Long-term nutritional study: anthropometrical and clinico-laboratory assessments in renal replacement therapy patients after intensive nutritional counselling
Date
2016-12-22
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Abstract
Sissejuhatus:
Krooniline neeruhaigus (KNH) on vaikselt ja algstaadiumis oluliste kaebusteta kulgev haigus, mis progresseerub lõpp-staadiumi neerupuudulikkuseni aastate ja sageli aastakümnete jooksul. KNH peamisteks tekkepõhjusteks Eestis on glomerulonefriit, suhkur- ja kõrgvererõhktõbi ning harvem muud kroonilised neeruhaigused. KNH lõpp-staadiumi haigete arvu suurenemine Eestis ja globaalselt on seotud eelkõige KNH progresseerumist põhjustavate riskitegurite laialdase esinemisega elanikkonna hulgas (hüpertensioon, suitsetamine, ülekaal, rasvtõbi, jm.), diagnostika- ja ravivõimaluste paranemisega ning dialüüsiaparatuuri täiustumisega. KNH-ga kaasnevalt areneb südame- ja veresoonkonna kahjustus ning KNH-ga patsientide kardiovaskulaarne suremus on üldrahvastikuga võrreldes oluliselt suurem.
Lõpp-staadiumi neerupuudulikkuse kõige efektiivsemaks ravimeetodiks on neerusiirdamine hemo- ja peritoneaaldialüüsi kõrval. Neeru siirdamise järgselt patsiendi üldseisund ja söögiisu paraneb ning sageli kehakaal suureneb. Teaduskirjanduses ilmub üha uusi andmeid siirdatud neeruga patsientide antropomeetriliste, densitomeetriliste ja biokeemiliste näitajate, toitumisharjumuste ja toiduvaliku kohta, kuid kehakaalu suurenemise ärahoidmise efektiivsete meetodite kohta on läbi viidud väga vähe uuringuid.
Käesoleva uurimustöö üldine eesmärk oli analüüsida lõpp-staadiumi kroonilise neeruhaige kehakoostist ja toitumisharjumusi. Me püstitasime hüpoteesi, et intensiivne toitumisalane nõustamine võimaldab muuta patsientide toitumisharjumusi nii, et peale neerusiirdamist ei teki olulist kehakaalu suurenemist.
Uuringu eesmärgid:
1. Analüüsida antropomeetriliste mõõtmiste tulemusi lõpp-staadiumi neerupuudulikkuse haigetel ning võrrelda dialüüsi ja transplanteeritud haigete kehakoostise andmeid.
2. Testida, kas intensiivsel toitumisalasel nõustamisel on efekti neerutransplantatsiooni mees- ja naishaigete kehakoostisele.
3. Hinnata intensiivse toitumis-alase nõustamise mõju antropomeetriliste, biokeemiliste ja toitumuse parameetrite muutustele peale jälgimisperioodi ning analüüsida nimetatud parameetrite omavahelisi seoseid eraldi siirdatud mees- ja naishaigetel.
4. Hinnata intensiivse toitumisalase nõustamise pika-aegset efekti kehakaalu suurenemisele neerutransplantatsiooni haigetel.
5. Hinnata makro- ja mikrotoitainete kasutust neerutransplantatsiooni haigetel 3-päeva menüü
alusel dünaamikas.
Uuritavad ja uurimismeetodid:
Uuring viidi läbi Tartu Ülikooli Kliinikumi Sisekliiniku nefroloogia osakonnas aastatel 2003–2005 ja 2015. Uuringul on Tartu Ülikooli inimuuringute eetikakomitee luba.
Esimesse uuringugruppi kaasati kliiniliselt stabiilses seisundis järjestikulised neeruasendusravi patsiendid (dialüüsravil ja siirdatud neeruga), kes andsid nõusoleku uuringus osalemiseks: 37 mees- ja 38 naispatsienti.
Teise uuringugrupi moodustasid stabiilses seisundis järjestikulised neerusiirikuga patsiendid, kes andsid nõusoleku uuringus osalemiseks: 12 meespatsienti (keskmine vanus 42,8 ± 16,1 aastat) ja 16 naispatsienti (keskmine vanus 47,0 ± 14,9 aastat). Uuringud viidi läbi kahe visiidi käigus: esimene visiit poolteist aastat ja teine visiit kolm aastat peale neerusiirdamist.
