Nutritional Status in Nocturnal Hemodialysis Patients - A Systematic Review with Meta-Analysis

Karin J R Ipema, Simone Struijk, Annet van der Velden, Ralf Westerhuis, Cees P van der Schans, Carlo A J M Gaillard, Wim P Krijnen, Casper F M Franssen, Karin J R Ipema, Simone Struijk, Annet van der Velden, Ralf Westerhuis, Cees P van der Schans, Carlo A J M Gaillard, Wim P Krijnen, Casper F M Franssen

Abstract

Background: Hemodialysis patients experience an elevated risk of malnutrition associated with increased morbidity and mortality. Nocturnal hemodialysis (NHD) results in more effective removal of waste products and fluids. Therefore, diet and fluid restrictions are less restricted in NHD patients. However, it is ambiguous whether transition from conventional hemodialysis (CHD) to NHD leads to improved intake and nutritional status. We studied the effect of NHD on protein intake, laboratory indices of nutritional status, and body composition.

Study design: Systematic review with meta-analysis.

Population: NHD patients.

Search strategy: Systematic literature search from databases, Medline, Cinahl, EMBASE and The Cochrane Library, to identify studies reporting on nutritional status post-transition from CHD to NHD.

Intervention: Transition from CHD to NHD.

Outcomes: Albumin, normalized protein catabolic rate (nPCR), dry body weight (DBW), body mass index (BMI), phase angle, protein intake, and energy intake.

Results: Systematic literature search revealed 13 studies comprising 282 patients that made the transition from CHD to NHD. Meta-analysis included nine studies in 229 patients. In control group controlled studies (n = 4), serum albumin increased significantly from baseline to 4-6 months in NHD patients compared with patients that remained on CHD (mean difference 1.3 g/l, 95% CI 0.02; 2.58, p = 0.05). In baseline controlled studies, from baseline to 4-6 months of NHD treatment, significant increases were ascertained in serum albumin (mean difference (MD) 1.63 g/l, 95% CI 0.73-2.53, p<0.001); nPCR (MD 0.16 g/kg/day; 95% CI 0.04-0.29, p = 0.01); protein intake (MD 18.9 g, 95% CI 9.7-28.2, p<0.001); and energy intake (MD 183.2 kcal, 95% CI 16.8-349.7, p = 0.03). Homogeneity was rejected only for nPCR (baseline versus 4-6 months). DBW, BMI, and phase angle did not significantly change. Similar results were obtained for comparison between baseline and 8-12 months of NHD treatment.

Limitations: Most studies had moderate sample sizes; some had incomplete dietary records and relatively brief follow-up period. Studies markedly differed with regard to study design.

Conclusions: NHD is associated with significantly higher protein and energy intake as well as increases in serum albumin and nPCR. However, the data on body composition are inconclusive.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Fig 1. Selection of articles for the…
Fig 1. Selection of articles for the systematic review on nutritional status in NHD patients.
Fig 2. Albumin—control group controlled studies.
Fig 2. Albumin—control group controlled studies.
(2a) Forest plot comparing albumin in NHD patients at baseline (before transition from CHD to NHD) and control CHD patients. (2b) Forest plot comparing albumin in NHD patients after 4–6 months on NHD and control CHD patients after 4–6 months follow up. (2c) Forest plot comparing albumin in NHD patients after 12 months on NHD and control CHD patients after 12 months follow up.
Fig 3. Albumin—baseline controlled studies.
Fig 3. Albumin—baseline controlled studies.
(3a) Forest plot comparing albumin in NHD patients at baseline (before beginning NHD) and after 4–6 months on NHD. (3b) Forest plot comparing albumin in NHD patients at baseline (before beginning NHD) and after 8–12 months on NHD.
Fig 4. normalized Protein Catabolic Rate.
Fig 4. normalized Protein Catabolic Rate.
(4a) Forest plot comparing nPCR in NHD patients at baseline (prior to beginning NHD) and after 4–6 months on NHD. (4b) Forest plot comparing nPCR in NHD patients at baseline (prior to beginning NHD) and after 8–12 months on NHD. (4c) Funnel plot comparing nPCR in NHD patients at baseline (prior to beginning NHD) and after 4–6 months on NHD.
Fig 5. Dry body weight.
Fig 5. Dry body weight.
(5a) Forest plot comparing dry body weight (DBW) in NHD patients at baseline (prior to beginning NHD) and after 4–6 months on NHD. (5b) Forest plot comparing dry body weight (DBW) in NHD patients at baseline (prior to beginning NHD) and after 8–12 months on NHD.
Fig 6. Body mass index.
Fig 6. Body mass index.
(6a) Forest plot comparing body mass index (BMI) in NHD patients at baseline (prior to beginning NHD) and after 4–6 months on NHD. (6b) Forest plot comparing body mass index (BMI) in NHD patients at baseline (prior to beginning NHD) and after 8–12 months on NHD.
Fig 7. Forest plot comparing phase angle…
Fig 7. Forest plot comparing phase angle in NHD patients at baseline (prior to beginning NHD) and after 12 months on NHD.
Fig 8. Forest plot comparing protein intake…
Fig 8. Forest plot comparing protein intake in NHD patients at baseline (prior to beginning NHD) and after 4–6 months on NHD.
Fig 9. Forest plot comparing energy intake…
Fig 9. Forest plot comparing energy intake in NHD patients at baseline (prior to beginning NHD) and after 4–6 months on NHD.

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