Nutritional Status Of Chronic Kidney Disease Patients Research Articles

The hidden and complex relationship between dietary phosphorus and malnutrition in hemodialysis patients with chronic kidney disease.

Chronic kidney disease (CKD) has always been a complicated global challenge, ranking as the 12th leading cause of death worldwide. Hemodialysis, being one of the most opted renal replacement therapies (RRTs) for patients with end-stage renal disease (ESRD), still possesses some limitations in preventing complications, such as malnutrition and mineral bone disease (CKD-MBD). While efforts have focused on controlling CKD-MBD parameters like calcium and phosphate, less attention has been given to dietary interventions. Moreover, the adoption of low-phosphorus diets for hemodialysis patients is very complex due to potential conflicts with the guideline-recommended high-protein dietary approach. This study sought to investigate the relationship between dietary phosphorus intake and nutritional status in CKD patients undergoing regular hemodialysis. This non-randomized cross-sectional study comprising 88 patients was conducted at the Hemodialysis Unit, RSUD Dr. Soetomo, Surabaya, East Java, using a three-day dietary record in March 2022. Relationships between variables were analyzed using Spearman and ANOVA tests. No significant positive association was found between dietary calcium with corrected calcium levels (p = 0.988; rs = -0.002) and between dietary phosphorus with plasma phosphate levels (p = 0.082; rs = 0.187). However, Spearman's analysis revealed a weak but positive correlation between dietary phosphorus and nutritional status (p = 0.022; rs = 0.215*). Our study highlights a positive relationship between dietary phosphorus and nutritional status among hemodialysis patients, offering insights into potential strategies for optimizing patient care and outcomes.

Relationship between Compound α-Ketoacid and Microinflammation in Patients with Chronic Kidney Disease.

Chronic kidney disease (CKD) refers to the presence of structural or functional abnormalities in the kidneys that affect health, lasting for more than 3 months. CKD is not only the direct cause of global incidence rate and mortality, but also an important risk factor for cardiovascular disease. Persistent microinflammatory state has been recognized as an important component of CKD, which can lead to renal fibrosis and loss of renal function, and plays a crucial role in the pathophysiology and progression of the disease. Simultaneously, compound α-Ketoacid can bind nitrogen-containing metabolites in the blood and accelerate their excretion from the body, thereby reducing the level of metabolic waste, alleviating gastrointestinal reactions in patients, and reducing the inflammatory response and oxidative stress state of the body. Compound α-Ketoacid contains amino acids required by CKD patients. In this review, we explore the relationship between compound α-Ketoacid and microinflammation in patients with CKD. The review indicated that compound α-Ketoacid can improve the microinflammatory state in CKD patients by improving the nutritional status of CKD patients, improving patient's acid-base balance disorder, regulating oxidative stress, improving gut microbiota, and regulating abnormal lipid metabolism.

Hubungan lama hemodialisis dengan nafsu makan dan status gizi pada pasien penyakit ginjal kronis

Background: Hemodialysis is an alternative therapy to replace kidney function for people with Chronic Kidney Disease (CKD). Proper dialysis procedures must be maintained to maintain nutritional balance. Failure in the dialysis procedure results in loss of nutrients in the dialysate, which can increase catabolism and acid reflux.Objectives: This study aims to analyze the relationship between the length of hemodialysis and appetite and the nutritional status of CKD patients receiving hemodialysis therapy twice a week at UPTDK RSUD Dr. Soekardjo City of Tasikmalaya in 2023.Methods: The research design used cross-sectional with consecutive sampling, namely as many as 69 CKD patients undergoing hemodialysis—statistical analysis using a chi-square test.Results: Most of the respondents (73,9%) had been on hemodialysis for a long time (≥24 months), most of the respondents (76,8%) had less appetite, and the majority of respondents (78,3%) were malnourished. The results of the correlation test showed that there was a relationship between the length of hemodialysis with appetite (p = 0,022 and OR = 4,3; 95% CI = 1,298-14,240) and nutritional status (p = 0,000 and OR = 11,5; 3, 103-42,621).Conclusion: Length of hemodialysis in patients with CKD has a significant relationship with appetite and nutritional status

