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AfiatinDept IP Dalam FK Unpad RS. Hasan Sadikin
BandungPernefri Korwil Jawa Barat
MANAGEMENT OF NUTRITIONAL SUPPORT IN DIALYSIS PATIENT
What is PEW?
• Protein Energy Wasting is the state of decreased body store of protein and energy fuels.
• In CKD, the conditions result in loss of lean body mass not only related to reduced nutrients intake but also included nonspecific inflammatory process.
MALNUTRITION
OvernutritionOBESITY
UndernutritionMALNUTRITION
Micronutrient Malnutrition
Macronutrient Malnutrition
Energy Malnutrition(marasmus)
Protein - Energy Malnutrition / Protein Energy Wasting
Protein Malnutrition(kwashiorkor)
CKD Stages & Protein-Energy Malnutrition/Wasting
Malnutrition(PEW in U.S.)
28%–48% Up to 75%
Prevalence
3.1% 7.6% 0.5%4.1%
Stage 3Moderate
Kidney Function
Stage 1Kidney Damage WithNormal or Kidney
Function
Stage 2Kidney Damage
With Mild Kidney Function
Stage 4Severe Kidney Function
Stage 5KidneyFailure
90 60 30 15 0
ESRD
130GFR
1. USRDS 2009 Annual Data Report; 2. Stratton JD et al. J Ren Nutr 2003; 13: 191-198;3. Fouque, Kalantar-Zadeh, Kopple et al. Kidney Int 2008;73: 391-3984. Kovesdy et al, AJCN 20095. Zhang et al, Lancet 2012.
PEW: Protein-Energy Wasting (uremic malnutrition)
Normal Appetite
Anorexia
U.S.
China 5.7% 1.6% 0.13%3.4%
Prevalence of PEW• These are stable dialysis patients, the real prevalence would be
even higher.• The prevalence in both PD and HD patients seems equally.
Study Year Country Data collection
Sample size
Age Method Prevalence
de Mutsert et al. 2009 Netherlands 1997-2000 1601 HD 59 SGA 28%
Cordeiro et al. 2009 Sweden 2003-2004 173 HD 65(51-74) SGA 43%
Rambod et al. 2009 USA 2001-2006 809 HD 5315 MIS>5 46.8%
Miyamoto et al. 2011 Sweden 2000-2008 280 HD 5315 SGA 30.3%
Vasselai et al 2008 Brazil Not stated 45 PD 515 SGA 35.6%
Chung et al. 2009 Korea 1994-2000 213 PD 513 SGA 40.4%
Wang et al. 2009 China 1999-2001 244 PD 512 SGA 44.3%
Szeto et al. 2010 China 2006-2007 314 PD 12 MIS>6SGA
60.2%28.7%
Leinig et al. 2011 Brazil 2001-2008 199 PD 513 SGA 64.7%
Pernefri korwil Jabar
2012 Indonesia Jawa Barat
Juli – Desember 2012
264 HD
Lama HD : 1 – 192 bulan
MIS> 6
40,7 %
Protein Energy Wasting (PEW)
• Decreased body stores of protein and energy fuels, including body protein and fat masses
Inadequate diet, anorexia Inflammation: cytokines
& adipokines
Metabolic acidosis, reduced anabolic drive,
insulin resistance, dialysis, sedentary
lifestyle
Undernutrition Wasting/Catabolism
The Mechanism of PEW
Robert et al., J Cachexia Sarcopenia Muscle, 2011;2:9-25
Chronic Kidney Disease
AnorexiaInflam-mation
Insulin resistance
Hypo-gonadism
Anemia
Fat loss Muscle Wasting
Weight lossWeakness & FatigueReduced muscle strength, VO2 max & physical
activity
Cachexia3 of 5
• Muscle strength decreased• Fatigue• anorexia• Low fat-free mass index
• Abnormal lab data - increased CRP, IL-6 - Anemia (Hb < 12 g/dL) - low albumin( <3.2 g/dL)
• Annual weight loss > 5% or BMI < 20 Kg/m2
Protein-Energy Wasting Syndrome
