Transcript Serum Albumin

Effect of nutritional counseling in the form of individualized meal
plan on serum albumin level among Hemodialysis patients
Author:Suheir Abdallah Khalil,Ph.D
Consultant Clinical Nutrition, Acting Chief- Clinical Nutrition Department
King Faisal Specialist Hospital & Research Center Jeddah, KSA
Co. Author:Prof. Yousif Babiker Yousif
Professor of Clinical Nutrition, Ahfad University for Women, Khartoum/Sudan
Global Facts: About Kidney Disease
• CKD is a worldwide public health problem.
• 10% of the population worldwide is affected by CKD, and millions
die each year.
• According to the Global Burden of Disease study, CKD was ranked
27th in the list of causes of total number of deaths worldwide in
1990, but rose to 18th in 2010.
• In 2013, nearly one million people died from CKD . it is a 135%
increase from the number of CKD -related deaths in 1990
• Among the major non-communicable killers (nearly 70 % of all
deaths globally), one of the lesser-recognized but increasingly
significant causes of death is CKD
Stages of CKD
ESRD
United States: The number of patients diagnosed with
ESRD is increasing by 5% each year. After one year of
treatment, those on dialysis have a 20-25% mortality
rate, with a 5-year survival rate of 35%.
Worldwide: The numbers are staggering. Estimates are
that 2 million people worldwide suffer from ESRD, and
the number of patients diagnosed with the disease
continues to increase at a rate of 5-7% per year
Source
U.S. Renal Data System, USRDS 2013 Annual Data Report: Atlas of End-Stage Renal Disease in the United States,
National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2014.
Complications of ESRD on Dialysis
Hypoalbuminemia
Hyperphosphatemia
Hyperkalemia
Fluid Overload
Nutrition in HD is very important in decreasing complications &
improving quality life of patients.
Hypoalbuminemia is a serious problem with kidney disease pt
Hypoalbuminemia
Non-nutritional
factors
Infection
Inflammation
Co-morbidities
Fluid overload
Inadequate dialysis
Nutritional factors
Poor energy &
protein intake
Anabolic &
catabolic stage
Blood loss
Metabolic acidosis
Hypoalbuminemia is a medical condition where levels of albumin in blood serum
are ↓ & Treatment focus on its underlying cause
• Some studies (Beddhu 2002, Panichi 2006)
describe hypoalbuminemia in HD patients as a
strong indicator for mortality & morbidity.
• As a result of malnutrition, albumin synthesis
decreases and develops hypoalbuminemia.
Assessment of Nutrition status with ESRD on HD
As Assessment of the nutrition status is an integral part of the
nutrition management. Several parameters should be evaluated
together including:
▪ Weight loss
history
▪Dietary protein
& energy intakes
▪Subcutaneous fat
& muscle mass
▪ BMI
▪ SGA
Several
biochemical
markers
(serum albumin,
prealbumin, &
transferrin)
have been used
to evaluate
visceral protein
stores.
Of these, serum
albumin has so
far been the most
commonly used
Serum Albumin
• one measure of total body protein, both muscle & visceral
which is the most frequently used marker of protein status and
is the standard recommended by KDOQI to be used in assessing
the nutritional status among CKD.
• A strong marker for the evaluation of malnutrition (estimated
prevalence of 10-70%) and Hypoalbuminemia among HD
patients
• A decreased albumin results in an increased in morbidity &
mortality. Which has been shown for ESRD patients whose
albumin is below 4.0 g/dL, and result in an excess risk of death.
• Serum albumin level at dialysis initiation is an
independent risk factor for mortality
• Serum albumin ≥ 4.0 g/dL at initiation of dialysis is
associated with reduced mortality risk.
• Only 11% of new dialysis patients had serum albumin
≥ 4.0 g/dL
• Animal protein
• comes from milk, meats,
chicken, fish, and eggs
• and contains all the needed
ingredients for tissue growth.
Low quality
High quality
• There are 0.2-0.5 g/kg or 10-14 g/day of protein, amino acids (aa) and peptide
losses with the dialysis fluid during HD
• pt do not consistently take the recommended amounts of energy and protein
for ESRD patients on HD (which lead to hypoalbuminemia). In research, it is
emphasized that the inadequate protein intake increases mortality
• The lost in amino acids needs to be replaced to avoid negative nitrogen
balance.
• According to "KDOQI)" and studies by other investigators, dietary protein
should be adjusted at least 1.2 g/kg/day in HD patients.
• According to ESPEN, adjusted diet protein should be consumed as 1.1-1.2
g/kg/d and should be high in the biological value (of animal origin) of 50 %
protein in HD patients.
• plant, protein
• comes from vegetables,
breads, and cereals
• and is lacking in some of the
ingredients tissues need to
grow.
•They are in need of individualized meal plans but they rarely
consult a dietitian.
• A special diet is needed for ESRD patients on HD.
• Recommended daily nutrients intake for an adult on HD are
Recommended daily nutrients intake for an adult on HD
Nutrients
Recommendation
Calorie
30-35 (30>60yr,35<60yr) kcal/kg/day
Protein
1.2 gm/kg/day
Phosphorus
17 mg/kg/day
Potassium
40 mg/kg/day
Fluids
urine output + 500-750 ml/day
• Individual Diet must be followed up closely by renal dietitians
50%
renal dietitian will
figure out the needs
to include a mixture of
both.
10-14 g free amino acids lost per treatment during dialysis
50%
The purpose of the study
This was an intervention study
to evaluate the effect of
nutritional counseling in the
form of individualized meal
plan on serum albumin level
among HD patients.
