Expanding your nutritional knowledge

Following are reviews of select abstracts from the 2014 meeting of the Council of Renal Nutrition that took place April 23-26 as part of the National Kidney Foundation’s Spring Clinical Meeting in Las Vegas. The abstracts were selected by NN&I editorial advisory board members Jane H. Greene, RD, LDN, and Peggy Harum, RD, LD.

Team focused approach to improving serum phosphorus levels among hemodialysis patients

JHG: Renal dietitians have tried bulletin boards, games, puzzles, and other teaching tools to help dialysis patients understand phosphorus management. Jacquelyn Martinez and colleagues at Satellite Healthcare in San Jose, California set out to identify ways to improve the effectiveness of education regarding phosphorus management and decided to evaluate the potential benefits of employing a team approach to educating hemodialysis patients in strategies for managing serum phosphorus.

Purpose
The purpose of the project was to improve bone and mineral outcomes in their hemodialysis patients by increasing the percentage of patients achieving a serum phosphorus level within the target range of 3.5-5.5 mg/dl. Usually mineral and bone disease management projects focus on rewarding the individual dialysis patients that achieve a phosphorus level within the target range, but this project focused on providing the rewards to members of the interdisciplinary care team instead.

Three teams of patient care technicians (PCTs) led by registered nurses (RNs) were created and all patients were assigned to a team. For the next three months the Phosphorus Teams presented monthly educational topics and demonstrations, developed by the unit’s registered dietitians, to their assigned patients. Topics included taking binders correctly, and the function of phosphate binders, using a variety of teaching methods. Serum phosphorus was drawn once a month and the percentage of patients in target range and of individual patients with serum phosphorus level outside of the goal range. Individual patients were informed of any improvements in serum phosphorus they achieved. Staff teams were rewarded with small prizes each month for any improvement in the percentage of patients achieving goal. At the end of the three-month project, a grand prize was awarded to the team with the largest percentage improvement throughout the project period.

Results
Patients within the phosphorus target range improved from 40% in range to 53.4% in range over the three-month period. With all patient care staff involved in education, patient knowledge increased, which may result in lasting improvement in phosphorus levels. Frequent contact and strong relationships between PCTs, RNs, and dialysis patients resulted in increased patient understanding of phosphorus control. Perhaps this could be a new approach for renal dietitians helping their dialysis patients understand the complex issue of mineral and bone disorders.

Is more better?

PH: People frequently decide to take large doses of vitamin C––not because it was prescribed by doctors, but because “it is supposed to help with colds and the flu.”

Dialysis patients that take large doses of vitamin C can develop kidney stones and high oxalate concentrations in plasma and soft tissues.
Ascorbic acid is an antioxidant and an important factor in the maturation of red blood cells. It also helps in the absorption of iron from the gut and mobilizes iron from tissue stores. It is a soluble compound that is not synthesized in the human body. Hence ascorbic acid deficiency could affect the anemia outcomes in hemodialysis patients.

In a new study done in Abu Dhabi entitled, “A reduction in ESA requirement with oral ascorbic acid in hemodialysis patients with functional iron deficiency,” results showed that patients who had a functional iron deficiency required less Darbipoietin, and the use of oral ascorbic acid, which reduces inflammation, possibly lead to the need for reduced doses of Darbipoietin.

The study suggests that there could be a potential financial incentive with anemia management by giving 1000 mg ascorbic acid three times per week.
At our clinic, we have two female patients that take large doses of vitamin C (on their own) and they have crystals in the bladder with intermittent bleeding. More studies need to be done to balance the risks of using ascorbic acid with the benefits.

Value of in-patient PTH levels in hospitalized ESRD patients

JHG: As background, synthesis and degradation of parathyroid hormone (iPTH) is regulated by serum calcium level via calcium sensing receptors on parathyroid cells. Alterations in calcium regulation and calcium concentrations are common during critical illness. Sampath Thiruveedi and colleagues at Lankenau Medical Center in Wynnewood, Pa. wanted to know if there is a transient and significant variability in iPTH and if s, to what degree.

Thiruveedi’s group retrospectively reviewed medical records of hospitalized ESRD patients from October 2006 to October 2012 in a teaching hospital. Data collected included corrected calcium, phosphorus, iPTH and medications used during any hospitalization in the six-year period. This data was compared with results from monthly lab work done at the outpatient dialysis center. 360 admissions were reviewed and complete data was available on 67 admissions of 46 patients. Of the 46 patients, 19 were male with mean age of 65 (range 37-87 years of age) and 14 were Caucasian.

Mean outpatient levels before hospitalizations were 361.8 iPTH, 9.27 corrected calcium and 4.89 for serum phosphorus. Mean inpatient levels were 322.3 iPTH, 9.92 corrected calcium, and 4.57 for phosphorus. In-patient corrected calcium was 9% higher and iPTH was 18% lower than corresponding outpatient values. Statistical analysis using paired T-test demonstrated significant difference between inpatient iPTH and outpatient iPTH (p<0.0004) as well as inpatient calcium and outpatient calcium before admission (p0.0021).

