Sakurai et al.

Renal Replacement Therapy (2017) 3:60

DOI 10.1186/s41100-017-0137-4

RESEARCH Open Access

Questionnaire survey on nutritional

supplement therapy and exercise training
at hemodialysis facilities in Japan
Satoko Sakurai1, Norio Hanafusa2*, Hideki Kato1, Shinji Iizaka3, Ryoko Murayama4 and Masaomi Nangaku1

Abstract
Background: Nutritional therapy and exercise training (ET) are important interventions for hemodialysis patients.
We investigated the status of nutritional therapy and ET provided at hemodialysis facilities across Japan.
Method: This was a cross-sectional study. The facilities investigated were 3993 facility member institutions of the
Japanese Society for Dialysis Therapy in August 2015. Data was collected on the facility type, number of staff
(doctors, nurses, and medic al engineers), presence of staff (clinical dietitians, pharmacists, and physical therapists),
proportion of elderly patients (age ≥ 65 years), patients with albumin ≤ 3.5 g/dL, and types of oral nutritional
supplements (ONS), intradialytic parenteral nutrition (IDPN), and ET in the facility. We summarized data on facilities
and patient characteristics and calculated the proportion of the nutrition that were ONS, IDPN, and exercise
interventions provided. We used multiple logistic analyses to examine the facility characteristics associated with the
provision of nutritional support and ET.
Results: We obtained responses from 1048 facilities (response rate 26.2%) and 88,492 patients (27.6%). Patients aged ≥
65 years accounted for 63.4% of all investigated patients. Patients with Alb ≤ 3.5 g/dL accounted for 37.6% of all
investigated patients. Meals during hemodialysis sessions were provided at 601 facilities (64%), ONS were used at 382
facilities (40%), and IDPN was administered at 471 facilities (46%). Exercise during hemodialysis sessions was provided at
190 facilities (20%). These trends did not change after adjustment of response rates by affiliations of facility type and
region. At the patient level, only a limited number of patients were provided with ONS, IDPN, and ET, 2.1, 2.7, and 3.0%,
respectively. ONS and IDPN were less likely to be offered in hospitals than in clinics without beds (odds ratio (OR) 0.21;
95% confidence interval (CI) 0.09–0.45) (OR 0.37; 95% CI 0.17–0.82). ET was also less likely to be offered in hospitals (OR
0.20; 95% CI 0.08–0.49).
Conclusions: Nutritional support therapy is provided in a considerable number of hemodialysis facilities, ET is increasing
but offered by fewer facilities compared to other countries, while a limited number of patients were provided with ET.
Keywords: Hemodialysis, Questionnaire, Nutritional therapy, Exercise training, National survey

Background more [1]. Protein energy wasting (PEW), frailty, and sarco-
The aging population features prominently among penia are often found in patients with advanced chronic
hemodialysis patients and is influencing the epidemio- kidney disease and end-stage kidney disease [2, 3]. These
logical characteristics of this patient group. The average conditions are reportedly associated with each other.
age of incident patients and prevalent patients is more Moreover, they are related to higher mortality and mor-
than 65 years, and the increase in the dialysis population bidity [4–6], especially among elderly individuals in whom
is currently due to an increase in patients aged 70 years or physical functions and nutritional status have deteriorated.
Older patients are more vulnerable than younger popula-
tions to further decline in these parameters [2, 7–9].
* Correspondence: hanafusa@twmu.ac.jp
2
Department of Blood Purification, Kidney Center Tokyo Women’s Medical
In the dialysis population, the two primary options to
University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666, Japan maintain and even improve nutritional condition and
Full list of author information is available at the end of the article

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Sakurai et al. Renal Replacement Therapy (2017) 3:60 Page 2 of 10

