REVISIÓN

 

A clinical approach to the nutritional care process in protein-energy wasting hemodialysis patients^1-3

Enfoque clínico de atención nutricional en pacientes con desgaste protéico-energético en hemodiálisis

 

 

Mar Ruperto¹, Francisco J. Sánchez-Muniz¹ y Guillermina Barril²

¹From Departamento de Nutrición y Bromatología I (Nutrición). Facultad de Farmacia. Universidad Complutense de Madrid.
²Servicio de Nefrología. Hospital Universitario La Princesa. Madrid. Spain.

Correspondence

 

 

---

ABSTRACT

Introduction: Malnutrition/wasting/cachexia are complex-disease conditions that frequently remain undiagnosed and/or untreated in up to 75% of prevalent hemodialysis (HD) patients. The nutrition care process (NCP) based on assessment, diagnosis, intervention and monitoring of nutritional status is a systematic method that nutrition professionals use to make decisions in clinical practice.
Objective: This review examines from a clinical-nutritional practice point of view: a) nutritional status as a mortality causative factor; b) phenotypic characteristics of malnutri-tion/wasting/cachexia, and c) current trends of NCP with special emphasis on nutritional support and novel nutrient and pharmacologic adjunctive therapies in HD patients.
Method: A literature review was conducted using the Pubmed, Science Direct, Scielo, Scopus, and Medline electronic scientific basis. Studies which assessing nutritional status and nutritional support published from 1990 to 2013 in HD patients were included and discussed.
Results: From all the epidemiological data analyzed, NCP was the suggested method for identifying malnut rition/ wasting or cachexia in clinical practice. Nutrition support as an unimodal therapy was not completely able to reverse wasting in HD patients. Novel experimental therapeutic strategies including the use of appetite stimulants, ghrelin agonist, MC4-R antagonists, anabolic steroids, anti-inflammatory drugs, cholecalciferol, and other components are still under clinical evaluation.
Conclusion: Nutritional status is a strong predictor of morbidity and mortality in HD patients. The terms called malnutrition, wasting and cachexia have different nutritional therapeutics implications. The NCP is a necessary tool for assessing and monitoring nutritional status in the current clinical practice. Novel pharmacological therapies or specific nutrient supplementation interventions studies are required.

Key words: Nutritional care process. Malnutrition. Protein-energy wating. Cachexia. Nutritional support. Hemodialysis.

---

RESUMEN

Introducción: Malnutrición/desgaste proteico-energético (DPE)/caquexia son situaciones patológicas complejas frecuentemente infradiagnosticadas o no tratadas hasta en un 75% de los pacientes prevalentes en hemodiálisis (HD). El proceso de atención nutricional (PAN) basado en la evaluación, diagnóstico, intervención y monitorización del estado nutricional es un método que los profesionales de la nutrición utilizan para tomar decisiones en la práctica clínica.
Objetivo: Esta revisión examina desde la perspectiva de la práctica clínica nutricional: a) el estado nutricional como factor causante de morbi-mortalidad; b) las características fenotípicas de malnutrición, DPE y caquexia y, c) el PAN con especial énfasis en el soporte nutricional y las nuevas terapias nutricionales y farmacológicas en pacientes en HD.
Métodos: Revisión sistemática de la literatura usando las bases científicas electrónicas Pubmed, Science Direct, Scielo, Scopus y Medline. Se incluyeron estudios publicados desde 1990 hasta 2013 que valoraban el estado nutricional y/o el soporte nutricional en pacientes en HD.
Resultados: De todos los datos epidemiológicos analizados, el PAN fue el método sugerido para identificar malnutrición/DPE/caquexia. El soporte nutricional como tratamiento aislado no era capaz de revertir totalmente la malnutrición o el DPE. Nuevas estrategias terapéuticas experimentales incluyendo el uso de estimulantes del apetito, agonistas de grelina, antagonistas MC4-R, esteroides anabólicos, antiinflamatorios y colecalciferol entre otros componentes, están siendo aún evaluados clínicamente.
Conclusiones: El estado nutricional es un predictor de morbilidad y mortalidad en pacientes en HD. Malnutrición, DPE y caquexia son términos con implicaciones terapéuticas diferentes. El PAN es una herramienta necesaria para la evaluación y la monitorización nutricional en la práctica clínica habitual. Estudios con nuevas terapias farmacológicas o intervenciones con suplementación de nutrientes específicos son requeridos.

Palabras clave: Proceso de atención nutricional. Malnutrición. Desgaste protéico-energético. Caquexia. Soporte nutricional. Hemodiálisis.

---

Non-standards abbreviations
ACE: Angiotensin-converting-enzyme.
BIA: Bioelectrical impedance analysis.
BMI: Body mass index.
CKD: Chronic kidney disease.
CRP: C-reactive protein.
CVD: Cardiovascular disease.
DEI: Dietary energy intake.
DOPPS: Dialysis Outcomes and Practice Patterns Study.
DPE: Desgaste proteico-energético.
DPI: Dietary protein intake.
DXA: Dual-energy x-ray absorptiometry.
EN: Enteral nutrition.
GH: Growth hormone.
IDPN: Intradialytic parenteral nutrition.
IGF-1: Insulin growth factor-1.
KDoqi: Kidney Disease Outcomes Quality Initiative. HD: Hemodialysis.
HDF: Online hemodiafiltration.
HMB: Hydroxyl-methyl-butyrate.
IL-6: Interleukin 6.
ISRM: International Society of Renal nutrition and Metabolism.
Kt/V urea (sp):Single pool urea kinetic model.
MC4-R: Melanocortin-4 receptor antagonists.
MIS: Malnutrition-inflammation score.
NCP: Nutritional care process.
ONS: Oral nutritional supplements.
PA: Phase angle.
PAN: Proceso de atención nutricional.
PEG: Percutaneous endoscopic gastrostomy.
PEJ: Percutaneous endoscopic jejunostomy.
PEW: Protein-energy wasting.
PPAR-γ: Peroxisome proliferator-activated receptor-gamma.
s-albumin: Serum albumin.
SGA: Subjective global assessment. s-prealbumin: Serum prealbumin.
TNF-alpha;: Tumor necrosis factor alpha.
TPN: Total parenteral nutrition.
USRD: United States Renal Data System.

 

Introduction

Malnutrition, protein-energy wasting (PEW) and cachexia are prevalent complex conditions that frequently remain undiagnosed and untreated up to three quarters of hemodialysis (HD) patients^1-3. Although an improper diet may contribute to malnutrition by itself, others factors including, increase of resting energy expenditure, systemic inflammation, endocrine disorders and metabolic acidosis, might be able to initiate wasting/cachexia syndrome in chronic kidney disease (CKD).

Annual death rates in dialysis patients with wasting/ cachexia are close to 20%⁴. The Dialysis Outcomes and Practice Patterns Study (DOPPS)⁵ showed that a reduction of more than 5% in serum albumin (s-albumin) six months after initiation of dialysis was associated with a relative risk of death of 1.96. The NECOSAD study⁶ reported that wasting, inflammation and cardiovascular disease (CVD) remain as independent risk factors per se, whereas cumulatively they were also death risk factors. A recent spanish study⁷, showed over 40% of wasting at 24 moths of follow-up in a sample of HD patients. A common pathophysiological link between CVD, inflammation, and wasting was reported⁶⁸. The wasting/cachexia syndrome was clearly associated as an independent predictor of morbidity and mortality in incident HD patients during the subsequent two years on dialysis⁹.

Recently, a recent panel of experts suggested that utilizable criteria for clinical diagnosis and treatment of wasting so called, protein-energy wasting (PEW)^10,11, and establishes the following question, which nutritional indicators predict clinical outcomes most specifically?"

Current clinical guidelines recommend routine assessment of nutritional status at the early stages of CKD¹² and in dialysis patients^10,13. However, although a number of nutritional procedures are available, no single indicator can be considered as the ideal and reliable marker of malnutrition or PEW. As nutritional status appears to be a significant mortality prognostic factor, the nutrition care process (NCP)¹⁴ method based on assessment, diagnosis, intervention and monitoring might improve clinical outcomes in HD patients.

This review examines current clinical practice in HD patients based on the NCP as follows: a) nutritional status as a cause of morbidity and mortality; b) analysis of phenotypic characteristics of different terms: malnutrition, PEW and cachexia; and c) the current trends in nutritional intervention and monitoring with special emphasis on nutritional support and novel adjunctive strategies.

