Oral protein‐based nutritional supplement in people with chr | Figure 1

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Oral protein‐based nutritional supplement in people with chronic kidney disease requiring dialysis

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What is the issue?

People with chronic kidney disease requiring dialysis are at risk of developing malnutrition for many reasons and often do not eat enough because their appetite is poor. Oral nutritional supplements are commonly provided to people who do not eat enough to meet their needs. Provision of nutritional supplements to dialysis patients requires careful consideration of potassium, phosphate and fluid limits.

What did we do?

We aimed to determine if giving oral protein‐based nutritional supplements improved serum albumin levels and other measures of nutrition.

What did we find?

A total of 1278 people took part in 22 studies that were included in this review to investigate the effects of oral protein‐based nutritional supplements. All participants were adults on maintenance dialysis (79% haemodialysis and 21% peritoneal dialysis). The studies lasted from one to 12 months. The findings suggest that giving oral protein‐based nutritional supplementation probably results in a slightly greater increase in albumin level and may improve prealbumin level and mid‐arm muscle circumference. The increase in albumin level was more evident in participants who were on haemodialysis and in those who were malnourished. It is uncertain whether oral protein‐based nutritional supplementation affects potassium and phosphate levels. Oral protein‐based nutritional supplements may result in little or no difference in the risk of developing abdominal symptoms.There were some differences between the quality of the studies and their designs.

Conclusions

The authors conclude that oral protein‐based nutritional supplements appear to be effective in improving some nutritional markers in people who need dialysis; however, it remains uncertain whether these results translate to meaningful outcomes for this population. More research is required to determine the cost‐effectiveness of this treatment, and if it can bring benefit to patients such as feeling better and living longer.

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\ \ Cochrane Review; five trials (833 participants); comparing omega‐3 fatty acid fish oils against placebo in patients requiring long‐term haemodialysis. One was a very small pilot study of seven participants. Four studies involved patients with AVGs; there was only one study of AVFs. The outcomes were measured over a period of six or 12 months.\ Key findings\ In arteriovenous fistula (AVF) patients, we are moderately certain that fish oil supplements do not prevent blockage nor do they cause additional harm but the evidence only comes from one study. In arteriovenous grafts (AVG) patients, we are very uncertain of the evidence for preventing blockage or causing serious harm, but there may be an increased risk of mild digestive side‐effects such as a sensation of bloatedness, gas or a fishy aftertaste.\ Conclusions\ There is limited high quality data on the benefits of omega‐3 fish oil supplementation for preventing HD blockage in kidney failure patients. We did not find strong evidence that omega‐3 fish oil supplements could prevent blockage of HD vascular access or that it increases the risk of serious and non‐serious side‐effects. All the evidence for preventing blockages come from just one or two studies, so more and better quality studies are needed.](https://app.figure1.com/case-detail/332611b1-b822-438d-a311-d0649662071f)

\ \ What is the issue?\ People who are overweight or obese with chronic kidney disease (CKD) may experience a faster progression to kidney failure than those who are a healthy weight. Some people with more advanced kidney disease may require treatment such as dialysis or a kidney transplant. Being obese can make these treatments difficult and may increase a person's risk of health complications. There is limited research looking at whether weight loss interventions are safe and beneficial to help people with CKD lose weight, improve their kidney function, and live longer.\ What did we do?\ We conducted a review of the literature to examine the benefits of weight loss interventions for people with CKD who are overweight or obese.\ What did we find?\ We identified 17 studies involving 988 overweight or obese adults with CKD looking at whether weight loss interventions improved their health. Studies included adults with CKD stages 1 to 4 or kidney transplant recipients. None of the studies included participants who were undergoing dialysis or supportive care. Weight loss interventions included weight loss diets, physical activity programs, drugs to suppress appetite, and weight loss surgery. The main outcomes we were interested in were death, cardiovascular events, weight loss, body mass index (BMI), waist circumference, protein in the urine (proteinuria), and blood pressure (BP).\ After combining the available studies, its uncertain whether weight loss interventions helped people live longer or prevented cardiovascular events such as heart complications or stroke as none of the included studies measured these outcomes. We found when compared to no weight loss interventions, weight loss interventions may lead to more weight loss. There were little or no differences seen in BMI, waist circumference, proteinuria, or BP. We found that weight loss surgery achieved more weight loss than non‐surgical interventions. However, many of the studies included in this review were limited by small participant numbers, high risk of bias and inconsistent reporting of outcome measures leading to the overall quality of the evidence to be very low. This means that we cannot be sure that future studies would find similar results.\ Conclusions\ The evidence is not very certain but suggests that compared with usual care or control those who participated in weight loss interventions may experience some health benefits including improvements in body weight. Whether these benefits help reduce cardiovascular outcomes and the risk of death remains uncertain and require further study.](https://app.figure1.com/case-detail/3dc43479-ef80-441a-9e2e-3b6407af98d3)

