The document discusses evidence on nutritional interventions for renal disease. It summarizes four studies that examined the relationship between BMI and mortality in patients with end-stage renal disease as well as the effectiveness of cholecalciferol supplementation in raising vitamin D levels in patients with chronic kidney disease. The studies reported mixed results, with some indicating benefits of higher BMI or cholecalciferol supplementation and others finding no clear associations or effects. Additional research is needed to better understand these relationships.

1. Evidence Analysis of
Nutritional Interventions of
Renal Disease
Kimberly Eades, Adam S. Rosen – Dietetic
Interns
College of Saint Elizabeth
Dietetic Internship 2014-2016
Faculty Advisor:
Luanne DiGuglielmo, MS, RD, CSR
Clinical Coordinator College of Saint
Elizabeth
Learner Codes: 2090, 3010, 3020, 3030,
5090, 5280, 5340, 5370

2. END STAGE RENAL
DISEASE
 ESRD is when the kidneys stop working
well enough to live without dialysis or a
transplant
◦ Last stage (stage five) of Chronic Kidney
Disease (CKD)
◦ Kidneys are only functioning at 10-15% of
their normal capacity
 When kidney function is depleted, they
cannot efficiently remove waste or
excess fluid from the blood
 ESRD is permanent

3. IN ADULT PATIENTS RECEIVING DIALYSIS, IS A BMI OF ≥25
EFFECTIVE IN THE MORTALITY OF THOSE WITH END STAGE
RENAL DISEASE?
PATIENT QW
 38 year old female
◦ Height: 5’0”
◦ Weight: 262 lbs (119 kg)
◦ BMI: 51 – morbidly obese
 Medical History:
◦ Asthma
◦ CVA
◦ DM
◦ HTN
◦ Seizures
◦ Morbid Obesity
◦ CKD Stage 4
 Labs:
◦ RBC: 3.78 M/mm3 L
◦ H/H: 8.8 g/dL, 27.7% L
◦ BUN: 90 mg/dL H
◦ Creatinine 4.62 mg/dL H
◦ GFR: 13 mL L
◦ Accucheck: 207 mg/dL H
 Medication:
◦ Procrit, Flector, Levemir, Nicoderm, Lovenox, Zyloprim, Zoloft, Plavix, Catapress, Pepcid,
Procardia, Novolog, Trandate, Albuterol Sulfate, Lipitor

4. PICO QUESTION
POPULATION INTERVENTION COMPARISON OUTCOME
Adult patients
with ESRD on
dialysis
 BMI (>25) Patients with
 BMI (<25)
 Mortality
rates

5. OVERVIEW TABLE
TITLE & AUTHORS CONCLUSION
Cabezas-Rodriguez I et al. Influence of body
mass index on the association of weight
changes with mortality in hemodialysus
patients. Clinical Journal of the American
Society of Nephrology. 2013(8):1725-1732.
• Pt’s BMI modifies the strength of the
association between wt. changes with mortality.
• Confirms obesity paradox
• Underwt was associated with a higher
3-year mortality risk and overwt/obesity
had a survival benefit.
Glanton CW, Hypolite IO, Hshieh PB, Agodoa
LY, Yuan CM, Abbott KC. Factors associated
with improved short term survival in obese end
stage renal disease patients. Elsevier Science.
2003(13)2:136-143.
•Obesity in pts. with ESRD is associated
independently with reduced all cause mortality,
however, the relationship is complex:
• Stronger in African Americans
• Benefits males more than females
• Subgroup analysis suggests that
obesity is associated with increased risk
of infectious death in females
Hoogeveen EK et al. Obesity and mortality risk
among younger dialysis patients. Clin J Am Soc
Nephrol. 2012(7):280-288.
• Younger pts with a low or very high BMI had a
substantially elevated risk for death.
• In incident dialysis pts, obesity compared with
normal wt is associated with an almost 2-fold
increase in mortality rate.
• Pts younger than 65 at the start of
dialysis with a BMI > 30 have a 70%
higher risk for death compared with pts
with a normal BMI
• Among pts older than 65, there is no
association between obesity and mortality.

6. CONCLUSION
 Certain research indicated that, paradoxically to
the general population, obesity in the dialysis
population is associated with reduced mortality.
After reviewing the accessible articles, there was
a demonstration of positive effects of a BMI of
≥25. However, studies have shown that this
specific factor may lead to inconsistent results
(i.e. race, age, gender). Therefore, only a fair
amount of research has supported the “obesity-
survival paradox.” Many studies included various
factors, thus retrieving exact information for this
specific PICO question was deemed slightly
difficult. Additional studies are merited to improve
the assessment of a BMI of ≥25 on the dialysis
population.
 Grade II: Fair

7. CHOLECALCIFEROL
SUPPLEMENTATION
• Vitamin D is available in 2 forms
• D2 (ergocalciferol)
• D3 (cholecalciferol)
• Measured in International Units (IU’s) (1 µg
= 40 IU)
• Can be taken orally or parenterally
• Ca regulator, Antirickets
• May cause dry mouth, metallic taste, N/V,
constipation, diarrhea

