Energy supplementation of hemodialysis patients3 Margaret Geoffrey
A Allman, G Duggin,
Peter andA
M Stewart, Davidf Stewart Truswell
Twenty-one
ABSTRACT modialysis
completed
and the nutritional
patients
a trial
Tiller,
undergoing
of energy
John
regular
he-
supplementation.
Nine
patients added the glucose polymer Polycose to their usual diet and 12 acted as control subjects. The supplemented patients were asked to incorporate 100 or 150 g polymer, equivalent to 1600 or 2400 kJ (400 or 600 kcal) into their usual diet, daily for 6 mo. This resulted in a mean increase in energy intake of 1630 U (p < 0.05) and a mean weight gain of 3.1 kg (p 0.005). in a mean
The addition ofglucose polymer to the diet resulted increase in body fat of 1.8 kg and the lean body mass
3 mo. Patients who did not wish to participate, who were aged < 18 y, who lived
On the basis
occurrence
status
Methods
2 received
Introduction The
for supplementary drinks. This paper effect ofenergy supplemen-
hemodialysis.
allocated (names group 1 received
hemodialysis,
fluids
describes our controlled trial ofthe tation on the indices ofnutritional
in USA.
© 1990 American
Society for Clinical Nutrition
INCREASED
ENERGY
FOR
All patients were prescribed a water-soluble vitamin supplement to be taken after each hemodialysis treatment. This provided 15 mg thiamin hydrochloride, 15 mg riboflavin, 50 mg nicotinamide,
1000
chloride, and
10 g
mg ascorbic
acid,
cyanocobalamin,
1 50 Lg biotin/tablet.
10 mg pyridoxine
25 mg calcium
In addition,
separate tablets offolic The glucose-polymer
hydro-
took
one
acid (5 mg) after dialysis. supplement was packaged
or two
into vials la-
beled “dietary supplement.” To aid compliance individually dated and numbered. Patients were
the vials were given enough
supplement
for 1 mo and asked
glucose
mer
they
before
received
to return
the
next
unused
month’s
supply.
supplied =-800 kJ (200 kcal) and patients either 2 or 3 vials/d. The dietitian instructed the
polymer
usual
to their
dose
was
supplemented on the indices were not aware
The
or six times and
indices
(weight,
clinic
within
24 h oftheir
weight,
were
and
and
dietary
of increases
ofWeiner
thropometric
when
Weight
they
were
normally
was
measured
scale. Weight and height were used (kg)/height (m2)] ( 10). Fat skinfold
were
measured
on the
a Holtain biceps,
side
of the
close
All
a beam BMI were
(Croswell, subscapular,
Cryand
that
(1 1). The
subtraction
ofbody
abdominal,
and
flexible
tape.
lean
body
fat from calf
The
mass
total
was
did
body
circumferences
determined
weight. were
midupper-arm
The
muscle
upper
home
patients
clinic. In addition, commencing the tion
to measure
concentrations. Patients fore, were tated the
the day recorded
kept
blood
samples
were
fasting blood samples supplement and at the the
plasma
triglycerides
3-d
dietary
records
of, and the day after by use of household
by the dietitian. supplement
the
ir times
A practice
to familiarize
at the
were obtained before end of supplementaand
that
collected
selected
included
vitamin the
day
be-
dialysis. Foods and beverages measures and were quantirecord
the
patients
was kept with
before the
the glucose
on the
British
food
tables
(13).
The results were analyzed by use ofthe statistical component ofthe SIR program (Scientific Information Retrieval, Inc, Evanston, IL) and the SPSS program (SPSS Inc, Chicago, IL). The nutritional measurements ofthe two groups at the time of allocation and changes in the nutritional indices at 6 mo were compared by use of the Students I test for unpaired data. Within each group the food intakes initially and 6 mo later were compared by use of the Students t test for paired data. The patients’ general feeling ofwell being and side effects were compared by using the nonparametric Wilcoxon rank sign test for paired data.
starting
procedure.