physical function are nutritional therapy and exercise Data collection

training (ET), provided either within or outside the dialy- The collected data included the following:
sis facilities. For nutritional therapy, oral nutritional sup-
plements (ONS) given during hemodialysis can be 1. Facility details
associated with better survival of dialysis patients [10–13].
In fact, some dialysis facilities offer meals during the ses- Type: facility types were classified by their affiliation and
sions [14]. In the USA, dialysis facilities used to restrict size. The classification used by the JSDT annual survey for
eating during hemodialysis, but in recent years, they have affiliations of facilities, i.e., national university hospital, pri-
been shifting toward allowing patients to eat meals [15]. vate university hospital, national hospital, county municipal-
Many studies and meta-analyses have shown that ET im- ities hospital, hospital affiliated to the Japan Community
proves physical function, muscular strength, and func- Healthcare Organization, hospital affiliated to Japan Agricul-
tional capacity [16–18], although the details of how, when, tural Cooperatives, other public hospital, private general
and to whom ET should be given during hemodialysis ses- hospital, private hospital, and private clinic. On the other
sions remain unclear. hand, the original classification of four types according to
The needs for nutritional therapy and ET in dialysis their sizes were also investigated, i.e. clinic, clinic with beds,
facilities are expected to continue to increase, as are the hospital (< 200 beds), and hospital (≥ 200 beds). The survey
numbers of patients requiring such treatment. However, of medical facilities by Ministry of Health Labor and Welfare
it is not clear how many facilities are offering nutritional Japan determines the size of hospitals by the numbers of
therapy and ET, how many patients are receiving them, beds in the facility. The hospitals with 200 or more beds are
or what the detailed characteristics of these facilities are. considered large ones [19].
Such information is fundamental and indispensable for Region: prefecture and municipality in Japan.
the development of strategic plans for managing older Number of staff: number each of doctors, nurses, and
dialysis patients. clinical engineers.
This study sought to clarify the current status of Presence/absence of pharmacist, clinical dietitian, and
nutritional therapy and ET interventions provided at physical therapist providing care for patients on dialysis.
hemodialysis facilities in Japan, in order to identify appro- Background of treated patients as a whole: number of
priate intervention points and approaches for initiatives at patients aged ≥ 65 years, number of patients with
facilities in the future. albumin ≤ 3.5 g/dL. We used these cut-off values for the
reasons as follows. Regarding the age, the elderly persons
were defined as having a chronological age of 65 years in
Methods many countries including Japan at the time of this sur-
Study design vey [20], about albumin level, the European Society for
This was a cross-sectional study conducted using a Clinical Nutrition and Metabolism (ESPEN) guideline
nationwide questionnaire. described serum albumin < 3.5 g/dL as the criteria for
severe undernutrition for which nutritional therapy is
Study population indicated [21].
The study was conducted in member institutions of the
Japanese Society for Dialysis Therapy (JSDT). In total, 3993 2. Intervention provided at hemodialysis facilities: meals,
facilities were registered as member institutions of JSDT as ONS, intradialytic parenteral nutrition (IDPN), and ET
of August 2015. The survey collected data on the facilities
and patients receiving maintenance hemodialysis in these Statistical analyses
facilities during August 2015. Results are summarized as means and standard deviations
for data showing a normal distribution, and as medians
and interquartile ranges (IQR) for data not showing a
Study protocol normal distribution. Detailed data are shown as numbers
The questionnaire consisted of two parts. The first part and percentages.
contained questions regarding the facility itself, and the The following were excluded from analyses as outliers:
second part focused on the nutritional support and ET facilities where the percentage of aged (≥ 65 years) or
available at the facility (Additional file 1: Item S1). Ques- albumin ≤ 3.5 g/dL patients exceeded 100%.
tionnaires were sent to each facility by postal mail. We Because the response rates, that is the proportion of
asked that completed questionnaires be returned by fax facility that answered the question, differed by facility
by the end of October 2015. We also requested that the type and region, proportions of provision adjusted by
conditions of dialysis treatments should not be changed affiliations of facility type and region were calculated as
while answering this questionnaire. an average of the stratum-specific proportions weighted
Sakurai et al. Renal Replacement Therapy (2017) 3:60 Page 3 of 10

