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Granata S, Bruschi M, Verlato A, Pontrelli P, Gesualdo L, Stallone G, Zaza G. Autophagy Activation in Peripheral Blood Mononuclear Cells of Peritoneal Dialysis Patients. Kidney Int Rep 2023; 8:1852-1863. [PMID: 37705917 PMCID: PMC10496084 DOI: 10.1016/j.ekir.2023.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 06/09/2023] [Accepted: 06/19/2023] [Indexed: 09/15/2023] Open
Abstract
Introduction The complete systemic deregulated biological network in patients on peritoneal dialysis (PD) is still only partially defined. High-throughput/omics techniques may offer the possibility to analyze the main biological fingerprints associated with this clinical condition. Methods We applied an innovative bioinformatic analysis of gene expression microarray data (mainly based on support vector machine (SVM) learning) to compare the transcriptomic profile of peripheral blood mononuclear cells (PBMCs) of healthy subjects (HS), chronic kidney disease (CKD) patients, and patients on PD divided into a microarray group (5 HS, 9 CKD, and 10 PD) and a validation group (10 HS, 15 CKD, and 15 PD). Classical well-standardized biomolecular approaches (western blotting and flow cytometry) were used to validate the transcriptomic results. Results Bioinformatics revealed a distinctive PBMC transcriptomic profiling for PD versus CKD and HS (n = 419 genes). Transcripts encoding for key elements of the autophagic pathway were significantly upregulated in PD, and the autophagy related 5 (ATG5) reached the top level of discrimination [-Log10 P-value = 11.3, variable importance in projection (VIP) score = 4.8, SVM rank:1]. Protein levels of ATG5 and microtubule associated protein 1 light chain 3 beta (LC3B), an important constituent of the autophagosome, validated microarray results. In addition, the incubation of PBMCs of HS with serum of patients on PD upregulated both proteins. Autophagy in PBMCs from patients on PD was attenuated by N-acetyl-cysteine or Resatorvid treatment. Conclusions Our data demonstrated, for the first time, that the autophagy pathway is activated in immune-cells of patients on PD, and this may represent a novel therapeutic target.
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Affiliation(s)
- Simona Granata
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Maurizio Bruschi
- Laboratory of Molecular Nephrology, IRCCS Istituto Giannina Gaslini, Genova, Italy
- Department of Experimental Medicine, University of Genoa, Genoa, Italy
| | - Alberto Verlato
- Renal Unit, Department of Medicine, University Hospital of Verona, Verona, Italy
- Department of Medicine, Nephrology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Paola Pontrelli
- Nephrology, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Bari, Italy
| | - Loreto Gesualdo
- Nephrology, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Bari, Italy
| | - Giovanni Stallone
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Gianluigi Zaza
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
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2
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Metabolomics Profiling of Nephrotic Syndrome towards Biomarker Discovery. Int J Mol Sci 2022; 23:ijms232012614. [PMID: 36293474 PMCID: PMC9603939 DOI: 10.3390/ijms232012614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 10/05/2022] [Accepted: 10/13/2022] [Indexed: 11/17/2022] Open
Abstract
Nephrotic syndrome (NS) is a kidney illness characterized by excessive proteinuria, hypoalbuminemia, edema, and hyperlipidemia, which may lead to kidney failure and necessitate renal transplantation. End-stage renal disease, cardiovascular issues, and mortality are much more common in those with NS. Therefore, the present study aimed to identify potential new biomarkers associated with the pathogenesis and diagnosis of NS. The liquid chromatography–mass spectrometry (LC–MS) metabolomics approach was applied to profile the metabolome of human serum of patients with NS. A total of 176 metabolites were significantly altered in NS compared to the control. Arginine, proline, and tryptophan metabolism; arginine, phenylalanine, tyrosine, and tryptophan biosynthesis were the most common metabolic pathways dysregulated in NS. Furthermore, alanyl-lysine and isoleucyl-threonine had the highest discrimination between NS and healthy groups. The candidate biomarkers may lead to understanding the possible metabolic alterations associated with NS and serve as potential diagnostic biomarkers.
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3
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Canaud B, Kooman JP, Selby NM, Taal M, Maierhofer A, Kopperschmidt P, Francis S, Collins A, Kotanko P. Hidden risks associated with conventional short intermittent hemodialysis: A call for action to mitigate cardiovascular risk and morbidity. World J Nephrol 2022; 11:39-57. [PMID: 35433339 PMCID: PMC8968472 DOI: 10.5527/wjn.v11.i2.39] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 10/30/2021] [Accepted: 03/23/2022] [Indexed: 02/06/2023] Open
Abstract
The development of maintenance hemodialysis (HD) for end stage kidney disease patients is a success story that continues to save many lives. Nevertheless, intermittent renal replacement therapy is also a source of recurrent stress for patients. Conventional thrice weekly short HD is an imperfect treatment that only partially corrects uremic abnormalities, increases cardiovascular risk, and exacerbates disease burden. Altering cycles of fluid loading associated with cardiac stretching (interdialytic phase) and then fluid unloading (intradialytic phase) likely contribute to cardiac and vascular damage. This unphysiologic treatment profile combined with cyclic disturbances including osmotic and electrolytic shifts may contribute to morbidity in dialysis patients and augment the health burden of treatment. As such, HD patients are exposed to multiple stressors including cardiocirculatory, inflammatory, biologic, hypoxemic, and nutritional. This cascade of events can be termed the dialysis stress storm and sickness syndrome. Mitigating cardiovascular risk and morbidity associated with conventional intermittent HD appears to be a priority for improving patient experience and reducing disease burden. In this in-depth review, we summarize the hidden effects of intermittent HD therapy, and call for action to improve delivered HD and develop treatment schedules that are better tolerated and associated with fewer adverse effects.
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Affiliation(s)
- Bernard Canaud
- Global Medical Office, Fresenius Medical Care, Bad Homburg 61352, Germany
- Department of Nephrology, Montpellier University, Montpellier 34000, France
| | - Jeroen P Kooman
- Department of Internal Medicine, Maastricht University, Maastricht 6229 HX, Netherlands
| | - Nicholas M Selby
- Centre for Kidney Research and Innovation, Academic Unit for Translational Medical Sciences, School of Medicine, University of Nottingham, Derby DE22 3DT, United Kingdom
| | - Maarten Taal
- Centre for Kidney Research and Innovation, Academic Unit for Translational Medical Sciences, School of Medicine, University of Nottingham, Derby DE22 3DT, United Kingdom
| | - Andreas Maierhofer
- Global Research Development, Fresenius Medical Care, Schweinfurt 97424, Germany
| | | | - Susan Francis
- Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham NG7 2RD, United Kingdom
| | - Allan Collins
- Global Medical Office, Fresenius Medical Care, Bad Homburg 61352, Germany
| | - Peter Kotanko
- Renal Research Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10065, United States
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4
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Avramovski PJ, Petlichkovski A, Avramovska M, Ilkovska B, Sotiroski K, Nikleski Z, Sikole E. The Gamma Gap Predicts All-Cause Mortality in Chronic Dialysis Patients. Indian J Nephrol 2021; 31:212-217. [PMID: 34376932 PMCID: PMC8330655 DOI: 10.4103/ijn.ijn_342_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 03/08/2020] [Accepted: 04/03/2020] [Indexed: 11/21/2022] Open
Abstract
Introduction: The gamma gap (γ-gap) represents the total serum protein concentration minus the albumin concentration. The main aim of this study was to test whether the gamma gap is a predictor of mortality and whether it is associated with other predictors of mortality in chronic hemodialysis patients (CHPs). Materials and Methods: We studied a cohort of 100 CHPs with a mean age of 59 ± 12.3 years with duration of dialysis 6.5 ± 4.7 years. Serum proteins were determined by electrophoresis. The association of the gamma gap with serum C-reactive protein (CRP), fibrinogen and albumin concentration was evaluated for correlation. Cox regression analysis was used to identify the predictors of mortality. Results: The γ-gap correlates positively with CRP (r = 0.247, P = 0.013) and fibrinogen (r = 0.239, P = 0.016), and inversely with albumin (r = -0.430, P < 0.0001). The regression coefficients (b) and Exp (b) hazard ratio coefficients of covariates in Cox-regression survival analysis in all-cause outcomes were: b = 0.1486, Exp (b) = 1.1602 (P < 0.0001); b = 0.0655, Exp (b) = 1.0677 (P < 0.0015) and b = -0.118, Exp (b) = 0.8887 (P < 0.0009), for γ-gap, CRP and albumin, respectively. Conclusions: In patients on chronic hemodialysis, the gamma gap, along with serum albumin and CRP levels, is an independent predictor of mortality. Gamma gap levels correlate directly with serum CRP and fibrinogen levels and inversely with serum albumin levels.
