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This study aimed to evaluate the impact of a nutritional behavioral intervention on intuitive eating (IE) scores of overweight non-dialysis-dependent (NDD) women with chronic kidney disease (CKD) and to investigate the relationship of IE scores with demographic, nutritional, and quality of life parameters in this group.This is a prospective non-controlled clinical trial of a behavioral multi-session group intervention for dietary management. Each group comprised five to eight participants in 14 weekly or biweekly sessions lasting about 90 minutes each. The IE principles were discussed during the meetings. The IE scale (IES-2), translated and adapted to the study population, with a four-factor model was applied to assess IE attitudes. The 36-Item Short-Form Health Survey (SF-36) questionnaire was applied to assess health-related quality of life.Of the 33 patients who began participation in the study, 23 patients [median (interquartile): age = 62.0 years (58.0-68.0); 52.2% with diabetes; BMI = 32.6 kg/mThe nutritional behavioral intervention embracing IE principles was effective to improve IE attitudes for this group of CKD patients. These results are promising and may contribute to a paradigm change in the strategies to enhance motivation and adherence to dietary recommendations in this population.

In this narrative review, we briefly describe the general features of constipation, our understanding of its physiopathology, and its diagnosis and treatment, focusing on chronic kidney disease (CKD). Considering that constipation is poorly characterized in CKD, we referred to studies that used the Rome criteria to diagnose constipation in patients to describe a more realistic prevalence based on a standardized tool. A highly variable prevalence of the condition was reported, ranging from 4.5% to 71.7%. The main risk factors associated with constipation reported in these studies were advanced age, low fruit intake, presence of diabetes, and medication use, and the main consequence of constipation in CKD was a worse quality of life. We found a paucity of interventional studies for constipation treatment in CKD; however, in the general population, meta-analyses published in the last decade have reported the beneficial effects of non-pharmacological strategies, which may guide the management of constipated patients with CKD. These strategies include the consumption of fiber, prebiotics, and probiotics, as well as physical exercise and acupuncture. In conclusion, although constipation is a frequent complaint among patients with CKD, there remains a considerable knowledge gap regarding its epidemiology, prognosis, and treatment.

High energy intake combined with low physical activity generates positive energy balance, which, when maintained, favors obesity, a highly prevalent morbidity linked to development of non-communicable chronic diseases, including chronic kidney disease (CKD). Among many factors contributing to disproportionally high energy intakes and thereby to the obesity epidemic, the type and degree of food processing play an important role. Ultra-processed foods (UPF) are industrialized and quite often high-energy-dense products with added sugar, salt, unhealthy fats, and food additives formulated to be palatable or hyper-palatable. UPF can trigger an addictive eating behavior and is typically characterized by an increase energy intake. Furthermore, high consumption of UPF, a hallmark of Western diet, results in diets with poor quality. A high UPF intake is associated with higher risk for CKD. In addition, UPF consumption by patients with CKD is likely to predispose and/or to exacerbate uremic metabolic derangements, such as insulin resistance, metabolic acidosis, hypertension, dysbiosis, hyperkalemia, and hyperphosphatemia. Global sales of UPF per capita increased in all continents in the last decades. This is an important factor responsible for the nutrition transition, with home-made meals being replaced by ready-to-eat products. In this review, we discuss the potential risk of UPF in activating hedonic eating, and its main implications for health, especially for kidney health and metabolic complications of CKD. We also present various aspects of consequences of UPF on planetary health and discuss future directions for research to bring awareness of the harms of UPFs within the CKD scenario.

Over the last 2 decades, there has been a great accumulation of new evidence regarding the management of nutritional and metabolic aspects of kidney disease. The 2020 update to the KDOQI Clinical Practice Guideline for Nutrition in CKD provides a comprehensive up-to-date information on the understanding and care of patients with CKD. It provides updated information on nutritional aspects of kidney disease for the practicing clinician and allied health-care workers. The current manuscript provides an overview of the updated guideline statements on major subjects including nutritional assessment, dietary protein and energy intake, nutritional supplementation, micronutrients, and electrolytes. The guidelines are focused on dietary management rather than all possible nutritional interventions.

