Inflammation nutritional state and outcome in end stage renal disease.

Hypoalbuminemia and reduction in lean body mass are potentially a reflection of malnutrition and portend a poor prognosis in patients with end stage renal disease (ESRD). The classic understanding of this relationship has been that ESRD patients receive insufficient dialysis, reduce dietary intake and become malnourished. Inflammation also causes many of the same changes in serum protein composition and in body morphometry as malnutrition does even with adequate calorie and protein intake. It has recently been recognized that this, the acute phase response, occurs with frequency in ESRD patients and that both the physical attributes of malnutrition and reduction in the serum concentration of albumin, transferrin, prealbumin and apolipoprotein A-I all may lack a nutritional base. The serum concentration of the acute phase proteins, C reactive protein (CRP) and serum amyloid A (SAA), as well as the cytokines orchestrating the acute phase response, predict albumin concentration as well as a number of clinically important outcomes: specifically, erythropoietin resistance rejection of renal transplant and survival. ESRD per se does not cause the acute phase response, and indeed may blunt the response to infection. Activation of the acute phase response may be a consequence of the interaction of mononuclear cells with dialysis membranes, especially cuprophane, with endotoxin in dialysate, or represents either clinically evident or obscure infection. Evaluation of the acute phase response by measurement of CRP is advisable in the evaluation of hypoalbuminemia or other stigmata of malnutrition in dialysis patients.