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BACKGROUND: Obesity increases the comorbidity-adjusted relative risk of developing end-stage renal disease. Body mass index (BMI) > 30 kg/m(2) was a contraindication for transplant in our renal unit until 2008. STUDY DESIGN: Open-label prospective nonrandomized intervention. SETTING & PARTICIPANTS: All men and women aged 18-75 years with chronic kidney disease (CKD) and BMI > 30 or > 28 kg/m(2) with diabetes, hypertension, or dyslipidemia and otherwise suitable for kidney transplant if on dialysis therapy were eligible to enroll in the weight-management program. 64 patients were referred; 44 agreed to participate in the intervention group and 20 did not wish to take part and constitute the usual-care group. INTERVENTION: 24-month weight-management program that included a low-fat renal-specific diet, exercise, and orlistat, 120 mg, 3 times daily. OUTCOMES: Body weight, blood pressure (BP), kidney transplant wait listing. MEASUREMENTS: Body weight, BP, estimated glomerular filtration rate (eGFR; calculated using the 4-variable Modification of Diet in Renal Disease [MDRD] Study equation). RESULTS: 32 patients (73%) in the weight-management program group completed the follow-up evaluation. Baseline mean BMI was 35.7 +/- 4.5 (SD) kg/m(2) in the weight-management program group and 34.1 +/- 4.2 kg/m(2) in the usual-care group. 12 (38%) patients in the weight-management program and 9 (45%) in usual care had stages 3-4 CKD, with the remainder in stage 5 CKD on dialysis therapy. There were no differences in body weight, BP, or eGFR between groups at baseline. After 24 months, mean body weight was 94.6 +/- 16.1 kg in the weight-management program group versus 101.0 +/- 26.8 kg in the usual-care group (P < 0.001), and eGFR was 43 mL/min in the weight-management program group versus 18 mL/min in the usual-care group (P < 0.001). 9 of 26 (35%) otherwise eligible patients in the weight-management program and 1 of 18 (6%) patients in usual care were accepted for kidney transplant listing, with 3 transplants performed in the weight-management program group and 1 in the usual-care group. LIMITATIONS: Nonrandomized trial, small number of participants. CONCLUSIONS: The weight-management program group showed significant weight loss and weight-loss maintenance in obese patients with CKD and potentially enables obese patients with CKD to undergo kidney transplant. [ABSTRACT FROM AUTHOR]

Objective: Adherence to high quality dietary patterns is associated with lower risk of disease progression and all-cause mortality in chronic kidney disease (CKD). Self-efficacy and health literacy are recognised as factors that may lead to better adherence to high quality diets. However, these associations are not well studied in CKD. This study aims to explore the relationship between health literacy, self-efficacy, and diet quality in CKD., Methods: Participants with CKD stages 3a-5 recruited from three large tertiary hospitals were assessed using the Self-Efficacy for Managing Chronic Disease 6-item scale (SEMCD-6), the Health Literacy Questionnaire (HLQ) and the Australian Eating Survey (AES) Food Frequency Questionnaire. Diet quality was measured using the Australian Recommended Food Score (ARFS). Associations were examined using multivariable linear regression models, adjusted for sex and type 2 diabetes (T2D) diagnosis., Results: Sixty participants were included in the analysis. Mean age of participants was 74.5 years old and 58% were male. The mean ARFS was poor (Mean=29.9±9.1/73) and characterised by high intake of processed foods and animal protein, and low intake of fruit and vegetables. Mean SEMCD-6 was high (7.12±2.07/10). Self-efficacy and health literacy domains 6 - Actively engage with healthcare providers and 7 - Navigating healthcare system independently predicted diet quality in the adjusted model for sex and T2D., Conclusion: Adults with CKD report suboptimal diet quality. The results suggest that self-efficacy and aspects of health literacy should be considered when designing interventions aimed at improving diet quality in people with CKD., (Copyright © 2024. Published by Elsevier Inc.)

Background: Measurement of inpatient experience can allow for treatment tailored to patient preferences and needs. The patient experience of diabetes care has not been explored in Queensland hospitals., Aims: To investigate the experiences of patients with diabetes when hospitalised using the Queensland Inpatient Diabetes Survey (QuIDS)., Methods: In 2019 and 2021, patient experience surveys were collected as part of the statewide QuIDS, a cross-sectional study assessing the quality of inpatient care received by people with diabetes in Queensland, Australia. Patient responses were categorised and frequencies reported as percentages. Free text comments were analysed using thematic analysis methods. Pooled descriptive data were presented., Results: Responses were collected from 27 hospitals in 2019 (n = 526, 52.4% of all patients with diabetes) and 35 hospitals in 2021 (n = 709, 55.5%). Overall, patients were satisfied with their inpatient diabetes care. Areas for improvement identified by surveyed patients include the choice and timing of meals, staff knowledge about diabetes and increased diabetes self-management. Access to a specialist diabetes team was also identified as being potentially underutilised. Patient comments fell into four major themes: communication, food choices, patient autonomy and education., Conclusion: Many patients reported positive inpatient experiences; however, patients also expressed dissatisfaction with their inpatient diabetes care. Our data provide unique insight and an opportunity to improve standards of care and service provision for inpatients with diabetes., (© 2023 Royal Australasian College of Physicians.)

Potassium dysregulation can be life-threatening. Dietary potassium modification is a management strategy for hyperkalaemia. However, a 2017 review for clinical guidelines found no trials evaluating dietary restriction for managing hyperkalaemia in chronic kidney disease (CKD). Evidence regarding dietary hyperkalaemia management was reviewed and practice recommendations disseminated. A literature search using terms for potassium, hyperkalaemia, and CKD was undertaken from 2018 to October 2022. Researchers extracted data, discussed findings, and formulated practice recommendations. A consumer resource, a clinician education webinar, and workplace education sessions were developed. Eighteen studies were included. Observational studies found no association between dietary and serum potassium in CKD populations. In two studies, 40-60 mmol increases in dietary/supplemental potassium increased serum potassium by 0.2-0.4 mmol/L. No studies examined lowering dietary potassium as a therapeutic treatment for hyperkalaemia. Healthy dietary patterns were associated with improved outcomes and may predict lower serum potassium, as dietary co-factors may support potassium shifts intracellularly, and increase excretion through the bowel. The resource recommended limiting potassium additives, large servings of meat and milk, and including high-fibre foods: wholegrains, fruits, and vegetables. In seven months, the resource received > 3300 views and the webinar > 290 views. This review highlights the need for prompt review of consumer resources, hospital diets, and health professionals' knowledge.

