Effects of short-term recombinant human growth hormone therapy on plasma leptin concentrations in dialysis patients

Leptin in chronic kidney disease: a link between hematopoiesis, bone metabolism, and nutrition

Anemia, dyslipidemia, malnutrition, together with mineral and bone disorders are common complications in patients with chronic kidney disease (CKD). All are associated with increased risk of mortality. Leptin is a small peptide hormone that is mainly but not exclusively produced in adipose tissue. It is also secreted by normal human osteoblasts, subchondral osteoblasts, placental syncytiotrophoblasts, and the gastric epithelium. Leptin binds to its receptors in the hypothalamus to regulate bone metabolism and food intake. Leptin also has several other important metabolic effects on peripheral tissues, including the liver, skeletal muscle, and bone marrow. Leptin is cleared principally by the kidney. Not surprisingly, serum leptin appears to increase concurrently with declines in the glomerular filtration rate in patients with CKD. A growing body of evidence suggests that leptin might be closely related to hematopoiesis, nutrition, and bone metabolism in CKD patients. Results are conflicting regarding leptin in patients with CKD, in whom both beneficial and detrimental effects on uremia outcome are found. This review elucidates the discovery of leptin and its receptors, changes in serum or plasma leptin levels, the functions of leptin, relationships between leptin and the complications mentioned above, and pharmaceutical interventions in serum leptin levels in patients with CKD.

OPPORTUNITY™: a large-scale randomized clinical trial of growth hormone in hemodialysis patients

BACKGROUND

Adult maintenance hemodialysis (MHD) patients experience high mortality and morbidity and poor quality of life (QoL). Markers of protein-energy wasting are associated with these poor outcomes. The OPPORTUNITY™ Trial examined whether recombinant human growth hormone (hGH) reduces mortality in hypoalbuminemic MHD patients. Secondary end points were effects on number of hospitalizations, cardiovascular events, lean body mass (LBM), serum proteins, exercise capacity, QoL and adverse events.

METHODS

We performed a randomized, double-blind, placebo-controlled, multicenter multinational trial stratified for diabetic status. Clinically, stable adult MHD patients with serum albumin <4.0 g/dL were randomized to subcutaneous injections of hGH, 20 μg/kg/day, or placebo. Planned treatment duration was 24 months for 2500 patients. The trial was terminated early due to slow recruitment.

RESULTS

Seven hundred and twelve patients were randomized until trial termination; 695 patients received at least one dose of trial medication. Mean treatment duration was 20 weeks (no completers). There were no differences between groups in all-cause mortality, cardiovascular morbidity or mortality, serum albumin, LBM, physical exercise capacity or QoL. The hGH group, compared to placebo, displayed a reduction in body weight, total body fat, serum high-sensitivity C-reactive protein and possibly homocysteine and an increase in serum high-density lipoprotein-cholesterol and transferrin levels.

CONCLUSIONS

Although the OPPORTUNITY™ Trial was terminated early, treatment with hGH, compared to placebo, improved certain cardiovascular risk factors but did not reduce mortality, cardiovascular events or improve nutritional factors or QoL. The power for showing differences was substantially reduced due to the marked decrease in treatment duration and sample size.

Longitudinal study of leptin levels in chronic hemodialysis patients

Background

The influence of serum leptin levels on nutritional status and survival in chronic hemodialysis patients remained to be elucidated. We conducted a prospective longitudinal study of leptin levels and nutritional parameters to determine whether changes of serum leptin levels modify nutritional status and survival in a cohort of prevalent hemodialysis patients.

Methods

Leptin, dietary energy and protein intake, biochemical markers of nutrition and body composition (anthropometry and bioimpedance analysis) were measured at baseline and at 6, 12, 18 and 24 months following enrollment, in 101 prevalent hemodialysis patients (37% women) with a mean age of 64.6 ± 11.5 years. Observation of this cohort was continued over 2 additional years. Changes in repeated measures were evaluated, with adjustment for baseline differences in demographic and clinical parameters.

Results

Significant reduction of leptin levels with time were observed (linear estimate: -2.5010 ± 0.57 ng/ml/2y; p < 0.001) with a more rapid decline in leptin levels in the highest leptin tertile in both unadjusted (p = 0.007) and fully adjusted (p = 0.047) models. A significant reduction in body composition parameters over time was observed, but was not influenced by leptin (leptin-by-time interactions were not significant). No significant associations were noted between leptin levels and changes in dietary protein or energy intake, or laboratory nutritional markers. Finally, cumulative incidences of survival were unaffected by the baseline serum leptin levels.

