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Saint Louis University School of Nursing Baguio City

In Partial Fulfillment for the Requirements in Related Learning Experience

Journal on Chronic Kidney Disease

Submitted by: ABRENICA, Kimberly R. BSN 4-I2 LUMC MEDICAL WARD

Submitted to: Mrs. Joyce Kiat-ong Clinical Instructor

Date of Submission: February 12, 2012

I.

Summary of the Article:

Hyperphosphatemia (high levels of phosphate in the blood) commonly occurs in CKD patients on dialysis. Even when patients take medications to reduce phosphate acquired through their diet, about half of them cannot reduce phosphate to recommended levels. Because patients with hyperphosphatemia also have high levels of phosphate in their saliva, researchers tested whether there might be a benefit to binding salivary phosphate during periods of fasting, in addition to using phosphate binders with meals. Vincenzo Savica, MD, of the University of Messina, and Lorenzo A. Cal MD, PhD, of the University of Padova, Italy and their colleagues recruited 13 dialysis patients with high blood phosphate levels to chew 20 mg of phosphate-binding chewing gum twice daily for two weeks between meals, in addition to their prescribed phosphate-binding regimen. Dr. Savica and Dr. Cal's team found that salivary phosphate and blood phosphate levels significantly decreased during the first week of chewing, and by the end of two weeks, salivary phosphate decreased 55% and blood phosphate decreased 31% from levels measured at the start of the study. Salivary phosphate returned to its original level by day 15 after discontinuing the chewing gum, whereas blood phosphate took 30 days to return to its original value. While these observations are preliminary and require confirmation in a randomized, double blind, placebo controlled study with more participants, the findings indicate that this chewing regimen might help control phosphate levels in patients with CKD. "Adding salivary phosphate binding to traditional phosphate binders could be a useful approach for improving treatment of hyperphosphatemia in hemodialysis patients," the authors concluded. The study authors declare CM&D Pharma Limited, UK as a financial interest, for their supply of the experimental chewing gum.

II.

Reaction:

As a student nurse and a future member of the health care team, it is very significant for me to be updated with new interventions and therapeutic management appropriate for the condition of my patient because this will improve the care plan. Moreover, once it is already confirmed and presented to the public, it will develop more efficient and safe therapeutic regimen for patients suffering from chronic kidney disease, as a support or complement to their medications. Study shows that the condition of high levels of phosphate in the blood, known as hyperphosphatemia, generally takes place in chronic kidney disease patients on dialysis. The intake of various drugs with the aim of reducing the phosphate level in ones diet, sometimes remain unsuccessful in bringing about the desired result (http://www.healthjockey.com/2009/02/16/study-says-chewing-gum-beneficial-for-chronickidney-disease-patient/). These facts show that there is a need to determine if binding of the salivary phosphate during periods of fasting and the use of phosphate binders with meals, could bring about a positive effect in such patients. It is very significant that in every intervention that we plan for our clients and in all the health teaching that we advise them, we must have a scientific basis behind. This journal article will widen my horizon regarding the newly discovered medication regimen for CKD. This will also be a challenge for me to read articles from the book, magazines, and surf the internet regarding topics on phosphate-binding chewing gum and CKD. Through this study, these researchers hint at the use of such chewing gums in chronic kidney disease patients with the aim of reducing their phosphate levels. However, they also state that their study findings further

