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American Journal of Kidney Diseases

Oral Intradialytic Nutritional Supplement Use and Mortality in Hemodialysis Patients

Published:October 07, 2013DOI:https://doi.org/10.1053/j.ajkd.2013.08.007

      Background

      Hemodialysis patients have high mortality rates, potentially reflecting underlying comorbid conditions and ongoing catabolism. Intradialytic oral nutritional supplements may reduce this risk.

      Study Design

      Retrospective propensity-matched cohort.

      Setting & Participants

      Maintenance hemodialysis patients treated at Dialysis Clinic Inc facilities who were initiated on a nutritional supplement protocol in September to October 2010 were matched using a propensity score to patients at facilities at which the protocol was not used.

      Predictors

      Prescription of the protocol, whereby hemodialysis patients with serum albumin levels ≤3.5 g/dL would initiate oral protein supplementation during the dialysis procedure. Sensitivity analyses matched on actual supplement intake during the first 3 study months. Covariates included patient and facility characteristics, which were used to develop the propensity scores and adjust multivariable models.

      Outcomes

      All-cause mortality, ascertained though March 2012.

      Results

      Of 6,453 eligible patients in 101 eligible hemodialysis facilities, the protocol was prescribed to 2,700, and 1,278 of these were propensity matched to controls. Mean age was 61 ± 15 (SD) years and median dialysis vintage was 34 months. There were 258 deaths among protocol assignees versus 310 among matched controls during a mean follow-up of 14 months. In matched analyses, protocol prescription was associated with a 29% reduction in the hazard of all-cause mortality (HR, 0.71; 95% CI, 0.58-0.86); adjustment had minimal impact on models. In time-dependent models incorporating change in albumin level, protocol status remained significant but was attenuated in models incorporating a 30-day lag. Similar results were seen in sensitivity analyses of 439 patients receiving supplements who were propensity-matched to controls, with 116 deaths among supplement users versus 140 among controls (HR, 0.79; 95% CI, 0.60-1.05), achieving statistical significance in adjusted models.

      Limitations

      Observational design, potential residual confounding.

      Conclusions

      Prescription of an oral nutritional supplement protocol and use of oral protein nutritional supplements during hemodialysis are associated with reduced mortality among in-center maintenance hemodialysis patients, an effect likely not mediated by change in serum albumin levels.

      Index Words

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      Linked Article

      • Nutritional Supplement Use in Hemodialysis Patients
        American Journal of Kidney DiseasesVol. 63Issue 6
        • Preview
          We read with much interest the study by Weiner et al1 showing that use of a nutritional supplement protocol is associated with a significant reduction in mortality in hemodialysis (HD) patients. The study raises many important concerns. First, the HD patients included in the nutritional supplement protocol were not stratified on the basis of the presence of anorexia and/or low dietary calorie-protein intake. Second, characteristics of the HD patients did not include several variables (eg, markers of inflammation, comorbid conditions, and medications), and it is unknown whether these individuals had inflammation and/or were “fragile.” Third, none of the statistical models included markers of inflammation and the number and severity of comorbid conditions.
        • Full-Text
        • PDF
      • Etiological Versus Prognostic Models in Cohort Studies
        American Journal of Kidney DiseasesVol. 63Issue 6