1990 CRN ANNUAL MEETING ABSTRACTS •
INDICATES VERBAL PRESENTATION
• NUTRITIONAL STATUS OF HAEMODIALYSIS PATIENTS ON RECOMBINANT HUMAN ERYTHROPOIETIN THERAPY (r-HuEPO). S.E.Bennett, M.Edmunds, J.Feehally, J.Walls, Dept. of Nephrology, Leicester General Hospital, U.K. Increases in serum K and urea attributed to improved appetite and decreased dialyser efficiency have been recognised with increasing haemoglobin values (Hb) produced by r-HuEPO. This study was undertaken to examine various nutritional parameters in
patients on r-HuEPO therapy. 14 patients (7F 7M; mean age 42.8 years (23-72) were studied pre and after receiving r-HuEPO, 24 mths (5), 12 mths (6), 6 mths (3). Routine biochemical, haematological and anthropometric monitoring and PCR were performed. At 6 mths the mean Hb increased from 6g to 9.4g/dl (p
• THE EFFECT OF ALBUMIN REPLACEMENT ON SERUM ALBUMIN LEVELS OF RENAL TRANSPLANT RECIPIENTS WITH PROTEINURIA: REVIEW OF THREE CASES. Simone Camel,MS,RD, Mary Kunisch, MS,RD, Linda Cashman, MS,RD. Hermann Hospital, Houston, TX. The effectiveness of intravenous (i.v.) albumin replacement therapy on the restoration and maintenance of serum albumin levels was retrospectively studied in three male renal transplant recipients with nephrotic range proteinuria (~2gm/24 hr) secondary to graft rejection. Weight, urine output, proteinuria, serum albumin, i.v. albumin dose, BUN/creatinine, serum lipids, bilirubin, cyclosporine/prednisone dose, and oral intake were recorded from initiation of therapy to three months posttherapy. In all cases, albumin replacement began when serum albumin levels fell below 2.0gms/dl. Total doses of albumin administered during the 3 to 5 day treatment period were 200, 225, and 375 grams. Proteinuria increased with infusion as did urinary output; however, with concurrent treatment of graft rejection, calculated urinary protein losses ranged 3-20% of the infused dose, indicating retention of i.v. albumin. Serum albumin levels improved immediately and were maintained for 3 months at levels of 2.9-3.2 gm/dl. Albumin replacement therapy appears to be effective in restoring serum levels when treatment of the underlying cause of proteinuria is successful. Its effect on nutritional status when proteinuria does not diminish and its impact on long term renal graft function warrants further investigation.
INDICATES POSTER PRESENTATION
• Steroid-induced diabetes mellitus (SIDM) in black renal allograft recipients. Nabil Sumrani, Vera Delaney, Paula Daskalaki.s, Robert Davis, Joon Hong. SUNY at Brooklyn NY.
Despite mounting evidence that cyclosporine (CSA) inhibits pancreatic function, clinical data on srDM in black renal allograft recipients in the CSA is scarce. Betvleen 1983 and 1989, 234 renal. allografts were implanted in 229 black uremics. Of the 138 adult recipients, nondiabetic pre-transplant ('[x), whose allografts survived longer than 1 year (mean follow-up 3.9 ± 1.6 yrs), 28 (20.3%) developed SIDM. 46% and 75% were diagnosed by 6 and 12 months post-Tx respectively and 461 were insulin-dependent. srDM was more frequent in older recipients (mean age 45.3 ± 8.8 vs 39.5 ± 10.4 yrs) and recipients of cadaveric kidneys (24% vs 4%, P<0.05) but was independent of recipient gender, number of reTx, type of inducti on immunosuppr essi ve therapy, incidence of rejecti.on, percent body weight gain, total steroid or eSA dose and the use of B-blockers and/or diuretics. Renal function was identical i]1 srDl~ and control groups. Actuar ial 5-year graft survival was 82% in the SIDM compared with 78% in those who did not develop diabetes, with chronic rejection accounting for all graft losses (5) within the srDM group. Conclusions: the incidence of srDM in black renal allograft recipients was 20.3% but eliel not influence short-term patient or graft survival adversely . • PRACTICAL APPROACH TO ADMINISTRATION OF I. V• CALCITRIOL IN A DIALYSIS CLINIC. Sandy Detar, R.D., Chhaya Patel, M.A., R.D., John Valdin, M.D., BMA Dialysis of Alameda County, California. The purpose of the study was to determine whether a protocol for I.V. Calcitriol - Calcijex, implemented and monitored by dietitians (ROs), would be effective in clinical situation in
achieving parathyroid suppression as described by others. A contingency and treatment protocol was
established by RDs and nephrologists at the BMA dialysis unit.
