The effect of resistance exercise to augment long-term benefits of intradialytic oral nutritional supplementation in chronic hemodialysis patients.

Background: Resistance exercise combined with intradialytic oral nutrition (IDON) supplementation improves net protein balance in the acute setting in chronic hemodialysis patients. We hypothesized that combination of long-term resistance exercise and IDON would improve markers of muscle mass and strength further compared with IDON alone.

Methods: Thirty-two participants (21 male; mean age, 43 ± 13 years) on chronic hemodialysis were randomly assigned to IDON plus resistance exercise (NS + EX), or IDON (NS) alone for 6 months.

Prospective evaluation of waist circumference and visceral adipose tissue in patients with chronic kidney disease.

Background: Waist circumference (WC), a simple anthropometric measure, is associated with visceral adipose tissue (VAT) in cross-sectional studies, and thus has been used as a surrogate marker for VAT. However, associations between changes over time in WC and VAT have not been studied in chronic kidney disease (CKD) patients.

Methods: This prospective study included 87 nondialysis-dependent CKD patients (54 males, 56.

Factors associated with body-fat changes in prevalent peritoneal dialysis patients.

Background: Changes in body fat (BF) were shown to occur over time in peritoneal dialysis (PD) patients. However, the factors associated with BF changes have not been fully investigated in this population.

Methods: We studied 45 patients (25 were male; age, 53, SD +/- 15 years; 21 continuous ambulatory peritoneal dialysis/24 automated peritoneal dialysis; PD vintage, 14 ([range, 3 to 104] months; 40% were diabetic; 31% were previously treated by hemodialysis).

Resistance exercise augments the acute anabolic effects of intradialytic oral nutritional supplementation.

Background: An intriguing strategy to further enhance the anabolic effects of nutritional supplementation is to combine the administration of nutrients with resistance exercise. We hypothesized that the addition of resistance exercise to oral nutrition supplementation would lead to further increases in skeletal muscle protein accretion when compared to nutritional supplementation alone in chronic haemodialysis (CHD) patients.

Methods: We performed stable isotope protein kinetic studies in eight CHD patients during two separate settings: with oral nutritional supplementation alone (PO) and oral nutritional supplementation combined with a single bout of resistance exercise (PO + EX).

Early intervention improves mortality and hospitalization rates in incident hemodialysis patients: RightStart program.

Background And Objectives: Annualized mortality rates of chronic hemodialysis (CHD) patients in their first 90 d of treatment range from 24 to 50%. Limited studies also show high hospitalization rates. It was hypothesized that a structured quality improvement program (RightStart), focused on medical needs and patient education and support, would improve outcomes for incident CHD patients.

Evaluation of Cinacalcet Therapy to Lower Cardiovascular Events (EVOLVE): rationale and design overview.

Background And Objectives: The dramatically high rates of mortality and cardiovascular morbidity observed among dialysis patients highlights the importance of identifying and implementing strategies to lower cardiovascular risk in this population. Results from clinical trials undertaken thus far, including trials on lipid reduction, normalization of hematocrit, and increased dialysis dosage, have been unsuccessful. Available data indicate that abnormalities in calcium and phosphorus metabolism, as a result of either secondary hyperparathyroidism alone or the therapeutic measures used to manage secondary hyperparathyroidism, are associated with an increased risk for death and cardiovascular events.

Body composition and physical activity in end-stage renal disease.

Objective: The study objective was to examine the relationship between visceral and somatic protein stores and physical activity in individuals with end-stage renal disease.

Design: This was a prospective single-center study.

Setting: The study took place at the Vanderbilt University Outpatient Dialysis Unit and General Clinical Research Center.

Intradialytic oral nutrition improves protein homeostasis in chronic hemodialysis patients with deranged nutritional status.

Decreased dietary protein intake and hemodialysis (HD)-associated protein catabolism predispose chronic HD (CHD) patients to deranged nutritional status, which is associated with poor clinical outcome in this population. Intradialytic parenteral nutrition (IDPN) reverses the net negative whole-body and skeletal muscle protein balance during HD. IDPN is costly and restricted by Medicare and other payers.

