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NDT Advance Access originally published online on September 24, 2007
Nephrology Dialysis Transplantation 2007 22(12):3538-3546; doi:10.1093/ndt/gfm453
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© The Author [2007]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org


Lack of appetite in haemodialysis patients—associations with patient characteristics, indicators of nutritional status and outcomes in the international DOPPS

Antonio Alberto Lopes1,2, Stacey J. Elder2, Nancy Ginsberg3, Vittorio E. Andreucci4, José Miguel Cruz5, Shunichi Fukuhara6, Donna L. Mapes2, Akira Saito7, Ronald L. Pisoni2, Rajiv Saran8 and Friedrich K. Port2

1Department of Medicine of the Federal University of Bahia, Salvador, BA, Brazil, 2Arbor Research Collaborative for Health, Ann Arbor, MI, 3Renal Research Institute, New York, NY, USA, 4Universita Federico II, Naples, Italy, 5Nephrology Service, Hospital General Universitario ‘La Fe,’ Valencia, Spain, 6Kyoto University Graduate School of Medicine, Kyoto, 7Tokai University School of Medicine, Isehara, Kanagawa, Japan and 8Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA

Correspondence and offprint requests to: Friedrich K. Port, MD, MS, Arbor Research Collaborative for Health, 315 W. Huron, Suite 360, Ann Arbor, MI 48103, USA. Email: friedrich.port{at}ArborResearch.org



   Abstract
Top
 Abstract
Introduction
 Subjects and methods
 Results
 Discussion
 Acknowledgements
 References
 
Background. Identification of haemodialysis patients with problems related to lack of appetite should help prevent adverse outcomes. We studied whether a single question about being bothered by lack of appetite within the prior 4 weeks is related to nutritional status, inflammation and risks of death and hospitalization. Additionally, we assessed associations of lack of appetite with depression, dialysis dose and length of haemodialysis.

Methods. This study is an analysis of baseline and longitudinal data from 14 406 patients enrolled in the Dialysis Outcomes and Practice Pattern Study. Cox regression was used to assess whether the degree (not, somewhat, moderately, very much, extremely) that patients were bothered by lack of appetite is an independent predictor of death and hospitalization. Logistic regression was used to identify baseline characteristics associated with being bothered by lack of appetite.

Results. The risk of death was more than 2-fold higher [relative risk (RR) = 2.23; 95% confidence interval (CI) = 1.90–2.62] and the risk of hospitalization 33% higher (RR = 1.33; 95% CI = 1.19–1.48) among patients extremely bothered, compared with not bothered, by lack of appetite. These associations followed a dose–response fashion and remained statistically significant after adjustments for 14 comorbidities. Depression, shorter haemodialysis session, hypoalbuminaemia, lower concentration of serum creatinine and normalized protein catabolic rate, lower body mass index and higher leucocyte and neutrophil counts were independently associated with higher odds of being bothered by lack of appetite.

Conclusions. The data suggest that a single question about lack of appetite helps identify haemodialysis patients with poorer nutritional status, inflammation, depression and higher risks of hospitalization and death. The study calls attention to a possible beneficial effect of longer haemodialysis on appetite.

Keywords: appetite; depression; haemodialysis; hospitalization; mortality; nutrition



   Introduction
Top
 Abstract
 Introduction
Subjects and methods
 Results
 Discussion
 Acknowledgements
 References
 
Malnutrition is highly prevalent and strongly associated with higher mortality risk in the haemodialysis population [1]. Low food intake and food intake characteristics are factors that contribute to malnutrition in haemodialysis patients [2]. Thus, early identification of patients with eating behaviour disturbances could potentially reduce the burden of malnutrition through appropriate intervention. Unfortunately, the systematic use of food frequency questionnaires and dietary diaries are not practical for use in the clinical setting of a busy dialysis unit. Moreover, haemodialysis patients may not accurately recall their dietary intake of specific nutrients [3].

