MANAGEMENT OF NUTRITIONAL
SUPPORT IN DIALYSIS PATIENT
Afiatin
Dept IP Dalam FK Unpad RS. Hasan Sadikin
Bandung
Pernefri Korwil Jawa Barat
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
Overnutrition
OBESITY
Undernutrition
MALNUTRITION
Macronutrient
Malnutrition
Protein
Malnutrition
(kwashiorkor)
Micronutrient
Malnutrition
Energy
Malnutrition
(marasmus)
Protein - Energy
Malnutrition / Protein Energy Wasting
CKD Stages &
Protein-Energy Malnutrition/Wasting
ESRD
GFR
Stage 1
Stage 2
Kidney Damage With
Normal or  Kidney
Function
Kidney Damage
With Mild
 Kidney Function
130
90
Stage 3
Moderate 
Kidney
Function
60
Stage 5
Stage 4
Severe 
Kidney
Function
30
Kidney
Failure
15
0
Prevalence
U.S.
3.1%
4.1%
7.6%
0.5%
China
5.7%
3.4%
1.6%
0.13%
Malnutrition
(PEW in U.S.)
28%–48%
Normal Appetite
Anorexia
PEW: Protein-Energy Wasting (uremic malnutrition)
1.
2.
3.
4.
5.
USRDS 2009 Annual Data Report;
Stratton JD et al. J Ren Nutr 2003; 13: 191-198;
Fouque, Kalantar-Zadeh, Kopple et al. Kidney Int 2008;73: 391-398
Kovesdy et al, AJCN 2009
Zhang et al, Lancet 2012.
Up to 75%
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>6
SGA
60.2%
28.7%
Leinig et al.
2011
Brazil
2001-2008
199 PD
513
SGA
64.7%
Pernefri korwil
Jabar
2012
Juli –
Desember
2012
264
HD
MIS
>6
40,7 %
Indonesia
Jawa
Barat
Lama HD :
1 – 192
bulan
Protein Energy Wasting (PEW)
• Decreased body stores of protein and energy fuels, including body
protein and fat masses
Undernutrition
Inadequate diet,
anorexia
Wasting/Catabolism
Inflammation:
cytokines & adipokines
Metabolic acidosis,
reduced anabolic drive,
insulin resistance,
dialysis, sedentary
lifestyle
The Mechanism of PEW
Chronic Kidney Disease
Anorexia
Inflammation
Insulin
resistance
Weakness & Fatigue
Weight loss
Annual weight loss > 5%
or BMI < 20 Kg/m2
Anemia
Muscle Wasting
Fat loss
•
Hypogonadism
Reduced muscle strength, VO2 max & physical
activity
Cachexia
3 of 5
•
•
•
•
Muscle strength decreased• Abnormal lab data
- increased CRP, IL-6
Fatigue
- Anemia (Hb < 12 g/dL)
anorexia
- low albumin( <3.2 g/dL)
Low fat-free mass index
Robert et al., J Cachexia Sarcopenia Muscle, 2011;2:9-25
Protein-Energy Wasting Syndrome
The conceptual model of etiology and
consequences of PEW in CKD
Ikizler et al, Kideny Int 2013; May: 1-12
Mortality and BMI in 54,535 hemodialysis patients
2.2
Highest
Mortality
Relative Risk of All-Cause Death
2
Unadjusted
Case-mix*
1.8
Case-mix & MICS **
1.6
1.4
Overweight
1.2
Obese
Morbidly
Obese
1
0.8
Underweight
Normal
BMI
0.6
0.4
<18
18-19.99 20-21.49
21.522.99
23-24.49 25-27.49
27.529.99
30-34.99 35-39.99 40-44.99
>=45
Body Mass Index (kg/m2)
Kalantar-Zadeh et al, AJKD 2005, & Kidney Int 2003 (& multiple other publications)
1.00
Near Infra-Red body fat measurement in 535 Hemodialysis Patients
24-36%
0.98
>36%
0.94
0.96
12-24%
0.92
Lowest Body Fat
 Worse Survival
0.88
0.90
2.5 year survival
follow-up in 535
MHD Patients
0
100
200
300
nir12g = 1
Kalantar-Zadeh et al, Am J Clin Nutr 2006
400
<12%
500 600 700
cohort days
nir12g = 2
800
nir12g = 3
900 1000 1100
nir12g = 4
Mid-Arm Muscle Circumference
-.5
DEATH (Log hazard ratio)
0
.5
1
and 5-Year Mortality (2001-06) in 792 hemodialysis patients
0
20
40
60
MAMC percentile
80
100
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
Amino Acids
Gram /hour
dialysis
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; 41:13201332
Nutritional Requirements of CKD Stg 5 with dialysis
(NKF KDOQI)
Nutrients
Recommended intakes per day
Peritoneal Dialysis
Energy
Protein
Hemodialysis
35 Kcal/ kg IBW - <60 yrs
30-35Kcal/ kg IBW - ≥60 yrs
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
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.
