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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 6  |  Issue : 4  |  Page : 97-101

Eating during dialysis: An observational cohort study from India


1 Department of Clinical Nutrition and Dietetics, Yashoda Hospitals, Hyderabad, Telangana, India
2 Department of Nephrology, Yashoda Hospitals, Hyderabad, Telangana, India

Date of Submission02-Feb-2021
Date of Acceptance04-Feb-2021
Date of Web Publication20-Jul-2021

Correspondence Address:
Dr. Urmila Anandh
Department of Nephrology, Yashoda Hospitals, Secunderabad, Hyderabad, Telangana 500003
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jrnm.jrnm_6_21

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  Abstract 


Background: Patients on maintenance hemodialysis often develop malnutrition. Elderly patients with multiple comorbidities often are at risk. The catabolic nature of hemodialysis also contributes to the problem. Multiple interventions such as modifying dialysis timings and oral nutritional supplementation have been tried. Eating during dialysis is increasingly being considered as an intervention with a positive impact on the nutritional status of these patients. Materials and Methods: We designed a study to look into the dietary habits of our stable hemodialysis cohort and the difference in their intake on dialysis and nondialysis days. Results: Our study shows that even though patients hardly achieve their recommended dietary allowances targets, their nutrient intake is better on their dialysis days. They consume a significantly higher amount of protein and fats on dialysis days. Their energy intake is also higher on the days of their dialysis. Patients consume a significantly higher amount of protein and fats on dialysis days. Their energy intake is also higher on the days of their dialysis. Conclusions: Hemodialysis patients eat better on dialysis days and eating during dialysis should be encouraged.

Keywords: Dietary counseling, energy intake, fat intake, feeding, hemodialysis, protein intake


How to cite this article:
Premlatha S, Vasa H, Swetha A, Vaishnavi G, Priyanka S, Anandh U. Eating during dialysis: An observational cohort study from India. J Renal Nutr Metab 2020;6:97-101

How to cite this URL:
Premlatha S, Vasa H, Swetha A, Vaishnavi G, Priyanka S, Anandh U. Eating during dialysis: An observational cohort study from India. J Renal Nutr Metab [serial online] 2020 [cited 2021 Sep 26];6:97-101. Available from: http://www.jrnm.in/text.asp?2020/6/4/97/321988




  Introduction Top


Malnutrition is an important issue in patients on maintenance hemodialysis and plays an important role in their overall outcome.[1] Malnutrition is an important underlying factor in the development of cardiovascular disease and infections – two most important causes of mortality in patients on dialysis. Low serum albumin, creatinine, and cholesterol, all markers of malnutrition, are predictive of poorer survival in both hemodialysis and peritoneal dialysis.[2] Regular assessment of nutritional status of these patients and prompt treatment may improve overall outcome and survival. One of the interventions that is considered is to encourage feeding during dialysis. This intervention has shown to improve protein-energy wasting [3],[4] and health-related quality of life scores.[5] On the other hand, many studies have shown that dietary intake is less on the days of dialysis.[6],[7] To understand the impact of dialysis on nutritional intake, we embarked on a study to look into the overall dietary intake of our hemodialysis patients and whether there was any difference in their intake on the days of dialysis.


  Materials and Methods Top


An observational prospective cross-sectional study looking into the nutritional habits of patients on hemodialysis in our center was conducted from January 2019 to June 2020. The study included patients who were stable during dialysis and had no intercurrent illness/hospitalization in the last 1 month. Informed consent was obtained from all subjects involved in the study. These patients received regular dietary advice and counseling from in-house dietitians. Patients with psychological issues, erratic feeding habits, and not willing to be part of the study were excluded. Data collected and analyzed included demographic variables, comorbidities, laboratory variables, and dialysis details. Nutritional data included subjective global assessment (SGA) to look at the nutritional status of the cohort of the patients, their appetite on dialysis and nondialysis days, and their nutritional intake during dialysis and nondialysis days. The dietary survey was done using a 24-h dietary recall and food frequency questionnaire.

