Cachexia and protein-energy wasting in children with chronic kidney disease

Children with chronic kidney disease (CKD) are at risk for “cachexia” or “protein-energy wasting” (PEW). These terms describe a pathophysiologic process resulting in the loss of muscle, with or without loss of fat, and involving maladaptive responses, including anorexia and elevated metabolic rate. PEW has been defined specifically in relation to CKD. We review the diagnostic criteria for cachexia and PEW in CKD and consider the limitations and applicability of these criteria to children with CKD. In addition, we present an overview of the manifestations and mechanisms of cachexia and PEW. A host of pathogenetic factors are considered, including systemic inflammation, endocrine perturbations, and abnormal neuropeptide signaling, as well as poor nutritional intake. Mortality risk, which is 100- to 200-fold higher in patients with end-stage renal disease than in the general population, is strongly correlated with the components of cachexia/PEW. Further research into the causes and consequences of wasting and growth retardation is needed in order to improve the survival and quality of life for children with CKD.     

Protein energy wasting in children with chronic kidney disease

Background

In adults with chronic kidney disease (CKD), protein-energy wasting (PEW) is a risk factor for hospitalization and death. However, PEW in children with CKD is not well characterized or defined.

Methods

Using data from the Chronic Kidney Disease in Children study, we assessed three alternate definitions of PEW using biochemical parameters, body and muscle mass measurements, and reported appetite as described in adults: (1) a minimal PEW definition (≥2 of the four criteria); (2) a standard PEW definition (≥3 of the four criteria); (3) a modified PEW definition (≥3 of the four criteria plus a pediatric-focused criterion of short stature or poor growth).

Results

Of the 528 children analyzed in this study (median age 12 years, median glomerular filtration rate 45 mL/min/1.73 m², 39 % female, 18 % African American), 7–20 % met the spectrum of definitions for PEW. The unadjusted incidence rates for incident hospitalizations were 1.9-, 2.1-, and 2.2-fold higher for those children diagnosed with PEW using the minimal, standard, and modified definitions, respectively (P?=?0.08, 0.09 and 0.03). Following adjustment, only the modified PEW definition, which added short stature or poor growth as a criterion, showed modest significance (P?=?0.06).

Conclusions

The inclusion of a criterion based on growth may augment the definition of PEW and improve risk discrimination in children with CKD.     

Cerebral salt wasting syndrome: experimental study in rats

Introduction

The cerebral salt wasting syndrome (CSWS) is characterized by hyponatraemia secondary to excessive natriuesis with osmotic duiresis. This syndrome, frequently, occurs after subarachnoid haemorrhage (SAH), but may occur after any acute cerebral aggression.

Objectives

The aim of the study was to assess the frequency of the CSWS in animal models with, SAH, cerebral ischemia (CI), and cranial trauma (CT), and its correlation with the secretion of brain natriuretic peptide (BNP).

Method

Four groups of rats were selected: group SAH (n = 7) consisted of SAH induced by perforation of the carotid artery in its intracerebral part; group CI (n = 7) consisted of CI induced by ligature of the carotid artery; group CT (n = 7) consisted of induced CT; and a control group Sham (n = 7). Weight, serum sodium, BNP, and urinary sodium, were measured at baseline and 24 hours after.

Results

Rats with SAH had significant natriuresis and diuresis with negative sodium balance (–95.9 ± 447.4 μmol) with a significant difference (P < 0.05) compared to the rats of the CI and the Sham groups. There was no difference in the 24 hours level of BNP between the four different groups.

Conclusion

We conclude that SAH, in animal models, induced high diuresis with negative sodium balance in the first 24 hours. These findings were absents in the others groups. This was independent of the BNP secretion and may correspond to the early occurrence of a CSWS.     

The use of custom-designed midfacial and submalar implants in the treatment of facial wasting syndrome

Facial wasting syndrome is part of a lipodystrophy that occurs as a complication of highly active antiretroviral therapy. The loss of subcutaneous fat in the cheeks and temples results in a hollow-eyed, bony, emaciated appearance that is characteristic of the results of treatment of human immunodeficiency virus. Cessation of therapy results in a rebound in viral load and subsequent morbidity. The appearance of facial wasting syndrome is optimally treated with custom-designed implants that are made using high-resolution computed tomography combined with surgeon input and computer-aided design and manufacturing technology. Twenty-two patients with facial wasting syndrome were treated using either submalar implants (in more moderate cases) or custom-designed implants (in more severe cases). In each patient, the appearance of volumetric soft tissue restoration was successfully achieved, returning a permanent and more healthful appearance to the face.     

Renal salt wasting syndrome induced by Cisplatin: a case report

A 69-year-old woman diagnosed with a urinary carcinoma was admitted to the hospital for chemotherapy consisting of cisplatin (CDDP) and gemcitabine. Two days after administration of CDDP, she complained of general fatigue. The total urine volume was 5, 500 ml/day. Three days after she received CDDP, her serum sodium level decreased to 118 mEq/l, leading to disturbed consciousness. After the intravenous administration of saline, her serum sodium levels recovered to the normal value (137 mEq/l) without any complications. The diagnosis of renal salt-wasting syndrome was made on the basis of hyponatremia, high urinary sodium excretion and increased urinary output.     