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
FLOW OF NUTRITIONAL SUPPORT
PROCESS
IDENTIFICATION
POPULATION AT RISK (CHRONIC DISEASE)
SCREENING
YES
YES
NO
ASSESSMENT
NO
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
MIS : > 6
MALNUTRITION
NUTRITIONAL
INTERVENTION/SUPPORT
IS NEEDED
STEPS
DIETARY
RECALL
DIETARY
PLAN
Don’t make a plan
without knowing the real
problem
TREATMENT
MONITORING
EVALUATION
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
Nutrition Support in CKD
No
Total
Parenteral
Nutrition
(TPN)
Functional GIT
Yes
Enteral
Nutrition
(EN)
HDx
1st
Tube
feeding
(TF)
Oral (+edn & counseling):
+/-
• Food fortification
• Oral nutrition
supplementations (ONS)
+/PDx
Intra- Peritoneal
Nutrition
MO:
• Control co-morbidities/
inflammation
• Medications / Appetite stimulant
Intradialytic PN
(IDPN)
Nursing
Exercise
training
Multi-disciplinary
Approach
Psychosocial support
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
Kalantar-Zadeh … Ikizler, Nature Nephrology 2011
Oral Nutrition Support
Diet counseling
(+ prescription &
meal plan)
(1)
Food
±
(2)
±
Food enriching/
fortifications
(3)
Oral Nutrition
Supplements
Characteristic/
strategy
• Use energy & nutrient
dense foods & drinks
• adding protein, fat &
CHO to foods and
drinks, e.g. egg,
cheese, milk, milk
powder sugars, fats
• commercial modules
e.g. protein powder,
tasteless sugars
• Ready –made
formula & desserts
• protein & energy
bar
Advantage
• economical
• familiar items:
• taste
• texture
• cultural specific
• economical
• familiar items:
• taste
• texture
• cultural specific
• easy to use
• convenient
• easy handling (in
institutions) staff
and hygiene
Limitation
“larger” volume
“larger” volume
• cost
• acceptance
• taste
• possible intolerance
EXAMPLE 2
Mrs C, 42 year old,
CKD stg 5 on chronic hemodialysis
Problem : she has gastropathy ec
NSAID , she feel epigastric pain when
taking her meal
Height : 152 cm, 40 kg (Ideal BMI : 22--IBW 50.82 kg),
Her dry weight continue to decrease , 2
kgs in a month
weeks, No diarrhea
She 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
STEPS
DIETARY
RECALL
DIETARY
PLAN
Don’t make a plan
without knowing the real
problem
TREATMENT
MONITORING
EVALUATION
NUTRITIONIST IS A MUST IN THE
TEAM
EXAMPLE
Mrs 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/d
30 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
1 bowl of cereal
1 cup of tea with
2 tsp sugar
2 biscuits
LUNCH
1 cup of soft
steam rice
½ bowl of
chicken broth
Vegetable 1 cup
1 cup of tea
2 tsp sugar
DINNER
Milk 150 ml
1 cup of noodle
soup
Juice 100 ml
EXAMPLE
Mrs C, 40 year old, CKD stg 3 on chronic HD, 40 kg
ENERGY
NUTRIENTS
Energy
Mrs C requirement
1400 kcal/d
Mrs C actual
intake
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 groups
Need nutritional support - repletion
Nutrition Support in CKD
No
Total
Parenteral
Nutrition
(TPN)
Functional GIT
Yes
Enteral
Nutrition
(EN)
HDx
1st
Tube
feeding
(TF)
Oral (+edn & counseling):
+/-
• Food fortification
• Oral nutrition
supplementations (ONS)
+/PDx
Intra- Peritoneal
Nutrition
MO:
• Control co-morbidities/
inflammation
• Medications / Appetite stimulant
Intradialytic PN
(IDPN)
Nursing
Exercise
training
Multi-disciplinary
Approach
Psychosocial support
NEPHRISOL
KANDUNGAN
Unit
Per saji (61 g)
ENERGI
kkal
260
g
6
SFA
g
2
MUFA
g
2
PUFA
G
2
G
39
Laktosa
g
0
PROTEIN
g
13
LEMAK/FAT
KARBOHIDRAT
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 ESENSIAL
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 menu
BREAKFAST
LUNCH
DINNER
1 bowl of chicken
porridge
1 egg schootel
1 cup of tea with 2
tsp sugar
1 cup of soft steam
rice
1 bowl of sauted
beef and vegetable
100 ml fresh apple
juice
Nephrisol D
1 serving
1 steam tofu and
vegetable
10 am : Nephrisol D
1 serving
260 kcal prot 13 g
4 pm : Nephrisol D
1 serving
260 kcal prot 13 g
As 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