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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2020  |  Volume : 31  |  Issue : 6  |  Page : 1361-1365
Effect of branched chain amino acid supplementation on dialysis adequacy and nutritional parameters in hemodialysis patients


1 Department of Nephrology, Theodor Bilharz Research Institute, Giza, Egypt
2 Department of Internal Medicine, Cairo University, Cairo, Egypt
3 Department of Clinical Pathology, National Cancer Institute, Cairo University, Cairo, Egypt

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Date of Web Publication29-Jan-2021
 

   Abstract 


Malnutrition in hemodialysis (HD) patients is caused by deficient nutrient and protein intake and has a negative impact on patient outcomes. The assessment of dialysis adequacy in these patients depends to a large extent on the calculation of urea clearance using dialyzer clearance of urea (K) multiplied by the duration of the dialysis treatment (t, in minutes) divided by the volume of distribution of urea in the body (V, in mL); Kt/V. This study aims to detect the effect of branched-chain amino acid (BCAA) supplementation on Kt/V and other nutritional parameters such as serum albumin as well as body mass index. Forty-six patients from the HD Unit of Mostafa Mahmoud Hospital were included in this study. Daily intake of BCAA was continued for three months. At the start of the study, before the intervention, and at the end of the 3rd month, we measured serum albumin, valine, leucine, iso-leucine, and Kt/V. Analysis of data was performed using paired and independent t-test. We found that BCAA has a highly significant effect on increasing the level of albumin, leucine, isoleucine, valine, and Kt/V in HD patients (P <0.001) (Paired t-test). BCAA supplements could be used in this patient population to improve dialysis adequacy and outcome.

How to cite this article:
Zeid SA, Rabiee A, El Refaey FA, Sherif N. Effect of branched chain amino acid supplementation on dialysis adequacy and nutritional parameters in hemodialysis patients. Saudi J Kidney Dis Transpl 2020;31:1361-5

How to cite this URL:
Zeid SA, Rabiee A, El Refaey FA, Sherif N. Effect of branched chain amino acid supplementation on dialysis adequacy and nutritional parameters in hemodialysis patients. Saudi J Kidney Dis Transpl [serial online] 2020 [cited 2021 Mar 7];31:1361-5. Available from: https://www.sjkdt.org/text.asp?2020/31/6/1361/308346



   Introduction Top


Malnutrition is one of the common problems of hemodialysis (HD) patients that have a significant effect on morbidity and mortality.[1] In this group of patients there is progressive depletion of protein and energy stores, a condition which has been termed “Protein Energy Wasting”. It has a prevalence of 50%–75% among chronic kidney disease patients (stage IV-V).[2] Main causes of malnutrition among HD patients include deficient nutrient and protein intake due to anorexia, hyper-catabolic state associated with HD and uremic toxins.[3]

One of the most important aspects of the assessment of dialysis patients is the assessment of the dialysis adequacy, calculated by urea clearance through Kt/V or urea reduction ratio (URR). The “KDOQI Clinical Practice Guideline For Hemodialysis: 2015 Update” recommends a target spKt/V (single pool Kt/V) of 1.4 with a minimum of 1.2 for patients undergoing thrice-weekly HD sessions,[4] where K stands for delivered dialyzer urea clearance in milliliters per minute, t is the time in minutes measured from the beginning to end of dialysis and V is the patient’s volume of urea distribution in milliliters.[5]

Dialysis adequacy has been associated with the nutritional status in HD patients, as evidenced by the positive correlation between Kt/V and between serum albumin and body mass index (BMI).[6] The favorable effect of efficient dialysis on the nutritional status has also been confirmed by Hemayati et al., who detected a positive association between Kt/V and between protein catabolic ratio.[7] Whether this relationship can go in the opposite direction has been investigated by Afaghi et al., who found that protein-based oral nutritional supplements increase dialysis adequacy based on Kt/V and URR.[8]


   Aim Top


In this study, we aimed to assess the effect of daily oral supplementation with branched-chain amino acids (BCAA) on dialysis adequacy measured by Kt/V and on other nutritional parameters, such as serum albumin, valine, leucine, and isoleucine in dialysis patients.


   Subjects and Methods Top


Forty-six patients from the HD Unit of Mostafa Mahmoud Hospital were included in this study. They all underwent dialysis for a period not <6 months.

HD sessions were done three times weekly, 4 h each. Membranes used were high flux polysulfone membranes with a surface area 1.4 m2. Dialysate used was bicarbonate. All patients were dialyzed through AV fistula. Heparin dose was 5000 IU per session and patients did not receive any blood transfusions.