need to be confirmed in a randomized, double blind, placebo controlled study conducted on a larger group of patients (http://www.physorg.com/news153672483.html). According to the statistics, approximately 1,212,306 adult Filipinos are suffering from CKD (http://www.docstoc.com/docs/476194/CHRONIC-KIDNEY-DISEASE-The-PhilippineSituation), it may be caused by diet, lifestyle, genetic, or environment, whatever is the cause, we cant deny the fact that the economy we have right now is a big factor that contributes to this disease and other illnesses. Since this phosphate-binding chewing gum is still under further investigations and studies, it is not yet decided on how the packaging and marketing will be, but since it is a new discovery, it will be expected that it will be of high price, thus, not all can be assured of its distribution, especially in developing countries like the Philippines. The authors concluded that adding salivary phosphate binding to traditional phosphate binders could be a useful approach for improving treatment of hyperphosphatemia in hemodialysis patients (http://www.medicalnewstoday.com/articles/138863.php). There are also studies that it is not only indicated for clients with CKD, but it can also be for other beneficial purposes. "Chewing gum is an easy tool students can use for a potential academic edge," says Craig Johnston, Ph.D., the lead researcher and an instructor in nutrition at the Department of Pediatrics at Baylor College of Medicine. "We decreased overall snack intake by 40 to 60 calories. Having something in the mouth likely calms the appetite," explains Paula Geiselman, Ph.D, lead researcher and physiological psychologist. The American Dental Association says on its Web site that "chewing sugarless gum for 20 minutes following meals can help prevent tooth decay" and recommends looking for gum with its ADA-approved seal. The saliva produced in the mouth by the physical act of chewing can wash away acids and bacteria, thereby protecting teeth. Besides beating tooth decay, independent research finds that gum can aid in reducing the symptoms of acid reflux disease. The saliva flow can lead to an antacid effect in the stomach. There is also early evidence that gum chewing increases blood flow to the brain and the head by up to 25 percent, but no one can explain what impact that blood flow may have on cognition. As for dieting, one study from the Mayo Clinic finds that the body burns 11 calories an hour through working the jaw. "Overall gum chewing is more beneficial than it is harmful," says Dr. Michael Benninger, chairman of the Head and Neck Institute at the Cleveland Clinic in Ohio (http://articles.cnn.com/2009-04-22/health/chewing.gum.benefits_1_wrigley-science-institutegum-eighth-grade-math-students/3?_s=PM:HEALTH). This research study can be a basis for further researches regarding phosphatebinding chewing gum and CKD. While these observations are preliminary and require confirmation in a randomized, double blind, placebo controlled study with more participants, the findings indicate that this chewing regimen might help control phosphate levels in patients with CKD. "Adding salivary phosphate binding to traditional phosphate binders could be a useful approach for improving treatment of hyperphosphatemia in hemodialysis patients," the authors concluded (http://www.sciencedaily.com /releases/2009/02/090212150854.htm). III. References  http://www.renalandurologynews.com/chewing-gum-could-aid-in-phosphoruscontrol/article/180805/  American Society of Nephrology (2009, February 20). Chewing Gum Helps Treat Hyperphosphatemia In Kidney Disease Patients. ScienceDaily. Retrieved March 11, 2011, from http://www.sciencedaily.com /releases/2009/02/090212150854.htm  http:www.healthjockey.com/2009/02/16/study-says-chewing-gum-beneficial-for-chronickidney-disease-patient/

 http://articles.cnn.com/2009-04-22/health/chewing.gum.benefits_1_wrigley-scienceinstitute-gum-eighth-grade-math-students/3?_s=PM:HEALTH  http://www.docstoc.com/docs/476194/CHRONIC-KIDNEY-DISEASE-The-PhilippineSituation  http://jasn.asnjournals.org/content/20/3/639.full  American Society of Nephrology (2009, February 12). Chewing Gum Helps Treat Hyperphosphatemia In Kidney Disease Patients. ScienceDaily. Retrieved November 8, 2011, from http://www.sciencedaily.com /releases/2009/02/090212150854.htm  http://www.bioportfolio.com/resources/trial/68529/Double-Blind-Randomized-PlaceboControlled-Trial-Of-Fostrap-Chewing-Gum-In-Patients.html

IV.

