American Journal of Kidney Diseases
Volume 51, Issue 1 , Pages 160-161, January 2008

Low Protein Diet Supplemented With Ketoanalogues Makes Hemodialysis Withdrawal Possible

  • Tze-Wah Kao, MD

      Affiliations

    • Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
    • ,
  • Chia-Te Liao, MD

      Affiliations

    • Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
    • ,
  • Chih-Chung Shiao, MD

      Affiliations

    • Renal Division, Department of Internal Medicine, St. Mary’s Hospital, Lo Tung, Taiwan
    • ,
  • Yueh-Hsia Kuo, MS, RD

      Affiliations

    • Department of Dietetics, National Taiwan University Hospital, Taipei, Taiwan
    • ,
  • Kuan-Yu Hung, MD, PhD

      Affiliations

    • Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
    • ,
  • Kwan-Dun Wu, MD, PhD

      Affiliations

    • Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan

Article Outline

 

To the Editor:

Dialysis withdrawal is a common cause of death in dialysis populations.1 The mean survival time is short, usually less than 10 days.2 We present a patient who achieved long-term survival of more than 16 months after hemodialysis had been withdrawn.

A 70-year-old man requested discontinuation of dialysis due to frequent intradialytic hypotension. He had no alteration in consciousness or psychological problems. Before hemodialysis was withheld, he was informed of all possible consequences. His high-protein diet was replaced with one with lower protein (0.6 g/kg/d). A ketoanalogue product (Ketosteril; Fresenius Kabi, Bad Homburg, Germany) containing deaminated branched-chain essential amino acids and calcium was prescribed, and medications were adjusted appropriately. Changes in clinical and laboratory data are shown in the Table. Vitamin D3 was added when parathyroid hormone level increased; the level decreased after more ketoanalogues were taken.

Table. Clinical and Laboratory Data of the Patient After Dialysis Withdrawal
Week⁎
01816243240485664
Hb (g/dL)8.88.19.310.410.110.2 9.410.27.9
Albumin (g/dL)4.144.34.54.44.7 4.34.44.2
BUN (mg/dL)111107.3105.3101.799.6116.3 88.2113.3112.6
sCr (mg/dL)12.513.410.5109.611 11.814.514.8
K (mmol/L)5.74.45.55.15.85.3 4.24.65.1
Ca (mg/dL)8.48.48.48.48.3 88.28.8
P (mg/dL)6.16.34.94.74.4 5.45.95.1
iPTH (pg/mL)176 165 382331104
Vitamin D3 (μg/d) 0.250.50.5
Ketosteril†12141289658912
Body weight (kg)71 6763 61 65.56766
Residual kidney function (mL/min/1.73 m2)2

Note: To convert hemoglobin in g/dL to g/L, multiply by 10; serum albumin in g/dL to g/L, multiply by 10; serum creatinine in mg/dL to μmol/L, multiply by 88.4; blood urea nitrogen in mg/dL to mmol/L, multiply by 0.357; serum calcium in mg/dL to mmol/L, multiply by 0.25; serum phosphorus in mg/dL to mmol/L, multiply by 0.323; iPTH levels expressed in pg/mL and ng/L are equivalent.

Abbreviations: Hb, hemoglobin; BUN, blood urea nitrogen; sCr, serum creatinine; iPTH, intact parathyroid hormone

⁎Number of weeks after hemodialysis was put on hold.

†Number of Ketosteril tablets taken per day

Reported causes of dialysis withdrawal include dementia, terminal illness, progressive disability, chronic pain, and depression.3, 4 Although our patient had none of these conditions, we respected his right of autonomy5 to discontinue dialysis. Strategies employed included a low-protein diet, which may reduce proteinuria,6 delay renal failure,7 and alleviate uremic symptoms.8 When supplemented, a low-protein diet also prevents malnutrition9 and defers dialysis.8, 10 Our patient’s initial weight loss and progressive hyperparathyroidism were probably due to reduced meat intake and hypocalcemia, respectively. Higher doses of ketoanalogues helped preserve muscle mass and supply calcium.

In conclusion, for selected, well-informed patients having residual kidney function and able to adhere to a supplemented low-protein diet and medication control, long-term survival after hemodialysis withdrawal can be successfully achieved.

Letters to the Editor may be in response to an article that appeared in AJKD no more than 6 months previously, or may concern a topic of interest to current nephrology. The body of the letter should be as concise possible and in general should not exceed 250 words. Up to 10 references and 1 figure or table may be included. There is no guarantee that letters will be published. Letters are subject to editing and abridgment without notice.

Letters should be submitted via AJKD’s online manuscript handling site, www.editorialmanager.com/ajkd. More information, including details about how to contact the editorial staff for assistance, is available in the journal’s Information for Authors.

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Acknowledgements 

Support: The authors would like to thank the Ta-Tung Kidney Foundation and Mrs Hsiu-Chin Lee Kidney Research Fund for their generous support.

Financial Disclosure: None.

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References 

  1. Birmele B, Francois M, Pengloan J, et al. Death after withdrawal from dialysis: the most common cause of death in a French dialysis population. Nephrol Dial Transplant. 2004;19:686–691
  2. Fissell RB, Bragg-Gresham JL, Lopes AA, et al. Factors associated with “do not resuscitate” orders and rates of withdrawal from hemodialysis in the international DOPPS. Kidney Int. 2005;68:1282–1288
  3. Conneen S, Tzamaloukas AH, Adler K, Keller LK, Bordenave K, Murata GH. Withdrawal from dialysis: ethical issues. Dial Transplant. 1998;27:200;202-204
  4. Davison SN, Jhangri GS. The impact of chronic pain on depression, sleep, and the desire to withdraw from dialysis in hemodialysis patients. J Pain Symptom Manage. 2005;30:465–473
  5. Brown WW. The geriatric dialysis patient, in Henrich WL (ed): Principles and Practice of Dialysis (ed 3). In: Philadelphia: Lippincott Williams & Wilkins; 2004;p. 536
  6. Gansevoort RT, de Zeeuw D, de Jong PE. Additive antiproteinuric effect of ACE inhibition and a low-protein diet in human renal disease. Nephrol Dial Transplant. 1995;10:497–504
  7. D’Amico G, Gentile MG, Fellin G, Manna G, Cofano F. Effect of dietary protein restriction on the progression of renal failure: a prospective randomized trial. Nephrol Dial Transplant. 1994;9:1590–1594
  8. Walser M, Hill S. Can renal replacement be deferred by a supplemented very low protein diet?. J Am Soc Nephrol. 1999;10:110–116
  9. Mitch WE, Abras E, Walser M. Long-term effects of a new ketoacid-amino acid supplement in patients with chronic renal failure. Kidney Int. 1982;22:48–53
  10. Brunori G, Viola BF, Parrinello G, et al. Efficacy and safety of a very-low-protein diet when postponing dialysis in the elderly: a prospective randomized multicenter controlled study. Am J Kidney Dis. 2007;49:569–580

PII: S0272-6386(07)01485-0

doi:10.1053/j.ajkd.2007.10.033

American Journal of Kidney Diseases
Volume 51, Issue 1 , Pages 160-161, January 2008

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