Diet Quality Index in Kidney Health and Kidney Disease

Elevated malnutrition risk is a frequent finding in individuals on hemodialysis (HD)1Boaz M. Azoulay O. Schwartz I.F. et al.Malnutrition risk in hemodialysis patients in Israel: results of the status of nutrition in Hemodialysis Patients Survey Study.Nephron. 2019; 141: 166-176Crossref PubMed Scopus (5) Google Scholar and a range of protein-energy wasting (PEW) prevalence has been estimated at 28%-54%.2Carrero J.J. Thomas F. Nagy K. et al.Global prevalence of protein-energy wasting in kidney disease: a meta-analysis of Contemporary Observational studies from the International Society of Renal nutrition and metabolism.J Ren Nutr. 2018; 28: 380-392Abstract Full Text Full Text PDF PubMed Scopus (157) Google Scholar The etiology of PEW is multifactorial, with both metabolic and dietary contributors. To estimate dietary intake and its association with PEW in HD patients, the appropriate dietary intake method must be selected. Methods for measuring dietary intake include food frequency questionnaires, 24-hour recalls, food diaries, and others, each with its own set of advantages and limitations.3Shim J.S. Oh K. Kim H.C. Dietary assessment methods in epidemiologic studies.Epidemiol Health. 2014; 36e2014009Crossref PubMed Google Scholar To assess the quality of a diet, both a dietary intake method and a standard against which to compare the intake estimates must be selected. Validated diet quality indices might compare dietary intake to nutrient-based standards,4Gil Á. Martinez de Victoria E. Olza J. Indicators for the evaluation of diet quality.Nutr Hosp. 2015; 31: 128-144PubMed Google Scholar which is the foundation for the Total Nutrient Index, used to examine micronutrient exposure in United States adults.5Cowan A.E. Jun S. Tooze J.A. et al.A narrative review of nutrient based indexes to assess diet quality and the proposed total nutrient index that reflects total dietary exposures.Crit Rev Food Sci Nutr. 2021; : 1-11Crossref PubMed Scopus (3) Google Scholar Food-based indices compare the intake of food groups to food-based recommendations (such as the Food Pyramid) as per The Healthy Food Diversity Index.6Vadiveloo M. Dixon L.B. Mijanovich T. Elbel B. Parekh N. Development and evaluation of the US Healthy Food Diversity Index.Br J Nutr. 2014; 112: 1562-1574Crossref PubMed Scopus (37) Google Scholar The Healthy Eating Index combines both measures of food and nutrient intake, comparing individual intake to food groups and nutrient recommendations of the Dietary Guidelines for Americans. Indeed, higher Healthy Eating Index scores were associated with reduced risk of all-cause, cardiovascular, and cancer mortality and reduced risk of incident cardiovascular disease, cancer, type 2 diabetes, and neurodegenerative diseases.7Morze J. Danielewicz A. Hoffmann G. Schwingshackl L. Diet quality as assessed by the healthy eating index, alternate healthy eating index, dietary approaches to stop hypertension score, and health outcomes: a second update of a systematic review and meta-analysis of cohort studies.J Acad Nutr Diet. 2020; 120: 1998-2031.e15Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar Attempts to assess diet quality in HD patients have been made, largely by adapting diet quality indices for the general population to modifications recommended in the HD population.8Van Duong T. Tseng I.H. Wong T.C. et al.Adaptation and Validation of Alternative Healthy Eating Index in Hemodialysis Patients (AHEI-HD) and its association with all-cause mortality: a multi-center follow-up study.Nutrients. 2019; 11: 1407Crossref PubMed Scopus (8) Google Scholar Associations between diet quality measured using such indices and outcomes including PEW, inflammation scores, first hospitalization, first cardiovascular event, all-cause, and cardiovascular mortality have been reported.9Sualeheen A. Khor B.H. Balasubramanian G.V. et al.Benchmarking diet quality to assess nutritional risk in hemodialysis patients: applying adequacy and moderation metrics of the hemodialysis-healthy eating index.J Ren Nutr. 2022; 32: 726-738Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar,10Beberashvili I. Azar A. Sinuani I. et al.Geriatric nutritional risk index, muscle function, quality of life and clinical outcome in hemodialysis patients.Clin Nutr. 2016; 35: 1522-1529Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar However, it seems clear that the development of HD-specific diet quality scores will enhance both our ability to predict clinical outcomes and identify dietary inadequacies before clinical manifestations are apparent. In this issue of the Journal of Renal Nutrition, 24 articles are