 

Causative factors of morbidity and mortality in hemodialysis patients

Most of the identified traditional risk factors of morbidity and mortality in the general population are greatly different in HD patients. Epidemiological data from the United States Renal Data System (USRDS)⁴ showed that the relative risk of mortality increases in patients with BMI <18.5 kg/m². The DOPPS cohort study⁵ reported that each 5 kg/m² decrease in BMI was associated with 20% higher death risk. Conversely, a higher BMI (>25 kg/m²), due to a phenomenon known as "obesity paradox", was considered as a survival factor in the CKD population in some studies^15-17. Fleischmann et al.¹⁷ reported that overweight/obese HD patients showed lower rates of hospitalization and higher survival rates than their underweight counter-parts¹⁷. In the study of Beddhu et al.¹⁸ the protective effect of high BMI was limited to those patients with normal or high muscle mass. In addition, abdominal fat mass has been associated with inflammation, insulin resistance, hyperadipokynaemia, dyslipidaemia and oxidative stress in CKD patients^19-22. Postorino et al.²³ concluded that waist circumference is an independent predictor of all-cause and CV death from underweight to obesity in HD patients. Abnormal abdominal fat depots assessed by means of a conicity index in a sample of HD patients were linked to both inflammation and wasting as well as mortality risk factor²⁴. Even though these observations do not necessarily imply that principles of vascular pathophysiology differ between overweight/obesity HD patients, recent evidence^25,26 indicates that abdominal visceral adiposity intervenes in the classical relationship between CV risk factors, inflammation and wasting compared with observed outcomes in the general population.

Hypoalbuminemia is the strongest predictor of CVD and mortality in dialysis patients when compared with classical risk factors (hypertension, hypercholesterolemia, DM, obesity)^27-30 and non-traditional risk factors (anemia, oxidative stress, and dialysis modality)^9,31. A drop of 1-g/dL in s-albumin was associated with an increased mortality risk of 47% in HD patients³². Low serum prealbumin (s-prealbumin) concentration is also a recognized predictor of mortality in dialysis patients. Chertow et al.³³ reported that HD patients with s-prealbumin levels < 30 mg/dL showed a relative mortality risk of 2.64. Rambod et al.³⁴ found that baseline s-prealbumin concentrations < 20 mg/dL were associated with increased risk of mortality even in normoalbuminemic patients. A drop of 10 mg/dL in dialysis patients with s-prealbumin levels between 20 and 40 mg/dL was also associated with a 37% increase of death risk independent of s-albumin and inflammatory markers³⁴.

Inflammation is an overlapping condition whose prevalence in CKD patients is 30-50%^35-38. Serum C-reactive protein (CRP) and interleukin-6 (IL-6) are known inflammation biomarkers and independent predictors of CVD and mortality in dialysis patients³⁹. Some studies^38,40 have shown high morbidity and mortality rates associated with increase in acute-phase positive reactants (CRP, fibrinogen) and proinflammatory cytokines (IL-1, IL-6, tumor necrosis factor alpha: TNF-a) in HD patients. Honda et al.³⁸ reported that, in dialysis patients, IL-6 levels were predictors of CVD, while CRP and IL-6 levels were predictors of wasting, and that s-albumin, IL-6, and fetuin A were predictors of mortality. A novel actin-binding prognostic protein mainly secreted by myocytes and defined as plasma gelsolin has been recently involved as a useful biomarker of chronic inflammation, muscle mass, and immunity in CKD patients⁴¹. Follistatin, a myostatin binder, was highly increased in wasted and inflamed patients, which suggests a role as a potential mediator of wasting and survival in CKD patients⁴².

Pro-inflammatory cytokines such as plasma leptin, ghrelin and visfatin have also been involved as potential anorexigens in dialysis patients. A strong negative association exists between appetite and the level of CRP, IL-6, and TNF-α in HD patients⁴³. One third of CKD patients report anorexia or appetite loss; each unit increase in log of CRP levels was associated with a 49% increase in the relative risk of hospitalization and mortality rates over 12-months of clinical observation⁴³. In uremic patients a closed link between high leptin levels with impaired appetite and inflammation⁴⁴ has been reported. In addition, a higher increase of desacyl ghrelin has been found in anorexic HD patients than in non-anorexic patients⁴⁵. Patients with low circulating ghrelin concentrations have exhibited an increase of CRP and leptin levels as well as the highest mortality risk from all-cause and CV death risk⁴⁶. Visfatin a proinflammatory cytokine which is related to anorexia, inflammation and decreased circulating levels of amino acids in advanced CKD patients has been recently reported^47;48.

 

Phenotypic characteristics of Malnutrition/Protein-energy wasting/Cachexia in hemodialysis patients

Different terms and definitions have been used for these conditions associated with substantial loss of body stores, low protein-energy intake and inflammation in CKD patients. The term of malnutrition classified as marasmus or kwashiorkor, respectively is the consequence of a substantial decrease in energy and/or protein intake. Marasmus usually presents a starved appearance with diminished skinfold thickness, body weight loss and is not associated with significant comorbidity or non-inflammatory response (fig. 1) (table I). The classic study in healthy volunteers in Minnesota⁴⁹ showed that an inadequate intake of food itself does not contribute to wasting or cachexia. Under semi-starvation conditions and despite of 23% body weight loss and muscle wasting, s-albumin concentrations in these subjects dropped only slightly from 4.2 to 3.8 g/dL. In uremic patients on dialysis, Bistrian et al.⁵⁰ reported that s-albumin concentrations of marasmic patients were within the normal range. In fact, Chazot et al.⁵¹ showed that s-albumin and s-prealbumin levels were not sole markers of marasmus in over 20 year-HD patients⁵¹. Conversely, kwashiorkor is characterized by a marked hypoalbuminemia and fluid overload. While kwashiorkor s patients respond quickly to nutritional therapy, in marasmic patients it may be slower. It must be taken into account that uremic anorexia, catabolic HD procedure and other related factors could retard the nutritional repletion in marasmus´ patients.

The panel of experts from the International Society of Renal Nutrition and Metabolism (ISRNM)¹⁰ has defined the term "protein energy wasting" (PEW) to describe the mild-moderate forms of wasting in uremic patients. According to this definition, PEW is confirmed when at least three of the four features are present:¹⁰ a) altered laboratory markers (low s-albumin, prealbumin, or total cholesterol); b) reduced body mass (fat mass depletion or body weight loss); c) reduced muscle mass (muscle wasting or sarcopenia and reduced mid-arm muscle circumference) and, d) inadequate dietary intake (unintentional low dietary protein and energy intake¹⁰ (table I) (fig. 2). In contrast to malnutrition, PEW is associated with the elevation of pro-inflammatory cytokines⁵², endogenous muscle catabolism, hypoalbuminemia⁵³, uremic anorexia⁴³ and elevation of serum CRP⁵⁴ and CVD⁵⁵ in dialysis patients. Additionally, the ISRNM¹⁰ suggested that the term cachexia be reserved for only the most severe forms of PEW. The emerging concept defined as cachexia is a complex metabolic syndrome associated with underlying illness and characterized by loss or decreased of muscle strength with or without loss of fat (corrected for overload volume)⁵⁶. Cachexia differs in some diagnostic criteria of PEW in CKD patients. BMI < 20 kg/m² or weight loss of at least 5% ≤ in a period or equal or lower than 12 months and three of the following additional criteria are also required: anorexia, decrease muscle strength, fatigue, low fat-free mass index and altered laboratory parameters [s-albumin < 3.2 g/dL, anaemia (haemoglobin < 12 g/dL), including elevated inflammatory markers such as CRP or IL-6)] (table I). The differences in PEW compared to cachexia is that the latter encompasses only severe forms of metabolic depletion, whereas PEW is referred to mild degrees of depleted fat and muscle body mass.

 

Nutrition care process as systematic method in clinical practice

The Academy of Nutrition and Dietetics uses the concept Nutritional care process (NCP) as "a systematic problem-solving method that nutrition professionals use to critically think and make decisions to address nutrition-related problems and provide safe and effective quality nutrition care"^57,58. This method consists of four consecutive steps: nutrition assessment, diagnosis, intervention, and nutrition monitoring or evaluation. It is a stepwise approach to conducting thorough nutritional assessment to provide tailored nutrition care in renal patients¹⁴.

First and Second steps of Nutrition Care process: Nutritional assessment and diagnosis

Nutrition assessment consists of collecting biochemical data, anthropometric measurements, physical examination findings, food/nutrition history and patient history. Guidelines on Nutrition^11,13,59 recommend periodic assessment of nutritional status in the absence of malnutrition every 6-12 months in patients younger than 50. Over 5 years on HD and/or aged over 50, it is recommended every 3 months⁵⁹. The conjoint use of subjective (nutritional screening, clinical history and physical exam) and objective (anthropometrical and laboratory tests) methods to assess and diagnose nutritional status is required.

