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318

Nutrición
Hospitalaria

Trabajo Original Epidemiología y dietética

Effect of a personalized nutritional intervention program on nutritional status,

quality of life and mortality in hemodialysis patients
Efecto de un programa de intervención nutricional personalizado en el estado nutricional,
calidad de vida y mortalidad en pacientes en hemodiálisis
Lucía Visiedo1, Francisca López2, Francisco Rivas-Ruiz3, Begoña Tortajada1, Rafael Giménez4, Jimena Abilés1
1
Pharmacy and Nutrition Unit, ²Nephrology Unit, and ³Research and Innovation Unit. Hospital Universitario Costa del Sol. Marbella, Málaga. Spain. 4Department of Nutrition
and Bromatology. Universidad de Granada. Granada, Spain

Abstract
Objective: dietary advice provided through a nutritional intervention program (NIP) is recommended by renal clinic guidelines to prevent or
treat malnutrition, that could improve quality of life (QoL) and survival in hemodialysis (HD) patients. This study set out to evaluate the effect of a
personalized NIP on the nutritional status and its impact on QoL and mortality in dialyzed patients.
Material and methods: this was a 12-month intervention study with regular follow-up in which nutritional parameters were measured at baseline
and after 6 and 12 months. QoL was assessed by the Kidney Disease Quality of Life version 1.2 (KDQOL-SF) at baseline and at the end of the
study. All dialyzed patients received individualized consultations with a trained dietitian. The content of the nutritional education program included
a personalized meal plan and educational materials addressing nutrition to manage fluids, electrolytes, and vitamin D.
Keywords: Results: a total of 75 patients were included. After the NIP, visceral proteins, phosphorous, potassium and vitamin D levels had improved
significantly (p < 0.001). The percentage of well-nourished patients increased by 30 % (p < 0.001). At the end of the study, the well-nourished
Hemodialysis. Malnutrition.. patients had significantly improved scores on the general summary areas of the KDQOL-SF, reduced worry concerning fluid and dietary restrictions
Nutritional status. Quality of
life. Nutritional intervention
(p < 0.001), and the survival rate was 12 months longer (p < 0.01).
program. Mortality. Conclusion: the results of this study suggest that personalized NIP contributed to improved nutritional status, QoL and survival in HD patients.

Resumen
Objetivo: el asesoramiento dietético proporcionado a través de un programa de intervención nutricional (PIN) es recomendado por las guías
clínicas renales para prevenir o tratar la desnutrición, puediendo mejorar la calidad de vida (CV) y la supervivencia en pacientes en hemodiálisis
(HD). El objetivo de este estudio fue evaluar el efecto de un PNI personalizado sobre el estado nutricional y su impacto en la calidad de vida y la
mortalidad en pacientes dializados.
Material y métodos: estudio de intervención de 12 meses de duración, con seguimiento periódico de los pacientes en el que se midieron
los parámetros nutricionales al inicio, a los 6 y 12 meses. La CV fue evaluada por el cuestionario Kidney Disease Quality of Life versión 1.2
(KDQOL-SF) al inicio y al final del estudio. Todos los pacientes dializados recibieron consultas individualizadas con un dietista. El contenido del
programa de educación nutricional incluyó un plan de alimentación personalizado y materiales educativos sobre nutrición para el manejo de
fluidos, electrolitos y vitamina D.
Palabras clave: Resultados: se incluyeron un total de 75 pacientes. Después del PIN, los niveles de proteínas viscerales, fósforo, potasio y vitamina D habían
mejorado significativamente (p < 0,001). El porcentaje de pacientes bien nutridos aumentó un 30 % (p < 0,001). Al final del estudio, los pacientes
Hemodiálisis. Desnutrición. bien nutridos mejoraron significativamente las puntuaciones en las áreas de resumen general del KDQOL-SF, redujeron la preocupación por las
Estado nutricional. Calidad restricciones dietéticas y de líquidos (p < 0,001) y la tasa de supervivencia fue de 12 meses superior (p < 0,01).
de vida. Programa de
intervención nutricional. Conclusión: los resultados de este estudio sugieren que el PIN personalizado contribuyó a mejorar el estado nutricional, la calidad de vida y la
Mortalidad. supervivencia en pacientes en HD.