by their own proportion in the population. We used the Results

JSDT classification for facility type adjustment and six In total, 1048 facilities responded to the questionnaire
districts (Hokkaido and Tohoku, Kanto, Chubu and (response rate 26.2%). Regarding facility characteristics,
Tokai, Kansai, Chugoku and Shikoku, and Kyusyu and 41.3% of facilities were classed as a “clinic without bed” and
Okinawa) for region adjustment. Differences between 31.9% of facilities were located in the Kanto region (Table 1).
unadjusted and adjusted proportions of interventions The median number of total staff was 18 per facility
provided were compared by a chi-square test. (Table 2). In almost half of the facilities, pharmacists and
Multiple logistic analyses were used to explore the factors physical therapists were working, irrespective of affiliation to
associated with nutritional support and ET offered by the the dialysis center, while clinical dietitians were working in
facility. Dependent variables included the provision of 713 facilities (69.6%) (Table 3).
meals, ONS, IDPN, and ET at each facility. The facility- For patient characteristics, data were available regarding
related factors investigated were as follows: facility type 88,492 patients (response rate 27.6%), of which only 9.6%
(original four types); region (six regions); number of staff were hospitalized; the remaining 90.4% were outpatients.
(numbers of doctors, nurses, and clinical engineers) Elderly patients were predominant, with 63.4% of the
presented as quartiles; presence of staff (clinical dietitians, patients aged ≥ 65 years. The patients with serum albumin
pharmacists, and physical therapists); proportion of elderly ≤ 3.5 g/dL accounted for 37.6% of all investigated patients.
patients (age ≥ 65 years); and proportion of patients with The median number of patients per facility was 70 (IQR
albumin ≤ 3.5 g/dL. Reference data were set as follows: size 42–110) (Table 4).
of facility type; clinic without beds, region; Kanto, number
of staff; the first quartile values, and presence/absence of Nutritional and exercise interventions provided
staff; absence. We also performed a sensitivity analysis in Meals during hemodialysis sessions were provided at 601
which per-100-patient staffing level was used instead of facilities (63.9%), ONS were used at 382 facilities (39.8%),
actual number of staff as the covariate. In addition, we and IDPN was performed at 471 facilities (45.8%). ET
performed inverse probability of censoring weighted during hemodialysis sessions was provided at 190 facilities
analysis of affiliations of facility type and region specifically (20.2%). These trends did not change after adjustment by
for those facilities that provided responses to all items, facility type and region. In contrast, the actual patient
excluding facilities with logically erroneous data for sensi- numbers were lower; that is, the proportions of patients
tivity analyses to remove the effect of response rate. who were offered ONS, IDPN, and ET were 2.1, 2.7, and
First, we performed multivariate analysis with region and 3.0%, respectively, of the total patients (Table 5) The
affiliations of facility type as independent variables and proportions of the interventions provided in the facility
actual response rates of these 60 facility groups. Accordingly, were not associated with the probabilities of response
regression of facility group against response rate was deter- rates for this survey (Additional file 2: Table S2). This fact
mined to calculate the response probability of each facility indicated that the interest in providing these interventions
group. Subsequently, a response probability for each facility or the interest in responding to this survey might not
was assigned based on region and affiliations of facility type. affect the actual provision of these therapies.
Then, we performed multivariate analysis to investigate
factors affecting each therapy, with the reciprocal of the Table 1 Characteristics of facilities
response probability included as the weight for each facility.
Number of facilities (%)
The proportion of interventions provided was compared
Total facilities 1048
between hemodialysis facility groups with response probabil-
ities dichotomized by the median, using the chi-square test Facility type Clinic 430 (41.3)
to investigate the effects of the provision of interventions on Clinic with beds 120 (11.5)
the response probabilities. Hospital (< 200 beds) 212 (20.4)
We considered p < 0.05 statistically significant. All analyses Hospital (≥ 200 beds) 279 (26.8)
were carried out using JMP Pro 11.0 (SAS Institute, Unanswered 7
NC, USA).
Region Hokkaido, Tohoku 132 (12.8)
Kanto 328 (31.9)
Ethical issues Chubu, Tokai 163 (15.9)
The facility name was not specified in the questionnaire. Kansai 169 (16.5)
No data that could identify individual patients were Chugoku, Shikoku 101 (9.8)
collected. Return of the completed questionnaire was Kyushu, Okinawa 135 (13.1)
deemed as facility consent to participate. This study was
Unanswered 20
conducted in compliance with the Declaration of Helsinki.
Sakurai et al. Renal Replacement Therapy (2017) 3:60 Page 4 of 10