Nutritional screening is an identification step that is outside the actual care and provides access to the NCP by referral and/or screening of individuals or groups for nutritional risk⁵⁸ (fig. 2). Subjective global assessment (SGA) has been applied to subjectively evaluate patients at nutritional risk⁵⁹. A refinement of SGA known as the malnutrition-inflammation score (MIS)⁶⁰ has been significantly associated with coronary heart disease⁶¹, endothelial dysfunction⁶², poor quality of life⁶³, anorexia⁴³, hyporesponsiveness to erythropoietin⁶⁴, hospitalization and mortality in dialysis patients^60,63. Even though nutritional scoring systems are valuable tools for identifying dialysis patients at risk of malnu-trition/PEW/cachexia, a global assessment of nutritional status should consider a patient´s clinical history together with anthropometrical, biochemical, and inflammatory markers (fig. 3). The Kidney Disease Outcomes Quality Initiative (KDOQI)¹³ asserts that a single marker by itself does not provide a comprehensive assessment of nutritional status and, thus recommends a collective evaluation of multiple nutritional parameters.

Clinical nutrition history identifies changes in appetite, food intake (likes and dislikes), body weight loss, medication use, and interactions with other pathologies that might justify the modifications in one or several nutritional parameters. Physical examination by identifying clinical signs including changes in adipose tissue and muscle mass, edema and/or ascites, paleness, bruising, and skin lesions are indicators of nutritional risk (fig. 3). Additionally, dry body weight, skinfold thickness and mid-arm muscle circumference provide valuable information longitudinally on nutritional status. Anthropometric measures should be performed immediately after the dialysis session in the non-dominant or free vascular access arm⁵⁹. More sophisticated methods such as computed tomography, magnetic resonance image scans, and dual-energy X ray absorptiometry (DXA) are used for body composition analysis¹³.

Bioelectrical impedance analysis (BIA) is a validated method for evaluating hydration status and body composition in CKD and dialysis patients⁶⁵. Phase angle (PA) emerges as an additional indicator of nutritional status in wasted patients. Thus, the relative mortality risk of patients with PA values < 3^o was twice higher than patients with PA ≥ 4^o (target)⁶⁶. A study conducted in 64 HD patients⁶⁷ analyzed the suitability of the PA as a nutritional-inflammatory indicator. The prevalence of PEW was 81.2% in patients with a PA < 4^o and 35% in those with a value ≥ 4^o67. Prevalent HD patients with a PA < 4^o were shown to be wasted and inflamed⁶⁷. The conjoint use of BIA measurements, biochemical-nutritional parameters and inflammatory biomarkers may help to estimate dry body weight in hypoalbuminemic patients⁶⁷. Current clinical practice guidelines^10,13,59 do not include inflammatory biomarkers and body composition analysis measured by BIA. The evaluation of s-albumin and s-prealbumin [≥ 3.8 g/dL and ≥ 28 mg/dL, respectively (target)]⁵⁹ together with one marker of inflammation (e.g. CRP) and management of nutritional status may help to identify HD patients at high risk of mortality who might benefit from nutritional support⁶⁸.

Nutrition diagnoses list the problem, etiology, signs/symptoms (PES format)¹⁴. The problem (P) describes the alterations in the patient´s nutritional status. The etiology (E) or related factors are those factors that contribute to the cause of a particular problem. Finally, the signs and symptoms (S) are the defining characteristics obtained from the objective and subjective nutrition assessment data.

Third step of Nutrition Care Process:

Clinical approach to nutritional intervention

Nutrition intervention is needed for formulating and implementing the plan of nutrition care. There are four categories taken into account that identify the various types of nutrition interventions: a) adequacy of dialysis dose and scheme of hemodialysis (individualized treatment of dialysis: ultrapure water, biocompatible membranes, increasing the frequency-daily HD); b) nutritional counseling and oral nutrition supplementation; c) nutritional support (enteral nutrition and, intra-dialytic parenteral nutrition); d) coordination of nutrition care. In addition, interventions tailored to each one of type (malnutrition/PEW/cachexia) are required (fig. 4).

Adecuacy of dialysis dose and intensified dialysis strategies

Nutrition intervention remarkable factors to take into account in HD patients are the adequacy of the delivered dose (Kt/V urea single pool ≥ 1.2) and vascular access status. Dialysis adequacy is a prerequisite for achieving and/or maintaining nutritional status. In the HEMO study⁶⁹ no significant differences were found between high-flux and low flux dialysis membranes as well as within high and low dialysis doses as mortality causes. At present, the doses of dialysis that can improve nutritional status are still unknown.

Vascular access is a crucial factor in dialysis as a potential focus of inflammation. A low systemic inflammatory response, maximum biocompatibility of the system, and control of chronic foci of infection should be achieved⁷⁰. Observational studies^71-73 and randomized controlled trials^74,75 improving the efficiency of HD, by increasing frequency and duration of HD treatment, demonstrated better volume control and clearance efficiency of uremic toxins, middle molecular weight compounds and improved quality of life. Online hemodiafiltration (HDF) has attracted much attention as a promising optimum modality of HD due to efficient improvement in dialysis adequacy and clearing small and large-size uremic toxins⁷⁶. Studies on HDF patients showed fewer requirements of phosphate binders, better control of hypertension with fewer use of antihypertensive drugs, less doses of erythropoietin stimulating agents, and iron supplements as a result of abolishing or reducing the inflammatory response⁷⁷. However, a recent study⁷⁸ showed that treatment with HDF did not reduce all causes of mortality compared with treatment with low-flux membranes in conventional HD therapy as non-significant differences in s-albumin, s-CRP and s-cholesterol during follow-up were found⁷⁹. Further studies should be conducted for elucidating this issue.

Daily short or long-nocturnal HD in malnou-rished/PEW/cachectics patients are recommended as adjunctive therapy for 6-12 months⁵⁹. Daily dialysis results in less fluid overload, fewer medications and dietary restrictions, better blood pressure and phosphate control. Hemodialysis tailored to patient needs should be considered.

Nutritional counseling and oral nutrition supplementation

The recommended dietary energy and protein intakes for HD patients are 30-35 kcal/kg/day and 1.2 g protein/kg/day, respectively^13,59,80. Low dietary energy intake (on dialysis and non-dialysis treatment days) has been reported in these patients⁸¹. Preventive nutritional strategies include nutritional counseling adapted to each stage of CKD and dialysis modality, might help to reduce and/or prevent malnutrition and some of the PEW conditions. It is important to note, that prolonged and often unnecessary periods of fasting, multiple laboratory tests, missed meals due to dialysis, and restrictive diets during periods of intercurrent diseases are potential precursors of malnutrition and wasting. Periodic reevaluation and nutritional counseling are essential practices even in well-nourished patients. To ensure their nutritional intake HD patients must receive nutritional counseling and routine management of nutritional status^82,83. Oral nutrition supplementation (ONS) is the first choice of nutritional support in malnourished/PEW patients whose spontaneous intakes are ≤ 20 kcal/kg/day⁸⁴. ONS can provide additional 7-10 kcal energy/kg/day and 0.3-0.4 g protein/kg/day to meet dietary recommendations⁸⁵. Beutler et al.⁸⁶ compared the results of nutritional counseling alone with supplemented HD patients. S-albumin improved significantly in patients given ONS, but decreased in those who only received nutritional counseling. Seven of the twelve studies listed in table II, are randomized controlled trials reporting significant improvements in nutritional status. Recently, a retrospective matched-large cohort study⁸⁷ of in-center HD patients with low s-albumin was performed. A total of 5,227 HD patients receiving intra-dialytic ONS with matched-pairs controls were compared. In the intention-to-treat analysis, survival was 9% and up to 34% in the as-treated group when compared with controls. Results of the study support that providing ONS coincident with three-weekly HD sessions in hypoalbuminemic patients may increase protein and energy intakes and improve survival rate⁸⁷. To achieve protein and energy intakes, ONS should be received two-to-three times a day, preferably one hour after each main meal⁸⁵ as well as ONS given during dialysis session which increases adherence to the treatment and improves nutritional status⁸⁸.

Nutritionally complete formulas can be used, either as ONS or even as modular products (carbohydrates, lipids, proteins). Protein modular products may be ineffective in malnourished/PEW patients unless administered together with adequate energy intake. Hence, an ONS with 100% whey protein has a high biological value, and an absence of free phosphorous content may be preferred. Disease-specific formulae for CKD and dialysis patients (high energy density, low potassium, sodium and phosphorus) are tailored for the requirements of these patients. Cockram et al.⁸⁹ studied the effect of three medical nutritional products (one standard formula and two disease-specific formulas) in well-nourished HD patients. Disease-specific formulas improve serum phosphorus levels and the calcium/phosphorus ratio in comparison to the standard formulae. Fouque et al.⁹⁰ reported that renal-specific ONS might prevent malnutrition in HD patients without increasing the need for phosphate binders.