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Affiliation(s)
- Petar J Avramovski
- Docent in Faculty of Veterinary Medicine-Bitola, St. Clement of Ohrid University of Bitola, North Macedonia, Bitola, North Macedonia.,Primarius, Specialist of Internal Medicine, Department of Ultrasonography, Clinical Hospital Dr. Trifun Panovski, Partizanska b.b., North Macedonia
| | - Aleksandar Petlichkovski
- Professor of Human Genetics and Immunobiology, Director of Institute for Immunobiology and Human Genetics, Faculty of Medicine Skopje, University Ss. Cyril and Methodius University, Skopje, North Macedonia
| | - Maja Avramovska
- Specialist of Obstetrics and Gynecology, Clinical Hospital Dr. Trifun Panovski, Partizanska b.b., North Macedonia
| | - Biljana Ilkovska
- Specialist of Clinical Biochemistry, Clinical Hospital Dr. Trifun Panovski, Partizanska b.b., Bitola, North Macedonia
| | - Kosta Sotiroski
- Professor on Statistics at Faculty of Economics-Prilep, St. Clement of Ohrid University of Bitola, North Macedonia
| | - Zorica Nikleski
- Master of Public Health, Advanced Torrens University Sydney, Australia
| | - Emilija Sikole
- Institute of Preclinical and Clinical Pharmacology with Toxicology, Faculty of Medicine Skopje, University "SS. Cyril and Methodius", - Skopje, North Macedonia
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Gagnebin Y, Jaques DA, Rudaz S, de Seigneux S, Boccard J, Ponte B. Exploring blood alterations in chronic kidney disease and haemodialysis using metabolomics. Sci Rep 2020; 10:19502. [PMID: 33177589 PMCID: PMC7658362 DOI: 10.1038/s41598-020-76524-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 10/29/2020] [Indexed: 02/06/2023] Open
Abstract
Chronic kidney disease (CKD) is characterized by retention of uremic solutes. Compared to patients with non-dialysis dependent CKD, those requiring haemodialysis (HD) have increased morbidity and mortality. We wished to characterise metabolic patterns in CKD compared to HD patients using metabolomics. Prevalent non-HD CKD KDIGO stage 3b-4 and stage 5 HD outpatients were screened at a single tertiary hospital. Various liquid chromatography approaches hyphenated with mass spectrometry were used to identify 278 metabolites. Unsupervised and supervised data analyses were conducted to characterize metabolic patterns. 69 patients were included in the CKD group and 35 in the HD group. Unsupervised data analysis showed clear clustering of CKD, pre-dialysis (preHD) and post-dialysis (postHD) patients. Supervised data analysis revealed qualitative as well as quantitative differences in individual metabolites profiles between CKD, preHD and postHD states. An original metabolomics framework could discriminate between CKD stages and highlight HD effect based on 278 identified metabolites. Significant differences in metabolic patterns between CKD and HD patients were found overall as well as for specific metabolites. Those findings could explain clinical discrepancies between patients requiring HD and those with earlier stage of CKD.
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Affiliation(s)
- Yoric Gagnebin
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Geneva, Switzerland
| | - David A Jaques
- Service of Nephrology and Hypertension, Department of Medicine, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland.
| | - Serge Rudaz
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Geneva, Switzerland
- Swiss Centre for Applied Human Toxicology, University of Basel, Basel, Switzerland
| | - Sophie de Seigneux
- Service of Nephrology and Hypertension, Department of Medicine, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland
| | - Julien Boccard
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Geneva, Switzerland
- Swiss Centre for Applied Human Toxicology, University of Basel, Basel, Switzerland
| | - Belén Ponte
- Service of Nephrology and Hypertension, Department of Medicine, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland
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6
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Wolf JM, Stefanovski D, Silverstein DC. Retrospective evaluation of the influence of azotemia on plasma lactate concentrations in hypotensive dogs and cats (2008-2018): 337 cases. J Vet Emerg Crit Care (San Antonio) 2020; 30:449-454. [PMID: 32579283 DOI: 10.1111/vec.12982] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 09/10/2018] [Accepted: 09/14/2018] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To evaluate the relationship between azotemia and plasma lactate concentration in hypotensive dogs and cats presented to an emergency department. DESIGN Retrospective case-control study. SETTING University veterinary teaching hospital. ANIMALS The electronic medical record database was searched for dogs and cats presented to the emergency department that had severe azotemia (creatinine ≥ 443.1 μmol/L [5 mg/dL]), hypotension (systolic blood pressure ≤ 90 mm Hg), and a plasma lactate measurement within 2 h of each another. Non-azotemic, normotensive dogs and cats; non-azotemic, hypotensive dogs and cats; and azotemic, normotensive dogs and cats that presented to the emergency department were used as control populations. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Severely azotemic, hypotensive dogs (n = 10) and cats (n = 63) had a lower plasma lactate than non-azotemic, hypotensive dogs and cats (P = 0.031 and P < 0.001, respectively). Median plasma lactate concentrations in hypotensive dogs (1.75 mmol/L) and cats (1.90 mmol/L) with severe azotemia were within reference intervals. CONCLUSIONS Hypotensive dogs and cats with severe azotemia have decreased plasma lactate concentrations as compared to hypotensive, non-azotemic dogs and cats. The median plasma lactate in azotemic, hypotensive dogs and cats was within reference intervals. This may be due to either decreased cellular production of lactate or increased excretion of lactate. Further research is needed to determine which of these mechanisms is responsible and the clinical significance of plasma lactate concentrations in azotemic, hypotensive dogs and cats.
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Affiliation(s)
- Jacob M Wolf
- Department of Clinical Studies and Advanced Medicine, University of Pennsylvania School of Veterinary Medicine, Philadelphia, Pennsylvania, USA
| | - Darko Stefanovski
- Department of Clinical Studies and Advanced Medicine, University of Pennsylvania School of Veterinary Medicine, Philadelphia, Pennsylvania, USA
| | - Deborah C Silverstein
- Department of Clinical Studies and Advanced Medicine, University of Pennsylvania School of Veterinary Medicine, Philadelphia, Pennsylvania, USA
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7
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N-terminal Pro-B-Type Natriuretic Peptide and Malnutrition in Patients on Hemodialysis. Int J Nephrol 2020; 2020:9528014. [PMID: 32206350 PMCID: PMC7077038 DOI: 10.1155/2020/9528014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 02/11/2020] [Indexed: 11/17/2022] Open
Abstract
Natriuretic peptides, brain natriuretic peptide (BNP), and N-terminal probrain natriuretic peptide (NT-proBNP) are mainly known as diagnostic markers for heart failure with high diagnostic and prognostic values in the general population. In patients who are undergoing hemodialysis (HD), changes in NT-proBNP can be related to noncardiac problems such as fluid overload, inflammation, or malnutrition and can also be influenced by the dialysis characteristics. The current review aimed to summarize findings from studies on the association between NT-proBNP and malnutrition in HD patients. Articles published after 2009 and over a ten-year period were considered for inclusion. We first briefly discuss the traditional functions of NT-proBNP, and after, we describe the functions of this prohormone by focusing on its relation with protein energy wasting (PEW) in HD patients. Mechanisms that could explain these relationships were also discussed. Overall, 7 studies in which the investigation of the relations between NT-proBNP and nutritional status in HD patients were among the main objects were taken into account. NT-proBNP levels correlated with several factors described in the 4 categories of markers indicative of PEW (body mass and composition, muscle mass, biochemical criteria, and dietary intakes) and/or were associated with PEW. Interactions between several parameters could be involved in the association between NT-proBNP and malnutrition with a strong role of weight status. NT-proBNP is elevated in HD patients and is associated with malnutrition. Nevertheless, the prognostic value of NT-proBNP on nutritional status should be evaluated.
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8
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Woodrow G. Con: The role of diet for people with advanced Stage 5 CKD. Nephrol Dial Transplant 2019; 33:380-384. [PMID: 29165595 DOI: 10.1093/ndt/gfx294] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 01/31/2017] [Indexed: 01/05/2023] Open
Abstract
Restriction of dietary protein intake has been used in the management of chronic kidney disease (CKD) for many decades, yet remains controversial, with marked variations in its application in clinical practice. There is extensive literature on the subject, with some expert opinion advocating the use of protein restriction based on the balance of the available evidence. The largest randomized trial of low-protein diets is the Modification of Diet in Renal Disease study. Despite multiple secondary analyses, the essential intention-to-treat analysis failed to demonstrate a benefit in the primary outcome of rate of decline of glomerular filtration rate. There are criticisms of many published studies and meta-analyses, including the likelihood of publication bias and unsuitable biochemical endpoints that may be affected by dietary restriction in the absence of effects on kidney function, leading to false positive findings. It is also uncertain whether any benefits observed in these often older studies would be derived in patients undergoing modern standards of CKD management, including blood pressure control and renin-angiotensin blockade. Thus it is unclear whether, even in the strictly controlled environment of a clinical study, low-protein diets significantly slow CKD progression. Important questions exist regarding the applicability of these diets in routine clinical practice. Even in carefully selected study populations with intensive dietetic input, adherence to low-protein diets is poor. It is likely that only a small minority of CKD patients in routine practice could adhere to these diets, and although risks of malnutrition arising from protein restriction are uncertain, they will be greater in less supervised care outside of studies.
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Affiliation(s)
- Graham Woodrow
- Renal Unit, St James's University Hospital, Leeds, UK.,Leeds School of Medicine, University of Leeds, Leeds, West Yorkshire, UK.,Renal Unit, St James's University Hospital, Leeds, West Yorkshire, UK
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9
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Rodriguez-Niño A, Hauske SJ, Herold A, Qiu J, van den Born J, Bakker SJL, Krämer BK, Yard BA. Serum Carnosinase-1 and Albuminuria Rather than the CNDP1 Genotype Correlate with Urinary Carnosinase-1 in Diabetic and Nondiabetic Patients with Chronic Kidney Disease. J Diabetes Res 2019; 2019:6850628. [PMID: 31950064 PMCID: PMC6948305 DOI: 10.1155/2019/6850628] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 11/24/2019] [Accepted: 11/27/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Carnosinase-1 (CN-1) can be detected in 24 h urine of healthy individuals and patients with type 2 diabetes (T2DM). We aimed to assess whether urinary CN-1 is also reliably measured in spot urine and investigated its association with renal function and the albumin/creatinine ratio (ACR). We also assessed associations between the CNDP1 (CTG) n genotype and CN-1 concentrations in serum and urine. METHODS Patients with T2DM (n = 85) and nondiabetic patients with chronic kidney disease (CKD) (n = 26) stratified by albuminuria (ACR ≤ 300 mg/g or ACR > 300 mg/g) recruited from the nephrology clinic and healthy subjects (n = 24) were studied. RESULTS Urinary CN-1 was more frequently detected and displayed higher concentrations in patients with ACR > 300 mg/g as compared to those with ACR ≤ 300 mg/g irrespective of the baseline disease (T2DM: 554 ng/ml [IQR 212-934 ng/ml] vs. 31 ng/ml [IQR 31-63 ng/ml] (p < 0.0001) and nondiabetic CKD: 197 ng/ml [IQR 112-739] vs. 31 ng/ml [IQR 31-226 ng/ml] (p = 0.015)). A positive correlation between urinary CN-1 and ACR was found (r = 0.68, p < 0.0001). Multivariate linear regression analysis revealed that ACR and serum CN-1 concentrations but not eGFR or the CNDP1 genotype are independent predictors of urinary CN-1, explaining 47% of variation of urinary CN-1 concentrations (R 2 = 0.47, p < 0.0001). CONCLUSION These results confirm and extend previous findings on urinary CN-1 concentrations, suggesting that assessment of CN-1 in spot urine is as reliable as in 24 h urine and may indicate that urinary CN-1 in macroalbuminuric patients is primarily serum-derived and not locally produced.
