Protein-energy Wasting In Hemodialysis Patients Research Articles

A Novel Approach for Managing Protein-Energy Wasting in People With Kidney Failure Undergoing Maintenance Hemodialysis: Rationale and Call for Trials

Protein-energy wasting (PEW) is a unique presentation of protein-energy malnutrition in people with kidney disease that is characterized by body protein catabolism exceeding anabolism. PEW is especially common in patients undergoing maintenance hemodialysis (HD) treatment. Dietary guidelines for managing PEW in HD patients primarily focus on protein adequacy and typically promote the intake of animal-based protein foods. Although intake of protein and essential amino acids is important for protein synthesis, the emphasis on protein adequacy largely fails to address-and may actually exacerbate-many of the root causes of PEW. This perspective examines the dietary determinants of PEW in people undergoing HD treatment, with an emphasis on upstream disease-related factors that reduce dietary protein utilization and impair dietary intakes. From this, we present a theoretical diet model for managing PEW that includes etiology-based dietary strategies to address barriers to intake and treat disease-related factors, as well as supportive dietary strategies to promote adequate energy and protein intakes. Given the complexity of diet-disease interactions in the pathogenesis of PEW, and its ongoing burden in HD patients, interventional trials are urgently needed to evaluate alternative diet therapy approaches for PEW in this population.

Hemodialysis-Nutritional Flaws in Diagnosis and Prescriptions. Could Amino Acid Losses be the Sharpest "Sword of Damocles"?

This review aims to highlight the strengths and weaknesses emerging from diagnostic evaluations and prescriptions in an intent to prevent progression over time of malnutrition and/or protein-energy wasting (PEW) in hemodialysis (HD) patients. In particular, indications of the most effective pathway to follow in diagnosing a state of malnutrition are provided based on a range of appropriate chemical-clinical, anthropometric and instrumental analyses and monitoring of the nutritional status of HD patients. Finally, based on the findings of recent studies, therapeutic options to be adopted for the purpose of preventing or slowing down malnutrition have been reviewed, with particular focus on protein-calorie intake, the role of oral and/or intravenous supplements and efficacy of some classes of amino acids. A new determining factor that may lead inexorably to PEW in hemodialysis patients is represented by severe amino acid loss during hemodialysis sessions, for which mandatory compensation should be introduced.

P1579PREVALENCE OF PROTEIN-ENERGY WASTING IN HEMODIALYSIS PATIENTS IN THE EUROPEAN REGION OF THE RUSSIAN FEDERATION

Abstract Background and Aims One of the complications of hemodialysis therapy (HD) is the development of protein-energy wasting (PEW), which is an independent predictor of morbidity and mortality in this cohort of patients. The prevalence of PEW in hemodialysis patients in different regions of the world varies from 15% to 75% but has not been practically studied in the Russian Federation. To assess the prevalence of protein-energy wasting in hemodialysis patients in the European region of the Russian Federation. Method 645 hemodialysis patients were examined in 9 hemodialysis centers in 5 regions of the European part of the Russian Federation. Among the patients there were 345 women and 300 men, the average age was 56.8 ± 12.8 years. The duration of hemodialysis therapy was 8.4 ± 5.3 years. The diagnosis of PEW was established in accordance with the criteria: biochemical criteria (serum albumin < 3.8 g per 100 ml; serum prealbumin (transthyretin) < 30 mg per 100 ml; serum cholesterol < 100 mg per 100 ml); low body weight, reduced total body fat, or weight loss; a decrease in muscle mass; and low protein or energy intakes. The level of blood albumin was determined using the BCG method (bromocresol green). Estimation of protein and calorie intake was performed using 3-day food diaries filled out by patients. Results Insufficient protein intake according to the International Society of Renal Nutrition and Metabolism (ISRNM) recommendations was observed in 5.5 % of patients, calories in 4.1 %, combined deficiency in protein and calorie intake in 2.7% of patients. The prevalence of PEW was 51.2 %. The relationship between age and gender was not identified. The lowest prevalence of PEW is observed in patients with a hemodialysis therapy experience of fewer than 5 years (25,4 %) and gradually increasing by 2.5 times in patients with survival rates on HD for more than 10 years (χ2 = 22,580 р = 0.0001). Conclusion The prevalence of protein-energy wasting in hemodialysis patients in the European region of the Russian Federation is 51,2 %.