Introduction: Literature describing the impact of dietary intake on weight outcomes after bariatric surgery has not been synthesized. This study aimed to synthesize the evidence regarding any association between diet composition and weight outcomes post-bariatric surgery., Methods: CINAHL, Cochrane, Embase, MEDLINE and Scopus were searched for adult studies up to June 2021 that assessed any association between dietary intakes (≥1-macronutrient, food group, or dietary pattern) and weight outcomes at 12-months or longer after bariatric surgery. Risk of bias and quality assessments were conducted using the Scottish Intercollegiate Guidelines Network checklists and the NHMRC's Level of Evidence and Grades for Recommendations. Study findings were presented according to the time of post-surgery dietary intake assessment (≤12months, between 12 and 24 months, ≥24months)., Results: 5923 articles were identified, 260 were retrieved for full text screening, and 36 were eligible for inclusion (9 interventional including five randomized-controlled trials, and 27 observational cohort studies; sample sizes: 20-1610; total sample: 5065; follow-up periods: 1 year-12 years; level of evidence: II to IV, risk of bias: low to high). Findings on the association between long-term weight outcomes and dietary composition up to 24-months were mixed. After 24-months, studies consistently suggested no significant associations between weight loss and macronutrient composition or core food group patterns, or between carbohydrate, protein or food group patterns and weight recurrence. A single cohort study reported a weak association between diet quality score and weight-recurrence after 24-months., Conclusion: There was no strong evidence to support significant associations between diet composition and weight outcomes post-bariatric surgery. The heterogeneity in study design and quality may reduce generalizability to external populations. Individualized dietary recommendations may be useful to support long-term post-surgery weight outcomes. More studies are needed to define and measure diet quality in this patient cohort., Registration: PROSPERO (CRD42021264120)., (© 2023. The Author(s).)

Context: Diet quality indices (DQIs) were developed to score and rank adherence to dietary patterns in observational studies, but their use to measure changes in diet quality in intervention trials is becoming common in the literature., Objective: This systematic review and meta-analysis aimed to assess the effectiveness of DQIs to measure change in diet quality in intervention trials., Data Sources: MEDLINE, CINAHL, Embase, and the Cochrane Central Register of Controlled Trials databases were searched from January 1994 to June 2020. Two reviewers independently completed full-text screening. Eligible studies were randomized controlled trials that used validated a priori DQIs to measure change in diet quality in adults., Data Extraction: Data were extracted by an independent reviewer and reviewed by the research team. Risk of bias was assessed by the Cochrane Collaboration's Risk of Bias 2.0 tool., Data Analysis: The 34 included studies (52% of reviewed studies, 0.6% of initially identified studies) used 10 different DQIs, 7 of which were able to measure significant change in diet quality. Meta-analyses of pooled results demonstrated change in the Healthy Eating Index (MD 5.35; 95%CI, 2.74-7.97; P < 0.001) and the Mediterranean Dietary Adherence Screener (MD 1.61; 95%CI, 1.00-2.23; P < 0.001) scores. DQIs were more likely to measure change in diet quality if they reflected the diet pattern being implemented, if the intervention was significantly different from the baseline and control diets, and if the study was adequately powered to detect change., Conclusion: DQIs are responsive to change in diet quality in intervention trials when the index used reflects the dietary changes made and the study is adequately powered. The appropriate selection of a DQI to suitably match dietary changes and study populations is important for future dietary intervention trials., Systematic Review Registration: PROSPERO registration no. CRD42020181357., (© The Author(s) 2022. Published by Oxford University Press on behalf of the International Life Sciences Institute. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Diet quality indices (DQIs) are tools used to evaluate the overall diet quality against dietary guidelines or known healthy dietary patterns. This review aimed to evaluate DQIs and their validation processes to facilitate decision making in the selection of appropriate DQI for use in Australian contexts. A search of CINAHL, PubMed and Scopus electronic databases was conducted for studies published between January 2010 and May 2020, which validated a DQI, measuring > 1 dimension of diet quality (adequacy, balance, moderation, variety) and was applicable to the Australian context. Data on constructs, scoring, weighting and validation methods (construct validity, criterion validity, reliability and reproducibility) were extracted and summarised. The quality of the validation process was evaluated using COnsensus-based Standards for the selection of health Measurement INstruments Risk of Bias and Joanna Briggs Appraisal checklists. The review identified twenty-seven indices measuring adherence to: national dietary guidelines ( n 13), Mediterranean Diet ( n 8) and specific population recommendations and chronic disease risk ( n 6). Extensiveness of the validation process varied widely across and within categories. Construct validity was the most strongly assessed measurement property, while evaluation of measurement error was frequently inadequate. DQIs should capture multiple dimensions of diet quality, possess a reliable scoring system and demonstrate adequate evidence in their validation framework to support use in the intended context. Researchers need to understand the limitations of newly developed DQIs and interpret results in view of the validation evidence. Future research on DQIs is indicated to improve evaluation of measurement error, reproducibility and reliability.

As chronic kidney disease (CKD) progresses, the requirements and utilization of different nutrients change substantially. These changes are accompanied by multiple nutritional and metabolic abnormalities that are observed in the continuum of kidney disease. To provide optimal care to patients with CKD, it is essential to have an understanding of the applicable nutritional principles: methods to assess nutritional status, establish patient-specific dietary needs, and prevent or treat potential or ongoing nutritional deficiencies and derangements. This installment of AJKD's Core Curriculum in Nephrology provides current information on these issues for the practicing clinician and allied health care workers and features basic, practical information on epidemiology, assessment, etiology, and prevention and management of nutritional considerations in patients with kidney disease. Specific emphasis is made on dietary intake and recommendations for dietary patterns, and macro- and micronutrients. In addition, special conditions such as acute kidney injury and approaches to obesity treatment are reviewed., (Published by Elsevier Inc.)