Analysis of the Impact of Continuous Ambulatory Peritoneal Dialysis on Nutritional Status in Pediatric Chronic Kidney Disease

Background: Chronic kidney disease (CKD) is a serious problem for all age groups, particularly in children. Several studies have shown that patients with CKD who underwent dialysis, including Continuous Ambulatory Peritoneal Dialysis (CAPD), experienced malnutrition, short stature and growth retardation. This study aimed to evaluate the correlation between the indicators of CAPD regiments with the nutritional status of pediatric patients with CKD and factors that influence it.
 Method: We conducted a cross-sectional study by collecting secondary data from medical records such as disease stage and duration, the most recent CAPD regimen, etiology, and comorbidities. Data on nutritional status was then obtained by measuring body weight, height, and upper arm circumference. The measurement was then plotted using the WHO anthropometry application or the CDC growth chart. Demographic data such as the education level of father and mother, family economic status, age, and gender were obtained by filling out the Case Report Form (CRF).
 Result: A total of fifteen respondents were included in this study. Children with CKD who underwent CAPD primarily had normal nutritional status with very short stature. Furthermore, no significant association was found between the CAPD regiments with the nutritional status of children with chronic kidney disease who are undergoing CAPD (p>0.05).
 Conclusion: Children with CKD who underwent CAPD primarily had normal nutritional status with very short stature. There was no correlation between the parameters of CAPD regiments with the nutritional status of CKD patients who underwent CAPD. This indicates that the regiment used in this study is already quite satisfactory as it does not impact the nutritional status of those patients.

Serum PTH Associated with Malnutrition Determined by Bioelectrical Impedance Technology in Chronic Kidney Disease Patients.

Purpose Chronic malnutrition and cachexia are common in chronic kidney disease (CKD), and importance should be given to these complications because they affect the patient's quality of life and prognosis. This study analyzed the correlation between the serum PTH level, nutritional status, and body composition of patients with CKD. Methods CKD patients were enrolled in Center for Kidney Disease, Second Affiliated Hospital of Nanjing Medical University, from December 1, 2016, to November 30, 2020. Bioelectrical impedance technology was applied to estimate the body composition. The characteristics of the body composition were compared among different stages of CKD patients, and then the correlation between PTH and body composition was analyzed. Results 205 CKD patients were enrolled. Twenty-five patients were in stage 1 or 2 of CKD, 78 patients were in stage 3 or 4, 31 patients were in stage 5 without dialysis (referred to as CKD stage 5A), and 71 patients were in stage 5 with dialysis (referred to as CKD stage 5B). Body composition analysis showed that the patients had a phase angle (PA) of 5.02 ± 1.07°, a percentage of body fat (PBF) of 27.74 ± 8.8%, and a skeletal muscle mass index (SMI) of 7.4 ± 1.34 kg/m2. PBF peaked in the CKD stage 3/4 group and gradually decreased with the progression of CKD. The PA and SMI differed significantly between the CKD stage 1/2 and stage 5B groups. The proportion of low SMI did not differ significantly between the CKD stage 1/2 and stage 3/4 groups, but it was obviously higher in the CKD stage 5A and 5B groups. PTH was significantly correlated with BMI, hemoglobin, albumin, total cholesterol, triglycerides, and SMI. Binary logistic regression of low SMI showed that the odds ratio for PTH levels was greater than the upper limit of the normal range, which was 11.769 (p=0.043, 95% confidence interval: 1.078–128.536), and the model predictive power was 0.986 after correction for age, sex, height, weight, hemoglobin, serum calcium, serum phosphorus, serum total cholesterol, serum triglyceride, and basal metabolic rate. Conclusions Bioelectrical impedance analysis might be useful in estimating the nutritional status of CKD patients in terms of fat and muscle parameters. High levels of PTH are an independent risk factor for developing low SMI in CKD patients.

Obesity and Other Nutrition Related Abnormalities in Pre-Dialysis Chronic Kidney Disease (CKD) Participants.