Uurimismeetodid olid järgmised: antropomeetrilised mõõtmised, kehakoostise hindamine bioimpedansi ja densitomeetria abil, laboratoorsete näitajate kogumine ning toitumise uurimine 3-päeva menüüde alusel. Lisaks koostati spetsiaalne ankeet-sagedusküsimustik toitumise uurimise kohta (Food Frequency Questionnare, FFQ).
Antropomeetrilisi mõõtmisi teostati vastavalt klassikalise Martini (1928) ja Knussmann (1988) metoodika järgi. Mõõdeti 36 antropomeetrilist näitajat: kehakaal, pikkus, 2 keha sügavusmõõtu, 8 keha laiusmõõtu, 13 ümbermõõtu ja 11 nahavolti. Kõik mõõtmised teostati litsentseeritud antropometristi poolt. Nende mõõtmiste alusel arvutati indeksid ja kehakoostise näitajad: keharasvamass (kg; %), kehamassiindeks (BMI, kg/m2), kehapindala (m2), kehatihedus (g/cm3), Siri indeks (%), keskmine nahavoldi paksus (mm), nahaaluse rasvkoe mass (kg), suhteline rasvkoe mass kehakaalu suhtes. Kehakoostise tähtsamad komponendid on kehatihedus (Db) ja keharasvamass (FM), mida arvutati kahe regressioni võrrandi (Jack H. Wilmore ja Albert R. Behnke, Durnin ja Rahaman) alusel.
Densitomeetriline uuring teostati uuringu teisel visiidil. Osteopeenia ja osteoporoosi hindamiseks teostati regionaalne luutiheduse mõõtmine lülisamba lumbaalpiirkonnas. Mõõtmised teostati aparaadil GE LUNAR DPX-IQ densitomeeter (Madison, WI, US, software version 4.7e) sertifitseeritud tehniku poolt.
Laboratoorsed andmed koguti peale neeru siirdamist uuringu esimesel ja teisel visiidil. Vereseerumis määrati 18 olulist laboratoorset parameetrit, sealhulgas verelipiidide, parathormooni, homotsüsteiini ja tsüstatiin C tase.
Toitumise uurimine viidi läbi kasutades kahte meetodit: esimene meetod käsitles ühekordset ankeet-sagedusküsimustikku (FFQ), mida uuritav täitis ainult uuringu esimesel visiidil. Teine meetod käsitles 3-päeva menüüde kogumist mõlemal visiidil. Individuaalset toitumisalast nõustamist alustati kohe peale ankeet-küsitluslehe täitmist ja 3-päeva menüüde analüüsimist. Kroonilise neeruhaige toitumisalase nõustamise aluseks on antropomeetrilised ja kehakoostise näitajad ning laboratoorsed testid. Lisaks eelnevale arvestati ka haige toitumisharjumusi, kuid soovituslikul toiduvalikul lähtuti Eestis kehtivast ja autori poolt välja töötatud haiguspuhusest dieetide nomenklatuurist.
Statistiline analüüs:
Meie uuritavatel viidi läbi klassikalised antropomeetrilised mõõtmised ja mõõtmisandmete statistiline analüüs (statistikaprogramm SAS), mille alusel on toodud kirjeldava statistika näitajad antropomeetriliste tunnuste kohta (keskväärtused, standardhälbed) eraldi mees- ja naispatsientidel. Korrelatsioonianalüüsil uuriti seoseid antropomeetriliste ja kliinilis-laboratoorsete tunnuste ning toitainete kasutuse vahel, kasutades Pearsoni korrelatsiooni- analüüsi. Regressioonianalüüsiga arvutati parimad prognostilised mudelid siirdatud neeruga patsientide toitumise hindamiseks. Erinevate uuritavate gruppide tunnuste keskväärtuste hindamisel ja varasemate andmetega võrdlemiseks on kasutatud t-testi. Lubatud statistilise vea piiriks valiti 5% (p < 0.05).
