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 Table of Contents  
REVIEW ARTICLE
Year : 2022  |  Volume : 35  |  Issue : 3  |  Page : 949-954

Nutritional improvement in critically ill patients on renal replacement therapy: A systematic review


1 Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Critical Care, Tanta Medical Insurance Hospital, Tanta, Egypt

Date of Submission16-Feb-2022
Date of Decision24-Mar-2022
Date of Acceptance29-Mar-2022
Date of Web Publication29-Oct-2022

Correspondence Address:
Eslam M Agiba
Tanta, Algharbia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_57_22

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  Abstract 


Objective
To summarize the methods of nutritional improvement used in cases of protein-energy wasting in patients on maintenance hemodialysis.
Data analysis
Search papers, systematic reviews, and randomized clinical trials from 2004 to 2021 were reviewed in the available MEDLINE databases, which included PubMed, Medscape, Springer, Elsevier, and Science Direct.
Study selection
English language publications that focused on critically ill populations on renal replacement therapy requiring nutritional support were searched. Data extraction: studies by Cano and colleagues, Liu and colleagues, Oğuz and colleagues, Marsen and colleagues, Chioléro and Berger, Fiaccadori and colleagues, Ramakrishnan and Shankar, Al-Dorzi and Arabi, Bost and colleagues, Anderson and colleagues, and Fiaccadori and colleagues were gathered by two authors, which were then reviewed by another author. They extracted data related to the year, total population, method and duration of nutritional supplementation, inclusion criteria, exclusion criteria, and main results for each study. They also collected data on age, sex, length of nutritional aid by month, mean and SD of BMI, weight gain, prealbumin, nutritional status, and any adverse effects. Data synthesis: a structured systematic review was performed.
Findings
Intradialytic parenteral nutrition enhanced patients' health and clinically relevant nutritional outcomes as compared with oral (enteral) supplementation, with a substantial reduction in mortality. It can enhance some nutritional markers while having well-tolerated adverse effects, making intradialytic parenteral nutrition a feasible therapy option, particularly in circumstances when enteral nutrition cannot be delivered.
Conclusion
Complete dosage of enteral protein is probably more suitable in the late stages of critical illness, when enteral nutrition is insufficient in the first week. In general, enteral nutrition is favored over parenteral nutrition, should be begun early (within 24–48 h), and should be progressively raised to target over at least a few days.

Keywords: enteral, hemodialysis, parenteral nutrition, protein-energy wasting


How to cite this article:
Gaballah KM, Agiba EM, Sultan WE. Nutritional improvement in critically ill patients on renal replacement therapy: A systematic review. Menoufia Med J 2022;35:949-54

How to cite this URL:
Gaballah KM, Agiba EM, Sultan WE. Nutritional improvement in critically ill patients on renal replacement therapy: A systematic review. Menoufia Med J [serial online] 2022 [cited 2024 Mar 28];35:949-54. Available from: http://www.mmj.eg.net/text.asp?2022/35/3/949/359512




  Introduction Top


Nutritional status is the sum of visceral and somatic (muscle) protein reserves and energy balance[1]. Nutritional status assessment is crucial to determine protein-energy wasting (PEW)[2]. Monitoring of protein and energy intake is a large and difficult issue. Patients with PEW should be identified and risk stratified, as well as the causes and effects of PEW and the underlying illness conditions that contribute to PEW[3].

As a result, no single metric could accurately describe this condition, and assessing protein and energy intake would necessitate multiple assessments including nutritional markers for identifying PEW in maintenance hemodialysis (MHD) patients and their use in guiding nutritional therapy[4]. Some of these criteria are simple to test, widely accessible, and inexpensive, whereas others are complex, unavailable in multiple locations, or have an unfavorable cost–benefit ratio. Nitrogen balance studies or stable isotope tracer techniques are preferred in the research setting for measuring serious alterations or reactions to metabolic interventions while minimizing inconsistency and faults[5].