Downloaded from https://academic.oup.com/ajcn/article-abstract/51/4/558/4695131 by Queen Mary University of London user on 26 March 2018
Thirty-two
patients
met
the selection
criteria
12 unsupplemented)
and
ofthese
successfully
21
completed
the trial. The nine patients in the supplement group (seven men, two women) were aged 50 ± I 1 y ( ± SD) and had been on dialysis for 40 ± 23 mo. The 12 patients in the nonsupplement group (9 men, 3 women) were aged 41 ± 1 8 y and had on dialysis
ment
for 41
two
disease,
and
28 mo.
The
normally
reflux.
who failed
a transplant
who
the other by choice
±
ofthat
causes
died
(one
took
died before (three after
periods
and
one who
lowing
reasons
were
The
seven
never
commenced
who
one who
the supplement),
until
out before
by those
dial-
in the supple-
included
it), and four who the glucose polymer
dropped given
failure
nephropathy,
patients
the study
the supplement
starting taking
renal
in our chronic
analgesic
to complete (and
ofthe
found
ie, glomerulonephritis,
group
received
a was
Hemoglobin, hematocrit, lymphocyte counts, plasma electrolytes, total protein, albumin, transferrmn, urea, creatinine, glucose, and triglycerides were determined each month. For hospital patients the blood samples were collected before dialysis. For
commencing
analysis
polycystic
arm, with
minus
is based
before
starting the supplement. by use ofthe DIAR YAN computer of Human Nutrition, Adelaide,
Division
which
ysis population,
not
circumference
calculated from midupper-arm circumference triceps skinfold thickness measurement (12).
analyzed
were representative
by the
measured
were
(CSIRO
just
6 mo after
A visual analogue scale was used to detect any effect of the supplementation on the patients’ feelings of well being and to pinpoint side effects such as a change in appetite, bowel habits, vomiting, or abdominal discomfort. Patients were required to mark their responses on a linear scale and the responses were then given a numerical score between one and five.
been
have a vascular access for hemodialysis. The sum of four skinfold thickness measurements was used to determine the percentage body fat by using the values published by Durnin and Womersley
intakes
kept
1 and
(9 supplemented,
for the an-
to calculate thicknesses
body
Food
were
then
Results
to deter-
with
and
to
hydrated.
(9) were used
measured by the same observer with mych, UK) skinfold caliper; triceps,
in-
after dialysis. For at the follow-up
so that
and Lourie
assessments.
anbody
were made either to patient availability. in body water, the pa-
regularly examined by their physician their hydration status was normal.
The methods
suprailiac
Patients
included
biochemistry,
weight
were
polymer
thicknesses,
records
St atistical
The
patients
monitored
fat skinfold
last dialysis
ie, their
meal.
was monitored. being studied.
Dietary
559
vial
to take to add
glucose
at the hospital were measured the measurements were made
patients were mine whether
balance [weight
The
of the
measurements month according
the problem
dialyzed patients
asked patient
at each
per day.
effect
that
hematology,
tients home
foods
status changes
height,
take. The anthropometric monthly or every other
dry
the
of nutritional ofthe specific
To overcome
and
25 g four
circumferences),
their
liquids
for 6 mo
nutritional
thropometry
usual
were the
poly-
Each
PATIENTS
polymer program Australia)
pantothenate,
patients
DIALYSIS
his death
and
dropped out for various
starting discontinued
it). The
fol-
the poly-
mer: one said she did not want to put on “too much weight,” one “felt too ill” to participate, and the other said she “had lost her appetite” since commencing the glucose polymer. Three of the patients in the nonsupplemented plants and one died during the course
group received transofthe study. The attrition
meant that the groups became unbalanced regarding the numbers of men and women. The results for men and women were therefore grouped together. Table I compares selected nutritional measurements of the two groups at the time ofallocation to treatment. No significant differences
were
surements
after
completed mented weight,
with
detected.
the 6-mo
The
changes
study
phase,
in anthropometric
for the patients
mea-
who
the trial, are shown in Table 2. The group supplewith glucose polymers had significant increases in BMI, body fat, and lean body mass when compared
the nonsupplemented
group.