Tulemused:
1. Esimese uuringugrupi neeruasendusravil olnud haigete antropomeetriliste mõõtmiste tulemused näitasid, et uuritud dialüüsi ja neerusiirikuga haigete gruppide keskväärtusete näitajad olid sarnased. Neerutransplantatsiooni järgselt tavaliselt haigete ureemiline seisund taandub, üldseisund paraneb ja isu suureneb, mis omakorda avaldub kehakaalu suurenemises, kuid meie esimesse uuringugruppi kaasatud neerusiirikuga haigetel ei esinenud veel olulist kehakaalu suurenemist.
2. Teise uuringugrupi moodustasid neerusiirikuga haiged, kellel viidi läbi antropomeetrilised mõõtmised ja dietoloogi poolt toitumisalane intensiivne nõustamine 1,5 aastat peale neerusiirdamist (1. visiit) ja 3 aastat peale neerusiirdamist (2. visiit). Transplanteeritud haigete kehakoostist hinnati eraldi meestel ja naistel. Peale intensiivset toitumisalast nõustamist olid uuritavatel paljude antropomeetriliste näitajate muutused kooskõlas kehakaalu suurenemisega. Samas, meeste kehakaalu suurenemine oli peale jälgimisaega statistiliselt oluline, kuid naistel mitte. See võib olla seletatav sellega, et naised järgisid dietoloogi-poolseid soovitusi ja kehakaalu hoolsamalt võrreldes meestega.
3. Intensiivse toitumisalase nõustamise järgselt kliinilisest aspektist lähtudes, esinesid olulised biokeemiliste näitajate muutused, põletikulise staatuse (CRV) normaliseerumine ja lipiidide taseme normi piirides püsimine nii meestel kui naistel.
4. Antropomeetriliste ja biokeemiliste näitajate vahelised seosed olid meestel ja naistel erinevad. Meestel esinesid antropomeetriliste mõõtmiste seosed põletikunäitajatega ja naistel lipiididega. Vaatamata intensiivsele toitumisalasele nõustamisele jäid need seosed püsima ka korduval mõõtmisel (3 aastat peale neerusiirdamist). Need seosed väärivad tähelepanu, sest põletikuline staatus ja hüperlipideemia on üldtuntud kardiovaskulaarsed riskitegurid. On teada, et lõpp-staadiumi neerupuudulikkuse haigetel, sealhulgas neerutransplantatsiooni järgselt, on peamised surmapõhjused neeruhaigetel just kardiovaskulaarsed tüsistused.
5. Antropomeetriliste näitajate usaldusväärseid seoseid mikro- ja makrotoitainete kasutusega 3-päeva menüüde andmete alusel ei esinenud. Järelikult nimetatud seosed ei oma kliinilist tähtsust.
6. Intensiivse toitumisalase nõustamise efektiivsus avaldus ka kaugtulemusi uurides: 10 aastat peale neerusiirdamist ei esinenud statistiliselt usaldusväärset kehakaalu suurenemist nõustamist saanud transplanteeritud meeste ega naiste seas erinevalt neerusiirikuga kontrollhaigetest.
7. Peamiste toitainete kasutamisel leidsime valkude ja süsivesikute tarbimise suurenemist jälgimisperioodi ajal naistel, kuid mitte meestel ning rasvade kasutus jäi normi piiresse nii naistel kui meestel. Nii naiste kui ka meeste osas on nende makro- ja mikrotoitainete kasutamine kooskõlas Eesti toitumis- ja toidusoovitustega. Järelikult, intensiivne toitumisalane nõustamine oli efektiivne, patsientide toitumisharjumused paranesid niivõrd, et kehakaal ei suurenenud, kuigi mõnede toitainete osas esines suurenenud tarbimise tendents, ei ületanud nende tarbimine kaasaegsete Eesti vabariigi toitumissoovituste referentsväärtusi.