Aims: To examine OzDAFNE participant feedback to determine if OzDAFNE results in positive participant reported outcomes and experiences, improves quality of life; and to identify areas for improvement., Methods: Quantitative and qualitative evaluations of participants' experience were undertaken prior to, and at the end of, every OzDAFNE program from 2010 to 2019. Evaluations included Likert scale and open-ended questions. Responses were analysed descriptively, for response rates and to identify themes. Mean difference in Problem Area in Diabetes (PAID) score was calculated from pre-course to 12 months., Results: 189 participants attended OzDAFNE. 93% rated the overall quality of OzDAFNE as "Excellent". Confidence in managing diabetes increased from 25% pre-OzDAFNE to 96% at completion. Major themes identified as most useful and relevant were carbohydrate counting (89/189), insulin adjustment (87/189) and exercise (46/189). At 12 months (n = 44), 97% were "mostly"/ "always" using OzDAFNE principles; 72% reported their diabetes control was "a lot better" than pre-OzDAFNE due to increased knowledge and implementation of principles. The value of the shared patient experience was reported at all time points. By 12 months, mean PAID score decreased significantly (p < 0.001)., Conclusions: The OzDAFNE patient experience was very positive, with high satisfaction reported. Increased confidence and knowledge and ongoing implementation of principles resulted in improved diabetes management. OzDAFNE offers a patient-centred approach that is valued by participants., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Individuals with coexisting chronic diseases or with complex chronic disease are among the most challenging and costly patients to treat, placing a growing demand on healthcare systems. Recommending effective treatments, including nutrition interventions, relies on standardised outcome reporting from randomised controlled trials (RCTs) to enable data synthesis. This rapid review sought to determine how the scope and consistency of the outcomes reported by RCTs investigating nutrition interventions for the management of complex chronic disease compared to what is recommended by the core outcome sets (COS) for individual disease states. Peer-reviewed RCTs published between January 2010 and July 2020 were systematically sourced from PubMed, CINAHL and Embase, and COS were sourced from the International Consortium for Health Outcomes Measurements (ICHOM) and the Core Outcome Measures in Effectiveness Trials (COMET) database. A total of 45 RCTs (43 studies) and 7 COS were identified. Outcomes were extracted from both the RCTs and COS and were organised using COMET Taxonomy Core Areas. A total of 66 outcomes and 439 outcome measures were reported by the RCTs. The RCTs demonstrated extensive outcome heterogeneity, with only five outcomes (5/66, 8%) being reported with relative consistency (cited by ≥50% of publications). Furthermore, the scope of the outcomes reported by studies was limited, with a notable paucity of patient-reported outcomes. Poor agreement (25%) was observed between the outcomes reported in the RCTs and those recommended by the COS. This review urges greater uptake of the existing COS and the development of a COS for complex chronic disease to be considered so that evidence can be better synthesised regarding effective nutrition interventions.

Background: A comprehensive evidence base is needed to support recommendations for the dietetic management of adults with chronic kidney disease (CKD). The present study aimed to determine the effect of dietary interventions with dietitian involvement on nutritional status, well-being, kidney risk factors and clinical outcomes in adults with CKD., Methods: Cochrane Central Register of Controlled Trials, CINAHL, MEDLINE, PsycINFO and EMBASE.com were searched from January 2000 to November 2019. Intentional weight loss and single nutrient studies were excluded. Risk of bias was assessed using the Cochrane risk-of-bias tool. Effectiveness was summarised using the mean difference between groups for each outcome per study., Results: Twelve controlled trials (1906 participants) were included. High fruit and vegetable intake, as well as a multidisciplinary hospital and community care programme, slowed the decline in glomerular filtration rate in adults with stage 3-4 CKD. Interventions addressing nutrition-related barriers increased protein and energy intake in haemodialysis patients. A Mediterranean diet and a diet with high n-3 polyunsaturated fatty acids improved the lipid profile in kidney transplant recipients., Conclusions: A limited number of studies suggest benefits as a result of dietary interventions that are delivered by dietitians and focus on diet quality. We did not identify any studies that focussed on our primary outcome of nutritional status or studies that examined the timing or frequency of the nutritional assessment. This review emphasises the need for a wider body of high-quality evidence to support recommendations on what and how dietetic interventions are delivered by dietitians for adults with CKD., (© 2021 The Authors. Journal of Human Nutrition and Dietetics published by John Wiley & Sons Ltd on behalf of British Dietetic Association.)

Low heart rate variability (HRV) is independently associated with increased risk of sudden cardiac death (SCD) and all cardiac death in haemodialysis patients. Long chain n -3 polyunsaturated fatty acids (LC n -3 PUFA) may exert anti-arrhythmic effects. This study aimed to investigate relationships between dialysis, sleep and 24 h HRV and LC n -3 PUFA status in patients who have recently commenced haemodialysis. A cross-sectional study was conducted in adults aged 40-80 with chronic kidney disease (CKD) stage 5 (n = 45, mean age 58, SD 9, 20 females and 25 males, 39% with type 2 diabetes). Pre-dialysis blood samples were taken to measure erythrocyte and plasma fatty acid composition (wt % fatty acids). Mean erythrocyte omega-3 index was not associated with HRV following adjustment for age, BMI and use of β-blocker medication. Higher ratios of erythrocyte eicosapentaenoic acid (EPA) to docosahexaenoic acid (DHA) were associated with lower 24 h vagally-mediated beat-to-beat HRV parameters. Higher plasma EPA and docosapentaenoic acid (DPA n -3) were also associated with lower sleep-time and 24 h beat-to-beat variability. In contrast, higher plasma EPA was significantly related to higher overall and longer phase components of 24 h HRV. Further investigation is required to investigate whether patients commencing haemodialysis may have compromised conversion of EPA to DHA, which may impair vagally-mediated regulation of cardiac autonomic function, increasing risk of SCD.

