Randomized controlled trial of nutritional counseling on body composition and dietary intake in severe CKD. Nutritional effects of carnitine supplementation in hemodialysis patients. L-carnitine infusions may suppress serum C-reactive protein and improve nutritional status in maintenance hemodialysis patients. Short-term effects of a very-low-protein diet supplemented with ketoacids in nondialyzed chronic kidney disease patients Dietary Protein Sources and Risk for Incident Chronic Kidney Disease: Results From the Atherosclerosis Risk in Communities (ARIC) Study. Effect of a high-protein diet on kidney function in healthy adults: results from the OmniHeart trial. Adaptive response to a low-protein diet in predialysis chronic renal failure patients. Use of a renal-specific oral supplement by haemodialysis patients with low protein intake does not increase the need for phosphate binders and may prevent a decline in nutritional status and quality of life. Quality of life during and between hemodialysis treatments: role of L-carnitine supplementation. Effects of a supplemented hypoproteic diet in chronic kidney disease. Bicarbonate supplementation slows progression of CKD and improves nutritional status. Effects of Nutritional Supplementation on Fatigue, and Autonomic and Immune Dysfunction in Patients with End-Stage Renal Disease: A Randomized, Double-Blind, Placebo-Controlled, Multicenter Trial Effects of L-carnitine on oxidative stress responses in patients with renal disease. Three month intervention with protein and energy rich supplements improve muscle function and quality of life in malnourished patients with non-neoplastic gastrointestinal disease--a randomized controlled trial. Very low protein diet supplemented with ketoanalogs improves blood pressure control in chronic kidney disease. L-carnitine supplementation for the treatment of fatigue and depressed mood in cancer patients with carnitine deficiency: a preliminary analysis. Diet and kidney disease in high-risk individuals with type 2 diabetes mellitus.
BACKGROUND Progressive loss of kidney function results in an increased risk of malnutrition . Despite this , there is little evidence informing the impact of nutrition intervention on predialysis patients with chronic kidney disease ( CKD ; stages 4 and 5 ) . STUDY DESIGN R and omized controlled trial . SETTING & PARTICIPANTS 56 out patients ( men , 62 % ; mean age , 70.7 + /- 14.0 [ SD ] years ) with CKD were r and omly allocated to intervention ( n = 29 ) or control ( n = 27 ) by using a concealed computer-generated sequence . INTERVENTION The intervention group , provided with individualized dietary counseling with regular follow-up aim ed at achieving an intake of 0.8 to 1.0 g/kg of protein and greater than 125 kJ/kg of energy , or control , receiving written material only . OUTCOMES & MEASURES Change in body composition ( body cell mass , measured by means of total-body potassium , in 40 of 56 participants ) , nutritional status ( Subjective Global Assessment ) , and energy and protein intake ( 3-day food record ) . RESULTS During the 12 weeks , the intervention group had 3.5 % ( 95 % confidence interval , -2.1 to 9.1 ) less decrease in body cell mass , 17.7-kJ/kg/d ( 95 % confidence interval , 8.2 to 27.2 ) greater increase in energy intake , greater improvement in Subjective Global Assessment ( P < 0.01 ) , and no significant difference in protein intake compared with the control group ( -0.04 g/kg/d ; 95 % confidence interval , -0.73 to 0.16 ) . The intervention was associated with greater increases in energy and protein intake in women than men ( interaction P < 0.001 for both ) . LIMITATIONS Power to detect change in body cell mass , potential bias in ascertainment of Subjective Global Assessment . CONCLUSIONS In predialysis patients with CKD , structured nutrition intervention had a greater effect on energy and protein intake in women than men . Additional investigations are warranted to determine the impact on body composition AIMS Carnitine is involved in fatty acid metabolism and it is cleared by dialysis . As it plays a role in energy utilization and because malnutrition is a frequent complication of HD treatment , we studied the effects of carnitine