Twenty-four hour dietary recall is a structured interview which captures information about all foods and beverages consumed by the respondent (in our case the dialysis patient) in the past 24 h (midnight to midnight). In this method of diet survey, a set of standardized cups suited to our local conditions were used. The 24-h recall for the nondialysis day was conducted on the day when the patient came for dialysis. For the dialysis day survey, the patient was asked to come to the hospital the day after their dialysis session. Both the surveys were conducted within 1 week of each other.

The food frequency questionnaire, a retrospective review of intake of food (organized into groups that have common nutrients), based on frequency was administered when the patient was stable and had consistent nutritional intake in the last 1 month.

All the data were merged into an Excel sheet for compilation and statistical analysis. All continuous variables were expressed as mean (±standard deviation [SD]). Chi-square test was used to look at the association between patient parameters and their impact on food intake. Nutrient values were estimated on both dialysis and nondialysis days and compared using the Student's t-test. P > 0.05 was considered significant.

All statistical tests were done using SPSS version 22 (IBM, Armonk, NY, USA).


  Results Top


One hundred dialysis patients consented to take part in the study. Almost two-third of the study participants were males (n = 64). The majority (54%) were in the 51–65 year age group. The youngest was 26-year-old and the oldest 75-year-old. The mean (± s. d.) age of the cohort was 54.7(±13.24) years. Eighty-five patients gave a history of hypertension, of which 78 were on antihypertensives. Forty-eight were type 2 diabetics and all but two were in some form of antidiabetic medications. Majority of the patients were on phosphate binders (sevelamer carbonate) and intravenous iron (ferric carboxymaltose). Erythropoietin use was noted only in 56% of the patients. Majority gave a history of chronic kidney disease of more than 3–4 years and 86% of the respondents were on dialysis in our center for more than 3 months [Table 1].
Table 1: Clinical details of patients in the study

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Majority of our patients (64%) were on thrice-weekly dialysis and the mean (± s. d.) intradialytic weight gain was 2.1(±1.09) kg. The laboratory investigations are given in [Table 2].
Table 2: Laboratory parameters of the study cohort

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The basic nutritional parameters revealed a majority of well-nourished patients (n = 64) according to SGA. Nobody was severely malnourished. The body mass index (BMI) assessment also revealed majority of patients (58%) having a normal BMI.

In 93 patients, the appetite was good on nondialysis days. Of these, 88 of them reported good appetite even on days of dialysis. Seventy-one patients reported no difficulty in eating during dialysis.

Majority of the patients (n = 67) were aware of the dietary guidelines for hemodialysis patients, but only 53 could comply with these guidelines. The major reason for this noncompliance was the strict restriction of fluids and overall unpalatability.

The dietary survey of the participating patients revealed that majority of them (n = 70) were nonvegetarian. Sixteen patients were ovo-vegetarian and the rest 14 were vegetarian. The most commonly consumed cereals were rice, wheat, and semolina. Red lentils and black gram dal were the two common pulses consumed by these dialysis patients. Ninety-nine percent of the patients consumed vegetables daily. Most patients were aware of the dietary guidelines and hence, did not consume fast foods and soft drinks. [Table 3].
Table 3: Frequency of food consumed by the dialysis cohort

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Despite the fact that majority of the patients stating that they have adequate appetite and also being aware of the dietary guidelines, the mean intake of macronutrients did not achieve the recommended targets. These patients have a significant deficit in energy, protein, and fat intake on both dialysis and nondialysis days. Dialysis patients also had a large deficit in their calcium intake. Contrary to the belief of health-care professionals caring for dialysis patients, the phosphorus intake was also lesser than recommended. The mean sodium and potassium intake was within the recommended dietary allowance range [Table 4] and [Table 5].
Table 4: Nutritional intake of the participants on nondialysis days

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Table 5: Nutritional intake of the participants on the day of dialysis