Lack of appetite is a highly prevalent symptom among haemodialysis patients. There are data to suggest that lack of appetite in haemodialysis patients is strongly related to inflammation and may function as a mediating factor linking inflammation to protein–energy malnutrition [4,5]. The degree of lack of appetite, however, may vary from day to day, with a tendency to be greater on haemodialysis treatment days [6,7]. This suggests that asking haemodialysis patients about the extent to which they have been bothered by lack of appetite in a certain time frame, e.g. the past 4 weeks, could be a more sensitive predictor of the risk of adverse outcome than simply asking patients to grade their appetite itself at a certain moment.

Considering that lack of appetite is one of the manifestations of uraemia, it seems plausible to expect that this symptom may be improved by increasing the dose of dialysis. In the HEMO study, however, a higher dialysis dose in patients receiving standard haemodialysis was not significantly associated with improvement in appetite and other measures of nutritional status [8]. One possible explanation for this negative finding is the effect of post-dialysis fatigue on reducing appetite, which may be mediated by the higher rate of fluid removal and episodes of hypotension in the attempt to increase dialysis dose [9,10]. Consistent with this possibility, longer haemodialysis sessions have been associated with improved appetite and survival, which could be explained by the lower risk of episodes of haemodynamic instability [10]. These findings call attention to the possibility that longer haemodialysis sessions could also be associated with lower odds of the self-reported problems with lack of appetite. To prevent malnutrition among haemodialysis patients, it is important to identify patient characteristics and psychological problems associated with lack of appetite [2,11,12].

Using nationally representative samples of facilities and haemodialysis patients from the 12 countries participating in the Dialysis Outcomes and Practice Patterns Study (DOPPS), we investigated whether patient responses to a question concerning the degree of being bothered by lack of appetite in the past 4 weeks was associated with the risks of death and hospitalization, while taking into account the effects of comorbidities. We also assessed whether the degree of problems with lack of appetite was associated with socio-demographic characteristics, comorbidities, conventional measures of nutritional status, white blood cell (WBC) and neutrophil counts as proxy for inflammation, symptoms of depression, dialysis dose and duration of the haemodialysis session.



   Subjects and methods
Top
 Abstract
 Introduction
 Subjects and methods
Results
 Discussion
 Acknowledgements
 References
 
The data used for the present analysis are from DOPPS I and DOPPS II. The DOPPS is an international, prospective, observational study of adult haemodialysis patients (aged 18 years or older), based on nationally representative samples of randomly selected dialysis facilities [13,14]. DOPPS I data were collected in five European countries (101 facilities from France, Germany, Italy, Spain andUK), Japan (65 facilities) and US (145 facilities). Data collection began in 1996 in the US, 1998 in Europe, and 1999 in Japan and continued through 2001. DOPPS II was initiated in 2002 and continued through 2004. It included dialysis facilities from the DOPPS I countries as well as facilities from Australia, Belgium, Canada, New Zealand and Sweden. As a result, the number of facilities increased from 308 in DOPPS I to 340 in DOPPS II. Within each participating facility, 20–40 patients were randomly selected, depending on facility size.

The main analysis was based on data from 14 406 patients from DOPPS I and II who answered a question about lack of appetite from the Kidney Disease Quality of Life - Short Form (KDQOL-SF) questionnaire [15] and who had been on dialysis for at least 120 days. The patients were asked to consider ‘to what extent were you bothered during the past four weeks by lack of appetite?’ The five possible responses to this question were: not at all, somewhat, moderately, very much and extremely. The other measures of nutritional status were body mass index (BMI) in kg/m2, serum albumin, serum creatinine and normalized protein catabolic rate (nPCR) in grams/kilogram/day, assessed at the study start. BMI was based on patient post-dialysis weight; laboratory values were based on pre-dialysis measurements. The nPCR was determined using the two-point model of urea kinetics, as was the single-pool Kt/V (sp Kt/V) [16].