Nutrition evaluation must comprise monthly dry weight, serum albumin, and subjective global assessment (SGA) measurements in patients with end-stage renal disease who are receiving MHD[6]. Along with exact numbers, trends throughout time should be considered when evaluating particular thresholds. At the moment, serum albumin has the highest utilization frequency as a monitoring test for people at risk of PEW[7]. A continuous reduction in serum albumin levels of larger than 0.3 g/dl over a period of 2–3 months or longer should prompt a more extensive review of nutritional status. This evaluation may involve dietary interviews, anthropometry, dual-energy radiograph absorptiometry, and, if accessible, more complex procedures. Direct measurements of inflammation, such as serum C-reactive protein, are quite useful in this scenario and may be used to evaluate the efficacy of targeted therapy[7].

Three nutritional scores used in several scientific studies should be assessed, namely, Mini-Nutritional Assessment, SGA, and the score of International Society of Renal Nutrition and Metabolism[8],[9],[10].

Mini-Nutritional Assessment scores[8] anthropometric assessment (BMI, weight loss, and arm and calf circumferences), general assessment (lifestyle, medication, mobility, and presence of signs of depression or dementia), short dietary assessment (number of meals, food and fluid intake, and autonomy of feeding), and subjective assessment (self-perception of health and nutrition). The nutritional status is qualified as satisfactory only when the score is more than or equal to 24. There is a risk of malnutrition when the score is between 17 and 23.5. The nutritional status is termed as poor when the score is below 17.

The SGA score[9] enables patients to be classified into one of three unique categories: A (optimal nutrition), B (moderate malnutrition), or C (severe malnutrition). Dialysis patients are placed into one of these groups on the basis of two subjective criteria: medical history and physical examination. Each aspect of the medical history or physical examination is assigned a score (A, B, or C) using the SGA grid. When score A is prevalent worldwide, the patient receiving MHD is considered in excellent nutritional condition; when score B is prominent, the patient is said to be in moderate to minor malnutrition; and when score C is dominant, the patient is said to be in severe malnutrition[11],[12].

According to International Society of Renal Nutrition and Metabolism[10] criteria, a patient on dialysis is said to be malnourished when at least three of the four following criteria are present: serum albumin less than 38 g/l; BMI less than 23 kg/m2; predialysis serum creatinine value less than 665 μmol/l; and protein intake (nPNA) less than 0.80 g/kg/day[13].

The aim of the study was to summarize the nutritional methods used in cases of PEW in patients with MHD.


  Methods Top


Data sources

Search papers, systematic reviews, and randomized clinical trials were reviewed in the available Medline databases, which included PubMed, Medscape, and Science Direct, and materials available on the internet. The search included previous studies until 2021.

Study selection

The published studies included in the review were independently assessed for following inclusion criteria:

English language publications in peer-reviewed journals.

Focused on critically ill populations on renal replacement therapy who required enteral and parenteral nutritional support.

Data extraction

Studies by Cano and colleagues, Liu and colleagues, Oğuz and colleagues, Marsen and colleagues, Korzets and colleagues, Capelli and colleagues, Cherry and Shalansky, Mortelmans and colleagues, Chioléro and Berger, Fiaccadori and colleagues, Ramakrishnan and Shankar, Al-Dorzi and Arabi, Bost and colleagues, Anderson and colleagues, and Fiaccadori and colleagues were gathered by two authors, which were then reviewed by another author. They extracted data on the year, total population, method and duration of nutritional supplementation, inclusion criteria, exclusion criteria, and main results for each study. They also collected data on age, sex, length of nutritional aid by month, mean and SD of BMI, weight gain, prealbumin, nutritional status, and any adverse effects. Quality assessment: the quality of all of the studies was assessed. Important factors included study design, attainment of ethical approval, evidence of a power calculation, specified eligibility criteria, appropriate controls, adequate information, and specified assessment measures. It was expected that confounding factors would be reported and controlled for and appropriate data analysis made in addition to an explanation of missing data.

Data synthesis

A structured systematic review was performed by data obtained from 15 studies (six randomized clinical trials[14],[15],[16],[17],[18],[19], one article[20], two cohort study[21],[22], and six reviews[23],[24],[25],[26],[27],[28]).


  Results Top


This study included the results of 15 previous investigations (six randomized clinical trials[14],[15],[16],[17],[18],[19], one article[20], two cohort study[21],[22], and six reviews[23],[24],[25],[26],[27],[28]).