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The intake however improved on dialysis days. They consumed a significantly higher amount of protein and fats on days when they were on dialysis. Their energy intake was also higher on the days of their dialysis. The intake of sodium and potassium was higher on dialysis days as they usually follow a less restrictive diet on that day [Table 6]. This improvement may reflect the practice of eating less restrictive food items during dialysis in our center.
Table 6: Nutritional intake on dialysis and nondialysis days

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  Discussion Top


Nutritional intake of patients on dialysis is often a neglected area for physicians who often dedicate their efforts in achieving dialysis adequacy targets. Due to this and many patient-related factors, malnutrition becomes an important issue in patients on maintenance hemodialysis.[8] Malnutrition is more common in the elderly, with significant comorbidities and who live alone.[9] Besides patient factors, factors related to hemodialysis also play an important role. Increased catabolism, persistent metabolic acidosis, and nutrient loss in the dialysate are contributory factors leading to protein deficit.[10],[11] Patients often eat less during dialysis because of fatigue, anorexia, anxiety of the treatment process, dialysis schedule disruptions, and restrictive dietary regimens.[12],[13] Studies have shown that there are greater energy deficits on days of dialysis than on nondialysis days.[14]

These deficits are compounded by various clinical studies which show that feeding during dialysis is fraught with complications such as intradialytic hypotension and other intradialytic adverse symptoms.[15] Almost 30% of dialysis centers in the United States prohibit eating during dialysis.[16] However, over the last few years, many centers across the world are encouraging patients to eat during dialysis.[17],[18]

With these issues in mind, our center devised a palatable and less restrictive menu on the day of dialysis. The menu was designed to look at the preferences of the patients and their choices were included to the extent possible. The menu looked into the concerns raised in the food frequency questionnaire and the 24-h dietary recall and tried to address the major deficits in the cohort of our dialysis patients. This resulted in interventions in our department over the years which improved dietary intake during dialysis. This is corroborated by the improved protein and energy intake on the dialysis days in our study. Our results reflect the benefit of eating during dialysis. This simple measure significantly improves both protein and energy intake on the day of dialysis. Whether this simple intervention will correct the deficiencies in their diet needs to be looked into the future. This intervention has a salutary impact on the handgrip strength of our patients on dialysis, as noted in another study from our center.[19] Supervised feeding during dialysis also adds to the now recognized benefit of dietary counseling on the nutritional status of hemodialysis patients.[20]

The limitation of our study is that it is a purely observational study. There is no information whether improved nutritional intake during dialysis leads to overall improved nutritional status in our patients. A long-term prospective follow-up study in a trial setting will only answer that question. However, a study looking at the handgrip of our hemodialysis patients reveals a reasonably well-nourished cohort. The strength of our study is that not only we look at the controversial issue of eating during dialysis but also consider the voices of the most important stakeholders – the patients. We believe that this small study will not only increase the practice of eating during dialysis in many other centers but also consider offering a less restrictive and more palatable menu to these patients.


  Conclusion Top


The practice of eating a less restrictive and palatable diet during dialysis significantly improves protein and energy intake of these patients on dialysis days. This simple intervention not only gives some flexibility to the patients regarding their dietary choices but may also improve their overall nutritional status long term. This practice should be considered as an important therapeutic intervention along with nutritional counseling in hemodialysis patients.

Acknowledgment

We acknowledge the contribution of Mr. Balaji for the statistical analyses of the data.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Caglar K, Fedje L, Dimmitt R, Hakim RM, Shyr Y, Ikizler TA. Therapeutic effects of oral nutritional supplementation during hemodialysis. Kidney Int 2002;62:1054-9.  Back to cited text no. 3
    
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Pupim LB, Majchrzak KM, Flakoll PJ, Ikizler TA. Intradialytic oral nutrition improves protein homeostasis in chronic hemodialysis patients with deranged nutritional status. J Am Soc Nephrol 2006;17:3149-57.  Back to cited text no. 4
    