To assess symptoms of depression, we used patient responses to two questions from the KDQOL-SF, originally from the Medical Outcomes Study SF-36 [17], as well as the scores of the 10-item version of the Center for Epidemiological Studies Depression Screening Index (CES-D) [18–20]. Using the KDQOL-SF, patients were asked to respond to the following questions: ‘Have you felt so down in the dumps that nothing could cheer you up?’ and ‘Have you felt downhearted and blue?’ The first question was assessed only in DOPPS I and the second in both DOPPS I and II. The six possible responses to these questions were: none of the time, a little of the time, some of the time, a good bit of the time, most of the time and all the time. The last three options were considered indicative of probable depression [21,22]. For the short version of the CES-D, a score ≥10 was considered as probable depression [23]. The CES-D questionnaire was used only in DOPPS II. WBC and neutrophil counts were used as proxy for inflammation status.

Statistical methods
Multivariable logistic regression was used to identify patient characteristics associated with being bothered by lack of appetite and to assess whether the degree of being bothered by lack of appetite was associated with the odds of cachexia and lower levels of serum albumin (≤3.5 vs > 3.5 mg/dl), serum creatinine (≤7.5 vs >7.5 mg/dl), nPCR (≤0.9 vs >0.9 g/kg/day) and BMI (≤20 vs >20 kg/m2). Cox regression was used to assess whether the different degrees to which patients were bothered by lack of appetite (assessed for DOPPS I and II) and the level of appetite (assessed in DOPPS II only) were associated with the risk of death and first hospitalization after study start. The Cox models were adjusted for facility clustering and the effects of age, black race, sex, physician-diagnosed depression and 13 other comorbid conditions [cancer (other than skin), cerebrovascular disease, congestive heart failure, coronary artery disease, other cardiovascular disease, diabetes mellitus, gastrointestinal bleeding, HIV/AIDS, hypertension, lung disease, neurological disease, peripheral vascular disease and recurrent cellulitis/gangrene], nausea, years on dialysis, dialysis dose by sp Kt/V, and treatment time. The Cox models were stratified by country and the phase of the study. All analyses were performed using SAS version 9.1 (SAS Institute, Cary, NC, USA).



   Results
Top
 Abstract
 Introduction
 Subjects and methods
 Results
Discussion
 Acknowledgements
 References
 
Table 1 shows that the percentage of patients with physician-diagnosed depression, several other comorbidities, nausea or cachexia increased with the degree of being bothered by lack of appetite. The percentage of patients with physician-diagnosed depression varied from ~10 to 27%, and the percentage of those with nausea increased from ~14 to 66% across the levels of being bothered by lack of appetite. Table 1 also shows significant associations between variables used as proxy for nutrition or inflammation with being bothered by lack of appetite. As the degree of being bothered by lack of appetite increased, the mean values of albumin, creatinine, nPCR and BMI decreased. An increase in WBC and neutrophil count correlated significantly with increased degrees of being bothered by lack of appetite.


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  		Table 1. Prevalent patient characteristics by categories of bothered by lack of appetite

 
As shown in Table 2, the adjusted odds of being bothered by lack of appetite in patients on dialysis at least 4 months were significantly (P < 0.05) and independently greater for older patients, women, blacks, patients with a physician diagnosis of depression [adjusted odds ratio (AOR) = 1.44, P < 0.0001] and those with nausea (AOR = 1.95, P < 0.0001). The adjusted odds of being bothered by lack of appetite increased by 2% (AOR = 1.02, P = 0.01) per each 103/mm3 more WBCs and by 3% (AOR = 1.03, P = 0.02) per each 103/mm3 more neutrophils. Kt/V as a continuous variable was not independently associated with being bothered by lack of appetite. In contrast, the adjusted odds of being bothered by lack of appetite was reduced by 8% per each 30 min more in treatment time (OR = 0.92 per each 30 min more, P = 0.02). It was also observed that the odds of being bothered by lack of appetite increased by 2% per one more prescribed oral medications independently of the covariates included in Table 2 (AOR = 1.02 per one more medication, P < 0.0001).