Table 2 Number of each type of medical staff per facility and Table 4 Patient characteristics: breakdown of total patients and
per number of patients and per facility number of patients per facility
Number of staff Number of staff per Number of Number of patients Rate of patients
per facility, median number of 10 patients patients (%) per facility, per facility
(IQR) and facility, median (IQR) median (IQR) (%, mean ± SD)
Total staff 18 (12–26) 2.5 (1.9–3.5) Total patients 88,492 70 (42–110)
Disciplines Doctor (full-time) 1 (1–3) 0.2 (0.1–0.5) Inpatients 8501 (9.6) 1 (0–9)
Doctor (part- 1 (0–4) 0.2 (0–0.5) Outpatients 79,991 64 (34–104)
time) (90.4)
Nurse (full-time) 7 (4–11) 1.1 (0.8–1.6) Patients aged ≥ 65 years 54,770 44 (26–69) (64.3 ± 14.4)
(n = 86,361) (63.4)
Nurse (part-time) 1 (0–2) 0.1 (0–0.3)
Patients with albumin 32,331 24 (11–41) (37.6 ± 20.4)
Clinical engineer 4 (1–6) 0.5 (0.3–0.8) ≤3.5 g/dL (n = 86,136) (37.6)
(full-time)
IQR interquartile range, SD standard deviation
Clinical engineer 0 (0–0) 0 (0–0)
(part-time)
pharmacists was not associated with the use of IDPN,
similar to the finding for clinical dietitians for ONS (p =
Polymeric formula was the type of ONS most frequently 0.73). ET was also less likely to be offered in hospitals
used (56.1%) followed by amino acid formula (31.1%) and (p < 0.01) and more likely in clinics with beds (p = 0.03).
formula for kidney failure patients (19.8%) (Fig. 1). Figure 2 The presence of physical therapists was positively associ-
indicates the proportions of patients receiving various ated with the implementation of ET (p < 0.01).
components of IDPN. More than half of the patients The facilities with higher proportion of the patients
(59.2%) received amino acids only. Most of the patients re- aged ≥ 65 years were more likely to use ONS and IDPN.
ceiving IDPN (91.3%) were given amino acids in some The facilities with higher proportion of the patients with
form; the proportion for glucose or lipids in some form serum albumin ≤ 3.5 g/dL were more likely to use IDPN,
was smaller (29.6 and 17.5%, respectively) (Fig. 2). but ONS showed no significant difference (Table 6). In
The types of ET offered by the facilities were diverse, the results of the sensitivity analysis, we analyzed the
including resistance training (RT) and aerobic training same factors weighted by the reciprocals of the response
(AT), with each intervention type accounting for almost probabilities and obtained similar results as the original
one-third of ET. Most patients (81.8%) performed ET analyses. Moreover, the proportion of the patients with
three times per week (Fig. 3). lower albumin levels was positively associated with the
Regarding exercise duration, almost half (50.2%) of the implementation of ONS (Table 7). Further sensitivity
patients performed ET for 15–29 min (Fig. 4). More analysis was conducted using per-100-patient staffing
than half of the facilities that did not offer ET at the time level and indicated similar results, except that the
of the study (61.1%) were considering implementation of number of doctors was negatively associated with the
ET in the future. likelihood of implementation of IDPN and that the
number of clinical engineers was no longer significant
Characteristic factors in facilities associated with each (Additional file 3: Table S3).
therapy
ONS were less likely to be offered in hospitals than in Discussion
clinics without beds (p < 0.01). To our surprise, the pres- This is the first nationwide survey concerning the types of
ence of a clinical dietitian was not associated with the nutritional therapy and ET for patients on hemodialysis in
use of ONS (p = 0.59). For IDPN, a similar relationship
was observed; the therapy was less likely to be used in Table 5 Facilities and patients providing nutritional therapy and
large hospitals than in clinics (p = 0.01). The presence of exercise training
Number of Number Unadjusted Adjusted p
patients (%) of proportion proportion valuea
Table 3 Facilities with and without relevant staff facilities (%) (%)
Number of facilities (%)
Meals 601 (61.1) (63.9) 0.21
Pharmacist Clinical Physical
dietitian therapist ONS 1873 (2.1) 382 (38.9) (39.8) 0.68

With staff working in HD 276 (26.9) 495 (48.3) 200 (19.6) IDPN 2425 (2.7) 471 (45.3) (45.8) 0.37

With staff not working in HD 272 (26.5) 218 (21.3) 314 (30.8) Exercise 2682 (3.0) 190 (19.2) (20.2) 0.57
ONS oral nutritional supplements, IDPN intradialytic parenteral nutrition
Without staff 478 (46.6) 312 (30.4) 506 (49.6)
Proportion of provision was adjusted for facility type and region
HD hemodialysis a
Unadjusted vs adjusted
Sakurai et al. Renal Replacement Therapy (2017) 3:60 Page 5 of 10

Fig. 1 Types of oral nutritional support. The low residue diet was most commonly used followed by amino acid formula and kidney failure formula.
Oral nutritional supplements (ONS) were offered by 399 facilities; however, this answer included multiple answers so the proportion of each
component was assessed among 523 answers

