Relationship between protein-energy wasting in adults with chronic hemodialysis and the response to treatment with erythropoietin

Abstract

Background It is known that one of the leading causes of morbidity in chronic kidney disease (CKD) is the anemic syndrome. Although the pathogenic mechanisms of anemia are multiple, erythropoietin deficiency appears as the dominant factor. Patients in hemodialysis (HD) have a high prevalence of protein energy wasting (PEW) that may explains the poor response to Erythropoietin (EPO). Methods Retrospective cohort study of patients on HD from January to December 2014. The participants were classified according to a diagnostic of PEW using the “Malnutrition Inflammation Score” (MIS) and bioimpedance analysis (BIA) measurement of body composition at the start of erythropoietin therapy and after 3 months of follow up. We performed descriptive statistics and analyzed the differences between groups with and without PEW considering their responsiveness. In addition, we calculated the relative risk of EPO resistance, considering p value < 0.05 as statistically significant. Results Sixty-one patients ended the follow up. Both groups were similar in basal hemoglobin, hematocrit and other hematopoiesis markers (p = NS). Patients without PEW have a decrease risk for poor response to treatment with EPO (RR = 0.562 [95% CI, 0.329–0.961-]) than those with PEW. Finally, hemoglobin concentrations were evaluated at baseline and every four weeks until week 12, finding a statistically significant improvement only in patients without PEW according MIS ( p < 0.05). Conclusions PEW is an incremental predictor of poor responsiveness to EPO in HD patients, thus, it is important to consider correcting malnutrition or wasting for a favorable response to treatment with EPO.

Association of the erythropoiesis-stimulating agent resistance index and the geriatric nutritional risk index with cardiovascular mortality in maintenance hemodialysis patients

“…Rattanasompattikul et al have reported that the ERI was independently correlated with malnutritional-inflammation score, a comprehensive scoring system of nutrition in maintenance HD patients, and that the score was worse in the 4 th quartile of ERI compared to the 1 st quartile[ 10 ]. Furthermore, González-Ortiz et al recently reported that HD patients with PEW, which was classified by malnutritional-inflammation score, have increased risks for the poorer response to ESA therapy than those without PEW[ 11 ]. In this study, the ERI was negatively, independently associated with GNRI, a marker of PEW; therefore, our findings supported that the ERI may be a plausible indicator of PEW.…”

“…The mechanisms of ESA hyporesponsiveness are not fully understood, but are likely to be multifactorial, relating to iron deficiency, inflammation, and malnutrition[ 9 ]. Recently, some studies have speculated that ESA hyporesponsiveness may be related to protein-energy wasting (PEW), a form of malnutrition characterized by loss of body protein and fuel reserves due to catabolic inflammation[ 10 , 11 ]. Okazaki et al recently reported that high ERI and low geriatric nutritional risk index (GNRI) were associated with an increased risk of all-cause mortality in HD patients[ 12 ].…”

<p>Erythropoietin Resistance in Patients with Chronic Kidney Disease: Current Perspectives</p>

“…Patients with CKD are at substantial risk of malnutrition, characterized by loss of protein energy (state of decreased body protein and energy fuel reserves). 13,29,30 Their nutritional status is affected by the general decrease in nutrient intake, dietary restrictions, intestinal malabsorption, inflammatory state, metabolic acidosis and dialysate losses (in dialysis patients). These situations increase the risk for micronutrient deficiencies (folic acid, vitamin B12, and iron) 31,32 and can favor the onset of anemia.…”

“…13 Observational studies have shown that nutritional status is associated with EPO resistance in HD patients, mainly because of malnutrition-inflammation status. 10,30,33,34 For this reason, the nutritional status and body composition of these patients must be carefully evaluated to implement early interventions to support adequate EPO response and consequently, decrease the incidence of anemia. 30 Individualized management of nutritional intake is a crucial aspect of care for individuals diagnosed with any stage of CKD, including those on maintenance dialysis.…”

“…10,30,33,34 For this reason, the nutritional status and body composition of these patients must be carefully evaluated to implement early interventions to support adequate EPO response and consequently, decrease the incidence of anemia. 30 Individualized management of nutritional intake is a crucial aspect of care for individuals diagnosed with any stage of CKD, including those on maintenance dialysis. Therefore, it is essential that such individuals receive tailored nutrition assessment and counseling to prevent and treat protein-energy wasting, mineral and electrolyte disorders, and other metabolic co-morbidities associated with CKD.…”