PEWの予防・治療：ISRNMコンセンサス

ISRNM（国際腎臓栄養代謝学会）による慢性腎臓病（CKDのStage3～5）のPEW（protein energy wasting） の予防と治療に関するコンセンサス論文を紹介します。

Ikizler TA, Cano NJ, Franch H, Fouque D, Himmelfarb J, Kalantar-Zadeh K, Kuhlmann MK, Stenvinkel P, Terwee P, Teta D, Wang AY, Wanner C. Prevention and treatment of protein energy wasting in chronic kidney disease patients: a consensus statement by the International Society of Renal Nutrition and Metabolism. Kidney Int. 2013 May 22. doi: 10.1038/ki.2013.147. [Epub ahead of print]

系統的レビューではないので偏りがあるかもしれません。栄養療法の有用性はかなり強調されています。栄養介入で死亡率を改善したという大規模RCTはありませんが、栄養状態が改善することで生命予後も改善するのではと考えられています。

現状では栄養療法に蛋白同化ステロイド、成長ホルモン、運動療法を併用した統合的な治療が最も有用なようです。これはまさにリハ栄養ですね。PEWに対する薬物療法のRCTがこれほど多く行われているとは知りませんでした…。日本でもやっているのでしょうか。

Abstract

Protein energy wasting (PEW) is common in patients with chronic kidney disease (CKD) and is associated with adverse clinical outcomes, especially in individuals receiving maintenance dialysis therapy. A multitude of factors can affect the nutritional and metabolic status of CKD patients requiring a combination of therapeutic maneuvers to prevent or reverse protein and energy depletion. These include optimizing dietary nutrient intake, appropriate treatment of metabolic disturbances such as metabolic acidosis, systemic inflammation, and hormonal deficiencies, and prescribing optimized dialytic regimens. In patients where oral dietary intake from regular meals cannot maintain adequate nutritional status, nutritional supplementation, administered orally, enterally, or parenterally, is shown to be effective in replenishing protein and energy stores. In clinical practice, the advantages of oral nutritional supplements include proven efficacy, safety, and compliance. Anabolic strategies such as anabolic steroids, growth hormone, and exercise, in combination with nutritional supplementation or alone, have been shown to improve protein stores and represent potential additional approaches for the treatment of PEW. Appetite stimulants, anti-inflammatory interventions, and newer anabolic agents are emerging as novel therapies. While numerous epidemiological data suggest that an improvement in biomarkers of nutritional status is associated with improved survival, there are no large randomized clinical trials that have tested the effectiveness of nutritional interventions on mortality and morbidity.Kidney International advance online publication, 22 May 2013; doi:10.1038/ki.2013.147.