Japan. In this study, we adopted age and serum albumin reimbursed by health insurance in Japan and has a well-
as the patients’ characteristics. The proportion of patients balanced nutrient composition. About 50% of all facilities
aged ≥ 65 years, which was 63.4% in this study, was almost were offering IDPN. These results were independent of re-
identical to that of 61.8% found by JSDT for the entire sponse probability. Although the typical composition of
Japanese dialysis population [1]. The prevalence of serum IDPN reported in the literature is a mixture of glucose,
albumin < 3.5 g/dL was slightly greater at 37.5% in the amino acids, and lipid emulsion [23], most facilities in the
present study than the 33.8% reported in a JSDT survey present study used only the amino acid formula for IDPN.
[22], a difference that may be due to the inclusion or ex- This is possibly because the staff focused on the amino acids
clusion of patients with serum albumin equal to 3.5 g/dL. removed by the dialysis procedure [24]. Other reasons could
Approximately 40% of all facilities were administering be the higher costs of lipid emulsion compared with amino
ONS, predominantly the low residue diet that can be acid formula, as well as the time and labor required by med-
ical staff to mix the components for IDPN preparations.
ONS administration may be associated with better
survival [12]. Although IDPN did not have an additive
effect to ONS in malnourished dialyzed patients [25],
IDPN works to facilitate protein anabolism in patients
receiving long-term hemodialysis in the acute phase
[26]. This is evidenced by significant concomitant
increases in lean body mass and albumin synthesis in
the liver [27]. Therefore, both ONS and IDPN can
potentially ameliorate malnutrition. In the present study,
the proportion of patients treated by nutritional therapy
was as small as 2%, while the proportion of patients with
serum albumin ≤ 3.5 g/dL was as high as 37.5%.
Therefore, it is possible that patients who should have
Fig. 2 Types of intradialytic parenteral nutrition. Proportion of each been treated by nutritional therapy did not receive it.
component and the mixtures used among the 2425 patients receiving However, hypoalbuminemia is not the sole indication for
intradialytic parenteral nutrition (IDPN) are shown. The amino acids
nutritional therapy, and this criterion could overestimate
formula alone was the most commonly used (59.0%). Including the
combination of amino acids with glucose or lipid emulsion, 91.3% of the actual proportion of patients needing nutritional
patients received IDPN containing amino acids (black arc with arrows therapy. Further clarification of the indications for
at both ends). On the other hand, 29.6% of the patients received IDPN nutritional therapy is required in actual clinical practice.
containing glucose (blue scattered arc with arrows), and only 17.5% A positive point to note, however, is that logistic analysis
received IDPN containing lipids (red arc with arrows). Abbreviations:
showed nutritional therapy is being administered to
AA, amino acids; Glu, glucose; LE, lipid emulsion
patients with low nutrition in some facilities in Japan.
Sakurai et al. Renal Replacement Therapy (2017) 3:60 Page 6 of 10

Fig. 3 Types and frequency of exercise training. Approximately 30% of patients underwent resistance training (RT) alone, aerobic training (AT) alone, or
RT and AT (A). Further, 82% of patients exercised three times per week (B)

ET was enforced in about 20% of the facilities, and ET performed on non-dialysis days is reportedly
only 3% of all the patients were receiving ET. Patients the most effective way of training, although difficul-
on dialysis have extremely limited exercise capacity ties in maintaining adherence have been demon-
and poor physical functioning [28]. It has been strated [34]. In the present study, a limited number
reported that sedentary behavior in patients on of facilities (up to 20%) provided ET on hemodialysis
hemodialysis is associated with an increased risk of days and only 9% provided ET on non-hemodialysis
death within 1 year even after adjusting for all covari- days. DOPPS showed that the proportion of facilities
ates [29]. However, ET might increase aerobic providing ET on dialysis and non-dialysis days was
capacity, muscle mass or strength, physical quality of about 10% in japan from 2005 to 2006 [35]. After a
life, and Kt/V [16, 30]. Additionally, ET during decade, we found the facilities offering the exercise
dialysis therapy is associated with few adverse events program on dialysis is increasing as discussed above,
[16, 31, 32]. However, a study from the Dialysis Out- but the facilities offering ET on non-dialysis days
comes and Practice Patterns Study (DOPPS) showed have not increased. Recently it reported that two
that the percentage of units offering exercise daily 10-min walking sessions during the off-dialysis
programs was 14% in Japan from 2009 to 2011, while days (every second day for patients on peritoneal dialysis)
27 and 37% of the facilities offered ET in Europe or at a prescribed walking speed may improve physical
Australia/New Zealand and in North America, performance and quality of life [36]. Our findings indicate
respectively [33]. This difference between DOPPS and that the awareness of ET needs to be further improved.
our study might indicate an increase in the facilities Each intervention type accounting for almost one-
offering ET over the last few years, as the benefits of third of ET. Recently many studies have reported the
ET have become widely accepted. evidences about exercise for dialysis patients. But the

Fig. 4 Exercise duration. Half of the patients underwent exercise for 15–29 min during a single session
Sakurai et al. Renal Replacement Therapy (2017) 3:60 Page 7 of 10