Nutrition and metabolism in kidney disease.

Nutritional and metabolic derangements are highly prevalent in patients with chronic kidney disease (CKD) and patients on renal replacement therapy. These derangements, which can be termed uremic malnutrition, significantly affect the high morbidity and mortality rates observed in this patient population. Uremic malnutrition clearly is related to multiple factors encountered during the predialysis stage and during chronic dialysis therapy.

Recombinant human growth hormone improves muscle amino acid uptake and whole-body protein metabolism in chronic hemodialysis patients.

Background: Intradialytic parenteral nutrition (IDPN), with or without exercise, has been shown to reverse the net negative whole-body and forearm muscle protein balances observed during hemodialysis. Pharmacologic doses of recombinant human growth hormone (rhGH) constitute another potential anabolic therapy in chronic hemodialysis patients.

Objective: Our goal was to examine the potential additive anabolic effects of rhGH compared with IDPN and exercise on protein and energy homeostasis.

Accelerated lean body mass loss in incident chronic dialysis patients with diabetes mellitus.

Background: End-stage renal disease (ESRD) patients display a higher incidence of poor nutritional status and are at high risk of hospitalization and death. Patients on renal replacement therapy (RRT) with a primary diagnosis of diabetes mellitus have the lowest survival rates along with highest hospitalization incidence.

Methods: In this study, we examined the importance of diabetes mellitus along with certain demographic and clinical variables in predicting the change in lean body mass (LBM) by dual-energy x-ray absorptiometry (DEXA), as a surrogate marker of somatic protein stores, in 142 incident ESRD patients (91 males, 52.

Increased muscle protein breakdown in chronic hemodialysis patients with type 2 diabetes mellitus.

Background: The presence of diabetes mellitus (DM) in chronic hemodialysis (CHD) patients has potential to increase body protein losses and muscle wasting.

Methods: In this study, we examined whole-body and skeletal muscle protein metabolism in 6 CHD patients with type 2 (T2) DM (2 male, 44.4 +/- 6.

Insulin resistance in critically ill patients with acute renal failure.

Mortality in critically ill patients with acute renal failure (ARF) remains high. Hyperglycemia associated with insulin resistance has been associated with adverse outcomes in critically ill intensive care unit (ICU) patients but has not been examined specifically in patients with ARF. We used data from a subcohort (n = 90) of the Program to Improve Care in Acute Renal Disease (PICARD), an observational study of 618 adult ICU patients with ARF in whom nephrology service consultation was obtained.

Physical activity patterns in chronic hemodialysis patients: comparison of dialysis and nondialysis days.

Objective: To determine physical activity patterns in chronic hemodialysis patients with a specific emphasis on the difference between dialysis and nondialysis days. Design A cross-sectional single-center study.

Setting: Vanderbilt University Outpatient Dialysis Unit.

Uremic malnutrition is a predictor of death independent of inflammatory status.

Background: Several studies have pointed out the influence of nutritional parameters and/or indices of inflammation on morbidity and mortality. Often, these conditions coexist, and the relative importance of poor nutritional status and chronic inflammation in terms of predicting clinical outcomes in chronic hemodialysis (CHD) patients has not been clarified.

Methods: We undertook a prospective cohort study analyzing time-dependent changes in several established nutritional and inflammatory markers, and their influence on mortality in 194 CHD patients (53% male, 36% white, 30% with diabetes mellitus, mean age 55.

Oxidative stress is increased in critically ill patients with acute renal failure.

Patients with acute renal failure (ARF) experience a high mortality rate. Dysregulated inflammation and altered metabolism may increase oxidative stress in ARF patients. Thirty-eight patients who met the Program to Improve Care in Acute Renal Disease (PICARD) Study inclusion criteria underwent plasma protein oxidation and plasma cytokine measurements.

Nutritional supplementation acutely increases albumin fractional synthetic rate in chronic hemodialysis patients.