Conclusions

Thus leptin levels reflect fat mass depots, rather than independently contributing to uremic anorexia or modifying nutritional status and/or survival in chronic hemodialysis patients. The importance of such information is high if leptin is contemplated as a potential therapeutic target in hemodialysis patients.

A review of the effects of growth hormone changes on symptoms of frailty in the elderly with chronic kidney disease

The incidence and prevalence of chronic kidney disease (CKD) is increasing worldwide, especially in the elderly. Recently, functional impairment and frailty have been recognized as factors affecting the quality of life, and outcomes in elderly patients with CKD and therapeutic interventions to improve function and reduce frailty are therefore being considered. Growth hormone (GH) levels decrease with age and GH actions are impaired in CKD patients. GH stimulates protein synthesis, bone, and glucose metabolism, and affects body composition by reducing body fat and increasing lean body mass. An increase in lean body mass may reduce frailty and thus avoid functional impairment. Thus, providing GH to elderly CKD patients could potentially improve outcomes and quality of life by lowering the risk of frailty and associated functional impairment. There are few studies assessing the long-term effects of GH administration on symptoms of frailty in elderly patients with CKD. In this review we will try to shed some light on the trials assessing the administration of GH to elderly subjects and to patients with CKD and focus on the possible role GH administration may play to improve frailty and quality of life in those patients.

OPPORTUNITY: a randomized clinical trial of growth hormone on outcome in hemodialysis patients

BACKGROUND

The mortality rate of maintenance hemodialysis (MHD) patients remains high. Measures of protein-energy wasting, including hypoalbuminemia, are strongly associated with their high mortality. Growth hormone (GH) may improve lean body mass (LBM) and serum albumin levels, and health-related quality of life (HRQoL), which are significantly and positively associated with survival in MHD patients. The OPPORTUNITY Trial will examine whether GH reduces mortality and morbidity and improves overall health in hypoalbuminemic MHD patients.

HYPOTHESIS

The primary hypothesis is that daily recombinant human GH injections, compared with placebo, improve survival in hypoalbuminemic MHD patients. Secondary hypotheses are that GH improves morbidity and health, including number of hospitalized days, time to cardiovascular events, LBM, serum protein and inflammatory marker levels, exercise capacity, and HRQoL, and has a favorable safety profile.

DESIGN/MEASUREMENTS

This is a prospective, double-blind, multicenter, randomized clinical trial involving 2500 MHD patients, up to 50% with diabetes mellitus, from 22 countries. Patients are randomized in a 1:1 ratio to receive daily injections of GH (20 microg/kg per day) or placebo for 104 weeks. Key inclusion criteria include clinically stable and well-dialyzed (Kt/V > or =1.2) adult MHD patients with serum albumin <4.0 g/dl. Exclusion criteria include active malignancy, active proliferative or severe nonproliferative diabetic retinopathy, uncontrolled hypertension, chronic use of high-dose glucocorticoids, or immunosuppressive agents and pregnancy.

CONCLUSIONS

The OPPORTUNITY Trial is the first large-scale randomized clinical trial in adult MHD patients evaluating the response to GH of such clinical endpoints as mortality, morbidity, markers of body protein mass, inflammation, exercise capacity, and HRQoL.

Pigs weaned from the sow at 10 days of age respond to dietary energy source of manufactured liquid diets and exogenous porcine somatotropin

