Protein-energy malnutrition (PEM) is very common in ESRD reaching close to 50% of patients, depending on the parameters used. Why is it important? Well, PEM is a powerful predictor of morbidity and mortality. Ballpark, for every 1g/L decrease in albumin, a 10% increase in mortality risk has been reported.
Its etiology is believed to be multifactorial:
- Inadequate nutritional intake due to taste abnormalities, gastropathy/enteropathy, anorexia and psychosocial (depression, poverty or ETOH abuse).
- Dialysis-related nutrient losses: about 10g of aminoacids are lost after each HD session!
- Catabolic state due to inflammation/uremia, metabolic acidosis and dialysis procedure (exposure of blood to HD membrane).
Without any complicated malnutrition score, we are usually able to recognize malnourished patients by their physical appearance and some metabolic abnormalities like low BUN/Cr preHD, low phosphate, low cholesterol, elevated ferretin and low Hb. The normalized protein catabolic rate can also help.
So, what can we do for that?
- Improve dialysis adequacy: e.g. daily hemodialysis has been shown to improve nutritional parameters. But at this time your dialysis nurse or patient might not agree with that…
- Oral nutrient supplementation: strong data supporting the use of these agents. If your patient’s albumin is below 3.5, you should be thinking about that! Choice should consider the price, palatability and lactose tolerance. Nepro is a classic – one can contains approx. 17g of protein, 23g of fat and 53g of carbs (475 kcal) – pack of 24 for $69; compared to regular protein cans (e.g. Boost), they have less phosphate and potassium. Protein powder without flavor is also a great choice since it can be added to any fluid, improves palatability and cost less. Even sports protein bars have been shown to be acceptable protein sources. Compliance is a major issue and many studies have given the supplements before/after HD session.
- Correction of metabolic acidosis with PO bicarbonate.
- Appetite stimulants: megestrol has been used on cancer patients but side effects are frequent in HD patients and is usually not recommended.
- Finally, intradialytic total parenteral nutrition should be considered only for patients unable to use the GI tract and severely malnourished.
Also check Dr Rubin’s blog on hidden inflammatory state for reversal conditions you should be considering as well…