Acupuncture, acupressure as useful adjuncts in managing malnutrition in renal patients.
Despite intensive dietary intervention, malnutrition remains prevalent in stage 5 CKD, affecting 20%-70% of all patients. Malnutrition, as evidenced by hypoalbuminemia, is strongly associated with increased morbidity and mortality in this patient population.
Both nutritional and non-nutritional factors have been identified as contributing to malnutrition in CKD and include poor appetite and intake, inflammation, GI problems, and other comorbidities. Because traditional dietary strategies have had limited success, it may be helpful to examine alternative approaches as an adjunct to improving nutrition outcomes in CKD.
Use of complementary and alternative medicine (CAM) has increased in recent years, prompting the need to examine the safety and efficacy of these therapies in an evidence-based manner. Toward this end, the National Center for Complementary and Alternative Medicine (NCCAM) was created in 2002 by the National Institutes of Health. With the growing use of dietary and herbal supplements in the general population, there are special health concerns for people with impaired renal function.
Among these are the risk of acute and chronic kidney injury and potential herb-drug interactions with commonly prescribed medications. In a survey of 452 hemodialysis patients, presented as a poster by my colleagues and me at the National Kidney Foundation (NKF) Spring Clinical Meetings in 2000, (Blair et al, J Ren Nutr. 2000; 10:111, abstract), more than 30% of subjects reported either current use (16%) or past use (16%) of nutraceuticals, including vitamins other than a prescribed renal multivitamin.
Lack of federal oversight of products classified as dietary supplements, inadequate product standardization, and scarcity of controlled trials have been cause for concern among renal health professionals. To improve “current good manufacturing practice” of dietary supplements, a final rule promoting the safe use of dietary supplements was enacted by the FDA in 2007 as a “critical component of the Dietary Supplement Health and Education Act of 1994 (DSHEA).” (See www.fda.gov/consumers/updates/dietarysupps 062207.pdf.)
With serious issues remaining as to the use of dietary and herbal supplements in CKD, other areas of complementary and alternative medicine may provide safer options. This review will explore the safety and efficacy of non-herbal CAM therapies, specifically acupuncture and acupressure, in addressing factors contributing to malnutrition in CKD patients.
Inflammation is a major cause of hypoalbuminemia in dialysis patients. Studies have demonstrated a reduction in proinflammatory cytokines, specifically interleukin (IL)-6 as a result of acupuncture therapy (Garcia et al, Adv Chr Kidney Dis. 2005;12:282-291). In addition to nutritional effects, inflammation also negatively impacts cardiovascular health, the leading cause of morbidity in CKD.
The World Health Organization has identified more than 40 health conditions that could be helped by acupuncture, and those relevant to nutrition include nausea and vomiting, weight control, dental pain, acute and chronic colitis (without organic components), hiccups, pharyngitis, and esophageal spasms. Research is in progress regarding use of acupuncture as an adjunct treatment for hypertension,hypercholesterolemia, and diabetes.
Acupuncture has been recognized as a complementary treatment for depression and anxiety, which is widespread in the dialysis population. A study by Kalender et al (Nephron Clin Pract. 2005;102[3-4]:115-121), noted an association of depression with markers of nutrition and inflammation in CKD and end-stage renal disease (ESRD).
Depression can impact appetite and food intake, so successful treatment may result in nutritional benefit. Considerations with regard to acupuncture as a treatment option include choosing a qualified provider, and use of disposable needles. Acupuncture may be contraindicated for patients with pacemakers or for those who bruise easily.
Acupressure, also known as acupoints massage, follows the same principles as acupuncture except that pressure rather than needles is used on specific points of the body. Although this noninvasive procedure is usually provided by practitioners, some acupressure techniques can be taught to patients for independent use. Risk factors for poor nutrition in which acupressure has been used successfully include depression, fatigue, and sleep disturbances, all common in stage 5 CKD patients.
In a study by Tsay et al (J Adv Nursing. 2003;42:134-142), 98 ESRD patients with sleep disturbances were randomized to acupressure, sham acupressure, or control, with intervention provided during thrice weekly dialysis sessions. At the end of the four-week study, improvements in sleep as well as quality of life were reported in the treatment group. In addition to impacting quality of life, poor sleep and depression in ESRD patients have been associated with increased levels of inflammatory cytokines and C-reactive protein, as well as decreased serum albumin.
The potential for improved nutrition outcomes in CKD through integration of CAM and traditional medicine is intriguing. Although there are concerns regarding safety and efficacy of CAM therapies, establishing an open dialogue with patients is important. To integrate CAM into evidence-based practice, it is necessary to have standardization of therapeutic methods, training and licensure of practitioners, and well-designed studies to examine outcome measures and confirm treatment benefit.