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Diets and enteral supplements for improving outcomes in chronic kidney disease

Nature Reviews Nephrology volume 7, pages 369–384 (2011)Cite this article

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Abstract

Protein-energy wasting (PEW), which is manifested by low serum levels of albumin or prealbumin, sarcopenia and weight loss, is one of the strongest predictors of mortality in patients with chronic kidney disease (CKD). Although PEW might be engendered by non-nutritional conditions, such as inflammation or other comorbidities, the question of causality does not refute the effectiveness of dietary interventions and nutritional support in improving outcomes in patients with CKD. The literature indicates that PEW can be mitigated or corrected with an appropriate diet and enteral nutritional support that targets dietary protein intake. In-center meals or oral supplements provided during dialysis therapy are feasible and inexpensive interventions that might improve survival and quality of life in patients with CKD. Dietary requirements and enteral nutritional support must also be considered in patients with CKD and diabetes mellitus, in patients undergoing peritoneal dialysis, renal transplant recipients, and in children with CKD. Adjunctive pharmacological therapies, such as appetite stimulants, anabolic hormones, and antioxidative or anti-inflammatory agents, might augment dietary interventions. Intraperitoneal or intradialytic parenteral nutrition should be considered for patients with PEW whenever enteral interventions are not possible or are ineffective. Controlled trials are needed to better assess the effectiveness of in-center meals and oral supplements.

Key Points

  • Protein-energy wasting (PEW) is common in patients with chronic kidney disease (CKD) and is manifested by low serum levels of albumin or prealbumin, sarcopenia, and weight loss

  • PEW is one of the strongest predictors of mortality in patients with CKD

  • Although PEW might be the result of non-nutritional conditions, dietary interventions such as enteral feeding with high-protein meals or supplements might improve nutritional status and outcomes

  • In-center meals and oral supplements during dialysis therapy and at home are inexpensive interventions that might improve survival and quality of life in patients with CKD

  • Adjunctive pharmacological therapies, such as appetite stimulants, anabolic hormones, and antioxidative or anti-inflammatory agents, might augment dietary interventions

  • Intraperitoneal or intradialytic parenteral nutrition should be considered for patients with PEW whenever enteral interventions are not possible or ineffective

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Figure 1: Baseline serum albumin concentration and survival in patients on hemodialysis.
Figure 2: Change in serum albumin levels and survival in hemodialysis patients.
Figure 3: Effect of nutritional therapy modality on forearm muscle homeostasis.
Figure 4: Serum albumin concentration and survival in patients with nondialysis-dependent CKD.
Figure 5: Proposed algorithm for enteral nutritional support in patients with CKD.

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Acknowledgements

The authors' work was supported by research grants R01 DK078106, R21 DK078012, and R21 DK077341 from the National Institute of Diabetes and Digestive and Kidney Diseases of the NIH, and a philanthropic grant from H. Simmons.'

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Authors and Affiliations

  1. Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, 90502, CA, USA

    Kamyar Kalantar-Zadeh & Rajnish Mehrotra

  2. Clermont Université, Université d'Auvergne, Unité de Nutrition Humaine, F-63000 Clermont-Ferrand, France

    Noël J. Cano

  3. Medizinische Klinik Nephrologie, Charité Berlin, Berlin, D-10117, Germany

    Klemens Budde

  4. NephroCare, Tassin, 69160, France

    Charles Chazot

  5. Salem VA Medical Center, Salem, 24153, VA, USA

    Csaba P. Kovesdy

  6. University of California, San Diego, La Jolla, 92093-0634, CA, USA

    Robert H. Mak

  7. The George Washington University, 20052, DC, Washington, USA

    Dominic S. Raj

  8. Case Western Reserve University, 44106, OH, Cleveland, USA

    Ashwini R. Sehgal

  9. Karolinska University Hospital, Stockholm, 14186, Sweden

    Peter Stenvinkel

  10. Vanderbilt University Medical Center, Nashville, 37232, TN, USA

    T. Alp Ikizler

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Contributions

All the authors researched data to include in the manuscript, contributed to discussion of content for the article, reviewed and edited the manuscript before submission, and revised the manuscript in response to the peer-reviewers' comments.

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Correspondence to Kamyar Kalantar-Zadeh.

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Competing interests

K. Kalantar-Zadeh has received grant/research support from Abbott Nutrition, B. Braun, National Kidney Foundation, Novo Nordisk, NutrePletion and Pentec Health. He has received speakers bureau honoraria from Abbott Nutrition. N. J. Cano has received grant/research support from Baxter, Danone, Fresenius Kabi and Nestlé. He has received speakers bureau honoraria from B. Braun and Danone. C. Chazot has worked as a consultant for Fresenius Medical Care and received grant/research support and speakers bureau honoraria from Fresenius Medical Care. C. Kovesdy has received grant/research support from Abbott Nutrition. R. Mak has received grant/research support from Abbott. R. Mehrotra has received grant/research support and speakers bureau honoraria from Baxter Healthcare. P. Stenvinkel has worked as a consultant for Abbott. T. A. Ikizler has worked as a consultant for Abbott Nutrition, Abbott Renal Care, Fresenius Medical Care and Renal Advantage, and received grant/research support from Fresenius Medical Care.

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Kalantar-Zadeh, K., Cano, N., Budde, K. et al. Diets and enteral supplements for improving outcomes in chronic kidney disease. Nat Rev Nephrol 7, 369–384 (2011). https://doi.org/10.1038/nrneph.2011.60

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