Chronic kidney disease (CKD) often requires several dietary adjustments to control the disease-related disturbances. This is challenging for both patients and healthcare providers, and particularly for dietitians, who deal closely with the poor adherence to dietary recommendations. Factors associated with poor adherence within the CKD scenario and the need for a shift in the paradigm have already been indicated in several studies; however, rarely are any different and/or potential strategies actually formulated in order to change this paradigm. In this review, we aimed to explore the concepts and factors surrounding adherence to dietary recommendations in CKD and further describe certain potential strategies for a nutritional counseling approach. Such strategies, while poorly explored within CKD, have shown positive results in other chronic disease scenarios. It is timely, therefore, for healthcare providers to acquire these new counseling skills; nevertheless, this would require a rethinking of the traditional attitudes and approaches in order to build a partnership, based on a nonjudgmental and compassionate style in order to guide behavior change. The reflections presented in this review may contribute towards enhancing motivation and the adherence to dietary recommendations in CKD patients.

The term sarcopenia was first introduced in 1988 by Irwin Rosenberg to define a condition of muscle loss that occurs in the elderly. Since then, a broader definition comprising not only loss of muscle mass, but also loss of muscle strength and low physical performance due to ageing or other conditions, was developed and published in consensus papers from geriatric societies. Sarcopenia was proposed to be diagnosed based on operational criteria using two components of muscle abnormalities, low muscle mass and low muscle function. This brought awareness of an important nutritional derangement with adverse outcomes for the overall health. In parallel, many studies in patients with chronic kidney disease (CKD) have shown that sarcopenia is a prevalent condition, mainly among patients with end stage kidney disease (ESKD) on hemodialysis (HD). In CKD, sarcopenia is not necessarily age-related as it occurs as a result of the accelerated protein catabolism from the disease and from the dialysis procedure per se combined with low energy and protein intakes. Observational studies showed that sarcopenia and especially low muscle strength is associated with worse clinical outcomes, including worse quality of life (QoL) and higher hospitalization and mortality rates. This review aims to discuss the differences in conceptual definition of sarcopenia in the elderly and in CKD, as well as to describe etiology of sarcopenia, prevalence, outcome, and interventions that attempted to reverse the loss of muscle mass, strength and mobility in CKD and ESKD patients.

Gut-derived uremic toxins have been associated with adverse outcomes in chronic kidney disease (CKD). Alterations in bowel habits, including constipation, seem to play an additional role in uremic toxicity. The aim of this study is to investigate the association of bowel habits with gut-derived uremic toxins and intestinal permeability in patients on automated peritoneal dialysis (APD). This cross-sectional study enrolled 58 APD patients (age 52.5 ± 15.1 years; dialysis vintage 14.1 (6.0–36.5) months). Constipation was defined according to the Rome IV criteria. Bowel habits were assessed by the Bristol Stool Scale (BSS

BACKGROUND AND AIMS Diet has been recognized as an important determinant of microbiota composition. In CKD, nutrients such as fiber and protein have been shown to influence the microbiota profile. However, since nutrients are not ingested in isolation, the overall assessment of diet, reflecting the synergy of nutrients, may potentially modify the relationship between the diet and gut microbiota. Therefore, our aim was to evaluate whether the quality of diet and its components associate with alpha diversity of gut microbiota and phyla composition in peritoneal dialysis (PD) patients. METHOD In this cross-sectional study, patients undergoing automated PD for at least 3 months, aged 18–75 years and clinically stable were enrolled. Those who were using prebiotics, probiotics, symbiotics and antibiotics within a period of 30 days before the study were not included. Participants received sterile materials to collect the feces sample and were instructed to keep it refrigerated and bring to the clinic within a period of 12 h. To evaluate α-diversity and phyla microbial profile, 16S ribosomal DNA was PCR-amplified and sequenced on an IlluminaMiSeq platform. The diet quality index (DQI), validated for the healthy Brazilian population, was calculated from a 3-day food record. This index is based on the energy density of 11 components (sugars and sweets; beef and pork; refined grains and breads; animal fat; poultry, seafood and eggs; whole grains, breads, tubers and roots; fruits; non-starchy vegetables; legumes and nuts; milk and dairy products and vegetable oils). Each component is scored from 0 to 5 or 10, and a final score ranged from 0 (worse) to 100 (better) is obtained. RESULTS Thirty-seven patients were included [52.4 ± 13.7 years; 54% men; 70% with diabetes; PD vintage 18.0 (5.0–46.5) months]. The distribution of gut microbiota's phyla is presented in Figure 1. Mean DQI was 47.8 ± 12.2, indicating that most of the patients (76%) were in an intermediate quality of diet. DQI was not associated with age, gender, PD vintage, BMI or the presence of diabetes. As can be seen in Table 1, although no association was found between DQI total score with the gut microbiota α-diversity indexes, the energy density of some components of DQI tended or was associated with those indexes. DQI total score was also not associated with any specific phyla, but the energy density of the components ‘sugars and sweets’ was negatively associated with Bacteroidetes (r= −0.389, P = 0.017) and positively with Firmicutes (r = 0.468, P = 0.003), while the inverse was observed for ‘legumes and nuts’, Bacteroidetes (r = 0.358, P = 0.029) and Firmicutes (r = −0.333, P = 0.044). CONCLUSION A healthier diet, with a larger amount of ‘whole grains, breads, tubers and roots’ and ‘legumes and nuts’ and, lower in ‘sugars and sweets’, seems to contribute to the α-diversity or Bacteroidetes colonization in peritoneal dialysis patients.

