1. Nutrition in Hemodialysis Patients 신장내과 1 년차 정지윤

2. Nutrition in Hemodialysis Patients 40-70% of Pts with ESRD are malnourished. Greater medical risk and increased mortality in undernourished patients –Low BMI, Hypoalbuminemia, low urea nitrogen and creatinine than expected Protein energy wasting is prevalent in patients undergoing maintenance hemodialysis.

3. Protein-Energy Wasting syndrome “State of decreased body stores of protein and energy fuels (Body protein and fat masses) - ISRNM, 2006 Kidney disease wasting –Occurrence of protein-energy wasting in CKD or AKI regardless of the cause

4. Etiology of PEW J Ren Nutr. 2013 Mar;23(2):77-90

5. Decreased protein & Energy intake Anorexia –35-50% ESRD patients Dietary restriction –not accompanied by appropriate counseling on alternative food choices and/or strategies to ensure adequate nutrient intake Psychological and acquired aspects –Depression –Social Behavior

6. Chronic inflammation Proinflammatory cytokines –CNS Effect : Decreased appetite –Muscle catabolism by Insulin/IGF-1 resistance in skeletal muscle Adv Chronic Kidney Dis.Adv Chronic Kidney Dis. 2013 Mar;20(2):181-9

7. Metabolic and Hormonal derangements Metabolic acidosis –Increases protein catabolism –Oxidation of essential amino acids  raise protein requirements –Suppression of insulin/IGF-1 signaling in muscle Hormonal derangements –GH and IGF-1 axis disruption  decrease anabolism –Increase parathyroidism H : Possible protein catabolic factor in uremia

8. Insulin resistance and deprivation DM –High prevalence of PEW Uremia –decreased food intake  reduced insulin secretion Inflammatory cytokines Acidosis, glucocorticoids Decreased insulin or insulin sensitivity can cause muscle protein losses

9. (Apoptotic protease) J Appl Physiol (1985). 2008 Dec; 105(6): 1772–1778

10. Dialysis procedure Nutrient losses into dialysate Dialysis –related inflammation Dialaysis related hypermetabolism –Increased resting energy expenditure

11. Comorbidities

12. Diagnosis of PEW

13. Nutritional Support Continuous dietary counseling Appropriate amount of dietary protein and calorie intake (dietary protein and energy intake >1.2g/kg/d and > 30kcal/kg/d) Oral nutritional support Intradialytic parenteral nutrition

14. Pharmacologic interventions Anabolic steroids –Nandrolone decanoate Appetitie stimulatns (Not proven) –Megesterol acetate, dronabinol, melatonin, thalidomide and ghrelin Growth Factor (Experimental) –Recombinant human GH, IGF-1 –Could have anabolic properties Anti-inflammatory interventions –Pentoxifyllin, Targeted anticytokine therapy (IL-1 ra, TNFa blocker), Statin, Thiazolidinedione, ACEi, Resistance exercise,Thalidomide Fish oil and Vit.E

15. References Etiology of the protein-energy wasting syndrome in chronic kidney disease: a consensus statement from the International Society of Renal Nutrition and Metabolism (ISRNM). J Ren Nutr. 2013 Mar;23(2):77-90. doi: 10.1053/j.jrn.2013.01.001. Optimal nutrition in hemodialysis patients Adv Chronic Kidney Dis. 2013 Mar;20(2):181-9. doi: 10.1053/j.ackd.2012.12.002.Adv Chronic Kidney Dis. D Fouque et al.: Protein–energy wasting in kidney disease Kidney International (2008) 73, 391–398