant, and almost 6500 patients are being treated with dialysis1. The majority of patients on dialysis are treated with hemodialysis (85 %), and the remainder is treated with peritoneal dialysis1,2.

Hemodialysis is a procedure to remove waste products and excess fluid from the blood. Worldwide, most hemodialysis patients dialyze thrice weekly for three to five hours. This dialysis schedule does not reflect the normal physiological process and is associated with substantial fluctuations in the fluid state, electrolytes, and acid base parameters3. Higher dialysis doses such as those with more frequent and/or longer hemodialysis sessions result hemodynamically more stable dialysis sessions, less over-hydration, better metabolic control, and improved quality of life3.

Frequent nocturnal hemodialysis, a combination of longer and also usually more frequent treatments, results in a much greater weekly removal of waste products such as uremic toxins and also facilitates fluid removal. Nocturnal in-center hemodialysis is an alternative for patients who have medical and/or social needs for nocturnal hemodialysis but, for one reason or another, cannot be treated at home. Most patients receiving nocturnal in-center hemodialysis are dialyzed three to four nights per week whereas the majority of nocturnal home hemodialysis patients dialyze five to six nights per week. Nocturnal hemodialysis is primarily performed with a single needle and with reduced blood and dialysate flows of 150 and 300 ml/min, respectively. In contrast, most patients on conventional hemodialysis are on a thrice weekly, four hour dialysis schedule with double-needle and blood and dialysate flows of 250-350 and 500-700 ml/min, respectively.

The training period for home hemodialysis is approximately 12 weeks during which the patient learns to operate the dialysis machine, puncture the vascular access, solve problems, and anticipate calamities. It is recommended that the patient has at least one month of experience with day-time home hemodialysis before beginning the training for nocturnal home hemodialysis. Most patients on nocturnal home hemodialysis have a spouse that assists with the treatment, however, the patient can also individually perform this treatment.

Nocturnal hemodialysis benefits patients in several different ways including less disruption of daytime activities and no disruptions of meals by the daytime hemodialysis sessions4-7. In most patients, uremic and dialysis-related symptoms diminish considerably within one week after the initiation of nocturnal hemodialysis treatment4. In virtually all patients, less medication is required after the conversion from conventional to nocturnal hemodialysis. In particular, phosphate binders can be reduced or discontinued7,8. The same applies to antihypertensive medication which is most likely a result of better volume control7,9. Various studies showed

12 INTRODUCTION

that the quality of life improves after conversion to nocturnal hemodialysis4,10,11. Therefore, it is not unexpected that the vast majority of patients do not want to return to conventional hemodialysis once nocturnal hemodialysis has been initiated4.

Nutritional statusHemodialysis patients experience diminished physical functioning with a loss of muscle mass and adipose tissue12,13 as well as an increased prevalence of malnutrition which is a major predictor of mortality and morbidity in hemodialysis patients14. The cause of malnutrition in hemodialysis patients is multi-factorial. First, reduced appetite and food intake15-17 play an important role in part due to various dietary restrictions, e.g., sodium, potassium, phosphate, and fluid18,19. The use of phosphate binders during meals can also negatively affect appetite6,7. Second, factors such as reduced physical activity, chronic inflammation, increased energy expenditure, fatigue, nausea, xerostomia, metabolic acidosis, and comorbid conditions contribute to malnutrition in this patient group13,14,20. Third, some patients are not able to shop for or prepare food19,20. Fourth, the dialysis procedure itself may have a role in protein energy wasting since hemodialysis may remove important nutrients such as amino acids21 and is an inflammatory trigger that may negatively affect nutritional status20,22. Finally, the hemodialysis procedure appears to increase the resting energy expenditure by unknown mechanisms23.

Most hemodialysis patients have reduced physical activity and develop muscle atrophy over time12,13. However, even after controlling for reduced physical activity, muscle atrophy is still more severe in hemodialysis patients compared with healthy controls13 (Figure 1).

13

Figure 1. A model of the many factors that may lead to malnutrition in hemodialysis patients.

There is no ‘gold standard’ for the assessment of nutritional status in hemodialysis patients. In clinical practice, a combination of parameters is used including dietary assessment, Subjective Global Assessment, anthropometry (dry body weight, body composition measured with bio-electrical impedance analysis, dual-energy X-ray absorptiometry, etc.), normalized protein catabolic rate, serum albumin and pre-albumin, and serum cholesterol18.

Several studies suggest that prolonged hemodialysis sessions, either at home or in-center, may improve clinical outcomes24-27 and nutritional status6,7,28. Receiving dialysis during the night may also facilitate a more ‘normal’ circadian rhythm with fewer disturbances in the eating pattern. Diet and fluid restrictions are usually less stringent in nocturnal hemodialysis patients compared with patients on conventional hemodialysis which is a result of the more intensive dialysis schedule. Nocturnal hemodialysis patients use significantly less or no phosphate binders, and this may also result in a better appetite6,7. All of these factors may alter the pattern of food consumption after the transition from conventional hemodialysis to nocturnal hemodialysis.