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Affiliation(s)
- Angelica Rodriguez-Niño
- Vth Department of Medicine (Nephrology/Endocrinology/Rheumatology), University Medical Center Mannheim, University of Heidelberg, Mannheim 68167, Germany
| | - Sibylle J. Hauske
- Vth Department of Medicine (Nephrology/Endocrinology/Rheumatology), University Medical Center Mannheim, University of Heidelberg, Mannheim 68167, Germany
| | - Anna Herold
- Vth Department of Medicine (Nephrology/Endocrinology/Rheumatology), University Medical Center Mannheim, University of Heidelberg, Mannheim 68167, Germany
| | - Jiedong Qiu
- Vth Department of Medicine (Nephrology/Endocrinology/Rheumatology), University Medical Center Mannheim, University of Heidelberg, Mannheim 68167, Germany
| | - Jacob van den Born
- Department of Nephrology, University Medical Centre Groningen, University of Groningen, Groningen 9700RB, Netherlands
| | - Stephan J. L. Bakker
- Department of Nephrology, University Medical Centre Groningen, University of Groningen, Groningen 9700RB, Netherlands
| | - Bernhard K. Krämer
- Vth Department of Medicine (Nephrology/Endocrinology/Rheumatology), University Medical Center Mannheim, University of Heidelberg, Mannheim 68167, Germany
| | - Benito A. Yard
- Vth Department of Medicine (Nephrology/Endocrinology/Rheumatology), University Medical Center Mannheim, University of Heidelberg, Mannheim 68167, Germany
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10
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Tanaka S, Ninomiya T, Taniguchi M, Tokumoto M, Masutani K, Ooboshi H, Kitazono T, Tsuruya K. Impact of blood urea nitrogen to creatinine ratio on mortality and morbidity in hemodialysis patients: The Q-Cohort Study. Sci Rep 2017; 7:14901. [PMID: 29097750 PMCID: PMC5668292 DOI: 10.1038/s41598-017-14205-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 10/02/2017] [Indexed: 11/16/2022] Open
Abstract
The association between blood urea nitrogen to creatinine ratio (UCR) and survival is uncertain in hemodialysis patients. We examined the influence of UCR on mortality and morbidity in hemodialysis patients. A total of 3,401 hemodialysis patients were prospectively followed for 4 years. The association between UCR with overall survival was analyzed using a Cox regression model. During a 4-year follow-up period, 545 patients died from any cause and 582 experienced MACE, 392 with coronary heart disease (CHD), 114 with infection-related death, 77 with hemorrhagic stroke, 141 with ischemic stroke, and 107 with cancer death. Every 1 increase in UCR level was significantly associated with an increased risk for all-cause mortality (hazard ratio [HR] 1.07; 95% confidence interval [CI] 1.03–1.12), CHD (HR 1.08; 95% CI 1.02–1.14), and infection-related death (HR 1.11; 95% CI 1.02–1.21). There was no evidence of a significant association between UCR and death from cancer, and incidence of stroke. A high UCR was significantly associated with an increased risk for all-cause mortality, infection-related death and incidence of CHD in hemodialysis patients.
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Affiliation(s)
- Shigeru Tanaka
- Division of Internal Medicine, Fukuoka Dental College, Fukuoka, Japan
| | - Toshiharu Ninomiya
- Department of Epidemiology and Public Health, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | | | - Masanori Tokumoto
- Division of Internal Medicine, Fukuoka Dental College, Fukuoka, Japan
| | - Kosuke Masutani
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hiroaki Ooboshi
- Division of Internal Medicine, Fukuoka Dental College, Fukuoka, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kazuhiko Tsuruya
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan. .,Department of Integrated Therapy for Chronic Kidney Disease, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
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11
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Bellizzi V, Cupisti A, Locatelli F, Bolasco P, Brunori G, Cancarini G, Caria S, De Nicola L, Di Iorio BR, Di Micco L, Fiaccadori E, Garibotto G, Mandreoli M, Minutolo R, Oldrizzi L, Piccoli GB, Quintaliani G, Santoro D, Torraca S, Viola BF. Low-protein diets for chronic kidney disease patients: the Italian experience. BMC Nephrol 2016; 17:77. [PMID: 27401096 PMCID: PMC4939662 DOI: 10.1186/s12882-016-0280-0] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Accepted: 06/14/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Nutritional treatment has always represented a major feature of CKD management. Over the decades, the use of nutritional treatment in CKD patients has been marked by several goals. The first of these include the attainment of metabolic and fluid control together with the prevention and correction of signs, symptoms and complications of advanced CKD. The aim of this first stage is the prevention of malnutrition and a delay in the commencement of dialysis. Subsequently, nutritional manipulations have also been applied in association with other therapeutic interventions in an attempt to control several cardiovascular risk factors associated with CKD and to improve the patient's overall outcome. Over time and in reference to multiple aims, the modalities of nutritional treatment have been focused not only on protein intake but also on other nutrients. DISCUSSION This paper describes the pathophysiological basis and rationale of nutritional treatment in CKD and also provides a report on extensive experience in the field of renal diets in Italy, with special attention given to approaches in clinical practice and management. Italian nephrologists have a longstanding tradition in implementing low protein diets in the treatment of CKD patients, with the principle objective of alleviating uremic symptoms, improving nutritional status and also a possibility of slowing down the progression of CKD or delaying the start of dialysis. A renewed interest in this field is based on the aim of implementing a wider nutritional therapy other than only reducing the protein intake, paying careful attention to factors such as energy intake, the quality of proteins and phosphate and sodium intakes, making today's low-protein diet program much more ambitious than previous. The motivation was the reduction in progression of renal insufficiency through reduction of proteinuria, a better control of blood pressure values and also through correction of metabolic acidosis. One major goal of the flexible and innovative Italian approach to the low-protein diet in CKD patients is the improvement of patient adherence, a crucial factor in the successful implementation of a low-protein diet program.
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Affiliation(s)
- Vincenzo Bellizzi
- Nephrology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Via San Leonardo, 84131, Salerno, Italy.
| | - Adamasco Cupisti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | | | | | - Giovanni Cancarini
- O.U. Nephrology, A.O. Spedali Civili Brescia and University of Brescia, Brescia, Italy
| | - Stefania Caria
- Territorial Department of Nephrology and Dialysis, ASL Cagliari, Italy
| | - Luca De Nicola
- Nephrology Division, Second University of Naples, Naples, Italy
| | | | | | - Enrico Fiaccadori
- Pathophysiology of Renal Failure Unit, University of Parma, Parma, Italy
| | - Giacomo Garibotto
- Nephrology Unit, University of Genoa and IRCCS A.O.U. San Martino IST, Genoa, Italy
| | - Marcora Mandreoli
- Nephrology and Dialysis Unit, Ospedale S. Maria della Scaletta, Imola (BO), Italy
| | | | - Lamberto Oldrizzi
- O.U. Nephrology and Dialysis, Fracastoro Hospital, San Bonifacio (VR), Italy
| | - Giorgina B Piccoli
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
- Nephrologie, CH Le Mans, Le Mans France, Italy
| | - Giuseppe Quintaliani
- O.U. Nephrology, Dialysis and Transplantation, Santa Maria della Misericordia Hospital, Udine, Italy
| | - Domenico Santoro
- Perugia Department of Internal Medicine, University of Messina, Messina, Italy
| | - Serena Torraca
- Nephrology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Via San Leonardo, 84131, Salerno, Italy
| | - Battista F Viola
- O.U. Nephrology, A.O. Spedali Civili Brescia and University of Brescia, Brescia, Italy
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12
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Platelet - derived CD154 antigen in patients with chronic kidney disease. Clin Biochem 2016; 49:243-7. [DOI: 10.1016/j.clinbiochem.2015.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 11/01/2015] [Accepted: 11/02/2015] [Indexed: 01/04/2023]
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13
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Stack S, Chertow GM, Johansen KL, Si Y, Kurella Tamura M. Pre-ESRD changes in body weight and survival in nursing home residents starting dialysis. Clin J Am Soc Nephrol 2013; 8:1734-40. [PMID: 24009221 DOI: 10.2215/cjn.01410213] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND OBJECTIVES Among patients receiving maintenance dialysis, weight loss at any body mass index is associated with mortality. However, it is not known whether weight changes before dialysis initiation are associated with mortality and if so, what risks are associated with weight gain or loss. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS Linking data from the US Renal Data System to a national registry of nursing home residents, this study identified 11,090 patients who started dialysis between January of 2000 and December of 2006. Patients were categorized according to weight measured between 3 and 6 months before dialysis initiation and the percentage change in body weight before dialysis initiation (divided into quintiles). The outcome was mortality within 1 year of starting dialysis. RESULTS There were 361 patients (3.3%) who were underweight (Quételet's [body mass] index<18.5 kg/m(2)) and 4046 patients (36.5%) who were obese (body mass index ≥ 30 kg/m(2)) before dialysis initiation. The median percentage change in body weight before dialysis initiation was -6% (interquartile range=-13% to 1%). There were 6063 deaths (54.7%) over 1 year of follow-up. Compared with patients with minimal weight changes (-3% to 3%, quintile 4), patients with weight loss ≥ 15% (quintile 1) had 35% higher risk for mortality (95% confidence interval, 1.25 to 1.47), whereas those patients with weight gain ≥ 4% (quintile 5) had a 24% higher risk for mortality (95% confidence interval, 1.14 to 1.35) adjusted for baseline body mass index and other confounders. CONCLUSIONS Among nursing home residents, changes in body weight in advance of dialysis initiation are associated with significantly higher 1-year mortality.
