Disease-related malnutrition in chronic kidney disease

Abstract

Purpose of reviewDisease-related malnutrition has complex and multifactorial pathophysiology. It is common in patients with chronic kidney disease (CKD) and has a devastating impact on morbidity and mortality. Given the rising numbers of patients diagnosed with CKD, disease-related malnutrition is an escalating clinical challenge. This review summarises current knowledge in relation to the development, screening and treatments for disease-related malnutrition in CKD Recent findingsNew research has identified other potential causes for the development of malnutrition in CKD, including changes in taste and smell, and effects of polypharmacy. Screening and assessment studies have investigated different tools in relation to the new Global Leadership Initiative on Malnutrition (GLIM) criteria. Different modalities of low protein diets and the potential use of pre and probiotics are being explored. Furthermore, the importance of nutritional support, and possibly exercise during dialysis is being examined in terms of reducing anabolic resistance and catabolism. SummaryFurther research is required to better understand the nuances of the pathophysiology of disease-related malnutrition in CKD. This work should inform not only consistent terminology and the application of assessment tools specific to disease-related malnutrition in CKD but also the development of novel interventions that reflect its multifaceted pathophysiology and impact.

Exercise and nutrition interventions for renal cachexia

“…Our analysis indicated similar results with consistent effects on muscle strength, and some on performance, but also with inconsistent effects on muscle mass. Of the high protein ONS nutritional studies [4], we found they also had a beneficial effect but no consistency with improving muscle mass, and this might relate to dose used. We noted that key factors relating to exercise participation and adherence, longer term intervention durations, progressive loading and higher intensities were potentially favourable in promoting significant gains.…”

“…A number of overlapping nutrition-related syndromes are prevalent in chronic kidney disease (CKD) patients, such as disease-related malnutrition, cachexia, protein-energy wasting (PEW), sarcopenia and frailty [2–5] Cachexia has been defined as “a complex metabolic syndrome associated with underlying illness and characterized by loss of muscle with or without loss of fat mass”, and linked to reduced quality of life (QoL), increased morbidity, disability and mortality [6]. Cachexia is closely related to PEW and may be considered as a more progressive and advanced degree of wasting [3].…”

Developing an Evidence and Theory Based Multimodal Integrative Intervention for the Management of Renal Cachexia: A Theory of Change

“…ii. Dietary counselling—Chronic disease-related malnutrition in ESKD is a complex issue given that disease specific factors such as inflammation must also be taken into consideration [ 19 , 20 ]. Koppe, Fouque & Kalantar-Zadeh [ 6 ] confirm that PEW is among the strongest predictors of mortality in patients with ESKD (hazard ratio of 3.03; confidence interval of 1.69–5.26 in 1068 haemodialysis patients).…”

“…Evidence suggests that providing nutrition counselling could be linked to improvements in the patients’ malnutrition inflammation scores and nutritional knowledge and status [ 61 , 62 ]. Disease-specific nutritional guidance and supplementation to provide adequate protein, energy and preserve lean muscle mass is therefore essential to the health of haemodialysis patients [ 19 , 94 , 95 , 96 , 97 , 98 , 99 ]. Evidence suggests that nutritional therapy and nutritional supplementation to renal patients during haemodialysis is an ideal opportunity to manage the PEW pathology actively and help to manage one of the most critical risks for mortality in haemodialysis patients [ 94 , 95 , 96 , 97 , 98 , 99 ].…”

“…In ESKD findings relating to multimodal trials are limited and evidence suggests that isolated interventions in the form of protein supplementation and nutritional energy have rarely proven to be very effective in improving outcomes [ 18 ]. The lack of improvement is likely to be due to the need to effectively treat other causative factors (e.g., inflammation or inflammatory burden) [ 19 , 20 ]. For optimal treatment of renal cachexia evidence suggests that a multimodal approach which includes exercise [ 21 , 22 ], anti-inflammatory agents [ 9 , 11 ] and nutritional support [ 1 , 8 , 11 ] is essential to target the multifactorial pathophysiology and attain at least additional, if not synergistic effects [ 18 ].…”