Forty seven patients were on the
protocol at least 90 days at the end of the six month period. Blood values were done bimonthly (Ca, P, Alk Phos, PTH). All patients were in~tructed by RD on phosphorus restriction. Calcijex was started upon acceptable serum levels
of Ca - <'10.5, P -<.6.5. Calcijex was held when the Ca X P was )73. Patient was referred to a nephrologist upon persistent Ca and P imbalance, and was evaluated for hyperparathyroidism and aluminum toxicity.
Calcijex was held 26% of the time, 22% of that time was due to high Ca, 78% was due to high P or high Ca X P. Ca level was significantly higher at the end of the study. Of the 47 patients, 22 had a 53% fall in PTH level. Protocol was applicable to dialysis clinic setting and easily monitored by RD with extra hours approved. It achieved the goal of suppressing PTH values in large number of patients with no morbidity detected. Further study is necessary to find factors that may identify the patients who do not respond to the protocol.
1990 CRN ANNUAL MEETING ABSTRACTS
• Does body weight gain adversely affect renal allograft outcome? Robert Davis, Nabil Sumrani, Millie Irizarry, Vera Delaney, Debbie Sonenblick, Joon Hong. SUNY at Brooklyn NY
• USE OF A COMPUTER GENERATED PATIENT NUTRITIONAL ASSESSMENT (PNA) FORM. Zoe Komaransky, R.D., L.D., Kathleen Hanrahan, M.H.A. Community Dialysis Center, Cleveland, Ohio. Nutritional assessments in our 370 patient unit now include anthropometries, kinetic modeling, drug/nutrient interactions and nutritional diagnostic statements. Intervention and documentation standards exist at state, federal and network levels. A computer generated form was developed to meet all these requirements. Necessary data is extracted from a relational data base and prints a single sheet per patient each month following labwork week. Pertinent data include the dialysis prescription, diet order, anthropometrics, %IBW, estimate of caloric need, and prescribed meds with known drug/nutrient interactions. A three month summary of diet-related lab data follows including K, BUN (pre/postl, pre2), Ca, P04, alk phos, iPTH, cholesterol, albumin, glucose, kt/v and nPCR. Averaged interdialytic weight changes and dry weight for the corresponding interval also appear. The R.D. formulates nutritional diagnostic statements (NOS) and plan of action based on the objective and subjective data. The computer-generated PNA has minimized R.D. data collection time, provided the basis for a comprehensive review of nutritional status, become a readily accessible record for use in patient care plan meetings and functions as a quality control tool in meeting state, federal and network standards of care. The PNA has allowed the R.D. to spend less time with the medical record and more time with patient intervention.
In order to study the influence of body weight change post-transplant (Tx) on renal allograft outcome, 196 cadaver donor, cyclosporine-treated, renal Tx recipients whose allografts survived more than 1 year, were divided into 5 groups: group A lost weight post-Tx; group B, C, D, E gained 010%, 11-20%, 21-30%, >31% of pre-Tx body ~leight in the post-Tx period, respectively. All groups were similar with respect to age, sex, race, number of Tx, original renal disease and immunosuppressive regimens. Graft survival Rejection Infection 2 yrs 4 yrs N A 21 B 77
47.6% 24.7% 23.1%
96.2% 80.6% HJ0.0%
86.5% 77.4% 80.8%
Contrary to what is generally believed, our data demonstrates no significant adverse effect of weight gain in the postTx period on graft survival, or incidence of either rejection or infection.