Background Microbiota-derived uremic toxins have been associated with inflammation that could corroborate with endothelial dysfunction (ED) and increase cardiovascular risk in patients with chronic kidney disease (CKD). This trial aimed to evaluate the effect of the prebiotic fructooligosaccharide (FOS) on endothelial function and arterial stiffness in nondialysis CKD patients. Methods In a double-blind controlled trial, 46 nondiabetic CKD patients were randomized to receive 12 g/day of FOS or placebo (maltodextrin) for 3 months. Total p-cresyl sulfate (PCS) and indoxyl sulfate by high-performance liquid chromatography, urinary trimethylamine N-oxide by mass spectrometry, C-reactive protein, interleukin-6 (IL-6), serum nitric oxide and stroma-derived factor-1 alfa were measured at baseline and at the end of follow-up; endothelial function was assessed through flow-mediated dilatation (FMD) and arterial stiffness by pulse wave velocity (PWV). Results The mean (± standard deviation) age of the study participants was 57.6 ± 14.4 years, with an estimated glomerular filtration rate of 21.3 ± 7.3 mL/min/1.73 m2. During the follow-up, regarding the inflammatory markers and uremic toxins, there was a significant decrease in IL-6 levels (3.4 ± 2.1 pg/mL versus 2.6 ± 1.4 pg/mL; P = 0.04) and a trend toward PCS reduction (55.4 ± 38.1 mg/L versus 43.1 ± 32.4 mg/L, P = 0.07) only in the prebiotic group. Comparing both groups, there was no difference in FMD and PWV. In an exploratory analysis, including a less severe ED group of patients (FMD ≥2.2% at baseline), FMD remained stable in the prebiotic group, while it decreased in the placebo group (group effect P = 0.135; time effect P = 0.012; interaction P = 0.002). Conclusions The prebiotic FOS lowered circulating levels of IL-6 in CKD patients and preserved endothelial function only in those with less damaged endothelium. No effect of FOS in arterial stiffness was observed.

Background: Decreased appetite is a symptom often found in chronic kidney disease. Poor appetite may negatively affect food intake, what in long-term may contribute to the development of protein–energy malnutrition. Methods: An Appetite and Food Satisfaction Questionnaire (AFSQ) was developed consisting of a question that assesses the level of appetite through a facial hedonic scale and five other questions adapted from the Buckner and Dwyer tool that assess some aspects related to food satisfaction. Each question received an arbitrary score of 0 to 3. The sum of the scores ranged from 0, the best, to 18, the worst condition. Nutritional status was assessed through seven-point SGA, bioelectrical impedance, anthropometry, and handgrip strength (HGS). Results: Eighty-four patients on peritoneal dialysis (PD; 58.3% women, mean age 54.7 ± 14.2 years, and body mass index (BMI) of 26.0 ± 4.8 kg/m2) were evaluated. Median AFSQ score was 4.0 (1.0–6.8; median and IQ). Patients were divided into tertiles according to the AFSQ score. Comparing the third tertile (score ≥ 6) with the first tertile (score < 2), the prevalence of malnutrition was greater (32.1% vs. 6.7%, respectively, p = 0.005), HGS adequacy was lower (74.6% vs. 87.3%, p = 0.001), and body cell mass index (5.7% vs. 7.4%, p = 0.001) and lean BMI were lower (11% vs. 13.4%, p = 0.001) in the third tertile. Conclusion: Poor appetite and food satisfaction determined by the questionnaire was related to worse nutritional markers, indicating AFSQ as a valid easy-to-use tool to be applied as an initial screening to identify PD patients with potential risk of malnutrition.

