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International Journal of Trend in Scientific

Research and Development (IJTSRD)

International Open Access Journal
ISSN No: 2456 - 6470 | www.ijtsrd.com | Volume - 2 | Issue – 4

Protein Energy Wasting in CKD Patients

Neha Jain
Department of Organization
Pt. J. N. M. Medical College, Raipur Chhattisgarh, India

A study was conducted to assess the nutritional status meals or supplements might improve the nutritional
of CKD patients visiting Dr. B. R. A. Memorial status and outcomes in dialysis patients.
hospital & Pt. J. N. M. medical College Raipur (c.g (c.g.)
.A total of 50 subject from both sexes having means Keywords: Chronic kidney disease, nutritional
age 49.61+_15.28 years undergoing hem dialysis were intervention, protein energy malnutrition, protein
enrolled for the study. Information regarding disease energy wasting
history and associates co morbidities wer were collected
from patients files.. nutritional status wa
was assessed by INTRODUCTION
anthropometric measurements using body mass index Management of the nutritional aspects of chronic
(BMI).the biochemical results including kidney kidney disease (CKD) presents a number of
profile , serum electrolytes and hemoglobin were challenges. In the general population, over nutrition is
recorded from the patient's file. Dietary data was a major problem. Over nutrition is considered a
obtained by using 24- hour dietary recall and food serious risk factor for developing metabolic
frequency questionnaire. the results indicated that age, syndrome, cardiovascular
ovascular disease, and CKD, with a
familial predisposition, hypertension, diabetes and subsequent increase in the risk of mortality. However,
heart disease increased the risk for renal failure. in patients with CKD, and especially in those
energy wasting (PEW) is common in patients undergoing maintenance dialysis, the so-called
so uremic
with chronic kidney disease (CKD). PEW is one of malnutrition (also referred to as protein-energy
the strongest predictors of mortality in patients with wasting [PEW]) is by far the strongest risk factor for
CKD. The International Society of Renal Nutrition adverse outcomes and death.[1]
death.[ Patients undergoing
and Metabolism (ISRNM) expert panel has defined dialysis die of the short-term
term consequences of PEW
PEW as a, “state of decreased body stores of protein and do not live long enough to die of risk factors
and energy fuels (body protein and fat masses)”. The associated with over nutrition.
nutrition This ‘time discrepancy
ISRNM panel has also proposed diagnostic criteria of hypothesis’[2]] suggests that, in a patient with CKD,
PEW with four categories. Cachexia is a severe form whose risk of short-term term mortality is high,
of PEW. The proposed causes of PEW are multi multi- interventions that improve nutritional status and
factorial and include nutritional and non non-nutritional prevent or correct wasting and sarcopenia have the
mechanisms. The literature indicates thathat PEW can be potential to save lives, as compared to the
mitigated or corrected with an appropriate diet and conventional interventions, such as, treating
enteral nutritional support that targets dietary protein hypercholesterolemia, hypertension or obesity.
intake. Dietary requirements and enteral nutritional Furthermore, studies related to the nutritional status
support must also be considered in patients with CKD have shown that malnutrition / wasting is common in
and diabetes mellitus and in children with CKD, in CKD, as approximately 18 – 75% of patients with
addition to dialysis patients. Features of ideal dietary CKD, undergoing maintenance dialysis therapy, show
supplement have also been discussed. Dietary evidence of wasting.
interventions such as enteral feeding with high

@ IJTSRD | Available Online @ www.ijtsrd.com | Volume – 2 | Issue – 4 | May-Jun

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International Journal of Trend in Scientific Research and Development (IJTSRD) ISSN: 2456-6470

One recently published 10-year cohort study evaluated inflammation in patients with CKD. These include
serum albumin, C-reactive protein, and carotid uremic malnutrition, uremic (renal) cachexia, protein-
atherosclerosis as predictors of a 10-year mortality in energy malnutrition, malnutrition-inflammation
hemodialysis patients. The results indicated that atherosclerosis syndrome or malnutrition-
serum albumin concentration was far superior as a inflammation complex (or cachexia) syndrome. Use
predictor of mortality than inflammatory markers (C- of non-uniform and ill-defined terminologies may lead
reactive protein) or the intima-media thickness of the to both conceptual errors and misinterpretation of
common carotid artery.[5] PEW, therefore, seemed to data. Hence, to avoid confusion the International
be a strong predictor of mortality in patients with Society of Renal Nutrition and Metabolism
CKD, and improving nutritional status by dietary and (ISRNM)'s expert panel has recommended the term
non-dietary interventions could be an important step ‘protein-energy wasting
toward improving the outcomes in CKD
NOMENCLATURE OF MALNUTRITION / The ISRNM expert panel has defined PEW to
WASTING SYNDROMES IN CHRONIC describe a “state of decreased body stores of protein
KIDNEY DISEASE and energy fuels (body protein and fat masses)”. This
Various different terms and definitions have been abnormality is often associated with diminished
used by different authors for conditions associated functional capacity related to metabolic stresses.
with loss of muscle and fat tissue, malnutrition, and

Table 1

As protein wasting and energy wasting may occasionally occur separately from each other, the term ‘protein
wasting’ or ‘energy wasting’ may be used to indicate the isolated occurrence of only one of these phenomena.