• USING COMPU'IERIZED RECIPE PROGRAMS FOR NUTRIENT ANALYSIS IN CLINICAL TRIALS - TIlE MODIFICATION OF DIET IN RENAL DISEASE (MDRD) STUDY. Fran L. Jones. Frani M. Averbach, Arlene W. Caggiula, Bonnie P. Gillis, Rebecca M. Meehan, JoAnn A Naujelis, Monica E. Yamamoto, and the MDRD Study, MDRD-Nutrition Coordinating Center (NCC), University of Pittsburgh, Pittsburgh, PA 15261 The MDRD Study is a multicenter clinical trial, sponsored by the NIH and HCFA, designed to determine whether the control of dietary protein and phosphorus intake and/or the reduction of blood pressure to two target levels will reduce the rate of progression of chronic renal disease. MDRD Study participants' diet modifications can be complex and may require significant chanl;es in usual eating patterns. Evaluation of dietary intake is done (in part) through bimonthly three-day food records. Patients are encouraged to include recipes for mixed items. Mixed dishes and recipes are very often difficult foods for the patient to describe. These items may be continually modified by the patient, with the help of the dietitian, to improve compliance to their study diet. This continual modification of foods creates a challenge for nutrient analysis. The significant differences in nutrients between standard and modified mixed items have resulted in the need for a computerized recipe program. "Cookbook" is a computerized reCipe program developed and used for the nutrient analysis of non-standard recipes in the MDRD Study. This multi-component program uses the University of Pittsburgh Nutrient Database and allows for the entry of modified and home recipes, and also mixed dishes. The program is able to adjust recipe nutrient totals for substituted, added, or deleted ingredients and to accommodate nutrient changes that occur in the item's preparation and cooking. "Cookbook" provides the ability to accurately assess the nutrient intake of the patients who consume mixed dishes and the ability to mOdify the patient's diet to meet MDRD Study goals.
A COMPARISON OF PERCENT BODY FAT IN DIALYSIS pOPULATIONS. Carol Liftman, M.S. R.D., Franklin pialysis Center/Pennsylvania Hospital, Philadelphia, PA. Infrared interactance is a noninvasive technique using a small portable, lightweight device which can be used to determine percent body fat in adults on hemodialysis (HD). This study compared the percent body fat of: 1) Diabetic vs nondia.betic patients on ED 2) Patients on HD VB Peritoneal Dialysis (PD) The nonaccess arm was measured in 65 patients
receiving HD. The nondominant arm was measured in 11 patients receiving PD. The body fat for females on HD (N=41) was 34.2 ± 5.5% (mean ± SD) compared to 30.7 ± 6.6% for females on PD (N=7). (SEM = 2.65, NS). For males on HD (N=24) the body fat was 23.7 ± 5.7% compared to males on PD (N=4) with 27.1 ± 2.3% (SEM = 1.63, NS). Diabetic females on HD (N=19) had a body fat of 35.3 ± 5.0% compared to nondiabetic females on HD (N=22) with a 33.2 ± 5.8% body fat (SEM = 1.7, NS). Diabetic males on HD (N=5) had a 25.1 ± 5.1% body fat with nondiabetic males (N=19) on HD having a 23.3 ± 5.7% body fat (SEM = 2.6, NS). It was concluded that percent body fat was not significantly different in patients on HO vs PO or between diabetic and nondiabetic patients on HD.
1990 CRN ANNUAL MEETING ABSTRACTS •
THE USE OF INFRARED INTERACTANCE TO DETERMINE PERCENT BODY FAT IN ADULTS ON HEMODIALYSIS. Carol Liftman, M.S. R.D., Franklin Dialysis c e n t e r / - Pennsylvania Hospital, Philadelphia, PA. Infrared interactance is a new noninvasive technique for assessing body composition. The equipment is a small, portable, lightweight device. The purpose of this study was to investigate the reliability of this technique with healthy
adults and adults on hemodialysis (liD), .:lnd to compare the values obtained from these two groups. The nondominant arm of 22 healthy adults (controls) was repeatedly measured on the same
Variations between measurements were
The nonaccess arm was then measured in 22 patients on HD. The average change pre-HD to post-HD was 0.0 ± 1.2% (mean ± SD). Comparison of Controls to HD Patients: Percent Body Fat (mean ± SD) Females 29.6 ± 6 • 4:=:::::===Controls (N=14) NS 34.2 ± 5.5 HD (N=41) Males 23.7 ± 5.9~ Controls (N=8) NS 23.7 ± 5.7 HD (N=24) Conclusions: 1) Infrared interactance is a safe, reliable, and easy technique for determining percent body fat in HD patients. 2) The measurement of percent body fat by infrared interactance is not altered by the fluid status of patients on HD. 3) The percent body fat of patients on HD was not significantly different than a random group of healthy controls .