Kehakaalu suurenemine leiab aset neerusiirdamise järgsetel esimestel aastatel ning seetõttu on oluline õigeaegne ja asjakohane patsientide teavitamine ning antropomeetriliste mõõtmiste regulaarne läbiviimine. Kliinilises tavapraktikas teeb seda patsiendi raviarst ja dietoloog annab oma soovitused vajadusel neerusiirdamise järgselt haiglast lahkudes. Edaspidine dietoloogi-poolne monitoorimine ei tarvitse alati olla enam järjepidev, kuna haigete üldseisund paraneb ja nad külastavad neerukeskust harvem. Transplanteeritud patsientide toitumisalane nõustamine peab olema individuaalne ja regulaarne, mis eeldab kõikide kliiniliselt oluliste andmete järjepidevat kogumist ja analüüsimist dünaamikas.
Optimal nutritional evaluation, the use of biochemistry together with anthropometry in clinical practice is of great importance in all chronic kidney disease phases, including the post-transplant period. The gain of body weight often develops after kidney transplantation and influences the long-term outcome. Much research has been carried out in the world studying the body composition of healthy people but there are limited data about the research where these methods together with other clinical parameters have been used for investigating patients with a transplanted kidney. The assessment of body composition in a complex manner, including the anthropometrical, blood biological and nutritional peculiarities of the patients with a transplanted kidney, have not been previously studied in Estonia. According to literature, the main problem after kidney transplantation is the gain of body weight, therefore, we planned to test if intensive nutritional counselling has an effect on a patient’s nutritional habits in preventing the gain of body weight. The general aim of the present study was to analyse the body build and nutritional habits of end-stage chronic kidney disease (CKD) patients. We hypothesised that intense nutritional counselling significantly improves nutritional habits, and, ultimately, the gain of body weight after kidney transplantation will be prevented. The specific aims of the present study were as follows: 1. To analyse anthropometric measurements data of the end-stage CKD patients and to compare the body composition of the dialysis and transplant patients. 2. To test if intensive nutritional counselling has an effect on body composition of kidney transplant male and female patients. 3. To evaluate the effect of intensive nutritional counselling on the changes of anthropometric, biochemical and nutritional parameters of kidney transplant patients after the follow-up and to describe gender-specific associations between the studied parameters. 4. To estimate the long-term effect of intensive nutritional counselling on anthropometrical measures of kidney transplant patients. 5. To evaluate the follow-up changes of the intake of nutrients of kidney transplant patients on the basis of a 3-day menu. Subjects of study and methods: The prospective long-term study was carried out during the years 2003–2005 and 2015 at the Department of Internal Medicine of the University of Tartu. In total, 150 chronic kidney disease patients were studied. The kidney transplant patients had their transplantation at the Transplant Center of the Tartu University Hospital. The first anthropometric study population consisted of 75 consecutive non-diabetic CKD patients (37 males and 38 females) of renal replacement therapy who had agreed to participate in the study and who were treated at the Nephrology Division of the Tartu University Hospital. The participation was voluntary and all patients signed a written informed consent. The transplanted patients’ population was formed from consecutive stable ambulatory non-diabetic kidney transplant patients (12 males at the age of 42.8 ± 16.1 years and 16 females at the age of 47.0 ± 14.9 years) who had agreed to participate in the study and who were monitored by the nephrologists at the Tartu University Hospital. The participation was voluntary and all patients signed a written informed consent. The transplanted patients’ control population was formed from 47 clinically consecutive stable ambulatory non-diabetic kidney transplant patients who had agreed to participate in the study and who were monitored by the nephrologists at the Tartu University Hospital or at the West-Tallinn Central Hospital. The participation was voluntary and all patients signed a written informed consent. All the measurements of 28 kidney transplant patients, including anthropometry, densitometry, biochemistry, the food frequency questionnaire (FFQ) and the 3-days dietary records, were analysed. The data of anthropometry, biochemistry and the 3-days dietary records analyses were performed in patients twice: one and a half years after the first cadaveric kidney transplantation and afterwards, three years after the kidney transplantation during the follow-up. Densitometry was performed in patients once after three years of the transplantation. The preventive nutritional counselling and dietary consultation by a dietitian were carried out for all the kidney transplant patients during one and a half years after the kidney transplantation. The initial data were compared with the results obtained at the end of the study. The last anthropometric measurements ten years after the kidney transplantation were carried out both in the counselled kidney transplant patients and in the control kidney transplant patients. Conclusions: 1. The anthropometrical profile in the studied dialysis and transplant patients was almost similar. No significant differences were found in the studied anthropometrical parameters of the dialysis and kidney transplant patients either in male or female patients’ groups which evidently can be explained by the fact that the transplanted patients were studied shortly after the transplantation. 