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Nutrition and Hypoalbuminuria
Effect of Growth Hormone on Biomarkers of Nutrition and Cardiovascular Disease
as well as on Quality of Life in Patients on Chronic Maintenance Haemodialysis
a report by
Bo Feldt-Rasmussen
Chief, Division of Nephrology, Rigshospitalet, University of Copenhagen
The number of patients with end-stage renal disease (ESRD) is rapidly HRQoL observed.
3,9
Biochemical and anthropometric markers of
increasing, primarily driven by the general increase in diabetes and nutrition – e.g. albumin, lean body mass (LBM), pre-albumin and
cardiovascular disease (see Figure 1).
1
In 2004, the overall incidence of transferrin – as well as inflammation – e.g. C-reactive protein (CRP) and
ESRD was 129 and 342 patients per million population in Denmark and interleukin (IL)-6 – have been strongly correlated with both mortality and
the US, respectively,
1,2
corresponding to an overall prevalence of 472,099 morbidity in these patients. This is exemplified in Figure 2, which shows
patients in the US.
1
Within Europe there are considerable differences in that risk of death increases with decreasing albumin levels in serum.
the incidence numbers, probably due to different levels of completeness
in national registries. Differences in incidence and prevalence in the Even if a strong correlation exists between markers of malnutrition and
background aetiologies – in particular diabetes – also play a role. The mortality and morbidity, and even if these markers can accurately predict
prevalence of diabetic patients in ESRD ranges from 22% in Denmark to risk of death, no clinical study has demonstrated that improvement of
approximately 39% in the US. these markers will lead to a decrease in mortality and morbidity. Recently,
however, data were published based on a retrospective evaluation of a
The mortality rate in patients on haemodialysis (HD) is 21% per year in longitudinal two-year cohort of 58,058 patients on chronic HD.
the US, but is generally – for reasons that remain to be elucidated – lower Interestingly, the data were the first to show that an increase in serum
in Western Europe (15–21% per year). The direct causes of mortality in albumin of 2g/l over a six-month period was a predictor of improved
the overall ESRD patient population are cardiovascular conditions (50%), survival in the following 18 months independent of baseline serum
infections (20%), malignancies (7%) and others (23%).
1
One of the main albumin. The authors conclude: “If this association is causal, an
risk factors linked to these causes of mortality is the general catabolic intervention that could increase serum albumin >3.8g/dl might reduce
state observed in these patients.
3
In addition to dialysis sessions, HD the number of MHD (maintenance haemodialysis) deaths in the US by
patients in the US are hospitalised for 14 days per year due to 10,000 annually.”
11
These findings have been supported by others.
12
co-morbidities.
1
Furthermore, the overall health-related quality of life Also, Rocco et al. recently demonstrated that failure to meet a treatment
(HRQoL) in these patients is dramatically reduced. goal of albumin exceeding 40g/l was associated with significantly
increased risk of death.
13
Malnutrition and Catabolism in Adult Patients on
Chronic Dialysis Although several interventions are available today for treatment of
A large group of adult patients on chronic maintenance HD (MHD) malnutrition in HD patients – e.g. dietary intervention, intradialytic
suffers from malnutrition caused by a combination of decreased food parenteral nutrition and nandrolone treatment
14,21
– these interventions
intake due to anorexia and multifactorial chronic catabolic state. It is are often of limited efficacy and not without compliance problems and
estimated that 20–55% of adult patients on chronic dialysis have side effects. Malnutrition and a high mortality rate remain a challenge in
clinically relevant signs of malnutrition,
4–8
the wide span being caused by the treatment of HD patients.
differences in nutritional assessment rather than actual differences
between populations. The majority of publications report 40–60% of In this context, growth hormone (GH) treatment may in the future
patients as malnourished. The state of malnutrition and the prove to be an important and efficient player due to its ability, through
malnutrition-induced systemic inflammation (and vice versa) have been anabolic effects, to improve biochemical markers of malnutrition. It
associated with the increased mortality and morbidity and decreased may thereby also reduce the morbidity and mortality of malnourished
patients on chronic MHD. This will be discussed in the following
sections, as will a new phase III trial soon to be launched in the US,
Bo Feldt-Rasmussen is Chief of the Division of Nephrology at
Europe and elsewhere.
Rigshospitalet, University of Copenhagen, Denmark. He is
Past President of the Danish Society of Nephrology and has
been a Board Member of the European Association of the
Growth Hormone Therapy
Study of Diabetes (EASD) and Chairman of the Post-graduate
The primary and most intensively studied action of the recombinant
Education Sub-Committee of the EASD (2001 to 2006).
He has published more than 130 scientific papers in human growth hormone (rhGH) somatropin is the stimulation of linear
international scientific journals. Dr Feldt-Rasmussen has been
growth in children. GH is approved in the US for the treatment of children
involved in a number of multinational intervention studies as
primary investigator and is a member of advisory boards.
with growth retardation due to GH deficiency (GHD), Turner syndrome,
idiopathic short stature and being born small for gestational age, and for
E: bo.feldt-rasmussen@rh.regionh.dk
adults with GHD (GHDA), short bowel syndrome and AIDS wasting.
Furthermore, in EU countries GH is approved for the treatment of short
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