Hunger in Patients with Kidney Disease – Why it matters and what to do about it?

As a new pediatric nephrology fellow, my first weeks taking care of patients on hemodialysis were overwhelming. Each of my patients had complex problems and intricate physiology, and I initially learned to focus on the numbers – clearance, blood pressures and weight – in order to optimize therapies for each patient’s clinical disease and status. About three months into fellowship, however, I was stumped by a young girl with ESRD whose numbers just didn’t make sense. She was losing weight, admitted repeatedly for infections, and had worsening clinical and laboratory parameters which wouldn’t improve with interventions. Despite nutritional supplements, additional dialysis sessions, and medication adjustments, nothing changed. Finally, the root cause became clear – she was hungry, and her family couldn’t afford to buy food. 

Unfortunately, this isn’t a rare experience in the United States. Food insecurity is common, affecting 16.6% of American households and 7.8% of American children – and appears to be more common in those with chronic illness, such as kidney disease. Food insecurity is defined as limited or uncertain availability of nutritionally adequate and safe foods, or limited or uncertain ability to acquire such foods in socially acceptable ways. I have seen families frequently make trade-offs between buying medication versus food, or choosing inappropriate food for their children’s medical problems due to cost. Parents have told me they often go hungry in order to feed their children – providing a human face to the statistics published by the U.S. Department of Agriculture (USDA) Economic Research Service showing that half of all parents or caregivers experiencing food insecurity shield their children from having to skip meals by skipping meals themselves. 

Why should food insecurity matter to nephrologists? Food insecurity is an essential social determinant of health with significant implications, including poorer overall levels of health, chronic medical conditions, and lower levels of psychosocial and physical functioning. A recent report showed that two-thirds of families with food insecurity have to choose between paying for medical care or food within the past year.These findings in children mirror studies in adult ESRD patients where food insecurity was associated with worse nutritional status and poorer quality of life. Among adults with chronic kidney disease, food insecurity accelerates disease progression, and may increase the risk of ESRD. Patients with food insecurity often use coping strategies which are deleterious for their health, including medication under-use or non-adherence, postponing or forgoing preventive care, or relying on a low-cost diet of energy rich but nutrient-poor foods. 

While awareness of food insecurity has increased in pediatrics and screening for food insecurity is frequently part of general pediatrics care, there no similar recommendations in either pediatric or adult subspecialties. Given the implications for our patients and their diseases, I would argue that all patients with kidney disease, especially those with ESRD, should be screened for food insecurity as part of their routine nephrology and dialysis care. Physicians, dietitians, and other health providers often counsel patients with kidney disease on dietary interventions, and awareness of food security status is paramount in providing optimal care. Many interventions and recommendations (such as a low-salt diet or phosphorus restriction) may be challenging or impossible to implement for patients who are food insecure. Screening should be performed with a standardized screening instrument, with several available and validated by the AAP, AAFP and USDA. Screening should be coupled with timely and appropriate referrals to food resources – an area of intervention that requires innovation, collaboration and community-based solutions. While eliminating food insecurity may be the eventual goal, the first step is to screen patients at risk; as only once we recognize, name, and quantify a problem can we start to identify solutions. 

 Post by Michelle Starr, NSMC Intern Class 2018

Boost it up!

Dealing with patients on dialysis can be challenging. In addition to the management of many comorbidities, nephrologists have to go down a list similar to a pilot’s checklist. Those include dialysis adequacy, access, electrolyte balance, fluid status, BP control, anemia management, Ca/PO4/vitD/PTH,… For last, when time allows, they might have room for the nutritional status box.

Protein-energy malnutrition (PEM) is very common in ESRD reaching close to 50% of patients, depending on the parameters used. Why is it important? Well, PEM is a powerful predictor of morbidity and mortality. Ballpark, for every 1g/L decrease in albumin, a 10% increase in mortality risk has been reported.


Its etiology is believed to be multifactorial:

1. Inadequate nutritional intake due to taste abnormalities, gastropathy/enteropathy, anorexia and psychosocial (depression, poverty or ETOH abuse).
2. Dialysis-related nutrient losses: about 10g of aminoacids are lost after each HD session!
3. Catabolic state due to inflammation/uremia, metabolic acidosis and dialysis procedure (exposure of blood to HD membrane).
   

Without any complicated malnutrition score, we are usually able to recognize malnourished patients by their physical appearance and some metabolic abnormalities like low BUN/Cr preHD, low phosphate, low cholesterol, elevated ferretin and low Hb. The normalized protein catabolic rate can also help.

So, what can we do for that?

1. Improve dialysis adequacy: e.g. daily hemodialysis has been shown to improve nutritional parameters. But at this time your dialysis nurse or patient might not agree with that…
2. Oral nutrient supplementation: strong data supporting the use of these agents. If your patient’s albumin is below 3.5, you should be thinking about that! Choice should consider the price, palatability and lactose tolerance. Nepro is a classic – one can contains approx. 17g of protein, 23g of fat and 53g of carbs (475 kcal) – pack of 24 for $69; compared to regular protein cans (e.g. Boost), they have less phosphate and potassium. Protein powder without flavor is also a great choice since it can be added to any fluid, improves palatability and cost less. Even sports protein bars have been shown to be acceptable protein sources. Compliance is a major issue and many studies have given the supplements before/after HD session.
3. Correction of metabolic acidosis with PO bicarbonate.
4. Appetite stimulants: megestrol has been used on cancer patients but side effects are frequent in HD patients and is usually not recommended.
5. Finally, intradialytic total parenteral nutrition should be considered only for patients unable to use the GI tract and severely malnourished.
   

Also check Dr Rubin’s blog on hidden inflammatory state for reversal conditions you should be considering as well...