Transcript Document

(Mal)Nutrition & CKD
Aasim Ahmad
[email protected]
Outline
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Goals of CKD management
Terminologies
Burden
Causes
Evaluation
Management
Rationale
Goals of CKD Management
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Achieve/maintain optimal nutritional status
Prevent protein energy malnutrition
Slow the rate of disease progression
Prevention/treatment of complications and other
medical conditions
DM
HTN
Dyslipidemias and CVD
Anemia
Metabolic acidosis
Secondary hyperparathyroidism
Nutrition & CKD an age old issue
• “After the first hemodialysis sessions in the early
sixties, Dr Scribner rapidly pointed out key questions
that emerged after these first treatments: how to
better control blood pressure, how to manage
chronic anemia, and which nutrients should be
recommended to these patients. Fifty years later in
2010, the two first issues have been largely solved.
By contrast, there is still much to do to fight protein–
energy wasting as present epidemiological studies
report between 30 and 50% of patients with signs of
malnutrition”.
Nutrition and chronic kidney disease Kidney International (2011) 80
Extensive literature on nutrition & CKD
Terminologies used
• Malnourishment -pure malnutrition can be
associated with reduced serum albumin
concentrations, but marked reductions are unusual
• Inflammation -while the presence of inflammation is
frequently associated with a decrease and
sometimes marked reductions of albumin in serum
albumin
• Protein Energy Wasting (PEW) • Cachexia - very severe form of PEW, often associated
with profound physiological, metabolic,
psychological, and immunological disorders
• Protein–energy wasting is determined by
anorexia, increased protein catabolism and
enhanced resting energy expenditure, with
inflammation playing a major role and leading
to accelerated protein catabolism and reduced
muscle and liver protein synthesis
This consensus paper recommends
the term
• Protein-energy wasting (PEW) instead of
malnutrition due to the tremendous influence
of inflammation, uremia, and catabolism on
nutrition status. The consensus paper
recommends standardizing the diagnosis of
PEW with 4 categories of assessments
Protein-Energy Wasting
(PEW) Categories
Malnutrition Clinical
Characteristics
• Appetite, food intake,
energy expenditure
• Body mass and composition
• Energy intake
• Nutrition scoring (SGA, MIS)
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• Laboratory markers
• Weight loss
Fat loss
Muscle wasting
Fluid accumulation
Hand grip strength
Deterioration of Nutritional Status
Begins Early
 GFR 28 – 35 mL/min or greater
 Protein–energy wasting affects up to 70–75%
of patients with end-stage renal disease
 Protein Energy Malnutrition (PEM) is often
present at the time patients begin dialysis.
 Malnutrition in pts beginning dialysis is a
strong predictor of poor clinical outcome
Causes of PEW in CKD Patients
1. Decreased protein and energy intake
a. Anorexia
i. Dysregulation in circulating appetite mediators
ii. Hypothalamic amino acid sensing
iii. Nitrogen-based uremic toxins
b. Dietary restrictions
c. Alterations in organs involved in nutrient intake
d. Depression
e. Inability to obtain or prepare food
Etiology of the Protein-Energy Wasting Syndrome in Chronic Kidney Disease: A Consensus
Statement From the International Society of Renal Nutrition and Metabolism (ISRNM) Journal of
Renal Nutrition, Vol 23, No 2 (March), 2013
2. Hypermetabolism
a. Increased energy expenditure
i. Inflammation
ii. Increased circulating proinflammatory cytokines
iii. Insulin resistance secondary to obesity
iv. Altered adiponectin and resistin metabolism
b. Hormonal disorders
i. Insulin resistance of CKD
ii. Increased glucocorticoid activity
3. Metabolic acidosis
4. Decreased physical activity
5. Decreased anabolism
a. Decreased nutrient intake
b. Resistance to GH/IGF-1
c. Testosterone deficiency
d. Low thyroid hormone levels
6. Comorbidities and lifestyle
a. Comorbidities (diabetes mellitus, CHF, depression,
