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Impairment of small intestinal protein assimilation in patients with end-stage renal disease: extending the malnutrition-inflammation-atherosclerosis concept^1,2,3,4

¹ From the Department of Medicine, Division of Nephrology (BB, PE, and YV) and the Laboratory of Digestion and Absorption (KV), University Hospital Gasthuisberg, Leuven, Belgium

Background: Protein malnutrition is a common finding in renal disease. Recently, we showed that impaired protein assimilation (digestion and absorption) may contribute to protein malnutrition in nondiabetic patients with chronic renal failure.

Objective: The aim of the present study was to evaluate whether these findings can be extended to the dialysis population. Moreover, relations with indexes of the malnutrition-inflammation-atherosclerosis (MIA) syndrome were investigated.

Design: Protein assimilation was evaluated in 24 healthy control subjects and in 40 patients with end-stage renal disease (ESRD; 14 treated with peritoneal dialysis and 26 with hemodialysis) by means of a [¹³C]protein breath test, quantification of the generation rate of p-cresol, or both methods. Both approaches provide reliable information on the efficiency of protein assimilation. Breath test results were expressed as the maximum percentage recovery per hour of the administered dose of ¹³C (%_max) and as the cumulative percentage recovery at the end of the test (%cum_end). Several indexes of nutritional status, inflammation, and atherosclerosis were assessed.

Results: Compared with the control subjects, ESRD patients had significantly lower breath-test derived indexes of protein assimilation [%_max = 3.75 ± 0.30 compared with 4.90 ± 0.25, P = 0.006; %cum_end = 12.41 (5.74–23.22) compared with 16.87 (9.42–22.99), P = 0.020] and a higher 24-h p-cresol generation rate corrected for dietary protein intake [3.89 (0.48–11.60) compared with 2.81 (0.21–11.20) mg p-cresol/g urea nitrogen; P = 0.028]. The presence of impaired protein assimilation was associated with indexes of the MIA syndrome.

Conclusion: Our study provides evidence that protein assimilation is impaired in ESRD patients. Moreover, this disorder is associated with the severity of the MIA syndrome.

Key Words: Malnutrition-inflammation-atherosclerosis syndrome • protein assimilation • p-cresol • breath test • end-stage renal disease

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