Advertisement
American Journal of Kidney Diseases

Multinutrient Oral Supplements and Tube Feeding in Maintenance Dialysis: A Systematic Review and Meta-Analysis

  • Rebecca J. Stratton
    Correspondence
    Address reprint requests to Rebecca J. Stratton, PhD, Institute of Human Nutrition, School of Medicine, University of Southampton, MP 113 Southampton General Hospital, Tremona Rd, Southampton, SO16 6YD UK.
    Affiliations
    Institute of Human Nutrition, University of Southampton

    Leicester General Hospital, Leicester, UK

    University Claude Bernard Lyon 1, Lyon, France

    Karolinska University Hospital at Huddinge, Stockholm, Sweden

    Royal Numico, Numico Research and Clinical Nutrition Division, Schiphol, The Netherlands
    Search for articles by this author
  • Gemma Bircher
    Affiliations
    Institute of Human Nutrition, University of Southampton

    Leicester General Hospital, Leicester, UK

    University Claude Bernard Lyon 1, Lyon, France

    Karolinska University Hospital at Huddinge, Stockholm, Sweden

    Royal Numico, Numico Research and Clinical Nutrition Division, Schiphol, The Netherlands
    Search for articles by this author
  • Denis Fouque
    Affiliations
    Institute of Human Nutrition, University of Southampton

    Leicester General Hospital, Leicester, UK

    University Claude Bernard Lyon 1, Lyon, France

    Karolinska University Hospital at Huddinge, Stockholm, Sweden

    Royal Numico, Numico Research and Clinical Nutrition Division, Schiphol, The Netherlands
    Search for articles by this author
  • Peter Stenvinkel
    Affiliations
    Institute of Human Nutrition, University of Southampton

    Leicester General Hospital, Leicester, UK

    University Claude Bernard Lyon 1, Lyon, France

    Karolinska University Hospital at Huddinge, Stockholm, Sweden

    Royal Numico, Numico Research and Clinical Nutrition Division, Schiphol, The Netherlands
    Search for articles by this author
  • Renée de Mutsert
    Affiliations
    Institute of Human Nutrition, University of Southampton

    Leicester General Hospital, Leicester, UK

    University Claude Bernard Lyon 1, Lyon, France

    Karolinska University Hospital at Huddinge, Stockholm, Sweden

    Royal Numico, Numico Research and Clinical Nutrition Division, Schiphol, The Netherlands
    Search for articles by this author
  • Meike Engfer
    Affiliations
    Institute of Human Nutrition, University of Southampton

    Leicester General Hospital, Leicester, UK

    University Claude Bernard Lyon 1, Lyon, France

    Karolinska University Hospital at Huddinge, Stockholm, Sweden

    Royal Numico, Numico Research and Clinical Nutrition Division, Schiphol, The Netherlands
    Search for articles by this author
  • Marinos Elia
    Affiliations
    Institute of Human Nutrition, University of Southampton

    Leicester General Hospital, Leicester, UK

    University Claude Bernard Lyon 1, Lyon, France

    Karolinska University Hospital at Huddinge, Stockholm, Sweden

    Royal Numico, Numico Research and Clinical Nutrition Division, Schiphol, The Netherlands
    Search for articles by this author
Published:August 01, 2005DOI:https://doi.org/10.1053/j.ajkd.2005.04.036
      Background: This systematic review aims to determine the potential benefits of enteral multinutrient support (oral or tube) in patients with chronic kidney disease (CKD) receiving maintenance dialysis. Methods: Studies of multinutrient oral supplements and enteral tube feeding that involved comparisons of nutritional support versus routine care (ie, usual diet), disease-specific formulae (with adapted macronutrient and micronutrient composition for use in maintenance dialysis patients) versus standard formulae, and enteral tube feeding versus parenteral nutrition are included in this review. The outcome measures sought were clinical (quality of life, complications, and mortality), biochemical (albumin and electrolyte levels), and nutritional (dietary intake and anthropometry). Meta-analyses were performed when possible. Results: This review of 18 studies (5 randomized controlled trials [RCTs], 13 non-RCTs) suggests that enteral nutritional support increased total (energy and protein) intake and increased serum albumin concentration by 0.23 g/dL (2.3 g/L; 95% confidence interval, 0.037 to 0.418 g/dL [0.37 to 4.18 g/L]; 1 RCT, 2 non-RCTs), with little effect on electrolyte status (serum phosphate and potassium). Few studies reported clinical outcome, and there was insufficient information to compare disease-specific versus standard formulae or enteral versus parenteral nutrition. Conclusion: This systematic review suggests that enteral multinutrient support significantly increases serum albumin concentrations and improves total dietary intake. This may improve clinical outcome, especially in malnourished patients, but insufficient published data exist to examine this. Additional research is required to investigate clinical, economic, and nutritional consequences of using oral supplements and tube feeding (using standard or disease-specific feeds) in patients with CKD receiving maintenance dialysis.

