Insulin Like Growth Factor -1 as an Assessment Tool for Nutritional State in Some Dialysis Modalities

Abstract

Malnutrition is a major issue in patients with end stage renal disease, adversely affecting morbidity, mortality, functional activity and patients’ quality of life. Therefore, it is vital to identify, treat and prevent conditions associated with poor clinical outcomes (Sungjin C et al., 2012). Malnutrition is common in CRF patients before the commencement of dialysis, In these patients, emphasis should be placed on prevention and/or correction of malnutrition because of its documented adverse effects on the outcomes of maintenance dialysis (Agaba EI and Agaba PA., 2004). Multiple factors, including the underlying diseases, are responsible for a decline in nutritional status in dialysis patient include uremia, decreased intake, Increased losses, Increased protein catabolism ((Manual of Clinical Dialysis ., 2009). Nutritional assessment of patients with chronic kidney disease is a vital function of health care providers (Steiber AL et al., 2004). Nutritional assessment requires interpretation of a combination of clinical and biochemical parameters (Sukhminder and Ishwardeep., 2012). To assess nutritional status, a complex technique such as a history of weight loss and anthropometric measurements were used as well as the malnutrition inflammation score (MIS) and subjective global assessment (SGA) (Vetchinnikova O et al., 2012). Subjective Global Assessment (SGA) is a tool that uses 5 components of a medical history (weight change, dietary intake , gastrointestinal symptoms , functional capacity, disease and its relation to nutritional requirements) and 3 components of a brief physical examination (signs of fat and muscle wasting , nutrition-associated alternations in fluid balance) to assess nutritional status, In chronic kidney disease patients , SGA is incorporated into the complete nutritional assessment (Alison L S et al., 2012). Biochemical markers, which may indicate poor nutrient intake, include reduced serum urea, albumin, pre-albumin, potassium, and phosphate. In the long term, reduction in serum creatinine may reflect reduced muscle mass, reduction in serum cholesterol, insulin like growth factor 1 (IGF-1) and transferrin (Sukhminder and Ishwardeep ., 2012). Insulin-like growth factor-I (IGF-I) is a hormone that functions as the major mediator of growth hormone (GH)-stimulated somatic growth, as well as a mediator of GH-independent anabolic responses in many cells and tissues. IGF-I is a small peptide that circulates in serum bound to high affinity binding proteins. IGF-I is an unusual peptide in this regard, since it is more than 99 percent protein-bound (Werner H et al., 2008). Pharmacokinetics of insulin-like growth factor-1 in CRF and Information regarding the impact of chronic renal failure (CRF) on IGF-1 serum clearance are limited. Thus, in advanced CRF, apart from a reduction in the total IGF-1 volume of distribution the pharmacokinetics of IGF-1 are largely unaltered (Rabkin R et al., 1996). IGF-I is significantly reduced well before changes in anthropometric measurements could be detected so, IGF-I is a useful and early marker of under nutrition in HD patients (Ivarsen et al., 2010). Serum albumin is a well-known marker of nutrition in ESRD patients. Serum albumin is still the most commonly used nutritional marker in ESRD patients (Dashti N et al., 2012). Serum prealbumin (transthyretin) is a valid and clinically useful measure of protein-energy nutritional status in maintenance dialysis patients. (Kopple JD et al., 2002). There is no uniform approach to assess the degree of severity of inflammation in individuals with kidney disease. Such positive acute-phase reactants as serum C-reactive protein (CRP) or ferritin are markers for which serum levels are elevated during an acute episode of inflammation. Serum levels of such negative acute phase Reactants as albumin or transferrin decrease during an inflammatory process (Kalantar Zadeh K and Kopple J., 2003). Among proinflammatory cytokines, interleukin-6 (IL-6) is reported to have a central role in the patho physiological process of adverse effects of inflammation in patients with renal disease. (Stenvinkel P et al., 2002) However, even these proinflammatory cytokines may be engendered during oxidative stress, which can happen in the setting of PEM (Tali MM et al., 2000). Proinflammatory cytokines are elevated in hemodialysis patients and have been associated with poor clinical outcomes, including increased risk of cardiovascular disease, hospitalization, and death (Kubotera N et al., 2013). Thus, identification of nutrition and growth abnormalities, followed by fast intervention with nutritional supplements might allow correction of deficits (Erfan M et al., 2012). Our study aimed to assess the nutritional status of patients with end stage renal disease (ESRD) undergoing peritoneal dialysis and hemodialysis with reference to the correlation between nutritional status as judged clinically by anthropometric measures; weight, BMI, MAC and SGA score in conjunction with serum IGF level as a laboratory marker on one side and laboratory markers of adequacy of dialysis and hsCRP as an inflammatory marker on the other side. For equalization of the results, 60 patients with ESRD; 20 patients were maintained on PD, 20 patients on low-flux hemodialysis (LFHD) and 20 patients on high-flux hemodialysis (HFHD). Also, there was non-significant difference between studied groups as regards age, gender, distribution according to underlying kidney pathology or duration of dialysis.