A recent randomized controlled trial⁹¹, assessed the effect of combined disease-specific formulas with antiinflammatory and antioxidative properties in HD patients during the hemodialysis session. Daily intakes of disease-specific formulas for 3-month observational period were well tolerated and associated with 0.2 g/dL improvement of serum albumin concentration in HD patients.

However, the principal limitations of ONS involve low patient compliance, gastrointestinal intolerance, unpleasant flavor and long-time use of the same formulas. High-energy formula (1.5-2 kcal/mL) to avoid volume overload is recommended^92,93. The combination of ONS and nutritional counseling is safe and may be useful in terms of improving nutritional status. To date, ideal ONS (100% whey protein, free from phosphorous, potassium and vitamin A), has not been formulated in HD patients. Current disease-specific formulas with antioxidative and anti-inflammatory components require further considerations.

Nutritional support

The second step of nutrition intervention for malnou-rished/PEW/cachectics patients who do not respond successfully to nutritional counseling and ONS involves: a) intradialytic parenteral nutrition (IDPN), alone or in combination with ONS, and b) enteral nutrition by nasoenteral tube feeding or ostomy (EN) (fig. 4).

IDPN involves the administration of a macro and micronutrient solution through the venous chamber and does not require additional vascular access in HD treatment. The volume administered can be ultrafil-trated during the HD session. As shown in figure 4, PEW/cachectic patients should receive daily nutritional support to achieve the nutritional requirements. Nonetheless, to date, IDPN studies on survival are controversial⁹⁴. Dezfuli et al.⁹⁴ demonstrated that s-albumin levels increased 3.5-fold in hypoalbuminemic HD patients receiving IDPN. Joannidis et al.⁹⁵ found that IDPN increased body weight but did not modify the inflammatory status of 6 patients. Foulks et al.⁹⁶ reported a body weight gain of at least 10% and a significant reduction of hospitalization and mortality rates in 45 hypoalbuminemic HD patients who received IDPN for 6 months. In a retrospective study, Chertow et al.⁹⁷ compared 1,679 HD patients who received one or more infusions of IDPN with 22,517 non-IDPN controls. The relative odds ratio for mortality depends highly on the decrease in s-albumin levels of the IDPN patients with ≤ 3.0 g/dL and on their increase in patients with > 4.0 g/dL⁹⁷. Furthermore, a prospective randomized controlled study⁹⁸ evaluated the effects of combining IDPN and ONS therapy with respect to the ONS treatment alone in 182 malnourished HD patients over one-year period. These investigators reported that the patients administered with IDPN together with ONS did not improve hospitalization rates, Karnofsky scores, BMI, biochemical parameters on 2-year mortality rates in comparison to patients receiving ONS alone. Multivariate analysis indicated that only the ONS group showed sustained s-albumin and prealbumin improvements after 1-year. Interestingly, s-prealbumin levels of ≥ 30 mg/dL during the first 3 months of ONS were associated with a decrease in the 2-year mortality rate⁹⁸. IDPN should be considered more of a therapeutic strategy for intravenous nutritional supplementation than a total nutrition support. Clinical guidelines on parenteral nutrition proposed in order to ensure optimal tolerance⁸⁴: a) IDPN should be infused at a constant rate during 4 h dialysis session; b) IDPN delivery should be progressively increased during the first week to a maximum of 16 mL/kg/day without ever exceeding 1000 mL/per HD session; and, c) ultrafiltration should be controlled and 75 mmol Na+ added per liter of IDPN solution to compensate for sodium losses⁸⁴. IDPN is recommended whether s-albumin < 3g/dL¹¹.

In addition, IDPN appears to reverse body protein catabolism during the HD session and to normalize the amino acid profile^99,100. Losses of 6-8 g of amino acids into the dialysate per dialysis session were reported¹⁰¹. Pupim et al.^99,100 investigated the effect of IDPN on protein metabolism in two randomized studies. In the first study⁹⁹, seven HD patients were randomized with or without IDPN two hours before, during, and two hours after the HD session by using a primed-constant infusion of L-(1-¹³C) leucine and L (ring-²H₅) phenylalanine. IDPN induced a large increase in whole-body protein synthesis and a significant decrease in whole-body protein proteolysis associated with an increase in forearm muscle protein synthesis getting a positive protein balance in whole body and forearm muscle compartments⁹⁹. In their second study, Pupim et al.¹⁰⁰ demonstrated that exercise combined with IDPN doubled forearm muscle essential amino acid uptake and net muscle protein accretion during the HD session. While the anabolic benefits of of IDPN provides only a transient improvement during HD session, ONS resulted in persistent anabolic benefits for muscle protein metabolism in postdialysis when anabolic benefits of IDPN had disappeared¹⁰².These results show that IDPN contributes to synthesis rather than catabolism and could counterbalance the catabolic effect of hemodialysis procedure.

PEW/cachectic patients who have spontaneous food intakes < 20 kcal/kg/day or are under stress conditions should receive daily nutritional support by enteral nutrition (EN). Nutritional support by tube feeding is less expensive, produces fewer metabolic and septic complications, and contributes much more to the digestive tract morphology maintenance than intravenous feeding⁸⁴. EN should be used when nutritional counseling, ONS therapy and IDPN are unable to achieve nutritional requirements⁹², or when stress conditions are presented⁸⁴. Enteral nutrition guidelines⁹² recommend nutritional support in CKD patients with a BMI < 20 kg/m², body weight loss >10% over the previous 6 months, s-albumin < 3.5 g/dL, and s-prealbumin < 30 mg/dL. EN by tube feeding (nasogastric or nasojejunal tube), or for long-term ostomy [percutaneous endoscopic gastrostomy (PEG) or percutaneous endoscopic jejunostomy (PEJ)], are preferred to intravenous nutritional support. Nasojejunal tube feeding is recommended in patients with gastroparesis or in those who are non-responsive to prokinetic drugs⁹². PEG or PEJ is indicated in PEW or cachectics patients who do not respond to conventional therapy for a period of more than 4 weeks⁹². Even though the use of specific renal-disease formulas is preferred, standard formulas whose compositions are adapted to the nutritional requirement of the patient, can also be used⁹². Oligomeric formulas containing partially digested proteins are indicated when dyspepsia and/or malabsorption are involved.

However, when EN cannot meet individual nutritional requirements, or it is contraindicated -due to GI dysfunction or other pathological conditions (peritonitis, intestinal obstruction, ileus, GI ischemia, or enterocutaneous fistulas)-, total parenteral nutrition (TPN) by a central or peripheral vascular access is recommended to allow the digestive tract to recover from the effects of the concomitant condition.

Fourth step of Nutrition Care Process: Nutrition Monitoring and Evaluation

The purpose of monitoring and evaluation is to determine the degree to which progress is being achieved⁵⁷. It requires and active commitment to measuring and registering the appropriate outcome indicators relevant to the nutritional diagnosis´ signs and symtoms. The re-evaluation of outcomes may also involve additional data collection in order to explore why the nutritional changes have not occurred as expected. Systematic use of these process provides consistency in the practice, adds value and demonstrates effectiveness of nutritional care.

 

Future adjuctive therapies

Combinations of new and promising therapeutic strategies including the use of appetite stimulants, growth hormone (GH), ghrelin agonist, melacortin-4 receptors (MC4-R) antagonists, anabolic steroids and anti-inflammatory drugs (steroids, pentoxifylline, statins, ACE inhibitors and anticytokine antibodies) are under clinical evaluation. These therapies are based on several studies^91;103-117 which are briefly commented on.