8. VITAMIN D
Serum 25-Hydroxyvitamin D [25(OH)D] Concentrations and Health*
nmol/L**ng/mL* Health status
<30 <12 Associated with vitamin D deficiency, leading to
rickets in infants and children and osteomalacia in
adults
30–50 12–20 Generally considered inadequate for bone and overall
health in healthy individuals
≥50 ≥20 Generally considered adequate for bone and overall
health in healthy individuals
>125 >50 Emerging evidence links potential adverse effects to
such high levels, particularly >150 nmol/L (>60 ng/mL)
* Serum concentrations of 25(OH)D are reported in both nanomoles
per liter (nmol/L) and nanograms per milliliter (ng/mL).
** 1 nmol/L = 0.4 ng/mL

9. CHRONIC KIDNEY DISEASE
 Also known as Chronic Kidney Failure
◦ Gradual loss of kidney function
 Kidneys filter waste and excess fluid
from the blood, which are then excreted
into the urine
◦ When chronic kidney disease reaches an
advanced stage, dangerous levels of fluid,
electrolytes and wastes can build up in the
body
 Nearly 26 million American adults have
CKD

10. IS CHOLECALCIFEROL SUPPLEMENTATION
EFFECTIVE IN RAISING VITAMIN D LEVELS IN
PATIENTS WITH CHRONIC KIDNEY DISEASE
(CKD)?
PATIENT OC
 36 year-old male
◦ Height: 5’10” (70 in)
◦ Weight: 179 lb (81.5 kg)
◦ BMI: 25.7 (overweight)
 Medical History:
◦ Iron deficiency anemia
◦ Acidosis
◦ Secondary hyperparathyroidism
◦ Hyperkalemia
◦ Hypercholesterolemia
◦ Hyperlipidemia
◦ SOB
◦ Protein caloric malnutrition
◦ Lipoprotein deficiency
◦ Disorders of phosphorus metabolism
 Labs:
◦ Hgb: 11.5 L, Transferrin: 172 L, BUN: 73 H, Creatinine: 11.1 H, Bicarbonate: 21 L,
Phosphorus: 5.5 H, Cholesterol: 201 H, LDL: 144 H, VLDL: 34 H, Triglycerides: 170 H
 Medication:
◦ Enalapril, Renvela, Heparin, vitamin D2, zinc

11. PICO QUESTION
POPULATION INTERVENTION COMPARISON OUTCOME
Adult patients
with CKD
Cholecalciferol
supplementatio
n
No use of
cholecalciferol
supplementatio
n
Increase in
serum vitamin
D levels

12. OVERVIEW TABLE
TITLE & AUTHORS CONCLUSION
Bansal B, Bansal SB, Mithal A, et al. A
randomized controlled trial of cholecalciferol
supplementation in patients on maintenance
hemodialysis. Indian Journal of Endocrinology
and Metabolism. 2014;18(5):655-661.
doi:10.4103/2230-8210.139227.
• Supplementation with cholecalciferol 60,000
unit/week for 6 weeks was insufficient to
achieve optimal levels of 25(OH)D in Indian
patients with CKD on MHD
Mieczkowski M, Żebrowski P, Wojtaszek E, et
al. Long-Term Cholecalciferol Administration in
Hemodialysis Patients: A Single-Center
Randomized Pilot Study. Medical Science
Monitor : International Medical Journal of
Experimental and Clinical Research.
2014;20:2228-2234.
doi:10.12659/MSM.892315.
• Oral cholecalciferol at a dose of 2000
IU/3×/week is an effective and safe way to
treat vitamin D deficiency in hemodialysis
patients, leading to a significant increase in
serum 1,25(OH)2D.
• However, it was insufficient to
suppress the activity of parathyroid
glands or to significantly change BMD
Chandra P, Binongo JNG, Ziegler TR, et al.
Cholecalciferol (Vita Min D3) Therapy And
Vitamin D Insufficiency In Patients With Chronic
Kidney Disease: A Randomized Controlled Pilot
Study. Endocrine practice : official journal of the
American College of Endocrinology and the
American Association of Clinical
Endocrinologists. 2008;14(1):10-17.
• Weekly cholecalciferol (50,000 IU)
supplementation appears to be an effective
treatment to correct vitamin D status in patients
with CKD

13. CONCLUSION
• Conclusion: The articles available on the subject
of raising serum vitamin D levels with the use of
vitamin D supplementation in CKD patients brings
about mixed, but mostly positive results. When
vitamin D serum levels fall below the required
range, many health problems are either
exacerbated or brought about such as diabetes,
cardiovascular disease, and osteoporosis. Some
of the articles highlight the medical grade dosage
of vitamin D supplementation (ex: 50,000 IU and
up) used in order to increase vitamin D levels in
CKD patients. While not all results were positive,
increased levels of serum vitamin D does
contribute to better calcium bone absorption, thus
slowing down the progression of aches and pains
associated with low vitamin D serum levels in
CKD patients.
• Grade: II Fair