provided from investigators around the globe that range by topics on acute kidney injury, chronic kidney disease (CKD), HD (including an article in children and an article on home hemodialysis), peritoneal dialysis, and kidney transplantation. The issue begins with an important and timely review of the publications on weight management for kidney transplant recipients; Pedrollo et al11Pedrollo E.F. Corrêa C. Nicoletto B.B. Corrêa Souza G. Leitão C.B. What is known about dietary interventions and body weight management after kidney transplantation? A Scoping review.J Ren Nutr. 2023; 33: 4-11Abstract Full Text Full Text PDF Scopus (1) Google Scholar report that a plethora of poor study designs have been published which complicates our ability to know what will work. Even with the randomized controlled trials these investigators located, benefits were lacking, demarcating the need for more rigorous research in this area. This issue of the Journal ends with a patient nutrition education piece for kidney transplant recipients.12Cook M. What to know about kidney transplant nutrition.J Ren Nutr. 2023; 33: 223-226Abstract Full Text Full Text PDF Scopus (1) Google Scholar Elsewhere in this issue, Dwyer and Kelepouris13Dwyer J.P. Kelepouris E. New directions in phosphorus management in dialysis.J Ren Nutr. 2023; 33: 12-16Abstract Full Text Full Text PDF Scopus (2) Google Scholar review the offerings of phosphate medication management and de Abreu et al14de Abreu D.B.V. Picard K. Klein M. Gadas O.M. Richard C. Barreto Silva M.I. Soaking to reduce potassium and phosphorus content of foods.J Ren Nutr. 2023; 33: 165-171Abstract Full Text Full Text PDF Scopus (0) Google Scholar evaluate methods of reducing dietary phosphorus and potassium in the cooking process. The Journal also provides an evaluation of diet education materials regarding phosphorous. Picard et al15Picard K. Razcon-Echeagaray A. Griffiths M. Mager D.R. Richard C. Currently available handouts for low phosphorus diets in chronic kidney disease continue to restrict plant proteins and minimally processed dairy products.J Ren Nutr. 2023; 33: 45-52Abstract Full Text Full Text PDF Scopus (1) Google Scholar point out that most diet education materials currently available for patients with kidney disease recommend restricting plant proteins and whole grains and call for a revamp of the dietary phosphate teaching materials. In line with this recommendation, Lambert et al16Lambert K. Designing dietary education materials for people with chronic kidney disease: recommendations for improving the quality of resources.J Ren Nutr. 2023; 33: 208-213Abstract Full Text Full Text PDF Scopus (1) Google Scholar examined the quality of printed diet education materials and found that most were written at the appropriate education level but only half met the criteria for understandability and that a poor 10% met criteria for clear communications. This reiterates the need for diet educators to become more fluent in developing teaching materials for patient with kidney disease. This begs the question on what tools should be used for evaluating the new online education materials using mobile applications. St-Jules et al17St-Jules D.E. Hu L. Woolf K. et al.An evaluation of alternative technology-supported counseling approaches to promote multiple lifestyle behavior changes in patients with type 2 diabetes and chronic kidney disease.J Ren Nutr. 2023; 33: 35-44Abstract Full Text Full Text PDF Scopus (1) Google Scholar report on a rigorous randomized controlled trial examining standard versus remotely delivered nutrition education for a weight management study in patients with diabetes, CKD, and body mass index ≥27 kg/m2. Dietitians and patient educators should consider quality guidelines for material development and encourage more research in this area to promote best practices to benefit patients. Also related is a report from Brazil on the lack of access to dietitians for receiving diet education prior to starting dialysis in that country.18Nerbass F.B. Lima H.D.N. Vieira Neto O.M. Sesso R. Lugon J.R. Prevalence and determinants of predialysis dietitian follow-up: results from the Brazilian dialysis registry.J Ren Nutr. 2023; 33: 97-102Abstract Full Text Full Text PDF Scopus (1) Google Scholar Baggio Nerbass et al18Nerbass F.B. Lima H.D.N. Vieira Neto O.M. Sesso R. Lugon J.R. Prevalence and determinants of predialysis dietitian follow-up: results from the Brazilian dialysis registry.J Ren Nutr. 2023; 33: 97-102Abstract Full Text Full Text PDF Scopus (1) Google Scholar found that only 12% had access to a dietitian before chronic dialysis was initiated. A report from the hemodialfiltration–Heart–Height