Background: Acute kidney injury (AKI) and obesity are independent risk factors for chronic kidney disease (CKD). This study aimed to determine if obesity modifies risk for CKD outcomes after AKI., Methods: This prospective multisite cohort study followed adult survivors after hospitalization, with or without AKI. The primary outcome was a combined CKD event of incident CKD, progression of CKD and kidney failure, examined using time-to-event Cox proportional hazards models, adjusted for diabetes status, age, pre-existing CKD, cardiovascular disease status and intensive care unit admission, and stratified by study center. Body mass index (BMI) was added as an interaction term to examine effect modification by body size., Results: The cohort included 769 participants with AKI and 769 matched controls. After median follow-up of 4.3 years, among AKI survivors, the rate of the combined CKD outcome was 84.7 per1000-person-years with BMI ≥30 kg/m 2 , 56.4 per 1000-person-years with BMI 25-29.9 kg/m 2 , and 72.6 per 1000-person-years with BMI 20-24.9 kg/m 2 . AKI was associated with a higher risk of combined CKD outcomes; adjusted-HR 2.43 (95%CI 1.87-3.16), with no evidence that this was modified by BMI (p for interaction = 0.3). After adjustment for competing risk of death, AKI remained associated with a higher risk of the combined CKD outcome (subdistribution-HR 2.27, 95%CI 1.76-2.92) and similarly, there was no detectable effect of BMI modifying this risk., Conclusions: In this post-hospitalization cohort, we found no evidence for obesity modifying the association between AKI and development or progression of CKD.

Background: Obesity and chronic kidney disease (CKD) are highly prevalent worldwide and result in substantial health care costs. Obesity is a predictor of incident CKD and progression to kidney failure. Whether weight loss interventions are safe and effective to impact on disease progression and clinical outcomes, such as death remains unclear., Objectives: This review aimed to evaluate the safety and efficacy of intentional weight loss interventions in overweight and obese adults with CKD; including those with end-stage kidney disease (ESKD) being treated with dialysis, kidney transplantation, or supportive care., Search Methods: We searched the Cochrane Kidney and Transplant Register of Studies up to 14 December 2020 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov., Selection Criteria: Randomised controlled trials (RCTs) and quasi-RCTs of more than four weeks duration, reporting on intentional weight loss interventions, in individuals with any stage of CKD, designed to promote weight loss as one of their primary stated goals, in any health care setting., Data Collection and Analysis: Two authors independently assessed study eligibility and extracted data. We applied the Cochrane 'Risk of Bias' tool and used the GRADE process to assess the certainty of evidence. We estimated treatment effects using random-effects meta-analysis. Results were expressed as risk ratios (RR) for dichotomous outcomes together with 95% confidence intervals (CI) or mean differences (MD) or standardised mean difference (SMD) for continuous outcomes or in descriptive format when meta-analysis was not possible., Main Results: We included 17 RCTs enrolling 988 overweight or obese adults with CKD. The weight loss interventions and comparators across studies varied. We categorised comparisons into three groups: any weight loss intervention versus usual care or control; any weight loss intervention versus dietary intervention; and surgical intervention versus non-surgical intervention. Methodological quality was varied, with many studies providing insufficient information to accurately judge the risk of bias. Death (any cause), cardiovascular events, successful kidney transplantation, nutritional status, cost effectiveness and economic analysis were not measured in any of the included studies. Across all 17 studies many clinical parameters, patient-centred outcomes, and adverse events were not measured limiting comparisons for these outcomes. In studies comparing any weight loss intervention to usual care or control, weight loss interventions may lead to weight loss or reduction in body weight post intervention (6 studies, 180 participants: MD -3.69 kg, 95% CI -5.82 to -1.57; follow-up: 5 weeks to 12 months, very low-certainty evidence). In very low certainty evidence any weight loss intervention had uncertain effects on body mass index (BMI) (4 studies, 100 participants: MD -2.18 kg/m², 95% CI -4.90 to 0.54), waist circumference (2 studies, 53 participants: MD 0.68 cm, 95% CI -7.6 to 6.24), proteinuria (4 studies, 84 participants: 0.29 g/day, 95% CI -0.76 to 0.18), systolic (4 studies, 139 participants: -3.45 mmHg, 95% CI -9.99 to 3.09) and diastolic blood pressure (4 studies, 139 participants: -2.02 mmHg, 95% CI -3.79 to 0.24). Any weight loss intervention made little or no difference to total cholesterol, high density lipoprotein cholesterol, and inflammation, but may lower low density lipoprotein cholesterol. There was little or no difference between any weight loss interventions (lifestyle or pharmacological) compared to dietary-only weight loss interventions for weight loss, BMI, waist circumference, proteinuria, and systolic blood pressure, however diastolic blood pressure was probably reduced. Furthermore, studies comparing the efficacy of different types of dietary interventions failed to find a specific dietary intervention to be superior for weight loss or a reduction in BMI. Surgical interventions probably reduced body weight (1 study, 11 participants: MD -29.50 kg, 95% CI -36.4 to -23.35), BMI (2 studies, 17 participants: MD -10.43 kg/m², 95% CI -13.58 to -7.29), and waist circumference (MD -30.00 cm, 95% CI -39.93 to -20.07) when compared to non-surgical weight loss interventions after 12 months of follow-up. Proteinuria and blood pressure were not reported. All results across all comparators should be interpreted with caution due to the small number of studies, very low quality of evidence and heterogeneity across interventions and comparators., Authors' Conclusions: All types of weight loss interventions had uncertain effects on death and cardiovascular events among overweight and obese adults with CKD as no studies reported these outcome measures. Non-surgical weight loss interventions (predominately lifestyle) appear to be an effective treatment to reduce body weight, and LDL cholesterol. Surgical interventions probably reduce body weight, waist circumference, and fat mass. The current evidence is limited by the small number of included studies, as well as the significant heterogeneity and a high risk of bias in most studies., (Copyright © 2021 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