.ESTIMATION OF PROTEIN INTAKE IN CAPD Debra Raizman, Johanna Dwyer, Alice Martin, Carol Stollar, Andrew Levey, Dialysis Clinics Inc., New England Medical Center, Boston,MA Protein intake was estimated in six peritoneal dialysis patients by urea kinetic modeling and food recalls. 24 hr recalls were collected over 5 consecutive days and a food frequency was obtained on day 1. Protein catabolic rate (peR) was calculated from 5 measurements of 24 hr urea nitrogen appearance in dialysate and urine, estimated non-urea ni trogen losses, including nitrogen lost as dialysate protein and amino acid ("-' 2 gm/d) and miscellaneous nitrogen losses (31 mg/kg/d). The mean coefficient of variation (CV) for the PCR was 4.6% (range 2-6.7%) versus the mean CV of the 24 hr recalls (28.9%, range 11.3-60%). The variance of recalls was significantly greater (p <: 0.01) than the variance of PCRs. The group correlation of recalls and food frequency with PCR were not statistically significant (r=. 47 and. 41) . Individual correlations between recall and PCR were significant at p 0.05 in only 2 of the 6 subjects. We conclude: 1) a single measure of PCR provides a better estimate of mean protein intake than a single measure of dietary recall. 2) PCR should be used to quantify average protein intake. 3) Food recalls can be used to describe types of food eaten.
• INCIDENCE & CAUSES OF IRON DEFICIENCY ANEMIA IN HEMODIALYSIS PATIENTS. Linda W. Moore, Sergio Acchiardo, John Sargent, Lisa Burk, Carol Headley, University Physicians Foundation-Dialysis, University of Tennessee Memphis, Memphis, 'IN. and Quantitative Medical Systems, Emeryville, CA.
• THE EFFECT OF TAILORING PHOSPHATE BINDER (PB) DOSAGE ON SERUM PHOSPHORUS (P) LEVELS IN ADULTCHRONICHEMODIALYSrS (HD) PATIENTS. Susan O. Smith, Linda W. Moore, Sergio Acchiardo, University Physicians Foundation, Memphis, TN and Carol O. Mitchell, Memphis State University, Memphis, 'IN.
Since an important factor in response to EPO therapy is adequate iron (Fe) availability, we decided to assess the Fe status of our hemodialysis (lID) pts before initiating EPO therapy. Of 104 pts not already receiving EPO, 72% had transferrin saturation <20% and 69% of the pts had serum ferritin <100 Ilg/l. Their average hematocrit (Hct) was 22%. We determined that our pts lose from 2 to 5 liters of blood per year, amounting to 3 to 8 mg of Fe/treatment when Hct is 22%. If Hct is 30%, Fe loss will be 4 to 11 mg per treatment. Protein is the major source of Fe in the diet and since the renal diet provides -15 mg of Fe/day, comparable to only about 1-2 mg of absorbed Fe, these patients require a significant amount of Fe replacement therapy. We studied 32 pts with Fe deficiency anemia. Each pt had iron studies consisting of serum Fe, total Fe binding capacity, transferrin saturation and serum ferritin as well as Hct on a weekly basis. Sixteen of the pts were on intravenous Fe dextran (NFe), administered after each dialysis for five weeks totalling 1.5 g, and 16 pts were treated with oral ferrous gluconate (POFe), -5g (72mg daily) given over 10 weeks. NFe pts increased their Hct from 19% to 27%. All pts treated with NFe corrected their transferrin saturation and 77% corrected serum ferritin. Pts treated with POFe improved hematocrits from 20% to 25% and two thirds of these pts improved their Fe status. We contend that a substantial number of HD pts have Fe deficiency anemia due to blood loss, that the renal diet is insufficient to combat this deficiency and IVFe is more efficient than POFe in treating Fe deficiency in HD pts.
Compliance with PB in HD patients is usually poor. The purpose of this study was to assess the effect of altering the pattern of PB ingestion to coincide with dietary intake of P with repeated individual instruction regarding the method and importance of taking the PB. Patient compliance was determined by monitoring serum P levels. Seventeen adult chronic HD patients were studied for 4 months (Grl) along with an age and sex matched control group (Gr2). Data included the following: biochemical parameters, protein catabolic rate (PCR), and reported dietary intake of protein (DPI) and P in the experimental group only. Each subject was instructed to continue taking the prescribed amount of PB but to adjust the times it was taken according to his eating pattern. The instructions were reinforced weekly for 2 months during regular HD treatments. At baseline, PCR in Gr2 was significantly higher than in Grl (67.81 ± 16.31 vs 56.94 ± 13.06; p < 0.05). At the end of the study, all parameters in Gr2 were essentially unchanged. Grl showed a slight decrease in serum P levels (5.19 ± 1.49 to 4.94 ± 1.52) in the face of increased DPr evidenced by a significant increase in PCR (56.94 ± 13.06 to 65.12 ± 15.96; p< 0.01). An increase in DPI is accompanied by an increase in dietary P intake due to the high P content of protein containing foods. Since serum P levels did in fact decrease while DPI increased, it indicates that compliance with PB therapy was improved. This type of intense individual instruction may be applicable to other aspects of patient care such as medications and diet.
