How to Overcome Anabolic Resistance in Dialysis-Treated Patients?

Giacomo Garibotto,Elisa Russo,Pasquale Esposito,Daniela Picciotto,Michela Saio,Francesca Viazzi,Daniela Verzola,Giuliano Brunori,Francesca Aimasso,Alessandro Laudon

doi:10.3389/fnut.2021.701386

Abstract

A current hypothesis is that dialysis-treated patients are “anabolic resistant” i. e., their muscle protein synthesis (MPS) response to anabolic stimuli is blunted, an effect which leads to muscle wasting and poor physical performance in aging and in several chronic diseases. The importance of maintaining muscle mass and MPS is often neglected in dialysis-treated patients; better than to describe mechanisms leading to energy-protein wasting, the aim of this narrative review is to suggest possible strategies to overcome anabolic resistance in this patient's category. Food intake, in particular dietary protein, and physical activity, are the two major anabolic stimuli. Unfortunately, dialysis patients are often aged and have a sedentary behavior, all conditions which per se may induce a state of “anabolic resistance.” In addition, patients on dialysis are exposed to amino acid or protein deprivation during the dialysis sessions. Unfortunately, the optimal amount and formula of protein/amino acid composition in supplements to maximixe MPS is still unknown in dialysis patients. In young healthy subjects, 20 g whey protein maximally stimulate MPS. However, recent observations suggest that dialysis patients need greater amounts of proteins than healthy subjects to maximally stimulate MPS. Since unneccesary amounts of amino acids could stimulate ureagenesis, toxins and acid production, it is urgent to obtain information on the optimal dose of proteins or amino acids/ketoacids to maximize MPS in this patients' population. In the meantime, the issue of maintaining muscle mass and function in dialysis-treated CKD patients needs not to be overlooked by the kidney community.

Highlights

Dialysis-treated patients with end-stage renal disease (ESRD) have a high prevalence of proteinenergy wasting (PEW), a condition of muscle and visceral protein stores loss which is not completely accounted for by a low nutrient intake [1]
We have briefly summarized our current evidence on factors which regulate muscle protein synthesis (MPS) in humans, as a background information for effective treatment of patients with advanced chronic kidney disease (CKD), mainly those on maintenance HD
According to the current NKF KDOQI/AND guidelines, “nutritional counseling should aim to achieve a dietary intake of 1.2 g protein and 30–35 kcal/kg body weight/day in dialysis patients at risk of malnutrition” [134]

Summary

INTRODUCTION

Dialysis-treated patients with end-stage renal disease (ESRD) have a high prevalence of proteinenergy wasting (PEW), a condition of muscle and visceral protein stores loss which is not completely accounted for by a low nutrient intake [1]. Protein and carbohydrate ingestion increase serum levels of insulin, which has a mild stimulatory effect on MPS [20,21,22] and decreases MPD Another factor which makes protein differently anabolic is the splanchnic AA removal from circulation [23, 24]. Patients with type 2 diabetic kidney disease often show a series of metabolic and nutritional changes linked both to diabetes and kidney failure, including insulin resistance and cardiovascular comorbidities [80], protein-energy wasting and sarcopenia [81] These patients undergo an increase in MPD, an effect primarily mediated by the ubiquitin-proteasome pathway [82, 83]. The effects of acidosis on the anabolic effects of protein feeding in dialysis patients have not been studied so far

Hemodialysis Procedure

Findings

DISCUSSION