Background: Diabetes and malnutrition are common in patients with kidney failure. We aimed to evaluate the postprandial glucose response to oral nutritional supplement drinks (ONSs) in patients with diabetes undergoing hemodialysis treatment., Methods: A randomized, single-blind crossover study was conducted in patients with diabetes, and requiring chronic hemodialysis. Patients consumed either a renal-specific ONS, macronutrient-matched ONS, or standard ONS on 3 separate study days, during dialysis, following an overnight fast. Blood was collected before and 15, 30, 45, 60, 90, 120, and 180 minutes post ingestion. Mean net incremental area under the curve (iAUC) and peak incremental blood glucose concentration were compared across conditions, using analyses of variance., Results: Consumption of the renal-specific ONS resulted in the lowest mean net iAUC (87.9 ± 169.0 mmol/L per 3 hours) compared with macronutrient-matched (188.0 ± 127.5 mmol/L per 3 hours) and standard ONS (199.5 ± 169.2 mmol/L per 3 hours) (F 2,30 = 5.115, P = 0.012, partial n 2 = 0.254). Pairwise comparisons demonstrated a mean difference of 100.1 mmol/L per 3 hours (95% CI, -2.8 to 202.9) in mean iAUC between the renal-specific ONS and macronutrient-matched ONS (P = 0.058). Peak blood glucose concentration, corrected for baseline, was significantly lower after the renal-specific ONS (1.40 ± 1.0 mmol/L) compared with both macronutrient-matched (2.02 ± 0.71 mmol/L, P = 0.036) and standard ONS (2.3 ± 1.06 mmol/L, P = 0.017)., Conclusion: A renal-specific ONS elicits a lower postprandial glucose response than either macronutrient-matched ONS or standard ONS in patients with diabetes during hemodialysis., (© 2020 American Society for Parenteral and Enteral Nutrition.)

Background: Screening of patients with renal disease for malnutrition risk on hospital admission provides an opportunity to improve prognosis. This study aimed to assess the validity and reliability of the Renal iNUT, a novel renal-specific inpatient nutrition screening tool., Methods: Adult inpatient admissions to three renal units were screened using the Renal Inpatient Nutrition Screening Tool (iNUT) and the generic Malnutrition Universal Screening Tool (MUST) and compared against nutritional status using Subjective Global Assessment (SGA) as the standard. Construct validity was assessed by Handgrip Strength (HGS), reliability by repeated iNUT administration and nurse opinion by questionnaire., Results: Of 141 admissions, 45% were malnourished (SGA score B or C). Using iNUT, 49% patients had increased malnutrition risk (score ≥1), 35.5% requiring dietetic referral (score ≥2). MUST indicated 20% at increased malnutrition risk and dietetic referral in 7%. iNUT was more sensitive than MUST in identifying increased malnutrition risk (92.1% vs 44.4%) and dietetic referral (69.8% vs 15.9%). Specificity of iNUT for increased risk was 82.1% and 92.3% for dietetic referral. 47% patients had sarcopenic-range HGS, with significant difference between iNUT score ≥2 and 0 (p < 0.001). iNUT reliability assessed by kappa was 0.74 (95% CI, 0.58 to 0.9), indicating substantial agreement. Nurse evaluation (n = 71) was highly favorable., Conclusions: The Renal iNUT is a valid and reliable nutrition screening tool when used by nurses admitting patients to specialist renal wards. In comparison with MUST, use of iNUT is likely to improve the identification of malnourished patients for nutritional intervention and dietetic referral., (Copyright © 2018 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

Background: Twelve weeks of renal rehabilitation (RR) have been shown to improve exercise capacity in patients with chronic kidney disease (CKD); however, survival following RR has not been examined., Methods: This study included a retrospective longitudinal analysis of clinical service outcomes. Programme completion and improvement in exercise capacity, characterised as change in incremental shuttle walk test (ISWT), were analysed with Kaplan-Meier survival analyses to predict risk of a combined event including death, cerebrovascular accident, myocardial infarction and hospitalisation for heart failure in a cohort of patients with CKD. Time to combined event was examined with Kaplan-Meier plots and log rank test between 'completers' (attended >50% planned sessions) and 'non-completers'. In completers, time to combined event was examined between 'improvers' (≥50 m increase ISWT) and 'non-improvers' (<50 m increase). Differences in time to combined event were investigated with Cox proportional hazards models (adjusted for baseline kidney function, body mass index, diabetes, age, gender, ethnicity, baseline ISWT and smoking status)., Results: In all, 757 patients (male 54%) (242 haemodialysis patients, 221 kidney transplant recipients, 43 peritoneal dialysis patients, 251 non-dialysis CKD patients) were referred for RR between 2005 and 2017. There were 193 events (136 deaths) during the follow-up period (median 34 months). A total of 43% of referrals were classified as 'completers', and time to event was significantly greater when compared with 'non-completers' (P = 0.009). Responding to RR was associated with improved event-free survival time (P = 0.02) with Kaplan-Meier analyses and log rank test. On multivariate analysis, completing RR contributed significantly to the minimal explanatory model relating clinical variables to the combined event (overall χ2 = 38.0, P < 0.001). 'Non-completers' of RR had a 1.6-fold [hazard ratio = 1.6; 95% confidence interval (CI) 1.00-2.58] greater risk of a combined event (P = 0.048). Change in ISWT of >50 m contributed significantly to the minimal explanatory model relating clinical variables to mortality and morbidity (overall χ2 = 54.0, P < 0.001). 'Improvers' had a 40% (hazard ratio = 0.6; 95% CI 0.36-0.98) independent lower risk of a combined event (P = 0.041)., Conclusions: There is an association between completion of an RR programme, and also RR success, and a lower risk of a combined event in this observational study. RR interventions to improve exercise capacity in patients with CKD may reduce risk of morbidity and mortality, and a pragmatic randomised controlled intervention trial is warranted., (© The Author(s) 2018. Published by Oxford University Press on behalf of ERA-EDTA.)