MON-119 APPLICATION OF GENDER SPECIFIC ULTRASONOGRAPHY CUT-OFFS TO DETERMINE RISK OF PROTEIN ENERGY WASTING IN HEMODIALYSIS PATIENTS

Muscle depletion in hemodialysis (HD) patients associates with protein energy wasting (PEW) but quantification of muscle mass is challenging in the outpatient HD setting. Quadriceps muscle thickness assessment by ultrasound imaging (UI) offers a potential surrogate measure for muscle mass, and we aimed to determine the applicability of gender specific UI cut-off values for identifying risk of PEW in HD patients. PEW risk assessment used the criteria set by International Society of Renal Nutrition and Metabolism (ISRNM), namely body mass index (BMI) <23 kg/m2, reduction >10% in mid-arm muscle circumference (MAMC) in relation to the 50th percentile of reference population, serum albumin <38 g/dL and dietary energy intake (DEI) <25 kcal/kg ideal body weight (IBW). Using a portable UI device, we measured the cross-sectional area of the quadriceps muscle namely rectus femoris (RFCSA) in 351 Malaysian HD patients participated in the on going multi-centered Palm Tocotrienol in Chronic Hemodialysis (PaTCH) screening study. Using receiving operating characteristic analysis, derived RFCSA cut-off values to identify patients at risk of PEW were <6.00 cm2 for men and <4.47 cm2 for women. Differences for PEW criteria and various nutritional parameters were examined based on gender specific categorization (men: <6.00cm2 vs >6.00cm2 and women: <4.47cm2 vs >4.47cm2). Mann-Whitney’s U tested continuous data while Chi-square tested categorical data. Both men (62%, p<0.001) and women (77%, p=0.003) with smaller RFCSA had a higher prevalence of PEW. As per PEW criteria, both men and women with smaller RFCSA had significantly poorer BMI (men: 21.08, IQR: 19.11-23.74kg/m2 vs 25.10, IQR: 22.96-27.50kg/m2, p<0.001; women: 20.54, IQR: 18.29-22.85 kg/m2 vs 25.49, IQR: 22.83-28.85 kg/m2, p<0.001) and MAMC (men: 22.74, IQR: 20.41-24.75cm vs 24.76, IQR: 23.58-26.36cm, p<0.001; women: 19.38 IQR: 17.73-22.45cm vs 23.57, IQR: 21.34-25.39cm, p<0.001). DEI was significantly lower only in men with RFCSA<6.00cm2 (22.53, IQR: 19.09-27.66kcal/kg IBW vs 25.67, IQR: 22.46-30.43kcal/kg IBW, p<0.001) but not in women (23.64, IQR: 20.16-29.34kcal/kg IBW vs 24.35, IQR: 20.90-28.18kcal/kg IBW, p>0.05). Irrespective of gender, significantly lower muscle and fat mass, handgrip strength, and higher Malnutrition-Inflammation Score (all p<0.05) were observed in patients with smaller RFCSA. Using gender-specific RFCSA cut-offs, the UI method enabled differential PEW identification based on ISRNM criteria, yet factoring heterogeneous body compositional differences mediated by gender.

Eradication Therapy for Helicobacter pylori Improves Nutrition Status Depended on Severity of Gastric Mucosal Atrophy and Plasma Ghrelin Level in Japanese Hemodialysis Patients

Introduction: The state of metabolic and nutritional derangement, called protein—energy wasting (PEW), has a major impact on mortality in hemodialysis (HD) patients. Ghrelin has multiple favorable functions and associates with the pathogenesis of PEW in HD patients. Plasma and gastric ghrelin levels are affected in H pylori status. Here, we investigated relationships among nutrition status, ghrelin level, H. pylori and severity of atrophy in HD patients and investigated the efficacy of H. pylori eradication therapy for improvement of nutrition status related with ghrelin in H. pylori—positive HD patients. Methods: H. pylori&#x2014;IgG and pepsinogen levels of 500 HD patients at 8 dialysis centers were measured. We classified H. pylori infectionstatus into three groups: present infection, past infection and non—infection. Plasma ghrelin levels were measured and we investigated above relationship among three groups. H. pylori—positives underwent endoscopy for evaluation of the severity of atrophy, and eradicated by PPI, amoxocollin and clarithromycin for 7days. We evaluated nutrition markers and ghrelin levels before and 1 year after eradication. Results: Acyl— and desacyl—ghrelin levels were 29.7±21.3 fmol/mland 279.2±168.5 fmol/ml, respectively. Acyl—ghrelin in the non—infection group was significantly higher than in the present and past infection groups. Acyl—ghrelin level was positively correlated with serum PG I level and PG I/II ratio and was significantly lower in patients with severe atrophy than in those with no atrophy (20.9±14.6and 40.4±21.9, p<0.001). Cholinesterase level was significantly increased after eradication compared with before eradication (303.2±76.0 vs. 287.3±68.1, p=0.029). In particular, cholesterol(before, 196.6±23.2; after, 206.1±25.9, p=0.042) and cholinesterase levels(before, 296.9±70.8; after, 316.4±73.8, p=0.049) increased more strongly in patients with mild-moderate atrophy than those with severe atrophy. Conclusion: Plasma ghrelin level was associated with endoscopic and serological severity of atrophy related with H. pylori infection in HD patients. Eradication improved nutrition status by increasing serum cholinesterase and cholesterol levels, especially those with mild and moderate gastric mucosal atrophy. In HD patients, eradication therapy may contribute to an improvement in prognosis associated with PEW.