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  		Table 2. AOR of the associations between patient characteristic and being bothered by lack of appetite vs not bothered for patients on dialysis more than 4 months, n = 14 402

 
The adjusted odds of being bothered by lack of appetite at lower levels of each of these nutritional indicators by degree of being bothered by lack of appetite are shown in Figure 1, with the referent group for albumin, creatinine, nPCR and BMI defined, respectively, as >3.5 g/dl, 7.5 mg/dl, 0.9 g/kg/day and 20 kg/m2. An increased degree of being bothered by lack of appetite was associated in a dose–response fashion with higher adjusted odds of having lower levels of each of these traditional measures of nutritional status, as well as with cachexia (data not shown).


Figure 1
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  		Fig. 1. AOR of the association between being bothered by lack of appetite and indicators of nutritional status. P-values <0.03 for all data points compared with their respective reference. Odds ratios are adjusted for age, sex, black race, years on dialysis, 14 summary comorbid conditions and country; accounted for facility clustering effects; n = 14 406.

 
Table 3 describes the percentage of patients in each country according to the degree that they were bothered by lack of appetite. Compared with patients treated in the US, lower adjusted odds of being bothered by lack of appetite were observed for patients treated in Belgium (AOR = 0.62, P = 0.001), Germany (AOR = 0.81, P = 0.02) and Japan (AOR = 0.74, P < 0.0001). After including number of prescribed medications in the model, these associations became weaker compared with the US (AOR = 0.67 for Belgium, 0.89 for Germany and 0.87 for Japan, the latter two AORs no longer being statistically significant (P > 0.2 each).


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  		Table 3. Percentage distribution by being bothered by lack of appetite in each country and the AOR of the association between country and being bothered by lack of appetite among patients on dialysis more than 4 months

 
As shown in Figure 2, the percentage of patients who reported that they were ‘so down in the dumps’ or ‘downhearted and blue’ that nothing could cheer them up at least for a good bit of the time during the 4 weeks that preceded the interview increased steadily (P-value for trend <0.0001 for both) by degree of being bothered by lack of appetite. The percentage of patients with a CES-D score ≥10 also increased in the same direction as the degree that the patients were bothered by lack of appetite (P-value for trend <0.0001). As shown in Table 4, the AOR of the associations between being bothered by lack of appetite and symptoms of depression remained statistically significant after adjustments for country, demographic variables, years on dialysis, nausea and comorbidities. The strength of these associations was increased by the exclusion of nausea from the logistic model, but the associations were not influenced by sp Kt/V with 1.2 as a cut-point (data not shown).


Figure 2
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  		Fig. 2. Percentage of patients with higher levels of symptoms of depression by degree of being bothered by lack of appetite. All P-values <0.001 compared with not being bothered by lack of appetite. Downhearted and blue n = 14 008; Down in the dumps n = 8623; CES-D n = 6952. All P-values for trend <0.0001.

 

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  		Table 4. AORs of the associations between being bothered by lack of appetite and self-reported indicators of probable depression

