APPETITE STIMULATION IN
DIALYSIS PATIENTS
Anne Marie Liles, PharmD, BCPS
Disclosures

I have nothing to disclose
Objectives
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
Describe the morbidity/mortality due to malnutrition
in patients with Chronic Kidney Disease (CKD).
Identify drug and non-drug treatments of
malnutrition in dialysis patients.
Describe the approach to treatment of malnutrition
in patients on dialysis.
Definitions
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Nutritional status = assessment of visceral and
muscle protein stores and energy balances
Protein energy wasting (PEW) = metabolic and
nutritional derangements
Cachexia = severe form of PEW
Ikizler TA. Optimal nutrition in hemodialysis patients. Adv Chronic Kidney Dis. 2013 March; 20 (2): 181-189.
Ebner N, et al. Mechanism and novel therapeutic approaches to wasting in chronic disease. Maturitas 2013; 75: 199-206.
Epidemiology of PEW
What is the prevalence of PEW in patients
receiving dialysis?
A. 20%
B. 30%
C. 40%
D. 60%
Epidemiology of PEW
Prevalence ranges from 20-60%
Ikizler TA. Optimal nutrition in hemodialysis patients. Adv Chronic Kidney Dis. 2013 March; 20 (2): 181-189.
Causes of PEW
Inadequate
Nutrient Intake
Inadequate
dose of dialysis
Nutrient losses
Increased energy
expenditure
Protein-Energy
Wasting
Co-morbidities,
Inflammation
Frequent hospitalizations
Metabolic and hormonal
derangements
Insulin resistance/
deprivation
Ikizler TA. Optimal nutrition in hemodialysis patients. Adv Chronic Kidney Dis. 2013 March; 20 (2): 181-189.
Consequences of PEW
Protein Energy Wasting
of CKD
↑ hospitalizations
↑ mortality
Ikizler TA, Cano NJ, Franch H, et al. 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; 84: 1096-1107.
Consequences of PEW
↓ Survival
Carrero JJ, et al. Am J Clin Nutr 2007 Mar; 85(3): 695-701.
↑Hospitalization
Lopes AA, et al. Nephrol Dial Transplant 2007; 22(12): 3538-3546.
Prevention of PEW
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Repeated nutritional counseling
Optimize renal replacement therapy (RRT) prescriptions
Optimize nutrient intake
Manage comorbidities
Metabolic acidosis
 Diabetes
 Inflammatory conditions
 Heart failure
 Depression

http://www.barnesjewish.org/wellawarefitness-center/nutritional-counseling
Ikizler TA, Cano NJ, Franch H, et al. 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; 84: 1096-1107.
When to Initiate Treatment
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Poor appetite or poor oral intake
↓ Dietary protein intake or dietary energy intake
Albumin < 3.8 g/dL or pre-albumin < 28 mg/dL
Unintentional weight loss
Worsening nutritional markers over time
Subjective global assessment (SGA) in PEW range
Ikizler TA, Cano NJ, Franch H, et al. 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; 84: 1096-1107.
Approach to Treatment
Start oral nutritional supplements
No improvement or worsening
Intensified therapy
• Alter RRT prescriptions
• Increase quantity of oral therapy
• Initiate tube feeding or PEG if
indicated
• Parenteral interventions (intradialytic
parenteral nutrition or total
parenteral nutrition)
Adjunct therapies
• Anabolic hormones
• Appetite stimulants
• Anti-inflammatory interventions
• Exercise
Ikizler TA, Cano NJ, Franch H, et al. 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; 84: 1096-1107.
Disclaimer
The medications discussed in this
presentation are not FDA approved for
appetite stimulation, weight gain, or
nutritional improvement in patients with
CKD.
Adjunct Therapy
What adjunct therapy are your patients taking for
PEW?
A. Anabolic steroids
B. Growth hormone
C. Anti-inflammatories
Anabolic Hormones
Growth Hormone