      Index Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Kidney Diseases
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Heimbürger O.
        • Qureshi A.R.
        • Blaner W.S.
        • Berglund L.
        • Stenvinkel P.
        Hand-grip muscle strength, lean body mass and plasma proteins as markers of nutritional status in patients with chronic renal failure close to the start of dialysis therapy.
        Am J Kidney Dis. 2000; 36: 1213-1225
        • Lawson J.A.
        • Lazarus R.
        • Kelly J.J.
        Prevalence and prognostic significance of malnutrition in chronic renal insufficiency.
        J Ren Nutr. 2001; 11: 16-22
        • Kopple J.D.
        McCollum Award Lecture, 1996.
        Am J Clin Nutr. 1997; 65: 1544-1557
        • Stratton R.J.
        • Green C.J.
        • Elia M.
        Prevalence of disease-related malnutrition.
        in: Stratton R.J. Green C.J. Elia M. Disease-Related Malnutrition An Evidence-Based Approach to Treatment. CABI, Wallingford, UK2003: 35-92
        • Kalantar-Zadeh K.
        • Kopple J.D.
        Trace elements and vitamins in maintenance dialysis patients.
        Adv Ren Replace Ther. 2003; 10: 170-182
        • Stenvinkel P.
        • Lindholm B.
        • Heimbürger O.
        Novel approaches in an integrated therapy of inflammatory-associated wasting in end-stage renal disease.
        Semin Dial. 2004; 17: 505-515
        • Stenvinkel P.
        • Heimbürger O.
        • Lindholm B.
        Wasting, but not malnutrition, predicts cardiovascular mortality in end stage renal disease.
        Nephrol Dial Transplant. 2004; 19: 2181-2183
        • Wolfson M.
        Effectiveness of nutrition interventions in the management of malnourished patients treated with maintenance dialysis.
        J Ren Nutr. 1999; 9: 126-128
        • Kopple J.D.
        Therapeutic approaches to malnutrition in chronic dialysis patients.
        Am J Kidney Dis. 1999; 33: 180-185
        • Akner G.
        • Cederholm T.
        Treatment of protein-energy malnutrition in chronic nonmalignant disorders.
        Am J Clin Nutr. 2001; 74: 6-24
        • Fedje L.
        • Moore L.
        • McNeely M.
        A role for oral nutrition supplements in the malnutrition of renal disease.
        J Ren Nutr. 1996; 6: 198-202
        • Bergstrom J.
        Nutrition in renal failure—The role of enteral feeding.
        Nestle Nutrition Workshop Series Clinical and Performance Program. 2000; 3: 247-254
        • Capelli J.P.
        • Kushner H.
        • Camiscioli T.C.
        • Chen S.M.
        • Torres M.A.
        Effect of intradialytic parenteral nutrition on mortality rates in end stage renal disease care.
        Am J Kidney Dis. 1994; 23: 808-816
        • Chertow G.M.
        • Ling J.
        • Lew N.L.
        • Lazarus J.M.
        • Lowrie E.G.
        The association of intradialytic parenteral nutrition administration with survival in hemodialysis patients.
        Am J Kidney Dis. 1994; 24: 912-920
        • Cano N.
        Intradialytic parenteral nutrition.
        J Ren Nutr. 2004; 14: 3-5
        • Beutler K.T.
        • Park G.K.
        • Wilkowski M.J.
        Effect of oral supplementation on nutrition indicators in haemodialysis patients.
        J Ren Nutr. 1997; 7: 77-82
        • Clement J.D.
        • Hasbargen J.A.
        Effect of oral supplementation on nutritional indices in chronic haemodialysis patients.
        J Am Soc Nephrol. 1997; 9 (abstr A0883): 189A
        • Cuppari L.
        • Medeiros F.A.M.
        • Papini H.F.
        • et al.
        Effectiveness of oral energy-protein supplementation in severely malnourished haemodialysis patients.
        J Ren Nutr. 1994; 4: 127-135
        • Patel M.G.
        • Raftery M.J.
        The use of dietary supplements in continuous ambulatory peritoneal dialysis patients.
        J Ren Nutr. 1997; 7: 129-133
        • Han D.S.
        • Lee I.H.
        • Noh S.K.
        • et al.
        The effect of oral nutritional supplement in malnourished CAPD patients.
        J Am Soc Nephrol. 1997; 9 (abstr A1212): 263A
        • Sharma M.
        • Rao M.
        • Jacob S.
        • Jacob C.K.
        A controlled trial of intermittent enteral nutrient supplementation in maintenance hemodialysis patients.
        J Ren Nutr. 2002; 12: 229-237
        • O’Reagan S.
        • Garel L.
        Percutaneous gastrojejunostomy for caloric supplementation in children on peritoneal dialysis.
        Adv Perit Dial. 1990; 6: 273-275
        • Warady B.
        • Weis L.
        • Johnson L.
        Nasogastric tube feeding in infants on peritoneal dialysis.
        Perit Dial Int. 1996; 16: S521-S525
        • Warady B.
        • Kriley M.
        • Belden B.
        • Hellerstein S.
        Nutritional and behavioural aspects of nasogastric tube feeding in infants receiving chronic peritoneal dialysis.
        Adv Perit Dial. 1990; 6: 265-268
        • Toigo G.
        • Aparicio M.
        • Attman P.O.
        • et al.
        Expert Working Group report on nutrition in adult patients with renal insufficiency (Part 2 of 2).
        Clin Nutr. 2000; 19: 281-291
        • Wolfson M.
        Management of protein and energy intake in dialysis patients.
        J Am Soc Nephrol. 1999; 10: 2244-2247
        • Zarazaga A.
        • Garcia-De-Lorenzo L.
        • Garcia-Luna P.P.
        • et al.
        Nutritional support in chronic renal failure.
        Clin Nutr. 2001; 20: 291-299
      1. Cochrane: Cochrane Reviewers Handbook 4.2.2 (updated March 2004). Available at: www.cochrane.org/resources/handbook/hbook.htm. Accessed: July 22, 2004