 
Patients who were bothered by lack of appetite showed a significantly higher risk of death and hospitalization after initiation of the study. Even those who reported that they were only somewhat bothered by lack of appetite had a 21% higher risk of death [unadjusted relative risk (RR) = 1.21; 95% CI = 1.11–1.32; P < 0.0001) and a 12% higher risk of hospitalization (unadjusted RR=1.12; 95% CI = 1.04–1.20; P = 0.002) than patients not bothered. The unadjusted risks of death and hospitalization increased steadily as the degree of being bothered by appetite increased. These risks were more than 100% higher for death (RR = 2.07; 95% CI = 1.75–2.45; P < 0.0001) and 40% higher for hospitalization (RR=1.40; 95% CI = 1.21–1.62; P < 0.0001) for patients extremely bothered compared with those not bothered. Figure 3 shows the adjusted estimates of the RR of death associated with being bothered by lack of appetite, using ‘not bothered’ as the reference category. The risk of death, adjusted for several covariates, was 57% higher for patients who reported that they were extremely bothered by lack of appetite during the 4 weeks that preceded the interview compared with those who were not bothered by lack of appetite (RR = 1.57, 95% CI = 1.31–1.89; P < 0.0001). The risk of death was 43% higher (RR = 1.43; P < 0.0001) and the risk of hospitalization was 22% higher (RR = 1.22; P < 0.0001) for patients with a WBC count >10 800/mm3 compared with a WBC count between 4800 and 10 800/mm3. The RR of the association between WBC count and mortality was reduced from 1.43 to 1.28 (P = 0.0008), and the association between WBC count and hospitalization was reduced from 1.22 to 1.17 (P = 0.001) after adjustment for being bothered by lack of appetite.


Figure 3
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  		Fig. 3. Adjusted RR of death associated with being bothered by lack of appetite. RRs were obtained by Cox models stratified by country for DOPPS I and II and adjusted for facility clustering, age, sex, race, years on dialysis, physician-diagnosed depression and 13 comorbid conditions; n = 14 399.

 
In an analysis restricted to DOPPS II data, the adjusted risk of death was also significantly higher (RR = 1.61; 95% CI = 1.23–2.10; P = 0.0005) for those extremely bothered (vs not bothered) by lack of appetite. These associations became stronger after excluding nausea from the Cox model. Different adjusted Cox models—with all variables included and with and without the inclusion of physician-diagnosed depression or being bothered by lack of appetite—were used to assess the effect of the interrelation between these two variables on mortality risk. In all models, higher levels of being bothered by lack of appetite and depression were significantly associated with higher mortality risk. It was noted that the association between depression and mortality risk became stronger after excluding being bothered by appetite from the adjusted model; RRs with and without being bothered by lack of appetite were 1.16 (P < 0.0001) and 1.24 (P < 0.0001), respectively. In contrast, the RR of the association between lack of appetite and mortality risk was very similar in models with and without depression (data not shown).

Being bothered by lack of appetite also was independently associated with hospitalization. The risk of first hospitalization, adjusted for all covariates, was 13% higher for patients who were extremely bothered by lack of appetite compared with those not bothered (RR = 1.13; 95% CI = 1.01–1.26; P = 0.02). In the analysis restricted to DOPPS II, the adjusted risk of hospitalization was 19% higher (RR = 1.19; 95% CI = 1.02–1.38; P = 0.03) for patients bothered by lack of appetite (vs not bothered). Similar to observations for mortality risk, the association between lack of appetite and hospitalization was observed to be stronger after excluding nausea from the Cox model.



   Discussion
Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Discussion
Acknowledgements
 References
 
The present analysis using data from the 12 DOPPS countries shows that a simple question to assess the extent to which someone is bothered by lack of appetite during the past 4 weeks is strongly associated with higher mortality risk and higher likelihood of hospitalization. Results from the DOPPS allow insights into these associations beyond those recently published [4–6] by showing that they follow a dose–response fashion, even after adjustments for demographic variables, time on dialysis and detailed assessment of comorbidities and country. This study also shows that the odds of depression and protein-malnutrition (according to conventional nutritional indicators) increased in the same direction as the degree of being bothered by lack of appetite. Our findings suggest that a simple item of the KDQOL-SF that assesses the degree to which a haemodialysis patient reports being bothered by lack of appetite during the past 4 weeks, may be used in daily clinical practice as a proxy for conventional measures of nutritional status. Our data call attention to the potential contribution of this simple question about lack of appetite towards identifying patients who may have undiagnosed depression, a highly prevalent problem, though often under-recognized and under-treated in the haemodialysis setting [23]. Even though age, sex and race are not modifiable characteristics, the differences by demographic characteristics observed in this study should be viewed as useful for identifying those haemodialysis patients who may need more attention to improve appetite. In the present study, the odds of being bothered by lack of appetite were significantly higher for older patients, women and blacks. The mechanisms responsible for these differences in appetite by demographic characteristics are not clear. There are data to suggest, however, that the differences between men and women in lack of appetite is mediated by sex-specific response to cytokines and sex hormones [24].