For those
four patients
who
560
ALLMAN
TABLE
ET
AL 6
I
Anthropometric, biochemical, hematological, and dietary data for the two groups at the time ofallocation into treatment groups* Supplemented (n=16) Weight
(kg)
Body
mass
Sum
offour
index
(kg/rn2)
2 1 .3 ± 2.4
64.3 ± I I .8 22.9 ± 2.2
29.2
33.4
2
L) 0
skinfold
thickness
measurements
(mm)
mass (kg)
body
± 1 3.8
11.6±4.8 48. 1 ± 8. 1
Bodyfat(kg) Lean
z
(n=16)
± 8.8
59.4
4
Nonsupplemented
± 9.1
-2
13.5± 3.4 50.8 ± 1 1.0
Midupper-arm circumference
(cm)
Midupper-arm
circumference(mm) Abdominal
244±30
(mm) albumin
Plasma
creatinine
(gIL)
(umol/L)
-4
± 3.0
0
4
TIME FIG I. Weight change
88±8
89±10
43 ± 4
6
months
1040 ± 206
± 261
12)t
1.1 (n=
4.9±
4.7±
for each ofthe
13 patients
who took glucose
polymer during the 6-month-supplementation never took it because of death, transplantation, dropped out are not included.
(fasting)
(mmol/L)
1.1
(n=
phase. Those or because
who they
respectively,
in-
ll)t
triglycerides
(fasting)
2.6 ± 1 . I (n
(mmol/L)
Hematocrit Protein
0.23 intake
SD.
*
.:
t
Some
120±41 No significant
patients
differences
failed
to observe
(n
2.3 ± 1.4 0.27 ± 0.07 1 . I 7 ± 0.33
1 2)t
=
± 0.04
I .09 ± 0.32
(gJkg)f
Energyintake(kJ/kg4
(n = (n=
120±35 were
the
1 1 )t
=
I 4) l4)
took
patients
the
did
not
ideal keep
supplement
were completed,
but
their
statistically
body
their
weight
their
results
were
not
(14).
Figures
out
or died
ofweight
before
different
from
the
6 mo
gain was not significantly
that
in those
who
the trial. dropouts
Simwas
finished
the
1 and 2 illustrate
the changes
in body
weight
for the
2
(n=9)
Weight(kg)
BMI (kg/rn2) Sum offour skinfold thickness measurements (mm) Bodyfat(kg) Lean body mass (kg) Midupper-arm circumference (cm) Midupper-arm muscle circumference(mm) Abdominal circumference (mm)
were
different
p
A Allman, G Duggin,
Peter andA
M Stewart, Davidf Stewart Truswell
Twenty-one
ABSTRACT modialysis
completed
and the nutritional
patients
a trial
Tiller,
undergoing
of energy
John
regular
he-
supplementation.
Nine
patients added the glucose polymer Polycose to their usual diet and 12 acted as control subjects. The supplemented patients were asked to incorporate 100 or 150 g polymer, equivalent to 1600 or 2400 kJ (400 or 600 kcal) into their usual diet, daily for 6 mo. This resulted in a mean increase in energy intake of 1630 U (p < 0.05) and a mean weight gain of 3.1 kg (p 0.005). in a mean
The addition ofglucose polymer to the diet resulted increase in body fat of 1.8 kg and the lean body mass
3 mo. Patients who did not wish to participate, who were aged < 18 y, who lived
On the basis
occurrence
status
Methods
2 received
Introduction The
for supplementary drinks. This paper effect ofenergy supplemen-
hemodialysis.
allocated (names group 1 received
hemodialysis,
fluids
describes our controlled trial ofthe tation on the indices ofnutritional
in USA.
© 1990 American
Society for Clinical Nutrition
INCREASED
ENERGY
FOR
All patients were prescribed a water-soluble vitamin supplement to be taken after each hemodialysis treatment. This provided 15 mg thiamin hydrochloride, 15 mg riboflavin, 50 mg nicotinamide,
1000
chloride, and
10 g
mg ascorbic
acid,
cyanocobalamin,
1 50 Lg biotin/tablet.