Their serum albumin was <4 g/dL and they had no active infection during the previous 4 months, no respiratory or heart failure, no chronic liver disease (including HBV and HCV), no cancer, dementia, or neurological diseases, and no recent surgery during the previous three months. They did not receive any nutritional supplements before the start of the study.

BCCA preparation used contained L-leucine 2.5 g, L-isoleucine 1.25 g, L-valine 1.25 g per serving (9.5 g).

Daily intake of BCAA was continued for three months and was explained to the patients and caregivers. Patients were reminded to take their supplements and followed up by phone calls. Nutritional counseling was done on a monthly basis.

At the start of the study, before the intervention, and at the end of the 3rd month, we measured serum albumin, valine, leucine, isoleucine, and Kt/V.


   Statistical Analysis Top


Analysis of data was performed using IBM SPSS Statistics version 25.0 for Windows (IBM Corp., Armonk, NY, USA).

Description of variables was presented as follows:

Description of quantitative variables was in the form of mean, standard deviation, minimum and maximum. The description of qualitative variables was in the form of numbers (No.) and percent (%). Data were explored for normality using Shapiro/Kolomogrov tests of normality. Comparison between quantitative variables was carried out by independent t-test which was used to test the difference between the means of two groups of a scale variable. Comparison between scale variable levels before and after the administration of BCAA was done by paired t-test. Calculation of the percent of the increase was as follows: Increase = New number - Original number. The result is divided by the original number and multiplied by 100. Percent of increase = Increase ÷ Original Number × 100.

The study was conducted in accordance with the Helsinki Declaration (1975). All participants gave written informed consent.


   Results Top


The study was conducted on 46 patients. Their demographic characteristics are represented in [Table 1] and [Table 2].
Table 1: Demographic characteristics of studied patients.

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Table 2: Frequency distribution of demographic variables.

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[Table 3] shows that BCAA has a highly significant effect on increasing the level of albumin, leucine, isoleucine, valine, and Kt/V in HD patients (P <0.001) (Paired t-test).
Table 3: Comparison of levels of albumin, leucine, isoleucine, valine, and Kt/V in hemodialysis patients before and after branched-chain amino acid supplementation.

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The percentage of increase for each parameter is presented in [Table 4].
Table 4: Percentage of increase of different parameters in the studied patients after branched chain amino acids supplementation.

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There were nine cases (19.6%) with a steady albumin level in spite of administration of BCAA and there was only one patient (2.25%) with a steady Kt/V.

There was no statistically significant difference between males and females regarding the percentage of increase in levels of albumin, leucine, isoleucine, valine, and Kt/V after BCAA supplementation. (Independent t-test)

There was no correlation between the percentage of increase of different parameters in the studied patients and between age or BMI, except for a moderately positive correlation found between the percentage of increase of leucine and between age (r = 0.395 and P = 0.007) (Pearson correlation test).

When different categories of BMI were compared for the percent of change of studied variables, we could not find a statistically significant difference between them (P >0.05).


   Discussion Top


In this study, we aimed to investigate the effect of BCAA supple-mentation on dialysis adequacy and on nutritional parameters in HD patients. Oral supplements have been invest-tigated before for their beneficial nutritional effects, but few studies have addressed the issue of a positive effect on dialysis adequacy.

In this study, we found a positive outcome of BCAA supplementation, not only on nutritional parameters, represented by serum albumin, leucine, isoleucine, and valine but also on dialysis adequacy represented by Kt/V, which increased from a mean level of 1.1 to 1.3.

This is in accordance with Afaghi et al, who proved that intake of oral nutritional supplements leads to an improvement in the dialysis adequacy of HD patients.[8] Other investigators, however, did not detect such an effect.

Bolasco et al found an increase in Kt/V after oral amino acid supplementation treatment, although this improvement was not a significant one.[9]

Another study done by Sezer et al did not find any improvement in dialysis adequacy guided by URR after oral nutritional supplement taken daily for six months.[10] This discrepancy in results between different studies could be caused by dietary habits or other factors affecting adequacy, hence the need for more detailed larger studies over a longer period to accurately assess the effect of BCAA supplementation in HD patients.

As regard to nutritional parameters in our study, there was a highly significant increase in serum albumin (P <0.001), with a mean rate of increase of 6.3%.