Objectives: To test the methodology of recruitment, retention and data completeness in a prospective cohort recruited after a hospitalised episode of acute kidney injury (AKI), to inform a future prospective cohort study examining the effect of obesity on AKI outcomes., Design: Feasibility study., Setting: Single centre, multi-site UK tertiary hospital., Participants: 101 participants (67M; 34F) with a median age of 64 (IQR 53-73) years, with and without obesity, recruited within 3 months of a hospitalised episode of AKI., Outcome Measures: Feasibility outcomes were recruitment (>15% meeting inclusion criteria recruited), participant retention at 6 and 12 months (≥80%) and completeness of data collection. Exploratory measures included recovery from AKI (regaining >75% of pre-AKI estimated glomerular filtration rate [eGFR]) at 6 months, development or progression of chronic kidney disease (CKD) (kidney function decrease of ≥25% +  rise in CKD category) at 12 months, and associations with poorer kidney outcomes., Results: 41% of eligible patients consented to take part, exceeding the target recruitment uptake rate of 15%. Retention was 86% at 6 months and 78% at 12 months; 10 patients died and three commenced dialysis during the study. Data were 90%-100% complete. Median BMI was 27.9 kg/m 2 (range 18.1 kg/m 2 -54.3 kg/m 2 ). 50% of the cohort had stage 3 AKI and 49% had pre-existing CKD. 46% of the cohort met the AKI recovery definition at 6 months. At 12 months, 20/51 patients developed CKD (39%) and CKD progression occurred in 11/49 patients (22%). Post-AKI interleukin-6 and cystatin-C were associated with 12 months decline in eGFR., Conclusions: Feasibility to conduct a long-term observational study addressing AKI outcomes associated with obesity was demonstrated. A fully powered prospective cohort study to examine the relationships between obesity and outcomes of AKI is warranted., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Background: Nutritional screening tools recommended for the general hospitalised population do not always adequately detect malnutrition risk in patients with kidney disease. The present study assessed the validity and reliability of the Nutrition Impact Symptoms (NIS) score as a nutrition screening tool for hospitalised inpatients prefer in nephrology wards., Methods: Nutritional status was classified using Subjective Global Assessment (SGA). NIS scores were calculated from the total score of responses to questions assessing symptoms impacting upon nutritional status from the patient-generated SGA. Concurrent validity of NIS score was assessed using a receiver operating characteristic curve to predict malnutrition risk against SGA. Predictive validity was examined against length of hospital stay (LOS) and 30-day re-admission using Poisson and logistic regression, respectively. Inter-rater reliability of NIS scoring between assessors was determined using intraclass correlation., Results: In 143 patients [90 males; mean (SD) age 57.8 (15.8) years], malnutrition prevalence was 38% (54/143) using SGA (rating B/C). Predicting malnutrition risk with an NIS score of ≥3 had a sensitivity of 0.89 and a specificity of 0.65 (area under the curve = 0.81 [95% confidence interval (CI) = 0.74-0.88]). For each 1-point increase in NIS score, the model predicted a 1.9% rise in the risk of an increased LOS (P = 0.002). Thirty-day re-admission was not associated with NIS score. Inter-rater reliability was moderate (mean difference = 0.53; intraclass correlation coefficient = 0.74; 95% CI = 0.57-0.85)., Conclusions: Nutrition impact symptoms score is a valid stand-alone nutrition screening tool for identifying malnutrition risk in nephrology inpatients and is associated with LOS., (© 2018 The British Dietetic Association Ltd.)

Background: The outcomes of intragastric balloon (IGB) placement to achieve weight loss in obese patients with chronic kidney disease (CKD) have not been reported to date. This study aimed to assess the safety and efficacy of the IGB as a weight-loss treatment among this patient population., Methods: A prospective, single-arm, 'first in CKD' interventional study was conducted in patients with a body mass index >35 kg/m2 and CKD stages 3-4, referred for weight loss. After clinical assessment, the IGB was endoscopically inserted into the stomach and kept in place for 6 months. Complications, adverse events, acceptability, weight loss and metabolic responses were monitored over 6 months., Results: Eleven participants were recruited over 18 months. Two patients withdrew (1 prior to IGB insertion and 1 early removal after 3 days due to persistent vomiting) from the study; 9 patients completed the study. There were 5 episodes of acute kidney injury (AKI), occurring in 3 patients. After 6 months, the mean body mass decreased by 9.6% (SD ±6.8). Median waist circumference and total cholesterol decreased significantly (-7.7 cm; interquartile range (IQR) -15.3 to -3.9; and -0.2 mmol/l; IQR -0.6 to -0.05, respectively), with no changes in estimated glomerular filtration rate, blood pressure, triglycerides, adipokines, inflammation, or arterial stiffness measured by carotid-femoral pulse wave velocity. At IGB removal, there was 1 new case each of gastritis and esophagitis., Conclusions: Treatment with IGB has only moderate efficacy on weight loss; yet it results in a high rate of complications in obese patients with established CKD. The risk of AKI may be raised due to increased risk of dehydration secondary to gastrointestinal symptoms associated with IGB placement and reduced baseline kidney function., (© 2016 S. Karger AG, Basel.)

Objective: Studies of the relationship between obesity and chronic kidney disease (CKD) in nationally representative population samples are limited. Our study aimed to determine if overweight and obesity were independently associated with the risk for CKD in the 2010 Health Survey for England (HSE)., Design: The HSE is an annually conducted cross-sectional study. In 2010 serum creatinine was included to determine the incidence of CKD in the population. CKD was defined as estimated glomerular filtration rate (eGFR) <60 ml/min per 1.73 m2 using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula. Multivariable logistic regression models were developed to calculate odds ratios and 95% confidence intervals for CKD risk by BMI (reference category: BMI=18.5-24.9 kg/m2) and adjusted for age, gender, ethnicity, smoking, diabetes and hypertension., Setting: A random sample of nationally representative households in England., Subjects: Adults (n 3463) with calculable eGFR and BMI were included., Results: The prevalence of CKD was 5.9%. The risk of CKD was over 2.5 times higher in obese participants compared with normal-weight participants in the fully adjusted model (BMI=30.0-39.9 kg/m2: adjusted OR=2.78 (95% CI 1.75, 4.43); BMI ≥ 40.0 kg/m2: adjusted OR=2.68 (95% CI 1.05, 6.85))., Conclusions: Obesity is associated with an increased risk of CKD in a national sample of the UK population, even after adjustment for known CKD risk factors, which may have implications for CKD screening and future national health service planning and delivery.

