Protein-energy Wasting In Chronic Kidney Disease Research Articles

Protein energy wasting in pre-dialysis chronic kidney disease patients in Benin City, Nigeria: A cross-sectional study.

Protein energy wasting (PEW) is common among chronic kidney disease (CKD) patients, especially those with advanced stage. It worsens frailty, sarcopenia and debility in CKD patients. Despite the importance of PEW, it is not routinely assessed during management of CKD patients in Nigeria. The prevalence of PEW and its associated factors were determined in pre-dialysis CKD patients. This was a cross-sectional study that involved 250 pre-dialysis CKD patients and 125 age- and sex- matched healthy controls. Body mass index (BMI), subjective global assessment (SGA) scores and serum albumin levels were used in PEW assessment. The factors associated with PEW were identified. P-value of < 0.05 was taken as significant. The mean age of CKD and control group were 52.3±16.0 years and 50.5±16.0 years, respectively. The prevalence of low BMI, hypoalbuminaemia and malnutrition defined by SGA in pre-dialysis CKD patients were 42.4%, 62.0% and 74.8%, respectively. The overall prevalence of PEW among the pre-dialysis CKD patients was 33.3%. On multiple logistic regression, the factors associated with PEW in CKD were being middle aged (adjusted odds ratio: 12.50; confidence interval: 3.42-45.00; p <0.001), depression (adjusted odds ratio: 2.34; confidence interval: 1.02-5.40; p = 0.046) and CKD stage 5 (adjusted odds ratio: 12.83; confidence interval: 3.53-46.60; p <0.001). PEW is common in pre-dialysis CKD patients and it was associated with middle age, depression and advanced CKD. Early intervention aimed at addressing depression in early stages of CKD may prevent PEW and improve overall outcome in CKD patients.

Correlation between serum trimethylamine-N-oxide concentration and protein energy wasting in patients on maintenance hemodialysis

Objectives Chronic kidney disease (CKD) is a serious health problem that is associated with several systemic changes, including protein energy wasting (PEW). However, the exact mechanism of PEW in CKD remains unclear. As one of the important intestinal flora metabolites and uremic toxins, trimethylamine-N-oxide (TMAO) is involved in CKD-associated mortality, which might play a role in the development of PEW in CKD patients especially in patients on maintenance hemodialysis (MHD). However, this possibility has not been investigated. Methods PEW was diagnosed in a group of CKD patients on MHD according to the criteria of the International Society of Renal Nutrition and Metabolism. Serum TMAO concentration was assessed by high-performance liquid chromatography and mass spectrometry. The association between TMAO concentration and PEW was assessed using linear regression and logistic analysis after adjustment for confounding factors, including basic characteristics, comorbidities, and laboratory findings. Results The circulating TMAO level was higher in the MHD patients than in control (healthy) individuals (5653.76 ± 2853.51 vs. 254.92 ± 197.88 ng/mL, p < 0.001). Further, after the MHD patients were screened for PEW, those with PEW were found to have significantly higher serum TMAO levels than those without PEW (6760.9 vs. 4016.1 ng/mL, p < 0.001). Further, the serum TMAO concentration exhibited a significant negative correlation with body mass index (BMI) and dietary protein intake. In the logistic regression analysis, after adjustment for confounding factors, the serum TMAO concentration was still significantly correlated with PEW occurrence. Conclusions The circulating TMAO level is significantly correlated with the prevalence of PEW in MHD patients. TMAO might be a potential target in the prevention and treatment of PEW in CKD especially ESRD.

Стоит ли назначать малобелковую диету пожилому пациенту с хронической болезнью почек?

There are no clear dietary recommendations for patients over 70 years of age, while stages 3-5 of chronic kidney disease (CKD) and protein-energy wasting (PEW) is common among this category of patients. Nutritional status is known to be one of the significant factors influencing the prognosis of patients receiving renal replacement therapy. The aim of the research was the analysis of the mechanisms of PEW, methods for assessing the nutritional status and effectiveness of diets with different protein content in patients with CKD based on literature data. Material and methods. The research material was the scientific literature presented in the domestic and international (eLIBRARY, PubMed, Google Scholar) databases, as well as clinical recommendations for the management of geriatric patients with CKD, dietary recommendations for patients with anorexia and other conditions. Results. The studies devoted to the mechanisms of PEW were analyzed. One of the leading causes of this condition is anorexia, in the pathogenesis of which uremic toxins, inflammation and hormonal disorders are involved (hormones such as gastrin, cholecystokinin, leptin, insulin, testosterone and others may be involved in the pathogenesis). A number of studies have shown that limiting protein to 0.6 g/kg day could significantly reduce uremic dyspepsia risk and slow CKD progression. At the same time, several researchers gave data on the ineffectiveness of a low-protein diet in patients with CKD and diabetes mellitus and a significant risk of malnutrition. Subjective global assessment, the mini nutrition assessment and the geriatric nutritional risk index can be distinguished among the methods of assessing nutritional status. Conclusion. Research data on the effectiveness of a low-protein diet in elderly patients with stage 3B-5 CKD are contradictory. PEW in CKD is common and largely determines survival; the mechanism of PEW is complex. The study of the optimal nutritional diet for elderly patients with predialysis stages of CKD still remains an urgent problem.