In recent times, the word ‘cachexia’ has been KIDNEY DISEASE WASTING
suggested as a term to denote PEW included in the According to the ISRNM expert panel, kidney
setting of kidney disease.[8] The ISRNM expert disease wasting (KDW) refers to the occurrence of
panel has suggested the use of cachexia for a severe protein-energy wasting in CKD or acute kidney
form of protein-energy wasting.[7] Cachexia refers injury (AKI), regardless of the cause. The clear
to a very severe form of PEW, often associated with majority of the ISRNM panel members prefer PEW
profound physiological, metabolic, psychological, to KDW for most circumstances. The panel believes
and immunological disorders.[9] The difference in that the term KDW is not a suitable substitute for
PEW compared to cachexia is that the latter PEW. The KDW simply implies that PEW is likely
encompasses only severe forms of metabolic to occur in people with CKD.
depletion, whereas, PEW can refer to mild degrees
of depleted protein and energy mass.

@ IJTSRD | Available Online @ www.ijtsrd.com | Volume – 2 | Issue – 4 | May-Jun 2018 Page: 2475
International Journal of Trend in Scientific Research and Development (IJTSRD) ISSN: 2456-6470
PROTEIN-ENERGY WASTING IN associated with increased morbidity, mortality, and
CHRONIC KIDNEY DISEASE: impaired quality of life. The potential consequences
Several small and large scale cohort studies have
revealed that protein-energy malnutrition is
Table 2


Evidence indicates that surrogates of PEW, such as, Regarding dietary protein recommendations in
low serum levels of albumin or inadequate protein CKD, the current Kidney Dialysis Outcome Quality
intake, correlate with mortality. Measuring the Initiative (K / DOQI) guidelines suggest a protein
serum levels of albumin remains the simplest test intake of 0.6 – 0.75 grams of protein per kilogram
that is readily available. Indeed, a low serum of body weight per day (g / kg / d) for patients in
albumin concentration is by far the strongest stages 1 – 4 of CKD. In stage 5, when the patients
predictor of poor outcomes and mortality, at least in are receiving dialysis, increased protein intake is
patients on dialysis, when compared with any other suggested (approx. 1.2 g / kg / d).[16] Table 4 has
risk factor, including the traditional risk factors mentioned selected nutritional parameter
(hypertension, hypercholesterolemia, diabetes requirements for varying levels of kidney disease
mellitus, and obesity) and the nonconventional risk based on the American Dietetic Association
factors (measures of anemia, mineral and bone guidelines
surrogates, and dialysis modality)
Table 4


Oral nutritional consideration: Intervention may begin with suggestions to enhance oral intake in
malnourished CKD patients

@ IJTSRD | Available Online @ www.ijtsrd.com | Volume – 2 | Issue – 4 | May-Jun 2018 Page: 2476
International Journal of Trend in Scientific Research and Development (IJTSRD) ISSN: 2456-6470
Materials & Methods:-. Total 50 patients were conventional cardiovascular risk factors in
admitted. All patients were subjected to routine patients with chronic heart failure. J Am Coll
blood investigations, blood glucose, urine analysis, Cardiol. 2004;43:1439–44.[Pub Med]
routine biochemical investigations, sickling, lipid
3. Kopple JD. McCollum Award Lecture, 1996:
profile, ECG, Serum Protein, ,X Ray chest,
Protein–energy malnutrition in maintenance
USG(KUB), serum calcium, potassium, chloride,
hemodialysis patients. Am J Clin Nutr. 1996
sodium, phosphorus, albumin, globulin, bilirubin
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triglyceride, HDL,LDL, VLDL,SGOT, SGPT, Hb
Electrophoresis, Serum Thyroid levels. 4. Kalantar-Zadeh K, Ikizler TA, Block G, Avram
MM, Kopple JD. Malnutrition–inflammation
CONCLUSIONS complex syndrome in dialysis patients: Causes
Fifty years after the first dialysis treatment, nutrition and consequence. Am J Kidney Dis. 2003;
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currently not well understood. However, there has 5. Kato A, Takita T, Furuhashi M, Maruyama Y,
been progress in understanding the nutritional Hishida A. Comparison of serum albumin, C-
targets in CKD patients. Before dialysis, there is reactive protein and carotid atherosclerosis as
good evidence that a longstanding nutritional care predictors of 10-year mortality in hemodialysis
plan, with control of protein intake, is efficient for patients. Hemodial Int. 2010; 14:226–32. [Pub
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proteinuria, and it is cost-effective. PEW is a
distinct condition in CKD patients. PEW is common 6. Kalantar-Zadeh K, Cano NJ, Budde K, Chazot
in CKD and is associated with adverse outcomes. C, Kovesdy CP, Mak RH, et al. Diets and
Dietary interventions and nutritional support seem enteral supplements for improving outcomes in
to be effective in mitigating or correcting PEW and chronic kidney disease. Nat Rev Nephrol. 2011;
improving the outcomes in patients with CKD. All 7:369–84.[PMC free article] [Pub Med]
patients with CKD should be assessed periodically 7. Fouque D, Kalantar-Zadeh K, Kopple J, Cano
(monthly or quarterly) for the presence of PEW and N, Chauveau P, Cuppari L, et al. A proposed
should be offered oral nutritional support whenever nomenclature and diagnostic criteria for protein-
required. Providing meals or oral nutritional energy wasting in acute and chronic kidney
supplements and other nutritional interventions to disease. Kidney Int. 2008; 73:391–8. [PubMed]
patients with CKD is the most promising way to
increase serum albumin concentration and improve 8. Kalantar-Zadeh K. Recent advances in
longevity and quality of life in this patient understanding the malnutrition–inflammation–
population. cachexia syndrome in chronic kidney disease
patients: What is next? Semin Dial. 2005;18:365
1. Kovesdy CP, Kalantar-Zadeh K. Why is 9. Martignoni ME, Kunze P, Friess H. Cancer
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2. Kalantar-Zadeh K, Block G, Horwich T,
Fonarow GC. Reverse epidemiology of

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