Chronic kidney disease (CKD) is increasing in sub-Saharan Africa. Undernutrition has been prevalent amongst end stage CKD patients, with limited data on the prevalence of obesity. The aim of this study was to assess the nutritional status of CKD patients using various methods sensitive to over and under-nutrition. Stage 3 to 5 CKD patients (glomerular filtration rate (GFR) < 60 mL/min/1.73 m2) attending a pre-dialysis clinic in Cape Town, were enrolled. Exclusion criteria included infectious and autoimmune conditions. Sociodemographic, clinical and biochemical data were collected, and anthropometric measurements were performed. Dietary intake was measured with a quantified food frequency questionnaire (FFQ). Statistical Package for the Social Sciences (SPSS) version 26 was used for statistical analysis. Seventy participants, with mean age of 41.8 ± 11.8 years, 52.9% females and 47.1% males were enrolled. Participants enrolled mainly had stage 5 kidney failure. Thirty percent were overweight (21) and 25 (36%) were obese, 22 (60%) of females were overweight and obese, while 13 (39.4%) of males were predominantly normal weight. Abdominal obesity was found in 42 (60%) of participants, mainly in females. Undernutrition prevalence was low at 3%. Dietary assessment showed a high sugar and protein intake. There was a high prevalence of overweight, obesity and abdominal obesity in CKD stage 35 patients, with unhealthy dietary intake and other nutritional abnormalities.

&lt;p&gt;Protein-Energy Wasting and Associated Factors Among Chronic Kidney Disease Patients at St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia&lt;/p&gt;

BackgroundProtein-energy wasting is a major issue in patients with chronic kidney disease (CKD), adversely affecting morbidity, mortality, functional activity, and quality of life. Assessment of nutritional status in CKD patients is important to ensure patient’s normal protein stores and avoid metabolic complications. However, in Ethiopia, there were very few studies done to assess the prevalence of protein-energy wasting (PEW) and its associated factors among CKD patients.ObjectiveTo assess protein-energy wasting and associated factors among chronic kidney disease patients at adult OPD St. Paulo’s Hospital Millennium Medical College, Addis Ababa Ethiopia.Materials and MethodsAn institution-based cross-sectional study was conducted from March to April 2019. Data were collected using a structured interviewer-administered questionnaire and anthropometric measurements, and laboratory data were collected from patient files. Data were entered into Epi-data version 3.1 and analyzed using SPSS version 20. Both bivariate and multiple logistic regression analyses were performed to identify associated factors. P values <0.05 were considered to declare statistical significance.ResultsIn this study, 274 respondents were interviewed with a response rate of 100%. The prevalence of protein-energy wasting in CKD patients was 23.4%. Chronic kidney disease patients at age ≥65 years were seven times more likely to have protein-energy wasting as compared to patients aged 18–34 years [AOR=7.0, 95% (CI: 2.4, 20.5)]. Patients who had a history of anorexia were 5.2 times more likely to have protein-energy wasting as compared to those who had no history of anorexia [(AOR=5.2, 95% (CI: 2.7, 10.3)] and were significantly associated with the risk of having CKD.ConclusionThe prevalence of protein-energy wasting among CKD patients was high and associated with age, physical activity, history of anorexia, and CKD stages. Interventions that address nutritional problems and lifestyle factors in CKD patients need to be implemented together with medical treatment.

Limitations of serum albumin level as a marker of nutritional status in hemodialysis patients

Introduction. Albumin is widely used to evaluate nutritional status. However, its usage on patients with chronic kidney disease (CKD) remains controversial. This study was conducted to determine whether serum albumin levels can be used indicator of nutritional status in end-stage CKD patients undergoing routine hemodialysis.Methods. This cross-sectional study included 535 subjects who underwent hemodialysis twice per week in 2017 from three hospitals in Jakarta, Indonesia. Data were collected from the medical records of the subjects and analysed using descriptive statistics and mean comparisons of independent samples.Results. Based on body mass index as a marker of nutritional status, the majority (85.9%) of subjects were not underweight. Almost an equal proportion of underweight subjects had normal serum albumin (15.1%) compared with hypoalbuminemia (14.4%). Hypoalbuminemia was found in 29.7% and 28.6% of non-underweight and underweight subjects, respectively. Moreover, there was no significant difference in serum albumin levels between underweight and non-underweight patients (p = 0.886, Mann-Whitney test).Conclusions. Our data do not support a role for serum albumin level as a marker for nutritional status in CKD patients.