supplementation on several nutritional parameters in HD patients . MATERIAL AND METHODS The main selection criterion was a body mass index ( BMI ; body weight/(height)2 ) < 22 kg/m2 . Fifty-three patients were enrolled to participate in this open and r and omized study . For 6 months , 28 patients received 15 mg/kg of intravenous L-carnitine at the end of each  hemodialysis ( HD ) treatment  ( Group A ) , the remaining 25 patients were controls ( Group B ) . The measured parameters were the post-dialysis body weight , serum albumin concentration ( nephelemetry ) , food intake assessed by a 3-day food question naire , nPNA ( normalized protein equivalent of nitrogen appearance ) , creatinine generation , and anthropometry . RESULTS Forty-five patients completed the study ( Group A : 14 F/9 M , 66.7 years old ; Group B : 11 F/11 M , 65.2 years old ) . At the beginning of the study , there were no differences between the groups for age , gender , HD duration , BMI , diabetes prevalence , plasma carnitine levels and measured nutritional parameters . 65.2 % and 77.3 % in each group were carnitine-deficient ( plasma total carnitine level < 35 micromol/l ) . After 6 months of L-carnitine supplementation , none of the nutritional parameters had changed in either group , except that serum albumin concentration decreased in both groups . Dividing each group according to their respective median serum albumin concentrations , daily energy and protein intakes , creatinine generation or triceps skinfold thickness did not show any difference in the various nutritional parameters with or without carnitine supplementation . CONCLUSION Carnitine supplementation , despite normalization of plasma carnitine levels , has no effect on the nutritional status of HD patients Scattered reports indicate that L-carnitine may suppress proinflammatory cytokines in sick individuals without renal disease and may improve protein synthesis or nitrogen balance either in patients without renal disease or in maintenance hemodialysis ( MHD ) or chronic peritoneal dialysis patients . We conducted an experimental study in MHD patients to evaluate the effects of L-carnitine treatment on inflammatory and protein-energy nutritional status .  MHD patients were assigned to receive intravenous injections of L-carnitine 20 mg/kg ( n = 48 ) or placebo ( n = 65 ) thrice weekly at the end of each hemodialysis treatment for 6 months . The carnitine-treated group showed a statistically significant decrease in serum C-reactive protein and increase in serum albumin and transferrin , blood hemoglobin , and body mass index . Conversely , in the placebo-treated group , a significant decrease was reported for serum albumin , serum transferrin , and body mass index , whereas the other considered measures did not change significantly . These preliminary findings suggest that in MHD patients , L-carnitine therapy may suppress inflammation , particularly among those patients with C-reactive protein > or =3 mg/dL , and may improve protein-energy nutritional status Objective : To evaluate the effects on the nutritional and metabolic parameters of a very-low-protein diet supplemented with ketoacids ( VLPD+KA ) in comparison with a conventional low-protein diet ( LPD ) in chronic kidney disease ( CKD ) patients . Design : Prospect i ve , r and omized , controlled clinical study . Setting : Outpatient Clinic of the Nephrology Division of Federal University of São Paulo , Brazil . Subjects : The study involved 24 patients with advanced CKD ( creatinine clearance < 25 ml/min ) that were r and omly assigned to either a VLPD+KA ( VLPD+KA group , 12 patients ) or to a conventional LPD with 0.6 g/kg/day ( LPD group , 12 patients ) . The patients were followed for 4 months . Results : Nutritional status was adequately maintained with both diets for the studied period . Protein intake and serum urea nitrogen decreased significantly only in the VLPD+KA group ( from 0.68±0.17 to 0.43±0.12 g/kg/day , P<0.05 ; from 61.4±12.8 to 43.6±14.9 mg/dl , P<0.001 ; respectively ) . Ionized calcium did not change in the VLPD+KA group but tended to decrease in the LPD group . Serum phosphorus tended to decrease in the VLPD+KA group probably as a result of