Physical exercise activates peroxisome proliferator-activated receptor-gamma (PPAR-γ) and increases insulin-like growth factor type 1 (IGF-1), insulin sensitivity, and protein synthesis^103,104. Omega-3 fatty acids can stimulate PPAR-γ by decreasing muscle tissue inflammation¹⁰³. Fish oil supplementation potentiates the effect of exercise¹⁰³ and decreases the inflammatory response to the HD procedure^105,106. Appetite stimulants (hydralazine sulfate, metoclopramide, prednisolone, megestrol acetate) may also improve nutritional status. Pentoxifylline with or without ONS combination showed a significant improvement in s-albumin concentrations⁹¹. Emerging therapeutic strategies with some effective results as thalidomide, COX-2 inhibitors, proteosome inhibitors and anti-myostatin peptibody are still under clinical evaluation. Recombinant human growth hormone (rhGH) and IGF-1 improved protein synthesis in dialysis patients participating in pilot studies with pentoxifylline^107,108. Garibotto et al.¹⁰⁹ showed significant improvement in net muscle protein balance over a 6-week administration of 50 μg rhGH in cachectic HD patients. Uremia produces peripheral resistance to anabolic hormones (GH, insulin, IGF-I) and their administration has been shown to improve whole-body protein homeostasis. Ghrelin or its analogs may constitute an orexigen therapeutic strategy in CKD patients. In two subsequent studies^110,111 subcutaneous ghrelin injection achieved in short-intermediate term induced a sustained positive change in anorexic dialysis patients. Nonetheless, ghrelin infusion induces lipolysis and insulin resistance independently of GH and cortisol¹¹². Further studies are needed to evaluate the adverse side effects and the long-term efficacy of ghrelin in improving appetite and nutritional status. Recently, oral administration of active MC4-R antagonists has been proposed as a promising candidate for the treatment of anorexia and involuntary weight loss in PEW/cachectic patients. In a mouse model of uremic cachexia, Cheung et al.¹¹³ demonstrated that intraperitoneal administration of NBI-12i (a MC4-R antagonists) stimulated food intake and increased lean body mass and fat mass in treated uremic mice. However, to date, reports of the effects of MCR4-R antagonists have not been presented in human studies. Antioxidant and anti-inflammatory nutrients as omega-3 fatty acids, gamma-tocopherol and phytoestrogens and physical exercise have been proposed. Cholecalciferol¹¹⁴, gamma-tocopherol and docohexanoic acid¹¹⁵ induced inflammation decrease in HD patients. In addition, nandrolone decanoate in association with exercise increases lean body mass, quadriceps muscle, and knee extensor muscle strength^116,117. The combination of aminoacids supplement has been tested. The mixture of hydroxyl-methyl-butyrate, arginine and glutamine was shown to be effective in increasing fat-free mass of middle-aged and elderly patients with advanced-stage cancer¹¹⁸ and in younger subjects with AIDS-associated wasting^119,120. The potential benefit of these therapies merits further research. Randomized controlled and large cohort studies are needed to determine the multimodal beneficial effects and clinical outcome of these promising therapeutic strategies.

 

Conclusions and future remarks

This article has reviewed some issues with regard to NCP (assessment, diagnosis, intervention and monitoring) as well as novel adjunctive therapies to be applied in HD patients. Lastly, clinical research for the prevention and treatment of malnutrition/PEW/ cachexia has been conducted. There is controversy on the development of malnutrition or other conditions such as inflammation or comorbidity related to PEW or cachexia. However, there seems to be less disagreement concerning the consistent association of nutritional status with poor outcomes in dialysis patients. PEW/cachexia is a predictable event in many HD patients, readily diagnosed by assessment of body weight, change in appetite, low albumin and a concomitant increase in bioinflammatory markers. At the onset and throughout the course of illness, HD patients should have access to a nutrition team, to take part in a rehabilitation program tailor-made to their needs and consider the use of specific nutritional support and pharmacologic interventions. As a compromised nutritional status is still a common feature of HD patients, the above simple assessments should form a consistent part of the clinical procedure to diagnoses and treatment as early as possible in order to improve survival and positively affect patients´quality. Furthermore, studies on nutritional status should also incorporate the beneficial role of tailored exercise programs. Novel and complementary therapies such as oral active MC4-R antagonist and proteosome inhibitors may be promising candidates for attenuating disease-associated anorexia and muscle wasting of PEW/cachectics patients. Further studies with nutrients and compounds as hydroxyl-methyl-butyrate and branched chain amino acids with a particular role in protein synthesis should be conducted. From all the epidemiological data analyzed, nutrition support as a unimodal therapy was not completely able to reverse mild PEW and cachexia. Thus, further holistic nutrition-dialysis approaches are required.

 

Statement of authorship

All authors have significantly contributed to the paper, had access to all the data in the study and approved the final version of the manuscript to be submitted for publication. MR is the corresponding author and guarantor and the paper and has contributed to the design, writing and discussion of the paper. GB and FJS-M have contributed to the critical reading and discussion of the paper.

 

References

1. Kyle UG, Pirlich M, Schuetz T, Luebke HJ, Lochs H, Pichard C. Prevalence of malnutrition in 1760 patients at hospital admission: a controlled population study of body composition. Clin Nutr 2003; 22: 473-81.         [ Links ]

2. Beddhu S, Cheung AK, Larive B, et al. Inflammation and inverse associations of body mass index and serum creatinine with mortality in hemodialysis patients. J Ren Nutr 2007; 17: 372-80.         [ Links ]

3. Mehrotra R, Berman N, Alistwani A, Kopple JD. Improvement of nutritional status after initiation of maintenance hemodialysis. Am J Kidney Dis 2002; 40: 133-42.         [ Links ]

4. USRD. US Renal Data System. USRDS 2010 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2010.         [ Links ]

5. Lopes AA, Bragg-Gresham JL, Elder SJ, et al. Independent and joint associations of nutritional status indicators with mortality risk among chronic hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study (DOPPS). J Ren Nutr 2010; 20: 224-34.         [ Links ]

6. de MR, Grootendorst DC, Axelsson J, Boeschoten EW, Krediet RT, Dekker FW. Excess mortality due to interaction between protein-energy wasting, inflammation and cardiovascular disease in chronic dialysis patients. Nephrol Dial Transplant 2008;23:2957-64.         [ Links ]

7. Gracia-Iguacel C, Gonzalez-Parra E, Perez-Gomez MV, et al. Prevalence of protein-energy wasting syndrome and its association with mortality in haemodialysis patients in a centre in Spain. Nefrologia 2013; 33: 495-505.         [ Links ]

8. Stenvinkel P, Heimburger O, Paultre F, et al. Strong association between malnutrition, inflammation, and atherosclerosis in chronic renal failure. Kidney Int 1999; 55: 1899-911.         [ Links ]

9. Kovesdy CP, Kalantar-Zadeh K. Why is protein-energy wasting associated with mortality in chronic kidney disease? Semin Nephrol 2009; 29: 3-14.         [ Links ]

10. Fouque D, Kalantar-Zadeh K, Kopple J, et al. A proposed nomenclature and diagnostic criteria for protein-energy wasting in acute and chronic kidney disease. Kidney Int 2008; 73: 391-8.         [ Links ]

11. Ikizler TA, Cano NJ, Franch H, et al. Prevention and treatment of protein energy wasting in chronic kidney disease patients: a consensus statement by the International Society of Renal Nutrition and Metabolism. Kidney Int 2013: 22 (Epub ahead of print).         [ Links ]

12. Johnson DW. KHA-CARI Guideline: Early chronic kidney disease: detection, prevention and management. Nephrology 2013; 18: 340-50.         [ Links ]

13. Clinical practice guidelines for nutrition in chronic renal failure. K/DOQI, National Kidney Foundation. Am J Kidney Dis 2000; 35: S1-140.         [ Links ]

14. Memmer D. Implementation and practical application of the nutrition care process in the dialysis unit. J Ren Nutr 2013; 23: 65-73.         [ Links ]

15. Kalantar-Zadeh K, Block G, Humphreys MH, Kopple JD. Reverse epidemiology of cardiovascular risk factors in maintenance dialysis patients. Kidney Int 2003; 63: 793-808.         [ Links ]

16. Fleischmann E, Teal N, Dudley J, May W, Bower JD, Salahudeen AK. Influence of excess weight on mortality and hospital stay in 1346 hemodialysis patients. Kidney Int 1999; 55: 1560-7.         [ Links ]

17. Fleischmann EH, Bower JD, Salahudeen AK. Are conventional cardiovascular risk factors predictive of two-year mortality in hemodialysis patients? Clin Nephrol 2001; 56: 221-30.         [ Links ]

18. Beddhu S, Pappas LM, Ramkumar N, Samore M. Effects of body size and body composition on survival in hemodialysis patients. J Am Soc Nephrol 2003; 14: 2366-72.         [ Links ]

19. Axelsson J, Rashid QA, Suliman ME, et al. Truncal fat mass as a contributor to inflammation in end-stage renal disease. Am J Clin Nutr 2004; 80: 1222-9.         [ Links ]

20. Odamaki M, Furuya R, Ohkawa S, et al. Altered abdominal fat distribution and its association with the serum lipid profile in non-diabetic haemodialysis patients. Nephrol Dial Transplant 1999; 14: 2427-32.         [ Links ]

21. Gohda T, Gotoh H, Tanimoto M, et al. Relationship between abdominal fat accumulation and insulin resistance in hemodialysis patients. Hypertens Res 2008; 31: 83-8.         [ Links ]

22. Gotoh H, Gohda T, Tanimoto M, Gotoh Y, Horikoshi S, Tomino Y. Contribution of subcutaneous fat accumulation to insulin resistance and atherosclerosis in haemodialysis patients. Nephrol Dial Transplant 2009; 24: 3474-80.         [ Links ]

23. Postorino M, Marino C, Tripepi G, Zoccali C. Abdominal obesity and all-cause and cardiovascular mortality in end-stage renal disease. J Am Coll Cardiol 2009; 53: 1265-72.         [ Links ]