Uremic malnutrition is associated with increased risk of hospitalization and death in chronic hemodialysis (CHD) patients. Most nutritional intervention studies in CHD patients traditionally have used concentrations of serum albumin as the primary outcome measure and showed slight or no significant improvements. A recent study showed that intradialytic parenteral nutrition (IDPN) improves whole-body protein synthesis in CHD patients.

Influence of initiation of maintenance hemodialysis on biomarkers of inflammation and oxidative stress.

Background: Chronic inflammation and oxidative stress are highly prevalent in patients with chronic kidney disease and end-stage renal disease (ESRD). These conditions contribute to high mortality rates associated with cardiovascular disease, the leading cause of death in this patient population. To our knowledge, no prospective studies have examined how initiation of maintenance hemodialysis (MHD) affects biomarkers of inflammation and oxidative stress status.

Protein homeostasis in chronic hemodialysis patients.

Purpose Of Review: Nutritional status is an important predictor of clinical outcome in chronic hemodialysis patients, as uremic malnutrition is strongly associated with an increased risk of death and hospitalization events. Decreased muscle mass is the most significant predictor of morbidity and mortality in these patients. Several factors that influence protein metabolism predispose chronic hemodialysis patients to increased catabolism and the loss of lean body mass.

Assessment and monitoring of uremic malnutrition.

Assessment and monitoring of protein and energy nutritional status are essential to prevent, diagnose, and treat uremic malnutrition, a condition highly prevalent and associated with increased morbidity and mortality in patients with advanced kidney failure. Comprehensive assessments of protein and energy nutritional status can be achieved by several measurements to quantitatively and qualitatively estimate protein content in visceral and somatic body compartments, in addition to measurements of energy balance. However, uremic malnutrition is a complex metabolic disorder in which not only net nutrient intake is lower than nutrient requirements, leading to decreased tissue function and loss of body mass, but it is also associated with many comorbid conditions.

Exercise augments the acute anabolic effects of intradialytic parenteral nutrition in chronic hemodialysis patients.

Decreased dietary protein intake and hemodialysis (HD)-associated protein catabolism are among several factors that predispose chronic hemodialysis (CHD) patients to uremic malnutrition and associated muscle wasting. Intradialytic parenteral nutrition (IDPN) acutely reverses the net negative whole body and forearm muscle protein balances observed during the HD procedure. Exercise has been shown to improve muscle protein homeostasis, especially if performed with adequately available intramuscular amino acids.

The extent of uremic malnutrition at the time of initiation of maintenance hemodialysis is associated with subsequent hospitalization.

Objective: End-stage renal disease (ESRD) patients with signs of uremic malnutrition at the time of initiation of maintenance hemodialysis (MHD) are likely to remain malnourished over the subsequent year. Because poor nutritional status is associated with worse clinical outcomes in MHD patients, we hypothesized that ESRD patients with evidence of uremic malnutrition at the time of initiation of MHD would have more hospitalization events compared with patients initiating MHD without signs of malnutrition during the first year of therapy.

Design/intervention: This was an observational cohort of incident MHD patients, with no specific nutritional intervention.

Uremic malnutrition: new insights into an old problem.

Uremic malnutrition is highly prevalent and is associated with poor clinical outcomes in end-stage renal disease (ESRD) patients. Inadequate diet and a state of persistent catabolism play major roles in predisposing these patients to uremic malnutrition and appear to have an additive effect on overall outcome. Recent studies highlight the existence of a complex syndrome involving chronic inflammation, metabolic abnormalities, and hormonal derangements contributing to the increased morbidity and mortality observed in ESRD patients.

Inflammatory signals associated with hemodialysis.

Background: Inflammation is highly prevalent in chronic hemodialysis patients. Because hemodialysis involves the contact of blood with "foreign" surfaces, and the documented activation of several humoral and cellular pathways during the procedure, the hemodialysis procedure has been suggested as a potential source of inflammation in this patient population. Earlier studies did not provide clear-cut evidence of the potential contribution of the hemodialysis procedure to inflammation, as assessed by markers of inflammation such as cytokine levels and acute-phase protein production.