Protein-energy wasting and nutritional supplementation in patients with end-stage renal disease on hemodialysis

BACKGROUND & AIMS

Protein-Energy Wasting (PEW) is the depletion of protein/energy stores observed in the most advanced stages of Chronic Kidney Disease (CKD). PEW is highly prevalent among patients on chronic dialysis, and is associated with adverse clinical outcomes, high morbidity/mortality rates and increased healthcare costs. This narrative review was aimed at exploring the pathophysiology of PEW in end-stage renal disease (ESRD) on hemodialysis. The main aspects of nutritional status evaluation, intervention and monitoring in this clinical setting were described, as well as the current approaches for the prevention and treatment of ESRD-related PEW.

METHODS

An exhaustive literature search was performed, in order to identify the relevant studies describing the epidemiology, pathogenesis, nutritional intervention and outcome of PEW in ESRD on hemodialysis.

RESULTS AND CONCLUSION

The pathogenesis of PEW is multifactorial. Loss of appetite, reduced intake of nutrients and altered lean body mass anabolism/catabolism play a key role. Nutritional approach to PEW should be based on a careful and periodic assessment of nutritional status and on timely dietary counseling. When protein and energy intakes are reduced, nutritional supplementation by means of specific oral formulations administered during the hemodialysis session may be the first-step intervention, and represents a valid nutritional approach to PEW prevention and treatment since it is easy, effective and safe. Omega-3 fatty acids and fibers, now included in commercially available preparations for renal patients, could lend relevant added value to macronutrient supplementation. When oral supplementation fails, intradialytic parenteral nutrition can be implemented in selected patients.

Calcium Intake, Vitamin D and Bone Health Status of Post-menopausal Chinese Women in Kuala Lumpur

Bone health status was investigated in 178 free-living Chinese post-menopausal women in Kuala Lumpur. Body mass index (BMI), body composition (using whole body DXA), calcium intake and serum 25-OH vitamin D status were measured along with biochemical markers of bone turnover, that is, pro-collagen Type 1 N-terminal peptide (P1NP), osteocalcin (OC) and C-telopeptide β cross link of Type 1 collagen (CTX- β). Bone mineral density (BMD) was measured using DXA (Hologic, USA) at the lumbar spine, femoral neck and total hip. Results showed that osteopenia was present in 50% of the subjects at the spine and 57.9% at the femoral neck. Osteoporosis was diagnosed in 10% of the subjects at both the femoral neck and spine. A total of 29.3% of the subjects had high levels of CTX- β. Mean serum level of 25-OH vitamin D was 60.4+15.6 nmol/L and 50.6% of the subjects had hypovitaminosis D (defined as < 50 nmol/l). Mean total calcium intake of the subjects was 497 + 233 mg, of which only 14% met the RNI for calcium with the additional intake of calcium supplements. Body fat was also significantly correlated (r=0.181, p< 0.05) with BMD at the spine but not BMD at the femoral neck. Lean body mass was positively correlated with BMD at the spine (r=0.289, p< 0.001) and femoral neck (r=0.295, p< 0.001). CTX-β was negatively correlated with BMD at the spine (r= -0.235, p< 0.001), whereas P1NP (r=-0.215, p< 0.001) and osteocalcin (r=-0.265, p< 0.001) were both negatively correlated with BMD at the femoral neck. Generally, the study found that women with osteopenia had higher levels of bone turnover markers, less lean body mass and lower calcium intake than women with normal BMD. In conclusion, this study demonstrated that the majority of free living Chinese post-menopausal women in Kuala Lumpur have low calcium intake, low 25-OH vitamin D status and low bone mass and elevated biochemical markers of bone turnover.

Developing a nutrition education package for Malaysian hemodialysis patients

OBJECTIVE

To develop an education package with uniform nutrition messages appropriate for Malaysian patients undergoing hemodialysis.

METHODS

Nutritional problems and socioeconomic, ethnic, cultural, and religious factors influencing food habits of HD patients were considered in planning the package. The package comprised a Flipchart and 55 food Fotocards. The Flipchart used a modular format to target nutrition education in stages. The food Fotocards were designed to help the patient plan a daily menu and enjoy greater food variety. Photographs related to common food servings carried symbols for significant nutrient sources of energy, protein, fat, sodium, potassium, and phosphate. A traffic-light color system quantified potassium and phosphate content. The package was evaluated by 25 respondents, composed of nephrologists, nurses, dietitians, and patients.

RESULTS

Eighty percent of evaluators rated the Flipchart as good and 20% rated it as excellent, whereas 28% rated the Food Fotocards as good and 72% rated them as as excellent.

CONCLUSION

This package is a useful nutrition education tool for both health educators and dietitians to present first-line nutrition advice to patients undergoing hemodialysis.