This review analyzed clinical trials that supplemented omega-3 fatty acids in hemodialysis patients and the effects on inflammation and nutrition markers. Daily doses of 2.4-3.0g of omega-3 fatty acids decreased inflammatory markers like TNF-α, IL-6, and CRP and improved nutrition markers like albumin. Smaller doses of 1.3-2.1g also showed improvements with longer supplementation periods. Additional benefits were seen when tocopherols were added. Doses up to 3.0g per day appeared to be safe with no reported adverse effects. Further research is still needed to determine optimal dosing amounts, sources, and administration methods for omega-3 fatty acids in hemodial

1. Influence of Omega-3 Fatty Acid Supplementation on Inflammatory and Nutrition Markers in Hemodialysis Patients
Raquel Kairis, MS, RD, LDN and Jack Logomarsino, PhD, RD, LD/N
Purpose:
The aim of this review was to analyze clinical trials
supplementing omega-3 fatty acids in hemodialysis
patients and the consequential effects to inflammation
and nutrition markers.
Methods:
PubMed and CINAHL searches using MeSH terms were
utilized to identify relevant research trials. Relevant and
reliable trials published in the last 15 years that
supplemented omega-3 FA in HD patients were selected
for analytical review.
Reference Supplementation Subjects Time Period Results
Moreira, Gaspar, et al.33 Sardine (90g, 11.6g n-3
PUFA) weekly
63 maintenance HD pts with CRP
≤5mg/dL
8 weeks No significant change in CRP.
Szklarek-Kubicka, Fijalkowska-
Morawska, et al.34
10% n-3 PUFA emulsion 20 chronic HD pts with serum
albumin < 39g/L
11 treatments,
6 months
No significant change in CRP or albumin.
Perunicic-Pekovic, Rasic, et
al.25
2.4g n-3 PUFA daily 35 maintenance HD pts, 16
healthy controls
2 months Significant ↑ HDL (+0.24mg/dL), albumin (+3mmol/L), hemoglobin (+15) (P=0.0001) Significant ↓
IL-6 (-2.89pg/mL), TNF-α (-1.48pg/mL) (P=0.0001).
Tayyebi-Khosroshahi, H.,
Houshyar, J., et al.28
3g n-3 PUFA daily 37 maintenance HD pts 2 months Significant ↓ TNF-α (-4.56pg/mL). (P=0.038)
Kooshki, Taleban, et al.32 2.08g n-3 PUFA daily 34 maintenance HD pts 10 weeks Significant ↓ mean soluble intercellular adhesion molecule type 1 (-50ng/mL). (P < 0.05)
Rasic-Milutinovic, Perunicic, et
al.26
2.4g EPA + DHA daily 35 maintenance HD pts 8 weeks Significant ↓ serum insulin (-17.65mU/L), insulin resistance (-5.12), TNF-α (-1.63pg/mL), IL-6 (-
1.30pg/mL), CRP (-20.9mg/L), ferritin (-151.1ug/L). (P < 0.01)
Gharekhani, Khatami, et al.36 1.8g n-3 PUFA daily 45 maintenance HD pts 4 months No significant change in nutrition markers, TNF-α, CRP, IL-6, BMI, transferrin. Significant change in
ferritin (165.45) (P < 0.001) and IL-10 to IL-6 ratio (0.64 pg/mL). (P=0.003)
Daud, Tubie, et al.35 30mL liquid pro + 2.4g
n-3 PUFA 3x/week
63 maintenance HD pts with
albumin ≤ 3.9g/dL
6 months Significant change in LDL/HDL (-1.3mg/dL) ratio. (P=0.004) Significant increase in albumin
(+0.1g/dL). (P=0.07)
Ewers, Riserus, et al.27 3g n-3 PUFA daily 40 maintenance HD pts 12 weeks Significant ↓ CRP (-1.69mg/L) (P=0.01). Significant ↑ EDW (-0.49kg) (P=0.04).
Lemos, de Alencastro, et al.29 2g flaxseed oil daily 160 maintenance HD pts 120 days Significant ↓ CRP (-3.9mg/L) (P < 0.001) Significant ↓ number of inflamed patients (-24.7%)
(P=0.004).
