title: Improving albumin levels among hemodialysis patients: a community-based randomized controlled trial.
abstract: BACKGROUND
  Low albumin level is a strong predictor of mortality and morbidity among hemodialysis patients, yet few interventions are available to improve albumin levels. Moreover, the relative importance of nutritional barriers versus inflammation in contributing to hypoalbuminemia is unclear. We sought to determine whether targeting specific nutritional barriers will improve albumin levels.
  
  
  METHODS
  We conducted a randomized controlled trial involving 180 patients with baseline albumin levels less than 3.7 g/dL (<37 g/L) at 44 long-term hemodialysis facilities. Study coordinators identified and intervened on specific barriers present among intervention patients, whereas control patients continued to receive the usual care. Barriers targeted included poor nutritional knowledge, poor appetite, help needed with shopping or cooking, low fluid intake, inadequate dialysis dose, depression, difficulty chewing, difficulty swallowing, gastrointestinal symptoms, and acidosis.
  
  
  RESULTS
  At baseline, intervention and control patients had similar albumin levels, dietary intakes, levels of inflammatory markers, and numbers of nutritional barriers. After 12 months, intervention patients had greater increases in albumin levels compared with control patients (+0.21 versus +0.06 g/dL [+2.1 versus +0.6 g/L]; P < 0.01), as well as greater increases in energy intake (+4.1 versus -0.6 Kcal/d/kg; P < 0.001) and protein intake (+0.13 versus -0.06 g/d/kg; P < 0.001). The intervention appeared most effective for barriers related to poor nutritional knowledge, help needed with shopping or cooking, and difficulty swallowing. About half the subjects had elevated levels of inflammatory markers, but there was no relationship between change in levels of albumin and inflammatory markers.
  
  
  CONCLUSIONS
  A nutrition intervention tailored to patient-specific barriers resulted in modest improvements in albumin levels regardless of levels of inflammatory markers.
authors.affiliation: Division of Nephrology, MetroHealth Medical Center, Cleveland, OH 44109, USA.
authors.forename: Janeen B
authors.initials: JB
authors.lastname: Leon
authors.forename: Jeffrey M
authors.initials: JM
authors.lastname: Albert
authors.forename: Gina
authors.initials: G
authors.lastname: Gilchrist
authors.forename: Irving
authors.initials: I
authors.lastname: Kushner
authors.forename: Edith
authors.initials: E
authors.lastname: Lerner
authors.forename: Suzanne
authors.initials: S
authors.lastname: Mach
authors.forename: Angela
authors.initials: A
authors.lastname: Majerle
authors.forename: David
authors.initials: D
authors.lastname: Porter
authors.forename: Edmond
authors.initials: E
authors.lastname: Ricanati
authors.forename: Laurine
authors.initials: L
authors.lastname: Sperry
authors.forename: Catherine
authors.initials: C
authors.lastname: Sullivan
authors.forename: Jennifer
authors.initials: J
authors.lastname: Zimmerer
authors.forename: Ashwini R
authors.initials: AR
authors.lastname: Sehgal
mesh_terms: D001066:Appetite; D015415:Biomarkers / Q000097:blood; D003680:Deglutition Disorders; D003863:Depression; D004032:Diet; D005260:Female; D006801:Humans; D034141:Hypoalbuminemia / Q000209:etiology* / Q000517:prevention & control*; D007249:Inflammation; D008297:Male; D008875:Middle Aged; D009752:Nutritional Status; D010353:Patient Education as Topic; D006435:Renal Dialysis / Q000009:adverse effects*; D014882:Water-Electrolyte Balance
chemical_list: D015415:Biomarkers