Protein calorie malnutrition in chronic kidney disease

1. Prevention And Treatment Of
Protein Energy Wasting In
Hemodialysis Patients
INDRAPRASTHA APOLLO HOSPITAL
NEW DELHI
Dr Ritesh Banode

2. Defination
• The concept of protein energy wasting (PEW) was proposed in 2007 by
the International Society of Renal Nutrition and Metabolism (ISRNM)
• As a state of nutritional and metabolic derangements in patients with
chronic kidney disease (CKD) characterized by simultaneous loss of
systematic body protein and energy stores, leading ultimately to loss of
muscle and fat mass and cachexia
• PEW is highly prevalent among patients on chronic dialysis, and is
associated with adverse clinical outcomes, high morbidity/mortality rates
and increased healthcare cost.

3. Causes of PEW
1 The PEW is caused by
Hyper catabolic status,
Uremic toxins,
Malnutrition,
Inflammation,
2. The concept of PEW should be discriminated from malnutrition
because CKD-related factors may contribute to the development
of PEW, which are in addition to or independent from inadequate
nutrient intake due to anorexia and/or dietary restrictions

4. PEW

7. Mechanisms
Catabolic pathways that cause protein wasting include
1. activation of the ubiquitin–proteasome system (UPS),
2. caspase-3,
3. lysosomes and myostatin (a negative regulator of skeletal muscle
growth).
• These pathways can be initiated by complications associated with CKD,
such as metabolic acidosis, defective insulin signalling, inflammation,
increased angiotensin II levels, abnormal appetite regulation.

8. 3 out of the 4 listed categories along with at least one test in each of the selected category must be satisfied
for the diagnosis of kidney disease-related PEW. Each criterion should be documented on at least three
occasions, preferably 2–4 weeks apart.

9. Therapeutic Maneuvers To Prevent Or Reverse Protein And
Energy Wasting
• Prevention and treatment of PEW of CKD should involve an integrated
approach to limit protein and energy depletion, in addition to therapies
that will avoid further losses and replenish already wasted stores.
• These include optimizing dietary nutrient intake, appropriate treatment of
metabolic disturbances such as metabolic acidosis, systemic
inflammation, and hormonal deficiencies, and prescribing optimized
dialysis regimens
• In patients where oral dietary intake from regular meals cannot maintain
adequate nutritional status, nutritional supplementation, administered
orally, enterally, or parenterally, is shown to be effective in replenishing
protein and energy stores

11. Dietary nutrient intake in CKD
patients
• Important cause of PEW in CKD patients, especially those on maintenance
dialysis, is inadequate dietary protein and energy intake.
• Anorexia may develop as a result of retention of uremic toxins, dialysis
procedure, intercurrent illness, inflammation, acidemia, and/or
cardiovascular disease.Comorbid illness that affects gastrointestinal
function, depression, poor socioeconomic situation.
• Furthermore, additional nutrient loss during dialysis such as amino acids,
some peptides, blood, vitamins, trace elements, and glucose may further
predispose these patients to an increased risk of pew.

15. • Oral supplementation should be given two to three times a day,
preferably 1 h after main meals or during dialysis for MHD patients.
• Oral supplementation can provide an additional 7–10 kcal/kg per day of
energy and 0.3–0.4 g/kg per day of protein requiring a minimum
spontaneous intake of 20 kcal/kg per day of energy and 0.4–0.8 g/kg per
day of protein in order to meet the recommended dietary energy intake
and dietary protein intake targets.
• For patients who are unable to tolerate nutritional supplementation by
mouth, nasogastric tubes, percutaneous endoscopic gastroscopy, or
jejunostomy tubes can be considered.

16. Intradialytic parenteral nutrition
• Although the gastrointestinal route is the preferred choice for nutritional
supplementation, parenteral provision of nutrients, especially during the
HD procedure, has been shown to be a safe and convenient approach for
individuals who cannot tolerate oral or enteral administration of nutrients
• Multiple studies including several RCTs showed evidence for nutritional
improvements with the use of IDPN in MHD patients with overt PEW.
• The high cost of IDPN therapy and the regulatory concerns remain the
• greatest barriers to performing adequately powered clinical trials