Secondary Hyperparathyroidism and Protein-Energy Wasting in End-Stage Renal Disease.

Protein-energy wasting (PEW), a syndrome involving adverse changes in nutrition and body composition, is a serious problem associated with morbidity and mortality in patients with end-stage renal disease (ESRD). The pathogenesis of PEW is multifactorial, and the underlying mechanisms are not fully understood. However, recent translational work has provided compelling evidence for a causal role of parathyroid hormone (PTH) in the pathogenesis of adipose tissue browning and increased energy expenditure, a critical component of PEW in ESRD. These results provide a biological explanation for the clinical association between secondary hyperparathyroidism (SHPT) and PEW in hemodialysis patients and may serve as an additional rationale for treating SHPT. Large-scale clinical and epidemiological studies should determine the clinical significance of SHPT as a contributor to PEW and establish the optimal management of SHPT to ameliorate PEW.

Bioimpedance Spectroscopy as a Practical Tool for the Early Detection and Prevention of Protein-Energy Wasting in Hemodialysis Patients

To evaluate whether body composition monitor (BCM) could be a practical instrument for nephrologists to assess nutritional status in patients on hemodialysis (HD) and whether it is more effective in identifying patients at highest risk of developing protein-energy wasting (PEW) alone or in combination with other tools currently used for that purpose. Observational cross-sectional study in 91 HD patients (60±14years, 70.3% male, 24±4.1kg/m2 body mass index) from 2 different locations. Nutritional status was evaluated by anthropometric methods (biceps and triceps skinfold thickness, waist circumference, and arm muscular circumference), biochemical nutritional markers, malnutrition-inflammation score (MIS), and BCM. The patients were grouped into those with and without PEW by using classical criteria and then classified as being adequately or inadequately nourished according to a BCM flow chart to detect those requiring preferential nutritional intervention. A multivariate approach was used to calculate the risk of developing PEW. Anthropometric measurements revealed significantly lower body mass index (<23kg/m2; odds ratios [OR]=13.3 and P=0.001) and arm muscular circumference<p10 (OR=34, P<0.001) in the PEW group. MIS was above 5 in all the patients classified as having PEW. BCM showed that fat tissue index < p10 was significantly lower in this group (OR=1.52), and a decision tree using the lean tissue index < p10, fat tissue index<p10, and extracellular water>15% revealed that 42.9% of the patients would need nutritional monitoring. On multivariate analysis, insufficient nutritional status detected by BCM decision tree was an independent prognostic factor for developing PEW. About 9.89% of the patients were classified as PEW, with MIS > 5, and insufficient nutritional status detected by BCM required preferential nutritional intervention. BCM is a practical instrument for nephrologists to assess nutritional status in patients on HD and is useful for the early prevention and detection of PEW, as is able to identify differences in body composition, predict clinically important outcomes, and classify patients requiring preferential nutritional intervention.

The use of bioelectrical impedance phase angle for predicting protein-energy wasting in hemodialysis patients

Objective To evaluate the use of bioelectrical impedance phase angle (PhA) for predicting protein-energy wasting (PEW) in hemodialysis patients. Methods This cross-sectional study involved 144 patients who were on maintenance hemodialysis (MHD) in the blood purification centers of two tertiary hospitals in Guangzhou, where the body impedance analysis (BIA) was performed after the hemodialysis procedure and the prevalence of protein-energy wasting (PEW) was investigated by the 7-point subjective global assessment (SGA) among. Nutritional indices of the patients with PEW were compared with the well-nourished patients to identify independent variables that can predict PEW and determine the cut-off value of PhA as a predictor. Results The patients with PEW had significantly lower PhA values than the Non-PEWpatients(t=8.68, P=0.00). PhA was positively related with the nutritional indices reflecting function of body proteins or muscles, such as serum albumin(rs=0.25, P=0.00), prealbumin(rs=0.31, P=0.00), free fat mass index(rs=0.25, P=0.00), and mid-arm muscle circumference(rs=0.44, P=0.00). However, the correlations of PhA with fat mass(rs=0.04, P=0.66)and body fat percentage(rs=-0.04, P=0.66)were no statistical significance. Multivariate logistic regression analysis revealed that PhA(OR=4.48, P=0.00) and body mass index (OR=1.59, P=0.00)were independent predictors of PEW, but PhA was more potent than BMI. Receiver operating characteristic curve analysis suggested that the optimum PhA cut-off point for predicting PEW was 4.6. Conclusion PhA can be a useful independent predictor for PEW in hemodialysis patients and its cut-off value is 4.6. Key words: Hemodialysis; Protein-energy wasting; Bioelectrical impedance analysis; Phase angle

