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Although there is a higher nutrient requirement, food intake in haemodialysis patients is often inadequate. Protein nitrogen appearance (PNA) indirectly estimates the mean protein intake during the short interdialysis period, but it does not measure the daily nutrient intake, which is generally unknown. We carried out a longitudinal study aimed at estimating the daily nutrient intake and its relationship with the nutritional status of haemodialysis patients.We selected 28 haemodialysis patients with adequate nutritional status and no evidence of risk-factor for malnutrition. Patients were treated with biocompatible membranes, low-flux and high bicarbonate dialysis, Kt/V1.2, PNA1.1 g/kg/day and erythropoietin. We measured every four months daily PNA, protein and calorie intake (DPI, DCI) as well as weight gain (WG) during an entire week for one-year. The nutritional status was assessed by biochemical and BIA markers.Twenty seven subjects (8 F, 19 M; age 57.1 +- 2.7 yeas; dialysis age 105 +- 13 months) completed the trial. The mean interdialytic PNA did not change in both long- and short-interdialysis periods, resulting in the "normal" range (1.1 g/kg/day); however, daily levels of protein and calorie intake were significantly reduced on the third day during the long interdialysis interval. Eight patients showed time-averaged values of DPI and DCI lower than 0.8 g/kg/day and 25 Kcal/kg/day, respectively, on the third day (LOW group), values that were associated with similar changes in WG. Such a highly reduced nutrient intake during the third interdialysis day was associated with a normal PNA value (1.23 +- 0.05 g/kg/day vs 1.30 +- 0.06 in CON, NS) when measured during the short interdialysis period (S), just as it is in clinical practice; in contrast, when the PNA value was measured during the long interdialysis period it was found to be significantly reduced (1.07 +- 0.08 g/kg/day vs 1.37 +- 0.06 in CON, p0.05 and vs S, p0.05). During the study, the body weight progressively decreased from 68.0 +- 5.5 to 65.8 +- 5.9 kg (p0.05) in the LOW group, due to the decrease in lean body mass, as suggested by the reduction in serum creatinine (9.2 +- 1.1 vs 8.1 +- 0.7 mg/dL, p0.05), creatinine generation (835 +- 155 vs 723 +- 106 mg/die, p0.05) and serum albumin (3.96 +- 0.07 vs 3.66 +- 0.06 g/dL, p0.05). Moreover, reactance and phase angle declined in the LOW group (from 54 +- 4 to 44 +- 3 ohms, p0.05 and 5.5 +- 0.3 to 4.5 +- 0.3 degrees, p0.05, respectively). At the end of the study the nutritional status in the LOW group was reduced as compared to the CON group.In stable, well-nourished haemodialysis patients, in absence of known risk factors for malnutrition, the daily nutrient intake is variable and progressively reduce during the interdialytic interval. The measurement of interdialytic PNA, as is done in clinical practice, does not enable the discovery of such abnormal eating behaviour; the low daily nutrient intake, on the contrary, can be evidenced by the daily measurement of either PNA or weight gain, and it can also be inferred by the reduced PNA during the long interdialytic period. Finally, the persistent reduction in nutrient intake below the threshold of 0.8 g/kg/day of proteins and 25 Kcal/kg/day one day a week, is capable of inducing body protein wasting and moderate impairment of the nutritional status.

The potential stimulating effect of erythropoietin on the production of fetal proteins (FPs) has not been explored in human subjects. Therefore, the plasma levels of fetal fibrinogen (FF), carcinoembriogenic antigen (CEA), alpha-fetoprotein (AFP), and fetal hemoglobin (HbF) were measured in 12 uremic hemodialyzed patients before the first administration and after 1, 2, and 3 months of low-dose erythropoietin (r-Hu-EPO; 45 U/kg body wt I.V., thrice weekly). Such a treatment efficaciously increased total hemoglobin (Hb). CEA and AFP increased from 5.8 +/- 1.1 ng/ml and 2.9 +/- 0.9 ng/ml to the final value of 43.2 +/- 3.9 ng/ml and 8.7 +/- 1.1 ng/ml, respectively, in the absence of detectable neoplastic diseases. The levels of FF did not change. HbF levels increased from3% of Hb to the peak value of 48% at the end of the first month; subsequently, a progressive reduction in HbF was observed. Similar changes were detected in the reticulocyte count (RET). A striking correlation was found between HbF and RET (r = 0.8633, p0.0001), indicating that the increment in HbF was dependent on the erythroid activity. In conclusion, this study evidences broader than expected effects of erythropoietin on the synthesis of FP and suggests that (1) r-Hu-EPO markedly increases HbF in a condition of suppressed bone marrow activity, (2) the measurement of the cell proliferation markers CEA and AFP is unreliable during r-Hu-EPO therapy, and (3) the prothrombotic state associated with chronic r-Hu-EPO treatment in patients with uremia cannot be attributed to the presence of FF.

The aim of this study was to detect the potential occurrence of early abnormalities of body composition in patients with chronic kidney disease (CKD) at first referral to an outpatient nephrology clinic. Eighty-four patients with CKD (49 men and 35 women) were compared with 604 healthy control subjects (298 men and 306 women). Anthropometry and bioelectrical impedance analysis (BIA) were performed in all participants, whereas renal function, laboratory tests for nutritional status, and nutrient intake were assessed in the CKD group only. Creatinine clearance was 27.8 +/- 13.8 and 27.4 +/- 13.0 ml/min per 1.73 m(2) in male and female patients with CKD, respectively. No patient showed peripheral edema; frank malnutrition, defined by presence of serum albumin