The aim of this study is to evaluate the association between bowel habits and microbial-derived uremic toxins p-cresyl sulfate (PCS) and indoxyl sulfate (IS) in patients with non-dialysis-dependent chronic kidney disease (NDD-CKD).This is a cross-sectional analysis including 43 nondiabetic NDD-CKD patients (58% men; 59.0 ± 13.5 years; estimated glomerular filtration rate, 21.3 ± 7.9 mL/min/1.73 mThe frequency of constipation assessed by BSS and Rome III criteria was 33% (n = 14/43) and 35% (n = 15/43), respectively. The BSS3 exhibited higher PCS, independent of renal function and dietary protein-fiber ratio (β [95% confidence interval {CI}]: serum, total PCS = 1.54 [1.06-2.23], P = .02; serum free PCS = 1.40 [1.00-1.97], P = .05; urinary PCS = 1.78 [1.10-2.90], P .02). According to the Rome III criteria, a tendency for a higher serum total PCS (β [95% CI]: 1.39 [0.95-2.03 μmol/L], P = .09) and a significantly higher urinary PCS (β [95% CI]: 1.80 [1.11-2.94 μmol/24 h], P = .02) was found in constipated participants. No effect of a compromised bowel habit (Rome III criteria or BSS) was found on IS.Constipation may lead to production of PCS in nondiabetic NDD-CKD patients.

Potassium disorders are common in patients with kidney disease, particularly in patients with tubular disorders and low glomerular filtration rate. A multidisciplinary group of researchers and clinicians met in October 2018 to identify evidence and address controversies in potassium management. The issues discussed encompassed our latest understanding of the regulation of tubular potassium excretion in health and disease; the relationship of potassium intake to cardiovascular and kidney outcomes, with increasing evidence showing beneficial associations with plant-based diet and data to suggest a paradigm shift from the idea of dietary restriction toward fostering patterns of eating that are associated with better outcomes; the paucity of data on the effect of dietary modification in restoring abnormal serum potassium to the normal range; a novel diagnostic algorithm for hypokalemia that takes into account the ascendency of the clinical context in determining cause, aligning the educational strategy with a practical approach to diagnosis; and therapeutic approaches in managing hyperkalemia when chronic and in the emergency or hospital ward. In sum, we provide here our conference deliberations on potassium homeostasis in health and disease, guidance for evaluation and management of dyskalemias in the context of kidney diseases, and research priorities in each of the above areas.

Objective The role of vitamin D supplementation on vascular calcification (VC) in patients with chronic kidney disease (CKD) is controversial. The objective of this study was to evaluate the effects of long-term cholecalciferol supplementation on VC in nondialysis patients with CKD stages 3–4 with hypovitaminosis D. Design and Methods Eighty patients aged 18–85 years with creatinine clearance between 15 and 60 mL/min/1.73 m2 and serum 25(OH)D level Results During the study, VC did not change in the treated insufficient group (418 [81–611] to 364 [232–817] AU, P = 0.25) but increased in the placebo group (118 [37–421] to 199 [49–490] AU, P = 0.01). The calcium score change was inversely correlated with 25(OH)D change (r = −0.45; P = 0.037) in the treated insufficient group but not in the placebo group. Renal function did not change in the insufficient, treated, and placebo groups. In multivariate analysis, there was no difference in VC progression between the treated and placebo insufficient groups (interaction P = 0.92). In the deficient group, VC progressed (265 [84–733] to 333 [157–745] AU; P = 0.006) and renal function declined (33 [26–43] to 23 [17–49] mL/min/1.73 m2; P = 0.04). The calcium score change was inversely correlated with cholecalciferol cumulative doses (r = −0.41; P = 0.048) and kidney function change (r = −0.43; P = 0.033) but not with 25(OH)D change (r = −0.08; P = 0.69). Conclusion: Vitamin D supplementation did not attenuate VC progression in CKD patients with hypovitaminosis D. Conclusion Vitamin D supplementation did not attenuate VC progression in CKD patients with hypovitaminosis D.