The researchers concluded that iPTH and corrected calcium levels during acute inpatient hospitalization is not consistent with outpatient values, therefore they recommend not measuring iPTH during acute hospitalization because the transiently variable values should not drive therapeutic interventions.
In today’s cost sensitive environment, it certainly seems reasonable to give this a thought, especially if this lab work is included on an “order set” for dialysis patient admissions. This abstract suggests the iPTH could wait until the patient returns to the outpatient dialysis unit and check iPTH per unit protocol.

Cheers! – It’s for medicinal purposes

PH: According to the abstract, “Prevalence of kidney disease according to wine intake in the National Health and Nutrition Examination Survey (2003-2006),” wine intake is associated with a lower risk of cardiovascular disease, while chronic kidney disease is associated with an increase of CVD. Cross sectional analysis was performed on 5,852 NHanes participants. Wine intake was categorized as: none, ≤1 glass/day and ≥ 1 glass/day. The researchers examined the prevalence of CKD (GFR <60 mL/min) according to wine intake. Then they examined the association between wine intake and CVD stratified by CKD.

Of the 5,852 participants, 1,031 had CKD in this group; 2,455 ingested <1 glass wine/day, and 27 ingested ≥1 wine glass/day. The prevalence of CKD was lower in subjects who drank <1 wine glass/day compared to non-drinkers. After adjusting for multiple covariates, the data suggests that wine intake is associated with reduced odds of CKD and with reduced odds of CVD in individuals with CKD.

Further studies are needed to understand the mechanisms underlying this association, particularly in individuals with CKD. The authors suggested that although the type of wine was not specified, red wine seemed to be the favorite.

Patient identified barriers and facilitators to kidney transplantation

JHG: As a dietitian in the south with kidney transplant patients, I found this abstract led by fellow NN&I editorial advisory board member Teri Browne, PhD, MSW, NSW-C to be especially interesting.

Browne and colleagues conducted patient focus groups in Georgia, North Carolina and South Carolina to determine barriers and facilitators related to receiving a kidney transplant. Ninety-minute focus groups were conducted using a structured interview format as well as a brief written survey to determine interest and personal experience with kidney transplant. A constant comparative method was used to identify themes from the focus group transcripts.

Of the 40 participants, 14 (35%) were male, 25 (63%) were African Americans, and 46% were on dialysis for more than two years.
Patients identified five main barriers to transplantation: financial, medical, informational, attitude, and the composition and behavior of the dialysis team, the medical providers, and the members of their social network. The patients cited finances, younger age, information, attitudes and beliefs, as well as helpful medical professionals as facilitators for kidney transplant.

Although 40 patients is a small representation of all the dialysis patients in those three southern states, it is certainly a starting point when considering specific interventions that focus on patient-centered care.

Parathyroidectomy: What are the risks and benefits?

PH: Using data from the U.S. Renal Data System, a group of nephrologists examined 4,435 hemodialysis patients that underwent parathyroidectomy (PTX) during 2007-2009. Their aim was to evaluate outcomes post-PTX from a nationwide sample.

These patients were followed for up to a year after PTX for clinical events, with censoring at death, loss of Medicare coverage, transplant, change in dialysis modality or one-year follow up. Of the 4,435 patients who underwent PTX, 23.8% were rehospitalized and 8.3% were admitted to an ICU within 30 days of PTX discharge, 2% died before discharge or within 30 days after discharge. Comparing the year before with the year after PTX, there were more outpatient visits for hypocalcemia, emergency room/observation visits for hypocalcemia and hospital admissions with hypocalcemia. After PTX, total hospitalizations, hospital days and intensive care admissions increased significantly, as did various cardiovascular complications, including acute myocardial infarction and dysrhythmia. Fracture rate change was not statistically significant.

PTX is associated with significant morbidity in the 30 days and in the one year following the procedure. Definitions of clinical indications for this procedure should be improved to balance potential benefit and risk.

During the four years I spent in North Carolina working in dialysis clinics, I experienced only one patient with a remarkable PTX outcome. She had a PTH >5000 and was admitted for the PTX during which they removed one parathyroid gland. Needless to say, her PTX level did not normalize. Instead it was in the 2000 range. She was reluctantly convinced to have another PTX one year later. She did and they removed one more parathyroid gland – she died several months later.

The PCP’s involvement in preventing kidney failure

PH: This group launched a survey among primary care physicians about how they care for patients with kidney disease. Of 12,034 PCPs targeted, 848 opened the study email and 165 responded. Most respondents spent ≥ 50% of their time in clinical care. They were generally in private practice. Results showed:

Most PCPs (96%) felt eGFRs were helpful.
Approximately 75% and 91% of PCPs reported testing for albuminuria in non-diabetic hypertensive patients with an eGFR > 60 and < 60, respectively
Interestingly, PCPs expressed high levels of agreement with the definition of CKD; 30% were concerned with over-diagnosis in older adults with an eGFR in the stage 3a range. (As we know, a decrease in renal function is a normal part of aging.)
Most PCPs felt that ACEi/ARBs improved outcomes in CKD, though agreement was lower with severe vs. moderate albuminuria.
Many PCPs (51%) reported being unfamiliar with CKD guidelines, but were receptive to systematic interventions to improve their CKD care. They generally agreed with clinical practice guidelines regarding CKD definition and albuminuria testing.

Clearly, PCPs have the greatest opportunity to assist in decreasing the CKD population’s progression to Stage 5 CKD. How we can reach them with the available CKD guidelines remains the question.