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The recent research findings concerning syndromes of muscle wasting, malnutrition, and inflammation in individuals with chronic kidney disease (CKD) or acute kidney injury (AKI) have led to a need for new terminology. To address this need, the International Society of Renal Nutrition and Metabolism (ISRNM) convened an expert panel to review and develop standard terminologies and definitions related to wasting, cachexia, malnutrition, and inflammation in CKD and AKI. The ISRNM expert panel recommends the term 'protein-energy wasting' for loss of body protein mass and fuel reserves. 'Kidney disease wasting' refers to the occurrence of protein-energy wasting in CKD or AKI regardless of the cause. Cachexia is a severe form of protein-energy wasting that occurs infrequently in kidney disease. Protein-energy wasting is diagnosed if three characteristics are present (low serum levels of albumin, transthyretin, or cholesterol), reduced body mass (low or reduced body or fat mass or weight loss with reduced intake of protein and energy), and reduced muscle mass (muscle wasting or sarcopenia, reduced mid-arm muscle circumference). The kidney disease wasting is divided into two main categories of CKD- and AKI-associated protein-energy wasting. Measures of chronic inflammation or other developing tests can be useful clues for the existence of protein-energy wasting but do not define protein-energy wasting. Clinical staging and potential treatment strategies for protein-energy wasting are to be developed in the future.

Oxidative stress and cardiovascular disease are risk factor of patients with chronic kidney disease (CKD) on maintenance hemodialysis. We used the fluorescence of low-density lipoprotein as an index of its proinflammatory potential to examine any role that high-density lipoprotein (HDL) might have in promoting this effect. The total body fat of the patients was measured by means of near-infrared interactance and their quality of life by means of SF36 questionnaires. In 189 randomly selected patients, followed for 30 months, HDL was found to be significantly anti-inflammatory but with a large standard deviation. Fully 17% of the patients had a decidedly proinflammatory index along with inferior SF36 scores. The patients were divided into 10% increments of total body fat percentages up to 40%. HDL was found to be progressively proinflammatory the higher the body fat content. Patients with a higher HDL proinflammatory index had a higher 30-month adjusted hazard ratio for death than those whose HDL were seen to be anti-inflammatory. Our findings suggest an important role of inflammatory HDL in patients with CKD leading to poor outcome.Kidney International (2007) 72, 1149–1156; doi:10.1038/sj.ki.5002491; published online 29 August 2007 [ABSTRACT FROM AUTHOR]

Objectives: Lymphocyte percentage (LYM%), an independently measured value to reflect peripheral lymphocyte count and a possible nutritional marker, may be related to clinical outcome in maintenance dialysis (MHD) patients. Study design and setting: We examined the associations of the baseline white blood cell count (WBC) and LYM% with 12-month mortality and three measures of hospitalization in a cohort of 1,283 MHD patients from 10 outpatient DaVita dialysis clinics in Los Angeles County, as well as in a subcohort of 372 MHD patients with additional measures of inflammation, nutrition and comorbidity. Multivariate Cox and Poisson models that included 13 co-variates including case-mix features, dialysis dose, blood hemoglobin and serum albumin were explored. Results: Patients, aged 57.8 ± 15.2 years, included 49% men and 49% diabetics. Baseline WBC was 7,353 ± 2.427 per μl, and LYM% was 21.2 ± 7.3%. LYM% had significant correlations with "malnutrition-inflammation score" and inverse correlations with serum interleukin-6. The WBC and LYM% had significant but opposite predicting values for mortality and hospitalization, indicating that a high WBC and a low LYM% were each independently associated with increased mortality. After dividing each variable into four quartiles, only the highest WBC quartile (⩾ 8,500) but not the other middle two quartiles, predicted increased mortality. However, all three lower quartiles of LYM% vs. the highest quartile (based on quartile cutoffs of 16%, 20.3% and 25.5%) were significantly and progressively associated with greater risks of mortality and hospitalizations. The absolute lymphocyte count (LYM% times WBC/100) exhibited somewhat similar trends but its outcome predictability was not as strong as LYM%. Conclusions: A high WBC and a low LYM% are associated with significant increase in mortality and hospitalization in MHD patients. Lymphocyte percentage, compared to absolute lymphocyte count, appears to be a better nutritional and anti-inflammatory marker and a more sensitive predictor of mortality and hospitalization in MHD patients. [ABSTRACT FROM AUTHOR]

There is a high prevalence of protein-energy malnutrition in both nondialyzed patients with advanced chronic renal failure and in those individuals with end-stage renal disease who are receiving maintenance hemodialysis or chronic peritoneal dialysis therapy. Approximately one-third of maintenance dialysis patients have mild to moderate protein-energy malnutrition, and about 6 to 8 percent of these individuals have severe malnutrition. These statistics are of major concern because markers of protein-energy malnutrition are strong predictors of morbidity and mortality. The causes of protein-energy malnutrition in patients with chronic renal failure include: (1) decreased energy or protein intake; (2) concurrent chronic illnesses, and superimposed acute illnesses and possibly increased inflammatory cytokines; (3) the catabolic stimulus of hemodialysis; (4) losses of nutrients into dialysate, particularly amino acids, peptides, protein (with peritoneal dialysis), glucose (when hemodialysis is performed with glucose-free dialysate) and water-soluble vitamins; and (5) diagnostic or therapeutic (e.g., prednisone therapy) procedures that reduce nutrient intake or engender net protein breakdown. Other theoretically possible causes for protein-energy malnutrition include (6) chronic blood loss; (7) endocrine disorders (especially resistance to insulin and insulin-like growth factor-I, hyperglucagonemia, hyperparathyroidism and deficiency of 1,25-dihydroxycholecalciferol); (8) products of metabolism that accumulate in renal failure and may induce wasting, such as organic and inorganic acids; (9) loss of the metabolic actions of the kidney; and (10) the accumulation of toxic compounds that are taken up from the environment (e.g., aluminum). [ABSTRACT FROM AUTHOR]