The conceptual model of etiology and consequences of PEW in CKD
Ikizler et al, Kideny Int 2013; May: 1-12
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
2
2.2
<18 18-19.99 20-21.49 21.5-22.99
23-24.49 25-27.49 27.5-29.99
30-34.99 35-39.99 40-44.99 >=45
Body Mass Index (kg/m2)
Re
lati
ve
Ris
k o
f A
ll-C
au
se
De
ath
Unadjusted
Case-mix*
Case-mix & MICS **
Kalantar-Zadeh et al, AJKD 2005, & Kidney Int 2003 (& multiple other publications)
Mortality and BMI in 54,535 hemodialysis patients
Under-weight
Normal BMI
Over-weight
Obese Morbidly Obese
Highest Mortality
Protein-Energy
Malnutrition
0.88
0.90
0.92
0.94
0.96
0.98
1.00
prop
ortio
n su
rviv
ing
0 100 200 300 400 500 600 700 800 900 1000 1100cohort days
nir12g = 1 nir12g = 2 nir12g = 3 nir12g = 4
<12%
12-24%
24-36%
>36%
Kalantar-Zadeh et al, Am J Clin Nutr 2006
Lowest Body Fat Worse Survival
2.5 year survival follow-up in 535 MHD Patients
Near Infra-Red body fat measurement in 535 Hemodialysis Patients
-.5
0.5
1
DE
AT
H (
Log
haza
rd r
atio
)
0 20 40 60 80 100MAMC percentile
Mid-Arm Muscle Circumference and 5-Year Mortality (2001-06) in 792 hemodialysis patients
If FAT is good, M
USCLE is better!
Noori et al, CJASN 2010
Therapeutic Strategies for Prevention/Treatment of PEW in CKD on dialysis
Nutritional supplementation
Appetite stimulation
Acidosis correction
Inflammation/hormone modulation
Exercise & physical activity
Dialysis
Modified from: Robert et al., J Cachexia Sarcopenia Muscle, 2011;2:9-25
Goals of CKD Management
Achieve/maintain optimal nutritional status Prevent protein energy wasting Prevention/treatment of complications and other
medical conditions– DM– HTN– Dyslipidemias and CVD– Anemia– Metabolic acidosis – Secondary hyperparathyroidism
Proposed Algorithm for Nutritional Management and Support in CKD patients
Clinical diagnosis of PEW
On hemodialysis treatment : Negative protein balance is occurred • independently to protein intake• And caused by :
• amino acids loosing through dialyzer membrane • protein catabolism increasing due to glucose
loosing through dialyzer membrane
Nutrients loosing during hemodialysis treatment
Substance Gram /hour dialysis
Amino Acids 2.0
Protein / Peptide < 0.2
Glucose 8.0
Vitamins + + +
PERITONEAL DIALYSIS
• Amino acids loosing through peritoneal membrane : 5 – 15
gram/day
• Glucose absorption from dialysate :100 – 200 gram/day
• Vitamine and mineral loosing
Estimation of dialysate energy absorption
• Energy absorption : 60-70%• Amount :
– 1.5% / 2L solution = 78 Kcal– 2.5% / 2L solution = 130 Kcal– 4.25% / 2L solution = 221 Kcal
* Heimburger O, Waniewski J, Werynski A, Lindholm B. A quantitative description of solute and fluid transport during peritoneal dialysis. Kidney Int 1992; 41:1320-
1332
Nutrients Recommended intakes per day
Peritoneal Dialysis Hemodialysis
Energy 35 Kcal/ kg IBW - <60 yrs30-35Kcal/ kg IBW - ≥60 yrs
Protein 1.2-1.3g/kg IBW/ day(=50% of High Biological Value). Some nitrogen balance studies indicate that protein intake of ≥ 1.0 g/ kg IBW may be enough.