a significant reduction in dietary phosphorus ( 529±109 to 373±125 mg/day , P<0.05 ) associated to the phosphorus-binding effect of the ketoacids . No change in these parameters was found in the LPD group . Serum parathormone increased significantly only in the LPD group ( from 241±138 to 494±390 pg/ml , P<0.01 ) . The change in PTH concentration was negatively correlated with changes in ionized calcium concentration ( r=−0.75 , P=0.02 ) and positively correlated with changes in serum phosphorus ( r=0.71 , P=0.03 ) only in the LPD group . Conclusion : This study indicates that a VLPD+KA can maintain the nutritional status of the patients similarly to a conventional LPD . Besides , an improvement in calcium and phosphorus metabolism and a reduction in serum urea nitrogen were attained only with the VLPD+KA . Thus , VLPD+KA can constitute another efficient therapeutic alternative in the treatment of CKD patients .Sponsorship : This study was supported by CAPES , Oswaldo Ramos Foundation and Fresenius Kabi , Ltda OBJECTIVE Dietary protein restriction is recommended for patients with moderate to severe renal insufficiency . Long-term data on the relationship between dietary protein sources and risk for incident kidney disease in individuals with normal kidney function are largely missing . This study aim ed to assess the association between dietary protein sources and incident chronic kidney disease ( CKD ) . DESIGN Prospect i ve cohort . SETTING Atherosclerosis Risk in Communities study participants from 4 US communities . SUBJECTS A total of 11,952 adults aged 44 - 66 years in 1987 - 1989 who were free of diabetes mellitus , cardiovascular disease , and had an estimated glomerular filtration rate ( eGFR ) ≥ 60 mL/minute/1.73 m2 . MAIN OUTCOME MEASURE A 66-item food frequency question naire was used to assess food intake . CKD stage 3 was defined as a decrease in eGFR of ≥25 % from baseline result ing in an eGFR of less than 60 mL/minute/1.73 m2 ; CKD-related hospitalization ; CKD-related death ; or end-stage renal disease . Hazard ratios ( HRs ) and 95 % confidence intervals ( CIs ) were estimated using Cox proportional hazards regression . RESULTS During a median follow-up of 23 years , there were 2,632 incident CKD cases . Red and processed meat consumption was associated with increased CKD risk ( HRQ5 vs. Q1 : 1.23 , 95 % CI : 1.06 - 1.42 , ptrend = 0.01 ) . In contrast , higher dietary intake of nuts , legumes , and low-fat dairy products was associated with lower CKD risk ( nuts : HRQ5 vs. Q1 : 0.81 , 95 % CI : 0.72 - 0.92 , ptrend < 0.001 ; low-fat dairy products : HRQ5 vs. Q1 : 0.75 , 95 % CI : 0.65 - 0.85 , ptrend < 0.001 ; legumes : HRQ5 vs. Q1 : 0.83 , 95 % CI : 0.72 - 0.95 , ptrend = 0.03 ) . CONCLUSION There were varied associations of specific dietary protein sources with risk of incident CKD ; with red and processed meat being adversely associated with CKD risk ; and nuts , low-fat dairy products , and legumes being protective against the development of CKD BACKGROUND Consumption of a diet high in protein can cause glomerular hyperfiltration , a potentially maladaptive response , which may accelerate the progression of kidney disease . STUDY DESIGN An ancillary study of the OmniHeart trial , a r and omized 3-period crossover feeding trial testing the effects of partial replacement of carbohydrate with protein on kidney function . SETTING & PARTICIPANTS Healthy adults ( N=164 ) with prehypertension or stage 1 hypertension at a community-based research clinic with a metabolic kitchen . INTERVENTION Participants were fed each of 3 diets for 6 weeks . Feeding periods were separated by a 2- to 4-week washout period . Weight was held constant on each diet . The 3 diets emphasized carbohydrate , protein , or unsaturated fat ; dietary protein was either 15 % ( carbohydrate and unsaturated fat diets ) or 25 % ( protein diet ) of energy intake . OUTCOMES Fasting serum creatinine , cystatin C , and β2-microglobulin levels , estimated glomerular filtration rate ( eGFR ) . MEASUREMENTS Serum creatinine , cystatin C , and β2-microglobulin collected at the end of each feeding period . RESULTS Baseline cystatin C-based eGFR was 92.0±16.3 ( SD ) mL/min/1.73 m(2 ) . Compared