Received: 28/04/2023 • Accepted: 28/07/2023

Conflict of interest: the authors declare no conflict of interest.

Visiedo L, López F, Rivas-Ruiz F, Tortajada B, Giménez R, Abilés J. Effect of a personalized nutritional Correspondence:
intervention program on nutritional status, quality of life and mortality in hemodialysis patients. Lucía Visiedo. Pharmacy and Nutrition Unit. Hospital
Nutr Hosp 2023;40(6):1229-1235     Universitario Costa del Sol. A-7, km. 187. 29603
Marbella, Málaga. Spain
DOI: http://dx.doi.org/10.20960/nh.04756 e-mail: [email protected]
©
Copyright 2023 SENPE y ©Arán Ediciones S.L. Este es un artículo Open Access bajo la licencia CC BY-NC-SA (http://creativecommons.org/licenses/by-nc-sa/4.0/).
1230 L.   Visiedo et al.

INTRODUCTION This study was conducted in accordance with the ethical prin-
ciples set forth in the most recent version of the Declaration of
Nutritional intake and dietary patterns are potential determi- Helsinki and the standards of good clinical practice. All partici-
nants of health outcomes in hemodialysis (HD) patients. Patients pants signed an informed consent form prior to their inclusion
on maintenance HD require intensive nutritional education, good in the study.
instruction, as well as repeated reinforcement to cope with the
complex renal diet due to dietary and fluid restrictions and con-
trol of electrolytes that can limit food choices and make meals STUDY DESIGN
unappetizing, leading to reduced food intake and poor nutritional
adherence (1). One hundred and twenty patients underwent an initial assess-
Moreover, uremic metabolites, metabolic acidosis, inflamma- ment. Twenty-seven patients dropped out of the study due to
tion and the presence of other comorbidities can also worsen death (n = 16) or change of dialysis center (n = 11); and 18
appetite, decreasing protein and energy intake and increasing patients were excluded due to an invalid QoL questionnaire. Fi-
catabolic processes in this population (2). nally, 75 patients had a valid MIS and QoL questionnaire, which
All of the causes mentioned above could give rise to diet, fluid was the sample used for this study. Data for these patients were
and electrolyte imbalances that can lead to malnutrition in main- collected by non-purposive sampling, from January 2017 to De-
tenance HD patients. Malnutrition is mild to moderate in approx- cember 2019, and were retrospectively analyzed. Participants
imately 33 % of these patients and severe in approximately 6 % met the following inclusion criteria: adults (18 years or older) who
to 8 % (3), and its presence causes increased morbidity, de- had not previously consulted with a dietician and who had been
creased functional capacity and increased number and duration in the HD program for at least 3 months. HD sessions were held
of hospital admissions, leading to a low quality of life (QoL), being three times per week for 4 hours.
a major risk factor for mortality (3,4).
Dietary advice in HD patients is recommended by the Kidney
Disease Outcomes Quality Initiative (KDOQI), through a nutritional Nutritional assessment and kidney disease