1990 CRN ANNUAL MEETING ABSTRACTS
A4 • EFFECTS OF RECOMBINANT ERYTHROPOIETIN (EPO) ON NUTRITIONAL STATUS OF CHILDREN ON DIALYSIS. Cynthia J. Terrill. R.D., Pediatric Dialysis, University of Utah Medical Center, Salt Lake City, UT End stage renal disease (ESRD) frequently results in poor nutritional status. The reasons include anemia, and the anorexia and nausea associated with uremia and dialysis. Multiple dietary restrictions may also contribute to poor caloric intake. Suboptimal nutrition is particularly concerning in pediatric patients due to a direct adverse effect on linear growth and weight gain. Little research has been done on EPO and its effects on the nutritional status of pediatric patients. We hypothesized that with improvements in the pediatric patients' hematocrit through the use of EPO, nutrient intake would improve, with subsequent improvement in The 7 patients studied nutritional status and growth. ranged in age from 4 to 20 years (mean 9.9). We evaluated changes in height, weight, triceps skinfold (TSF), mid-arm muscle circumference (MAMC), and body mass index (BMI) during the six months following the initiation of EPO, and compared these values to preEPO measurements. Although patients and families reported an increase in appetite and oral intake, there was no significant change in the parameters studied. (P > .05) Since small population size may affect these results, further research would be beneficial in assessing the nutritional effects of EPO on pediatric patients.
INTERACTIVE COMPUTER LEARNING TECHNOLOGY IN RENAL DIALYSIS PATIENT EDUCATION. Betty Wedman,MS,RD,Doctoral Candidate,University of South Florida,St.Petersburg,FL Patients with end-stage renal disease were evaluated for effectiveness in learning nutrition basics of the renal diet through an interactive computer program. Pre and post test results were recorded on the computer program and evaluated at the conclusion of the study. Two cl inical settings were used to evaluate 18 patients during a 3 week period. Patients in the hospital setting had more acute medical problems than those in the physician's dialysis center, but the results were not signficantly different in this population sample. No assessment of previous nutrition education knowledge was made. Participants improved an average of 82% between the pre and post tests. Nine of the 18 participants got 0 correct on the 10 question pretest and scored 100% on the posttest. Test questions had not been validated before use in this project. Test results 111ustrate the value of an interesting, creative presentation when trying to impart diet information for patients with end-stage renal disease.
COMMON MISSING FOOD DETAILS AND 1HEIR IMPACT ON ESTIMATES OF PATIENTS' PROTEIN AND PHOSPHORUS INTAKES. Monica E. Yamamoto, Frani A Averbach, Arlene W. Caggiula, Bonnie P. Gillis, Fran L Jones, Rebecca M. Meehan, JoAnn A Naujelis and the MDRD Study. MDRD-Nutrition Coordinating Center (NCC), University of Pittsburgh, Pittsburgh, PA 15261 The Modification of Diet in Renal Disease (MDRD) Study is a multicenter, five-year clinical trial sponsored by the NIH and HCFA designed to determine whether control of dietary protein and phosphorus intakes and/or blood pressure will alter the progression of chronic renal disease. Dietary data collected by 24-hour recalls and 3-day food records are used to assist in the estimation of patients' dietary intakes and are examined for nutrient intake adequacy; compliance to diet prescriptions and preferred food choices. The use of dietary data for these purposes is dependent upon the accuracy and completeness of the patients' reports. To support the MDRD dietitians efforts to assist patients in providing required food intake details, data clarification requests sent to dietitians were examined to identify
common missing food details and their potential impact on protein and phosphorus intakes. In 1989, 934 requests for additional food detail were required for the 6,287 days of MDRD patients' intakes reported. Clarification requests dropped from 1 per 3 days of intake data to an average of 1 per 8 days after the first 4 months of 1989. Food detail problems were largely for missing, incomplete or unclear food descriptors and amounts consumed. Missing food details most frequently occurred for poultry, vegetables, bakery and mixed dish items. Missing details were not similar for 24-hour recalls and food records. Nutrient differences between similar food items with different descriptors or amounts were as great as 100% for key nutrients. This review identified specific recommendations for improving patient intake reporting as well as providing nutrient-based rationale for these food details.