Cachexia/Protein energy wasting syndrome in CKD: Causation and treatment

Abstract

Cachexia is a multifactorial syndrome defined by significant body weight loss, fat and muscle mass reduction, and increased protein catabolism. Protein energy wasting (PEW) is characterized as a syndrome of adverse changes in nutrition and body composition being highly prevalent in patients with CKD, especially in those undergoing dialysis, and it is associated with high morbidity and mortality in this population. Multiple mechanisms are involved in the genesis of these adverse nutritional changes in CKD patients. There is no obvious distinction between PEW and cachexia from a pathophysiologic standpoint and should be considered as part of the spectrum of the same nutritional disorder in CKD with similar management approaches for prevention and treatment based on current understanding. A plethora of factors can affect the nutritional status of CKD patients requiring a combination of therapeutic approaches to prevent or reverse protein and energy depletion. At present, there is no effective pharmacologic intervention that prevents or attenuates muscle atrophy in catabolic conditions like CKD. Prevention and treatment of uremic muscle wasting involve optimal nutritional support, correction of acidosis, and physical exercise. There has been emerging consistent evidence that active treatment, perhaps by combining nutritional interventions and resistance exercise, may be able to improve but not totally reverse or prevent the supervening muscle wasting and weakness. Active research into more direct pharmacological treatment based on basic mechanistic research is much needed for this unmet medical need in patients with CKD.

Protein energy wasting; what is it and what can we do to prevent it?

“…The role of dietary manipulations including fibre and probiotics to manipulate the gut microbiome; appetite simulants; and anti-inflammatory and anti-oxidant medications have been trialled but as yet are of unproven benefit [35].…”

Maintenance of Skeletal Muscle to Counteract Sarcopenia in Patients with Advanced Chronic Kidney Disease and Especially Those Undergoing Hemodialysis

“…Large numbers of different factors and/or mechanisms including persistent inflammation are considered to be involved with age-related muscle derangement (sarcopenia) in CKD/HD patients, with both expected and unexpected findings reported [ 4 , 16 , 59 , 60 ] [ 61 ], and new information presented even in the last few years. For example, uremic toxins such as indoxyl sulfate and p-cresol were shown to impair myogenic differentiation of cultured C2C12 skeletal muscle cells [ 62 ].…”

“…On the other hand, that recommendation is usually ⁓1.2 g/kg/day in dialysis patients to preserve muscle mass [ 6 ]. When a standard prevention approach is not enough, nutritional supplementation is considered, with many methods available, including oral supplementation, intradialytic parental nutrition, and tube feeding [ 4 , 6 , 61 , 130 ].…”

Intradialytic Nutrition and Hemodialysis Prescriptions: A Personalized Stepwise Approach

“…Even the terms indicating nutritional status in dialysis patients have changed: cachexia, malnutrition, protein energy wasting, and malnutrition inflammation syndrome (MIA) are all used to describe dialysis patients, sometimes with similar meaning, sometimes with different nuances (Table 2) [34][35][36][37][38][39][40][41][42][43][44][45][46][47][48]. Table 2.…”