SAT-109 ELABORATION OF A TEXTURE-MODIFIED FOOD DIDACTIC TOOL FOR PATIENTS WITH END-STAGE KIDNEY DISEASE UNDERGOING HEMODIALYSIS IN GUANAJUATO, MEXICO, WHO HAVE MISSING TEETH

The role of an adequate food intake on the preservation of an optimal nutritional status in patients with chronic kidney disease (CKD) undergoing dialysis, has been well described and there is significant evidence sustaining that a poor nutritional status can be related to several diseases, such as protein energy wasting syndrome, sarcopenia, it has a strong association with increased risk of hospitalization, worse clinical outcomes and even mortality. In order to ensure an adequate nutritional status and considering oral feeding as the classic pathway, we found imperative the necessity to offer options to patients who have masticatory issues due to dental loss. CKD patients undergoing dialysis usually have multiple comorbidities like diabetes, hypertension, mineral and bone disorder, inflammation, malnutrition, protein energy wasting, uremia, etc., which combined with aging and poor hygiene could promote oral cavity problems as periodontitis, cavities, gum disease and dental loss. Dental loss affects nutritional status of CKD patients in dialysis by interfering with the right intake of nutritious food. While it is true that some patients usually modify the texture of their meals in order to make chewing easier, sometimes the resulting dishes contain higher amounts of liquids than those they should consume (e.g. soups and jelly), which makes controlling of daily liquid intake harder. Thus, we aimed to elaborate a texture-modified food didactic tool for patients with CKD under hemodialysis who have missing teeth. From previous evidence in clinical practice guidelines, systematic reviews and original papers about nutritional requirements, based on food-texture modifications useful for patients with dental issues or deglutition problems and given that some recommendations can be extrapolated for patients with masticatory problems, we elaborated a didactic tool for CKD under hemodialysis patients, with dental loss. Subsequently, pertinent adjustments for patients undergoing dialysis were made: adequate use of liquids, restriction on high sources of sodium, phosphorus and potassium, and the incorporation of protein supplements and specialized polymeric formulas. We elaborated a didactic tool, digital and printed version, where the food-texture modifications for CKD under hemodialysis patients are described: double cooking, dicing, mincing, shredding, grating, pureeing and shaking. An extra section was included, where we designed easy to chew preparations that incorporate protein supplements and specialized polymeric formulas. For each technique, we described the making process, lists of ingredients and foods that can be used, taking into account low sources of sodium, phosphorus and potassium, as well as products we recommend avoiding. We also developed suggestions based on the loss of dental pieces according to their masticatory function: incisives, canines, premolars, molars or a combination of them. As far as we know, this texture-modified food didactic tool is the first step to help chronic hemodialysis patients with missing teeth, to improve their intake using low sources of phosphorus, potassium and sodium and without using more liquids than those required, giving them supplemented easy to chew meals. The recommendations herein could be used for other dialysis therapies users and by healthcare providers.

Effects of Carnitine on Nutritional Parameters in Patients with Chronic Kidney Disease: An Updated Systematic Review and Meta-Analysis.

