(mal)nutrition & ckd aasim ahmad [email protected]
TRANSCRIPT
Outline
• Goals of CKD management• Terminologies• Burden• Causes• Evaluation• Management• Rationale
Goals of CKD Management Achieve/maintain optimal nutritional status Prevent protein energy malnutrition Slow the rate of disease progression Prevention/treatment of complications and other
medical conditionsDMHTNDyslipidemias and CVDAnemiaMetabolic 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
• Appetite, food intake, energy expenditure
• Body mass and composition
• Nutrition scoring (SGA, MIS)
• Laboratory markers
Malnutrition ClinicalCharacteristics
• Energy intake
• 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 Patients1. Decreased protein and energy intake
a. Anorexiai. Dysregulation in circulating appetite mediatorsii. Hypothalamic amino acid sensingiii. Nitrogen-based uremic toxins
b. Dietary restrictionsc. Alterations in organs involved in nutrient intaked. Depressione. 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. Hypermetabolisma. Increased energy expenditure
i. Inflammationii. Increased circulating proinflammatory cytokinesiii. Insulin resistance secondary to obesityiv. Altered adiponectin and resistin metabolism
b. Hormonal disordersi. Insulin resistance of CKDii. Increased glucocorticoid activity
3. Metabolic acidosis4. Decreased physical activity5. Decreased anabolism
a. Decreased nutrient intakeb. Resistance to GH/IGF-1c. Testosterone deficiencyd. Low thyroid hormone levels
6. Comorbidities and lifestylea. Comorbidities (diabetes mellitus, CHF, depression,coronary artery disease, peripheral vascular disease)
7. Dialysisa. Nutrient losses into dialysateb. Dialysis-related inflammationc. Dialysis-related hypermetabolismd. 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 AssessmentRecognized 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 (1)
– 6-7 well nourished– 3,4,5 mild to moderately nourished– 1 or 2 severely malnourished
Subjective Global Assessment
• History– 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– 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
Albumin > 4.0 Stable, desirable dry weight Adequate fat stores and muscle mass Appropriate appetite and intake
Low Albumin Non-nutritional factors
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
g/kg
Kcal Na+
g/day
K+ Phos Calcium
g/day
1 .75 Based on energy expenditure
1-4 g to NAS
No restriction
Unless high
Monitor and restrict if nec
1.2-1.5
2 .75 Based on energy expenditure
1-4 g to NAS
No restriction
Unless high
Monitor and restrict if nec
1.2-1.5
3 .75 Based on energy expenditure
1-4 g to NAS
No restriction
Unless high
800-1000 mg/day
1.2-1.5
4 .6 30-35 kcal/kg
1-4 g to NAS
No restriction
Unless high
800-1000 mg/day
<2000 mg/day
5 0.6-0.75
30-35 kcal/kg
1-4 g to NAS
No restriction
Unless high
800-1000 mg/day
<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 protein-meat, 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• (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• 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 high-phosphorus 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 productsDried beans and peasNutsPeanut butterBran cerealsWhole wheat breadMeatsFood 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 Protein Sodium Phos
• Egg 06 Gms 55 mg 120 mg• Glass of milk 8.2 Gms 100 mg 300 mg• Half a Chicken breast 15 Gms 35 mg 130 mg• Meat (same size as above) 13 Gms 35 mg 240 mg• Lentils 8 Gms 02 mg 356 mg• 3 Bread/chapatis 9 Gms 450 mg/100 80 mg
• 1 pinch of table salt 147.80
Conclusion• The 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.
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
• 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 6monthsTotal body fat percentage o10%Muscle massMuscle wasting: reduced muscle mass 5% over 3 months or 10% over 6monthsReduced mid-arm muscle circumference areac (reduction 410% inrelation to 50th percentile of reference population)Creatinine appearancedDietary intakeUnintentional low DPI o0.80 g kg1 day1 for at least 2 monthse fordialysis patients or o0.6 g kg1 day1 for patients with CKD stages 2–5Unintentional low DEI o25 kcal kg1 day1 for at least 2 monthse
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 IBWProtein 0.6-0.8 gm/kg IBW
Sodium 1000-4000mgFluids Evaluate need to restrictPotassium Evaluate need to restrictCalcium <2000mg
Phosphorus 800-1000 mgVitamins 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
Food
Carbohydrate4 kcals/g
Protein4 kcals/g
Fat9 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 5 2 0
1 fruit 15 0 0
1 teaspoon fat/ oil
0 0 5