Previous research indicates that the neonatal pig does not alter feed intake in response to changes in the energy density of manufactured liquid diets. Also, the limited response of IGF-I to exogenous porcine ST (pST) previously observed in young pigs may be influenced by the source of dietary energy. Our objectives were to 1) determine the effect of a high-fat (HF; 25% fat and 4,639 kcal/kg ME; DM basis) or low-fat (LF; 2% fat and 3,481 kcal/kg ME; DM basis) manufactured liquid diet on pig performance; and 2) determine whether the limited response to exogenous pST in young pigs depends on the source of dietary energy. Two replicates of 60 pigs (n = 120; barrows and gilts distributed evenly), with an initial BW of 4,207 +/- 51 g, were weaned from the sow at 10 d of age and used in a randomized complete block design. Pigs were assigned by BW to one of six pens. Diets were formulated to provide a constant lysine:ME ratio and were fed on a pen basis for a duration of 9 d. On d 5, barrows and gilts within a pen were assigned randomly to receive either 0 or 120 microg of pST.kg BW(-1).d(-1) for 4 d. Pigs gained 336 +/- 9 g/d, which resulted in an ending BW of 7,228 +/- 120 g, regardless of dietary treatment (P > 0.15). Pigs fed the LF diet consumed 17% more DM per pen daily than pigs fed the HF diet (2,777 +/- 67 vs. 2,376 +/- 67 g/d, P < 0.01), but calculated ME intake did not differ between dietary treatments (P > 0.20). The G:F was 24% greater in HF- than in LF-fed pigs (P < 0.01). Plasma urea N concentrations were higher in the HF-fed pigs (11.0 +/- 0.6 mg/dL) than in pigs fed the LF diet (6.2 +/- 0.6 mg/dL; P < 0.05). Treatment with pST increased circulating IGF-I (P < 0.01) and decreased PUN (P < 0.01) concentration 32 and 25%, respectively, regardless of dietary treatment (P > 0.30). Circulating leptin averaged 1.8 +/- 0.1 ng/mL and was not affected by dietary treatment (P > 0.35) or pST (P > 0.40). These results suggest that the ST/IGF axis is responsive in the young pig and the increase in circulating IGF-I and growth is independent of the source of dietary energy. Also, young pigs respond to a lower energy density liquid diet with increased feed intake, without altering growth performance, apparently utilizing a mechanism other than circulating leptin.

Leptin and leptin receptor expression in skeletal muscle and adipose tissue in response to in vivo porcine somatotropin treatment

The present study was performed to examine the response of leptin and leptin receptor (Rb) genes to porcine somatotropin (pST) stimuli in finishing pigs. Twelve crossbred barrows (Yorkshire x Landrace) were used in this study. Animals were individually fed a basal diet containing 18% CP, 1.2% lysine, and 3.5 Mcal of DE/kg ad libitum (as-fed basis). At 90 kg, six pigs were treated with daily injections of recombinant pST (10 mg) in sterile bicarbonate buffer, whereas the other six pigs were injected with sterile bicarbonate buffer (controls). With initiation of pST treatment, the quantity of feed offered was 85% of calculated ad libitum intake based on BW and adjusted every 3 d. Diet restriction was designed to correct for the effects of the known inhibition in feed intake because of pST treatment in swine. Animals were maintained on treatment for 2 wk. A blood sample was obtained from each pig on d 14 of treatment, 6 h after pST injection. Tissue samples were collected on d 15, frozen in liquid N2, and stored at -80 degrees C before analysis for mRNA abundance. Total RNA was amplified by reverse transcription (RT) PCR with subsequent quantification of transcripts by capillary electrophoresis with laser-induced fluorescence detection. Samples included outer subcutaneous adipose tissue (OSQ), middle subcutaneous adipose tissue (MSQ), leaf fat (LF), liver, latissimus dorsi (LD), and biceps femoris (BF). Restricted feeding resulted in no change in BW of control pigs, whereas pST treatment increased BW by 6.9 +/- 0.5 kg (P < 0.001). Treatment with pST produced a 12-fold increase in serum ST concentration relative to control pigs (P < 0.002). Serum leptin concentration was increased by 17% in swine treated with pST relative to control pigs (P < 0.011). Leptin mRNA abundance was increased in liver by pST treatment (P < 0.05). Administration of pST decreased leptin Rb (Ob-Rb) mRNA abundance by 27% in liver (P < 0.044) and by 49.5% in OSQ (P < 0.025) relative to controls. The present data suggest that pST does not affect leptin expression independent of dietary intake because the restricted feeding regimen used in the present study precluded detection of major change in leptin gene expression. Changes in Ob-Rb mRNA abundance by pST treatment indicate that ST or the metabolic adaptations to ST have a role in regulating Ob-Rb expression.