2. The body composition characteristics indicated the systematic differences between the male and female patients of renal transplantation. After the intense nutritional counselling, the anthropometric measurement changes were in accordance with the increase of body weight after the follow-up which was statistically significant in the studied males but not in females. 3. The effect of intensive nutritional counselling on the changes of biochemical indices revealed the normalization of inflammatory status in most patients, and the studied lipids levels remained within normal reference values. 4. The associations between anthropometric and biochemical parameters were found to be different in male and female patients. In male patients, several anthropometrical parameters were associated with inflammatory parameters but in females with lipids. These associations deserve attention because inflammation and hyperlipidaemia are well-known cardiovascular risk factors. 5. The amount of consumed food (3-day menu indices of macro- and micronutrients) was not associated with the anthropometrical variables of the studied transplant patients which shows that there is no clinical significance of these correlations. 6. Intensive nutritional counselling was effective in the long term: ten years after the kidney transplantation, statistically significant body weight gain was not seen either in males or in females, but on the contrary, it was present in the kidney transplant patients with standard care control. 7. The increased consumption of proteins and carbohydrates after kidney transplantation was found in females but not in males. The consumption of fats was within the normal range. After intensive nutritional counselling, all the values of macronutrients remained within the normal range in accordance with the Estonian nutritional recommendations. We conclude that nutritional counselling and guidance is important and should be offered early and regularly after kidney transplantation to maintain body weight and appropriate nutritional state longitudinally. Post-transplant outcomes will be optimized by a team approach for the comprehensive management of the kidney transplantation recipient combined with vigilant surveillance to detect body weight gain in a timely fashion. However, long-term body weight gain data clearly showed that in our kidney transplant patient population, the patients who received intensive individual dietary counselling had much more educated behaviour in the long-term, thereby preventing body weight gain which is a really well-known risk factor for long-term graft failure as well as for cardiovascular complications and mortality.
Optimal nutritional evaluation, the use of biochemistry together with anthropometry in clinical practice is of great importance in all chronic kidney disease phases, including the post-transplant period. The gain of body weight often develops after kidney transplantation and influences the long-term outcome. Much research has been carried out in the world studying the body composition of healthy people but there are limited data about the research where these methods together with other clinical parameters have been used for investigating patients with a transplanted kidney. The assessment of body composition in a complex manner, including the anthropometrical, blood biological and nutritional peculiarities of the patients with a transplanted kidney, have not been previously studied in Estonia. According to literature, the main problem after kidney transplantation is the gain of body weight, therefore, we planned to test if intensive nutritional counselling has an effect on a patient’s nutritional habits in preventing the gain of body weight. The general aim of the present study was to analyse the body build and nutritional habits of end-stage chronic kidney disease (CKD) patients. We hypothesised that intense nutritional counselling significantly improves nutritional habits, and, ultimately, the gain of body weight after kidney transplantation will be prevented. The specific aims of the present study were as follows: 1. To analyse anthropometric measurements data of the end-stage CKD patients and to compare the body composition of the dialysis and transplant patients. 2. To test if intensive nutritional counselling has an effect on body composition of kidney transplant male and female patients. 3. To evaluate the effect of intensive nutritional counselling on the changes of anthropometric, biochemical and nutritional parameters of kidney transplant patients after the follow-up and to describe gender-specific associations between the studied parameters. 4. To estimate the long-term effect of intensive nutritional counselling on anthropometrical measures of kidney transplant patients. 