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New Strategies for Management of Malnutrition in Peritoneal Dialysis Patients

Malnutrition is not uncommon in peritoneal dialysis (PD) patients; various cross-sectional studies have found signs of malnutrition in 18% – 56% of these patients (1–3). Recent longitudinal studies have examined the evolution of nutritional status in patients treated with PD and there is now compelling evidence that, following an initial improvement, nutritional status gradually declines (3–6). The reason(s) for this are not clear. Johansson et al. (5) showed that, during long-term PD treatment, mean body cell mass remains unchanged during the first year of PD, but there may be a decrease in body cell mass despite maintenance, or even an increase in body energy stores. Likewise, we have found in a prospective study that, whereas body fat mass increases in most patients during 12 months of PD, lean body mass tends to decrease over time (7). Recently, Davies et al. (6) showed that, during long-term PD, malnutrition develops mainly in patients who lose residual renal function. The etiology of malnutrition in PD is complex and may include a number of factors, such as poor food intake, anorexia, nausea and vomiting due to inadequate control of uremic toxicity, delayed gastric emptying, hormonal derangements, inadequate control of acidosis, comorbidity, and inflammation. As with hemodialysis (HD) patients, it is generally believed that suboptimal nutritional status is associated with increased morbidity and mortality in PD patients. The CANUSA study showed that nutritional status is a strong independent predictor of survival (8,9). Likewise, low serum albumin levels have also been reported to be a strong independent predictor of total and cardiovascular mortality in PD patients (10,11). However, in this respect, it should be emphasized that factors other than malnutrition can influence serum albumin concentration — especially inflammatory complications and chronic heart failure — since serum albumin level merely reflects the presence of systemic disease (11,12). RELATION BETWEEN INFLAMMATION, MALNUTRITION, AND ATHEROSCLEROSIS