1.2-1.3g/kg IBW/ day(=50% of High Biological Value). Some nitrogen balance studies indicate that protein intake of ≥ 1.0 g/ kg IBW may be enough.
Fats 30% of total energy supply
Water and sodium
As per residual diuresis 750 – 1000 ml + diuresis
Potassium 40-80mmol. Individualized depending on serum levels
2-3 gr/d
Calcium Individualized, usually not <1000mg/ day
1000 mg/d
Phosphorous 8-17 mg/ kg or 800-1000 mg/ day (adjusted to higher protein needs), when serum phosphorous is > 5.5 mg/ dl²
800 – 1200 mg/d
¹Carrero JJ, Heimburger O, Chan M, Axelsson J, Stenvinkel P and Lindholm B. Protein energy malnutrition/ wasting during peritoneal dialysis. In: Nolph and Gokal’s textbook of Peritoneal Dialysis. Krediet RT, Khanna R, eds. 3rd Edn. NY: Springer, 2009: 611-647.²National Kidney Foundation. K/DOQI clinical practice guidelines for managing bone metabolism in chronic kidney disease. Am J Kidney Dis2003; 42(suppl 1):S1-S92
Nutritional Requirements of CKD Stg 5 with dialysis (NKF KDOQI)
FLOW OF NUTRITIONAL SUPPORT PROCESS
ASSESSMENTYES NO
SCREENINGYES NO
IDENTIFICATIONPOPULATION AT RISK (CHRONIC DISEASE)
DIAGNOSIS AND INTERVENTION
MONITORING AND EVALUATION (MONEV)
SCREENING TOOL FOR DIALYSIS PATIENTS
• MALNUTRITION INFLAMMATION SCORE
• SGA : + Dialysis aspects• PHYSICAL EXAMS• BODY MASS INDEX• LABORATORY PARAMETERS
NUTRITIONAL INTERVENTION/SUPPORT IS NEEDED
MIS : > 6MALNUTRITION
DIETARY RECALL
DIETARY PLAN TREATMENT
STEPS
Don’t make a plan without knowing the real
problem
MONITORINGEVALUATION
NUTRITIONIST IS A MUST IN THE TEAM
NUTRITIONAL MONITORING AND EVALUATION
• Make a schedule to evaluate the nutritional support
• Evaluate by the tools• Interval : 2 weekly or monthly
NUTRITIONIST IS A MUST IN THE TEAM
Kalantar-Zadeh … Ikizler, Nature Nephrology 2011
Nutritional Therapy / Nutritional Support
Enteral• Oral Nutrition Support • Meals during dialysis treatment• Tube feeding
Parenteral• IDPN (intra-dialytic parenteral nutrition)• TPN
Pharmacologic• Appetite stimulators• Anti-Depressant• Anti-inflammatory• Anabolic &/or muscle enhancing
EXAMPLE 2Mrs C, 42 year old,CKD stg 5 on chronic hemodialysis Problem : she has gastropathy ec NSAID , she feel epigastric pain when taking her mealHeight : 152 cm, 40 kg (Ideal BMI : 22---IBW 50.82 kg), Her dry weight continue to decrease , 2 kgs in a month weeks, No diarrheaShe feels fatique, she took days off 2-3 time a week (she is a teacher )HD 2 times a week
MIS 12
Need nutritional
support
DIETARY RECALL
DIETARY PLAN TREATMENT
STEPS
Don’t make a plan without knowing the real
problem
MONITORINGEVALUATION
NUTRITIONIST IS A MUST IN THE TEAM
EXAMPLEMrs C, 40 year old, CKD stg 5 on chronic HD, 40 kg Height: 152 BMI :17.39 Ideal Body Weight : 50.82 kg (BMI 22)ENERGYNUTRIENTS Requirements Mrs C requirement