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Affiliation(s)
- Shobha Stack
- Department of Medicine, Stanford University School of Medicine, Palo Alto, California;, Departments of †Epidemiology and Biostatistics and, ‡Medicine, Division of Nephrology, University of California, San Francisco, California, §Geriatrics Research Education and Clinical Center, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
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14
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Abstract
Protein energy wasting is common in patients with CKD and ESRD and is associated with adverse clinical outcomes, such as increased rates of hospitalization and death, in these patients. A multitude of factors can affect the nutritional and metabolic status of patients with CKD, including decreased dietary nutrient intake, catabolic effects of renal replacement therapy, systemic inflammation, metabolic and hormonal derangements, and comorbid conditions (such as diabetes and depression). Unique aspects of CKD also confound reliable assessment of nutritional status, further complicating management of this comorbid condition. In patients in whom preventive measures and oral dietary intake from regular meals cannot help them maintain adequate nutritional status, nutritional supplementation, administered orally, enterally, or parenterally, is effective in replenishing protein and energy stores. The advantages of oral nutritional supplements include proven efficacy, safety, and compliance. Anabolic steroids and exercise, with nutritional supplementation or alone, improve protein stores and represent potential additional approaches for the treatment of PEW. There are several emerging novel therapies, such as appetite stimulants, anti-inflammatory interventions, and anabolic agents.
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Affiliation(s)
- T Alp Ikizler
- Department of Medicine, Division of Nephrology, Vanderbilt University School of Medicine, Nashville, Tennessee
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15
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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; 84:1096-107. [PMID: 23698226 DOI: 10.1038/ki.2013.147] [Citation(s) in RCA: 408] [Impact Index Per Article: 37.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Revised: 02/28/2013] [Accepted: 03/07/2013] [Indexed: 02/06/2023]
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.
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16
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Ikizler TA. Optimal nutrition in hemodialysis patients. Adv Chronic Kidney Dis 2013; 20:181-9. [PMID: 23439378 DOI: 10.1053/j.ackd.2012.12.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Revised: 12/03/2012] [Accepted: 12/06/2012] [Indexed: 11/11/2022]
Abstract
Protein-energy wasting (PEW) is highly prevalent in patients undergoing maintenance hemodialysis (MHD). It is important to note that there is a robust association between the extent of PEW and the risk of hospitalization and death in these patients, regardless of the nutritional marker used. The multiple etiologies of PEW in advanced kidney disease are still being elucidated. Apart from the multiple mechanisms that might lead to PEW, it appears that the common pathway for all of the derangements is related to exaggerated protein degradation along with decreased protein synthesis. The hemodialysis procedure per se is an important contributor to this process. Metabolic and hormonal derangements such as acidosis, inflammation, and resistance to anabolic properties of insulin resistance and growth hormone are all implicated for the development of PEW in MHD patients. Appropriate management of MHD patients at risk for PEW requires a comprehensive combination of strategies to diminish protein and energy depletion and to institute therapies that will avoid further losses. The mainstay of nutritional treatment in MHD patients is provision of an adequate amount of protein and energy, using oral supplementation as needed. Intradialytic parenteral nutrition should be attempted in patients who cannot efficiently use the gastrointestinal tract. Other anabolic strategies such as exercise, anabolic hormones, anti-inflammatory therapies, and appetite stimulants can be considered as complementary therapies in suitable patients.
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17
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Ramirez SPB, McCullough KP, Thumma JR, Nelson RG, Morgenstern H, Gillespie BW, Inaba M, Jacobson SH, Vanholder R, Pisoni RL, Port FK, Robinson BM. Hemoglobin A(1c) levels and mortality in the diabetic hemodialysis population: findings from the Dialysis Outcomes and Practice Patterns Study (DOPPS). Diabetes Care 2012; 35:2527-32. [PMID: 22912431 PMCID: PMC3507600 DOI: 10.2337/dc12-0573] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Lowering hemoglobin A(1c) to <7% reduces the risk of microvascular complications of diabetes, but the importance of maintaining this target in diabetes patients with kidney failure is unclear. We evaluated the relationship between A(1c) levels and mortality in an international prospective cohort study of hemodialysis patients. RESEARCH DESIGN AND METHODS Included were 9,201 hemodialysis patients from 12 countries (Dialysis Outcomes and Practice Patterns Study 3 and 4, 2006-2010) with type 1 or type 2 diabetes and at least one A(1c) measurement during the first 8 months after study entry. Associations between A(1c) and mortality were assessed with Cox regression, adjusting for potential confounders. RESULTS The association between A(1c) and mortality was U-shaped. Compared with an A(1c) of 7-7.9%, the hazard ratios (95% CI) for A(1c) levels were 1.35 (1.09-1.67) for <5%, 1.18 (1.01-1.37) for 5-5.9%, 1.21 (1.05-1.41) for 6-6.9%, 1.16 (0.94-1.43) for 8-8.9%, and 1.38 (1.11-1.71) for ≥9.0%, after adjustment for age, sex, race, BMI, serum albumin, years of dialysis, serum creatinine, 12 comorbid conditions, insulin use, hemoglobin, LDL cholesterol, country, and study phase. Diabetes medications were prescribed for 35% of patients with A(1c) <6% and not prescribed for 29% of those with A(1c) ≥9%. CONCLUSIONS A(1c) levels strongly predicted mortality in hemodialysis patients with type 1 or type 2 diabetes. Mortality increased as A(1c) moved further from 7-7.9%; thus, target A(1c) in hemodialysis patients may encompass values higher than those recommended by current guidelines. Modifying glucose-lowering medicines for dialysis patients to target A(1c) levels within this range may be a modifiable practice to improve outcomes.
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18
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19
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The role of the ubiquitin-proteasome system in kidney diseases. Clin Exp Nephrol 2012; 16:507-17. [PMID: 22684356 DOI: 10.1007/s10157-012-0643-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Accepted: 04/30/2012] [Indexed: 12/22/2022]
Abstract
Proteins in mammalian cells are continually being degraded and synthesized. Protein degradation via the ubiquitin-proteasome system (UPS) is the major pathway for non-lysosomal proteolysis of intracellular proteins and plays important roles in a variety of fundamental cellular processes such as regulation of cell cycle progression, differentiation, apoptosis, sodium channel function, and modulation of inflammatory responses. The central element of this system is the covalent linkage of ubiquitins to targeted proteins, which are then recognized by the 26S proteasome composed of adenosine triphosphate-dependent, multi-catalytic proteases. Damaged or misfolded proteins, as well as regulatory proteins that control many critical cellular functions, are among the targets of this degradation process. Consequently, aberration of the system leads to dysregulation of cellular homeostasis and development of many diseases. Based on the findings, it is not surprising that abnormalities of the system are also associated with the pathogenesis of kidney diseases. In this review, I discuss (1) the basic mechanism of the UPS, and (2) the association between the pathogenesis of kidney diseases and the UPS. Diverse roles of the UPS are implicated in the development of kidney diseases, and further studies on this system may reveal new strategies for overcoming kidney diseases.
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20
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Bonanni A, Mannucci I, Verzola D, Sofia A, Saffioti S, Gianetta E, Garibotto G. Protein-energy wasting and mortality in chronic kidney disease. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2011; 8:1631-54. [PMID: 21655142 PMCID: PMC3108132 DOI: 10.3390/ijerph8051631] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2011] [Revised: 04/29/2011] [Accepted: 05/03/2011] [Indexed: 02/06/2023]
Abstract
Protein-energy wasting (PEW) is common in patients with chronic kidney disease (CKD) and is associated with an increased death risk from cardiovascular diseases. However, while even minor renal dysfunction is an independent predictor of adverse cardiovascular prognosis, PEW becomes clinically manifest at an advanced stage, early before or during the dialytic stage. Mechanisms causing loss of muscle protein and fat are complex and not always associated with anorexia, but are linked to several abnormalities that stimulate protein degradation and/or decrease protein synthesis. In addition, data from experimental CKD indicate that uremia specifically blunts the regenerative potential in skeletal muscle, by acting on muscle stem cells. In this discussion recent findings regarding the mechanisms responsible for malnutrition and the increase in cardiovascular risk in CKD patients are discussed. During the course of CKD, the loss of kidney excretory and metabolic functions proceed together with the activation of pathways of endothelial damage, inflammation, acidosis, alterations in insulin signaling and anorexia which are likely to orchestrate net protein catabolism and the PEW syndrome.
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Affiliation(s)
- Alice Bonanni
- Division of Nephrology, Dialysis and Transplantation, Department of Internal Medicine, Azienda Ospedale Università San Martino, Genoa University, Viale Benedetto XV 6, Genoa, Italy; E-Mails: (A.B.); (I.M.); (D.V.); (A.S.); (S.S.)
| | - Irene Mannucci
- Division of Nephrology, Dialysis and Transplantation, Department of Internal Medicine, Azienda Ospedale Università San Martino, Genoa University, Viale Benedetto XV 6, Genoa, Italy; E-Mails: (A.B.); (I.M.); (D.V.); (A.S.); (S.S.)
| | - Daniela Verzola
- Division of Nephrology, Dialysis and Transplantation, Department of Internal Medicine, Azienda Ospedale Università San Martino, Genoa University, Viale Benedetto XV 6, Genoa, Italy; E-Mails: (A.B.); (I.M.); (D.V.); (A.S.); (S.S.)
| | - Antonella Sofia
- Division of Nephrology, Dialysis and Transplantation, Department of Internal Medicine, Azienda Ospedale Università San Martino, Genoa University, Viale Benedetto XV 6, Genoa, Italy; E-Mails: (A.B.); (I.M.); (D.V.); (A.S.); (S.S.)
| | - Stefano Saffioti
- Division of Nephrology, Dialysis and Transplantation, Department of Internal Medicine, Azienda Ospedale Università San Martino, Genoa University, Viale Benedetto XV 6, Genoa, Italy; E-Mails: (A.B.); (I.M.); (D.V.); (A.S.); (S.S.)
| | - Ezio Gianetta
- Department of Surgery, Azienda Ospedale Università San Martino, Genoa University, Largo R. Benzi, Genoa, Italy; E-Mail:
| | - Giacomo Garibotto
- Division of Nephrology, Dialysis and Transplantation, Department of Internal Medicine, Azienda Ospedale Università San Martino, Genoa University, Viale Benedetto XV 6, Genoa, Italy; E-Mails: (A.B.); (I.M.); (D.V.); (A.S.); (S.S.)
