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How Important Is the Problem of Malnutrition in Chronic Dialysis Patients?

The development of chronic renal failure favors the development of both cachexia (decreased muscle protein and fat) and kwashiorkor (decreased splanchnic protein). The cause of this malnutrition is rather complex, involving anorexia and decreased nutrient intake as well as alterations in intermediary metabolism. Iatrogenic protein restriction to limit the accumulation of nitrogenous wastes (probably the major cause of the uremic syndrome itself) and the potential deleterious effect of protein and proteinaceous components (phosphorus, H’) on progression of renal insufficiency also favor this tendency toward protein malnutrition. A similar problem is encountered in the patient who has reached end-stage renal disease and requires dialytic therapy. Again, the tendency for malnutrition and the need to maximize protein intake are counterbalanced by the increase in intermediary nitrogenous products that follow protein feeding and produce uremic symptoms. Dialysis periodically removes some of these compounds and allows for some increase in protein intake. A balance between dialysis and protein intake is therefore needed so that nitrogenous waste levels are maintained below those which lead to uremia, while allowing near normal nutrition. As a first step, one has to identify an acceptable level for uremic toxins or at least compounds related to uremic toxins (e.g., urea, a marker for nitrogenous products of low molecular weight). Urea nitrogen kinetics will then allow for a dialysis prescription that, for a given protein intake, maintains the BUN in an acceptable range at the beginning of each hemodialysis treatment (usually between 80 and 100 mg/dl). Such a range will be found in a patient using an average dialyzer for 4 hours three times a week, with a daily protein consumption of about 1 g/kg body weight and about 30-35 kcal/ kg. Similarly, a regimen of four 2-liter exchanges a day provides the average CAPD patient with a comparable level of BUN throughout the day. One has to be careful, however, since a given level of BUN with a known dialytic prescription does not necessarily indicate a healthy, stable nitrogen balance. For instance, a urea nitrogen appearance rate of 11 g/day (equal to 70 g protein breakdown/day) may be the result of the consumption of 70 g of protein or 50 g protein intake plus 20 g of endogenous protein breakdown (catabolism). After having accurately defined a catabolic state, one should attempt to further identify the underlying pathophysiology. Consider, for example, two patients-an acutely ill, previously well-nourished patient, and one who has suffered months of chronic semistarvation. Each might have the same degree of