with the carbohydrate and unsaturated fat diets , the protein diet increased cystatin C-based eGFR by ~4 mL/min/1.73 m(2 ) ( P < 0.001 ) . The effects of the protein diet on kidney function were independent of changes in blood pressure . There was no significant difference between the carbohydrate and unsaturated fat diets . LIMITATIONS Participants did not have kidney disease at baseline . CONCLUSIONS A healthy diet rich in protein increased eGFR . Whether long-term consumption of a high-protein diet leads to kidney disease is uncertain Ar and omized , controlled study of 12 patients with mild chronic renal failure was design ed to assess the metabolic effects of a low-protein diet supplemented ( n = 6 ) or not ( n = 6 ) with ketoanalogs of amino acids . The protein intake was prescribed so that both groups were isonitrogenous . The dietary survey each month included a 3-d food record and a 24-h urine collection for urea measurement . After a 4- to 6-wk equilibrium period ( st and ard occidental diet , 1.11 g of protein and 32 kcal/kg per d ) , patients reduced their protein intake to reach 0.71 g of protein/kg per d during the third month . Energy intake was kept constant ( 31 kcal/kg per d ) during the 3-mo period . Compliance to the diet was achieved after 2 mo of training . Leucine turnover measurement was performed before and at the end of the 3-mo low-protein period . There was no clinical change , whereas total body flux decreased by 8 % ( P < 0.05 ) and leucine oxidation by 18 % ( P < 0.05 ) . No difference could be attributed to the ketoanalogs themselves . Thus , under sufficient energy intake , a low-protein diet is nutritionally and metabolically safe during chronic renal failure . The nitrogen-sparing effect of a low-protein diet is still present during mild chronic renal insufficiency BACKGROUND Protein-energy wasting is a frequent and debilitating condition in maintenance dialysis . We r and omly tested if an energy-dense , phosphate-restricted , renal-specific oral supplement could maintain adequate nutritional intake and prevent malnutrition in maintenance haemodialysis patients with insufficient intake . METHODS Eighty-six patients were assigned to a st and ard care ( CTRL ) group  or were prescribed two 125-ml packs of Renilon 7.5(R ) daily for 3 months ( SUPP ) .  Dietary intake , serum ( S ) albumin , prealbumin , protein nitrogen appearance ( nPNA ) , C-reactive protein , subjective global assessment ( SGA ) and quality of life ( QOL ) were recorded at baseline and after 3 months . RESULTS While intention to treat analysis ( ITT ) did not reveal strong statistically significant changes in dietary intake between groups , per protocol ( PP ) analysis showed that the SUPP group increased protein ( P < 0.01 ) and energy ( P < 0.01 ) intakes . In contrast , protein and energy intakes further deteriorated in the CTRL group ( PP ) . Although there was no difference in serum albumin and prealbumin changes between groups , in the total population serum albumin and prealbumin changes were positively associated with the increment in protein intake ( r = 0.29 , P = 0.01 and r = 0.27 , P = 0.02 , respectively ) . The SUPP group did not increase phosphate intake , phosphataemia remained unaffected , and the use of phosphate binders remained stable or decreased . The SUPP group exhibited improved SGA and QOL ( P < 0.05 ) . CONCLUSION This study shows that providing maintenance haemodialysis patients with insufficient intake with a renal-specific oral supplement may prevent deterioration in nutritional indices and QOL without increasing the need for phosphate binders End-stage renal disease affects every aspect of a patient 's life , including perception of health and quality of life . It is likely that a hemodialysis patient 's perceptions of health-related quality of life directly influence compliance with medical , nursing , and nutritional prescriptions . Because L-carnitine supplementation is known to enhance muscle strength and energy in hemodialysis patients , we hypothesized that L-carnitine supplementation would enhance a hemodialysis patient 's perception of health-related quality of life . To test this hypothesis , 1 g L-carnitine or placebo was administered