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Review
. 2022 Oct 25;14(21):4489.
doi: 10.3390/nu14214489.

Fluid Overload and Tissue Sodium Accumulation as Main Drivers of Protein Energy Malnutrition in Dialysis Patients

Bernard Canaud  1   2 , Marion Morena-Carrere  3 , Helene Leray-Moragues  4 , Jean-Paul Cristol  3   4
Affiliations
Review

Fluid Overload and Tissue Sodium Accumulation as Main Drivers of Protein Energy Malnutrition in Dialysis Patients

Bernard Canaud et al. Nutrients. .

Abstract

Protein energy malnutrition is recognized as a leading cause of morbidity and mortality in dialysis patients. Protein-energy-wasting process is observed in about 45% of the dialysis population using common biomarkers worldwide. Although several factors are implicated in protein energy wasting, inflammation and oxidative stress mechanisms play a central role in this pathogenic process. In this in-depth review, we analyzed the implication of sodium and water accumulation, as well as the role of fluid overload and fluid management, as major contributors to protein-energy-wasting process. Fluid overload and fluid depletion mimic a tide up and down phenomenon that contributes to inducing hypercatabolism and stimulates oxidation phosphorylation mechanisms at the cellular level in particular muscles. This endogenous metabolic water production may contribute to hyponatremia. In addition, salt tissue accumulation likely contributes to hypercatabolic state through locally inflammatory and immune-mediated mechanisms but also contributes to the perturbation of hormone receptors (i.e., insulin or growth hormone resistance). It is time to act more precisely on sodium and fluid imbalance to mitigate both nutritional and cardiovascular risks. Personalized management of sodium and fluid, using available tools including sodium management tool, has the potential to more adequately restore sodium and water homeostasis and to improve nutritional status and outcomes of dialysis patients.

Keywords: dialysis adequacy; fluid depletion; fluid overload; malnutrition; sodium; water.

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Conflict of interest statement

BC is scientific consultant for FMC, MM-C, HL-M, J-PC have no conflict of interest.

Figures

Figure 1
Figure 1
Causes of protein–energy malnutrition in dialysis patients.
Figure 2
Figure 2
Clustering factors that favor the protein–energy-wasting process.
Figure 3
Figure 3
Proposed pathophysiologic link between sodium, fluid volume, and PEM.
Figure 4
Figure 4
Four clinical steps involved in sodium, water, and fluid volume management in HD patient.
See this image and copyright information in PMC

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