Nutrition in Chronic Kidney Disease: Nephrology Dialysis Transplantation Notable Advances in 2018

Philippe Chauveau

Disclosures

Nephrol Dial Transplant. 2019;34(6):893-896. 

In This Article

Towards a More Liberalizing Diet in Haemodialysis Patients

In the past decades, lowering plasma phosphate levels in haemodialysis (HD) patients was one of the main targets to try to limit the high mortality rate in this population. Study cohorts demonstrated the complexity of the problem. Restricted phosphate intake, which leads to protein restriction, aggravates malnutrition and mortality. Calcium-based binders increase vascular calcification. Poor compliance to a large number of pills limits the interpretation of cohort studies with long follow-ups. Komaba et al.[11] in NDT published a 3-year survey of dialysis patients using lanthanum–carbonate as phosphate binder. Improved survival was significant only in patients with hyperphosphataemia. Statistical power was probably limited by the duration of the survey. A total of 2292 patients were included in the historical cohort. The authors extended the follow-up period to 7 years in a paper published recently in NDT.[12] They completed the study with a propensity score analysis, matching 562 patients to 562 who were not treated with lanthanum. In the entire cohort, both hyperphosphataemia and poor nutritional status were associated with higher mortality risk. The propensity score analysis showed that prescription of lanthanum was associated with better survival (23% lower risk; see Figure 2, from their paper). There was no difference in plasma phosphate control between the two groups, but nutritional status was better preserved in the lanthanum group. The survival benefit was not attenuated by adjustments for time-varying phosphorus. The authors hypothesized that prescription and compliance to lanthanum lead to a more liberalizing dietary regimen versus aggressive dietary phosphate restriction in the control group. The main limitation is that there were no data about dietary protein intake. Protein intake assessment using the urea kinetic model (no difference between groups) is not a valuable reflection of protein intake in the long term. Despite this limitation, this study provides an argument for promoting a more liberalizing diet for dialysis patients.

Figure 2.

Kaplan–Meier analysis of survival comparing the lanthanum group and the propensity score-matched controls. From Komaba et al. [12].

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