Understanding Development of Malnutrition in Hemodialysis Patients: A Narrative Review

Abstract

Hemodialysis (HD) majorly represents the global treatment option for patients with chronic kidney disease stage 5, and, despite advances in dialysis technology, these patients face a high risk of morbidity and mortality from malnutrition. We aimed to provide a novel view that malnutrition susceptibility in the global HD community is either or both of iatrogenic and of non-iatrogenic origins. This categorization of malnutrition origin clearly describes the role of each factor in contributing to malnutrition. Low dialysis adequacy resulting in uremia and metabolic acidosis and dialysis membranes and techniques, which incur greater amino-acid losses, are identified modifiable iatrogenic factors of malnutrition. Dietary inadequacy as per suboptimal energy and protein intakes due to poor appetite status, low diet quality, high diet monotony index, and/or psychosocial and financial barriers are modifiable non-iatrogenic factors implicated in malnutrition in these patients. These factors should be included in a comprehensive nutritional assessment for malnutrition risk. Leveraging the point of origin of malnutrition in dialysis patients is crucial for healthcare practitioners to enable personalized patient care, as well as determine country-specific malnutrition treatment strategies.

Assessment of the influence of expanded hemodialysis on the rate of removal of middle molecular weight uremic toxins

“…After a single session of extended hemodialysis, the serum albumin concentration in all patients was higher than 35 g/L (35.50  0.72 g/L). During an extended hemodialysis session, less than 4.0 g of albumin (≤ 4.0 g/4h) is lost, which is of great importance in order to prevent the development of malnutrition (33). Microinflammation and increased serum leptin concentrations of patients treated with regular dialysis play a significant role in the development of malnutrition.…”

“…Leptin is a middle molecular weight adipokin (MW -17 kDa), which reduces the appetite of patients treated with regular dialysis (energy intake  30 kcal/kg/day, protein intake less than 0.8 g/kg/day). Body mass index -BMI  20 kg/m 2 , serum albumin concentration  35 g/L, serum prealbumin concentration less than 0.30 g/L and normalized protein degradation rate -nPCR  1.0 g/kg/day are factors risk of adverse outcome in patients treated with regular dialysis (33). Studies show that extended hemodialysis effectively removes proinflammatory cytokines and leptin, reduces microinflammation, reduces serum leptin concentrations, prevents the development of malnutrition, and improves the outcome of these patients (33,34).…”

“…Proinflammatory cytokines and proteins play a significant role in the development of microinflammation, while leptin plays a significant role in the development of malnutrition in patients treated with regular hemodialysis (3). Microinflammation, malnutrition and oxidative stress are significant non-traditional risk factors, resulting in the development of accelerated atherosclerosis (atherosclerotic cardiovascular disease), hemodialysis-related amyloidosis, erythropoietin resistance and anemia (3)(4)(5)(6)(7)(8)(9)(10).…”

Association Between Alkaline Phosphatase and Muscle Mass, Strength, or Physical Performance in Patients on Maintenance Hemodialysis

“…Short-term mortality continues to decrease due to the improvements in dialysis technology; however, long-term complications continue to increase. Malnutrition combined with a decrease in muscle mass or physical performance is an emerging concern in patients on long-term HD (3). These are associated with a decrease in the quality of life and an increase in morbidity or mortality.…”

Beta-2 microglobulin removal with postdilution online hemodiafiltration - comparison of three different dialysis membranes

“…They have diverse biological roles and are associated with chronic inflammation, cardiovascular disease, and other complications in HD patients [1]. Microinflammation, malnutrition, and oxidative stress are important non-traditional risk factors for the development of atherosclerosis and resistance to erythropoietin [1][2][3][4][5].…”