Related Literatures Chew on this: Gum may be good for body, mind

April 22, 2009|By A. Chris Gajilan Special to CNN If you're looking to curb your appetite and improve your memory, you're probably exercising, eating healthier foods and trying to get some sleep. Those things are all good, but maybe you should try chomping on a stick of sugar-free gum. At least that's what research funded by the Wrigley Science Institute and being presented at the Experimental Biology 2009 meeting this week may have you think. The data are part of a growing body of research that is giving Americans more reasons to pop some gum in their mouths and chew away.One line of research suggests that gum should no longer be treated as contraband in schools. This newest study indicates that chewing gum can lead to better academic performance. Researchers at the Baylor College of Medicine took 108 eighth-grade math students from a Houston, Texas, charter school and divided them into two groups, following them for 14 weeks. One group chewed gum while doing homework and during test-taking situations. The other group did not chew gum at all. The results were surprising. The gum-chewing students had a 3 percent increase in their standardized math test scores compared with those who did not chew gum. Also, the students who chewed gum had better final grades compared with the non-chompers. "Chewing gum is an easy tool students can use for a potential academic edge," says Craig Johnston, Ph.D., the lead researcher and an instructor in nutrition at the Department of Pediatrics at Baylor College of Medicine.He also reports that teachers anecdotally found that students who chewed gum required fewer breaks, paid better attention and stayed quiet longer than those who did not. Another study adds to a growing body of evidence centering on chewing gum satiety and cravings. Investigators at Louisiana State University took 115 people who regularly chewed gum and fed them lunch. They measured their cravings before and after lunch. They found that those subjects, who chewed gum three times hourly after lunch, ate fewer high-calorie snacks. The chewers also reported decreased feelings of hunger and cravings for sweet foods. "We decreased overall snack intake by 40 to 60 calories. Having something in the mouth likely calms the appetite," explains Paula Geiselman, Ph.D, lead researcher and physiological psychologist.So, is chewing gum the next in fad diet trends? Nutritionists and doctors are prescribing a healthy dose of caution. "The only reason to do these studies is to sell more gum," warns Marion Nestle, Ph.D., a nutritionist at New York University and author of "What to Eat." But Nestle does admit that it may have some minor benefit, "Gum has no calories. If it helps people eat less, it could be useful."As for boosting academic performance, Nestle is familiar with results showing that feeding breakfast to hungry kids results in better schoolwork, but she's quick to burst the bubble on the LSU study.

Nestle remains cautious about the funds being pumped into research by the gum industry. "Sponsored studies almost invariably produce results favorable to the economic interests of the sponsor. [They] are always designed in ways that fail to control for alternative explanations for the results."Aside from the industry-funded findings, there is solid evidence that gum chewing brings big benefits in dental health and acid reflux disease. The American Dental Association says on its Web site that "chewing sugarless gum for 20 minutes following meals can help prevent tooth decay" and recommends looking for gum with its ADA-approved seal. The saliva produced in the mouth by the physical act of chewing can wash away acids and bacteria, thereby protecting teeth. Besides beating tooth decay, independent research finds that gum can aid in reducing the symptoms of acid reflux disease. The saliva flow can lead to an antacid effect in the stomach. There is also early evidence that gum chewing increases blood flow to the brain and the head by up to 25 percent, but no one can explain what impact that blood flow may have on cognition. As for dieting, one study from the Mayo Clinic finds that the body burns 11 calories an hour through working the jaw. "Overall gum chewing is more beneficial than it is harmful," says Dr. Michael Benninger, chairman of the Head and Neck Institute at the Cleveland Clinic in Ohio. "This isn't like smoking. The downsides are minimal," Benninger adds. "There are people who probably shouldn't chew gum such as people with Temporomandibular Joint and Muscle Disorders, or TMJ, people with chronic tension headaches or if you grind your teeth at night." As manufacturers come up with new flavors, packages and brands, gum's popularity continues to grow. Sales topped $1.2 billion last year alone, and sales of sugar-free gum increased by more than 11 percent in 2008, according to marketing research provider Information Resources Inc. It's definitely big business for what may be the world's oldest confection. Ancient cultures around the world found their own forms of gum. The Greeks called it mastiche. Mayans chewed on the sap of the sapodilla tree and called it chicle. Native Americans introduced the sap of the spruce tree to early European settlers in New England. Interestingly, tree sap is long gone from the current treat. Today's gum consists of synthetic ingredients and is made sweet. It can be made sugar-free by adding sorbitol, a substance that can have laxative effects at high doses.As for the notion that gum can stay in your stomach for years if swallowed, experts said that's a myth. Gum is passed through the body and not digested. While the Wrigley Science Institute declines to say just how much money it's spending on research, it's open about its objective. "We're providing more reasons why consumers should chew," said Gil Leveille, Ph.D., executive director of the Wrigley Science Institute. But medical experts agree that gum chewing may be a tool, as people struggle to chip away at the obesity problem. According to the American Dietetic Association, "If you chew two sticks of gum at 20 calories instead of eating one to two chocolate chip cookies at 140 calories, you can save 120 calories." Source:http://articles.cnn.com/2009-04-22/health/chewing.gum.benefits_1_wrigley-scienceinstitute-gum-eighth-grade-math-students/3?_s=PM:HEALTH

