High Protein Treatment to Enhance CKD Patients Quality of ... · Sisa kebutuhan kalori harian setelah dikurangi kalori dari protein 39 gram Lipid2 30% dari total asupan kalori Rasio

High Protein Treatment to

Enhance CKD Patients Quality of

Life (Dialysis Stage)

HAERANI RASYID

DEPARTEMEN GIZI KLINIK

DEPARTEMEN ILMU PENYAKIT DALAM-

FAKULTAS KEDOKTERAN - UNIVERSITAS HASANUDDIN

Quality of Life Concept

• Person’s quality of life cannot be defined with

certainty, only theirself can define it, because

the quality of life is a subjective one.

Gerasimoula K, Lefkothea L, Maria L, et al. Quality of life in hemodialisis patients. Materia socio-medica. 2015 Oct;27(5):305.

Mollaoglu M. Quality of life in patients undergoing hemodialysis. In Hemodialysis 2013. InTech

Quality of Life of

dialysis Patients

How to Improve the Quality of Life of

dialysis Patients

• Treat Anemia → Hemoglobin levels between of 10-12 g%

• Treat Malnutrition/Protein Energy Wasting

• Treat Depression

• Assess sexual function

• Give social support

Rasyid H. Pengaturan nutrisi pada pasien penyakit ginjal kronik: Fokus diet rendah protein. National congress XII and annual scientific meeting 2014 Indonesia society of

nephrology. 2014 Oct; p.221-7

Rasyid H. Manajemen protein energy wasting pada gagal ginjal; Tantangan dalam menurunkan angka morbiditas dan mortalitas pasien dialisis. Disampaikan pada pidato

Nutrition problem in dialysis patients

How to prevent PEW ??

Ko, Gang Je; Obi, Yoshitsugu et al. 2017. Curr Opin Clin Nutr Metab Care

KDOQI Nutrition in Chronic Renal Failure. AJKD. 2000

In HD process there are

removal of:

• amino acids (about 10 -

12 g per HD),

• some peptides,

• low amounts of protein (<

1-3 g per dialysis,

including blood loss),

• and small quantities of

glucose (about 12 to 25 g

per dialysis if glucose-free

dialysate is used)

• Peritoneal protein losses

average about 5 to 15

g/24 hours,

• During episodes of

peritonitis, dialysate

protein may be

considerably higher.

• Peritoneal amino acid

losses average about 3

g/d,145 and some

peptides are dialyzed

Dialysis treatment may stimulate protein catabolism, body

hypermetabolisme, loss of nutrient which aggravates PEW in

ESRD patients

Recommended Energy and Protein Intakes

for Dialysis Patients to Prevent PEW

ESPEN NKF-KDOQI

Hemodialysis 1.2-1.4 g/kgBW/d, at least

50% high biologic value

1.2 g/kgBW/d at least 50%

high biologic value

Peritoneal dialysis 1.2-1.5 g/kgBW/d at least

50% high biologic value

1.2-1.3 g/kgBW/d, at least

50%high biologic value

Energy 35 kcal/kgBW/d < 60 years : 35

kcal/kg/BW/d

> 60 years : 30-35

kcal/kg/BW/d

Fouque, Denis. 2013. ESPEN LLL Program

KDOQI Nutrition in Chronic Renal Failure. AJKD. 2000

Factors Affecting Lack of Dietary Protein Intake

in Maintanance Dialysis Patients

• Lack of knowledge

• Did not heed nutritional advice

• Loss of appetite affect by depression, dialysis

vintage, dialysis adequacy, age, comorbid, fluid

overload

• Afraid of hyperphosphatemia and acidosis

metabolic

.Therrien M, Byham-Gray L et al. 2015. National Kidney Foundation

How to achieve target of dietary

energy and protein intake

• Nutritional Status Assessment

• For individual identified as being risk for PEW : in-center meal

or ONS are recommended

• For those responding poorly to therapy, it recommends to

increase the quantity of supplement or looking at nutrition

support, through EN, PN or IDPN.