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21
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Verzola D, Procopio V, Sofia A, Villaggio B, Tarroni A, Bonanni A, Mannucci I, De Cian F, Gianetta E, Saffioti S, Garibotto G. Apoptosis and myostatin mRNA are upregulated in the skeletal muscle of patients with chronic kidney disease. Kidney Int 2011; 79:773-82. [PMID: 21228768 DOI: 10.1038/ki.2010.494] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Apoptosis and myostatin are major mediators of muscle atrophy and might therefore be involved in the wasting of uremia. To examine whether they are expressed in the skeletal muscle of patients with chronic kidney disease (CKD), we measured muscle apoptosis and myostatin mRNA and their related intracellular signal pathways in rectus abdominis biopsies obtained from 22 consecutive patients with stage 5 CKD scheduled for peritoneal dialysis. Apoptotic loss of myonuclei, determined by anti-single-stranded DNA antibody and terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling assays, was significantly increased three to fivefold, respectively. Additionally, myostatin and interleukin (IL)-6 gene expressions were significantly upregulated, whereas insulin-like growth factor-I mRNA was significantly lower than in controls. Phosphorylated JNK (c-Jun amino-terminal kinase) and its downstream effector, phospho-c-Jun, were significantly upregulated, whereas phospho-Akt was markedly downregulated. Multivariate analysis models showed that phospho-Akt and IL-6 contributed individually and significantly to the prediction of apoptosis and myostatin gene expression, respectively. Thus, our study found activation of multiple pathways that promote muscle atrophy in the skeletal muscle of patients with CKD. These pathways appear to be associated with different intracellular signals, and are likely differently regulated in patients with CKD.
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Affiliation(s)
- Daniela Verzola
- Division of Nephrology, Dialysis and Transplantation, Department of Internal Medicine, Azienda Ospedale Università San Martino, Genoa, Italy
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22
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Rhee EP, Souza A, Farrell L, Pollak MR, Lewis GD, Steele DJR, Thadhani R, Clish CB, Greka A, Gerszten RE. Metabolite profiling identifies markers of uremia. J Am Soc Nephrol 2010; 21:1041-1051. [PMID: 20378825 DOI: 10.1681/asn.2009111132] [Citation(s) in RCA: 146] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
ESRD is a state of small-molecule disarray. We applied liquid chromatography/tandem mass spectrometry-based metabolite profiling to survey>350 small molecules in 44 fasting subjects with ESRD, before and after hemodialysis, and in 10 age-matched, at-risk fasting control subjects. At baseline, increased levels of polar analytes and decreased levels of lipid analytes characterized uremic plasma. In addition to confirming the elevation of numerous previously identified uremic toxins, we identified several additional markers of ESRD, including dicarboxylic acids (adipate, malonate, methylmalonate, and maleate), biogenic amines, nucleotide derivatives, phenols, and sphingomyelins. The pattern of lipids was notable for a universal decrease in lower-molecular-weight triacylglycerols, and an increase in several intermediate-molecular-weight triacylglycerols in ESRD compared with controls; standard measurement of total triglycerides obscured this heterogeneity. These observations suggest disturbed triglyceride catabolism and/or beta-oxidation in ESRD. As expected, the hemodialysis procedure was associated with significant decreases in most polar analytes. Unexpected increases in several metabolites, however, indicated activation of a broad catabolic program, including glycolysis, lipolysis, ketosis, and nucleotide breakdown. In summary, this study demonstrates the application of metabolite profiling to identify markers of ESRD, provide perspective on uremic dyslipidemia, and broaden our understanding of the biochemical effects of hemodialysis.
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Affiliation(s)
- Eugene P Rhee
- Massachusetts General Hospital, 149 13th Street, 8th Floor, Boston, MA, USA
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23
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Noori N, Kopple JD. Effect of Diabetes Mellitus on Protein-Energy Wasting and Protein Wasting in End-Stage Renal Disease. Semin Dial 2010; 23:178-84. [DOI: 10.1111/j.1525-139x.2010.00705.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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24
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Daugirdas JT, Depner TA, Greene T, Levin NW, Chertow GM, Rocco MV, Stokes JB. Effects of Reduced Intradialytic Urea Generation Rate and Residual Renal Clearance on Modeled Urea Distribution Volume andKt/Vin Conventional, Daily, and Nocturnal Dialysis. Semin Dial 2010; 23:19-24. [DOI: 10.1111/j.1525-139x.2009.00688.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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25
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Lecker SH. Given the Science on Malnutrition, How Does the Clinician Respond? Practical Lessons for and Application to the Dialysis Patient. Clin J Am Soc Nephrol 2009; 4 Suppl 1:S64-70. [DOI: 10.2215/cjn.02650409] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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26
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Ikizler TA. Nutrition support for the chronically wasted or acutely catabolic chronic kidney disease patient. Semin Nephrol 2009; 29:75-84. [PMID: 19121477 DOI: 10.1016/j.semnephrol.2008.10.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Because of the number of factors affecting the nutritional and metabolic status in patients with advanced chronic kidney disease or who are on maintenance dialysis, the prevention and treatment of protein-energy wasting (PEW) of chronic kidney disease should involve a comprehensive combination of maneuvers to diminish protein and energy depletion, in addition to therapies that will avoid further losses. The available evidence suggests that nutritional supplementation, administered orally or parenterally, is effective in the treatment of maintenance dialysis patients with PEW in whom oral dietary intake from regular meals cannot maintain adequate nutritional status. Increased oral nutrient intake during dialysis and at home is the ideal choice for this intervention. In clinical practice, the advantages of intradialytic oral nutritional supplements include proven efficacy and compliance. Therefore, at a minimum, oral nutritional supplementation given intradialytically should be attempted in maintenance dialysis patients with PEW, accompanied by individualized dietary advice for appropriate intake at home. In ones who cannot tolerate oral feeding, other forms of nutritional supplementation including intradialytic parenteral nutritional are a reasonable strategy. Although not proven conclusively, nutritional interventions in the form of supplementation may lead to considerable improvements in mortality, hospitalization, and treatment costs.
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Affiliation(s)
- T Alp Ikizler
- Department of Medicine, Division of Nephrology, Vanderbilt University School of Medicine, Nashville, TN 37232-2372, USA.
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27
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Rajan VR, Mitch WE. Muscle wasting in chronic kidney disease: the role of the ubiquitin proteasome system and its clinical impact. Pediatr Nephrol 2008; 23:527-35. [PMID: 17987322 PMCID: PMC2259254 DOI: 10.1007/s00467-007-0594-z] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2007] [Revised: 06/13/2007] [Accepted: 06/14/2007] [Indexed: 02/06/2023]
Abstract
Muscle wasting in chronic kidney disease (CKD) and other catabolic diseases (e.g. sepsis, diabetes, cancer) can occur despite adequate nutritional intake. It is now known that complications of these various disorders, including acidosis, insulin resistance, inflammation, and increased glucocorticoid and angiotensin II production, all activate the ubiquitin-proteasome system (UPS) to degrade muscle proteins. The initial step in this process is activation of caspase-3 to cleave the myofibril into its components (actin, myosin, troponin, and tropomyosin). Caspase-3 is required because the UPS minimally degrades the myofibril but rapidly degrades its component proteins. Caspase-3 activity is easily detected because it leaves a characteristic 14kD actin fragment in muscle samples. Preliminary evidence from several experimental models of catabolic diseases, as well as from studies in patients, indicates that this fragment could be a useful biomarker because it correlates well with the degree of muscle degradation in dialysis patients and in other catabolic conditions.
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Affiliation(s)
- Vik R. Rajan
- Nephrology Division M/S: BCM 285, Baylor College of Medicine, One Baylor, Plaza, Alkek N-520, Houston, TX 77030 USA
| | - William E. Mitch
- Nephrology Division M/S: BCM 285, Baylor College of Medicine, One Baylor, Plaza, Alkek N-520, Houston, TX 77030 USA
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28
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Abstract
Uremic wasting is strongly associated with increased risk of death and hospitalization events in patients with advanced chronic kidney disease (CKD). Recent evidence indicates that patients with advanced chronic kidney disease are prone to uremic wasting due to several factors, which include the dialysis procedure and certain comorbid conditions, especially chronic inflammation and insulin resistance or deficiency. While the catabolic effects of dialysis can be readily avoided with intradialytic nutritional supplementation, there are no established alternative strategies to avoid the catabolic consequences of comorbid conditions other than treatment of their primary etiology. To this end, there is no indication that simply increasing dietary protein and energy intake above the required levels based on level of kidney disease is beneficial in patients with advanced chronic kidney disease. However, aside from the potential adverse effects such as uremic toxin production, dietary protein and energy intake in excess of actual needs might be beneficial in maintenance dialysis patients as it may lead to weight gain over time. Clearly, the role of obesity in advanced uremia needs to be examined in detail prior to making any clinically applicable recommendations, both in terms of ''low'' and ''high'' dietary protein and energy intake.
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29
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Abstract
Patients with chronic kidney disease (CKD), including those who are treated with hemodialysis, frequently develop hypoalbuminemia and a decrease in body weight. These abnormalities are usually attributed to malnutrition, but true malnutrition (ie, a disorder due to an abnormal diet) is rarely the mechanism causing decreased protein stores. Hypoalbuminemia is closely related to evidence of inflammation, and a decrease in muscle mass is caused by activation of muscle protein breakdown. In uremic rodents and patients, the initial step in the loss of muscle protein is activation of caspase-3, which cleaves the complex structure of muscle to provide substrates for the ubiquitin-proteasome pathway (UPP). The activity of caspase-3 can be detected by the presence of a characteristic 14-kDa actin fragment in the insoluble fraction of a muscle biopsy specimen. Abnormalities in cell signaling activate caspase-3 and the UPP; a key abnormality is decreased activity in the phosphatidylinositol-3-kinase/Akt pathway, leading to activation of caspase-3 and a specific E3 ubiquitin conjugating enzyme, atrogin-1/MAFbx. Inflammatory cytokines also represent a potential cell signaling abnormality that activates muscle protein breakdown, possibly because cytokines activate the E3 ubiquigin conjugating enzyme, MuRF1. An understanding of these pathways could help the clinician to identify therapeutic targets for preventing loss of muscle protein.
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Affiliation(s)
- William E Mitch
- Division of Nephrology, Baylor College of Medicine, Houston, Texas 77030, USA.