10 mg pyridoxine
25 mg calcium
In addition,
separate tablets offolic The glucose-polymer
hydro-
took
one
acid (5 mg) after dialysis. supplement was packaged
or two
into vials la-
beled “dietary supplement.” To aid compliance individually dated and numbered. Patients were
the vials were given enough
supplement
for 1 mo and asked
glucose
mer
they
before
received
to return
the
next
unused
month’s
supply.
supplied =-800 kJ (200 kcal) and patients either 2 or 3 vials/d. The dietitian instructed the
polymer
usual
to their
dose
was
supplemented on the indices were not aware
The
or six times and
indices
(weight,
clinic
within
24 h oftheir
weight,
were
and
and
dietary
of increases
ofWeiner
thropometric
when
Weight
they
were
normally
was
measured
scale. Weight and height were used (kg)/height (m2)] ( 10). Fat skinfold
were
measured
on the
a Holtain biceps,
side
of the
close
All
a beam BMI were
(Croswell, subscapular,
Cryand
that
(1 1). The
subtraction
ofbody
abdominal,
and
flexible
tape.
lean
body
fat from calf
The
mass
total
was
did
body
circumferences
determined
weight. were
midupper-arm
The
muscle
upper
home
patients
clinic. In addition, commencing the tion
to measure
concentrations. Patients fore, were tated the
the day recorded
kept
blood
samples
were
fasting blood samples supplement and at the the
plasma
triglycerides
3-d
dietary
records
of, and the day after by use of household
by the dietitian. supplement
the
ir times
A practice
to familiarize
at the
were obtained before end of supplementaand
that
collected
selected
included
vitamin the
day
be-
dialysis. Foods and beverages measures and were quantirecord
the
patients
was kept with
before the
the glucose
on the
British
food
tables
(13).
The results were analyzed by use ofthe statistical component ofthe SIR program (Scientific Information Retrieval, Inc, Evanston, IL) and the SPSS program (SPSS Inc, Chicago, IL). The nutritional measurements ofthe two groups at the time of allocation and changes in the nutritional indices at 6 mo were compared by use of the Students I test for unpaired data. Within each group the food intakes initially and 6 mo later were compared by use of the Students t test for paired data. The patients’ general feeling ofwell being and side effects were compared by using the nonparametric Wilcoxon rank sign test for paired data.
starting
procedure.
Downloaded from https://academic.oup.com/ajcn/article-abstract/51/4/558/4695131 by Queen Mary University of London user on 26 March 2018
Thirty-two
patients
met
the selection
criteria
12 unsupplemented)
and
ofthese
successfully
21
completed
the trial. The nine patients in the supplement group (seven men, two women) were aged 50 ± I 1 y ( ± SD) and had been on dialysis for 40 ± 23 mo. The 12 patients in the nonsupplement group (9 men, 3 women) were aged 41 ± 1 8 y and had on dialysis
ment
for 41
two
disease,
and
28 mo.
The
normally
reflux.
who failed
a transplant
who
the other by choice
±
ofthat
causes
died
(one
took
died before (three after
periods
and
one who
lowing
reasons
were
The
seven
never
commenced
who
one who
the supplement),
until
out before
by those
dial-
in the supple-
included
it), and four who the glucose polymer
dropped given
failure
nephropathy,
patients
the study
the supplement
starting taking
renal
in our chronic
analgesic
to complete (and
ofthe
found
ie, glomerulonephritis,
group
received
a was
Hemoglobin, hematocrit, lymphocyte counts, plasma electrolytes, total protein, albumin, transferrmn, urea, creatinine, glucose, and triglycerides were determined each month. For hospital patients the blood samples were collected before dialysis. For
commencing
analysis
polycystic
arm, with
minus
is based
before
starting the supplement. by use ofthe DIAR YAN computer of Human Nutrition, Adelaide,
Division
which
ysis population,
not
circumference
calculated from midupper-arm circumference triceps skinfold thickness measurement (12).
analyzed
were representative
by the
measured
were
(CSIRO
just
6 mo after
A visual analogue scale was used to detect any effect of the supplementation on the patients’ feelings of well being and to pinpoint side effects such as a change in appetite, bowel habits, vomiting, or abdominal discomfort. Patients were required to mark their responses on a linear scale and the responses were then given a numerical score between one and five.
been
have a vascular access for hemodialysis. The sum of four skinfold thickness measurements was used to determine the percentage body fat by using the values published by Durnin and Womersley
intakes
kept
1 and
(9 supplemented,
for the an-
to calculate thicknesses
body
Food
were
then
Results
to deter-
with
and
to
hydrated.
(9) were used
measured by the same observer with mych, UK) skinfold caliper; triceps,
in-
after dialysis. For at the follow-up
so that
and Lourie
assessments.
anbody
were made either to patient availability. in body water, the pa-
regularly examined by their physician their hydration status was normal.