Study says chewing gum beneficial for chronic kidney disease patient

A latest study states that chewing a certain type of gum can possibly aid in treating high phosphate levels in dialysis patients with chronic kidney disease. It is stated that these chewing gums, made with a phosphate-binding ingredient, could help in maintaining proper phosphate levels in such patients, and also prevent the onset of heart diseases. The condition of high levels of phosphate in the blood, known as hyperphosphatemia, generally takes place in chronic kidney disease patients on dialysis. The intake of various drugs with the aim of reducing the phosphate level in ones diet, sometimes remain unsuccessful in bringing about the desired result. The saliva of such patients is also said to contain high levels of phosphate. Thus the study investigators wanted to determine if binding of the salivary phosphate during periods of fasting and the use of phosphate binders with meals, could bring about a positive effect in such patients. The study was conducted by Vincenzo Savica, MD, of the University of Messina, along with Lorenzo A. Cal, MD, PhD, of the University of Padova, Italy, and colleagues. They assessed about 13 dialysis patients with high blood phosphate levels, for the purpose of this study. These patients, along with continuing their prescribed phosphate-binding regime, were also asked to chew 20 mg of phosphate-binding chewing gum twice a day between meals, for a period of 14 days. A considerable reduce in the amount of salivary phosphate and blood phosphate levels in these patients was noticed after this time period. It is said that the salivary phosphate level reduced by about 55 percent, while the blood phosphate level reduced by about 31 percent in these patients. It was also noticed that a couple of days after curbing the use of these chewing gums, both salivary phosphate and blood phosphate returned to their original level. Through this study, these researchers hint at the use of such chewing gums in chronic kidney disease patients with the aim of reducing their phosphate levels. However, they also state that their study findings further need to be confirmed in a randomized, double blind, placebo controlled study conducted on a larger group of patients. Their findings are present online and will soon be published in the March 2009 issue of the Journal of the American Society Nephrology. Source: http:www.healthjockey.com/2009/02/16/study-says-chewing-gum-beneficial-for-chronickidney-disease-patient/

