Management of protein-energy wasting in non-dialysis-dependent chronic kidney disease: reconciling low protein intake with nutritional therapy

May 3, 2013The American journal of clinical nutrition

Balancing low protein diets and nutrition to manage weight and muscle loss in chronic kidney disease without dialysis

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Abstract

The prevalence of protein-energy wasting (PEW) in early to moderate chronic kidney disease (CKD) is ≥20-25%.

PEW is characterized by a decline in body protein mass and energy reserves, including muscle and fat wasting.
Activation of proinflammatory cytokines and hypercatabolic states contribute to the progression of PEW in CKD.
Anorexia in CKD patients leads to inadequate intake of protein and energy, which may be exacerbated by dietary restrictions.
Worsening uremia increases vulnerability to the harmful effects of uncontrolled diets, such as elevated phosphorus and potassium levels.
Uremic metabolites can cause oxidative stress, endothelial dysfunction, and further decline in kidney function.
Nutritional interventions in CKD may include dietary modifications and supplements, but their effects on clinical outcomes in PEW patients require more research.

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Protein-energy wasting (PEW), characterized by a decline in body protein mass and energy reserves, including muscle and fat wasting and visceral protein pool contraction, is an underappreciated condition in early to moderate stages of chronic kidney disease (CKD) and a strong predictor of adverse outcomes. The prevalence of PEW in early to moderate CKD is ≥20-25% and increases as CKD progresses, in part because of activation of proinflammatory cytokines combined with superimposed hypercatabolic states and declines in appetite. This anorexia leads to inadequate protein and energy intake, which may be reinforced by prescribed dietary restrictions and inadequate monitoring of the patient's nutritional status. Worsening uremia also renders CKD patients vulnerable to potentially deleterious effects of uncontrolled diets, including higher phosphorus and potassium burden. Uremic metabolites, some of which are anorexigenic and many of which are products of protein metabolism, can exert harmful effects, ranging from oxidative stress to endothelial dysfunction, nitric oxide disarrays, renal interstitial fibrosis, sarcopenia, and worsening proteinuria and kidney function. Given such complex pathways, nutritional interventions in CKD, when applied in concert with nonnutritional therapeutic approaches, encompass an array of strategies (such as dietary restrictions and supplementations) aimed at optimizing both patients' biochemical variables and their clinical outcomes. The applicability of many nutritional interventions and their effects on outcomes in patients with CKD with PEW has not been well studied. This article reviews the definitions and pathophysiology of PEW in patients with non-dialysis-dependent CKD, examines the current indications for various dietary modification strategies in patients with CKD (eg, manufactured protein-based supplements, amino acids and their keto acid or hydroxyacid analogues), discusses the rationale behind their potential use in patients with PEW, and highlights areas in need of further research.

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Management of protein-energy wasting in non-dialysis-dependent chronic kidney disease: reconciling low protein intake with nutritional therapy

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