24. Cordeiro AC, Qureshi AR, Stenvinkel P, et al. Abdominal fat deposition is associated with increased inflammation, protein-energy wasting and worse outcome in patients undergoing haemodialysis. Nephrol Dial Transplant 2010; 25: 562-8.         [ Links ]

25. Postorino M, Marino C, Tripepi G, Zoccali C. Abdominal obesity modifies the risk of hypertriglyceridemia for all-cause and cardiovascular mortality in hemodialysis patients. Kidney Int 2011; 79: 765-72.         [ Links ]

26. Zoccali C, Postorino M, Marino C, Pizzini P, Cutrupi S, Tripepi G. Waist circumference modifies the relationship between the adipose tissue cytokines leptin and adiponectin and all-cause and cardiovascular mortality in haemodialysis patients. J Intern Med 2011; 269: 172-81.         [ Links ]

27. Lowrie EG, Lew NL. Death risk in hemodialysis patients: the predictive value of commonly measured variables and an evaluation of death rate differences between facilities. Am J Kidney Dis 1990; 15: 458-82.         [ Links ]

28. Foley RN, Parfrey PS, Harnett JD, Kent GM, Murray DC, Barre PE. Hypoalbuminemia, cardiac morbidity, and mortality in end-stage renal disease. J Am Soc Nephrol 1996; 7: 728-36.         [ Links ]

29. Owen WF, Lowrie EG. C-reactive protein as an outcome predictor for maintenance hemodialysis patients. Kidney Int 1998; 54: 627-36.         [ Links ]

30. Beddhu S, Kaysen GA, Yan G, et al. Association of serum albumin and atherosclerosis in chronic hemodialysis patients. Am J Kidney Dis 2002; 40: 721-7.         [ Links ]

31. Kato A, Takita T, Furuhashi M, Maruyama Y, Hishida A. Comparison of serum albumin, C-reactive protein and carotid atherosclerosis as predictors of 10-year mortality in hemodialysis patients. Hemodial Int 2010; 14: 226-32.         [ Links ]

32. de MR, Grootendorst DC, Indemans F, Boeschoten EW, Krediet RT, Dekker FW. Association between serum albumin and mortality in dialysis patients is partly explained by inflammation, and not by malnutrition. J Ren Nutr 2009; 19: 127-35.         [ Links ]

33. Chertow GM, Goldstein-Fuchs DJ, Lazarus JM, Kaysen GA. Prealbumin, mortality, and cause-specific hospitalization in hemodialysis patients. Kidney Int 2005; 68: 2794-800.         [ Links ]

34. Rambod M, Kovesdy CP, Bross R, Kopple JD, Kalantar-Zadeh K. Association of serum prealbumin and its changes over time with clinical outcomes and survival in patients receiving hemodialysis. Am J Clin Nutr 2008; 88: 1485-94.         [ Links ]

35. Herselman M, Esau N, Kruger JM, Labadarios D, Moosa MR. Relationship between serum protein and mortality in adults on long-term hemodialysis: exhaustive review and meta-analysis. Nutrition 2010; 26: 10-32.         [ Links ]

36. Beberashvili I, Sinuani I, Azar A, et al. IL-6 levels, nutritional status, and mortality in prevalent hemodialysis patients. Clin J Am Soc Nephrol 2011; 6: 2253-63.         [ Links ]

37. Bologa RM, Levine DM, Parker TS, et al. Interleukin-6 predicts hypoalbuminemia, hypocholesterolemia, and mortality in hemodialysis patients. Am J Kidney Dis 1998; 32: 107-14.         [ Links ]

38. Honda H, Qureshi AR, Heimburger O, et al. Serum albumin, C-reactive protein, interleukin 6, and fetuin a as predictors of malnutrition, cardiovascular disease, and mortality in patients with ESRD. Am J Kidney Dis 2006; 47: 139-48.         [ Links ]

39. Zhang W, He J, Zhang F, et al. Prognostic role of C-reactive protein and interleukin-6 in dialysis patients: a systematic review and meta-analysis. J Nephrol 2013; 26: 243-53.         [ Links ]

40. Zoccali C, Benedetto FA, Mallamaci F, et al. Inflammation is associated with carotid atherosclerosis in dialysis patients. Creed Investigators. Cardiovascular Risk Extended Evaluation in Dialysis Patients. J Hypertens 2000; 18: 1207-13.         [ Links ]

41. Lee PS, Sampath K, Karumanchi SA, et al. Plasma gelsolin and circulating actin correlate with hemodialysis mortality. J Am Soc Nephrol 2009; 20: 1140-8.         [ Links ]

42. Miyamoto T, Carrero JJ, Qureshi AR, et al. Circulating follis-tatin in patients with chronic kidney disease: implications for muscle strength, bone mineral density, inflammation, and survival. Clin J Am Soc Nephrol 2011; 6: 1001-8.         [ Links ]

43. Kalantar-Zadeh K, Block G, McAllister CJ, Humphreys MH, Kopple JD. Appetite and inflammation, nutrition, anemia, and clinical outcome in hemodialysis patients. Am J Clin Nutr 2004; 80: 299-307.         [ Links ]

44. Ruperto M, Sanchez-Muniz FJ, Barril G.Plasma leptin levels and inflammation biomarkers in well nourished and malnourished haemodialysed patients (abstract) Proceeding of Nutrition Society 2010; 69: 265.         [ Links ]

45. Muscaritoli M, Molfino A, Chiappini MG, et al. Anorexia in hemodialysis patients: the possible role of desacyl ghrelin. Am J Nephrol 2007; 27: 360-5.         [ Links ]

46. Carrero JJ, Nakashima A, Qureshi AR, et al. Protein-energy wasting modifies the association of ghrelin with inflammation, leptin, and mortality in hemodialysis patients. Kidney Int 2011; 79: 749-56.         [ Links ]

47. Axelsson J, Witasp A, Carrero JJ, et al. Circulating levels of visfatin/pre-B-cell colony-enhancing factor 1 in relation to genotype, GFR, body composition, and survival in patients with CKD. Am J Kidney Dis 2007; 49: 237-44.         [ Links ]

48. Carrero JJ, Witasp A, Stenvinkel P, et al. Visfatin is increased in chronic kidney disease patients with poor appetite and correlates negatively with fasting serum amino acids and triglyceride levels. Nephrol Dial Transplant 2010; 25: 901-6.         [ Links ]

49. Keys A., Brozek J, Hensschel A, Mickelsen O, Taylor HL. The biology of human starvation. The University of Minnesota Press, Minneapolis 1950. p. 63-130.         [ Links ]

50. Bistrian BR, McCowen KC, Chan S. Protein-energy malnutrition in dialysis patients. Am J Kidney Dis 1999; 33: 172-5.         [ Links ]

51. Chazot C, Laurent G, Charra B, et al. Malnutrition in long-term haemodialysis survivors. Nephrol Dial Transplant 2001; 16: 61-9.         [ Links ]

52. Kaysen GA. Association between inflammation and malnutrition as risk factors of cardiovascular disease. Blood Purif 2006; 24: 51-5.         [ Links ]

53. Kaysen GA, Stevenson FT, Depner TA. Determinants of albumin concentration in hemodialysis patients. Am J Kidney Dis 1997; 29: 658-68.         [ Links ]

54. Iseki K, Tozawa M, Yoshi S, Fukiyama K. Serum C-reactive protein (CRP) and risk of death in chronic dialysis patients. Nephrol Dial Transplant 1999; 14: 1956-60.         [ Links ]

55. Carrero JJ, Nakashima A, Qureshi AR, et al. Protein-energy wasting modifies the association of ghrelin with inflammation, leptin, and mortality in hemodialysis patients. Kidney Int 2011; 79: 749-56.         [ Links ]

56. Evans WJ, Morley JE, Argiles J, et al. Cachexia: a new definition. Clin Nutr 2008; 27: 793-9.         [ Links ]

57. Academy of Nutrition and Dietetics. International Dietetic and Nutrition Terminology (IDNT) Reference Manual: Standardized Language for the Nutrition Care process. 2013.         [ Links ]

58. Lacey K, Pritchett E. Nutrition Care Process and Model: ADA adopts road map to quality care and outcomes management. J Am Diet Assoc 2003; 103: 1061-72.         [ Links ]

59. Fouque D, Vennegoor M, ter WP, et al. EBPG guideline on nutrition. Nephrol Dial Transplant 2007; 22 Suppl 2: ii45-ii87.         [ Links ]

60. Kalantar-Zadeh K, Kopple JD, Block G, Humphreys MH. A malnutrition-inflammation score is correlated with morbidity and mortality in maintenance hemodialysis patients. Am J Kidney Dis 2001; 38: 1251-63.         [ Links ]