Objective: To determine if participation in a weight loss program impacted upon a composite end point of all-cause mortality and cardiovascular morbidity in obese patients with chronic kidney disease (CKD)., Design: Retrospective cohort study., Subjects: All patients with a body mass index (BMI) >30 kg/m(2) or >28 kg/m(2) with at least 1 comorbidity (hypertension, diabetes, or dyslipidemia) referred to an established weight management program (WMP) from 2005 to 2009 at a metropolitan tertiary teaching hospital were eligible for inclusion in the study cohort., Intervention: Twelve-month structured weight loss program., Main Outcome Measures: Combined outcome of all-cause mortality, myocardial infarction, stroke, and hospitalization for congestive heart failure; kidney transplantation waitlisting., Results: A total of 169 obese patients with CKD commenced the WMP and 169 did not-becoming the observational control group (CON). There were no significant differences between groups for age, BMI, sex, ethnicity, smoking, hypertension, or kidney function at baseline, although CON included more patients with diabetes than WMP (49% vs. 38%, P = .03). Kaplan-Meier survival analysis with log-rank test differed between groups for the combined outcome (P = .03). Cox regression analysis with adjustment for age, sex, ethnicity, hypertension, diabetes, kidney function, baseline BMI, and smoking status, indicated that patients in WMP had a significantly longer event-free period for the combined outcome, than those in CON (adjusted hazard ratio 0.53; 95% confidence interval [CI] 0.29-0.97; P = .04). Participation in the WMP did not increase the likelihood of kidney transplantation waitlisting (odds ratio [OR] 1.06; 95% CI 0.39-2.87; P = .9). Lower baseline BMI and greater weight loss over 12 months were the only factors related to kidney transplantation waitlisting (adjusted R(2) = 0.426)., Conclusions: Participation in a structured weight loss program may be associated with improved outcomes in obese patients with CKD., (Crown Copyright © 2015. Published by Elsevier Inc. All rights reserved.)

Background: Exercise capacity, which is predictive of all-cause mortality and cardiovascular disease risk, is reduced significantly in patients with non-dialysis-dependent chronic kidney disease. This pilot study examined the effect of moderate-intensity exercise training on kidney function and indexes of cardiovascular risk in patients with progressive chronic kidney disease stages 3 to 4., Study Design: Single-blind, randomized, controlled, parallel trial., Setting & Participants: 20 patients (aged 18-80 years; 17 men) randomly assigned to rehabilitation (n=10) or usual care (n=10). Participants were included if they were 18 years or older and had evidence of rate of decline in creatinine-based estimated glomerular filtration rate (eGFRcr)≥2.9mL/min/1.73m(2) per year for 12 months preintervention. Patients were excluded if they had unstable medical conditions or had recently started regular exercise., Intervention: The rehabilitation group received resistance and aerobic training (3 days per week) for a 12-month period. The usual care group received standard care., Outcomes: Kidney function assessed by comparing mean rate of change in eGFRcr (mL/min/1.73m(2) per year) from a 12-month preintervention period against the 12-month intervention period. Pulse wave velocity (PWV), peak oxygen uptake (Vo2peak), and waist circumference assessed at 0, 6, and 12 months., Measurements: eGFR assessed using creatinine, cystatin C (eGFRcys), and a combination of both values (eGFRcr-cys)., Results: 18 participants (rehabilitation, 8; usual care, 10) completed the study. A significant mean difference in rate of change in eGFRcr (+7.8±3.0 [95% CI, 1.1-13.5] mL/min/1.73m(2) per year; P=0.02) was observed between the rehabilitation and usual care groups, with the rehabilitation group demonstrating a slower decline. No significant between-group mean differences existed in absolute eGFRcr, eGFRcr-cys, or eGFRcys at 12 months of study intervention. Significant between-group mean differences existed in PWV (-2.30 [95% CI, -3.02 to -1.59] m/s), waist circumference (-7.1±12.8 [95% CI, -12.4 to -3.2] cm), and Vo2peak (5.7 [95% CI, 1.34-10.10] mL/kg/min). Change in eGFRcr was correlated inversely with PWV (r=-0.5; P=0.04) at 12 months., Limitations: Small sample size, inconsistency between primary and secondary measures of kidney function., Conclusions: The effect of a 1-year exercise intervention on progression of kidney disease is inconclusive. A larger study with longer follow-up may be necessary., (Copyright © 2015 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Existing nutritional guidelines suggest that protein requirements of adults with stage five chronic kidney disease undergoing haemodialysis (HD) or peritoneal dialysis (PD) are increased as a result of protein losses during dialysis. The present review aimed to update previous guidance and develop evidence-based practice guidelines on the protein requirements of adults undergoing maintenance dialysis., Methods: Following a PICO approach (Participants or Population, Intervention or Exposure, Comparison and Outcome), four research questions were formulated to investigate the total protein requirement and protein quality required by adults undergoing HD and PD. A comprehensive, systematic review was undertaken using the databases Medline, EMBASE and the Cochrane Library from 2005 to September 2009 for HD studies and from 1997 to September 2009 for PD studies., Results: The literature search yielded 2931 studies, which were assessed for inclusion. Following appraisal, 19 studies in HD and 18 studies in PD met the inclusion criteria and were systematically reviewed. Limited good quality evidence supports the recommendations that: (i) adults undergoing maintenance HD require a minimum protein intake of 1.1 g kg(-1) ideal body weight (IBW) per day; and (ii) adults undergoing maintenance PD require a minimum protein intake of 1.0-1.2 kg(-1) IBW per day, in conjunction with an adequate energy intake. There were no studies that addressed the quality of protein for either HD or PD., Conclusions: Evidence suggests that nutritional status may be maintained with lower protein intakes than previously recommended. However, the evidence base is limited and further randomised controlled trials are required to establish the optimal protein intake for dialysis patients., (© 2013 The Authors Journal of Human Nutrition and Dietetics © 2013 The British Dietetic Association Ltd.)