Background End-stage renal disease results in B cell lymphopenia and low levels of vitamin D. Since the link between vitamin D deficiency and B lymphocytes dysfunction are not clear in patients with end-stage renal disease, we suggest that vitamin D adequacy and factors related to the homeostasis of these cells should be investigated. B lymphocytes homeostasis is a process mainly regulated signals of grown and death as interleukin (IL)-7, B cell-activating factor (BAFF)/BAFF-receptor and CD95 expression. Objective As vitamin D serum levels were reduced in patients with end stage renal disease and it is associated with human B homeostasis, we evaluated the effect of cholecalciferol supplementation on dialysis. Design Randomized, double blind clinical trial in dialysis patients with 25OH Vitamin D deficiency for a period of 12 weeks. Main Outcome Measure In a pilot study, we investigated the effect of cholecalciferol supplementation (100,000 UI once per week or placebo. In vitro, peripheral blood mononuclear cells isolated by Ficoll-Hypaque centrifugation from 12 healthy volunteers were incubated with healthy or uremic serum in the presence or absence of 25 (OH)DC with 5% CO. Results There was an increase in the serum 25(OH)D level in the cholecalciferol group. No differences were found in BAFF and IL7 levels and CD95 and BAFF-R expression in B lymphocytes from patients on dialysis after cholecalciferol supplementation. Uremic serum induced an increase in the IL-7, BAFF, BAFF-R and CD95 expression compared with the control. However, we observed no effect of incubation of 25(OH)D3 and 1,25(OH)2D3 on the expression of IL-7, BAFF, BAFF-R and CD95 when incubated in the presence of normal or uremic serum. Conclusion Our results suggest that vitamin D is not involved in mechanisms of regulation of differentiation and survival in B lymphocytes. In conclusion, further studies are needed to explore the effects of vitamin D on B lymphocytes to better evaluate the possible impact of vitamin D on humoral response in the CKD population.

Background and Aims Approaches promoting eating guided by internal cues, such as intuitive eating (IE), have emerged as an alternative to decrease the impact of external cues on eating behavior while simultaneously avoiding the risk for dysfunctional eating. IE helps to connect with internal cues (i.e. hunger and satiety) and feelings rather than relying on external strategies to regulate what, how much and when to eat. In obese women, IE-based approaches have shown to enhance motivation and adherence to lifestyle changes, hence improving metabolic and psychological parameters, quality of life and diet quality. However, studies evaluating IE in chronic kidney disease (CKD) patients are scarce. Thus, we aimed to evaluate the impact of a behavioral multi-session group intervention on IE scores of overweight non-dialysis-dependent (NDD) CKD women. Method This is a prospective non-controlled clinical trial of a behavioral multi-session group intervention for dietary management. It was conducted with overweight women with chronic kidney disease (CKD). Each group comprised 5-8 participants in fifteen weekly or biweekly sessions lasting about 90 minutes. Most of IE principles were discussed throughout the meetings. IE scale 2 (IES2) translated and adapted to Brazilian population and composed of 23 questions with 5-point Likert response scale ranging from 1=“strongly disagree” to 5=“strongly agree” and four-factor model (Unconditional Permission to Eat, Eating for Physical Rather than Emotional Reasons, Reliance on Hunger and Satiety Cues, and Body-Food Choice Congruence) was applied before and after the intervention. The higher the score, the higher the intuitive eating attitudes. Results Of the 33 patients that initiated the study, 23 patients [age=62.0 (58.0-68.0) years; schooling= 9.0 (7.0-12.0) years of study; BMI=32.6 (30.2-39.3); eGFR=28.0 (22.0-31.0) ml/min/1.73m²] completed the intervention. Figure 1 shows the results regarding IES2. Conclusion The intervention approaching IE principles was effective to improve IE attitudes in the studied patients. With exception for “body-food choice congruence”, all IE subscales improved after intervention. These results are promising and may contribute to a paradigm change in the strategies aiming to enhance motivation and adherence to dietary recommendations in CKD population.

