What are the guidelines for appetite stimulants in patients with End-Stage Renal Disease (ESRD)?

Appetite Stimulant Guidelines for ESRD Patients

There are no specific guidelines for appetite stimulants in ESRD patients, but nutritional interventions should be prioritized before considering pharmacological appetite stimulants to address protein-energy malnutrition.

Understanding Malnutrition in ESRD

Protein-energy malnutrition (PEM) is common in ESRD patients and associated with increased morbidity and mortality:

• Spontaneous reduction in dietary protein intake and progressive decline in nutritional status often occurs as kidney function deteriorates 1
• Malnutrition at the initiation of dialysis is predictive of future mortality risk 1
• The decline in nutritional parameters becomes particularly notable when GFR falls below 25 mL/min 1

Nutritional Requirements for ESRD Patients

The K/DOQI guidelines recommend:

• For maintenance hemodialysis (MHD) patients: 1.2 g protein/kg body weight/day, with at least 50% being of high biological value 1
• For chronic peritoneal dialysis (CPD) patients: 1.2-1.3 g protein/kg body weight/day, with at least 50% being of high biological value 1
• Energy intake of 35 kcal/kg/day for patients younger than 60 years and 30-35 kcal/kg/day for those 60 years or older 1

Stepwise Approach to Managing Poor Appetite in ESRD

Step 1: Nutritional Assessment and Counseling

• Regular monitoring of nutritional status should be a routine component of care (every 1-3 months) 1
• More frequent assessment is needed if there is inadequate nutrient intake, frank PEM, or illness that may worsen nutritional status 1

Step 2: Dietary Interventions

• Education and dietary counseling should be the first steps to maintain adequate protein intake 1
• Creative menu planning considering patient's food preferences 1
• Use of foods, beverages, and nutritional supplements with high energy density 1

Step 3: Nutritional Support

• If dietary counseling is unsuccessful, consider nutritional support including food supplements, tube feeding, or intravenous nutrition 1

Step 4: Consider Renal Replacement Therapy

• If PEM develops or persists despite vigorous attempts to optimize protein and energy intake with no apparent cause other than low nutrient intake, initiation of maintenance dialysis or renal transplant is recommended 1

Pharmacological Appetite Stimulants

While specific guidelines for appetite stimulants in ESRD are lacking, the International Society of Renal Nutrition and Metabolism suggests the following options as adjunctive treatments 2:

• Megestrol acetate
• Dronabinol
• Mirtazapine
• Cyproheptadine

Important considerations when using appetite stimulants in ESRD:

• These should be used as adjunctive treatments alongside nutritional supplementation 2
• Careful monitoring for adverse effects is essential as ESRD patients have increased risk of adverse drug reactions 3
• Drug dosing may need adjustment due to altered pharmacokinetics in ESRD 3
• Consider potential drug-drug interactions with other medications commonly used in ESRD 3

Special Considerations

• A palliative approach to ESRD is a reasonable alternative to dialysis for individuals with limited life expectancy, severe comorbidities, or those wishing to avoid medical interventions 4
• For patients receiving intensive hemodialysis, phosphate dialysate additives may be needed if hypophosphatemia persists after stopping phosphate binders and liberalizing diet 1
• When increasing dietary protein intake, adjustments in therapy (dialysis dose, phosphate binders, bicarbonate supplementation, cholesterol management) should be considered 1

Monitoring Response to Interventions

• Regular assessment of nutritional parameters including serum albumin, transferrin, and anthropometric measurements 1
• Evaluation of protein and energy intake 1
• Assessment of quality of life and functional status 1