Background/aims: Clinical studies have shown increased levels of hepcidin causing functional iron deficiency in obese individuals. This study examined whether obesity contributes to increased hepcidin and hemojuvelin levels in adult hemodialysis patients., Methods: In a case-control design, 37 obese [body mass index (BMI) >30 kg/m(2)] stable hemodialysis patients and 37 patients with normal BMI (20-25 kg/m(2)), matched for age, gender and race, who fulfilled a strict set of inclusion and exclusion criteria were included in the study. Serum hepcidin and hemojuvelin, markers of iron status and inflammation, and routine hematological and biochemical variables were measured on samples obtained prior to the midweek hemodialysis session., Results: Obese and nonobese patients (BMI 35.1 ± 3.4 vs. 22.8 ± 1.4 kg/m(2); p < 0.001) were similar with regard to basic comorbidities and use of erythropoietin and iron. Levels of hemoglobin, hypochromic red cells and reticulocytes were similar in the two groups. Serum iron and transferrin saturation levels were on the low side and not different between obese and lean individuals; total iron-binding capacity showed a trend towards higher levels in obese patients (48.4 ± 8.3 vs. 44.9 ± 7.4 μmol/l; p = 0.065). Levels of serum ferritin (651 ± 302 vs. 705 ± 327 μg/l; p = 0.46), hepcidin (118.3 ± 67.7 vs. 119.3 ± 78.0 ng/ml; p = 0.95) and hemojuvelin (1.90 ± 1.11 vs. 1.94 ± 1.24 mg/l; p = 0.90) were high but similar between the two groups. Serum hepcidin showed a significant correlation only with ferritin (r = 0.287, p = 0.013)., Conclusions: Hepcidin and hemojuvelin levels are already considerably elevated in dialysis patients, but obesity does not have an additional impact. Further studies should examine whether increased weight contributes towards hepcidin elevation in predialysis individuals, in whom there is a lesser burden of systemic inflammation., (© 2013 S. Karger AG, Basel.)

Background: The effectiveness of lifestyle-based weight loss programs in obese patients with chronic disease has not been widely studied. This study examined the effectiveness of a weight management program (WMP), and sought to determine factors associated with successful weight loss in obese patients with chronic kidney disease (CKD)., Methods: In this prospective cohort study, all patients with a body mass index (BMI) of >30 kg/m(2) referred to our clinic from January 2005 to December 2008 and who commenced a structured WMP of an energy-reduced renal diet, exercise, and pharmacotherapy were included in the analyses. Changes in body weight and associated variables up to 24 months were assessed with intention-to-treat mixed linear models and predictors of weight loss were identified with multiple linear regression., Results: One hundred and thirty-five patients (56% male), of mean age 52.2 years and BMI 36.4 kg/m(2) commenced the WMP. Significant weight loss was achieved for all patients at 6, 12, 18, and 24 months. Weight loss at 12 months was predicted by compliance and age, but not by baseline BMI, blood pressure (BP), stage of CKD or pharmacotherapy use. Greater compliance was associated with decreased systolic BP, with no change in mean antihypertensive medication dose., Conclusions: Significant weight loss was achieved, demonstrating the effectiveness of the WMP, and compliance with a structured program improved weight loss and systolic BP.

Obesity increases the risk of progression of chronic kidney disease (CKD) towards kidney failure and may preclude access to kidney transplantation. Weight loss surgery remains relatively novel in obese patients with CKD, with several studies reporting results using Roux-en-Y bypass and adjustable gastric banding. However, in obese patients with CKD, kidney failure after bypass surgery and gastric band erosion after kidney transplantation have been reported. We present the first report of laparoscopic sleeve gastrectomy (LSG) performed for the treatment of obesity in patients with CKD. Weight loss, blood pressure and lipids, estimated kidney function, surgical complications and adverse events were studied. Nine obese patients with CKD (five of whom were undergoing haemodialysis treatment) underwent LSG, with median body mass index decrease of 8.4 kg/m(2) and excess weight loss of 43.0% after 6 months. Four of the five patients on haemodialysis were added to the kidney transplantation waiting list as a result of weight loss achieved with LSG. Adverse events occurred in three patients: myocardial infarction (one patient), acute kidney injury secondary to dehydration (one patient) and compromised dialysis access (one patient). There was one complication-a gastric leak, detected 7 months after LSG, requiring further surgical intervention and nasojejunal feeding, and no mortality. Our preliminary evidence suggests that LSG is an effective treatment for obesity in patients with CKD. However, there may be additional risk associated with the procedure in patients with CKD, requiring further study.

Objective: This study investigated common components of classification of nutrition screening risk in the prediction of clinical end-points (mortality and morbidity) in hemodialysis patients over a 3-year period (2005 to 2008)., Design: This was a retrospective cohort study., Setting: This study was conducted at a Hemodialysis centre., Participants: The study included patients on maintenance hemodialysis in June 2005., Intervention: Assessment of nutrition risk was carried out using components of Protein-Energy Wasting criteria., Main Outcome Measure: Clinical outcome at the 3-year follow-up (June 2008) was measured as mortality and morbidity (as unplanned hospital admissions). Risk of mortality was investigated independent of comorbidities, age, gender, ethnicity, and dialysis vintage using Cox proportional hazards model., Results: A total of 217 patients met the inclusion criteria (143 male [66%]; age, 60.5 ± 15.6 years). Patients who lost ≥5% body weight in the 6 months before the study commenced, had a 3-fold (Hazard Ratio = 3.0; 95% confidence interval: 1.2 to 7.5) independent greater risk of death (P = .02). Low serum albumin (<38 g/L) resulted in higher morbidity and mortality; however, this was not statistically significant when adjusted for confounders. Body mass index was only available in 64% (138 of 217) of the cohort at baseline, and was not related to clinical outcome at the 3-year follow-up., Conclusion: Unintentional weight loss is independently predictive of clinical outcome in this cohort of dialysis patients. It is recommended that nutrition screening tools include weight loss as a key component in classification of risk and for prioritizing patient care., (Crown Copyright © 2010. Published by Elsevier Inc. All rights reserved.)