Improvement of Albumin Control in Hemodialysis Patients—What Is Possible?

Murat H Sipahioglu, Nathan W Levin
US Nephrology, 2008;3(2):54-58
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Epidemiological studies have consistently shown a strong association between malnutrition and inflammation in dialysis patients.9 The term malnutrition–inflammation complex syndrome (MICS) is used to indicate the combination of malnutrition and inflammation in dialysis patients.10 Malnutrition with inflammation reduced albumin synthesis.11,12 Since MICS is common in dialysis patients,13 it may be the leading cause of low serum albumin in these patients. It is not obvious which of these two factors has a greater effect on serum albumin concentrations.14

Depending on the method used to determine nutritional status, the frequency of malnutrition in HD patients is reported to vary from 20 to 70%.15 When urea kinetic modeling is used, the routine measurement of protein catabolic rate (PCR) provides an insight into nutritional intake. The main reasons for malnutrition are loss of appetite (due to the effects of uremic toxins, pro-inflammatory cytokines, and leptin), medications that can impair nutrient absorption, inadequate dialysis dose and gastroparesis (by slowing gastric emptying due to autonomic neuropathy), and dietary restriction. Serum albumin concentration may decrease slightly with development of malnutrition. However, malnutrition alone has very little effect on plasma albumin level, as evidenced by the fact that anorexia nervosa patients do not show hypoalbuminemia until the terminal period of disease.16 Inflammation is a physiological response mounted against both the injurious agent and injured tissues. A chronic inflammatory process is common in end-stage renal disease (ESRD) patients and may be a major factor determining outcomes.

There are many potential reasons for inflammation in dialysis patients:

• encounter between blood and dialyzer surface, especially cuprophane and regenerated cellulose dialyzers—the use of such membranes is rare in the US;
• dialysate contaminated with endotoxin—endotoxin contamination of water for dialysis and dialysate is derived primarily from biofilm coating the internal surfaces of water and concentrate loops and tanks (predominately bicarbonate);
• catheters coated internally with biofilm after bacterial growth;
• infections, particularly from permanent jugular venous catheters;
• reduced clearance of pro-inflammatory cytokines;
• oxidative stress with reduced levels of antioxidants; and
• increased presence of comorbid conditions, for example sodium and fluid overload.

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