care plan and individualized dietary counseling emphasizing the quality of life
work of the dietitian nutritionist to prevent or treat potential or
ongoing nutritional deficiencies and alterations as an essential The assessment and the tools used to determine nutritional
task for optimal care of the patients with chronic kidney disease status and QoL are described in the methodology of the scientific
(CKD) (5). article of the previous descriptive study (11). The MIS score was
An early nutritional intervention program (NIP) during regular used to determine nutritional risk (12), and QOL was measured
follow up has been shown to prevent nutritional insufficiencies, using the validated Spanish version of the KDQOL-SF version 1.2
avoid malnutrition and improve the QoL of HD patients (6-9), can (13).
have a positive impact on their survival (3,10). Therefore, the ob-
jective of this study was to evaluate the effect of an NIP after one
year of follow-up on the nutritional status of HD patients and its Nutritional Education Program
impact on QoL and mortality.
All dialyzed patients received individualized consultations with
a trained dietitian over the study period. Each consultation last-
MATERIALS AND METHODS ed for about 35 to 40 minutes and focused on adequate food
intake for each patient’s energy and protein needs. All patients
STUDY POPULATION were comprehensively assessed every 3 months, or on a more
frequent basis in the case of malnourished patients and those at
This was a longitudinal intervention study of a cohort of main- nutritional risk, to check adherence to the prescribed nutritional
tenance HD patients with 12 months of follow-up. The nutrition- treatment and prevent further deterioration of nutritional status.
al care model for HD patients was set in accordance with the According to the KDOQI clinical practice guidelines (5), protein
clinical guidelines of the National Kidney Foundation’s Kidney intake for each patient was calculated as 1.0-1.2 g/kg of real,
Disease Outcomes Quality Initiative on nutritional support for HD ideal or adjusted body weight. We also calculated the energy
patients (5). intake for each patient as 25-35 kcal/kg of real, ideal or adjust-
As per hospital protocol, the malnutrition-inflammation score ed dry weight. Moreover, we suggested a daily recommended
(MIS) questionnaire is administered every 3 months and the KD- sodium intake below 2300 mg, a potassium intake of 1500-
QOL-SF is administered twice a year. Both are performed at the 2000 mg/day and a phosphate intake of 800-1000 mg/day. In
beginning of HD sessions by a nutritionist and trained nursing addition, we calculated levels of serum calcidiol to correct vitamin
assistants who work in the Nephrology Unit. D deficiency or insufficiency using the same treatment strategies
Ethical approval was granted by the Costa del Sol Research Ethics accepted for the general population. The daily recommended vi-
Committee on May 30, 2019 with approval number 85-05-2019. tamin D intake was 800-1000 IU/day.