Himmelfarb, Phinney, et al.30 308mg tocopherols and
800mg DHA daily
57 maintenance HD pts 8 weeks Significant ↓ IL-6 (-4.6pg/mL), WBC count (0.5 103/uL), and neutrophil fraction. (0.4 103uL) (P <
0.05) No significant change in CRP.
Saifullah, Watkins, et al.31 1.3g n-3 PUFA daily 23 maintenance HD pts 12 weeks Significant ↑ omega-3 index (+275% EPA, + 69% DHA). (P=0.0282) Significant ↓ CRP (-3.3mg/L).
(P=0.0282)
Gharekhani, Khatami, et al.37 1.8g n-3 PUFA daily 45 maintenance HD pts 4 months Significant change IL-10 to IL-6 ratio (+0.64pg/mL). (P < 0.001) Significant change in ferritin
(+165.5ng/mL). (P=0.003)
Gharekhani, Khatami, et al.38 1.8g n-3 PUFA daily 54 maintenance HD pts 4 months Significant ↓ depression score (-10.08) (P=0.001) Significant change in ferritin (-165.5ng/mL).
(P=0.003) Significant ↑ IL-10 to IL-6 ratio (0.64pg/mL). (P=0.000)
Results:
Supplementation with Significant Improvement
Daily doses of 2.4-3.0g omega-3 FA decreased inflammatory
and improved nutritional markers.25,26,27,28 Serum DHA was
significantly associated with inflammation (IL-6 and TNF-α)
and albumin.25 Tumor necrosis factor-α (TNF- α), IL-6, and
CRP markers showed significant reduction with 2.4-3.0g
omega-3 FA daily.26,27,28 Additionally patients’ dry weight
significantly improved.27 Two studies added tocopherols to
2.0g of flaxseed oil and 800mg DHA respectively; the
combination supplements decreased the number of
inflamed patients (CRP, IL-6) and boosted the immune
response.30,31 Soluble intercellular adhesion molecule -1
(sICAM-1) decreased with 2090mg omega-3 FA daily.32
Results:
Supplementation with No Significant Improvement
When provided three days a week, a 11.6g omega-3 FA
sardine sandwich, a protein drink containing 2.4g omega-3
FA, and 10g refined omega-3 FA emulsion were unable to
significantly affect inflammation or nutrition markers.33,34,35
Additionally 1.8g of omega-3 FA daily in three separate
studies did not produce significant change in markers.36,37,38
Compliance and Safety:
Based on serum EPA levels, 74% of HD patients adhered to
a prescribed omega-3 FA supplement.39 No adverse events
were reported in any of the trials reviewed. According to
the FDA daily supplementation of 3g EPA/DHA is safe.42
Implications for Practitioners:
Omega-3 FA doses of 2.4-3.0g daily as capsules for 8 weeks can reduce inflammation and improve nutritional status. Longer periods of supplementation can show improvements with smaller
doses of 1.3-2.1g omega-3 FA daily. Additional benefit may come from added tocopherols. Further research is needed to determine optimal source, time period, and administration of
omega-3 FA in the HD patient population. In doses of 3.0g daily, omega-3 FA can be safely recommended but should be monitored for prolonged bleeding and interacting medications.
Introduction and Background:
Hemodialysis (HD) has a prevalence of approximately
430,273 patients in the US. 1 Only 52% of patients remain
living three years after initiating treatment. HD patients
had significantly higher levels of C-reactive protein (CRP)
and lower levels of albumin and pre-albumin. Acute
inflammation began during HD treatment and further
intensified during a 2 hour period following treatment as
evidenced by increased interleukin-6 (IL-6) and
fibrinogen.3 Albumin was decreased due to inflammation,
poor nutritional status, and suppressed synthesis.5
Nutritional status and CRP were independent predictors
of mortality within 3 years of incident treatment.8
A precursor to eicosanoids, omega-3 fatty acids (FA) play a
regulatory role in providing anti-inflammatory
properties.15 Seventy-six percent of HD patients did not
meet the American Heart Association recommendation
for fish intake, twice weekly equating to 1g EPA/DHA.20