      2. UK National Health Service Centre for Reviews and Dissemination: Finding studies for systematic reviews: A basic checklist for researchers, in National Health Service Centre for Reviews and Dissemination. Centre for Reviews and Dissemination Publications Office. York, UK, University of York. Available at: www.york.ac.uk/inst/crd/revs.htm.2000. Accessed: July 22, 2004

        • UK National Health Service Centre for Reviews and Dissemination
        Undertaking Systematic Reviews of Research on Effectiveness. (ed 2). University of York, York, UK2001
        • Moher D.
        • Cook D.J.
        • Eastwood S.
        • et al.
        Improving the quality of reports of meta-analyses of randomised controlled trials. The QUORUM statement. Quality of reporting meta-analyses.
        Lancet. 1999; 354: 1896-1900
      3. Agency for Health Care Policy and Research: Acute pain management: Operative or medical procedures and trauma. Clin Pract Guidel 92: 1992 (Appendix B). Available at: http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat6.chapter.8991. Accessed July 18, 2005.

        • Jadad A.
        • Moore R.
        • Carroll D.
        • et al.
        Assessing the quality of reports of randomized clinical trials.
        Control Clin Trials. 1996; 17: 1-12
        • Morgan W.C.
        • Bushman B.J.
        Integrating Results Through Meta-Analytic Review Using SAS Software. SAS Institute Inc, Cary, NC1999
        • Mantel N.
        • Haenszel W.
        Statistical aspects of the analysis of data from retrospective studies of disease.
        J Natl Cancer Inst. 1959; 22: 719-748
        • Egger M.
        • Davey Smith G.
        • Schneider M.
        • Minder C.
        Bias in meta-analysis detected by a simple, graphical test.
        BMJ. 1997; 315: 629-634
        • Mosteller F.
        • Rourke R.E.K.
        • Thomas G.B.
        Probability With Statistical Applications (ed 2). Addison-Wesley, London, England1970
        • Acchiardo S.R.
        • Riley M.L.
        Five year’s experience with oral nutritional supplements (ONS) in haemodialysis (HD) patients (pts). Are they useful?.
        J Am Soc Nephrol. 2002; 13 (abstr SA-P0742): 415A
        • Boudville N.
        • Rangan A.
        • Moody H.
        Oral nutritional supplementation increases caloric and protein intake in peritoneal dialysis patients.
        Am J Kidney Dis. 2003; 41: 658-663
        • Caglar K.
        • Fedje L.
        • Dimmitt R.
        • et al.
        Therapeutic effects of oral nutritional supplementation during hemodialysis.
        Kidney Int. 2002; 62: 1054-1059
        • Cockram D.B.
        • Hensley M.K.
        • Rodriguez M.
        • et al.
        Safety and tolerance of medical nutritional products as sole sources of nutrition in people on hemodialysis.
        J Ren Nutr. 1998; 8: 25-33
        • Dare B.K.
        • Whiteside E.J.
        • Wilson D.E.
        An evaluation study to assess the potential use of Renamil (formerly named Ren-o-mil) for patients with chronic renal failure.
        J Hum Nutr Diet. 1997; 10: 25-36
        • Heaf J.G.
        • Honore K.
