Wasting in Chronic Kidney Disease – a Complex Issue

Abstract

Chronic kidney disease (CKD) has become a global health burden and is associated with increased morbidity and mortality. In particular, wasting is highly prevalent in later stages of the illness with muscle loss being a common problem. The aetiology and progression of this wasting is complex and multiple states have been identified linked to wasting in CKD. These include: 'malnutrition', 'disease-related malnutrition', 'protein-energy wasting', 'cachexia', 'sarcopenia', 'frailty' and 'muscle wasting'. The purpose of this paper is to review these terms in the context of CKD. Common features include weight loss, loss of muscle mass and muscle function principally driven by CKD disease specific factors and inflammatory mediators. Disease-related malnutrition would appear to be a more appropriate term for CKD than malnutrition as it take in to consideration disease specific factors such as inflammation for example. Frailty is commonly associated with age-related decline in physiological function. Development of novel screening tools measuring across multiple domains of nutritional status, muscle and physical function may be useful in CKD. Research into potential treatments are currently underway with focus on multi-modal therapies including nutrition, resistance training and anabolic drugs such as myostatin blockade and selective androgen receptor modulators. A better understanding of different states and terms may help guide assessment and treatment opportunities for patients.

Resistance exercise and nutritional interventions for augmenting sarcopenia outcomes in chronic kidney disease: a narrative review

“…In CKD Stages 2–5D, PEW is found to be prevalent in 11–54%, while 28–52% prevalent in transplanted patients 9 . Causes include amongst others; uremia‐induced alterations such as low dietary intake, pro‐inflammatory environment, and high nutrients requirements leading to a hypercatabolic state 30 . Despite common causes of malnutrition across the CKD spectrum, interventional nutritional strategies differ based on CKD stage.…”

Developing an Evidence and Theory Based Multimodal Integrative Intervention for the Management of Renal Cachexia: A Theory of Change

“…ii. Dietary counselling—Chronic disease-related malnutrition in ESKD is a complex issue given that disease specific factors such as inflammation must also be taken into consideration [ 19 , 20 ]. Koppe, Fouque & Kalantar-Zadeh [ 6 ] confirm that PEW is among the strongest predictors of mortality in patients with ESKD (hazard ratio of 3.03; confidence interval of 1.69–5.26 in 1068 haemodialysis patients).…”

“…In ESKD findings relating to multimodal trials are limited and evidence suggests that isolated interventions in the form of protein supplementation and nutritional energy have rarely proven to be very effective in improving outcomes [ 18 ]. The lack of improvement is likely to be due to the need to effectively treat other causative factors (e.g., inflammation or inflammatory burden) [ 19 , 20 ]. For optimal treatment of renal cachexia evidence suggests that a multimodal approach which includes exercise [ 21 , 22 ], anti-inflammatory agents [ 9 , 11 ] and nutritional support [ 1 , 8 , 11 ] is essential to target the multifactorial pathophysiology and attain at least additional, if not synergistic effects [ 18 ].…”

Disease-related malnutrition in chronic kidney disease

“…Terms such as cachexia, age-related sarcopenia, and proteinenergy wasting (PEW) have been used interchangeable within the literature alongside malnutrition [3,6]. Difficulties in distinguishing between syndromes can be compounded by an overlap in commonly associated criterion [7]. For example, reduced muscle mass which is a criterion for malnutrition is also a criterion in PEW, cachexia and sarcopenia [6].…”