Energy 35 kcal/kg IBW/d30 kcal/kgIBW/d(>60 yrs)Or to attain IBW
1400 kcal/d
Protein 1.2 g/kg IBW/d 48 g/d
Sodium(mmol/d) 80-100 80-100
Potassium (mmol/d) 70 70
Phosphorus (mg/d) <1000 1000
Fluid (ml/d)) Urine Output + 500 1000 ml
Mrs C daily intake recall
BREAKFAST LUNCH DINNER
1 bowl of cereal
1 cup of tea with 2 tsp sugar
1 cup of soft steam rice ½ bowl of
chicken broth Vegetable 1 cup
Milk 150 ml1 cup of noodle
soupJuice 100 ml
2 biscuits 1 cup of tea2 tsp sugar
EXAMPLEMrs C, 40 year old, CKD stg 3 on chronic HD, 40 kg
ENERGYNUTRIENTS
Mrs C requirement Mrs C actual intake
Energy 1400 kcal/d 800 kcal/d
Protein 48 g/d 20 g/d
Sodium(mmol/d) 80-100 120
Potassium (mmol/d) 70 <70
Phosphorus (mg/d) 1000 500
Fluid (ml/d)) 1000 ml 1100 ml
Meeting : 57.1 % of estimated energy and 41.6 % protein requirements
Unbalanced and inadequate intake of the core food groupsNeed nutritional support - repletion
NEPHRISOL
KANDUNGAN Unit Per saji (61 g)
ENERGI kkal 260
LEMAK/FAT g 6
SFA g 2
MUFA g 2
PUFA G 2
KARBOHIDRAT G 39
Laktosa g 0
PROTEIN g 13
ASAM AMINO ESENSIAL g 7.43
LEUCIN g 1.43
ISOLEUCIN g 1.06
VALIN g 0.99
TRIPTOFAN g 0.19
FENILALANIN g 0.79
METIONIN g 0.81
TREONIN g 0.73
LISIN g 1
HISTIDIN g 0.43
ASAM AMINO NON ESENSIAL 5.14
ARGININ g 0.41
ASPARTAT g 0.90
GLUTAMAT g 2.22
SERIN g 0.53
GLISIN g 0.17
ALANIN g 0.56
TIROSIN g 0.35
TOTAL ASAM AMINO 12.57
RASIO ASAM AMINO
AAE 60
NAAE 40
VITAMIN
Vitamin A % 15
Vitamin D3 % 6
Vitamin E % 10
Vitamin C % 10
Vitamin B1 % 25
Vitamin B2 % 25
Vitamin B6 % 30
Vitamin B12 % 10
Asam Folat % 15
Asam Pantotenat % 15
MINERAL
Kalsium % 20
Fosfor % 10
Magnesium % 8
Seng % 15
Selenium % 15
Natrium % 3
Kalium % 2
Mrs C daily menuBREAKFAST LUNCH DINNER
1 bowl of chicken porridge
1 egg schootel1 cup of tea with 2
tsp sugar
1 cup of soft steam rice
1 bowl of sauted beef and vegetable100 ml fresh apple
juice
Nephrisol D 1 serving
1 steam tofu and vegetable
10 am : Nephrisol D1 serving
260 kcal prot 13 g
4 pm : Nephrisol D1 serving
260 kcal prot 13 gAs pudding
2 biscuits
THE CALORIES INCREASE GRADUALLY TO MEET THE NEED FOR THE IDEAL BODY WEIGHT (50 KG = 1500 Kcal/day)
My patient
• Mr Nanang, 43 years old• CKD Stage 5 ec glomerupathy on chronic HD (4
years)• His appetite was decreased , no infection, no GI
complaint, HD was adequate. His dry BW decrease 2 kgs in 3 weeks.
• He started to increase his daily intake by consume Nephrisol D , and he is taking 3 box (9 servings) a week
• His dry weight was increased 3 kgs in a month
Mr. Nanang
FAILURE WITH ORAL NUTRITION SUPPORT
INTRADIALYTIC PARENTERAL NUTRITION
Complimentary if
ONS only meet :
20 kcal/kg/day and protein intake < 0,8 gr/kg/day