Chronic Kidney Disease and Nutrition Support.

Individuals with chronic kidney disease (CKD), particularly those undergoing maintenance dialysis, are prone to protein-energy wasting (PEW), the latter of which can be ameliorated with different methods of nutrition support. Dietary counseling guided by dietitians is the key for preventing and managing PEW in CKD. If dietary counseling per se fails to meet the recommended energy and protein requirements, the addition of oral nutrition supplements (ONSs) would be necessary. When these initial measures cannot attain the recommended energy and protein requirements, nutrition support, including enteral tube feeding or parenteral nutrition (PN), should be considered as a viable option to improve nutrition status. Partial PN, comprising intraperitoneal PN (IPPN) and intradialytic PN (IDPN) therapies, may be attempted as supplemental nutrition support in patients with PEW requiring peritoneal dialysis and hemodialysis, respectively. Despite the debatable effectiveness of IPPN for patients undergoing peritoneal dialysis, it remains a feasible means in these patients. The indications for IPPN in patients undergoing peritoneal dialysis include inadequate dietary intake of energy and protein, and barriers of oral intake and other forms of enteral supplementation such as issues with suitability, tolerance, and compliance. Nonetheless, in the case of spontaneous dietary consumption of energy and protein meeting the difference between the IDPN provision and the nutrition targets, the use of IDPN is rational. In patients with PEW and malfunctioning gastrointestinal tract, as well as those whose enteral intake (with or without partial PN) is below the recommended nutrient requirements, total PN becomes a relevant nutrition intervention.

Algorithm on enteral nutrition in chronic kidney disease

Abstract Patients with chronic kidney disease (CKD) are a heterogenous group regarding the cause and grade of kidney injury, associated risk factors and metabolic complications related to the progression of kidney disease. The presence of comorbidities, especially diabetes mellitus and cardiovascular diseases, adds to the diversity of this patient group. In addition, even an individual patient needs different nutrition interventions in the course of his illness. Nutritional therapy is one of the pillars of CKD treatment from the early stages on. Later it becomes even more important, because the prevalence of patients with protein-energy wasting (PEW) is growing with the declining of renal function. PEW is manifested by poor appetite, low serum levels of albumin, sarcopenia and unintenional weight loss. The causes of PEW in CKD are multifactorial , but all are leading to imbalance between energy and protein intake and demand, and finally in higher susceptibility for infections, frailty and lower quality of life. PEW is also among the strongest predictors of mortality. More and more randomized studies prove the positive effects of nutritional therapy on measures of protein-energy nutritional status. The strongest predictor of outcomes and mortality seems to be low serum albumin, regardless if hypoalbuminemia is of nutritional or non-nutritional (e.g. inflammatory) cause. Also evidence is growing for benefits of enteral nutrition therapy on survival of patients with CKD, at least for the dialysis patients. The evidence for pre-dialysis CKD patients is still scarce. With the periodical nutritional assessment of CKD patients by means of diatery interviews and diaries, biochemical markers, antropometric measures and nutritional scoring systems (MIS, SGA), we can select patients with PEW and start with enteral nutrition therapy. Simultaneously we must identify and treat the reason for malnutrition. We have to start with nutritional counselling to enhance the spontaneous intake of proper nutrients and calories and if not adequate, continue with oral supplements. Enteral nutrition includes also tube feeding, if oral intake is not possible (e.g. a swallow disorder). Enteral intake of nutritients is important for the gastrointestinal system, because it stimulates the metabolism and appetite, keeps the gut barrier intact, which has a major role on the immune system, is physiologic and is cheaper than for example parenteral nutrition. Patients with CKD 3-5 not on dialysis differ from patients with CKD 5 on dialysis treatment, especially, but not exclusively, in their demand for protein intake. In the predialysis era a low protein, low phosphorus diet is indicated (intake < 0,8 g proteins / kg / day), because it lowers the burden of phosphorus and uremic toxins deriving mostly from proteins, decreases metabolic acidosis and pobably slows the progression of renal decline. With counselling and adding protein supplements without or with low phophate content, we can prevent malnutrition, which is otherwise inevitable when adhering to the prescribed diet. With supplements we can also assure that the patient receives 50% proteins of high biological value. Dialysis patients on hemodialysis and peritoneal dialysis have higher demand on protein intake: 1,2 g / kg / day and 1,3 g / kg / day respectively, because of the catabolic processes elicited by the pocedure and losses of amino acids and proteins during the treatment. Oral supplements can make up for the deficit in patients who may not succeed in getting the proper amount of proteins by spontaneous food intake.Besides protein and energy we also have to provide other macro- and micronutrients, like vitamins and minerals, during the therapy. A periodic assessment of the nutrition status during enteral nutrition therapy is necessary to evaluate the efficacy and need for continuing of the interventions. In this presentation an algorithm for enteral nutrition in patients with CKD 3-5 and patients on dialysis is proposed. The algorithm is based on recent guidelines for enteral nutrition in CKD patients and adapted in our clinical practice. Keywords: chronic kidney disease, enteral nutrition, dialysis

