Differences and Effects of Metabolic Fate of Individual Amino Acid Loss in High-Efficiency Hemodialysis and Hemodiafiltration

Hemodialysis—Nutritional Flaws in Diagnosis and Prescriptions. Could Amino Acid Losses Be the Sharpest “Sword of Damocles”?

“…BIA measurements should therefore be taken once dry weight or ideal weight is purported to have been reached, where possible at least 30 min after dialysis and following urination [ 55 , 56 ]. Indeed, the HD population studied displayed a worsening of intracellular dehydration, hypervolemia and cell mass wasting [ 22 ], all of which may potentially result in a reduction in muscle mass and strength. Furthermore, in overweight and obese HD patients, BIA-derived FFM, BCM and Å are significantly lower compared to normal-weight patients and BMI-matched controls.…”

“…Indeed, due to their low molecular weight, AAs are lost in industrial quantities over one year of thrice weekly hemodialysis, particularly when using methods such as hemodiafiltration and hemofiltration, in which additional convective losses occur due to ultrafiltration. Recently, a study group on AAs kinetics in extracorporeal methods showed annual losses > 800 g/year in thrice weekly hemodialysis patients with a consequent, significant loss of lean body and, in particular, muscle mass protein [ 20 , 22 ]. Considering the more contained loss of Total AAs (TAAs) manifested using high-efficiency hemodialysis with a surface dialyzer area of 1.8 m 2 over a 240-min session, losses could be managed by varying dialytic strategy as shown in Table 2 .…”

“…This metabolic effect could slow down or prevent decline into malnutrition and/or protein-energy wasting in patients required to sustain years of treatment and avoid the use of amino acids in muscle mass to produce energy [ 90 ]. A post-hoc analysis [ 22 ] confirmed a severe loss of AAs during hemodialysis and/or hemodiafiltration (HDF), with detection of a marked loss of total AAs (5 g/session), corresponding to more than 65% of all AAs. Regarding individual AAs, glutamine displayed a consistent increase (+150%), whereas all other AAs decreased after 12 months of HD/HDF.…”

“…This situation may deteriorate further when an ESKD patient starts hemodialysis treatment. In addition to the issues listed above, patients may also experience (a) hypercatabolic status during and up to several hours after HD [ 15 ]; (b) oxidative stress and chronic inflammation [ 16 , 17 ]; (c) progressive decrease in diuresis with loss of residual kidney function (RKF) caused by hemodialysis treatment applied in the lack of a tailored hemodialytic dose as recommended by precision medicine [ 18 ]; (d) insignificant depuration of protein-bound uremic toxins (PUBT) (particularly indoxyl-sulphate and p-cresol [ 19 ]), (e) loss of amino acids during hemodialysis (over 0.8 g/year) with progressive decrease of muscle mass; and (f) increased insulin resistance [ 20 , 21 , 22 ]. In the absence of therapeutic/nutritional countermeasures, protein-energy wasting will develop [ 23 ].…”

Precision Nutrition and Personalized Diet Plan for Kidney Health and Kidney Disease Management

“…Murtas et al. 26 studied the loss of arterial blood concentration of nonessential, essential, and branched-chain amino acids comparing on-line modern high-efficiency hemodialysis and hemodiafiltration in 10 patients who were randomized to these modalities and reported a reduction of essential and nonessential amino acids, which after 12 months led to progressive deterioration of lean mass and emergence of sarcopenia. Hence, it is possible that amino acid supplementation may be needed to prevent hypercatabolism and cachexia.…”