Background and Aims According to some studies, it seems that advanced chronic kidney disease (CKD) has the potential to cause alterations in the composition of patients gut microbiota. Most of these data have been provided by comparing the microbiota profile between patients and healthy individuals. However, well-known factors that influence the microbiota composition such as age, environment and diet were not considered in the majority of these comparative studies. In the present study, we aimed to compare the gut microbiota composition between patients on peritoneal dialysis (PD) and age-paired healthy household contacts. Method This is a cross-sectional study. Patients undergoing automated PD for at least 3 months, aged 18 to 75 years and clinically stable were enrolled. Those who were using prebiotics, probiotics, symbiotics and antibiotics within a period of 30 days before the study, were not included. A healthy control group was composed by individuals living in the same home and with similar age of the patients. Participants received sterile materials to collect the feces sample and were instructed to keep it refrigerated and bring to the clinic within a period of 12h. To evaluate the microbial profile, 16S ribosomal DNA was PCR-amplified and sequenced on an IlluminaMiSeq platform. Diet was evaluated using a 3-day food record and the diet quality was analyzed by a Brazilian Diet Quality Index. Rome IV questionnaire was applied to diagnose constipation. Nutritional status was assessed by 7-point subjective global assessment (SGA) and body mass index (BMI). Fasting blood samples were collected and clinical data were obtained from interviewing the participants and from the patient’s charts. Data are presented in percentage, mean ± standard deviation or median (interquartile range). Results Twenty patients (PD group) and 20 healthy household contacts (control group) were studied. In PD group: 70% were men, 53.5 (48.2 - 66) years old, 50% had diabetes, BMI 25.9 ± 4.8 kg/m², 95% well-nourished, 40% constipated, 14 (5.2 – 43.5) months on dialysis and 80% had residual diuresis. In control group: 30% were men, 51.5 (46.2 - 59.7) years old, BMI 28.7 ± 3.5 kg/m² and 20% constipated. Except of sex (p = 0.01) and BMI (p = 0.04), there were no other differences between groups. Comparing dietary intake between groups, no difference was found in daily energy [PD: 20.8 ± 5.4 kcal/kg/d vs. control: 22.0 ± 5.6 kcal/kg/d, p = 0.51], protein (PD: 0.8 ± 0.2 g/kg/d vs. control: 0.9 ± 0.2 g/kg/d, p = 0.23) and fiber [PD: 14.1 (10.7 – 21.1) g/d vs. 13.7 (10.4 – 18.0) g/d, p = 0.85]. In addition, the Diet Quality Index was also not different between groups (PD: 52.3 ± 15.6 vs. control: 54.5 ± 14.8, p = 0.65). Regarding microbiota composition, no difference was found between groups in alfa diversity (Figure 1), beta diversity (p>0.05), and genera differential abundance (Figure 2). Conclusion In the present study, no difference in the gut microbiota composition was found between patients on PD and healthy household contacts sharing a similar environment and diet. This result suggests that CKD and PD seem not to alter significantly gut microbiota composition.

Determination of resting energy expenditure (REE) is an important step for the nutritional and medical care of patients with chronic kidney disease (CKD). Methods such as indirect calorimetry or traditional predictive equations are costly or inaccurate to estimate REE of CKD patients. We aimed to develop and validate predictive equations to estimate the REE of non-dialysis dependent-CKD patients. A database comprising REE measured by indirect calorimetry (mREE) of 170 non-dialysis dependent-CKD patients was used to develop (n = 119) and validate (n = 51) a new REE-predictive equation. Fat free mass (FFM) was assessed by anthropometry and by bioelectrical impedance (BIA). The multiple regression analysis generated three equations: (1) REE (kcal/day) = 854 + 7.4*Weight + 179*Sex – 3.3*Age + 2.1 *eGFR + 26 (if DM) (R2 = 0.424); (2) REE (kcal/day) = 678.3 + 14.07*FFM.ant + 54.8*Sex – 2*Age + 2.5*eGFR + 140.7* (if DM) (R2 = 0.449); (3) REE (kcal/day) = 668 + 17.1*FFM.BIA – 2.7*Age − 92.7*Sex + 1.3*eGFR − 152.3 (if DM) (R2 = 0.45). The estimated REE (eREE) was not different from the mREE (P = 0.181), a high ICC was found and the mean difference between mREE and eREE was not different from zero for the three equations in the validation group. eREE accuracy between 90 and 110% was observed in 55.3%, 62.5% and 61% of the patients for Eqs. (1), (2) and (3), respectively. The equations showed acceptable accuracy for REE prediction making them a valuable tool to support practitioners to provide more reliable energy recommendations for this group of patients.

Gastrointestinal symptoms are common in patients in hemodialysis treatment and were frequently associated with low intake of dietary fibers and liquids, oral iron supplementation, phosphate binders, and low level of physical activity. Thus, the aim of this study was to evaluate the effect of baru almond oil in comparison with mineral oil supplementation on bowel habits of hemodialysis patients. Thirty-five patients on hemodialysis (57% men, 49.9 ± 12.4 years) were enrolled in a 12-week single-blind clinical trial. Patients were allocated (1 : 2) by sex and age into (1) the mineral group: 10 capsules per day of mineral oil (500 mg each) or (2) the baru almond oil group: 10 capsules per day of baru almond oil (500 mg each). Bowel habits were assessed by the Rome IV criteria, Bristol scale, and self-perception of constipation. Food consumption, physical activity level, and time spent sitting were also evaluated at the baseline and at the end of the study. After 12 weeks of supplementation, the baru almond oil group showed reduced Rome IV score (6.1 ± 5.5 vs 2.8 ± 4.3, p = 0.04 ) and the straining on the evacuation score (1.2 ± 1.4 vs 0.4 ± 0.7; p = 0.04 ), while the mineral group did not show any change in the parameters. The frequency of self-perception of constipation was lower in the baru almond oil group after intervention (45.0% vs 15.0%, p = 0.04 ). Baru almond oil improved bowel habit and the straining on evacuation in hemodialysis patients.

