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Review
, 18 (3), 254-62

Latest Consensus and Update on Protein-Energy Wasting in Chronic Kidney Disease

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Review

Latest Consensus and Update on Protein-Energy Wasting in Chronic Kidney Disease

Yoshitsugu Obi et al. Curr Opin Clin Nutr Metab Care.

Abstract

Purpose of review: Protein-energy wasting (PEW) is a state of metabolic and nutritional derangements in chronic disease states including chronic kidney disease (CKD). Cumulative evidence suggests that PEW, muscle wasting and cachexia are common and strongly associated with mortality in CKD, which is reviewed here.

Recent findings: The malnutrition-inflammation score (KALANTAR Score) is among the comprehensive and outcome-predicting nutritional scoring tools. The association of obesity with poor outcomes is attenuated across more advanced CKD stages and eventually reverses in the form of obesity paradox. Frailty is closely associated with PEW, muscle wasting and cachexia. Muscle loss shows stronger associations with unfavorable outcomes than fat loss. Adequate energy supplementation combined with low-protein diet for the management of CKD may prevent the development of PEW and can improve adherence to low-protein diet, but dietary protein requirement may increase with aging and is higher under dialysis therapy. Phosphorus burden may lead to poor outcomes. The target serum bicarbonate concentration is normal range and at least 23 mEq/l for nondialysis-dependent and dialysis-dependent CKD patients, respectively. A benefit of exercise is suggested but not yet conclusively proven.

Summary: Prevention and treatment of PEW should involve individualized and integrated approaches to modulate identified risk factors and contributing comorbidities.

Conflict of interest statement

Conflict of interest

KKZ has received honoraria from Abbott, Abbvie, Aveo and Fresenius. CPK has received honoraria from Sanofi-Aventis.

Figures

Figure 1
Figure 1. The conceptual model for CKD progression, PEW, and its consequences
Complications include hypertension, anemia, malnutrition, bone and mineral disorder, infection, and decreased quality of life as well as cardiovascular disease.
Figure 2
Figure 2. The conceptual model for etiology of PEW in CKD and direct clinical implications
PEW is the result of multiple mechanisms inherent to CKD, including undernutrition, systemic inflammation, comorbidities, hormonal derangements, the dialysis procedure, and other consequences of uremic toxicity. PEW may induce infection, CVD, frailty, and depression, and these complications may also increase the extent of PEW in CKD.
Figure 3
Figure 3. A combination of changes in dry weight and serum creatinine concentrations during the first 6 months of the cohort as a predictor of mortality in 50,831 patients receiving hemodialysis [38]
Cr = serum creatinine; Wt = weight.

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