Epidemiology of dialysis patients and heart failure patients

The epidemiology of maintenance dialysis patients and heart failure patients has striking similarities. Both groups have a high prevalence of comorbid conditions, a high hospitalization rate, a low self-reported quality of life, and an excessively high mortality risk, mostly because of cardiovascular causes. Observational studies in both dialysis and heart failure patients have indicated the lack of a significant association between the traditional cardiovascular risk factors and mortality, or the existence of a paradoxic or reverse association, in that obesity, hypercholesterolemia, and hypertension appear to confer survival advantages. The time discrepancy between the 2 sets of risk factors, that is, overnutrition (long-term killer) versus undernutrition (short-term killer) may explain the overwhelming role of malnutrition, inflammation, and cachexia in causing the reverse epidemiology, which may exist in more than 20 million Americans. We have reviewed the opposing views about the concept of reverse epidemiology in dialysis and heart failure patients, the recent Die Deutsche Diabetes Dialyze study findings, and the possible role of racial disparities. Contradictory findings on hyperhomocysteinemia in dialysis patients are reviewed in greater details as a possible example of publication bias. Additional findings related to intravenous iron and serum ferritin, calcium, and leptin levels in dialysis patients may enhance our understanding of the new paradigm. The association between obesity and increased death risk in kidney transplanted patients is reviewed as an example of the reversal of reverse epidemiology. Studying the epidemiology of dialysis patients as the archetypical population with such paradoxic associations may lead to the development of population-specific guidelines and treatment strategies beyond the current Framingham cardiovascular risk factor paradigm.

Effects of central infusion and immunoneutralization of growth hormone on the timing of puberty and plasma leptin levels in the female rat

Growth hormone (GH) levels increase during puberty though its role in puberty onset is still unclear. An interaction is suggested between GH and leptin, as triggering factor of puberty. To evaluate the role of GH on the timing of puberty and its relation with leptin, we centrally administered recombinant human GH (rhGH; 1 microg/day) to normally fed or food-restricted (FR) prepubertal female rats, and monitored time of vaginal opening (VO). Median time of VO was equally postponed in FR animals and in normally fed rhGH-infused rats: median time of VO was respectively 35 and 34 vs. 27 d. Central infusion of rhGH in FR rats partially restored the delay in VO. Plasma leptin levels were increased in rhGH-infused animals, normally fed or FR. Centrally infused anti-rat GH (0.6 microg/day) did not affect plasma leptin levels, but advanced median time of VO (25 vs. 28 d) in pair-fed female rats but not in ad lib-fed animals. The effects of the centrally infused compounds appear to depend on the dietary regime imposed on the prepubertal animals. Furthermore, plasma leptin levels show no direct or predictive relation to the time of VO. The data indicate an involvement of GH in puberty onset, but do not explain the mechanism employed.

Leptin responses to insulin administration in children with short stature

Abstract The aim of the study was to investigate the effect of standard insulin tolerance test on plasma leptin levels in children with idiopathic short stature (ISS) and in children with growth hormone deficiency (GHD). Furthermore, plasma leptin levels were analyzed with regard to age, body mass index (BMI), and plasma levels of human growth hormone and of insulin-like growth factor-1 (IGF-1). Sixty-three patients with a height below the third percentile, an age of 10.24 +/- 0.40 years and a BMI standard deviation score (SDS) of -0.78 +/- 0.13 (weight SDS -0.07 +/- 0.12; height SDS -2.39 +/- 0.10) were investigated (mean +/- SD). Based on responses to insulin tolerance test, the patients were classified as ISS (n = 49) or GHD (n = 14). Plasma leptin levels were significantly lower in all patients 60 minutes ( P < .001) and 120 minutes ( P < .001) after insulin administration. This effect was independent of GHD, and no difference in leptin decrease was found when comparing patients with ISS to those with GHD. A correlation was found when comparing plasma leptin levels of all patients to BMI SDS (r = 0.43; P < .001) and plasma IGF-1 levels (r = 0.31; P < .01). Furthermore, positive correlation was found when BMI SDS was compared to IGF-1 (r = 0.25; P < .05). In summary, we found that insulin administration in children with short stature decreases plasma leptin levels, equally in those with and without GHD.

Megestrol Acetate in a Moderate Dose for the Treatment of Malnutrition-Inflammation Complex in Maintenance Dialysis Patients

BACKGROUND

Malnutrition-inflammation complex syndrome and anorexia, common conditions in maintenance dialysis patients, are strongly associated with higher mortality and hospitalization and lower quality of life (QoL) in this population. Megestrol acetate, 800 mg/day, has been shown to increase appetite and food intake and to mitigate inflammation in cachectic AIDS and cancer patients, leading to weight gain, but it is also associated with side effects at this dose.

METHODS

We evaluated the efficacy of the oral solution of megestrol acetate in half of its conventional dose in improving the nutritional state and inflammation in 10 hypoalbuminemic dialysis patients (albumin < 3.7 g/dL). Six women and 4 men, ages 60.2 years, took 400 mg of megestrol acetate solution daily for 16 weeks. Anthropometry, dual energy x-ray absorptiometry, 24-hour diet recalls, and biochemical measurements of nutrition and inflammation, including serum C-reactive protein and leptin, were performed.