We also observed differences by country in the percentage of patients bothered by lack of appetite. The study suggests that patients treated in Japan, Belgium and Germany are less bothered by lack of appetite compared with patients treated in the US. These differences in lack of appetite by country cannot be fully explained by prevalence of comorbidities, demographic factors, years on dialysis, length of dialysis session and Kt/V. However, these differences were reduced after adjustment for number of prescribed oral medications. This suggests that the differences in problems with appetite by country could be partially explained by differences in practice patterns related to prescription of medication.

Our results suggest that even among patients treated by conventional thrice-weekly haemodialysis, longer duration of the haemodialysis session is independently associated with lower odds of being bothered by lack of appetite. This finding is consistent with the results from another DOPPS publication that showed that in the setting of thrice-weekly haemodialysis, longer duration of the treatment session was independently associated with lower mortality risk [10]. The absence of significant association between higher Kt/V and lower odds of being bothered by lack of appetite among haemodialysis patients observed in our study is also consistent with findings from the HEMO Study [8]. In fact, the HEMO Study did not observe differences between the dose and flux groups in the decline of appetite score over the follow-up. Possibly, the potential benefit of simply increasing Kt/V with fixed session length may be counterbalanced by the negative effect of post-dialysis fatigue on appetite in patients treated by standard haemodialysis thrice-weekly [25,26]. The potential beneficial effects of longer haemodialysis sessions in appetite and survival could be explained, at least partially, by higher middle molecular clearance and better control of blood pressure and volume [10]. Our findings regarding Kt/V and duration of haemodialysis sessions are also consistent with data that show that daily haemodialysis (defined as more than five sessions per week with sessions of 2–2.5 h) is associated with less post-dialysis fatigue and an improvement in appetite, despite the similar weekly Kt/V between patients treated by standard and daily haemodialysis [27,28]. A clinical trial is needed to determine, among patients receiving standard haemodialysis thrice-weekly, the treatment time that is ideal to reduce the odds of lack of appetite, increase survival and prevent hospitalization. In addition to haemodialysis prescription, the eating habits of patients receiving haemodialysis deserve special attention. It has been shown that for most patients, appetite and nausea are related to specific types of foods [2,29]. Thus, nutrition counseling may help prevent malnutrition by simply guiding haemodialysis patients with poor appetite or nausea towards food choices that are more suitable for both their appetite and nutritional requirements.

In our study, hypertension was independently associated with lower odds of being bothered by lack of appetite. The reason for this finding is not clear. It is known, however, that the association between blood pressure and outcomes in haemodialysis patients do not follow the same pattern as observed in the general population [30]. Previous observations suggest a possible role of antihypertensive medication in nutrition status indicators, particularly weight loss and wasting [31]. There is a suggestion that this protective effect is more related to enalapril than to other classes of antihypertensives. To assess a possible influence of antihypertensive medication on the finding, we performed a post hoc analysis and could not observe a significant reduction in the odds of being bothered by lack of appetite, either in patients prescribed enalapril or antihypertensives of any class.