61. Elsurer R, Afsar B, Sezer S, Arat Z, Ozdemir FN, Haberal M. Malnutrition inflammation score is associated with coronary artery disease in hepatitis C virus-infected hemodialysis patients. Eur J Clin Nutr 2008; 62: 1449-54.         [ Links ]

62. Aguilera A, Sanchez-Tomero JA, Bajo MA, et al. Malnutritioninflammation syndrome is associated with endothelial dysfunction in peritoneal dialysis patients. Adv Perit Dial 2003; 19: 240-5.         [ Links ]

63. Rambod M, Bross R, Zitterkoph J, et al. Association of Malnutrition-Inflammation Score with quality of life and mortality in hemodialysis patients: a 5-year prospective cohort study. Am J Kidney Dis 2009; 53: 298-309.         [ Links ]

64. Kalantar-Zadeh K, McAllister CJ, Lehn RS, Lee GH, Nissenson AR, Kopple JD. Effect of malnutrition-inflammation complex syndrome on EPO hyporesponsiveness in maintenance hemodialysis patients. Am J Kidney Dis 2003; 42: 761-73.         [ Links ]

65. Chertow GM, Lazarus JM, Lew NL, Ma L, Lowrie EG. Bioimpedance norms for the hemodialysis population. Kidney Int 1997;52:1617-21.         [ Links ]

66. Chertow GM, Jacobs C, Lazarus JM, Lew N, Lowrie EG. Phase angle predicts survival in hemodialysis patients. J Ren Nutr 1997; 7: 204-7.         [ Links ]

67. Ruperto M, Barril G., Sánchez-Muniz FJ, Cigarran S., Sánchez Tomero JA. El ángulo de fase es un parámetro de utilidad diagnóstica del síndrome de malnutrición-inflamación en pacientes prevalentes en hemodiálisis periódica. Nutr Hosp 2010; 25 (Supl. 1): 3.         [ Links ]

68. Brown RO, Compher C. A.S.P.E.N. clinical guidelines: nutrition support in adult acute and chronic renal failure. JPEN 2010; 34: 366-77.         [ Links ]

69. Cheung AK, Levin NW, Greene T, et al. Effects of high-flux hemodialysis on clinical outcomes: results of the HEMO study. J Am Soc Nephrol 2003; 14: 3251-63.         [ Links ]

70. Huarte E, Barril G, Cebollada J, Cerezo S, Coronel F, Doñate T, et al. Consenso de Nutrición y Diálisis. Dial Traspl. 2006; 27: 138-61.         [ Links ]

71. Culleton BF, Walsh M, Klarenbach SW, et al. Effect of frequent nocturnal hemodialysis vs conventional hemodialysis on left ventricular mass and quality of life: a randomized controlled trial. JAMA 2007; 298: 1291-9.         [ Links ]

72. Barrett BJ, Parfrey PS, Morgan J, et al. Prediction of early death in end-stage renal disease patients starting dialysis. Am J Kidney Dis 1997; 29: 214-22.         [ Links ]

73. Perl J, Chan CT. Home hemodialysis, daily hemodialysis, and nocturnal hemodialysis: Core Curriculum 2009. Am J Kidney Dis 2009; 54: 1171-84.         [ Links ]

74. Chertow GM, Levin NW, Beck GJ, et al. In-center hemodialysis six times per week versus three times per week. N Engl J Med 2010; 363: 2287-300.         [ Links ]

75. Rocco MV, Larive B, Eggers PW, et al. Baseline characteristics of participants in the Frequent Hemodialysis Network (FHN) daily and nocturnal trials. Am J Kidney Dis 2011; 57: 90-100.         [ Links ]

76. Pedrini LA, De C, V, Comelli M, et al. Long-term effects of high-efficiency on-line haemodiafiltration on uraemic toxicity. A multicentre prospective randomized study. Nephrol Dial Transplant 2011; 26: 2617-24.         [ Links ]

77. Ayus JC, Achinger SG, Mizani MR, et al. Phosphorus balance and mineral metabolism with 3 h daily hemodialysis. Kidney Int 2007;71:336-42.         [ Links ]

78. Grooteman MP, van den Dorpel MA, Bots ML, et al. Effect of online hemodiafiltration on all-cause mortality and cardiovascular outcomes. J Am Soc Nephrol 2012; 23: 1087-96.         [ Links ]

79. Gross M, Maierhofer A, Tetta C, Senecal L, Canaud B. Online clearance measurement in high-efficiency hemodiafiltration. Kidney Int 2007; 72: 1550-3.         [ Links ]

80. Toigo G, Aparicio M, Attman PO, et al. Expert Working Group report on nutrition in adult patients with renal insufficiency (part 1 of 2). Clin Nutr 2000; 19: 197-207.         [ Links ]

81. Burrowes JD, Larive B, Cockram DB, et al. Effects of dietary intake, appetite, and eating habits on dialysis and non-dialysis treatment days in hemodialysis patients: cross-sectional results from the HEMO study. J Ren Nutr 2003; 13: 191-8.         [ Links ]

82. Bossola M, Muscaritoli M, Tazza L, et al. Malnutrition in hemodialysis patients: what therapy? Am J Kidney Dis 2005; 46: 371-86.         [ Links ]

83. Wilson B, Fernández-Madrid A, Hayes A, Hermann K, Smith J, Wassell A. Comparison of the effects of two early intervention strategies on the health outcomes of malnourished hemodialysis patients. J Ren Nutr 2001; 11: 166-71.         [ Links ]

84. Cano NJ, Aparicio M, Brunori G, et al. ESPEN Guidelines on Parenteral Nutrition: adult renal failure. Clin Nutr 2009; 28: 401-14.         [ Links ]

85. Kalantar-Zadeh K, Cano NJ, Budde K, et al. Diets and enteral supplements for improving outcomes in chronic kidney disease. Nat Rev Nephrol 2011; 7: 369-84.         [ Links ]

86. Beutler KT, Park GK, Wilkowsky MJ. Effect of oral supplementation on nutrition indicators in hemodialysis patients. J Ren Nutr 1997; 7: 77-82.         [ Links ]

87. Lacson E Jr, Wang W, Zebrowski B, Wingard R, Hakim RM. Outcomes associated with intradialytic oral nutritional supplements in patients undergoing maintenance hemodialysis: a quality improvement report. Am J Kidney Dis 2012; 60: 591-600.         [ Links ]

88. Caglar K, Fedje L, Dimmitt R, Hakim RM, Shyr Y, Ikizler TA. Therapeutic effects of oral nutritional supplementation during hemodialysis. Kidney Int 2002; 62: 1054-9.         [ Links ]

89. Cockram DB, Hensley MK, Rodriguez M, et al. Safety and tolerance of medical nutritional products as sole sources of nutrition in people on hemodialysis. J Ren Nutr 1998; 8: 25-33.         [ Links ]

90. Fouque D, McKenzie J, de MR, et al. Use of a renal-specific oral supplement by haemodialysis patients with low protein intake does not increase the need for phosphate binders and may prevent a decline in nutritional status and quality of life. Nephrol Dial Transplant 2008; 23: 2902-10.         [ Links ]

91. Rattanasompattikul M, Molnar MZ, Lee ML, et al. Anti-Inflammatory and Anti-Oxidative Nutrition in Hypoalbuminemic Dialysis Patients (AIONID) study: results of the pilot-feasibility, double-blind, randomized, placebo-controlled trial. J Cachexia Sarcopenia Muscle 2013; 4: 247-57.         [ Links ]

92. Cano N, Fiaccadori E, Tesinsky P, et al. ESPEN Guidelines on Enteral Nutrition: Adult renal failure. Clin Nutr 2006; 25: 295-310.         [ Links ]

93. Kooman J, Basci A, Pizzarelli F, et al. EBPG guideline on haemodynamic instability. Nephrol Dial Transplant 2007; 22 Suppl 2: ii22-ii44.         [ Links ]

94. Dezfuli A, Scholl D, Lindenfeld SM, Kovesdy CP, Kalantar-Zadeh K. Severity of hypoalbuminemia predicts response to intradialytic parenteral nutrition in hemodialysis patients. J Ren Nutr 2009; 19: 291-7.         [ Links ]

95. Joannidis M, Rauchenzauner M, Leiner B, et al. Effect of intra-dialytic parenteral nutrition in patients with malnutritioninflammation complex syndrome on body weight, inflammation, serum lipids and adipocytokines: results from a pilot study. Eur J Clin Nutr 2008; 62: 789-95.         [ Links ]

96. Foulks CJ. The effect of intradialytic parenteral nutrition on hospitalization rate and mortality in malnourished hemodialysis patients. J Ren Nutr 1994; 4: 5-10.         [ Links ]