.Therrien M, Byham-Gray L et al. 2015. National Kidney Foundation

Ikizler T A et al. 2013. International Society of Renal Nutrition amd Metabolism Consensus

Dietary Approach to Increase Energy

and Protein Intake• A good understanding of the concepts of protein intake, protein

types, constituents and portion sizes by dialysis patients is important

Ameh O I et al. 2016. BMC Nephrology

Justification of the additional need of dialysis patients for

supplemented meals and nutrition

Kalantar-Zadeh K et al. 2013. National Kidney Foundation

Oral Nutrition Support

• Oral supplementation should be given 2-3x/day, preferably 1 h

after main meals or during dialysis for MHD patients.

• Oral supplementation can provide an additional 7–10 kcal/kg

per day of energy and 0.3–0.4 g/kg per day of protein

• Its requiring a minimum spontaneous intake of 20 kcal/kg per

day of energy and 0.4–0.8 g/kg per day of protein in order to

meet the recommended dietary energy intake and dietary

protein intake targets.

Ikizler T A et al. 2013. International Society of Renal Nutrition amd Metabolism Consensus

The effects of oral

supplementation in MHD patients

Ikizler T A et al. 2013. International Society of Renal Nutrition amd Metabolism Consensus

INTRADIALYTIC PN• IDPN is recommended only if a patient has a spontaneous intake of at

least 20 kcal/kg/day and 0.8–0.9 g/kg/day of proteins

• Calculate the maximum macronutrient amount given by IDPN per dialysis (4 h) as energy 15 kcal/kg/dialysis and aminoacids: 0.8 g/kg/dialysis;

• IDPN is given only during hemodialysis sessions, the maximum calorie density of all-in-one admixtures is about 1 kcal/ml, and it is suggested not to exceed 1,000 ml of fluids, 1,000 kcal and 50 g of amino acids per dialysis session

• Start nutrient administration after 15 min of dialysis, when dialysis machine pressures and patient parameters are stable

• Start slowly, with 1/3 of the targeted amount in the first week, 2/3 in the second week and full amount from the 3rd week

• Remove fluid added with IDPN by adjusting the ultrafiltration rate as per patient’s needs

• Check pre-dialysis electrolytes

Sabatino A et al. 2014. J Nephrol

Recommendatio

ns on Indications

for IDPN

Safe IDPN

Sabatiano et al, Italian Society of Nephrology 2014

The effect of oral IDPN in MHD patients

Ikizler T A et al. 2013. International Society of Renal Nutrition and Metabolism Consensus

Use of Intradialytic Parenteral Nutrition in Patients

Undergoing Hemodialysis

Sarav M and Friedman AN, Nutrition in Clinical Practice, 2018, 767-771

Its important to control Phosphate if Protein target achieved

Jenis Nutrisi Kebutuhan pasien DialisisNephrisol-D

per sajian (diet 2000 Kkal)

Asupan kalori

total harian1

<60 tahun: 35 kkal/kgBB/hari

60 tahun ke atas: 30-35

kkal/kgBB/hari

350 kkal20 % kebutuhan

harian

Protein1

HD: 1,2 gram/kgBB/hari

PD: 1,2-1,3 gram/kgBB/hari12 gram

17,3% kebutuhan

harian

Minimal 50% terdiri atas protein

bernilai biologis tinggi

AAE 7,43 gram, AANE 5 gram

(rasio tepat 60 : 40)

Karbohidrat2Sisa kebutuhan kalori harian setelah

dikurangi kalori dari protein39 gram

Lipid2

30% dari total asupan kalori

Rasio asam lemak tak jenuh : asam

lemak jenuh = 1 : 1

Total lipid 6 gram

Rasio asam lemak tak jenuh : jenuh 2 :

1

1K/DOQI. Am J Kidney Dis 2000; 35 (6 suppl 2): S1-S1032Kopple JD, Massry SG. Nutritional Management of Renal Disease. Pennsylvania : Williams & Wilkins, 1997: 17

Sample

MineralAKG PGK

Mg/hari

Nephrisol-D*

Per saji %

Natrium 750-1500 70 mg* 5

Kalium 2000 112 mg* 6

Kalsium 1400-1600 133 mg* 8

Fosfor 300-600 161 mg* 26

Mg 200-300 23 mg* 8

Energi 350 Kkal/saji

Lemak 12 g [31%]

Protein 13 g [15%]

Karbohidrat 49 g [54%]