Why it may work
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Resistance to growth hormone → premature decline in body
composition
Benefits
↑ in lean body mass (LBM) – +2.5kg over 6 months
 ↓C-reactive protein and homocysteine
 ↑ HDL cholesterol
 ↑ transferrin


Potential disadvantages
Only recommended for short-term use
 Injectable dosage form

Ikizler TA, Cano NJ, Franch H, et al. 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; 84: 1096-1107.
Ikizler TA. Optimal nutrition in hemodialysis patients. Adv Chronic Kidney Dis. 2013 March; 20 (2): 181-189.
Feldt-Rasmussen B, et al. Growth hormone treatment during hemodialysis in a randomized trial improves nutrition, quality of life, and
cardiovascular risk. J Am Soc Nephrol. 2007; 18: 2161-2171.
Anabolic Steroids

How they work
http://www.sportsci.org/encyc/anabster/anabster.html
Anabolic Steroids
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Benefits
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↑ body weight and body
mass index (BMI)
↑ mid-arm muscle
circumference
↑ total protein and prealbumin
↑ transferrin
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Potential disadvantages
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Virilizing effects in women
Cardiomyopathy
Hepatocellular carcinoma
↓ HDL
Hypercoagulation
Irregular menses
Testicular atrophy
Infertility in men
Injectable
Limit use to 6 months
Ikizler TA, Cano NJ, Franch H, et al. 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; 84: 1096-1107.
Anti-inflammatories
Potential Therapies

Pentoxifylline (Trental) + amino acids
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Etanercept (Enbrel®)
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Blocks inflammatory process
Improves protein breakdown
Blocks inflammatory process
↑ albumin and pre-albumin
Other options
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Nutritional anti-oxidants
Omega-3 fatty acids
Vitamin D (cholecalciferol)
Herbal products – green tea extract, curcumin, pomegranate juice
Ikizler TA, Cano NJ, Franch H, et al. 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; 84: 1096-1107.
Ikizler TA. Optimal nutrition in hemodialysis patients. Adv Chronic Kidney Dis. 2013 March; 20 (2): 181-189.
Appetite Stimulants
Appetite Stimulants
What appetite stimulants are your patients taking?
A. Megestrol Acetate (Megace®)
B. Dronabinol (Marinol®)
C. Mirtazapine (Remeron®)
D. Cyproheptadine
Megestrol Acetate
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Progestin
Available as tablet, oral suspension, and ES oral suspension
Common adverse effects
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Hypertension, rash, hot sweats, weight gain, diarrhea, flatulence,
indigestion, nausea, vomiting, insomnia, mood swings impotence
Serious adverse effects
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
®
(Megace )
Adrenal insufficiency, anemia, deep venous thrombosis, pulmonary
embolism, thrombophlebitis
Precautions
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Renal impairment - increased risk of toxic reactions
Elderly – increased risk of thromboembolic events and possibly death
Micormedex®
Dronabinol
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®
(Marinol )
Cannabinoid
Precautions
 Dependence
 Hypotension,
hypertension, syncope, or tachycardia
may occur
 May exacerbate mania, depression, or schizophrenia
 May lower seizure threshold
Micromedex®
Mirtazapine
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®
(Remeron )
Antidepressant
Precautions
Suicidal ideation
 Hyponatremia
 Seizures
 Orthostatic hypotension
 Serotonin syndrome
 Liver damage
 Agranulocytosis, neutropenia
 Renal impairment – start low, go slow
 Titrate dose upon discontinuation

Micromedex®
Cyproheptadine
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Antihistamine
Antiestrogenic properties
Precautions
 Sedation
 Dizziness
 Hypotension
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May be more effective in mild to moderate disease
Facts and Comparisons®
Potential Other Options
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Thalidomide
Melatonin
Ghrelin
Ikizler TA. Optimal nutrition in hemodialysis patients. Adv Chronic Kidney Dis. 2013 March; 20 (2): 181-189.
APPETITE STIMULATION IN
DIALYSIS PATIENTS
Anne Marie Liles, PharmD, BCPS
annemarieliles@gmail.com