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Abstract: PO2024

Approach to Nutritional Protein Intake in Hemodialysis Patients with Hyperphosphatemia: Associations with Mortality in the DOPPS

Session Information

Category: Health Maintenance, Nutrition, and Metabolism

  • 1300 Health Maintenance, Nutrition, and Metabolism

Authors

  • Yamamoto, Suguru, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
  • Bieber, Brian, Arbor Research Collaborative for Health, Ann Arbor, Michigan, United States
  • Komaba, Hirotaka, Tokai University School of Medicine, Isehara, Japan
  • Kitabayashi, Hiroki, Kyowa Kirin Co., Ltd., Tokyo, Japan
  • Nomura, Takanobu, Kyowa Kirin Co., Ltd., Tokyo, Japan
  • Cases, Aleix, Universitat de Barcelona, Barcelona, Spain
  • Combe, Christian, Université de Bordeaux, Bordeaux, France
  • Pisoni, Ronald L., Arbor Research Collaborative for Health, Ann Arbor, Michigan, United States
  • Robinson, Bruce M., Arbor Research Collaborative for Health, Ann Arbor, Michigan, United States
  • Fukagawa, Masafumi, Tokai University School of Medicine, Isehara, Japan
Background

Pts undergoing hemodialysis (HD) have poorer nutritional status than the general population, and worse nutritional status is associated with poor outcomes. Hyperphosphatemia is common in HD pts due to abnormal mineral and bone metabolism. Nephrologists manage hyperphosphatemia by prescribing phosphate binders and/or promoting dietary protein restriction; the latter may, however, adversely affect nutritional status. We address the hypothesis that, even in the presence of hyperphosphatemia, liberalizing dietary protein leads to better outcomes.

Methods

The analysis includes 11,628 HD pts in 12 countries in DOPPS phase 4 (2009-11), from 254 facilities where the medical director reported facility practices. The primary exposure variable was response to the following question: “For pts with s. albumin 3.0 g/dL and phosphate 6.0 mg/dL, do you typically recommend to (A) increase or (B) not change/decrease dietary protein intake?” The primary outcome was all-cause mortality, analyzed by Cox regression. Linear regression was used to model associations between the exposure and intermediate nutrition markers. Models were adjusted for country, case-mix, and lab values.

Results

In the case scenario, 91% of medical directors in N. America recommended to increase protein intake compared to 58% in Europe (range=36-83% in 7 countries) and 56% in Japan. Advice to increase dietary protein intake was associated with 0.33 mg/dL higher s. creatinine levels (95% CI: 0.08-0.57) while clinically meaningful associations were not observed for s. albumin and phosphorus. Advice to increase dietary protein intake was weakly associated with lower mortality-HR (95% CI)=0.89 (0.77-1.03). The association with survival was stronger in pts with age 70+ yrs and for those without diabetes (p=0.08 and 0.20 for interaction).

Conclusion

In this large international cohort study, the medical director’s preference to recommend increase in dietary protein intake for HD pts with low albumin and high phosphorus levels was most common in N. America and associated with higher s. creatinine levels and potentially lower all-cause mortality. Further research into the possible benefits of protein intake liberalization for HD pts, even in the presence of hyperphosphatemia, is warranted.

Funding

  • Commercial Support