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Effect of a personalized nutritional intervention program on nutritional status, 1231
quality of life and mortality in hemodialysis patients

The content of the nutritional education program included a and frequency distribution for qualitative variables. To evaluate
focus on individual energy and protein needs, tips to restrict the pre-post change, the McNemar test was used for categorical
intake of potassium, phosphorus, sodium and fluid and advice variables, and Student’s t-test (or Wilcoxon singed-rank test) for
on how to prevent hypovitaminosis D. Three types of education- quantitative paired samples. To evaluate changes in the three
al materials in the form of pamphlets were created and given assessments in the quantitative variables, the generalized lin-
to patients: 1) an individual meal plan; 2) a list of “cautionary” ear model for repeated measures was used. Finally, survival was
foods and cooking tips for low sodium, potassium and phospho- evaluated by means of survival curves using the Kaplan-Meier
rus intake; and 3) a list of foods rich in vitamin D with general method, comparing categories using the log-rank test. The level
recommendations. These recommendations were developed by of statistical significance was set at p < 0.05. SPSS v28 statisti-
nutritionists from the Pharmacy and Nutrition Department of Hos- cal software was used.
pital Universitario Costa del Sol.
In the first session, general information on nutrition therapy
and a recommended meal plan were given to the patients. Food RESULTS
exchange lists for preparing diets and planning individualized
menus were used (14) based on the food composition table Among the 75 HD patients, 66 % were men, and 47 % had
adapted to the Spanish population (15). diabetes mellitus. The Charlson comorbidity index predicted a
Later, the patients were instructed on how to control or prevent 10-year mortality of 14 % for the participants of the study. The
the development of hyperpotassemia, hypernatremia or hyper- mean age of the patients was 71 ± 13 years, and their mean
phosphatemia according to each patient’s serum concentration dialysis duration was 3 ± 3 years.
of these electrolytes. In the educational materials, foods were To examine the changes in clinical outcome with continuous
classified graphically according to low, medium or high content. nutritional counseling over time, baseline nutritional parameters
Cooking techniques and food processing methods that help were compared with the measurements at 6 and 12 months of
reduce their concentration were also included. Lastly, a list of follow-up (Table I).
foods classified according to their vitamin D content was given, The MIS scale score was two points lower at the end of the
promoting greater consumption of these foods in patients with study (p < 0.001), indicating a relatively less serious risk of de-
hypovitaminosis D and in patients in whom low intake of vitamin veloping malnutrition. In this regard, the presence of nutritional
D-rich foods was observed in the food diary. In addition, all pa- risk had a reduction rate of 12.5 % at the end of the study.
tients were informed of the importance of consuming vitamin D There were no significant changes in body composition (weight
and its repercussions on their health. or BMI), with 45 % of the patients having a BMI in the normal
In successive consultations, changes in the patients’ diets weight range at the end of follow-up. During the NIP, 23 % of the
were assessed and tailored solutions were suggested to achieve patients experienced weight loss, 52 % of whom lost weight in
adequate intake. Knowledge was consolidated and education on a balanced and healthy way following the nutritionist’s recom-
nutritional therapy was reinforced if needed. mendations.
Regarding the nutritional diagnosis, figure 1 shows the per-
centage change in the nutritional status of the patients at base-
Laboratory evaluations line, 6 months and 12 months. The number of patients with se-
vere protein-calorie malnutrition decreased by 19 %, while the
Blood measurements were taken in the morning after an percentage of patients diagnosed as well-nourished increased
8-hour overnight fast every 3 months. Blood samples consisted by 30 % (p < 0.001), with well-nourished patients representing
of electrolyte assay (phosphorus, potassium, sodium) and bio- 59 % of the total study population.
chemical parameters (hemoglobin, cholesterol, total proteins, In addition, of the 53 patients who had some degree of mal-
albumin, transferrin, prealbumin, C-reactive protein and 25-hy- nutrition at the start of the study and who were likely to improve
droxyvitamin D [25(OH)D]) assessed by standard laboratory after the nutritional intervention, nutritional status improved in 42
methods. of them (p < 0.001).
Concerning nutritional management, during the NIP, 100 %
of the patients received individualized nutritional recommenda-
Statistical methods tions and a diet based on weight-adjusted portions, as well as
informative material about fluid intake, potassium, phosphorus,
Data are presented as means ± standard deviation. Categori- protein, sodium and additives management. Sixty-five percent of
cal variables are shown as percentages. The Pearson correlation the patients required renal-specific oral nutritional supplements
coefficient was used for independent quantitative variables, the for patients in renal replacement therapy and 14 % required per-
Mann–Whitney U test for dichotomous qualitative variables and the sonalized intradialytic parenteral nutrition.
ANOVA test for qualitative variables with three or more categories. All patients responded to the KDQOL-SF version 1.2 question-
Descriptive analysis was performed using measures of cen- naire while being monitored by trained staff at the beginning and
tral tendency, dispersion and position for quantitative variables, at the end of the study.

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1232 L.   Visiedo et al.

