Abstract
Protein-energy malnutrition (PEM) is a common phenomenon in maintenance dialysis (MD) patients and a risk factor for poor quality of life and increased morbidity and mortality, including cardiovascular death, in these individuals. The association between undernutrition and adverse outcome in MD patients, which stands in contrast to that seen in the general population, has been referred to as reverse epidemiology. Measures of food intake, body composition tools, nutritional scoring systems, and laboratory values are used to assess the degree of severity of PEM, but no uniform approach is available for rating the overall severity of PEM. Epidemiologic studies suggest that inflammation is a missing link between PEM and poor clinical outcome in MD patients, and the existence of a malnutrition inflammation complex syndrome is suggested in these patients. Inflammation may be due to subclinical and clinically apparent illnesses. Some investigators suggest that PEM may predispose to illness and inflammation. There is a paucity of information concerning the effect of nutritional therapy on morbidity and mortality in MD patients. Interventional studies of the effect of nutritional support on outcome often are difficult to interpret because of small sample sizes, short duration of study, and other limitations. Large-scale, randomized, clinical trials of the effects of nutritional intake, nutritional status, and inflammation on clinical outcome are needed to define better the relationships between these factors in MD patients. © 2001 by the National Kidney Foundation, Inc.
Highlights
This paradoxical observation has been referred to as reverse epidemiology in the endstage renal disease (ESRD) population and has been observed with regard to the impact of blood pressure on mortality in maintenance dialysis (MD) patients and in other conditions associated with chronic illnesses or debility.[8,9]
There appears to be a strong association between protein-energy malnutrition (PEM) and inflammation in MD patients, and in these individuals, PEM and inflammation are associated with increased morbidity and mortality, including risk of cardiovascular death.[11,12,13]
The nature of the relationships between PEM and inflammation and the relative contributions of these two entities to clinical outcome have not been elucidated clearly.[10,11,12,13]. These considerations are important because the annual mortality rate among MD patients is unacceptably high despite many improvements in dialysis treatment,[1] and PEM and inflammation are strong risk factors for mortality.[10,11,12,13]
Summary
Atlas of End Stage Renal Diseases in the United States. MD, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 2000. 2. Kalantar-Zadeh K, Kopple JD, Block G, Humphries MH: Association between SF36 quality of life measures and nutrition, hospitalization and mortality in hemodialysis. 3. Nicolucci A, Procaccini DA: Why do we need outcomes research in end stage renal disease? Nicolucci A, Procaccini DA: Why do we need outcomes research in end stage renal disease? J Nephrol 13:401404, 2000
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