Afiatin Dept IP Dalam FK Unpad RS. Hasan Sadikin Bandung Pernefri Korwil Jawa Barat.

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