Table I. Changes in nutritional parameters through personalized nutritional

counseling over time
Baseline 6th month 12th month p value
MIS 7.8 ± 3.2 6.6 ± 2.5 5.8 ± 2.3 < 0.001
Weight (kg) 67.9 ± 13.1 67.7 ± 13.1 65.9 ± 13.1 0.594
BMI (kg/m2) 25.7 ± 4.42 25.5 ± 4.47 25.1 ± 4.46 0.638
Hemoglobin (g/dl), M (SD) 10.6 ± 1.40 10.7 ± 1.17 11.0 ± 1.45 0.026
Cholesterol (mg/dl), M (SD) 138.4 ± 36.58 136.6 ± 24.77 148.4 ± 29.54 0.027
Albumin (g/dl), M (SD) 3.11 ± 0.62 3.17 ± 0.47 3.51 ± 0.48 < 0.001
Total protein (g/dl), M (SD) 5.89 ± 0.86 5.89 ± 0.81 6.48 ± 0.64 < 0.001
Transferrin (mg/dl), M (SD) 156.5 ± 32.1 161.7 ± 28.8 170.5 ± 37.0 < 0.001
Prealbumin (mg/dl), M (SD) 19.8 ± 7.89 22.5 ± 6.53 27.9 ± 8.0 < 0.001
Sodium (mEq/L), M (SD) 138.7 ± 3.22 138.6 ± 3.1 136.4 ± 2.8 0.948
Potassium (mEq/L), M (SD) 5.3 ± 0.84 5.0 ± 0.68 4.8 ± 0.55 < 0.001
Phosphorus (mg/dl), M (SD) 4.9 ± 1.51 4.3 ± 0.89 4.0 ± 0.88 < 0.001
Vitamin D (ng/ml), M (SD) 13.1 ± 12.04 18.7 ± 2.93 26.2 ± 12.16 < 0.001
Data are expressed as mean ± standard deviation for normal data. MIS: malnutrition-inflammation score; BMI: body mass index. p value is representative over time.

Figure 1. Nutritional status over the course of

the intervention. Data are expressed as % (MN:
malnutrition; PE: protein-energy).

Nutritional status was compared to scores on the KDQOL-SF Fluid and dietary restrictions are two aspects that are both-
components. Well-nourished patients had better scores on the ersome in the daily life of HD patients and are addressed in
general summary areas than malnourished patients both at the effects of kidney disease dimension. After starting the NIP,
baseline and at the end of the study. Statistically significant dif- there was a 63.4 % (p < 0.001) reduction in feeling bothered
ferences were found in scores on the general areas of the SF-36 by fluid restrictions and a 90.2 % (p < 0.001) reduction in
questionnaire in both periods (Table II). feeling bothered by dietary restrictions (Fig. 2).
The subareas with significantly higher scores at the end of The five-year survival rate of well-nourished (52.8 ±
the study in well-nourished patients on the specific part were 3.2 months) and malnourished (40.2 ± 2.7 months) patients
symptoms/problems, effects of kidney disease, cognitive func- was studied, with the survival rate being 12 months higher in
tion, quality of social interaction, dialysis staff encouragement, the cohort of well-nourished patients (p < 0.01). Furthermore,
and patient satisfaction with the care received; and on the ge- adjusted for age, malnourished patients had a hazard ratio of
neric part (SF-36) these were role-physical, pain, social function death of 3.4 (95 % CI: 1.2-9.8) compared to well-nourished
energy/fatigue and general health. patients (Fig. 3).

[Nutr Hosp 2023;40(6):1229-1235]

Effect of a personalized nutritional intervention program on nutritional status, 1233
quality of life and mortality in hemodialysis patients

Table II. Changes in scores on the general summary areas of the KDQOL-SF according
to nutritional status by personalized nutritional counseling over time
Nutritional status
Baseline 12th month p value
Well-
Malnourished Well-nourished Malnourished
nourished
Kidney disease component summary 56.3 ± 8.5 52.6 ± 10.6 58.5 ± 7.7 54.3 ± 6.8 0.05
Physical component summary 49.1 ± 11.1 31.4 ± 11.6 46.3 ± 11.7 35.9 ± 11.4 0.001
Mental component summary 47.7 ± 7.6 42.4 ± 8.6 48.9 ± 8.2 45.8 ± 9.2 0.05
Data are expressed as mean ± standard deviation for normal data. p value is representative over time.

A B

Figure 2. A. Fluid restriction. B. Dietary restriction of the patients over the course of the study. McNemar’s statistical test was used; p < 0.001.

Figure 3. Cumulative survival of the

patients according to nutritional sta-
tus. Log-rank statistical test was used;
p < 0.01.