Chewing Gum Could Aid in Phosphorus Control Alison Steiber, PhD, RD, LD October 11, 2010 Phosphate disturbances have been widely discussed by many, including this author in previous columns. Hyperphosphatemia in CKD patients is independently associated with both secondary hyperparathyroidism and cardiovascular disease. In CKD, serum phosphorus begins to rise when glomerular filtration rate (GFR) falls below 30 mL/min/1.73 m2. By the time patients are on hemodialysis (HD), approximately 40% have serum phosphorus concentrations greater than 6.5 mg/dL. Serum phosphorus is similar to many tightly controlled biochemical indices of human metabolism in that at concentrations both higher and lower than physiologically normal mortality is increased. In fact, serum phosphate concentrations higher than 6.5 mg/dL are associated with a 27% increase in the relative risk of death. Current protocols Current treatment for hyperphosphatemia in CKD patients involves dietary restriction of phosphate and the use of phosphate binders. In HD patients, the dialysis process also assists in phosphate control. These interventions, however, have not been completely successful, as approximately 50% of patients do not achieve goals established by the Kidney Disease Outcome Quality Initiative. Food sources of phosphorus are similar to protein sources. Diet prescriptions that limit phosphorus and protein can achieve adequate control of both in predialysis patients, but this often is not the case with dialysis patients. HD patients are educated about the importance of limiting phosphorus intake to 800-1000 mg per day, but this is extremely difficult to achieve. The typical western diet contains approximately 1000-1200 mg of phosphate per day with, conservatively, an additional 500 mg/day from food additives such as monocalcium phosphate or sodium phosphate, depending on the amount of fast or processed foods consumed. Given the difficulty of dietary restrictions in phosphate control, pills that bind phosphate are commonly used. Common phosphate binders Tonelli et al (N Engl J Med. 2010;362:1312-1324) has suggested that an ideal binder is one that effectively binds dietary phosphate, does not increase patients' pill burden, has no side effects and no systemic absorption, and is inexpensive. Currently, the commonly used phosphate binders are calcium carbonate, calcium acetate, sevelamer hydrochloride, lanthanum carbonate, and magnesium hydroxide. These binders are reasonably safe and moderately bind dietary phosphates. The cost of these binders is substantial: approximately $750 million worldwide. The binders can contribute significantly to patients' pill burden (up to around six pills per day), and they may be systemically absorbed. Calcium-based binders increase patients' serum calcium concentrations. A new weapon: salivary phosphate However, Savica et al. (J Am Soc Nephrol. 2009; 20:639-644) have recently reported a new weapon in phosphate control. These researchers have discovered a chewing gum that may come very close to being an ideal phosphate binder. Saliva contains phosphate at a level five times that of serum. Salivary phosphate has been shown to be inversely associated with GFR in CKD patients, thus as the GFR decreases, salivary phosphorus concentration increases. In fact, both CKD and HD patients have increased salivary phosphorus excretion compared with healthy controls. Binding salivary phosphorus could decrease the body phosphorus burden and thus lower serum phosphorus.

With these facts in mind, Savica's group tested chitosan as a potential binder of salivary phosphate. They found that a middle viscosity deacylated chitosan was able to effectively bind phosphate. The gum is inexpensive to manufacture, is not believed to be absorbed systemically, and does not contribute to patients' pill burden. However, the impact on serum phosphate needed to be tested. Therefore, a pilot trial was conducted over six weeks. HD patients with serum phosphorus concentrations greater than 6 mg/dL were enrolled in the study. These patients were educated about sticking to a 1.2 g protein/day diet six months prior to the study. During the study, the patients were given all the gum and sevelamer they would require throughout the study. Unused pills and gum were returned at the end of the study to measure patient compliance with individual prescription. Chitosan-loaded gum shows promise Patients were instructed to chew the chitosan gum for 60 minutes during fasting periods in the morning and the afternoon and to use of sevelamer with meals. The gum was only used during weeks 1 and 2, but sevelamer was used throughout the six weeks. The results of this brief pilot trial showed no significant changes in serum calcium during the six weeks; however, the mean serum phosphorus level declined significantly from week 0 to 2 (from 7.60 to 5.25 mg/dL). Additionally, serum phosphorus did not return to baseline levels until week 6 (7.55 mg/dL). This new gum shows great initial promise. If further research confirms the safety and efficacy of the chitosan gum, dialysis patients would have an inexpensive means to control phosphorus nonsystemically and which does not contribute to their daily burden. This could greatly impact their quality of life and the risk of death. Dr. Steiber is Coordinator of the Dietetic Internship/Master's Degree Program at Case Western Reserve University in Cleveland. Source:http://www.renalandurologynews.com/chewing-gum-could-aid-in-phosphoruscontrol/article/180805/