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.

ASSOCIATION OF SERUM ALBUMIN AND SUBJECTIVE GLOBAL ASSESSMENT ON INCIDENT PERITONEAL DIALYSIS PATIENTS

serum albumin the biomarker most frequently used as one of three biochemical criteria for diagnosis of protein energy wasting (PEW). However, as a nutritional parameter it's unreliable in chronic kidney disease (CKD). The subjective global assessment (SGA) has been recommended for nutritional evaluation and the PEW in CKD. determine association between the levels of serum albumin and SGA in patients with end stage renal disease (ESRD) who started peritoneal dialysis (PD). a cross-sectional study in patients with ESRD were evaluated prior to starting PD. Levels of serum albumin were determined and nutritional assessment was performed by SGA. 69 patients, 46 (67%) men and 23 (33%) women, average age 39.97 ± 18.30 years old, serum albumin 2.75 ± 0.65 g/dl, creatinine 18.91 ± 10.98 mg/dl, urea 314.80 ± 152.74 mg/dl and BMI 23.37 ± 3.79 kg/m2, median of GFR 3 (1-12) mL/min/1.73m2. The SGA showed that 34.8% was well nourished, 40.6% had risk of moderate PEW and the 24.6% had severe PEW. There was no association (p = ns) between the levels of serum albumin and SGA. the present study shows hypoalbuminemia and PEW are very frequent. The identification of levels of serum albumin and SGA at the beginning of PD in our population could be predictors of mortality. Serum albumin is not a useful tool for nutritional assessment in patients with ERSD who initiate PD.

Using megestrol acetate to ameliorate protein-energy wasting in chronic kidney disease.

Various populations are affected by chronic kidney disease (CKD), and a low dose appetite stimulant megestrol acetate (MA) is sometimes recommended in patients with CKD to ameliorate protein-energy wasting (PEW). Patients with CKD are at greater risk of developing PEW since the progression of their disease can cause decreased nutrient intake, catabolic effects, systemic inflammation and metabolic changes. Providers can detect PEW in CKD by identifying low serum levels ≤3.8 g/dl of albumin, <30 mg/dl of transthyretin, or <100 mg/dl of cholesterol. Other characteristics include BMI <22 kg/m(2) (for ≤65 years), unintentional weight loss of ≥5% in three months or ≥10% in six months, body fat percentage <10%, with muscle wasting of a reduction of ≥5% in three months or ≥10% in six months of muscle mass. A review of research was completed and data collected from small population-based retrospective studies to determine the effect of MA. Clinical trials demonstrated the effectiveness of MA by showing increases in BMI up to 9%, albumin levels up to 1.1 g/dl, with reported protein and energy intake increases from 27% to 42%. There are potential adverse effects of using MA in CKD. After reviewing the available literature, the benefits of using MA should be evaluated against the potential side effects. For further examination of MA's potential benefits, long-term, prospective, large clinical trials should be carried out.

Predictors of protein-energy wasting in haemodialysis patients: a cross-sectional study.