There was one large prospective cohort) and 55 relatively small studies, with follow-up duration ranging from 12 weeks to 2 years [Table 1]. The mean patient age was 65 years (range, 37–80 years) with an even distribution of male to female patients (mean: 50% male).
Table 1: Comparison between efficacy of enteral nutrition and parenteral nutrition

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Intradialytic parenteral nutrition (IDPN) did not improve patients' health or clinically relevant nutritional outcomes compared with enteral supplementation. The French Intradialytic Nutrition Evaluation Study (FineS) by Cano et al.,[14] on 186 malnourished patients with chronic hemodialysis reported that 1 year of IDPN treatment plus enteral supplements did not improve 2-year mortality, hospitalization rate, quality of life, or nutritional indicators compared with enteral supplements alone. For ethical reasons, both intervention and control groups were given enteral supplements. In addition, in an randomized controlled clinical trial (RCT) by Liu et al.[15], using amino acid plus glucose infusion, there were no differences in improvements in median BMI, serum albumin, serum prealbumin, or SGA score compared with enteral supplements. A significant improvement in nutritional indicators was reported in only one study by Oğuz et al.[16], with a single, small (N = 20) prospective cohort from Turkey, which reported significantly increased mean serum albumin after 4 months in patients receiving IDPN but not in patients receiving enteral supplementation.

One RCT by Cano et al.[14] reported that 12–14% of patients experienced adverse events, causing discontinuation of IDPN. Commonly reported adverse events included nausea, muscle pain, infections, hyperglycemia, and procedural complications. No differences in adverse events between intervention and control groups were reported, and some of these events may be common in this population due to the disease state and treatment regimen.

Another RCT by Marsen et al.[20] on 107 cases reported that IDPN significantly increased prealbumin (P < 0.05), showing rapid rise within 16 weeks of treatment and sustained response thereafter. In the full analysis set (N ¼ 83), 41.0% of 39 patients receiving IDPN achieved a relevant increase in prealbumin over baseline at week 4 compared with 20.5% of 44 patients in the control group. Considerably more patients with IDPN therapy achieved an increment of prealbumin more than 30 mg/l at week 16 (48.7 vs. 31.8%).

In a study by Korzets et al.[17], patients received IDPN for 1.5–48 months. A total of 18 patients received IDPN less than 6 months. IDPN was safe for all patients. Throughout this period, dialysis remained adequate. Weight loss in all patients ceased after ~ 2 months of IDPN. Protein catabolic rate (PCR), serum albumin, prealbumin, cholesterol, and creatinine levels all increased significantly. CRP dropped from 77 ± 86 to 9 ± 10 mg/l.

Another study by Capelli et al.,[21] involving 81 patients receiving thrice-weekly hemodialysis treatments and who had either a low serum albumin and/or protein catabolic rate, compared the effect of IDPN on mortality rates. A total of 50 patients received IDPN, and 31 patients did not. The results of the study revealed a better survival rate (64 vs. 52%) for patients treated with IDPN. The IDPN-treated group had a significantly better survival rate (P < 0.01). Serum albumin increased by 12% in the survivors.

Cherry and Shalansky[22] conducted a study on 24 cases. The mean duration of treatment was 4.3 months. Dry body weights were significantly lower 6 and 3 months before the start of IDPN therapy than at baseline and significantly higher 6, 9, and 12 months after the start of therapy. Serum albumin levels were also significantly higher at 3 and 9 months than at baseline. The percentage of treatment courses in which patients had a serum albumin concentration of more than or equal to 34 g/l was 12% at baseline, 39% at 6 months, and 47% at 9 months. Adverse effects consisted primarily of excess fluid gain and hyperglycemia. IDPN therapy significantly increased body weight and serum albumin levels in malnourished hemodialysis patients.

Of the 26 enrolled patients in the study by Mortelmans et al.[18], 16 completed the study. The remaining 10 patients withdrew mainly because of muscle cramps and nausea during the initiation phase of the treatment. In the 16 treated patients, body weight, which had decreased in the pretreatment period from 58.2 ± 1.3 kg (6 months) to 54.8 ± 10.1 kg at the start of the study, increased again up to 57.1 ± 10.7 kg after 9 months of IPN (P < 0.05). Serum transferrin and prealbumin increased from 1.7 ± 0.4 to 2.0 ± 0.4 g/l and from 0.23 ± 0.05 to 0.27 ± 0.10 g/l, respectively. Bone densitometry showed an increase of tissue mass, mostly related to a rise in fat tissue. Triceps skinfold (P < 0.05) and arm muscle compartment of the midarm (P = 0.07) increased as well. No such changes were observed in the patients who withdrew from treatment.