coronary artery disease, peripheral vascular disease)
7. Dialysis
a. Nutrient losses into dialysate
b. Dialysis-related inflammation
c. Dialysis-related hypermetabolism
d. Loss of residual renal function
Schematic representation of the causes and manifestations
of the protein–energy wasting syndrome in kidney disease
A proposed nomenclature and diagnostic criteria for protein–energy wasting in acute and chronic
kidney disease Kidney International 2008 -73
Evaluation
Clinical practice guidelines-UK
Renal association
Guideline 1.1.1 – Screening methods for
undernutrition in CKD
• We recommend that all patients with stage 4-5 CKD
should have the following parameters measured as a
minimum in order to identify undernutrition (1C):
– Actual Body Weight (ABW) (< 85% of Ideal Body Weight
(IBW))
– Reduction in oedema free body weight (of 5% or more in
3 months or 10% or more in 6 months)
– BMI (<20kg/m2)
– Subjective Global Assessment (SGA) (B/C on 3 point
scale or 1-5 on 7 point scale)
Guideline 1.2 – Frequency of screening for
undernutrition in CKD
• We recommend that screening should be
performed (1D);
– Weekly for inpatients
– 2-3 monthly for outpatients with eGFR <20 but not on
dialysis
– Within one month of commencement of dialysis then
6-8 weeks later
– 4-6 monthly for stable haemodialysis patients
– 4-6 monthly for stable peritoneal dialysis patients
Screening may need to occur more frequently if risk of
undernutrition is increased (for example by
intercurrent illness)
Subjective Global Assessment
• Valid assessment tool
• Strong correlation with other subjective and
objective measures of nutrition
• Highly predictive of nutritional status in a number of
different patient groups including CKD
• Quick, simple and reliable
Subjective Global Assessment
Recognized by KDOQI as a useful measure of PEM
• Provides a nutritional score based on 2
components
– Medical history: history of wt. loss (6 months),
eating habits, GI symptoms, physiological functions
and metabolic stress
– Physical assessment: visual assessment of loss of
subcutaneous fat and muscle mass
• Patient is scored on a 7–point scale
– 6-7 well nourished
– 3,4,5 mild to moderately nourished
– 1 or 2 severely malnourished
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Subjective Global Assessment
• History
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Unintentional weight loss over the past 6 months
Pattern and amount of weight loss is considered
Weight change in past 2 weeks
Weight of <5% is small, loss >10% is significant
Dietary intake change (relative to normal)
GI symptoms >2 weeks (nausea, vomiting, diarrhea,
anorexia)
– Functional capacity (energy level: daily activities,
bedridden)
– Metabolic demands of primary condition noted
Subjective Global Assessment
• Physical Exam
• Each feature is noted as normal, mild,
moderate, or severe based on clinician’s
subjective impression
– Loss of subcutaneous fat measures in the triceps
and the mid-axillary line at the lower ribs
– Muscle wasting in the quadriceps and deltoid area
– Presence of edema in ankle or sacral region
– Presence of ascites
SGA Rating
• Determined by subjective weighting
• May choose to place more emphasis on weight loss, poor
dietary intake, subcutaneous tissue loss, muscle wasting
• Must be trained in this technique to achieve consistency
• Scoring may predict development of infection more
accurately than other objective measures of nutritional
status (albumin)
– A = well nourished (60% reduction in post-op complications)
– B = moderately malnourished ( at least 5% wt loss with decreased
intake and subcutaneous loss)
– C = severely malnourished (4X more post op complications, 10%
wt loss and physical signs of malnutrition)
• Ascites and edema decrease significance of body weight
Subjective Global Assessment
• Advantages
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Predicts post-surgical complications
Does not require lab testing
Can be taught to a broad range of health professionals