\ \ Cochrane Review; 104 studies (13,744 people).\ Phosphate binders are often prescribed to people with chronic kidney disease (CKD), with the intention of reducing the absorption of dietary phosphate from the gastrointestinal tract.\ Key findings\ Sevelamer treatment may have decreased death for those patients given this medication instead of calcium. The phosphate binders probably caused constipation, but risks of other side‐effects are uncertain. It is uncertain whether phosphate binders reduced heart complications, stroke, bone pain, or calcification of blood vessels.\ Conclusion\ Overall, it is uncertain whether specific phosphate binders are beneficial to patients with CKD. There is a possibility that sevelamer may prevent death compared to calcium‐based binders, but it is uncertain whether this may be caused by an increased risk of calcium‐based binders, a lower risk with sevelamer treatment, or the possibility that both may be true. It is uncertain whether phosphate binders help prevent complications of kidney disease, but sevelamer may be preferred to calcium binders.\ No differences were found in the effects of treatment for patients on dialysis vs. those not on dialysis, although most studies evaluating treatment with calcium‐based binders were among dialysis patients and those comparing binders with placebo were among people not treated with dialysis.](https://app.figure1.com/case-detail/53b02968-fbbc-4586-8d13-3779075c510b)

\ \ Aldosterone antagonists in addition to renin angiotensin system antagonists for preventing the progression of chronic kidney disease\ What is the issue?\ People who have chronic kidney disease (CKD) have a higher risk of heart disease and declining kidney function. Increased amounts of protein in the urine is a sign of kidney stress and is linked to declining kidney function. Medications used to lower blood pressure and reduce protein levels in the urine ‐ in particular, angiotensin‐converting enzyme Inhibitors (ACEi) and angiotensin receptor blockers (ARBs) ‐remain the core treatment to prevent the declining of kidney function in CKD.\ Protecting kidney function with these medications may however be incomplete and adding an aldosterone antagonist (blocker) (for example, spironolactone, canrenone, eplerenone, or finerenone) may better protect kidney function in the long‐term. By blocking the production of aldosterone, the kidneys excrete more water which can lead to a lowering of blood pressure. However, they can cause side effects including enlargement of male breast tissue, and when used with ACEi or ARBs may cause high levels of potassium in the blood or a decline in kidney function.\ What did we do? We reviewed the available studies looking at the addition of aldosterone blockers to standard treatment in people with CKD to see if they slowed the decline of kidney function and the subsequent need for dialysis or a kidney transplant. We looked at whether they reduced heart disease, the amount of protein in urine, or improved blood pressure. We also looked at whether aldosterone blockers were safe in terms of risks of male breast enlargement, potassium levels in the blood, and short‐term effects on kidney function.\ What did we find? We found that adding aldosterone blockers to a patient's current medications (ACEi or ARBs), lowered both protein in the urine and systolic blood pressure. Kidney function declined, however the effects on survival were uncertain. The addition of aldosterone blockers increased the amount of potassium in the blood. This may require medication changes, extra blood tests, and may be potentially harmful. Treatment with aldosterone blockers also increased the chance of short‐term decline in kidney function and enlargement of male breast tissue.\ Conclusions It is unclear as to whether aldosterone blockers protect kidney function or prevent heart disease in people who have CKD.](https://app.figure1.com/case-detail/615348d3-3f00-42d1-8079-14f7eda07b94)

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