97. Chertow GM, Ling J, Lew NL, Lazarus JM, Lowrie EG. The association of intradialytic parenteral nutrition administration with survival in hemodialysis patients. Am J Kidney Dis 1994; 24: 912-20.         [ Links ]

98. Cano NJ, Fouque D, Roth H, et al. Intradialytic parenteral nutrition does not improve survival in malnourished hemodialysis patients: a 2-year multicenter, prospective, randomized study. J Am Soc Nephrol 2007; 18: 2583-91.         [ Links ]

99. Pupim LB, Flakoll PJ, Brouillette JR, Levenhagen DK, Hakim RM, Ikizler TA. Intradialytic parenteral nutrition improves protein and energy homeostasis in chronic hemodialysis patients. J Clin Invest 2002; 110: 483-92.         [ Links ]

100. Pupim LB, Flakoll PJ, Ikizler TA. Exercise improves albumin fractional synthetic rate in chronic hemodialysis patients. Eur J Clin Nutr 2007; 61: 686-9.         [ Links ]

101. Ikizler TA, Flakoll PJ, Parker RA, Hakim RM. Amino acid and albumin losses during hemodialysis. Kidney Int 1994; 46: 830-7.         [ Links ]

102. Pupim LB, Majchrzak KM, Flakoll PJ, Ikizler TA. Intradialytic oral nutrition improves protein homeostasis in chronic hemodialysis patients with deranged nutritional status. J Am Soc Nephrol 2006; 17: 3149-57.         [ Links ]

103. Nagahuedi S, Popesku JT, Trudeau VL, Weber JM. Mimicking the natural doping of migrant sandpipers in sedentary quails: effects of dietary n-3 fatty acids on muscle membranes and PPAR expression. J Exp Biol 2009; 212: 1106-14.         [ Links ]

104. Kopple JD, Wang H, Casaburi R, et al. Exercise in maintenance hemodialysis patients induces transcriptional changes in genes favoring anabolic muscle. J Am Soc Nephrol 2007; 18: 2975-86.         [ Links ]

105. Perunicic-Pekovic GB, Rasic ZR, Pljesa SI, et al. Effect of n-3 fatty acids on nutritional status and inflammatory markers in haemodialysis patients. Nephrology (Carlton) 2007; 12: 331-6.         [ Links ]

106. Saifullah A, Watkins BA, Saha C, Li Y, Moe SM, Friedman AN. Oral fish oil supplementation raises blood omega-3 levels and lowers C-reactive protein in haemodialysis patients -a pilot study. Nephrol Dial Transplant 2007; 22: 3561-7.         [ Links ]

107. Garibotto G, Barreca A, Sofia A, et al. Effects of growth hormone on leptin metabolism and energy expenditure in hemodialysis patients with protein-calorie malnutrition. J Am Soc Nephrol 2000; 11: 2106-13.         [ Links ]

108. Biolo G, Ciocchi B, Bosutti A, Situlin R, Toigo G, Guarnieri G. Pentoxifylline acutely reduces protein catabolism in chronically uremic patients. Am J Kidney Dis 2002; 40: 1162-72.         [ Links ]

109. Garibotto G, Barreca A, Russo R, et al. Effects of recombinant human growth hormone on muscle protein turnover in malnourished hemodialysis patients. J Clin Invest 1997; 99: 97-105.         [ Links ]

110. Wynne K, Giannitsopoulou K, Small CJ, et al. Subcutaneous ghrelin enhances acute food intake in malnourished patients who receive maintenance peritoneal dialysis: a randomized, placebo-controlled trial. J Am Soc Nephrol 2005; 16: 2111-8.         [ Links ]

111. Ashby DR, Ford HE, Wynne KJ, et al. Sustained appetite improvement in malnourished dialysis patients by daily ghrelin treatment. Kidney Int 2009; 76: 199-206.         [ Links ]

112. Caso G, Garlick PJ. Control of muscle protein kinetics by acid-base balance. Curr Opin Clin Nutr Metab Care 2005; 8: 73-6.         [ Links ]

113. Cheung WW, Kuo HJ, Markison S, et al. Peripheral administration of the melanocortin-4 receptor antagonist NBI-12i ameliorates uremia-associated cachexia in mice. J Am Soc Nephrol 2007;18:2517-24.         [ Links ]

114. Stubbs JR, Idiculla A, Slusser J, Menard R, Quarles LD. Chole-calciferol supplementation alters calcitriol-responsive monocyte proteins and decreases inflammatory cytokines in ESRD. J Am Soc Nephrol 2010; 21: 353-61.         [ Links ]

115. Himmelfarb J, Phinney S, Ikizler TA, Kane J, McMonagle E, Miller G. Gamma-tocopherol and docosahexaenoic acid decrease inflammation in dialysis patients. J Ren Nutr 2007; 17: 296-304.         [ Links ]

116. Johansen KL. The role of nandrolone decanoate in patients with end stage renal disease in the erythropoietin era. Int J Artif Organs 2001; 24: 183-5.         [ Links ]

117. Johansen KL, Painter PL, Sakkas GK, Gordon P, Doyle J, Shubert T. Effects of resistance exercise training and nandrolone decanoate on body composition and muscle function among patients who receive hemodialysis: A randomized, controlled trial. J Am Soc Nephrol 2006; 17: 2307-14.         [ Links ]

118. May PE, Barber A, D´Olimpio JT, Hourihane A, Abumrad NN. Reversal of cancer-related wasting using oral supplementation with a combination of beta-hydroxy-beta-methylbutyrate, arginine, and glutamine. Am J Surg 2002; 183: 471-9.         [ Links ]

119. Clark RH, Feleke G, Din M, et al. Nutritional treatment for acquired immunodeficiency virus-associated wasting using beta-hydroxy beta-methylbutyrate, glutamine, and arginine: a randomized, double-blind, placebo-controlled study. JPEN J Parenter Enteral Nutr 2000; 24: 133-9.         [ Links ]

120. Rathmacher JA, Nissen S, Panton L, et al. Supplementation with a combination of beta-hydroxy-beta-methylbutyrate (HMB), arginine, and glutamine is safe and could improve hematological parameters. JPEN JParenter Enteral Nutr 2004; 28: 65-75.         [ Links ]

121. Stenvinkel P, Heimburger O, Lindholm B, Kaysen GA, Bergstrom J. Are there two types of malnutrition in chronic renal failure? Evidence for relationships between malnutrition, inflammation and atherosclerosis (MIA syndrome). Nephrol Dial Transplant 2000; 15: 953-60.         [ Links ]

122. Milano MC, Cusumano AM, Navarro ET, Turin M. Energy supplementation in chronic hemodialysis patients with moderate and severe malnutrition. J Ren Nutr 1998; 8: 212-7.         [ Links ]

123. Kuhlmann MK, Schmidt F, Kohler H. High protein/energy vs. standard protein/energy nutritional regimen in the treatment of malnourished hemodialysis patients. Miner Electrolyte Metab 1999; 25: 306-10.         [ Links ]

124. Patel MG, Kitchen S, Miligan PJ. The effect of dietary supplements on the nPCR in stable hemodialysis patients. J Ren Nutr 2000; 10: 69-75.         [ Links ]

125. Sharma M, Rao M, Jacob S, Jacob CK. A controlled trial of intermittent enteral nutrient supplementation in maintenance hemodialysis patients. J Ren Nutr 2002; 12: 229-37.         [ Links ]

126. Kalantar-Zadeh K, Braglia A, Chow J, et al. An anti-inflammatory and antioxidant nutritional supplement for hypoalbuminemic hemodialysis patients: a pilot/feasibility study. J Ren Nutr 2005; 15: 318-31.         [ Links ]

127. Leon JB, Albert JM, Gilchrist G, et al. Improving albumin levels among hemodialysis patients: a community-based randomized controlled trial. Am J Kidney Dis 2006; 48: 28-36.         [ Links ]

128. Scott MK, Shah NA, Vilay AM, Thomas J, III, Kraus MA, Mueller BA. Effects of peridialytic oral supplements on nutritional status and quality of life in chronic hemodialysis patients. J Ren Nutr 2009; 19: 145-52.         [ Links ]

129. Malgorzewicz S, Rutkowski P, Jankowska M, Debska-Slizien A, Rutkowski B, Lysiak-Szydlowska W. Effects of renal-specific oral supplementation in malnourished hemodialysis patients. J Ren Nutr 2011; 21: 347-53.         [ Links ]

 

 

Correspondence:
Mar Ruperto.
Departamento de Nutrición y Bromatología I (Nutrición).
Facultad de Farmacia.
Plaza Ramón y Cajal, s/n.
Universidad Complutense de Madrid.
28040 Madrid.
E-mail: marruperto@yahoo.com

Recibido: 20-X-2013.
1.^a Revisión: 19-XI-2013.
Aceptado: 18-XII-2013.