study in children is provided by Paglialonga et al,19Paglialonga F. Monzani A. Prodam F. et al.Nutritional and anthropometric indices in children receiving haemodiafiltration vs conventional haemodialysis - the HDF, heart and height (3H) study.J Ren Nutr. 2023; 33: 17-28Abstract Full Text Full Text PDF Scopus (1) Google Scholar wherein they demonstrate weight and height were negatively associated with ghrelin concentration and that the type of dialyzer (conventional vs. hemodialfiltration) may make a difference in these children. Another unique population is included in this issue of the Journal. Patients with acute kidney injury (AKI) were evaluated for predictors of requirement for dialysis within 90 days after an episode of AKI. Emuron et al20Emuron D. Thomas K. Mullane R. The nutritional risk index as a predictor of 90-day dialysis dependence after acute renal failure: a Pilot study.J Ren Nutr. 2023; 33: 29-34Abstract Full Text Full Text PDF Scopus (1) Google Scholar found that the Nutritional Risk Index could aid in assessing who will move on to chronic dialysis after AKI. Also, Pasricha et al21Pasricha S.V. Allard J.P. Alqarni K.A. Davis M.J. Chan C.T. Case studies of intradialytic total parenteral nutrition in nocturnal home hemodialysis.J Ren Nutr. 2023; 33: 219-222Abstract Full Text Full Text PDF Scopus (1) Google Scholar provide a case series of patients receiving nocturnal home hemodialysis which provides readers some insight into this intensive kidney replacement therapy and how the healthcare team select and care for patients having this therapy. Betz and Penniston22Betz M.V. Penniston K.L. Primary contributors to dietary acid load in patients with urolithiasis.J Ren Nutr. 2023; 33: 53-58Abstract Full Text Full Text PDF Scopus (1) Google Scholar and Moghari et al23Moghari L. Taghizadeh M. Soleimani A. Akbari H. Sharifi N. Dietary acid load and predialysis serum bicarbonate levels in patients with End-Stage Renal disease.J Ren Nutr. 2023; 33: 172-180Abstract Full Text Full Text PDF Scopus (1) Google Scholar both evaluated dietary acid load (DAL) in different applications. Betz and Penniston report on the impact of DAL in urolithiasis in patients with CKD22Betz M.V. Penniston K.L. Primary contributors to dietary acid load in patients with urolithiasis.J Ren Nutr. 2023; 33: 53-58Abstract Full Text Full Text PDF Scopus (1) Google Scholar and Moghari et al23Moghari L. Taghizadeh M. Soleimani A. Akbari H. Sharifi N. Dietary acid load and predialysis serum bicarbonate levels in patients with End-Stage Renal disease.J Ren Nutr. 2023; 33: 172-180Abstract Full Text Full Text PDF Scopus (1) Google Scholar evaluated the DAL impact on predialysis bicarbonate concentration of patients on HD. Food availability during SARS-CoV-2 pandemic was reviewed in a study by Vargas-Vazquez et al.24Vargas-Vázquez C. González-Ortíz A. Bertrán-Vilà M. Espinosa-Cuevas A. Impact of SARS-CoV-2 pandemic on food Security in patients with chronic kidney disease.J Ren Nutr. 2023; 33: 78-87Abstract Full Text Full Text PDF Scopus (2) Google Scholar Pourafshar et al25Pourafshar S. Sharma B. Kranz S. et al.Patterns of fruit and vegetable intake in adults with and without chronic kidney disease in the United States.J Ren Nutr. 2023; 33: 88-96Abstract Full Text Full Text PDF Scopus (2) Google Scholar report from the National Health and Nutrition Examination Survey that United States adults with CKD consume too few fruits and vegetables. Rizk et al26Rizk J.G. Streja E. Wenziger C. et al.Serum creatinine-to-cystatin-C ratio as a potential muscle mass surrogate and racial differences in mortality.J Ren Nutr. 2023; 33: 69-77Abstract Full Text Full Text PDF Scopus (3) Google Scholar provide a report that contributes to the knowledge base for serum biomarkers for health and mortality risk in patients with CKD from the US Veteran population, highlighting the utility of cystatin-C as a nutrition status marker. Huang et al27Huang Y. Zhang X. Tang X. et al.A low prognostic nutritional index is a risk factor for high peritoneal transport status in patients undergoing peritoneal dialysis.J Ren Nutr. 2023; 33: 201-207Abstract Full Text Full Text PDF Scopus (1) Google Scholar provide an insight on markers of nutrition risk that correlate with high peritoneal transporters in patients on peritoneal dialysis. Elgenidy et al28Elgenidy A. Amin M.A. Awad A.K. Husain-Syed F. Aly M.G. Serum zinc levels in chronic kidney disease patients, hemodialysis patients, and healthy controls: systematic review and meta-analysis.J Ren Nutr. 2023; 33: 103-115Abstract Full Text Full Text PDF Scopus (1) Google Scholar report on their meta-analysis of serum zinc concentrations in