Compares favorably with objective measurements
Validated in liver transplant, dialysis, and HIV patients
• Disadvantages
– Subjective and dependent on the experience of the observer
– Not sensitive enough to use in following nutrition progress
Optimal Nutritional Status
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Albumin > 4.0
Stable, desirable dry weight
Adequate fat stores and muscle mass
Appropriate appetite and intake
Low Albumin
 Non-nutritional factors
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Infection
Inflammation
Co-morbidities
Fluid overload
Inadequate dialysis
Blood loss
Metabolic acidosis
Calories
• Recommended energy intake = 30 to 35 day
kcals/kg
• Spares body protein
• Maintains neutral nitrogen balance
• Promotes higher serum albumin levels
• Challenges
• Decreased appetite from uremia
• Various CKD dietary restrictions
• Finding food sources for added calories
Stages of CKD Nutrient
Recommendations
Pro Kcal
g/kg
Na+
g/day
K+
Phos
Calcium
g/day
1
.75
Based on
energy
expenditure
1-4 g to No restriction Monitor and
NAS
restrict if nec
Unless high
1.2-1.5
2
.75
Based on
energy
expenditure
1-4 g to No restriction Monitor and
NAS
restrict if nec
Unless high
1.2-1.5
3
.75
Based on
energy
expenditure
1-4 g to No restriction 800-1000
NAS
mg/day
Unless high
1.2-1.5
4
.6
30-35
kcal/kg
1-4 g to No restriction 800-1000
NAS
mg/day
Unless high
<2000
mg/day
5
0.6- 30-35
0.75 kcal/kg
1-4 g to No restriction 800-1000
NAS
mg/day
Unless high
<2000
mg/day
PROTEIN
Protein
• Important for growth and maintenance of
body tissue
• Provides energy and fights infection
• Keep fluid balance in the blood
• 2 types of Protein
– High Biological Value (HBV) or animal proteinmeat, fish, poultry, eggs, tofu, soy milk, and dairy
– Low Biological Value (LBV) or plant protein –
breads, gains, vegetables, dried beans and peas
and fruits
Reduction of protein intake
• Most of the scientific societies worldwide
recommend a daily allowance of 0.6–0.8 g
protein/kg/day for CKD 3-5 patients with or
without diabetes
• Decreasing protein intake is particularly
important in patients with proteinuria, including
those with diabetic nephropathy,
– decreases proteinuria as efficiently as ACE-I
– has an additional effect on proteinuria reduction
– improves serum lipid profile
– Decreases cardiovascular mortality
K/DOQI protein guidelines
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(Average American Intake = 1.2 g per kg/day)
0.75 grams per kg/day for CKD stages 1 thru 3
0.6 grams per kg/day for CKD stages 4, 5
50% of the dietary protein should be HBV
– HBV protein produces less nitrogenous waste
• 45 to 60 grams protein per day
• No Protein Restriction for Dialysis Patients
• 1.2 g per kg/day hemodialysis
– 10-12 grams lost per HD treatment
• 1.3 g per kg/day peritoneal dialysis
– 5-15 grams lost per PD treatment
Dietary Protein Restriction…
• Reduces nitrogenous waste
• Reduces inorganic ions
• Reduces metabolic/ clinical disturbance
(uremia)
• Slows rate of decline in GFR
Reduction of protein intake
• Limiting protein intake is associated with an
instant
– decrease in wasted products and uremic toxins,
blood urea
– nitrogen levels, and acid load.
– reduction in oxidative stress, amelioration of
insulin resistance,
– better control of metabolic bone disorders in
response to a reduced phosphate load, and
subsequent improvement in anemia
Protein in Foods
• 1 oz meat, poultry, fish = 7 g
– ¼ cup tuna
– ½ cup beans, peas, or lentils
– 2 Tablespoons peanut butter
– 2 egg whites = 7 g
• 1 cup milk = 8 g
– 1 oz cheese
– 1/3 cup cottage cheese
• 1 cup veg = 2 g
• 1 slice bread = 3 g
– ½ cup rice or pasta
– ½ cup cereal
• Fruit, fats, sugars = 0
Protein
 The following list contains foods and their
protein content:
 ▪ 1 egg=7 g protein
▪ 1-2 ounce (oz) chicken thigh=14 g protein
▪ 8 oz skim milk=8 g protein
▪ 1 slice of bread=2 g protein
▪ 1 cup (C) cooked rice=4 g protein
▪ ½ C corn=2 g protein
Phosphorous
Phosphorus
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A mineral found in almost all foods.