CKD 3期患者随机尿蛋白/尿肌酐比值与24h尿蛋白定量的相关性分析

目的：分析随机尿蛋白/尿肌酐比值与24 h尿蛋白定量的相关性,探讨随机尿蛋白/尿肌酐比值是否可以替代24 h尿蛋白定量,检测尿蛋白的排泄情况。方法：对184例慢性肾脏病（CKD）3期患者同时留取随机尿和24 h尿液标本,分别进行随机尿蛋白,尿肌酐与24 h尿蛋白定量测定,计算随机尿蛋白/尿肌酐比值,与24 h尿蛋白定量结果进行相关性分析。应用ROC曲线分析24 h尿蛋白定量≥1.0 g和≥0.15 g时与随机尿蛋白/尿肌酐比值间的相对应关系。结果：随机尿蛋白/尿肌酐比值与24 h尿蛋白定量呈良好正相关（r=0.771,P〈0.001）。应用ROC曲线分析随机尿蛋白/尿肌酐比值相应24 h尿蛋白定量1.00 g及0.15 g的诊断界点分别为0.83 g/gcr及0.16 g/gcr时敏感性与特异性最佳。结论：随机尿蛋白/尿肌酐比值可以反映CKD3期患者的尿蛋白排泄量,可替代24 h尿蛋白定量。     

Cachexia, malnutrition, the refeeding syndrome, and lessons from Goldilocks

Cachexia has plagued clinicians for centuries. Although all cachexia is related to malnutrition, cachexia associated with malignant diseases differs from starvation cachexia in that it is more recalcitrant to nutritional therapy. All cachexia responds to judicious nutritional support; however, cancer cachexia worsens autonomously as the disease advances and cannot be arrested or reversed by any known form of nutrition, hormonal, or pharmacologic therapy. Cachexia must be treated cautiously to avoid overfeeding syndrome, which may result in serious or dangerous complications or death.     

Fat-soluble vitamins in advanced CKD/ESKD: a review

Patients requiring dialysis often experience a significant decline in their nutritional status through a combination of chronic disease, reduced appetite, and dietary restrictions, which places them at risk for vitamin deficiencies. The concept of vitamin deficiency has evolved from obvious deficiency states to the subtle effects that suboptimal intake may have on chronic disease prevalence or progression. The purpose of this study was to summarize the current state of knowledge regarding the status of the fat-soluble vitamins (A, D, E, and K) in patients with chronic kidney disease receiving hemodialysis.     

Hyponatremia in neurologic intensive care: cerebral salt wasting syndrome and inappropriate antidiuretic hormone secretion

Hyponatraemia is a frequent complication in neurologically injured patients; it is a secondary cerebral injury. Hyponatraemia leads to consciousness problems, convulsions, worsening of the neurological status and thus the neurological evaluation. Hyponatraemia is secondary to free water retention (inappropriate ADH secretion) or to renal salt loss. The cerebral salt wasting syndrome (CSWS) has been described with head injury, subarachnoid haemorrhage and after several sorts of brain insults. It is characterised by an increased natriuresis and diuresis. Diagnosis is based on hyponatraemia, hypernatriuresis, increased diuresis and hypovolaemia. However, inappropriate ADH secretion and CSWS share several diagnostic criteria. The atrial natriuretic factor and the C-type natriuretic factors play a role in the development of the CSWS. The diagnostic approach and monitoring are based on the assessment of sodium and water losses. Therapy is based on correction of the circulating volume and natraemia. Speed of correction is a matter of debate: slow correction presents the risk of further neurological injury whereas rapid correction presents the risk of central pontine myelinosis.     

粉尘爆炸的成因与防治

With the development of industrial technology,dust explosion accidents have increased,causing serious losses of people's lives and property.With the development of economy,we should lay further emphasi...     

Cerebral salt wasting syndrome in a patient with viral meningoencephalitis

A 53-year-old male was admitted to our hospital for a high fever. He suffered a change in personality, memory loss and disorientation as well. The findings of cerebrospinal fluid showed monocytosis, but the titers of glucose, C1 and ADA were all normal. Although there was no bacterium in the CSF, the patient's electroencephalography finding was abnormal. We diagnosed his condition as viral meningoencephalitis and started treatment with antiviral agents. Blood chemistry showed serum sodium of 130 mEq/l and plasma osmolarity was reduced to 272 mOsm/kg, while urine osmolarity was high at 353 mOsm/kg. Two potential causes of hyponatremia in this patient were the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) or cerebral salt wasting syndrome (CSWS). Physical findings revealed a contracted extracellular fluid volume, strongly suggesting the presence of CSWS. The massive urine sodium loss overcoming sodium intake supported this diagnosis. After treatment with vigorous sodium and volume replacement for over 4 weeks, hyponatremia as well as meningoencephalitis were improved without any complication. To the best of our knowledge, this is the first report on CSWS in a patient with viral meningoencephalitis.     

Protein versus energy in protein energy malnutrition

The balance of evidence indicates that protein deficiency is more constant than energy deficiency in cases of kwashiorkor. I suggest that well-conducted dietary histories with early home visits would confirm this in South African cases. In areas and groups from which kwashiorkor patients come, a pre-kwashiorkor state has to be detected by laboratory tests, e.g. plasma albumin measurement. Simple anthropometric measurements are not enough. Strategies for prevention must depend on local attitudes and resources, but throughout the world enthusiasm for protein-rich vegetable mixtures has waned. Selective provision of milk powder for sick children in clinics may be a cost-effective measure.