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30
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Mitch WE. Proteolytic mechanisms, not malnutrition, cause loss of muscle mass in kidney failure. J Ren Nutr 2006; 16:208-11. [PMID: 16825021 DOI: 10.1053/j.jrn.2006.04.014] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Hypoalbuminemia and muscle atrophy are frequently found in patients with chronic kidney disease (CKD) and patients being treated by dialysis. These abnormalities are usually attributed to malnutrition, meaning that they are caused by an inadequate diet. However, the evidence indicates that malnutrition is rarely the mechanism causing loss of protein stores. Instead, low values of serum albumin are closely related to the presence of inflammation and loss of muscle mass is attributable to activation of specific proteases. In uremic rodents and patients, the initial step in the loss of muscle protein is an activation of caspase-3. This cleaves the complex structure of muscle, and its action can be detected by the presence of a characteristic 14-kDa actin fragment in the insoluble fraction of muscle. The second step in uremia-induced loss of muscle protein is an activation of the ubiquitin-proteasome system, which rapidly degrades proteins released by caspase-3 cleavage of muscle proteins. Activation of both caspase-3 and the ubiquitin-proteasome system occur when there is suppression of the cellular signaling pathway activated by insulin/insulinlike growth factor 1, the phosphatidylinositol 3-kinase/Akt pathway. A potential therapeutic target for preventing loss of muscle protein is to stimulate activity of this signaling pathway.
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Affiliation(s)
- William E Mitch
- Nephrology Division, Baylor College of Medicine, Houston, TX 77030, USA.
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31
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Löfberg E, Gutierrez A, Anderstam B, Wernerman J, Bergström J, Price SR, Mitch WE, Alvestrand A. Effect of bicarbonate on muscle protein in patients receiving hemodialysis. Am J Kidney Dis 2006; 48:419-29. [PMID: 16931215 DOI: 10.1053/j.ajkd.2006.05.029] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2005] [Accepted: 05/03/2006] [Indexed: 11/11/2022]
Abstract
BACKGROUND Metabolic acidosis stimulates whole-body net protein breakdown in healthy adults and patients with kidney failure, but few studies investigated how acidosis affects protein metabolism in individual tissues, such as skeletal muscle. METHODS We evaluated the effect of metabolic acidosis on protein turnover in skeletal muscle, assessed by means of phenylalanine kinetics and free amino acid concentrations in plasma and muscle. Long-term hemodialysis patients (n = 16) were divided into 2 groups in an open crossover study design. In group A, we administered bicarbonate supplements and increased blood standard bicarbonate levels from 17.8 +/- 0.03 to 27.1 +/- 1.2 mEq/L (17.8 +/- 0.03 to 27.1 +/- 1.2 mmol/L). In group B, we decreased bicarbonate supplements, which caused a decrease in standard bicarbonate levels from 26.6 +/- 0.7 to 18.6 +/- 0.3 mEq/L (26.6 +/- 0.7 to 18.6 +/- 0.3 mmol/L). RESULTS Net phenylalanine efflux from leg tissues (muscle) was significantly less when acid-base balance was corrected compared with acidosis (10.8 +/- 1.5 versus 18.6 +/- 3.8 nmol/min/100 g tissue; P = 0.014), as was the rate of phenylalanine appearance (28.3 +/- 3.0 versus 38.4 +/- 5.9 nmol/min/100 g tissue; P = 0.016); the rate of phenylalanine disposal was unchanged. Cortisol and C-reactive protein levels in blood were unchanged after correction of acidosis, as were levels of messenger RNAs encoding components of the ubiquitin-proteasome pathway in muscle biopsy specimens. CONCLUSION Our findings indicate that acidosis increases protein breakdown in skeletal muscle, but additional studies are needed to identify the pathways stimulated to degrade muscle protein in response to acidosis.
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Affiliation(s)
- Erland Löfberg
- Department of Clinical Science, Intervention, and Technology, Division of Renal Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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Mahan JD. Applying the Growth Failure in CKD Consensus Conference: evaluation and treatment algorithm in children with chronic kidney disease. Growth Horm IGF Res 2006; 16 Suppl A:S68-S78. [PMID: 16750646 DOI: 10.1016/j.ghir.2006.04.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Growth failure is a common and significant clinical problem for children with chronic kidney disease (CKD), particularly those with chronic renal insufficiency (CRI). Children with CRI (typically defined by a glomerular filtration rate [GFR] <75 mL/min/1.73 m2) who have growth impairment exhibit a variety of medical and psychological problems in addition to increased mortality. Growth failure in children with CKD is usually multifactorial in etiology, including abnormalities in the growth hormone (GH)-insulin-like growth factor (IGF)-I axis and a variety of nutritional and metabolic concerns characteristic of CKD. Proper management of these factors contributes to better growth in affected children. Although the safety and efficacy of recombinant human GH (rhGH) therapy in promoting growth in children with CKD are well established, recent data indicate that the use of rhGH administration in children with CKD and growth failure remains low. Recently, guidelines were developed by the Consensus Conference for Evaluation and Treatment of Growth Failure in Children with CKD. This paper focuses on the application of these guidelines to children with CKD.
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Affiliation(s)
- John D Mahan
- Department of Pediatrics, Division of Pediatric Nephrology, The Ohio State University College of Medicine, Columbus, OH, USA.
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Mahan JD, Warady BA. Assessment and treatment of short stature in pediatric patients with chronic kidney disease: a consensus statement. Pediatr Nephrol 2006; 21:917-30. [PMID: 16773402 DOI: 10.1007/s00467-006-0020-y] [Citation(s) in RCA: 106] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2005] [Revised: 09/15/2005] [Accepted: 10/20/2005] [Indexed: 10/24/2022]
Abstract
Growth failure is a clinically important issue in children with chronic kidney disease (CKD) and is associated with significant morbidity and mortality. Many factors contribute to impaired growth in these children, including abnormalities in the growth hormone (GH)-insulin-like growth factor-I (IGF-I) axis, malnutrition, acidosis, and renal bone disease. The management of growth failure in children with CKD is complicated by the presence of other disease-related complications requiring medical intervention. Despite evidence of GH efficacy and safety in this population, some practitioners and families have been reluctant to institute GH therapy, citing an unwillingness to comply with daily injections, reimbursement difficulties, or impending renal transplantation. Suboptimal attention to growth failure management may be further compounded by a lack of clinical guidelines for the appropriate assessment and treatment of growth failure in these children. This review of growth failure in children with CKD concludes with an algorithm developed by members of the consensus committee, outlining their recommendations for appropriate steps to improve growth and overall health outcomes in children with CKD.
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Affiliation(s)
- John D Mahan
- Department of Pediatrics, Division of Pediatric Nephrology, The Ohio State University COMPH, Columbus, OH, USA.
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Lecker SH, Goldberg AL, Mitch WE. Protein degradation by the ubiquitin-proteasome pathway in normal and disease states. J Am Soc Nephrol 2006; 17:1807-19. [PMID: 16738015 DOI: 10.1681/asn.2006010083] [Citation(s) in RCA: 863] [Impact Index Per Article: 47.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Stewart H Lecker
- Nephrology Division, Beth Isreal Deaconess, Harvard Medical School, Boston, Massachusetts, USA
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Adams GR, Vaziri ND. Skeletal muscle dysfunction in chronic renal failure: effects of exercise. Am J Physiol Renal Physiol 2006; 290:F753-61. [PMID: 16527920 DOI: 10.1152/ajprenal.00296.2005] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
A number of chronic illnesses such as renal failure (CRF), obstructive pulmonary disease, and congestive heart failure result in a significant decrease in exercise tolerance. There is an increasing awareness that prescribed exercise, designed to restore some level of physical performance and quality of life, can be beneficial in these conditions. In CRF patients, muscle function can be affected by a number of direct and indirect mechanisms caused by renal disease as well as various treatment modalities. The aims of this review are twofold: first, to briefly discuss the mechanisms by which CRF negatively impacts skeletal muscle and, therefore, exercise capacity, and, second, to discuss the available data on the effects of programmed exercise on muscle function, exercise capacity, and various other parameters in CRF.
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Affiliation(s)
- Gregory R Adams
- Department of Physiology and Biophysics, University of California, Irvine 92697-4560, USA.
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Bellizzi V, Scalfi L, Terracciano V, De Nicola L, Minutolo R, Marra M, Guida B, Cianciaruso B, Conte G, Di Iorio BR. Early changes in bioelectrical estimates of body composition in chronic kidney disease. J Am Soc Nephrol 2006; 17:1481-7. [PMID: 16611719 DOI: 10.1681/asn.2005070756] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
The aim of this study was to detect the potential occurrence of early abnormalities of body composition in patients with chronic kidney disease (CKD) at first referral to an outpatient nephrology clinic. Eighty-four patients with CKD (49 men and 35 women) were compared with 604 healthy control subjects (298 men and 306 women). Anthropometry and bioelectrical impedance analysis (BIA) were performed in all participants, whereas renal function, laboratory tests for nutritional status, and nutrient intake were assessed in the CKD group only. Creatinine clearance was 27.8 +/- 13.8 and 27.4 +/- 13.0 ml/min per 1.73 m(2) in male and female patients with CKD, respectively. No patient showed peripheral edema; frank malnutrition, defined by presence of serum albumin <3.5 g/dl plus body mass index <20 kg/m(2); or protein intake <0.6 g/kg per d. At the BIA, patients with CKD showed lower resistance (R) and abnormal mean impedance vectors for the bivariate normal distribution of R/height and reactance/height. Phase angle also was reduced (-22%), especially in patients with diabetes. When BIA-derived data were considered, total body water was slightly higher (+4.3% in men; +3.5% in women) and body cell mass was lower (-6.7% in men; -7.7% in women) in patients with CKD. No difference in either BIA parameters or nutritional indexes was observed among various CKD stages. Despite the absence of overt malnutrition, patients with CKD exhibit altered BIA variables from the early phases of renal disease. These alterations are related to the renal dysfunction, are more marked in the presence of diabetes, and mainly indicate the presence of overhydration in the absence of edema. Therefore, BIA represents an attractive clinical tool to detect impairment of body composition from the early stages of CKD.
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Affiliation(s)
- Vincenzo Bellizzi
- Nephrology and Dialysis Unit, "A. Landolfi" Hospital, Via Melito, Solofra, 83029 Italy.