Methods:
The study was conducted
on MHD patients
attending one of the
biggest HD Center in
Khartoum.
Inclusion Criteria
• ESRD patients on regular HD (2-3
times weekly)
• Patient, who dialyzed for at least 3
months, dialyzed 4 hours per session
• Both sexes ˃18 years of age
• Consent given for participation in
the study
• Absence of active underlying disease
• Absence of active infection (free
from infections and inflammations)
• No requirement for hospitalization
during the month preceding the
study
Exclusion Criteria
• Patients younger than 18 years of
age
• Having infections or inflammations,
• having any underlying disease
• on hospitalization during the
month preceding the study
• Not on regular HD receiving HD
more or less than 2-3 times per
week.
• Refuse to sign Consent form
• 134 adult patients (males & females) were divided into a test
group (n=77) and a control group (n=57).
• The test group after nutritional counseling, consumed
individualized diets for a period of 6 months that provided
adequate amounts of energy and protein according to the
recommendations of the National Kidney Foundation while
the control group continued consuming their usual diets.
• Serum albumin was determined at baseline and every 2
months.
• Data were analyzed using SPSS.
Nutritional status differences of the study patients according to changes in serum
albumin in both groups.(n=134)
baseline
2 mo
4 mo
6 mo
Result & Discussion:
• In this study, baseline serum
albumin levels were similar in
both groups
• values obtained were below the
4.0 g/dl recommended by
NKF/DOQI for adults on HD
• which reflects the high incidence
of hypoalbuminia among both
groups.
Result & Discussion:
After 6 months serum albumin
levels increased in the test group
but not in the control one; the
difference was highly significant
within the test group (P=0.000)
and between the test and
control groups (P=0.000).
• This is explained by the higher
intake of energy and protein by
the test group which showed
gradual increases in the albumin
level during the intervention
period.
•
Conclusion:
• The study demonstrated that effective nutritional counseling
rendered to MHD patients in the form of individualized meal
plans that provided adequate energy & protein was effective in
the control and improvement of serum albumin level among
these patients.
• Therefore, nutritional counseling by qualified dietitians should be
mandatory in renal units as part of the medical therapy
management to reduce the incidence of hypoalbminemia among
HD patients.
References
•
•
•
•
•
•
•
•
Alharbi K A (2010). Assessment of nutritional status of patients on hemodilaysis: a
single center study from Jeddah, Saudi Arabia. FIU Electronic Theses and
Dissertations. Paper 178. http://digitalcommons.fiu.edu/etd/178
Bernardo A P, Fonseca I, Rodrigues A , Carvalho M J. Cabrita A (2009). Overweight
Rather Than Malnutrition Is Widely Prevalent in Peritoneal Dialysis Patients.
Advances in Peritoneal Dialysis. 25:119-124.
Byham-Gray, L. and Wiesen,K (2004). A clinical guide to nutrition care in kidney
disease, American Dietetic Association.
Cho J, Hwang J, Lee S, Jang SP, Kim W (2008). Nutritional status and the role of
diabetes mellitus in hemodialysis patients. Nutrition Research Practice Journal.
2(4): 301–307.
Goldsmith, D, Jayawardene, S. and Ackland, P (2008). ABC of kidney disease.
Blackwell Publishing Ltd.
Jha V, Garcia-Garcia G, Iseki K, et al. Chronic kidney disease: global dimension and
perspectives. Lancet. Jul 20 2013;382(9888):260-272.
Kalantar-Zadeh K, Ikizler TA, Block G, Avram MM, Kopple JD.: Malnutritioninflammation complex syndrome in dialysis patients: Causes and
consequences.Am J Kidney Dis42: 864–881, 2003
Kopple JD.: McCollum Award Lecture, 1996: Protein-energy malnutrition in
maintenance dialysis patients.Am J Clin Nutr65: 1544–1557, 1997
References
•
•
•
•
•
•
•
•
Kopple JD.: National kidney foundation K/DOQI clinical practice guidelines for
nutrition in chronic renal failure.Am J Kidney Dis37[Suppl 2]: S66–S70, 2001
Levey AS, Atkins R, Coresh J, et al. Chronic kidney disease as a global public health
problem: approaches and initiatives - a position statement from Kidney Disease
Improving Global Outcomes. Kidney Int. Aug 2007;72(3):247-259.
Locatelli F, Cannata-Andia JB, Drueke TB (2002). Management of disturbances of
calcium and phosphate metabolism in chronic renal insufficiency, with emphasis
on the control of hyperphosphataemia. Nephrology Dialysis Transplantation.
17:723–731.
Mahan LK and Escott-Stump (2008). Krause's Food, Nutrition, and Diet Therapy.
12th edition. W.B. Saunders Company. USA.
Poole R, Hamad A (2008). Nutrition Supplements in Dialysis Patients: Use in
Peritoneal Dialysis Patients and Diabetic Patients. Advances in Peritoneal Dialysis.
24:118-124.
Saxena A, Sharma RK (2004). An update on methods for assessment of nutritional
status in maintenance dialysis patients. Indian Journal of Nephrology. 14: 61-66.
Siddiqui UA, Halim A, Hussain T (2007). Nutritinal Profile and inflammatory status
of stable chronic Hemodialysis Patients at Nephrology Department, Military
Hospital Rawalpindi. Journal of Ayub Medical College. 19(4):29-31.
U.S. Renal Data System, USRDS 2013 Annual Data Report: Atlas of End-Stage Renal
Disease in the United States, National Institutes of Health, National Institute of
Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2014.
[email protected]
King Faisal Specialist Hospital & Research Center Jeddah, KSA