RESULTS

At the end of the 16 weeks of intervention, weight and body mass index increased by 9%, body fat proportion by 31%, and triceps skinfold by 40% (P < .01). Serum albumin increased from 3.0 to 3.3 g/dL and continued to increase significantly to 3.6 g/dL after 3 months postintervention (P = .03). Serum leptin increased from 5.2 to 10.7 ng/mL (P = .09). Daily protein and energy intake increased progressively up to 27% to 42% by the end of the trial (P < or = .01). In 8 patients without acute infection, serum C-reactive protein declined from 1.24 to 0.78 mg/L (P = .06). QoL and appetite were reported to be improved. No major side effects were observed, and all 10 patients completed the 16 weeks of daily intake of megestrol acetate without interruption.

CONCLUSIONS

Megestrol acetate oral solution in half of its conventional dose is safe and improves the nutritional state, inflammation, and anorexia in maintenance dialysis patients. Larger-scale placebo-controlled randomized studies are needed to confirm the beneficial effects of 400 mg/day of megestrol acetate in dialysis patients.

Metabolic acidosis and malnutrition-inflammation complex syndrome in chronic renal failure

Metabolic acidosis, a common condition in patients with renal failure, may be linked to protein-energy malnutrition (PEM) and inflammation, together also known as malnutrition-inflammation complex syndrome (MICS). Methods of serum bicarbonate measurement may misrepresent the true bicarbonate level, since the total serum carbon dioxide measurement usually overestimates the serum bicarbonate concentration. Moreover, the air transportation of blood samples to distant laboratories may lead to erroneous readings. In patients with chronic kidney disease (CKD) or end-stage renal disease (ESRD), a significant number of endocrine, musculoskeletal, and metabolic abnormalities are believed to result from acidemia. Metabolic acidosis may be related to PEM and MICS due to an increased protein catabolism, decreased protein synthesis, endocrine abnormalities including insulin resistance, decreased serum leptin level, and inflammation among individuals with renal failure. Evidence suggests that the catabolic effects of metabolic acidosis may result from an increased activity of the adenosine triphosphate (ATP)-dependent ubiquitin-proteasome and branched-chain keto acid dehydrogenase. In contrast to the metabolic studies, many epidemiologic studies in maintenance dialysis patients have indicated a paradoxically inverse association between mildly decreased serum bicarbonate and improved markers of protein-energy nutritional state. Hence metabolic acidosis may be considered as yet another element of the reverse epidemiology in ESRD patients. Interventional studies have yielded inconsistent results in CKD and ESRD patients, although in peritoneal dialysis patients, mitigating acidemia appears to more consistently improve nutritional status and reduce hospitalizations. Large-scale, prospective randomized interventional studies are needed to ascertain the potential benefits of correcting acidemia in malnourished and/or inflamed CKD and maintenance hemodialysis patients. Until then, all attempts should be made to adhere to the National Kidney Foundation Kidney Disease and Dialysis Outcome Quality Initiative guidelines to maintain a serum bicarbonate level in ESRD patients of at least 22 mEq/L.

Ozonated autohemotherapy in patients on maintenance hemodialysis: influence on lipid profile and endothelium

Ozonated autohemotherapy (O3-AHT) is used in the treatment of atherosclerotic ischemia of lower limbs (AILL). The impact of ozone on serum lipids and endothelium injury is of particular interest since these factors are important in the development of atherosclerotic lesions. To evaluate this issue, a prospective, placebo-controlled study was designed. Twelve hemodialyzed subjects with AILL received autohemotherapy with oxygen as a control followed by O3-AHT with ozone concentration of 50 micro g/ml. Serum lipids and plasma activity of von Willebrand factor (vWF) were measured. After O3-AHT, total cholesterol significantly decreased compared to the baseline (-8.34%) [P < 0.01]. LDL cholesterol was also significantly lower than the initial value (-17.71%) [P < 0.001]. No significant changes in the activity of vWF were found after the first session of O3-AHT and after all nine sessions of O3-AHT. The study demonstrated that O3-AHT did not affect deleteriously the endothelium in patients with chronic renal failure on maintenance hemodialysis. It may stimulate beneficial changes in serum lipid profile manifesting as a decrease in the total- and LDL-cholesterol levels.