Chewing Gum Helps Treat Hyperphosphatemia In Kidney Disease Patients ScienceDaily (Feb. 12, 2009) Chewing gum made with a phosphate-binding ingredient can help treat high phosphate levels in dialysis patients with chronic kidney disease (CKD), according to a study appearing in the March 2009 issue of the Journal of the American Society Nephrology (JASN). The results suggest that this simple measure could maintain proper phosphate levels and help prevent cardiovascular disease in these patients. Hyperphosphatemia (high levels of phosphate in the blood) commonly occurs in CKD patients on dialysis. Even when patients take medications to reduce phosphate acquired through their diet, about half of them cannot reduce phosphate to recommended levels. Because patients with hyperphosphatemia also have high levels of phosphate in their saliva, researchers tested whether there might be a benefit to binding salivary phosphate during periods of fasting, in addition to using phosphate binders with meals. Vincenzo Savica, MD, of the University of Messina, and Lorenzo A. Cal MD, PhD, of the University of Padova, Italy and their colleagues recruited 13 dialysis patients with high blood phosphate levels to chew 20 mg of phosphate-binding chewing gum twice daily for two weeks between meals, in addition to their prescribed phosphate-binding regimen. Dr. Savica and Dr. Cal's team found that salivary phosphate and blood phosphate levels significantly decreased during the first week of chewing, and by the end of two weeks, salivary phosphate decreased 55% and blood phosphate decreased 31% from levels measured at the start of the study. Salivary phosphate returned to its original level by day 15 after discontinuing the chewing gum, whereas blood phosphate took 30 days to return to its original value. While these observations are preliminary and require confirmation in a randomized, double blind, placebo controlled study with more participants, the findings indicate that this chewing regimen might help control phosphate levels in patients with CKD. "Adding salivary phosphate binding to traditional phosphate binders could be a useful approach for improving treatment of hyperphosphatemia in hemodialysis patients," the authors concluded. The study authors declare CM&D Pharma Limited, UK as a financial interest, for their supply of the experimental chewing gum. Source: American Society of Nephrology (2009, February 12). Chewing Gum Helps Treat Hyperphosphatemia In Kidney Disease Patients. ScienceDaily. Retrieved November 8, 2011, from http://www.sciencedaily.com /releases/2009/02/090212150854.htm

Double Blind Randomized Placebo Controlled Trial of FOSTRAP Chewing Gum in Patients With CKD and Hyperphosphatemia Summary The phosphorus content in saliva is increased in chronic kidney disease. We hypothesize that a chewing gum that binds salivary phosphorus would be a novel, effective agent to reduce serum levels of phosphorus in patients with chronic kidney disease. We are testing this hypothesis using a chewing gum called FOSTRAP which has been shown to be effective in a small, non-randomized study in patients with chronic kidney disease on hemodialysis. Description A double-blind, randomized, placebo, controlled trial with an open label extension for those subjects with end stage renal disease (ESRD). Patients with ESRD will be randomized to receive either FOSTRAP 20 mg BID, FOSTRAP 40 mg BID or matching placebo 2x/day. All subjects will participate in a 4 week chewing period followed by a 4 week follow up period. All subjects will then enter an open label 2 week extension phase in which they will receive FOSTRAP 20 mg TID. Patients with chronic kidney disease (CKD) not on dialysis will receive either FOSTRAP 20 mg 3x/day or placebo TID for 4 weeks followed by a 4 week follow up period. Study Design Allocation: Randomized, Control: Placebo Control, Endpoint Classification: Safety/Efficacy Study, Intervention Model: Parallel Assignment, Masking: Double Blind (Subject, Caregiver, Investigator, Outcomes Assessor), Primary Purpose: Treatment Conditions Hyperphosphatemia Intervention FOSTRAP Chewing Gum, FOSTRAP Chewing Gum, FOSTRAP Chewing Gum, FOSTRAP Chewing Gum, Placebo chewing gum Source: http://www.bioportfolio.com/resources/trial/68529/Double-Blind-Randomized-PlaceboControlled-Trial-Of-Fostrap-Chewing-Gum-In-Patients.html