Normal kidneys will balance the amount of
phosphorus in our bodies. When the kidneys
fail the phosphorus increases in the blood.
It is necessary to limit and/or avoid highphosphorus foods.
Control of phosphorus is often difficult for
kidney failure patients.
Dietary goal is 1-1.5gms/day
Normal range <5.5
Phosphorus
Foods high in phosphorus include:
 Dairy products
 Dried beans and peas
 Nuts
 Peanut butter
 Bran cereals
 Whole wheat bread
 Meats
 Food Additives
Sodium
Low sodium intake
• High dietary sodium intake is associated with high
blood pressure, worsening of proteinuria and a
blunting of the response to agents that block the RAAS
(it also increases thrist)
• Irrespective of blood pressure, dietary sodium
restriction should be a component of nutrition therapy
for all patients with proteinuria, including those on
RAAS blockade
• Effect of reducing sodium in diet is more pronounced in
– Hypertensives
– Elders
– African Americans
Guidelines
• Kidney Disease Improving Global Outcomes (KDIGO)
guidelines recommend a sodium restriction of less
than 2000 mg per day in people with stages 1
through 4 CKD
• Canadian Hypertension Education Program(CHEP)
guidelines recommend limiting sodium intake to no
more than
– 1500 mg of sodium per day for those younger than 50
years of age
– 1300 mg for those between 50 and 70 years of age
– and no more than 1200 mg for those over the age of 70
Limitation
• Restricting sodium intake to the recommended
levels is often difficult to achieve in practice,
especially for those younger and more active
individuals requiring larger caloric intakes.
Nutrition counselling should focus on
processed and prepackaged foods (including
canned soups and deli meats), meals taken
outside of the home and bread products that
have high sodium content.
DASH Diet
• Dietary Approaches to Stop Hypertension (DASH)
diet is a dietary pattern commonly recommended,
along with a sodium restriction, for nutritional
treatment of hypertension in people with diabetes
because of its potent reductions in both blood
pressure and its effect on insulin resistance
• Principles of the DASH diet include the use of whole
grains, fruits and vegetables, and low-fat dairy
products. As a result, the diet is designed to be high
in potassium and phosphorus and may be best suited
only to individuals with stage 1 to 2 CKD
Algorithm for nutritional management
Protein, sodium & phosphorous
• 70Kg @ 0.6Gms/Kg = 42 Gms Proteins, Na 1500mg &
Phos 1500 mg
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Protein
Egg
06 Gms
Glass of milk
8.2 Gms
Half a Chicken breast
15 Gms
Meat (same size as above) 13 Gms
Lentils
8 Gms
3 Bread/chapatis
9 Gms
• 1 pinch of table salt
Sodium
55 mg
100 mg
35 mg
35 mg
02 mg
450 mg/100
147.80
Phos
120 mg
300 mg
130 mg
240 mg
356 mg
80 mg
Conclusion
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nutritional response to therapy is directly
correlated with severity of PEW at baseline.
• The nutritional response to therapy is directly
correlated with the amount of nutrients
delivered.
• Underlying systemic inflammatory response
does not hinder the beneficial effects of
nutritional supplementation.
• Diabetic patients differ in their response to
nutritional therapy and may require
individualized prescription
• The route of administration of nutritional
supplementation (that is, oral or parenteral)
does not have any significant effect on the
response to therapy as long as equal and
adequate amounts of protein and calories are
provided.
• The optimal targets for dietary protein and
energy intake in maintenance hemodialysis
(MHD) patients is >1.2 g/kg/day and
>35 kcal/kg/day, respectively.