orally to 101 patients immediately before and after every hemodialysis treatment for 6 months . To assess health-related quality of life from the patient 's perspective , the Medical Outcomes Study Short Form 36 instrument was administered before the study and at 1.5-month intervals for the duration of the study . In addition , a 10-item question naire design ed to assess common intradialytic symptoms was administered at the end of each dialysis treatment . Other parameters analyzed included Kt/V(urea ) and level of nutrition . In the 6-month group , oral L-carnitine supplementation had an early positive effect on general health ( P < 0.02 ) and physical function ( P < 0.03 ) , but the perceived effect was not sustained throughout the 6 months of the study . In the 3-month group , L-carnitine supplementation improved vitality ( P < 0.02 ) and general health ( P < 0.01 ) . There was no association between Kt/V(urea ) and perceived health-related quality of life . Serum albumin concentration was directly correlated to how patients perceived the quality of their lives OBJECTIVE We assessed the effect of a severe hypoproteic diet supplemented with ketoanalogues ( SVLPD ) for 48 weeks on certain metabolic disorders of chronic kidney disease ( CKD ) . DESIGN We performed a prospect i ve , open-label , parallel , r and omized , controlled trial . SETTING The study took place in the Nephrology Department at the Dr Carol Davila Teaching Hospital of Nephrology , Bucharest , Romania . PATIENTS A total of 53 nondiabetic patients with CKD with an estimated glomerular filtration rate less than 30 mL/min/1.73 m(2 ) ( Modification of Diet in Renal Disease formula ) , proteinuria less than 1 g/g urinary creatinine , good nutritional status , and anticipated good compliance with the diet were r and omly assigned to two groups . INTERVENTION Group I ( n = 27 ) received the SVLPD ( 0.3 g/kg/d of vegetable proteins and ketoanalogues , 1 capsule for every 5 kg of ideal body weight per day ) . Group II ( n = 26 ) continued a conventional low mixed protein diet ( 0.6 g/kg/d ) . OUTCOME MEASURES Nitrogen waste products retention and calcium-phosphorus and acid-base disturbances were primary efficacy parameters , and " death " of the kidney or the patient and the estimated glomerular filtration rate were secondary efficacy parameters . The nutritional status and compliance with the diet were predefined as safety variables . There were no differences between groups in any parameter at baseline . RESULTS In the SVLPD group , serum urea significantly decreased ( 56 + /- 7.9 mmol/L vs. 43.2 + /- 10 mmol/L ) , and significant improvements in serum bicarbonate ( 23.4 + /- 2.1 mmol/L vs. 18.1 + /- 1.5 mmol/L ) , serum calcium ( 1.10 + /- 0.17 mmol/L vs. 1.00 + /- 0.15 mmol/L at baseline ) , serum phosphates ( 1.45 + /- 0.66 mmol/L vs. 1.91 + /- 0.68 mmol/L ) , and calcium-phosphorus product ( 1.59 + /- 0.11 mmol(2)/L(2 ) vs. 1.91 + /- 0.10 mmol(2)/L(2 ) ) were noted after 48 weeks . No death was registered in any group . Significantly lower percentages of patients in group I required renal replacement therapy initiation ( 4 % vs. 27 % ) . After 48 weeks , estimated glomerular filtration rate did not significantly change in patients receiving SVLPD ( 0.26 + /- 0.08 mL/s vs. 0.31 + /- 0.08 mL/s at baseline ) , but significantly decreased in controls ( 0.22 + /- 0.09 mL/s vs. 0.30 + /- 0.07 mL/s ) . The compliance with the keto-diet was good in enrolled patients . No significant changes in any of the parameters of the nutritional status and no adverse reactions were noted . CONCLUSION SVLPD seems to ameliorate the nitrogen waste products retention and acid-base and calcium-phosphorus metabolism disturbances and to postpone the renal replacement therapy initiation , preserving the nutritional status in patients with CKD Bicarbonate supplementation preserves renal function in experimental chronic kidney disease ( CKD ) , but whether the same benefit occurs in humans is unknown . Here , we r and omly assigned 134 adult patients with CKD ( creatinine clearance [ CrCl ] 15 to 30 ml/min per 1.73 m(2 ) ) and serum bicarbonate 16 to 20 mmol/L to either supplementation with oral sodium bicarbonate or st and ard