        • Valeur D.
        • Randlov A.
        The effect of oral protein supplements on the nutritional status of malnourished CAPD patients.
        Perit Dial Int. 1999; 19: 78-81
        • Holley J.L.
        • Kirk J.
        Enteral tube feeding in a cohort of chronic hemodialysis patients.
        J Ren Nutr. 2002; 12: 177-182
        • Kuhlmann M.K.
        • Schmidt F.
        • Kohler H.
        Oral nutritional support in malnourished HD patients.
        J Am Soc Nephrol. 1997; 8 (abstr A0924): 199A
        • Kuhlmann M.K.
        • Schmidt F.
        • Kohler H.
        High protein/energy vs standard protein/energy nutritional regimen in the treatment of malnourished hemodialysis patients.
        Miner Electrolyte Metab. 1999; 25: 306-310
        • Mareckova O.
        • Schuck O.
        • Teplan V.
        • et al.
        A nutritionally defined liquid diet for haemodialized patients.
        Cas Lek Cesk. 1995; 134: 77-79
        • Patel M.G.
        • Kitchen S.
        • Miligan P.J.
        The effect of dietary supplements on the nPCR in stable hemodialysis patients.
        J Ren Nutr. 2000; 10: 69-75
        • Sayce H.A.
        • Rowe P.A.
        • McGonigle R.J.S.
        Percutaneous endoscopic gastrostomy feeding in haemodialysis outpatients.
        J Hum Nutr Dietet. 2000; 13: 333-341
        • Shah N.A.
        • Mueller B.A.
        • Thomas J.
        • Kraus M.A.
        • Scott M.K.
        Effects of supplemental enteral nutrition on nutritional status and quality of life in ESRD patients receiving hemodialysis.
        J Am Soc Nephrol. 1999; 10 (abstr A1535): 303A
        • Shenkin A.
        • Cederblad G.
        • Elia M.
        • Isaksson B.
        International Federation of Clinical Chemists. Laboratory assessment of protein energy status.
        Clin Chim Acta. 1996; 253: S5-S59
        • dos Santos N.S.J.
        • Draibe S.A.
        • Kamimura M.A.
        • et al.
        Is serum albumin a marker of nutritional status in hemodialysis patients without evidence of inflammation?.
        Artif Organs. 2003; 27: 681-686
        • Combe C.
        • McCullough K.P.
        • Asano Y.
        • et al.
        Kidney Disease Outcomes Quality Initiative (K/DOQI) and the Dialysis Outcomes and Practice Patterns Study (DOPPS).
        Am J Kidney Dis. 2004; 44: S39-S46
        • Lowrie E.G.
        • Lew N.L.
        Death risk in haemodialysis patients.
        Am J Kidney Dis. 1990; 15: 458-482
        • Owen W.F.
        • Lew N.L.
        • Liu Y.
        • Lowrie E.G.
        • Lazarus J.M.
        The urea reduction ratio and serum albumin concentration as predictors of mortality in patients undergoing hemodialysis.
        N Engl J Med. 1993; 329: 1001-1006
        • Lowrie E.G.
        • Huang W.H.
        • Lew N.L.
        Death risk predictors among peritoneal dialysis and hemodialysis patients.
        Am J Kidney Dis. 1995; 26: 220-228
        • Dwyer J.T.
        • Larive B.
        • Leung J.
        • et al.
        Nutritional status affects quality of life in Hemodialysis (HEMO) Study patients at baseline.
        J Ren Nutr. 2002; 12: 213-223