Table 6 Logistic regression analysis

Variable ONS IDPN Exercise
OR (95% CI) p value OR (95% CI) p value OR (95% CI) p value
Clinic 1 reference 1 reference 1 reference
Clinic with beds 0.66 0.38–1.11 0.12 1.15 0.68–1.96 0.60 0.50 0.28–0.95 0.03
Hospital (< 200 beds) 0.49 0.22–1.05 0.07 0.50 0.23–1.10 0.08 0.20 0.08–0.49 < 0.01
Hospital (≥ 200 beds) 0.21 0.09–0.45 < 0.001 0.37 0.17–0.82 0.01 0.08 0.03–0.20 < 0.001
Doctor Q1 1 reference 1 reference 1 reference
Q2 0.95 0.59–1.53 0.83 0.76 0.48–1.21 0.25 0.85 0.46–1.63 0.62
Q3 0.62 0.37–1.05 0.08 0.64 0.38–1.07 0.09 0.97 0.50–1.94 0.94
Q4 0.85 0.50–1.45 0.55 0.86 0.51–1.45 0.56 1.39 0.71–2.79 0.34
Nurse Q1 1 reference 1 reference 1 reference
Q2 1.21 0.81–1.84 0.36 0.83 0.55–1.24 0.36 1.00 0.56–1.79 1.00
Q3 1.71 1.14–2.60 0.01 1.70 1.14–2.56 < 0.01 1.66 0.98–2.83 0.06
Q4 1.64 1.03–2.60 0.04 1.71 1.08–2.70 0.02 1.58 0.90–2.81 0.11
Clinical engineer Q1 1 reference 1 reference 1 reference
Q2 1.17 0.67–2.06 0.58 1.51 0.88–2.63 0.13 1.59 0.73–3.80 0.25
Q3 1.92 1.09–3.44 0.03 2.65 1.51–4.71 < 0.001 1.95 0.88–4.72 0.10
Q4 2.76 1.56–5.00 < 0.001 3.32 1.88–5.95 < 0.001 5.93 2.76–14.03 < 0.001
Presence of pharmacist (vs absence) 0.99 0.54–1.81 0.98 0.90 0.49–1.66 0.73 1.03 0.50–2.07 0.93
Presence of clinical dietitian (vs absence) 1.13 0.73–1.73 0.59 1.01 0.65–1.55 0.97 1.94 1.15–3.29 0.01
Presence of physical therapist (vs absence) 1.84 1.05–3.28 0.03 1.95 1.09–3.55 0.02 3.48 1.85–6.66 < 0.001
Regions Hokkaido/Tohoku 0.79 0.44–1.27 0.29 1.58 0.95–2.64 0.08 2.85 1.48–5.46 < 0.01
Kanto 1 reference 1 reference 1 reference
Chubu/Tokai 1.01 0.63–1.60 0.97 1.62 1.03–2.58 0.04 2.05 1.12–3.73 0.02
Kansai 1.00 0.64–1.56 1.00 1.76 1.13–2.76 0.01 1.98 1.10–3.52 0.02
Chugoku/Shikoku 0.90 0.51–1.57 0.71 1.51 0.87–2.63 0.15 2.03 0.97–4.16 0.06
Kyushu/Okinawa 0.76 0.44–1.30 0.31 0.72 0.42–1.23 0.23 2.69 1.37–5.29 <0.01
Patients aged ≥ 65 years (per 10%) 1.14 1.01–1.28 0.03 1.16 1.03–1.30 0.01 1.07 0.93–1.25 0.35
Patients with albumin ≤ 3.5 g/dL (per 10%) 1.03 0.95–1.12 0.44 1.09 1.01–1.17 0.03 0.95 0.86–1.05 0.35
Abbreviations: OR odds ratio, CI, confidence interval

best way to offer ET in dialysis patients remains practice patterns implemented in a facility could affect
unclear. The current study demonstrated that the the clinical outcomes of patients treated at that facility.
actual types of ET were diverse across the facility So it is important for every dialysis facility to be aware
offering ET. Many investigations have employed ET as of the usefulness and safety of ET in order to prevent
an intervention for at least 30 min, three times a PEW progression to further unfavorable outcomes. In
week [16]. The duration of ET in Japanese facilities fact, over half of the total facilities included in this sur-
was found to be shorter in this study, possibly be- vey intended to offer ET.
cause the Japanese dialysis population investigated The present investigation into the background factors
here was older than that in the reported clinical trials relating to the implementation of these therapies
(aged 40–50 years) [16]. indicated that clinics tend to offer such therapies rather
DOPPS reported an important finding: patients who than hospitals. In general, clinics without beds manage
exercise regularly showed better survival than those who larger numbers of chronic patients over longer terms,
do not (HR 0.73, 95% CI 0.69–0.78); moreover, patients enabling them to provide these therapies more fre-
who received treatment at a facility with a higher quently than the other facility types. In contrast, we can
frequency of exercise also had better survival (HR per consider that the patients in hospitals have different
10% increase in regularly exercising patients 0.92, 95% characteristics from those in clinics; they require the
CI 0.89–0.94) [35]. These results demonstrate that the treatment for acute conditions because the hospitalized
Sakurai et al. Renal Replacement Therapy (2017) 3:60 Page 8 of 10

