[Results of therapeutics strategy of protein-energy wasting in chronic hemodialysis: a prospective study during 12 months]

Introduction: Undernutrition (UN) in chronic hemodialysis (CHD) is a recurrent complication and constitutes a major public health problem. This work aims to evaluate the effects of our nutritional strategy (NS) developed among malnourished patients (pts) in CHD. This is a prospective observational study conducted for 12 months (M) in a cohort of 132 pts in CHD including 49 women, mean age 66 ± 16 years and the dialysis vintage 72 ± 74 months. This NS is based on the action of a multidisciplinary team; it provides for moderate UN pts one first phase of an optimization of protein and energy intake in the daily meals; then depending on the clinical course a second phase of oral supplementation at home. For severe UN pts, the optimization of daily meals and the oral supplements at home are reinforced with perdialytic oral supplementation. This modality was also prescribed for moderate UN pts with poor compliance at home. In case of loss of appetite, anorexia, gastrointestinal intolerance or inadequate oral intakes the relay is made by the intradialytic parenteral nutrition (IPN). Methods consist in the evaluation of the serum albumin (ALB), CRP, normalized PCR (nPCR), and Kt/V ratio of urea at baseline (day (D) 0) and at endpoint (M12). The ALB was measured by immunoturbidimetry. Three nutritional profiles were defined, severe UN if ALB ≤ 35 g/L, moderate UN if 35 <ALB <38 g/L, no UN if ALB ≥ 38 g/L. The therapeutic goal is to obtain a target ALB ≥ 38 g/L, protein intake exceeding 1g/kg/d and energy intake exceeding 35 Kcal/kg/d. The criteria of effectiveness are obtaining the ALB defined target, changes in numbers of pts in 3 nutritional profiles and mortality rate on 1 year.

Results: We observe a significant improvement in all nutritional indicators at M12. The numbers of pts with severe UN and moderate UN decreased (P < 0,05), respectively from 32 to 14% and from 27 to 18% (D0 versus M12). The UN frequency has been reduced about 50% (P < 0,05) lowering from 59 to 32%. The mortality rate of 4% (5/132 pts) in 1 year was very low. The therapeutic goal is achieved under the conjunction of 3 essential conditions, the improvement of the inflammatory syndrome, an effective dialysis and optimal protein and caloric intake. At the start and the end of the study, the role of inflammation appears crucial because ALB is greater if CRP <10mg/L versus CRP ≥ 10 mg/L (at M12: 40 versus 38 g/L, P = 0.002); an inverse correlation is observed between CRP and ALB (R(2) = 0,080, P = 0.002).

Conclusion: An effective NS reduces the frequency of UN in CHD, improves the quality of life the pts and lowers mortality rates. An oral nutritional supplement during dialysis constitutes an important component of treatment. The control of inflammation and optimizing dialysis are decisive factors of success.