Protein-energy wasting (PEW) is a highly prevalent condition in haemodialysis patients (HD). The potential usefulness of nutritional-inflammatory markers in the diagnosis of PEW in chronic kidney disease has not been established completely. We hypothesised that a combination of serum albumin, percentage of mid-arm muscle circumference and standard body weight comprises a better discriminator than either single marker of nutritional status in HD patients. A cross-sectional study was performed in 80 HD patients. Patients were categorised in two groups: well-nourished and PEW. Logistic regression analysis was applied to corroborate the reliability of the three markers of PEW with all the nutritional-inflammatory markers analysed. PEW was identified in 52.5% of HD patients. Compared with the well-nourished patients, PEW patients had lower body mass index, serum pre-albumin and body cell mass (all P<0.001) and higher C-reactive protein (s-CRP) (P<0.01). Logistic regression analyses showed that the combination of the three criteria were significantly related with s-CRP >1mg dL(-1) , phase angle <4°, and serum pre-albumin <30mg dL(-1) (all P<0.05). Other indicators, such as lymphocytes <20% and Charlson comorbidity index, were significantly involved (both P<0.01). A receiver operating characteristic curve (area under the curve) of 0.86 (P<0.001) was found. The combined utilisation of serum albumin, percentage of mid-arm muscle circumference and standard body weight as PEW markers appears to be useful for nutritional-inflammatory status assessment and adds predictive value to the traditional indicators. Larger studies are needed to achieve the reliability of these predictor combinations and their cut-off values in HD patients and other populations.

Gelsolin and adipokines are associated with protein-energy wasting in hemodialysis patients.

Protein-energy wasting (PEW) contributes to mortality in hemodialysis (HD) patients. Adipokines regulate energy homeostasis and body weight. Circulating gelsolin can modulate inflammation and is correlated with HD mortality. Whether adipokines and gelsolin play important roles in PEW remains unclear. Based on the criteria proposed by the International Society of Renal Nutrition and Metabolism, we examined the associations between PEW and biomarkers (gelsolin, leptin, adiponectin, interleukin-6, tumor necrosis factor alpha [TNF-α]) in 188 stable HD patients. Patients with PEW had significantly lower serum leptin levels, and tended to have higher adiponectin, TNF-α, and lower gelsolin levels. Logistic regression analysis revealed that gelsolin, leptin, adiponectin, and blood urea nitrogen were independently associated with PEW score. Serum creatinine, TNF-α, gender, renin-angiotensin system (RAS) blockade, and lipid-lowering agents were not associated with PEW score. Patients on lipid-lowering agents had lower PEW scores and those with RAS blockade had higher PEW scores. Our study confirms that gelsolin, adiponectin, and leptin are significant associates with PEW in HD patients. Further understanding of how these factors contribute to PEW may help design novel therapeutic strategies for PEW in chronic kidney disease.

Asymmetrical dimethylarginine triggers lipolysis and inflammatory response via induction of endoplasmic reticulum stress in cultured adipocytes

Protein energy wasting, a state of decreased stores of body protein and fat, is a risk factor for mortality in advanced chronic kidney disease (CKD). Little is known about the mechanism underlying loss of fat in CKD. Accumulation of asymmetric dimethylarginine (ADMA) is prevalent in advanced CKD. Here we assessed the effect of ADMA on cellular perturbation in cultured 3T3-L1 adipocytes. Exposure of adipocytes to ADMA induced lipolysis and decreased perilipin A, with no alteration of lipases expression or activity. ADMA treatment also upregulated the expression of inflammatory adipocytokines via activation of nuclear factor-kappaB (NF-kappaB). Blocking the inflammatory responses with NF-kappaB inhibitor partly inhibited the ADMA-induced lipolysis. Furthermore, ADMA treatment triggered endoplasmic reticulum (ER) stress, revealed by phosphorylation of PKR-like eukaryotic initiation factor 2alpha kinase, eukaryotic translational initiation factor 2alpha, c-Jun NH2-terminal kinase, and overexpression of glucose-regulated protein 78. Treatment with ER stress inhibitor completely abolished the ADMA-induced lipolysis and inflammatory responses. Moreover, conditioned medium from the ADMA-treated adipocytes increased protein degradation in cultured C2C12 myotubes, suggesting that the ADMA-induced adipocyte perturbation may promote skeletal muscle proteolysis. These data suggest that elevated ADMA promoted the adipocyte perturbation through induction of ER stress, which might have implication for protein energy wasting in CKD.