Protein energy malnutrition is a common problem in patients with chronic kidney disease (CKD). Scattered reports indicate that supplementation of Carnitine may improve patients' clinical symptoms, with significant improvement in nutritional parameters. This systematic review was done to document the evidences of Carnitine effects in nutritional status of CKD patients. Peer-reviewed RCTs on Carnitine administration at any dose in CKD patients with at least four weeks of follow-up were including in the meta-analysis. Online databases (PubMed/Medline, ISI Web of Science, Embase, and Scopus) were searched to October 2017 using selected MeSH terms related to the study topic. Data was extracted independently by two reviewers using a standard form and then cross-checked. Statistical analyses were carried out with Comprehensive Meta-analysis software. Data are presented as standard mean difference (SMD) and 95% confidence interval (CI). According to the predefined criteria, a total of 14 randomized controlled clinical trials were included and screened for data extraction by two reviewers, separately. The preliminary results extracted from meta-analysis have shown that Carnitine can significantly increase the levels of albumin (SMD: -0.861; 95% CI: -1.321, -0.402), total protein (SMD: -0.418; 95% CI: -0.695, -0.141), total cholesterol (SMD: -0.350; 95% CI: -0.564, -0.135), LDL cholesterol (SMD: -0.362; 95% CI: -0.551, -0.173), transferrin (SMD: -1.465; 95% CI: -1.822, -1.108), and hemoglobin (SMD: -0.525; 95% CI: -0.732, -0.318); however there were no conclusive effects of Carnitine on body weight (SMD: -0.057; 95% CI: -0.404, 0.291) and BMI (SMD: -0.567; 95% CI: -1.548, 0.415), in pooled analyses. The results of this meta-analysis showed that there are considerable useful pieces of evidence so far about the effect of Carnitine on nutritional factors; however, there is still doubt about some evidences with this regard. It seems necessary to carry out clinical trials with stronger designs to evaluate the impact of these primary outcomes on the patients' clinical conditions. Having this evidences, the potential role of Carnitine in improving malnutrition consequences in CKD patients would be clearly defined.

Recent advances in the pathophysiology and management of protein-energy wasting in chronic kidney disease

Protein-energy wasting (PEW) is a syndrome that consists of metabolic and nutritional abnormalities that often occur in chronic kidney disease (CKD), and PEW has been found to be associated with increased morbidity and mortality. A review was conducted to identify publications detailing the pathophysiology and management of PEW in CKD. The International Society of Renal Nutrition and Metabolism (ISRNM) has recently published the consensus statement of current knowledge regarding the etiology of PEW in CKD. Although insufficient food intake due to poor appetite and dietary restrictions contributes to the development of PEW, many other factors must be present for PEW to develop. The others include uremia-induced alterations such as increased energy expenditure, chronic inflammation, metabolic acidosis, and endocrine disorders that lead to a state of hypermetabolism and result in excess muscle and fat catabolism. In addition, comorbid conditions associated with CKD, low physical activity, frailty, and dialysis itself also contribute to the development of PEW. Serial assessments of the nutritional status of CKD patients by means of several scoring tools, including the Subjective Global Assessment (SGA), Malnutrition Inflammation Score (MIS), Geriatric Nutritional Risk Index (GNRI), and PEW diagnostic criteria, are recommended to diagnose and manage PEW. This review summarized recent advances in the etiology and evaluation of PEW of CKD patients. However, there are few treatment options for PEW with proven efficacy in terms of improved quality of life, morbidity, and mortality. Proposed therapeutic interventions need to be evaluated in randomized controlled trials to determine whether they improve clinically relevant outcomes.

Nutritional Risk Screening in patients with chronic kidney disease.

Knowledge concerning nutritional status of patients with chronic kidney disease (CKD) is limited. Nutritional Risk Screening-2002 (NRS-2002) has been used to evaluate the nutritional aspects of patients according to the recommendation of European Society for Clinical Nutrition and Metabolism. Here we aim to assess the prevalence and characteristics of nutritional risk in CKD patients by using NRS-2002. NRS-2002 scores of 292 CDK patients were recorded in first 24 hours subsequent to their admission to hospital. All patients have never been on dialysis. BMI, weight and various biochemical parameters were also characterized for these patients. Possible correlations between these parameters and NRS-2002 score were investigated. The overall prevalence of nutritional risk was 44.9% (53.6% in CKD stage 4-5 patients and 38.3% in stage 1-3 patients). Statistically significant differences were found in serum Albumin, Haemoglobin B, and lymphocyte counts between patients with or without increased nutritional risk. Under the situation that attending physicians were completely unaware of NRS-2002 scores, only 35.1% of the patients at risk received nutritional support. The nutritional risk status was associated with CKD stages but independent from primary diagnosis type. More attention should be paid to the nutritional status in CKD patients (including early stage patients). We recommended using NRS-2002 for nutritional risk assessment among non-dialysis CKD patients in routine clinical practice.

