Prevention and treatment of protein energy wasting in chronic kidney disease patients: a consensus statement by the International Society of Renal Nutrition and Metabolism

Abstract

Protein energy wasting (PEW) is common in patients with chronic kidney disease (CKD) and is associated with adverse clinical outcomes, especially in individuals receiving maintenance dialysis therapy. A multitude of factors can affect the nutritional and metabolic status of CKD patients requiring a combination of therapeutic maneuvers to prevent or reverse protein and energy depletion. These include optimizing dietary nutrient intake, appropriate treatment of metabolic disturbances such as metabolic acidosis, systemic inflammation, and hormonal deficiencies, and prescribing optimized dialytic 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. In clinical practice, the advantages of oral nutritional supplements include proven efficacy, safety, and compliance. Anabolic strategies such as anabolic steroids, growth hormone, and exercise, in combination with nutritional supplementation or alone, have been shown to improve protein stores and represent potential additional approaches for the treatment of PEW. Appetite stimulants, anti-inflammatory interventions, and newer anabolic agents are emerging as novel therapies. While numerous epidemiological data suggest that an improvement in biomarkers of nutritional status is associated with improved survival, there are no large randomized clinical trials that have tested the effectiveness of nutritional interventions on mortality and morbidity.

A Comparison of the Phosphorus Content in Prescription Medications for Hemodialysis Patients in Japan

“…12) Current recommendations for phosphorus intake in CKD stages 3 5 are to reduce phosphorous intake to 800 1000 mg/d, in conjunction with use of phosphate binders if this is considered necessary. 13) Although noncontrolled evidence is not unanimous in this regard, the results of a recent large randomized controlled trial (RCT) indicated that a low-phosphorus diet can be used to decrease serum phosphorus andˆbroblast growth factor-23 levels. 14) Another recent RCT showed that the use of this diet combined with the use of phosphate binders proved to be more eŠective than each of these approaches alone.…”

A Patient with CKD and Poor Nutritional Status

“…The efficacy of oral supplementation has been studied in multiple settings (reviewed by Ikizler et al [52]). The beneficial nutritional effects of these supplements range from improvements in serum biomarkers, such as albumin, prealbumin, and transferrin, to gains in different body compartments, such as weight and lean body mass.…”

The Obesity Paradox and the Role of Inflammation

“…It may include dialysisrelated strategies, such as avoiding the use of central venous catheters, and regimens associated with improving inflammatory status, such as daily dialysis for short time periods, appropriate fluid management, or anti-inflammatory interventions. 11 However, an optimal approach for treating the wasting syndrome remains to be found.…”

“…In this context, inflammation is regarded an important feature of the wasting syndrome, which commonly occurs in patients on dialysis. 11 Up to three quarters of patients on dialysis are affected by wasting. 12 Wasting is a severe syndrome, characterized by poor food intake, low muscle mass, inflammation, and development of comorbid conditions.…”