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Chance WT, Sheriff S, Dayal R, Friend LA, Thomas I, Balasubramaniam A. The role of polyamines in glucagon-like peptide-2 prevention of TPN-induced gut hypoplasia. Peptides 2006; 27:883-92. [PMID: 16274854 DOI: 10.1016/j.peptides.2005.09.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2005] [Revised: 09/23/2005] [Accepted: 09/26/2005] [Indexed: 11/23/2022]
Abstract
Total parenteral nutrition (TPN) of rats has been demonstrated to produce hypoplasia of gut mucosa, and to be associated with reduced immune response and elevated translocation of bacteria from gut to mesenteric lymph nodes, spleen and liver. Treatment of rats being maintained on TPN with the proglucagon fragment, glucagon-like peptide-2 (GLP-2), has been shown to totally prevent small intestine mucosal hypoplasia. In the present study, we found that depletion of polyamines with alpha-difluromethylornithine (DFMO) significantly reduced the efficacy of GLP-2 in preserving gut mucosa in rats maintained on TPN for 8 days. Co-infusion of GLP-2 with TPN prevented loss of protein and mucosa in duodenum, jejunum and ileum, but not in colon. Addition of DFMO to the infusate prevented the protective effects of GLP-2 in the duodenum and jejunum. In the jejunum, putrescine and spermidine were reduced in DFMO-treated rats, while the ileum exhibited reductions of these polyamines in rats infused with TPN or TPN plus GLP-2. DFMO infusion further reduced these polyamines in the ileum, while levels of spermine were increased. Concentrations of ornithine decarboxylase were elevated in jejunum of rats infused with TPN or TPN plus GLP-2, but were reduced significantly in DFMO-treated rats. These results suggest that normal levels of polyamines are necessary for the expression of GLP-2-induced hyperplasia. Differential effects of GLP-2 and DFMO across gut segments may relate to regional differences in proliferative and anti-apoptotic effects of the treatments.
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Affiliation(s)
- William T Chance
- Medical Research Service, VA Medical Center, Cincinnati, OH, USA.
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Chuang CK, Lin SP, Chen HH, Chen YC, Wang TJ, Shieh WH, Wu CJ. Plasma free amino acids and their metabolites in Taiwanese patients on hemodialysis and continuous ambulatory peritoneal dialysis. Clin Chim Acta 2006; 364:209-16. [PMID: 16087168 DOI: 10.1016/j.cccn.2005.07.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2005] [Revised: 07/01/2005] [Accepted: 07/01/2005] [Indexed: 11/24/2022]
Abstract
BACKGROUND The high prevalence of protein-energy malnutrition is a critical issue for patients with end stage renal disease (ESRD) on hemodialysis (HD) or continuous ambulatory peritoneal dialysis (CAPD). Levels of plasma and intracellular amino acids are significant indicators of protein metabolism and nutritional status assessment. We measured plasma FAAs in patients on maintenance dialysis and to provide information in monitoring the therapeutic strategy, particularly in AA supplementary therapy or protein restriction. METHODS Fifty-five patients with ESRD were investigated, 25 on HD (male : female=14 : 11; 48-67 y) and 30 on CAPD (male : female=17 : 13; 45-64 y). The subjects had been on dialysis for an average of 13 months (range, 9 to 22 months). Their plasma FAAs (including their intermediate metabolites) were measured by ion exchange chromatography before and after HD or during CAPD and were compared with data obtained from 20 age- and sex-matched healthy controls. RESULTS The total plasma FAA levels (urea and free ammonia, NH3 were excluded) in pre-HD samples (3911 +/- 709 micromol/l) was significantly higher than in the other groups (2570 +/- 378 in control, 3210 +/- 640 in post-HD, and 3468 +/- 271 in CAPD samples). The mean plasma FAA concentrations differed significantly between pre-HD and controls and between pre-HD and CAPD samples (p<0.05). No significant differences were found among the other group comparisons. Comparing individual FAA concentrations, only citrulline differed significantly among all groups (p<0.05), whereas serine, glutamine, beta-alanine, beta-aminoisobutyric acid, and gamma-aminobutyric acid were not different. Concentrations of some FAAs involved in the urea cycle, e.g., arginine, aspartic acid, citrulline, and ornithines, and solutes urea and NH3, were significantly increased. Ratios of tyrosine/phenylalanine and valine/glycine ratios were markedly reduced in all patients on dialysis compared with controls. CONCLUSION FAAs either from dietary uptake or protein catabolism are substantially retained in the plasma of patients with ESRD, possibly producing higher levels of the waste products (urea and NH3) through the urea cycle and ammonia metabolism in liver. Maintenance dialysis can effectively eliminate excess FAAs in plasma, as there was a 17.9% reduction post-HD. The abnormalities in FAA metabolism found in patients with ESRD necessitate careful consideration of dialysis and dietary measures.
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Affiliation(s)
- Chih-Kuang Chuang
- Department of Medical Research, MacKay Memorial Hospital, Taipei, Taiwan, ROC
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Abstract
Despite improvement in many aspects of the care of maintenance hemodialysis (HD) patients, protein-calorie malnutrition, which is characterized by an insidious loss of somatic protein, is common and is a major risk factor for increased morbidity and mortality. We present here an overview of the current knowledge on protein metabolism in uremic patients with the expectation of providing insights into the mechanisms involved in HD-associated catabolism and outlining the rationale underlying intradialytic nutrition. We concentrate on the discussion of muscle protein metabolism because muscle is the predominant site of protein storage, and its integrity is mandatory for the maintenance of a good quality of life.
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Affiliation(s)
- Julien Bohé
- JE2411 and Medical Intensive Care Unit, Lyon-Sud University Hospital, Pierre-Bénite, France.
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Bossola M, Muscaritoli M, Tazza L, Giungi S, Tortorelli A, Rossi Fanelli F, Luciani G. Malnutrition in Hemodialysis Patients: What Therapy? Am J Kidney Dis 2005; 46:371-86. [PMID: 16129199 DOI: 10.1053/j.ajkd.2005.05.031] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2005] [Revised: 05/31/2005] [Accepted: 05/31/2005] [Indexed: 11/11/2022]
Abstract
Malnutrition is common in hemodialysis patients and is a powerful predictor of morbidity and mortality. Although much progress has been made in recent years in identifying the causes and pathogenesis of malnutrition in hemodialysis patients, as well as recognizing the link between malnutrition and morbidity and mortality, no consensus has been reached concerning its management. Along with such conventional interventions as nutritional counseling, oral nutritional supplements, and intradialytic parenteral nutrition, novel preventive and therapeutic strategies have been tested, such as appetite stimulants, growth hormone, androgenic anabolic steroids, and anti-inflammatory drugs, with contradictory and nonconclusive results. Malnutrition still remains a great challenge for nephrologists in the third millennium.
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Affiliation(s)
- Maurizio Bossola
- Istituto di Clinica Chirurgica, Università Cattolica del Sacro Cuore, Rome, Italy.
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Suliman ME, Qureshi AR, Stenvinkel P, Pecoits-Filho R, Bárány P, Heimbürger O, Anderstam B, Rodríguez Ayala E, Divino Filho JC, Alvestrand A, Lindholm B. Inflammation contributes to low plasma amino acid concentrations in patients with chronic kidney disease. Am J Clin Nutr 2005. [DOI: 10.1093/ajcn/82.2.342] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Mohammed E Suliman
- From the Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - A Rashid Qureshi
- From the Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Peter Stenvinkel
- From the Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Roberto Pecoits-Filho
- From the Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Peter Bárány
- From the Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Olof Heimbürger
- From the Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Björn Anderstam
- From the Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Ernesto Rodríguez Ayala
- From the Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - José C Divino Filho
- From the Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Anders Alvestrand
- From the Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Bengt Lindholm
- From the Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
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Suliman ME, Qureshi AR, Stenvinkel P, Pecoits-Filho R, Bárány P, Heimbürger O, Anderstam B, Rodríguez Ayala E, Divino Filho JC, Alvestrand A, Lindholm B. Inflammation contributes to low plasma amino acid concentrations in patients with chronic kidney disease. Am J Clin Nutr 2005; 82:342-9. [PMID: 16087977 DOI: 10.1093/ajcn.82.2.342] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Inflammation and malnutrition are common in chronic kidney disease (CKD) patients, and plasma concentrations of free amino acids (AAs) in these patients are often abnormal. Malnutrition contributes to alterations in AA concentrations. OBJECTIVE The objective was to study the effects of inflammation on plasma AA concentrations. DESIGN Concentrations of plasma AAs, serum albumin, and several inflammatory markers were analyzed in 200 fasting, nondiabetic CKD patients who were close to the start of renal replacement therapy. The nutritional status of these patients was assessed by a subjective global assessment. RESULTS The patients with inflammation [C-reactive protein (CRP) concentrations >10 mg/L] or malnutrition had lower AA concentrations than did the patients with no inflammation or malnutrition. The presence of both inflammation and malnutrition was associated with more marked reductions in AA concentrations than was malnutrition alone. Significant inverse correlations were observed between the plasma concentrations of most of the essential and nonessential AAs and inflammatory markers, whereas serum albumin concentrations were positively correlated with several AA concentrations. A stepwise multivariate regression analysis showed that serum CRP concentrations were independently associated with low concentrations of the sums of both nonessential AAs and all AAs. An analysis of all-cause mortality with a Kaplan-Meier test showed that the patients with higher AA concentrations had significantly better survival than did the patients with lower AA concentrations. CONCLUSIONS Plasma AA concentrations are low in CKD patients with inflammation and are inversely correlated with concentrations of inflammatory markers. Although inflammation and malnutrition are closely related, CRP concentrations were independently associated with low concentrations of the sums of both nonessential AAs and all AAs, which suggests an independent role of inflammation as a cause of low plasma AA concentrations in CKD patients.