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Scott MK, Shah NA, Vilay AM, Thomas J 3rd, Kraus MA, Mueller BA. Effects of peridialytic oral supplements on nutritional status and quality of life in chronic hemodialysis patients. J Ren Nutr 2009;19:145-52.  Back to cited text no. 5
    
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Burrowes JD, Larine B, Cochran DB, Dwyer J, Kusek JW, McLeroy S, et al. For the HEMO Study Group. Effects of dietary intake, appetite, and eating habits on dialysis and non-dialysis treatment days in hemodialysis patients: Cross-sectional results from the HEMO study. J Ren Nutr 2003;13:191-8.  Back to cited text no. 6
    
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Bossola M, Muscaritoli M, Tazza L, Tortorelli A, Fanelli FR, Luciani G, et al. Variables associated with reduced dietary intake in hemodialysis patients, J Ren Nutr 2005;15:244-52.  Back to cited text no. 7
    
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Laville M. Fouque D. Nutritional aspects in hemodialysis. Kidney Int 2000;58 Suppl 76:S133-9.  Back to cited text no. 8
    
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Omari AM, Omari LS, Dagash HH, Sweileh WM, Natour N, Zyoud SH. Assessment of nutritional status in the maintenance haemodialysis patients: A cross-sectional study from Palestine. BMC Nephrol 2019;20:92.  Back to cited text no. 9
    
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Lim VS, Bier DM, Flanigan MJ, Sum-Ping ST. The effect of hemodialysis on protein metabolism. A leucine kinetic study. J Clin Invest 1993;91:2429-36.  Back to cited text no. 10
    
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Kaplan AA, Halley SE, Lapkin RA, Graeber CW. Dialysate losses with bleach reprocessed polysulfone dialysers. Kidney Int 1995;47:573-8.  Back to cited text no. 11
    
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Bossola M, Muscaritoli M, Tazza L, Panocchia N, Liberatori M, Giungi S, et al. Variables associated with reduced dietary intake in hemodialysis patients. J Ren Nutr 2005;15:244-52.  Back to cited text no. 12
    
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Kalantar-Zadeh K, Tortorici AR, Chen JL, Kamgar M, Lau WL, Moradi H, et al. Dietary restrictions in dialysis patients: Is there anything left to eat? Semin Dial 2015;28:159-68.  Back to cited text no. 13
    
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Stark S, Snetselaar L, Hall B, Stone RA, Kim S, Piraino B, et al. Nutritional intake in adult hemodialysis patients. Top Clin Nutr 2011;26:45-56.  Back to cited text no. 14
    
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Agarwal R, Georgianos P. Feeding during dialysis – Risks and uncertainities. Nephrol Dial Transplant 2018;33:917-22.  Back to cited text no. 15
    
16.
Benner D, Burgess M, Stasios M, Brosch B, Wilund K, Shen S, et al. In-center nutrition practices of clinics within a large hemodialysis provider in the United States. Clin J Am Soc Nephrol 2016;11:770-5.  Back to cited text no. 16
    
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Kistler BM, Fitschen PJ, Ikizler TA, Wilund KR. Rethinking the restriction on nutrition during hemodialysis treatment. J Ren Nutr 2015;25:81-7.  Back to cited text no. 17
    
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Kalantar-Zadeh K, Ikizler TA. Let them eat during dialysis: An overlooked opportunity to improve outcomes in maintenance hemodialysis patients. J Ren Nutr 2013;23:157-63.  Back to cited text no. 18
    
19.
Birajdar N, Anandh U, Premlatha S, Rajeshwari G. Hand grip strength in patients on maintenance hemodialysis: An observational cohort study from India. Indian J Nephrol 2019;29:393-7.  Back to cited text no. 19
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20.
Vijaya KL, Aruna M, Narayana Rao SV, Mohan PR. Dietary counseling by renal dietician improves the nutritional status of hemodialysis patients. Indian J Nephrol 2019;29:179-85.  Back to cited text no. 20
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