Nutritional screening, assessment, and support are essential in patients with acute kidney injury to provide adequate nutritional support to meet energy demands by the patients as concluded in the studies by Chioléro and Berger[23], Fiaccadori et al.[24] and Ramakrishnan and Shankar[25]. In addition, Fiaccadori et al.[24] concluded that patients with acute kidney injury on renal replacement therapy should receive at least 1.5 g of protein per kg per day, which could be reached by parenteral nutrition.

Enteral nutrition is preferred in general to provide the nutritional supplement for the patients, as conclude by the study by Al-Dorzi and Arabi[26]. However, in certain occasions, when enteral nutrition fails to provide the required nutritional supplement or when patients fail to respond to enteral nutrition, protein-energy (PE) must be used as stated by Bost et al.[27] and Anderson et al.[28]. Fiaccadori et al.[19] concluded that to provide the optimal nutritional supplement, a combination of enteral and parenteral nutrition is required [Table 2].
Table 2: Nutritional supplement in critically ill patients

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  Discussion Top


Poor results and huge expenses result from untreated PEW. Treating PEW in hemodialysis patients, as well as boosting oral intake and employing enteral nutrition supplements, is therefore a focus. IDPN was demonstrated to be beneficial in several investigations. Oğuz et al.[16] conducted a small randomized controlled trial with 20 patients who matched the requirements. Half of the malnourished HD patients were given 0.9 g/kg/week Essential amino acid (EAA) orally, whereas the other half were given the same quantity parenterally (parenteral group). Oral EAA therapy at high doses has been linked to bad taste, nausea, and vomiting. Owing to complaints, four orally supplemented patients were transferred to the parenteral group in the current trial, whereas the parenteral group had none. Moreover, biochemical parameters increased statistically, indicating that parenteral EAA treatment is more reliable, effective, and comfortable than oral EAA treatment in malnourished HD patients.

The study by Marsen et al.[20] found that short-term IDPN can successfully improve prealbumin, which acts as a proxy indicator for outcome and survival in malnourished hemodialysis patients. Prealbumin is the best nutritional indication. Elevated prealbumin levels are a well-known prognostic indication for patients. The experiment found that prealbumin levels improved significantly as early as 16 weeks after starting IDPN treatment, with a sustained response lasting 12 weeks after that. More patients experience a considerable (i.e., at least 15% or >30 mg/dl) increase in prealbumin after IDPN treatment.

Against these findings was the study by Cano et al.[14]. The effect of IDPN on mortality and morbidity in malnourished hemodialysis patients was examined in this study for the first time. A total of 93 patients were randomly assigned to receive IDPN at each hemodialysis session for 1 year, whereas 93 were treated as controls. Oral supplements were given to both. Both groups improved nutritionally. The two groups had similar mortality rates (42% over 2 years). The addition of IDPN had no effect on hospitalization rate or Karnofsky score changes. Both groups' BMI, serum albumin, and prealbumin increased without IDPN. The study concluded that adding IDPN to oral supplements has no benefit.

Among the included studies, the study by Korzets et al.[17], demonstrated the safety of IDPN as there is no need for enteral feedings or feeding via a percutaneous gastrostomy – methods that carry risks of fluid overload, aspiration, and damage to the gastrointestinal tract.

The use of IDPN for 4.3 months in malnourished hemodialysis patients reversed a significant downward trend in dry body weight before the therapy began and increased dry body weight 6, 9, and 12 months later, according to Cherry and Shalansky[22]. There was also a significant decrease in serum albumin levels 6 months before IDPN therapy and a significant increase 3 and 9 months later. IDPN significantly reduced the risk of death in patients with serum albumin more than 34 mg/dl. The study had one limitation: fewer patients were evaluable at 9 and 12 months of follow-up owing to death or kidney transplantation.


  Conclusion Top


Although a patient is in the late stages of a severe illness and enteral nutrition is insufficient during the first week, a whole dose of enteral protein is likely to be more appropriate. In general, enteral nutrition is preferred over parenteral nutrition, and it should be started as soon as possible (within 24–48 h) and gradually increased to the objective over a period of at least a few days.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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