116 ABSTRACTS

Following the nutritional assessment, the renal dietitian identi- fies areas that require further nutritional intervention. In treating patients, renal dietitians are responsible for educating patients on the process of renal osteodystrophy, the role of medications and usage, and appropriate dietary choices and lifestyle changes. Renal dietitians can recommend necessary vitamins, nutritional supplements, and modifications in calcitriol therapy. Continued monitoring and individualization of care by the renal dietitian are key to successful management of renal osteodystrophy.

As an integral part of the interdisciplinary hemodialysis team, the renal dietitian plays a diverse role to provide effective nutritional care to improve patient outcomes ~fl renal osteodystrophy.

5. A STRATEGY FOR IMPROVING NUTRITION IN HAEMODIALYSIS PATIENTS: CLINICAL AUDIT DEM- ONSTRATES EFFICACY: Susan Hyde, and Stephanie Jago. Renal Unit, Victoria Hospital, Lichfield, StaffordshIre, England.

In 1994, we audited patients’ dietary knowledge and compli- ance by asking them to complete a questionnaire, and by recording their B.M.I., biochemistry, and fluid gains. The results showed various inadequacies. After multidisciplinary discussion to implement change, we devised a strategy to improve patient knowledge. This comprised production of a personalised Unit and Dietary Informanon Folder enabling dietary fact sheets to be tailored to patients’ specific needs. Large-scale colour posters were designed to reinforce this diet information, and displayed in both unit and out-patient waiting areas. Domiciliary visits are currently undertaken by the Dietitian and Named Nurse to provide private counselling for both patient and carer. 19 patients out of the original 30 audited are still dialysing on unit, and we re-audited in 1996 using original protocol. Results demonstrate the strategy has led to improved levels of patients’ potassium and phosphate, and that they showed a greater understanding of their daily dietary requirements. There was an 80% reduction in those with high potassium levels, and a 60% reduction in those with high phosphate levels, but there was no significant reduction in fluid gains, which were already acceptable in 1994. The domicili- ary visits proved particularly beneficial in stimulating patient compliance. We conclude that this strategy is an economical and effective method of improving patients’ dietary knowledge and compliance, and normalising biochemical parameters.

6. SOLUTIONS TO CHALLENGES ENCOUNTERED IN OBTAINING ANTHROPOMETRIC MEASURES AMONG HEMODIALYSIS (HD) PATIENTS IN THE HEMODIALY- SIS (HEMO) STUDY S. McLeroy, L. Akpele, C. Chumlea, D. Cockram, R.R. Henry, L. Paranandi, D. Poole, L. Uhlin from the HEM0 Study, NIDDK, NIH, Bethesda, MD.

Anthropometric measures (AM) provide useful indications of nutritional status which is an important and modifiable risk factor for morbidity and mortality among persons undergoing HD. AM are required data for the HEM0 Study, a clinical trial to evaluate dose of dialysis (Kt/V) and membrane flux. AM measures are also being gathered in the HEM0 Study to provide reference data for the HD population. Standardized AM procedures, similar to methods used in the NHANES studies, are utilized by certified dietitians in the HEM0 Study. Weight, stature, knee height, mid-arm circumference, elbow breadth, calf circumference, and skinfold thicknesses (biceps, triceps, subscapular) are taken at BL and yearly during Follow-Up.

Several challenges been reported by the HEM0 dietitians tn gathering AM on some individuals. Systematic solutions to deal with these special sxuations have been provided by the HEM0 Study dietitians and the anthropometry consultant. Some of these solutions are described here. Because hydration status can affect skinfold and circumference values, all AM are taken after dialysis. The non-access arm is measured. However, if there is an old vascular access site m the arm to be measured, slight adjustments are made and noted. If height cannot be measured, knee height is used to calculate height. In cases of double amputations, a documented or reported height is used. For those individuals with excessively loose or tight skin, a special code is recorded on

the AM form. Some individuals are chair- or bed-fast. AM can be taken, but the techniques may need some adjustment from the standing position in order to obtain reliable and accurate data.