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1234 L.   Visiedo et al.

DISCUSSION The results of this study demonstrate that the difference in

mean scores on the general summary areas of the KDQOL-SF
Clinical practice guidelines in CKD recommend that patients according to nutritional status before and after the intervention
in maintenance HD have a dietary interview and receive nutri- was higher in well-nourished patients than in malnourished pa-
tional counseling with a renal dietitian at least every 3 months tients. Since our results support the positive effects of educa-
and more often in the case of malnourished patients or those tional intervention on patient knowledge, QOL and the different
at high nutritional risk (5,6). Following these recommendations, dimensions of health, it can be concluded that education as a
since 2017, patients in the hemodialysis unit of the Costa del whole and dietary educational intervention as a specific ap-
Sol Hospital have benefited from the early nutritional intervention proach can facilitate improved patient health status, reduce the
program led by dietitian nutritionists as the findings of the pres- consequence of disease and improve QOL (general and specific
ent study show that, in agreement with results of previous in- areas) in HD patients, in line with the results of other scientific
ternational studies (7-9,16-18), nutritional intervention improves reports (18,28).
nutritional status, QoL and increases mean survival. Malnutrition has been shown to have a negative correlation
A lack of dietary adherence can affect nutritional status lead- with morbidity and mortality in HD patients (10,29). Data from
ing to renal disease progression and readmission, as well as our study show that after one year of nutritional management,
negatively impacting patient response to HD and deterioration of well-nourished patients had a higher 12-month survival rate
nutritional status and QoL (19). The results of this study demon- than malnourished patients (p < 0.01). Our findings are con-
strated a statistically significant improvement in the control of sistent with those of Blumberg et al. (10), who reported that
fluid restriction and dietary management in hemodialysis patients the deterioration of nutritional status during the first 3 months
through a nutritional educational program with encouragement on dialysis significantly increases the risk of death during the
and positive reinforcement (p < 0.001), showing less worry in first 3 years on dialysis. Data from the large Dialysis Outcomes
their daily life, better knowledge of their diet and an improvement and Practice Patterns Study cohort also considered that mal-
in their quality of life. These results are in agreement with other nourished HD patients have an increased risk of mortality, with
studies in the scientific literature (19-22). patients with severe malnutrition having a 33 % higher mortality
Improved adherence to nutritional recommendations not only risk than those who are well nourished (30). These data do not
resulted in a 30 % (p < 0.001) improvement in the nutritional prove that poor nutritional intake or malnutrition is a cause of
status of the well-nourished patients, but also an improvement in the high mortality in malnourished maintenance HD patients.
serum levels of visceral proteins and cholesterol at the end of the However, the data are consistent with the thesis that malnutri-
follow-up. Similar to our results, Jo et al. showed that after the tion or inadequate nutrient intake does contribute to high mor-
sixth month of nutritional intervention, albumin and cholesterol tality in these patients.
levels improved significantly (9). Other research associates this This study was designed as intervention research, but there
improvement with the use of oral nutritional supplements and was no control group of patients who did not receive nutritional
intradialytic parenteral nutrition (23,24). In our study, 65 % of counseling, which is a limitation of the study.
the population required oral nutritional supplements. These may To conclude, our study findings suggest that the NIP during
improve serum albumin levels and other nutritional parameters, regular follow up in dialyzed patients ensures the effectiveness of
which together with the support of nutritional, counseling and the nutritional training through individualized counseling and specific
intervention of dietitians, may improve clinical outcomes. dietary plans and materials, improving nutritional status, QoL and
Overall, the results also showed that nutrition education sig- increasing survival. However, to evaluate the effectiveness of an
nificantly improved the electrolyte status of the patients. Serum NIP more objectively, studies including a control group that does
potassium and phosphorus levels at 12 months were significant- not receive nutritional counseling are needed.
ly reduced (p < 0.001). In the study by Garagarza et al. (8), the
number of patients with hyperkalemia decreased by 16.2 % after
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