patients with CKD and patients on HD compared to healthy controls. Barril et al29Barril G. Nogueira A. Cigarrán S. et al.Differences in malnutrition inflammation score of hemodialysis patients associated with hemodialysis factors. A Spanish multicenter epidemiologic study.J Ren Nutr. 2023; 33: 140-146Abstract Full Text Full Text PDF Scopus (0) Google Scholar report on the utility of the Malnutrition-Inflammation Score applied in patients on HD in Spain. Perkins et al30Perkins R.K. van Vliet S. Miranda E.R. et al.Advanced glycation end products and inflammatory cytokine profiles in maintenance hemodialysis patients after the ingestion of a protein-dense meal.J Ren Nutr. 2023; 33: 181-192Abstract Full Text Full Text PDF Scopus (1) Google Scholar evaluated a high-protein meal influence on circulating inflammatory biomarkers and muscle biopsy findings in patients on HD compared to healthy controls, providing more insight into the impact of HD on inflammation. Biotic supplements are evaluated in reports from McFarlane et al31McFarlane C. Kelly J.T. Conley M. Johnson D.W. Campbell K.L. Consumers' perspectives and experiences of prebiotics and probiotics for gut health in chronic kidney disease.J Ren Nutr. 2023; 33: 116-125Abstract Full Text Full Text PDF Scopus (1) Google Scholar and from Chen et al.32Chen C. Wang J. Li J. Zhang W. Ou S. Probiotics, prebiotics, and synbiotics for patients on dialysis: a systematic review and meta-analysis of randomized controlled trials.J Ren Nutr. 2023; 33: 126-139Abstract Full Text Full Text PDF Scopus (1) Google Scholar McFarlane provides information on patient acceptance of these supplements using semi-structured interviews with patients having CKD.31McFarlane C. Kelly J.T. Conley M. Johnson D.W. Campbell K.L. Consumers' perspectives and experiences of prebiotics and probiotics for gut health in chronic kidney disease.J Ren Nutr. 2023; 33: 116-125Abstract Full Text Full Text PDF Scopus (1) Google Scholar Hearing the patient's voice is an integral part of understanding outcomes related to prescribing supplements or other approaches to improve nutrition status, thus making the methods used by these researchers broadly applicable. Chen et al32Chen C. Wang J. Li J. Zhang W. Ou S. Probiotics, prebiotics, and synbiotics for patients on dialysis: a systematic review and meta-analysis of randomized controlled trials.J Ren Nutr. 2023; 33: 126-139Abstract Full Text Full Text PDF Scopus (1) Google Scholar provide a meta-analysis of randomized controlled trials of probiotics, prebiotics, and synbiotics for patients on HD. They found these supplements to be useful for reducing inflammation. Two studies report on sarcopenia in kidney disease. Beberashvili et al33Beberashvili I. Azar A. Khatib A. et al.Sarcopenic obesity versus nonobese sarcopenia in hemodialysis patients: differences in nutritional status, quality of life, and clinical outcomes.J Ren Nutr. 2023; 33: 147-156Abstract Full Text Full Text PDF Scopus (2) Google Scholar assessed patients on HD for sarcopenia and sarcopenic obesity. They found that sarcopenic obesity was associated with higher levels of several nutrition biomarkers compared to patients with sarcopenia alone and thus contribute to the understanding of the obesity paradox in HD. Zhow et al34Zhou C. Lin X. Ma G. Yuan J. Zha Y. Increased predialysis extracellular to intracellular water ratio is associated with sarcopenia in hemodialysis patients.J Ren Nutr. 2023; 33: 157-164Abstract Full Text Full Text PDF Scopus (1) Google Scholar found a prevalence of sarcopenia to be 36% in their HD population and correlated elevation of extracellular/intercellular water assessed by bioelectrical impedance analysis (BIA) which was independent of body mass index and other markers of sarcopenia risk. Hydration status estimated by BIA is also assessed in studies reported by Schotman et al35Schotman J. Rolleman N. van Borren M. et al.Accuracy of bioimpedance spectroscopy in the detection of hydration changes in patients on hemodialysis.J Ren Nutr. 2021; 33: 181-192Google Scholar who question the accuracy of BIA for assessing changes in hydration status for patients on HD and Cheng et al36Cheng D. Luo H. Ren S. Wang N. Wu J. The effects of fluid hydration status on ultrasound muscle measurement in hemodialysis patients.J Ren Nutr. 2023; 33: 214-218Abstract Full Text Full Text PDF Scopus (1) Google Scholar report that hydration changes impact the accuracy of muscle measurement in HD. The Journal of Renal Nutrition begins 2023 with a series of reports that encourage all of us to engage in research to improve the care of patients with kidney disease. We hope you are challenged to be part of this venture!