This is in accordance with Hiroshige et al, who found a significant improvement in serum albumin levels in HD patients after daily oral BCAA supplementation for six months. After stopping BCAA, the serum albumin of patients in their study decreased again, although not to their baseline levels.[11]

Valine, leucine and isoleucine levels in our study increased significantly after the three-month supplementation period. Again, this was similar to the results of Hiroshige et al,[11] who also found a positive change in the serum levels of these parameters throughout the duration of supplementation.

In a study by Eustace et al, oral supplementation of essential amino acids significantly increased serum albumin levels in dialysis patients. It also improved muscle metabolism, as evidenced by increased grip strength.[12] This was confirmed in another report by De Bisschop et al, who detected improvement in muscle metabolism, measured by P[31] spectros-copy, after amino acid supplementation in uremic patients.[13]


   Conclusion Top


BCAA could be used in HD patients to improve dialysis adequacy and outcome, although larger studies over a longer period of time need to be conducted to understand the effect of BCAA supplementation on dialysis adequacy and on different nutritional parameters in these patients.

Conflict of interest: None declared.



 
   References Top

1.
Acchiardo SR, Moore LW, Latour PA. Malnutrition as the main factor in morbidity and mortality of hemodialysis patients. Kidney Int Suppl 1983;16:S199-203.  Back to cited text no. 1
    
2.
Ikizler TA, Cano NJ, Franch H, et al. Prevention and treatment of protein energy wasting in chronic kidney disease patients: A consensus statement by the International Society of Renal Nutrition and Metabolism. Kidney Int 2013;84:1096-107.  Back to cited text no. 2
    
3.
Kalantar-Zadeh K, Ikizler TA, Block G, Avram MM, Kopple JD. Malnutrition-inflammation complex syndrome in dialysis patients: Causes and consequences. Am J Kidney Dis 2003;42:864-81.  Back to cited text no. 3
    
4.
National Kidney Foundation. KDOQI Clinical Practice Guideline for Hemodialysis Adequacy: 2015 Update. Am J Kidney Dis 2015;66:884-930.  Back to cited text no. 4
    
5.
Hemodialysis Adequacy 2006 Work Group. Clinical practice guidelines for hemodialysis adequacy, update 2006. Am J Kidney Dis 2006;48 Suppl 1:S2-90.  Back to cited text no. 5
    
6.
Iseki K, Kawazoe N, Fukiyama K. Serum albumin is a strong predictor of death in chronic dialysis patients. Kidney Int 1993;44: 115-9.  Back to cited text no. 6
    
7.
Hemayati R, Lesanpezeshki M, Seifi S. Association of dialysis adequacy with nutritional and inflammatory status in patients with chronic kidney failure. Saudi J Kidney Dis Transpl 2015;26:1154-60.  Back to cited text no. 7
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8.
Afaghi E, Tayebi A, Ebadi A, Sobhani V, Einollahi B, Tayebi M. The Effect of BCAA and ISO-WHEY Oral Nutritional Supplements on Dialysis Adequacy. Nephrourol Mon 2016; 8:e34993.  Back to cited text no. 8
    
9.
Bolasco P, Caria S, Cupisti A, Secci R, Saverio Dioguardi F. A novel amino acids oral supplementation in hemodialysis patients: A pilot study. Ren Fail 2011;33:1-5.  Back to cited text no. 9
    
10.
Sezer S, Bal Z, Tutal E, Uyar ME, Acar NO. Long-term oral nutrition supplementation improves outcomes in malnourished patients with chronic kidney disease on hemodialysis. JPEN J Parenter Enteral Nutr 2014;38:960-5.  Back to cited text no. 10
    
11.
Hiroshige K, Sonta T, Suda T, Kanegae K, Ohtani A. Oral supplementation of branched-chain amino acid improves nutritional status in elderly patients on chronic haemodialysis. Nephrol Dial Transplant 2001;16:1856-62.  Back to cited text no. 11
    
12.
Eustace JA, Coresh J, Kutchey C, et al. Randomized double-blind trial of oral essential amino acids for dialysis-associated hypo-albuminemia. Kidney Int 2000;57:2527-38.  Back to cited text no. 12
    
13.
De Bisschop E, Allein S, Van der Niepen P, et al. Effect of amino acid administration on uremic muscle metabolism: A 31P-spectros-copy study. Kidney Int 1997;51:1182-7.  Back to cited text no. 13
    

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Correspondence Address:
Sameh Abou Zeid
Department of Nephrology, Theodor Bilharz Research Institute Giza
Egypt
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DOI: 10.4103/1319-2442.308346

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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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    Abstract
   Introduction
   Aim
   Subjects and Methods
   Statistical Analysis
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   Discussion
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