care for 2 yr . The primary end points were rate of CrCl decline , the proportion of patients with rapid decline of CrCl ( > 3 ml/min per 1.73 m(2)/yr ) , and ESRD ( CrCl < 10 ml/min ) . Secondary end points were dietary protein intake , normalized protein nitrogen appearance , serum albumin , and mid-arm muscle circumference . Compared with the control group , decline in CrCl was slower with bicarbonate supplementation ( 5.93 versus 1.88 ml/min 1.73 m(2 ) ; P < 0.0001 ) . Patients supplemented with bicarbonate were significantly less likely to experience rapid progression ( 9 versus 45 % ; relative risk 0.15 ; 95 % confidence interval 0.06 to 0.40 ; P < 0.0001 ) . Similarly , fewer patients supplemented with bicarbonate developed ESRD ( 6.5 versus 33 % ; relative risk 0.13 ; 95 % confidence interval 0.04 to 0.40 ; P < 0.001 ) . Nutritional parameters improved significantly with bicarbonate supplementation , which was well tolerated . This study demonstrates that bicarbonate supplementation slows the rate of progression of renal failure to ESRD and improves nutritional status among patients with CKD Background Fatigue is a predictor of cardiovascular events in patients with end-stage renal disease ( ESRD ) undergoing hemodialysis treatment . We hypothesized that multinutritional support would improve quality of life , fatigue symptoms , and potential quantitative measures including endocrine , immune and autonomic functions in patients with ESRD undergoing hemodialysis . Methods Two hundred and two hemodialysis patients were r and omly assigned to receive active treatment ( containing vitamin B1 , vitamin B2 , niacin , vitamin B6 , vitamin B12 , folic acid , vitamin C , carnitine , coenzyme Q10 , naïve galacto-oligosaccharide , and zinc ) or placebo after each dialysis session for 12 weeks . The patients and attending physicians were blinded to the treatment , and 172 patients ( 86 in each group ) completed the study . Fatigue was evaluated via fatigue question naire at 0 , 4 , and 12 weeks . To assess human herpes virus ( HHV ) 6 and 7 reactivation , numbers of viral DNA copies were determined in saliva by polymerase chain reaction at weeks 0 and 12 . Autonomic function was determined via measurement of beat-to-beat variation by using acceleration plethysmography . Results Clinical characteristics , changes in fatigue , quality of life score , endocrine functions , and laboratory data did not differ significantly between the two groups . Several parameters of heart rate variability significantly increased after nutritional treatment compared to placebo . Nutritional drink for 12 weeks significantly suppressed HHV7 DNA copy numbers . Similarly , HHV6 DNA copy numbers tended to be decreased by treatment but without reaching statistical significance . Conclusions Nutritional supplementation may modulate immune and autonomic dysfunction in ESRD patients undergoing hemodialysis PURPOSE Hemodialyzed patients demonstrate elevated oxidative stress and reduced functional status . Exercise induces health benefits , but acute exertion up-regulates oxidative stress responses in patients undergoing hemodialysis . Therefore , the aim of the present study was to examine the effect of L-carnitine supplementation on i ) exercise performance and ii ) blood redox status both at rest and after exercise . METHODS Twelve hemodialysis patients received either L-carnitine ( 20 mg kg(-1 ) i.v . ) or placebo in a double-blind , placebo-controlled , counterbalanced , and crossover design for 8 wk . Participants performed an exercise test to exhaustion before and after supplementation . During the test , V˙O2 , respiratory quotient , heart rate , and time to exhaustion were monitored . Blood sample s , collected before and after exercise , were analyzed for lactate , malondialdehyde , protein carbonyls , reduced and oxidized glutathione , antioxidant capacity , catalase , and glutathione peroxidase activity . RESULTS Blood carnitine increased by L-carnitine supplementation proportionately at rest and after exercise . L-carnitine supplementation  increased time to fatigue ( 22 % ) and decreased postexercise lactate ( 37 % ) , submaximal heart rate , and respiratory quotient but did not affect V˙O2peak . L-carnitine supplementation  increased reduced/oxidized glutathione ( 2.7-fold at rest , 4-fold postexercise ) and glutathione peroxidase activity ( 4.5 % at rest , 10 % postexercise ) and decreased malondialdehyde ( 19 % at rest and postexercise ) and protein carbonyl ( 27 % at rest , 40 % postexercise ) concentration . CONCLUSIONS Data suggest that a 2-month L-carnitine supplementation may be effective in attenuating oxidative stress responses , enhancing antioxidant status , and improving performance of patients with end-stage renal disease BACKGROUND Malnutrition is a common problem in patients with digestive disease and is associated with impaired outcome . OBJECTIVE We investigated the effect of a three-month post-hospital nutritional intervention with high protein and energy supplements on body composition , muscle function and quality of life ( QoL ) in malnourished GI patients . PATIENTS AND INTERVENTION Eighty malnourished patients with benign digestive disease were r and omized to receive either oral nutritional supplements ( ONS ) for three months in addition to dietary counselling ( DC ) ( ONS patients ) or only dietary counselling ( DC patients ) . METHODS Nutritional status was determined with the subjective global assessment , body composition by bioelectrical impedance and anthropometry , muscle function with h and -grip strength and peak flow . QoL was assessed by the 36-item short-form question naire . RESULTS Age , body cell mass ( BCM ) , muscle function , gender distribution and QoL did not differ between ONS patients ( n=38 ) and DC patients ( n=42 ) at baseline . Body weight and BCM improved significantly in both groups after three months . However , h and -grip strength ( 26.1+/-11.3 - 31.5+/-10.1 kg , p<0.0001 ) and peak flow ( 329.2+/-124.0 - 388.9+/-108.4 l /min , p=0.004 ) improved only in the ONS patients and remained unchanged in the DC patients . Similarly , all eight scales of the QoL improved in the ONS patients compared with merely three in the DC patients . DC patients experienced significantly more readmissions ( n=20 ) than ONS patients ( n=10 ) during the study period ( p=0.041 ) . CONCLUSION A three month intervention with high protein oral supplements improves outcome in malnourished patients with digestive disease in terms of functional status , QoL and rehospitalization Blood pressure ( BP ) is hardly controlled in chronic kidney disease ( CKD ) . We compared the effect of very low protein diet ( VLPD ) supplemented with ketoanalogs of essential amino acids ( 0.35 g/kg/day ) , low protein diet ( LPD , 0.60 g/kg/day ) , and free diet ( FD ) on BP in patients with CKD stages 4 and 5 .  Vegetable proteins were higher in VLPD ( 66 % ) than in LPD ( 48 % ) .  LPD was prescribed to 110 consecutive patients ; after run-in , they were invited to start VLPD .  Thirty subjects accepted ; 57 decided to continue LPD ; 23 refused either diet ( FD group ) . At baseline , protein intake ( g/kg/day ) was 0.79+/-0.09 in VLPD , 0.78+/-0.11 in LPD , and 1.11+/-0.18 in FD ( P<0.0001 ) . After 6 months , protein intake was lower in VLPD than LPD and FD ( 0.54+/-0.11 , 0.78+/-0.10 , and 1.04+/-0.21 g/kg/day , respectively ; P<0.0001 ) . BP diminished only in VLPD , from 143+/-19/84+/-10 to 128+/-16/78+/-7 mm Hg ( P<0.0001 ) , despite reduction of antihypertensive drugs ( from 2.6+/-1.1 to 1.8+/-1.2 ; P<0.001 ) . Urinary urea excretion directly correlated with urinary sodium excretion , which diminished in VLPD ( from 181+/-32 to 131+/-36 mEq/day ; P<0.001 ) . At multiple regression analysis ( R2=0.270 , P<0.0001 ) , BP results independently related to urinary sodium excretion ( P=0.023 ) and VLPD prescription ( P=0.003 ) , but not to the level of protein intake . Thus , in moderate to advanced CKD , VLPD has an antihypertensive effect likely due to reduction of salt intake , type of proteins , and ketoanalogs supplementation , independent of actual protein intake Nutritional factors are among the postulated causes of fatigue , a highly prevalent symptom in the cancer population , with serious impact on patients ' quality of life . Deficiency of the micronutrient carnitine may play a role by reducing energy production through fatty acid oxidation . We present preliminary data of an open-label , dose-finding study to determine safety and maximally tolerated dose ( MTD ) of 1 week of L-carnitine supplementation in cancer patients with fatigue and carnitine deficiency . Patients who met inclusion /exclusion criteria underwent carnitine level determination . Eighty-three percent of these patients ( 15/18 ) had carnitine deficiency . Preliminary data analysis of 13 patients showed that total carnitine increased from 30.0 + /- 6.9 to 41.0 + /- 12.1 ( mean + /- SD ) after 1 week of supplementation ( P = 0.01 ) , and free carnitine increased from 24.3 + /- 6.1 to 33.8 + /- 9.8 ( P = 0.004 ) . Outcome measures were fatigue ( BFI score ) , depression ( CES-D ) , sleep disruption ( ESS ) , and performance status ( Karnofsky ) . Median ( min , max ) BFI score at baseline was 73 ( 46 , 82 ) versus 50 ( 3 , 82 ) after 1-week supplementation ( P = 0.009 ) . CES-D score at baseline was 29 ( 16 , 42 ) and 22 ( 8 , 32 ) after 1 week ( P = 0.028 ) . ESS at baseline was 46.5 ( 0 , 69 ) and 30.4 ( 0 , 72 ) after 1 week ( P = 0.015 ) . Karnofsky score did not change significantly ( P = 0.38 ) . We are currently conducting a r and omized , double-blind , placebo-controlled study to rigorously assess the role of L-carnitine for the treatment of fatigue and depression in cancer patients IMPORTANCE Type 2 diabetes mellitus and associated chronic kidney disease ( CKD ) have become major public health problems . Little is known about the influence of diet on the incidence or progression of CKD among individuals with type 2 diabetes . OBJECTIVE To examine the association between ( healthy ) diet , alcohol , protein , and sodium intake  , and incidence or progression of CKD among individuals with type 2 diabetes . DESIGN , SETTING , AND PARTICIPANTS All 6213 individuals with type 2 diabetes without macroalbuminuria from the Ongoing Telmisartan Alone and in Combination With Ramipril Global Endpoint Trial ( ONTARGET ) were included in this observational study . Recruitment spanned from January 2002 to July 2003 , with prospect i ve follow-up through January 2008 . MAIN OUTCOMES AND MEASURES Chronic kidney disease was defined as new microalbuminuria or macroalbuminuria or glomerular filtration rate decline of more than 5 % per year at 5.5 years of follow-up . We assessed diet using the  modified Alternate Healthy Eating Index ( mAHEI ) . The analyses were adjusted for known risk factors , and competing risk of death was considered . RESULTS After 5.5 years of follow-up , 31.7 % of participants had developed CKD and 8.3 % had died . Compared with participants in the least healthy tertile of mAHEI score , participants in the healthiest tertile had a lower risk of CKD ( adjusted odds ratio [ OR ] , 0.74 ; 95 % CI , 0.64 - 0.84 ) and lower risk of mortality ( OR , 0.61 ; 95 % CI , 0.48 - 0.78 ) . Participants consuming more than 3 servings of fruits per week had a lower risk of CKD compared with participants consuming these food items less frequently . Participants in the lowest tertile of total and animal protein intake had an increased risk of CKD compared with participants in the highest tertile ( total protein OR , 1.16 ; 95 % CI , 1.05 - 1.30 ) . Sodium intake was not associated with CKD . Moderate alcohol intake reduced the risk of CKD ( OR , 0.75 ; 95 % CI , 0.65 - 0.87 ) and mortality ( OR , 0.69 ; 95 % CI , 0.53 - 0.89 ) . CONCLUSIONS AND RELEVANCE A healthy diet and moderate intake of alcohol may decrease the incidence or progression of CKD among individuals with type 2 diabetes . Sodium intake , within a wide range , and normal protein intake are not associated with CKD . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00153101
Having this evidence s , the potential role of Carnitine in improving malnutrition consequences in CKD patients would be clearly defined
Protein energy malnutrition is a common problem in patients with chronic kidney disease ( CKD ) .
Scattered reports indicate that supplementation of Carnitine may improve patients ' clinical symptoms , with significant improvement in nutritional parameters .
This systematic review was done to document the evidence s of Carnitine effects in nutritional status of CKD patients .