The health-related quality of life seems to improve following the conversion from conventional hemodialysis to nocturnal hemodialysis as indicated by several studies, e.g., in the areas physical functioning, pain index, vitality, emotional and social functioning, health perceptions, and physical role4,10,26. Appetite is an

14 INTRODUCTION

important determinant of quality of life16 and most patients report an increase in appetite after the transition from conventional to nocturnal hemodialysis6,7.

Dietary treatmentMalnourished hemodialysis patients require regular dietary counseling by a dietician who can tactfully eliminate barriers to adequate food intake (e.g. poor appetite, knowledge, expensive foods, not being capable of shopping) and make recommendations to optimize the dietary intake of protein and energy19. Hemodialysis patients usually have regular contact with the dietician every four to six weeks. During these visits, the nutritional status is evaluated by discussing appetite, monitoring weight, and examining laboratory results. Dietary restrictions on sodium, potassium, phosphate, and fluid intake are necessary for adequate metabolic control and may help prevent pruritus, bone-mineral disease, cardiovascular diseases, hemodynamic instability, disequilibrium, and sudden death by hyperkalemia18. However, at the same time, these restrictions may affect the intake of various nutrients including protein. Dietary counseling is crucial to maintain optimal nutrition intake despite all of the dietary restrictions20,29.

Before beginning nocturnal hemodialysis, patients receive additional information on (changes in) the diet that occur following the transition to nocturnal hemodialysis. Advice regarding energy intake, protein intake, and sodium restriction are basically unchanged. Potassium restriction is less strict or even suspended depending on the laboratory measurements and the frequency of nocturnal hemodialysis. The dose of phosphate binders is usually halved or completely discontinued by the nephrologist on the day of the transition to nocturnal hemodialysis. There are currently no specific fluid guidelines for the more intensive hemodialysis modalities. Fluid restriction, according to the European best practice guidelines, is 500 - 1000 ml per day in addition to the daily urine volume. Additionally, a 4% to 4.5% weight gain in proportion to dry weight is considered acceptable in patients with an optimal nutritional intake and salt restriction18,30 (Table 1).

15

Table 1. Dietary recommendations in patients on conventional and nocturnal hemodialysis.

Conventional hemodialysis#

Nocturnal in-center hemodialysis

Nocturnal home hemodialysis

Energy 30-40 kcal/kg IBW 30-40 kcal/kg IBW 30-40 kcal/kg IBW

Protein 1.1 g/kg IBW/day 1.1 g/kg IBW/day 1.1 g/kg IBW/day

Sodium 2000 - 2300 mg 2000 - 2300 mg 2000 - 2300 mg

Fluid 500 - 1000 ml (+ daily urine output)<4-4.5% IDWG/DBW

Less strict Less strict

Potassium 1950 - 2730 mg Less strict Less strict or no restriction

Phosphate 800 - 1000 mg Less strict or no restriction

Less strict or no restriction

Phosphate binders

Most patients need phosphate binders

Halve the amount Usually no need to use phosphate binders

Abbreviations: IBW: ideal body weight; IDWG: interdialytic weight gain; DBW: dry body weight. # European best practice guidelines on nutrition, 200718.

Interdialytic weight gain (IDWG) is primarily the result of salt and water intake between dialysis sessions which directly reflects the compliance with diet and fluid restriction31,32. Several authors have indicated that high sodium concentrations should be avoided in patients on nocturnal hemodialysis since it could induce thirst and lead to an increased IDWG33,34. However, studies investigating the optimal sodium concentration in nocturnal hemodialysis are lacking.

Several studies showed that a higher IDWG is associated with higher predialysis blood pressures and increased mortality rates35-39. IDWG is also increasingly recognized as an indicator of nutritional status32,40,41. A decrease in IDWG is expected after the conversion to nocturnal hemodialysis36, however, in contrast, most studies reported an increase in IDWG normalized for the frequency of dialysis per week5,25,42 probably as a result of more liberal fluid intake33.

Aim and outline of this thesisThe aims of this thesis are to describe the effects on nutritional status and body composition following the transition from conventional hemodialysis to nocturnal hemodialysis and to explore the relation between IDWG and nutritional status.

In Chapter 2, we study whether food preference differs between nocturnal home hemodialysis patients and those on conventional hemodialysis. In this study, food preference is used as an indicator of taste perception. A decreased appetite in hemodialysis patients may be an important factor in the development

16 INTRODUCTION

of malnutrition. In chapter 3 we study whether the transition from conventional hemodialysis to nocturnal hemodialysis has an effect on protein intake. Chapter 4 describes the effect of one year of nocturnal hemodialysis on body composition, in particular on total mass, fat mass, and fat-free mass. Patients who made the transition to nocturnal hemodialysis are compared with patients that continued to receive conventional hemodialysis. In chapter 5 we put our findings into perspective with the current state of literature by performing a systematic review on the effect of nocturnal hemodialysis on protein intake, body composition, laboratory indices of nutritional status, and body composition. In chapter 6, we explore the determinants and consequences of IDWG in detail. We aimed to identify the major determinants of a high IDWG and its effect on nutritional parameters and blood pressure. In chapter 7, we summarize the previous studies, discuss the primary findings, offer recommendations for future research, and highlight the practical application of our findings.

17

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18 INTRODUCTION

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