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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2004  |  Volume : 15  |  Issue : 2  |  Page : 140-143
The Effect of Active Nutritional Counseling in Improving Biochemical Nutritional Parameters and Fluid Overload Problems in Maintenance Hemodialysis Patients

Nephrology, Hypertension & Renal Transplant Division, Department of Medicine, King Fahad National Guard Hospital, Riyadh, Saudi Arabia

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Management of nutritional status is an integral part of the management of patients with renal disease on maintenance hemodialysis (HD). We investigated whether active nutritional counseling can improve biochemical nutritional parameters and fluid overload problems in patients on HD. A total of 110 patients, on three times per week HD, were enrolled in the study. Information regarding patient characteristics was collected with the help of a questionnaire. Patients with hypoalbuminemia, hyperkalemia, hyperphosphatemia, and more than three kilograms inter-dialytic weight gains were identified and were given active nutritional counseling. The above parameters were followed over a seven-month period. Active nutritional counseling resulted in significant decrease in the prevalence of hyperkalemia as well as high inter-dialytic weight gains (p < 0.001). However, the prevalence of hypoalbuminemia and hyperphosphatemia remained unchanged over the study period. Our study suggests that active nutritional counseling can improve certain important biochemical parameters and fluid overload problems in patients on maintenance HD.

Keywords: Active nutritional counseling, Hemodialysis, Hypoalbuminemia.

How to cite this article:
Raza H, Courts A, Quadri K, Qureshi J, Al Ghamdi G, Al Flaiw A, Al Hejaili F, Huraib S. The Effect of Active Nutritional Counseling in Improving Biochemical Nutritional Parameters and Fluid Overload Problems in Maintenance Hemodialysis Patients. Saudi J Kidney Dis Transpl 2004;15:140-3

How to cite this URL:
Raza H, Courts A, Quadri K, Qureshi J, Al Ghamdi G, Al Flaiw A, Al Hejaili F, Huraib S. The Effect of Active Nutritional Counseling in Improving Biochemical Nutritional Parameters and Fluid Overload Problems in Maintenance Hemodialysis Patients. Saudi J Kidney Dis Transpl [serial online] 2004 [cited 2021 Apr 14];15:140-3. Available from: https://www.sjkdt.org/text.asp?2004/15/2/140/32895

   Introduction Top

Despite the advances made in renal replace­ment therapy for end-stage renal disease, malnutrition is still common among patients on dialysis. [1],[2] The prevalence is estimated to be 10-70% in patients undergoing hemodialysis (HD) and 18-51% in patients on Continuous Ambulatory Peritoneal Dialysis (CAPD). Inadequate nutritional intake is an important contributor for protein energy malnutrition in these patients and a strong relationship exists between low serum albumin levels and increased mortality in patients on dialysis. [3],[4] Recurrent episodes of fluid overload and hyperkalemia, for which patients frequently need extra sessions of dialysis, is common in patients on regular HD. The aim of our study was to see whether active nutritional counseling by a renal dietitian, in addition to optimum medical therapy, can lead to an improvement in patients' biochemical nutri­tional markers and decrease the incidence of hyperkalemia and fluid overload problems.

   Methods Top

A total of 110 patients on three times per week regular HD at The King Fahad National Guard Hospital dialysis unit were enrolled in the study. Biochemical parameters including serum albumin, potassium, phosphorous were recorded over a seven-month period. The patients' inter-dialytic weight gains were also recorded. Information regarding patient characteristics including gender, age, their interest and knowledge regarding diet and the daily fluid allowance was collected with the help of a questionnaire. Patients with hypoalbuminemia, hyperkalemia, hyperphos­phatemia and high inter-dialytic weight gains were identified. These patients were given active nutritional counseling (explanation about dietary and fluid restrictions with the help of charts twice per week) by an expe­rienced renal dietitian in addition to optimum medical therapy by the nephrologist. The trend noticed in the nutritional parameters and inter-dialytic fluid gains in these patients was observed during the period of study.

   Results Top

The study population consisted of 110 patients. The age-groups and information regarding diet, dialysis adequacy, etc. are shown in [Table - 1].

Analysis of adequacy of dialysis showed that 72% of the patients had urea reduction ratio (URR%) of more than 65. Target para­meters in specifically identified patients were reviewed before and after active nutritional counseling and it was seen that there was a significant improvement in the prevalence of hyperkalemia and inter-dialytic weight gain. However, no significant effect was seen with regard to the serum albumin level and hyperphosphatemia [Table - 2].

   Discussion Top

End-stage renal disease (ESRD) is a chronic debilitating illness resulting in decreased appetite, nausea and vomiting causing inade­quate nutritional intake which commonly leads to malnutrition. Because of the nature and long course of the disease, it is common for the patient to feel frustrated and this may lead to non-compliance with the dietary restri­ctions. However, if the importance of different parameters is repeatedly emphasized to the patient, this may result in improvement in compliance and hence improved nutritional and other clinically important parameters. Evidence from large multi center trials utilizing nutritional intervention indicates that frequent nutritional counseling results in better compliance with the intervention and improves outcome. [5],[6],[7],[8] However, these studies were not conducted in patients on maintenance dialysis. A recent study done on pre-dialysis patients showed that dietary advice along with appropriate use of nutritional supplements can maintain and even improve nutritional status in renal failure patients. [9] Intensive initial nutritional counseling, followed by follow-up every one or two months, has been recommended by the National Kidney Foundation DOQI clinical practice guidelines for nutrition in patients on maintenance dialysis.