Anthropometric and biochemical profile of children and adolescents with chronic kidney disease in a predialysis pediatric interdisciplinary program.

This is longitudinal retrospective observational cohort study that evaluated anthropometric and biochemical variables of children and adolescents admitted to a Predialysis Interdisciplinary Management Program (PDIMP) responsible for the follow-up of children and adolescents at stages 2 to 4 of chronic kidney disease (CKD) at a tertiary center. One hundred thirty-eight patients with CKD on predialysis treatment with median age at admission of 9 years and the median follow-up time of 5 years were evaluated. Seventy-four (53%) had CKD stage 3 at admission and 70 (51%) reached CKD stage 5 at the end of the follow-up. There was no significant difference between the mean initial and final hemoglobin and serum albumin. However, the final serum bicarbonate presented a significant improvement. Analyses stratified according to clinical variables of interest showed a significant improvement in body mass index (BMI) Z score, especially in the subgroup of children admitted under two years of age. In relation to stature-for-age Z score, data show a significant improvement in stature SD at the end of the study. In conclusion, the present study showed improvement of nutritional status of CKD patients and that the deterioration of renal function was not correlated with BMI-for-age Z score.

Applicability of subjective global assessment and malnutrition inflammation score in the assessment of nutritional status on chronic kidney disease.

Up to now, there is no single method that provides complete and unambiguous assessment of the nutritional status in chronic kidney disease (CKD). Therefore, it has been recommended the use of many nutritional markers. The subjective global assessment (SGA) contains questions regarding the clinical history and physical examination. Subsequently, other versions of the SGA were developed. The malnutrition inflammation score (MIS) was also developed from the original version of the SGA and consists of 70% of the items common to SGA in addition to objective questions. Since many modifications were proposed in the original form of SGA, the use of these questionnaires in CKD patients has increased substantially in clinical practice. Therefore, this paper aims to review the applicability of the SGA and MIS when applied to assess the nutritional status of CKD patients.

Estado nutricional e ingestão alimentar de pacientes em diálise peritoneal contínua com e sem hiperparatireoidismo secundário

Secondary hyperparathyroidism (SHPT) is a common and early complication in chronic kidney disease (CKD) patients. Studies have suggested that high levels of parathyroid hormone (PTH) may have deleterious effects on the nutritional status of patients with CKD. Thus, the aim of this study was to compare the nutritional status of CKD patients in continuous peritoneal dialysis (CPD) with and without SHPT. The aim of this study was to compare the nutritional status of CKD patients in continuous peritoneal dialysis (CPD) with and without SHPT. 74 patients were evaluated, including adults and seniors, divided into two groups according to PTH levels. In group 1 (n = 18) levels of PTH higher than 300 pg/mL and in group 2 less than or equal to 300 pg/mL. The nutritional status of patients was assessed by anthropometry, biochemical and subjective global assessment (SGA). Food intake was measured by food record for 3 days. We also collected clinical data, such as calcium and serum phosphorus, and the presence of inflammation was assessed by measuring C-reactive protein ultra-sensitive (CRP US). The average age of the population studied was 54.97 ± 17.06 years, with predominance of adult patients (58.1%) and females (56.8%). The time of CPD expressed in median was 17 months (7.75-33). Through ASG, it was shown a prevalence of 36.5% of the population undernourished. In the analysis of difference between the groups in relation to anthropometry, biochemical indicators and ASG as well as food intake, there were no differences between the groups. There were no differences in nutritional status and dietary intake between patients with and without SHPT.