Table 7 Logistic regression analysis with inverse probability of response rate weighting for facility type and region
Variable ONS IDPN Exercise
OR (95% CI) p value OR (95% CI) p value OR (95% CI) p value
Clinic 1 reference 1 reference 1 reference
Clinic with beds 0.68 0.52–0.88 < 0.01 1.18 0.96–1.54 0.22 0.56 0.41–0.78 < 0.001
Hospital (< 200 beds) 0.51 0.36–0.73 < 0.001 0.59 0.41–0.85 < 0.01 0.24 0.16–0.37 < 0.001
Hospital (≥ 200 beds) 0.22 0.15–0.33 < 0.001 0.43 029–0.64 < 0.001 0.10 0.06–0.16 < 0.001
Doctor Q1 1 reference 1 reference 1 reference
Q2 0.94 0.74–1.18 0.56 0.89 0.71–1.12 0.33 0.88 0.65–1.20 0.41
Q3 0.59 0.46–0.76 < 0.001 0.66 0.52–0.85 < 0.01 0.88 0.64–1.23 0.46
Q4 0.85 0.66–1.09 0.20 0.84 0.65–1.08 0.18 1.64 1.19–2.30 < 0.01
Nurse Q1 1 reference 1 reference 1 reference
Q2 1.07 0.87–1.30 0.52 0.89 0.73–1.08 0.23 1.14 0.87–1.51 0.34
Q3 1.65 1.35–2.01 < 0.001 1.76 1.45–2.14 < 0.001 1.73 1.34–2.24 < 0.001
Q4 1.62 1.30–2.01 < 0.001 1.69 1.35–2.10 < 0.001 1.70 1.30–2.24 < 0.01
Clinical engineer Q1 1 reference 1 reference 1 reference
Q2 1.10 0.85–1.43 0.47 1.46 1.13–1.89 < 0.01 1.77 1.21–2.65 < 0.01
Q3 1.84 1.41–2.42 < 0.001 2.74 2.10–3.60 < 0.001 1.93 1.30–2.93 < 0.01
Q4 2.66 1.41–3.51 < 0.001 3.36 2.56–4.44 < 0.001 6.36 4.34–9.52 < 0.001
Presence of pharmacist (vs absence) 1.05 0.78–1.41 0.76 0.81 0.60–1.10 0.17 1.04 0.74–1.47 0.80
Presence of clinical dietitian (vs absence) 1.13 0.91–1.40 0.26 1.02 0.82–1.27 0.83 2.05 1.58–2.66 < 0.001
Presence of physical therapist (vs absence) 1.76 1.36–2.29 < 0.001 1.97 1.51–2.59 < 0.001 2.41 1.80–3.25 < 0.001
Regions Hokkaido/Tohoku 0.69 0.54–1.27 < 0.01 1.60 1.24–2.07 < 0.001 2.86 2.06–3.96 < 0.001
Kanto 1 reference 1 reference 1 reference
Chubu/Tokai 0.99 0.72–1.12 0.33 1.52 1.23–1.90 < 0.001 2.33 1.76–3.07 < 0.001
Kansai 1.00 0.80–1.23 0.92 1.53 1.24–1.91 < 0.001 1.77 1.33–2.34 < 0.001
Chugoku/Shikoku 0.71 0.55–0.92 < 0.01 1.35 1.05–1.75 0.02 2.40 1.72–3.33 < 0.001
Kyushu/Okinawa 0.63 0.49–0.81 < 0.001 0.63 0.49–0.81 < 0.001 3.00 2.20–4.09 < 0.001
Patients aged ≥ 65 years (per 10%) 1.13 1.07–1.20 < 0.001 1.22 1.16–1.30 < 0.001 1.04 0.96–1.11 0.34
Patients with albumin ≤3.5 g/dL (per 10%) 1.04 1.00–1.08 0.03 1.09 1.06–1.14 <0.001 0.98 0.93–1.03 0.36
Abbreviations: OR odds ratio, CI confidence interval