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Affiliation(s)
- Mohammed E Suliman
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
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Du J, Mitch WE. Identification of pathways controlling muscle protein metabolism in uremia and other catabolic conditions. Curr Opin Nephrol Hypertens 2005; 14:378-82. [PMID: 15931008 DOI: 10.1097/01.mnh.0000172726.75369.b2] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Major progress has been made in defining two key steps that mediate muscle protein degradation in kidney disease and other catabolic conditions. These advances are identified and discussed. RECENT FINDINGS Activation of caspase-3 in muscle was discovered to be the initial step in breaking down the complex structure of myofibrils. Caspase-3 cleaves the complex structure, yielding substrate proteins and protein fragments that are degraded by the ubiquitin-proteasome system. Activation of caspase-3 occurs when insulin receptor substrate-1-associated phosphatidylinositol 3 kinase activity is suppressed in different models of catabolic conditions. The E3 ubiquitin ligases, MAFbx (also called atrogin-1) and MuRF1, were previously shown to play an essential role in muscle wasting. Several reports show that the insulin receptor substrate-1-associated phosphatidylinositol 3 kinase/Akt pathway activates forkhead transcription factors to increase expression of MAFbx/atrogin-1 and MuRF1. This response induces muscle protein wasting. In addition, chronic activation of the transcription factor, nuclear factor-kappaB, induces muscle atrophy. SUMMARY The insulin-like growth factor-1/insulin receptor substrate-1-associated phosphatidylinositol 3 kinase/Akt cellular signaling pathway coordinately regulates two proteolytic pathways, caspase-3 and the ubiquitin ligases MAFbx/atrogin-1 and MuRF1 to control muscle protein degradation. These pathways represent therapeutic targets in diseases that cause muscle wasting.
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Affiliation(s)
- Jie Du
- Department of Medicine, University of Texas Medical Branch, Galveston, Texas 77555-1064, USA
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Veeneman JM, Kingma HA, Stellaard F, de Jong PE, Reijngoud DJ, Huisman RM. Oxidative Metabolism Appears to Be Reduced in Long-Term Hemodialysis Patients. Am J Kidney Dis 2005; 46:102-10. [PMID: 15983963 DOI: 10.1053/j.ajkd.2005.04.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND As part of a study of whole-body protein metabolism in hemodialysis (HD) patients, we obtained values for whole-body bicarbonate production in control subjects and HD patients before and during dialysis by using stable isotopically labeled bicarbonate. Indirect calorimetry measurements have shown normal or increased energy expenditure in HD patients, which has been used to explain the malnutrition in many of these patients. However, this method becomes inaccurate when the dynamics of whole-body bicarbonate production change during measurement, as is the case with HD patients during dialysis. METHODS Whole-body bicarbonate production was measured in 6 control subjects, 9 patients on a nondialysis day (HD-), and 8 patients during an HD session (HD+) by means of a primed constant infusion of carbon 13 (13C)-labeled sodium carbonate (NaH13CO3). 13C-abundance of expired carbon dioxide was measured by means of isotope ratio mass spectrometry. RESULTS Carbon dioxide production was 141 +/- 12, 123 +/- 11*, and 148 +/- 19 micromol/kg/min for the control, HD-, and HD+ groups, respectively (*P < 0.05 compared with the control and HD+ groups). Values for energy expenditure were derived and were 29.1 +/- 2.4, 24.9 +/- 2.1*, and 32.6 +/- 2.0 kcal/kg/day, respectively (*P < 0.05 compared with the control and HD+ groups). CONCLUSION Whole-body oxidation in HD patients is reduced compared with control subjects. During dialysis, bicarbonate turnover, as well as carbon dioxide expiration, increases because of the influx of bicarbonate from the dialyzer.
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Affiliation(s)
- Jorden M Veeneman
- Department of Internal Medicine, Division of Nephrology, University Hospital Groningen, The Netherlands
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Veeneman JM, Kingma HA, Stellaard F, de Jong PE, Reijngoud DJ, Huisman RM. Membrane Biocompatibility Does Not Affect Whole Body Protein Metabolism during Dialysis. Blood Purif 2005; 23:211-8. [PMID: 15809504 DOI: 10.1159/000084891] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2004] [Indexed: 11/19/2022]
Abstract
BACKGROUND Protein-calorie malnutrition is present in 30-50% of dialysis patients. The lack of biocompatibility of the dialysis membrane, which results in low-grade inflammation, could be responsible for this malnutrition. We investigated whether protein-energy malnutrition could be partly due to incompatibility of the dialyzer during the dialysis session. METHODS Five patients were dialyzed during 2 periods of 3 weeks (cross-over) with either a single-use low-flux polysulfone or cellulose triacetate (biocompatible) or a single-use cuprophan (bio-incompatible) membrane. As a measure of whole body protein metabolism, a primed constant infusion of L-[1-(13)C]-valine was used during a 4-hour dialysis session. RESULTS Cuprophan was a more powerful activator of the complement system than other membranes. Protein metabolism parameters during both study protocols were not different and resulted in the same protein balance during polysulfone/cellulose triacetate (-15 +/- 3) and cuprophan (-13 +/- 2 micromol/kg/h) dialysis. CONCLUSION In stable hemodialysis patients with no apparent complications, protein metabolism during dialysis is not affected by the compatibility of the dialysis membrane.
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Affiliation(s)
- Jorden M Veeneman
- Department of Internal Medicine, Division of Nephrology, University Hospital Groningen, NL-9700 RB Groningen, The Netherlands
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Abstract
Nutritional status is an important predictor of clinical outcome in end-stage renal disease (ESRD) patients, especially in patients on chronic hemodialysis. Uremic malnutrition is strongly associated with increased risk of death and hospitalization events in this patient population, and decreased muscle mass is the most significant predictor of these outcomes. Several factors that influence protein metabolism predispose chronic hemodialysis patients to increased catabolism and loss of lean body mass. The available evidence suggests that low protein and energy intake associated with advanced uremia along with catabolic consequences of dialytic therapies can lead to the development of uremic malnutrition. Recent studies show that the hemodialysis procedure induces a net protein catabolic state at the whole-body level as well as skeletal muscle. There is evidence to suggest that these undesirable effects are due to decreased protein synthesis and increased proteolysis. Provision of nutrients, either in the form of intradialytic parenteral nutrition or oral feeding during hemodialysis, can adequately compensate for the catabolic effects of the hemodialysis procedure. While the mechanisms of these effects are not studied in detail, changes in extracellular amino acid concentrations, along with certain anabolic hormones such as insulin, are important mediators of these actions.
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Affiliation(s)
- T Alp Ikizler
- Department of Medicine, Division of Nephrology, Vanderbilt University Medical Center, 1161 21st Avenue South & Garland, Nashville, TN 37232, USA.
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Ray C. Protein supplementation in patients using peritoneal dialysis. J Ren Nutr 2005; 15:260-4. [PMID: 15827901 DOI: 10.1053/j.jrn.2004.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- Cynthia Ray
- DaVita Dietitian, DaVita Inc, Provo, UT 84604, USA.
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Lim VS, Ikizler TA, Raj DSC, Flanigan MJ. Does Hemodialysis Increase Protein Breakdown? Dissociation between Whole-Body Amino Acid Turnover and Regional Muscle Kinetics. J Am Soc Nephrol 2005; 16:862-8. [PMID: 15716333 DOI: 10.1681/asn.2004080624] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Hemodialysis (HD) is a protein catabolic procedure. Whole-body amino acid turnover studies identify dialysate amino acid loss and reduced protein synthesis as the catabolic events; proteolysis is not increased. Regional amino acid kinetics, however, document enhanced muscle protein breakdown as the cause of the catabolism; muscle protein synthesis also increased but to a lesser magnitude than the increment in protein breakdown. This discordance between whole-body and regional kinetics is best explained by the contrasting physiology between the muscle and the liver. During HD, muscle releases amino acids, which then are taken up by the liver for de novo protein synthesis. There seems to be a somatic to visceral recycling of amino acids. Evidence supporting this concept includes the increased fractional synthesis of albumin and fibrinogen during HD. It should be emphasized that region- or organ-specific kinetics vary, and whole-body turnover is a composite of all of the visceral and somatic compartments taken together. Reduced whole-body protein synthesis may be a compensatory adaptation to dialysate amino acid loss with a consequent reduction in plasma amino acid concentration. Notwithstanding the protein catabolic nature of HD, evidence is accumulating that intradialytic nutritional supplementation may blunt its catabolic effect.
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Affiliation(s)
- Victoria S Lim
- Department of Medicine, University of Iowa College of Medicine, Room T310, General Hospital, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242, USA.
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Chauveau P, Vendrely B, El Haggan W, Barthe N, Rigalleau V, Combe C, Aparicio M. Body composition of patients on a very low-protein diet: a two-year survey with DEXA. J Ren Nutr 2004; 13:282-7. [PMID: 14566765 DOI: 10.1016/s1051-2276(03)00117-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND It has been reported that patients on a very-low-protein diet (VLPD) maintain a satisfactory nutritional status because of a conserved adaptive metabolic response. However, only few studies have examined the course of nutritional status and body composition in the long term (2 years). METHODS Thirteen stable patients (8 men; age, 55 +/- 12 years; glomerular filtration rate (GFR), 15 +/- 5 mL/min) receiving a VLPD (0.3 g/kg/day protein) supplemented with amino acids and ketoanalogues (SVLPD) were studied for 2 years. A joint visit with a physician and a dietitian and routine blood and urine analyses were performed every month. Dual-energy x-ray absorptiometry (DEXA), which was used to assess modification of body composition, and GFR (urinary 51Cr-EDTA) and urinary urea and creatinine excretion, which were used to assess nutritional status and compliance to the diet, were assessed every 3 months. RESULTS GFR, albumin, and prealbumin levels remained stable. Urea urinary excretion decreased at 3 months and then slightly increased at 2 years, but the calculated protein intake remained low at 0.38 +/- 0.1 g/kg/day. Energy intake remained close to 30 kcal/kg/day. No significant change was observed for total fat mass or percent fat mass. After an initial decrease, lean body mass stabilized at 6 months and then increased significantly from 6 to 24 months (P =.02, paired t-test); the mean increase during this period was of 2 kg, that is, 4.6%. Urinary creatinine excretion showed the same profile. Total bone mass, lumbar or hip site bone mass, and Z-score significantly decreased from T0 to 1 and 2 years (P <.05). CONCLUSION This study confirms that a supplemented VLPD is nutritionally safe for a long period, but attention must be paid to bone mass.
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