• Routine nutritional markers such as serum
albumin and prealbumin can be used as
surrogate markers not only of nutritional
status but also possibly of hospitalization,
cardiovascular outcomes, and survival.
Thank you
[email protected]
The conceptual model for etiology and
consequences of protein energy wasting (PEW) in
chronic kidney disease
Figure 1
Journal of Renal Nutrition 2013 23, 77-90DOI: (10.1053/j.jrn.2013.01.001)
Copyright © 2013 Terms and Conditions
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AN INTEGRATIVE APPROACH FOR PREVENTION AND TREATMENT OF PEW IN CKD: SUMMARY AND
RECOMMENDATIONS
Because of its metabolic and functional importance in whole body homeostasis, preservation of
muscle mass is the ultimate goal in the management of PEW in CKD patients. In normal conditions,
apart from genetic determinants, protein anabolism is determined by nutrient availability,
especially amino acids, and a greater ratio of anabolic to the catabolic hormones, that is, insulin,
androgens, growth factors, and catecholamines. In CKD and ESRD patients, where a number of
catabolic signals dominate, it is critical to maintain a dietary protein and energy intake relative to
needs. Preemptive treatment of concurrent conditions that contribute to catabolism, such as
metabolic acidosis, insulin resistance, and systemic inflammation, is of paramount importance for
the prevention of development PEW. A holistic approach to dialytic prescription is necessary to
avoid the adverse nutritional side effects of uremic toxin retention. Nonconventional dialytic
strategies may remove the necessity for overrestrictive diets in maintenance dialysis patients
leading to improved nutritional status.38
When supplemental nutrition is indicated, it is crucial to take into account all the determinants of
body and muscle mass:
– protein and energy content,
– exercise,
– anabolizing hormones
Subjective Global Assessment
• Alternative method to assess nutritional status of
hospitalized patients
• Combines information from the patient’s history
with parts of a clinical exam
Criteria
•Serum chemistry
•Serum albumino 3.8 g per 100 ml (Bromcresol Green)a
•Serum prealbumin (transthyretin) o30mg per 100 ml (for maintenance
dialysis patients only; levels may vary according to GFR level for patients
with CKD stages 2–5)a
•Serum cholesterol o100mg per 100 mla
•Body mass
•BMI o23b
Unintentional weight loss over time: 5% over 3 months or 10% over 6
months
Total body fat percentage o10%
Muscle mass
Muscle wasting: reduced muscle mass 5% over 3 months or 10% over 6
months
Reduced mid-arm muscle circumference areac (reduction 410% in
relation to 50th percentile of reference population)
Creatinine appearanced
Dietary intake
Figure 2
Journal of Renal Nutrition 2013 23, 77-90DOI: (10.1053/j.jrn.2013.01.001)
Copyright © 2013 Terms and Conditions
Reverse epidemiology of obesity in dialysis patients
compared with the general population
Kalantar-Zadeh K et al. Am J Clin Nutr 2005;81:543-554
Medical Nutrition Therapy
Recommendations (Stages 3 to 5)
Calories
30-35 kcals/kg IBW
Protein
0.6-0.8 gm/kg IBW
Sodium
1000-4000mg
Fluids
Evaluate need to restrict
Potassium
Evaluate need to restrict
Calcium
<2000mg
Phosphorus
800-1000 mg
Vitamins
Individualized
Subjective Global
Assessment…features
• Medical History
– Weight change
– Dietary intake
– GI symptoms
– Functional impairment
• Physical Examination
– Loss of subcutaneous fat
– Muscle wasting
– Oedema and ascites
Carbohydrate Protein
Fat
4 kcals/g
4 kcals/g
9 kcals/g
1 cup milk
12
8
0 –10
1 oz meat
0
7
1 – 12
1 oz bread
15
3
0
1 cup veg
1 fruit
5
15
2
0
0
0
1 teaspoon
fat/ oil
0
0
5
Food