In our study population, only 47% of patients knew the importance of high serum potassium level and 32% could not name any three foods rich in potassium and this lack of insight could be a significant reason for the higher prevalence of hyperkalemia. Active nutritional counseling resulted in significant improve­ment in incidence of hyperkalemia and inter­dialytic fluid gain. Both these parameters are clinically important as recurrent fluid over­load leads to increased cardiac strain causing left ventricular hypertrophy and ultimately dilatation. This in turn leads to higher cardiac mortality in such patients. [4],[10] Hyperkalemia is the most important metabolic abnormality associated with cardiac arrhythmias in patients with ESRD. It can cause depression of myocardial contractility and leads to atrial standstill and ventricular and junctional hyper­excitability. [11] It has been reported to cause acute hypotension and shock-like picture in dialysis patients. [12]

Also, by significantly decreasing the pre­valence of hyperkalemia and fluid overload episodes which frequently result in need for extra sessions of dialysis, we can decrease the cost of health care as well as reduce the workload of already overstretched medical staff who are serving in busy dialysis units.

Unfortunately, there was no significant improvement in the prevalence of hypo­albuminemia and hyperphosphatemia in our study. The reasons may be multifactorial; our study population comprised of a higher proportion of elderly patients with multiple co-morbid conditions limiting their nutritional intake, e.g. diabetes mellitus causing auto­nomic neuropathy leading to diarrhea, diabetic gastropathy and dental problems. Another aspect of this problem is the patient's dependence on his/her family as regards food selection. We need to educate the patient's family members on the need to provide appropriate food with adequate calories and protein to the patient. Nutritional counseling should take into account patient's educational background and provide information in a way which can be comprehended by the patient. As was obvious in our study, 60% of our patients could not read their native language.

In conclusion, our study demonstrates signi­ficant improvement in important nutritional and clinical parameters by active nutritional counseling. However, the program of nutri­tional counseling should be structured to meet the requirement of the targeted population taking into consideration their educational level and cultural differences. Perhaps further improvement can be achieved if patient's family members are motivated and actively involved in the nutritional counseling program.

   References Top

1.Thunberg BJ, Swamy AP, Cestero RV. Cross sectional and longitudinal nutritional measurements in maintenance hemodialysis patients. Am J Clin Nutr 1981;34:2005-12.  Back to cited text no. 1  [PUBMED]  
2.Schoenfeld PY, Henry RR, Laird NM. Assessment of nutritional status of the cooperative dialysis study population. Kidney Int 1983,23(Suppl 13):S80-8.  Back to cited text no. 2    
3.Lowrie EG, Lew NL. Death risk in hemodialysis patients: the predictive value of commonly measured variables and an evaluation of death rate differences between facilities. Am J Kidney Dis 1990;15:458-82.  Back to cited text no. 3  [PUBMED]  
4.Kopple JD. Dietary protein and energy requirements in ESRD patients. AM J Kidney Dis 1998;32:S97-104.  Back to cited text no. 4  [PUBMED]  
5.Caggiula AW, Christakis G, Farrand M, et al. The multiple risk intervention trial (MRFIT), IV. Intervention on blood lipids. Prev Med 1981;10:443-75.  Back to cited text no. 5    
6.Blair SN, Applegate WB, Dunn AL, et al. Activity Counseling Trial (ACT): Rationale, design and methods. Activity counseling trial research group. Med Sci Sports Exerc 1998;30:1097-106.  Back to cited text no. 6    
7.Gillis BP, Caggiula AW, Chiavacci AT, et al. Nutrition intervention program of the Modification of Diet in Renal Disease Study: a self management approach. J Am Diet Assoc 1995;95:1288-94.  Back to cited text no. 7  [PUBMED]  
8.Whelton PK, Appel LJ, Espeland MA, et al. Sodium reduction and weight loss in the treatment of hypertension in older persons: a randomized controlled trial of nonphar­macologic interventions in the elderly (TONE). TONE Collaborative Research Group. JAMA 1998;279:839-46.  Back to cited text no. 8    
9.Cliffe M, Bloodworth LL, Jibani MM. Can malnutrition in predialysis patients be prevented by dietetic intervention? J Ren Nutr 2001;11(3):161-5.  Back to cited text no. 9    
10.Abullo JG. Large interdialytic weight gains: causes, consequences and corrective measures. Semin Dial 1998;11:25-32.  Back to cited text no. 10    
11.Fauchier JP, Cosnay P, Latour F. The heart and hyperkalemia. Arch Mal Coeur Vaiss 1984;77:23-33.  Back to cited text no. 11  [PUBMED]  
12.Kes P, Orlic-Cunovic D, Trubelja N. Acute hypotension and shock in the hyperkalemic patients on maintenance haemodialysis. Nephron 1996;72(3):484-6.  Back to cited text no. 12    

Correspondence Address:
Hammad Raza
Nephrology & Hypertension Division – 1531, Department of Medicine, King Fahad National Guard Hospital, P.O. Box 22490, Riyadh 11426
Saudi Arabia
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PMID: 17642765

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