The methods
suprailiac
Patients
included
biochemistry,
weight
were
polymer
thicknesses,
records
St atistical
The
patients
monitored
fat skinfold
last dialysis
ie, their
meal.
was monitored. being studied.
Dietary
559
vial
to take to add
glucose
at the hospital were measured the measurements were made
patients were mine whether
balance [weight
The
of the
measurements month according
the problem
dialyzed patients
asked patient
at each
per day.
effect
that
hematology,
tients home
foods
status changes
height,
take. The anthropometric monthly or every other
dry
the
of nutritional ofthe specific
To overcome
and
25 g four
circumferences),
their
liquids
for 6 mo
nutritional
thropometry
usual
were the
poly-
Each
PATIENTS
polymer program Australia)
pantothenate,
patients
DIALYSIS
his death
and
dropped out for various
starting discontinued
it). The
fol-
the poly-
mer: one said she did not want to put on “too much weight,” one “felt too ill” to participate, and the other said she “had lost her appetite” since commencing the glucose polymer. Three of the patients in the nonsupplemented plants and one died during the course
group received transofthe study. The attrition
meant that the groups became unbalanced regarding the numbers of men and women. The results for men and women were therefore grouped together. Table I compares selected nutritional measurements of the two groups at the time ofallocation to treatment. No significant differences
were
surements
after
completed mented weight,
with
detected.
the 6-mo
The
changes
study
phase,
in anthropometric
for the patients
mea-
who
the trial, are shown in Table 2. The group supplewith glucose polymers had significant increases in BMI, body fat, and lean body mass when compared
the nonsupplemented
group.
For those
four patients
who
560
ALLMAN
TABLE
ET
AL 6
I
Anthropometric, biochemical, hematological, and dietary data for the two groups at the time ofallocation into treatment groups* Supplemented (n=16) Weight
(kg)
Body
mass
Sum
offour
index
(kg/rn2)
2 1 .3 ± 2.4
64.3 ± I I .8 22.9 ± 2.2
29.2
33.4
2
L) 0
skinfold
thickness
measurements
(mm)
mass (kg)
body
± 1 3.8
11.6±4.8 48. 1 ± 8. 1
Bodyfat(kg) Lean
z
(n=16)
± 8.8
59.4
4
Nonsupplemented
± 9.1
-2
13.5± 3.4 50.8 ± 1 1.0
Midupper-arm circumference
(cm)
Midupper-arm
circumference(mm) Abdominal
244±30
(mm) albumin
Plasma
creatinine
(gIL)
(umol/L)
-4
± 3.0
0
4
TIME FIG I. Weight change
88±8
89±10
43 ± 4
6
months
1040 ± 206
± 261
12)t
1.1 (n=
4.9±
4.7±
for each ofthe
13 patients
who took glucose
polymer during the 6-month-supplementation never took it because of death, transplantation, dropped out are not included.
(fasting)
(mmol/L)
1.1
(n=
phase. Those or because
who they
respectively,
in-
ll)t
triglycerides
(fasting)
2.6 ± 1 . I (n
(mmol/L)
Hematocrit Protein
0.23 intake
SD.
*
.:
t
Some
120±41 No significant
patients
differences
failed
to observe
(n
2.3 ± 1.4 0.27 ± 0.07 1 . I 7 ± 0.33
1 2)t
=
± 0.04
I .09 ± 0.32
(gJkg)f
Energyintake(kJ/kg4
(n = (n=
120±35 were
the
1 1 )t
=
I 4) l4)
took
patients
the
did
not
ideal keep
supplement
were completed,
but
their
statistically
body
their
weight
their
results
were
not
(14).
Figures
out
or died
ofweight
before
different
from
the
6 mo
gain was not significantly
that
in those
who
the trial. dropouts
Simwas
finished
the
1 and 2 illustrate
the changes
in body
weight
for the
2
(n=9)
Weight(kg)
BMI (kg/rn2) Sum offour skinfold thickness measurements (mm) Bodyfat(kg) Lean body mass (kg) Midupper-arm circumference (cm) Midupper-arm muscle circumference(mm) Abdominal circumference (mm)
were
different
p