17. Renal replacement therapy
• Dialysis adequacy has long been viewed as a cornerstone among
measures to prevent and treat PEW in maintenance dialysis patients.
• However , the higher delivered dose of dialysis neither prevented nor
reversed the decline of several indices of nutritional status in prevalent
MHD patients as compared with conventional dose of dialysis.
• Hemodiafiltration has also been promoted as an efficient method for the
removal of uremic toxins; however,no randomized prospective studies are
available on the effects of hemodiafiltration on nutritional parameters

18. Systemic inflammation
• inflammation is a major driving force for the uremic phenotype, which
commonly includes both premature cardiovascular disease and PEW
•
• Elimination of use central hemodialysis catheters in MHD patients.
• Short daily dialysis, associated with improved inflammatory status, and
lower levels of interleukin 6 (IL-6)
• Appropriate management of fluid status might improve systemic
inflammation in ESRD patients

19. Alkali therapy for metabolic
acidosis
• Metabolic acidosis is a common complication in advanced CKD, and it
induces muscle wasting by stimulating adrenal glucocorticoid secretion.
• In addition, acidosis stimulates the oxidation of essential amino acids and
therefore raises protein requirements for MHD patients.
• There is strong evidence that correcting metabolic acidosis has beneficial
effects on nutritional parameters in patients with CKD
• low serum bicarbonate concentrations were associated with all-cause
mortality in the range of <22 mEq/L, but not ≥23 mEq/L in ESRD patients
requiring dialysis

20. Exercise
• Dialysis patients have often extremely low physical activity, and resultant
muscle disuse is an underrepresented risk factor for muscle wasting.
• This is important in that exercise interventions could prevent or even
reverse muscle wasting.
• progressive resistance training induces skeletal muscle hypertrophy,
increases muscular strength, and improves health-related quality of life
both in patients with CKD

21. Emerging therapies for treatment
of PEW in CKD
• Appetite stimulants: Examples of pharmacologic agents that may
stimulate appetite include megestrol acetate, dronabinol,
cyproheptadine, melatonin, thalidomide, and ghrelin.
• Anti-inflammatory interventions: Nutritional antioxidants, long-chain
omega-3 fatty acids, and cholecalciferol are shown to have anti-
inflammatory effects.
• Growth hormone: Recombinant human GH, an approved treatment of
short stature in pediatric CKD patients.
• Anabolic steroids :Anabolic steroids stimulate net muscle protein
synthesis by inducing mRNA expression of skeletal muscle androgen
receptor, and increasing the intracellular pool of amino acids derived from
protein degradation.

22. • Pentoxifylline: Its administration in CKD patients has been shown to
improve protein breakdown along with an incremental anabolic effect
when combined with a balanced amino acid mixture.
• Etanercept, a tumor necrosis factor receptor antagonist, IL-1receptor
antagonist also tried in small studies but needs larger-scale studies
examining the efficacy and safety of anticytokine therapies as nutritional
interventions in CKD patients.

24. Thanks

25. Refference
• Prevention and treatment of protein energy wasting in chronic kidney disease patients: a consensus
statement by the International Society of Renal Nutrition and Metabolism T. Alp Ikizler1 , Noel J. Cano2 ,
Harold Franch3 , Denis Fouque4 , Jonathan Himmelfarb5 , Kamyar Kalantar-Zadeh6 , Martin K.
Kuhlmann7 , Peter Stenvinkel8 , Pieter TerWee9 , Daniel Teta10, Angela Yee-Moon Wan
• Latest Consensus and Update on Protein Energy-Wasting in Chronic Kidney Disease Yoshitsugu Obia,b,
Hemn Qadera,b, Csaba P. Kovesdyc , and Kamyar Kalantar-Zadeha,b aDivision of Nephrology and
Hypertension, University of California Irvine, Orange, California, USA bHarold Simmons Center for Kidney
Disease Research and Epidemiology, University of California Irvine, Orange, California, USA cUniversity of
Tennessee Health Sc
• Etiology of the Protein-Energy Wasting Syndrome in Chronic Kidney Disease: A Consensus Statement From
the International Society of Renal Nutrition and Metabolism (ISRNM)
• Juan Jesús Carrero, PhD, Peter Stenvinkel, MD, PhD, Lilian Cuppari, PhDT. Alp Ikizler, MD, Ph Kamyar
Kalantar-Zadeh, MD, PhDGeorge Kaysen, MD, PhD, William E. Mitch, MD, PhD S. Russ Price, PhD
• ,