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Contempory issues in management
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What is protein-energy wasting?
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Metabolic acidosis, reduced anabolic drive, insulin resistance, dialysis, sedentary lifestyle
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Presentation outline
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How prevalent is PEW?
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How prevalent is PEW?
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Prevalence of PEW in contemporary dialysis populations
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What is PEW?
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Poor appetite (anorexia)
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Who is the culprit?
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Short-term appetite regulation
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Ghrelin
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RCT 1-week intervention with subcutaneous acyl-ghrelin
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Anorexia due to inflammation
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Melanocortin-4 Receptor Antagonists
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Indirect causes of anorexia in CKD
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Gastric/Instestinal problems
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Improving appetite in CKD patients
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What is PEW?
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Inflammation induces muscle catabolism
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Inflammation has direct catabolic effects
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Inflammation has indirect catabolic effects
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GH resistance in uremia is mainly caused by inflammation
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Muscle protein homeostasis (mg/kgFFM/min)
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Forearm muscle protein metabolism
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AA depletion is not the only cause of HD-induced protein catabolism
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Diabetes
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Insulin resistance
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Metabolic acidosis
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Presentation outline
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809 stable HD patients USA
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PEW associates with Mortality
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Is the association between PEW and death causal or an epiphenomenon?
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PEW is a short-term killer
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How should we interpret it?
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Presentation outline
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Easy tools for clinical monitoring?
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BMI is not a good marker of obesity/nutritional status in CKD
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PEW is present also in obese individuals.
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Albumin
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PEW is both malnutrition and inflammation (catabolism)
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Prognosis of mortality
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Nutritional support improves albumin
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Nutritional support improves albumin
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Albumin: simple, useful and readily available.
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In dialysis patients , serum creatinine concentration is good surrogate of muscle mass.
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My proposal for simple screening
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Changes in albumin
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Changes in dry weight
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Changes in creatinine
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Taking into consideration concurrent estimates of fat and muscle provides additional diagnostic information
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To this we should always add...
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"Would I be surprised if this patient died in the next year?"
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What did I say?
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Final reflection
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