Objective: To determine the effect of a tailored intervention on albumin levels among hemodialysis patients.
Design: Randomized controlled trial.
Setting: Eight freestanding chronic hemodialysis units in northeast Ohio.
Subjects: Eighty-three randomly selected adult patients who had been on dialysis for at least 6 months and had a mean albumin <3.7 g/dL (bromcresol green method) or <3.4 g/dL (bromcresol purple method) for the last 3 months. To better elucidate the feasibility and outcomes of the intervention, we selected more intervention than control patients.
Intervention: Dietitians of the 52 intervention patients determined whether any of the following potential barriers to adequate protein nutrition were present for each patient: (1) poor knowledge of protein-containing foods, (2) poor appetite, (3) needing help shopping or cooking, (4) low fluid intake, and (5) inadequate dialysis. Depending on the specific barriers present, the dietitians (1) educated patients on protein-containing foods, (2) recommended snacks for which patients had preserved appetite, (3) helped set up social supports, (4) provided recommendations on fluid intake, and/or (5) arranged for improved dialysis. Dietitians of the 31 control patients continued to provide usual care.
Main outcome measures: Change in albumin after 6 months, stratified as minimal change (less than.25 g/dL increase or decrease), moderate improvement (.25 to.49 g/dL increase), and large improvement (increase of .50 g/dL or more). To examine the role of inflammatory states, we also determined serum C-reactive protein levels at the beginning and end of the trial.
Results: Among intervention patients, 29% had a minimal change in albumin, 44% had a moderate improvement, and 27% had a large improvement. Among control patients, 74% had a minimal change in albumin, 19% had a moderate improvement, and 6% had a large improvement (P <.001 for comparison of intervention and control subjects). About 60% of subjects had high baseline C-reactive protein levels (> 10 mg/L). However, there was little relationship between change in albumin and either baseline C-reactive protein levels or changes in C-reactive protein levels (P = .83).
Conclusion: A nutrition intervention tailored to patient-specific barriers resulted in improved albumin levels even among patients with high C-reactive protein levels. Further work is needed to refine and test this intervention on a larger sample.