The effect of hemodialysis, peritoneal dialysis and renal transplantation on nutritional status and serum micronutrient levels in patients with end-stage renal disease; Multicenter, 6-month period, longitudinal study

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Abstract

Purpose

Nutritional status and micronutrient levels of end stage renal disease (ESRD) patients may vary depending on the mode of renal replacement therapy (RRT). We aimed to compare the effects of hemodialysis, peritoneal dialysis (PD) and renal transplantation (RT) on micronutrient levels and nutritional status in ESRD patients.

Patients and Methods

A total of 77 ESRD patients who had not received RRT were included in this prospective longitudinal study. All ESRD patients underwent a blood serum analysis that assessed the micronutrients such as selenium, copper, zinc, chromium, retinol, thiamine and vitamin B6 as well as a nutritional status assessment. After the baseline assessments and the initiation of RRT was accomplished, all patients were followed for 6 months.

Results

The study showed significant improvements in subjective global assessment scores (percentage increases in score A were 26.6 and 36.6; p = 0.039 and p = 0.001; respectively), mid-arm circumference and the skin-fold thicknesses (p < 0.001, p < 0.001; respectively) in the RT and hemodialysis groups. The examinations at sixth month revealed a significant increase in body weight (4.8 kg; p = 0.002) and albumin levels (0.6 g/dL; p < 0.001) in only RT group. Zinc, thiamin and vitamin B6 were the most deficient micronutrients (44.1 %, 24.7 % and 35.1 %; respectively) in ESRD patients. There was a significant increase in selenium and retinol levels (p = 0.020 and p < 0.001; respectively) but a significant decrease in thiamin levels (p = 0.041) in RT patients. A significant increase in retinol levels (p = 0.028) and a significant decrease in thiamin levels (p = 0.022) was observed in the hemodialysis patients. However, no significant change in micronutrient levels was observed in the PD patients.

Conclusion

The results support the recommendation that ESRD patients should be supplemented with water-soluble vitamins, especially thiamine and vitamin B6, and trace elements, especially zinc. RT appears to be superior to other modes of RRT when examining SGA score, anthropometric measurements, albumin and micronutrient levels.

Introduction

Malnutrition is very common among end stage renal disease (ESRD) patients [1]. It is known that malnutrition increases morbidity and mortality; possibly due to the specific micronutrient deficiencies [2,3]. Therefore, the micronutrients serum levels is of extreme importance in assessing the nutritional status and providing optimal management among ESRD patients and patients receiving renal replacement therapy (RRT).

Studies have suggested that variations of RRT such as hemodialysis, peritoneal dialysis (PD) and renal transplantation (RT) are associated with different clinical outcomes [4]. RT is the preferred treatment for most patients with ESRD, in terms of quality of life and survival rate [5]. In current studies, RT has not been compared in terms of nutritional status with other types of RRT. Malnutrition is one of the main complications in the late post- transplant period in which adequate nutritional status and plasma micronutrients may improve the outcomes [6]. Little research has been done to evaluate the influence of immunosuppressive drugs on the concentrations of plasma micronutrients in RT patients.

Micronutrient deficiencies in patients receiving RRT may be caused by poor food intake, intestinal dysfunction, inflammation, dialysate/ urine losses and abnormal metabolism [7]. Micronutrient levels may vary according to demographic region and traditional nutritional practices. At this point, it can be assumed that the 3 different types of RRT will not have a similar effect on micronutrient levels and nutritional status. However, at this time it is not known whether or not PD, hemodialysis or RT will have an enhancing or reducing effect on micronutrient levels. The present study aims to compare the effects of hemodialysis, PD and RT on the different micronutrient levels and nutritional status in patients with ESRD.

Section snippets

Design and participants

This prospective observational multi-center study took place from November 2015 to May 2017 at three different territorial care hospitals. The study was performed in accordance with the Helsinki Declaration and was approved by local ethics committee (Ethics Committee approval code: 2015/168). Written informed consent was obtained from all patients.

Adult ESRD patients who did not receive RRT, but were planning on starting one of the three types of RRT were included in the study. The plan was to

Results

A total of 77 ESRD patients (43 men and 34 women) participated in the study. Thirty of these patients underwent RT, 30 patients underwent hemodialysis and 17 patients underwent PD. The main causes of ESRD were hypertensive nephropathy (27 patients) and diabetic nephropathy (19 patients). The mean age of the study population was 52 ± 16.3. RT patients were significantly younger than hemodialysis patients (p < 0.001). The duration of ESRD was similar among the groups. The clinical and demographic

Discussion

The present study showed that the nutritional status and micronutrient levels of ESRD patients varied depending on the type of RRT and RT had some advantages compared to other types of RRT. The main limitation of micronutrient studies in dialysis patients is that they base conclusions on a single sample of anthropometric and biochemical parameters with no previous results prior to the start of RRT. Therefore, this study is the first that objectively demonstrates the effects of RRT on

Conclusion

We showed that performing a detailed nutritional assessment in ESRD patients to detect not only malnutrition but also micronutrient deficiency is of extreme importance. Our results support the recommendation that ESRD patients should be supplemented with mostly water soluble vitamins, especially thiamine and vitamin B6, and minerals such as zinc. The present investigation indicates that hemodialysis, PD and RT leads to different changes in the levels of micronutrients and other nutritional

Funding

This study was supported by TUBITAK (The Scientific and Technological Research Council of Turkey, Grant Number: 115S901). The funding source had no role in the design or the results obtained from the study.

Transparency document

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CRediT authorship contribution statement

Oguzhan Sıtkı Dizdar: Conceptualization, Methodology, Writing - original draft. Abdulmecit Yıldız: Investigation, Resources. Cuma Bulent Gul: Visualization, Investigation. Ali Ihsan Gunal: Supervision. Alparslan Ersoy: Formal analysis, Validation. Kursat Gundogan: Methodology, Writing - review & editing.

Declaration of Competing Interest

The authors declare that they have no conflicts of interest.

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