In summary, AM are useful in assessing nutritional status. Although challenges have been encountered in obtaining mea- sures, it is important to document these in an effort to establish standard procedures for AM reference in the HD population.

7. BODY CELL MASS @CM) AS DETERMINED BY TO- TAL BODY POTASSIUM (TBK) IS REDUCED IN HEMO- DIALYSIS (HD) PATIENTS Slzaron Stall, Nancy S. Ginsberg, Maria V. DeVita, Paul M. Zabetakis, Robert Lynn, Gilbert Gleim,Vaughn Folkert, Jack Wang, Richard N. Pierson, Jr.. Michael F. Michelis, Lenox Hill Hospital, Baumritter Kidney Center, Columbia University, New York, NY.

Total body potassmm is an indicator of body cell mass (BCM) the metabolically active tissue of the body. Our group has shown previously that TBK/FFM was significantly lower in peritoneal (PD) patients vs. laboratory controls, (p < .OOl), suggesting BCM depletion. We studied 20 HD patients by the same technique using a whole body K40 counter with K”’ calibration. Fat free mass was assessed by Dual X-ray Absorptiometry (DXA) using a Lunar model DPX.

Cohort TBK FFM-DXA K/FFM

Wq) (kg) bWW

HD;n=ZO (lOM, 1OF) 2817 i 157 50.8 k 2.1 55.3 -c 1.7

Controls* 3087 2 1815 0.5 + 2.6 60.7 T 0.7

P 0.28 0.91 0.008

*matched non-urenuc laboratory controls; mean 5 SEM

As was previously demonstrated in our PD patients, TBK/FFM in HD patients is also significantly reduced when compared to non-uremic laboratory controls, p < ,008. We conclude that both HD and PD patients have reduced TBK/FFM when compared to laboratory controls. Since BCM may be a marker for malnutrition, this important finding of reduced TBK/FFM as an index of decreased BCM, requires further investigation.

8. NO INFLUENCE OF LOW DOSE STEROIDS ON BODY COMPOSITION. E&ttie C.H. van detl Ham, J.P. van Hooff. University Hospital of Maastricht, Dept. of Internal Medicine, Division Nephrology, Hypertension and Transplanta- tion, Maastricht, The Netherlands.

Since 1988 renal transplant (RTx) patients in our centre are using tailor made cyclosporine immunosuppression. This means that in Caucasian patients, without T-cell antibodies, with a first cadaveric kidney graft, immunosuppression consists of cyclospo- nine (whole blood HPLC through level: < month 3: 0,15- 0,20mg./l.; > 3 months: 0.10-0.15 mg./l.) and a low dose steroids (10 mg./day from day 2 onwards). After 30 days the dosage is tapered to 5 mg. in two months. When a patient remains rejection free, steroids are tapered to 0 mg. in 3 months. The aim of the investigation was to determine the effect of steroid use on body compositlon. Body composition is measured by dual- energy x-ray absorptiometry (DEXA). So far 16 patients with 5 mg. steroids and 16 patients without steroids, transplanted between 1988 and 1994, were studied. Patient groups were comparable (age, sex, Quetelet Index and follow-up after trans- plantation). The percentage of body fat in the steroid- and steroid-free group is not significantly different (respectively 32.1% + 10.5% and 30.0% ? 11.8%). The distribution of this body fat to the arms (12.3% 2 3.4% for the steroid group versus 12.0% ? 3.9% for the steroid-free group), legs (30.7% 5 5.1% versus 31.7% 2 4.9%) and the trunk (50.7% 5 5.7% versus 49.7% 5 5.0%) also does not differ significantly between the groups. So far maintenance dosage of 5 mg prednisolone has no influence on body composition compared to steroid-free patients.