patients in other nephrology department tend to have background. This fact shows the medical director of
many comorbidities. the facility might have different criteria to implement
The results obtained from the analyses where staff ET from those for ONS and IDPN.
number was standardized by patient number confirmed Surprisingly, the provision of ONS or IDPN was
that IDPN is being predominantly offered in clinics independent of the presence of dietitians or pharmacists in
without beds. the facility. This might indicate these therapies might be
Interestingly, our results indicate that the number of readily available irrespective of the professionals available,
staff—key elements of each facility—was positively corre- although the involvement of dietitians or pharmacists might
lated with the implementation of nutritional therapy or improve the quality or effectiveness of these therapies.
ET. In particular, the results obtained from the analyses There are several limitations to this study. The first is
standardized by facility type and region revealed stronger that this observational study did not examine the data of
associations between these factors. individual patients. Therefore, we could not investigate
Curiously, the proportions of the older patients or the detailed relationship between patient characteristics
the patients with lower albumin levels were positively and the interventions or clinical outcomes. However, the
associated with the implementation of ONS or IDPN. aim of the study was to investigate the overall status of
On the other hand, ET did not have such associations these therapies in Japan, which has not been investigated
with the proportions of the patients with such previously. Second, the response rate for the
Sakurai et al. Renal Replacement Therapy (2017) 3:60 Page 9 of 10

questionnaire was not high 26% of all facilities. Although questionnaire design. SI contributed to the data analysis. HK, RM, and MN
detailed patient characteristics were not investigated and reviewed and finalized the manuscript for intellectual content. All authors
read and approved the final manuscript.
we cannot eliminate the effects of differences in patients
characteristics between responded and non-responded Ethics approval and consent to participate
facilities, the proportions of older patients or the The study was approved by the Ethics Committee of the University of Tokyo
patients with albumin of 3.5 g/dl or less were not School of Medicine on 7 September 2015 (approval number 10943).
virtually different from the entire dialysis population in
Consent for publication
Japan. On the other hand, the response rate did differ Not applicable.
across the facility types. However, adjustment by affili-
ations of facility type or region yielded no significant Competing interests
differences in the proportion of facilities offering Satoko Sakurai: none. Norio Hanafusa: NH received research funding from
Meiji Co., Ltd., a manufacturer of oral nutritional supplements and was also a
these interventions. former member of a division that is funded by Terumo Corporation.
However, this study has no association with that funding and the
Conclusions relationship did not affect the interpretation of this study’s results. Hideki
Kato: none. Shinji Iizaka: none. Ryoko Murayama: RM is a member of a
Many hemodialysis facilities provided nutritional inter- division that is funded by Terumo Corporation. However, this study has no
vention and for ET are also increasing, while a limited association with that funding and the relationship did not affect the
number of patients provided ET. And the number of interpretation of this study’s results. Masaomi Nangaku: MN served as
consultancy or advisory boards of Akebia, Bayer, Kyowa Hakko Kirin, Daiichi
staff was positively correlated with the implementation Sankyo, Astellas, Taisho, Mitsubishi Tanabe, JT, speaker bureaus of Kyowa
of nutritional therapy or ET. We consider it important Hakko Kirin, Daiichi Sankyo, MSD, Astellas, AstraZeneca, Alexion, Mitsubishi
to assess the indications for nutritional therapies and ET Tanabe, JT, and Chugai. However, this study has no association with that
funding and the relationship did not affect the interpretation of this study’s
for each patient appropriately and to provide patients results. This research did not receive any specific grant from funding
with appropriate and detailed knowledge about such agencies in the public, commercial, or not-for-profit sectors.
therapies for their proper and wider use. Moreover, the
standardization of nutritional therapy and ET is needed
Publisher’s Note
in the future. Springer Nature remains neutral with regard to jurisdictional claims in published
maps and institutional affiliations.
Additional files Author details
1
Division of Nephrology and Endocrinology, The University of Tokyo
Additional file 1: Item S1. Questionnaire. (PDF 194 kb) Graduate School of Medicine, Tokyo, Japan. 2Department of Blood
Additional file 2: Table S2. Proportion of facilities providing Purification, Kidney Center Tokyo Women’s Medical University, 8-1
interventions based on lower and higher response probabilities. (PDF 88 kb) Kawada-cho, Shinjuku-ku, Tokyo 162-8666, Japan. 3School of Nutrition,
College of Nursing and Nutrition, Shukutoku University, Chiba, Japan.
Additional file 3: Table S3. Logistic regression analysis with conducted 4
Department of Advanced Nursing Technology, The University of Tokyo
using per-100-patient staffing level. (PDF 111 kb) Graduate School of Medicine, Tokyo, Japan.

Abbreviations Received: 6 June 2017 Accepted: 27 November 2017

95% CI: 95% confidence interval; AA: Amino acids; AT: Aerobic training;
DOPPS: The Dialysis Outcomes and Practice Patterns Study; ESPEN: The
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