Relationship of leptin and insulin-like growth factor I to nutritional status in hemodialyzed children

Malnutrition is prevalent in patients with end-stage renal disease (ESRD). Elevated serum leptin levels were thought to contribute to the anorexia and poor nutrition in renal failure. However, studies of the relationship between nutritional status and leptin concentration in chronic renal failure have yielded conflicting results. Plasma insulin-like growth factor I (IGF-I) level has been used as an indicator of nutritional status in patients with renal failure. The relationship between leptin and IGF-I is controversial. The present study was conducted with the aim of assessing the relationship between nutritional status, hyperleptinemia, and serum IGF-I. Seventeen ESRD patients (8 male, 9 female), aged 8-18 years (mean 15.3+/-3.3 years) and undergoing standard hemodialysis for 58.8+/-23.1 months were enrolled. Nine age-matched healthy children served as controls. In all patients, energy and protein intakes were 40-70 kcal/kg per day and 1-1.54 g/kg per day, respectively. Predialysis serum leptin and IGF-I levels were measured by radioimmunoassay. Body mass index was decreased in 13 (76%) patients. Triceps skinfold thickness (TST) was reduced (below the 5th percentile) in 7 (41%), whereas mid arm circumference and mid arm muscle circumference were reduced in 14 (82.5%) and 13 (76.5%), respectively. The median serum leptin level was significantly higher in patients than in controls [13.7 interquartile range (IQR) 30.50 pg/ml vs. 6.50 IQR 8.65 pg/ml, P=0.01]. The median serum IGF-I level was lower in the patients (205.1 ng/ml IQR 194.4 ng/l) than controls (418.0 ng/l IQR 310.5 ng/ml) ( P=0.01). IGF-I levels were more decreased in patients with severe malnutrition, defined according to TST (145.0 ng/ml IQR 125.5 ng/l) than patients without malnutrition (301.2 ng/l IQR 218.8 ng/ml) ( P=0.03) and healthy children ( P=0.002). Although statistically not significant, IGF-I levels tended to be decreased, while leptin levels were increased. The median plasma insulin concentration was 15 microU/ml (1.63-45.80) and did not correlate with leptin and IGF-I levels. In conclusion, the results of this study confirm the presence of high circulating plasma leptin levels, which may be one of the many factors involved in the pathogenesis of the malnutrition in children on hemodialysis.

Leptin, ghrelin, and proinflammatory cytokines: compounds with nutritional impact in chronic kidney disease?

Metabolic and nutritional derangements are prominent features of the uremic syndrome. Recent evidence suggest that several large-molecular-weight molecules that often are elevated in uremia, such as leptin, ghrelin, and proinflammatory cytokines, may have nutritional impact in this patient group. On the basis of present knowledge, these compounds could be regarded as suspected but not established uremic toxins. The discovery of the ob gene, its product leptin, and cerebral leptin receptors has undoubtedly widened our understanding of obesity and the underlying molecular and physiologic mechanisms that regulate food intake and body weight. Moreover, the recent discovery of leptin receptor isoforms in several peripheral organs suggests that leptin besides having a central function also has several important peripheral biological functions. Because uremic patients in general have an inappropriate elevation of circulatory leptin, further research is necessary to determine the potential biological effects of elevated leptin levels in end-stage renal disease. Also, because many symptoms and findings prevalent in the uremic syndrome are known to be associated with elevated levels of proinflammatory cytokines, such as interleukin-6, future studies are needed to evaluate the role of specific anti-inflammatory treatment strategies in malnourished uremic patients.

Protein and energy nutrition among adult patients treated with chronic peritoneal dialysis

Protein-energy malnutrition (PEM) in adult patients treated with chronic peritoneal dialysis (CPD), which is highly prevalent and frequently severe in its manifestation, poses a significant therapeutic dilemma. The causes of PEM include inflammation, low nutrient intake, nutrient losses during dialysis, metabolic acidemia, coexisting illnesses, and possibly the endocrine disorders of uremia. Treatment strategies for PEM in CPD patients include the following: attempt to treat the potentially reversible causes of anorexia, increase nutrient intake (by nutritional counseling, oral food supplements, consideration of appetite stimulants and intraperitonial amino acid solutions), and the correction of metabolic acidosis. Coexisting illnesses engendering PEM should be treated. Experimental evidence suggests that such agents as anabolic steroids, human growth hormone, insulin-like growth factor-I, and L-carnitine may engender positive protein balance in these individuals. Finally, the use of anti-inflammatory agents to improve the nutritional status of malnourished CPD patients remains to be defined. There is a need to carry out clinical trials that examine whether an improvement in the nutritional status of CPD patients is associated with an improvement in their mortality, morbidity and/or quality of life.