While the present study offers insights into possible mediators of the associations between lack of appetite and haemodialysis outcomes, methodological limitations to definitive conclusions cannot be ignored. Because the associations of being bothered by lack of appetite with conventional indicators of nutritional status were examined cross-sectionally, it is not possible to know how often problems with lack of appetite precede the development of cachexia and changes in other indicators of poor nutritional status, such as lower levels of albumin, creatinine, nPCR and BMI. Another limitation of our study is the lack of data on powerful markers of inflammation such as cytokines and C-reactive protein. In a previous DOPPS publication, it was shown that higher WBC count was associated with poorer nutritional status measures and higher risk of death [1]. By using WBC and neutrophil counts as proxy for inflammation we found that higher counts were associated with higher odds of being bothered by lack of appetite, independent of several covariates. We also observed that the strength of association between WBC count and both mortality and hospitalization was reduced after adjustment for being bothered by lack of appetite. This finding is an additional support to the hypothesis that reduced appetite is an intermediate step that links inflammation to death [4].

There are data to suggest that, in addition to inflammation, gastroparesis due to autonomic neuropathy may also contribute to lack of appetite among haemodialysis patients [32–34]. Gastroparesis is likely a major problem for diabetic patients, both type 1 and type 2 [32,33]. In our study, the percentage of diabetic patients was significantly higher among patients bothered by lack of appetite. Diabetes, however, was not significantly associated with the adjusted odds of being bothered by lack of appetite, suggesting that differences in covariates explain part of the effects of diabetes on appetite.

Because our analysis of the association between symptoms of depression and being bothered by lack of appetite was cross-sectional, it is not possible to determine if there was a time sequence in the appearance of these two factors. However, the observed increase in the strength of the association between depression and death after excluding the variable being bothered by lack of appetite is consistent with the possibility that lack of appetite also acts as an intermediate factor in the pathogenetic pathway that links depression to death among haemodialysis patients. These results are consistent with data from clinical trials that show evidence that the treatment of depression improves the nutritional status of haemodialysis patients [35,36]. The fact that the association between depressive symptoms and being bothered by lack of appetite was strong and followed a dose–response fashion even after adjustments for several covariates (age, sex, race, years on dialysis, 13 summary comorbid conditions and country) should be viewed as evidence that this is not a spurious association. Moreover, we showed a consistency in this association by using different indicators of depressive symptoms, specifically two questions from the KDQOL-SF and the scores of the CES-D.

In conclusion, this study shows that a simple question to assess the degree that a patient is bothered by lack of appetite is strongly associated in a dose–response fashion with mortality risk, hospitalization rate, conventional indicators of poor nutritional status and the prevalence of depression. Thus, this study provides evidence that even a single assessment of a patient's self-reported problems with appetite by a simple question can help identify haemodialysis patients at higher risk of adverse outcomes. We propose that this simple question from the KDQOL, i.e. ‘during the past 4 weeks, to what extent were you bothered by lack of appetite?’, be used in clinical practice to identify haemodialysis patients who need more detailed evaluation and specific interventions to improve survival and quality of life. The results support development of clinical trials to assess the efficacy of longer duration of dialysis sessions and treatment of depression in preventing or controlling lack of appetite among haemodialysis patients.



   Acknowledgements
Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Discussion
 Acknowledgements
References
 
The DOPPS is supported by research grants from Amgen, Inc. and Kirin Brewery, Ltd, without restrictions on publications. Initial research was presented as an abstract—Elder SJ, Lopes AA, Andreucci V et al. Appetite in haemodialysis patients and associations with indicators of nutritional status and mortality in the international Dialysis Outcomes and Practice Patterns Study (DOPPS). Nephrol Dial Transplant 2006; 21 [Suppl 4]: iv456–iv457—at the European Renal Association/European Dialysis and Transplant Association, 15–18 July 2006, in Glasgow, UK.

Conflict of interest statement. F.K.P. holds grants from Amgen and Kirin. The remaining authors declare no conflicts of interest.



   References
Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Discussion
 Acknowledgements
 References
 

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Received for publication: 31.10.06
Accepted in revised form: 12. 6.07


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