A systematic evaluation of bioelectrical impedance measurement after hemodialysis session.BackgroundThere is still no definitive indication about the ideal point of time to perform bioimpedance analysis (BIA) in hemodialysis patients. Furthermore, the interpretation of data in this regard is difficult because there is still no comprehensive information about the fluctuations in BIA variables occurring in these subjects. The aim of this study was to assess BIA changes occurring in hemodialysis and specifically in the dry-weight state.MethodsWe studied 27 anuric patients (20 males and 7 females; age 56.1 ± 13.7years) on chronic hemodialysis. Single-frequency BIA (R, resistance; Xc, reactance; and PhA, phase angle) was performed (1) before and at the end of hemodialysis (dialysis period); (2) 15, 30, 60, 90, and 120 minutes after hemodialysis (postdialysis period); and (3) 24, 48, and 68hours after hemodialysis (interdialysis period).ResultsBody weight decreased by 2.8 ± 0.8kg during hemodialysis, was unchanged during the postdialysis period, and progressively rose during the interdialysis period. At the same time, BIA variables significantly increased during hemodialysis (R, 453 ± 74 and 542 ± 98 ohm; Xc, 38 ± 10 and 53 ± 16 ohm; P < 0.05), remained stable over the 120-minute period after treatment (R, 538 ± 94, 539 ± 95, 538 ± 94, 541 ± 95, and 544 ± 95 ohm; and Xc, 53 ± 15, 53 ± 15, 51 ± 16, 52 ± 16, and 52 ± 16 ohm; NS), and subsequently declined [R, 471 ± 79 (P =

To define whether reference values for bioimpedance analysis (BIA) can be predicted in healthy individuals, individual characteristics and BIA variables resistance index=height(2)/parallel resistance and reactance index=height(2)/parallel reactance) were evaluated in non-obese healthy individuals:863 men and 769 women with an age range 20-70 years and body mass index (BMI)19.0-29.9 kg/m(2). The following predictive equations were obtained using multiple regression analysis:Resistance index (cm(2)/ohm)Males 21.06 + 0.087xage + 1.091xweight -1.801xBMI,Females 20.35 + 0.037xage + 0.878xweight - 1.343xBMIReactance index (cm(2)/ohm)Males 0.57 + 0.117xweight - 0.096xBMIFemales 1.42 + 0.078xweight - 0.075xBMI. In conclusion, reference BIA values seem to be reasonably predicted based on individual characteristics.

Background In maintenance haemodialysis patients, daily food intake is changeable; however, its relationship with nutritional status is unexplored. This study aimed to evaluate the isolated, long-term effect of daily nutrient intake on nutritional status in haemodialysis patients. Methods We performed a prospective 1-year controlled study in 27 chronic haemodialysis patients, without recognized risk factors for malnutrition. Each day for 1 week, four times in the year, we measured protein nitrogen appearance, and assessed dietary protein (DPI) and energy (DEI) intake from dietary diaries. We compared the nutritional outcome of patients spontaneously reducing nutrient intake below the threshold of 0.8 g/kg body weight/day for DPI and 25 kcal/kg body weight/day for DEI during the week (LOW, n = 8), with controls at adequate nutrient intake (CON, n = 19). An interventional 6-month study was then carried out in LOW to verify the cause-effect relationship. Results All patients showed a day-by-day reduction of whole nutrient intake during interdialytic period, which was mostly relevant in the third interdialytic day (L3). During the 1-year study, even in the presence of adequate dialysis dose and normal inflammatory indexes, body weight (68.0 +/- 5.5 to 65.8 +/- 5.9 kg), serum albumin (3.96 +/- 0.07 to 3.66 +/- 0.06 g/dl) and creatinine (9.2 +/- 1.1 to 8.1 +/- 0.7 mg/dl) significantly decreased in LOW but not in CON. Diaries evidenced in LOW a reduced number of meals at L3 that was explained by the fear of excessive interdialytic weight gain. During the interventional study, daily DPI and DEI increased at L3; this was associated with a significant increment of body weight, and serum albumin and creatinine levels. Conclusions In maintenance haemodialysis patients the persistent, marked reduction of daily nutrient intake, even if limited to a single day of the week, is an independent determinant of reversible impairment of nutritional status.

Maintenance hemodialysis (HD) patients were studied to assess the effect on hemoglobin (Hb) concentration induced by the cyclic variation in hydration status.Forty-nine HD patients were examined in three consecutive HD sessions in a 1-week treatment period. In a subgroup of 23 patients, Hb levels also were investigated during the long interdialytic interval.Hb levels at the end of the long interdialytic interval were significantly lower by 0.5 to 0.6 g/dL (5 to 6 g/L) than those at the end of short intervals. Among all pre-HD and post-HD Hb values, levels measured at the end of short intervals were closest to the mean Hb value of the week, derived from calculation of the area under the curve (12.0 +/- 0.2 g/dL [120 +/- 2 g/L]). Intradialytic Hb increments were different in the three sessions (+1.6 +/- 0.1 g/dL [+16 +/- 1 g/L] after the long interval, +1.1 +/- 0.1 g/dL [+11 +/- 1 g/L] and +1.1 +/- 0.1 g/dL [+11 +/- 1 g/L] after short intervals [P0.001] and proportionate to weight loss [-3.4 +/- 0.1, -2.7 +/- 0.1, and -2.6 +/- 0.1 kg, respectively; P0.001]). Hb level increment and weight loss correlated directly (r = 0.527; P0.0001); each 1 L of ultrafiltration (UF) led to an increase in Hb level of approximately 0.4 g/dL (4 g/L). Plasma refilling accounted for an approximately 45% decrement in the intradialytic increase in Hb level 2 hours post-HD.This study suggests that: (1) the end of the short interdialytic period is the most appropriate timing for anemia assessment, and (2) the remarkable hemodiluting effect of post-HD plasma refilling protects against excessive increments in Hb levels induced by UF.