CKD-Associated Complications: Progress in the Last Half Century. Группа авторов

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СКАЧАТЬ the voluntary protein and energy intake from daily food [19]. Another study demonstrated that essential amino acids containing branched amino acids improved dietary protein and energy intake in hemodialysis patients [20]. These results indicate that proper nutritional management can enhance dietary intake and improve nutritional status, getting patients started on a favorable cycle.

Nutritional intervention during dialysis sessions has become popular. Patients who receive oral nutritional support (ONS) during dialysis sessions have an almost 30% lower risk of death, especially those with lower serum albumin levels [21]. A recent study in which patients were given either a protein- and energy-rich diet or a low-protein diet during dialysis sessions showed that those on the protein-rich diet exhibited an increase in serum albumin for only 8 weeks [22]. International Society of Renal Nutrition and Metabolism guidelines on food intake during hemodialysis sessions describe the advantages and disadvantages of food intake during sessions and recommend dietary intake if it can be tolerated by the patient [23].

On the other hand, there are still concerns about food intake during hemodialysis, such as hypotension, vomiting, aspiration, and asphyxiation. Patients with malnutrition-wasting conditions often experience these complications. Moreover, the loss of appetite often seen in older dialysis patients can prevent them from eating during dialysis therapy. IDPN can be of help in such patients. Even though IDPN did not exhibit the add-on effect seen with ONS in randomized controlled trials performed in patients with malnutrition-wasting conditions [24] and some of the nutrients provided through IDPN can be eliminated during the dialysis process, the intervention can improve nutritional status in those patients who are not eligible for dietary intervention or cannot eat enough food [19]. As such, the European Society of Parenteral and Enteral Nutrition guidelines for kidney disease patients recommend IDPN for patients who have insufficient dietary intake and who are not adherent to ONS [25]. Therefore, IPDN itself is an option for nutritional therapy.

      Eating is an important aspect of QOL because appetite is one of the most fundamental human desires. Furthermore, food or taste preferences should be taken into consideration in dietary therapy as they can affect adherence. A multidisciplinary approach is indispensable to maximize the efficacy of nutritional therapy.

      Exercise Training

Nutritional therapy combined with exercise training was shown to have a sustained effect on protein synthesis even after dialysis sessions when the intervention was given before the sessions [26]. Also, intradialytic nutritional support was found to improve physical function and QOL in patients with PEW only when the therapy was combined with aerobic exercise training during dialysis sessions [27]. Thus, a combination of nutritional support and exercise training is more efficient than either of them alone.

Many dialysis patients have reduced ADL, and almost half of this population is reported to be sedentary, especially on dialysis days. Intradialytic exercise training has gained attention as a means to improve physical function [28]. Several systematic reviews unequivocally demonstrated that intradialytic exercise training can improve VO₂ peak, Kt/V, and QOL measured with the Short Form Health Survey-36 [29, 30]. The Japanese Society of Renal Rehabilitation guidelines strongly recommend exercise training in dialysis patients.

A study that investigated the efficacy and adherence to exercise training according to the timing of its application found that supervised exercise training on non-dialysis days was more efficient than training done on dialysis days or without supervision, even though adherence was lower if it was performed on non-dialysis days [31]. Matsuzawa et al. [30] demonstrated that the number of steps on non-dialysis days measured with a pedometer can be a powerful predictor of subsequent survival in dialysis patients. The predictive power was maximized if the cut-off value was set at 3,752 steps per day. Patients with fewer than 4,000 steps per day experienced a higher mortality rate for 84 months thereafter (HR 2.37; 95% CI 1.22–4.60) [32].

Exercise training may also have a favorable effect on nutritional status. A study investigating the effect of exercise training on ghrelin or obestatin, cytokines that affect nutritional status or appetite, found that patients in the exercise group exhibited an increase in acyl-ghrelin, an active form of ghrelin [33]. Thus, exercise training might improve appetite and thus nutritional status in patients.

      Individualized Management of Older Dialysis Patients

Older patients are generally susceptible to malnutrition-wasting conditions. However, the degree to which each patient exhibits these conditions varies. We investigated the heteroscedasticity of clinical indices in patients grouped by age based on data reported by the Japanese Society for Dialysis Therapy Renal Data Registry. Clinical indices relating to wasting such as creatinine, creatinine generation rate, and albumin exhibited higher heteroscedasticity in older than in younger dialysis patients [34]. Some patients look older than their actual biological age and such patients often experience worse clinical outcomes [1].

      Age is the most powerful predictor of death. We demonstrated that the primary diagnosis of ESRD was not associated with survival after initiation of dialysis in older dialysis patients, but primary diagnosis did affect survival in younger patients [1]. As such, clinical intervention barely improves survival in older patients and alternative goals might be considered, such as improvement in QOL or ADL.

      Heterogeneity among patients should be considered in malnutrition-wasting conditions. Dietary restriction can be considered for robust patients, but enhancing dietary intake and physical activity is important for frail older patients. Thus, in older dialysis patients, medical professionals should consider individualized strategies such as nutritional intervention and exercise training.

      Conclusions

      The dialysis population is becoming older, and older dialysis patients often develop malnutrition-wasting conditions. Nutritional interventions and exercise training are crucial to address these conditions. However, older patients are a heterogeneous population in terms of malnutrition-wasting conditions and individualized management should be considered.

      Disclosure Statement

      N.H. received lecture fees from Bayer Yakuhin K.K. and Kyowa Hakko Kirin, Co. Ltd.

      Funding Source

      The authors received no funding for this СКАЧАТЬ