Determination of resting energy expenditure (REE) is an important step for the nutritional and medical care of patients with chronic kidney disease (CKD). Methods such as indirect calorimetry or traditional predictive equations are costly or inaccurate to estimate REE of CKD patients. We aimed to develop and validate predictive equations to estimate the REE of non-dialysis dependent-CKD patients.A database comprising REE measured by indirect calorimetry (mREE) of 170 non-dialysis dependent-CKD patients was used to develop (n = 119) and validate (n = 51) a new REE-predictive equation. Fat free mass (FFM) was assessed by anthropometry and by bioelectrical impedance (BIA).The multiple regression analysis generated three equations: (1) REE (kcal/day) = 854 + 7.4*Weight + 179*Sex - 3.3*Age + 2.1 *eGFR + 26 (if DM) (RThe equations showed acceptable accuracy for REE prediction making them a valuable tool to support practitioners to provide more reliable energy recommendations for this group of patients.

Objectives The aims of the study were to evaluate the quality of the diet of nondialysis-dependent patients with chronic kidney disease and to investigate the impact of dietary counseling in the quality of the diet of these patients. Methods In the cross-sectional analysis, 3-day food records of 100 nondialysis-dependent patients with chronic kidney disease patients, in the first visit to the renal dietitians, were evaluated using the Diet Quality Index (DQI). Under-reporters were excluded. DQI is comprised by 10 components: 6 are food groups (fruits, vegetables, cereals, milk and dairy, meats and eggs, and legumes); 3 are nutrients (total fat, sodium, and cholesterol), and the last one is the diet variety. Each component is scored from 0 to 10, according to the adequacy of the Brazilian dietary guideline, and an overall score ranging from 0 (poor) to 100 (good) is obtained. In a subsample of 44 patients, a prospective analysis was performed to compare the DQI and its components before and after dietary counseling. Results The median DQI score was 68.6 (62.3-75.6; interquartile range), which means that most of the patients (92%) had a diet that "needs improvement" (DQI between 50 and 80 points). The DQI components with the lowest scores (lower adequacy) were sodium (0.0 [0.0-0.9]), dairy (3.9 [2.1-6.0]), and vegetables (6.0 [2.8-9.5]), whereas meat/egg, legumes, and cholesterol had the highest scores. Vegetables, legumes, and diet variety components were significantly lower in the lower tertiles of DQI. After a median follow-up of 25.0 (17.0-35.8) months comprising 6 (5-10) visits to the dietitian, energy, protein, and micronutrients intake were significantly reduced. The dietary counseling did not improve the overall DQI (after: 69.0 [69.0-74.8]; P = .95) and, a significant reduction in the score of legumes (from 10.0 [2.7-10.0] to 7.8 [4.7-10.0], P = .00) and diet variety (from 7.0 [5.3-10.0] to 6.0 [4.0-9.0], P = .02) components were observed. Conclusion The diet of this cohort of patients needs to be improved, particularly regarding vegetables, food variety, and sodium intake. Dietary counseling had no positive impact on the diet quality. This result highlights the importance of focusing the dietary counseling not simply on nutrient or food restriction but providing healthy food choices aiming to improve the overall diet quality of the patients.

BackgroundMicrobial-derived uremic toxins, p-cresyl sulfate (PCS), indoxyl sulfate (IS) and indole 3-acetic acid (IAA), have been associated with the burden of chronic kidney disease (CKD). Prebiotics have emerged as an alternative to modulate the gut environment and to attenuate toxin production. This trial aims to investigate the effect of a prebiotic fructooligosaccharide (FOS) on uremic toxins of non-dialysis-dependent CKD (NDD-CKD) patients.MethodsA double-blind, placebo-controlled, randomized trial was conducted for 3 months. In all, 50 nondiabetic NDD-CKD patients [estimated glomerular filtration rate (eGFR) ResultsFrom 50 participants (54% men, 57.3 ± 14.6 years and eGFR 21.4 ± 7.6 mL/min/1.73 m2), 46 completed the follow-up. No changes in dietary intake or gastrointestinal symptoms were observed. There was a trend in the difference of serum total ΔPCS (treatment effect adjusted for baseline levels: −12.4 mg/L; 95% confidence interval (−5.6 to 0.9 mg/L; P = 0.07) and serum-free Δ%PCS [intervention −8.6 (−41.5 to 13.9%) versus placebo 3.5 (−28.8 to 85.5%); P = 0.07] between the groups. The trend in the difference of serum total ΔPCS was independent of eGFR and dietary protein:fiber ratio intake. No difference was found in urinary PCS. Aside from the decreased high-density lipoprotein cholesterol in the intervention, no differences were observed in the change of IS, IAA or other secondary outcome between the groups.ConclusionsOur result suggests the potential of FOS in reducing serum total and free PCS in nondiabetic NDD-CKD patients.

