Associations of Dietary Protein and Energy Intakes With Protein-Energy Wasting Syndrome in Hemodialysis Patients

Abstract

Introduction: The associations of dietary protein and/or energy intakes with protein or energy wasting in patients on maintenance hemodialysis are controversial. We examined these in the Hemodialysis (HEMO) Study.

Methods: In 1487 participants in the HEMO Study, baseline dietary protein intake (grams per kilogram per day) and dietary energy intake (kilocalories per kilograms per day) were related to the presence of the protein-energy wasting (PEW) syndrome at month 12 (defined as the presence of at least 1 criteria in 2 of the 3 categories of low serum chemistry, low body mass, and low muscle mass) in logistic regression models. In additional separate models, protein intake estimated from equilibrated normalized protein catabolic rate (enPCR) was also related to the PEW syndrome.

Results: Compared with the lowest quartile, the highest quartile of baseline dietary protein intake was paradoxically associated with increased risk of the PEW syndrome at month 12 (odds ratio [OR]: 4.11; 95% confidence interval [CI]: 2.79-6.05). This relationship was completely attenuated (OR: 1.35; 95% CI: 0.88-2.06) with adjustment for baseline body weight, which suggested mathematical coupling. Results were similar for dietary energy intake. Compared with the lowest quartile of baseline enPCR, the highest quartile was not associated with the PEW syndrome at 12 months (OR: 0.78; 95% CI: 0.54-1.12).

Discussion: These data do not support the use of dietary protein intake or dietary energy intake criteria in the definition of the PEW syndrome in patients on maintenance hemodialysis.

Keywords: chronic kidney disease; hemodialysis; protein-energy wasting.

Figure 1

Prevalence of protein-energy wasting (PEW) criteria at month 12 in the entire cohort (N = 1487). BMI, body mass index; MAMC, mid-arm mass circumference; Wt, weight.

Figure 2

Scatterplots of baseline dietary protein intake (DPI) with month 12 protein-energy wasting variables.

Figure 3

Scatterplots of baseline dietary energy intake (DEI) with month 12 protein-energy wasting variables.

Figure 4

Scatterplots of baseline equilibrated normalized protein catabolic rate (enPCR) with month 12 protein-energy wasting variables.

Figure 5

Logistic regression models relating baseline dietary protein intake (DPI) and dietary energy intake (DEI) quartiles to the presence of the protein-wasting energy (PEW) syndrome at month 12 without (panels a and c) and with (panels b and d) adjustment for baseline body weight (N = 1487). (a,c) Model adjusted for baseline age, sex, race, duration of end-stage renal disease, dialysis access, Kt/V, flux group, smoking, alcohol use, diabetes, IHD, cerebrovascular disease, pulmonary vascular disease, congestive heart failure, cancer, and clinical center. (b,d) Model with additional adjustment for baseline postdialysis weight. CI = confidence interval; IHD = ischemic heart disease; OR = odds ratio.

Figure 6

Natural cubic spline regression models relating baseline dietary protein intake (DPI) and dietary energy intake (DEI) as continuous variables with the presence of the protein-wasting energy (PEW) syndrome at month 12 without and with adjusting for baseline body weight (N = 1487). (a,c) Model adjusted for baseline age, sex, race, duration of end-stage renal disease, dialysis access, Kt/V, flux group, smoking, alcohol use, diabetes, IHD, cerebrovascular disease, pulmonary vascular disease, congestive heart failure, cancer, and clinical center. (b,d) Model with additional adjustment for baseline postdialysis weight. CI = confidence interval; IHD = ischemic heart disease.

Figure 7

Logistic and spline regression models relating baseline equilibrated normalized protein catabolic rate (enPCR) to the presence of the protein-wasting energy (PEW) syndrome at month 12 without and with adjustment for baseline body weight (N = 1487). (a,c) Model adjusted for baseline age, sex, race, duration of end-stage renal disease, dialysis access, Kt/V, flux group, smoking, alcohol use, diabetes, IHD, cerebrovascular disease, pulmonary vascular disease, congestive heart failure, cancer, and clinical center. (b,d) Model with additional adjustment for baseline postdialysis weight. CI = confidence interval; IHD = ischemic heart disease.