SUN-PP005: Extracellular Mass-to-Body Cell Mass Ratio is a Sensitive Index of Protein-Energy Wasting in Hemodialysis Patients

SUN-PP005: Extracellular Mass-to-Body Cell Mass Ratio is a Sensitive Index of Protein-Energy Wasting in Hemodialysis Patients

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.

Leptin Parameters are Associated with Inflammation and Both Anthropometric and Serum Markers of Protein-Energy Wasting in Hemodialysis Patients

Leptin Parameters are Associated with Inflammation and Both Anthropometric and Serum Markers of Protein-Energy Wasting in Hemodialysis Patients

Comparison of various scoring methods for the diagnosis of protein–energy wasting in hemodialysis patients

The present study was designed to determine the cutoff points for the diagnosis of mild-to-moderate and severe protein-energy wasting (PEW) based on dialysis malnutrition score (DMS) and malnutrition inflammation score (MIS), and the sensitivity, specificity, accuracy, area under receiver operating characteristic (ROC) curve, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR(+)) and negative likelihood ratio (LR(-)) of DMS and MIS in comparison with subjective global assessment (SGA) in hemodialysis (HD) patients. In this study, 291 HD patients were randomly selected from among 2,302 adult HD patients in Tehran hemodialysis centers. The PEW in these patients was determined by SGA, DMS and MIS. According to the cutoff points derived from the area under ROC curves, scores of 7-13 for DMS represented normal status or without PEW; 14-23, mild-to-moderate PEW; and 24-35, severe PEW. For MIS, scores of 0-7 represented normal status or without PEW; 8-18, mild-to-moderate PEW; and 19-30, severe PEW. In comparison with SGA, the sensitivity, specificity, accuracy, area under ROC curve, PPV, NPV, LR(+) and LR(-) of DMS were 94 %, 88 %, 92 %, 97 %, 93 %, 92 %, 7.8 and 0.07, respectively. Those of MIS were 87 %, 96 %, 91 %, 97 %, 97 %, 83 %, 22.0 and 0.13 in comparison with SGA, respectively. The results of the present study indicate that the DMS and MIS are almost similar to SGA for identifying PEW in HD patients, but it seems that the DMS is a more appropriate alternative tool for SGA in hospital routine assessments.

Prevalence of Protein-energy Wasting and Its Various Types in Iranian Hemodialysis Patients: A New Classification

Background: This study was designed to determine the prevalence of protein-energy wasting (PEW) and its various types in hemodialysis (HD) patients in Tehran, Iran. Methods: For this cross-sectional study, 291 HD patients were randomly selected. The nutritional status of the patients was determined by subjective global assessment (SGA) and their dietary intakes were assessed using a 4-day dietary recall. In addition, serum high-sensitive C-reactive protein (hs-CRP) was measured. Results: The prevalence of mild-to-moderate and severe PEW based on SGA was 60.5% and 1% in Tehran HD patients, respectively. The prevalence of various types of PEW in HD patients was 20.5% type I (inadequate energy or protein intake without inflammation), 65.5% type IIa (inadequate energy or protein intake with inflammation), and 14% type IIb (adequate energy and protein intake with inflammation). Of the total HD patients with no PEW based on SGA, about 3.5% had type 0 normal nutritional status (adequate energy and protein intake without inflammation), 34% had type I normal nutritional status (inadequate energy or protein intake without inflammation), 55.5% had type IIa normal nutritional status (inadequate energy or protein intake with inflammation), and 7% had type IIb normal nutritional status (adequate energy and protein intake with inflammation). Conclusion: PEW in Tehran HD patients is considerably prevalent and PEW type IIa is the most common type. In addition, HD patients with no PEW based on SGA should also be paid attention because they may be in the early stages of inadequate intake of energy and/or protein and inflammation.