The association between chronic kidney disease (CKD) and obesity can decrease the patients’ cardiopulmonary capacity, physical functioning and quality of life. The search for effective and practical alternative methods of exercise to engage patients in training programs is of great importance. Therefore, we aimed to compare the effects of home-based versus center-based aerobic exercise on the cardiopulmonary and functional capacities, quality of life and quality of sleep of overweight non-dialysis-dependent patients with CKD (NDD-CKD). Forty sedentary overweight patients CKD stages 3 and 4 were randomly assigned to an exercise group [home-based group (n = 12) or center-based exercise group (n = 13)] or to a control group (n = 15) that did not perform any exercise. Cardiopulmonary exercise test, functional capacity tests, quality of life, quality of sleep and clinical parameters were assessed at baseline, 12 and 24 weeks. The VO2peak and all cardiopulmonary parameters evaluated were similarly improved (p

Body-fat gain is a common finding among peritoneal dialysis (PD) patients, and the accumulation of adipose tissue occurs predominantly in the abdominal area. Waist circumference (WC) is a reliable marker of abdominal obesity and its association with worse outcomes has been demonstrated in non-dialysis and haemodialysis patients. We aimed at investigating whether WC measurements as well as the changes over time in WC were able to predict mortality in PD patients. This prospective study included 109 patients undergoing PD (57 % male, age 52 (sd16) years, 32 % diabetics, 48 % BMI≥25 kg/m2). WC was measured at the umbilicus level (empty abdominal cavity), and values >88 cm for women and >102 cm for men were considered high. Nutritional status and laboratory parameters were also evaluated. WC was measured at baseline and after 6 months, and mortality was registered during a period of 48 months. High WC was observed in 55 % of women and in 23 % of men at baseline. After 6 months, 61 % of the patients showed an increased WC. At the end of the study, twenty-seven deaths were registered. A significant increase in WC was observed only in the non-survivor group. In the Cox regression analysis adjusting for sex, age, duration on dialysis, diabetes, BMI, serum albumin and C-reactive protein, high WC at baseline as well as the 6-month increase in WC were independently associated with mortality. This study demonstrated that a high WC and the increase over time in WC were both predictors of mortality in PD patients.

Background The consumption of nuts and edible seeds is associated with the improvement of the metabolic profile and reduction of cardiovascular diseases. However, the effects of its subproducts, such as oil, are still poorly studied. This study aimed to evaluate the effect of the baru almond oil supplementation on inflammation, oxidative stress, body composition, lipid profile, and plasma fatty acids of hemodialysis patients. Methods In a randomized, double-blind, 12-week placebo-controlled clinical study, hemodialysis patients were supplemented with 5 g of baru oil (BG, n = 17) or 5 g of mineral oil (placebo, BP, n = 12). Body composition, renal function, ultra-sensitive C-reactive protein (us-CRP), oxidative stress, plasma fatty acids, and lipid profile were analysed before and after the intervention. Results Patients were aged 50.5 ± 2.2 years and the average time of dialyses was 52,1 ± 42,6 months. The BG decreased us-CRP concentration compared to PG (-1.2 ± 0.2 vs. + 0.8 ± 0.2 mg / L,d = 0.88; p = 0.01). Baru almond oil supplementation was not effective in improving body composition, lipid profile, and oxidative stress. Conclusion Baru almond oil supplementation decreased us-CRP concentration in patients with chronic kidney disease under hemodialysis treatment.

SUMMARY A healthy diet is an essential requirement to promote and preserve health, even in the presence of diseases, such as chronic kidney disease (CKD). In this review, nutritional therapy for CKD will be addressed considering not only the main nutrients such as protein, phosphorus, potassium, and sodium, which require adjustments as a result of changes that accompany the reduction of renal functions, but also the benefits of adopting dietary patterns associated with better outcomes for both preventing and treating CKD. We will also emphasize that these aspects should also be combined with a process of giving new meaning to a healthy diet so that it can be promoted. Finally, we will present the perspective of an integrated approach to the individual with CKD, exploring the importance of considering biological, psychological, social, cultural, and economic aspects. This approach has the potential to contribute to better adherence to treatment, thus improving the patient's quality of life.