Physicians' Academy for Cardiovascular Education

Protein energy wasting in CKD patients

Slides (presentation) - Feb. 22, 2012

Protein energy wasting in CKD patients

Presentation prepared by
Dr. Juan J Carrero
Karolinska Institutet
Stockholm, Sweden
Presented at PACE Renal Master Class in Madrid, February 17-18, 2012

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

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