5. To evaluate the follow-up changes of the intake of nutrients of kidney transplant patients on the basis of a 3-day menu. Subjects of study and methods: The prospective long-term study was carried out during the years 2003–2005 and 2015 at the Department of Internal Medicine of the University of Tartu. In total, 150 chronic kidney disease patients were studied. The kidney transplant patients had their transplantation at the Transplant Center of the Tartu University Hospital. The first anthropometric study population consisted of 75 consecutive non-diabetic CKD patients (37 males and 38 females) of renal replacement therapy who had agreed to participate in the study and who were treated at the Nephrology Division of the Tartu University Hospital. The participation was voluntary and all patients signed a written informed consent. The transplanted patients’ population was formed from consecutive stable ambulatory non-diabetic kidney transplant patients (12 males at the age of 42.8 ± 16.1 years and 16 females at the age of 47.0 ± 14.9 years) who had agreed to participate in the study and who were monitored by the nephrologists at the Tartu University Hospital. The participation was voluntary and all patients signed a written informed consent. The transplanted patients’ control population was formed from 47 clinically consecutive stable ambulatory non-diabetic kidney transplant patients who had agreed to participate in the study and who were monitored by the nephrologists at the Tartu University Hospital or at the West-Tallinn Central Hospital. The participation was voluntary and all patients signed a written informed consent. All the measurements of 28 kidney transplant patients, including anthropometry, densitometry, biochemistry, the food frequency questionnaire (FFQ) and the 3-days dietary records, were analysed. The data of anthropometry, biochemistry and the 3-days dietary records analyses were performed in patients twice: one and a half years after the first cadaveric kidney transplantation and afterwards, three years after the kidney transplantation during the follow-up. Densitometry was performed in patients once after three years of the transplantation. The preventive nutritional counselling and dietary consultation by a dietitian were carried out for all the kidney transplant patients during one and a half years after the kidney transplantation. The initial data were compared with the results obtained at the end of the study. The last anthropometric measurements ten years after the kidney transplantation were carried out both in the counselled kidney transplant patients and in the control kidney transplant patients. Conclusions: 1. The anthropometrical profile in the studied dialysis and transplant patients was almost similar. No significant differences were found in the studied anthropometrical parameters of the dialysis and kidney transplant patients either in male or female patients’ groups which evidently can be explained by the fact that the transplanted patients were studied shortly after the transplantation. 2. The body composition characteristics indicated the systematic differences between the male and female patients of renal transplantation. After the intense nutritional counselling, the anthropometric measurement changes were in accordance with the increase of body weight after the follow-up which was statistically significant in the studied males but not in females. 3. The effect of intensive nutritional counselling on the changes of biochemical indices revealed the normalization of inflammatory status in most patients, and the studied lipids levels remained within normal reference values. 4. The associations between anthropometric and biochemical parameters were found to be different in male and female patients. In male patients, several anthropometrical parameters were associated with inflammatory parameters but in females with lipids. These associations deserve attention because inflammation and hyperlipidaemia are well-known cardiovascular risk factors. 5. The amount of consumed food (3-day menu indices of macro- and micronutrients) was not associated with the anthropometrical variables of the studied transplant patients which shows that there is no clinical significance of these correlations. 6. Intensive nutritional counselling was effective in the long term: ten years after the kidney transplantation, statistically significant body weight gain was not seen either in males or in females, but on the contrary, it was present in the kidney transplant patients with standard care control. 7. The increased consumption of proteins and carbohydrates after kidney transplantation was found in females but not in males. The consumption of fats was within the normal range. After intensive nutritional counselling, all the values of macronutrients remained within the normal range in accordance with the Estonian nutritional recommendations. We conclude that nutritional counselling and guidance is important and should be offered early and regularly after kidney transplantation to maintain body weight and appropriate nutritional state longitudinally. Post-transplant outcomes will be optimized by a team approach for the comprehensive management of the kidney transplantation recipient combined with vigilant surveillance to detect body weight gain in a timely fashion. However, long-term body weight gain data clearly showed that in our kidney transplant patient population, the patients who received intensive individual dietary counselling had much more educated behaviour in the long-term, thereby preventing body weight gain which is a really well-known risk factor for long-term graft failure as well as for cardiovascular complications and mortality.
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Keywords
neeruasendusravi, neerusiirdamine, patsiendid, kehakaal, ülekaalulisus, dieet, antropomeetria, kidney replacement therapy, kidney transplantation, patients, body weight, overweight, diet, anthropometry