Nutrition and chronic kidney disease

The incidence of malnutrition disorders in chronic kidney disease (CKD) appears unchanged over time, whereas patient-care and dialysis techniques continue to progress. Despite some evidence for cost-effective treatments, there are numerous caveats to applying these research findings on a daily care basis. There is a sustained generation of data confirming metabolic improvement when patients control their protein intake, even at early stages of CKD. A recent protein-energy wasting nomenclature allows a simpler approach to the diagnosis and causes of malnutrition. During maintenance dialysis, optimal protein and energy intakes have been recently challenged, and there is no longer an indication to control hyperphosphatemia through diet restriction. Recent measurements of energy expenditure in dialysis patients confirm very low physical activity, which affects energy requirements. Finally, inflammation, a common state during CKD, acts on both nutrient intake and catabolism, but is not a contraindication to a nutritional intervention, as patients do respond and improve their survival as well as do noninflamed patients.

Appetite-regulating Hormones in Chronic Kidney Disease Patients

Inflammation and loss of appetite is the most common problem in patients with chronic kidney disease (CKD). This comparative cross-sectional study aimed to characterize the changes in circulating levels of ghrelin, obestatin, leptin, all of which have an effect on food intake, and proinflammatory cytokines interleukin (IL)-6 and tumor necrosis factor-alpha (TNF-α) in patients with CKD who were undergoing different treatments. Study participants included 36 patients who had undergone hemodialysis (body mass index [BMI]: 22.3 ± 4.17 kg/m(2)); 41 who had undergone peritoneal dialysis (BMI: 23.5 ± 3.10 kg/m(2)), 30 with early stage CKD (BMI: 24.4 ± 3.32 kg/m(2)), and 31 healthy subjects (24.3 ± 2.14 kg/m(2)). The patients with CKD were kept under a standard diet with restricted salt, potassium, and protein intake. Levels of leptin, acylated ghrelin, obestatin, TNF-α, and IL-6 were measured by commercially available enzyme-linked immunosorbent assay kits. Total nitrite/nitrate was analyzed using colorimetric assay kit. Significantly high leptin levels, accompanied by low acylated ghrelin levels, were observed in patients with CKD. Maintenance dialysis did not affect these levels. TNF-α and IL-6 levels were significantly higher in CKD patients than in healthy subjects, the highest being in dialysis patients. Obestatin levels were relatively low in patients who had undergone hemodialysis. Low acyl-ghrelin levels, accompanied with high levels of TNF-α and IL-6 may be involved in the loss of appetite and poor nutritional status in CKD patients.

Correction of Metabolic Acidosis to Ameliorate Wasting in Chronic Kidney Disease: Goals and Strategies

Metabolic acidosis is an important cause of protein-energy wasting, commonly observed in chronic kidney disease (CKD). This wasting is, in part, a result of the imbalance between protein degradation and synthesis induced by metabolic acidosis. The increase in protein degradation seen with metabolic acidosis is largely secondary to increased activities of the adenosine triphosphate-dependent, ubiquitin-proteasome system and branched-chain ketoacid dehydrogenase. Studies consistently have shown increased protein degradation with lower serum bicarbonate levels and/or arterial pH; however, the evidence for the anti-anabolic effects of metabolic acidosis is less consistent. In contrast to these metabolic studies, many cross-sectional studies have shown a direct relationship between the severity of metabolic acidosis and the adequacy of nutritional status in CKD patients. Moreover, lower serum bicarbonate levels have been associated with better survival in some epidemiologic studies of patients undergoing maintenance hemodialysis. It is likely that these relationships are confounded by the direct association of dietary protein intakes with metabolic acidosis-controlling the survival data for measures of dietary protein intakes, malnutrition, and inflammation shows a rather steep increase in the risk of death with lower serum bicarbonate levels. Two randomized controlled studies have shown that correction of metabolic acidosis is associated with reduction in risk for hospitalization in chronic peritoneal dialysis patients; the studies in maintenance hemodialysis patients have been small and inconsistent. For now, metabolic studies and data from clinical trials lend support to the recommendations made by the Nutrition Workgroup of the Kidney Disease Outcomes Quality Initiative to maintain serum bicarbonate levels of 22 mEq/L or greater in all CKD patients. Limited data suggest that a higher serum bicarbonate level (around 24 mEq/L) may be even more beneficial, particularly in chronic peritoneal dialysis patients.